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The role of perceived stress on prenatal care utilization: implications for social work practice.

Although infant mortality rates have declined during the past decade, the United States is 23rd lowest in international ranking in infant mortality, below most other industrialized countries (MacDorman et al., 1994). Low birthweight is the leading cause of infant mortality (Kiely, Brett, Yu, & Rowley, 1994). Numerous studies have documented the positive effect of prenatal care on birth outcome (Institute of Medicine, 1985; Kiely & Kogan, 1994). Women who receive early and continuous prenatal care have lower numbers of low-birthweight babies than women who enter prenatal care late and who do not make the recommended number of prenatal visits.

The Institute of Medicine (1988) identified several types of barriers to the use of prenatal care, including sociodemographic factors such as poverty, inner-city or rural residence, ethnic minority status, young maternal age, lower education levels (less than high school completion), unmarried marital status, and high parity (more than three births), which have all been associated with inadequate prenatal care utilization. Financial and system-related factors associated with inadequate prenatal care utilization include financial barriers: lack of medical insurance, difficulty obtaining child care, problems with transportation, and issues associated with prenatal clinic, such as long waits to see the doctor and negative attitudes of clinic personnel to low-income women. Finally, the Institute of Medicine identified several attitudinal barriers to prenatal care, including issues related to unplanned pregnancy (denial or apathy, ambivalence towards pregnancy, fear of parental discovery, and concealment), issues related to lifestyle (including drug and alcohol abuse), issues related to inadequate social support, and issues related to excessive stress. Maternal psychological or emotional stress may affect a woman's prenatal care utilization by reducing her ability to gain access to and to negotiate the system or by decreasing prenatal care as a priority in her life.

Although there have been numerous studies of prenatal care utilization (see for example Bedics, 1994; Giblin, Poland, & Ager, 1990; Joyce, Diffenbacher, Greene, & Sorokin, 1983; Kelley, Perloff, Morris, & Liu, 1992; Lia-Hoagberg et al., 1990; McDonald & Coburn, 1988; Moss & Hensleigh, 1989; Poland, Ager, & Olson, 1987; Sable, Stockbauer, Schramm, & Land, 1990; Sable & Wilkinson, 1998; St Clair, Smeriglio, Alexander, Connell, & Niebyl, 1990; Watkins, 1968), the effects of stress have rarely been investigated explicitly. Most of these studies focused on internal (emotional and social) and external (structural) factors as barriers to prenatal care use. Both sets of factors can in fact be used as proxy measures of stress.

Two studies posited that stress would be related to delayed entry to care; however, the findings from both were unable to support the hypothesis. In Watkins's (1968) historical study, 120 married African American mothers were interviewed about their prenatal care use. Watkins created a stress proxy from several problem situations but found that there was no difference in stress between the women who began care early and those who delayed care. Moss and Hensleigh (1989) in their study of adolescents examined the effects of stress, social support, and Hispanic ethnicity on entrance into care. Late entry to care was correlated with lower levels of stress, but when additional factors were included in the model, the effects of stress were not significant.

In contrast, Bedics (1994) interviewed 44 women who did not receive prenatal care and found that the majority had experienced stressful life events during their pregnancy. She concluded that stressful life events make negotiating a difficult service system nearly impossible for women who face financial and other structural barriers. Others who have interviewed women about prenatal care use also have found that emotional and social concerns that indicate stress interfere with their ability to obtain care (Giblin et al., 1990; Lia-Hoagberg et al., 1990). In none of these studies, however, were women asked to assess their level of stress during their pregnancies.

The purpose of the study discussed in this article was to examine the relationship between perceived stress and stressful life events during pregnancy and their association with prenatal care utilization. The relationship of Medicaid status, as a proxy indicator of poverty, also was examined, because high levels of stress are associated with being poor (Chomitz, Cheung, & Lieberman, 1995). In previous studies, Medicaid-eligible women were more likely to have received inadequate prenatal care because of inadequate access to prenatal care providers or other systems barriers such as long waiting time for appointments (Institute of Medicine, 1988; Sable et al., 1990). In Missouri, more than half the low-birthweight births occur to Medicaid mothers, and it is anticipated that the proportion of low-birthweight infants born to Medicaid mothers will continue to increase (Pierson et al., 1994). By 1993, following the Medicaid expansion mandated by the Federal Omnibus Budget Reconciliation Acts of 1987 (P.L. 100-203) and 1989 (P.L. 101-239), nearly 75 percent of Missouri women receiving inadequate prenatal care were Medicaid eligible (Missouri Department of Health, 1995).

It is important for social workers to have a better understanding of the effect of stress on health behaviors and outcomes to refine the types of interventions designed to reduce stress among pregnant women. It is critical for policymakers and program administrators to understand this relationship so adequate resources that can increase effective utilization of the prenatal care system and improve pregnancy outcomes are allocated for social work intervention with pregnant women.

METHODS

Study Population

The study used data from the National Institute of Child Health and Human Development (NICHD)/Missouri Maternal and Infant Health Survey (MMIHS), which was designed as a population-based, case-control study of all Missouri resident very low-birthweight (VLBW, [less than] 1500 grams) infants born between December 1, 1989, and March 31, 1991. Moderately low-birthweight (MLBW, 1500-2499 grams) and normal-birthweight (NBW, 2500+ grams) infants served as controls for singletons. Multifetal pregnancies were not included in this analysis. A detailed description of the study method is described elsewhere (Pierson et al., 1994; Sable et al., 1997; Sable & Herman, 1997; Sable & Wilkinson, 1998).

Because of poor response to the MMIHS survey during a pilot study of women delivering at five large, high-volume delivery hospitals that provide services for poor people, two separate methods for completing the surveys were developed. For these five hospitals (two in St. Louis, one in Kansas City, one in central Missouri, and one in southwestern Missouri) in-hospital postpartum interviews were conducted. The rest of the study population was canvassed by mail using the birth/fetal death certificate database file to capture the target population. Each study participant was compensated $15 for completing the survey. For the in-hospital interviews, control mothers were selected stratifying race (black, not black) and age (under 20, 20 to 24, and 25 plus). The in-hospital component made up 35.5 percent of the study population and 39.2 percent of completed surveys.

For the mailed questionnaire a stratified, random sampling method was used to select a similar number of MLBW and NBW controls stratifying race (black, not black), maternal age (10 to 19, 20 to 24, and 25 plus), and urban or nonurban residency. Three mailings and a telephone follow-up were attempted. If there was still no response, community health nurses or social workers attempted personal interviews.

Through these intensive efforts an overall response rate of 76 percent was achieved - 84 percent for the five hospitals and 71 percent for the mailed survey. The study population consisted of 450 maternal surveys for fetal deaths, 779 singletons for VLBW cases, 799 singleton MLBW controls, and 800 singleton controls for mothers having NBW infants, a total of 2,828 surveys. The overall refusal rate was 12 percent, and the no response rate was 12 percent.

More than half the women were in their twenties, one-quarter were under age 20, and one-quarter were 30 years or older (Table 1). The women were more likely to be white, married, high school graduates, and employed during their pregnancy. Almost half were Medicaid and Women, Infants and Children (WIC) recipients, and this was the first birth for one-third of the participants. One-third of the women smoked during pregnancy. About one-fifth (22.1 percent) of the women reported drinking during their first trimester of pregnancy (Table 1); however, the number of women who reported drinking later in pregnancy decreased over the second (14.1 percent) and third (9.8 percent) trimesters.

Variables

The dependent variable was adequacy of prenatal care. This study used the definition of inadequate prenatal care from the Bureau of Health Data Analysis (BHDA), Missouri Department of Health, which takes gestational age into account. Inadequate prenatal care is defined either as late entry into care (after four months of pregnancy) or by number of total visits (fewer than five visits for pregnancies less than 37 weeks, or fewer than eight visits for 37 or more weeks' pregnancies). For example, a woman who had 10 prenatal visits but who initiated care in the sixth month would be classified as having received inadequate prenatal care, as would a woman who initiated care in the first trimester but who had only four prenatal visits. The standard for adequate care recommended by the American College of Obstetricians and Gynecologists (ACOG) specifies that the normal patient should generally be seen at least every four weeks for the first 28 weeks of pregnancy, every two weeks until the 36th week, and weekly thereafter (ACOG, 1982). Thus, using the BHDA standard results in a smaller number of women in the inadequate care group than does the ACOG standard and provides a sharper contrast between groups. Adequacy of care was determined from birth certificate data.
Table 1. Characteristics of the Population, Missouri Maternal and
Infant Health Survey, Singletons Only (N = 2,828)

Characteristic Percent(a)

Inadequate prenatal care 27.3

Age

under 20 23.8
20-24 27.9
25-29 25.0
over 30 23.1

Race

Black 37.0
White 62.2
Other 0.8
Unmarried marital status 46.6
Education (in years)
less than 12 29.8
12 38.8
more than 12 31.3
Worked during pregnancy 74.4
Medicaid participant 45.9
WIC participant 47.8
First birth 32.6
Smoked during pregnancy 33.4
Drank during the first trimester 22.1

Income ($)

[less than] 10,000 34.8
10,000-14,999 11.7
15,000-24,999 15.3
25,000-39,999 15.8
[greater than or equal to] 40,000 13.0

Unknown 9.3

NOTE: WIC = Women, Infants and Children.

a Percents may not add to 100 because of rounding and missing
values.


The independent variables were the major life events that occurred during pregnancy and perceived stress. To measure the major life events, women were asked, "During your most recent pregnancy, did any of the following events occur to you?" They were asked to check any of the items on the list that applied to them (Table 2). To measure perceived stress, women were asked, "In general, how often did you feel stress during your recent pregnancy?" Possible responses were "almost always," "often," "sometimes," and "almost never."

Control variables were drawn from birth certificate data (maternal age, race, education, marital status, smoking during pregnancy, prior pregnancy, and weight for height) and from the questionnaire (health during pregnancy and source of survey). Birth certificates were linked to death certificates to determine whether the baby had died.

The disproportionately higher rates of inadequate prenatal care, low birthweight and infant mortality for African Americans have been well documented (Kiely et al., 1994; Kleinman & Kessel, 1987; MacDorman et al., 1994). In this study we made one racial comparison. Black mothers were compared to all other mothers. It should be noted at the onset that this case-control study controlled for race by matching VLBW cases with controls by race. The NICHD/MMIHS was set up in this way because of the difference in birthweight distribution between black infants and all other infants. Mothers of racial or ethnic groups other than white or black were less than I percent of the total study population. Ethnic minority women who were not black had birthweight distributions more similar to white women than to black women, and therefore, were included in the not black group.

Data Analysis

The crude odds ratios of receiving adequate prenatal care were calculated for each of 30 major or life events. In one analysis of the entire sample and four analyses stratified by race or Medicaid status, adjusted odds ratios and 95 percent confidence intervals were calculated from beta coefficient estimates of standard errors produced by stepwise logistic regression. The logistic regression analyses examining the adequacy of prenatal care controlled for maternal age, marital status, maternal education, race, smoking during pregnancy, health during pregnancy, and whether the source was mailed a questionnaire or was in one of the five hospitals. Race was not included as a control variable for the analysis of mothers by race. The data analysis was conducted with SAS for Windows (Version 6.12) software.

RESULTS

Women who moved to another residence, had living conditions change a lot, or added another person to their household were significantly more likely to have received inadequate prenatal care (Table 2). Homeless women also were more likely to have received inadequate care.

Women with relationship problems (changes in the number of arguments with partner, separation from partner, getting back together with partner, and problems with parents or in-laws) were more likely to have inadequate care. Conversely, women who got married during their pregnancy were less likely to have received inadequate prenatal care. Neither divorce nor sexual problems were related to adequacy of prenatal care (Table 2).

Employment issues did not differentiate between the two groups with the following exceptions. Women who changed responsibilities at work or had trouble with their boss were less likely to have received inadequate prenatal care.

Being the victim of a crime did not differentiate between the two groups. However, legal issues such as getting in trouble with the law during pregnancy did. Women who reported that they were arrested or that their partners were arrested during the pregnancy were more likely to have received inadequate prenatal care. Furthermore, women who had been involved in a physical fight were more likely to have received inadequate prenatal care than women who had not (Table 2). Illness and death of partners, family members, or friends did not differentiate between the two groups. Neither did a major personal injury (excluding pregnancy complications) for the woman.

Financial issues such as "going into debt over your head" and loss of or major damage to personal property did not differentiate between the two groups. However, women who had taken out a mortgage or loan were less likely to have received inadequate prenatal care. Women who reported not being able to get the services they or their children needed, such as Aid to Families with Dependent Children, food stamps, WIC, or Medicaid, were more likely to have received inadequate care (Table 2).

More than 20 percent of the study population reported that they "almost always felt stress" during their pregnancy. Women who reported that they "almost always felt stress" during their pregnancy were more likely to have received inadequate prenatal care than were mothers who reported lower levels of stress (Table 3). Women who were not black and Medicaid recipients who reported that they almost always felt stress during their pregnancy were also less likely to have received inadequate prenatal care (Table 3). Among the black [TABULAR DATA FOR TABLE 2 OMITTED] [TABULAR DATA FOR TABLE 3 OMITTED] women and women who were not on Medicaid, however, the odds of inadequate prenatal care were not significant.

DISCUSSION

Women who received inadequate prenatal care reported many major life events that contribute to stress. Certain life events may reflect the effects of poverty, such as frequent and various changes in one's living arrangements, involvement in the legal system, and difficulty in obtaining social and health care services. We cannot discern from the data collected if the stresses that these women reported are a direct result of the life-change events they experienced or if the stresses of poverty created these events. In either case, it is clear that the presence of these events and the presence of poverty are correlated with inadequate prenatal care.

For women whose living arrangements are tenuous - those who must move without choice or who find themselves homeless - the effort that must be expended to obtain prenatal care may be more than they can manage (Bedics, 1994). Similarly, women who are involved in legal struggles may place prenatal visits low on their list of priorities. Finally, if women cannot get needed social services, their access to care, which is limited already, is likely to be even more limited (Brown, 1989).

Relationship issues are not necessarily related to a woman's economic status. Although divorce was not related to adequacy of prenatal care, marriage during pregnancy seems to have had a buffering effect against inadequate prenatal care. Most other relationship problems were associated with inadequate prenatal care. Women who had been in a physical fight were more likely to have received inadequate prenatal care. Unfortunately, no question was asked that specifically addressed partner abuse, but we can speculate that domestic violence may account for at least some of the physical fights.

Women who perceived that they almost always felt stress during their pregnancy may have experienced these major life events, or their stress may have come from other sources. For example, the stress may or may not have been related to whether the pregnancy was planned or wanted, and further research is needed to assess the relationship between maternal stress and unplanned or unwanted pregnancy.

What can we conclude from the fact that women who perceived that they almost always felt stress was significantly associated with inadequate prenatal care among Medicaid recipients and white mothers? Women who receive Medicaid are poor, so stress associated with poverty may be the primary contributor to their stress. It is plausible that the effects of poverty have a strong influence on the degree of perceived stress among pregnant women.

Vosler (1996) described a phenomenon of families who live near or below the poverty line that is known as "stress pileup." Families with limited resources are constantly challenged to make choices about how to spend those resources. For a woman who must chose between feeding her children, paying her rent, or obtaining prenatal care, the decision to forego care not only will be made but also will be a component of stress pileup. Each decision made in a stress-overloaded situation is made on the basis of immediate need. Future planning becomes futile (Vosler, 1996). Thus, although she may understand the long-term value of prenatal care, the poor and stressed woman may find it necessary to buy food rather than spend her meager resources on the needed child care and transportation to attend a doctor's visit that appears to have little immediate value. If she feels iii, she is more likely to seek care (Leatherman, Blackburn, & Davidhizar, 1990; Patterson, Freese, & Goldenberg, 1990).

It is interesting, although perhaps not puzzling, that black women who almost always felt stress were not more likely to have inadequate care, whereas white women who felt stress were. This response to stress by black women may be reflective of resilience in black families because of certain cultural characteristics. Recent research on family strengths has identified some of these characteristics and found them to be generally well represented in black families. Some of these resilience factors are family unity, role flexibility, and the ability to mobilize social networks through extended family and religious and neighborhood affiliations (Vosler, 1996). The findings of this study may reflect the resilience of black families.

The results of any study must be considered within the framework of the study design selected. A major limitation of this study was the retrospective nature of the questionnaire. The mothers' postpartum responses to the questions about stress during pregnancy may not have adequately reflected their true stress levels during the pregnancy. Recall bias may have been further introduced and influenced by the outcome of the pregnancy. A woman who experienced a lot of stress during her pregnancy but who had a healthy child may not remember the stress as vividly as a woman who had a very low-birthweight infant. Additional bias may have been introduced into the study by using two different modes of data collection: (1) questionnaires filled out by the mothers at the hospital in the postpartum period and (2) mailed questionnaires three months following the birth, although we attempted to reduce this bias by controlling for "source" of survey (hospital or mailed questionnaire). It is possible that the mother's recollection about stress during pregnancy differed at these different times. Nevertheless, we believe that these two modes of data collection were justified to achieve a higher response rate, particularly among low-income mothers who were less likely to respond to the pilot survey. Another limitation of this study is that it was a case-control study in which controls were chosen on the basis of race (black, not black), age, and urban or rural location for the mail subset, which prevented looking at race except as an effect modifier.

The relationship between stress and inadequate prenatal care in this study is not causal. It is possible that the barriers to obtaining prenatal care (for example, women who were ineligible for Medicaid but who lacked other means to pay for it, lack of transportation, lack of child care, and so forth) contributed to the women's stress.

Another limitation of the study is that although we know what major life events occurred to the women, we do not know if these were the events that contributed to their perceived stress. Other sources of stress might have included unwanted pregnancy, lack of support from family and friends, alcohol or drug use by the woman or her partner, environmental or domestic violence, other effects of poverty (such as lack of resources for children, including child care), and lack of transportation (including transportation to health care services) among others.

CONCLUSION

The finding of the positive relationship between stress during pregnancy and inadequate prenatal care support earlier findings (Olds & Kitzman, 1993; Sable et al., 1990) and have obvious implications for social work practice. Several of the significant life events also may be indicative of a life of poverty (housing instability, lack of medical insurance or participation in Medicaid, and inability to get other needed services), which contributes to individual and familial stress. It may be that the stress of poverty contributes to lack of prenatal care utilization. Policymakers and program administrators should be aware that stress, including stress related to a life of poverty, may play a role in inadequate prenatal care utilization.

Social work intervention in perinatal settings that is intended to reduce stress among pregnant women, particularly among poor women, should assume as high a priority as preparation for childbirth classes. Enhanced prenatal care that includes psychosocial services has been shown to reduce the risk of both low-birthweight and preterm birth (Wilkinson, Korenbrot, & Greene, 1998). When asked about the value of psychosocial services offered as part of enhanced prenatal care, a group of women stated that stress reduction was the most important aspect of those services to them (Wilkinson & Gonzalez-Calvo, 1998).

Innovative programs that provide social support to pregnant women, such as Resource Mothers, should continue to be developed and evaluated. Weiss (1995) argued that home visits are a necessary but insufficient component of all programs seeking to serve pregnant women and families. She suggested that the most effective programs are comprehensive, continuous, and family focused. Program effectiveness depends on the availability and quality in the community of other services for families, as well as on the capacity of the families to connect with such services. Social workers can play a key role in linking pregnant women to these services and by providing effective services coordination. In communities where such services are lacking, social workers can assert leadership in interagency coordination to develop community services that address the psychosocial and resource needs of pregnant women.

Further analysis of the kinds of stress women experience is needed so that interventions can be more specifically targeted. Prenatal clinics need not be the only place where social workers can intervene. Practitioners working with pregnant women in any setting, including child welfare, mental health, criminal justice, and other social services, can help their clients reduce levels of stress by helping the women develop problem-solving skills and stress-management techniques if they are appropriate. Practitioners may not know that stress can affect prenatal care utilization and pregnancy outcomes, and agencies should include this information in their training. In addition, because one of the keys to effective prenatal care is early care, social workers should learn to inquire about the possibility of pregnancy when working with new clients, to assist women with stress reduction and with getting early care. Waiting for the obvious signs of pregnancy makes early entry to care impossible. Social work intervention for stress reduction on behalf of pregnant women has the potential to contribute to improved prenatal care utilization.

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ABOUT THE AUTHORS

Marjorie R. Sable, DrPH, MSW, is assistant professor, School of Social Work, University of Missouri, Columbia, 726 Clark Hall, Columbia, MO 65211; e-mail: sablem@missouri.edu. Deborah Schild Wilkinson, PhD, MPH, is assistant professor, School of Social Welfare, University of Kansas, Lawrence.
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Date:May 1, 1999
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