A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women.

OBJECTIVE To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care. DATA SOURCES AND STUDY SETTING We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021. STUDY DESIGN Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery. DATA COLLECTION / EXTRACTION METHODS Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes. PRINCIPLE FINDINGS We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common. CONCLUSIONS Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.