Original
Article
Prenatal Care in the Paso del Norte Border Region
Judith T. Fullerton, PhD, CNM, FACNM
Carlene Nelson, PhD, CNM
Rachel Shannon, MSN, CNM
Julia Bader, PhD
OBJECTIVES:
The impact of a Medicaid-managed care system on access to prenatal care
was investigated.
STUDY DESIGN:
Postpartum interviews and medical chart abstractions were conducted
among 493 Hispanic women who reside on the El Paso Texas/Juarez
Mexico border (the Paso del Norte region). Descriptive analysis identified
barriers and facilitators to prenatal care. Logistic regression identified the
impact of social and demographic characteristics on selected maternal
and infant outcomes.
RESULTS:
The factors reported by these women as barriers to timely entry and
sustaining enrollment in prenatal care were related to the availability of
social support networks and affiliation with the Mexican/Hispanic culture
(acculturation). Having Medicaid-managed care or other insurance was
associated with receiving more adequate levels of prenatal care. Women
who crossed the border to seek perinatal services were more likely to have
infants who received higher levels of neonatal care (odds ratio 0.500; 95%
CI [0.264, 0.946]).
CONCLUSIONS:
The promotion of preconceptional, prenatal, and family planning services is
strongly recommended as a strategic, regional, public health intervention.
Journal of Perinatology (2004) 24, 6271. doi:10.1038/sj.jp.7211028
Published online 22 January 2004
INTRODUCTION
Expansion of access to health care services and cost containment
have been foremost among the outcome objectives of the US health
School of Nursing (J.T.P.C.N), University of Texas at El Paso, TX, USA; Department of
Mathematical Sciences (J.B.), University of Texas at El Paso, TX, USA; and Department of
Obstetrics and Gynecology (C.N., R.S.), Texas Tech University Health Sciences Center, USA.
Statistical assistance was provided by University of Texas at El Paso Statistical Consulting
Laboratory via NIH RCMI Grant 2G12-RR08124.
Address correspondence and reprint requests to Judith Fullerton, PhD, CNM, FACNM, 7717
Canyon Point Lane, San Diego, CA 92126, USA.
62
care system financing reforms initiated within the past two decades.
One broadly implemented reform strategy is managed care. A
substantial proportion of pregnant women in the US lack access to
perinatal health-care services because they are underinsured,
uninsured, or otherwise unable to pay directly for these services.
Accordingly, several states have adopted managed care models as
the funding infrastructure for their publicly funded maternal and
infant health care programs.1
The health-promoting effects of prenatal care, and its
importance as a contributing factor to the health and well-being of
women and infants has been extensively investigated (limited and
recent references are provided). A substantial body of literature
addresses the effects of participating in (entering and sustaining) a
program of prenatal care.28 A similar body of literature reviews
the essential elements of the content of that care.913 The factors
that promote or impede womens access to prenatal care1418 have
also been documented. Findings from these studies provided
evidence in support of the Healthy People 201019 objective that 90%
of women should enter prenatal care during the first trimester.
Nevertheless, disparities remain between communities, and between
women of varying ethnicities and cultures in both access to and
utilization of prenatal care services.20
Evaluations of perinatal health care services provided within
managed care systems have produced mixed results. Positive
outcomes have been documented for satisfaction21 and the
adequacy of prenatal care utilization.22,23 Negative outcomes have
included certain adverse maternal outcomes,24 increased perinatal
mortality, and higher proportions of extremely low-birth-weight
(LBW) babies born in hospitals that did not have appropriate
neonatal intensive care capabilities.25 Untimely entry to or
inadequate prenatal care has also been documented because of
the lengthy and cumbersome process of establishing eligibility
for these programs.26,27 Howell28 conducted a comprehensive
review of the published literature on expanding Medicaid for
pregnant women. This review includes the data reported by Dubay
et al.,29 who conducted the single national study that assesses
whether the Medicaid expansions for lower-income pregnant
women met the policy objectives of improved access to care and
improved birth outcomes. Howell concludes that the expansions led
to modest improvements in earlier access to care for low-income
women, but that there is no clear evidence of change in the LBW or
prematurity rates or any reduction in infant mortality.
Texas initiated a Medicaid-managed care system in the late
1990s, implementing it in El Paso in 2000. In 1996, Texas ranked
Journal of Perinatology 2004; 24:6271
r 2004 Nature Publishing Group All rights reserved. 0743-8346/04 $25
www.nature.com/jp
Prenatal Care in Paso del Norte Border Region
46th in the nation for the percent of women (all ethnicities) who
received pregnancy care in the first trimester.30 The percentage of
Hispanic women residing in El Paso County who received care in
the first trimester was substantially below the state figure in each
year of the 4-year period 1997 through 2000 (state range: 78.2 to
79.3% for all women, 70.2 to 72.7% for Hispanic women; range of
59.6 to 63.2% for Hispanic women, El Paso County). The LBW rate
for Hispanic births of 6.9 in the year 2000 was comparable to the
6.8 state rate, even though only 47.4% of Hispanic women in El
Paso County received care that was deemed adequate in terms of
the Kessner Index,31,32 and 10.9% of women had not received any
prenatal care. It was anticipated that expansion of funding for
services would lead to improvement in these measures of the
quality of perinatal care. A study was designed to provide baseline
information about barriers and facilitators to prenatal care for
Hispanic women residing in the El Paso Texas/Juarez Mexico
region, including the role of Medicaid-managed care as a factor in
promoting access to health care services.
The conceptual model selected for the study was developed by
Khan and Bhardwaj33 as a framework for evaluation and planning
activities related to peoples access to health care services. The
model defines health care access as the outcome of a process of
care that involves interactions between the health care system, the
characteristics of potential users in a specified area, and as
moderated by health-care-related public policy and planning
efforts.
MATERIALS AND METHODS
Design
A descriptive and correlational survey research design was selected
to achieve the goals of the study.
Human Subjects
Approval for conducting this research among this vulnerable
population group was received through The University of Texas at
El Paso Committee on the Protection of Human Subjects and the
Texas Tech University Health Sciences Center Institutional Review
Board for the Protection of Human Subjects. Informed consent was
obtained by bilingual research assistants, speaking the language
preferred by the respondent, and documented by signature affixed
to a consent form that was also presented in either English or
Spanish.
Setting
El Paso County (the Paso del Norte region) is the westernmost
point in the state of Texas, bordering on the state of New Mexico
and the city of Juarez, Mexico. Census data for the year 2000
indicate that the population was 78.2% Hispanic.34 Thomason
Hospital, the El Paso city/county hospital, is the major clinical
affiliate for Texas Tech University Health Sciences Center
Journal of Perinatology 2004; 24:6271
Fullerton et al.
(TTUHSC). In the fiscal year 1998 to 1999, 33% of the hospitals
clients were Medicaid-eligible, and an additional (nearly) one-third
were uninsured, of whom presumptive eligibility for Medicaid
would have covered all pregnant women with family incomes up to
185% of the federal poverty level. Perinatal care is provided by
physicians, nurse-midwives, nurse practitioners, and other licensed
health care providers in the hospitals outpatient clinics and in a
broadly dispersed network of community-based clinic facilities, a
majority of which contract with TTUHSC personnel as service
providers. Thomason Hospital also provides care to women who are
transferred by other perinatal health services providers (including
both state-documented and noncredentialed midwives) who refer to
the hospital facility in time of need. These patients are considered
not to have received prenatal care, and are, for the most part, self-
paying (uninsured) clients.
Study Subjects
The sample of 493 women was drawn from the population of
women who gave birth in Thomason Hospital during a 2-month
period in July and August 2000. With few exceptions, the entire
population of women who were admitted to the postpartum unit
following delivery during the study time period was approached for
participation. Each exception was due to an extraordinary
circumstance related to the patients health. This sample
represented virtually all of the Hispanic births that occurred in this
setting during this time period, and, because Thomason Hospital is
the largest provider of health services to both documented and
undocumented Hispanic women in this region, was estimated to
represent the substantial majority of births to Hispanic women in
the community. A very low (less than 1%) rate of refusal was
documented.
Power and effect size calculations indicated that a sample of 94
women (47 per group) would achieve 80% power to detect a 20%
difference in the proportions of women on an outcome of interest
(i.e., cesarean section) at a significance level equal to 0.05, or 308
(154 in each group) to detect a difference of 10%.
Data Sources
A maternal/infant chart abstraction tool and a dual-language
survey research instrument were developed. Information abstracted
from the medical record included major outcome variables that
have been demonstrated in other studies (cited previously) to be
affected by engagement in a program of prenatal care. The
domains of interest addressed in the survey questionnaire included:
seeking prenatal care (barriers and facilitators, including womens
experience with the newly implemented Medicaid-managed care
eligibility process), receiving prenatal care (experience and
perceptions), acculturation, social support, health behaviors during
pregnancy (including substance use and abuse), border market
purchasing practices, domestic violence, family planning practices
and intentions, future health care intentions (for mother and
63
 Fullerton et al.
infant), and crossing the border for health care services (present
pregnancy and future intentions).
The full details of the process used in the translation, linguistic
adaptation, and assurance of cultural relevance, appropriateness,
and psychometric properties of this tool are published elsewhere.35
Briefly, content validity of the instrument was confirmed by linking
to the published literature and by receiving affirmation of the
relevance of all survey items from a panel of perinatal experts. A
certified translator crafted the English-to-Spanish form. Another
individual who was also an expert in obstetrical terminology
amended the Spanish form as necessary, and then backtranslated
to the English language. The cultural and linguistic relevance of
the survey items and of the language used in both English and
Spanish forms was affirmed by Hispanic community group leaders,
and in focus groups conducted among pregnant Hispanic women
from the target community. Inter-rater reliability (IRR) among
survey workers was assured by the testretest method (for
individual abstractors) and by computation of the kappa statistic
between abstractor pairs.
Procedures
Bilingual and bicultural (Hispanic) undergraduate Bachelor of
Science in Nursing students who had completed their obstetrical
nursing course were recruited to serve as research assistants (RA).
Two additional graduate nursing students were appointed as team
leaders (TL). The RA/TL were trained in the procedures for chart
abstraction and conduct of the interview in a series of training
workshops, using sample charts and proctored, mock interviews, in
the interest of enhancing IRR. Reassessment and retraining
occurred through the period of data collection. The use of bilingual
and bicultural RAs was a strategy designed to promote clear
communication36 and also to reduce the potential that survey
participants would provide a response that was deemed to be
socially desirable within the (perceived) dominant (American)
culture.37
The RAs approached all women who delivered in Thomason
Hospital within 1248 hours of delivery. Priority for interviews
were given to those who had self-identified as being Hispanic
(Mexican, or any ethnic or cultural stream), as documented in the
medical record (38,39).
The semistructured interview was conducting using the study
survey instrument as a written guide. The RA sat at the
respondents bedside, facing in the same forward direction. The
RA read the survey questions aloud, while the respondent
concurrently followed the progress of the interview using the
written guide, gaining cues to the content and meaning of the
questions by reading the questions in either or both languages, as
dictated by individual skills. This method allowed the respondent
to avoid self-disclosure of her literacy status, and reduced the
potential for bias that would have resulted from exclusion of
nonliterate clients.
64
Prenatal Care in Paso del Norte Border Region
RESULTS
Demographic Data
In all, 493 interviews were conducted and linked to the maternal
and newborn medical record. The demographic characteristics of
the respondents are presented in Table 1. The sample was
composed of younger women, of average education, a majority of
whom had given birth to their first or second child. One-quarter of
the respondents reported that they owned their own homes, 71%
rented or lived in the home of another person, and four were
homeless or lived in a shelter facility.
The women were, in the large majority, unemployed, or
working in domestic settings (maids, housekeepers, child care
providers). Those who were employed in other occupations were in
clerical (secretary) or service (waitress, caretaker) capacities, and
were unlikely to receive health insurance as an employee benefit.
One-quarter of these women were insured via the Medicaid-
managed care system.
Information Obtained from the Medical Record
Although there is a protocol for transmitting client information
within the network, prenatal care data were, unfortunately, missing
for many women who had received care in the community-based
clinics. A profile of their participation in prenatal care is presented
in Table 1 and Figure 1.
Major maternal morbidities documented during the prenatal
period included abruptio placenta (three women) and placenta
previa (n 4), preterm labor (n 24), gestational diabetes
(n 36), various infections (including sexually transmitted
infections and urinary tract infections) (n 70), and pregnancy-
induced hypertension (n 24). Laboratory documentation of
anemia was present in the records of 35 women. However, as noted,
there were substantial missing data for the prenatal period.
Major morbidities recorded during the intrapartum and
postpartum periods (for which records were available and
complete) included abruptio placenta (n 3), chorioamnionitis
(n 28), failure to progress (n 42), fetal intolerance of labor
(n 28), breech presentation (n 18), and shoulder dystocia
(n 9). The protocol of active management of labor40 and of the
third stage41 is favored at Thomason Hospital. Accordingly, 305 of
the 493 women (62%) had oxytocin for induction (n 32, 7%) or
augmentation (n 273, 55%) of their labors. The method of
delivery and birth attendants are presented in Table 2.
The postpartum period was complicated by anemia (n 12),
hypertension (n 2), hematoma (n 2), late onset of
hemorrhage (n 5), chorioamnionitis (n 11), and other
infections (n 3). One woman experienced a prolapsed uterus.
The mean birthweight of the 497 infants (four sets of twins),
born at gestational ages of 24 to 42 weeks, was 3242 g, with a
range of 840 to 4511 g. A total of 38 infants were less than or equal
to 5 and 1/2 lb at birth (LBW) and 49 were assessed as preterm
(less than 37 weeks of gestation at birth).
Only 40 infants demonstrated Apgar scores less than 7 at 1
minute and only five infants scored below 7 at 5 minutes. Infant
Journal of Perinatology 2004; 24:6271
Prenatal Care in Paso del Norte Border Region Fullerton et al.

Table 1 Demographic Characteristics Table 1 Continued

Characteristic n % Characteristic n %

Language of interview Other providers of care 48 12.9

Spanish only 378 77.0
Spanish and English 61 12.4 Mean Range
English only 52 10.6 Age 25.42 1444
Gestational age at the first 17.6 242
Fund source
prenatal visit (weeks)
Medicaid-managed care 115 23.7
Self pay 259 53.5
Other (including other 110 22.7
insurance) complications included meconium-stained fluid (n 58, 12%)
and respiratory distress (n 54, 11%), although oxygen was used
Marital status to support the neonatal transition of 288 newborns. One infant
Single 148 30.1 required cardiac compression and resuscitation. In total, 101
Married 241 49.1 infants were transferred to a higher level of care, 82 (17%) to
Living with 77 15.7 intermediate care, and 19 (4%) to neonatal intensive care. One
Separated 15 3.1 infant who was born with congenital anomalies incompatible with
Divorced 7 1.4 life was transferred to a tertiary care facility and died within 72
Widowed 3 0.6 hours of birth. The majority of infants were being fed at the breast
(n 158, 32%) or by a combination of breast and bottle feeds
Number of prior births and abortions (n 217, 44%) at discharge.
0 200 40.6
1 131 26.6 Information Obtained from the Guided Interviews
2 92 18.7
The women reported receiving prenatal care at a variety of public
3 44 8.9
and private health facilities both in the US and in Mexico. This
4 18 3.7
5 5 1.1
care was provided by physicians, certified nurse-midwives, nurse
6 3 0.6 practitioners, state-certified (direct entry) midwives, and
undocumented midwives. Two-thirds of the women were able to
Education of respondent obtain care at the first provider site that they called, but five women
None 9 1.8 had to call a total of four providers in order to receive an
Part of elementary school 26 5.4 appointment. The women expressed very positive opinions about
All of elementary school 50 10.3 the value of prenatal care, and one-third of the women expressed
Part of middle school 46 9.5
the opinion that women should begin pregnancy care even before
All of middle school 81 16.7
she becomes pregnant (an endorsement of preconceptual care).
Part of high school 104 21.5
All of high school 91 18.8
Table 3 presents the issues that women indicated were most
Technical, college, 85 17.6 important as facilitating factors or barriers to seeking, entering
university into, and sustaining a program of prenatal care.
Postgraduate 1 0.2 Approximately 20% of the respondents (n 96) had received
prenatal care and given birth in the Paso del Norte region within
Entry into prenatal care by trimester the previous 5 years, and approximately one-half of these women
First 149 30.2 (n 49) were enrolled in the Medicaid-managed care system that
Second 132 26.8
had very recently been introduced to the region. These women were
Third 60 12.2
able to compare the impact of the new system on the experience of
No prenatal care 68 13.8
(missing data) 84 17.0
finding a site for prenatal care. Three-quarters of these respondents
reported that they found it to be easier (n 38, 78%) to do so. Six
Prenatal care (n 371) received at women (12%) found no difference between the two experiences,
University-sponsored or 265 71.4 and five (10%) stated that it was more difficult.
affiliated clinics The vast majority of respondents (over 90% of women) placed
Community clinics/health 58 15.6 highest value on the following components of prenatal care: testing
centers not affiliated of blood pressure, blood and urine, measurement of the babys
with the University growth and auscultation of the fetal heart tones, and performance

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 Fullerton et al. Prenatal Care in Paso del Norte Border Region

Figure 1. Distribution of participants by the Kotelchuck Index. The following cutpoints, based on biophysiological gestational parameters, rather
than the computerized mathematical formula, were used to assign gestational weeks and months in the computation of the Kotelchuck Index, in the
interest of increasing the accuracy of gestational age assignment:6971 first trimester Month 1 (weeks 1 to 6) Month 2 (weeks 7 to 10) Month
3 (weeks 11 to 14); second trimester Month 4 (weeks 15 to 18) Month 5 (weeks 19 to 23) Month 6 (weeks 24 to 27); third trimester Month
7 (weeks 28 to 31) Month 8 (weeks 32 to 36) Month 9 (weeks 37 to 42).
Mexico, such as candy wrappers, pencils, erasers, and rulers, items
that are likely to be purchased by women with small children in
Table 2 Method of Delivery, and Attendants at Birth
their families, and/or pregnant women. Further, there is ready
n % availability of herbal medicines and over-the-counter drugs and
greater ease of access to prescription pharmaceuticals from
Method of delivery*
Mexican pharmacies.44,45 Several of the women reported that they
C-section 127 25.9
had, in fact, crossed the border (in either direction) to purchase
Forceps 2 0.4
Vacuum 15 3.1
food (41%), medications (32%), and baby items (25%). One-third
Vaginal (breech/assisted) 5 1.0 of the respondents indicated that they had ingested medicinal
Vaginal (vertex/spontaneous) 326 66.5 substances (cough syrup, aspirin, diet pills, allergy medications,
Vaginal birth after C-section 15 3.1 antacids, laxatives, herbs, antibiotics, and sleeping pills) that had
Total vaginal vertex 358 73.1 not been prescribed for their use.
Few women reported smoking, drinking, or the use of drugs
Birth attendant prior to their pregnancies. Fewer still reported personally engaging
Physician 411 83.4 in these behaviors during the term of their pregnancy. Exposure to
Certified nurse midwife 79 16.0 second-hand smoke was, however, reported by over one-third of
Other 3 0.6
survey participants. Nine women experienced domestic violence
*Information missing for infants born outside of the hospital. within the year prior to pregnancy and six reported this as
Three sets of twins were delivered by C-section; one set was a vaginal/vertex/ occurring during the time of pregnancy. Several experienced more
spontaneous delivery.
than one event.
Only approximately one-half of the pregnancies were planned,
although the large majority (82%) of women accepted (wanted) the
of an ultrasound. Only half of the women wished to learn the sex pregnancy. They made appropriate plans for postpartum and newborn
of the infant (contrary to a commonly held perception). Rather, health care and planned (89%) to use contraceptives in the future.
they desired prenatal tests, including an ultrasound, in order to Almost three in every 10 respondents had crossed the border from
receive reassurance that the fetus was healthy. Mexico to Texas to receive some of their prenatal care and/or to
The consumer behaviors of these border-resident women were of deliver their infant in the United States. In the event of another
particular interest. Recent research by Amaya and Pingatore42,43 pregnancy, the women expressed a preference that the infant be born
and colleagues conducted in the El Paso/Juarez region has in the United States (81%). US citizenship was seen as desirable
demonstrated the presence of lead-based ink in the labels used on (58%), although the perception of better quality of care was endorsed
plastic bags, such as those found in produce departments, and in as equally important. Hospital information system data indicated that
several brands of packaged goods manufactured and purchased in the vast majority of respondents were legal residents of the region.

66 Journal of Perinatology 2004; 24:6271

Prenatal Care in Paso del Norte Border Region Fullerton et al.

Table 3 Major Factors that Affected Receiving Regular Prenatal Care maternal and infant outcomes. The two maternal outcomes
selected as response variables were pregnancy-induced hypertension
n %
(because usual prenatal care practices may lead to detection and/or
Positive factors (facilitators) prevention) and C-section (because some factors that predispose to
Belief that prenatal care is important 468 94.9 operative deliveries, such as breech presentation or gestational
Medical staff listened to questions 433 87.8 diabetes, can also be ameliorated during the antepartum period).
Written information was in the clients 432 87.6 The two infant outcomes selected as response variables were the
language requirement of cardiac or respiratory support at birth, and the
Verbal instructions and information were easy 431 87.4
transfer to a higher level of care (because some factors, such as
to understand
premature birth, which lead inevitably to these outcomes, may also
Office staff was friendly 430 87.2
Staff spoke the clients language 427 86.6
be capable of early detection and prevention).
Appointment schedule was convenient 423 85.8 Five predictor variables (groups) were entered into the
The waiting area was comfortable 422 85.6 logistic regression analysis (Table 4). A first grouping was
Transportation was available 387 78.5 formed according to the source of funding for obstetrical health
Was helped by someone to set up a first 370 75.1 care; these included Medicaid-managed care (n 115), self-pay
prenatal care appointment (n 259), and other (including other insurance, n 110), as
Laboratory waiting time was convenient 345 70.0 shown in Table 1. A second predictor variable was the adequacy
Spouse or family encouraged the woman to 343 69.6 of prenatal care, as measured by the Kotelchuck Index.46,47 The
seek care two groups included those with no or inadequate care,
A place for prenatal care was close to the 277 56.2 compared with those with intermediate or adequate levels of
clients home
care, as shown in Figure 1. Social support, the third predictor, is a
Someone was available to take care of the 229* 83.9
construct that has been associated with improved pregnancy
other children during a prenatal appointment
Friends encouraged the woman to seek care 193 39.2
outcomes.48,49 Two groups were formed according to the
level of social support as it was defined for this study, that is, high
Negative factors (barriers) (women who reported that they were not afraid to tell their family
Lack of insurance/cash to pay for care 275 55.8 or friends about the pregnancy, and who were provided with
Seen by a different provider at each visit 181 36.7
encouragement and/or support from friends and family to seek
Had to wait too many days to receive the first 100 20.3
prenatal care or to make an appointment (n 113, 24%), or low
visit
Afraid to tell spouse/family about the 96 19.5
(women who did not receive any one or more of these supportive
pregnancy affirmations, n 355, 76%). The fourth variable was any drinking/
Worried about the Immigration and 44 8.9 smoking/drug use during pregnancy. Choosing to
Naturalization Service cross the border to receive any antepartum or intrapartum health
Pregnancy was too far advanced for 37 7.5 care service (n 135, 28%, compared to noncrossers) was selected
enrollment at the site as the fifth predictor variable. There were no significant
predictors for four of the response variables, but border crossing was
*A total of 273 eligible respondents (Para 1 or higher).
a significant predictor to the response variable: infants transferred to
a higher level of care. About 29% of those who crossed the border, vs
Nevertheless, a few women (n 44, 9%) did express the concern 19% of those who did not cross the border, had infants transferred to
that seeking prenatal care would alert the Immigration and a higher level of care. The estimate of the odds ratio was 0.500, with
Naturalization Service to their presence in the United States. a 95% confidence interval (0.264, 0.946), indicating a 50%
reduction in the risk of transfer for those who did not cross the
Health Policy and Health System Impacts border to receive obstetrical health care services.
The relationship between insurance status and receiving prenatal care There was, however, no association between LBW or preterm
(Kotelchuck Index) was assessed in w2 analysis. Women who had birth (PTB) and funding status, or having crossed the US/Mexico
Medicaid-managed care, or other private insurance, were significantly border for perinatal services. Neither of the demographic variables
more likely to receive adequate, intensive, or intermediate levels of was predictive of LBW or PTB in logistic regression analysis.
care. Women who were uninsured were more likely to receive
inadequate or no prenatal care (w2 value 15.9, p 0.0143). SIGNIFICANCE
Logistic regression was used to assess the relationships between Khan and Bhardwaj developed their model of health care access as
certain demographic variables, including Medicaid-managed care a framework for guiding the process of health care planning. The
insurance coverage for prenatal care, and selected measures of model requires that health planning include a consideration of

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 Fullerton et al. Prenatal Care in Paso del Norte Border Region

Table 4 Results of Logistic Regression on the Effects of Five Predictor Variables on Selected Maternal and Neonatal Outcomes
Predictor variable/effect* Pregnancy-induced C-section Cardiac or respiratory Transfer to a higher
hypertension support at birth level of care

p-Value Odds ratio p-Value Odds ratio p-Value Odds ratio p-Value Odds ratio

Source of funding: Medicaid-managed care Not 0.8521 0.4876 0.3859

vs self-pay included 1.271 0.739 0.555
vs other funding 1.186 1.620 0.605
Kotelchuck Index: none or inadequate care 0.6287 0.698 0.7968 1.094 0.0771 0.501 0.6691 0.864
vs higher levels of care
Social support: higher vs lower 0.4295 1.811 0.6761 0.859 0.5410 0.758 0.2126 0.623
Border crossing: no vs yes 0.9552 1.043 0.3219 0.724 0.2115 0.614 0.0332** 0.500
Substance use: no vs yes Not included 0.4412 1.663 0.9620 0.968 0.3642 1.828

*All respondents in this analysis are also within the group assessed as having lowest acculturation status (n 329).
**p< 0.05.

factors that act as facilitators or barriers to effective interface
between available services (potential access) and utilization of
services (realized access).
The factors that influence pregnant women to seek entry into
prenatal care, and then to sustain participation in the program have
been investigated among populations of lower-income women,
women of various ethnicities and cultures, and, more recently, women
enrolled in Medicare-managed care programs. The Hispanic women
who participated in this study identified many of the same structural
barriers to care that have been reported in this body of literature. The
Khan and Bhardwaj model would define these things as spatial
characteristics of the health care system. The women in this study
defined them as a restriction in the number and location of health
facilities that required many women to have to call several places, the
need to wait very long periods of time to receive a first appointment,
and/or as requiring a means of paying for those services. Cokkinides
demonstrated in a study conducted in South Carolina that the
obstacles to Medicaid application and enrollment had an adverse
impact on the adequacy of prenatal care utilization (Kotelchuck
Index), for both black and white women.27 The majority of Medicaid-
funded, Hispanic women in the Paso del Norte region, who had given
birth both prior to and following the introduction of the Medicaid-
managed care system, reported that finding a site at which to receive
prenatal care was easier under the new system. Nevertheless,
although women who had Medicaid-managed care insurance were
more likely to receive adequate levels of prenatal care, an immediate
improvement in the adequacy of prenatal care utilization could not be
demonstrated, when compared with community baseline statistics.
In contrast to other findings, the Paso del Norte women reported
that they did have transportation to the care site, which was often
located in their own community, a positive impact of the
community clinic network that has been promoted in this region.
Griffin et al.22 report that an improvement in the adequacy of
prenatal care was demonstrated for Medicaid-managed care clients
in Rhode Island after the program was extended outward from the
hospital service center into community health centers and private
physician offices.
The aspatial characteristics of the health care system in the
Khan and Bhardwaj model include the availability of personnel to
provide culturally competent services, and again, the findings of
the present study are atypical. The women reported that staff were
friendly and spoke Spanish. On the other hand, women saw several
different providers, indicating their interest in (but failure to
receive) continuity of care, a concept that has proven benefits for
improved maternal and perinatal outcomes, and increased
satisfaction with care.50
Characteristics of the potential users of services are defined in
the model as the attitudes, values, preferences, and prejudices of
both the individual and of the community of residence, that is, the
biopsychosocial factors that influence access to prenatal care.
Planning for health services in the Paso del Norte region must
include consideration of the additional influence that the
somewhat unique community characteristic of border residence
may have on health behaviors, which may, in turn, affect health
outcomes. For example, many women in this study reported
crossing the border to receive health care from traditional
community healers (parteras, promotoras) and to purchase
across-the-counter and prescription pharmaceuticals concurrently
with their enrollment in US-based prenatal care services. Similar
findings have been reported in studies conducted in other
southwestern United States/Mexico border communities.5153
This proximity may also influence the pattern and/or degree of
acculturation among regional residents. Accommodation to the
majority culture has also been demonstrated to have a relationship
with an increase in risk for certain birth outcomes, such as LBW,
among Hispanic women who deliver in the United States.18,5457
Bryd et al.,58 who studied breastfeeding intention and practice
among Hispanic women from the same US/Mexico border

68 Journal of Perinatology 2004; 24:6271

Prenatal Care in Paso del Norte Border Region
community, found that the most acculturated women were the
least likely to have breast fed previously or to intend to breast feed
their newborn.
Language spoken, read, and written, and place of birth (parents
and respondent) are core elements that appear within the various
tools available for measurement of acculturation,58,59 and therefore
they were selected as proxy measures of the concept in this study.
Only 64 (14%) of the respondents were identified as more
American oriented on the scale developed for this research project;
therefore, we were unable to use acculturation as a sixth predictor
variable in the assessment of outcomes. However, the fact that the
vast majority of women were more oriented to their Mexican
cultural expectations, beliefs, and behaviors reinforces the potential
importance of the aspatial individual and community Bhardwaj conceptual model) is likely to be a necessary, but not
characteristics that are defined in the conceptual model as likely
barriers to health care services for women of this region. Receiving
social support and the locus of control for personal decision-
making (eg, planning for pregnancy, seeking prenatal health care)
are two examples of the determinants of pregnancy health
behaviors that might be affected by acculturation status.
Nothnagle et al.60 found that lack of financial access to care,
even after a period of Medicaid expansion in California, was
associated with a significant increase in the risk of not receiving
prenatal care. Egeter et al.61 found that rates of untimely care were
highest among women who had to make their initial application
for funds during their pregnancy. Currie and Grogger62 identified
the paradox inherent in raising income levels for Medicaid
eligibility, which increased use of the prenatal care services, while,
at the same time, reducing welfare caseloads, which reduced family
income and also reduced participation in prenatal care. Nothnagle
argues that policies to reduce late entry into care/no care should
not focus only on solving logistical barriers to care (e.g.,
streamlining the eligibility process) but should also focus on
prepregnancy social factors, which were found to be equally
predictive of an increased risk of not receiving care. Women in the
California study who had not planned their pregnancies and who
received little support from their family and community to seek
prenatal care were at a nearly twofold greater risk of late care and
almost a fourfold greater risk of no care.
Social support is another construct that has been well studied as
a factor that promotes (facilitates) earlier entry into prenatal
care.48,49 The construct of social support was measured in the Paso
del Norte study in terms of the encouragement provided by friends
and family to seek prenatal care, and, according to this measure,
the overwhelming majority of women (76%) were identified as
having a very low level of support, and over one-half of the women
reported that their pregnancies were unplanned.
The pregnancies were nevertheless wanted.63 Pagnini and
Reichman64 and Hulsey,65 studying separate populations, cited the
wantedness of the pregnancy to be the risk factor with the
greatest impact on the timing of prenatal care. Women whose
Journal of Perinatology 2004; 24:6271
Fullerton et al.
pregnancy was unwanted had dramatically reduced odds of
entering care early.
This study confirmed that Hispanic women who reside in the
Paso del Norte region constitute a population that is
characteristically different from those among whom previous
studies of access to prenatal care have been conducted. Border
proximity is a community characteristic that presents both
challenges and opportunities. Accordingly, the factors reported by
these women as barriers to timely entry and sustaining enrollment
in prenatal care were somewhat different from those cited in
several previous studies of the issue. The expansion of access to
prenatal care services through the implementation of a system of
Medicaid-managed care (potential access in the Khan and
sufficient, intervention to promote more timely entry into these
services (realized access). Health policy planning for this region
must include consideration of the strength or weakness of existing
social support networks and the degree of affiliation with the
Mexican/Hispanic culture in designing community-specific
strategies for health promotion. A richer understanding of these
networks may also contribute to a clearer understanding of the
evidence that, despite less utilization of, and later entry into
prenatal care by Mexican-American women, the outcomes for
women and infants were similar to those of the Caucasian
reference population (the Hispanic health paradox).6668
The exception to the generally favorable outcomes is a finding
that should be of particular importance to regional health
planners. Women who reported that they crossed the border to seek
perinatal health care services were more likely to have infants who
received higher levels of care, a finding that portends substantial
adverse financial impact. These women also indicated their
intention to seek cross-border health care services for future
pregnancies. The engagement of agencies and providers on both
sides of the US/Mexico border in primary prevention activities,
specifically, the promotion of preconceptional, prenatal, and family
planning services, is strongly recommended as a strategic, regional,
public health intervention.
Acknowledgements
The project described was supported by a grant from the Paso del Norte Health
Foundation through the Center for Border Health Research Initiative. Its contents
are solely the responsibility of the authors and do not necessarily represent the
official views of the Paso del Norte Health Foundation or the Center for Border
Health Research Initiative.
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