Women and Birth 27 (2014) e28–e35

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Women and Birth journal homepage: www.elsevier.com/locate/wombi

Original Research – Quantitative

Facilitators of prenatal care access in rural Appalachia Julia C. Phillippi a,*, Carole R. Myers b, Mavis N. Schorn a a b

Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, United States College of Nursing, University of Tennessee, Knoxville, 1200 Volunteer Boulevard, Knoxville, TN 37996, United States


Article history: Received 1 May 2014 Received in revised form 20 July 2014 Accepted 4 August 2014 Keywords: Prenatal care Health services accessibility Appalachia Midwifery Patient-centered care


Background: There are many providers and models of prenatal care, some more effective than others. However, quantitative research alone cannot determine the reasons beneficial models of care improve health outcomes. Perspectives of women receiving care from effective clinics can provide valuable insight. Methods: We surveyed 29 women receiving care at a rural, Appalachian birth center in the United States with low rates of preterm birth. Semi-structured interviews and demographic questionnaires were analyzed using conventional qualitative content analysis of manifest content. Findings: Insurance was the most common facilitator of prenatal access. Beneficial characteristics of the provider and clinic included: personalized care, unrushed visits, varied appointment times, short waits, and choice in the type and location of care. Conclusion: There is a connection between compassionate and personalized care and positive birth outcomes. Women were willing to overcome barriers to access care that met their needs. To facilitate access to prenatal care and decrease health disparities, healthcare planners, and policy makers need to ensure all women can afford to access prenatal care and allow women a choice in their care provider. Clinic administrators should create a welcoming clinic environment with minimal wait time. Unrushed, woman-centered prenatal visits can increase access to and motivation for care and are easily integrated into prenatal care with minimal cost. ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

The World Health Organization (WHO)1 and the United States Centers for Disease Control and Prevention (CDC)2 call for increased access to prenatal care to improve perinatal outcomes and decrease health disparities. Early and consistent prenatal care is associated with lower rates of maternal death3 and preterm birth4 and increased breast-feeding rates.4–6 In addition, highquality prenatal care can improve perinatal outcomes for women with pre-existing medical conditions.6–8 While a causal link between prenatal care and health outcomes is impossible to establish, the strong association between prenatal care and improved outcomes supports the need for high-quality care in pregnancy for all women. However, providers of prenatal care do not all have an equal effect on maternal and fetal outcomes. Care provided by nursemidwives results in fewer preterm births when compared with

* Corresponding author at: 517 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, United States. Tel.: +1 615 343 2683. E-mail address: [email protected] (J.C. Phillippi).

physician-led care.9 Birth centers also have positive outcomes when compared with hospitals for low-risk women.10,11 However, since midwives and birth centers usually provide care to lower-risk women than physicians and hospital-based clinics, women receiving care from midwives and within birth centers may see a variety of provider types depending on their physical or emotional needs.11 This type of customized, interprofessional care has been shown to be beneficial in improving perinatal outcomes.12 While research supports collaborative, interprofessional care in pregnancy, it is not clear what components of these innovative models improve health outcomes. Several causal mechanisms have been proposed including improved maternal communication, health literacy, and greater involvement in care.9,13,14 While data correlating prenatal care models and perinatal outcomes are useful in demonstrating efficacy, numeric information does not explain the reasons behind the success or address women’s perspectives. The National Committee for Quality Assurance (NCQA) and the Agency for Healthcare Research and Quality (AHRQ) call for all healthcare to be centered around individual needs.15 However,


1871-5192/ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

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clinicians, administrators, and healthcare planners lack evidence about the desires and needs of women seeking prenatal care, and the voices of women most at risk for poor perinatal outcomes are not well represented in studies of women’s experiences of care.16,17 Women who are marginalized in society due to race, socio-economic status, and/or location are at risk of poor perinatal outcomes for a variety of reasons.18,19 However, clinics and clinicians need to meet the needs of these women to improve health outcomes. A reduction in health disparities is only possible if prenatal care is accessible to all women, regardless of their income, language, race, or location. Research on women’s experience of access is needed to explore how effective models resonate with women’s emotional, social, and physical needs. If providers and administrators have more information on successful prenatal care, they can adjust prenatal visits and clinic structures to meet the needs of vulnerable women, consistent with patient-centered care.15 Our qualitative descriptive study examined women’s access to prenatal care at a rural Appalachian birth center in the United States with low rates of preterm birth. Nurse-midwives have provided prenatal care in this underserved region for over twenty years, using interprofessional collaboration as needed. At the time of the study, the center had a preterm birth rate less than onefourth the state average,20 despite the region’s persistently high rates of high poverty and poor perinatal outcomes.21–24 The women’s comments about facilitators of care are useful in understanding components of effective care that may improve prenatal outcomes.


then asked about her decision between individual and group format prenatal care. The final question, ‘‘Is there anything else you would like to tell me about your ability to get prenatal care?’’ was designed to allow the opportunity for unstructured comments. The primary author conducted the interviews. All interviews, except one, were conducted at the center during clinic hours. One interview was conducted at a local library per participant request. Oral and written consents were obtained prior to the interview. Family members were allowed in the interview room and occasionally participated in the discussion, but their comments were not included in the analysis as they had not given consent to participate. A structured questionnaire was used to obtain demographic information and determine if the woman was in a group at-risk for poor prenatal care utilization; this information was used to deepen the researchers’ understanding of facilitators of care. The questionnaire was developed by the research team based on the current literature on prenatal care access17 and then edited by a nurse-midwife with research experience with women in Appalachia. To avoid prompting the discussion, the questionnaire was administered at the end of the interview. Each questionnaire was numerically linked with the appropriate interview. The primary author dictated field notes using the method described by Patton following each interview,34 information from the field notes was added to final transcripts to contextualize the women’s verbal comments. 2.2. Study location

1. Theoretical framework Critical realism was the theoretical basis for the study25 as it acknowledges the dynamic interplay between a person or people and the structures created by those people. Critical realism has been an effective framework for the study of healthcare access,26– 28 and is an ideal basis for the study of prenatal care access as there are maternal, structural, and societal/cultural aspects involved in a woman’s ability to access prenatal care.29 For instance, aspects of the woman and the clinic interact to affect the woman’s decisions.29 Beliefs about the body, pregnancy, and personal responsibility stem from societal constructs and influence individuals’ decisions, resulting in health consequences. The larger society can also affect decisions though provision of health insurance, availability of affordable transportation, and flexibility of work schedules. 2. Methods 2.1. Study design The goal of the research was to explore the experience of women receiving care at the exemplar birth center to identify facilitators. Since the focus was on the women’s perspective, a qualitative descriptive design was used.30,31 Institutional review board approval was obtained from the University of Tennessee, Knoxville. Three types of data were used to explore the women’s experience of access, interviews, demographic questionnaires, and field notes. Data were analyzed using conventional (inductive) qualitative content analysis of manifest content.32,33 Semi-structured interviews were the primary data source. The primary author asked five main questions during the interviews; each question could include prompts for more information. The first question, ‘‘What helps you get prenatal care?’’ was followed up with, ‘‘Has this changed over the time you have been pregnant?’’ The second major question was, ‘‘Are you getting what you want out of prenatal care?’’ Participants were then asked, ‘‘What do you want to get from prenatal care?’’ The woman was

The study was conducted at a birth center in the state of Tennessee in the United States. The birth center is located in a region of the United States known as Appalachia, defined by its proximity to a large mountain chain that runs down the Eastern side of the Country (see Fig. 1). Historically, this region has been known for high rates of poverty and poor health outcomes, and this rural county is consistent with the trends of the larger Appalachian region.24,36 One-third of county land is designated as national forest,37 and 20% of the population lives below the poverty line, a higher rate than surrounding urban counties.38 Thirty-two percent of the center’s pregnant clients lived within the county. Forty-seven percent of the women lived in a contiguous county; many adjacent counties did not have an obstetric provider.39 Nineteen percent of the center’s pregnant clients crossed at least two county lines for prenatal care. Since the center was the only free-standing birth center in a 50-mile radius, women traveling long distances were often seeking birth center care. In 2011, the center had a 2.8% preterm birth rate for established pregnant clients compared with the state average of 12.8%.20 In addition, the birth center had a low cesarean birth rate (5.2% for those admitted in labor) when compared with a state average of 24.2% for women without a previous cesarean.35 The birth center, accredited by the Commission for the Accreditation of Birth Centers, employed three nurse-midwives to provide antepartum, intrapartum, and postpartum care. The center offered a range of appointments times. The clinic was open Monday through Friday, opening at eight in the morning three days of the week and offering appointments until seven in the evening one night a week. All women who called for an appointment were seen for an initial visit, regardless of their insurance status or medical history. At the initial appointment, women were provided with information about the state’s Medicaid-replacement programs, known as TennCare and CoverKids. These state insurance programs were available to women with low-incomes. At the time of the study, prenatal care was available at no cost to qualifying women with TennCare and CoverKids. However, the

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Fig. 1. Location of the study within the United States.

availability and income requirements of these programs changed frequently based on state and federal funding. After the initial history and physical, low-risk women were cared for independently by the nurse-midwives, and women with medical risk factors were seen by the regional perinatologist to develop a plan for prenatal care and birth. The nurse-midwives provided antepartum care for women with a variety of risk factors, in collaboration with the perinatalogists, and subsequently assisted the women in giving birth at either the birth center or the local hospital. Women at risk of poor intrapartum outcomes were referred to the regional medical center in labor but received prenatal and postpartum care at the birth center. 2.3. Sample recruitment After Institutional Review Board approval, pregnant, adult, English-speaking women receiving individual prenatal care were recruited for study participation from February through May 2011. Flyers were placed in women’s charts and on bulletin boards. In addition, the midwives and the primary author spoke with potential participants when they were at the center for regularly-scheduled care. Women were recruited at any point in pregnancy. The women opted into the study by meeting with the primary author after a prenatal visit or requesting an interview appointment. Participants received a $15 gift card at the completion of the interview. Recruitment continued until saturation of findings was achieved. 2.4. Data analysis The data were analyzed using conventional (inductive) qualitative content analysis of manifest content as described by

Elo and Kyngas 32 and Graneheim and Lundman.33 Conventional, also known as inductive, content analysis develops categories from the data rather than from the literature.40 The steps in conventional content analysis are data immersion, selection of a unit of analysis, open coding, creation of categories, and data abstraction.32 In the immersion step of analysis, the primary author listened to the recordings and read the transcripts, field notes, and questionnaires several times to understand the whole of the data. Following immersion, the primary author open coded all transcripts. Open coding involved grouping related comments into meaning units.32 The content of the interviews was clearly divided into three meaning units: facilitators of prenatal care access, the decision between individual and group prenatal care, and reasons for choosing birth center care. The analysis of the information about facilitators of prenatal care will be presented in this manuscript; women’s comments about the decision between individual and group prenatal care are published separately.41 To facilitate coding and validation, transcripts were entered into ATLAS-ti, a qualitative analysis computer program.32 All study authors independently open coded all comments about facilitators of care and met to compare initial codes.33 Through dialog, the team members agreed on the major data codes and defined each code. The primary author then re-coded all the comments about facilitators of prenatal care using the research-team schema. Following the second coding, all codes were examined for overlap and value by examining each code for congruence with the code definition and potential overlap with other codes. Redundant codes were combined, and the core meaning of codes defined and refined.32 Codes sharing commonalities were grouped into themes, which were refined and reduced to their essential meaning.32 All study authors reviewed the final results to ensure codes and themes were comprehensive, concise, and represented the women’s comments. Member checking was performed using the midwives who provided care at the clinic since all participantprovided phone numbers were not valid when contact was attempted. Two of the midwives employed at the center during data collection reviewed the results and stated they were an appropriate and valid representation of facilitators of access for that population.

3. Results Twenty-nine women completed an audio-recorded interview and a demographic questionnaire. Women provided vivid narratives of their lives and how their larger circumstances affected their ability to get prenatal care and have a healthy pregnancy. The stories were complex and diverse and often involved insurance paperwork, insurmountable housing problems, high gas costs, and unsupportive or jailed partners. The women acknowledged their ability to access care was complex and fluid, changing with their life circumstances. For instance, when asked what clinics, doctors, and midwives could do to help women get prenatal care. One participant replied: What type of woman, though? Because it depends. If you drive a Mercedes and your husband’s, you know, in the military or something, you’ve got all kinds of access to stuff like that, but if you’re like me and you’re broke and you have a single car- you know, you can’t even afford to eat, you know, you’re going to have problems getting stuff like this. The data from the demographic questionnaire demonstrated that participants had experienced many of commonly reported barriers to prenatal care, such as unplanned pregnancy, needs of

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existing children, and travel-related barriers.17 Fifty-nine percent of participants were not trying to get pregnant at the time of conception. The majority (72%) of the women had at least one child at home during the day. Forty-one percent of the women were working outside the home during pregnancy. The range of travel times to the center was 10–480 min with a median commute of 20 min. However, these women were able to obtain prenatal care despite the barriers. Within their stories, the grit of everyday life was juxtaposed with compassionate, kind, and supportive providers and clinic staff who took time to know them, listen, and provide support, increasing their desire to get care. Women mentioned a wide range of facilitators, going beyond logistics to describe how the attitudes of the clinic staff and providers made time at the clinic more valuable and enjoyable. There were three main categories of facilitators: insurance, provider characteristics, and clinic characteristics. Insurance was the most commonly mentioned facilitator. Characteristics of the provider and clinic were equally represented. 3.1. Insurance Insurance was the most commonly mentioned facilitator of prenatal care access. While data on payer status (Medicaid, Military, or Private Insurance) was not collected, many women spontaneously mentioned they were using the Medicaid program from the state of Tenneessee, known as TennCare, to pay for their perinatal care, and had very favorable comments. ‘‘It’s like how do you pay for a hospital stay and emergencies and stuff? It’s kind of a tough thing, you know. I would say TennCare has been a huge reason why, you know, it’s been easier for us.’’ ‘‘It’s normally just a funding problem. You know, as far as - we’ve been able to afford it personally, but, you know, being able to get State help (Medicaid) is very nice’’ ‘‘No, I haven’t had any trouble getting any prenatal care -with none of my pregnancies. The state helped in that position’’ Many women commented that even though they or their spouse were working, they were unable to afford or obtain private health insurance. However, the women preferred Medicaid when compared to private insurance due to prohibitively high deductibles and co-payments with private plans, while state Medicaid did not have out-of-pocket expenses. ‘‘I couldn’t come to the doctor like the way I do if I had to have my own insurance. If I had to pay for my own insurance and/or have to pay for out-of-pocket, I couldn’t do it.’’ ‘‘I have great insurance through work, so financially that helps. I don’t have TennCare, so it doesn’t help that much. It’s going to be it’s going to be a pretty (large amount)’’ Women were pleased that they qualified for state insurance and often surprised at the ease of the process in Tennessee. Two women had personal experience applying for pregnancy-related Medicaid in other states and felt the process was cumbersome, lengthy, and impaired their ability to obtain prenatal care. One woman stated that since processing of her Medicaid application in another state was going to take 35 days, she drove to Tennessee for prenatal care. Another woman moved back to Tennessee after a negative experience attempting to get care in another state. ‘‘It was very difficult. There’s people that know how to work those things, and I’m just not one of them.’’


3.2. Provider characteristics Attributes of the provider and characteristics of the clinic were equally represented in the women’s comments. Women had 30 comments about how the provider of care made it easier for them to get prenatal care. Positive characteristics of the provider included provision of personalized, compassionate care, not seeming rushed through the prenatal visit, and answering questions. 3.2.1. Personalized care Women had 15 comments about personalized care. The women expressed prenatal care was more than a series of measurements; it was moment to be heard in the midst of their stressful lives. They enjoyed their time with the midwives, and felt each provider viewed them as a whole and unique person. ‘‘that (previous) doctor was not as personalized, you know. In-out. Don’t spend no time with me and that was it. Here you get more of a 1-on-1.’’ ‘‘I want someone that actually cares and knows what I am goin’ through. It’s really - they actually cares and not just doing their job. Actually cares about my health and the baby’s health and somebody that actually understands instead of just an appointment, a paycheck. I’m just going to be blunt. But that’s how I feel about it. Yeah. If I come in, you know, and there’s something bothering me I don’t want to - I don’t want to feel like I’m just complaining - feel like I’m just there. I want somebody to actually listen and not think that I’m just making it up off the top of my head. And actually know what I’m going through’’ ‘‘. . .to feel like I am a human - and to feel like I’m not just another name on a piece of paper to be checked off and - almost like a cattle call kind of thing. You know, I like prenatal care to be when they actually care about - you know, not just how’s the baby doing, but how’s Mom doing, you know, physically, emotionally, you know. And that to me is really, really important, and that’s what I get here. That’s why I like it here.’’ 3.2.2. Unrushed The value of an ‘‘unrushed’’ prenatal visit was the second most commonly mentioned attribute of providers. Women’s comments suggested a relaxed visit helped them remember their questions and learn more about pregnancy and birth. ‘‘I like how it’s just - they’ll sit in there and they’ll talk to you about everything that you have questions about, and they’re not trying to rush off or leave or anything like that. They’ll sit there and actually sit - have a conversation with you about care.’’ ‘‘We had an OB over in (city) that we went to a couple of times and we didn’t like him a lot - because you were there for maybe what, five minutes? And then you were gone. It was just very impersonal. It was more like you were just on this conveyor belt, you know, here’s another Mom. Here you can just sit down, and you’re so relaxed. You can talk to them because you don’t feel like you’re being rushed. You don’t feel like, you know, they’re coming in with their white coats and their little gadgets, and they’re just ready to go onto the next person.’’ 3.2.3. Gender There were five comments about the value of a female provider in making it easier for participants to get care. Two of these women said female providers were more compassionate, and one participant was uncomfortable having a male provider see her


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unclothed. Gender was the only non-modifiable provider characteristic mentioned by participants. 3.2.4. Questions answered Having their questions answered was viewed as an essential part of prenatal care by participants as it verified pregnancy was proceeding normally and assisted birth planning. Participants were motivated to come in for care since they knew their questions would be answered. Through their stories, women conveyed that asking questions was part of safe, high quality care as the provider was less likely to miss something. ‘‘Here they sit down with me and they talk to me. We go over every little detail, any questions that I have.’’ ‘‘For me it’s good coming every week. I am that kind of woman that I’m umm - ‘How’s the baby?’ ‘The position is good?’ And every time that I come I have a question because I feel something different for here (points to side of abdomen) - different for another side (points to other side of abdomen), and if I come every week I can ask, you know - and have more information. ‘No, it’s normal. Don’t worry. It’s okay.’ So I like it much better like that.’’ ‘‘They’re constantly asking questions and making sure everything’s going good. They’ve answered any questions we’ve had. This is my husband’s first baby, so he’s had, you know, a lot of questions. He’ll ask me, but then he’ll be like, ‘‘I’m going to ask them just to be sure.’’ 3.3. Clinic characteristics The women had an equal number of comments about the clinic and the provider of care when asked about facilitators of prenatal care access. Women valued choices in their prenatal care, both in the location of the clinic and the style of care provided. It was important for women to easily get appointments when they needed to be seen and at times that worked with their work and transportation schedule. They stated a welcoming, pleasant, and family-friendly clinic atmosphere was important in assisting their access to care. 3.3.1. Alternative approach Women stated one of the hardest components of accessing prenatal care was finding a clinic that provided the type of care they wanted. Participants were all receiving prenatal care at a birth center, even though many were planning to birth at a regional hospital due to medical risk factors. The women stated they wanted a practice that supported a less medical approach and more options for prenatal care. Many participants had previous prenatal care in other locations and with other provider types and felt their previous care was unfulfilling or even dehumanizing. Some participants associated less personalized care with overuse of potentially harmful medications and procedures. With this pregnancy, they were intentionally opting for a different approach. Three participants were driving to the clinic from another state, solely to receive midwifery care. Finding a practice that supported their choices was an important component to their access process. ‘‘They work with you here, and that’s what I like, you know, not make you feel guilty if you want to do something a little different or - you know. If you want a natural birth it’s like that’s what they’re here for. And they don’t make you feel weird and like an outcast for not wanting medications or something.’’ ‘‘I didn’t know that there was this different type of care, so I had to do a lot of research to try to find the best fit for me.’’

‘‘I was living in (area) when I first got pregnant, and I - I have hospital issues. I mean seriously, who wants to have their kid in the hospital? Potluck. You don’t know what you’re going to get. And then the whole stranger looking at you when you’re your most vulnerable. Yeah, not good for me. So I was looking for a maternity center. And I googled, and all I found was places that weren’t maternity centers - and at that point I said, ‘‘I have to move back to Tennessee. I’m having my baby here.’’ That’s how hard it was to find one.’’ Women felt more invested if they were able to make decisions about which clinic to attend and contribute to the content of individual visits. In addition, it was important to one participant to decide if students could participate in her visits. 3.3.2. Appointment times Appointment availability was mentioned by seven women as an important facilitator of access. Women commented that the center’s wide range of appointment times allowed scheduling of prenatal care to meet their needs. Transportation availability, work commitments, and the needs of children were commonly mentioned with scheduling concerns. Early morning appointments were helpful to women with children to avoid conflict with naps or school pick-up, while later appointments were better for women who shared a car or worked a job with traditional business hours. ‘‘I don’t drive. And I don’t work, just my husband, and sometimes he has to finish late. And I have a different option, for - maybe one day I can come three o’clock, I can come at four - and I don’t have any problem.’’ ‘‘Thank God, they have after five care. And so that - having that flexibility- has been easy for me’’ 3.3.3. Atmosphere Six women mentioned the overall tone and atmosphere of the clinic made it easier to come to the clinic. ‘Relaxing’ was used to describe the clinic by three participants. Women expressed they felt good entering the clinic as they were acknowledged by the staff and made to feel welcome. ‘‘And, you know, as soon as I walked in- I was like, yeah. It’s a real relaxing environment.’’ ‘‘Everyone here is just really nice, and it’s just kind of like a calm atmosphere - and that’s really what I was - what I was looking for. The other place I was at was more - its more doctors and it was more of a medical side of things and I just - it wasn’t really my area of - Like that I felt comfortable with, so, yeah, coming here was actually really great. I felt super awesome making that decision.’’ ‘‘I just wanted to come here - because all you see is smiling faces and - it just makes you feel right at home’’

3.3.4. Short wait times Five women said short wait times for appointments were an important facilitator, both for initial visit and subsequent visits. Women wanted to be seen as soon as possible for their initial appointment to make sure their pregnancy was normal, and then to be seen quickly when they were experiencing problems. ‘‘A lot of places said that the doctors don’t see you until 10 weeks but the Maternity Center will see you earlier. Maybe if they didn’t make them wait so long. It’s a little scary too, especially for new moms.’’

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‘‘If I need to call and say, ‘I need to come in,’ they’re like, ‘Okay come on over.’’’ 3.3.5. Location Five women commented on the physical location of the clinic as helpful in their ability to get prenatal care. However, the comments about location were cursory, without much depth or explanation. One woman, who was driving 45 min to this clinic, mentioned the distance as convenient when compared with having to drive to a major city to get the style of care she wanted. Women mentioned location as a lesser consideration when compared with the other facilitators; the same number of women mentioned location as a facilitator as there were women driving over an hour for prenatal care. 3.3.6. All care in one location Two women who had previously received care at other clinics felt it was helpful to have all prenatal care in one location including labs, provider visits, and basic ultrasounds. 3.3.7. Family inclusive Only one woman mentioned the value of inclusion of her family members when asked about facilitators of prenatal care access. ‘‘. . .from the beginning I felt like he was included. Because I don’t it ever want it to be me and my doctor.’’ However, women often had their partners or preschool children present with them for the interview, which occurred following a regular prenatal visit, suggesting participants appreciated the ability to involve their family members in their care. 3.4. Other facilitators Women mentioned a variety of other people and things that helped them get prenatal care, these included having transportation, flexible work schedules, supportive family members, and activities to keep children busy during visits. 3.4.1. Transportation Four women commented specifically on transportation as a facilitator of access to care. However, for many more women transportation was presented as a barrier to care. One woman had recently moved to the area from a metropolitan area and stated that the availability of buses and taxis in the city made it much easier when compared with having to wait for her partner to come home from work. Women’s narratives of access often included detailed information on how much money they spent on gas or car care, and the number of minutes spent in the car. While the state government provided free transportation to appointments, only one woman was using the service. Two women had negative statements about the service, including the comment that children were not allowed. 3.4.2. Work schedules Two women mentioned flexible work schedules as a facilitator of access. Work was frequently mentioned when women discussed the value of flexible appointment times, suggesting women may prefer to schedule prenatal appointments around their work to avoid taking time away from paid employment. 3.4.3. Supportive family Two women stated that family members helped them get prenatal care. In addition, many other women had family members with them through the interview or mentioned them favorably when discussing their path to access.


‘‘I do have, like, so many people supporting me at the same time. I have my family members, especially my biggest sister. I’m with her right now (living with her), and she gives me all the support I need, like to get through my pregnancy, and if I need things she’s there to support me in anything. . .’’ 3.4.4. Child activities One participant mentioned that children’s activities helped her get prenatal care as they kept her child busy. The waiting room and one exam room also included play areas for toddlers. 4. Discussion Limitations to this study include the small, fairly-homogenous sample from one geographic location. However, the comments of the participants show women’s perspectives of care and support several ongoing initiatives to improve the accessibility, quality of healthcare. In addition, this study provides information about how high-quality woman-centered care has effects on health outcomes. Women in this study were overwhelmingly pleased to have health care coverage to pay for their prenatal care. The women preferred the state health insurance program as they did not need to pay premiums or deductibles to receive care. Lack of insurance is a barrier to early initiation of prenatal care in multiple studies.17,19,42,43 In Tennessee, 18.2% of all women do not have insurance prior to pregnancy, which may delay their ability to get early care. 44 However, the generous insurance coverage provided by Tennessee through a Medicaid waiver was helpful to the study participants. In the State of Tennessee, there are a variety of provider types providing prenatal care including obstetricians and gynecologists, family practice physicians, physicians’ assistants, nurse practitioners, nurse-midwives, and Certified Professional Midwives. However, there is shortage of all provider types in rural areas. In 2004, the last year for which data is available, 20% of Tennessee counties did not have any prenatal care provider, and 39% of Tennessee counties were classified as obstetric provider shortage areas.45 Over half of all providers of prenatal care within the state practiced in the four major metropolitan counties,45 requiring rural women to drive long distances. However, geographic location was less important to participants than personalized and compassionate care. The provider and the clinic were crucial components of the women’s access process. In the Healthy People 2020 report, access is described as a three-step process, including: gaining entry into the health care system, accessing a place where needed services are provided, and finding a provider with whom the individual can communicate and trust.46 The importance of this triad is wellillustrated by the study participants. The women intentionally chose a clinic where they felt unrushed and were encouraged to be active participants on their prenatal care. The facilitators related to clinic and provider are consistent with current definitions of patient-centered care. Patient-centered care can improve outcomes through client-provider engagement15 as it involves a partnership between the person and the provider to ensure care is both evidence-based and tailored to the individual’s needs and expectations.47 In addition, the NCQA states patientcentered care should use team-approach, involving a variety of types and levels of healthcare professionals as indicated.15 The descriptions of facilitators of access to care included these components as the women were made to feel involved, validated, and welcomed at the clinic. In addition, the women valued continuity of care with nurse-midwives and referral to regional physician providers as needed.


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The rural women in the study had many life circumstances associated with poor health outcomes. Consistent with the lifecourse perspective, personal and societal stressors can influence the health of women in pregnancy and later life.48 While social determinants of health have impact, the welcoming clinic atmosphere and the personalized care was encouraging to the participants and may act as a protective factor, dampening their stress and encouraging positive behavior change.48 While it is difficult to establish a clear causal link with patient-centered care and positive health outcomes, it is worth exploring this connection in future research. This sense of connection and involvement may also be linked with the positive outcomes seen in studies of nurse-midwifery care. The participants in this study were receiving care at a community health clinic staffed by nurse-midwives in collaboration with an interprofessional healthcare team49; many participants were using the clinic as an access point into the regional care network. Until passage of recent national laws, nurse-midwives received only 65% of physician’s fees, but the Affordable Care Act mandates greater payment, at 100% of the physician fee schedule.50 Greater reimbursement could improve financial feasibility of nursemidwifery care, expanding access. Availability of diverse provider-types allow women more choices and control in prenatal care. The women in this study juggled healthcare along with finances, housing, relationships, work, and family but described their time in the clinic as a respite from the hard demands of their lives. The facilitators mentioned by the women were opposite of the barriers described in the literature and provide evidence for providers and healthcare planners on what effectively assists vulnerable women in obtaining prenatal care. The practice implications from this study range from small changes to reframing the provision of care. Expanded clinic hours allow women to schedule appointments around work, children, and transportation needs. In addition, a welcoming clinic environment is a low-cost adjustment that could increase women’s desire for prenatal care. Friendly staff, helpful over the phone and welcoming in person, are essential in making prenatal care an enjoyable and worthwhile experience. Providers who seem unrushed and genuinely interested are important to women and do not increase cost. These study results show the participants’ perspective of access and demonstrate that the link between improved health outcomes and effective prenatal care may be related to greater engagement of the woman. Future research should further explore the link between women’s perceptions, engagement, and health outcomes. In addition, more information is needed on effective models of prenatal care. 5. Conclusion While limited by sample size and one location of data collection, this study provides useful information valuable to policy makers, healthcare planners, clinics, and providers as they increase access to prenatal care. While future research is needed, this data supports that health insurance coverage and womancentered care with minimal wait times increase women’s access to beneficial care during pregnancy. Acknowledgements We would like to thank Marian Roman and Joanne Hall for their assistance with initial study design. Funding was provided by Sigma Theta Tau International, Iota and Gamma Chi chapters. Each chapter provided $500 of support for participant gift cards and interview transcription. Neither chapter provided input into data collection, analysis, interpretation of findings, or dissemination of results.

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Facilitators of prenatal care access in rural Appalachia.

There are many providers and models of prenatal care, some more effective than others. However, quantitative research alone cannot determine the reaso...
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