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. Author manuscript; available in PMC: 2024 Jul 16.
Published in final edited form as: Matern Child Health J. 2023 Jun 27;27(10):1811–1822. doi: 10.1007/s10995-023-03733-1

Prenatal Care Utilization Challenges and Facilitators for a Growing Latino Community in the Midwest

Juliana Teruel Camargo 1,2, Romina L Barral 3, Elizabeth H Kerling 1, Lillian Saavedra 4, Susan E Carlson 1, Byron J Gajewski 5, Mariana Ramírez 4
PMCID: PMC11251489  NIHMSID: NIHMS1999088  PMID: 37369811

Abstract

Background

Latina women are less likely to start prenatal care in the first trimester and to attend the recommended amount of prenatal visits compared to their non-Latina white counterparts.

Objectives

This study aimed to assess challenges and facilitators to first-trimester prenatal care (FTPNC) and prenatal care utilization (PNCU) in a Midwestern urban area with a growing immigrant Latino community.

Methods

This study used a mixed-method approach based on the Theoretical Domains Framework. Nine semi-structured interviews were conducted with healthcare professionals that worked in birth centers, clinics, or hospitals that provided prenatal care (PNC) services for Latina women. Eight focus groups and quantitative surveys were conducted with Latina women and their supporters in Kansas City metropolitan area.

Results

FTPNC was challenged by women’s immigrant status, lack of healthcare coverage due to immigrant status, and complexity of Medicaid application. PNCU was challenged by the cost of PNC when diagnosed with gestational diabetes, lack of healthcare coverage, PNC literacy, late access to gynecologists/obstetricians, inadequate interpretation services, transportation, and mental health distress. Meanwhile, FTPNC was facilitated by social support and connectedness. PNCU was facilitated by Spanish-proficient providers and interpreters, effective nonverbal communication and education techniques, and pregnancy prevention access and education.

Conclusions for Practice

Results from this study highlight important targets to improve PNC for Latina women. Participants called for various types of support to address identified challenges, ranging from information on social media about PNC services to broader efforts such as building trust from the community toward PNC providers and making PNC services affordable for women with gestational diabetes.

Keywords: Prenatal Care, Health Services Accessibility, Hispanic Americans, Emigrants and Immigrants, Gestational Diabetes

Introduction

Prenatal care (PNC), or healthcare during pregnancy, comprises preventative healthcare such as physical exams, vaccination, weight checks, urine, and blood tests, imaging tests, including ultrasound exams, and childbirth education (WHO, 2003; US Department of Health and Human Services, 2017). Effective PNC starts early in pregnancy. First-trimester prenatal care (FTPNC) aims to detect potential health problems, prevent them if possible, and refer individuals to appropriate care (WHO, 2015). In fact, FTPNC and regular prenatal care utilization (PNCU) lead to improved health outcomes for both women and children (Osterman and Martin, 2016). Lack of early and consistent access to PNC can lead to adverse health outcomes. This evidence comes from a growing body of literature, including a recent study that assessed the impact of the decline in routine obstetrics activities on pregnancy health, in the context of the COVID-19 pandemic lockdown. The study found that patients with less access to routine obstetrics activities had a significant increase in pregnancy hypertensive disorder, gestational diabetes, epidural analgesia, and operative vaginal deliveries compared to patients with regular access to obstetric activities before the lockdown (Justman et al., 2020). FTPNC and PNCU also save resources for the health system; it is estimated that for every $1 (US) spent on PNC, $3.38 (US) is saved in medical care costs for infants (National Academy for State Policy, 2008).

Even though PNC is considered an essential primary care service, racial and ethnic disparities in PNC exist in the United States (US). Previous studies found PNC disparities for Latina women at societal, community, interpersonal, and individual levels. At the societal level, Latina women had low access to FTPNC and low use of PNC services during administrations that promoted anti-immigrant rhetoric compared to those without anti-immigrant rhetoric (Pacheco Young et al., 2022). At the community level, Latina women who reside in underserved areas, such as immigrant enclave neighborhoods or the Texas-Mexico border, reported higher rates of late access to PNC and lower PNCU compared to pregnant white women residing in neighborhoods that were not immigrant enclaves and Latina women residing in other states bordering with Mexico (Selchau et al., 2017; Noah, 2017). At the interpersonal level, Latina women who were immigrants had delayed access to PNC and a lower PNCU compared to US citizens (Rhodes et al., 2015). At the individual level, Latina women who were uninsured, had Medicaid coverage, were nulliparous and unaware of pregnancy had lower FTPNC and PNCU than women who had private insurance, were multiparous and aware of pregnancy (Docherty & Johnston, 2015; Selchau et al., 2017).

Historically, immigrants are a crucial group to be considered in PNC disparities research due to the number of births from immigrants and the lack of policies that facilitate access to PNC for this population. The US is at a historic high of 44.9 million immigrant residents, with Latin Americans representing the largest group (Capps and Ruiz Soto, 2019). At the same time, the Latino population accounted for over half of the US population growth between 2000 and 2010, led mainly by increased birth rates (Johnson & Lichter, 2016). In fact, the US Census projects that 1 in 3 births will be from Latina individuals by 2052 (Mathews and Hamilton, 2017). Historically, the Latino population was mainly located in just nine states: Arizona, California, Colorado, Florida, Illinois, New Jersey, New Mexico, New York, and Texas (Passel et al., 2022). However, new immigration routes have increased the presence of the Latino population in midwestern states such as Kansas and Missouri (Passel et al., 2022).

The health of immigrant Latinos is greatly impacted by public policies at federal, state, and local levels that directly influence their access to healthcare services such as PNC. State-level policy studies have found state laws restricting immigrants’ rights and stigmatizing undocumented/unauthorized immigrants that directly impacted their utilization of preventive healthcare services (Perreira & Pedroza, 2019). An example is the state-level policy that requires local law enforcement officials to comply with federal immigration authorities and detain individuals suspected of being in the country illegally. The law allows law enforcement officials to question the immigration status of individuals during routine traffic stops and arrests. Additionally, the state-level law includes provisions that penalize local officials who enact policies that limit cooperation with federal immigration authorities (Caraveo et al., 2021; Gomez & O’Leary, 2019). Notably, there is a paucity of studies looking into the growing Latino population who have followed recent immigration routes.

Even though birth rates among the Latino population are fueling the US population growth, Latina women still experience PNC disparities that lead to higher maternal morbidity (e.g., excessive weight gain, pregnancy hypertension, and gestational diabetes) (Howell et al., 2017); labor complications (e.g., cesarean, and shoulder dystocia) (Hefele et al., 2018); and adverse perinatal complications (e.g., low birth weight, preterm birth, and small for gestational age infants) (Bediako et al., 2015) compared to the non-Latino white population.

The harsh immigration climate during the past administration reshaped what we knew about the Latino population’s perceptions and attitudes towards healthcare and state policy differences regarding immigrants’ eligibility to access healthcare services (Capps & Ruiz Soto, 2019). Therefore, new and unique challenges to accessing and using PNC may exist for Latina women depending on the state they reside in (Perreira & Pedroza, 2019; Rhodes et al., 2015). A study conducted during the past administration with Brazilian immigrants’ about their access and utilization of PNC and overall healthcare services in Massachusetts identified socio-cultural differences in care delivery, fear of being unable to access and pay for PNC, and inconsistent quality of interpreting services as challenges to healthcare service utilization (Lindsay et al., 2016). A systematic review evaluated PNCU in European immigrant women and identified unplanned pregnancy, younger age, absence of a partner, multiparity, and poor language proficiency as potential barriers to adequate PNC (Heaman et al., 2013).

Still, there is a paucity of studies examining challenges to PNC services in geographic areas with new settlements of Latino immigrants. Newly settled immigrants lack the social capital of communities that have been in the US for decades (Capps & Ruiz Soto, 2019). Their health needs may be affected by a lack of knowledge in navigating many systems, including the healthcare system. The objective of this study was to assess challenges and facilitators to FTPNC and PNCU as perceived by Latina women, their supporters, and healthcare professionals in a Midwestern urban area with a growing immigrant Latino community.

Methods

We used the COREQ criteria for reporting qualitative research. Women were included if they were aged 18 years or older, self-identified as Latina, lived in the Kansas City area, had been pregnant within the previous five years, and could join a focus group in person. Participating women were asked to invite a person who supported them during their pregnancy (e.g., spouse, baby’s father, mother, grandmother, and friends) to attend a ‘supporter’ focus group. Healthcare professionals were included if they were healthcare workers (providers, community professionals, and healthcare administrators) at PNC locations (birth centers, clinics, or hospitals) that provided PNC for Latina women in the Kansas City area and could join one in-person semi-structured interview. No formal exclusion criteria were specified. All participants received a $30 gift card for their time. Focus groups participants also received a light dinner and had childcare available during the session.

Recruitment

We conducted focus groups with Latina women and their supporters and structured interviews with healthcare providers from July to September 2017. Recruitment for the focus groups occurred through calls to a convenience sample of women who previously participated in our parent randomized clinical trial and from flyers and personal invitations in community clinics and community-based events in the Kansas City area. Recruitment of healthcare professionals also involved a convenience sample from the settings we recruited for our parent randomized clinical trial. The research team contacted those who indicated an interest in participating in scheduled interviews and focus groups. All study procedures were approved by the University of Kansas Medical Center Institutional Review Board and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All study participants gave their informed oral and written consent on their language of preference prior to their inclusion in the study.

Data-Collection Strategies

We used semi-structured interviews and focus groups. The approach inquiry used was based on the Theoretical Domains Framework (Michie et al., 2005), to assess perceived challenges and facilitators for Latina women FTPNC and PNCU in the Kansas City area. The Theoretical Domains Framework (TDF) was developed for implementation research and is a theoretical framework instead of a theory. TDF is a synthesis of 33 theories of behavior and behavior change. It is clustered into 12 domains that provide a theoretical list of explanations of behaviors using cognitive, affective, social, and environmental influences (Atkins et al., 2017). We created the semi-structured topic guide for the semi-structured interviews and focus groups based on the TDF and previous US government report on barriers to accessing PNC (Brown, 1988). The topic guide provided questions and prompts and was pilot tested. Interviews and focus group guides included questions about PNC knowledge, behavior, factors leading to provider selection, obstacles, perceived differential treatment, and recommendations.

Focus Groups Procedures

Two-trained bilingual researchers (JTC and MR), who have Master’s in Social Work (MSW), Master’s in Public Health (MPH), and Ph.D. in Medical Nutrition (Ph.D.), conducted in-person focus groups, while two other bilingual researchers, who are medical and nutrition students, took field notes. All the bilingual researchers were part of the research team at the time of the study and were research center director, PhD candidate, and research staff. All researchers were female. The two bilingual researchers who conducted the focus groups had been formally trained in qualitative research methodology, and the research team trained researchers who took field notes. Participants invited to the focus groups could either have interacted with research team through participation in the parent randomized clinical trial or have never interacted with researchers. Participants knew before the focus groups that the objective of the study was to understand barriers and facilitators for Latina women in the Kansas City area to access and use PNC services. Focus groups lasted 60–90 min and were conducted in Spanish and separately for women and their supporters, which resulted in 8 groups (4 with women and 4 with supporters). Focus groups were audio-recorded and downloaded on a safe and password-protected computer drive. Woman’s age (< 35 or ≥ 35 years old) and length of stay in the US (< 5 or ≥ 5 years) were used for stratification to reach thematic saturation (Hennink et al., 2019). The decision to stratify women by age was based on age-related pregnancy risk (Lomelino Pinheiro et al., 2019), and the decision to stratify years living in the US based on 5 years is based on the policy regulation that immigrants do not qualify for public health insurance (e.g. Medicaid) until they are lawfully present in the US for 5 years (Department of Health and Human Services, 2017). Data saturation was judged in line with recommendations for the theory-driven interview and focus group studies (Symon & Cassell, 1998).

Focus Groups Quantitative Surveys

Latina women and their supporters completed a survey before participating in focus groups. Surveys included questions related to sociodemographics, acculturation (Marin et al., 1987), health literacy (Lee et al., 2010), stress (Cervantes et al., 2016), depressive symptoms (Löwe et al., 2005), PNCU (CDC, 2013), obstetric history, and quality of life (CDC 2000).

Sociodemographic questions included: (a) education attainment: “what is the highest degree or level of school this person has completed?” with response categories: grades 1 through 11, 12 grade – no diploma, regular high school diploma, GED or alternative credential, some college, associates degree, bachelor’s degree, master’s degree, professional degree beyond bachelor’s degree, and doctorate degree; (b) annual household income: Total family income in 2016 before taxes of all family members living in the household, with response open-ended and later categorized by average distribution; (c) Occupational status: “Are you currently…?” with response categories: employed, self-employed, unemployed, a homemaker, a student, military, retired, unable to work; (d) Marital status: “What is your marital status?” with response categories: single/never married, married or domestic partnership, widowed, divorced, separated; (e) Nativity: “Where were you born?” with response categories: in the United States, outside the United States –U.S. Territory (e.g., Puerto Rico, U.S. Virgin Islands, Guam) or name of foreign country, etc. (f) For those who were not born in the US, Time living in the US: “about how long have you been in the United States?” with response open-ended in number format, and later categorized by less than 10 years or 10 and more years.

Acculturation was measured using the short acculturation scale for Hispanics/Latinos (SASH). This 4-item scale measures language use, media, and ethnic social relations. Answers are a 5-point bipolar scale with options of: only English, English better than Spanish, Both equally, Spanish better than English, and Only Spanish. Scores ranges from 1 to 5, and a score < 3.00 represents a lower level of acculturation (Marin et al., 1987). Health literacy was measured using the Short Assessment of Health Literacy-Spanish & English (SAHL-S&E). The 18-item tool measures health literacy through the domains of prose, numeracy, information seeking, and interactive media navigation (Lee et al., 2010).

Stress was measured using the Hispanic Stress Inventory (HSI) version 2. We used 3 subscales: (1) Access to healthcare stress, which includes items assessing stress related to lack of health insurance, problems paying medical bills, and lack of quality health care (8 items); (2) immigration stress, which includes items assessing exposure to traumatic events during the immigration sojourn, fear of being deported, problems finding work, family separations, and limited contact with family (9 items); (3) discrimination stress, which includes items assessing perceived discrimination due to both immigration status and Hispanic/Latino ethnicity (11 items). For each item, participants indicated whether they had experienced the stressor (Yes/ No) and if they had experienced they rated how stressful the event was on a 5-point Likert scale (1 = Not at all worried/tense, 2 = A little worried/tense, 3 = moderately worried/tense, 4 = very worried/tense, 5 = extremely worried/tense). For items where participants reported they had not experienced a stressor, the appraisal score was coded to 1 (not at all worried/tense) (Cervantes et al., 2016).

Depressive symptoms were assessed with the two-item Patient Health Questionnaire-2 (PHQ-2). The PHQ-2 questions included: “Over the last two weeks, how often have you been bothered by any of the following problems?” The two items are “little interest or pleasure in doing things” and “feeling down, depressed, or hopeless”. For each item, the response options are “not at all”, “several days”, “more than half the days”, and “nearly every day”. Answers are scored as 0,1,2 and 3, respectively, resulting in a final score that ranges from 0 to 6. A score ≥ 3 indicates presence of depressive symptoms (Löwe et al., 2005).

PNCU was measured using questions retrieved from the Pregnancy Risk Assessment Monitoring System (PRAMS). We included questions about being currently pregnant, number of previous pregnancies, number of live births, gestational diabetes at any pregnancy, preeclampsia at any pregnancy, type of health insurance coverage during last pregnancy, the facility where had access to PNC at last pregnancy, assess to PNC as soon as wanted in the last pregnancy, PRAMS list of common barriers to assess PNC at last pregnancy, and average waiting room time during PNC at last pregnancy (CDC, 2013).

Quality of life was measured using the Healthy Days Core Module (CDC HRQOL-4), through the question, “Would you say that, in general, your health is” with the response options: excellent, very good, good, fair, or poor. Later answers were combined as excellent, very good, and good or fair/poor (CDC 2000).

Semi-Structured Interviews Procedures

Healthcare professionals participated in interviews that lasted 60–90 min and were conducted in either English or Spanish, according to the participants’ language preferences. Two-trained bilingual researchers (JTC and MR), who have Master’s in Social Work (MSW), Master’s in Public Health (MPH), and Ph.D. in Medical Nutrition (Ph.D.), conducted in-person interviews. One conducted the in-person interview while the other took field notes. All the bilingual researchers were part of the research team at the time of the study and were research center director and PhD candidate. All researchers were female. The two bilingual researchers who conducted the in-person interview had been formally trained in qualitative research methodology. Participants invited to the interviews could either have interacted with research team through academia or have never interacted with researchers. Participants knew before the interviews that the objective of the study was to understand barriers and facilitators for Latina women in the Kansas City area to access and use PNC services. Semi-structured interviews were audio-recorded and downloaded on a safe and password-protected computer drive.

Analysis

Quantitative data from the surveys were managed using REDCap version 6.11.5. Descriptive statistics were reported for each survey item using the software IBM SPSS version 25.0. The data-analytic strategy used was based on the generation of themes. A research staff transcribed the audio recordings from focus groups and interviews verbatim. Transcripts were not returned to participants for comments or corrections. Interview and focus groups transcriptions underwent thematic analysis in Atlas. ti to identify salient themes following an adapted framework of challenges for FTPNC and PNCU (Brown, 1988). A coding tree is not provided in this manuscript. To ensure reliability, 2 coders started coding the transcripts independently, and coding disagreements were reconciled by consensus (Onwuegbuzie & Leech, 2007). Once the coders agreed and their coding was consistent, one coder finalized coding the rest of the transcripts.

Results

Sample Description

We conducted focus groups with 50 participants (24 women and 26 supporters). Most women were immigrants (87.5%), had a low level of acculturation (1.61 out of 5.00), were married (95.8%), and had a high school degree (41.7%). Supporters were all immigrants (100%) with a low level of acculturation (1.66 out of 5.00) and had completed less than a high school education (53.8%). Women reported higher immigration stress compared to their supporters. While supporters reported higher discrimination stress than women (Table 1).

Table 1.

Sociodemographic, health literacy, stress, and depressive disorder symptoms characteristics of focus groups participants (n = 50)

Characteristics Women
(n = 24)		 Supporters
(n = 26)
← Mean (95% CI) →
Acculturation1 1.61 (1.28, 1.95) 1.66 (1.34, 2.00)
Access to healthcare stress2 1.30 (1.00, 3.90) 1.50 (1.00, 4.90)
Immigration stress3 3.50 (1.20, 4.70) 3.10 (1.10, 4.50)
Discrimination stress4 2.60 (1.70, 3.80) 3.70 (1.80, 4.30)
Depressive disorder symptoms5 0.50 (0.00, 2.90) 1.00 (0.00, 3.00)
← n (%) →
Time living in the US
 < 10 years 9 (37.5) 19 (73.1)
 ≥ 10 years 15 (62.5) 7 (26.9)
Nativity
 US 3 (12.5) 0 (0.0)
 Mexico 16 (66.7) 17 (65.4)
 Central America 6 4 (16.7) 6 (23.1)
 South America 7 1 (4.1) 3 (11.5)
Occupational status
 Employed 9 (37.5) 14 (53.8)
 Homemakers 15 (62.5) 10 (38.5)
 Unemployed 0 (0.0) 2 (7.7)
Marital status
 Married 23 (95.8) 20 (76.9)
 Divorced/Widowed 1 (4.2) 2 (23.1)
 Single 0 (0.0) 4 (15.4)
Education attainment
 Less than high school 5 (20.8) 14 (53.8)
 High school degree 10 (41.7) 7 (26.9)
 Some college or more 9 (37.5) 5 (19.3)
Annual household income
 < US$ 20,000 7 (29.2) 9 (34.6)
 US$ 20,000 to 39,999 10 (41.7) 11 (42.3)
 ≥ US$ 40,000 7 (29.1) 6 (23.1)
Functional health literacy
 Adequate 13 (54.2) 17 (65.4)
 Inadequate 11 (45.8) 9 (34.6)
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1

Acculturation is continuously scaled from 1 (least acculturated) to 4 (most acculturated)

2

Access to healthcare stress is continuously scaled from 1 (not at all worried) to 5 (extremely worried)

3

Immigration stress is continuously scaled from 1 (not at all worried) to 5 (extremely worried)

4

Discrimination stress is continuously scaled from 1 (not at all worried) to 5 (extremely worried)

5

Depressive disorder symptoms are continuously scaled from 0 (not at all feeling down) to 4 (feeling depressed nearly every day)

6

Included: El Salvador and Honduras

7

Included: Ecuador and Venezuela

On average, women reported 3 pregnancies, and 30% were pregnant at the study time. One in 4 women in the study was affected by pregnancy-related chronic diseases, primarily gestational diabetes. Approximately 83% of women did not have health insurance (private or public) during pregnancy, and half received their PNC in hospital clinic facilities (Table 2).

Table 2.

Women health and PNC characteristics of women participating in the focus groups (n = 24)

Characteristics < 35 years
(n = 12)		 ≥ 35 years
(n = 12)
← Mean (95% CI) →
Number of pregnancies 2.25 (1.53, 2.97) 3.08 (2.02, 4.15)
 Number of live births 2.00 (1.46, 2.54) 3.08 (2.02, 4.15)
← n (%) →
Currently pregnant
 Yes 2 (16.7) 5 (41.7)
 No 10 (83.3) 7 (58.3)
Gestational diabetes in any pregnancy
 Yes 2 (16.7) 7 (58.3)
 No 10 (83.3) 5 (41.7)
Preeclampsia in any pregnancy
 Yes 1 (8.3) 0 (0.0)
 No 11 (91.7) 12 (100.0)
Self-assessed health status
 Excellent, very good, good 10 (83.3) 8 (66.7)
 Fair or poor 2 (16.7) 4 (33.3)
Type of health insurance coverage
 Private 2 (16.7) 1 (8.3)
 Public 0 (0.0) 1 (8.3)
 Uninsured 10 (83.3) 10 (83.3)
Facility that had access to PNC
 Hospital clinic 6 (50.0) 6 (50.0)
 Health department clinic 2 (16.7) 3 (25.0)
 Safety net clinic 3 (25.0) 1 (8.3)
 Private clinic 1 (8.3) 2 (16.7)
Got PNC as soon as she wanted
 Yes 10 (83.3) 10 (83.3)
 No 2 (16.7) 2 (16.7)
Reported at least one barrier to access PNC 4 (33.3) 5 (41.7)
Reported barriers to access PNC
 Did not want PNC 0 (0.0) 1 (8.3)
 Did not want anyone else to know about the pregnancy 0 (0.0) 2 (16.7)
 Did not know was pregnant 0 (0.0) 3 (25.0)
 No childcare 0 (0.0) 1 (8.3)
 No time off from work 0 (0.0) 1 (8.3)
 Doctor or health plan could not start as early 1 (8.3) 2 (16.7)
 No transportation 2 (16.7) 2 (16.7)
 No money or insurance 2 (16.7) 2 (16.7)
Average waiting room time during PNC
 Less than 15 min 3 (25.0) 4 (33.3)
 15 to 30 min 4 (33.3) 5 (41.7)
 30 to 60 min 5 (41.7) 3 (25.0)
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We conducted semi-structured interviews with 9 healthcare professionals. The interviewees were 45% healthcare providers, which included gynecologists, obstetricians, nurses, nurse practitioners, and medical students; 33% were healthcare administrators, which included public health department administrators; and 22% were social and community health workers.

Immigrant Status and Healthcare Coverage as Challenges to FTPNC

In this sample, most women were immigrants (Table 1), and having an unauthorized immigration status was consistently reported as a challenge to FTPNC. Due to unauthorized immigration status, most women in this sample were uninsured (Table 2) and consequently had limited access to prenatal care services.

On average, women and supporters reported having high immigration stress scores (Table 1). In the focus groups and interviews, fear of being deported when seeking care was a consistent topic among healthcare providers, women, and supporters. According to a healthcare professional: “I also think that when we have a change in our political world in administration, people are afraid to come in here. People are afraid we will turn them in or ICE (Immigration and Customs Enforcement) will be here and come get people.”

Medicaid Complexity and Lengthy Application Delay FTPNC

Most participants did not have healthcare coverage during pregnancy (Table 2). Those eligible for healthcare coverage through Medicaid reported that applying for the coverage was difficult and lengthy, which may delay FTPNC. A healthcare professional said: “So the waiting time for Medicaid and the waiting time for applying is one barrier, but another barrier is how to fill out the application. To whom ask for help? Years ago, you would only fill out an application to Medicaid of two pages. But now it is twenty and so pages.”

Friends, Family, and Social Media as Navigation Resources to Access FTPNC

Participants shared that learning where to access PNC was complicated. Participants tended to perceive the information as complex for multiple reasons, like being new to the city. A Participant in the women’s focus group reported: “I arrived here pregnant of four months, five months. And I had a very bad experience at the beginning because I did not know how the health system worked here. So, I was completely lost as to where to look for a gynecologist. I did not have a reference for somebody that could give me any advice or something from here.”

As a way to access prenatal care, participants learned where to go for FTPNC from family, friends, and social media referrals. In the words of a participant from the women’s focus group: “Like when I got here from my country, I did not know I was pregnant. So a girl, the wife of a cousin of mine, is a citizen here, and she told me that we had to go to that clinic because it was the best hospital for me to have my baby. Because she had her babies there, and so she took me there for care.”

The Cost of PNC, when Diagnosed with Gestational Diabetes, is a Challenge for PNCU

Gestational diabetes (GDM) was a relevant chronic disease for this sample (Table 2). Most participants reported that they had to pay out-of-pocket for PNC visits, exams, and delivery due to their healthcare coverage (Table 2). However, PNC costs seemed to be even more burdensome when they were diagnosed with GDM. Participants consistently reported that GDM diagnosis led to more visits and exams and, consequently, a higher cost of care, which they could not afford. A participant who had GDM said: “I asked them if there was any way or any program that could help me to pay. They gave me a discount. I believe it was $150 per ultrasound. But it is still a lot to pay every week.”

PNC Literacy Challenges PNCU

In this sample, 34 to 46% had inadequate functional health literacy (Table 1), and health insurance literacy was also an essential topic for participants. Multiple participants consistently said they struggled to understand private and public health insurance systems, coverage, and payment. Participants reported difficulties in understanding health insurance coverage during pregnancy. A participant from the women’s focus group shared: “They told me – you have an appointment with the gynecologist the next day, okay. When I got to the appointment, the staff said – did you bring the $80 copayment? And I replied – nobody told me anything. So, I think that they should, the person who is scheduling the appointment, say – hey, look, you have to bring this to the appointment. So we are prepared to pay.”

Focus group participants reported that they were unaware of what PNC consisted of and when to start it. In the words of a participant in the women’s focus group: “The truth, I believe, is that we are all lost about when to start prenatal care. And I think that the clinics/services or something should have, how do I say, more informative campaigns about it. Because if you ask twenty women, one will say a date, and the other will say something different. And what prenatal consists of that, we do not know for sure. There is no information, no information.”

Late Access to Gynecologists/Obstetricians Creates Mistrust for PNCU

Even though most participants had access to PNC through a hospital clinic (Table 1) throughout the interviews and focus groups, they consistently reported only having access to a gynecologist/obstetrician close to delivery. As a result, many perceived not seeing a gynecologist/obstetrician early in pregnancy as substandard PNC and discrimination.

Inadequate Interpretation Services Led to Misunderstanding, Mistrust, and Low PNCU

There were multiple reports that prenatal care information was misunderstood due to interpreters who were not proficient in Spanish. Supporters, in particular, felt intimidated to assist in language interpretation because of the specificity of medical terminology. Additionally, a shortage of interpreters was shared, which may cause longer waiting times for women observed in the surveys (Table 2). A participant from the women’s focus group said: “Once I had an interpreter, that, oh my gosh, when they said he was an interpreter…I understand a lot of English, but I do not speak English, but I understand, and I did not understand his Spanish translation, so I said no. My daughter, who is 22 years old, told me that there are many interpreters like that one. I told her – why didn’t you say that you could translate for me, mi hija (my daughter)? She replied – no, because what if I translate something wrong? This is very delicate. So, I said – oh well…”.

The Multiple Ways How Transportation is a Challenge to PNCU

Our surveys pointed out that about 17% of women perceived transportation as a barrier to FTPNC, and in the focus groups and interviews, transportation emerged consistently as an important barrier. First, not having public transportation readily available in the region was a challenge. In the words of a healthcare professional: “Transportation is huge. Recently we started doing taxi vouchers. There is no public transport, well there is in this county, but it is not very good at all, and I don’t even know where there is a bus stop around here, to be honest with you.”

Second, low English proficiency seemed to limit women’s ability to ask for directions even if they had access to public transportation. A participant from the women’s focus group shared: “How do I do? I said. Two blocks from here, there is a bus stop, they said. I have been living in the United States for 15 years, but I never took a bus, I said with my broken English.”

Third, many immigrants could not have a driver’s license due to their unauthorized immigration status. Both women and their supporters reported a perceived fear of getting a ride or driving without a driver’s license, getting pulled over or involved in a car accident, and consequently being deported. A participant from the women’s focus group confirmed the statement: “For me, yes, because I don’t have a driver’s license, and I am afraid to drive.”

Mental Health Distress as a Challenge to PNCU

Both women and supporters reported high levels of stress (Table 1). Domestic violence, stress, and anxiety also emerged as topics concerning mental health distress in the focus groups and interviews. According to a healthcare professional: “At least some women have some very distinct barriers: an abusive relationship or maybe a non-desired pregnancy. These are other circumstances.”

Spanish-Proficient Providers and Interpreters Develop Trust for PNCU

Participants reported they were more likely to engage in PNC visits when they had access to Spanish-proficient interpreters and providers than when they had who a provider who spoke “some” or no Spanish. According to a healthcare professional: “Because sometimes, I’ve gone in with someone, with a provider who speaks enough Spanish for basic prenatal appointments, and like that patient barely talks. And we’re just like – make sure the baby’s okay, say, the baby’s doing good, ¿algunas preguntas? (any questions?). The patient says no, and you’re on your way. So if you have the interpreter, she [the mom] is more likely to ask questions.”

Effective Nonverbal Communication and Communication Strategies to Facilitate PNCU

Women and supporters perceived good patient-provider communication as essential during prenatal care. However, focus group participants and healthcare providers had unique perspectives of what effective communication means. For the focus group participants, effective provider communication was perceived as more than verbal and included nonverbal communication such as facial expressions, gestures, eye contact, tone of voice, and empathetic posture. A participant from the supporter’s focus group said: “Feel special in the sense that they are listening to you, taking thirty minutes, listening to what you have to say, and not thinking about the other 100 things they have to check. This, for me, is priceless, and you can notice it. When you talk to him or her, you can see that they are not with you or when they are likeblah, blah, blah, next. You can notice it.”

On the other hand, healthcare providers perceived that patient-provider interaction was improved through communication strategies, such as repetition and teach-back, and observing patients’ non-verbal communication cues, such as body language. A healthcare professional stated: “Usually, you ask them – okay, so what did you understand about this discussion? Um, or, I mean, non-verbal cues as well. They’re giving you a look like – um, I’m not sure, or what are you saying to me? Eh, reword it. I think the best way is to kind of repeat what they understand back to you, and then, if, if they’re not. You can gauge if they understand it or not that way.”

Pregnancy Prevention Access and Education as a Motivator for PNCU

Women and supporters reported a desire to learn about different types of pregnancy prevention options while getting prenatal care. A participant from the supporter’s focus group said: “Um, so I ask you, can we have a procedure (tubal ligation) here? I am asking you that because I was chatting about it with other girls that are friends of mine… another day. Where can we have access to procedures (tubal ligation) here? Because my friends say they want to do it because we do not want to have even more babies.”

The education about the topic was reported as a motivation to engage in the care. In the focus groups, participants consistently reported learning about pregnancy prevention options only on the day of delivery, when it was too late to make a decision. Moreover, Participants in both focus groups and interviews reported fewer options available for pregnancy prevention methods when women did not have private insurance. A healthcare professional shared: “On the prenatal care side, umm, most of what we notice is umm access to contraception. So, somebody who does not have health insurance has some postpartum contraceptive options. Umm, but those are limited now. They can’t do the levonorgestrel implant. They used to be able to do that here. They have IUD (intrauterine device) access, but when they’re seen for their postpartum visit, they are included in a sort of waiting list to get an IUD. Whereas women who have insurance have the option to get an IUD placed even immediately after birth. They (insured women) can get any kind of contraception they want even before they leave the hospital.”

Discussion

The results of this study highlight challenges and facilitators for FTPNC and PNCU perceived by Latina women, their supporters, and healthcare professionals in a Midwestern urban area with a growing Latino immigrant community. Participants perceived PNC cost and lack of healthcare coverage were the main obstacles to access PNC. Our findings are consistent with a study conducted in California with a multi-race/ethnic cohort that reported the type of insurance (private vs. public) as a factor in early access to PNC. Those with public insurance may have delayed access to PNC (Baer et al., 2019). In the United States, eligibility for public insurance, Medicaid, requires that financial and immigration status criteria be met. Therefore, lawfully present immigrant pregnant individuals are eligible for public insurance. However, there is significant variation by the state since it is up to the states to remove or enforce the 5-year waiting period for immigrants to be eligible for Medicaid. Our study highlights the increased obstacles in access to PNC for Latina immigrants in states (Kansas and Missouri) that have the 5-year bar for legal permanent residents to access Medicaid, leaving many immigrants who are lawfully present without access to healthcare coverage (Derose et al., 2007). A study in Oregon demonstrated that providing PNC coverage for immigrants, regardless of immigration status, significantly improved healthcare use and pregnancy outcomes (Swartz et al., 2017). Moreover, a study that included 32 states in the US demonstrated that providing PNC coverage for immigrants is a cost-effective strategy that improves health outcomes and efficient use of Medicaid funds (Rodriguez et al., 2020).

Our study identified language proficiency as another critical limitation for Latina immigrants in the Midwest to FTPNC and PNCU. A study in the immigrant population of the Netherlands found similar results, where Dutch language proficiency was associated with late or very late access to PNC (Heetkamp et al., 2020). Not being proficient in a language impacts PNC access and the interaction between pregnant patients and their providers. The finding is consistent with a previous study that demonstrated, through a path model with pregnant women in the Midwest, that factors like cultural competency, provider interaction, perceived discrimination, and satisfaction predicted 30% of PNC decision-making (Evans & Sheu, 2019).

Some of the barriers identified by our participants could be addressed to improve PNC access and utilization. The use of technology, like social media and websites, and a pregnancy support system through family and friends as navigators appear to be potential solutions for this access and utilization obstacle. A feasibility study of a targeted digital media campaign with African American pregnant women in Florida reported that the digital campaign on multiple social media platforms improved knowledge of PNC and the impact of low birthweight health (Bonnevie et al., 2021). Developing programs to navigate PNC also may enhance PNC for Latina women. Evidence supporting this approach is a Community Health Worker Program (Safe Start) in Philadelphia, PA, which supports pregnant women navigating PNC to improve perinatal outcomes. The program demonstrated improved engagement in PNC, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays (Cunningham et al., 2020).

Patient-provider communication is another barrier that could be addressed by training providers on the roles of culture in communication (Hoff et al., 2004). The focus group participants gave examples of non-verbal cues that could be used to improve communication. Additionally, communication strategies, such as teach-back and think-pair-share, are strategies that have been shown to promote patient engagement in PNC (Krikorian Atkinson et al., 2021).

There are significant limitations to this study. First, this is a mixed-methods study, and as a limitation of qualitative methodology, our results may not be generalizable. Second, our sample is predominantly low-income and might not be applicable to other groups. Third, most participants were of Mexican heritage, which is consistent with the Latino population in the region of the study. While Mexicans and Mexican Americans represent most Latino communities in our area, Kansas/Missouri, the results observed may not translate to different Latino heritage groups.

Conclusions

Results from our study highlight important targets to improve PNC for midwestern Latina women, primarily immigrants. For example, financial challenges could be overcome through access to maternal healthcare coverage and support from women diagnosed with gestational diabetes. System capacity barriers could be addressed by hiring more healthcare providers for community centers proficient in languages other than English. Organizational challenges could be overcome by improving access to transportation and information in multiple languages. As well as training providers in patient communication based on culture and context; and on active learning techniques for patient engagement. Individual challenges may be addressed with access to social services and mental care for cases related to emotional health and immigration struggles. Finally, pregnancy prevention barriers could be overcome with early access, beginning of PNC, to information about pregnancy prevention resources and education. Based on this study’s findings, a potential intervention to target access to timely and consistent PNC for Latina women would be to train friends and family members as PNC navigators.

Significance.

Minoritized communities have historically low FTPNC and PNCU. However, access and use of PNC may be affected and improved by specific communities’ cultural, social, and patient-provider interactions within specific geographical areas. For a primarily immigrant Latino community living in a midwestern metropolitan area, FTPNC and PNCU were challenged by immigration status, lack of healthcare coverage, difficulty completing public healthcare coverage application, cost of PNC when diagnosed with gestational diabetes, PNC literacy, limited access to women’s health providers, inadequate interpretation services, transportation, and mental health distress. However, social support, connectedness, appropriate interpretation services, bilingual providers, empathetic nonverbal communication, spoken communication strategies delivered at the provider’s office, access to PNC, and pregnancy prevention education were considered facilitators to FTPNC and PNCU.

Acknowledgements

The authors would like to thank all participants in the study. The authors would also like to thank Juntos Center for Advancing Latino Health for helping to coordinate the study at community centers in Metro Kansas. Jay Doc Free Clinic, Johnson County Health Department, Wyandotte County Health Department, United Healthcare community outreach, University of Kansas Women’s Healthcare, and Uzazi Village for authorizing interviews. Least, but not last, our staff and collaborators: Ana Paula Cupertino, Ana Paulina Monroy, Andros Garcia Saldivar, Gonzalo Molina, Katia Arista, Nydia Marlene Smith, Norma Molina, Sarah Crawford, and Stephanie Horton.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publications of this article. Funding for the parent randomized clinical trial Assessment of Docosahexaenoic Acid On Reducing Early Preterm Birth (ADORE Trial) NICHD R01HD083292. Funding for this supplement study Finding Opportunities for Clinical Care and Trial Participation Among Underrepresented Samples (ADORE FOCUS) NICHD 3R01HD083292-02S1. Funding for JTC doctorate Brazilian National Council for Scientific and Technological Development (CNPq) – Science without borders (PICC 202992/2014-4), and Ringle Health Professions Scholarship – The University of Kansas Medical Center. The funders had no role in study design, data collection, data analysis, data interpretation, or manuscript writing.

Footnotes

Code Availability Not applicable.

Declarations

Conflict of Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publications of this article.

Ethics Approval Human Subjects approval was obtained from University of Kansas Medical Center, Kansas City.

Consent to Participate Informed consent was obtained from each participant.

Consent for publication Not applicable.

Data Availability

Not applicable.

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Associated Data

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Data Availability Statement

Not applicable.

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