With the passage of Medicare and Medicaid legislation, access to all health care services has improved. Nevertheless, a disparity in utilization of prenatal care persists between black and white women. Research shows timely and adequate prenatal care may reduce the risk of low birthweight and other adverse pregnancy outcomes and that black women may benefit more than white women from timely prenatal care. Black women more often receive less timely and adequate prenatal care than their white counterparts. The article explores the contributory factors to reduced utilization among black women.

Data for the analysis come from a survey conducted by Michigan Department of Health. The sample was comprised of women who delivered during the period from December 11, 1988 to January 9, 1989. Of the initially eligible women, 1915 out of 2106 completed the questionnaire during their hospital stay. Women who reported a pregnancy complication or had multiple births were excluded since their response might not have represented the response of the archetypal pregnant woman. Thus, the final sample size consisted of 1771 women who had singleton births and did not experience pregnancy complications. Factors that influence utilization of care are divided into two major categories – predisposing and enabling factors. The predisposing factors reflect mostly sociodemographic characteristics that increase or decrease the propensity to use health care services. The predisposing variables assessed in the article were marital status (married or unmarried but living with father during the pregnancy), age, educational attainment, and per capital income. Enabling factors are defined as resources or circumstances that allow a person to act on her inclination. The enabling variables considered were health insurance status, distance one must travel to receive prenatal care, and the number of prenatal clinics in a person’s residential county. The three dependent variables were contacts (total prenatal visits), timing of first visit, and Kessner index (adequacy of prenatal care).

The black and white women differed with regard to most demographic factors, which reflect the predisposing factors. 82% of the white women were married or living with the father during their pregnancy, while only 29% of the black women were. White women had both higher levels of educational attainment and per capita income than their black counterparts. Thus, except for age, which was not statistically significant, favorable predisposing factors were more prevalent among the white women than among the black women. 69% of the white women compared to 39% of the black women had private health insurance. White women had to travel over twice the distance that black women did for prenatal care (19.6 vs. 8.1 miles). Also, based upon the prenatal clinic availability index calculation, black women had more clinics surrounding their residence than the white women did. Thus, a difference was observed among the black and white women regarding the enabling factors. Furthermore, the quality and quantity of the prenatal care varied by the two racial groups. Black women received significantly fewer total prenatal visits, initiated their prenatal care later and their prenatal care was more often identified as less than adequate according to Kessner index. Controlling for the predisposing factors, race effect was significant with respect to contacts, first visit, and Kessner index. Thus, the findings imply that racial differences in prenatal care utilization were not a result of the differences in the predisposing factors. Furthermore, the analysis indicated that race effect was significant with respect to total number of visit and Kessner index when controlling for the enabling variables. This finding suggests that racial differences persist in total number of prenatal visits and adequacy of the care regardless of the enabling factors. In contrast, the timing of the first prenatal visit was not significantly related to race but was a consequence of the enabling factors.

Predisposing factors did not explain the observed racial differences in prenatal care. However, enabling factors contributed to racial differences in initiation of care, but not in total prenatal visits or adequacy. Also, higher educational level attainment and having private insurance strongly increased prenatal care utilization among black women, but the black women in the study were significantly less likely to be well educated and have private insurance than the white women. The availability of prenatal clinics contributed to more timely initiation of care, but did not affect overall number of visits or adequacy of the care. Black women tended to live in urban areas, which are heavily populated with health clinics. The services provided in the health clinics may be limited in comparison to those offered by many private physicians. While a black woman may have the same desire to seek out prenatal care and convenient accessibility to prenatal care clinics may further enable the black woman to initiate care; it may not be sufficient to sustain her continuing the care. Black women may experience negative treatment within the health care delivery system. These experiences include adverse patient-physician interaction and adverse conditions related to Medicaid dependency such as long waiting room delays, difficulty in obtaining appointments, and finding physician who accept Medicaid payment. Thus, “the stronger effect of private insurance and clinic availability for African-American women compared to white women does suggest that structural factors play a particularly important role in determining prenatal care utilization for black women and may, in fact be more important than cultural and behavioral differences.”