1
Chapter 1: Introduction to the Study
Introduction
Health disparities are significant health challenges experienced by minority
pregnant women who are at a relative disadvantage in the United States. Minority
populations, including African Americans and non-White Hispanics or Latinos,
experience health disparities and adverse health outcomes when seeking access to health
care services (Kirzinger, Hamel, Muñana, & Brodie, 2018). Healthy People 2020 (2015)
reported that health disparities occur across many dimensions, including minority groups
and socioeconomic status (SES), disproportionately affecting mothers and infants, and
they emphasized that improving maternal and infant health outcomes is an essential
public health goal for the United States. Researchers have recognized that the potential
health benefits from health visiting practices of minority pregnant women are a facilitator
for promoting health and improving maternal and infant mortality and quality of life
(Cowley et al., 2015). Therefore, health visiting practices can provide from this lens the
health of the next generation and predict the future challenges of the public health of
women, infant, and the health care system.
Some subgroups in the United States are at a relative disadvantage and more
likely to experience barriers to health care access, receive less quality of care, and report
poorer health outcomes more often than other advantaged groups (Agency for Healthcare
Research and Quality [AHRQ], 2016). The AHRQ (2016) reported that approximately
25.8% of African Americans, 34.9% of non-White Hispanics or Latinos, and 35.5% of
the populations whose family incomes fall below the federal poverty level reported
2
barriers to accessing the health care system. These barriers to accessing health services
lead to unmet health care needs, delays in receiving appropriate care, and financial
burdens (Healthy People 2020, 2015). African Americans and non-White Hispanics or
Latinos receive worse health care than Whites do for 38% of all quality measures, and
individuals with lower income receive more inadequate care than do those with higher
income, defined by the AHRQ as family income four times the federal poverty level or
higher, for 62% of all quality measures. Also, current literature showed that minority
pregnant women are one of the medically underserved subgroups in the United States.
Like other disadvantaged subgroups, minority pregnant women experience lower SES
and are less likely to gain the timely use of personal health services or achieve the best
health outcomes (Docherty & Johnston, 2015; Gabbe et al., 2017). Similarly, the U.S.
Department of Health and Human Services (HHS) reported in April 2017 that, compared
with Whites, racial-ethnic minority populations were less likely to receive the preventive
care they need to remain healthy, less likely to gain access to quality health care, and
more likely to suffer from severe diseases and report poorer health outcomes (Robert
Wood Johnson Foundation [RWJF], 2018).
Evidence from research has shown that the implementation of an advanced
community-based prenatal support programs results in significant improvements in
maternal and infant health in disadvantaged neighborhoods at the local, state, and federal
levels (Docherty & Johnston, 2015; Gabbe et al., 2017; Ramsey & Mayes, 2018). These
support programs include PNC; evidenced-based education with specifically trained staff;
Children’s Health Insurance Program (CHIP); Medicaid and Medicare, and Supplemental
3
Nutrition Program for Women, Infants, and Children (WIC); and other resources to target
vulnerable and underserved populations. Evidence has suggested amid current healthcare
reforms and rising immigration minority groups are at a disproportionate risk of being
uninsured, lack access to care, have poor health status, and experience poorer health
outcomes. The impact of uninsured on healthcare costs was nearly $185 billion in 2017
(Garfield, Damico, & Orgera, 2018). Further, the financial burden of uninsurance is as
burdensome for uninsured individuals, with nearly 50% of personal bankruptcy filings
being a result of medical expenses (Consumer Financial Protection Bureau [CFPB],
2017; Hamel et al., 2016).
Covered in this chapter is the background, the problem statement, the purpose of
the study, the research questions (RQs), and the nature of the study. Additionally,
Andersen and Newman’s Framework of Health Services Utilization (ANFHSU) is the
theoretical foundation underpinning this study. Other areas highlighted in the remainder
of this chapter include the nature of the study, definitions of key terms, assumptions,
scope and delimitations, limitations, and significance.
Background to the Study
Less literature has given focus or voice to minority pregnant women’s perception
of health disparity and health-related outcomes. Health disparity has been a longstanding
issue in the United States mainly affecting racial/ethnic minorities and individuals of low
SES. Coordinated efforts to address health disparities and achieve equity for all began in
the 1990s with the publication of Healthy People 2020 initiatives (Douthit, Kiv,
Dwolatzky, & Biswas, 2015). Twenty-eight years later, health disparities are even more
4
complicated and remain an elusive victory facing arguably the most robust economy in
the world, the United States. Other notable efforts to reduce health disparities involved
the Institute of Medicine (IOM) 2002 report titled “Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care,” following the 1991 congressional request
(IOM, 2002). The IOM report emphasized evidence of discrimination, exclusion,
prejudice, and stereotyping by health care providers (HCPs) as contributing to disparities
in care (IOM, 2002).
This definition of health disparity by IOM (2002) provided more clarity and yet
alarming attention:
racial and ethnic disparities in health care exist even when insurance status,
income, age, and severity of conditions are comparable, and because death rates
from cancer, heart disease, and diabetes are significantly higher in racial and
ethnic minorities than in whites, these disparities are unacceptable. (p. 666)
Healthy People 2020 (2014) defines health disparity as
the difference in health because of the economic disadvantage including the lack
of resources and opportunities that adversely affect groups of people based on
their racial or ethnic group, SES and or geographic location and the subsequent
inability to afford goods, services, and influence, or other “characteristics
historically linked to discrimination or exclusion.” (p. 1)
These differences in health care occur in the broader context of historical and
current social and economic inequality which is often a prevalent racial-ethnic
discrimination of American life (IOM, 2002). Research literature has shown persistent
5
and well-documented disparities in maternal–child health outcomes among childbearing
women of low SES, women of color, adolescent women, and rural women and a parsed
view showed that the social and economic toll of ill health among women and children is
notably costly (Bloom, 2011; Smith, 2015). Moreover, racial/ethnic minority
childbearing women experience cultural and interpersonal barriers when accessing
services due to the hierarchical social structures resulting in the power dynamics of the
patient-provider interaction (Zimmermann, Carnahan, Paulsey, & Molina, n.d.), resulting
in inadequate care and less favorable outcomes for these women (Centers for Disease
Control and Prevention [CDC] (2013).
There are structural measures of the presence or absence of specific resources that
facilitate health care for racial/ethnic pregnant women, such as having health insurance or
continued care, easy access to care, and the successful outcome received from much-
needed services. Hall, Dalton, and Johnson (2014) research revealed that the poor and
unequal reproductive health outcomes in the United States reflect the inadequate and
differential delivery because of limited service use seen among low-income, unemployed,
or uninsured women and women with less educational attainment than younger and more
socioeconomically advantaged women. Beckham, Urrutia, Sahadeo, Corbie-Smith, and
Nicholson’s (2015) research showed that socioecological conditions interfered with low-
income, minority women’s capacity to engage in health-seeking behaviors postpartum.
Moreover, when there is clinical uncertainty from the HCPs, these inequalities may
contribute to racial-ethnic disparities (Chapman, Kaatz, & Carnes, 2013; IOM, 2002).
6
These factors have been detrimental to equally gain equitable care and successful
outcomes for marginalized women.
Population health outcome indicators measure health care, health status, and
quality of life (Health People 2020, 2015; World Health Organization [WHO], 2015).
Improving health outcomes has been a top priority for health agencies and health research
organizations (AHRQ, 2016; CDC, 2014; Healthy People 2020, 2014; WHO, 2015).
Racial-ethnic minority status and socioeconomic factors are inarguably salient
contributors to health disparities in minority pregnant women with limited health
resources. These factors include sex, age, lack of healthcare, unemployment, and
geographic location (Healthy People 2020, 2015). Lack of health care resources is a
significant factor in how minorities and socioeconomic factors influence health
disparities and health-related outcomes (Docherty & Johnston, 2015) toward successful
receipt of health services. Unless there is adequate access to health care resources and
transparency in underserved subgroups, the existence of these programs may not help
promote equitable access and use toward successful outcomes.
Amidst the progress in policy and program interventions aimed at improving
health care service at the local state and federal levels, not all are benefiting equally
because of overarching factors such as SES or racial-ethnic designation preventing
successful health outcome in reflecting the policy-driven and health-related objectives
(Healthy People 2020, 2014). Addressing language and geographic barriers and
increasing access to insurance are part of the coordinated efforts required to not just
address but to reduce health disparities. Health disparities are a barrier to high-quality
7
care in that, at all levels when seeking care, more impoverished individuals are less likely
to seek preventive care and adhere to national screening and treatment guidelines (CDC,
2014). Gabbe et al. (2017) found that that first-time pregnancies and first-time clinic
users demonstrated challenges in navigating the health care system and showed a strong
association with delayed PNC and late pregnancy recognition. For minority pregnant
women, having health care resources available and targeted to their needs at all stages of
pregnancy is the intended outcome to avoid mortality of the mother and infant. Health
disparities and variations in access to care experienced by minority pregnant women
include (a) perinatal services, (b) prenatal and postnatal services, (c) newborn screening,
(d) nutrition and breastfeeding access to antenatal and postnatal care, (e) hospital
maternity beds postpartum, (f) insurance, and (g) well-baby visits.
There is existing literature on health disparities reflecting the inadequate and
differential delivery in access, use, and health-related outcomes (Hall et al., 2014;
Liddell, Burnette, Roh, & Lee, 2018). Researchers have argued that contributing factors
such as race, ethnicity, SES, geographic location, and poverty are key causes of structural
and systemic indifferences (Cowley et al., 2015; Zimmermann et al., n.d.). The key to
removing health disparity and increasing successful health-related outcomes is obtaining
health care services, hence the importance of the presence of specific resources that
facilitate health care, including timely use of personal health services, attaining good
access to care, finding providers who meet their needs, and continuing care (Guerra-
Reyes & Hamilton, 2017; Selchau et al., 2017). Findings from Guerra-Reyes &
Hamilton; Selchau et al study suggests that with the rising diversity and the projected
8
growing immigration, there needs to be rigid advocacy for vulnerable populations and
those less likely to access or use health care (Docherty & Johnston, 2015).
This qualitative, narrative descriptive study potentially provides a thorough
understanding of minority pregnant women’s unique experiences related to health
disparity and health outcome (Smith, 2014) and barriers to accessing health care from the
individual’s point of view. The results of this study may influence positive social change
by providing valuable insights about minority pregnant women’s perspectives about their
experiences of health disparities (Kennard, 2016), thus supporting their achievement in
navigating the health care system to prevent delayed treatment and gaps in care. Minority
pregnant women might be able to access the timely use of personal health services, attain
good access to care and ongoing care, and find providers who meet their needs, which
might reduce the health disparity gap (Vardeman-Winter, 2017).
Problem Statement
The United States benefits when everyone in the country is afforded the
opportunity to live a long, healthy, and productive life, yet health disparities persist. For
this to happen, the United States health care system needs interventions aimed at closing
the health disparity gap. Evidence from the literature has shown that early-life
interventions significantly influence health outcomes as adults, suggesting there is a need
to implement effective policy and program interventions to target early-development
health challenges (Bullock, 2015; Shonkoff, 2014). The central role of Healthy People
2020 is to ensure everyone is afforded the equal opportunity to be healthy regardless of
their racial-ethnic background. The AHRQ (2016), Healthy People 2020 (2014), and
9
WHO (2014) support the growing discourse surrounding early-development interventions
which strongly influence the health outcomes of the adult population. The AHRQ and
Healthy People 2020, not surprisingly, have highlighted the need for improvement in
health disparity and health-related outcomes.
Research has shown that there are persistent health disparities among minority
subgroups (Cowley et al., 2015). There are differences in health because of the economic
disadvantage, including the lack of resources and opportunities, that adversely affect
groups of people based on their racial-ethnic identity, SES, and/or geographic location,
which is historically linked to discrimination or exclusion (Healthy People 2020, 2014)
and is responsible for contributing to poor health outcomes. The Kaiser Family
Foundation (KFF; 2018) explained that the uninsured rates among the non-elderly
population are 8.4%, and 2.9% among children, which accounts for 11% of Blacks, 18%
of Hispanics, and 7% of Asians as of 2017 (Kirzinger et al., 2018), which contributes to
widening the health disparity gap. Health disparities may underlie adverse outcomes for
minority pregnant women and infants. When health disparity affects pregnant women, it
creates distresses that may be compounded by existing family difficulties of being a new
or single mother of color who is also uninsured or unemployed, resulting in more
significant conflict and increased risk for adverse physical and psychosocial outcomes
(Martinez, Chandra, Febo-Vazquez, & Mosher, 2013). However, the United States has
yet to devise equal opportunity access to quality health care systems strategically focused
on targeting communities at highest risk. Many health concerns disproportionately affect
10
the minority population such as infant mortality and mental health (Center for Disease
Control and Prevention, 2014).
Evidence from research has revealed that African American women are
marginalized in multiple domains of life and live in a context of reproductive
disadvantage leading to racial inequalities in health (Beckham et al., 2015; Guerra-Reyes
& Hamilton, 2017; Liddell et al., 2018). In another article on health disparity among
minority pregnant women, Zimmermann et al. (n.d.) discussed some of that evidence
experienced by marginalized groups. Second, socioeconomic disadvantage has exposed
how unique challenges interfered with low-income, minority women’s capacity to engage
in health-seeking behaviors and health service use across the reproductive life course
(Scherman, Tolosa, & McEvoy, 2018). The right to health quality indicates shared
responsibility to be healthy not only in medical care but in health-promoting physical and
social environments in homes, community, and workplace. Findings from the
abovementioned research support the claim that health disparity exists and the need for
additional research into understanding how to mitigate the disparity. Hence, this study
helped fill a gap in the research by focusing specifically on the examination of self-rated
health disparities and health-related outcomes by first-time use of a clinic among
pregnant minority women, which cannot be fulfilled unless there is improved access
linking coordinated resources to comprehensive care regardless of ability to pay.
Purpose of the Study
The purpose of this study is to identify (a) what SES, provider’s perception of
their race-ethnicity, knowledge, and care-seeking factors influenced first-time pregnant
11
minority women’s access and use of health care, and (b) what first-time pregnancy health
disparity may be unique to this population. Minority childbearing women experiencing
their first pregnancy face a unique set of challenges as they navigate the health care
system without resources, with little or no insurance, resulting in health disparities and
uncertain health outcomes to avoid adverse pregnancy outcomes. To address this gap, for
this study I used a qualitative paradigm, conducting interviews to develop an
understanding of minority pregnant women’s perspectives on their unique challenges in
accessing health care.
Research Questions
Narrative descriptive studies subsume a group of approaches that rely on the
spoken words or visual representation of participants. These approaches typically focus
on the lesson learned from the experiences of individuals as told through their own
stories. Narrative approaches are considered real-world measures when real-life problems
are investigated. Narrative research is guided by the validation of the audience (Creswell,
2009). Narrative description facilitates the identification of events directly from the
context of and lessons experienced by these women (see Creswell, 2009). With these
constructs in mind, I framed three narrative descriptive study questions. These RQs were
used to obtain the responses needed to identify (a) what SES, provider’s perception of
their race-ethnicity, knowledge, and care-seeking factors influenced first time pregnant
minority women’s access and use of health care, and (b) what first time pregnancy health
disparity may be unique to this population.
12
RQ1: How do the experiences of women, minority and underserved, of
childbearing age, as they seek health care, affect their ability to achieve positive
pregnancy outcomes (defined as term vaginal delivery, appropriate birth weight for infant
and pregnancy weights for mother, and to avoid postpartum depression and infant
mortality)?
RQ2: What are the self-reported health disparities in first-time pregnant minority
women as they seek health care for the first time?
RQ3: How have the experiences of health disparity affected the health-related
outcomes in first-time pregnant minority women as they sought health care for the first
time?
Theoretical Framework
The theoretical underpinning for my study was the ANFHSU (Andersen, 1968).
Andersen developed the original model in 1968 and extended it through numerous
iterations to adopt health outcomes. Andersen developed the model to (a) to facilitate the
understanding of why individuals use health services, (b) describe and measure equitable
access to health care, and (c) contribute to the development of policy interventions for
promoting equal access to health care, thus suggesting the need to explore factors that
enable or inhibit access to health care. In this model, the use of health services is
determined by three dynamics which are predisposing factors, enabling factors, and
perceived and actual need (Andersen, 1968).
The ANFHSU has been used extensively in numerous studies to investigate the
use of health services (Babitsch, Gohl, & von Lengerke, 2012) and was the most
13
appropriate choice for this study. The ANFHSU is not only relevant to my study, but it is
the most commonly used framework for studies focused on obtaining the individual’s
perception of their experiences as they access and use health care services (Aday &
Andersen, 1974; Han & Redlich, 2018). In this study, I sought to understand health
disparity and health outcomes experienced by minority pregnant women.
Nature of the Study
The nature of my study used a qualitative approach. Qualitative research is
consistent with understanding health disparity and health-related outcomes experienced
by minority pregnant women (Smith, 2014) and the unique barriers and challenges to
accessing care. Keeping the focus on how health disparity and health behaviors in
minority pregnant women exist is relevant to the ANFHSU. The results of my study may
provide findings that will help understand health disparity from pregnant minority
women experiencing the disparities, using qualitative narrative descriptive methods to
address the local patterns of health care that are provided to these women. Narrative
description is recommended because it facilitates the identification of events directly
from the context of and lessons experienced by these women. A narrative descriptive
approach includes in-depth interviews and journaling, which was optimal for collecting
data on pregnant minority women personal histories, perspectives, and experiences, and
when sensitive topics are being explored. It is also ethical to allow participants to review
their data and the interpretations and offer their views regarding them (Creswell, 2009),
allowing them “an opportunity to provide context and an alternative interpretation”
14
(Patton, 2002, p. 561) and adding their own perspectives to provide insight into their
motivations which addressed the issues of quality and rigor.
I used purposive selection to ensure study participants included only pregnant
Black/African Americans or non-White Hispanics or Latinos who experienced the
phenomenon of health disparities when seeking health care and are willing to articulate
their unique experiences to participate in the study. I collected data through one-on-one,
face-to-face interviews conducted in a private room to ensure privacy and confidentiality
of each study participant. Face-to-face interviews allowed direct interaction to explore
experiences, perception, and perspectives of participants, which established the
foundation for understanding the phenomenon under study through the lens of each
participant, as emphasized by (Patton, 2002).
I used Braun and Clarke’s (2006) six-phase guide thematic analysis technique as
used by (Beng et al., 2014) and explained by Braun and Clarke, to become familiar with
the data, generate initial codes, search for themes, review themes, define themes, and
write-up the data collected. I used NVivo, a computer-assisted qualitative data analysis
software (CAQDAS) system for organizing and storing the data collected and aid the
analysis process (Woods, Paulus, Atkins, & Macklin, 2016). Braun and Clarke’s six-
phase guide thematic analysis technique allowed me to produce an exhaustive description
of the phenomenon under inquiry.
Definitions
In this section, I define the meaning of recurrent key terms and phrases used in
this study.
15
Health care access: Healthy People 2020 (2014) argued that access to
comprehensive and quality health care services means achieving equitable health care
services to preserve or improve health for populations health outcomes. Measuring health
care access encompasses three key components including coverage, services, and
timeliness. In my study, access to health care refers to the timely use of personal health
service and visiting practices to achieve the best health outcomes.
Health disparities: Health disparities have been used in multiple contexts; there is
consensus on the meaning. Although the term health care is often used to define racial-
ethnic minority disparities (Healthy People 2020, 2015), in my study, health disparities
refer to the definition by the National Institutes of Health (NIH, 2015) stating, “Health
Disparities are gaps in quality of health and health care that mirror differences in SES,
racial and ethnic background, and education level” (p. 1). Also, NIH added that the
differences in health occur because of the economic disadvantage including the lack of
resources and opportunities experienced by minorities or racial-ethnic disadvantage
groups.
Maternal, infant, and child health: Maternal health encompasses the health care
dimension of women of childbearing age from pre-pregnancy, during pregnancy, labor
and delivery, and the postpregnancy period and infant and child health. The WHO (2015)
referred to maternal health as the health of women during pregnancy, delivery, and the
postdelivery period, whereas infant health refers to infant health and infant care,
including promoting infant health before birth, newborn screening, basics of infant
health, feeding, and immunization (WHO, 2015). Child health refers to physical, mental
16
and emotional well-being in the absence of disease (WHO, 2015). Healthy People 2020
(2015) explains that the well-being of mothers, infants, and children determines the
health of the next generation and helps to predict public health challenges in the future
for families, communities, and the health care system. Moreover, healthy birth outcomes
can identify early treatment of health conditions among infants, prevent mortality and
ensures children reach their full potential.
Minorities or minority population: The terms minorities and minority populations
are used interchangeably to represent the vulnerable, disadvantaged, and underserved
populations. In my study, minorities refer to populations living in the United States with
inadequate access to health care services and barriers to receiving essential care and
receive lower-quality treatments compared to members of a privileged social group. The
HHS states explicitly that self-identifying or the designation as a minority include one or
more attributes such as living at or below the poverty level; being uninsured; has a
language barrier; has knowledge deficit of the health care system, difficulty accessing
health care, and/or provider perceived unmet needs (RWJF, 2018).
Socioeconomic status: SES is the combined measure of the economic,
sociological, and work experience of the person, individual, or family in relation to
others. The CDC (2014) stated that SES is a broad concept that includes economic, social
position, and work measured by wealth, education, and income respectively. In my study,
SES refers to the measurement of an individual’s economic and social position in relation
to others based on income, occupation, geographic location, education, and access to
care. SES groups can be grouped into three categories such as the upper, lower, and
17
middle class (Markus & Conner, 2013). My study focused on the lower social level of the
socioeconomic hierarchy. In the next section, I highlight assumptions which form the
foundation of my study.
Assumptions
Underlying my study was the assumption that the availability of scientific
evidence about health disparities experienced by pregnant minority women in the United
States would enable the understanding of maternal and neonatal-life health needs and
health outcomes of this population. I assumed that study participants voluntarily would
share their unique experiences of health disparities as they seek health care through
providing honest answers to all interview questions. Another assumption was that the
available literature on the phenomenon being investigated could help inform policy and
the implementation of effective program interventions to confront the root causes of
health disparities, particularly socioeconomic inequalities. If these interventions were
effective, they would improve equity in health care access and use, which would result in
tremendous improvements in the health and well-being and quality of life for all
Americans. I also assumed that the knowledge deficit of the nature and outcome of
barriers to access essential health care was a result of poor health outcomes among
minority pregnant women.
Many available kinds of literature have supported the overwhelming findings that
programs supporting family planning and maternal health helped to reduce poor health
outcomes for mother and infant (Black et al., 2017; Creanga et al., 2014; Johnson et al.,
2006; S. Lee et al., 2016). I assume that disseminating the findings from my study would
18
highlight the areas of urgency and health disparities for the pregnant minority women
more transparent to prioritize the government’s policy agenda. In creating this awareness,
HCPs at the forefront of policymaking and policymakers would not only address the
urgency but advance the agenda of health disparities. My study is assumed to be in line
with United States health agencies agenda and national priority in reducing health
disparities in essential health care access to promote quality health among individuals,
groups, communities, and populations in the United States.
These assumptions were necessary to facilitate how I saw the population I
explored and what I hope would happen as a result of my study. The main reason I did
this study was to fill the gap in the literature related to the minority pregnant women’s
perception of health disparity and inequality. Many available kinds of literature have
contributed and supported the overwhelming findings that programs supporting family
planning and maternal health help to reduce poor health outcomes for the mother and
infant.
Scope and Delimitations
My study was limited to understanding the details of health care access
experienced by minority pregnant women in the United States. The focus of my study
advanced from findings indicating that minority pregnant women were one of the
medically underserved populations in the United States. Regardless of growing efforts to
address health disparities among different subgroup populations in the United States,
study findings have indicated that minority pregnant women experience more challenges
in accessing ongoing health care and report poorer health outcomes compared to those in
19
more privileged social status (Caldwell et al., 2016; J. Chen, Vargas-Bustamante,
Mortensen, & Ortega, 2016). In my search of the literature, I found no qualitative study
focused on understanding first-time pregnant minority women accessing health care for
the first time. The lack of details about first-time health care access experienced by first-
time pregnant minority women in available literature was the primary rationale for my
study.
My study was conducted in a large metropolitan area (MA) in the Northeast
region of the United States, one of the largest in MA and one of the most populous areas
for minorities (World Population Review, 2018). The U.S. Census Bureau (2017) has
shown since 2018, the population of MA is estimated at 622,000, and the racial and
ethnic breakdown of the city include Blacks at 63.7% and Hispanics, Latinos, or Spanish
of any race at 4.2%. I do not live in this area or interact with the population which is the
focus of my study. I included self-identified Blacks/African Americans and non-White
Hispanics or Latinos who are first-time pregnant women and first-time accessing health
care. Focusing my study on first-time pregnant Black and non-White Hispanic or Latino
women who are also first-time accessing health care excludes other racial-ethnic pregnant
women and multiparity women.
The screening process for participants in my study excluded mothers, other racial-
ethnic pregnant women, or other illegal or undocumented pregnant women. My rationale
for the exclusion is keeping in line with the population focus of my study and that
multiparity women may be intensely emotional and may not respond accurately or
comfortably from their recollection. Furthermore, eliciting information from pregnant
20
undocumented women in the United States could jeopardize those who may be visitors
who overstayed, and excluding this population ensured that all participants included in
my study are eligible for care. Understandably, the exclusion is necessary to ensure it
would not undermine my study.
Another illustration is to avoid acculturation on the area being studied of health
disparities in first-time pregnant minority women seeking health care for the first time.
The purpose of my research was to understand that minority women experiencing their
first pregnancy face a unique set of challenges in navigating the health care system
without adequate resources. Therefore, it was assumed that including acculturated first-
time pregnant minority women in my study could undermine the potential to understand
the experience of health disparity by first-time health care seekers.
The characteristics of the recruited participants I used in my narrative descriptive
study might be challenging for transferability to other settings or similar groups or
populations. The participants were from the northeast area MA, a state that has offered
health and supplemental insurance and has included the Affordable Care Act (ACA)
since 2010. Findings from my study may not be transferable to first-time pregnant
minority women or in other states with different insurance policies or states that did not
adopt the ACA. Furthermore, from a cultural standpoint, health-seeking behaviors may
differ between cultures and may not inform the general population of first-time pregnant
minority women experiences of health disparity when seeking health care for the first
time across communities in the United States.
21
Limitations
Limitation from the study may include the recruiting of participant criteria of my
narrative descriptive study. Study participants purposively selected may not represent
adequately the general experience of health disparities seeking health care for the first
time among first-time pregnant minority women in the United States. My central role in
the recruiting selection and being the primary study instrument may become a problem
for biases or distortion of research outcomes in my study. However, considering the
implications of the potential problems of biases in my qualitative research, I used
reflexivity and reflexive journal as one effort to address the potential distortions or
preconceptions I might unwittingly introduce into my qualitative designs. Reflexivity is a
significant concept directed at the greatest underlying threat to the trustworthiness of
qualitative research outcomes (Patton, 2002), specifically, the social interaction
component of the interviewer-interviewee relationship. Therefore, to understand my role
as the interviewer and the interview context to establish trustworthiness, utilizing the
technique of “mutual collaboration” helped enhance transparency and accountability
(Shelton, Smith, & Mort, 2014).
Significance of the Study
This qualitative study is essential because it filled a gap in understanding by
focusing specifically on health disparities and health outcomes from the perspectives of
first-time pregnant minority women and their first time accessing a clinic in an urban
neighborhood. My project is unique in that it addressed an under-researched area, views
from the women themselves, surrounding their unique experiences related to health care
22
access, health disparity, and barriers to care related to socioeconomic factors and
minority groups (see Ganle, 2016; Vardeman-Winter, 2017). The results of my study may
provide valuable insights about minority childbearing pregnant women’s perspectives
about their experiences of health disparities (Kennard, 2016), thus supporting their
achievement in navigating the health care system to prevent delayed treatment and gaps
in care. These potential findings could foster positive change in nursing practice. As a
practice discipline, nursing may benefit from this research because it could provide
nurses with insight into some of the barriers these women face in accessing and
navigating healthcare and healthcare services. Being able to create care environments that
welcome pregnant women and encourage them to ask questions and share their concerns
could increase the patient’s compliance with their treatment plan because they perceive
they are a part of the team. Looking at the study findings from new perspectives could
lead to positive social change beyond nursing.
Walden University defines positive social change as, “a deliberate process of
creating and applying ideas, strategies, and actions to promote the worth, dignity, and
development of individuals, communities, organizations, institutions, cultures, and
societies” (About Us, para 1, 2018). Identifying the perspectives of women experiencing
health disparities related to socioeconomic factors and ethnicity/race could engage
women to partner in their development of their own health and that of their unborn child.
Their ideas and approaches to accessing healthcare under difficult circumstances could
help providers mitigate factors that create those difficulties as well as to develop services
that foster more accessible navigation of those services. Facilitating the developing
23
family’s access to healthcare and information could benefit communities by enabling the
family members to become more engaged and involved in their local communities.
Growing communities depend on their citizens for stability and growth that is fostered by
healthy citizens, involved organizations, and diverse perspectives.
Summary
Health disparities are the difference in health because of the economic
disadvantage including the lack of resources and opportunities that adversely affect
groups of people (Semega, Fontenot, & Kollar, 2017), such as pregnant minority women,
SES and/or geographic location. Minority pregnant women are one of the medically
underserved populations in the United States (Cohen, Zammitti, & Martinez, 2017).
Women from racial-ethnic minority groups and low-income communities have limited
and fragmented access to quality maternity care services and experience disparities in
access and adverse outcomes of maternity care in the United States. Although there are
policy interventions at the local, state, and national levels to mitigate health disparities,
research has indicated evidence of persistent challenges in disparities in health care
access and health-related outcomes between minority pregnant women than more
privileged pregnant women (Bloom, 2011).
This narrative descriptive study provided study participants with an opportunity to
identify events directly from the context of and lessons experienced when seeking access
to PNC. Chapter 1 provided a synopsis and background of the challenges of health
disparities, the problem statement, the purpose of the study, the nature of the study, and
the RQs. Additionally, Chapter 1 emphasized how the ANFHSU underpined this study of
24
the events from their experiences and lessons learned from the challenges of health
disparities. Finally, recurrent key terms were defined followed by the scope of the study,
assumptions, limitations and delimitations, and the significance.
In Chapter 2, provided additional detail from the literature to support why this
study was needed, what we currently know, how we have usually explored the area of
health disparities empirically, and why narrative descriptive design is an effective
approach to understanding this area. I also describe the research that has used the
ANFHSU to illustrate its utility in framing my RQs. Chapter 3 presented details of the
chosen methodology for my study, Chapter 4 presented the results of my study, and in
Chapter 5, I discussed the findings of my study and provided conclusions and
recommendations.
25
Chapter 2: Literature Review
Introduction
Health care access disparities are among the primary health challenges
experienced by minority pregnant women in the United States. Minority groups including
Black/African Americans and non-White Hispanics/Latinos experience worse health
outcomes attributed to health disparities when seeking health care services in the United
States (Parekh, Jarlenski, & Kelley, 2018; Roman et al., 2017; Sacks, Greene, Burke, &
Owen, 2015). Policy interventions noted by researchers (Lorch, 2017; Meghea, Raffo,
VanderMeulen, & Roman, 2014; Roman et al, 2009; Tschudy, Toomey, & Cheng, 2013)
are implemented to mitigate disparities related to health care focused on the highest risks
and social determinants of health (SDH), specifically SES (Durkin et al., 2015; Kothari,
Romph, Bautista & Lenz, 2017). Studies remain sparse on the effect of health disparities
and health outcomes on first-time pregnant minority women seeking health care services
for the first time, such as Black/African Americans and non-White Hispanics or Latinos.
Minority populations, such as Black/African American and Hispanic American women,
face unique social and cultural stressors that are different than those faced by their
privileged counterparts, and these differences have significant consequences for the
physical and mental health of pregnant women which contribute to the burden of
perinatal health inequalities (D’Anna-Hernandez & Rivera, 2014).
Black/African Americans’ and Hispanic/Latino Americans’ poor health outcomes
are attributed mainly to this population’s lower SES (Durkin et al., 2015; Kothari et al.,
2017). Also, few researchers have explored the health needs among first-time pregnant
26
minority women focusing on opportunities for access to reliable information and
opportunities for essential perinatal care. Lack of relevant literature challenges efforts to
advance effective, evidence-based policy to facilitate care access tailored to meet the
health needs among low-income pregnant women.
Minority Americans experience harsher health circumstances and disparities in
access to care compared to privileged Americans. Racial/ethnic diversity in this country
is increasing, and an estimation by the U.S. Census Bureau (2015) reports that by 2045
the minorities will represent 51% of the United States population. There is an urgent need
to address how barriers to quality health care influence short- and long-term effects for
pregnant minority women, such as stressors, depression, morbidity, and mortality. Delays
and gaps in essential health care needs adversely affect health outcomes and are linked to
self-reported physical stressors and psychological states (Berkowitz, Traore, Singer, &
Atlas, 2015), and a strong need to recognize health challenges experienced by pregnant
minority women and health risks of the unborn infant exists.
Current research on health care disparities has indicated that inequalities refer to
differences in access and utilization of healthcare services, especially the quality of
services provided among population groups (Boslaugh, 2019). These include
Black/African Americans and Hispanic/Latino Americans who are less likely than White
Americans to have a reliable source of health care. The IOM report, in 2002, found that
ethnic disparities in health care grossly affect members of minority groups in the United
States who tend to receive lower quality care than non-minorities. The IOM reports
further suggested that these inequalities were rooted in social and cultural factors such as
27
stereotypes, language and geographic barriers, and attitudes toward the healthcare system
(Barr, 2014; Boslaugh, 2019; LaVeist & Isaac, 2013). Particularly, Boslaugh (2019) notes
that more indigent children are less likely than higher-income children to visit a dentist
annually. There is a strong need for comprehensive health policy interventions tailored to
satisfy the complex health care needs of minority population exists.
Although previous researchers examined the health outcomes of minority women
in the United States, most of have been on larger ethnic populations such as non-Hispanic
Whites, Asians, and Europeans, but less on Black/African American and Hispanic/Latino
American pregnant women. A gap exists in knowledge focusing specifically on the
examination of self-reported health disparities and health-related outcomes by first-time
use of prenatal services among first-time pregnant minority women. Despite the growing
number of children born to Black/African Americans and Hispanic/Latino Americans, no
consistent research reflects understanding minority pregnant women experiences when
seeking PNC. Although there is an acute awareness of the effect of early-age
development on the adult population health outcomes (Bullock, 2015; Campbell et al.,
2014; Shonkoff, 2014; WHO, 2015), little consideration is applied to the efficacy of
researching minority pregnant women. In my review of the literature, I have not found
one study that specifically addressed first-time pregnant minority women’s perspective
on their experiences of health disparity seeking PNC services for the first time. The
absence of adequate science-based evidence about first-time pregnant minority women’s
unfulfilled health care needs generates a gap in developing and implementing actual
policy interventions to fulfill these requirements. This narrative descriptive study allowed
28
me to gather necessary data about health disparities in accessing health care experienced
by minority pregnant women to close the knowledge gap.
The purpose of this narrative descriptive qualitative study is to (a) identify what
SES, provider’s perception of their race-ethnicity, knowledge and care-seeking factors
influenced first time pregnant minority women’s access and use of health care, (b)
discover what first-time pregnancy health disparity may be unique to this population, and
(c) learn how health disparities affect the overall experience and perceptions of first-time
pregnant minority women toward seeking health care services for the first time. The
detailed description of health disparity from childbearing women experiencing the
disparities augments the current literature gap on the topic. The results of my study may
provide findings that will help understand health disparity from minority pregnant
women experiencing the disparities to address the local patterns of health care that are
afforded to these women. Such an understanding could facilitate the development and
implementation of evidence-based and sustainable policy interventions tailored to meet
the needs of the study participants. Hence, this research could enhance positive social
change and improve the health outcomes of minority pregnant women and their
offspring.
This literature review drew on major studies surrounding health disparities,
health-related outcomes, and minority pregnant women in the United States. Studies have
indicated ongoing challenges in health care access in the United States, mainly among
minority groups (Borders et al., 2015; Scherman et al., 2018), and the adverse effects
health disparities have on their offspring when compared with their non-minority
29
counterparts (Durkin et al., 2015; Kothari et al., 2017; Nurius & Logan-Green, 2012).
The frequently reported health disparities in the review of the literature in my study
include (a) prenatal and postnatal; (b) breastfeeding; (c) nutrition and breastfeeding
prenatal, perinatal and postnatal; (d) weight gain during pregnancy; (e) well-
baby/postpartum check-up; and (f) insured (Caldwell et al., 2016; Lorch & Enlow, 2016;
Taylor & Nies, 2013). Health disparities were reported in minority pregnant women
outcomes, such as differences in maternal and infant mortalities based on racial-ethnic
and income status and among minority and non-minority newborn (Creanga et al., 2014;
S. Lee et al, 2015; Lu, Highsmith, de la Cruz, & Atrash, 2015; Semega et al., 2017). I
gave particular attention to demonstrating the current disparities in health and health care
access among different subgroups, as well as the urgent need to address these disparities,
regardless of ability to pay.
First, evidence from research reveals that Black/African American women are
marginalized in multiple domains of life and live in a context of reproductive
disadvantage leading to racial inequalities in health (Beckham et al., 2015; Guerra-Reyes
& Hamilton, 2017; Liddell et al., 2018). Another article showing health disparity among
racial-ethnic childbearing women (Zimmermann et al., n.d.) discussed some of that
evidence experienced by marginalized groups. Second, socioeconomic disadvantage
exposed how unique challenges interfered with low-income, minority women’s capacity
to engage in health-seeking behaviors and health service use across the reproductive life
course (Scherman et al., 2018). The right to health quality indicates shared responsibility
to be healthy not only in medical care but in health-promoting physical and social
30
environments in homes, community, and workplace. To fill a gap in the literature by
focusing specifically on the examination of self-rated health disparities, I explored the
health-related outcomes of first-time use of a clinic among minority pregnant women.
Findings from the research support the overwhelming evidence that health
disparity exists within minority groups, yet fewer studies have focused on first-time
health-seeking behaviors and health-related outcomes by first-time pregnant minority
women. Thus far, no single study explored health disparity for first-time pregnant
minority women as they seek health care services for the first time. Also, studies have
indicated that socioeconomic disadvantage among minority pregnant women becomes
challenges influencing poorer health outcomes across the reproductive life course
(Beckham et al., 2015; Scherman et al., 2018).
Literature Search Strategy
I searched, collected, and reviewed literature published within 5 years of the
completion of this dissertation and relevant to the study problem of health disparity and
the significance of health care access in the racial-ethnic minority communities especially
among minority pregnant women, and are described here. I reviewed peer-reviewed
journal articles and other publications, information from government agencies, official
websites, including conference papers using keywords searched on health disparities,
access disparities, and minority women. Academic databases used to locate literature
relevant to this study include Academic Search Complete, CINAHL Plus, ProQuest
Nursing and Allied Health Source, ProQuest Central, ProQuest Health and Medical
Complete, Complementary Index, MEDLINE with full text, PsycINFO, PubMed, Social
31
Sciences Citation Index, and Thoreau multi-database search. I also searched relevant
journals including American Journal of Psychiatry, American Journal of Public Health,
Annals of Epidemiology, Family Community Health, Health Communication, Health
Service Resource, International Journal of Nursing Studies, Journal of American Medical
Association of Pediatrics, Journal of Global Health, Journal of Health Care for the Poor
and Underserved, Journal of Women’s Health, Maternal and Child Health Journal,
Maternal and Child Nutrition, Maternal Child Health Journal, Medical Care, Science,
Morbidity and Mortality Weekly Report, Nursing, Nursing Research, Public Health, and,
Women and Birth. I also included search engines such as Google Scholar. Lastly, I
searched government and health agency websites including those of the AHRQ, MA
Department of Health, CDC, HHS, Healthy People 2020, NIH, and WHO.
I restricted my search to materials published within the last five years to ensure
they were current and relevant, with exceptions to historical events, statistics, and
theoretical methods foundations. Older sources were used as references to emphasize the
extent of health disparities and that it is not a new topic in American history on the health
care delivery system. Because of the limited research on first-time pregnant women
seeking health care for the first time, I primarily reviewed studies on health and health
care access disparities among racial-ethnic minorities and minority subgroups.
To limit my research results and increase access to current and relevant and
literature pertaining to my study, I used combined keywords and search terms such as
health disparity, access disparity, health care disparities, health equity, health outcomes,
health services accessibility, health inequalities, maternal health, income inequalities,
32
minority disparities, minority pregnant women, PNC, perinatal care, minority health,
maternal health, maternal child health, maternity and infant mortality, SES, status
disparities, and underserved population. I also used phrases to expand my search
including barriers to health care access, barriers and influences of SES, and health
disparities among minority and non-minority pregnant women.
Theoretical Foundation
Theoretical or conceptual frameworks and models underpin the method design to
support the researcher in grounding their studies. The theoretical framework is the
general representation of tested theories that embody how phenomena occur and the
conceptual framework is the researcher’s idea on how to explore the research problem
(Bradbury-Jones, Taylor, & Herber, 2014; Green, 2014). Theoretical framework
describes a broader relationship, and conceptual framework is more specific in defining
the relationship; however, both frame the design of the research to explain the outcomes
(Green, 2014). In qualitative studies, researchers use theoretical and conceptual
frameworks to support their research arguments, determine their RQs, give direction to
focus discussion and interviews, and justify the methodology choice (Green, 2014).
In qualitative research, theoretical or conceptual contexts are used to frame the
design or explain the outcomes of the research (Green, 2014). Green (2014) argues that
the term theoretical framework should be used when one theory is used to underpin the
study and that conceptual framework draws on concepts from the theories and findings to
guide research. Bradbury-Jones et al. (2014) argued that theory is the chain connecting
different parts of the study (e.g., problem statement, the purpose of the study, research
33
questions, literature review, methodology, and findings) to establish consistency and
coherence.
Andersen and Newman Framework of Health Services Utilization
The ANFHSU (Aday & Andersen, 1974; Aday & Andersen, 1981; Andersen
1995; Andersen & Newman, 1973) was the theoretical framework used in my study.
Andersen developed the model in the 1960s, which has gone through four phases to (a)
facilitate the understanding of why individuals use health services, (b) describe and
measure equitable access to health care, and (c) contribute to the development of policy
interventions for promoting equitable access to health care (Andersen, 1968, 1995;
Andersen & Newman, 1973, 2005; Rigg et al., 2014). The ANFHSU was designed to
determine circumstances that either facilitate or impede the utilization of health care
services (Andersen, 1995). Andersen characterized the individual’s access to and use of
health services into three functional categories predisposing factors, enabling factors and
needs factors (Andersen, 1995). Andersen’s original model expanded through several
iterations with the most recent encompassing health services utilization to health
outcomes, including feedback loops (Andersen, 1995). Hence, Andersen’s fourth phase
of the health services utilization represents the integration of the health care system, an
individual’s belief in the health system and decision to seek health care and the health-
related outcomes.
Andersen’s (1995) describes predisposing factor as the socio-cultural
characteristics including the social structure of how a person’s culture or education may
influence their coping skills in the face of an illness and how the attitude and value they
34
place on the health care system may influence their access to and use of health services in
their time of need. Predisposing factors described by C. Brown, Barner, Bohman, and
Richards (2009) include demographic characteristics as age and gender and social
structure as race-ethnicity, educational attainment, occupation, and social interaction.
Health belief is concerned with attitudes and knowledge individuals have towards the
health care system and access to and use of health services based on their demographic
characteristics and social structure (Coley et al. 2018). Andersen’s framework assumes
that the individual’s perceived benefits influence their health-seeking behavior; therefore,
exploring the predisposing factors of health beliefs can facilitate the understanding of the
minority pregnant women access to and use of health services. Hence, the ANFHSU may
be used to explain minority pregnant women health behaviors in the presence of health
disparities to accessing health care services.
Enabling factors are factors such as resources and the knowledge to access health
services, earn enough income, acquire and sustain health insurance, and the availability
of health care providers and facilities (Andersen, 1995; Andersen & Newman, 1973,
2005). The paradigm of enabling resources assumes that individuals and families
experience in accessing health care is determined by potential availability and
opportunities to access health care. Here is an example, a minority pregnant women’s
ability to afford health insurance, income sufficiently provides for the family, and the
availability of maternal child health professionals could define the nature of health
disparity within this population when seeking essential access to health care services.
35
Need factors, as described by Andersen (1995), involves both perceived and
evaluated need. Andersen defines perceived need as the immediate cause that generates
one’s need for health service use. Whereas evaluated need is the professional decision
about an individual’s health in determining their health status and need for medical
attention. Moreover, perceived needs are the attitudes, values, and knowledge individuals
place on the health care system that influence their perception of their need for health
service use. Hence, the perceived essential health care needs of minority pregnant women
could affect the perceived inequalities this population experience as they seek health care
services.
Figure 1 provides a distinct framework of Andersen and Newman’s proposed relationship among variables.
OUTCOMES
Figure 1.
Andersen and Newman Framework of Health Service Utilization. The purpose of
this framework is to discover conditions that either facilitate or impede utilization. This
model is based on extensive and well-elaborated literature revision.
Perceived Health Status Evaluated Health
Status Satisfaction
ENVIRONMENT
•Health Care
System
•Available
Health Care
Resources
POPULATION
CHARACTERISTIC
S
•Predisposing
•Characteristics
and Perception of
the Disparity
•Enabling
•Characteristics of
the Service
Enabling Factors
•Need
•Treatment
Seeking process
HEALTH
BEHAVIOR
• Health
Attitudes and
Perceptions
• Health
Services
Utilization
36
To further illustrate how these factors, influence health care service use among
individuals, Andersen and Newman (1995) revisited the model and introduced the
concept of mutability. The idea is that if a concept has more mutability, it can be easily
changed to promote access equality to health care services, perhaps resulting in behavior
modification. For instance, an increase in enabling resources, equitable access, adequate
income, or sustainable health insurance, would increase health service use. Rather than a
factor with less mutability, such as characteristics which fall under demographics, age or
sex, are impossible to change (Andersen & Newman, 1995). Hence, factors influencing
health disparities experienced by minority pregnant women can be explored using
ANFHSU to determine mutability to mitigate changeable inequalities as oppose to those
with low mutability. Classifications of causes of health disparities among minority
pregnant women may lead to the development of policy interventions targeting health
care access inequalities within this population.
The initial model was not without criticism because of attempts to study why a
family uses health care services (Guendelman, 1991; Portes, Kyle, Eaton, 1992), because
of the heterogeneity of family members, the study shifted from the family to individuals.
The sixth iteration of Andersen’s framework focused more on the individual of
vulnerable populations going beyond health care use and adopting health outcomes
(Andersen, Davidson, Baumeister, 2015). The use of a feedback loop to illustrate health
outcomes could affect characteristics such as health beliefs and need (True et al., 1997).
The reconceptualization of the model makes a distinction between potential and realized
access. Andersen also reiterated that the model functions to predict and explain health
37
services use. The model builds upon health status to include health outcomes, consumer
satisfaction, personal health practices and emphasizes more of a public health approach
of prevention, as advocated by (Andersen, 1995; Evans & Stoddart,1990). The numerous
iterations of ANFHSU addressed many concerns and criticisms and through the many
years of refinement, making it the most appropriate model for studying health care access
and use.
Though there are other approaches for studying health care access and services
use including sociocultural and sociodemographic (Blanas et al., 2015; Fortin, Cao &
Fleury, 2018; Lo, Parkinson, Cunich, & Byles, 2016; Strain, 1990), ANFHSU was ideal
for my study. The ANFHSU was not only applicable to the conceptualization of the
phenomenon under research but it was considered one of the most commonly used
frameworks in studies focused on understanding individual’s access to and use of health
care services (Andersen, 2015; Lix, 2015; Tomiak, Berthelot, Guimond & Mustard,
2005). My study aims to understand health disparities experienced by minority pregnant
women seeking essential health care services. Andersen’s constructs predisposing,
enabling and need factors are most appropriate because it facilitates the identification of
events directly from the context of and lessons experienced by minority pregnant women
and their perspective on unique challenges in accessing health care. The constructs of the
ANFHSU model make a distinction between potential and realized (actual) access
(Andersen & Newman, 1995), which informs barriers and facilitators influencing health
disparities experienced by minority pregnant women.
38
Health Disparities in Health Care Access
Quality health care services in the broader context of equitable access are the
catalyst for better care and health outcomes achievable by all populations. The broader
literature indicates prioritizing early-life development programs results in reduce health
risks among populations and promotes better health outcomes for communities when
interventions aimed at goals are effective (Bellis, Hughes, Leckenby, Hughes, &
Harrison, 2014; Bellis et al., 2015; Manning, Homel, & Smith, 2010; Osler, Avlund, &
Mortensen, 2013). The U.S health care system supports the early-life development and
(AHRQ, 2017; Healthy People 2020, 2015; WHO, 2015) identified improvements on all
aspects of health care to establish enhanced health outcomes for all populations. Studies
showed that with income policies and decades of economic growth and despite
considerable investments in the public health infrastructure and extensions of Medicaid
coverage for the underserved, health disparities remain critical goals that requires
prioritizing equitable access for racial-ethnic minority populations (Adams, Gavin, &
Benedict, 2005; Bloom, 2011; Parekh et al., 2018; Roman et al., 2017). In confronting the
challenges of the persistent and pervasive threat of health disparities in the U.S, requires
understanding the multiple layers of health disparities experienced by various populations
and necessitates peeling back those layers.
The literature indicates health disparities continue to exist in populations such as
minority pregnant women in low-income communities and the socioeconomic context
establishes that characteristics of race, location, and low-income status affect health
outcomes by those experiencing the disparities (Bloom, 2011; Durkin et al., 2015; Parekh
39
et al., 2018; Roman et al., 2017). The pervasiveness of health disparities in the United
States include variations in (a) perinatal services, (b) prenatal and postnatal services, (c)
newborn screening, (d) nutrition and breastfeeding access to antenatal and postnatal care,
(e) maternity beds postpartum, (f) insurance, and (g) well-baby visits (Caldwell et al.,
2016; Lorch & Enlow, 2016). Health disparities suggestively influence the quality of
health outcomes, including gestational weight gain, infant growth, birth weights,
neurodevelopment outcomes, maternal and infant mortality (CDC, 2014; Taylor & Nies,
2013). The NIH (2015) has emphasized that one of the most public health research
challenges is "unraveling the underlying reasons for ethnic variations in low birth weight
and preterm delivery” (para 12). Considering the significance of the persistence of health
disparities, it is crucial to understand these variations of the underlying ecological
mechanisms that are responsible.
The direct economic burden of health care on the society of an unhealthy
population because of health disparities and health care access disparities create both
short-term and long-term financial stress on society. Health disparities are inconsistent
with the values of society and are a significant threat to the national asset and social
investment of future generations essential for the health of the next home, community and
work life (Bloom, 2011). Given the significance of early-life experience influence on
population health outcomes and the economic burden of health disparities in early-life
development, the US health care system should place more emphasis on programs
benefiting maternal health. The WHO proposes a defined conceptual framework to assess
interventions to address SDH and reduce health disparities and improve health outcomes
40
among minority pregnant women in the United States (Lorch & Enlow, 2016). The role
of social determinants in illuminating racial-ethnic disparities in minority pregnant
women outcome requires a robust intervention approach to understand the underlying
influence leading to adverse outcomes. Consideration given to implementing policy
interventions to enhance minority pregnant women outcomes requires understanding the
limitations in understanding the SDH care access experienced by the target population
(Bloom, 2011; Hall et al., 2014). For example, maternal age, education, and insurance
status, as well as individual-level or community-level SDH, should be explored. A
collaborative approach integrating evidence-based intervention policies and programs
may facilitate the understanding and provide useful solutions to improve care access to
and use of essential health services.
Racial-ethnic minority groups in the United States represent the fastest growing
population, with literature remaining sparse on health outcomes. There is growing
evidence from the literature suggesting obstetric complications are sensitive to the quality
of care provided during pregnancy and at delivery (Louis-Jacques, Deubel, Taylor &
Stuebe, n.d), as a result of the disparities gap stemming from inadequate or gaps in
essential care during pregnancy. Minority infants are at a disadvantage from not receiving
essential parental care during the critical developmental stage, receiving suboptimal
breastfeeding (Bartick et al., n.d), necessary for growth and development and adult health
outcome. Children, born to minority women, face specific challenges and rarely can grow
up in the care of their parents and spend more time in daycare (Bloom, 2011).
Contributing factor suggests minority mothers of low SES tend to work more than one
41
job to support their family, hence, limiting the time spent as a family unit compared to
high-income families. Improving the health care access experience of minority pregnant
women, key considerations addressing SDH disparities such as the burden of disease in
populations, the adverse impact of economic consequences of poor health, and enhancing
quality access to essential care services can significantly improve the health outcomes of
United States populations (CDC, 2014; E. Howell & Zeitlin, 2017; KFF, 2018).
Researchers suggest that minority pregnant women in the United States are indeed
a part of the vulnerable population (Docherty & Johnston, 2015; E. Howell & Zeitlin,
2017). Minority pregnant women are at a higher risk of experiencing harsher
socioeconomic circumstances related to the microeconomic level of low household’s
incomes and impoverished neighborhoods. Similarly, minority pregnant women
experience disproportionate adverse obstetric and perinatal outcomes because of gaps in
essential care because they are less likely to gain access to quality health care compared
to non-minority or privileged counterparts (Bartick et al., n.d; Bromley, Nunes, Phipps,
2012; E. Howell & Zeitlin, 2017). Disparity gaps are responsible for variations in
socioeconomic circumstances experienced by different groups seeking access to and use
of health care in the U.S (Caldwell et al., 2016; E. Howell, Egorova, Balbierz, Zeitlin, &
Hebert, 2016: E. Howell & Zeitlin, 2017). Racial-ethnic minorities experience a
disproportionate number of adverse outcomes, and the national data documented
Black/African American women showed a pregnancy-related mortality rate of three to
four times higher than White women (E. Howell & Zeitlin, 2017), and perinatal heath
representing the most substantial disparity among all the conservative population
42
measures (Callaghan, 2012). Socioecological conditions such as low-income, lack of
insurance, unemployed women and women with less educational attainment, lower
quality care, gaps in care, delayed treatment, and limited access to care influence and
exacerbate health disparities and the risk of poor health outcomes compared to
nonminority and more privileged population groups.
Health and Health Care Disparities
Health disparities in health care access, utilization, and health outcomes are
significant social injustices primarily affecting minority population groups in the 21st
century. Health disparities are a public health concern affecting low-income and racial-
ethnic minorities and threatened by economic, societal, cultural, environmental, and
social circumstances (Benfer, 2015; Healthy People 2020, 2015; Semega et al., 2017).
Health disparities are health differences threatened by cultural, economic, environmental
and social disadvantage and “historically linked to discrimination or exclusion” (Healthy
People 2020, 2014, p. 1). Researchers find that health disparities and health outcomes are
concentrated in racial-ethnic minority communities and low-income neighborhoods and
the highest rate of poverty is within the African American population at 26.2%, Hispanics
at 23.6%, the Asian population at 12% and the lowest at 10.1% is the White population
(Benfer, 2015; Caldwell et al., 2016; Hall et al., 2014). The National Healthcare
Disparities Report (NHDR) in 2014 informed conditions experienced by specific
populations in which they live and work, reflects the variations in health status impeded
by inequitable social structures (AHRQ, 2015).
43
Despite efforts to improve health among low-income neighborhoods, minority
communities are impeded by inequitable social structures not designed to consider
multilevel structural and social determinants (Caldwell et al., 2016). Health disparities
continue to be a challenging national health concern in the U.S health care system and
persist through complex mechanisms (A. Brown et al., 2019; Hughes, Baker, Kim, &
Valdes, 2019). There are several kinds of literature about health disparities, the extent of
the problem, consequences of populations health outcomes and a collective number of
innovative programs and policies interventions (Beck, Sandel, Ryan, & Kahn, 2017; A.
Brown et al., 2019). Few explicitly focused their impact on minority health, and health
disparities using evidence-based structural interventions aimed at the multilevel structural
and social determinants and support sustained improvements. For instance, minority
populations experience multiple levels of structural disadvantage such as structural
conditions in which individuals are born, live, learn, and work are recognized as critical
determinants contribute to poor health outcomes (A. Brown et al., 2019).
Determinants of Health Disparities
Attainment in the highest level in health, health care, and population health
outcomes are essential to the quality of lives across the nation. The literature has shown
factors influencing health disparities include racial-ethnic backgrounds, educational
attainment, health care access, SES (C. Brown et al., 2019; Docherty & Johnston, 2015;
Kirzinger et al., 2018). Similarly, social determinants include access to health care by
sex, age, income, disability status, and geographical characteristics emphasizes
socioeconomic disadvantages among different populations (Durkin et al., 2015; Kothari
44
et al., 2017). Racial-ethnic minorities, marginalized, and underserved populations are
more likely to experience health disparities when compared to nonminority and
privileged populations (Beckham et al., 2015; Guerra-Reyes & Hamilton, 2017; Liddell
et al., 2018). The NHDR, in 2014, reported that racial-ethnic minorities such as
Black/African Americans, non-White Hispanics/Latino Americans are more likely to
receive a more inferior quality of care than Whites reflecting 42% of quality measures
(AHRQ, 2016).
The 2014 NHDR indicate that low-income groups and more indigent individuals
receive inferior care than individuals with higher income, reflecting 61% of quality
measures. Black/African Americans and non-White Hispanic/Latino Americans
experience more enormous challenges accessing health care when compared to their
White counterparts (AHRQ, 2016). Racial-ethnic minority children experience higher
health disparities in receipt of various preventable health care services when compared to
nonminority children counterparts (C. Brown et al., 2019). Racial-ethnic minority
households at the low end of the socioeconomic ranking are more likely to experience
higher behavioral, mental and physical health issues when compared to nonminority and
privileged counterparts at the more top end (Han & Redlich, 2018; Hughes et al., 2019).
Socioeconomic health burdens such as obesity, depression and drug use and abuse were
common among lower-income neighborhoods at the lower end of socioeconomic ranking
(Han & Redlich, 2018; Hughes et al., 2019). The 2010 U.S. Census Bureau reported that
20% of American children live in low-income households or at or below the poverty
45
level, with Black/African American and non-White Hispanic/Latino American children
accounting for the largest percentage (Semega et al., 2017).
The literature highlights that the persistence of health disparities and the
increasingly diverse population in the U.S pose a severe public health threat (Hsieh &
Ruther, 2017; Miller et al., 2017; Yearby, 2018). Many promising health interventions
have targeted factors of health disparity on the interpersonal and community-level, the
evidence on how enduring these interventions are in supporting sustained improvements
in population health and reducing health disparities remain sparse and need further
understanding (C. Brown et al., 2019). There is a need not only to recognize and generate
awareness surrounding the causes of disparities in health access and health outcomes
experienced by various populations but to develop interventions to sustain improvements
in population health (Miller et al., 2017; Roman et al., 2017). Supporting evidence should
help to inform effective policy interventions focused on eliminating the causes of health
disparities, promote health equity, access and use, for all Americans despite their ability
to pay.
History of Black/African American Population in the United States
Black/African Americans, one of the largest of the many racial-ethnic groups in
the United States mainly of African ancestry, although many have non-Black ancestors
(Anderson & Metzger, 2011; Bondarenko, 2017). Black/African American population
nationally have significantly varied since institutionalized slavery and the Civil War in
the U.S (Anderson & Metzger, 2011; Bondarenko, 2017). The beginning of the 21st
century, there were over 36 million Black/African Americans living in the south and
46
concentrated in large cities; 2 million in New York City, 1 million in Chicago, and
Detroit, Houston, and Philadelphia had between 500,000 to 1 million Black/African
Americans (U.S. Census Bureau, 2017). The exploration of better economic opportunities
has primarily dictated the changes over the years, such as migration to the north, state-by-
state. Although Black/African Americans have attained improved opportunities through
the years, some lingering challenges, such as economic well-being, educational
attainment, income equality, and quality health care access and use, trail other groups of
people in the U.S (Semega et al., 2017). The U.S. Census Bureau reported as of 2017
there are 46.8 million Black/African population in the United States 87.1% completing
high school with 87.3% age 25 and older obtaining a high school diploma or higher, 9.5%
unemployment rate, 19.2% poverty rate and 10% without insurance (U.S. Census Bureau,
2017). Females make up 52.2% of the population and of that 50.3% are between age 18-
34, 62.3% are employed 8.7% unemployed, single female with children under age 5
makes up 42.7%, and 3.9% poverty rate for unmarried women with children under 5
(U.S. Census Bureau, 2017).
History of Hispanic/Latino American Population in the United States
The U.S. Census of 1790, the first known U.S. Census noted there were 20,000
people of Hispanic and Latino living in British colonies which were based on their
surnames (Lieberson & Waters, 1988). The history of Hispanic/Latinos spanned 400
years, Hispanics (criollo or mestizo) became the first American citizens in the southwest
territories following the Mexican American War ending 1783, remained the majority
until the 20th century (Blakemore, 2017; Chavez 2002). As of late 1783, Spain held
47
claim to 50% of the United States until it was reclaimed in 1800 by the treaty of San
Ildefonso (Chisholm, 1911). The history of Hispanic/Latino-American discrimination
primarily began in 1848, during the Mexican American War (Chavez 2002). The
Guadalupe Hidalgo Treaty in 1848 marked the end of the war, granting 55% of Mexican
territory to the United States (Pitt & Gutierrez, 1999), which became new citizens.
Mexicans who decided to stay in what is now the United States territory were granted
citizenship, gaining significant Mexican American population (Pitt & Gutierrez, 1999). In
the 19th century, the influx of Mexico migration to the United States became common,
allowing American employers to capitalize on cheap labor (Blakemore, 2017). Anti-
Latino immigration sentiment was visible in which Latinos have barred entry into Anglo
establishments and experienced segregation into poor urban areas (Blakemore, 2017;
Rodriguez & Ruiz, 2000). Although Latinos were American citizens and crucial to the
United States economy, the pretext of discrimination encompassed their language, skin
color, to their country’s origin. Anglo-Americans treated Latinos as a foreign underclass,
and they experienced stereotypes by speaking Spanish considered lazy, stupid, and
undeserving even noted cases of prejudices turning fatal (Blakemore, 2017; De León,
2015; Rodriguez & Ruiz, 2000). Historians William D. Carrigan and Clive Webb noted
mob violence against Spanish-speaking people was common in the late 19th and early
20th centuries, estimating thousands of Latinos killed by mobs, though only 547
documented cases (Mendoza, 2014; Rodriguez & Ruiz, 2000).
In the 1870s, Hispanic/Latino American children were expected to attend separate
Mexican schools in the southwestern U.S (Mendoza, 2014; Ruiz, 2006). By the 1940s,
48
about 80% of Hispanic/Latino children attended different schools. Spanish schools lacked
necessary supplies and enough teachers, offered vocational schooling instead of the full
12-year instructional classes and Spanish children were forced to attend based on their
complexion and last name and also considered inferior in aptitude, English language,
personal hygiene, and economic contribution (Mendoza, 2014; Rodriguez & Ruiz, 2000).
It is estimated there are 54 million Hispanic/Latinos Americans in the United States and
approximately 43 million of them speak Spanish. Today, Hispanic/Latino Americans
represent the largest minority in the United States and anti-Latino prejudice is still
visible. In 2016, a survey by the Pew reported as many as 52% of Hispanic/Latino
American reported they had experienced discrimination (Mendoza, 2014; Rodriguez &
Ruiz, 2000).
In the 1920s the anti-Mexican sentiment grew into the great depression, and
unemployment soared, and Anglo-Americans accused Mexicans of stealing their jobs. As
the fear grew, the government prevented charitable aids and forcibly removed
approximately 2 million Hispanic/Latinos from the United States although 60% were
American citizens (Lacy, 2001; Rodriguez & Ruiz, 2000; Ruiz, 2006). Repatriations were
common among American employers and Anglo-Americans who drove, provided train
tickets, or raided gathering of Hispanic/Latino Americans and forced them to the border
(Lacy, 2001; Rodriguez & Ruiz, 2000; Ruiz, 2006). INS officials illegally deported
approximately 82,000 Hispanic/Latino during the 1930’s era (Lacy, 2001; Rodriguez &
Ruiz, 2000; Ruiz, 2006). Light-Skinned Hispanic/Latino Americans tried to pass as
Spanish, not Mexicans to evade deportation, and those with disabilities and illnesses were
49
removed hospitals and deported (Lacy, 2001; Rodriguez & Ruiz, 2000; Ruiz, 2006).
When deportation ended in 1936, roughly 2 million Hispanic/Latino Americans were
informally repatriated, and one-third of Los Angeles’ Mexican and Texas’ Mexican-born
populations left the country (Lacy, 2001; Rodriguez & Ruiz, 2000; Ruiz, 2006). There
was anti-Hispanic/Latino discrimination school segregation similar to explicit laws
preventing Black/African American children from attending school with White children
in the south; there were no segregation laws in the southwestern U.S (Lacy, 2001;
Rodriguez & Ruiz, 2000; Ruiz, 2006). Similar to Black/African Americans,
Hispanic/Latino Americans were excluded from movie theaters, restaurants, and schools
(Lacy, 2001; Rodriguez & Ruiz, 2000; Ruiz, 2006).
Characteristics of Black/African Americans in the United States
The U.S Black/African American population is heterogeneous, primarily because
of immigration of Blacks from Africa and Caribbean countries. Among the 11% of
Black/African Americans who are born outside the U.S, more than 50% are from the
Caribbean (Mckinnon & Bennett, 2005). Caribbean Blacks are an important population
subgroup, primarily concentrated in large East Coast cities (Council on Foreign
Relations, 2014; U.S. Census Bureau, 2017). Whereas Caribbean Blacks and African
Americans share a racial identity, Caribbean Blacks differ in ethnicity, economic status,
educational attainment, environmental exposures, and physical health (Council on
Foreign Relations, 2014; U.S. Census Bureau, 2017). Studies reportedly note that African
immigrants, when compared to other immigrant groups such as Hispanic/Latinos, are
considered favorably in educational attainment, English language proficiency, and
50
unemployment rates (Bideshi & Kposowa, 2012; Kusow, 2014). Comparatively, statistics
indicated that on average African immigrants complete 14 years of education, compared
to African Americans at 12.4 years, Afro-Caribbeans at 12.6 years, Asian Americans at
13.9 years, and Whites at 13.5 years (Kusow, 2014).
Although Blacks/African American represents all levels on the socioeconomic
ladder (Kusow, 2014), there are noticeable disparities in educational attainment and
adequate income even though these studies in the United States have consistently found
that Black/African Americans persistently experience poor socioeconomic conditions
(Kusow, 2014). Consistent with previous studies indicating that even with high
educational and occupational attainment of Black/African Americans, who constitute
17% of the population, experience racism and exclusion, and currently have higher rates
of poverty, unemployment, and chronic medical conditions when compared to Whites
(HHS, 2017; U.S. Census Bureau, 2017). Race and ethnicity remain critical factors in the
prevalence of disparities among Black/African Americans and Hispanic/Latino American
group.
As the United States becomes increasingly more racially and ethnically diverse, it
increases in wealth and income inequality. There are significant variances of analysis of
incomes for Black/African Americans compared to White Americans. A large body of
the literature indicates that there is a connection between health and income inequality
(Cobb, & Stevens, 2017; Matthew & Brodersen, n.d.). In an uncomfortable way, the
wealth and income gap are evident along racial and ethnic lines. The Institute on Assets
and Social Policy reports in 2015 that the typical Black/African American household has
51
6% and Hispanic/Latino household has 8% of the wealth of the average White household
(Kochhar & Fry, 2014; Picketty & Saez, 2013; Traub et al., 2015). In more specific
terms, the U.S. Census Bureau Survey of Income and Program Participation reported that
White households had $111,146 in wealth holdings when compared to $7,113 for median
Black/African American and $8,348 for median Hispanic/Latino household (Picketty &
Saez, 2013; Traub et al., 2015). Disparities in homeownership fall along the racial-ethnic
lines accounting for 73% of White homeowners when compared to 45% of Black/African
and 47% for Hispanic/Latino homeowners (Picketty & Saez, 2013; Traubet al., 2015). A
college education means flourishing in the labor market, acquire financial stability, and
increase wealth. Gaps in educational attainment have widened over the last decade along
the racial-ethnic lines, in which 34% of Whites completed four-years colleges when
compared to 20% of Black/African Americans and 13% of Hispanics/Latinos (Bloome,
Dyer & Zhou, 2018). As college costs become a challenge to college attainment, it forces
households to take on student debts. But for Black/African or Hispanic/Latino Americans
obtaining a bachelor’s degree is to escape the racial wealth gap. The return on investment
after a four-year degree is considerably higher for median White family return of
$55,869, Black/African American family return of $4,960 and Hispanic/Latino family
$4210 (Bloome et al., 2018).
The labor markets provide economic security, among other things from earned
income, employer-provided healthcare, and retirement plans. Inequality persists in the
labor market and is responsible for the 25% growth in the racial wage gap and 11% for
unemployment (Bloome et al., 2018). Income or wage disparity in the labor market may
52
come from discrimination in employment or geographic barriers to jobs. Typically, a
White family earns $50,400 when compared to the typical Black/African American
family earning $32,028 and the average Hispanic/Latino family earning $38,690. The
standard White family earns $50,400, whereas the typical Black family earns $32,038,
and the typical Latino family earns $36,840. The wealth return to a dollar of earned
income is determined by the amount the individual has the opportunity to save (Z. Chen
& Gotway Crawford, 2012; Deurzen, Ingen & Oorschot, 2015; Traub et al., 2015). In
relative terms of the wealth gap, if you earn 80 cents on the dollar a White family earns, it
leaves you with 20% less opportunity to save because of the need to meet your
consumption may require every dollar earned. Arguably, Black/African Americans and
Hispanic/Latino Americans earn a lower return on their income and are less able to save
every dollar of their return on income into wealth (Deurzen et al., 2015). In specific text,
the White family will see a return of $19.80 for every dollar earned when compared to
$4.94 for Black/African American and $3.85 for Hispanic/Latino families (Deurzen et al.,
2015). Comparatively, uneducated Blacks/African American and Hispanic/Latino
Americans are the recipient of low-level jobs, such as cleaning and janitorial jobs, retail
and restaurant workers and live at the lower end of the socioeconomic ladder (Bloome et
al., 2018).
Characteristics of Hispanics/Latinos in the United States
The terms Hispanic or Latino refer to an ethnicity sharing a common culture,
history, and language. Scholars have reported since 2003 that Hispanics/Latinos have
surpassed Black/African Americans as the largest racial-ethnic minority group (Deurzen
53
et al., 2015). The Pew Research Center 2016 reports Hispanic/Latino Americans
comprise more than 18% or 57 million of the United States population. Whereas Hispanic
and Latin Americans come from diverse social, economic, and geographic backgrounds,
depending on their family heritage, cultural similarities are bringing these diverse
backgrounds together (Flores, 2017; Kochhar & Fry, 2014). The most common cultural
characteristic of the Hispanic/Latino American culture is the Spanish language. In 1980,
Spanish speakers in the United States represented 11 million or 5% of the population, by
2012 Spanish speakers increased to 13% or 38 million according to the Pew Research
Center, it is common for Hispanic families to teach their children Spanish. The Pew
Research Center reports that over 50% of the Hispanic/Latino American population
reside in California, Texas, and Florida, representing 14 million in California, 10 million
in Texas and 4 million in Florida population respectively (Kochhar & Cilluffo, 2018).
The New York Hispanic/Latino population grew to over three million. In addition to
these states, many other cities in the United States have a very vibrant Hispanic and
Latino American community.
The Hispanic-Latino population in the United States since, 2016, represents the
nation’s largest ethnic or racial minority. The U.S. Census Bureau (2015) projected that
the Hispanic/Latino population in the United States will constitute 28.6% or 119 million
by 2060. The Hispanic/Latino origin in the United States as of 2016 were 63.2%
Mexican, 9.5% Puerto Rican, 3.8% Salvadoran, 3.9% Cuban, 3.3% Dominican, and 2.5%
Guatemalan, others were Central American and South American origin (U.S. Census
Bureau, 2015). There are nine states with one million or more Hispanic/Latino residents
54
as of 2016, they are Arizona, California, Colorado, Florida, Illinois, New Jersey, New
Mexico, New York and Texas, representing 54.4% of the Hispanic/Latino population
(U.S. Census Bureau, 2015). Families and children represent 16.7 million of the number
of Hispanic households in the United States in 2016. There are 48% of Hispanic married-
couple households, 57.5% had children younger than age 18, and 67.2% lived with two
parents in 2016. There were 13.3% or 40 million United States residents age 5 and older
who spoke Spanish at home, and 57.5% of Hispanic Spanish speakers spoke English very
well in 2016. Majority of Hispanic/Latino Americans claim a Christian faith,
Catholicism, or Protestant (U.S. Census Bureau, 2017).
Trends in Hispanic/Latino Americans in the United States
There is a 19.4% poverty rate among Hispanic/Latino Americans, 16% who
lacked health insurance, in 2016 (U.S. Census Bureau, 2017). There are 61.7% of
Hispanic/Latino Americans age 25, and older who have at least a high school diploma,
15.3% or 5 million age 25 and older with a bachelor’s degree or higher, 1.6 million age
25 and older with an advanced degree, 17.4% enrolled in college, and 24.7% enrolled in
kindergarten through 12th grade, in 2016. Of the Hispanic/Latino Americans, 34.2% was
foreign-born, and between 2011 – 2015 there were 62.4% or 22.3 million noncitizens
living in the United States who were born in Latin America or the Caribbean (U.S.
Census Bureau, 2017). There were 67.3% Hispanic/Latin Americans age 16 and older in
the labor force, and 21.2% of those employed work in arts, business, management, and
science occupation, in 2016 (U.S. Census Bureau, 2017). In the 2016 election, 9.2% were
55
Hispanic/Latin Americans compared to 4.7% voting in 1996, and 7.3% voters in the 2014
congressional election (U.S. Census Bureau, 2017).
In summary, the United States has and will continue to experience a cultural shift
of the increase in the number of diverse groups through immigration making for a diverse
population. Many migrate to the United States in pursuit of better socioeconomic
opportunities or to join families. Many various groups seek opportunities in the United
States whereas others are less able to or afforded similar opportunities or circumstances
for many different reasons. Health disparity and health-related outcome address this
under-researched area, from the perspectives of the women themselves, surrounding their
unique experiences related to health care access and barriers to care related to
socioeconomic factors and racial-ethnic groups. It is necessary to understand the essential
health needs of Black/African Americans and Hispanic/Latino Americans (Douthit et al.,
2015; Markus & Conner, 2013) and tailor policy interventions to address the unique
challenges of these populations.
Health of Minority Pregnant Women in the United States
The United States remains one of the few countries with the most diverse
population and attracts 22% of the world’s immigrants (Council on Foreign Relations,
2014). The rapid growth of immigrants in the United States population including
Hispanics/Latinos and Blacks/Africans groups since the 1980s (Council on Foreign
Relations, 2014), has made the health of racial-ethnic minority a substantively significant
public health concern. Douthit et al. (2015) argue that minority groups are one of the
most underserved population subgroups and expose some critical barriers to health care
56
access. Considerably, the health concerns encompass barriers to health care access,
essential health care needs, and variations in use patterns among minority pregnant
women (Han & Redlich, 2018). Much of the literature focuses more on maternal weight
gain and less exploring areas such as significant barriers to access, challenges, health
risks and health outcomes (Douthit et al., 2015). Improving negative health-seeking
behavior in minority pregnant women according to (KFF, 2018) includes improving
health insurance, provider availability, provider linguistic and cultural sensitivity, and
quality of care.
Minority Health Policy Issues
The 2010 U.S. Census reports more than 36% of the population belongs to a racial
or ethnic minority group. The health of the minority population determines the health of
the nation as the United States becomes increasingly diverse in the past century (CDC,
2014). Though health indicators such as infant mortality and life expectancy may have
improved for most Americans; however, some minorities still experience a
disproportionate burden of preventable disease, disability, and death when compared to
non-minorities (CDC, 2014). The literature has shown a small researched area of
minority pregnant women because of their low population in the United States (Douthit et
al., 2015), a parsed view showed that the socioeconomic toll of poor health among
women and children is notably costly (Bloom, 2011). An urgent need to design policy
interventions and sustainable programs tailored to reach these high-risk minority pregnant
women and reduce their risk of poor birth outcomes exits. Insufficient scientific evidence
impedes the efforts of policymakers, providers, insurance companies, and community
57
organizers to determine targeted and sustainable interventions to meet the specific needs
of this population’s current and ongoing health challenges.
Minority Health Outcome and Health Paradox
Minority pregnant women experience pregnancy with less internal (control over
circumstances) and social (partner support) resources that could assist them in coping
with or reducing their stress, according to Public Health researchers (Erving, Thomas, &
Frazier, 2019), a study in racial and ethnic differences in “personal capital” during
pregnancy. For instance, when a woman loses her job and insurance during pregnancy,
having a partner or family to help emotionally and financially can help reduce stress as
well as the less negative outcome on her pregnancy. Studies indicate that the risks
associated with poverty, being a single parent, and low levels of acculturation, contribute
to low personal capital for many minority pregnant women. The health advantage of
minority pregnant women is known as personal capital (Keyes, 2009; Erving et al.,
2019). Literature comparing minority pregnant women and nonminority pregnant women
on personal capital reveals better health outcomes among nonminority groups (Erving et
al., 2019).
Varied disparities in postnatal outcomes exist between women of different race-
ethnicities because of the prevalence of inadequate receipt of PNC. These disparities are
rooted in maternal health behaviors, sociocultural differences, and access to and quality
of health care. One of the major health indicators for pregnant women is the health
advantage of antenatal care coverage (at least four times during pregnancy) which
contribute to better health outcomes for mother and infant. Studies indicate that the
58
differences in personal capital vary by race and ethnicity in unique ways. For example,
Hispanics/Latinos historically had better health outcomes than Black/African American
and White women of comparable SES, which is commonly called the “Hispanic/Latino
Paradox.” However, various studies indicated Hispanic/Latino women reported lower
personal capital than White women (Erving et al., 2019). The differences in personal
capital were explained by low SES of the Hispanic/Latino women. For instance, deficits
in medical care perinatal care (Erving et al., 2019), in access to and quality of care.
Health indicators for pregnant women proposed by Healthy People 2020 (2015)
encompass infant deaths and preterm live births. Having access to and use of quality care
provides an opportunity for early identification and treatment of existing health risks,
prevent future health problems for mother and infant to avoid death, disability and
unhealthy weight (CDC, 2014; Healthy People 2020, 2015; Martin et al., 2009). Wide
disparities in the literature in perinatal outcomes exist among women of different racial
ethnicities. These disparities include educational attainment, maternal lifestyles, medical
care utilization such as PNC (AHRQ, 2016; Martin et al., 2009), and more importantly,
levels of late and no PNC. Studies on pregnant women mostly focus on weight gain and
complication and are much scarce attending to health care access and utilization
(Scherman et al., 2018).
The specific cause of the phenomenon of Hispanics paradox decisive factor is the
birthplace and that of the birthing or neonatal practices. A lack of breastfeeding and birth
trauma collective in American obstetrics and subsequent mental and physical illness,
compounded by the impact of psychological problems (Bower, 1998; Bower, 2004;
59
Horvath et al., 2016; Turra & Goldman, 2007), are theories of low mortality among
immigrants. It is suggested that there is a tendency for ill immigrants to return to their
birth country before death and that new immigrants are healthier when compared to their
birth country population. Others believe that Hispanic Paradox is a myth and inaccurate
counting of Hispanic deaths in the United States resulting in an underestimation of
Hispanic/Latino mortality (Smith & Bradshaw, 2006).
The Black-White Health Paradox
Findings from the literature reveal that Black/African Americans have lower rates
of some common mental disorders, considered mentally resilient and seen as having
higher rates of flourishing when compared to their White counterparts (Erving et al.,
2019). The lower rates are due in part that Black/African Americans experience greater
social inequality and exposure to discrimination (Keyes, 2009). Although there are
reported higher rates of physical morbidity linked to distinctive risk factors for emotional
distress and mental illness compared to the general population, Black/African Americans
showed mental health advantage than Whites but longer duration (Erving et al., 2019).
Findings, when controlled for perceived discrimination, indicates that Black/African
American advantage showed 12 of the 13 signs of flourishing, which suggest better
mental health if discrimination was omitted (Erving et al., 2019). However, adaptive
behaviors may be considered the central reason for the resilience seen in the
Black/African American population.
Studies suggest minority pregnant women were more likely to have unmet
medical care needs citing reasons such as cost, depression, frequent mental distress, and
60
poor health when compared with nonminority pregnant women (G. Gonzales & Blewett,
2014; G. Gonzales, Quinones, & Attanasio, 2019; Howard et al., 2014; Lobel et al.,
2008). Numerous studies have shown some women were more likely to report anxiety
and stress during pregnancy. Reports of higher stress levels during pregnancy are linked
to complications such as miscarriages, preterm births, and low birthweight infants (Lobel
et al., 2008; Schetter & Tanner, 2012). Health, access to care, and health risk are factors
influencing adverse pregnancy outcomes (Everett, Kominiarek, Mollborn, Adkins, &
Hughes, 2018; G. Gonzales et al., 2019). No health insurance, usual source of care and/or
personal doctor were indicated as unmet medical care needs (G. Gonzales and Blewett,
2014; Howard et al., 2014; Hsieh & Ruther, 2017). Healthy People 2020 (2015)
recommends, pregnant women should see their obstetrician at least four times during
their pregnancy for routine checkup, some minority pregnant women are not experiencing
the same health equity and favorable health outcomes. The American College of
Obstetricians and Gynecologist reported disparities in health care access and services
among racial/ethnic women in the first trimester varies among different racial
backgrounds. In which Asians represents 84%, Black/African Americans represent 74 %,
Hispanic/Latino represents 76%, and Whites represents 89% of women in receipt of PNC
(Finer & Zolna, 2014; March of Dimes, 2016; Martinez et al., 2013).
Despite the amount of attention documenting health disparities in morbidity and
mortality, many questions are unanswered regarding the socioeconomic conditions that
lends focus to health equity and health outcomes (Colen, Ramey, Cooksey & Williams,
2018). Even with overwhelming studies and interventions meant to increase health equity
61
among all populations regardless of their ability to pay, policy program falls short in
ensuring sustainable programs targeting high-risk minority pregnant women. There is a
gap in understanding the minority pregnant women access to care and use across the
reproductive life course (Scherman et al., 2018), needs further examination. More
research and programs should focus on perinatal care targeting diverse families before,
during and after pregnancy (Lobel et al., 2008), this may help understand and correct the
health disparities of the minority population. Studies suggest low-income, single and
minority pregnant women would benefit from programs offering comprehensive
resources, such as individual, group, and couples counseling, group PNC, legal aid for
single mothers to obtain child support, and neighborhood-based childcare (E. Howell et
al., 2016).
Review of the Current Related Studies
As the United States becomes increasingly diverse, the health care community is
more aware of how stressors affect minority populations differently, and that there is a
justifiable need for research and policy intervention focused on targeting high-risk and
underserved populations. Although there is limited research on first-time pregnant
minority women access to and use of health care services, there is a need to understand
the health need and health outcomes of this population (Beckham et al, 2015; Guerra-
Reyes & Hamilton, 2017; Liddell et al., 2018). Evidence from research reveals that
minority American women are marginalized in multiple domains of life and live in a
context of reproductive disadvantage leading to racial inequalities in health (Beckham et
al., 2015; Guerra-Reyes & Hamilton, 2017; Liddell et al., 2018). The literature for
62
decades demonstrated that health disparity tends to be pronounced along the racial/ethnic
lines (Colen et al., 2018), and the relationship of SES of self-rated health across this
group. Health disparities exist in access to and use of essential health care services and
resources, including obstetric care, and are seen in population health outcomes between
minority and nonminority populations.
In a study by Chedid and Phillips (2019), they used a multijurisdictional approach
across Australia, Canada, Ireland, United Kingdom, and lastly the United States to
examine the effect of prenatal health programs targeted reducing prenatal health
disparities among at-risk populations. The study indicated prenatal health programs could
be achieved by accessible and inclusive prenatal health care through the collaboration of
provider training and community stakeholders. Chedid and Phillips (2019) assessed
prenatal health guidance documents from clinical associations and regional governments
to evaluate and mitigate variable risks to pregnancy. The studies were categorized by the
type of outcome examined; 14/20 focused on minority pregnant women health outcomes.
The concentration of prenatal programs focusing on minority women indicates the
importance in the provision of accessible health education, services, and resources
focused on women early life in enhancing public health outcomes (Ramsey & Mayes,
2018).
In the study by Chedid and Phillips (2019), they examined the effect of federal
programs focused on removing health disparities and improving health outcomes for
minority pregnant women. The study indicated the impact of the program varied by
geographical location and sociodemographic population. Chedid and Phillips used a
63
multijurisdictional approach across Australia, Canada, Ireland, United Kingdom, and the
United States to evaluate two programs targeting health disparities in minority pregnant
women outcomes: evidence-based, surveillance/monitoring, and expert/stakeholder
collaborations. They examined prenatal health in areas of health education, PNC, and
related services to women. The concentration of programs focused on minority pregnant
women indicates the importance of increasing first‐trimester PNC use throughout the
perinatal capacity.
Despite the HHS recommendation for community involvement to remove health
disparities for high-risk and underserved population’s access to health care services and
resources, Chedid and Phillips (2019) argue that although standardized guidelines inform
clinical screening, PNC, and testing, gaps exist regarding comprehensive prenatal health
programs to mitigate variable risks to pregnancy. They found that researchers associate
health disparities with race and ethnicity and variations in SES. Minority pregnant
women with low SES were found to receive more indigent care and adverse health
outcomes when compared with nonminority counterparts. The studies used in this review
emphasized the value of prenatal health by integrating PNC services with health
programs (Chedid & Phillips, 2019). This current study is unique and different from other
studies as it aims to understand health disparities and health outcomes described by the
experienced perceived minority pregnant women.
In a related study, Tesfaye, Chojenta, Smith, and Loxton (2018) believed that
access to and disparities of care experienced by minority pregnant women are somewhat
interrelated, and the origins are undoubtedly multifactorial. In this study, Tesfaye et al.
64
noted that existing health care access models focused on individual-level factors, e.g.,
financial limitation or cultural health belief, such as the ANFHSU (Andersen & Newman,
1998) generate gaps in efforts to understand and mitigate health disparities. Disparities in
pregnant women health have been observed among various racial and ethnic populations
and different SES (Tesfaye et al., 2018). The authors argued that understanding the nature
and extent of disparities in maternal behaviors that affect maternal or infant health
outcome should be explored (Tesfaye et al., 2018). They further implied that identifying
these disparities can inform public health authorities in developing policies and programs
targeting minority pregnant women at highest risk for adverse health outcomes (Tesfaye
et al., 2018). In response, (Tesfaye et al., 2018). explored existing health care access and
utilization models, e.g., ANFHSU and IOM, to develop a new model.
Community health workers together with policymakers and organizational leaders
can facilitate the process toward understanding variations in health care access and use of
health care services through government interventions and policy development (Tesfaye
et al., 2018), thus increasing antenatal attendance and promoting awareness of obstetric
complication addressing PNC. The local and state level, public health programs can
achieve the goal of taking essential steps to identify population’s health needs together
with researchers, health care providers, and stakeholders to ensure the availability of
health care services most beneficial to support this group. Mostly, public health programs
have an essential role in achieving standards aimed at guaranteeing competency in
providing sustainable and effective public health care services. The established standards
are the foundation for evaluating the effectiveness of the evidence-based public health
65
policy intervention (Tesfaye et al., 2018). The authors recommend approaching
disparities in public health in identifying concrete steps toward policy interventions to
improve health care access and address gaps using modifiable factors of the framework
for program consideration (Tesfaye et al., 2018). Many factors cause disparities in health
outcomes, in which the authors suggest these factors are amenable to the modification to
increase interventions for antenatal care uptake to mitigate poor utilization.
In another study about the prenatal outcome, Mazul, Salm Ward, and Ngui (2017)
examined low-income African American women perspective on barriers and facilitators
related to the use of PNC services to address variations in mortality. Mazul et al. reported
that early and consistent PNC services reduce mortality and improve poor birth
outcomes. The team conducted six focus groups with 29 and two independent structured
interviews with minority pregnant women to understand barriers and facilitators to
receive PNC. In this study, Mazul et al. (2017) noted that minority pregnant women
reported various barriers such as structural (e.g., transportation, insurance, negative
attitudes towards PNC, perceived poor quality of care, unintended pregnancy, and
psychosocial stressors) and facilitators include positive experiences (trusting relationships
with providers, respectful HCPs, social support). The authors argued that suggestions to
improve care mirrored the facilitators identified to make PNC better accessible, available,
and more reflect the complex needs of this population (Mazul et al., 2017). Findings from
the study highlighted essential components in PNC model to facilitate the process to
engage low-income African American women.
66
In a related study by preformed Parekh et al. (2018) to investigate prenatal
disparities in health care use between Black/African, Hispanic, Asian, and White
pregnant women in Pennsylvania. Findings from the study indicated late, or no use of
health care services contributed to adverse health outcomes in racial/ethnic minority
women compared with White women (Parekh et al., 2018). The authors performed a
cross-sectional evaluation representing pregnant women who delivered live births from
November 2011 to 2015 to assess the variations of gaps in the provision and timeliness of
prenatal and postpartum care for women enrolled in Pennsylvania Medicaid relevant to
differences in outcomes by race, ethnicity, region, year, and MCO (Parekh et al., 2018).
The study findings noted wide disparities in perinatal outcomes between
Black/African and Hispanic/Latino American women and White and Asian women.
Remarkably, Black/African and Hispanic/Latino American women reported less frequent
and timeliness of prenatal and postpartum care when compared with Asian and White
American women (Martin et al., 2017; Parekh et al., 2018). Disparities by race revealed
that White and Asian women had higher likelihoods of all outcomes when compared to
Black/African American women. The findings were consistent with NVSR and KFF
where White women represented 12-15% higher rates of timeliness in PNC when
compared with Black/African American women (Martin et al., 2009; Martin et al., 2017).
In an open letter to 2012 presidential candidates the American College of Obstetricians
and Gynecologists provided statistical data of scientific facts to emphasize the
importance of PNC in reducing premature births, which is the cause of premature
newborn death and disability, costs of preterm births ($26.5 billion annually or $52,000
67
per infant born preterm), and strategies for prevention (Martin, 2012; Martin et al., 2017).
Potential reasons for regional disparities include geographical barriers of access to care
such as transportation costs, variation in health literacy, and increased difficulty
communicating with patients for coordinating care. Disparities in ethnicities showed
Hispanic/Latino women had regular PNC when compared with other ethnicities. Potential
explanations are different cultural norms by the region where some Hispanic
communities may use formal healthcare systems more than others as well as various SDH
(Parekh et al., 2018). Parekh et al. (2018) reported the differences by year where measure
performance worsened in 2014 and rise in 2015, were due to closure in obstetrical units,
transportation to clinics and severe winter conditions. Pennsylvania Medicaid expansion
was responsible for improvements in PNC. Disparities within MCO showed that when
plan performance worsened, racial inequality within the MCOs widened, resulting in the
worst Black-White variation occurring in the frequency of PNC outcome (Parekh et al.,
2018). Interestingly, the authors noted that the women enrolled in Medicaid of different
races were similar across a variety of socioeconomic confounders. Parekh’s et al. (2018)
study results suggest that the need for studies to facilitate the process in understanding
disparities by race, region, and MCO in promoting health equity.
Pregnant women in Pennsylvania met Medicaid eligibility criteria and were
enrolled in the Medicaid program, expanding available insurance coverage and health
care services before becoming pregnant. Although, PNC disparities have generally
improved over the last two decades in the United States and despite the expansion in
insurance coverage, study results indicated that statistically substantial differences and
68
disparities in health care use continued to exist between Black/African and
Hispanic/Latino Americans and Asian and White Americans (Parekh et al., 2018).
Despite health insurance coverage, disparities persisted, which is consistent with IOM
Unequal Treatment Report findings that reported disparities in health equity for minority
populations when accounting for health insurance and income (Parekh et al., 2018;
Smedley, 2008). Hence, there is a need consider the underlying factors of specific
population groups, such as racial-ethnic minorities, in studies and policy interventions for
addressing health disparities and health outcomes in the use of PNC services.
In a similar study based on a collated county-level birth data, Docherty and
Johnston (2015) explored the influence of Hispanic ethnicity on disparities in first-
trimester PNC utilization and health outcomes among minority and nonminority pregnant
women. The authors used maternal race and ethnicity birth data from 2000 to 2010 in all
36 Oregon and 39 Washington counties recorded at the time of delivery (Oregon Health
Authority, 2012a), ethnicity was categorically recorded as Hispanic -White or Other, and
non-Hispanic: White, African American, Native American, Asian, Native Hawaiian, and
Pacific Islander. Using data from both sources, the authors considered disparities for
various health indicators (e.g., maternal tobacco use, maternal education, and pregnancy
deliveries funded by OHP/Medicaid) between maternal non-White and White ethnicities
(Docherty & Johnston, 2015). The authors used time-series regression analysis for both
states to assess the influence of maternal determinants impact of first-trimester care
utilization.
69
Study findings indicated maternal education and Medicaid status significantly
influenced disparities in health outcomes. There was a strong association between health
outcomes, maternal education, and poverty level variables (Docherty & Johnston, 2015).
The authors also found that controlling for county poverty determined if the use of first-
trimester PNC of non-White mothers with access to Medicaid was magnified or mitigated
(Docherty & Johnston, 2015). For example, non-White mothers with Medicaid coverage
experienced the worst health outcomes when compared with White mothers with
Medicaid coverage. Docherty and Johnston (2015) attributed disparities in first-trimester
PNC use between nonminority and minority women, e.g., maternal education,
immigration status, and the percentage of Medicaid coverage.
The study findings of Docherty and Johnston (2015) were consistent with similar
investigations on minority pregnant women that associate health disparities with health
outcomes between minority and nonminority for characteristics unique to minority
pregnant women. Factors include maternal education, un-insurance or limited insurance,
and quality PNC use (Coley & Aronson, 2013; Hahn, 2013; Kenney, Coyer & Anderson,
2013). Although Docherty and Johnston’s study showed variations in negative births
among minority and nonminority families to maternal education and Medicaid status,
research revealed that controlling for county poverty did not remove disparities and
exposed an available gap that needs to be further explored. The justification of the current
study is to explore health disparities and health outcomes from the perspective of
minority pregnant women.
70
In a similar study on minority pregnant women in the United States, Gadson,
Kpovi, and Mehta (2017) argued that disparities in PNC utilization influence maternal
outcomes. The authors explained that the racial/ethnic maternal morbidity and mortality
are rising in the United States and Black/African American women are at highest risk for
these outcomes when compared with other race/ ethnicities. Black/African American
women were less likely to have timeliness and more likely to be inadequate users of PNC
services. Persistent health disparities in health care access are linked to maternal
morbidity and mortality (Gadson et al., 2017). The rate of occurrence of severe maternal
morbidity has increased in the United States and is experienced by minority women when
compared with their White counterparts (Gadson et al., 2017; James, Thomas, Ranji,
Lillie-Blanton, & Wyn, 2009; S. Lee et al., 2015). Lack of or late PNC potentially
influences maternal outcomes. PNC is a useful mechanism to engage women in the early
stages of pregnancy providing risk assessment such as psychosocial, cultural, and
educational support to enhance maternal outcomes.
To mitigate the challenges of health disparities, Gadson et al. (2017) argued that
there is a need for PNC innovations demonstrating the potential to engage with the social
determinants of maternal health. Their study is consistent with other researchers (Creanga
et al., 2015; Edmonds, Mogul, & Shea, 2015; Heaman et al., 2015) that there are risks for
late entry into PNC and the calling for careful examination in the variations of social
determinants such as insurance status, availability of social support, SES, neighborhood,
and transportation. Gadson et al. emphasized that all likely play some role in PNC
utilization and there can be no sustained solution to health disparities in minority health
71
without considering the complexities of underlying causes including income equality,
access to education, financial security, free of violence and freedom of decision-making
power. The authors further pointed out understanding of the psychosocial factors such as
pregnancy-related stress, mental illness, and partner violence contribute to maternal
morbidity and mortality. This current study explored the minority pregnant women
perception of access disparities of their experiences in accessing health care.
Summary
Research cited in this review of the literature indicated that health care disparities
are a complex challenge for minority pregnant women’s’ access to PNC disparities exist
in the United States. Even with the implementation of policy and program interventions
at the local, state and federal levels to improve health equity, studies reveal evidence of
persistent inequalities in health care access and use among minority and nonminority
pregnant women (Creanga et al., 2015; Gadson et al., 2017). The literature review
indicated that health care access disparities negatively affect minority pregnant women
who are uninsured, have low income, live in poverty neighborhoods and do not have
access to quality PNC (Docherty & Johnston, 2015; Gadson et al., 2017; Parekh et al.,
2018), which influences poor health outcomes for mother and infant. Researchers
indicated disparities in access to and use of health care experienced by minority pregnant
women (Edmonds et al., 2015; Johnson et al., 2011; Meyer et al., 2016). The studies
reviewed emphasized health disparities in prenatal outcomes such as variations in
maternal and infant morbidity and mortality along the racial-ethnic lines, and income and
72
insurance status (Chedid & Phillips, 2019; A. Collins, 2006; Edmonds et al., 2015; Hahn,
2013; Parekh et al., 2018).
Researchers argued that health care disparities and minority health are complex
challenges which are a well-researched and ongoing problem in the United States health
care system (Bloome et al., 2018; Creanga et al., 2014; E. Howell et al., 2016; Walker &
Chestnut, 2010). Also, in the review, researchers voiced that several policies and program
interventions focused on mitigating health disparities such as WIC, CHIP, and Medicaid.
However, it is important to highlight there is a substantial unmet gap in the literature on
health care disparities and health outcomes from the perspective of the experience of
minority pregnant women. In my review of the research in this chapter, there is clear
evidence of the gap in the literature focused on the health of minority pregnant women.
Moreover, there was a lack of research focused on health from the perspective of first-
time minority pregnant women.
In Chapter 2, I provided an extensive review of the literature relevant to this
current study in which I discussed an exhaustive understanding of health access disparity
experienced by minority pregnant women in the United States. Since there is an existing
gap in the literature concerning the health of minority pregnant women, I completed an
exhaustive review of the literature on health disparities and health outcomes from the
perspective of minority pregnant women. Most of the literature focused on maternal child
mortality and morbidity, hence, supporting the need for further research in minority
pregnant women health outcome from their perspective. In Chapter 3, I discussed the
research methodology used to underpin this study, including the study population,
73
sampling methods, and study instruments. Chapter 3 further highlighted how I collected,
organized, analyzed, and disseminated the research findings. Also, in this chapter,
covered potential study limitations and the strategies I used to minimize the weaknesses.
74
Chapter 3: Research Method
Introduction
Socioeconomic factors and racial-ethnic identity influence the growing health
disparity experienced by minority pregnant women as they seek prenatal health care for
the first time. Salient factors such as race, ethnicity, occupation, and unemployment
contribute to disparities in the uninsured rates among the non-elderly population of 8.4%
and children 2.9% (Kirzinger et al., 2018). Moreover, the HHS reported in April 2017
that racial-ethnic minorities are less likely to receive the preventive care they need to
remain healthy, more likely to suffer from serious diseases, and less likely to gain access
to quality health care (RWJF, 2018). Despite the reports indicating health disparities
disproportionately affect racial-ethnic minorities, there is little research focused on
understanding minority pregnant women experiences as they seek health care services for
the first times.
In this chapter, I emphasized the details of the research methodology I used to
address the study problem and purpose. I detailed the steps I followed to explore the
experience from the perspective of minority pregnant women health disparities as they
seek health care services. In this chapter, I provided details relating to the research design
and explanation of my rationale, my role as the researcher, research questions, context of
the study, recruitment strategies, criteria for selecting participants, data collection, and
procedures for analyzing data. I also highlighted strategies for addressing issues of
trustworthiness, including credibility, transferability, dependability, confirmability,
reliability (coding where applicable), and ethical procedures.
75
Research Design and Rationale
For this study, I chose a design that most closely aligned with the different
components of the study to ensure that the study results addressed the central RQ (see
Creswell, 2009; Patton, 2002). Research design is a framework created to find answers to
different parts of the research, such as research questions, problem, purpose, and methods
to ensure the cohesiveness of the study. It gives the direction of and systematizes the
research (Patton, 2002).
In narrative research, the primary RQ is formed by the personal interest of the
researcher (Hageman & Frederick, 2013). Qualitative research involves the gathering of
narratives, either written, oral, or visual, focused on the meanings people assign to their
experiences by providing insight that describes the complexity of human lives. Narrative
description RQs aim to facilitate the identification and understanding of events directly
from the context of and lessons experienced by participants (Trahar, 2013; Caine et al.,
2018). With the constructs in mind, I formulated the following three questions to guide
this study:
• RQ1: How do the experiences of women, minority and underserved, of
childbearing age as they seek health care affect their ability to achieve positive
pregnancy outcomes (defined as term vaginal delivery, appropriate birth
weight for infant and pregnancy weights for mother, and to avoid postpartum
depression and infant mortality)?
• RQ2: What are the self-reported health disparities in first-time pregnant
minority women as they seek health care for the first time?
76
• RQ3: How has the experiences of health disparity affect the health-related
outcomes in first-time pregnant minority women as they seek health care for
the first time?
These three research questions allowed me to gain an understanding of the health
disparity experienced by first-time pregnant minority women as they seek health care for
the first time in the United States.
Phenomenon
In this study, I explored the phenomenon of health disparity in health care access
experienced by minority pregnant women in the United States. Amid current healthcare
reforms and rising immigration, racial-ethnic groups are at disproportionate risk of being
uninsured, lack access to care, and experience poorer health outcomes. Inequities in SES
have continued to negatively impact the effectiveness of improvement in quality access
measures (AHRQ, 2017), including health insurance or a usual source of care, easy
access to care, and the outcome of successful receipt of needed services. Early access to
PNC is essential to the outcome of successful receipt of services required for both mother
and child (Heaman et al., 2015). When there is the presence of specific resources that
facilitate health care, including timely use of personal health services, attaining good
access to care, finding providers who meet their needs, and ongoing care, gaps in care
and delayed treatment are reduced by 35% (AHRQ, 2017). Timely access to ongoing care
during pregnancy has been shown to reduce the infant mortality rate and improve health
outcome. Hence, the infant mortality rate increased by 7% between 2016 and 2017
among non-Hispanic Black infants but decreased by 7% among non-Hispanic White
77
infants and 13% among Hispanic infants (AHRQ, 2017), which emphasizes that even
with facilitators to health care they are still barriers competing with the patient’s
perception of need. The purpose of this research study is to identify (a) what SES,
provider’s perception of their race/ethnicity, (b) knowledge and care-seeking factors
influenced first-time pregnant minority women’s access and use of health care, and (c)
what first-time pregnancy health disparity may be unique to this population.
Research Tradition
This study followed a narrative description of qualitative tradition, which
provides informative value and advocates for the usefulness of narrative inquiry.
Narrative inquiry is appropriate for real-world measures, and when real life problems are
investigated (Caine et al., 2018; Gilstein, 2018). The narrative approach is a way of
organizing events and accounts of actions incorporating facts of time and place and
represents a connected succession of events (Caine et al., 2018; Gilstein, 2018). The
narrative inquiry affords the researcher the understanding of the experiences from the
direct personal accounts and provides facilitating contexts encouraging participants to tell
comprehensive stories about important moments in their lives (Caine et al., 2018;
Gilstein, 2018; Trahar, 2013). Using a narrative approach enabled me to obtain subjective
information in a narrative inquiry space by engaging with participants about experiences
of their storied lives (F. Connelly & Clandinin, 2006).
Scholars from various disciplines have used a narrative approach in studies
focused on gaining a detailed understanding of the experiences from direct personal
accounts of study participants concerning a specific phenomenon being studied (Caine et
78
al., 2018; Gilstein, 2018; Trahar, 2013). Caine et al. (2018) used narrative to capture the
experiences of the personal dimensions of social justice, considering the relationship
between individual experience and cultural context. Coxon, Sandall, and Fulop (2015)
used narrative study to explore the influence of pregnancy and birth experiences on
women’s choice of birth in obstetric units. Authors Coxon, Sandall and Fulop suggested,
that in-depth narrative interviews, nonverbal observation, and descriptive content within
the interview provided greater insight into real-life events of women with complicated
pregnancies.
Narrative face-to-face interviews not only allowed me to create constructed
stories from study participants but also helped me make sense of the ambiguity,
complexity and multi-layered nuances of human lives as well as enable me to observe
nonverbal responses. Thus, a narrative approach was appropriate for this study to
examine and make sense of past accounts and interpreted events to bring together layers
of understanding personal experiences of pregnant minority women. The use of open-
ended, semistructured narrative questions allowed participants to shape their story from
memorable and interesting knowledge in a conversational manner.
Role of the Researcher
Researchers play a fundamental part in qualitative research. In contrast to
quantitative studies, where the investigator can be independent of the study, in qualitative
research, the researcher is the primary instrument of the study and is centrally involved at
each step of the research process (Caine et al., 2018; S. Lee et al., 2014; Sutton & Austin,
2015). In qualitative designs, such as the narrative approach, the researcher prescribes the
79
decisions throughout the study. The ways in which shared stories are shaped through
dialogue and co-construction, the researcher must ensure a reflexive layer concerning
their positioning of the study under investigation to not compromise the study findings
(Caine et al., 2018; Sutton & Austin, 2015). As a primary instrument, I played a central
role in this study, including the design of the study and validating the data collection
tools. Further, I had the sole responsibility in participant selection, collecting and
analyzing data, interpreting results, and documenting final findings. I have no
relationship with any of the participants.
As a researcher, I was responsible for remaining objective to recognize and limit
any personal biases which could influence the process or final findings of the study. I
made sure to set aside all my preconceptions and prejudices and remain objective during
the interview process with participants. I set aside any biases by engaging in the self-
reflective process of “bracketing” (Tufford & Newman, n.d.) about the phenomenon in
question and attend to participants with an open mind. Some qualitative research scholars
have argued that bracketing should occur during the conceptualization and through the
research (Rolls & Relf, 2006), whereas other authors have advocated limiting bracketing
to the analysis phase (Sorsa, Kiikkala, & Åstedt-Kurki, 2015). Bracketing draws
awareness to presuppositions at each aspect including project conceptualization, research
questions, data collection, data analysis, and writing from critical analysis and
understanding (Tufford & Newman, n.d.). Since preconceptions may surface at initial
stage and filter into other stages of the study, monitoring biases throughout the study can
be a source of insight and awareness to potential problems (Tufford & Newman, n.d.).
80
Commitment to methods of bracketing include reflexive journaling at the beginning of
the study, which may raise the awareness of or prepare for potential role conflicts, memos
were used to reflect my engagement with the data. Both methods of bracketing
complemented one another and remained well-intended in different stages of this study. I
also ensured that the study has met IRB and federal requirements for the moral and
ethical treatment of human participants (Levy, 2015; Trahar, 2013). Participants had the
autonomy and freedom to volunteer to participate and share their experiences. They also
had the right to terminate their participation at any time, even in the middle of an
interview, if necessary. I ensured the privacy and confidentiality of study participants
information provided throughout the interview process.
Methodology
Participant Selection Logic
This study targeted pregnant minority women living in the northeast metropolitan
region of the United States. Purposive sampling is the most appropriate choice selected
for the study participants. The purposive sampling strategy is justified for this study to
elicit information-rich cases related to the phenomenon being studied (Benoot, Hannes, &
Bilsen, 2016; Palinkas et al., 2015). Purposive sampling allowed me to select first-time
pregnant minority women using essential health care for the first time in their pregnancy
and are prepared to articulate their experiences voluntarily. Although there are no rules to
the size of recruiting participants in narrative and other qualitative studies, (Mason, 2010;
O’Reilly & Parker, 2012; Patton, 2002) noted that qualitative researchers should acquire
participants that are large enough to obtain enough data to sufficiently describe the
81
phenomenon being investigated and address the research questions. Saturation point is
when the recruitment of additional participant(s) results in the replication or redundancy
of data (Marshall, Cardon, Poddar, & Fontenot, 2013). Some researchers have debated
the concept of reaching saturation, suggesting saturation does not determine the number
of recruited participants. Though there are limited guidelines intended to be reference
tools for qualitative recruited participants, these authors agree that saturation can be
achieved at a comparatively low level (Guest, Bunce, & Johnson, 2006; Fusch & Ness,
2015), and generally thick data does not necessarily equal rich data, and the depth of data
is typically more important than numbers (Burmeister & Aitken, 2012; Fusch & Ness,
2015). Guest et al. (2006) study reached saturation after achieving rich data from their
interview analysis of approximately 12 participants. In a related narrative study that used
in-depth unstructured interviews to pregnant women in India to understand health
information-seeking behaviors, barriers to care and access, and the negative associations
between poverty, low levels of literacy, and women adverse maternal and child health
outcomes, Das & Sarkar (2014) used 10 expectant mothers from rural India who provided
rich data which was adequate for their study.
Of the comparable studies cited above, I recruited 12 participants, which I
anticipated would provide rich and adequate information to answer my research
questions. Participants I recruited in this study self-identified as Black/African American
and Hispanic/Latino American first-time pregnant woman living in the northeast
metropolitan region of the country. As reported earlier, the northeast MA is largely
condensed areas of multi-ethnicities with 63.7 % Black/African Americans and 4.2%
82
Hispanic/Latino Americans (U.S. Census Bureau, 2017). This northeast metropolitan
region is considered one of the largest MA with 622,000 population since 2018 and host
to multi-diverse communities (World Population Review, 2018).
After receiving my IRB approval number [09-18-19-0078198], I collaborated
with multiple community health care workers, churches, Catholic charities, and ethnic
restaurants and grocery stores to recruit study participants. Catholic charities and
churches were common points of contact for Hispanics and Latinos to go for spiritual
guidance and financial and emotional support. Community centers were other points of
recruiting efforts.
I collaborated with local business owners, church organizer, community health
care workers to distribute study fliers at community centers, clinics, churches, local
restaurants, and grocery stores to recruit study participant with detailed information to
contact the researcher. Publicizing my study through announcements and fliers were
appealing and helped to facilitate the recruitment efforts to interesting parties. Also, the
local Hispanic/Latino market was used to publicize my study, which is accessible to their
customers. Hispanic/Latino markets are high traffic for multi-ethnic customers in the
MA. The recruitment flier included my telephone number and email address for potential
participants to contact me for information about the study. I used a community center
venue for my interviews because it is a diverse community, strategically populated multi-
ethnic cities, which is already an accessible commonplace.
I employed additional recruitment processes as plan B, which included referrals to
ensure I had adequate responses from participants. Although, I was unsure of the number
83
of participants I would need to gather rich data to reach saturation, I ensured beforehand
to avoid unforeseen delays. I used the first two study participants recruited to conduct a
pilot study to test the quality of my designated methodology, which included the study
recruitment plan, data collection tools, and data analysis techniques. The pilot study
informed me if the interview guide could generate rich data to answer the research
questions. There were no modifications needed to the interview questions for my primary
study.
I ensured potential participants recruited for my study were provided with the
background information about the study, and I conducted a demographic survey and
eligibility screening, which is crucial to the study. I scheduled an appropriate time
following the screening with participants interested in participating in the study at their
convenience to complete the interview. Potential participants recruited for the study who
did not meet the criteria were informed of their ineligibility and thanked for their interest
and time. Eligibility for this study met the following requirements:
• Are legal, female who self-identifies as Black/African American and non-
White Hispanic/Latino American 18 years or older.
• First-time pregnant minority women.
• First-time accessing professional health care (i.e., prenatal or essential care).
• Are willing to travel to the interview venue to voluntarily participate and
discuss their experiences in a private voice-recorded interview.
• Can read and speak English.
• All participants signed an informed consent before participating in the study
84
(required by Walden University’s IRB).
Instrumentation and Data Collection
As the principal instrument in this study, I implemented other tools to facilitate
participant selection and data collection process. Deciding on the appropriate data
collection method is central to enhancing the quality and credibility of the data collected
(Burmeister & Aitken, 2012; Fusch, 2015). In considering the quality of instrumentation
and the collection of data, Fusch (2015) noted that the interviewer should focus on the
rigor in which data collection was executed. Narrative study is used within the context of
a method of inquiry in qualitative research to understand the study participant (Chase,
2005), specifically focused on stories told by individuals account of a series of events
rather than replicating results for the mean of another setting from the study findings
(Burmeister & Aitken, 2012; Creswell, 2009; Fusch, 2015). The main aim is to recognize
study participants appropriate for the study to provide rich data to reach saturation point
(Burmeister & Aitken, 2012; Fusch, 2015). I created the interview guide that I used to
conduct face-to-face interviews for this study (see Appendix D).
Face-to-face interviews are beneficial and preferred choice as the primary data
collection method for the study. Following the initial eligibility screening, I scheduled
face-to-face interviews with study participants conducted in a private office space. Using
a private office space ensured privacy, confidentiality, and uninterrupted scheduled time
allotted. I provided a comfortable rapport to establish mutual trust with study participants
to allow them to share their stories of events. Before the interview, I shared a short
background about the study, reviewed informed consent signatures of all study
85
participants, and asked study participant’s permission to record the full interview. I
conducted one-on-one, face-to-face, semistructured interviews using open-ended
questions to obtain a detailed account of events of their experiences of health disparities.
Face-to-face interviews and note-taking can supplement the audio recording of an
interview. In the face-to-face approach, notes can be used to capture nonverbal language
or elements of the interview (Doody & Noonan, 2013; Irvine, Drew, & Sainsbury, 2013),
including body language and mannerisms. Face-to-face interviews enable the interviewer
to follow-up on questions and nonverbal communication behind articulated responses by
participants, which will produce richer texts to elicit a more in-depth understanding of the
issue being investigated (Mealer & Jones, 2014). The use of several data collection
techniques allowed me to compare transcribed data with field notes to ensure high
fidelity, accuracy, and consistency in the quality of data using triangulation during
analysis. Member checking is another valuable source of data and insight, allowing
participants to review the interpretations. Indeed, member checking is a follow-up data
collection which extends the researcher’s data analysis (Creswell, 2009).
Audio Recording: Audio recording has been used more and more as the primary
data collection tool in social research. Many qualitative studies collect audio data during
interviews and transcribed into written form for comparison and accuracy with other data
collecting tools (Bailey, 2008; Sutton & Austin, 2015). Transcribing is a technical task
involving decisions about non-verbal proportions of interaction and data interpretation
(i.e., distinguishing ‘I don’t know’ from ‘I don’t, no’) into an interpretive process (Sutton
& Austin, 2015). An audio recording was used as the primary source of data collecting in
86
this study.
Field Notes: Field notes are written language representing a linguistic variety of
participants articulation from verbal interaction. Written representations help gather data
which may not be captured by other data collection tools and reflects the researcher’s
interpretation (Creswell, 2009). Field notes represent a record of observational data by
the researcher of contextual data collected in the field (Sutton & Austin, 2015). Field note
was used to help complement the audio recording, which cannot capture quotations or
salient attributes of participants behavior (i.e., nervous laughter) or nonverbal cues. Field
notes provided valuable context and an added layer in understanding the phenomenon
being investigated during data analysis.
Memos: Memoing is the recording of reflective field notes by the researcher to
themselves about the phenomenon in question or what they are learning from the data
(Groenewald, 2008). Memos contribute significantly to the credibility of the qualitative
research process (Groenewald, 2008). Jotting down keywords, brief phrases, and quotes,
during unobtrusive moments, helped to jog my memory when comprehensive fieldnotes
were collected.
NVivo 12 Pro and thematic analysis data analysis technique (Braun & Clarke,
2006; Yahmady, Hilal, & Alabri, 2013) was used to catalog and analyze collected data.
The thematic analysis developed by Braun and Clarke (2006) as a “method for
identifying, analyzing and reporting patterns within data” (p. 79). I chose thematic
analysis as my method of analysis because it allows flexibility of use with the theoretical
framework and rich, detailed, and complex description of collected data (Braun & Clarke,
87
2006). Thematic analysis guidelines:
1. Familiarizing yourself with your data by transcribing data by actively reading
and rereading data and take notes on initial ideas before coding;
2. Generating initial codes with the aid of NVivo software and data identified by
similar codes collated together;
3. Searching for themes included a broader level of themes by sorting different
codes into potential themes into a collection of themes and sub-themes;
4. Reviewing themes may involve the refinement of themes into one theme, or
the breakdown of themes into smaller components, (level 1) ensures data
forms coherent patterns or (level 2) relationship between the themes reflect
the meaning of the data;
5. Defining and naming themes should identify and capture the essence of the
themes;
6. Finally, producing the report involves providing sufficient evidence of each
theme of the data, which is the final analysis. Validating findings with each
participant was included in this step.
Transcripts
The graphical illustration of Braun and Clarke’s thematic analysis method
outlines the guideline to interpret, analyze, and report the with the theoretical framework
providing rich, detailed description of the data collected.
88
Phase Process Result Reflexivity Journal Entries
1
Read and re-read data to become
familiar with specific data patterns that
occur.
Preliminary codes and
detailed notes.
List preliminary codes in journal,
describing the meaning and source of the
code.
2
Generate the initial codes, document
where and how patterns occur.
Through data reduction, collapse data
into labels to create categories for
more efficient analysis and meaning of
codes.
Comprehensive codes of
how data answers
research question.
Detail information how and why codes
were combined, what questions the
researcher have about data, and how
codes are related.
3
Combine codes into principal themes
to accurately depict the data.
Describes exactly what the themes
mean and what is missing from the
analysis.
List of potential themes
for more analysis.
Note how the codes were interpreted and
combined to form themes.
4
Look at how the themes support the
data and the principal theoretical
perspective. If analysis is incomplete,
then revision is needed.
Recognition pattern of
themes are patterned to
tell an accurate story
about the data.
Notes included the process of
understanding themes and how they fit
together with the specified codes;
answers to the research questions; and
data-driven questions need to be
sufficiently supported by the data.
5
Define what each theme, which
aspects of data are being captured,
and what is interesting about the
themes.
Comprehensive analysis
of what themes
contribute to
understanding the data.
Describe each theme within a few
sentences.
6
Writing the final report to decide which
themes make meaningful contributions
within the data. Conduct “member
checking" to confirm if the description
is an accurate representation.
Provide rich description
of the results.
Note why specific themes are more useful
at making contributions and describe the
process of selecting the way in which the
results would be reported.
Figure 1. Graphical illustration of the process of Braun & Clarke (2006) data analysis model.
89
I used NVivo 12 Pro qualitative data analysis software to code statements
significant to the phenomenon of health disparities in pregnant minority women as they
seek PNC narrated by study participants. NVivo 12 Pro facilitated the organization and
analyzed the data transcribed into groups and themes in an efficient way to ensure easier
understanding of the phenomenon in question.
Trustworthiness
Trustworthiness is an essential concept in the research process and is pertinent for
qualitative researchers to establish that the research findings are credible, confirmable,
dependable, and transferable are evident in their study. Researchers must establish
trustworthiness through the quality of the whole research process and support the
argument that the research findings are significant (Hadi & Jose Closs, 2016). Having
these components of trustworthiness in qualitative research confirm a level rigor in the
choice of instrumentation, participants recruited, collection of data, and analysis
technique.
Because researchers are the principal study instruments and actively make study
decisions, Hadi and Jose Closs (2016) argues that researcher biases notedly are the
greatest underlying threat to trustworthiness in qualitative studies. Therefore, to enhance
the trustworthiness of this study, as a researcher, I used reflexivity to examine
assumptions and preconceptions I had and the crucial implications on the overall study
(Berger, 2015). The process of reflexivity allowed the transparency regarding my
position and personal motivations, possible influence in being objective during data
collection and analysis, and the threat to the accuracy of the research outcomes (Berger,
90
2015; Hadi & Jose Closs, 2016; Sorsa, Kiikkala, & Åstedt-Kurki, 2015).
Credibility is the confidence of the researcher in the truth and accuracy of the
research findings. I conducted a pilot study to test the quality of the interview process to
help identify potential researcher biases and ensure the choice of data collection generate
data which accurately answers the research question. Qualitative researchers can use
triangulation to show the research study’s findings are credible (L. Connelly, 2016; Hadi
& Jose Closs, 2016; Patton, 2002). Credibility contributes to trustworthiness of data
through (a) prolonged engagement with participants, (b) persistent observations in the
field, (c) triangulation, (d) participant checks, and (e) researcher reflexivity. Notedly,
triangulation and member checks are primarily, and commonly used methods to ensure
credibility (L. Connelly, 2016; Hadi & Jose Closs, 2016; Lincoln & Guba, 2002) and was
conducted for internal consistency and added rigor in this study. Moreover, a thorough
description of source data and emerging analysis added richness to study findings.
To ensure confirmability and dependability in this study, I have clearly outlined
the methodology and thoroughly applied it throughout the research process. I have thus
so far provided the rationale for methodological decisions and implemented the
interpretive judgment in this study (Jefferies et al., 2019). The degree of neutrality,
consistency, and ensuring clarity of methodology used in this study allow readers who
may not share my interpretive views to discern how I reached the research findings.
Establishing and maintaining an audit trail includes highlighting every step of the data
analysis process to provide a rationale for the decisions throughout this study. NVivo’s
query was useful to audit study’s findings accurately portray participants’ responses
91
(Yahmady et al., 2013). I applied the audit trail technique as recommended by Miles,
Huberman, & Saldaña (2014) to facilitate the consistent organizing, documenting, and
tracking of data collection.
Ethical Consideration
Ethical standards imposed by Walden University’s Institutional Review Board
(IRB) and federal regulations force research studies involving human subjects to meet
regulated guidelines to protect the human rights of participants (Walden University,
2012g). All ethical requirements by Walden University’s IRB was followed throughout
this study. Walden University requirement is that Ph.D. students do not engage in
recruitment activities or data collection without IRB approval and assigned number. I
included IRBs approval number to all documents used in recruitment activities or data
collection such as study invitation poster, consent form, etc. All potential participants
were briefed on the background of the study highlighting their rights to participate and
withdraw from the study and ensure participation is voluntary, confirmed by
acknowledgment.
Eligible participants signed the informed consent confirming they are
volunteering to participate in this study. Participants were made aware that they have the
right to withdraw without any consequences and informed that the interview would
remain private and confidential and strictly used only for academic and research
purposes. I confidently secure all data collection and ensure sole access to the collected
data and securely destroy all data post-study rule of 5-years to protect all participant’s
information.
92
In ensuring complete privacy and confidentiality of study participants, interviews
were conducted in a private office to an allotted time without an interruption in advance
and to secure secondary private office space to prevent any unforeseen issues. A “do not
disturb – session in progress” sign was placed outside the room to ensure uninterrupted
sessions and noise reduction. Most importantly, pseudo names were assigned to identify
study participants. To ensure participation was not be encouraged through gifts or gains, I
provided each participant $10 gift card thanking them for participating in the study. Data
such as anonymized unidentifiable interview transcripts, audiotapes and hard copies are
stored separately and secured in a locked cabinet and computer files password-protected
and having sole access to all research data.
Summary
The central research question in this study focused on the experiences of health
disparities among first time pregnant minority women as they seek health care for the
first time. I explored a qualitative narrative approach to understand the phenomenon in
the question of health disparities in access to care narrated by minority pregnant women
experiencing the phenomenon and voluntarily share the series of events. In this chapter, I
discussed the research design and rationale for selecting qualitative narrative approach as
the appropriate choice for this study. I discussed the importance of transparency of my
role as a researcher, the logic for recruiting methods, possible recruitment, participant
selection, and the study instrument I used for data collection. Also covered in this chapter
are the techniques for organizing and analyzing the collection of data, the importance of
addressing trustworthiness and ethical concerns to enhance the trustworthiness and
93
transparency of this study. In Chapter 4, I discussed details of the setting, participants’
demographic background, data collection, evidence of the research quality, and research
outcomes.
94
Chapter 4: Results
Introduction
The purpose of this inquiry was to understand (a) what SES, provider’s perception
of their race-ethnicity, knowledge, and care-seeking factors influenced first-time pregnant
minority women’s access and use of health care, and (b) what first-time pregnancy health
disparity may be unique to this population. I conducted in-depth, face-to-face interviews
with 12 Black/African American and non-White Hispanic/Latino American first-time
pregnant women using semistructured narrative description questions (see Appendix D)
to gather detailed data required to answer the three RQs that follow:
• RQ1: How do the experiences of women, minority and underserved, of
childbearing age as they seek health care affect their ability to achieve positive
pregnancy outcomes (defined as term vaginal delivery, appropriate birth weight
for infant and pregnancy weights for mother, and to avoid postpartum depression
and infant mortality)?
• RQ2: What are the self-reported health disparities in first-time pregnant minority
women as they seek health care for the first time?
• RQ3: How has access disparities affect the overall experience and perception of
first-time pregnant minority women as they seek health care for the first time?
In this chapter, I discussed details of the setting, participant’s demographic
background, data collection, evidence of the research quality, and research outcomes.
Pilot Study
Following IRB approval and updating the study invitation flyer, consent form,
95
and interview guide, I collaborated with community organizations to recruit potential
study participants. I recruited and completed a pilot study with two initial study
participants. Pilot studies are a fundamental phase of a study that allows the researcher to
conduct and evaluate the feasibility of some crucial components, e.g., process, resources,
or data management of the full-scale study (F. Gonzales, Le, & Perry, 2014). The pilot
study helped me to test critical steps of the study methodology, including the participant
recruitment rate, time and resources, problems with data collection tool (see Appendix
D), and data analysis techniques. Results of the conducted pilot study indicated the
feasibility of the interview guide to generate the needed data to address precisely the
study questions. The recruitment process for the main study was identical to the pilot
study without change to the protocol. The pilot study participants met the eligibility
criteria detailed in the study invitation flyer (see Appendix A). I screened participants
using the initial eligibility screening tool since there were no changes to the protocol (see
Appendix B) and requested that participants complete the demographic data form (see
Appendix C). Before the interview, I read the consent form in the entirety to each
participant to dismiss any ambiguity then obtained their signature as an indication of
consent to participate in the pilot study. Both pilot study participants’ answers to the
interview questions explicitly addressed the three research questions. More importantly,
the responses of the pilot study participants confirmed the alignment of the study flyer,
demographic form, eligibility screening tool, and the consent form with the study
problem and purpose. During the recruitment and interview process, study participants
did not seek further clarification indicating all study documents were easily
96
understandable. The voice recorders produced uninterrupted feedback indicating privacy
of the interview room. Without issues of the pilot study, the result was successful;
without changes to protocol about the interview guide. The experience of completing a
pilot study provided crucial insight into my interviewing skills (strengths and
weaknesses), which augmented my confidence during the primary study interviews.
Study Setting
The participants’ responses to the interview questions formed the only data source
used in this study. Face-to-face interviews conducted with each study participant took
place in a private room at a local community center in the MA. Irvine, Drew, &
Sainsbury (2013) emphasized that face-to-face interviews are far more advantageous in a
private setting enabling researchers to leverage visual and personal interaction to connect
with participants allowing them to feel safe and understood to open up and share their
emotions freely. Privacy is paramount in one-on-one interviews, allowing participants to
let their guard down and trust the qualitative interview process (Mealer & Jones, 2014).
Participants felt an overall sense of comfort to share the series of events and lessons
learned from their experiences because of uninterrupted privacy. Social cues, such as
voice, intonation, or body language of the participant, can provide the interviewer
additional information that can be added to the verbal response from the interview
questions (Doody & Noonan, 2013; Irvine, Drew, & Sainsbury, 2013).
I decided to engage participants in light conversation to ensure a level of comfort
and to build a trusting relationship before the start of the interview. In line with the
assertions of Irvine et al. (2013), showing a welcoming start helped me earn the
97
participants’ trust enabling them to share freely their series of events from their
experiences, which allowed me to capture their emotions during the interview process.
During this time, I gave participants a $10 gift card as an assurance that it was not
compulsory to complete the interview to be compensated. As stated in previous chapters,
I used additional data collection tools, including field notes and memos to record
additional data from observing and listening to participant responses during the interview
process. The importance of triangulation provides the consistency of results generated by
different data collection methods (Denzin, 1978; Montgomery & Bailey, 2007; Patton,
1999; Tessier, 2012), which helped facilitate a more in-depth understanding. Because a
single method may not adequately illustrate the phenomenon or produce an
understanding, I used data from field notes and memos to enhance my recorded interview
transcriptions, which corroborated my findings (Patton, 1999). Patton asserted that the
triangulation method provides a rich, robust, comprehensive, and well-developed study.
After obtaining responses to all interview questions, I addressed any outstanding
concerns, then briefed participants on the next steps after data collection and thanked
them equally for participating in the study.
Participant Demographics
Participants provided relevant demographic information needed explicitly for this
study by completing the demographic checklist (see Appendix C), including participants’
age, marital status, race/ethnicity, current place of residence, level of education,
employment status, household income, and health insurance status. Table 1 outlines the
key demographic information of recruited study participants. The age of participants
98
ranged between 23 years and 44 years. Approximately 20% of participants were married,
60% were single mothers, and 30% lived with boyfriends. Almost 55% of the participants
self-identified as Black/African American and (45%) as non-White Hispanic/Latino
American. All study participants (100%) confirmed residence in the targeted geographic
area. More than 70% reported having a high school degree, 20% reported an associate
degree or equivalent diploma, 10% reported a bachelor’s degree or higher, and only two
participants (20%) had education below high school level. More than 55% of the
participants were not working at the time of the interview; only 45% had employment,
and overall, 20% were enrolled in higher education. I assigned random pseudonyms to
maintain confidentiality (i.e., Taylor, Tiffany, Tammy, Toya, Tamica, Tori, Tess, Tandy,
Terri, Tina, Tanya, Tommy).
99
Table 1
Demographics of Study Participants (N = 12)
Participants Age Marital status Residence Education Employment Household
income
Taylor 31 Single MA HS Employed Low
Tiffany 28 Single MA LHS Employed Low
Tammy 25 Lives w/boyfriend MA HS Unemployed Low
Toya 30 Married MA Associate’s Employed Middle
Tamica 26 Single MA HS Unemployed Low
Tori 42 Single MA Bachelor’s Employed Middle
Tess 27 Lives w/boyfriend MA HS Unemployed
Low
Tandy 35 Married MA HS Unemployed Low
Terri 23 Single MA LHS Unemployed Low
Tina 29 Lives w/boyfriend MA HS Unemployed Middle
Tanya 24 Single MA HS Employed Low
Tommy 44 Divorced/Single MA Associate’s Employed Low
Note. MA = Metropolitan Area; HS = High school; LSH = Less than high school.
Data Collection
I collected data from 12 first-time pregnant minority women, living in different
cities in the MA, who volunteered to share the series of events and lessons learned from
their experiences through answering the interview questions listed in Appendix D.
Participants were (a) legal United States residents or citizens, (b) Black/African
American and non-White Hispanic/Latino women living in northeast MA, (c) 18 years
and older, (d) first-time pregnant minority women, (e) first-time use of prenatal or
essential care, (f) able to speak and read basic English.
100
Table 2
Eligibility Characteristics of Study Participants (N=12)
Mother’s name Type of health insurance Gestation at time of prenatal
care visits
Taylor
Tiffany
Tammy
Toya
Tamica
Tori
Tess
Tandy
Terri
Tina
Tanya
State-funded
State-funded
State-funded
Private
State-funded
State-funded
State-funded
State-funded
State-funded
State-funded
State-funded
11 weeks
9 weeks
12 weeks
5 weeks
8 weeks
6 weeks
10 weeks
10 weeks
12 weeks
14 weeks
9 weeks
Tommy
State-funded
6 weeks
Note. All participants recruited in this study responded to invitation flyers (see Appendix A)
First-time pregnant minority women who showed an interest in participating in
the study contacted me directly using the information provided on the study invitation
flyers. I gave each prospective participants a brief introduction to the study and
completed an initial screening process (Appendix B) that lasted 7 to 10 minutes to
determine eligibility. After determining the eligibility of prospective participants and
confirming their interest to participate, we worked together to schedule a convenient date
for the face-to-face interview. Potential participants who did not meet the screening
101
criteria were informed immediately of their ineligibility and thanked for their interest and
time. During the interviews, I asked the study participants several semistructured
questions relating to the phenomenon of access disparities in PNC services listed in the
interview guide. Walden University’s IRB and dissertation committee approved the
content of the data collection tool—interview guide. As mentioned, I emphasized the
confidentiality of participants by omitting their real names and assigned pseudo-names,
used during data collection, analysis, and reporting of study findings. Interviews
conducted without incident for all participants, with no significant concerns during the
process. The duration of each interview lasted approximately 30 and 45 minutes, during
which study participants voluntarily shared stories of the series of events and lessons
learned of their personal experiences related to the phenomenon of access disparities in
PNC.
I used an audio-tape recorder for the interviews. To supplement audio-recording
of each interview, note-taking were used to capture nonverbal language and elements of
the interview and field notes to complement the audio recording, capturing quotations
and salient attributes of participants’ behavior (i.e., nervous laughter) or nonverbal cues.
Memoing in addition to notetaking and field notes provided additional recording of
reflective field notes about the phenomenon in question. Jotting down keywords, brief
phrases, and quotes, during unobtrusive moments, helped to jog my memory when
collecting comprehensive fieldnotes. There were no variations from the initial plan set
forth of the multiple approach to record the data during the interview process.
102
After completing the interview process, I immediately transferred all recorded
interviews to a single file folder on my computer secured with an encrypted passcode. I
transcribed all interview audio-recordings into word documents. I conducted member
checking of the transcribed data with all participants via phone calls in which two
participants requested slight changes which were edited and reflected in the data.
I stored duplicate copies on an external device stored in a secured safe to ensure
the transcribed data is in multiple secured locations to avoid data loss from an unexpected
technology failure. Also, I have placed field notes and memos securely in a pass-coded
cabinet accessible only to me.
Participant Profiles
Below are brief profiles of 12 first-time pregnant minority women I interviewed
in this study identified by only the assigned pseudo-names. Each profile detailed the
participant’s demographics, including age, marital status, residence, education level,
employment status, household income, and insurance status. Also, profiles include
information related to the types of health insurance participants had during the time of
PNC, as well as the time of gestation of their first PNC visit.
Participant 1, Taylor, was a 31-year-old married woman living in northeast MA at
the time of the interview. She identified herself as a legal female born in northeast MA.
Taylor has a high school diploma from an area school in northeast MA and is currently
employed part-time as a cashier at a grocery store. Taylor noted that having a high school
diploma puts her in a low household income bracket and is qualified for the free state-
103
funded health insurance program for low-income earners. She used the state-funded
health insurance program to access PNC services.
Participant 2, Tiffany, was a 28-year-old single woman living in the area at the
time of the interview. She had lived in northeast MA by the time of data collection. She
came to the United States from Guatemala in 2012 to live with her family. Tiffany
reported low household income working as a babysitter three to four times per week and
shares she will not have a job the further along she gets in her pregnancy. She obtained
PNC using state-funded insurance for pregnant women, and her health insurance status
remained the same at the time of data collection. She reported less than high school
education.
Participant 3, Tammy, a 25-year-old woman, is one of the youngest participants in
this study at the time of the interview. She identified herself as being born in the United
States and living in northeast area all her life. Tammy has a high school diploma and
believes it is the main reason why she can never find a good-paying job. She is currently
unemployed and is living with her boyfriend, who works for BC. Their household income
is low, qualifying her for the state-funded health insurance. Tammy reported that she
used this state-funded insurance for all her PNC needs.
Participant 4, Toya, was a 30-year-old woman living in northeast area at the time
of the interview. She is born in the United States and moved from Tennessee to northeast
area in 2015 with her husband. Toya is one of two participants with a post-high school
(Associate’s) degree in which she states she has always been able to hold employment.
She has private insurance through her husband’s job and can access her scheduled PNC
104
service. Toya is one of three women in this study who reported middle household
income.
Participant 5, Tamica, was a 26-year-old single woman living in the northeast area
at the time of the interview. She self-identified as a naturalized United States citizen from
Mexico. She arrived in the United States in 2011 with her parents. She believed she
would be married after becoming pregnant, which she discussed with her then finance;
however, based on cultural differences and distance, they decided to dissolve the
relationship. Tamica is currently unemployed with a high school diploma and relies on
her mother financially and reports her dad has ill health. Tamica has presently applied for
state welfare ahead of the birth of her child. She obtained all her PNC using state-funded
health insurance.
Participant 6, Tori was a 42-year-old single woman who is born in the United
States and living in northeast area at the time of the interview. Tori is the only participant
in this study with a bachelor’s degree and one of two participants with a post-high school
degree. Tori is currently employed and reported that she is in a middle-income household
bracket. She reported that she used to have a decent job with great health benefits until
new management changed the health benefits, which made it harder for her to afford
private insurance. Tori believed that at her age, she could be in a high-risk pregnancy
bracket and needed all the prenatal and postnatal care services available. She has used the
state-funded health insurance for the past two months for her healthcare needs.
Participant 7, Tess, was a 27-year-old woman who lives with her boyfriend and
his parents in the northeast area at the time of the interview. She self-identified as a legal
105
immigrant from Mexico. Tess moved to the northeast area, 2012, in the hopes of going to
school and becoming a schoolteacher. Tess shared that she always seems to acquire low
paying jobs even though she can speak the English language and feels undervalued. Tess
noted that she completed high school but still had jobs working minimum wage since
moving to the United States. She is now unemployed since becoming pregnant and must
rely on her boyfriend and his family financially. She reported that even though her
boyfriend works, she has lower household income, adding that that is why they had to
live with her boyfriend’s parents and qualified for public health insurance. Tess used
public health insurance to meet her PNC needs.
Participant 8, Tandy, was a 35-year-old married woman living with her husband
in the northeast area at the time of the interview. She self-identified as a legal immigrant
from Honduras who had moved to the United States in 2012 with her husband. At the
time she moved to the United States, she wanted to have children and be a stay at home
mom while her husband works. She graduated high school back in her home country but
never went on to community college because she felt her husband’s income could
provide for the family even though she reports lower household income currently. She
shared her husband’s job does not offer health insurance for them and is frustrated
because she is pregnant and needs help with her PNC needs. Tandy used private health
care for her PNC needs provided by her husband’s employer.
Participant 9, Terri, was a 23-year-old single woman living in the northeast area at
the time of the interview. She reported that she is a United States citizen and has lived in
northeast area her entire life. Terri is the second person in this study with less than a high
106
school diploma, and she regrets not finishing high school because her father is
incarcerated, and she needed to help her severely ill mother. She finds herself in a
problematic predicament being pregnant and unemployed and without the help of a
significant other or partner to give her the support she needs. Although other family
members help with her mother, they have their own lives and family burden. She was
currently seeking employment because her mom is doing much better, and she wants to
be independent and support her child financially. Unfortunately, she is no longer in
contact with her ex-boyfriend and must rely on public health insurance for her PNC
needs.
Participant 10, Tina, was a 29-year-old unmarried woman living in the northeast
area at the time of the interview. She self-identified as a United States born citizen living
in the area all her life. She was living with her boyfriend at the time of the interview and
shared that although her boyfriend works a good job because they are unmarried, she is
not entitled to his health insurance. She shared that working as a home health aide and
lifting her patients became unbearable as she hit her second trimester. Tina preferred to
find a job that does not require much standing or lifting. Tina’s boyfriend work with the
police department and his income place them in a middle-income household status. Tina
obtained PNC services using state public health insurance.
Participant 11, Tanya, was a 24-year-old, unmarried single woman living in the
northeast area at the time of the interview. She self-identified as a legal immigrant from
Tijuana, Mexico. At the time of the data collection, Tanya reported moving to the United
States at age 16 with her parents. They moved to the United States in 2011 because of her
107
grandparent’s sponsorship. Tanya has a high school diploma and is employed as a
certified nursing assistant at a rehab facility and worked a part-time job at the hospital
after becoming pregnant. She was enrolled in a phlebotomy class at her part-time job at
the hospital. Tanya is estranged from her boyfriend and reported a low household
income. She used public health insurance provided by the state for all her PNC needs.
Participant 12, Tommy, was a 44-year old divorced single woman living in the
northeast area at the time of the interview. She self-identified as a United States citizen,
living in the area for the past 22 years after moving from Ohio with her then-husband in
1997. Tommy is employed, holds an associate degree in fine arts, and is in the first year
of school to become a licensed practical nurse. She works full-time as a dietary aide at a
skilled nursing facility. She reports that her new boyfriend is the father, and he is still in
her life, but they do not live together. Tommy reported a low household income and
qualified for state-funded health insurance.
Data Analysis
In this section, I describe the procedures I followed to analyze the data using the
Thematic Analysis 6-step narrative descriptive data analysis technique as detailed in
Beng et al. (2014). Data analysis started after interviewing the first study participant and
developed side-by-side with data collection. I followed the Thematic Analysis 6-step data
analysis technique with the aid of NVivo software previously highlighted in Chapter 3.
The data collected was transcribed into notes. I listened to the audio-recording
several times to ensure accuracy then transcribed the data into a note pad. After
transcribing each participant’s data onto a note pad, I listened to the audio-recording
108
again and read the notes to confirm the accuracy of and to correct any errors in the
transcript. I followed the first step in the 6-step thematic analysis as recommended by
Braun and Clarke (2006) by reading and re-reading the transcripts to become familiar
with the body of data and other relevant data (i.e., interviews, field notes, memo). At this
stage, I made useful notes and jotted down early impressions to capture my thoughts
about the participants.
In this second step, I generated initial codes way. The use of NVivo 12, a
qualitative data analysis software, helped to organize, manage, analyze, and condense
transcribed data into codes. New codes were generated and sometimes there were the
modification of existing codes with each identified theme as suggested by Braun Clarke
(2006). I identified themes by hand initially, working through hardcopies of the
transcripts using multiple highlighters, combing through the data more than once until
themes emerged.
In Step 3, I grouped commonly used words using a table organized with two
columns. One column lists inductive categories and the other column lists participants’
responses. In other words, data units included specific words, phrases, sentences, and or
paragraphs identified as useful. I looked at the themes that were significant then
categorized the themes into larger thematic groups as recommended by Braun and Clarke
(2006). At the end of this step the codes were organized into broader themes that
reflected specific response to the research question (i.e., they described data patterns
relevant to the research question).
109
For example, assigned code reflected each data unit, i.e., a participant’s response
relevant to a code is labeled to reflect a specific code. When participants mentioned the
code, it is noted to reflect the number of data units related to that code. After thoroughly
reviewing each transcript and coded all data, I reviewed the codes. I deleted data not
relevant to my research question, to reflect a set of codes related to the study.
Table 3
Sample of Initial Codes
C P D units
Community should offer support
Doctor should provide equal care
Doctor should provide vital education
Doctor’s role
Would use other sources instead of doctor
Nurse should be a point of resource
Nurse could be an advocate
Nurse’s role
Insurance has impact on care
Would use other sources instead of doctor
Irregular appointment attendance
Unable to judge if questions interpreted properly
Fear of unspecified disadvantages
Interaction has an emotional impact
7
6
2
1
5
5
3
1
2
1
9
11
7
8
8
7
3
2
6
4
4
1
3
2
10
11
8
9
During this phase, Step 4, I reviewed, modified and developed the preliminary
themes that were identified in Step 3 for useful and relevant data until the categories were
saturated. I refined themes into one theme and coherent patterns to reflect the meaning of
the participants responses, defined and named themes to identify and capture the essence
of the themes, and validate findings with the data collected.
110
Table 4
Sample of a Theme
T and Ass Categories N . of
P
N . of Data
U
Prenatal Access Disparities
Convenience of PNC access
Insurance types
Uninsured
Meaning of health access disparities
Types of prenatal access disparities
Disparities in access to specialized care
Unemployment & Low income
Limited insurance coverage
Lack of money impacts care
Limited or no access to privatized care
Limited access to specialized care/doctors
Long waiting times
Incomplete or deficient care
Low level of PNC
Limited access to health care information
12
3
2
9
7
8
11
10
6
8
4
4
7
8
5
3
4
3
11
8
15
14
10
7
8
7
4
8
14
5
4
In Step 5, I defined and made final refinement of the themes with the goal of
identifying the significance of what each specific theme (Braun & Clarke, 2006). At this
stage, I asked myself, what does the theme convey? How do the subthemes interrelate
and relate to the main theme? How do the relevant themes relate to other themes? When
discrepancies raised in the answers to these questions, I adjusted the theme’s creation by
separating, combining, or deleting and recreating a new theme.
Here I draw on Braun and Clarke’s (2006) framework and applied it in a
meaningful and systematic manner to define and clarify the process of analysis within the
context of PNC access disparities. The findings from the study reflect the phenomenon of
access disparities in PNC as viewed from the lenses of participants’ accounts of events. I
111
remained consistent throughout the interview process of study participants asking all the
same questions. The combined use of NVivo 12 and the Thematic Analysis 6-step data
analysis technique enabled me to deduce meaning from the narratives and series of events
participants shared about their personal experience related to the phenomenon of access
disparities in PNC. Interview questions generated consistent responses throughout that
addressed the study questions, and I was able to organize and arrange the data collected
consistently to RQs and corresponding IQs.
I analyzed and interpreted the organized data using constructs of ANFHSU, the
theoretical framework that guided this study. I created nodes for each interview question
rereading data and notetaking on initial ideas from transcribed data capturing best the
study participants’ personal experiences with the phenomenon of access disparities in
PNC. Analyzing the data in this format allowed me to remain organized, to visualize the
data, to capture meaning on participant’s responses, and to understand themes as well as
emerging patterns. There were no discrepancies in the relevant cases.
Evidence of Trustworthiness
Credibility
The initial step I took to ensure the credibility of this study was to conduct a pilot
study to test the authenticity of the interview guide. The pilot study aimed to ensure that
the data collection tool gathered accurate data needed to answer the three research
questions. In Castillo-Montoya’s (2016) pilot study, she revealed that interview guides
could be strengthened through piloting the interviews to help identify flaws or limitations
within the interview design. The pilot study helped me prepare for the primary study,
112
maintain consistency, and ensure that planned data collection procedures were able to
generate needed data (Dikko, 2016). Also, I collected different forms of data to support
the interview process, including field notes, memos, and audio, allowing triangulation
during analysis establishing data consistency, hence strengthening the credibility of study
findings (Cleary et al., 2014; Harding, 2013). Similarly, as noted by Tufford and
Newman (n.d), I applied bracketing and set aside any preconceptions and prejudices.
Remaining objective during the interview process enabled me to maintain a thorough
reflection on my study as it progressed.
Transferability
To achieve transferability, I gathered a rich descriptive research context to
provide a robust and detailed account of the women’s experiences during data collection
to define the scope of this study. The facets of data collection helped provide a more
robust and fuller understanding of the research setting. Thus, results from this study may
be applicable to similar studies conducted by researchers investigating the similar context
of the problem, in comparable situations, on related groups or populations (Dye et al.,
2019). During the process of this entire study, I remained objective to set aside any
preconceptions and prejudices from influencing the study process and findings.
Dependability
To enhance dependability, I thoroughly applied the methodology appropriate for
this study. One example, I consistently applied IRB approved ethical guidelines to recruit
and interview participants, and during data analysis. I used a research journal and
established and maintained audit trails to a keep record of the study process to establish
113
study validity and to demonstrate quality research. Audit trails provide detailed step-by-
step reports of each stage of the research process, thus enabling future researchers to
repeat this study in similar settings on similar study groups or populations (Miles et al.,
2014). The interested readers wanting to learn more about the quality of this study may
gain insight from reviewing the research journal of this study, where I recorded how I
maintained objectivity and essential steps I used to address possible researcher biases.
Confirmability
I defined clearly, applied thoroughly, and ensured my research is operationally
sound throughout the study process to achieve confirmability. The rationale for providing
clarity of the study methodology was to ensure readers with different interpretations can
differentiate how I arrived at my study conclusions. NVivo’s query tools helped in
facilitating the process of abridging and organizing the extensive qualitative data and
auditing findings (Yahmady et al., 2013). I maintained audit trails to track the
comprehensive background of the data and the motivation and rationale for all
methodological decisions taken throughout the study. The technique of audit trails, as
emphasized in Miles et al. (2014), is to document, organize and track throughout the data
process. Audit trails afforded me the opportunity to summarize my thoughts and
rationale, thus ensuring the level of confidence of the research findings based on the
participants’ narratives.
Results
I interviewed each study participant privately on the date specified and schedule
at the agreed-upon venue. Once I completed transcribing and analyzing the data of my
114
first recorded interview, I knew it was vital to include examples of verbatim sentences
and spoken words accurately as narrated by the study participants during the interview
process. During the transcription and analysis process, it became evident that majority of
the participants provided similar responses to the interview questions. During the
transcription process, I gave particular attention to sound and intonation expressed by
participants’ capturing all the details conveyed during the interview processes. Getting
the story behind the participant’s account of their experience contributed rich information
on the detailed narrative.
Also, I used field notes to capture and record nonverbal communication and
behaviors of participants during the interview process, including eye contact, facial
expressions, gestures, and pauses. Initially, I sought to present the data using the ten
interview questions (IQs) in which study participants responded. After participants’
responses presented close similarities between emerging themes, I continued with my
data analysis and used themes instead. In this study, I sought to present the voices of first-
time pregnant minority women as they narrated the personal account of each unique
experience of prenatal access disparities. I used the six themes and 14 subthemes that
emerged from analyzing participant responses to interview questions . Themes were
selected and refined based on the relationship between phrase, statement, and word as
they emerged during data analysis in NVivo 12.
Five participants responded to interview questions IQ9, and one participant
responded to interview questions IQ10. All five responses to IQ9 emerged as coherent
patterns supplementing the other eight interview questions in which I integrated them into
115
the main IQ they addressed. Only one participant responded to IQ10. Otherwise, there is
no distinction between the results for IQs 9 and 10 from participants’ responses.
Research Question 1: Prenatal Access Disparities Experienced by First-Time
Pregnant Minority Women
The first research question was: How do the experiences of women, minority and
underserved, of childbearing age as they seek health care affect their ability to achieve
positive pregnancy outcomes (defined as term vaginal delivery, appropriate birth weight
for infant and pregnancy weights for mother, and to avoid postpartum depression and
infant mortality? Expecting to generate quality responses, I ensure that all participants
enrolled in this study had (a) sought and used prenatal services, (b) a clear understanding
of what health access disparities mean, and (c) had experienced the phenomenon of
access disparities in PNC. To achieve this goal, I developed four interview questions
(IQs) that generated responses by study participants:
IQ1. Tell me about the various forms of prenatal health services you sought and
used since you suspected or found out you are pregnant.
IQ2. What do you understand by health prenatal/access disparities?
IQ3. Can you describe to me an instance(s) when you experienced prenatal/access
disparities or when you felt you were being treated differently in the process of
seeking prenatal services?
IQ9. Is there anything else you want to share with me concerning your PNC
service experiences in relation to prenatal/access disparities?
116
Data analysis showed all participant responses to RQ1 held comparable meaning.
All participants reported experiencing one or more forms of access disparities in the
process of seeking PNC. Three emerging themes from participant responses to RQ1: (i)
types of PNC services, (ii) meaning of health access disparities, and (iii) types of prenatal
access disparities, including five subthemes (i) access to obstetrical disparities, (ii) care
quality disparities, (iii) patient information access disparities, (iv) health literacy
disparities, and (v) waiting time disparities.
Theme 1: Types of PNC services. Although participants admitted challenges in
accessing PNC services, they used at least one or more types of PNC services since
becoming pregnant before data collection time. When asked to tell me the kinds of
prenatal services they had used since becoming pregnant, some participants did not
quickly grasp the term “prenatal services.” However, after providing a short explanation
of types of prenatal services, all participants reported various kinds of care they had used,
including obstetric, STI screening, and family planning services. Also, several late
trimester services or delayed entry into PNC were reported because of the lack of
education or insurance coverage, public or pregnancy-related coverage, ambivalence
about or unintended pregnancy, negative perception of health care providers, and
behavioral constructs (i.e., prenatal initiation, alcohol, and tobacco use). Tiffany shared
the PNC she used after finding out she was pregnant. She reported:
. . . I tried to attend regular PNC visits during pregnancy to monitor the health of
my baby. I first used state-funded insurance when I was 9-weeks pregnant. During
these appointments, the nurses checked my vital signs and such, and they gave me
117
wellness questions to fill out. Occasionally, during these visits, they would do
ultrasounds or blood work. At one point, during my prenatal appointment, the
doctor prescribed me prenatal vitamins.
In a similar account, Tamica shared that with limited access to private
transportation, she ensured that she attended the recommended prenatal appointments.
She had learned about the importance of maternal care in receipt of adequate essential
services and outcomes, and wanted to avert any risks:
I must admit that it was not easy for me to attend all recommended care because I
had no car, I’m unemployed and single being 2-months pregnant . . . but because I
wanted to learn more about my pregnancy, I tried not to miss any recommended
PNC services with limited state-funded health insurance. I wanted to understand if
I am missing anything or if there are important things to know or do being
pregnant. I think I attended all my prenatal visits. During these visits, the doctor is
in and out, and I normally do not learn anything new even though I ask questions
about this and that.
Whereas variations were reported in the number of PNC services used by
individual participants, data analysis indicated that each used one or more types of PNC
services. For instance, when asked to explain prenatal services she used after becoming
pregnant, Tess stated, “I used the community health services in the past 2-months after I
found out I was pregnant.” The doctor there sometimes was a baby doctor; otherwise, just
a regular doctor checking my blood pressure but not always doing ultrasounds. Similarly,
Terri stated, “I have used PNC services at the community center because this what I
118
could afford since I am not working. I went for pregnancy checkups and was
recommended resources like birthing classes.”
Theme 2: Meaning of health access disparities. After asking study participants
to share the types of prenatal services they used since becoming pregnant, it was vital for
me to elicit their understanding of health access disparities. The rationale was to
understand participants’ perception of what health disparities informed their views about
their experience of prenatal access disparities. Their responses elicited varied phrases,
statements and words without any ambiguity of the meaning of health access disparities.
When asked what health access disparities meant to her, Tori stated:
It means having not the same kind of health access and health care as everyone
else or someone with more privilege, you get lesser care, and when you’re rich you get
better care as if you are not valued as a person. I will never have access to a private
doctor or specialists because of access disparities. The way it is….is that with no private
insurance there is limited access to a medical team, you may not have access to certain
doctors or specialists because of your public or free insurance. Some doctors don’t take
certain types of insurance. Therefore, your access to better health care or better services
like seeing a specialist doesn’t exist because of the types of insurance. That’s the types of
disparities I experienced.
Likewise, Terri’s response suggests a clear grasp in her description of health
access disparities:
. . . well, health care access disparities to me is not having the same or equal
access to quality care no matter where you’re from or the color of your skin or
119
how you speak. I know that it is not equal health services given to everyone the
same, some get better and others not so much because of your race and when you
speak, they think you are stupid or don’t understand. This is what I go through,
my experiences.
Compared to other participants, such as Tess, Tonya responded with much
confidence in her precise response, giving the impression that she knew what health
access disparities were. She replied: “To me, this is the unfair treatment or the differences
in access or availability of care, services, or facilities in a certain setting.”
Responses from other study participants, including Tiffany, Tandy, Tina, Tanya,
Terri, Tommy, and Tamica, provided similar insights. Similar views on health access
disparities surrounded inequalities in quality care or access to quality care. Interestingly,
Taylor and Tammy explained that their understanding of health access disparities
unconventionally as tragic. Taylor, when asked what health access disparities mean to
her, she felt they just don’t care if she existed, and Tammy spelled out in no uncertain
terms, “they just don’t like me, they don’t like our kind” in response to the question
directly. Tori reported:
To me . . . health access disparities . . . mean . . . not having equal opportunity or
opportunities to proper care when needed. Everyone do not get the same good
treatment in care that they should which I think is determined by the providers
based on the policy you tend to have. The environment and community where all
patients, all people who need care are not treated the same, even with the same
diagnosis. All of this is determined by your zip code because better treatment and
120
care comes when you have money or better insurance. For example, Black and
Brown people don’t get the same opportunities in life like White people do. When
you have free insurance, it’s like you are a nobody. Even though I work, I can’t
afford the type of good insurance to get to the best quality care; we are treated
poorly and unfair.
Like Tori’s response, Toya reported:
I know first-hand what health access disparities is like to not have access to the
best health care, the doctors, or quality of care. Access disparities means second
class health care services, which is long wait, being skipped and not being valued
to get the best treatment or even simple information about how to keep yourself
healthy and even for necessary and timely treatment. I used to have private
insurance with my job and will now have to rely on public health insurance
because my job has made changes to their health insurance policy for employees,
and I will only have supplemented insurance because I can’t afford the increase.
Another point I am trying to make is, why should we find out late that something
is wrong with our pregnancy or have babies that are underweight because no one
is teaching us anything?
Theme 3: Types of prenatal access disparities. Statements, phrases, and words
supporting recent first-time pregnant minority women accounts of their experience
unequal access to PNC services compared to other counterparts emerged from most
participants. More than 91% (11/12) of all study participants reported they experienced
one or more types of disparities. Only one participant, Toya a 30-year-old, married
121
woman who reported a middle household income status did not believe she was treated
indifferently compared to similar care seekers. However, she reported she started using
public health insurance, and can see a difference, which was a negative experience.
Participants reported several types of access disparities, including disparities in access to
obstetrical and diagnosis services, gaps in care quality, disparities in patient information
access, and disparities in waiting time.
Disparities in access to specialized services and diagnoses services. More than
50% (6/12) of the total study participants reported having failed to obtain some form of
necessary specialized care or diagnoses they needed in the process of seeking prenatal
services. Taylor shared her frustration regarding her failure to access specialty care, such
as obstetric care during pregnancy, which she attributed to disparities. She shared that she
did not always have access to an obstetrician or the same obstetrician who knew or had
seen and treated her previously. That disparity in access to specialized care contributed to
her maternal weight gain. She showed signs of frustration in her facial expressions, in her
tone, and body language when she spoke of not seeing a specialist for over six weeks
after an ultrasound result indicated a complication with her pregnancy. Taylor stated:
I don’t know how to begin to tell you of my frustration or if I can find the words
to tell you what I experienced when I went to see doctors during my pregnancy. I
have a strong belief that it was because I did not have insurance as well as my
skin color:
The results from my ultrasound showed that my baby was not developing well,
that the baby’s lung is underdeveloped, and her head was not proportionate with
122
the rest of her body. I was given specific instructions to see a neonatal
pulmonologist. Inopportunely, the appointment was delayed between 4 - 5 weeks.
If I had private insurance, I would not have had to wait for this long. This only
happen to people like me who rely on public health insurance and have no choice
but to take what they give me or see who they say to see when they say to see
them.
Tamica, a 26-year-old woman, reported an incidence of unequal access to
specialty PNC and diagnoses services similar to that of Taylor. Tamica recounted that
when she visited for one of her prenatal appointments in the second trimester, the doctor
indicated that she had protein in her urine and higher than usual blood pressure. She was
given specific instructions to see an obstetrician immediately but was never told why and
became overwhelmed and stressed by the information. Infuriatingly, she could not see a
recommended specialist immediately because of the availability schedule. She viewed
this as access disparity in specialized care. During the interview, Tamica responded
fervently, when discussing her account of these events:
I always feel less than when I go in for my doctor visits or appointments because I
believe I am always treated different, with the long waits or not scheduled for my
recommended follow up appointments timely. Let me share this one experience
because it bothers me to this day, and I will continue to tell everyone I know.
During one of my regular prenatal visits, the doctor told me I may have
preeclampsia, and I never understood what that meant or how this could have
cause me and the life of my baby. Overwhelmed with the news, I asked the doctor
123
to explain preeclampsia. and what does it mean for me and my baby? He
responded that I needed to see a specialist who will determine the appropriate care
for me . . .. I was never given an appointment to see the specialist after waiting to
speak with the receptionist and was told I will be called the next day with an
appointment date and time for the specialist’s appointment. Unfortunately, after
calling the following day and the day after, which took 3-weeks when I finally got
a chance to see the specialist. I have lost all interest in the health care system due
to the treatment of people like me who not understand certain risks about being
pregnant and not being able to afford proper health insurance.
Similar to Taylor and Tiffany’s experiences, four pregnant minority women (i.e.,
Tori, Tandy, Tommy, and Tanya) reported some form of unequal access to PNC,
specialty care, and diagnoses services. Notably, Tori and Tanya said that they were
recommended to see specialists for different prenatal reasons primary care providers
(PCPs), could not order recommended tests because the type of health insurance did not
cover those services. Tori shared that it was frustrating to learn that the type of specialist
she needed to see was unobtainable purely because her insurance could not cover or
found unnecessary, such expenses.
Similarly, Tanya shared that she was diagnosed with a medical condition that
required urgent surgery, but she had to wait for approval from state-funded health
insurance to determine if treatment and procedure were necessary or emergent, which
took 8-days. Frustratingly, Tanya stated that “If I had private insurance, I would have had
same-day treatment and attention. I would have been able to see the specialist the same
124
day.” She added further that variations in access to specialized PNC based on the type of
insurance a person has are ridiculous when it comes to a person’s health, and there should
be no compromise.”
Disparities in quality care. Several participants reported that the quality of care
they received from the health care team, including doctors, nurses, and other providers
varied from individuals from the front desk receptionist to discharge. Participants
perceived care quality in terms of the receipt of care when they seek care at health care
facilities. Some patients reported feelings of being undervalued or unimportant at some
point during their prenatal visits, others reported a sense of disingenuousness from the
staff and health care members.
Tandy shared an experience she viewed as receiving low-quality care compared to
similar care seekers:
. . . having public health insurance puts you at the bottom of the totem pole
because you are viewed as not being able to afford private insurance, and in this
instance, you can’t get certain appointments or specialist. The best appointments
of the day are given to those with private insurance, which means that you are
given appointments at inconvenient times, such as early morning or late evening.
What I witness is that a Black and Brown pregnant woman who has been waiting
for hours in waiting room do not have a right to ask the receptionist question
about their appointments. I have waited for my prenatal checkup appointment 2.5
hours past my scheduled time. I have not been treated nicely when asked about
the long wait and White women have been given the respect when asking the
125
same question. I decided to move to the appointment desk to ask what was going
on. I have witnessed these instances too many times to count from other pregnant
women who looks like me being treated as if I am a bother to them or invisible or
insignificant and unimportant.
Related to the experience of disparities in quality of care in receipt of seeking
PNC services by different patients as reported by Terri, several other participants
recounted scenarios of receiving less quality care compared to other care seekers. Tammy
shared that the doctors she saw during pregnancy always seemed less patient and
examined her quickly, never gave her any information, and she never replied to her
concerns. To Tammy, this was a disparity in quality of care:
. . . I must admit that I felt less than like I was nothing, and I always noted how
other pregnant patients had longer time with the doctor than me, which bothered
me a lot. Why wouldn’t this bother me when my appointment is sometimes less
than 10 minutes, and other pregnant women appointments are at least 30 or more
minutes with the doctor. I know I am not paranoid because I checked the time
because I couldn’t believe what was happening. The doctors I had seen were less
than interested in spending time answering any questions I had, or they never
once asked if I had any questions or concerns for them during my prenatal visits.
They always seem very dismissive and disrespectful in such a way in being less
attentive during my examination and focused more on my records than me. I
would say in my experience I have been treated poorly many times by these
doctors.
126
For Tandy, it was her experience she recollected that they will call her to
reschedule her appointment or having gone to her appointment to be told her appointment
was canceled or the long waiting times in the waiting rooms for her prenatal visits
without any explanations which she viewed as disparities in quality of care.
Disparities in patient information access. Five participants (i.e., Tina, Toya,
Tanya, Tommy, and Terri), about 42%, believed that their process of seeking PNC
involved disparities about access to information. These pregnant minority women
reported that members of the health care team, including doctors and nurses, were
unwilling to share critical health information about their health status. Tina, a 29- year-
old woman who developed diabetes during her pregnancy was never referred to an
endocrinologist or given any information regarding her diabetes or how it would affect
her unborn baby which she viewed as disparities in patient information access:
… going to the doctor means seeing someone who knows what the heck they are
doing, and you want to trust them, but how would you feel if you weren’t given
the information you needed to keep you and your baby healthy? This is how they
do us, we are nobody to them, and we don’t matter… but because of my skin
color. I prefer to get the information I needed to help me with the important things
I need to know. I want to be able to rely on the quality of information the doctors
and nurses give me each time. For example, my family friend went through
something similar when she was pregnant and told me some things that happened
with her baby. . .. They didn’t even give me an explanation on what was going on,
or what it means for my baby. I wasn’t told who to see, what I needed to do to
127
reverse the diabetes thing but that I must schedule my next appointment. No one
cared, not the nurse not the doctor, no one. I was disappointed because these
doctors are supposed to inform us when something is not right; I shouldn’t have to
rely on friends to tell me these things. She had a large baby because she
developed diabetes during pregnancy; it continued after she had the baby, she
never had diabetes before just like me; this was news to me…. And to think I
could use this bit of information; I want a healthy baby just like everyone else.
Terri, a 23-year-old woman without high school education and reported low-
income household shared that accessing her health information online is not always
possible, and she is limited in accessing her information:
I do not own a computer, and this means I must sometimes go to family or a
friend to have access, even so, what does this all mean? If they did not explain to
me any results or what these numbers are, then I still don’t know what they are
talking about…. I’m not in the medical or health field. Therefore, “getting the
information online doesn’t mean a thing to me if I don’t understand the important
patient information online. I don’t get any updates or information when I go to my
appointments; the doctors and nurses don’t talk to me about much. You would
think they would be interesting’ in knowing how I am managing with my
pregnancy; all they care about is to run in and out the room without even a
discussion, some of them don’t even make eye contact. The nurses are no better,
they tell you to go the patient portal and access the information from the
appointment. Every prenatal visit I go to, I always asked the doctors to share with
128
me while I am in the examination room to tell me my test results, but they
basically told me to go online. Sometimes you feel too ashamed to say I don’t
understand, or I have a problem with computers, I just go along with it and never
speak up for myself. I don’t know if something is wrong unless they tell me and
make recommendations. But when you don’t have the education like they expect
you to do, it’s like they look down on you. I believe everyone should have equal
access to their health information, and they should help to make sure we do. Terri
views these issues as disparities in patient information access.
Disparities in waiting times. During interviews, I asked participants to share
incidences where they felt that they experienced access disparities in the process of
seeking PNC services. Four participants viewed differences in waiting times as a type of
access disparities. These participants reported their waiting time to be oppressively longer
than that of similar pregnant care seekers during their scheduled doctor’s visits. They felt
it was unfair for patients with appointments to arrive 15 minutes early to accommodate
the doctor and wait for more than an hour, and more upsetting to see those who come in
after being called first to see the doctor. These four pregnant minority women knew that
disproportionate waiting times were a type of access disparity they faced in the process of
seeking PNC services. Tina reported that:
. . . they make you sit in the waiting room and wait for long hours; we are
pregnant women…it’s sad to see how they could treat anyone like that … it hurts
me because we must sit there and take it. Some days you are not feeling your best,
morning sickness or just plain depressed, so to sit there an hour or more and wait
129
for your scheduled appointment, it’s not like I just walked in off the street. When
you are waiting for the same doctor, you see other pregnant women who come in
long after you are going in before you seen by the same doctor makes no damn
sense. The receptionist become’ short with you when ask you voice your concern;
they are not interested to hear you or to give you an answer . . . it’s frustrating
because all you are asking for is for them to communicate with us, our time is
important too. No one tells you anything, not even the nurses, yet you see others
coming after you, and they are called in before to see the doctor, it’s upsetting and
painful to see that you are treated differently because of your skin color. This is
not a onetime thing, it happens every time I go for my doctor’s appointment, yet
you can’t say anything about it. Listen, some people get priority or special
treatment over me –cause as I’m waiting, they come in, check-in, and are
immediately taken back there to see the doctor. Something need to change, and
we needed to be treated the same, no matter where you come from or live. I see
how they treat me and others like me, and I don’t mean being pregnant, I mean
my skin color, our skin color.
Similar to Tina’s response, Tess referenced incidences during her prenatal
appointment visits when she waited longer to see her provider than her pregnant White
counterparts who came in much later, laughed and joked with the receptionists and did
not have to wait:
. . . I can share many incidences of not being treated equally during my prenatal
visits; I almost dread the time when I must go for my appointments. I know it is
130
going to be a long wait, and to watch other pregnant women go in before me,
these women are never Black or Brown women. This is hard to swallow because
of the unequal treatment I faced when I went to see doctors during my pregnancy.
I’m not one to hold my tongue; I complain cause I have a scheduled
appointment… it bugs me to be waiting an hour or more to see the doctor when
you see pregnant women who look like you, then it becomes upsetting, and there
is no way you can sit there and say nothing. I am not the only one to have
complained about it . . .. There was not one time I can remember when I went for
my prenatal check-up and was seen within 45 minutes of my appointment. It was
unbearable those days in my second trimester it seems to have gotten worst, that I
had to wait for hours. Treat others how you would want to be treated. I hated
seeing others come in long after I did and was seen before I did …. I could see if
this was a onetime thing …. it happened every time I went in for my prenatal
visits. There was no way you could not be mindful of the differences, and the fact
that other patients who came after me would see the same doctor, yet before me,
is what made the whole experience difference.’ This is never right, and it is unfair
to treat pregnant women differently for whatever reason. This is still a painful
experience for me, and they wonder why some people get stressed out. As for me,
I like to point this out to them when I go for my appointments; I want them to
realize that I can see what they are doing to people like me because I am not the
right color.
131
Summary of Results for Research Question 1
The first research question addressed (a) the types of PNC services first-time
pregnant minority women used after becoming pregnant before data collection time, (b)
what health care access disparities meant to first-time pregnant minority women who
participated in this study, and (c) the types of access disparities recently experienced. All
participants reported that they had sought and used PNC services.
Though participants used different phrases, statements, or words to describe
health care access disparities, there remains no significant variation in their responses.
Participants demonstrated to have a shared understanding of the meaning of health care
access disparities. Although some participants responded precisely, others contributed
detailed explanations equal to a full paragraph. Meanwhile, other participants appearing
to have no exact words, directly communicated about situations they believe they
experienced disparities to articulate their meaning of health care access.
Most first-time pregnant minority pregnant women I enrolled in this study
perceived seeking PNC services experienced one or more access disparities. More than
92% (11/12) of the participants reported incidents in which their perception represents the
unequal treatment compared to other counterparts. Only one participant, Toya, a 30-year
old married pregnant woman, stated that she could speak on both sides of the coin
because she was not treated differently in any way when she had her private insurance
compared to other counterparts. However, she now realizes the differences recently in
wait time, access to patient information now that she has used the state-funded health
insurance.
132
Disparities in access to specialized services and diagnoses, disparities in quality
care, disparities in patient information access, and disparities in waiting time represent
the types of access disparities reported by first-time pregnant minority women recruited
in this study.
More than 58% (7/12) of the total study participants reported needing essential
care and were not a recipient of some form of specialized care or diagnoses they required
in the process of seeking prenatal services. Similarly, several participants reiterated that
the quality of care they received from obstetricians, nurse practitioners, nurses, and other
health care providers varied from the time of arrival to discharge.
Also, four participants (33%) believed that in their process of seeking PNC
involved disparities pertaining to access to health information. These first-time pregnant
minority women reported obstetricians, and nurses were reluctant to provide pertinent
health information about their health compared to other patients. Lastly, four participants
reported differences in waiting times as a type of access disparities. These participants
described their waiting time to be unreasonably longer than their other counterparts
during their prenatal visits. They felt appointment times were mostly not on schedule and
felt rushed during actual inpatient visits.
Research Question 2: Circumstances Leading to Prenatal Access Disparities Among
First-Time Pregnant Minority Women
Research question 2 (RQ2) focused on participants’ shared views relating to
factors surrounding prenatal access disparities reported in their responses to research
question 1 (RQ1). To obtain responses needed to answer RQ2, I asked all participants the
133
following three interview questions (IQs).
• IQ4: In your opinion, what led to differences in treatment or the disparities
you experienced in the process of seeking prenatal services?
• IQ5: How, if at all, did your status of being a Black/African or
Hispanic/Latino American contributed to the different forms of
prenatal/access disparities you experienced?
• IQ6: How, if at all, did your SES contribute to the different forms of
prenatal/access disparities you experienced?
Analysis of responses to RQ2 highlighted participant’s perception to be the
primary causes of the access disparities they experienced in the process of seeking PNC
services. The themes and subthemes emerging from participant responses to the three IQs
that addressed RQ2: What are the self-reported health disparities in first-time pregnant
minority women as they seek PNC for the first time? Themes: Cause of prenatal access
disparities. Subthemes: (i) Racial/ethnic discrimination, (2) health insurance types, (iii)
income status, and (iv) SES.
Theme 4: Causes of prenatal access disparities. More than a few subthemes
emerged out of participant responses to RQ2, including racial/ethnic discrimination,
health insurance types, income status, and SES. But for precise analysis and
representation of results, I refined all subthemes under one theme: causes of prenatal
access disparities. Over 92% (11/12) of the total study participants attributed prenatal
access disparities they experience to at least one source. Only one participant stated she
134
had experienced no prenatal access disparities experience when she had private insurance
added and some indifferences with public insurance.
Racial/ethnic discrimination. Most of the participants perceived and reported
racial/ethnic discrimination as the primary cause of prenatal access disparities.
Profoundly, phrases and words reflected racial/ethnic discrimination were most
referenced in participant responses to IQ4. About 75% (9/12) of the total participants
attributed the prenatal access disparities they reported to racial/ethnic discrimination.
Participants who were less forthcoming to mention amenably that racial/ethnic
discrimination contributed significantly to disparities used different ways to share their
experiences and views. Tommy recounted the unequal treatment she experienced at her
prenatal visit from the moment she entered by the receptionist of her doctor’s office as
nothing short of racial/ethnic discrimination. She responded:
. . . It’s obvious that when you arrive for your prenatal visit, some patients
received a nice welcome and others pretend as if you don’t exist . . . like, when
White patients enter, the receptionists begin to talk with them and respond to their
million questions. What I witness over and over is that patients like me, who look
like me, don’t get the same welcome from the receptionist…they behave snooty
and hardly want to provide you any information when you ask them . . .
something as simple as where is the bathroom. Whenever I’m here for my
prenatal appointment or any other person of my race, they behaved basically like
they didn’t have time for us or as if we were just plain bothering them with our
questions.
135
In a similar response, Tina, a 24-year old pregnant minority woman, attributed the
information access disparities when she went to one of her prenatal visits; she
experienced racial/ethnic discrimination. She responded:
Being ignored or insulted or spoken down to because you asked a question is
frustrating to be treated like a nobody because of my race. I rely on the
information given by the doctors and nurses and want to be understood,
considered, and respected. If I ask you if you can clarify or simply ask the nurse
to clarify something I do not understand before I leave the doctor’s office, it
should not turn into a federal case. When I leave and call back into the doctor’s
office, I will be on hold the entire day or transferred from one person to the next. I
have witnessed nurses and doctors sharing with White pregnant women important
patient information than they with Black and Brown pregnant women. For
example, once I was in the doctor’s office for my prenatal visit, I could hear the
doctor explaining and answering questions of a White pregnant woman before he
came into the examination room to see me, even though he was more than an hour
late he used my time for someone else. The nurses even spend time talking with
the White pregnant women and refuse to give the same attention to my kind,
cause’ we are minorities. I’m so sick of this…the racial discrimination. Why give
them all that time, and if women like me who don’t have the answers, ask you
questions about our pregnancy, we are hurried off or ignored. We have a living
human inside of us, and we want to make sure our baby is doing well just like
anybody else.
136
Similarly, Terri, a 23-year old single unemployed, pregnant woman spoke of a
time, the obstetrician ordered an ultrasound of both legs because of swelling … I
can remember her saying this is important I get this done as soon as possible. I
was never told why I needed this ultrasound by the nurse, and it’s not from lack of
asking. I waited another 35 minutes in the waiting room to get a scheduled
appointment for the ultrasound. Nothing was clarified, I did not know what the
ultrasound was meant for legs, and no one would tell me … I know the
ultrasounds I have for my belly is to see how my baby is doing. Such racial
discrimination to not be told as I can see doctors talking to White pregnant
women about their test results, I can see them smiling and talking and hear the
doctor giving suggestions. I don’t know anything about pregnancy; I feel alone
and abandoned by the health care system. Sometimes I’d like to think or say they
are just overworked or overwhelmed. This truly hurts my feelings, I have actually
cried once waiting in the waiting room, and not one person from the staff to the
nurse or doctor asked if I was ok, not one. One week following my appointment
and ultrasound tests, no one thought I needed to know the result of the test . . .
they didn’t explain to me what was going on (I learned from the x-ray tech why I
needed the ultrasound), but no one would tell me the results other than everything
is fine. I was disappointed because I see doctors and nurses and staff continue to
interact with White pregnant women, and I am not given the same treatment ever.
It bothered me to watch White pregnant women get all the information about their
pregnancy, but not for us Black and Brown woman.
137
Likewise, Tiffany associated the care quality disparities she experienced during
her hospital visits for prenatal appointments to racial/ethnic discrimination. She
responded:
This seems like a recurrent dream, going to my prenatal appointment and never
seeing the same doctors consistently. It always seems like someone new or some
kind of intern. The doctors I saw, although I made my appointments for my visits,
just like for all other patients, I always received one 10-minute visit or less, and
other pregnant women who didn’t look like me received at least 30 minutes with
the doctor. I mean …. the rooms are thin, and you can hear the doctor–patient
interacting because you have nothing else to do but to listen since you sit in the
cold room for ten minutes or more waiting, and others are not, for the doctor to
come in. Once I asked the doctor a question, one in particular she would always
turn her back to me and walk out of the room while answering me….the
appointments lasted less than 10 minutes, it always bothered me to see how other
pregnant women whose appointments were before mine would be in the rooms for
30 or more minutes with the doctor and mine was always well below 10 minutes .
. . . I believe that this particular doctor was a major racist who I never wanted to
see again, especially not when I’m pregnant.
Tanya made it clear about what contributed to the prenatal access disparities she
experienced; her response inferred that racial/ethnic discrimination played a central role:
This was no doubt because of my background, my culture, my color . . . the way I
speak, I not dumb, you know. I know lately, some people believe we don’t belong
138
here, I can hear the whispers and mocking. This is no different when I go for my
prenatal visits, especially the girl at the front desk, they despise us as people who
don’t know anything, they don’t treat us the same as people with their same skin
color, they look at us differently, I speak English very well yet they talk to me as
if I’m a little child who can’t read or write. There is little interaction between us
and the staff, the nurses and doctors or some of them ask me cultural questions as
if I don’t care to come in or believe in seeing a doctor because of my culture. I
missed a few appointments because I just couldn’t get there, and they just assume.
Right now, what I see is that they don’t care about us unless you are White, so
because of the way I look and speak, they immediately think I just want
everything for free and have a bunch of kids and get free care and food and not
work. The doctors don’t care to talk to me; I am shy, but I do ask questions I
know they can understand, but they just discriminate against me, and the nurses
are just as bad giving me everything to read in Spanish language even though I
am speaking to them in English. I know it’s because of where I am from and the
current climate in this country and being pregnant, so I am here to take what they
are supposed to get, that’s disparities.
In a similar response, Tiffany cited racial/ethnic discrimination as the cause for
the disparities in accessing PNC services she experienced, “I mean. . . as I explained
before, I think the problem was with my race and the fact that I had moved to the United
States.”
Health insurance types. In their responses, most of the participants believed and
139
reported that that the type of insurance they had at the time of seeking PNC contributed
significantly to the access disparities. Participants inferred that the quality of care, access
to specialized diagnoses, patient information access, and waiting times varied
considerably depending on the type of health insurance, public or private. Terri stated:
When you have public health or state-funded insurance, they see you as a person
less than them, needing assistance which is taking from their pockets or taking
from them. It’s as if you cannot afford to take care of yourself and that the state
must take care of you using taxpayer’s money, and they feel you do not deserve to
use the taxpayers’ money. So, if you are getting help from the state, then you
don’t want to work and looking for handout. It just may be that I am looking for
some help to get back on my feet because I have fall on hard times, or it could just
be illness or anything else. But to treat me like I am a nobody is just difficult and
unforgiving.
Tommy, another participant who attributed the disparities she encountered in the
process of seeking PNC to the type of health insurance she had maintained:
When you have state-funded insurance, they don’t see you as they see someone
else with private insurance or insurance from their job or spouse. I know this has
contributed to the quality of care I received each time I come to my appointment.
What is the difference here, it’s not like I come to see the doctor and they don’t
get paid…they are not seeing me for free? You can talk to them nicely on the
phone when they don’t know who you are, but once you are in from of them and
they quickly learn the type of insurance you have, their behavior changes, from
140
rude to ruder. Can I just tell you that you get the worst appointments times, either
way too early or way too late? One time I got an appointment for the exact time
when the doctor goes for lunch…I didn’t know at the time until I got there 15
minutes early and saw the doctor leaving the exact time, I had my scheduled
appointment. I asked the receptionist if the doctor was leaving for the day when
she said rudely, “if she was, I would have told you so.” It doesn’t matter when
you get to schedule your appointments; the best times are given to those with
better insurance, when you have public or state-funded health insurance, we get
weird hours. For example, it’s always early morning, late evening, or during lunch
hours when all nurses and doctors are out on lunch, and you end up waiting for
hours. Not to mention, you will still be waiting also in the cold examining room.
Tandy, a 35-year-old married woman who is unemployed referred to her
insurance type:
State-funded or public health insurance as the primary cause of the disparities in access to
specialized care and diagnostic services she experienced. Tamica responded:
….. the type of insurance you have means exactly how you will be treated
because it determines which services you can access and what you cannot access.
Depending on the health insurance you have, it will not be able to see some
specialists. You are limited in accessing certain doctors and hospitals as well as
procedures unless you have private insurance. For example, with state-funded
insurance, you cannot see doctors who don’t take your kind of insurance. It’s
simple; you will never have access to better doctors, health care, resources or
141
better service because of the type of insurance . . .. so, if you have been referred to
see a specialist or have certain tests, it will not happen, at least not with my
insurance. Everything else requires authorization before gaining access to
specialized care, which means this takes a long time. For others with private
insurance, they get to choose the doctor and the hospital they want when they
want.
Toya was disappointed with her transition from private insurance to semiprivate,
and for the first time, had to use public health insurance. She reported previously she
never had any issues before when she had the private insurance, and she could go to any
doctor within the network and had the best doctors and services and but now it is such a
drastic change. I now have long waiting times, and I’m not seen as often as I would like,
neither do I get to choose the doctor. This first doctor I saw did not spend 10 minutes
with me; she never answered my questions and told me I can access everything from the
visit online from the patient portal. I am happy I can still pay for my medications, and I
cannot wait to go back to private insurance and not a moment too soon. The way they
treat you is terrible, not even to spend time to go over tests or answer specific questions.
Tamica reported she could not access some of her prescriptions because she was low on
cash with little money to pay out of pocket, and the state-funded health insurance did not
cover certain prescriptions. She asserted:
. . . I’m just saying, the type of health insurance you have can contribute to health
access disparities. The health insurance limits the types of services, doctors, and
procedures you can get when you visit the hospital. I had this stressful experience
142
when I had no money to pay for a medication I needed, public health insurance
covered some medications, and I tried to seek other kind of state help to help pay
for my expensive medication. This is my experience of not having the right
insurance to get you the medications you need…. which is sad.
Income status. Nearly all study participants felt that their status of having limited
education and being a minority contributed significantly to what they viewed as
inequalities in the process of seeking PNC services. Some participants reported that
sometimes it felt as though being a minority meant that you didn’t deserve to have
anything good in life. A few believed that even with a degree, the pay scale was still
inadequate, and the inequalities in pay were apparent. All study participants reported
feeling that because they are minorities that they were viewed as less important than other
people, which added to prenatal access disparities in some indirect ways, nonetheless,
contributing factors. For instance, we live in the worst neighborhoods, go to the worst
schools, and therefore have the lowest-paying jobs. Less than 50% of the participants
believe that their immigration status contributed to communication challenges because of
the language barrier. These contributing factors determined the type of insurance
available to them and their SES, all of which are contributing and influencing factors
directly underpinned the disparities in the process of accessing PNC services among this
population.
Tandy responded with frustration in her voice and sad facial expressions that as a
minority pregnant woman with low household income and being unemployed she only
had access to less experienced doctors and nurses:
143
At this point, you cannot access a specialist; you cannot choose the doctor you
want easily being in a low household income bracket. You do not have the freedom of
choice to see a doctor who you like and when you like. You get what you get; you never
see the same doctors because it is the state-run center, and you are given the kind of
doctors they give you…and for the prenatal visits, you will see the nurse practitioner but
not an obstetrician or a gynecologist. You are lucky if you see the same doctor for the rest
of your pregnancy, this is because you cannot afford to see a good doctor, so you must be
grateful for what they give you because they don’t consider you to be important. This
disparity bothered me because health care should be a rite of passage for everyone
equally. No one should be treated less significantly than anyone when it comes to your
health, and everyone should have the same access to health care services, but
unfortunately, that’s not the case.
Toya, a 30-year-old married pregnant woman who obtained care using private
health insurance, attributed the inequalities she encountered in accessing PNC services to
her skin color and background. She responded:
. . . sometimes I think it would matter that you have private insurance, you are
employed and educated…overall what they see is your color, which contributed to access
disparities. When you don’t understand much about the health care system or understand
your rights, you face discrimination of all sorts. It is important to know even the basics of
your rights because it helped go a long way. When I looked at how badly I have been
treated as a patient, I never voiced my complaints or do anything because I didn’t know
my rights.
144
Tiffany’s emotional response and a shaky voice said that as an immigrant, and
being around nonimmigrants, she was always treated indifferently, even lately it has
gotten worse, which she perceived to have caused the disparities she experienced in
accessing care services. She stated that:
. . . I know, I think our status, the fact that we are Hispanics, the fact that I am an
immigrant these people know we come here for a better life, that we are here running
from even worse situations, and evidently anything goes. I hear the mocking or, some
saying, they should go back to their country because they believe we come here not to
work and get everything for free and just have babies so the state can take care of them
for free. These are the ridiculous stereotypes that is imposed on every one of us, no
matter what we have achieved or earn in life or contribute to society.
Socioeconomic status. In the process of analyzing responses to RQ2, it was
evident that some participants felt and shared the experience that their low SES
contributed to PNC access disparities. The low SES of participants reported influencing
factors, including education status, employment status, and immigration status, which
determined their household income status. Fifty percent (6/12) of the minority pregnant
women are unemployed, and about 66% (8/12) of the total study participants reported
low household income status. Participants stated that employment status and household
income determined the insurance type one can afford (public or private) access to the best
doctors and prescriptions. Almost all participants believe that in America, the zip code
you are born in can determine your future, your job, and your problems.
Taylor felt that if she had a better income, she would have a better option of
145
choosing an ideal private insurance and not using state-provided insurance, viewed
widely as the insurance for the poor, underprivileged, or the lazy people who don’t want
to work. She responded:
If I had better income, there is no doubt; I would get my own private insurance,
which would enable me to see whichever doctors I wanted to or choose which
specialist to see, especially being pregnant. I would be treated better; I could see
caring staff members who would give me better care and discuss with me the
important things I need to know about my pregnancy to have a healthy baby.
There is nothing like a good-paying job that provides employees great health
benefits as opposed to public health insurance, where you receive less quality of
care.
Terri noted that minorities live in low SES conditions, which an influencing factor
determining the type of health care and insurance available to them. State-funded health
generally covers basic minimum care and do no cover some medications of specialized
services or procedures. She shared:
….. that because I had no job, I had to rely on state-funded insurance for pregnant
women, which is not only limited, but you are allowed what you have because of
your status. Because of my low household income, I was denied access to quality
care services or access to personalized care or let me just say a specialist enjoyed
by those who can afford the luxury of private insurance or private doctors or
specialists with access to tests and procedures and advanced treatments.
Tommy, another participant who perceived the low SES of minority women as an
146
influencing factor contributing to access disparities in PNC services. She responded:
It significantly contributed because it played an enormous role in the type of
insurance you have and the doctor you can or cannot see. My household income
helped determine the type of doctors I would get to see and in what area I would
be able to go to see them…. which means you cannot just go anywhere you want.
Come to think of it, not all doctors accept state-funded or public health insurance,
and they are the best doctors. For example, because I have public health
insurance, I could not get prescribed prenatal vitamins with public health
insurance.
Summary of Results for Research Question 2
The second research question (RQ2) was designed to explore first-time pregnant
minority women’s perceptions on what led to access disparities in PNC services
experienced by this population. The aim was to elicit participants to share their
assessments on factors that influenced prenatal access disparities they reported in their
responses to RQ1. Eleven of 12 participants response referred to one or more reasons of
access disparities. Only one participant felt access disparities did not impede her PNC
services, did not respond to RQ2. Whereas several subthemes emerged from the analysis
of participant responses to RQ2, including racial/ethnic discrimination, health insurance
types, income status, and SES, I was able to refine the themes into one major theme –
contributor to prenatal access disparities.
Most participants perceived and reported racial/ethnic discrimination as the major
contributor to access disparities. Phrases, statements, and words representing racial/ethnic
147
discrimination were the most referenced in participant responses to IQ4. Approximately
92% (11/12) of participants attributed the access disparities they reported to racial/ethnic
discrimination. In contrast, some of the participants appeared less candid in admitting
openly that racial/ethnic discrimination contributed to the disparities they experienced but
expressed their views by referring to skin color. In addition to racial/ethnic
discrimination, several participants voiced that the type of insurance or insurance status at
the time of seeking PNC contributed significantly to the access disparities. Participants
stated that disparities in access to quality care, access to specialized care and diagnoses,
patient information access, and waiting times varied considerably based on whether one
had public or private insurance.
Data analysis showed that most study participants felt their status of being
pregnant minority women contributed to what they viewed as health inequalities in the
process of seeking PNC services. Some participants reported that sometimes they felt that
being a woman makes them feel invisible or that their health is less important. Other
participants shared that being a minority woman added to access disparities in indirect
ways. For instance, racial/ethnic status contributed to health information challenges,
which determined the type of available insurance, income, education, and SES which,
directly influenced disparities in the process of accessing PNC services among this
population.
Lastly, analyzing responses to RQ2 revealed that some participant’s perceptions
that their low SES contributed to their experience of prenatal access disparities. The low
SES of participants were influenced by several factors, including marital and employment
148
status, which determined their household income levels. Fifty percent 6/12) of all the
participants were unemployed, and approximately 75% (9/12) of the study participants
reported low household income status. Participants communicated that household income
and employment status determined the insurance type they had, and the quality of
treatment received from HCPs.
Analyzing responses to RQ2 revealed five subthemes (e.g., racial/ethnic
discrimination, health insurance types, income status, education status, and SES) that
emerged from participant responses were not exclusive. For instance, racial/ethnic status
influenced the low SES reported by first-time pregnant minority women, in determining
the kind of insurance obtainable to this population. Similarly, income status contributed
to obtaining affordable insurance that led to access disparities in PNC services among the
population of focus in this study.
Research Question 3: Effects of Access Disparities on the Experience of Seeking
Prenatal Services Among First-Time Pregnant Women
Research question 3 (RQ3) aimed at exploring how access disparities affected the
participants’ overall experience in the process of seeking PNC services. To generate
participant responses needed to address RQ3, I asked participants the following interview
questions (IQs):
IQ7. How, if at all, did the access disparities you experienced affect your feelings
and decisions towards seeking subsequent PNC?
IQ8. How, if at all, did access disparities affect your overall experience of seeking
PNC services?
149
IQ9. Is there anything else you want to share with me concerning your PNC
service experiences in relation to prenatal/access disparities?
Analyzing responses to RQ3 revealed that pregnant minority women who
participated in this study felt that overall access disparities had a negative effect on their
experience of seeking PNC services. All participants reported at least one negative aspect
in which access disparities affected their PNC-seeking process.
How have the experiences of health disparity affected the health-related outcomes in
first-time pregnant minority women as they seek PNC for the first time?
Emergent theme and subthemes for research question 3
RQ3. How do access disparities affect the overall experience and perceptions of recent
first-time pregnant minority women towards seeking prenatal services? Theme: Negative
experience in seeking PNC services.
Theme 5: Effects of access disparities. Five subthemes (i.e., feeling
undervalued, emotional distress, changing providers, skipping appointments, missing
care, and loss of trust in the HCPs) emerged from participant responses to RQ3. To
explain in more comprehensive terms the analysis and presentation of results, I refined
the five subthemes under one major theme: consequences of access disparities from
personal experience of seeking prenatal services.
Feeling undervalued. Participants perceived disparities in accessing PNC
services as a discriminatory treatment that makes you feel undervalued or insignificant.
In their responses to RQ3, four participants reported that the access disparities they
experienced diminished their sense of value resulting in an unwelcomed feeling to the
150
providers. Notably, Tammy responded:
. . . I felt like I didn’t matter to anyone whenever I went for my prenatal visits, the
reception at from the time I entered the facility throughout prenatal examination
felt cold and disappointing. Personally, the staff were unpleasant and uncaring;
they behaved as if I was a bother to them, which suggested you were not
welcome. I felt unloved and alone, and most of all, I didn’t feel respected …. I
never expected to feel so less than, as if I didn’t matter, which made me sad, I
sometimes cried. The look I was given as if you don’t belong here or you are just
looking for a handout always stayed in the back of my mind. It made me question
who I am, and if I was as insignificant as they made me feel, and yeah, maybe,
I’m nothing then.
Tina shared her annoyance and disappointment with the whole health care team
and thought they had the role of helping others in my position, and treating some kindly
and others like trash. I felt unworthy and unwanted, and I hated feeling this way and
deserved better treatment:
. . . so why treat some so nicely and others with disregard. It’s very obvious that
anyone can see what they’re doing, I’m not blind. To think they treat me like this
every time I come here…. I’m ignored and taken for a fool. I sit and wait; I’m
spoken to like I’m a nobody, and this saddens me.
No one wants to feel like they are less than, you know, when someone looks
down on you like you are nothing, it affects your self-confidence, and you start
feeling like crap. This is how they all treated me, from the staff, nurses, and
151
doctors. I would never treat anyone they made me to feel, and why would anyone
go out of their way to make someone feel unwelcome and rejected. All I think
about is changing location, finding a different provider or facility.
Emotional distress. Other participants perceived disparities in accessing PNC
services to cause them emotional distress with reluctance in going to their regular
prenatal visits during pregnancy. When asked to share her overall experience with the
challenges of seeking care in the presence of access disparities, Tommy was emotional in
her response. She expressed:
. . . I never wanted to go to my second prenatal appointment or any more after that
but knew I had to because I didn’t have anywhere else to go. It was too much to
sit around for hours waiting to see a doctor or nurse …. feeling as if I was a
burden or something. I have scheduled appointments one after the other, so there
was no reason to treat me any different when you know I’m coming every month.
I was worried of and had anxiety every time I had to go for my prenatal
appointments, and I hated feeling this way. Being in this health care place didn’t
seem anyone cared about me or what I was going through because of the way
there were treating me truly hurt me. You try to be nice and greet them politely,
but they will not treat you as you did, instead they treat you like you are a nobody.
It’s hurtful that after being disregarded, a White patient shows up and is given the
royal treatment. Yeah, it’s emotionally upsetting and nasty like you shouldn’t
exist.
Tanya, a 35-year-old married, unemployed woman, shared a similar view to that of
152
Tommy concerning the effect access disparities had on her experience of seeking PNC
services. She reported:
. . . you have to visit the doctor because you are pregnant, they know you are
pregnant, and it just seems like they want to upset you. It’s like you are taking,
taking, taking, and you don’t deserve anything, they make you feel like a
complete nobody, or you are second class. . .. that’s how they make me feel as if I
am the bottom and they are on top. They don’t treat other patients who do not
look like me this way; they get top treatment, respectful greeting, and fun
conversations. They don’t have to wait like me. . .. waiting like two hours or so. I
am haunted by the treatment I have to endure when I go for my prenatal visits,
and I don’t care to come, but what other choices do I have? I don’t want this
feeling, especially since I’m pregnant. I didn’t expect any form of discrimination
or to be disrespected. I’m not stupid, you know, I know if it wasn’t for my skin
color, I wouldn’t be treated this awful. This is so very hurtful and distressful, an
emotional Tandy reflected.
Changing providers. Several participants emphasized in their responses that the
access disparities they encountered in the process of seeking PNC services provoked
them to change providers reluctantly. Participants conveyed that the decision to change
providers was not their first choice because having a doctor that knows you or knows
your case is important or even at the same facility because at least they have your
information. The decision to change was not decided on frivolously but was given the
same consideration of the balance of a stable relationship with providers and the benefit
153
of a healthy mindset, although very challenging. The participants who felt they had no
other choice but to change providers reported that it was in their best interest to avoid an
unpleasant atmosphere, especially since I’m pregnant. Terri, who perceived that her PNC
resulted in quality disparities, which she attributed to the doctor’s behavior towards her,
she had to change doctor in her second trimester. She reported:
. . . discussions about her behavior towards me was met with disregard or
downplaying my concerns. So, I decided to change doctors in my second trimester
because I needed to keep my sanity, let me tell you, her behavior was deeply
disturbing. I changed the facility because I realized it was not working out;
nothing was going to change. I just couldn’t deal with it; do I continue to miss
appointments or just stop going altogether. Yeah, it was misery. How do you find
someone you can truly trust and who you feel cares about you enough to treat you
as a person? They gave me a hard time for changing, but I had stopped going to
my scheduled appointments, I think I missed one or two visits with this doctor. I
didn’t want to feel put down or low like I’m not doing anything right, as if I’m
stupid. Just respect me, and that’s all I ask, it’s not that hard. I just couldn’t end
up being depressed while I’m pregnant too.
Toya and Tina were two other study participants who reported that their
experience of access disparities in the process of seeking PNC resulted in a change in
providers. Toya stated:
. . . how I did this was to choose the days I knew that particular provider did not
come to the facility. This didn’t happen by choice; it was because you usually
154
never get to see the same doctor all the time, it might be two months or so before
you might see the same doctor based on the appointment days you were given. So,
I looked into this further, so the days I knew the doctor would come into the
facility, I made sure I wasn’t available, so I would be scheduled opposite dates.
Tina reported a similar response when she replied that, “you know. . . I wanted to
just move away and go live with my boyfriend, so I wouldn’t have to see these
people again. I asked for a transfer to another doctor because I was not happy with
how the staff treated me at my prenatal visits, I was refused immediately, so I
decided to take the early morning appointment times to offset this issue, but it was
basically the same. You really don’t want to change doctors because they have
your record and know about you and your medical history and would seem like to
know what’s going on with you sooner. However, staying with this doctor
would’ve made me emotionally unstable, and I’m already struggling with the
thought of pregnancy right now, and I didn’t need the added stress.
Skipping appointments. Participants also reported that the indifference in
treatment by HCPs influenced their decisions to skip recommended appointments
because of past experience and interactions with said providers. At least three study
participants referenced in their responses that they missed one or more of their prenatal
appointments intentionally because they were treated poorly by their providers in
previous visits and did not want a repeat of the same experience. Tori indicated that if I
skipped an appointment because I couldn’t stand to be belittled when I didn’t get a
recommended prescription or follow up with a particular test, then so be it. I needed to
155
feel a real human connection or have a meaningful conversation, which shows me that
you, as a doctor, are genuine in treating me with care and not just a paycheck at the end
of the week. Am I a person or just another number at the end of a folder…? I can’t get an
answer from you at all about the concerns I have with my pregnancy, being extremely
scared, yet you have not inquired about how I am doing or managing. Do you even know
if I can afford the prescription or if I’m in a stable relationship with support? Then…. it is
not worth it to go for appointments where providers treat you so low. She responded:
. . . I do not wish to see someone who undervalues my existence or treat me so
badly that it affects my self-confidence and my wellbeing while I am pregnant. You can’t
treat a person less than and expect them to want to be around you…even if they rely on
you partly by no choice of theirs and when they think you are nothing. . . they treat you
like nothing. So, if I am not dying, I feel better about not going, and I know where to go
if I have an emergency.
Similarly, Tandy disclosed that she skipped several appointments, though not
back to back, and not because she does not value health, but she could not get passed
what she perceived as an ugly and unwarranted treatment by her HCPs. She shared:
Though I am not proud of skipping my appointments intentionally, I felt I had no
choice, and I will not lose my sanity over being treated badly because of my skin color. . .
I’m not blind; you have one set of behavior for one group and another set of the other. I
dreaded the doctors’ appointment, I felt a pit in my stomach every prenatal visit, and I
became understandably paranoid and felt unsafe that somehow because of the way they
treated me there was no reason for me to go back. I could no longer trust doctors, and
156
though I value health, I hated going to my prenatal appointments. It was always a tense
visit; they never regarded me as a person with feelings who wanted the same things they
want in life, a happy, healthy life, and family. It became hard to keep going to the
appointments where they show you that you are not valued.
Loss of trust in the providers. Some study participants felt that the major effect
access disparities had on their experience of seeking PNC services was the loss of trust in
providers. Participants indicated that they had confidence and trust in HCPs providers but
have changed their opinions when they had their prenatal visits. Tandy admitted that she
had high expectations about HCPs until she became pregnant and started seeking PNC
using public insurance:
The disparities I lived seeking PNC, made me distrust the health care team, from
the nurses to doctors. I never expected our interactions to be so horrible, but it’s worse
than that; I have zero trust in the providers when I experienced access disparities early in
my pregnancy. I am convinced that disparities in access to specialized care contributed to
a negative health outcome. The lack of communication and trusting patient-provider
relationship make me think negatively about nurses and doctors. The doctors never cared
about me, they never explained anything to me or even a followed up much less answered
my call. I cannot even understand how being pregnant and having concerns would not
have been a high priority for the doctors who are to ensure their patients remain healthy. I
felt like the nurse and doctors showed no compassion and don’t care about the health
outcomes of some patients. Patients that look like me were taken less seriously, and the
doctors performed their job as an obligation. There was just a lack of compassion.
157
Similarly, Toya indicated that access disparities left a negative effect on her
perception towards HCPs. She reported:
The inequalities in accessing PNC gave me a very negative impression of nurses’
and doctors’ treatment toward certain patients. There was a time I never thought I
would say this, but there was variance in how doctors treated minority patients
than their White counterparts, but it was upsetting not to mention. You know
there is a lack of promoting equality and not treating people the same way. I have
had experience with both types of insurance, and let me just say, when you have
public insurance, they disrespect and degrade you like you are just poor and rely
on others for a handout. The insurance is there for a reason, and you get qualified
for it, it’s not a handout. The idea of being treated because of how you look. . .
whether it’s your race or your ethnicity or the way you speak should not
determine the type of care you receive from the professional health care team. I
continue to be truly disappointed and feel I can’t trust the health care team, and
this made me become my own advocate. I feel they were not there for me, and
they will never be there for me. Bottom line is. . . the ultimate trust I had in HCPs
is gone.
Summary of Results for Research Question 3
Research question three (RQ3) addressed the influence of access disparities in the
process and experience of seeking prenatal and essential services among first-time
pregnant minority women residing in the BCBC. In response to RQ3, participants shared
their insights about the influences of access disparities have had on their experience of
158
seeking PNC services. Collectively, first-time pregnant minority women’s participation
in this study felt that access disparities had a negative effect on their experience of
seeking prenatal or essential care services. Five subthemes (i.e., feeling undervalued,
emotional distress, changing providers, skipping appointments, and loss of trust in
providers) emerged from participant’s responses to RQ3. To explain in more
comprehensive terms the analysis and presentation of results, I refined the five subthemes
under one major theme: effects of access disparities from personal experience of seeking
PNC services.
The participants who reported disparities in accessing PNC services in their view
collectively believe discriminatory treatment that makes the victim feel undervalued or
unimportant. In their responses to RQ3, four participants referenced that the access
disparities they experienced diminished their sense of wellbeing and felt ignored,
undeserving, and unwelcome to the providers. To reiterate this negative perception, other
participants reported that access disparities made them emotional, and they dreaded their
regular prenatal visits during pregnancy.
Similarly, some study participants felt that the major effect access disparities had
on their experience of seeking PNC services was a loss of trust in providers. Participants
indicated that they had a lot of confidence and respect for providers until they needed
PNC services. Also, several participants highlighted in their responses that the access
disparities they encountered in the process of seeking PNC services forced them to
change providers prematurely and obligatorily. Participants reported that the decision to
change providers was raw because they understand very well the benefits of having a
159
continuous relationship with providers but had no choice. Although it is not what they
wanted to happen, the participants who changed providers believed that it was in their
best interest to avoid what they viewed as unequal treatment and distressing recurrent
experience.
Also, some participants reported that the inequalities in treatment by the HCPs
influenced their decisions to skip their prenatal appointments because of their negative
experience. Three study participants referenced in their responses that they missed one or
more of their doctor’s appointments intentionally because they were treated poorly in
their previous visits and were reluctant to repeat the same negative.
Summary
The purpose of this chapter was to provide an analysis of the unique experience of
first-time pregnant minority women in relation to the phenomenon of access disparities in
PNC as recounted in response to research questions that underpinned this study. To
understand further the study phenomenon, access disparities in first-time pregnant
minority women, I created three research questions that underpinned this study. I
recruited 12 study participants who met the eligibility criteria listed in Appendix B. The
12 participants responded to the interview questions that shaped the data used in this
study. Here outlines subthemes, themes, and key findings that emerged from analysis of
participants’ responses to research questions. Subthemes: (i) Disparities in access to
specialized services and diagnoses, (ii) disparities in care quality, (iii) disparities in
patient information access, (iv) disparities in waiting times, (v) racial/ethnic
discrimination, (vi) health insurance types, (vii) income status, and (vii) SES. Themes: (i)
160
feeling undervalued, (2) causes of prenatal access disparities, (iii) emotional distress, (iv)
changing providers, (v) skipping appointments, and (vi) loss of trust in providers. Key
findings: (i) types of PNC services, (ii) meaning of health access disparities, (iii) types of
prenatal access disparities, (iv) causes of prenatal access disparities, (v) effects of access
disparities (vi) all (100%) participants used one or more forms of PNC services, (vii) all
participants understood the meaning of health care access disparities, (viii) more than
92% reported access disparities in PNC services, (ix) more than 60% failed to access
needed specialized care or diagnostic services, (x) more than 90% attributed access
disparities to racial/ethnic discrimination, insurance types, income status, and SES.
RQ1 was designed to produce inclusive participant responses surrounding access
disparities first-time pregnant minority women experienced in the process of seeking
PNC services. All participants reported they had sought and used prenatal or essential
care after becoming pregnant and had experienced access disparities during this time.
Seemingly, all participants confirmed or acknowledged understanding the meaning of
health access disparities. Themes that emerged from participant responses to RQ1 were,
(1) types of PNC services, (2) meaning of health access disparities, and (3) types of
prenatal access disparities, including access to specialized services and diagnoses
disparities, quality care disparities, patient information access disparities, and waiting
time disparities. All first-time pregnant minority pregnant women who participated in this
study reported having experienced one or more types of access disparities in the process
of seeking PNC. Analysis of participant responses to RQ1 showed several participants
reported experiencing comparable access disparities.
161
RQ2 was designed to explore first-time pregnant minority women’ perceptions of
what factors influenced access disparities in PNC services experienced by this
population. Analyzed responses to RQ2 emphasized areas study participants perceived to
be the main influences of the access disparities they experienced in the process of seeking
and using PNC services. Almost all participants responded highlighted one or more
influences of access disparities. One of 12 participants felt her experience with PNC
services did and did not involve access disparities was the sole participant who responded
to RQ2 as experiencing disparities after a change in insurance status. Racial/ethnic
discrimination, health insurance status, income status, and SES were the subthemes that
emerged from the analysis of participant responses to RQ2. To explain in more
comprehensive terms the analysis and presentation of results, I refined the five subthemes
under one major theme: causes of prenatal access disparities.
RQ3 was designed to explore how access disparities affected study participants’
overall experience in the process of seeking PNC services. In response to RQ3,
participants shared their perceptions of the influence access disparities had on their
experience of seeking PNC services. In general, first-time pregnant minority women who
participated in this study felt that access disparities had a negative influence on their
experience of seeking PNC services. Five subthemes (i.e., feeling undervalued, emotional
distress, changing providers, skipping appointments, and loss of trust in providers)
emerged from participant responses to RQ3. To explain in more comprehensive terms the
analysis and presentation of results, I refined the five subthemes under one major theme,
“effects of access disparities from personal experience of seeking prenatal services.”
162
Chapter 4 presented an analysis of responses from participants of the three
research questions that underpinned this study and a description of study results relating
to the phenomenon of access disparities in PNC from the accounts of events experienced
by first-time pregnant minority women. Also included in this chapter is a summary of
data collection and data analysis procedures and descriptions surrounding evidence of
quality in this research. Chapter 5 provided a brief summary of the study’s purpose, an
interpretation of the study results, limitation of the study, recommendations, and
implications for social change.
163
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
The purpose of this study was to (a) identify what SES, provider’s perception of
their race-ethnicity, knowledge, and care-seeking factors influenced first-time pregnant
minority women’s access disparity in the use of health care, (b) explore what first-time
pregnancy health disparity may be unique to this population, and (c) understand how
access disparities affected participants’ overall experience of seeking PNC services.
Earlier studies on pregnant minority women’s health focused on maternal and child
mortality, which left health needs and challenges of first-time pregnant women less
known (Parekh et al., 2018). Hence, the information generated in this study potentially
fills a gap in the literature on access disparities in the prenatal health of first-time
pregnant minority women.
Furthermore, the results of my study may provide valuable insights about
minority childbearing pregnant women’s perception of their experiences of health
disparities (Kennard, 2016), attain good access to care and ongoing care, and find
providers who meet their needs, which will reduce the health disparity gap. Thus, the
information can be used to maximize and support their achievement in navigating the
health care system to prevent delayed treatment and gaps in care and improve their
quality of life not only for themselves but for their family and this population.
The study findings that emerged from analyzing participant responses were
generated through conducting in-depth, face-to-face semistructured interviews with 12
first-time pregnant minority women who volunteered to participate in this study. I used
164
semistructured narrative inquiry questions (see Appendix D) designed to produce answers
from participants in response to the three research questions that underpinned this study. I
compared the results to findings of the literature review in Chapter 2 to gain insight into
whether this study added or failed to add new knowledge to the existing body of
knowledge on the phenomenon of access disparities in PNC of first-time pregnant
minority women. The ANFHSU (Andersen, 1968, 1995; Andersen & Newman, 1973,
2005) provided the theoretical lens I used to analyze and interpret findings from this
narrative study.
The main findings that emerged from the analysis of participants’ responses
revealed participants were treated unequally in the process of seeking PNC services when
compared to their White counterparts. Participants’ perception of the differences in
treatment as types of access disparities were factors influenced primarily by racial-ethnic
discrimination, health insurance status, income status, and SES. There was an
overwhelming consensus among first-time pregnant minority women who participated in
this study who believed that access disparities adversely affected their experience of
seeking prenatal or essential health services. In this chapter, I discussed the interpretation
of the findings from this study, limitations of this study, recommendations and
suggestions for future research, and implications for social change. The chapter ends with
the conclusions and remarks about my personal experiences as the researcher in this
study.
165
Interpretation of Findings
In this section is the interpretation of study findings on the topic of experiences of
prenatal access disparities experienced by first-time pregnant minority women. Upon
review of the literature, it became evident that earlier studies of minority pregnant
women’s health focused largely on maternal-child mortality populations, whereas the
unique health needs and challenges of first-time pregnant minority women minority
remained less known (Parekh et al., 2018). Findings from this study potentially fill a gap
in the literature on access disparities in first-time pregnant minority women in the process
of seeking health care services for the first-time. The three RQs that underpinned this
study were as follows: How do the experiences of women, minority and underserved, of
childbearing age as they seek PNC affect their ability to achieve positive pregnancy
outcomes (defined as term vaginal delivery, appropriate birth weight for infant and
pregnancy weights for mother, and to avoid postpartum depression and infant mortality)?
What are the self-reported access disparities in first-time pregnant minority women as
they seek PNC for the first time? And, how has access disparities affect the overall
experience and perceptions of first-time pregnant minority women towards seeking PNC
services? Because most participants provided similar responses to the three RQs, I
interpreted the result to reflect the themes that emerged from the RQs from the lens of the
ANFHSU and the context of relevant literature reviewed in Chapter 2.
Research Question 1 Findings and Relevant Literature Reviewed
The following three themes emerged from participant responses to interview
questions (IQs) generated data to address RQ1:
166
• Types of PNC services.
• Meaning of health access disparities.
• Types of prenatal access disparities.
Participants admitted to using several types of PNC during the gestational period
before data collection, including obstetric care and family planning services. Whereas
some participants reported more than others, of the 12 participants in this study reported,
none reported complete underuse of needed prenatal or essential care services. These
results support the findings of Bellis et al. (2014), Bellis et al. (2015), Osler et al. (2013),
and Manning et al. (2010), and support the increasing emphasis on the significance of
early life development to adult health outcomes. The commitment of first-time pregnant
minority women seeking and using PNC services may partly be a result of their increased
understanding of the benefits associated with using recommended prenatal and essential
care on the future health of both mother and child.
Most participants obtained PNC services using Medicaid for pregnant women,
which is in line with the findings of Parekh et al. (2018) that there is evidence of
commitment at the local, state, and federal levels to improve access to adequate PNC, of
the assumption that early continual PNC would result in positive effect on birth
outcomes, including the reduction of low infant birth weight, infant mortality and
morbidity rates for the low-income population through prenatal health-promoting
programs. However, Gold and Kennedy (1985), Parekh et al. (2018), and March of
Dimes (2013) suggested that if a substantial number of women continue late enrollment
in PNC or essential services the expansions may negate promoting significantly early use
167
of PNC programs. Approximately 92% (11 of 12) of participants can be attributed to
Medicaid-covered pregnancy health, a state health insurance program provided to
residents of MA who meet specific criteria by measuring their family income to the
poverty level.
Although there is no consensus on the precise definition of health disparities,
Healthy People 2020 (2014) defined health disparities as the difference in health because
of the economic disadvantage including the lack of resources and opportunities that
adversely affect groups of people based on their racial or ethnic group, SES and or
geographic location and the subsequent inability to afford goods, services, and influence,
or other “characteristics historically linked to discrimination or exclusion” (p. 1).
Similarly, participants used varied phrases, sentences, or words to simplify what health
care access disparities meant to them, resulting in no discrepancies between Healthy
People 2020 definition of health disparities and the meaning given by study participants.
For instance, participant Tammy described health disparities as the inequality in health
care provided to different groups of people because of the way they look or where they
live, their race or ethnic background, and income status. Congruently, Tori reiterated,
from experience it is the unequal or differences in the care and services available
to people like me, or adequate clinics or health centers and nice nurses and
doctors for us… it doesn’t matter that we don’t have the means or not rich.
Participants referred to inequalities frequently in access to care or services in their
description of their perception of health disparities. Tess shared,
168
because we live in these neighborhoods, it seems like they have forgotten us, we
don’t get the best care, we don’t have the best nurses and doctors… not even get
to see a specialist unless we are dying, yeah…. Talk about unfair.
Participants’ perceptions of the meaning of health access disparities reflected the
four major indicators of measuring health access (e.g., health insurance, adequate service,
available HCPs, timeliness emphasized by Healthy People 2020 (2015). Further,
equitable access to health care, means where all Americans can secure an adequate level
of care without excessive burdens. A person’s ability to access health services has a
profound effect on every aspect of his or her health (Healthy People 2020, 2015).
Moreover, Tamica reiterated the significance of the component of coverage and quality
service in measuring access to care when she expressed that, “we need a society without
discrimination, where all patients are given equal care, no matter the color of your skin, if
you are rich or poor, where you come from or live, or how you speak.”
Tommy, in her explanation of the meaning placed on health care access, similarly
emphasized the need for HCPs to remove all forms of inequality in care services to
ensure that everyone in receipt of care are afforded equal opportunity to quality health
care access and services, and the availability of quality health care facilities and HCPs no
matter where you live or your ability to pay.
The literature indicated the prevalence of worse health care disparities are densely
concentrated among minority populations including such as Blacks, African Americans,
Hispanics, Latinos, Indian Americans, and immigrants when compared to their White
counterparts (Gadson et al., 2017; James et al., 2009; S. Lee et al., 2015). Study results
169
indicated that greater than 95% of first-time pregnant minority women who voluntarily
participated in this study reported experiencing access disparities in the process of
seeking PNC services. Several participants reported incidences of receiving indifferent or
unequal treatment compared to other care seekers seeking similar treatment, and in their
perception, contributed to access disparities that negatively affected their care experience.
These results are supported by findings of Gadson et al. (2017), James et al. (2009), and
S. Lee et al. (2015) who argued that minority populations such as African Americans,
Latino Americans, Indian Americans, and immigrants disproportionately experience
disparities in access to health care services in the United States that contribute to their
adverse health outcomes. Results from this study are also supported by Bloom (2011),
Durkin et al. (2015), Parekh et al. (2018), and Roman et al.’s (2017) findings suggested
that pregnant minority women and or low-income families, and/or those from various
background experience disparities in access to care in the United States.
More than 92% (11/12) of the participants reported incidences of access
disparities, including disparities in access to specialized services and diagnoses, quality
of care, access to patient information, and waiting time disparities. Notably, greater than
50% (7/12) of the study participants failed to access adequate PNC and the assumption of
early continual PNC, support the findings of Durkin et al. (2015), that despite policy and
program interventions at local, state, federal levels to improve the availability of access to
healthcare, some population subgroups in the United States continue to experience
disparities in access to PNC services. Traub et al. (2016) suggested that improvements in
national outcomes require a comprehensive intervention approach that addresses clinical
170
factors and socioeconomic determinants to better foster coordinated care. Thus, Traub et
al. (2016) findings explain why first-time pregnant minority women experienced
disparities in PNC services despite having access to insurance and providers.
This study revealed that the quality of care provided showed indifferences of
participants’ experiences in receipt of seeking PNC. Participants shared that they were
treated differently from the time of their prenatal appointment, including staff, nurse
practitioners, and doctors. Several researchers (Smith et al., 2015; Miller et al., 2017)
indicated that minority individuals experience prejudice that made them vulnerable to
being treated differently in the process of seeking care. Similar studies showed disparate
treatments for similar care or treatment and wide divergence in general health status
among racial-ethnic groups (J. Lee, 2015; Arce, Goldstein, Mitani, Lenihan &
Winkelmayer, 2013). In a study conducted by Parekh et al. (2018) showed that pregnant
minority women who had public health insurance experienced poorer treatment and often
poor engagement from HCPs, confirming the findings of this study.
Also, almost 70% of the participants experienced disparities in access to patient
information in the process of seeking prenatal or essential care services. Terri, a 23-year-
old woman, who holds less than high school education, explained that the current
emphasis of accessing patient information online, including test-results limited her full
access to patient information. These results reflect the findings of Liddell et al. (2018),
consistent variations in access to health information among minority individuals.
Whereas educated Americans had higher odds of using the internet to seek information
compared to less well-educated who had no computer access had less access to healthful
171
information (DesRoches et al., 2010; J. Lee, 2015). Participants experienced similar cases
of information-access disparities in this study, which magnified the findings of several
other cases. Also, the findings of disparities in access to patient information support
results of Prey, Restaino, and Vawdrey (2014) and J. Lee (2015), that minority patients
had less access to their patient information when compared to their nonminority
counterparts.
Almost 90% of participants experienced variations in waiting times for their
prenatal or essential care appointments. Even with scheduled appointments prior to their
visits, participants reported they waited unreasonably longer than other nonminority care
seekers during their prenatal visits. Participants report was consistent with Prentice,
Davies, and Pizer’s (2014) study indicating structural inequalities in waiting time during
physician visits. In relation to findings of this study, Taylor and Francis (2018) noted that
minority pregnant women reported long wait times, and rushed visits varied from one
patient to another, which they report as disparities in care. Similarly, Hernandez and
Rossel’s (2015) study indicated that a lack of consistency in waiting time reflects a
negative influence on the meaning patients’ place on the health care system and their
desire to seek needed care. Also, findings of Parekh et al. (2018) showed that the
common belief that adequate health insurance coverage improves health care use but may
be ineffective with increased in-office waiting times and rushed visits. In general, results
from participant responses to RQ1 reflect the literature reviewed in this, study which
supports that prenatal access disparities are major ongoing health challenges experienced
by minority populations such as African Americans, Hispanics, Latino Americans, and
172
immigrants. These studies indicated that access disparities play a key role in adverse
health outcomes among these population Subgroups. More than 92% (11 of 12) of the
study participants admitted that they accessed and used different types of PNC services
during which they experienced numerous access disparities.
Research Question 2 Findings and Relevant Literature Review
Research Question 2 (RQ2): What are the self-reported access disparities in first-
time pregnant minority women as they seek PNC for the first time?
Study participants reported similar views and opinions about factors influencing
access disparities in the process of seeking and using PNC services. More than 92% of
the first-time pregnant minority women who participated in this study attributed access
disparities in prenatal to one or more influencing factors. No participant reported their
care did not involve access disparities. Subthemes that emerged from RQ2 include racial-
ethnic discrimination, health insurance status, income status, and SES. In the analysis and
presentation of results, I grouped all subthemes under one theme: factors influencing
prenatal access disparities.
Although participants highlighted several factors influencing inequalities in
access to PNC services, the majority, 11/12 or approximately 92%, reported racial-ethnic
discrimination as the primary reason for access disparities. Participants said that they
were treated differently or unequally during their prenatal appointments when compared
to their White counterparts. These findings expand upon the existing body of knowledge
investigated by several researchers (Johnson et al., 2011; Mazul et al., 2017; Parekh et al.,
2018; Roman et al., 2017; Vardeman-Winter, 2017; Walker & Chestnut, 2010) of the
173
challenge of persistent health care disparities in the health care system and exclusions
along racial-ethnic lines.
Previous studies by (Frieden, 2014; Kirzinger et al., 2018; Martino et al., 2013;
Parekh et al., 2018) have found substantial racial/ethnic disparities in almost all health
indicators, including access. Similar studies have shown negligible evidence that
racial/ethnic disparities in child health remain consistently challenging, comparing Black-
White disparities of infant mortality have grown increasingly more significant over time
(Kothari et al., 2017; Martin et al., 2009, 2017; Parekh et al., 2018). Participants shared
their experience of the feeling of discrimination, or some form of indifferent treatment
persisted throughout their prenatal visits. They reported that treatment among patients
varied based on our skin color or background. These results are substantiated by study
findings of Mazul et al. (2017); Meyer et al. (2016); Yearby (2018) that racial and ethnic
backgrounds contribute significantly to health care disparities. Comparable studies by (E.
Howell et al., 2016; Hsieh & Ruther, 2017; Kenney et al., 2013) support previous study
findings that pregnant minority women are more prone to disparities compared to
nonminority pregnant women. These studies directly support the existence of
racial/ethnic discrimination experienced by the participants in this study.
Most participants attributed disparities in accessing PNC services as a
contributing and influencing factor to the type of insurance in receipt of PNC.
Participants maintained that their form of insurance coverage limited the opportunity of
the level of access and use of care services. Contrasting views of one participant with
private insurance were without restriction in the choice of provider or service use. There
174
is a limitation of state-provided insurance or Medicaid insured during pregnancy afforded
to participants in receipt of PNC services from only Medicaid-approved providers. The
perception of participants reporting that health insurance restrictions influenced
disparities in their access to PNC is consistent with the findings of (Kenney et al., 2013;
Hahn, 2013; Heaman’s et al., 2015) study, which suggest state-insured patients suffer
disproportionately from health disparities when compared with their privately insured or
White counterparts. In their study, C. Brown et al. (2019) found that even with the
expansion of insurance coverage the differences in outcomes persist among Medicaid
patients and privately insured patients, emphasizing the finding that differences in
insurance type contributed significantly to access disparities in PNC services reported by
participants in this study. Hence, supporting the need for comprehensive interventions
addressing the persistent multilayered challenges of health disparities beyond expanding
insurance coverage.
Similarly, results from this study indicated that almost all participants attributed
access disparities in PNC services to their low-income status. Participants maintained that
their low-income status was in relation to incomplete knowledge of the healthcare
delivery system, influencing challenges that exacerbated the disparities in access in the
receipt of care. Results from the study expand upon existing findings reported by Bloome
(2018), Bromley et al. (2012), and Border et al. (2015) that minority pregnant women
subgroups in the United States experience greater barriers to care, receive poorer quality
of care, and report poorer health outcomes when compared with nonminority pregnant
women subgroups. Also, access to care disparities based on income status, as detailed in
175
this study, coincides with results of a pilot study conducted by F. Gonzales et al. (2014),
which indicated that minority pregnant women remain as one of the medically
underserved population Subgroups in the United States.
The findings on income status as a cause for disparities in access to PNC services
magnifies the results that were identified in studies by Kochhar & Cilluffo (2018); Mazul
et al. (2017). This report indicated that income inequality was the catalyst to barriers and
challenges, including poverty, marginalization, and limited access to social benefits and
health services, resulting in adverse health-related outcomes. Also, the finding
highlighted that health disparities faced by low-income minority pregnant women in
access to care experienced more significant disparities from factors such as
discrimination, exclusion, unequal access to education and employment, and lack of
adequate and sustainable social support (Sacks et al., 2015).
Further, some participants reported that their SES was the single most factor
influencing the challenges of experiencing prenatal access disparities. Almost 65% of the
participants confirmed unemployment, and nearly 67% confirmed low-income household
status. These participants maintained that their low SES limited their health insurance
choice to state-funded or Medicaid, their choice of HCPs and prenatal facilities, and
sometimes lack the funds to pay for their prescriptions. These findings from this study are
consistent with results from several studies by (Bloome, 2018; Bromley et al., 2012;
Border et al., 2015), found that greater disparities in health care access and the poor
health outcomes among pregnant minority women are significantly influenced by a high
prevalence of socioeconomic inequalities in the United States. Owing to no employment
176
and low income in most cases of pregnant minority women with low SES tend to depend
on government programs and resources.
Researchers argued that factors influencing inequalities include low-income
status, race/ethnicity, SES, insurance status, and geographical location significantly
contribute to prenatal access disparities (Saez & Zucman, 2016). Similarly, substantive
findings from RQ2 supported results from several studies (Parekh et al., 2018; Semega et
al., 2017; Smith, 2017; Taylor & Nies, 2013; Traub et al., 2015; Vardeman-Winter, 2017)
found that health disparities stem from several factors. These factors include racial/ethnic
background, SES, geographical location, education levels, insurance status,
discrimination, and social support. However, most participants attributed access
disparities to racism, prejudices and stereotypes, and marginalization as differences of
major factors influencing the barriers and challenges in health access disparities among
minority pregnant populations.
Research Question 3 Findings and Relevant Literature Review
Research Question 3 (RQ3): How have access disparities affect the overall
experience and perceptions of first-time pregnant minority women towards seeking PNC
services?
Several subthemes, including feeling undervalued, emotional distress, changing
health care providers, skipping appointments, and loss of trust in providers, emerged
from RQ3. For a better analysis of results, I grouped all subthemes under one theme – the
effects of access disparities in the process of seeking PNC services. Overall, participants
reported that access disparities had a negative impact on their experience of seeking care
177
and prenatal outcomes. These reports are supported by findings from several studies by
(Gadson et al., 2017; A. Gavin, Nurius & Logan-Green, 2012; Lobel eta al., 2008; Lorch
& Enlow, 2016; Matthew & Brodersen, n.d; Miller et al., 2017; Taylor & Nies, 2013),
which found poor health outcomes of minority pregnant women population are a result of
low socioeconomic and health care disparities in the United States.
Findings from RQ3 showed some participants who experienced access disparities
reported feeling undervalued, disregarded, and insignificant to the HCPs, and others
suffered emotional distress, which reflected their care-seeking behaviors. Martinez’s et
al., 2013) study indicated that socially disadvantaged and marginalized people suffered
from physiological resentment and reported poorer health outcomes on average than
people who belong to more socially advantaged and inclusive groups. Similarly, access
disparities among some participants reported a loss of trust in HCPs and the United
States’ health care delivery system. Findings from Mazul et al. (2017) study showed
greater evidence of negative attitudes towards HCPs and perceived poor quality of care,
which reflected lower patient satisfaction among minority pregnant women subgroups.
Other participants indicated that access disparities influenced them to engage in
seeking new HCPs frequently, which interrupted their opportunities to enjoy the benefits
of establishing a stable doctor-patient relationship. Findings from this study indicated that
participants intentionally missed or delayed recommended care to avoid suffering
mistreatment related to access disparities. These findings were supported by Mazul et al.
(2017) study, which indicated that health care disparities contributed to fewer use of
preventive health care services among pregnant minority women when compared to their
178
White counterparts. The IOMs report of Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care emphasized evidence of discrimination, exclusion,
prejudice, and stereotyping by HCPs as contributing to disparities (Coley et al. 2018).
This report showed little evidence that minorities commitment and use of recommended
routine preventive health service, which further supports the findings of this study.
Interpretation and reporting protocol describe the steps used to report the findings of this
study through a single researcher’s lens.
Theoretical Lens
Andersen developed the original model ANFHSU in 1968 designed to explore
why individuals use health care services and have extended the framework through
numerous iterations to adopt health outcomes. Further, Andersen’s model helped
facilitate the process of understanding why families use health care services, define and
measure equitable access to health care, and contribute to the development of policy
interventions for promoting equal access to health care. Hence, the need to explore
factors that enable or inhibit access to health care (Andersen, 1968, 1995). ANFHSU
proposed the reality of factors that enable or impede an individual’s use of health care
services and categorized them into three groups: predisposing, enabling, and need factors
(Andersen, 1968). ANFHSU provided the lens of analysis to explore access disparities in
PNC services experienced first-time pregnant minority women in northeast MA. More
than 92% (11/12) of the participants who sought PNC services acknowledged that they
experienced one or more forms of access disparities in the process of seeking PNC
179
services. Notably, one participant admitted to not experiencing or noticing access
disparities until she started using public insurance.
Study findings reflected the existence of access disparities experienced by study
participants in the process of seeking PNC services, which were attributed to several
influencing factors such as racial/ethnic discrimination, health insurance status, income
status, SES, and education status. The three categories determined by Andersen are
predisposing, enabling, and need (perceived and evaluated) factors deduce to enable or
impede health care services use. These categories provided valuable insight into the
multifaceted layers of access disparities experienced by first-time pregnant minority
women in the process of seeking PNC services. Andersen stated inequitable access to
care occurs when predisposing (i.e., sociocultural characteristics, attitude and value
individuals place on the health care system), enabling (i.e., available resources and
knowledge to access health services, income to acquire and sustain quality health
insurance, availability of HCPs and facilities, and need (i.e., perceived is the immediate
cause of an individual’s need for health service use and evaluated is the professional
decision in determining health status), and the need for medical attention.
ANFHSU’s perception of the existence of factors that enable or impede an
individual’s use of health care services is consistent with racial/ethnic discrimination and
income status predisposing factors. These factors contributed to inequitable access to
PNC services among first-time pregnant minority women. Participants argued that the
predisposing factor of being racial-ethnic minorities coupled with being pregnant
interfered with their process of seeking and using care significantly in the form of
180
racial/ethnic discrimination, which contributed to their experiences of access disparities.
Almost all participants believed they were treated indifferently or unequally at their
prenatal visits.
Similarly, health insurance types, income status, and SES perceived by
participants as major reasons influencing their experience of access disparities, which are
components of ANFHSU’s enabling resources. These components of enabling factors
clarified why participants perceived their low SES characterized by unemployment status
and low household income contributed to their experience of access disparities in the
process of PNC services. For instance, low-income status and SES dictated the type of
insurance, available facilities, and choice in HCPs to first-time pregnant minority women.
Also, the component of health beliefs as used in the ANFHSU provided insight on why
12 study participants who experienced prenatal access disparities, more than 50%
reported they missed the recommended care intentionally as a result of access disparities.
The commitment to continue seeking the recommended PNC amidst access disparities
reflected the attitude and value first-time pregnant minority women attach health.
ANFHSU not only provided lenses for analysis, but its conceptualization
encompassed all facets of this study. More importantly, the model’s assumption of the
existence of enabling and impeding (i.e., predisposing, enabling, and need) factors that
influence an individual to access and use health care services illustrate the disparities in
access to PNC, their causes, and the effect these disparities had on participants. This
study converged a review of the literature with a landscape lens of interviews with key
participants to provide an overview of studies in access disparities.
181
Limitations of the Study
Limitations of this narrative descriptive study included the participant recruited
criteria from the execution of the study as described in chapter one. The design of this
study inclusion of Black/African and Hispanic/Latino American women may offer
transferability to similar groups, other minority groups and communities yet limitations
of this study could also influence transferability and credibility; thus, weakening study
findings. Although the findings of this study is highly relevant, there were an inherent
limitation on ethnic differences that needed to be highlighted.
First, recruited participants were limited to two minority subgroups inclusive to
Black/African American and Hispanic/Latino American women. The characteristics of
the participants used in this narrative descriptive study were limited to two subgroups of
women to transfer findings to similar populations or settings outside the scope of this
study. Other minority groups of women, white or other ethnicities may share similar
disparities unique to this type of population. Although health disparity is seen mostly in
underserved neighborhoods made up of racial/ethnic groups, barriers unique to this
population in accessing PNC or specialized care system of similar minority groups of
similar background, other women were excluded from this study. Other racial/ethnic
minority groups could have included, e.g., Asian American, Native American, American
Indian or immigrant women.
Second limitation is the other women in this setting who received similar care
who were non-Hispanic or non-African American such as White women or refugees who
shared the same commonality in the receipt of PNC services. Background similarities
182
included SES, low-income, unemployment, and lack of insurance. These other women
not included in this study may have responded similarly to the IQs based on similar
experiences and more importantly, similar settings. Similarly, these women are in a group
as higher need for specialty services because of the pervasive influence of poverty and
poor decision making which may be contributing factors to the situation these women are
in or the overall problem to access. Addressing other minority groups outside the ones
explored in this study could further help to understand from their perspective their
experience in the receipt of PNC and specialty services or their engagement with HCPs or
other health care staff during their care visits. It would help to understand if factors
influencing disparities are systemic or structural among women with low SES or self-
identified racial/ethnic characteristics.
Third limitation include systems issue where other groups of women do not have
what would be considered good access and good care. These issues may include limited
appointment availability, HCP/specialty shortage, constrained financial resources to
health care sites, need for policy changes, and limited education about health care sites.
Health care organization must prioritize and build capacity and convenient care options
and patient services to mobilize patient access opportunities.
Race/ethnicity or culture in the context of health behavior has been defined by
HHS (2017) as unique shared values, beliefs, and practices directly or indirectly
associated with a health-related behavior or the adoption of the health information.
Healthy People 2020 (2014) defined race/ethnicity or culture as the learned and shared
beliefs and values of a designated or specific group transmitted intergenerationally which
183
influence thoughts and actions. The current study followed the rigorous methods to
achieve the findings interpreted with reference to relevant theoretical and policy
perspectives, in order to derive recommendations for research and practice.
Recommendations
I am confident that there is a strong need for a new qualitative review employing
gold standard methods to capture the critical assessment of minority pregnant women
beyond Blacks/African American and Hispanic/Latino American pregnant women in
receipt of PNC services. The limitations of the present study led to several
recommendations for future researchers.
First, the study participants consisted of a limited recruitment, within a limited
geographic area, and two specific subgroups. Future researchers may consider focusing
priorities conducting a similar study using wider national participant recruitment, in a
different geographic area or location, and incorporating a wider subgroup of racial/ethnic
minority pregnant women to provide further transferability of the results. This study
presents the opportunity for future qualitative research to be conducted prioritizing
emphasis on other minority pregnant women in the receipt of PNC focused on timely
obstetrical care and extended specialized care services may bring about substantive
inquiries and impart further understanding of factors influencing prenatal disparities and
implement strategic policy intervention to address prenatal disparities. If replicating this
study, future researchers should consider expounding the questions related to factors
influencing access disparities on their newborn.
184
Extending the areas of the research to the patterns of HCS and systems issues may
help highlight other issues of a fractured HCS. Health care systems issues domain should
focus on limited appointment availability, HCP/specialty shortage, constrained financial
resources for health care/specialty sites, policy changes, and limited education about
health care sites. Health care organization must prioritize and build capacity and
convenient care options and patient services to mobilize patient access opportunities.
Access to health services means "the timely use of personal health services” to achieve
optimal health outcomes. Requiring three distinct steps include (a) gaining entry into the
HCS (usually through insurance coverage), (b) ease in accessing a location offering PNC
or specialty care services (availability), and (c) finding an HCP who patient trusts, can
engage and communicate with (doctor-patient relationship). Access to health care affects
the overall physical, social, and mental health status and quality of life (Healthy People
2020, 2015).
Due to the narrative descriptive design of this study, participants’ limited
responses within the defined scope of this study could benefit from new studies focused
on areas that emerged that were beyond the purpose and scope of this study. I would
recommend the long-term monitoring of the health outcome of first-time racial/ethnic
minority postpartum mothers and their one-year-old newborn who experienced access
disparities to establish the long-term effects of access disparities on health outcomes for
this population.
185
Implications
This study provided first-time pregnant minority women an opportunity to voice
their interpretation of their experiences on access disparities in the domain of PNC. This
study added new knowledge to the existing body of knowledge of PNC services of the
pregnant minority populations in the United States. Dissemination of the information
generated in this study and the study findings could contribute meaningfully to the gap in
the literature on first-time pregnant minority women in the receipt of health care access
for the first time, unambiguously the domain of PNC services.
Potential Positive Social Change Implications
The potential for positive social change contributions of this study may involve
increased awareness of the challenge in PNC services such as access disparities in first-
time pregnant minority women experience in the United States. The findings of this study
will be made available to the study population, HCPs and health institutions, community
leaders, advocacy groups, and the general public when published to generate
transparency of the access challenges in prenatal health among minority pregnant women.
To increase awareness of the findings of this study, I will remit to discuss and interpret
the substantive results of this study at research forums, including conferences and
workshops at the national and international levels.
I will work with research and private and public organizations committed to
addressing health disparities and promoting health equity among pregnant minority
women. Hopefully, the results of my study may provide valuable insights that will be
used by policymakers to design, develop, and implement evidence-based sustainable
186
policy and program interventions tailored to address the specific health needs of minority
pregnant women. As a result, these policy interventions will help to maximize and
support their achievement in navigating the health care system to prevent delayed
treatment and gaps in care and improve prenatal health outcomes for minority pregnant
women in the United States.
Theoretical Implications
This study supported the use of Andersen and Newman’s (1995) predisposing,
enabling and needs factor in identifying and understanding health care disparities and
interventions. Andersen’s framework helped guide the research to underscore factors that
influenced health care disparity. The study also implied that the ANFHSU not only
provided in-depth look at health care behaviors of participants, but also their perceived
health status. Participants perceived their predisposing characteristics, i.e., education,
occupation, ethnicity, social interaction, and culture would not meet their needs of their
care-seeking behavior and the kind and amount of treatment that would be provided after
presenting to an HCP. Other research did not show the use of Andersen’s extended phase,
outcomes, which is a potential implication of the present study. The study does, however,
imply that the extended phase of Andersen and Newman’s framework may provide
illustrative value for researchers studying this and similar issues.
Recommendations for Action
The results of this study are congruent with previously published literature by
(Callaghan, 2012; Creanga et al., 2014; D’Angelo, Bryan, & Kurz, 2016; Docherty &
Johnston, 2015; Gabbe et al., 2017; F. Gonzales et al., 2014; G. Gonzales et al., 2019; E.
187
Howell et al., 2016; Lu et al., 2015) emphasize that pregnant minority women are a
marginalized and medically underserved subgroup and suffers disproportionately from
health care disparities in the United States. Given the collective awareness of the
significance of early life development in relation to the overall health outcomes in adult
populations, urgent policy and program intervention to address PNC needs of pregnant
minority women subgroups in the United States is strongly recommended. For this to
occur, there is a need to generate awareness among scholars, researchers, health care
providers, and policymakers of the sweeping health challenges prominently faced by
pregnant minority women subgroup population.
Implications for Future Research
I propose it would be useful for the Department of Health and Human Services
through agencies such as AHRQ and NIH to create incentives that attract researchers to
investigate in the area of health of pregnant minority women. There is a need to
strengthen existing policy, mobilize new policy, and maximize program interventions in
response to access disparities in health care facilities across the United States.
The primary goal of public health stakeholders’ is to reduce health disparity
across cultural lines in the United Sates. The HHS (2016) released a report in 1985
documenting the existing health disparity among minorities which they called “an affront
both to our ideals and to the ongoing genius of American medicine” (p. 12). The national
stakeholder strategy in achieving health equity provided an all-encompassing path for
eliminating health disparities through two key components using cooperative and
strategic actions. These actions include the blueprint for guided action at the local, state,
188
and national levels and targeted initiatives reinforced by public and private sector
partners. Other program strategies designed to bridge the gaps among impacted
communities imposed a critical step toward bringing individuals and organizations within
the health arena collectively with other individuals and organizations with similar
influences in health. Together negotiation and policy decision-making toward achieving
health equity has the potential to achieve sustainability.
For researchers, the study implies the undeterred need to view with a critical lens
and understand the fundamental factors influencing the existential health care disparities.
Qualitative research may revive and awaken the existential issues by those experiencing
the problem and their attitudes towards specific stakeholders in health care and public
health policy, as with this study. Qualitative researchers share the understanding that is
their role to distinguish their population and potential barriers, such as health and health
care disparity, and socioeconomic factors that may influence behaviors. This study in
addition, promotes awareness to researchers of the need for strategic action to solutions to
remove prenatal disparities among minority women. It is required for the health care
sector to preserve the transparency in health care initiatives, increase the transparency of
the actions taken to improve health disparity, including the strategic development, actions
and monitoring of health statistics, especially, among minority subgroup population.
The Offices of the Institute for Minority (2017) in conjunction with the AQHR,
observed policy approaches concurrently with public health issues, and reported that
effective strategy to earn the public’s trust is to increase transparency of data and metrics
to illustrate quality indexes. Hence, researchers should be transparent in their data
189
collection methods to the public to equally increase public trust in research. Transparency
necessitates accountability throughout the health care system. Therefore, it is
recommended that individuals, community organizers, health care providers, and
stakeholders’ partner with researchers to improve population health outcomes. Finally,
these practices are likely to strengthen the relationship among researchers, minority
communities, and HCPs.
I hope the dissemination of the results of this study will foster the interest of
future researchers to undertake similar appraisal of pregnant minority women in the
United States and in countries such as Canada and other European countries. The
development of researchers’ interest in investigating health needs and challenges of
pregnant minority women will help to not only bridge the current literature gap but to
close the gap central to health outcomes of this vulnerable population.
Implications for Practice
An integrated community action is vital to influence societal change and remove
health care disparities (CDC, 2013), and all stakeholders should work to serve as an
integrated stakeholder. The study results revealed several recommended functions that
nursing practice could serve in reducing health care disparities. In accordance with the
national stakeholder strategic action in achieving health equity is to increase
transparency, strengthen and broaden leadership, improve health outcomes, improve
cultural and linguistic competencies and health-related workplace diversity, and improve
data availability, diffusion, and use of research and evaluation health outcomes for racial,
ethnic, and underserved population.
190
Health care providers should undergo a mandatory sensitivity training to identify
and minimize the negative impact associated with prenatal disparities among minority
groups. A health care management system should implement a reporting system of health
outcomes to understand the underlying causes of access disparities and find reliable
solutions to mitigate the problem. Staff may also benefit from an incentive program for
those who show a commitment to promote equitable care.
The role of nursing practice is to serve the community through nurse-led quality
improvement initiatives aimed at providing information and education about common
health issues for first-time pregnant women. Nurses could inform racial/ethnic minority
pregnant women in underserved and vulnerable populations of the importance of early
and timely PNC visits and risk factors of perinatal complications. The CDC (2019)
released a report containing data from 2011 to 2015, showing Black women experienced
42.8% or 3.3 times as high pregnancy-related deaths for every 100,000 live births when
compared to their White counterparts. The study further revealed that 700 women die
from pregnancy-related complications annually.
The results of the present study suggested Blacks/African American and
Hispanic/Latino American pregnant women in the receipt of PNC are treated differently
than non-minority pregnant women, receive less-significant amount of care, and are less
likely to receive consistency care or specialized care. Nurse-led health communication
enhance and improve health service experience through coordinated health education,
communications, and interactions. Previous researchers have similarly indicated
encouraging benefits from nurse-supported PNC initiatives (Picklesimer, Billings, Hale,
191
Blackhurst, & Covington-Kolb, 2012; Tenenbaum Potter, 2017). The findings supported
community-based participatory action has the potential to promote the connection
between educational attainment and long-term health benefits.
Knowledge transfer generated by research support health care information and
program intervention related to health disparities and health equity. Community-based
participation could build capacity of the PNC system that indirectly reduces costs at all
levels, reduce unexpected hospital visits when preventative measures is in place. Further,
potential findings could foster positive change in nursing practice. As a practice
discipline, nursing may benefit from this research because it could provide nurses with
insight into some of the barriers these women face in accessing and navigating healthcare
and healthcare services. The information from such research could be implemented at all
levels of nursing practice to remove barriers for this population.
Implications for Policymakers
Having the ability to identify a social change issue and understanding the values
influencing specific populations, provides the opportunity for public policy reform (Dye,
1972). Thus, this study provides several indications of the needs of first-time pregnant
minority women regarding PNC disparity and health care reforms by policymakers.
These implications may be especially salient for reducing health care disparities as
policymakers take actions to revise the ACA. The existential problem of PNC disparities
persistently affecting the same subgroups or populations were used to derive policy
implications from the present study. The perception of first-time pregnant minority
women health needs as identified from this study generated salient themes, became the
192
first steps of stakeholder’s responsibility the underserved and vulnerable populations.
Circumstances diverting attention from the current issue of PNC and access disparities
can impact any component of the policy process.
Steps in policy reform process must be valued and accurately documented,
confirm routine analysis of alternative strategic solutions until the health disparity goals
are met. Quality health care and health services should remain a prioritizing focus for the
nation, as the present study indicates persistent health care disparities with devastating
effects for the population under study. The problem should provide the impetus for
unlimited coordination with stakeholders, such as the minority women examined in the
present study. Stakeholders with in-depth knowledge and experience in the problem, such
as pregnant minority women from underserved populations, as active representatives in
policymaking can limit interferences impeding positive change. Hence, building capacity
at all levels of decision making can promote community solutions.
Policy-based participation on the needs identified from this study with
stakeholders, community leaders, and hospital agencies would bridge the gap to achieve
population health goals (IOM, 2015). An implication from this study is integrating policy
revisions that mandate enhanced partnerships that include stakeholders at all levels and
open venues to address issues of PNC disparities. Stakeholders at all levels can provide
valuable insight to policymakers and help shape the policy that place value on their lives.
Stakeholders at all levels have the potential opportunity for soliciting community input to
integrate valuable information and prevent nuances of political biases, from interfering
with policy faced by minority populations. Policymakers could use this information to
193
expand coordination, collaboration, and to target policy demands on funding priorities
and involvement in research and services. This study can also inform future policy
strategies based on the theoretical perspectives of Andersen & Newman.
Policymakers major implication should focus major emphasis from the issues in
this study including preventing financial obstacles to care through the delivery of
insurance or other payment sources. Increase the capacity of the PNC system including
department of health clinics, the network of private physicians providing care for low-
income and Medicaid-enrolled (Roman, Raffo, Zhu, Meghea, 2014), outpatient
departments, and community health centers, low-income community-based obstetrics
clinic (IOM, 2017), and similar point of care settings. Improve institutional practices for
easier accessibility, adequate and acceptable care by low income and underserved
populations (Picklesimer et al., 2012). Identify women in need of PNC by mobilizing a
variety of approaches, including hotlines, canvassing communities using outreach or
paraprofessional workers, cross-agency referrals, and the providing incentives (Shah,
Revere & Toy, 2018). Provide social support to encourage continuity in PNC visits and to
increase the likelihood of healthy pregnancies and the smooth transition into parenthood
(Heaman et al., 2015).
Knowledge transfer generated by research extends to decision making about
policies and program intervention related to health disparities and health equity. Lastly, I
hope sincerely that the findings and insights generated by this narrative descriptive
research on access disparities in PNC services experienced by pregnant minority women
194
will elicit action that will result in sustainable positive social change in the form of
enhanced health care outcomes for the study population.
Conclusion
Minorities are considered the largest underserved population who are at the
greatest risk for deaths in childbirth and infant mortality (CDC, 2013). This study was
conducted to explore first-time pregnant minority women’s account of access disparities
in the process of seeking PNC. Data was collected from direct sources, the pregnant
women, living in the northeast region of the country. Andersen and Newman’s (1968)
framework of health service utilization were used to understand the factors and
characteristics of minority pregnant women with possible health care disparities qualified
as low socioeconomic status and explanation for the policy implications including
stakeholders at all levels. It was found that some factors counted, including
race/ethnicity, SES, residency, availability of services, income, education, and
employment may have presented as barriers to PNC access influencing health care
disparities (Dutta, 2018; Howell, & Zeitlin, 2017; Petersen, Davis, Goodman, et al.,
2019).
Enhancing equal access to health services were important to the participants in
this study, yet most participants encountered unequal or limited treatment to essential
services during their pregnancy. Some participants either could not afford comprehensive
insurance or basic insurance plan. Public health professionals are in the position to
potentially foster the communication between all stakeholders to provide resources to
establish equitable access at all levels of health services. Alarmingly, there seems to be
195
gaps in care services in the health care delivery system for minorities, especially when
the health care system confirms deficiencies of resources even with the amendment to the
ACA. Essential care should be easily accessible and not challenging to these women in
the receipt of PNC. PHPs are catalyst to opening the dialogue to mobilize interventions
which would save lives and reduce burden to these women.
Participants understood the value of health care and the importance of PNC which
they could not personally afford. One of the primary barriers to PNC service was
affordability. Racial/ethnic status was also a contributing barrier preventing most from
quality care access and as noted from the participants. Congress, legislators and
community leaders are essential part of the process addressing how health disparities
impact the health of the individual, their family and the community, especially, the
underserved minority women subgroup population. Scholars and HCPs have an equal
role to bring awareness and voice to policymakers, to gain acknowledgment and establish
a path to integrate services to community by broadening outreach capabilities to build
capacity.
Interviews also revealed that the participants valued equal treatment in quality
care services by specialty HCPs who value them equally and provide quality care for
everyone equally. HCPs have the benefit in having a voice in policy-making decision
affecting communities’ health. The participants from this study were eager to stretch their
voice to the challenges and expect to have an influence on addressing PNC disparities.
Fully understanding the influencing factors surrounding health care disparities is most
vital to designing targeted, effective, and sustainable policy reform. Researchers,
196
scholars, and PHPs have an empowering role to help minority pregnant women through
the barriers predisposing them to PNC disparity. Those in the role may develop programs
to educate and advocate grounded on the needs of the minority pregnant women and
advocate the needs to health care policymakers and legislators. Other HCPs and
community leaders can identify from this study and assess the health care needs and
appraise what type of actions are required for improving the health of these women. Also,
they may communicate these actions to HHS (2014) and other legislators for policy
support. Partnering with health care system agencies as a stakeholder will facilitate the
implementation of improved programs.
A community participatory approach that engages diverse stakeholders may help
to reduce health disparities. There is a significant relationship between an individual’s
behavior, health behaviors, and health behavior outcomes (Shepherd et al., 2014), which
suggest that maximizing resources can empower individuals to become well informed,
which can improve statistical outcomes and improved health for the underserved
communities (HHS, 2017). As a lifelong learner, I feel strongly about the goal to
empower individuals through education and providing equal opportunities to end all
health care disparities at the local, national and global levels. I believe in lending support
to empower individuals, strengthen communities, and provide opportunities that will help
to bridge the divide and disparities gap. Empowering individuals to make an actionable
difference in the lives of others can enable that individual to make a positive difference to
empower others at an individual or community level.
197
In this study, I disclose the voices of the pregnant minority women who feel
undervalued by HCPs in the receipt of PNC. I acknowledged and brought the health care
needs and concerns to the forefront. I will unremittingly push the findings to legislators,
community leaders, HCPs, and PHPs with a personal goal to respond to the unnecessary
burden for those negatively affected by the challenges of PNC access in relation to health
disparities. Mobilizing strategies, invigorating organizations and communities, and
including diverse stakeholders will help facilitate accountability and call to action to
address health care disparities, which would thrust the underserved communities within
the goal of health equity across racial and cultural lines in the United States. The more
strategies and more organizations and communities involved in facilitating accountability
and addressing health care disparities, the more likely underserved communities will
experience a better quality of life and thrive.
