There is some evidence to in d ic a te th a t under-users of the p o stnatal services are con sisten t under—users, ie the same groups make scant use of a ll. h ealth services not ju s t p a rtic u la r ones (Douglas, 1964), w h ils t a number of researchers found uptake a n te n a ta lly to be p re d ic tiv e of p o stnatal uptake (McKinlay, 1972a; Z in kin & Cox, 1976b). S im ila r problems may be id e n tifie d in both spheres.
2 .1 .1 . Lower socioeconomic groups: A socio medical problem
The antenatal services are u n d e r-u tilis e d in a number of ways: la te attendance fo r antenatal care, whereby a mother does not come to the a tte n tio n of th e h e a lth services in tim e fo r adequate care to be given; non-attendance a t antenatal checks; missed appointments and low attendance ra te s a t p rep aratio n and re la x a tio n classes.
CHAPTER 2: S tu d ie s o f underusage
Latecomers fo r an ten atal care would appear to be more 'a t r is k ' of a bad outcome to th e ir pregnancies, w ith a p e rin a ta l death ra te in la te bookers f iv e tim es th a t in those who come e a rly to the a tte n tio n of the services (P rin g le , 1977).
Women of lower socioeconomic s ta tu s c o n trib u te th e highest proportion of u n d e r-u tilis e rs of an ten atal services as judged by tim e of f i r s t attendance - a trend which is s t i l l in evidence, (McKinley, 1970a). From data c o lle c te d in 24 areas of England and Wales during 1975, C hild Poverty Action Group (1978) found th a t only o n e -th ird of women in terview ed had attended p rep aratio n classes. Here the range was from 81 per cent attendance in s o cial class I to 21 per cent attendance in s o cial class V. There was also a tendency fo r lower socioeconomic group mothers to s ta r t an ten atal care la t e , ( i . e . a fte r the f if t e e n t h week of pregnancy). In her d is t r ic t study of attendance a t an ten atal classes, Perkins (1978b) found the expected c la s s -lin k e d d e c lin e in uptake. There is a f e l t need fo r an ten atal care fo r these groups, voiced not only by the p ro fessio n als but also by the mothers themselves. In Graham's^(197^) 1976-77 survey, mothers overwhelm ingly acknowledged the importance of an ten atal care, c itin g such fe a tu re s as the m onitoring of c h ild development, prevention and d e te ctio n of com plications, and the re cu rre n t need fo r reassurance as th e major reasons fo r attendance.
2 .1 .1 .1 . Factors c o n trib u tin g to under—u t ilis a t io n
McKinley (1970a) sees under—u t ilis a t io n by c e rta in groups as leading to long-term socio-m edical problems. He reasons th a t non-users of the
CHAPTER 2 i S tu d ie s o f underusage
an ten atal services who experience normal p a rtu ritio n w ithout com plications a re l ik e ly to perceive an ten atal care as irre le v a n t and unnecessary, and to perpetuate th e ir 'u n s a tis fa c to ry behaviour' through subsequent pregnancies.
C ertain groups are thought to become habituated to episodic and fragmented care, thereby crea tin g a hew and increasing socio-m edical problem. I t is , therefore^ th e ,a ttitu d e s of c e rta in groups which he sees as c re a tin g a major, problem. This approach appears to place re lia n c e upon the cu rren t .appropriateness of e x is tin g s erv ice s , assuming th a t the f a u lt lie s w ith the consumer. The d e s ir a b ility , appropriateness, w e ll-p u b lic is e d or even pleasant nature of the e x is tin g services cannot be assumed. No co n sideration is given to possible fa u lts in the services which may have helped c rea te the problem of 'u n s a tis fa c to ry behaviour' in the f i r s t p lace. McKinley is , however, w ell aware of the shortcomings of stu d ies which leave the c lie n t 's p ersp ective out of account, and in fa c t,, c r it ic is e s such studies in a subsequent paper (1970b).
In a fu rth e r study (1972b) McKinley examines the in flu e n c e of p rem arital conception and of o b s te tric com plications on subsequent delay in seeking an ten atal care. There were s ig n ific a n tly higher le v e ls of o b s te tric com plications in women who had conceived p re m a rita lly , although p re m arita l conception by i t s e l f had no delaying e ffe c t on f i r s t an ten atal v is it s . However, those women experiencing no major o b s te tric problems during f i r s t pregnancy tended to delay f i r s t v is it s in subsequent pregnancies. The sample excluded unmarried mothers and r e lie d s o le ly on re tro s p e c tiv e h o s p ita l data. No ra tio n a le was given fo r s e le c tio n of the seven types of o b s te tric
L n n r <c.r\ zs o iu u it i b u i uuutrr uiauyt;
com plications m onitored. Inferences are drawn regarding the degree of 'r a t io n a lit y ' observed in th e behaviour of each maternal sub-group.
The study o ffers'ju d g em en tal o u tsid e view of mothers' behaviour, which is view ed.as ir r a t io n a l given th e ir s ta tu s as 'a t r is k ' in medical term s.
2 .1 .2 . T h e .C lie n t P erspective
This study provides a good example of the 'socio-dem ographic' approach to the a n aly s is of u n d e r -u tilis a tio n . Major conceptual problems w ith the approach concern the. p a r t ia lit y of the data, the d e te rm in is tic nature of the model employed, ( i . e . the women are perceived as responding in a passive manner to the p lay of so cial fo rces around them); and th e in v a lid it y of the c r ite r io n of 'r a t io n a lit y ' employed. No consideration is given to what the mothers thought of the s e rv ic e s , the nature of the services on o ffe r .
2 .1 .2 .1 . Mothers face a c o n flic t of re s p o n s ib ility
Graham (197q) ch ara c te ris e s many proposed 's o lu tio n s ' to the problem of under—u t ilis a t io n as presupposing th a t the blame fo r non-attendance should re s t squarely on the fa m ily , w h ils t adverse fa c to rs in the services are overlooked. She claim s th a t 'Blaming the fa m ily ' u s u a lly takes the form of assuming non-attenders to be 'irre s p o n s ib le ' and prone to r is k -ta k in g . These assumptions are questionable in the lig h t o f-s tu d ie s which have looked in depth a t maternal fe e lin g s . In her study, she found mothers to be the reverse of irre s p o n s ib le , and in fa c t fre q u e n tly facin g a 'c o n flic t of r e s p o n s ib ilit y ', w ith u n c e rta in ty about what to do fo r th e b est. The problem is , th e re fo re , not adequately represented by the 'u n fo rtu n a te ' or 'i r r a t i o n a l '
tJHHrtfcK jU I a t u a i e t ui umuo
r "
a ttitu d e s on th e p a rt of c e rta in u n d e r-u tilis in g groups. Her in-depth in terview s w ith mothers atten d in g fo r an ten atal checks a t a h o sp ital c lin ic showed high le v e ls of d is s a tis fa c tio n w ith the care, received .
2 .1 .2 .2 . Mothers found p ro visio n disappointing
Few mothers had a c tu a lly enjoyed atten d in g or expressed the view th a t they had learn ed anything.
The general impression was of a ta s k -o rie n te d approach to care, w ith d iffe r e n t members of s t a f f assuming re s p o n s ib ility fo r fragm ents of the process. 80% said they would p re fe r to see the same member o f s ta ff on each occasion. Contact w ith s ta ff was lim ite d to the tim e taken to perform each su b -ro u tin e . The impression created was th a t i t was s ta ff tim e th a t was 'a t a premium', ra th e r than th e ir s and queueing was common in order to minimise 'tim e -w a s tin g ' by s t a f f . Mothers were re lu c ta n t to ask questions and 'to waste the d o c to r's tim e ', f e l t they were given in s u ffic ie n t inform ation when they did ask questions, and thought th ere were 'to o many th e re ' fo r in d iv id u a l a tte n tio n to be p o ssib le.
Many of the fin d in g s and proposals included in the Graham study are supported by data from s m all-s ca le studies c a rrie d out in 24 areas of England and Wales <CPAG/DHSS, 1978). These in d ica te d th a t most c lie n ts tended to see use of the services as an o b lig a tio n ra th e r than as a p o s itiv e experience. Dissem ination of inform ation was also seen to be p roblem atic. Some did not re ce ive adequate in fo rm atio n regarding f a c i l i t i e s a v a ila b le w h ils t a number expressed th e ir exasperation w ith 'co n fu sin g ' advice from d iffe r e n t p ro fe s s io n a ls .
The a c c e s s ib ility and tim ing of c lin ic s was not id e al w h ils t concern was expressed a t excessive w aitin g tim es and overcrowding. The c o n tin u ity , completeness and a v a ila b ilit y of a woman's medical h is to ry .and. in fo rm atio n on outcome of te s ts and exam inations was lackin g .
2 « 1 .2 .3 . Suggested i mprovements f or s erv i ces
Suggested s o lu tio n s thus vary considerably according to th e type of study undertaken and the th e o re tic a l p e rsp e c tive (s ) of th e*research er concerned. M aternal, suggestions fo r 'improvements' included the fo llo w in g : care to be provided w ith in walking distan ce of home; reduce w aitin g tim e in c lin ic s ? m o re /free ly a v a ila b le inform ation about th e ir care; and a 24-hour phone-in serv ice .
2 .1 .3 . Inadequacies in provision
Some of th e b e n e fits thought to accrue from attendance are: increased understanding of term inology; increased f a m ilia r it y w ith the h o s p ita l; assistance in overcoming the discom forts associated w ith pregnancy and c h ild b irth ; so cial contact w ith other m others-to-be; and an increased understanding of the processes of pregnancy and c h ild b irth ( G i l le t t , 1976).-
There are a number of problem atic issues revo lvin g around th e e valu atio n of an ten atal classes. Some researchers p re fe r to examine the exten t to which antenatal classes help the mechanical aspects of c h ild b ir th , reducing the length of lab our, q u a n tity of pain r e lie v in g drugs p rescrib ed , or frequency of forceps d e liv e rie s . Others look a t the exten t to which such classes may p o s itiv e ly a ffe c t th e woman's emotional experience of c h ild b ir th , increasing confidence, reducing fe a r , and improving the 'q u a lity ' of the experience.
CHAPTER 2i S tudies o f underusag*
2 .1 * 3 .JUl-Both. p ro fe s sio n a ls and, mothers found problems w ith p ro v isio n Classes, a re .. .. .so .v arie d in p resen tatio n and content, th a t meaningful comparisons are d i f f i c u l t . Women who e le c t to attend classes are a s e lf-s e le c te d group so th a t com parative re s u lts are only meaningful fo r atten d ers of classes, however d is p ara te these, may be ( G i l le t t , 1976). Furtherm ore, classes are themselves only one of a number of fa c to rs which might be.expected to c o n trib u te to a 'good' outcome and experience of pregnancy and c h ild b ir th .
P erkin s' (1978a, 1978b) study in Nottingham shire found th a t classes were held m ainly in th e daytime and so made no attem pt to c a te r fo r couples. They were aimed in the main a t women in la t e pregnancy and showed l i t t l e i f any im ag in ative consideration of what a fa th e r 's
needs might be in r e la tio n to the impending b ir th . At the c lin ic s , no p ro visio n was made fo r care of other ch ild re n in the fa m ily who may accompany th e ir mother, and advice to women concerning tim in g and content of classes appears to have been ra th e r lim ite d . There also appeared to be a c e rta in lack of c la r it y regarding o b je c tiv e s ~of the classes among p a rtic ip a n t h e alth v is ito r s . The classes themselves did not seem to form a c le a r ly in te g ra l p a rt of supportive h e a lth s e rv ic e p ro visio n in pregnancy, b irth and parenthood. When consumers were asked th e ir reasons fo r non-attendance a t classes, two major groups of problems emerged c le a r ly cognate w ith problems discussed in o th er stu d ies of p ro v isio n . These were the dissem ination of in fo rm atio n and p ra c tic a l problems re la tin g to attendance.
CHAPTER 2: S tu d ie s o f underusage
2 .1 .3 .2 .- Dissem ination of in fo rm atio n
C e rta in m aternal groups did not appear to know what was happening with regard to p ro visio n of classes and when they d id , they were unsure of th e degree of im portance which they should attach to attendance at