Low-income women in an Oregon city of approximately 35,000 inhabitants have limited access to prenatal care services during their pregnancies. The purpose of this study was to uncover the impacts of several factors on the experiences of twenty-seven health department clients with public health department prenatal care practitioners and with local private obstetricians. Ethnographic interviews were conducted with the clients, two health department practitioners, two local obstetricians, and one local direct-entry midwife. The focal finding that emerged from the research was that the clients preferred the care of the health department practitioners to that of obstetricians, even though the health department providers could not deliver the women's babies. The major impacts on the clients' experiences included fragmented service delivery and availability, economic and social restrictions on prenatal care options, biomedical constructs of a healthy pregnancy, and provider role constructions and attitudes towards Medicaid recipients and uninsured pregnant women. Local physicians' mechanistic philosophy, professional dominance and profit orientation afforded them a narrow understanding of the needs and identities of low-income women. Local public health workers are less professionally autonomous than medical doctors but their service orientation allowed them the potential to better serve low-income clients. Based on the twenty-seven clients' perceptions of their care providers and the services available to them, recommendations are made for more empowering, comprehensive prenatal care services in this county. Recommended changes to the public health system entail expanded funding for more appropriate programs and to establish continuity of care for health department clients from pregnancy through the postpartum period. The incorporation of direct-entry midwives into the prenatal and birthing care options open to low-income women is also recommended. Senate Bill 1063, which creates a process for direct-entry midwives to become state-licensed in order to be reimbursed by the Office of Medical Assistance Programs for perinatal services, is considered in terms of its implications for low-income women, the Oregon community of direct-entry midwives, and the texture of Oregon reproductive health care. / Graduation date: 1994

A model for health care utilization was applied to a sample of low income women. Demographic Predisposing, Psychosocial Predisposing, Illness Level, and Enabling indicators were examined separately for African American (n = 266), Anglo American (n = 200), and Mexican American (n = 210) women. Structural Equation Modeling revealed that for African American and Anglo American women, Illness Level, the only significant path to Utilization, had a mediating effect on Psychosocial Predisposing indicators. The model for Mexican Americans was the most complex with Enabling indicators affecting Illness Level and Utilization. Psychosocial Predisposing indicators were mediated by Illness Level and Enabling indicators which both directly affected Utilization. Implications of the results for future research are addressed.

This study attempted to determine the relation between womens' anticipation of Esteem-Threat, their level of satisfaction, and their utilization of prenatal care services in the public assistance setting. One-hundred twenty-six women completed a battery of questionnaires during an initial clinic visit. Measures of patient datisfaction were completed after a minimum of four clinic visits. Results showed a significant linear relation between womens' anticipation of Esteem-Threat and satisfaction with services. No relations were found between Esteem-Threat and the timing of entry into prenatal care. A small, statistically significant relation was found between Esteem-Threat and the number of appointments kept. Results are discussed in the context of the limitations of the sample and the psychometric properties of the measures. Future applications of the Esteem-Threat model are also discussed. / Ph. D.

This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.