1 Introduction

Since the year 2000, maternal mortality rates have increased despite a global trend in the opposite direction, now 3–4 times higher than that of other developed nations [1]. Approximately 700 persons die due to pregnancy or its complications, and 8 out of 10 pregnancy-related deaths are preventable [2]. Pregnancy-related deaths are those that occur within one year of pregnancy – one third (31%) during pregnancy, one third (36%) during labor or within one week of birth, and one third (33%) one week to one year postpartum. Black women had the fastest rate of increase in maternal deaths between 2007 and 2014, and in some cities, have maternal death rates up to 12 times higher than Non-Hispanic White women Black, American Indian and Alaska Native (AIAN), and Native Hawaiian and Other Pacific Islander (NHOPI) persons have higher shares of preterm births, low birthweight births, or births for which they received late or no prenatal care compared to White person [3]. Previously, the overall leading cause of pregnancy-related death was cardiovascular conditions, though recent data found that mental health conditions (22.7%), hemorrhage (13.7%), and cardiovascular conditions (12.8%) were the top 3 causes in the United States from 2017 to 2019—further emphasizing the importance of preventative care [4]. Inadequate prenatal care in low-resource settings is a major causal factor linked to high maternal mortality [4]. Thus, early prenatal care is considered a major contributing factor to improved maternal and fetal outcomes [5, 6].

Importantly, differences in maternal mortality and morbidity are disproportionately high in various sociodemographic groups. Even for Black persons with a college education or higher, pregnancy-related mortality is 5.2 times higher than White persons with the same educational level, and 1.6 times higher than White women with less than a high school education [7]. For infant mortality, major risk factors include preterm birth (before 37 weeks), low birthweight (< 5.5 pounds), and not receiving any prenatal care. In parallel, Black, NHOPI, and AIAN persons have higher rates of preterm birth, low birthweight births, and pregnancies in which prenatal care initiated in the 3rd trimester. Young or teenage pregnancy persons are also at higher risk or morbidity, as they are more likely to be unplanned and involve late and irregular prenatal care. Research has also shown that racism and chronic stress contribute to poor maternal and fetal outcomes, including higher rates of mistreatment during their pregnancy—even after controlling for insurance status, income, and age [8].

Exactly how prenatal care confers health benefits, though, is to be complex and multifactorial. While over 98% of pregnant persons receive some PNC before delivery in the United States, only 77.1% initiate PNC in the first trimester of pregnancy and many people have barriers to accessing routine PNC [3]. Among persons with pregnancy-related deaths in 2011 to 2013, 24.5% initiated PNC after the 2nd trimester and 8.5% received no PNC. Additionally, having no PNC or late PNC was correlated with not attending postpartum visits. In addition to having higher mortality from pregnancy-related complications (cardiomyopathy, hypertensive disorders of pregnancy, hemorrhage, etc.), Black and Hispanic women are 4-times and 2-times more likely, respectively, to have less than five PNC visits compared to White women [9]. Thus, addressing barriers in access to care—which may result in late entry or inadequate PNC—may help mitigate adverse pregnancy-related outcomes.

Accessibility of prenatal care is impacted by many social, psychological, environmental, and health system factors [10]. Documented health system barriers include the cost of transportation, long wait times at the clinic, brevity of visits, unhappiness with the care provided, lack of childcare, inflexible clinic hours, cost of care, difficulty scheduling timely visits, and the endorsement of experiences of racism [10, 11] In one study, there was a negative correlation between the timeliness of prenatal care and the perceived barrier of being unable to leave school or work, difficulty scheduling appointments, and the number of visits [12]. Disparities also exist at the health system level and quality improvement efforts should focus on redesigning essential services to increase accessibility, utility, and satisfaction with prenatal care services [14, 15].

1.1 Purpose

While there is a multifactorial etiology to racial and ethnic disparities in pregnancy outcomes, we chose to explore a possible modifiable risk factor for maternal morbidity and mortality—sociodemographic disparities in PNC access. This study was conducted at Loyola University Medical Center, located in Maywood, Illinois, which is considered a federally designated Medically Underserved Area and serves people who face economic, cultural, or linguistic barriers to health care. Maywood’s population is 13.6% White (5.7% White alone, non-Hispanic or LatinX), 60.6% Black or African American, and 30.5% Hispanic or LatinX, Regarding education, only 15.5% of people 25 years or older have bachelor’s degrees or higher. From 2018 to 2022, the median household income was $64,767 with an average of 3.03 persons per household. 15.2% of people are in poverty, 9.7% of less than 65 years of age have a disability, and 15.8% are without health insurance. This study examines the common health system barriers to PNC, racial disparities in PNC, and the impact of patients’ self-reported barriers on their healthcare utilization and pregnancy outcomes. Our primary objective was to pinpoint the obstacles that are most pertinent to our patients, utilizing this knowledge to develop impactful initiatives aimed at enhancing access to quality prenatal care and ultimately, achieving better outcomes.

2 Materials and methods

2.1 Study design and procedures

A retrospective cohort study was conducted involving postpartum patients on the Labor and Delivery (L&D) at Loyola University Medical Center, a medically underserved urban academic medical center, to assess PNC experiences and health system barriers. From February to May 2022, medical student researchers recruited patients from L&D, totaling a quarter of the fiscal year. All deliveries were screened for eligibility prior to survey administration. Paper survey and consents were available in English and Spanish. A certified translator was used as indicated. The 10-question survey was designed for completion in 15 min or less, utilizing Likert scales, multiple choice, and short answer questions. Surveyors explained the study purpose, type of information collected, and emphasized that participation was voluntary and would not impact their medical care. Surveyors employed strategies to overcome potential difficulties to survey completion in the postpartum period—kept interventions short (5 min, on average), and utilized paper surveys that could be left for completion in private, over several hours,

After completion of the surveys, we conducted retrospective chart reviews to record patient demographics, prenatal care, obstetric history, and pregnancy and neonatal outcomes. Patient information was de-identified and entered into Red Cap and paper surveys and consents were appropriately discarded. Data was analyzed for statistically significant associations to inform recommendations for interventions to reduce disparate access to prenatal care.

2.2 Participants

Participants were included if they were aged 18 or greater, fluent in English or Spanish, had a live birth during the study period, received most of their prenatal care from specified Loyola facilities (Maywood, Burr Ridge, or Oakbrook locations), and participated voluntarily. Majority of care was defined as at least 50% of prenatal care visits attended. Participants were excluded if they did not meet inclusion criteria, had no prenatal care, were unable to be consented due availability (eg, sleeping, not in room at time of survey, etc.), or declined to participate.

2.3 Data collected

The survey of 10 questions addressed respondents’ demographic factors (location of prenatal care, education level, income), barriers to prenatal care (missing work or school, transportation, parking, childcare, convenience of appointments) out-of-pocket costs of prenatal care, (transportation, parking, childcare), and suggestions to improve prenatal care (reduced parking fee, prepaid public transportation tickets, telemedicine, improved scheduling). Questions regarding barriers to prenatal care, out-of-pocket costs, and suggestions to improve prenatal care utilized Likert scales, “Yes” or “No”, and short answer questions. Likert scales were defined in each question (Fig. 1).

Fig. 1
figure 1

Types of barriers to prenatal care by race and ethnicity. Overall trends in reported barriers identify scheduling issues, wait times, and inability to leave work or school as common barriers to prenatal care. * statistically significant (p < 0.05)

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After collection, surveys were assessed for completion. Surveys < 50% complete or with incorrect patient information (eg, Medical Reference Number (MRN)) were excluded. After collection demographic information, prenatal care information, pregnancy outcomes, and neonatal outcomes were collected via chart review. Data gathered from the medical record included demographic information (age, race, and ethnicity), obstetric history (gravity and parity), prenatal care information (gestation at initiated prenatal care, the number of prenatal care visits attended, and the number of prenatal care visits canceled or missed), comorbidities during pregnancy (obesity, hypertension, diabetes, intrauterine growth restriction (IUGR), Group B Strep (GBS) + result, anemia), delivery complications (tachysystole, fetal decelerations, chorioamnionitis, and postpartum hemorrhage), and neonatal outcomes (arterial cord pH, Apgar score, and NICU admission).

2.4 Data analysis

Descriptive statistics were used to report patient characteristics in our study population. Patient-reported barriers between racial and ethnic groups, education level, and income were reviewed. Continuous data were compared using one and two-way ANOVAs and were reported as a mean and percentage. Categorical data were compared using the chi-square or Fisher’s exact test as appropriate. Next, we looked at the impact of race, ethnicity, income, and education status on PNC initiation and attendance. Data were analyzed using one and two-way ANOVA, post hoc Tukey analysis and Wilcoxon signed-rank tests. An alpha cutoff of 0.05 was used for all significance tests. These data were analyzed using R.

3 Results

Between February and May of 2022, a total of 251 patients had live births at Loyola University Medical Center. 194 of these patients consented to participate in the study and completed the survey (77.3%), thus were eligible for chart review. 57 of the eligible patients (22.7%) were excluded from the study—21 (10.6%) declined to participate, 33 (16.8%) did not complete the survey, and 3 surveys (1.5%) were lost.

3.1 Sociodemographic characteristics of participants

The median age at delivery was 31 with a range from 26 to35. For race, 90 patients (46.9%) identified as White, 33 (16.5%) identified as Black, and 70 (36.3%) identified as Other. For ethnicity, 92 patients (47.4%) identified as Hispanic, and 99 (51.0%) identified as non-Hispanic. For location of prenatal care, 134 participants (70.2%) received prenatal care at Loyola’s Maywood campus, 41 patients (21.5%) received care at Loyola’s Oakbrook and 13 patients (6.8%) at Loyola’s Burr Ridge Centers. For highest level of education, we identified 46 participants (25.3%) who completed some or all of high school, 77 participants (39.7%) who completed some or all of community college, and 70 participants (36.1%) who completed a bachelor's degree, master's degree, or doctorate. For income, 88 patients (45.4%) of patients made below $45,000 in annual income (Table 1).

Table 1 Demographic characteristics of study participants
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3.2 Obstetric history, prenatal care, pregnancy and neonatal outcomes

The average gravity of participants was 2.6 pregnancies, 1.8 term deliveries, 0.2 preterm deliveries, 0.6 abortions, and 2 living children. For 30.4% of patients, this was a first-time pregnancy. The average gestation of initiation of prenatal care was 12w5d (3.4–39.1). The average number of prenatal visits attended was 15.0 (2–30) and 2.1 missed or canceled visits (0–14). The most common comorbidities in the study population were obesity (61.3%), hypertension (32.0%), anemia (19.1%), and diabetes (18.6%). 14.4% of patients were GBS + and received prophylactic antibiotics. Overall, 35 deliveries (18.0%) had complications, with the most common complication being postpartum hemorrhage (5.2%). Other complications include tachysystole in 2 deliveries (1.0%), fetal decelerations in 6 deliveries (2.1%), and chorioamnionitis in 7 deliveries (3.6%). Average arterial cord pH was 7.25, Apgar scores of 8 and 9 at 1 and 5 min, respectively (rounded to whole numbers), and 18.6% of newborns were admitted to the NICU after delivery.

3.3 Reported barriers to prenatal care

Barriers to prenatal care were reported on a Likert scale from 0 to 5, with 0 meaning that the barrier had no impact on the patient’s ability to attend their PNC visits and 5 meaning that the barrier had a significant impact. Nine possible barriers were included on the survey (cost of transportation, cost of parking, difficulty arranging childcare, cost of childcare, long wait times at the clinic, difficulty scheduling visits, having too many visits, and lack of knowledge about how COVID19 impacted routine PNC). On average, participants reported between 2 and 3 barriers to care. Of note, we categorized race to include “White”, “Black or African American”, and expanded “Other” to also include participants who identified as “Two or more races”, “Native Hawaiian and Other Pacific Islander”, “American Indian and Alaska Native”, and “Asian”. In other sections, we compare these categories with Hispanic ethnicity (Table 2).

Table 2 Reported barriers to prenatal care by participant demographics
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There were no statistically significant differences in the number of barriers patients reported based on race, ethnicity, or income. However, there was a correlation between education level and the number of reported barriers. Patients with a high school degree or less and patients with a bachelor’s degree or higher (2.61 barriers) reported more barriers than those who attended community college (2.33 barriers, 2.61 barriers, 1.62 barriers, respectively) (p = 0.03) (Table 2).

The most reported barriers were “difficulty scheduling visits” (39.6%), “couldn’t leave work or school” (30.2%), and “long wait times at clinic” (27.8%) (Fig. 1). “Difficulty scheduling visits” was the most common barrier for White (44.9%), Other (41.4%), and Hispanic (44.4%) patients, while “cost of transportation” was the most common for Black (28.1%) patients. The only significant difference based on race and ethnicity was for women that reported “too many visits” as a barrier to PNC (p = 0.028). 30% of White patients and 33.3% of patients categorized as Other reported having too many visits, compared to 9.4% of Black patients and 22.5% of Hispanic patients (Fig. 1).

Although patients with a high school education and bachelor’s degree reported more barriers than those with a community college degree, the differences were not statistically significant (Fig. 2). 45.7% of patients with a bachelor's degree or greater reported having difficulty scheduling visits, 41.4% couldn’t leave work or school, and 32.9% reported having too many visits. Patients with a community college degree also reported difficulty scheduling visits, having too many visits, and being unable to leave work or school were barriers to care. 36.4% of patients with a high school degree or lower said cost of transportation was a major barrier, and 32.6% were also affected by the cost of parking. (Fig. 2).

Fig. 2
figure 2

Types of barriers to prenatal care by education status. Overall trends in reported barriers based on completion of some or all of high school, some or all of community college, or a bachelor’s degree and higher

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3.4 Prenatal care utilization

Race and ethnicity significantly impacted gestation at the initiation of prenatal care. On average, Hispanic patients had delayed initiation of care at 13w6d, compared to non-Hispanic patients, at 10w5d (p = 0.009). This did not impact the number of prenatal visits or the number of visits canceled or missed (Table 3). However, on average, patients with a high school degree or less initiated PNC at 16w0d, compared to those with a bachelor's degree or higher, at 11w0d (p < 0.001). Patients who attended high school or community college also attended significantly less visits than those with a bachelor’s degree, approximately 14 visits and 16 visits, respectively (p = 0.01) (Table 3). Income significantly impacted the gestation of initiation of prenatal care. Patients with an annual income < $45,000 initiated care at 13w3d, compared to 12w0d and 9w1d for patients making > $45,000, respectively (p = 0.02). There was no interaction between income and education on gestation at the initiation of PNC (Table 3). Of the health system barriers studied, “long wait times at the clinic” was associated with delayed initiation of PNC at 14w1d at initiation, compared to 12w0d for those who not report this as a barrier (p = 0.01).

Table 3 Gestational age at initiation of prenatal care and subsequent attendance by participant race/ethnicity, education, and income
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3.5 Prenatal satisfaction and attendance

Patients were surveyed about interventions to improve satisfaction and attendance with prenatal care. The proposed interventions were rated on a Likert scale from 0–5, with 0 meaning that the intervention would have no impact on the patient’s attendance or satisfaction with their PNC visits and 5 having a significant impact. For this analysis, we compared suggestions from patients without barriers to care (answering 0 to all questions about barriers to care) with patients who reported any barrier to care (answering 1–5 on any of the barriers to care.

3.6 Satisfaction

Of patients that reported barriers to PNC, 92.5% reported that having all ultrasound visits fall on the same day as obstetric visits would increase their satisfaction with their care (Table 4). Of patients that did not report any barriers to PNC, 64.7% said that this would improve their satisfaction. 78.3% of patients with barriers to care reported that free or reduced parking would increase their satisfaction, compared to 61.8% of patients with no barriers. Having some visits performed via telehealth would improve satisfaction for 58.6% and 32.4% of patients with barriers and no barriers to PNC respectively. Finally, prepaid public transportation tickets would improve satisfaction for 36.4% of patients with barriers and for 27.9% of patients with no barriers.

Table 4 Satisfaction and attendance with prenatal care among participants who did not report barriers to care, compared to those who reported at least one barrier to care
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3.7 Attendance

Having all ultrasound visits fall on the same day as obstetric visits was an intervention that most patients reported would improve their PNC attendance. 60.6% of patients with barriers to care and 21.4% without barriers reported this would increase their attendance. For patients with barriers, 44.4% said that telehealth would improve their attendance and 33.3% reported that free or reduced parking would improve their PNC attendance (Table 4).

4 Discussion

This study found that most patients faced several health system barriers when accessing PNC, and for some, this resulted in delayed initiation of PNC and fewer PNC visits. Though the exact gestational age is not defined, late presentation, such as in the 3rd trimester, and poor adherence to PNC are associated with adverse maternal behaviors, increased rates of maternal mortality, and low birth weight [6, 9, 13]. On average, participants reported between two and three barriers to PNC – which was not significantly different across race, ethnicity, or income. Interestingly, patients with ≤ a high school degree or ≥ a bachelor’s degree reported more barriers than other education levels. We did not observe differences in pregnancy complications, delivery complications, or admission to the neonatal intensive care unit (NICU) based on race, ethnicity, education, location of prenatal care, or type of reported barrier. In other words, all our patients experienced some kind of barrier to care. However, this cohort still experienced an overall complication rate of 18% and have significant sociodemographic risk factors for adverse outcomes – 70% of prenatal care was in a medically underserved area (Maywood, IL), 50% of patients were Hispanic, 65% had ≤ community college education, and 49% made < $49,000 a year. In terms of satisfaction with care, 93% of patients who reported barriers to care said that having their ultrasound and prenatal visits on the same day would increase their satisfaction. 79% suggested free or reduced parking, and 59% suggested having some portion of care via telehealth.

Early prenatal care provides a critical window to mitigate personal and systemic factors that contribute to worse maternal or fetal outcomes, such as screening for medical conditions, fetal anomalies, weight gain, and to provide education about exercise, diet, prenatal vitamins, and substance use. A study examining 31,642 responses from the 2016 Pregnancy Risk Assessment Monitoring System (PRAMS), structural and financial barriers were common barriers to care [16]. This study found that patients who were younger, received Women, Infants, Children (WIC), or had less education were more likely to report financial barriers to early prenatal care – but were less likely to report health systems structural barriers to care (i.e. not having appointments available, doctor/health care plan not being willing to start care). For participants in our study, approximately 30–40% of patents reported “difficulty scheduling visits”, “inability to leave work or school”, and “long wait times at the clinic” as major barriers. The most reported barrier among Black patients was “cost of transportation” compared to “difficulty scheduling visits” among White, Other, and Hispanic persons. We found that White patients and those we grouped into “Other” (Asian, American Indian, Pacific Islander, or Two or more races) – were more likely to report “too many PNC visits” compared to Hispanic and Black patients. Though we did not observe a correlation between pregnancy outcomes and sociodemographic characteristics, our data found less prenatal care utilization associated with ethnicity, education, and income.

As mentioned in the Study Design section, we chose barriers based on feedback from patients in the Loyola L&D unit. Patients all delivered at Loyola University Medical Center, and 70% received > 50% of their prenatal care here. The remaining 30% of patients received their care at Loyola clinics located in areas not considered medically underserved. On average, patients initiated care at 12w6d (3.4–39.1 visits), attended 15 visits (2–30 visits), and missed 2.1 visits (0–14 visits). In the study mentioned prior, 15% of patients wished they received prenatal care earlier, and 77% of women initiated prenatal care in the 1st trimester. Patients who were younger, less educated, geographically isolated, and were racial/ethnic minorities initiated care later. In our study at Loyola, Hispanic patients delayed prenatal care by 3 weeks compared to non-Hispanic White patients (13w6d vs. 10w5d). Patients who completed “some or all high school” delayed care by 5 weeks compared to patients with a bachelor's degree or higher (16w0d vs. 11w0d). Individuals with an income below $45,000 delayed care more than 4 weeks later than those exceeding $140,000 (13w3d vs. 9w1d). Similar studies found major differences in the timing of pregnancy detection and initiation of care. Other studies found that identifying as Hispanic, who received WIC benefits, were < 24 years old, had < bachelor’s degree, were unmarried, or had > 1 prior birth detected their pregnancies up to 5 weeks later than women not in these categories. Effective interventions may be those that increase the availability and flexibility of appointments—shorter wait times, visits that consolidate clinic appointments, ultrasound scans, and lab work, and at-home monitoring options. Providers would likely benefit from these changes and may allow for longer appointments.

4.1 Interpreting disparities in prenatal care

Disparities in adverse pregnancy outcomes and access to PNC are multifactorial and deeply intertwined with social determinants of health. One study found that education status was the strongest predictor of maternal mortality [3]. Others found cardiovascular disease to be the leading cause, while more recent studies cite mental health as the most common cause of pregnancy-related death [17]. These studies found that racial disparities persist across all education levels, which may reflect increased barriers to care for racial/ethnic minorities. Researchers emphasized that the experience of racism and segregation, rather than maternal race itself, is the key factor that influences health outcomes. Insurance coverage before, during, and after pregnancy impact positive maternal and fetal outcomes. Racial/ethnic minorities are more likely to be uninsured, with Medicaid often filling gaps of care. However, if uninsured prior to pregnancy, women may not receive the 60-day postpartum coverage because they are considered parents, rather than pregnant persons, at the time of enrollment. Research has documented that racism and chronic stress are associated with higher rates of perinatal depression, preterm birth, and infant mortality in Black and African Americans [8]. Disparities in pregnancy outcomes may be consequences of systemic racism resulting from de-investment in non-White neighborhoods, access to legal systems, education, jobs, and healthcare services. Distrust of the health system based on historical and contemporary discrimination often manifests as disparities in maternal health. There is also a powerful role of culturally competent and concordant care, with studies finding significantly less mortality in Black infants who were treated by Black physicians [18]. This topic has received more attention after cases of maternal deaths and near misses in which providers did not, or were slow to, listen to their patients. For Hispanic or LatinX patients, a phenomenon called the Hispanic or Latino health paradox, has been proposed [19]. Despite increased barriers to care—socioeconomic, language, cultural—Hispanic women and infants have similar outcomes as Whites. These discrepancies might be explained by variations between subgroups of Hispanic people, with recent immigrants having better outcomes. Delayed initiation of care and decreased prenatal attendance was observed in patients with ≤ high school education. As mentioned earlier, less education is associated with increased financial barriers to care. Additionally, many teen pregnancies are unplanned, resulting in delayed prenatal care and increased risk of complications.

5 Recommendations

The difference in prenatal care utilization highlights a crucial concept—that sociodemographic groups often experience barriers differently. Therefore, approaches aimed at encouraging early prenatal care visits among patients with lower levels of education could emphasize cost reduction, whereas interventions improving appointment convenience might be advantageous for more educated patients. For example, encouraging early prenatal care by increasing awareness about eligible prenatal providers (e.g. family physicians) for resource-limited patients, versus multiple prenatal locations for people with easy access to transportation.

5.1 Patient opinions

Engaging patients, caregivers, and key stakeholders when designing interventions is vital to creating successful interventions [20]. For example, one study reported a 44% increase in patients starting PNC in the first trimester after redesigning operational and clinical processes, extending hours of operation, and increasing patient education and outreach. Reportedly, the success of the intervention was largely due to the engagement of patients and key stakeholders through surveys, focus groups, and graded feedback. Other studies showed that patient and community engagement in research improves patient satisfaction with their care, community health literacy, and intervention participation.

5.2 Virtual visits

Participants in this study indicated that “having ultrasound visits fall on the same day as obstetric visits” and “having some telehealth visits” would improve their PNC attendance. Virtual visits are a valuable tool to address common barriers such as difficulty leaving work/school, scheduling difficulties, and lack of reliable transportation. Prenatal visits may occur over incurs 12–14 visits, not including lab visits and ultrasound appointments. Since the COVID-19 pandemic, there have been several randomized control trials examining the scope of virtual monitoring in obstetric patients [21]. Studies have shown that remote monitoring of blood pressure, fetal heart rate, and fetal growth (via tape measure) is as accurate as in-clinic assessment [22]. In a study of low-risk pregnant women, having a reduced-frequency prenatal care model increased satisfaction (94%) compared to usual care (79%). The intervention included 8 in-person appointments with an Obstetrician, 6 virtual visits via phone or video with a nurse, a home fetal Doppler and sphygmomanometer, and access to an online community of other pregnant women. The usual care included 12 pre-scheduled clinic appointments with an Obstetrician. There was no difference in perceived quality of care or maternal/fetal clinical outcomes. Maternal stress was significantly lower for the intervention group at 14 weeks and 36 weeks. While this model may not be appropriate for high-risk patients, providers should weigh risks with the benefits of increasing prenatal care access on a case-by-case basis.

5.3 Group prenatal care

The profound benefits of group prenatal care for low-resource communities have gained recognition in recent years. In a study of > 2,400 participants between 2014 and 2018, researchers found significantly lower rates of premature delivery, low birth weight infancts, and NICU admission in patients receiving group care [23]. This effect was even greater for Black patients. Their model included 10 two-hour sessions with 8–12 participants due during the same month. Sessions were led by an Obstetrician or midwife and included information on nutrition, physical activity, and mental and sexual health. As many health systems are oversaturated and struggling with low provider-to-patient ratios, group care may create important opportunities for appointment flexibility. Group care allows for longer appointments and consistent providers—rather than 10–15 min appointments with rotating providers, patients can see the same provider for 2-h sessions. These models are designed to increase patient education and provide opportunities for social support [24].

6 Strengths and limitations

6.1 Strengths

The study highlights the critical impact of delayed prenatal care initiation on maternal and fetal health outcomes, reinforcing findings from previous research. It identifies significant disparities in prenatal care utilization based on race, ethnicity, education, and income, offering detailed insights into demographic factors influencing care timing. By examining factors like education, income, and neighborhood safety, the study deepens understanding of how social determinants of health affect maternal health outcomes and access to prenatal care. It advocates for effective interventions such as improving appointment availability, reducing wait times, and offering at-home monitoring options to enhance patient engagement and satisfaction. The study emphasizes the role of patient and community engagement in designing successful interventions, showcasing examples where such approaches have significantly improved prenatal care initiation rates. Overall, the research contributes valuable data on disparities in prenatal care access and outcomes, suggesting targeted interventions and highlighting the need for inclusive healthcare strategies that address social determinants of health.

6.2 Limitations

The study's sample population was restricted to individuals with prior prenatal care at Loyola University Medical Center, excluding those with no prior care and those experiencing adverse fetal outcomes. This limits insights into high-risk cases and may affect the generalizability of findings. Analysis was constrained by a small sample size and a short study period of three months, limiting the ability to detect rare pregnancy complications or establish correlations with prenatal barriers effectively. The study did not find significant associations between race/ethnicity, education level, and pregnancy outcomes or barriers to prenatal care, potentially due to sample size limitations.

Survey administration within 24–48 h postpartum posed challenges, including patient fatigue and varying circumstances that affected survey completion rates and possibly introduced recall bias. The survey's complexity may have hindered participant understanding, suggesting potential biases in responses related to health and cultural literacy barriers. Issues with income data collection, including participants leaving sections blank or seeking clarification, further complicated exploration of socioeconomic and racial disparities in prenatal care access.

7 Conclusions

In conclusion, this study underscores the significant health system barriers that patients face when accessing prenatal care, which contribute to delayed initiation and fewer visits. Addressing these barriers is crucial as early prenatal care not only screens for medical conditions and provides essential education but also plays a pivotal role in mitigating adverse maternal and fetal outcomes. The findings reveal disparities based on race, ethnicity, education, and income, highlighting the need for targeted interventions that improve accessibility and convenience for diverse demographic groups. Moreover, the study emphasizes the complex interplay of social determinants of health, such as racism and socioeconomic disparities, which profoundly impact maternal health outcomes and access to care. Moving forward, engaging patients and stakeholders in intervention design will be essential to implementing effective strategies that enhance prenatal care utilization and ultimately improve maternal and fetal health outcomes across different healthcare settings.