title: Barriers, motivators and facilitators related to prenatal care utilization among inner-city women in Winnipeg, Canada: a case-control study.
abstract: BACKGROUND
  The reasons why women do not obtain prenatal care even when it is available and accessible are complex. Despite Canada's universally funded health care system, use of prenatal care varies widely across neighborhoods in Winnipeg, Manitoba, with the highest rates of inadequate prenatal care found in eight inner-city neighborhoods. The purpose of this study was to identify barriers, motivators and facilitators related to use of prenatal care among women living in these inner-city neighborhoods.
  
  
  METHODS
  We conducted a case-control study with 202 cases (inadequate prenatal care) and 406 controls (adequate prenatal care), frequency matched 1:2 by neighborhood. Women were recruited during their postpartum hospital stay, and were interviewed using a structured questionnaire. Stratified analyses of barriers and motivators associated with inadequate prenatal care were conducted, and the Mantel-Haenszel common odds ratio (OR) was reported when the results were homogeneous across neighborhoods. Chi square analysis was used to test for differences in proportions of cases and controls reporting facilitators that would have helped them get more prenatal care.
  
  
  RESULTS
  Of the 39 barriers assessed, 35 significantly increased the odds of inadequate prenatal care for inner-city women. Psychosocial issues that increased the likelihood of inadequate prenatal care included being under stress, having family problems, feeling depressed, "not thinking straight", and being worried that the baby would be apprehended by the child welfare agency. Structural barriers included not knowing where to get prenatal care, having a long wait to get an appointment, and having problems with child care or transportation. Attitudinal barriers included not planning or knowing about the pregnancy, thinking of having an abortion, and believing they did not need prenatal care. Of the 10 motivators assessed, four had a protective effect, such as the desire to learn how to protect one's health. Receiving incentives and getting help with transportation and child care would have facilitated women's attendance at prenatal care visits.
  
  
  CONCLUSIONS
  Several psychosocial, attitudinal, economic and structural barriers increased the likelihood of inadequate prenatal care for women living in socioeconomically disadvantaged neighborhoods. Removing barriers to prenatal care and capitalizing on factors that motivate and facilitate women to seek prenatal care despite the challenges of their personal circumstances may help improve use of prenatal care by inner-city women.
authors.affiliation: College of Nursing, Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg, MB R3T 2N2, Canada. Maureen.Heaman@umanitoba.ca.
authors.forename: Maureen I
authors.initials: MI
authors.lastname: Heaman
authors.forename: Michael
authors.initials: M
authors.lastname: Moffatt
authors.forename: Lawrence
authors.initials: L
authors.lastname: Elliott
authors.forename: Wendy
authors.initials: W
authors.lastname: Sword
authors.forename: Michael E
authors.initials: ME
authors.lastname: Helewa
authors.forename: Heather
authors.initials: H
authors.lastname: Morris
authors.forename: Patricia
authors.initials: P
authors.lastname: Gregory
authors.forename: Lynda
authors.initials: L
authors.lastname: Tjaden
authors.forename: Catherine
authors.initials: C
authors.lastname: Cook
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D003863:Depression / Q000523:psychology; D005195:Family Relations; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008350:Manitoba; D009042:Motivation; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011247:Pregnancy; D049168:Pregnancy, Unplanned / Q000523:psychology; D011275:Pregnancy, Unwanted / Q000523:psychology; D011295:Prenatal Care / Q000523:psychology / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D014186:Transportation; D014505:Urban Population; D055815:Young Adult