Unplanned Pregnancy, Recent Relocation Among Top Barriers to Early Prenatal Care in US

Unawareness of pregnancy, scheduling difficulties, and periods of transition were identified as main barriers to early entry into prenatal care among a medically-vulnerable patient population. Findings come from a recent mixed-models study published in BMC Pregnancy and Childbirth.

In the study of 169 women in the US who started prenatal care after their first trimester at a large federally qualified health center (FQHC), researchers identified the following prenatal care delay themes after conducting an initial chart review:

• Being in periods of transition (21.2%)
• Unplanned pregnancy (16.8%)
• Issues with linkage to care, including no show/cancellations (15.5%)
• Unaware of pregnancy (9.7%)

“Worldwide, the leading cause of mortality and morbidity in women of reproductive age are complications during pregnancy and childbirth,” corresponding author Valerie N. Holt, DO, MPH, family medicine resident physician, School of Osteopathic Medicine, AT Still University, Mesa, Arizona, and colleagues wrote. “Despite its robust healthcare infrastructure, the United States continues to lag behind other developed countries in regard to maternal and child health outcomes.”

According to Holt and coauthors, the US maternal mortality rate increased from 20.1 deaths per 100 000 live births in 2019 to 32.9 in 2021. The average infant mortality rate, a marker associated with maternal health, is 5.4 deaths per 1000 live births. Timely entry into prenatal care, along with consistent prenatal care visits throughout pregnancy, can significantly improve health outcomes for both the mother and infant.

“Despite the importance of early prenatal care, medically vulnerable populations are less likely to initiate prenatal care during the first trimester,” researchers wrote. “Given the vulnerable patient populations served by FQHCs, continued efforts should be focused identifying care gaps from the patient perspective and implementing initiatives to reduce them.”

Holt and colleagues conducted the current study to identify factors that contribute to delayed initiation of prenatal care at an FQHC in Brooklyn, New York, due to its large, diverse patient population. Participants started prenatal care during their second or third trimester (ie, after 13 weeks and 6 days of gestation) between August 2021 and July 2022. For each participant, they determined primary and secondary patient-specified reasons for prenatal care delays.

The mean age of the cohort was 28 years and the mean gestational age of entry into prenatal care was 19 weeks, according to the study. Overall, 8% of participants had recently moved to Brooklyn from outside New York City or the US, 9% had difficulties scheduling an initial prenatal visit within their first trimester, 10% did not learn of their pregnancy until after the first trimester, and 7% were teenagers.

Also, women who delayed prenatal care were more likely to be Spanish-speaking, younger in age, and to experience a relatively long delay between pregnancy confirmation and prenatal care entry. Moreover, researchers noted that patient age at the initial prenatal visit was the primary determinant of delayed entry.

“Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry,” Holt et al concluded. “Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.”

Reference: Holt VN, Pelegrí E, Hardy M, et al. Patient-perceived barriers to early initiation of prenatal care at a large, urban federally qualified health center: a mixed-methods study. BMC Pregnancy Childbirth. Published online June 21, 2024. doi:10.1186/s12884-024-06630-9