What's Keeping Me From Early Prenatal Care?: Social justice and health literacy

Background: Maryland is one of the wealthiest states but ranks in the bottom third in infant mortality and low-birth weight infants. To address this disparity, legislators increased Medicaid eligibility for pregnant women in 2008. One year later, enrollment was not increasing within Prince George's County where rates exceeded Maryland's. This disparity prompted the state health department to ask why and what could be done to improve communications. Purpose: To determine the barriers and facilitators for receiving Medicaid and early prenatal care and to provide the state department with recommendations for closing the gap. Methods: A health literacy framework guided the qualitative study of eligible, pregnant African-American women ages 18-26 in Prince Georges' County. Data was collected from users, providers, experts and an assessment of materials. Focus groups with the women and interviews with health clinic staff and a community advocate were conducted. The Medicaid application and informational materials were analyzed using the Suitability of Materials assessment. Overall findings were reviewed by two external professionals with related national expertise. Results: Thirteen barriers and eight facilitators to enrollment and access to early prenatal care were identified ranging from intrapersonal to systems problems. None of the printed materials supplied by the state department of health met the standards of clear communications for health literacy; most had not been seen by the pregnant women. Findings were consistent with experiences of experts. Recommendations for revising the application and materials and for changes in dissemination may be applicable to other counties and states.