Factors affecting prenatal care utilization
This review gives an overview of factors affecting non-western women’s use of prenatal care in western societies. Therefore, ‘factors’ were described in the broadest sense, comprising experiences, needs and expectations, circumstances, characteristics and health beliefs of non-western women. The results indicate that non-western women’s use of prenatal care is influenced by a variety of factors, and that several factors may simultaneously exert their effect. The categories migration, culture, position in the host country, social network, expertise of the care provider and personal treatment and communication were found to include both facilitating and impeding factors for non-western women’s prenatal care utilization. The category demographics, genetics and pregnancy and the category accessibility of care only included impeding factors. The only aspect of the conceptual framework of Foets et al. that was not found in the studies included in this review was ‘professionally defined need’.
In a systematic review conducted by Feijen-de Jong
et al., ethnic minority was found to be one of the determinants of inadequate prenatal care utilization in high income countries [
16]. As ethnic minority status does of itself not explain prenatal care utilization, our review adds relevant information to the review by Feijen-de Jong and colleagues, and gives more insight into the factors behind these women’s prenatal care utilization, at least for those of non-western origin. The demographic and socioeconomic factors found in our review are largely in line with the results of Feijen-de Jong
et al.. However, we did not find any factors concerning pattern or type of prenatal care, planned place of birth, prior birth outcomes and health behaviour. Our results are also in line with the review by Heaman
et al., who reported that demographic, socioeconomic and language factors affected prenatal care utilization by first generation migrant women [
17]. In addition to these two reviews, we found several other factors at the individual and health service levels that impeded or facilitated non-western women’s prenatal care utilization.
To our knowledge, this is the first review of prenatal care utilization by non-western women that has combined quantitative, qualitative and mixed-methods studies. By doing this, we were able to find a very wide range of factors affecting non-western women’s prenatal care utilization. This is clearly evident from the barriers. A comparison shows that the quantitative studies made a full contribution to inadequate users’ demographic, genetic and pregnancy characteristics. All three factors in this category: namely being younger than 20, multiparity and unplanned pregnancy were derived from one quantitative study. The qualitative studies contributed fully to expertise factors as well as personal treatment and communication factors. Care providers lacking knowledge of cultural practices, poor communication and perceiving yourself as having been badly treated by a care providers were only derived from qualitative studies and the qualitative part of the mixed methods study. Besides providing all the barriers in a specific category, quantitative and qualitative studies also complemented each other by both providing barriers in the same category (migration, culture, position in the host country, social network, accessibility), sometimes even by means of the same barrier. The factors: lack of knowledge of or information about the Western healthcare system, poor language proficiency, dependency on husband, belief that prenatal care is not necessary, financial problems, lack of time, acquiring or following advice from family and friends, and transport and mobility factors were all reported in quantitative as well as qualitative studies.
By combining different study designs, we were also able to provide more in-depth insight into the mechanisms of some factors. For instance, we obtained more insight into the mechanisms of the factor multiparity reported in two previous quantitative studies. Qualitative studies showed that multiparous women did not perceive prenatal classes as necessary because they had already given birth. Furthermore, multiparous women reported lack of childcare as a reason for not attending prenatal classes. Perhaps these two reasons also play a role in multiparous women’s utilization of medical care during pregnancy.
In the introduction, non-western women’s risk for adverse pregnancy outcomes was described according to region of origin. By placing this review’s findings in a regional perspective, some noteworthy insights were gained about factors affecting these high risk groups’ health care utilization. As to individual barriers, lack of knowledge of the Western healthcare system was described among all four regional groups distinguished in this review (sub-Saharan African, North African, Asian and Turkish). Health beliefs were reported among sub-Saharan African (Somali) and Asian women. Dependency on husband was reported among Asian and North African women. However, adherence to cultural practices, acquiring or following advice from family and friends, lack of assertiveness and lack of time were only described in studies conducted among Asian women. As to health service barriers, accessibility factors were reported in studies conducted among Asian and North African woman. On the other hand, expertise and personal treatment factors were only found among sub-Saharan African (Somali) women.
These insights can be used to develop a more targeted approach towards specific groups. For example by placing emphasis on ‘dependency on husband’ for Asian and North African women, and ‘personal treatment’ for sub Saharan women. However, this should be done carefully. Some factors may seem to play no role for certain ethnic groups, while they were simply not included or discussed in these studies.
The individual and health service facilitators were all derived from qualitative studies conducted among Asian women and Turkish women. Nevertheless, these facilitating factors can be applicable to other ethnic groups, as they relate to difficulties also reported by these groups (e.g. improved communication).
Several factors such as lack of knowledge or information of the western healthcare system, poor language proficiency and poor communication applied to women of various ethnic origins. On the other hand, some factors were highly specific to a country, culture or religion. Muslim women, for example, were found to refuse combined session with males while other women might have fewer gender issues. Extrapolation of the results is therefore less applicable. The factors reported to facilitate prenatal care utilization were mostly suggestions made by women. As women based these suggestions on their own experiences with prenatal care, we decided to include these in our review.
In a systematic review conducted by Simkahada et al., perceiving pregnancy as a normal state and seeing little direct benefit from antenatal care were reported as barriers to antenatal care utilization in developing countries [
36]. In our review, we found somewhat similar impeding beliefs about prenatal care in two studies conducted among first generation women. Furthermore, Simkhada and colleagues reported unsupportive family and friends as a barrier to antenatal care utilization which was also found in our review. These similarities between non-western women in industrialized western countries and women in developing countries indicate that some women seem to continue to have certain beliefs, attitudes and needs they had prior to migration. A comparison between first and second generation non-western women would be very useful, but was not possible. Only one study included second generation women but presented the results in combination with first generation women.
Even though we included only high-income countries with universally accessible healthcare, we found that financial factors did affect non-western women’s prenatal care utilization. One explanation for this finding might be that women may not be aware of the universal accessibility of care, and therefore perceive lack of money as a barrier to prenatal care. It might also be that, even though women are currently legally resident (which was an inclusion criterion of our review), they reflect back on periods when this was not the case.
Methodological reflections
One noteworthy point is the large number of qualitative studies included in this review, as compared to quantitative studies. During the review process, we identified several quantitative studies focusing on factors affecting prenatal care utilization by non-western women among their study population. Regrettably, we had to exclude most of these studies as they lacked a sub-analysis specifically for non-western women. By doing a sub-analysis specifically for non-western women in future quantitative studies on prenatal care utilization, more insights can be gained on factors affecting their use of prenatal care.
The studies included in this review all considered different subgroups of non-western women. However, the immigrant generation of the women was not reported in five studies and factors were not specified according to generation in the only study that included first and second generation women.
The factors found in the qualitative studies were mostly part of women’s experiences, needs and expectations with prenatal care. These studies did not specifically focus on inadequate users, and therefore did not include a definition. On the contrary, two of the three quantitative studies defined inadequate use, but did so differently (Additional file
3). This difference in definition between the quantitative studies and the lack of definition in qualitative studies complicates comparison and integration of the study results.
The included studies showed a large variance in methodological quality. Nevertheless, we decided not to exclude studies with a low quality score, in order to prevent loss of any relevant factors in this review. Instead we compared the results of the high and low methodological quality studies against each other, and did not find any contradictory results.
Two main strengths of this study are the use of a broad search string and not applying a language restriction, to minimize the chance of missing relevant studies. Also the inclusion of quantitative, qualitative and mixed-methods studies adds to the strength, as this increases the chance of finding different types of relevant factors affecting prenatal care utilization. Another strength is the restriction to countries with universally accessible healthcare. Therefore, results are more comparable and generalizable to other countries with a similar organization of their healthcare system. The use of a theoretical framework to sort the factors found is another strength of the study, as this gives a clear overview of the factors and the level at which they exert their effect.