1. Laura L. McDermott, PhD, FNP, RN Gale A. Spencer, PhD, RN Binghamton University Decker School of Nursing THE RELATIONSHIP AMONG BARRIERS AND FACILITATORS TO PRENATAL CARE AND BIRTH OUTCOMES IN A RURAL COUNTY

2. PRESENTER DISCLOSURES The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose” Laura L. McDermott, PhD, FNP, RN Gale A. Spencer, PhD, RN

3.  As of 2010, upstate New York lags behind national averages and Healthy People 2010 goals for access to first trimester PNC with only 76.1% of women accessing care in the first trimester of pregnancy.  Rural women face unique challenges.  Importance of PNC.  Previously identified PNC barriers & facilitators. INTRODUCTION

4.  While research has clearly identified barriers to prenatal care and they have been well identified, access to prenatal care in the 1 st trimester has not greatly improved over the past decade.  Most research in the U.S. has focused on barriers to prenatal care in urban or suburban settings.  Research conducted in rural populations limited.  Few studies have been conducted on access to prenatal care within the first trimester of pregnancy among rural women. PROBLEM STATEMENT

5.  The purpose of this study was to examine the barriers and facilitators regarding access to prenatal care in a rural county without a hospital or birthing center within its geographical boundaries and with few health care providers who offer obstetrical care.  Prenatal care in Tioga County, New York was studied in depth using variables found in the 2008 Electronic Birth Certificate (EBC) data base and the Prenatal Risk Assessment Monitoring System (PRAMS) questionnaire which was distributed and collected from Tioga County women who gave birth in 2008. PURPOSE OF THE STUDY

6.  Adapted from the Behavioral Model of Utilization created Anderson and Aday (1998).  Frequently utilized framework for analyzing factors associated with patient access to health care services.  Uses a system perspective to integrate a range of personal, environmental, provider-related, and health behavior variables that either facilitate or impede a person to seek medical care, or in this case prenatal care. CONCEPTUAL FRAMEWORK

8. Study design  This study uses a descriptive correlational design.  Two different data bases were used. 1. Secondary data from the EBC data for women who gave birth in Tioga County in 2008 2. Primary data collected from women who gave birth in Tioga County 2008 who completed and returned the CDC PRAM’s Questionnaire  The PRAMS questionnaire was mailed to all the women who gave birth in Tioga County in 2008. After the data collection of the PRAMS data the two data bases were combined into one for analysis. METHODOLOGY

9. Sample  Consisted of all the women who lived in Tioga county and gave birth in 2008 (n = 508).  Age range - 14 to 45 years (mean age = 27 years).  Race: 97.3% Caucasian.  Level of education 8 th grade or less (2%), 9 th – 12 th grade (8.5%), High school graduate or GED (27%), Some college credit but no degree (22%), Associate’s degree (13.5%), Bachelor’s degree (17%), Master’s degree (10%), Doctorate degree (2%). METHODOLOGY

10.  Human subject protection approval was granted on April 27 th, 2009.  Instruments  NYS Electronic Birth Certificate Data (EBC)  Center for Disease Control and Prevention (CDC) PRAMS questionnaire  Data collection  PRAMS questionnaire was collected by researcher.  Cover letter and pre-numbered survey was mailed to all mothers who gave birth in Tioga county in 2008.  Pre-paid self-addressed return envelope and incentive of a five dollar gift certificate for each return survey.  Data collection started on June 1 st and ended August 1 st, 2009.  Analyzed with SPSS 16.0 METHODOLOGY

11. 1.What is the relationship between type of health insurance coverage and access to prenatal care during the first trimester of pregnancy for women who live in a rural county? 2.What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county? 3.What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county? 4.What is the relationship between each of the enabling resources (e.g. wait time for appointment, financial resources, insurance coverage, transportation, Medicaid card, work, child care, time constraints, secrecy of pregnancy, and other reasons) and access to prenatal care in the first trimester for pregnancy in women who live in a rural county? RESEARCH QUESTIONS

12.  What is the relationship between type of health insurance coverage and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?  The relationship was found to be statistically significant X 2 = 8.450, p = 0.015  The logistic regression for this question identified the following results: Those women who had private insurance coverage were 2.113 times more likely to access prenatal care in the first trimester of pregnancy than women who had Medicaid insurance. Those women who had private insurance were 4.0 times more likely to access prenatal care in the first trimester of pregnancy than women who self- paid. While the Wald is not statistically significant at 0.055, it approaches statistical significance. RESEARCH QUESTION 1

13.  What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?  The relationship was found to be statistically significant X 2 = 9.114, p = 0.028  The logistic regression for this question identified the following results: Those women who were aged 20-29 were 3.297 times more likely to access prenatal care in the first trimester of pregnancy than women who were 14-19 years of age. RESEARCH QUESTION 2

14.  What is the relationship between demographic factors (age and marital status) and access to prenatal care during the first trimester of pregnancy for women who live in a rural county?  The relationship was found to be statistically significant. X 2 = 5.113, p = 0.024  The logistic regression for this question identified the following results: Those women who were married were 1.964 times more likely to access prenatal care in the first trimester of pregnancy than women who were single. RESEARCH QUESTION 3

15.  What is the relationship between each of the enabling resources (e.g. wait time for appointment, financial resources, insurance coverage, transportation, Medicaid card, work, child care, time constraints, secrecy of pregnancy, and other reasons) and access to prenatal care in the first trimester for pregnancy in women who live in a rural county?  The relationship was found to be statistically significant. X 2 = 7.716; p = 0.005  The logistic regression for this question identified the following results: Those women who did want others knowing they were pregnant are 7.773 times more likely to access prenatal care in the first trimester of pregnancy than women who did not want others knowing they were pregnant. RESEARCH QUESTION 4

16. RESEARCH QUESTION 4 OVERALL LOGISTIC REGRESSION ANALYSIS Enabling ResourcesBWaldSig. Odds Ratio Appointment0.5450.2990.5840.58 Financial resources1.0631.2560.2620.345 Transportation1.0050.6490.4200.366 Work-0.8020.3220.6530.559 Insurance Coverage-.0.4010.0320.5702.231 Medicaid Card0.5820.2020.8591.494 Child Care23.4680.0001 Time Constraints-47.2930.0000.9993.458 Secrecy1.8621.2960.2550.155 Other1.9921.7060.1910.136 Constant-2.26564.4090.9990.000 Not Statistically Significant Accept the Null Hypothesis

17.  Women with private insurance were twice as likely to access prenatal care in the 1 st trimester of pregnancy than women who had Medicaid and four times as likely as women who indicated self pay for prenatal care.  A statistically significant relationship was found between mothers identifying that they did not want anyone to know that they were pregnant and access to prenatal care in the 1 st trimester. DISCUSSION OF THE FINDINGS

18.  Statistically significant relationship was found between Age and access to prenatal care in the 1 st trimester of pregnancy.  Women aged 20-29 were more likely to seek prenatal care in the 1 st trimester of pregnancy than women who were 19 or younger or 30+.  Statistically significant relationship was found between marital status and access to prenatal care in the 1 st trimester of pregnancy.  Married women were more likely to enter prenatal care in the 1 st trimester of pregnancy than single women.  Women who were married were more likely to have a greater number of enabling resources than women who were single. DISCUSSION OF THE FINDINGS

19.  Replication study should be conducted in other rural areas with different racial/ethnic background.  Rural South  Re-evaluation of facilitators and barriers in the 1 st trimester of pregnancy with the expansion of Medicaid and universal health insurance. IMPLICATIONS FOR FUTURE RESEARCH

20. This study was unique in several ways:  1 st study to link PRAMS and EBC data for one county.  Allows the researcher to analyze barriers and facilitators at the county level  Rural women encountered more facilitators and fewer barriers to prenatal care.  Hardiness  86.7% of Tioga County women accessed prenatal care in the 1 st trimester of pregnancy. CONCLUSION