Views of the total sample
Three themes that could indicate a need for systems change were pervasive across focus groups: drug lifestyle, role of baby's father, and staff/provider attitudes. These three general themes were mentioned as barriers to as well as potential motivators of care.
Frequently mentioned issues from all groups are presented, then exemplars and insights from specific types of focus groups are added. These exemplars provide a sense of the beliefs operating in vulnerable populations. Each barrier to prenatal care that is discussed was mentioned at least thirty-five times across at least nine focus groups. Each motivator of prenatal care discussed was mentioned at least sixteen times across seven focus groups.
Theme one: drug lifestyle
One of the pervasive themes apparent in all types of focus group was related to drug lifestyle. From community focus groups, this was the most frequent code representing a barrier to prenatal care. Women voiced that drug lifestyles delayed initiation of prenatal care. Women also feared that their provider would find out about current drug use. This was particularly poignant in community focus groups, as the sampling was not purposive for substance abusers; yet drug lifestyles were defining issues for the community. A community member summed it up in the following:
"Their priority is drugs, and the appointment is secondary."
In drug-dependent women focus groups, drug lifestyle was also the most frequently mentioned barrier to prenatal care. The drug lifestyle dominated any concern about having prenatal care. As one focus group participant put it:
"The fast life, just plain laziness, withdrawal symptoms"
prevented adherence to prenatal care.
"Do you think that I'm going to look at my watch and say: 'it's nine o'clock everybody, so put down the [crack] pipe so I can go to my prenatal care appointment'?"
Another participant in the substance abusing women focus group summed it up as follows:
"I was using heroin and crack cocaine. What led me here (detox) was I was sick and tired of being sick and tired and I knew I could be a better parent to my children and I just was tired. I was fed up and I just couldn't take it no more. I was just worn out and I knew that my mother was a drug user and I knew that it kept her away from me and I knew how I felt by my grandmother raising me my whole entire life."
For homeless participants, the effect of drug use on the unborn child and the new baby was important. This concern is characterized in the following quotes:
"I was so far out, drugging and using, I had a son that was born, he was born at five months, he weighted 1 lb. and 8 oz. I had him at [hospital] and they were really looking for him to die because it was no way that he was suppose to survive that young. Thank the Lord that he did and now he is four years old now. He has a respiratory problem; he has to have a machine. So far he is doing okay. That was due to my addiction, not getting the proper prenatal care because I just drugged all the time."
"Just because the baby have all parts of their body, you still cannot tell whether you gonna affect that baby later on in life, that's what a lot of people fail to realize, you know they can have learning disabilities."
"On TV I see these babies with the bottle in their mouth and I was drugging in my first month. I just started crying and I said: 'I can't do this to my child.' So I stopped. I just stopped. Every time I got pregnant I could stop drugging. Soon after I had that baby I just went right on back."
Significant others focus groups were also quite revealing about how the drug lifestyle was a barrier to prenatal care, as in the following quotes:
"And I was out there smoking crack. So I wasn't there for her and I blame myself for that because if I had been there, not saying that she wouldn't have had a miscarriage, but maybe I could have got her to the hospital. Maybe just being there to support. Maybe other women are experiencing that too. That the father of the unborn child is not around. Maybe they are worried that he don't care."
One aspect of drug lifestyle, prenatal care/drug treatment interaction, was mentioned as an important potential motivator. Prenatal care and drug treatment facilitated each other through interacting requirements that women in detoxification programs receive prenatal care, and women in prenatal care abusing drugs receive high priority referrals for detoxification centers/programs (detox). Participants noted that to receive a referral into drug treatment, one must first enter detox. However, according to focus group participants, if they were not currently drugging, they could not get detox treatment. Thus, to get into detox, participants reported using drugs before going for prenatal care, causing positive drug urine screens, resulting in priority detox referrals.
Theme two: role of baby's father
For all focus group participants, the most frequently mentioned motivator was the role of baby's father. When there was male involvement, there was a belief that the woman's overall condition improved. For example, one significant other focus group participant commented:
"When my girlfriend was pregnant [she] had to take care of this, take care of that, and she was smoking and drinking, and I was going behind her saying that's the wrong thing to be doing. Won't you do this. [In] certain ways I stood behind her [to] make sure she was doing the right things. [She] started going to programs and liking them. [You] must make sure that they make appointments on time and just spend the time..."
One significant other participant summed up the majority of the group's feelings when he said:
"...and the Black male, what we can do, is be the support unit for them, we could be a shoulder for them in a way where we could take them to their appointments if we have time, or we could be a sounding board for [them] if they have problems. If they're eating the wrong food, try to convince them to eat the right food, cause, not only are they carrying the babies themselves, if we're the father, it's our baby also. And if it's not our baby we still play a part, because it's part of our generation, so we'll be a community."
While the men strongly vocalized the need to support women, they admitted that their actual behavior could be a barrier to care. Two quotes significant others illustrate this:
1) "Let's not lose perspective here. Now we admit we have an obligation too. I'm saying that the women are out there too, but we as men have an obligation. We give these babies to these women. Why can't we take some time out and tell the woman what she needs to do, even though she may not listen. Why can't we say: 'give me the baby, I'll take it to the doctor?' "
2) " Some men are scared of responsibility so they are gonna say whatever they think could hurt the woman and, or mess the woman up to the point that it mess her and the baby up, make them wait or what have you. Scared of responsibility."
A grandmother participant of the community focus groups also voiced this issue, as in the following quote:
" ...because there's a lot of children being born, that if born will never know their fathers, because they're killed. That's a setback for the mothers, then the mothers are going to be father and mother, and that's a strain. That's a strain on one person-a young person, too. No, don't be kind. Be blunt. Be to the point. How many of you still have that man? How many of you even see that man? How many of you even talk to him on the phone, even know where he is, if he's not in Lord's – most of em are in Lord's, you know that's in the cemetery. But the ones that are still alive, and not locked up, they're out there with some other dummy, pregnant, thinking the same thing that you're thinking."
Further, a community leader said:
"And somebody's going to have to sit up some place in an auditorium, in a school, and ask the pertinent question: how many of you all think you all are going to keep your men by having a baby?"
Participants in the drug-dependant women focus groups supported that role of baby's father was a barrier to care, as in the following:
"I didn't go for my prenatal care or nothing. I stayed home, I was lazy, wouldn't do nothing. My baby's father sent me through so much stuff, I was like forget it."
Third general theme: staff or provider attitude
The attitude of health care providers and staff was another important issue, although not as pervasive as drug lifestyle or role of baby's father. This code, representing a barrier to prenatal care, was frequently identified in all group types except significant others.
Staff attitude was generally framed such that if staff were friendly, it would motivate care, as in the following from drug dependent women focus groups:
"Thank you. And, how are you? And, Good morning, how did you rest last night? We got to go back to the basics; they need to start taking a group and start sending them out to seminars. Start having these seminars where learning to care, if you're in that field, you got to learn how to care about people, [or] what the hell are you doing with that type of job?"
One participant said:
"When providers find out you use drugs, they treat you bad, i.e., like an addict. [They] put you on the table like you're a piece of meat, it all has to do with, 'oh you've been sent over here from [treatment site]', you know what I'm saying. Addicts, being addicts, under privileged, and you done been through the ringer and you're trying to get your life back into perspective and they treat you like a bunch of crap."
Significant others in the community focus groups also saw staff or provider attitudes as important, as in the following:
"I will come back. But first you have to motivate me to get me in the door. Maybe you're looking for a program, something that teenagers are looking for, whatever gimmick to get me in there."
Homeless women emphasized the complexity of this issue in the following quote:
"...nurses and staff. And they need to advertise it to the community, not just come free for a service, anywhere, you coming free for a service that is a good service that you would receive anywhere else. You need not know it's a free service."
Substance abusing women stated the following:
"In the community they say you better go to the doctor, you know you're suppose to go to the doctor but you don't want to go to the doctor because the doctor is not private anymore. He's got a list and he tells everybody he knows...because there is no one there with that one-on-one kind of treatment. It's just like, yeah your pregnant, get in line, wait your turn."