Increasing Prenatal Care Utilization among African American Women in Washington, DC

Mommy Mobile of Washington D.C.Increasing Prenatal Care Utilization among African American

Women in Washington, DC

The Behavioral and Social Sciences Applied to Public Health

PMO 530

Running Head: INCREASE PRENATAL CARE IN D.C. 2

Table of Contents Background...........................................................................................................................................3

Problem Analysis..................................................................................................................................4

Contributing Factors to IMR.................................................................................................................5

Broad Intervention Objectives..............................................................................................................6

Audience Analysis................................................................................................................................6

Current Attitudes...................................................................................................................................7

Prior Interventions................................................................................................................................8

SMART Objectives...............................................................................................................................9

Specific.............................................................................................................................................9

Measurable......................................................................................................................................10

Achievable......................................................................................................................................10

Short term objectives..................................................................................................................................10

Long term objectives..................................................................................................................................11

Relevant/Time specific...................................................................................................................11

Theoretical Perspective.......................................................................................................................11

Intervention Design and Dissemination/Implementation....................................................................15

Mommy Mobile...............................................................................................................................15

Conclusion..........................................................................................................................................17

References...........................................................................................................................................19

Appendix A.........................................................................................................................................22


BackgroundPrenatal care was developed in response to detect eclampsia through regular screenings

of women throughout their pregnancy (Stout, 1997). Eclampsia is a life-threatening condition for

the mother and baby if not treated. Organized prenatal care started in 1901 by social reformers

and nurses who visited pregnant women in their homes (Stout, 1997). These early initiatives

provided support to low income mothers through education. It was not until 1985 when the

Unites States introduced a national policy to provide all pregnant women prenatal care (PNC) in

an effort to reduce the risk of low birth weight (LBW) (Stout, 1997). Today, prenatal care starts

after a confirmed pregnancy test, typically in the first trimester. It usually consists of monthly

check-ups unless considered a high-risk pregnancy, where more attention may be necessary to

monitor the mother and baby.

Preterm babies are defined as born before 37 weeks of gestation, while a low birth weight

baby is one that is born at term but weighs less than 2500g (5.5 lbs.) (El-Mohandes et al., 2011).

These babies normally require “neonatal intensive care and are vulnerable to developmental

disease and retardation” (Stout, 1997). Infants of LBW and gestation are the principle

contributors to infant mortality (El-Mohandes et al., 2011).

Infant mortality rate (IMR) is the number of deaths occurring in the first year of life per

1,000 live births. It is widely used to describe the health status of a nation and is typically used

for international comparisons (Heisler, 2012). Despite extensive progress, the Unites States still

falls short compared to its international counterparts. The IMR average for the Organization for

Economic Cooperation and Development (OECD) is 4.6, whereas the United States is 6.6 as of

2008 (Heisler, 2012).


Problem AnalysisInfant mortality continues to be an important indicator of health disparities in the United

States, more so in Washington, D.C. The relative contribution of preterm to LBW in infant

mortality is high, especially in African Americans where it is more than double the rate reported

in the overall U.S. population. The IMR for African-Americans in Washington, D.C. was 17 per

1000 live births in 2005, two times the rate reported for whites (El-Mohandes et al., 2011).

Although D.C. has recently experienced a historical low in IMR, it still has one of the highest in

the nation and is a critical health issue in the District of Columbia (Figure 1).

(Plecha, 2013)


Contributing Factors to IMRMany studies have shown a correlation between LBW and lack of PNC. Women who

receive PNC in the first trimester have better pregnancy outcomes, to include reduced risk of

LBW and preterm births than women who receive late or no PNC (Daniels, Noe, Mayberry,

2006). This is especially true in Washington, D.C. where there is a high IMR and a lower usage

of PNC. African American women were less likely to enter PNC within the first trimester

compared to White women - 67.1% and 90.9% respectively in 1999 (Milligan et al., 2002).

There are multiple known risk factors for poor perinatal outcome, including perceived racial

discrimination, young maternal age, low level of maternal education, poverty, inadequate

housing, lack of social support, unintended childbearing, and adverse health behaviors during

pregnancy such as alcohol abuse, smoking, and drug abuse (Kiely et al., 2011). Disenfranchised

members of the community, such as homeless and substance abusing women, utilize PNC less

because they believe it is not important (Milligan et al., 2002). Specific factors that contribute to

infant mortality in Washington, D.C. are as follows:

● LBW; this is the #1 cause in IMR; primary factor is lack of early PNC use

● Prematurity; a contributing factor of LBW

● High pre-pregnancy weight/Body Mass Index (BMI)

● Unmarried mother

● Medicaid beneficiary; this is indicative of socioeconomic status (SES)

These factors may compound each other and have a spiraling effect. Lack of PNC contributes to

premature childbirth, which equates to LBW, and so on (Plecha, 2013).


Broad Intervention ObjectivesIt is necessary to study previous and current public health programs that have focused on

infant mortality, preterm/LBW, and PNC within lower SES populations. Large federal initiatives

such a Healthy People can provide overall objectives, which then can be customized by local

community initiatives. One goal of Healthy People 2020 is to reduce infant mortality from 6.7 to

6.0 infant deaths per 1,000 live births - a 10% improvement. Another objective of Healthy

People 2020 is to increase the proportion of pregnant women who receive early and adequate

PCN from 70.5% to 77.6% - a 10% improvement (Healthy People 2020).

For Washington, D.C., local initiatives need to focus on improving access and utilization

of PNC. Short-term goals are to increase awareness of PNC importance and decrease stigmas

associated with lack of social support. Long terms goals are to decrease IMR in Washington,

D.C. to below the national average through improved PNC initiative such as the Mommy Mobile

of D.C.

Audience AnalysisAccording to the 2010 census, the total population of Washington D.C. was 601,703, of

which, 49.5% were black (Census, 2010). The 2011 District of Columbia Department of Health

Infant Mortality Report announced a decrease in infant mortality from 11.5 per 1,000 live births

in 2003 to 7.4 in 2011 (Plecha, 2013). Furthermore, from 2007-2009 IMRs in the District were

highest among non-Hispanic black groups (11.7%) as opposed to non-Hispanic white groups

(5.2) and Hispanic groups (6.7) (See Figure 2). For maximum improvement, it is prudent to focus

on African American females in D.C.


“Previous studies show that PNC utilization among high-risk women, regardless of the

related socio demographic factors such as young age, single, low education and high poverty

residency; lowered the risks of maternal morbidity and mortality (Johnson et al., 2003, p103).”

Johnson et al., (2003) observed that 68.6% of African American mothers sought early PNC.

Washington, D.C. is divided into 8 Wards, with the most dense target population in Wards 5

through 8 (see Appendix A). These specific wards are located on the east and south sides of the

District and are adjacent to one another. Appendix A has maps that show IMR, live birth rates,

low birth rates and preterm birth rates for each ward. Of the 8 wards, 5 through 8 consistently

had the worst rates and are where our Mommy Mobile of D.C. initiative will focus its efforts.


Current AttitudesIn a study conducted by Johnson et al (2003), negative attitudes towards pregnancy and

PNC were associated with late PNC. This study observed ten main psychological barriers, which

are listed in order of magnitude:

1) Unplanned pregnancy (41.6%)

2) Will go to emergency room if pregnancy complications occur (34.7%)

3) Receive advice about pregnancy from friends and family (34.3%)

4) Received pregnancy test late (31.1%)

5) Considering abortion (29.7%)

6) No health insurance (22.8%)

7) Unaware of pregnancy (27.7%)

8) Under stress (22.8%)

9) Unhappy about being pregnant (22.1%)

(Plecha, 2013)


10) No money to pay for PNC (21.8)

(Johnson et al., 2003, p. 107-108)

Prior InterventionsThere have been several federal programs aimed at improving health status, economic

and social circumstances, of low-income women and children (Office of the Director, 2012). The

District of Columbia Department of Health (DOH) initiated the Infant Mortality Action Plan

focused on three strategies for improvement:

Increase capacity and impact of DOH home visitation program for pregnant

women

Enhance collaboration between DOH Community Health Administration‘s

initiatives and other sector government serving at risk women and families

Increase coordination between government and the community to ensure a

comprehensive, citywide approach to reducing infant mortality

(Office of the Director, 2007)

The above-mentioned strategies could explain the historical IMR of 7.4 deaths per 1000 in 2011.

In 2012, the District reaffirmed its commitment to these strategies and included a

multidisciplinary study based on unique collaboration with public health data and market

research to make data-driven decisions to target areas with high IMR (Office of the Director,

2012).

SMART ObjectivesS pecific


The objective of Mommy Mobile of D.C. (M&M DC) is to promote early PNC utilization among

African American females in wards five through eight, one weekend per ward. This effort is to

reduce LBW and ultimately reduce infant mortality from fall of 2015 to fall 2017.

Promote and support the national goal of Healthy People 2020. Reduce low birth

weight from 8.2% to 7.8%. Reduce infant deaths from 6.7 to 6.0 infant deaths per

1,000 live births.

M easurable The following methods are used to measure the effectiveness of M&M DC after two years:


(cdc.gov)

● Increase PNC use by 7% in first trimester from 73% to 80% (CDC figure, 2005)

● Decrease LBW from 15% to 10% (Healthy People 2020)

● Reduce IMR by 10% from 7.4/1000 to 6.6/1000 (Healthy People 2020)

A chievable Short term objectives

● First Contact - African American females in Wards five through eight will be

surveyed from January 2015-October2015

● Each ward is visited one weekend per month, ward participants will be tracked

with informed consent.

● Initial survey participants will receive positive incentives, i.e., baby gift baskets

and coupons


Long term objectives● Utilize the Health Belief Model to make follow up surveys for October 2015-2017

● Positive incentive for surveyors of initial and follow-up will be given gift cards to

local stores

● With collected data (one to two years), analyze the utilization of M&M DC

● Comparative data analysis to the sample population of M&M DC after one year to

predict a probability model of who will require M&M DC and expand to two

M&Ms in second year of implementation

R elevant/ T ime specific African American women in D.C. will view PNC as a powerful free tool to utilize

in order to benefit the baby, healthy birth weight, and reduce infant mortality

● Analyze the utilization of M&M DC from January 2015-December 2017. We

expect to see Increase PNC use by 7% in first trimester from 73% to 80%.

Decrease LBW from 15% to 10%. Reduce IMR by 10% from 7.4/1000 to

6.6/1000

Theoretical PerspectiveThe behavioral problem that D.C. continues to face is the lack PNC utilized by African

American mothers who are of lower SES. We will use the Health Belief Model to address this.

Perceptions of the threats, susceptibility and severity, that are posed by this problem will be

explored. Benefits of receiving PNC will outweigh potential barriers. The interventions and

strategies discussed will improve cues-to-action and influence the decision to initiate action (self-

efficacy).

Table 2 illustrates the constructs strategies to change behavior.


Health Belief Constructs Definition Potential Change StrategiesPerceived Susceptibility1. If I do not receive prenatal care, my baby will die

because of low birth weight.2. If I do not receive prenatal care, my baby will die

because of preterm delivery.3. If I do not receive prenatal care, to include

vitamins (folic acid) my baby will be born with birth defects.

4. If I do not receive prenatal care, I can die from eclampsia.

How susceptible the low SES pregnant African-American women feel about delivering a LBW or preterm baby.

1. Early education by healthcare provider explaining the importance of prenatal care and how it can affect the baby as well as her health.

2. Public Service Announcements making women and men aware of implications of smoking, alcohol, poor nutrition during pregnancy and its effect of low birth weight and preterm delivery.

3. Social media advertisement depicting mother with lack of prenatal vitamins leading to LBW infants.

Perceived Severity1. Mothers’ belief that low birth weight and preterm

delivery can be life threatening to her infant.2. Mothers’ belief that not receiving PNC can have

an impact on the child and their quality of life.3. Mothers’ awareness that 7 out of 1,000 babies die

within the first day of being born.4. Mothers’ belief that her own weight-gain during

pregnancy influences her baby’s growth.

The degree of effect to which low SES pregnant African-American women feel low birth weight and preterm deliveries can have.

1. Women magazine advertising showing a mother going in for PNC check-up before first trimester and coming out smiling and happy holding an ultrasound picture of a healthy baby.

2. Social media advertisement showing a LBW baby with caption “my mother never received PNC”

3. Advertise on billboards for healthy mothers (three or four) walking and exercising while pregnant with caption “let’s do it for our baby”

Perceived Benefit1. Mother believes that prenatal care is important to

her baby’s health and birth weight.2. Mother believes that prenatal care can protect her

baby from disease throughout their entire life.3. Prenatal care can save the baby’s life.4. Prenatal care can save her life.5. Mother believes that prenatal care can improve

her own health, both physically and emotionally.

Low SES pregnant African-American women’s belief that prenatal care is important and can actually have a positive impact on the infant’s health throughout their entire life as well as her own.

1. Educating society through community outreach programs (i.e., local church, community centers) that nearly 80% of women who are at a high risk for delivering a low birth weight baby can be identified on the first prenatal visit.

2. Advertisement of Free Mommy Mobile DC services on mass media (i.e., Twitter, Facebook) with information of date, location, services offered. (picture healthy smiling pregnant woman at M&M DC)

3. Providing take home educational pamphlets at Mommy Mobile emphasizing benefits of positive life choices and prenatal care.


Health Belief Constructs Definition Potential Change StrategiesPerceived Barriers1. Mother is unaware of the benefits and importance of

prenatal care.2. Mother may lack knowledge of available resources;

may not know prenatal care is locally available, no cost, location, or what organization is providing the services.

3. Mother may lack knowledge of transportation and/or childcare availability.

4. Mother may lack knowledge of pregnancy.5. Poor (negative) family and social support regarding

pregnancy; mother may be adolescent.6. Fear of rejection from society; mother does not want

anyone to know that she is pregnant.7. Mother is facing depression of pregnancy or denial

Low SES pregnant African-American women’s belief about things that may prevent her from being able to receive prenatal care.

1. Advertisement of Mommy Mobile through mass media (i.e., Twitter, Facebook) with information of date, location, and services offered. Emphasize comfortable, safe, and private setting.

2. Advertise on public service announcement that Mommy Mobile has licensed healthcare providers that address both physical prenatal care needs (i.e., folic acid), as well as psychological care needs (counseling and positive reinforcement).

3. Pamphlets on community outreach meetings and show how it creates a positive support system for mother.

4. Advertise on billboards near districts 5-8 that Mommy Mobile conveniently travels through each District ward and has available local no cost childcare (i.e., local YMCA).

5. Positive Incentives- coupons for baby supplies, baby gift basket, and gift-cards to local stores to completion of prenatal care through M&M DC.


(emotionally unstable).8. Mother lack confidence in ability to stop smoking,

using illegal drugs or drinking alcohol during pregnancy.

Cues to Action1. Education from healthcare providers, public service

announcements, and society in promoting prenatal care.

2. Education on the importance of family’s engagement and support for pregnancy and prenatal care. Advice from a family member reminding of importance of prenatal care.

3. Close friend talks about Mommy Mobile traveling through the neighborhood next week.

4. Public Service Announcements on the importance of prenatal care for baby and mother.

Low SES pregnant African-American received education on the benefits of prenatal care from the start of pregnancy, availability of resources, and access to those resources.

1. Schedule follow-up appointment at local clinic/hospital; providing continuity of care and support. Providing a systems integration approach to prenatal care enabling linkages with the medical community for follow-up, case management, and ancillary services.

2. Encourage participation in tobacco cessation program or nutritional classes held at community outreach center or local church organized through Mommy Mobile.

3. Encourage participation in support group meeting attendance of “Mommy Mobile Mothers to Be” at local community center or church for positive social support group.

4. Create reminder application for smart phones to alert the time of PNC every month and the location and times of M&M DC

Self-Efficacy1. Mother has received the education and support

necessary to feel confident and comfortable in her ability to attend prenatal care appointments.

Low SES pregnant African-American women’s confidence in ability to attend prenatal care appointments and make positive life choices regardless of any barriers.

1. Educate mother’s social support on ways to support mother to continue to make positive life choices for her and her baby.

2. Provide population-wide preconception and prenatal education through brochures and social media to encourage family planning, reproductive health, and health promotion.


In order to maximize compliance with accepted standards for PNC, it is important to

determine and understand the structural, psychosocial, and socio-demographic factors that may

contribute to the use of prenatal care services. Since pregnancy is not considered a sickness or

disease, PNC can be thought of as a type of preventive health service. The Health Belief Model

(HBM) has been developed to conceptualize the basis for the use of preventive health care,

assuming that cognitive attitudes in patients or prospective patients determine health actions and

utilization of services. It has been tested in a variety of circumstances and found to be positively

related to obtaining preventive health services (Stout, 1997).

The HBM has seven components that can be used to guide the formation of a PNC

program for low SES African American women in Washington, D.C. Generally, the process

begins when a woman realizes that she may be pregnant. The first component of the Health

Belief Model is perceived susceptibility, the degree to which African American women feel

personally susceptible to delivering a LBW or premature infant. The second component of the

Health Belief Model is perceived severity, degree to which the woman values the condition as

serious. This appraisal may be through emotional arousal at the thought of her baby dying or

through consideration of the consequences of a preterm or LBW infant. Consequences include

the baby’s cognitive development, and intellectual ability. She may view the consequences very

serious. Perceived severity is a cognitive component that may be influenced by education and

knowledge (Stout, 1997).

The third component, perceived benefits, is the degree to which a woman believes that

obtaining PNC will be beneficial and effective. It guides that force to a specific action, based on

the beliefs about the outcome of the action. The fourth component, perceived barriers, is the

degree to which the negative aspects of accessing PNC serve as barriers, causing avoidance. If


the pregnant woman views obtaining PNC as dangerous, painful, inconvenient, unpleasant,

costly, and so forth, she may choose not to receive it. If she feels that the benefits outweigh the

barriers, she may be more apt to take action.

Both the fifth and sixth components of the Health Belief Model are modifying factors and

cues to action. Modifying factors can include the demographics, sociopsychological (attitudes,

beliefs, culture, and environment), and structural variables that reflect a low SES African

American woman’s perception of susceptibility, severity, benefits, and barriers. Cues to action

can be as simple as a friend’s advice or reading a billboard of how prenatal care can save a

baby’s life. Lastly, the seventh component of the health belief model is self-efficacy, the

mother’s confidence that she can obtain PNC. Even if a pregnant woman perceives that the

benefits outweigh the barriers and has a cue to act, she may still not believe she can be successful

at achieving adequate PNC thus may not engage in the action (Stout, 1997).

The HBM simplifies a complex issue; increasing prenatal care access among low SES

African American women in Washington, D.C. It suggests hypotheses concerning the constructs

and their relationships among modifiers, beliefs, and PNC seeking actions. Also, it offers the

advantages of selfishness, intuitive logic, the ability to consider many relevant psychological

factors, considerable empirical support, as well as familiarity amongst researchers in other areas.

Thus can lead to future collaborative studies (Bluestein & Rutledge, 1993).

Intervention Design and Dissemination/Implementation Mommy Mobile

One of the biggest obstacles to health care among the underserved populations in

Washington, D.C. is access to care. This may be due to exorbitant health care costs or lack of


transportation. Lucile Packard Children’s Hospital at Stanford University Medical Center in

northern California developed a successful women’s mobile clinic program (Edgerley et al.,

2007). It addressed barriers such as access to care, transportation, and no health insurance. The

van provided services such as pregnancy tests, annual exams, screening for STIs, breast exams,

and contraception. On average, the Lucile Packard patients received prenatal care three weeks

earlier than women using other services did. Pregnancy outcome did not vary by much as

compared to other pregnancies in the area. The only notable difference was that women who

used the van had 8% less intensive care unit admissions (Edgerley et al., 2007). Early access to

PNC also gave low SES women consults to nearby clinics for perinatal care and information on

items such as MediCal, WIC and domestic abuse. Modeling a similar van after Stanford’s

women health van will overcome barriers such as substandard access to care and lack of

insurance.

The Mommy Mobile of Washington DC (M&M DC) will help overcome the challenges

that low SES African American mothers face in the District. M&M DC will include:

● Funding from Federal grants/NIH grants

● Staff (Volunteers)

○ One certified OBGYN nurse (Nurse Practitioner preferred)

○ One family practice physician (or resident combined with nurse

practitioner)

○ One Medical Assistant (can come from community college clinical

medical assistant programs-as a clinical practicum)

● The staff will be weekend volunteers - 9am-5pm Saturday and Sunday


M&M DC Monthly Schedule

1st Week 2nd Week 3rd Week 4th Week

Ward 5 Ward 6 Ward 7 Ward 8

● Tests offered

○ Ultrasound (sponsored or rented from. GE $47,000/year), can detect sex of

baby and prenatal conditions such as cleft lip and palate and assist in

scheduling postnatal appointment with a surgeon (Matthews et al., 1998)

○ Laboratory work (blood count to include folic acid levels, etc.)

○ Urine HCG confirmation testing (free from nearby community clinic)

● PNC vitamins (sponsored by Abbott $10 for 30 day pack)

● Resources

○ Information packet (Washington, D.C. Department of Health)

○ Counseling for PNC such as family support and domestic violence etc.

● Community clinic follow-up appointments offered

ConclusionWith the growing disparity between SES groups in United States, it is imperative that we

focus our efforts on those who have the greatest need for proper medical care. One popular song

says, “The children are our future”. Now, let us focus on those children by providing PNC to the

less fortunate in our nation’s capital. Modeling an intervention strategy such as the Mommy


Mobile of D.C. can address negative behavioral problems that are prevalent in African American

mothers. Through mobile preventive health care African American mothers can overcome

structural barriers such as lack of access, lack of health insurance, being unaware of PNC

location, and long wait times for appointments (Johnson et al., 2003). M&M DC may also

provide relief of psychological barriers such as stress, transient living situations, and

embarrassment of using free clinic services with their neighbors watching. With a mobile health

clinic, participants can visit a different ward to avoid such embarrassment. Through cues to

action such as positive feedback on social media (Twitter/Facebook) and evidence of positive

incentives (gift baskets, coupons, and gift cards), the participants’ perceived susceptibility can be

curved. Previous beliefs such as relying on the emergency room, self-care, and or believing PNC

is not necessary will fade (Johnson et al., 2003). The mother’s confidence to access free PNC in

the four low SES Wards of D.C. will increase due to the accessibility of M&M DC.


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Increasing Prenatal Care Utilization among African American Women in Washington, DC

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