Child Care as a Barrier to Perinatal Health Care in Illinois

Abstract

Purpose

Within a multi-state Collaborative Improvement and Innovation Network addressing the social determinants of health during 2017–2020, the Illinois Department of Public Health led an exploratory project to understand how the availability of child care affects maternal health care utilization. The project assessed whether lack of child care was a barrier to perinatal health care utilization and gathered information on health facility practices, resources, and policies related to child care

Description

TWe surveyed (1) birthing hospitals (n = 98), (2) federally qualified health centers (FQHCs) (n = 40), and (3) a convenience sample of postpartum persons (n = 60).

Assessment

Each group reported that child care concerns negatively affect health care utilization (66% of birthing hospitals, 50% of FQHCs, and 32% of postpartum persons). Among postpartum persons, the most common reported reason for missing a visit due to child care issues was “not feeling comfortable leaving my child(ren) in the care of others” (22%). The most common child care resource reported by facilities was “staff watching children” (53% of birthing hospitals, 75% of FQHCs); however, most did not have formal child care policies or dedicated space for children. Fewer than half of FQHCs (43%) discussed child care at the first prenatal visit.

Conclusion

The project prompted the Illinois Title V program to add a child care-related strategy to their 2021–2025 Action Plan, providing opportunity for further examination of practices and policies that could be implemented to reduce child care barriers to perinatal care. Systematically addressing child care in health care settings may improve health care utilization among birthing/postpartum persons.

Purpose

Social determinants of health (SDoH) refer to the conditions in the places where people live, learn, work, pray, and play that affect a wide range of health risks and outcomes and can influence health care access, utilization, and quality (Centers for Disease Control and Prevention [CDC], 2021). One SDoH that is undervalued is the availability of child care; lack of child care acts as a logistical barrier to accessing health care, affecting parents’ ability to seek medical services for themselves. Specifically, childbearing persons may delay or forgo health care due to problems getting child care, especially in low-income communities (Ranji et al., 2018). In a recent study of women of reproductive age, approximately half (52.7%) reported foregoing health care for themselves in the past year due to lack of child care and lack of child care was the most frequently indicated reason for missing outpatient care (Gaur et al., 2020).

Timely and adequate care during the perinatal period (pregnancy, labor and delivery, and postpartum) is especially important to ensure that pregnant persons achieve optimal outcomes (Kilpatrick et al., 2017). Improving access to perinatal care is a key theme emerging from the reviews of U.S. maternal deaths (Review to Action, 2018); to achieve optimal maternal outcomes, it is vital to understand the barriers to timely and adequate perinatal care. Child care is an important factor influencing prenatal care initiation (Johnson et al., 2011; Fryer et al., 2019), prenatal care attendance (Mazul et al., 2017; Phillippi, 2009), high-risk obstetric care attendance (Campbell et al., 2000), and referrals for mental health conditions in the postpartum period (Boyd et al., 2011).

In 2017, the Association of Maternal and Child Health Programs (AMCHP) launched an Infant Mortality Collaborative Improvement and Innovation Network (CoIIN) for 13 states to collaborate on addressing SDoH (Stampfel, 2017). Within the CoIIN, the Illinois Department of Public Health (IDPH)’s Title V Program led a multidisciplinary team that chose to focus on child care. Our aims were to explore facility and patient perspectives on how child care can affect perinatal health care utilization and to understand existing child care practices, resources and policies within health care facilities.

Description

Early in the project, the team held an informal focus group with one Healthy Start’s program staff to assess the need for child care services among their clients. Participants (n = 10) reported that parents could apply for existing state child care services/subsidies for employment or school, but not for health care visits. To help meet their clients’ child care needs, some Healthy Start staff acknowledged watching children while parents completed visits at a co-located federally qualified health care center (FQHC). This information highlighted system-level gaps around availability of child care support and a need to better understand these gaps.

The team sought to explore perspectives of both patients and facilities to better understand child care and perinatal health care access. After scanning the literature for existing questions/instruments, we developed survey instruments for three respondent groups: birthing hospitals, FQHCs, and postpartum persons. Data collection took place over a one-year period (March 2019–2020).

Birthing Hospital Survey

We developed a nine-question survey to capture current child care practices, resources, and policies of labor and delivery units in Illinois birthing hospitals. The survey was distributed to all 117 birthing hospitals in Illinois through in-person meetings of the state’s 10 regionalized perinatal networks during March–July 2019. Team members introduced the project, distributed surveys, and facilitated discussion. One survey per hospital was completed by the labor and delivery unit nurse manager. Responses were collected on paper, entered into Microsoft Excel, and analyzed in SAS 9.4.

Federally Qualified Health Center Survey

We developed an 11-question survey to capture current child care practices, resources, and policies of Illinois’ over 500 FQHC and FQHC-look-alike facilities/sites which are administered by various agencies across the state (HRSA, 2023). The Illinois Primary Health Care Association (IPHCA) distributed the survey to their members, who represented all FQHC/FQHC-look-alike agencies statewide (approximately 50 agencies at that time) via email during June–September 2019. There may have been more than one member per agency. We encouraged one response per facility rather than per agency, in case there were differences between facilities within the same agency. Because the survey was anonymous, we could not verify if there were multiple responses per facility. Responses were collected in Survey Monkey and analyzed in SAS 9.4.

Postpartum Persons Survey

We developed a seven-question survey for postpartum persons to report how child care affected their ability to access health care. We reviewed questions from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS) to look for model questions but found few related to child care. We drafted new questions using PRAMS formatting and style as a guide and translated the survey into Spanish.

To survey a convenience sample of postpartum persons, we enlisted assistance from two Healthy Start programs located in FQHCs, and one local health department. All three sites were located in urban counties in different geographic areas in Illinois. Partners recruited participants with a child under 1 year of age between September 2019–March 2020. Each participant completed: (1) three demographic questions, (2) the child care survey, and (3) six de-briefing questions related to the questions’ clarity. Participants received a $25 gift card for participation. Responses were collected on paper, entered into Microsoft Excel, and analyzed in SAS 9.4.

Assessment

Birthing Hospital Survey

Among Illinois birthing hospitals, 84% (98/117) responded, representing all 10 regional perinatal networks. Of the responding hospitals, 46% (45/98) were located in the Chicago metropolitan area, and 54% (53/98) were located across the rest of the state in either small metropolitan or rural areas. Two-thirds (66%) indicated that child care was an issue affecting their patients’ labor and delivery and postpartum care experiences (Table 1). Over one-third (37%) reported that pregnant patients brought children aged 13 years and younger with them when they arrived at the hospital for labor and delivery on a regular basis (daily or weekly).

Table 1.

Child care practices and policies in Illinois birthing hospitals, Illinois birthing hospital child care survey, 2019 (n = 98)

Topic	N (%)
Has your facility identified child care as an issue/barrier?
Yes	65 (66.3%)
No	21 (21.4%)
Don’t Know/Missing	12 (12.2%)
Pregnant patients brought their children (0–13 years) with them for labor and delivery
Normal occurrence: Daily or weekly	36 (36.7%)
Not normal occurrence: Monthly or rarely	60 (61.2%)
Not sure/missing	2 (2.0%)
Patients on the postpartum unit had children (0–13 years) with them in their room for extended periods of time prior to discharge
Normal occurrence: Daily or weekly	20 (20.4%)
Not normal occurrence: Monthly or rarely	73 (74.5%)
Not sure/missing	5 (5.1%)
Children (0–13 years) of pregnant or postpartum patients are observed unattended (in patient room, waiting area, hallways, etc.)
Normal occurrence: Daily or weekly	14 (14.3%)
Not normal occurrence: Monthly or rarely	75 (76.5%)
Not sure/missing	9 (9.2%)
Resource(s)a available to assist families
Social worker watches children	13 (13.3%)
Volunteer watches children	17 (17.3%)
Administrative personnel watch children	15 (15.3%)
Nursing personnel watch children	47 (48.0%)
Community organization member watches children	6 (6.1%)
Someone on site who can help contact relatives or friends	48 (49.0%)
At least one of the above resources	71 (72.4%)
Is there a dedicated space for children?
Yes, labor and delivery	15 (15.3%)
Yes, postpartum	10 (10.2%)
Do you have a policy related to children accompanying adult patients?
Yes, formal, written policy	33 (33.7%)
Yes, informal, verbal policy or depends on staff present	12 (12.2%)
No standard policy in place	35 (35.7%)
Not sure/missing	18 (18.4%)

^aQuestion allowed facilities to choose all options that applied, so percentages do not add up to 100%

About three quarters (72%) indicated they have some type of resource available for pregnant/postpartum persons who bring children with them to the labor and delivery unit or whose family drops off children for extended stays on the postpartum unit. The most common resources reported were “hospital personnel to watch children” (53%) or “someone on site who can help contact relatives or friends” (49%), with nurses being the most common personnel to offer assistance. Very few indicated that they have a designated space for children in the labor and delivery unit (16%) or postpartum unit (10%). Only one-third had a formal (written) policy (34%) about children arriving with adults in need of care. Of those with a formal (written) policy, 58% indicated that their staff (social worker, nurse or administrative position) watched children. However, we did not ask hospitals if their formal policy included regulations related to staff watching children; as such, we are unable to determine how many hospitals’ policies did or did not allow staff to watch unattended children. However, some hospitals did describe having a policy that did not allow staff to watch unattended children due to liability reasons or staffing issues, and some reported the practice of calling the Illinois Department of Children and Family Services if patients are not able to find someone to watch their children.

Federally Qualified Health Center Survey

We received 40 responses to the FQHC survey. Half (50%) indicated that their FQHC had “identified child care as a barrier to women seeking care for themselves” (Table 2). However, despite reporting this barrier, slightly less than half (43%) discussed child care issues with their patients at the first prenatal visit.

Table 2.

Child care practices and policies in Illinois federally qualified health centers (FQHCs), Illinois FQHC child care survey, 2019 (n = 40)

Topic	N (%)
Has your facility identified child care as an issue/barrier?
Yes	20 (50.0%)
No	10 (25.0%)
Not sure	10 (25.0%)
Do you discuss child care issues with your patients at their first visit for prenatal care?
Yes	17 (42,5%)
No	17 (42.5%)
Not sure/Missing	6 (15.0%)
Does your clinic allow patients to bring children aged 13 years and younger to their prenatal or postpartum care appointments?
Yes	34 (85.0%)
No	2 (5.0%)
Not sure/Missing	4 (10.0%)
Pregnant patients brought their young children (age 0– 4)
Normal occurrence: Daily or weekly	30 (75.0%)
Not normal occurrence: Monthly or rarely	6 (15.0%)
Not sure/missing	4 (10.0%)
Pregnant patients brought their school aged children (age 5–13)
Normal occurrence: Daily or weekly	22 (55.0%)
Not normal occurrence: Monthly or rarely	14 (35.0%)
Not sure/missing	4 (10.0%)
Postpartum patients brought their young children (age 0– 4)
Normal occurrence: Daily or weekly	31 (77.5%)
Not normal occurrence: Monthly or rarely	6 (15.0%)
Not sure/missing	3 (7.5%)
Postpartum patients brought their school aged children (age 5–13)
Normal occurrence: Daily or weekly	22 (55.0%)
Not normal occurrence: Monthly or rarely	14 (35.0%)
Not sure/missing	4 (10.0%)
Pregnant or postpartum patients cancelled their appointment because of lack of childcare
Normal occurrence: Daily or weekly	7 (17.5%)
Not normal occurrence: Monthly or rarely	17 (42.5%)
Not sure/missing	16 (40.0%)
Resource(s)a available to assist families
Social worker watches children	5 (12.5%)
Volunteer watches children	0 (0.0%)
Administrative personnel watch children	20 (50.0%)
Nursing personnel watch children	21 (52.5%)
Community organization member watches children	0 (0.0%)
Someone on staff connects/refers patients to available community resources	14 (35.0%)
At least one of the above resources	35 (87.5%)
Is there a dedicated space for children?
Yes	12 (30.0%)
No	26 (65.0%)
Missing	2 (5.0%)
Do you have a policy related to children accompanying adult patients?
Yes, formal or informal	3 (7.5%)
No standard policy in place	24 (60.0%)
Not sure/Missing	13 (32.5%)

^aQuestion allowed facilities to choose all options that applied, so percentages do not add up to 100%

More than three-quarters of FQHC respondents reported it was a regular occurrence (daily or weekly) for pregnant (78%) and postpartum (78%) patients to bring their young children (age 0–4) with them to appointments. Most (88%) indicated they have some type of resource available to assist patients with temporary child care needs. The most common resources reported were “clinic personnel to watch children” (75%) or “someone on staff to connect patients to community resources” (35%), usually nurses or administrative staff.

Fewer than one-third (30%) reported their facility had a designated space for children to stay while their parents attend appointments. Only 8% indicated their facility had a formal (written) or informal (verbal) policy about children arriving with an adult patient. Despite this, most FQHC (85%) reported allowing children to accompany their parents in the examination room during the appointment.

Postpartum Persons Survey

We surveyed 60 postpartum persons across three sites—57% were non-Hispanic Black, 28% were non-Hispanic white, 12% were Hispanic, and 3% were multi-racial. Approximately 27% of participants had less than a high school education, and the majority were 25 years or older. The survey was completed in English (83%) and Spanish (17%).

Participants reported various child care concerns (Table 3). One-third (32%) indicated that during their most recent pregnancy or since their new baby was born, they had to reschedule or skip a health care visit for themselves because they had no one to watch their child(ren). The most common reasons for not having anyone to watch their children were: “not feeling comfortable leaving their child(ren) in the care of others” (22%), “expense of child care” (20%), and “child care plans falling through” (17%). During the de-briefing process, some participants verbally reported positive factors that had helped them access health care services, such as receiving perinatal health care at a facility that was “family–friendly,” having clinic staff watch children during appointments, and having local social support to watch their children.

Table 3.

Reporting of child care as a barrier to perinatal health care among Illinois postpartum persons^a, Illinois postpartum persons child care survey, 2019–2020 (n = 60)

Topic	N (%)
During your most recent pregnancy or since your new baby was born, did you have to reschedule or skip a health care visit for yourself because you had no one to watch your child(ren)?
Yes	19 (31.7%)
No	41 (68.3%)
During your most recent pregnancy or since your new baby was born, did you have to reschedule or skip any of the following types of health care visits for yourself because you had no one to watch your child(ren)?b
Prenatal care	9 (15.0%)
Postpartum care	8 (13.3%)
Annual check up	8 (13.3%)
Emergency room visit	8 (13.3%)
Specialist appointment (example: cardiologist)	4 (6.7%)
Tests recommended by my doctor	6 (10.0%)
Dental care	5 (8.3%)
None of the abovec	40 (66.7%)
During your most recent pregnancy or since your new baby was born, did you have to reschedule or skip a health care visit for yourself because you had no one to watch your child(ren) for any of the following reasons?b
Getting someone to watch my child(ren) was too expensive	12 (20.0%)
My health care provider would not allow me to bring my child(ren)	3 (5.0%)
I was unable to transport my child(ren) to someone who could watch them	7 (11.7%)
I did not feel comfortable leaving my child(ren) in the care of others	13 (21.7%)
Transportation provided by my insurance company did not allow my child(ren) to accompany me on my health care visit	4 (6.7%)
My child care plans fell through	10 (16.7%)
None of the abovec	41 (68.3%)

^aWith a child up to 1 year of age

^bQuestion allowed facilities to choose all options that applied, so percentages do not add up to 100%

^cThese questions were not based on a skip pattern from the first yes/no question, and we did not apply logic checks to force “no” responses to later indicate “none of the above” for the types of visits or reasons for child care issues. Therefore the 41 “no” responses from the first question are not necessarily the same people who responded “none of the above” for the subsequent questions

Discussion

In this exploratory project, we collected data from three different groups to triangulate information about the impact of child care on perinatal health care utilization in Illinois. Child care was identified to be an issue affecting health care utilization by each of the three groups. One in three postpartum persons reported child care as a barrier to their health care utilization. Most respondents from birthing hospitals and FQHCs also affirmed child care as a barrier to care, yet supportive practices and policies related to child care were highly varied and not particularly robust. In fact, while many birthing hospitals and FQHCs reported having resources to aid parents with child care for appointments, this was mainly comprised of staff watching children. In addition, we found that fewer than half of the FQHCs reported discussing child care issues with their patients at their first prenatal care visit. This suggests the need for more health care providers to discuss child care barriers with patients both during the first prenatal care visit and then to connect these patients to facility or community resources, reducing their likelihood of missing future appointments.

Other studies have identified strategies to address child care within health facilities by creating child-friendly waiting rooms (Rodin et al., 2019), designing examination rooms to accommodate families (Rodin et al., 2019), welcoming newborns and other children at visits (Phillippi, 2009; Fryer et al., 2021), and providing child care on site (Phillippi, 2009). One study found that 87.9% of female respondents felt a hospital-based day care would help them attend outpatient visits (Gaur et al., 2020); this study prompted the sponsoring healthcare system to collaborate with a non-profit community-based organization to provide no-cost child care for caregiver’s children while the caregivers received medical care (Alvarez et al., 2022). Results from the first year of implementation revealed that among the mostly Hispanic or Black enrollees, 81% reserved a child care appointment and 68% used a child care appointment. The most common clinic appointment type for which child care was reserved was OB/GYN (Alvarez et al., 2022). Health care systems could follow this example and also consider providing child care outside of normal business hours to accommodate labor and delivery patients.

One–fifth of our postpartum respondents did not feel comfortable leaving their children in the care of others. This suggests that “family–friendly” health care settings, such as the creation of “family–friendly” exam rooms where children can accompany their parent, may be beneficial. Health professionals may become surrogate child care workers when parents bring their child to appointments. Qualitative assessments could be used to better understand pregnant and postpartum persons’ vision for a “family friendly” health care setting and potentially assess acceptability of a facility’s proposed child care resources. This project found few existing child care-related policies among the responding facilities, suggesting a lack of standards for how child care resources within health settings are either provided or made available through partners. The creation of “family–friendly” child care policies in health care facilities may be mutually beneficial for patients and staff. If child care resources are available, patients’ stress and responsibility to find care could possibly be reduced. Likewise, the burden on health care providers to provide child care could be removed or lessened if alternate resources are found. Going forward, there is also an opportunity to assess how the incorporation of telehealth visits could improve access to perinatal health care while simultaneously eliminating barriers to in-person visits resulting from lack of child care (Peahl et al., 2021).

This project successfully accomplished the aims of exploring facility and patient perspectives on how child care affects perinatal health care utilization and assessing child care practices, resources, and policies within health care facilities. A strength of this project was that most (84%) of Illinois’ birthing hospitals participated, which was obtained through robust partnerships with the administrative perinatal centers.

On the other hand, limitations of the project include the small convenience samples for the FQHC and postpartum surveys, making the findings from these surveys not generalizable to the entire state. For the FQHC survey, we cannot verify that only one survey was completed per facility because the surveys were anonymous. We also lack information about the number and characteristics of IPHCA members, so we cannot assess the FQHC survey’s response rate or representativeness. The postpartum survey participants were more likely to be non-Hispanic Black than the general population of postpartum persons in Illinois. Because the postpartum persons survey was administered through two Healthy Start programs and a local health department, participants may be more likely to be low-income than the general population of postpartum persons, and thus may have been more likely to experience child care issues than the general population. However, it is also possible that the postpartum persons surveyed may have had more support for child care than those not enrolled in community-based programs because Healthy Start programs provide case management services and assistance to overcome barriers to care (HRSA, 2022). Therefore, it is not known whether our project overestimates or underestimates the true impact of lack of child care on perinatal health care utilization in the general population. Future research could continue to explore child care as a barrier to perinatal health care among birthing peoples with varying sociodemographic characteristics in order to inform strategies for improving perinatal health care utilization.

Despite the limitations, this exploratory project suggests that child care access is an important determinant of perinatal health care utilization in Illinois and suggests potential arenas to address child care in health care facilities. The results of this project prompted the Illinois Title V Program to add a strategy to their 2021–2025 Action Plan to develop suggested strategies and approaches that can be implemented in clinic and hospital settings (Illinois Maternal and Child Health Services Title V Block Grant, 2021). The team intended to convene partners in 2020 to discuss and pilot potential “family–friendly” practices, but this work was halted due to shifting priorities during the COVID-19 pandemic.

Conclusion

We developed and deployed three novel survey instruments to collect information about child care practices and their relationship to perinatal health care utilization from Illinois birthing hospitals, FQHCs, and postpartum persons. These surveys showed that access to child care is an issue affecting perinatal health care utilization in Illinois. Importantly, child care support policies and practices varied by facility with few institutions providing direct support beyond ad hoc utilization of staff resources suggesting room for improvement in mitigating child care as a barrier to perinatal health care.

Significance.

What is already known on this subject?

Child care is a social determinant of health affecting parents’ ability to seek medical services. Research has shown that child care is an important factor affecting health care utilization during the perinatal period (prenatal, labor and delivery, and postpartum).

What this study adds?

The results of this project indicate that lack of child care is a barrier to health care utilization for some Illinois residents who are pregnant or up to one year postpartum. However, child care resources reported by health care facilities were limited and most facilities reported not having formal child care policies in place.

Data Availability

Data are not available publicly; survey instruments are available from corresponding author upon request.