Barriers to Adequate Prenatal Care Utilization in American Samoa

1. Barriers to Adequate Prenatal Care Utilization in American Samoa Bethel Muasau-Howard1, Nicola Hawley2, Carolyn Brown2, Ofeira Nu’usolia3, John Ah-Ching1 & Stephen T McGarvey2 1LBJ Tropical Medical Center, Pago Pago, American Samoa 2International Health Institute, Department of Epidemiology, Brown University, 3Tafuna Clinic, American Samoa Community Health Centers, Department of Health, American Samoa

2. Background American Samoa Unincorporated territory of the United States 2,600 miles southeast of Hawaii and 1,800 miles northeast of New Zealand Land Area: Approx. 76 square miles Population: 57,291 (2000 Census)

3. Background • Ensuring that pregnant women have universal and timely access to prenatal care is a global public health priority • - Millennium Development Goal #5 • Optimal pre-delivery care usually consists of medical screening, physical and ultrasound exams, education and counseling and if necessary assistance with social services • BUT despite provision of prenatal care being a priority there are still well recognized disparities in prenatal care utilization and consequently maternal and child health outcomes • - Almost all maternal deaths (99%) occur in low and middle income countries • (LMICs)

4. Background • It is well documented that women in LMICs tend to access prenatal care late and attend an insufficient amount of appointments • The reasons for under-utilization of prenatal care vary widely and are often intertwined with local culture or local healthcare infrastructure • Accurate assessment of prenatal care utilization and the associated barriers to its access is the critical first step in the development of targeted public health programs to improve prenatal care access overall and in at risk groups

5. Aim The aim of this research was to describe the utilization of prenatal care in American Samoa and to identify predictors of inadequate prenatal care utilization

6. Methods • Clinic records were available for 1036 women who received prenatal care at the Tafuna Family Health Center (TFHC) or the Lyndon B Johnson (LBJ) Tropical Medical Center between 2001 and 2008 • - Every woman whose records were available for review delivered their infant at LBJ • where approximately 97% of the ~1300 deliveries per year occur • Of these women 692 were Samoan, had singleton births and complete data on their prenatal care, delivery and infant outcomes • Clinic records were reviewed to determine: • - the week of gestation at the woman’s first prenatal care visit • - the total number of prenatal care visits they attended • - the length of their gestation • - socio-demographic characteristics of the women and their • partners • Data collection was approved by the Brown University IRB and the American Samoa Department of Health

7. Adequacy of Prenatal Care Utilization Index • The index reports on two dimensions: • 1. The timing of initiation (Adequacy of Initiation) • 2. The number of visits a women attends relative to the amount she • is expected to attend based on the American College of • Obstetricians and Gynecologists (ACOG) guidelines • (Adequacy of Received Services) • An index summary variable was also created that combined the two dimensions into a single measure of prenatal care adequacy • Kotelchuck M (1994) An evaluation of the Kessner adequacy of prenatal care index and a proposed adequacy of prenatal care utilization index. Am J Pub Heath 84(9), 1414-1420

8. Results – Sample Characteristics

9. Results – Adequacy of Prenatal Care

10. Results • Adequacy of Received Services was associated with the timing of prenatal care initiation • Women who initiated care early were more likely to have adequate plus care • Those who initiated care late were more likely to receive inadequate care

11. Results – Predictors of Prenatal Care Utilization • Parity was negatively associated with timing of initiation • - women who had delivered four or more infants initiated care • more than two weeks later than primiparous women (25.81 vs. 23.39 weeks, • P=0.02) • Unemployment was associated with later prenatal care access • - women who were unemployed accessed prenatal care later than those • employed in management, professional or sales occupations (25.36 vs. 23.72 • weeks, P=0.03) • Having a partner who was also unemployed further delayed the initiation of prenatal care • - women in this situation accessed prenatal care more than four weeks later • than women who were employed & had an employed partner (27.61 vs. 23.50 • weeks, P=0.03) • Year of delivery was associated with both timing of initiation & adequacy of received care • - women who delivered in 2007-2008 accessed prenatal care earlier and • attended more appointments than those in 2001-2006

12. Results – Year of Delivery & LBJ’s Prenatal Care Incentive Scheme * ** * P<0.05 ** P<0.01 • The Prenatal Incentive Scheme was introduced in 2006. Women qualify if they attend their first prenatal care visit before the end of the first trimester and agree to attend at least 80% of all their visits thereafter • These data suggest the scheme is having a positive impact on utilization although we don’t have actual enrollment numbers for this sample

13. When we asked women about the importance of prenatal care…. • Qualitative interviews conducted with women at the clinics suggest that knowledge of the importance of prenatal care is ubiquitous among Samoan women. • “Prenatal care is so important for a healthy baby and for us” • “…..It’s very, very important. You know for the sake of the mom and • the baby. For the safety of the unborn” • Despite this knowledge, prenatal care in this sample was late and sporadic • - 83.2% of women were classified as receiving • inadequate care based on the combined index of • their timing of initiation and the adequacy of • received services after initiation

14. Recommendations Based on these Findings • Multiparous Women Should Be Reminded of the Importance of Prenatal Care • - Although women may think they have learned everything in previous pregnancies • they should be encouraged to attend • - Support for those women with childcare issues should be provided • Improving health care accessibility is key • - Financial constraints faced by those who are unemployed likely prohibit attendance • More research is needed about other potential barriers • -Do women recognize their pregnancy early? • - Is there anxiety around prenatal care or accessing healthcare in general? • - Are waiting times too long? • - Are there other unique cultural barriers we are missing?

15. Conclusion • During the period 2001-2008 prenatal care utilization in American Samoa was poor – which is a major concern • Prenatal care utilization was associated with several maternal socio-demographic characteristics which suggest that improving healthcare accessibility will be key in encouraging women to attend prenatal care • The significant improvements in the timing of initiation of prenatal care and the utilization of received services seen in 2007-2008 suggest that the prenatal care incentive program implemented at LBJ since 2006 is a very positive step toward addressing issues of prenatal care utilization in this population

16. Acknowledgements • Co-Authors: Nicola Hawley, Carolyn Brown, Ofeira Nu-usolia, • John Ah-Ching, Stephen McGarvey • Brown Students: Sam Urlacher, Sarah Raifman • Tafuna Clinic Staff • LBJ Tropical Medical Center Staff

17. Fa’afetai