Kugler
JP, Connell FA, Henley CE.
An evaluation of prenatal care utilization in a military
health care setting.
Military Med 1990;155(1):33-8. Utilization of prenatal care
may be considered an indicator of the function of the health
care delivery system. Its pattern reflects the socioeconomic
and demographic characteristics of the client population, economic
access barriers, institutional and administrative barriers,
and logistical issues. Although many studies have evaluated
prenatal care utilization in a civilian setting, only one prior
military study documented the association of low levels of prenatal
care with increased rates of prematurity and neonatal mortality.
The objective of this study was to identify the contribution
of socio-demographic factors to prenatal care use and to quantify
the risk associated with deficient prenatal care within a military
setting. The study population included all singleton deliveries
of black and white (only black and white infants were included
due to variations in racial coding for other groups) infants
from 1982 to 1985 in a large military hospital equipped with
full service obstetric neonatal intensive facilities. The analysis
progressed in three stages. The analysis included 7,599 military
births. The first stage measured the distribution of utilization
among the different socio-demographic groups. The second analysis
quantified the contribution of the first stage identified risk
factors to the level of care obtained. The final stage evaluated
various perinatal outcomes with less than satisfactory prenatal
care utilization.
Level of prenatal care utilization was measured using Kessner’s
prenatal care index, which takes into account trimester of first
prenatal visit, gestational age at delivery, and frequency of
visits. Five independent risk factors were identified with the
receipt of less than adequate care: being single, young maternal
age (<age 20), high risk based upon combinations of maternal
age and parity, being black, and off-post residence at time
of delivery, particularly among low-income women. 50.2% of the
white women were identified as having adequate prenatal care
utilization, while only 42.6 % of the black women were. Being
black was associated with a relative risk (RR) of 1.15 (95%
CI of 1.1-1.2) and attributable risk of 7.65%. Low income had
a similar relative and attributable risk.
The level of prenatal care utilization was examined because
inadequate prenatal care is associated with poor perinatal outcome.
The proportion of the military cohort that had adequate prenatal
care utilization (48%) closely approximated the proportion observed
in a study conducted among civilians from health maintenance
group, was more favorable than among Medicaid and uninsured
women (37%), and much less favorable in comparison to women
with private insurance (81%).
As stated above, the risk factors associated with receipt of
less than adequate care in order of significance were young
maternal age (< 20 years), black race, off post location,
high risk combinations of age and parity, and residence in low
income off-post census tract. The importance of the findings
is that these previously identified risk factors were found
to be independent. Thus, being black is a risk factor regardless
of socioeconomic status. Although most formal economic barriers
to care are absent in a military health care delivery setting,
indirect financial costs are present. These indirect costs focus
on the geographical distance and related time to reach medical
facility and the burden of child care that is required during
the prenatal care visit. The authors cite the limitations of
the study. The study was not designed to examine a number of
other relevant factors: educational status, actual income, specific
occupation of the active duty sponsor, and race other than black
and white, particularly since “there is a rich variety
of racial and ethic groups in the military.” Furthermore,
the study did not directly interview the women; thus, personal
information concerning the effect of health behavior attitudes,
social support, family structure, and the impact of frequent
paternal separation for military functions on prenatal care
utilization could not be evaluated. The study was conducted
from 1982 to 1985 when most likely the women who delivered at
the military medical center were wives of military men. Presently,
more women and minorities are members of the military; therefore,
the importance of further research is necessary to explore the
association in our changing military milieu. Nevertheless, the
article demonstrates the universal inadequate use of prenatal
care among black and low-income women.
