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RESEARCH |
Stella M. Yu and Michael D. Kogan are with the Maternal and Child Health Bureau, Office of Data and Information Management, Rockville, Md. Greg R. Alexander is with the Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham. Renee Schwalberg is with the Maternal and Child Health Information Resource Center, Washington, DC.
Correspondence: Requests for reprints should be sent to Stella M. Yu, ScD, MPH, Maternal and Child Health Bureau, Office of Data and Information Management, 5600 Fishers Lane, 18A-55, Rockville, MD 20857 (e-mail: syu{at}hrsa.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This study examined the predictors of 3 patterns of prenatal care use (no care, late initiation of care, and inadequate use after early initiation) for 4 Asian American ethnic groups in the United States.
Methods. Single live births to US resident mothers of Chinese, Japanese, Korean, and Vietnamese ancestry (n = 273 604) were selected from the 1992–1996 US natality files. Logistic regression was used to analyze the effects of maternal characteristics on the 3 use measures.
Results. Korean Americans and Vietnamese Americans had the lowest levels of prenatal care use. Young or single motherhood, high parity for age, and low educational attainment were the main risk factors for low use.
Conclusions. Considerable variability exists in prenatal care use among Asian American ethnic groups.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Early access to and adequate use of prenatal care have been associated with positive birth outcomes among Asian Americans,1–7,14–16 and because it provides the opportunity for health education and the early identification and treatment of pregnancy complications and medical conditions, prenatal care has been promoted to reduce ethnic variations in adverse pregnancy outcomes.1–7,14–29 Although the reasons for ethnic variations in prenatal care use are not fully understood, financial obstacles, language barriers, and cultural beliefs are frequently cited precursors to inadequate use, along with transportation problems, lack of spousal support, the need for child care, and inconvenient office hours.16,30–37
To date, no study has examined the use of prenatal care by Asian Americans at the national level. The objective of this study was to examine the sociodemographic predictors of 3 patterns of prenatal care use—no care, late initiation of care, and inadequate use after an early initiation of prenatal care—for the 4 largest Asian American ethnic groups in the United States: Japanese, Chinese, Koreans, and Vietnamese.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Adequacy of prenatal care use was defined by the R-GINDEX, which incorporates 3 variables (trimester when prenatal care began, number of visits, and the gestational age of the infant at birth) to assess adequacy of use.25,31 Gestational age in completed weeks was calculated as the interval between date of delivery and date of last menstrual period.
High educational attainment was defined as 13 or more years of education (i.e., beyond high school). Low educational attainment was defined as less than 12 years of education (i.e., less than high school). Because adolescents have not had the same opportunity to achieve the level of education as adults, adolescents 2 or more years above the grade level for their age were classified as having high educational attainment, whereas those 2 or more years below their expected grade level for their age were defined as having low educational attainment. This coding scheme facilitates the examination of the impact of low educational attainment in isolation from the influence of young maternal age.38
Parity was determined by the number of previous live births. Having children at home may represent a potential barrier to care owing to child care concerns. High parity for age was defined as 1 or more previous births for adolescents, 3 or more previous births for mothers aged 18 to 21 years, 4 or more previous births for mothers aged 22 to 24 years, and 5 or more previous births for mothers aged 25 years and older.39
Chi-square analyses were used to test for differences in the proportion of maternal risk characteristics among ethnic groups. Owing to the large number of cases in the data file, most comparisons would be anticipated to be statistically significant. Logistic regression analyses were used to examine the independent effects of sociodemographic characteristics on prenatal care use. Three separate models were run. The first model compared the receipt of no prenatal care with the receipt of any prenatal care. The second model compared early (first trimester) initiation of prenatal care with later initiation. Women with no prenatal care were excluded from the second model. The third model focused solely on women who started care in the first trimester, comparing inadequate with adequate or intermediate prenatal care use. This latter model was designed to specifically target women who began care early but then did not maintain the recommended schedule of visits. The independent characteristics considered in each logistic regression analysis included nativity status, similarity of parental ethnicity, maternal ethnicity, age, educational attainment, and parity. For each of the 4 ethnic groups, the logistic regression analysis comparing first trimester initiation of prenatal care with later entry into care was repeated to assess ethnic-specific predictors of early prenatal care use.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). The percentage of mothers who were unmarried ranged from 6.2% of Korean American women to 17.9% of Vietnamese American women. Vietnamese American women were most likely to be adolescents, while Korean American women were the least likely to be 35 years or older. Vietnamese American women were most likely to be of high parity for age or to have low educational attainment. Japanese American women were the least likely to be foreign born (52.9%) or to have the same ethnicity as the father.
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The results of the logistic regression analyses are presented in Table 2. Unmarried women, teenagers, and those with high parity for age and low educational attainment were significantly more likely to have no prenatal care. High educational attainment and having the same race as the father were protective against receiving no prenatal care. Compared with Chinese Americans, the other 3 Asian American subgroups had a greater risk of not receiving any prenatal care.
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). Older and more highly educated women were more likely to begin care early. Compared with Chinese Americans, Korean Americans had a greater risk of late initiation of care, while Vietnamese Americans were less likely to start prenatal care after the first trimester.
On the basis of the logistic regression analyses of less-than-adequate use for women who initiated care in the first trimester, mothers who were unmarried and foreign born and had high parity for age and the same ethnicity as the father were significantly more likely not to maintain an adequate use schedule after starting care early (Table 2). Maternal age of 35 years and older, primiparity, and high educational attainment were protective factors. Compared with Chinese Americans, Korean Americans were significantly more likely to have inadequate prenatal care after a first trimester start of care.
Table 3 provides the logistic regression results of the 4 ethnic-specific models of prenatal care initiation after the first trimester. For all ethnic groups, single marital status, maternal age younger than 18 years, high parity for age, and low educational attainment were risk factors for a late start of care, while high educational attainment was protective. Primiparity increased the risk of starting care late for Vietnamese Americans but decreased the risk for Korean Americans. Being foreign born increased the risk of starting care late for all ethnic groups except Vietnamese Americans; for this ethnic group, being foreign born markedly decreased the risk. Having the same race as the father increased the risk of a late initiation of care for Korean Americans but was protective for Japanese Americans and Vietnamese Americans.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Many of the risk factors for no or late initiation of care found in this study were the same as those reported for the US population generally: young or single motherhood, high parity for age, and low educational attainment. These results corroborate findings reported elsewhere that similar maternal characteristics are associated with the poor use of prenatal care among other Asian American ethnic groups.4 However, 2 notable exceptions emerge from the present data: the protective effect of foreign-born status for Vietnamese Americans and the elevated risk for Korean Americans when the mother and father have the same race. Future studies of the determinants of prenatal care and other health service use should focus on the role of the spouse and acculturation.
This study is limited by our inability to examine sociocultural determinants of the use of prenatal care among Asian Americans. The cultural acceptability of aspects of prenatal care, the availability of culturally and linguistically competent prenatal services, and women's knowledge and beliefs about the importance of care during a normal pregnancy are likely to be important factors, particularly for recent immigrants. The lack of information in vital records about a woman's economic status and her length of time in the United States also limits our ability to explain the correlates of inadequate prenatal care use.
The US Department of Health and Human Services includes as one of its Healthy People 2010 objectives increasing to 90% the proportion of live-born infants whose mothers receive adequate prenatal care.40 In addition, 1 of the 2 overarching goals of Healthy People 2010 is the elimination of health disparities across racial and ethnic groups. This emphasis underlines the importance of further investigation to determine the particular ethnicspecific determinants of prenatal care and to identify approaches to better encourage the appropriate use of prenatal care by pregnant women of all ethnic groups.
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Footnotes |
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S. M. Yu conceptualized the initial design and analysis of the study, contributed to the writing, and coordinated revisions. G. R. Alexander coordinated the data analysis and contributed substantially to the study's conception and design and to the drafting of the report. R. Schwalberg contributed to the literature review and the revisions. M. D. Kogan contributed to the analysis and the revisions.
Accepted for publication January 11, 2001.
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References |
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