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Hispanics
and Prenatal Care Over the past 20 or 30 years the population of the United States has been undergoing some dramatic changes. One of the most striking is the growth of the Hispanic population. Between 1970 and 1990, the Hispanic population in the U.S. grew by 145%. 1 In 1998, this ethnic group was estimated to comprise 11.4% of the total US population or 30.7 million people. By the year 2050, Hispanics are expected to constitute 24.5% of the total U.S. population and to be the largest minority group in the United States. The U.S. Census Bureau defines the term Hispanic as those individuals who are of Mexican, Puerto Rican, Cuban, Central/South American, or other Spanish culture or origin, regardless of race. Although this is the classification used by the government, many individuals prefer the term Latino to describe individuals in this ethnic group. The term Hispanic is thought to exclude Brazilians and to identify more with the European culture of Spain, rather than the pre-existing indigenous cultures and the important African cultures. It also emphasizes the panish language as a commonality, while Brazilians and some US-born individuals do not speak the language. 2, 3 The term "Latino" is seen by some as a more encompassing term that better represents this group of people who share a common history, customs and traditions. Although all individuals of Latin American descent are classified as Hispanic or Latino, they are very much unique and different from one another. These classifications do not reflect the true heterogeneity of the population. Hispanic individuals originate from 32 different countries, including the indigenous population, European culture and African culture. The combination of these races varies between countries and each individual country also has their own unique history. The heterogeneity is further influenced by the degree of assimilation, immigration experience, group's history and ethnic/national origins. In the past, Hispanics have been called the silent or invisible minority because few researchers have studied Hispanics' health needs, health status, health beliefs, health behavior or family roles. However, research is needed because many Hispanics have serious health and social problems that health care providers can be instrumental in alleviating. 4 Fortunately, since the early 1990's, there has been a change in the number of researchers who have chosen to study Hispanics. In the health care arena, certain behaviors have been identified that are representative of this population in the United States. They are more likely not to have a regular health care provider and instead use emergency services more often. They have been shown to have higher incidences of specific conditions, such as non-insulin dependent diabetes mellitus (NIDDM), heart disease, hypertension, obesity, tuberculosis, cervical, pancreatic and stomach cancers. 5 They show delayed and minimal use of screening practices and preventive health services and health insurance tends to be lacking. Numerous studies 6, 7, 8, 9, 10, 11 have been conducted on the availability and accessibility of health care to Hispanics in general and also on more focused areas such as cancer screening/care and prenatal care. All of these studies have identified barriers which limit the access and availability of medical services to Hispanics across the United States. The barriers include: level of education, lack of health insurance, lack of transportation, language and communication differences, immigration status, unique cultural beliefs and attitudes, religion, lack of knowledge about available services, logistics of clinic site (accessibility by phone and transportation, waiting time to schedule appointment and at the actual appointment, child care facilities, clinic hours, etc.), fear and mistrust of health care system, and discrimination. For Hispanics, communication tends to be guided by cultural values of respeto and personalismo (respect and personalism). 2, 12, 13 They tend to avoid confrontation and conflict by not disagreeing, expressing any doubts or asking questions. They view the physician as an authority figure and respect his or her opinion. Trust is of importance as are personal, rather than impersonal or institutional relationships. This presents a problem in clinics where there are rotating staff members, because there is no continuity for the patient. It also affects patients in clinics where there is a lack of patient-doctor interaction. In a personal account from the mother of a young woman with neurofibromatosis, she states that she would like to see health care providers "educated and trained in recognizing cultural differences, in being less formal but more perceptive of the need for establishing a personal rapport and trust, "simpatia", with the patient and families". 3 Lazarus and Phillipson also found that "...advice from physicians and other health care providers was more crucial to their perinatal health and the well-being of their fetuses than outside sources or cultural traditions." 14 Hispanics value physicians who show interest in their personal feelings and experiences. A key factor in the underutilization of medical services by Hispanics is their lack of knowledge of the existence of such services. Many Hispanics are unaware of traditional US institutions, processes and services, and are unfamiliar with delivery of services in small and large cities. 15 This creates further difficulty in getting access to adequate medical care. Solis et al. observed that institutional access was more important in use of preventive health care services than acculturation. "For each Hispanic group, having a routine place for health care, health insurance coverage and a regular provider were each significantly associated with greater recency of screening." 15 Since many Hispanics are having difficulty in accessing medical services, they are more than likely to have delayed health care. All of these barriers also impact Hispanic women's use and satisfaction with prenatal care. 16 It has been shown in most studies that Hispanic women tend to initiate prenatal care late in the pregnancy (3rd trimester or no prenatal care). Only ~60% of Hispanic women initiate prenatal care in the 1st trimester as compared to 80% of white women. 11 With the previously mentioned barriers facing pregnant women, it makes it difficult for them to be seen by a physician early in the pregnancy. Oftentimes women have to wait 1 - 2 weeks between the time they schedule the appointment and the time they are seen in the clinic. Other reasons for late prenatal care are for concealment of the pregnancy from family members and the tendency not to utilize prenatal care when the pregnancy is thought to be normal and healthy. Urban poverty or residing in a distressed urban neighborhood can also have a negative effect on initiation of prenatal care. 17 Hispanic women are 3.5 times as likely as non-Hispanic white women to have late prenatal care. 18 Overall, Hispanic women also have low rates of infant mortality and low birth weight infants. 19, 20 The rates are comparable to those of non-Hispanic whites, but are lower than those of any minority group. Differences do exist within the Hispanic group based on country of origin and length of time in the United States. Puerto Rican women tend to be at higher risk for low birth weight infants than Mexican women. Mexican women who are recent immigrants tend to have lower rates of low birth weight infants than those of Mexican women who have lived in the United States for a number of years. 21 Factors such as country of origin and length of time in the US can impact pregnancy outcome and benefits of prenatal care. The Hispanic population has unique cultural beliefs and values, as well as social pressures which may impact their health behaviors. It is useful for health care professionals to learn more about this ethnic group in order to better serve them. As part of my master's research project, surveys were distributed to Hispanic women to assess their knowledge and attitudes about prenatal testing and genetic counseling. A total of 214 Hispanic women were surveyed. Of those, very few reported familiarity with CVS, MSAFP or triple screen. Most women were familiar with the procedures of ultrasound and amniocentesis. When asked about their attitudes towards prenatal testing, most women either did not know about them or did not think they were useful. Another series of questions examined important factors for women in medical decision-making. Between physicians, religion and family, physician's advice was ranked the highest in most cases. They were also ranked the highest as sources of prenatal testing information, medical information and influences on decisions about prenatal testing. Barriers to care were reported as insurance, risks and lack of awareness. Based on the present data, it appears that most Hispanic women have limited knowledge about the existence and availability of prenatal tests. They place a great deal of importance on information received from their doctor. Therefore, physicians and nurses providing services to this population should be informed of better ways to educate and reach out to the Hispanic women. REFERENCES
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