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Prenatal care, a set of services provided to improve pregnancy outcomes and engage the expectant mother, family members, and friends in health care decisions, is critical for the health of both mother and infant. About 26% of pregnant women in the United States do not seek prenatal care until after the first trimester; 6% seek prenatal care at the end of pregnancy or not at all (U.S. Department of Health and Human Services, 2014). Inadequate prenatal care is a risk factor for low-birthweight and preterm births as well as infant mortality during the first year (Partridge, Balayla, Holcroft, & Abenhaim, 2012). In addition, use of prenatal care predicts pediatric care, and thereby health and development, throughout childhood (Deaton, Sheiner, Wainstock, Landau, & Walfisch, 2017).

Prenatal care and birth practices vary by culture. Here, a pregnant woman receives prenatal care from an extension worker in Ethiopia.

Jenny Matthews / Alamy Stock Photo

Why do women delay or avoid seeking prenatal care? A common reason is the lack of health insurance (Baer et al., 2019). Although government-sponsored health care is available for the poorest mothers, many low-income mothers do not qualify for care or lack information on how to take advantage of care that may be available. Figure 3.6 lists other barriers to seeking prenatal care, including difficulty in finding a doctor, lack of transportation, demands of caring for young children, ambivalence about the pregnancy, depression, lack of education about the importance of prenatal care, lack of social support, poor prior experiences in the health care system, and family crises (Daniels, Noe, & Mayberry, 2006; Heaman et al., 2015; Mazul, Salm Ward, & Ngui, 2016).

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Figure 3.6 Reasons for Delayed Prenatal Care Among Women, 2009–2010

Source: U.S. Department of Health and Human Services et al. (2013).

Moreover, there are significant ethnic and socioeconomic disparities in prenatal care. As shown in Figure 3.7, prenatal care is linked with maternal education. About 86% of women with a college degree obtain first-trimester care, compared with less than two-thirds of women with less than a high school diploma (U.S. Department of Health and Human Services, 2014). In addition, women of color are disproportionately less likely to receive prenatal care during the first trimester and are more likely to receive care beginning in the third trimester or no care (see Figure 3.8). Native Hawaiian and Native American women are least likely to obtain prenatal care during the first trimester, followed by Hispanic, African American, Asian American, and White American women (Hamilton, Martin, Osterman, Driscoll, & Rossen, 2017). In the most extreme case, only about half of Native Hawaiian or other Pacific Islander women obtain first-trimester care, and one in five obtains late or no prenatal care. Ethnic differences are thought to be largely influenced by socioeconomic factors, as the ethnic groups least likely to seek early prenatal care are also the most economically disadvantaged members of society and are most likely to live in communities with fewer health resources, including access to physicians and hospitals, sources of health information, and nutrition and other resources.

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Figure 3.7 Timing of Prenatal Care Initiation, by Maternal Education, 2012

Source: U.S. Department of Health and Human Services et al. (2013).

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Figure 3.8 Prenatal Care Beginning in the First Trimester and Late or No Care, by Race and Ethnicity, in the United States, 2016

Source: Hamilton et al. (2017).

Although prenatal care predicts better birth outcomes, cultural factors also appear to protect some women and infants from the negative consequences of inadequate prenatal care. In a phenomenon termed the Latina paradox, Latina mothers, despite low rates of prenatal care, tend to experience low-birthweight and mortality rates below national averages. These favorable birth outcomes are striking because of the strong and consistent association between socioeconomic status and birth outcomes and because Latinos as a group are among the most socioeconomically disadvantaged ethnic populations in the United States (McGlade, Saha, & Dahlstrom, 2004; Ruiz, Hamann, Mehl, & O’Connor, 2016).

Several factors are thought to account for the Latina paradox, including strong cultural support for maternity, healthy traditional dietary practices, and the norm of selfless devotion to the maternal role (known as marianismo) (Fracasso & Busch-Rossnagel, 1992; McGlade et al., 2004). These protective cultural factors interact with strong social support networks and informal systems of health care among Latino women, in which women tend to take responsibility for the health needs of those beyond their nuclear households. Mothers benefit from the support of other family members such as sisters, aunts, and other extended family. In this way, knowledge about health is passed down from generation to generation. There is a strong tradition of women helping other women in the community, and warm interpersonal relationships, known as personalismo, are highly valued (Fracasso & Busch-Rossnagel, 1992; McGlade et al., 2004).

Although these cultural factors are thought to underlie the positive birth outcomes seen in Latino women, they appear to erode as Latino women acculturate to American society. The birth advantage has been found to decline in subsequent American-born generations. Recent findings have called the existence of the Latina paradox into question, as some samples have illustrated that the negative effects of socioeconomic disadvantage cannot be easily ameliorated by cultural supports (Hoggatt, Flores, Solorio, Wilhelm, & Ritz, 2012; Sanchez-Vaznaugh et al., 2016).