Low-Income pregnant Women's Quality of Prenatal care

This research project focused on the quality of prenatal care for low-income women in Salt Lake City, Utah. A standardized instrument, The Quality of Prenatal Care Questionnaire was used to guide this study. It focused on Information Sharing, Anticipatory Guidance, Sufficient Time, Approachability, Availability, and Support and Respect. During the months of November and December of 2018, the primary investigator administered the Quality of Prenatal Care Questionnaire to low-income pregnant women in a primary care clinic in Salt Lake City, Utah. A consent form was given for the participants to sign, which then was followed by a short demographic questionnaire, and then followed by the Quality of Prenatal Care Questionnaire. This study was approved by the Institutional Review Board at the University of Utah. Results showed that women reported adverse experiences when it comes to Anticipatory Guidance, which narrowed down on patients being well informed to make their own decisions regarding their prenatal care and providers providing them with enough options for their birth experience, and Sufficient Time, which covered the time providers spend with patients and answering their questions. Women reported that their provider did not did not spend much time talking about expectations for labor and delivery, did not link them to programs in the community that were helpful to her, their provider felt rushed, they did not always have time to answer their questions, they did not make time for them to talk, and they did not make time to listen either. Practice implications to these results indicate that providers need to establish better time management with their patients, as well as establish more in-depth communication with their patients. Other implications are continuing research surrounding the quality of prenatal care with a larger and more diverse sample to obtain experiences from women who see different providers. To increase quality of prenatal care for women, providers need to increase the education and knowledge they give their patients and spend more time addressing their concerns and answering their questions.

LOW-INCOME PREGNANT WOMEN’S QUALITY OF PRENATAL CARE By Madison Abele A Senior Honors Thesis Submitted to the Faculty of The University of Utah In Partial Fulfillment of the Requirements for the Honors Degree in Bachelor of Social Work In The College of Social Work Approved: Jason Castillo Thesis Faculty Supervisor Jason Castillo Chair, Department of Social Work __________________________ Jason Castillo Honors Faculty Advisor __________________________ Sylvia D. Torti, PhD Dean, Honors College April 2018 Copyright © 2018 All Rights Reserved ABSTRACT ii This research project focused on the quality of prenatal care for low-income women in Salt Lake City, Utah. A standardized instrument, The Quality of Prenatal Care Questionnaire was used to guide this study. It focused on Information Sharing, Anticipatory Guidance, Sufficient Time, Approachability, Availability, and Support and Respect. During the months of November and December of 2018, the primary investigator administered the Quality of Prenatal Care Questionnaire to low-income pregnant women in a primary care clinic in Salt Lake City, Utah. A consent form was given for the participants to sign, which then was followed by a short demographic questionnaire, and then followed by the Quality of Prenatal Care Questionnaire. This study was approved by the Institutional Review Board at the University of Utah. Results showed that women reported adverse experiences when it comes to Anticipatory Guidance, which narrowed down on patients being well informed to make their own decisions regarding their prenatal care and providers providing them with enough options for their birth experience, and Sufficient Time, which covered the time providers spend with patients and answering their questions. Women reported that their provider did not did not spend much time talking about expectations for labor and delivery, did not link them to programs in the community that were helpful to her, their provider felt rushed, they did not always have time to answer their questions, they did not make time for them to talk, and they did not make time to listen either. Practice implications to these results indicate that providers need to establish better time management with their patients, as well as establish more in-depth communication with their patients. Other implications are ii continuing research surrounding the quality of prenatal care with a larger and more iii diverse sample to obtain experiences from women who see different providers. To increase quality of prenatal care for women, providers need to increase the education and knowledge they give their patients and spend more time addressing their concerns and answering their questions. iii iv TABLE OF CONTENTS ABSTRACT ii INTRODUCTION 1 LITERATURE REVIEW 2 METHODS 6 RESULTS 10 DISCUSSION 14 CONCLUSION 18 REFERENCES 20 iv INTRODUCTION 1 According to the annual study done by the Utah Department of Health, in 2016 there were 50,242 live births to Utah residents (2018). Out of those births, “91.9% were born to White mothers; 1.5% Black/African American; 1.0% American Indian/Alaskan Native; 2.5% Asian; 1.4% Native Hawaiian/Other Pacific Islander; 0.5% other race; and 1.2% unknown race. 15.7% of births were to mothers who consider themselves Hispanic.” (Utah Department of Health, 2018). According to research done by the Center for American Progress, in Utah, the number of those who are in poverty is 306, 902 (2018). 39.1% are African American, 12.2% are Asian American, 17.6% are Latino, 31.3% are Native American, and 9.0% are White (2018). Out of those people, 11.8% of them were working-age (18-64 years old) women who fell below the poverty line (2018). These statistics show that there are a lot of women giving birth and there are a lot of women in poverty here in Utah. Prenatal care or the healthcare pregnant women receive while they are pregnant, not only takes care of the woman, but the baby as well (Office of Women's Health, 2018) According to the National Institute of Child Health and Human Development (NICHD), prenatal care reduces the risk of pregnancy complications, decreases the fetus and infants risk for complications, and helps educate the mothers on which medications are safe for her to take (2017). All in all, prenatal care is important to both the mother and the fetus and should be prioritized. Unfortunately, women who are poor are more likely to experience adverse pregnancy outcomes than non-poor women (Sheppard, Zambrana, and O'Malley, 2004). High-risk pregnant mothers, lack of quality and access of care, and public health practices are associated with preterm births and low birth weight which can not only 2 affect the long-term health of the baby but significantly increase the risk for infant mortality (Utah Department of Health, 2013). Providing quality prenatal and postpartum care is the primary prevention strategy to reduce maternal and infant death (Sheppard, Zambrana, and O'Malley, 2004) LITERATURE REVIEW Infant Death Throughout the 20th century, the rate of infant deaths has been on a decline. However, throughout the United States, it seems that in the past few years, the decline has come to a halt (Utah Department of Health, 2013). According to the Utah Department of Health, the state of Utah, specifically the Salt Lake Valley, has had a rise in infant mortality rates (2013). The numbers have jumped from 5.1/1000 live births to 5.4/1000 (Utah Department of Health, 2013). Now although a slight increase, it is still an unnecessary increase that should be able to be prevented. “Infant mortality is a major indicator of the health of a nation, as it is associated with a variety of factors such as maternal health, quality and access to health care, socioeconomic conditions, and public health practices.” (Utah Department of Health, 2013). A recent study done by the Utah Department of Health shows that there has been a 3.2% increase in infant mortality rate (2013). It seems according to the data that perinatal conditions are certain causes of death that are the biggest contributor to Utah’s infant mortality rate (Utah Department of Health, 2013). These causes are heavily related “to pregnancy- related issues, primarily preterm birth and low birth weight” (Utah Department of Health, 2013). 2 3 Preterm Births and Low Birth Weight Unfortunately, the number of infants with low birth weights is notably worse in the Salt Lake Valley (7.4%) compared to statewide (6.9%) (Utah Department of Health 2012). Low birth weight has been associated with a higher risk later in life for diseases (Negrato and Gomes, 2013). The research states that “under-nutrition during neonatal life plays a critical role, beyond prenatal development, in the long-term programming of health and disease” (Negrato and Gomes, 2013). Pre- and neonatal under-nutrition should be avoided to prevent long-term deleterious consequences (Negrato and Gomes, 2013). Preterm births in Utah, although not the higher than the national rate, are still a concern due to the high cost of them, especially for low-income or uninsured women. “The average charges of preterm births in Utah is almost $60,000 (Utah Department of Health, 2013). Isolating the extremely preterm infants (<27 weeks gestation) of which the average cost increases to almost $100,000 (Utah Department of Health, 2013). In just 2010 alone, Medicaid spent more than 70% of its funding for births on preterm births (Utah Department of Health, 2013). Postnatal Outcomes Prenatal care has some impact on postnatal care of both the mother and the infant. (Reichman, Corman, Noonan, & Schwartz-Soicher, 2010). Adequate prenatal care can have effects on “mothers’ health behaviors, use of pediatric health care, and their children’s health by increasing awareness of how their behaviors and environment can impact the health of their child” (Reichman, et al., 2010). Examples of this would-be education on smoking and breastfeeding because research has shown that “prenatal smoking interventions are effective in reducing postpartum relapse among mothers who 3 quit smoking during pregnancy” and “prenatal breastfeeding education increases 4 breastfeeding” (Reichman, et al., 2010). Quality prenatal care can also connect mothers to health care and social service systems, which they may have never been connected to before (Reichman, et al., 2010). Barriers There are many consequences of low quality care or infrequent care. Women, especially low-income women, have a lot of barriers arise that prevent them from accessing treatment altogether. Such barriers can include family and friends intervening or becoming involved, issues relating to the healthcare system, and personal issues (Cook, Selig, Wedge, & Gohn-Baube, 1999). There are other factors that can have a negative effect on a woman's care. These can include “lack of financial resources and inadequate or no health insurance; high rates of preexisting chronic disease conditions; low maternal education; age; disrupted families and lack of social support; problems of transportation and child care, and recent immigrant status combined with financial problems” (Dunkel-Schetter, Scrimshaw, & Zambrana, 1991). In addition to these factors, the relationship with the baby’s father was correlated with how quickly the mother initiated prenatal care and the presence of substance abuse was correlated with the number of visits the mother had with her provider (Dunkel-Schetter, Scrimshaw, & Zambrana, 1991). Although family and friends can be a source of support for pregnant women, they can also be a large barrier to receiving treatment. Problems arise when women may not want to let their family or friends know about the pregnancy. Hiding their pregnancy can prevent women from getting enough care when they need it. It may also make it difficult 4 for women to go to their appointments in fear that their pregnancy will be revealed 5 (Cook, et al., 1999) In general, lack of family and friend support is a barrier (Cook, et al., 1999). Family can not only provide practical support, such as getting rides to appointments, but also emotional support. “Personal problems and psychological distress, such as depression, anxiety, and ambivalence about the pregnancy” can affect how often women attend their prenatal care appointments (Cook, et al., 1999). The healthcare system, unfortunately, can put in place a lot of barriers for women trying to access prenatal care. “Crowded clinics, scheduling difficulties (for example, limited availability of appointments, frequent busy signals when telephoning clinic), long waiting times, and interaction with insensitive health care professionals” are all factors that affect a woman's experience with her accessing prenatal care (Cook, et al., 1999). In addition to insensitive health care professionals, the level of trust a patient has with their provider is integral to the care they receive. “Factors related to greater trust specific to patient-provider relationships were: continuity of the patient-provider relationship, effective communication, demonstration of caring and perceived competence. Women with less trust in their physicians reported an unwillingness to follow his/her advice.” (Sheppard, Zambrana, and O'Malley, 2004). In addition, these women that reported a low level of trust with their providers also stated that there were issues of discrimination due to being uninsured (Sheppard, Zambrana, and O'Malley, 2004). Conclusion In response to this, other researchers have considered identifying high-risk pregnant women and implementing evidence-based protocols to provide optimal care (Utah Department of Health, 2013). Implementing prevention strategies seems to be the 5 most effective to avoid such health disparities, especially when it comes to low-income 6 and uninsured women. “Given the crisis of inequity in maternal and child health, organizations such as the World Health Organization, USAID and the Institute of Medicine have made commitments to improve pregnancy outcomes by improving access health services through community-based initiatives such as Maternal Health and Safe Motherhood Interventions and home visitation programs.” (Sheppard, Zambrana, and O'Malley, 2004). However, accessibility is not the only factor that goes into women and their healthcare. The quality of the care and the patient-provider relationship is just as important (Sheppard, Zambrana, and O'Malley, 2004). Low-income and uninsured women have reported not only lack of quality in care but lack of trust in their provider's, which influences their prenatal and postnatal care (Sheppard, Zambrana, and O'Malley, 2004). Unfortunately, there is not much research being done in Utah concerning lowincome women and their quality of prenatal care. This gap in the research needs to be explored. This research project will focus on two questions: (1) What are low income and uninsured women’s experience when it comes to the quality of their prenatal care in the Salt Lake Valley? (2) In what areas can providers improve the prenatal care they provide? METHODS Participant Selection This study was approved by the Institutional Review Board (IRB) at the University of Utah. Referrals were sought through contact with local health clinics and hospitals that work with low income, pregnant women: St. Mark's Hospital, University of Utah South Main Clinic, and Fourth Street Clinic. St. Mark's Hospital and Fourth Street 6 Clinic were unable to collaborate on the research project or refer any participants over. 7 However, the University of Utah South Main Clinic was able to collaborate on the project and refer women to the study. The University of Utah South Main Clinic has an obstetrics/gynecology clinic that accepts most insurance, including Medicaid, CHIP, and Medicare (South Main Clinic, 1998). They also offer discounted rates for patients without any insurance (South Main Clinic, 1998). A meeting was set up with the clinic manager to explain the study, selection criteria, recruitment incentives, data collection, and the proposed standardized instrument. Before approving the project, Collaborative Institutional Training Initiative (CITI) and Health Insurance Portability and Accountability (HIPPA) training were verified by the South Main Clinic manager. Participants were selected through a convenience sampling approach. All participants who were referred to the study by the medical assistant fit the criteria of women who were 18 years of age or older, pregnant, receiving prenatal care services at South Main Clinic, and either uninsured or receiving Medicaid benefits. The criteria of being uninsured were selected due to findings from Sheppard, Zambrana, and O’Malley that showed that women that reported a low level of trust with their providers also stated that there were issues of discrimination due to being uninsured (2004). The data collection location was chosen to be the most convenient to the participants, but not to interfere with the everyday clinic operations. The provider rooms in South Main Clinic were chosen to be the location so that the patients would not have to go anywhere to participate and that way the research could be conducted around the provider schedules. 7 8 Study Design The medical assistant at South Main Clinic was aware of the appointments and providers schedules, so she referred patients who fit the requirements of the study. If patients agreed to learn more about the study, the Principal Investigator went into the provider room where the patients were waiting and informed them of the study and the incentive they would receive if they did participate. A female interpreter was on standby in case any of the participants spoke Spanish and were not fluent in English. The interpreter was referred by the College of Social Work. If patients agreed to participate, an Informed Consent Form was given to them to sign. It was available in both English and Spanish. The form was translated by the Spanish translator that was on standby. After the form was given, the right for patients to stop participating at any time was stressed. All participants will be informed that there are no foreseeable short- or long-term physical, financial, or legal risks to participating in the study. It was also reiterated that the study was completely anonymous and it would have no effect on the services they received at South Main Clinic. Attached to the Informed Consent Form was the Quality of Prenatal Care Questionnaire (QPCQ) containing questions addressing participants’ demographics, insured status, socioeconomic status, and perceptions of their reproductive healthcare institutions policies, programs, and services. This survey was also available in both English and Spanish. The form was translated by the Spanish translator on standby. The survey took about 10 minutes to complete. After completing the survey, participants will be given a $5 gift card to Target for participating in the study. 8 9 Study Instrument The Quality of Prenatal Care Questionnaire (QPCQ) had been previously tested by Heaman et al. (2014) and used in other research done. It is a valid and reliable instrument that is used to compare the quality of care as well as evaluate the relationship between quality of care and maternal and infant health outcomes (Heaman et al., 2014). It includes forty-six questions that are broken up into six subsections (Heaman et al., 2014). First was Information Sharing, which focused on how prenatal care providers answered patient questions, kept confidential information, and made sure that their patients understood reasons for tests and their results (Heaman et al., 2014). Next was Anticipatory Guidance, which narrowed down on patients being well informed to make their own decisions regarding their prenatal care and providers providing them with enough options for their birth experience (Heaman et al., 2014). Following that was Sufficient Time, that covered the time providers spend with patients and answering their questions (Heaman et al., 2014). After that, Appropriability was addressed, which dived into the provider’s approachability with patients (Heaman et al., 2014). Next came Availability, a section that included patient’s knowledge on how to contact their provider and how available the clinic/office staff or their provider was when they needed them (Heaman et al., 2014). The last section was Support and Respect that covered items related to patients being respected by their prenatal care providers when it came to their concerns and their own decisions (Heaman et al., 2014). Data Analysis and Interpretation Once the Informed Consent Forms and The Quality of Prenatal Care Questionnaires were collected, the data from the surveys were entered into the statistical 9 10 software program, Statistical Package for the Social Sciences (SPSS). All of the collected surveys were stored in a locked file cabinet at the University of Utah College of Social Work. After all of the data from the surveys was entered into Statistical Package for the Social Sciences (SPSS), the data was reviewed to detect and correct for any errors in the entry of the data (i.e., missing data, typing errors, coding errors). Once the data had been reviewed, the first set of analyses were exploratory in nature and consisted of descriptive statistics describing characteristics of the sample population. The second set of analyses consisted of running a crosstab analysis to convey differences between groups with a number of different variables. RESULTS Descriptive Characteristics of Sample Descriptive statistics were used to determine the demographic characteristics of the participants. See Table 1 in the Appendix for the presentation of the findings. Eight participants chose to participate in the study. The majority had Medicaid benefits (50%), but other participants were uninsured (25%) or had another type of insurance (25%). There was a range of household income, with three women making less than $25,000 a year (37.5%), one making $25,000 to $34,999 a year (12.5%), two making $35,000 to $49,999 a year (25%), one making $50,000 to $74,999 a year (12.5%), and one making $100,000 to $149,999 a year (12.5%). The majority of women who participated were 1824 years old (50%), however, there were quite a few who were 25-30 years old (37.5%), and there was one who was 31-36 years old (12.5%). All of the women who participated were diverse in their ethnic origin. Three women were Hispanic or Latino (37.5%), three women were White (37.5%), and two women were Black or African American (25%). 10 11 Lastly, most women who participated were Single or ever married (50%), however, there were women who Lived with a partner (37.5%) and one who was Married or in a domestic partnership (12.5%). Sample’s Perception of Prenatal Care In addition to running descriptive statistics on this study, crosstab analysis was also run to identify existing differences between women by age, race or ethnic origin, marital status, income, and health insurance status. Age Age was a very prominent factor is the experiences of the women who participated. Women seemed to have positive experiences with their providers, except when it came to Anticipatory Guidance and Sufficient Time. More specifically, women who were 18-24 years old reported more adverse experiences. According to the data, when it came to Anticipatory Guidance, it seems that the provider did not spend much time talking about expectations for labor and delivery for one woman who was 18-24 years old. Another woman 31-36 years old reported that their provider did not link them to programs in the community that were helpful to her. A second woman who was 18-24 years old expressed that her provider did not give her adequate information about depression in pregnancy. Others reported issues regarding Sufficient Time. Following women between the age of 18-24 reported that their provider felt rushed, they did not always have time to answer their questions, they did not make time for them to talk, and they did not make time to listen either. 11 12 Race or Ethnic Origin More women of color seemed to report unfavorable experiences with their providers with both Anticipatory Guidance Women who identified as both Hispanic or Latino and White reported issues concerning their provider not giving them enough options and information. One woman who was Hispanic or Latino reported that her provider did not spend time talking about expectations for labor and delivery. Two women who were White reported that her provider did not link her to programs in the community that were helpful to her and one reported that her provider did not give her adequate information about depression in pregnancy. A majority of women who reported themselves as women of color reported adverse experiences concerning Sufficient Time with their provider. One woman who was White and one woman who was Hispanic or Latino reported that their provider was rushed. Three responses, reported from a Black or African American woman, reported that her provider did not always have time to answer their questions, did not make time for them to talk, and did not take time for them to listen. Marital Status Issues with Anticipatory Guidance were reported only by women who were living with a partner, married, or in a domestic partnership. One woman living with a partner reported her provider did not spend time talking about her expectations for labor and delivery, and another woman who reported living with a partner reported that her provider did not give her adequate information about depression during pregnancy. One woman who was married or in a domestic partnership reported that her provider did not link her to programs in the community that were helpful to her. 12 13 Sufficient Time was also a concern for those either living with a partner, married, or in a domestic partnership. Two women, one who was living with a partner and the other who was married or in a domestic partnership, reported that their provider was rushed. Three reports were made from those reporting that they were single, never married, highlighting that their provider did not always have time to answer their questions, they did not make time for them to talk, and they did not take time to listen. Income With Anticipatory Guidance, three concerns were expressed by multiple women with ranging household incomes. One woman, with an income between $50,000 to $74,999, reported that her provider did not spend time talking with her about her expectations for labor and delivery. Another, whose income ranged from $35,000 to $49,999 reported that her provider did not link her to programs in the community that were helpful to her. Lastly, one woman with an income $100,000 to $149,999 reported that her provider did not give her adequate information about depression in pregnancy. More women who were low income, specifically with a household income less that than $25.000, reported adverse experiences with their providers related to Sufficient Time. One woman who with an income less than $25,000, and even one woman with an income between $35,000 to $49,999, reported that her provider was rushed. In addition, women who reported an income of less than $25,000 expressed that their provider did not always have time to answer her questions, did not make time for her to talk, and did not take time to listen. 13 14 Insurance Women that were either uninsured or had another type of insurance were mostly concerned with their care regarding Anticipatory Guidance. One woman without any insurance coverage reported that her provider did not spend time talking with her about her expectations for labor and delivery. Two women with another type of insurance reported that her provider did not link her to programs in the community that were helpful to her and that her provider did not give her adequate information about depression in pregnancy. When concerning Sufficient Time, two women, one who was uninsured and one with another type of insurance coverage (not Medicaid), both reported that they felt their provider was rushed. Three women with Medicaid all reported that their provider did not always have time to answer their questions, they did not always take time for them to talk, and they did not take time for them to listen. DISCUSSION Data from the surveys concluded some of the same information found in the literature. More specifically, the factor of “patient-provider relationships surrounding effective communication”, was reinforced by the participant’s answers (O'Malley, Sheppard, & Zambrana, 2004). The answers of the women who participated highlighted two concepts: Anticipatory Guidance and Sufficient Time. Anticipatory Guidance surrounds the idea of the provider not giving the patient enough options and information to make a decision about their birth plan. The issues that arose with the provider were the lack of information given about helpful programs in the community, information about depression in pregnancy, and expectations for labor and 14 15 delivery. These common themes arose particularly with both white women and Hispanic or Latino women who were either living with a partner, married, or in a domestic partnership. By having a partner or spouse, the provider may have thought that the women already had enough support, so they did not need to provide any additional support in the appointment. Sufficient Time focuses on the time prenatal care providers spend addressing women’s questions and the time spent in an appointment. The issues the women brought up was that their provider felt rushed, did not always have time to answer their questions, did not make time for her to talk, and did not make time to listen. These responses reoccurred frequently with women who were 18-24 years old, Black or African American, Single (never married), had an income less than $25.000, and were eligible for Medicaid benefits. With both concepts, inefficient communication between the provider and the patient was apparent. This is problematic because the literature states that effective communication is a factor related to strengthening level of trust a patient has with their provider, which is integral to the care they receive (Sheppard, Zambrana, and O'Malley, 2004). In the end, patients with a lower level of trust with their providers can be more unwilling to follow advice concerning their care (O'Malley, Sheppard, & Zambrana, 2004). Practice Implications The results of the surveys indicate the need for more changes inside the clinics that provide prenatal care for pregnant women. More specifically, providing information and education to women. As reported by the women, the need for information about 15 16 depression in pregnancy and referrals to programs in the community is apparent. Either providers need to ensure that they can include this information when they see patients for their care, or clinics need to include a social worker to provide this support. Providers can potentially include these pieces of information when they see patients when they come in for visits. Earlier on might be beneficial so that women can have these resources throughout their pregnancy. Clinics can supply prenatal care providers with different reliable resources in the community so that they know where to refer patients to. By providing resources and information to patients during visits, providers can establish more effective and helpful communication which can build trust and improve prenatal care. Alternatively, clinics can provide a social worker to provide the support for patients that they need. Social workers can speak with patients about programs in the community that are helpful to pregnant women, especially low-income women, and they can also provide resources for mental health during and after pregnancy. Social workers can also be on hand to provide any other support that is needed. Time management for providers is more difficult to remedy. Providers see many patients per day and it might be difficult for them to spend more time with each one. A possible suggestion would be to limit the number of patient’s providers see each day. By limiting the number of patients, providers can spend more time with each woman for an appointment. That way, patients won’t feel providers are rushed or that they don’t have time to express their concerns about their pregnancy. Another suggestion would be to hire more providers. This may be difficult to due to a clinic budget, so it would need to be a case by case basis, but it is an option. By having more providers, one provider won’t feel 16 17 so pressured to see so many patients per day. Each provider can share the client load and spend more time with each patient. Lastly, the simplest suggestion would be for providers to be more mindful of the visits they have with patients. Effective communication is an integral factor in establishing trust with their patient (Sheppard, Zambrana, and O'Malley, 2004). Providers may be able to set aside five to ten minutes at the end of each appointment to answer patient questions and give time for patients to express their concerns. By making sure they listen to patients express their worries, they might be able to remedy a lot of patient’s issues with providers and having a sufficient amount of time with them. Research Implications There is a need for more research in order to further explore the quality of prenatal care for low-income women. Due to the small sample size of eight participants from South Main Clinic, more research, with a larger sample size, will need to be completed to better understand the level of care women are receiving here in the Salt Lake Valley. Furthermore, it would be beneficial to include more patients from different clinics. It would be important to diversify the sample population to get feedback from patients that see different providers in different healthcare organizations. That way, research can show which clinics are providing quality prenatal care and what they are doing that makes their healthcare they provide so effective. It was also shed some light on the clinics and providers that need to improve their care they provide. Lastly, it also would be beneficial to include women of a variety of different socioeconomic status, so a valid comparison can be made between household income and the care women receive. 17 18 Limitations Unfortunately, there were many limitations to this study. Only being able to conduct research at one clinic was a major limitation to the study. By limiting the data collection to South Main Clinic, only participants from that clinic who see a specific provider were able to relay their experiences. That leads to the next limitation, which is only being gathering eight participants from the study. It simply was not a large enough sample size to conduct research that be effectively analyzed. Research done through multiple locations, with multiple providers, and more participating women is needed to effectively determine whether the prenatal care that is provided is high quality care for low-income women here in the Salt Lake Valley. Next, there were some limitations when it came to recruiting women for the study. Working with the medical assistant proved to be somewhat difficult. They had a very hectic schedule, so some participants that they referred over did not always meet the requirements of the study. For example, there were some participants that had a high that was not discovered out until after the survey was completed. In addition to the variety of incomes of the participants, another limitation of the study, specifically the demographic questionnaire, was not including how far along each woman was in their pregnancy. Providers may limit the information they disclose to patients depending on where they are in their pregnancy, so it would’ve been an important question to include to make a more accurate analysis on the care that is being provided. CONCLUSION Unfortunately, women who are poor are more likely to experience adverse pregnancy outcomes than non-poor women. (Sheppard, Zambrana, and O'Malley, 2004). 18 19 There are many consequences, such as maternal and infant death or low preterm births, to low quality care (Utah Department of Health, 2013). This is a serious issue that needs to be addressed in health clinics and hospitals across the United States, and specifically in Utah. Healthcare providers should consider the implications of the care they provide, and strive to practice excellent care, especially when it comes to low-income women that already have many barriers preventing them from receiving quality prenatal care (Cook, Selig, Wedge, & Gohn-Baube, 1999; Cook, et al., 1999; (Sheppard, Zambrana, and O'Malley, 2004). Providers should also be mindful of the time they share with patients. Making sure that patients feel that they are having their concerns addressed and their questions answered, in addition to them feeling like the provider is not rushed are recurring aspects in women’s experience with their care. Providers should also be mindful of the information and education they provide. Women feeling like they are not getting enough information and connection to community resources are also recurring aspects in their experiences with their prenatal care provider. Future research should be conducted to further expand the conversation of the prenatal care low-income women receive. 19 REFERENCES 20 Center for American Progress. (2018). Utah Report - 2017. Retrieved March 17, 2018, from https://talkpoverty.org/state-year-report/utah-2017-report/ Cook, C. A., Selig, K. L., Wedge, B. J., & Gohn-Baube, E. A. (1999). Access barriers and the use of prenatal care by low-income, inner-city women. Social Work, 44(2), 129-139. Heaman, M. I., Sword, W. A., Akhtar-Danesh, N., Bradford, A., Tough, S., Janssen, P. A., ... & Helewa, M. E. (2014). Quality of prenatal care questionnaire: instrument development and testing. BMC pregnancy and childbirth, 14(1), 188. National Institute of Child Health and Human Development (NICHD). (2017). What is prenatal care and why is it important? Retrieved March 15, 2018, from https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/prenatal-care Negrato, C. A., & Gomes, M. B. (2013). Low birth weight: causes and consequences. Diabetology & metabolic syndrome, 5(1), 49. Office of Women's Health. (2018). Prenatal care. Retrieved March 15, 2018, from https://www.womenshealth.gov/a-z-topics/prenatal-care Reichman, N. E., Corman, H., Noonan, K., & Schwartz-Soicher, O. (2010). Effects of prenatal care on maternal postpartum behaviors. Review of Economics of the Household, 8(2), 171-197. Sheppard, V. B., Zambrana, R. E., & O’Malley, A. S. (2004). Providing healthcare to low-income women: a matter of trust. Family Practice, 21(5), 484-491. South Main Clinic. (2018). Retrieved March 05, 2018, from https://healthcare.utah.edu/locations/south-main-clinic/ 20 Utah Department of Health. (2013). Utah Health Status Update: Healthy Utah Babies: 21 The Challenge. Retrieved March 30, 2018, from https://health.utah.gov/ Utah Department of Health (2016). Complete Health Indicator Report of Birth Rates. Retrieved March 15, 2018, from https://ibis.health.utah.gov/indicator/complete_profile/BrthRat.html Zambrana, R. E., Dunkel-Schetter, C., & Scrimshaw, S. (1991). Factors which influence use of prenatal care in low-income racial-ethnic women in Los Angeles County. Journal of Community Health, 16(5), 283-295. 21 APPENDIX The Demographic Characteristics of the Participants 22 22