Disparities in early prenatal care and barriers to access among American Indian and white women in North Dakota

Abstract

Purpose American Indians/Alaska Natives (AI/AN) have received minimal attention in research on determinants of prenatal care access. We sought to gain an understanding of structural and sociocultural determinants of prenatal care access among AI/AN and White women in North Dakota (ND). Methods Data were drawn from the 2017 to 2018 North Dakota Pregnancy Risk Assessment Monitoring System (n = 1,166). Late prenatal care was assessed with 2 variables: late prenatal care initiation (>13 weeks gestation) and “Did you get prenatal care as early in your pregnancy as you wanted?” (yes/no). Those not satisfied with timing of prenatal care initiation reported 12 prenatal care barriers (yes/no). Logistic regression estimated odds ratios and 95% confidence internals for late prenatal care among AI/AN and other race/ethnicity women compared to White women. Models included maternal sociodemographic, medical, and behavior factors. Chi‐square was used to examine the prevalence of prenatal care barriers by race/ethnicity. Findings AI/AN women had increased risk of late prenatal care initiation (OR: 1.93, 95%CI: 1.20, 3.09) and were more dissatisfied with timing of prenatal care initiation (OR: 1.73, 95% CI: 1.07, 2.78) compared to White women. AI/AN women reported higher prevalence for 8 of 12 (66%) barriers to care, including lack of transportation. Lack of health insurance was more prevalent among White women than AI/AN women (45%‐8.5%; P<.01). Conclusions Socioeconomic barriers to prenatal care are more prevalent among AI/AN women. This may be a consequence of systematic separation of AI/AN populations from health care resources. Alternative prenatal care delivery methods and expansion of health insurance may improve prenatal care access in ND.

Adverse Childhood Experiences, Interpersonal Violence, and Racial Disparities in Early Prenatal Care in North Dakota (ND PRAMS 2017–2019)

“…Sebens and Williams (2022) reported that lack of health insurance, money, transportation, and childcare; being too busy; and wanting to keep pregnancy a secret were all significant ( p < 0.05) barriers to PNC in ND, for all of which American Indian women report a higher prevalence than White women. However, small sample sizes for the self-reported barriers to PNC in ND PRAMS limit analysis to bivariate associations (Sebens & Williams, 2022). Additionally, a qualitative study interviewed 58 American Indian women in the Northern Plains regarding their perceptions of PNC, identifying communication difficulties with physicians, long wait times for appointments, and feeling uncomfortable seeing a male physician as barriers that inhibit American Indian women from seeking timely and continuous PNC (Hanson, 2012).…”

“…Confounders were identified based on prior literature. Sociodemographic factors represent resource access, in which those who are young, unmarried, have low income, no health insurance, or who live far from healthcare facilities have more difficulty obtaining care (Aved et al, 1993; Cha & Masho, 2013; Holcomb et al, 2021; Sebens & Williams, 2022). Confounders included annual income (≤$40,000, > $40,000; based on the sample median), Medicaid status prior to pregnancy (has Medicaid, has other health insurance, or has no health insurance), rurality (rural or urban residence), maternal age in years (<20, 20–35, >35), maternal education (≤high school, > high school), and marital status (married, other).…”

“…Confounders included annual income (≤$40,000, > $40,000; based on the sample median), Medicaid status prior to pregnancy (has Medicaid, has other health insurance, or has no health insurance), rurality (rural or urban residence), maternal age in years (<20, 20–35, >35), maternal education (≤high school, > high school), and marital status (married, other). Medical conditions and health behaviors may motivate persons to access PNC to ensure the health of their pregnancy (Cha & Masho, 2013; Sebens & Williams, 2022). Medical and health behavioral confounders included substance use before pregnancy (yes or no to any smoking, alcohol, e-cigarettes, marijuana), pre-existing chronic disease (yes or no to any diabetes, hypertension, depression), pregnancy intention (wanted now, wanted later or never), and pre-pregnancy BMI (<25, ≥25).…”

“…Department of Health and Human Services, n.d.). In an analysis of 2017 to 2018 North Dakota Pregnancy Risk Assessment Monitoring System (ND PRAMS) data, American Indian women had two-fold higher odds of late PNC compared to White women, despite controlling for sociodemographic and medical factors (Sebens & Williams, 2022). Given the American Indian population is the second largest racial/ethnic group in North Dakota (ND) (U.S.…”

“…In 2018, 77% of pregnant women in the United States initiated PNC in the first trimester; however, American Indian women had lower prevalence (65%) of first trimester PNC than other racial/ ethnic groups: (Non-Hispanic Black 67.1%; Hispanic 72.7%; Non-Hispanic Asian 81.8%; Non-Hispanic White 82.5%) (U.S. Department of Health and Human Services, n.d.). In an analysis of 2017 to 2018 North Dakota Pregnancy Risk Assessment Monitoring System (ND PRAMS) data, American Indian women had two-fold higher odds of late PNC compared to White women, despite controlling for sociodemographic and medical factors (Sebens & Williams, 2022). Given the American Indian population is the second largest racial/ethnic group in North Dakota (ND) (U.S. Census Bureau, 2022), and rurality presents a challenge for accessing PNC (Gjesfjeld & Jung, 2011), further investigation into determinants of racial/ethnic disparities in PNC specific to ND is warranted to reduce inequities, particularly among American Indian women (Holcomb et al, 2021).…”