In the United States, there is an estimated 3 million agricultural and seasonal farmworkers [1]. Twenty-two percent are female, and the majority is of childbearing age [1]. In the Southeast, the greatest number of farmworkers resides in the state of Florida [2]. Migrant farmworkers’ housing is typically substandard and crowded or non-existent, with many farmworkers living in areas not meant for human habitation, such as motor vehicles [1]. Their working conditions are harsh and they endure pesticide exposure, intense heat and dehydration, and work in an uncomfortable posture either bent over or on their knees [3]. Due to their working and living conditions, farmworkers are at increased risk of injury and illness.

Despite this risk, farmworkers have among the lowest levels of health care access and utilization. Besides poverty, this underserved population faces many barriers to accessing healthcare including lack of health insurance, language/literacy issues, transportation difficulties, low educational attainment, poor health, geographic isolation, and a migratory lifestyle [4]. For instance, 85% of migrant farmworkers lacked any form of health insurance, compared to 37% of low-income adults nationally [5]. In 2000 only 20% of migrant farmworkers used any health care services in the preceding two years [5]. As a result, a disproportionate percentage of farmworkers are at increased morbidity and mortality [4]. Lack of accessible health care can be particularly problematic for subgroups of farmworkers who have increased need for care, such as pregnant women.

Adequate and timely prenatal care is vital to healthy outcomes of both mother and baby. It is so vital that it has been included in the goals of Healthy People 2020 [6].

According to the Maternal and Child Health Bureau, “babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight, and five times more likely to die, than those whose mothers received prenatal care” [7]. Additionally, lack of adequate prenatal care has been associated with preterm delivery, infant mortality, and complications during delivery [8]. Therefore, adequate prenatal care is critical for reducing maternal and infant morbidity and mortality.

Despite the importance of prenatal care, many female farmworkers face tremendous challenges to accessing prenatal care services. Past studies have found that among pregnant farmworkers about 30% do not have their first prenatal visit until their second trimester, and about 14% do not have their first visit until their third trimester [4]. This is especially worrisome because these women are already at increased risk for spontaneous abortion, preterm labor, and fetal abnormalities due to malnutrition, periodic dehydration, pesticide exposure, poor living conditions, and prolonged manual labor [3].

In response to this need, programs and policies have been instituted in the state of Florida that facilitate access to prenatal care services for farmworkers and other disadvantaged women. Specialty programs and neighborhood clinics have been opened to help reduce access issues. Furthermore, pregnant farmworkers can access emergency Medicaid coverage for outpatient prenatal care. Still, little is known about the farmworker’s access to and experiences with prenatal care services. We found few studies that examine farmworkers’ experiences in prenatal care settings and whether or not this results in improved maternal and fetal outcomes. The purpose of this study is to examine farmworker’s access to and experiences with prenatal care services in South Florida.

Participants

From March 1, 2013 to June 16, 2013, we recruited 100 participants from the local community in venues where female farmworkers congregate, and in the fields where they work. Eligible participants were: 1) female farmworkers aged 18 years and older; 2) currently living in South Florida; 3) pregnant in South Florida during the last 2 years; and 4) speak English or Spanish. Potential participants were excluded from the study if they were unable to speak English or Spanish; or received prenatal care outside of South Florida. The participation rate was 100%; every woman who screened eligible agreed to participate in the study. The study was approved by the Nova Southeastern University’s Institutional Review Board (IRB) on February 20, 2013.

Procedures

At select venues, researchers approached participants, described the study and obtained verbal permission to administer a brief screening questionnaire. Administration of the eligibility screen was in safe and private areas. Eligible women were invited to participate in the study. We then scheduled eligible participants for an in-person appointment to obtain written informed consent and conduct the interview. We reimbursed participants with a $10 gift card for participation.

After obtaining informed written consent, a bilingual researcher interviewed the participant. Prior to initiating the interview, the interviewer instructed the participant on the overall format of the questions and the response categories. The interviewer then read each question and its response categories out loud. The participant then selected the response, which the interviewer recorded on a paper form. Paper forms were entered into an Excel file and then imported into SPSS for analysis.

Instrument

The quantitative survey explores the experience of female farmworkers with prenatal care during their most recent pregnancy that occurred within the past two years. We used past literature to design the survey, which we then pilot tested. The survey consists of 53 items, and is designed to gather data on demographic factors, past pregnancy history, and prenatal care experience.

Demographic factors: Participants reported their age, marital status, country of birth, current zip code, years of education, weekly monetary earnings, medical insurance status, and method of payment for medical services. This section contains 8 items that use either a multiple choice or fill in the blank format.

Past pregnancy history: This section consists of 18 items that use a multiple choice or fill in the blank format. Participants reported their pregnancy and delivery history including methods of delivery, pregnancy and delivery complications, and maternal and child outcomes.

Prenatal care experience and satisfaction: This section consists of 25 multiple choice, fill in the blank, and Likert-type items, where the participant indicated their satisfaction with their prenatal care experience by selecting one of the following choices: 1) All of the time; 2) Most of the time; 3) Some of the time; and 4) None of the time. Questions for this section were developed Wong et al. [9].

Data analysis

Our analysis focused on evaluating timely and adequate prenatal care, and maternal and newborn outcomesduring their most recent pregnancy that occurred within the past two years. We defined timely prenatal care, as receiving prenatal care during the woman’s first trimester of pregnancy, which is the recommendation in national medical guidelines [10]. National guidelines also recommend that women receive regular prenatal visits, about seven to 11 times per pregnancy [10]. Therefore, we defined adequate prenatal care as a woman receiving the recommended number of prenatal care visits. Maternal outcomes were evaluated by examining complications during pregnancy and/or delivery, use of emergency or planned cesareans, and the number of days the mother spent in the hospital after delivery. Pregnancy and/or delivery complications were also used to evaluate newborn outcomes. Additionally, newborn outcomes were evaluated with preterm delivery, and low birth weight.

All statistical analyses were done using SPSS version 20. We computed frequencies, means and other measures of central tendency to describe the sample and to examine our variables of interest.

Study population

Participant characteristics are found in Table 1. Participants had a mean age of 28 (range=19-35), mean years of education of 5 (range=0-12), and a mean average weekly income of $141 (range=$0-$300) (Table 1). The majority of participants were born outside of the United States. Half of the participants received prenatal care from community clinics (42%), and half received prenatal care from special prenatal care programs (54%).

Table 1: Description of Sample.

Prenatal care

The majority of participants received prenatal care during the first trimester of their pregnancy (97%), received 7-12 (64%) or 13-15 (26%) prenatal care visits, and paid for their visits with emergency Medicaid (97%). Forty-five percent of participants rated the overall quality of their care as excellent, while an additional 36% rated the overall quality as very good. All of the participants were either very satisfied (53%) or satisfied (46%) with the prenatal care they received.

Maternal and newborn outcomes

The majority of our participants had positive maternal outcomes. Eighty-nine percent of the participants stayed in the hospital for a maximum of two days after they delivered their baby. Only seven percent of women had problems during delivery, which included anemia, elevated or depressed blood pressure, and excessive hemorrhage. In addition, 94% of participants delivered their babies vaginally; only 5% had an emergency cesarean section

The majority of babies born to our participants in the past two years had positive newborn outcomes. Babies born within the last two years to the participants weighed an average of 7.5 pounds (range 6.13- 9.70); none of the babies were of low birth weight. Additionally, none of the babies had congenital problems like Down syndrome, spina bifida, cleft lip or palate, or heart problems. None of the babies died during childbirth.

This is one of the few studies that examined female farmworkers experience with prenatal care during her most recent pregnancy, and the relationship between prenatal care and maternal and fetal outcomes. We are happy to report that the majority of farmworker women in our sample received the recommended number of prenatal care visits and started prenatal care within the first trimester. Our participants experienced positive maternal and newborn outcomes and overall they were satisfied with the prenatal care they received. Although these findings may seem contrary to what has previously been reported, they can in large measure be attributed Florida’s health care policy granting pregnant women access to prenatal care services through presumptive eligibility for emergency Medicaid. Viewed from this lens, our findings underscore the importance of timely and adequate prenatal care and demonstrate that the poor maternal and infant outcomes can be reversed if pregnant women can access timely prenatal care services.

Timely and adequate prenatal care

Unlike other studies, in which 30% of female farmworkers do not have their first prenatal visit until their second trimester [4]; in our study, 97% of participants received prenatal care in the first trimester. Although this percent is higher than the national average for Hispanic/ Latino women, which is 74%, the national average has been increasing over the past 10 years [11,12]. Healthy People 2010 credit this increase in part to the increased access to Medicaid coverage for pregnancyrelated services and improved outreach by Medicaid program [6]. This underscores the importance of ensuring that all pregnant women, regardless of ability to pay, have access to prenatal care services.

Increased access to medicaid coverage

Studies suggest that farmworkers face many barriers to receiving prenatal care including poverty, and lack of health insurance [4]. Currently, all pregnant women in Florida can qualify to receive Medicaid during their pregnancy through Presumptive Eligibility for Pregnant Women (PEPW). All pregnant women with family income less than or equal to 185% of the Federal Poverty Level qualify for PEPW. There is currently no asset limit nor is citizenship/alien status a factor of eligibility [13]. The healthcare coverage starts during their first trimester and lasts until delivery. PEPW only covers outpatient prenatal care. Simplified Eligibility for Pregnant Women (SEPW) provides full Medicaid coverage for pregnant women who are eligible with a family income at or below 185% of the Federal Poverty Level. SEPW coverage also extends through delivery and two months post-partum [13]. Furthermore, Emergency Medical Assistance(EMA) for Non-Citizens is available to cover a serious medical emergency for non-citizens who are Medicaid eligible. This coverage includes the emergency labor and delivery of a child [14]. The results of our study point to the importance of sustaining policies that help ensure access to prenatal care for all pregnant women.

Outreach of south florida medicaid programs

The percentage of women in our study who received timely prenatal care was also higher than the percentage of Hispanic women living in Florida in 2010 who received prenatal care during their first trimester [11]. It is possible that our study participants received timely and adequate prenatal care because they are living in an area of south Florida that has a variety of venues in which to receive prenatal care. Although our study population was recruited from a remote, rural area, there are a number of specialty prenatal care services and community clinics that service the pregnant farmworkers. For example, the Miami- Dade Health Department in a partnership with the March of Dimes runs a mobile health clinic that specifically cares for pregnant women in the South Florida area. Past studies on migrant farmworkers have found that some of the barriers they face to receiving prenatal care are transportation difficulties, and geographic isolation [4]. Specialty programs like a mobile health clinic may help to overcome such barriers for the migrant farmworker community. Such programs may have helped our study participants overcome the barriers that farmworkers usually face to receiving prenatal care, and contributed to our findings.

It is also possible that the women in our study sample were more educated about the importance of receiving prenatal care during their first-trimester. Eighty-six percent of the women in our sample had been pregnant previously; therefore, it is possible that they learned about the importance of prenatal care during a prior pregnancy. Additionally, our recruiting occurred over only a few months, and many Florida farmworkers migrate with the crop seasons up and down the east coast. Therefore, it is possible that the participants were individuals who are more established in the community and are not as migratory as other farmworkers. It is possible that our recruitment period may not have overlapped with some farmworkers’ migratory schedule and consequently they were not included in the study.

Maternal and newborn outcomes

The majority of our participants had positive maternal and neonatal outcomes. Only 7% of our participants delivered via emergency cesarean section, and none had a planned cesarean section. This is lower than the national average in 2011 of 32% of all births in 2011 were cesarean section to Hispanic women [11]. All of the babies born to our participants in the past two years were born full-term, and not below the recommended birth weight. Within the state of Florida in 2008, 13% of Hispanic women delivered preterm babies, and 7% delivered low-birth weight babies [11]. These findings are not surprising given that our participants had access to timely and adequate prenatal care.

Additionally, all of our participants received care from either the community health clinic or specialty programs which require women to have uncomplicated pregnancies. At these programs, if a woman is discovered to have a high-risk pregnancy they are referred to a local hospital for prenatal care. This too, may help explain our positive outcomes. It is also possible that our study participants were healthy overall as compared to a national sample, which leads them to have positive maternal and newborn outcomes.

Study limitations and future directions

Notwithstanding the positive outcomes of our study, it has several limitations. First, the cross-sectional design allows for the description of associations, but does not allow for causal inferences. Second, some selection bias may have occurred because the majority of our sample came from either community health clinics or specialty programs who pre select women who have uncomplicated pregnancies. Third, all of our data is self-report and we did not have access to participants’ medical records. Prospective, longitudinal studies that include both self-report and biological data are needed to more accurately determine the association between prenatal care and positive maternal and neonatal outcomes among farm working women. These must also monitor access and use of prenatal care services and how changes in health care policy and legislation facilitate or hinder access to prenatal care. In these times of health care reform legislation, it is critical to retain provision that help to ensure that all pregnant women have access to prenatal care.