Factors predicting the initiation of prenatal care in Mexican women

Abstract

Objective

to describe factors related to the initiation of prenatal care (PNC) among pregnant Mexican women.

Design

descriptive correlational.

Setting

public prenatal clinic in Monterrey, Mexico.

Participants

253 pregnant Mexican women aged 13–46 years.

Measurements and findings

structured interviews were conducted to obtain information concerning demographics, reproductive history, current pregnancy, perceptions of benefits and barriers of PNC, negative attitudes towards pregnancy and social support. Late initiation of PNC was reported by 47% of participants. Factors related to PNC initiation were education, perceived benefits or barriers, and negative attitudes towards pregnancy. Women who initiated PNC at an early stage were more likely to live with a partner, had a higher educational level and anticipated desirable personal benefits of PNC. Perceptions of barriers to PNC impeded early initiation of care. Social support did not influence PNC initiation. Negative attitudes towards pregnancy increased the likelihood of late PNC initiation.

Key conclusions and implications for practice

screening for negative attitudes towards pregnancy, partner status, educational level and perceived health-care barriers among pregnant Mexican women is important. Health-care providers may then address these psychosocial risk factors through PNC interventions promoting early initiation of care.

Introduction

Prenatal care (PNC), one of the most widely used preventive health services worldwide, is the cornerstone for health care of pregnant women and their unborn children. Consensus within the international community is that early and adequate PNC supplied by a health-care provider improves perinatal outcomes (World Health Organization, 2002). Early initiation of PNC has been associated with increased birth weight and decreased length of newborn hospitalisation in women at risk for adverse pregnancy outcomes (Michigan Department of Community Health, 2004).

The Mexican Official Norm NOM-007-SSA2-1993, ‘Attention of the pregnant woman during pregnancy, labour and puerperal stage’ (Secretary of Health of Mexico, 1993), recommends that pregnant women initiate PNC during the first 12 weeks of pregnancy. Despite this recommendation, in 2003, only 35% of Mexican pregnant women initiated PNC during the first trimester of pregnancy (National Institute of Statistic, Geographic and Informatics of Mexico, 2006). Late initiation of PNC in Mexico may be multifactorial. A review of prenatal programme in the USA has shown that efforts to improve access to PNC may fail due to multiple psychosocial factors affecting decision-making (Cook et al., 1999; Hulsey, 2001). It is important to understand these psychosocial factors, which may affect early initiation of PNC in Mexican women. The purpose of this study was to describe psychosocial factors affecting initiation of PNC in Mexico utilising the Health Promotion Model (HPM) (Pender et al., 2002).

The HPM (Pender et al., 2002) offers a guide to explore complex psychosocial concepts that motivate individuals to carry out or engage in behaviours directed towards the enhancement of health. It integrates constructs from the expectancy-value theory and social cognitive theory within a nursing perspective. The HPM describes the multidimensional nature of individuals’ interactions with their interpersonal and physical environment as they pursue health. This model has been utilised in research related to the prediction of specific health behaviours.

Pender et al. (2002) defined health promotion as behaviour motivated by a desire to increase well-being and actualise human health potential. Health protection is behaviour motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness. According to the HPM, the individual plays a critical role in decision-making concerning health because, on a daily basis, personal decisions are made affecting one's state of health. Early initiation of PNC represents health promotion behaviour because the woman is acting to promote positive pregnancy outcomes.

The HPM proposes that individual characteristics can influence health behaviour directly or indirectly through the perception of barriers and benefits. Descriptive studies in Mexico have reported socio-demographic and socio-economic barriers to early initiation of PNC such as low socio-economic level and education, transportation problems and multiparity (Bronfman-Pertzovsky et al., 2003; Frank et al., 2004).

Behaviour-specific cognitions and affect in the HPM are considered to be of major motivational significance. These variables constitute a critical core for nursing because they may be modified through interventions. Four HPM concepts, namely perceived benefits, perceived barriers, interpersonal influence and situational influence, were used in this study.

The HPM proposes that anticipated benefits to actions are mental representations of positive consequences that promote the execution of behaviour. Perceived benefits are seen as direct motivators of the behaviour. Individuals tend to invest time and resources in activities with a high likelihood of positive outcomes. Previous research indicates that women who perceive having a healthy baby and learning about PNC as beneficial were more likely to initiate PNC at an early stage (Fuller and Gallegher, 1999; Erci, 2003).

Health-care barriers include perceptions concerning the unavailability, inconvenience, expense, difficulty or time-consuming nature of a particular action (Pender et al., 2002). These barriers may be real or imagined and are often viewed as blocks, hurdles and personal costs of engaging in given behaviours. Perceived barriers may result in avoidance of related health promotion behaviours. Barriers cited in previous research include personal barriers (psychological and personal problems, embarrassed to be examined, inconvenient to attend appointments, difficulties with the health provider, substance use) and structural barriers (difficulty with appointments, transportation problems difficulty with clinics) (Roberts et al., 1998; Cook et al., 1999; Fuller and Gallegher, 1999; Erci, 2003; Johnson et al., 2003; Bloom et al., 2004).

The HPM proposes that family, friends and health providers are important sources of interpersonal influences that can affect the commitment and execution of health behaviour. Social support provided by family members or employers for a woman who desires pregnancy has been identified as a significant incentive for early initiation of PNC (Erci, 2003).

Pender et al. (2002) reported that personal perceptions and cognitions of any situation or context can facilitate or impede engagement in health behaviour. The HPM indicates that individuals are incited to perform and do perform more competently in situations or contexts in which they feel compatible and secure instead of solitary, insecure or threatened. Women with unplanned pregnancies may have negative attitudes that affect decisions to initiate PNC at an early stage (Mize, 1999; Bouchard, 2005). The association between PNC initiation and negative attitudes such as rejecting the need for PNC, considering abortion, unintended pregnancy and hiding pregnancy from others have been identified as a significant barrier that can predict late initiation of PNC (Hulsey, 2001; Johnson et al., 2003).

This study, based upon the HPM, proposed to test the following hypotheses.

• Pregnant women initiate PNC at an early stage when they anticipate that it will provide desirable personal benefits.

• Perceptions of barriers to PNC may impede early initiation of PNC.

• Family, friends and health providers are important sources of interpersonal influence that may increase or decrease early initiation of PNC.

• Negative attitudes towards pregnancy decrease the likelihood of early initiation of PNC.