Forty-One Miles to the Nearest Prenatal Visit: Transportation, Income and Late Entry Into Prenatal Care in a Rural County
Student Name
American College of Education
NUR4043: Community Health and Vulnerable Populations
Module 2 Assignment
Instructor Name
May 11, 2026
The Health Indicator
This analysis concerns pregnant residents of Ashford County, the composite rural county of about 38,000 people used throughout this course. The health indicator is the percentage of live births to county residents in which prenatal care began in the first trimester, drawn from birth certificate records, the same source behind the federal natality files released by the CDC. For the most recent three-year period, pooled because the county records only about 400 births a year, the composite figure is 64.8 percent, compared with 76.1 percent for the state over the same period. Put the other way, roughly one in three births in the county began prenatal care after the first trimester or not at all, compared with about one in four statewide.
The indicator matters because early care is when pregnancy dating, screening for gestational diabetes and hypertension risk, and counseling on substance use and nutrition are most useful. Healthy People 2030 includes an objective to increase the proportion of pregnant people who receive early and adequate prenatal care (Office of Disease Prevention and Health Promotion [ODPHP], n.d.), which places this indicator among the nation's tracked measures rather than a local preference. A gap of eleven percentage points on a nationally tracked measure is large enough to need an explanation, and the explanation is unlikely to lie inside the clinic.
Three Determinants and Their Figures
Healthy People 2030 sorts social determinants into five domains, running from economic stability and education through health care access, the built environment of neighborhoods, and the social and community context people live in (ODPHP, n.d.). The three determinants examined here fall into three of those domains, and each has a figure and a source.
The first is transportation, part of the neighborhood and built environment. The county has no fixed-route public transit. According to composite American Community Survey figures, 8.9 percent of occupied households have no vehicle, compared with 5.6 percent statewide, and many more share one vehicle among several working adults. A Medicaid transportation benefit exists but must be booked at least 48 hours in advance through a regional broker. The second is geographic access to care, part of health care access and quality. The county hospital closed its labor and delivery unit four years ago, and its affiliated obstetric clinic moved to the regional center 41 miles away; one family practice in the county still sees pregnant patients, but only for the first visit. The third is income, part of economic stability. The composite median household income is $48,300, and 19 percent of children live below the poverty line, compared with 14 percent statewide.
Other determinants were considered and set aside for this paper. Educational attainment in the county is close to the state average, and the proportion of residents with limited English proficiency is under two percent, so neither seems likely to explain a gap of this size. Housing instability matters for pregnant women everywhere, but the county's eviction and homelessness counts are low and could not be tied to birth data. Choosing three determinants with clear figures and plausible pathways keeps the analysis focused on the links that the available data can actually examine, rather than listing every factor that might play some part.
Linking Each Determinant to the Indicator
Transportation links to the indicator most directly. A first prenatal visit usually requires at least one trip for the visit itself and often a second for laboratory work or an ultrasound. For a household without a vehicle, each trip means borrowing a car, arranging a ride or booking the Medicaid service two days ahead, and a woman who learns she is pregnant at seven or eight weeks may reach the end of the first trimester before those arrangements line up. National survey data show that transportation barriers are not rare: in 2017, an estimated 5.8 million people in the United States delayed medical care because they did not have transportation, and the burden fell most heavily on people living in poverty and on Medicaid recipients (Wolfe et al., 2020). A review of transportation barriers to health care found consistent associations between distance, lack of a vehicle and missed or delayed appointments across many populations (Syed et al., 2013).
Geographic access compounds the transportation problem. The closure of the county's obstetric unit turned a ten-minute trip into an 82-mile round trip for most prenatal visits. Kozhimannil et al. (2018) examined 179 rural counties that lost hospital-based obstetric services between 2004 and 2014 and found that the more remote of those counties, the ones with no neighboring urban area, then saw more babies born outside a hospital, more delivered at hospitals that had no obstetric unit, and a rise in preterm birth. Their study did not measure the timing of prenatal care, so it cannot show that closures delay first visits, but it establishes that losing local obstetric services changes how and where rural women receive care. Distance does not only add miles; it moves the first prenatal visit to a place that is harder to reach without planning, and planning is exactly what a household short on cars and cash has least of.
Income acts through both of the other determinants and on its own. Households near the poverty line are less likely to own a reliable vehicle, less able to take unpaid time off for a daytime appointment, and more likely to delay care while insurance coverage is being arranged. In this county, a pregnant woman without coverage must apply for pregnancy Medicaid before most practices will schedule a first visit, adding one more step to the first trimester.
How Strong Are the Links?
The evidence supports a strong link between transportation and delayed care in general and a plausible link between obstetric unit closures and changes in rural birth care, but the county data alone cannot prove that any one determinant caused the lower first-trimester figure. County-level comparisons are ecological: they show that a county with fewer vehicles and farther clinics also has later prenatal care, not that the individual women who entered care late were the ones without vehicles. Other factors that were not measured here, such as unintended pregnancy rates, substance use and trust in the health system, could also contribute.
Two additional data sources would strengthen the analysis. Birth certificate data can be divided by maternal residence within the county, so a map of first-trimester entry by ZIP code, set against distance to the regional clinic, would test whether the gap is larger in the more remote parts of the county. And the Medicaid transportation broker's records of canceled or unfilled prenatal rides would show how often the benefit fails at the moment it is needed. Both are available to a county health department without a new survey.
Conclusion
Late entry into prenatal care in Ashford County is best understood as the product of three determinants that reinforce one another: a shortage of household vehicles and public transit, the loss of local obstetric services and incomes that leave little room for extra trips or missed work. Of the three, transportation is the determinant a community health nurse can most directly influence, through partnerships with the Medicaid broker, the remaining family practice and the regional clinic to schedule first visits closer to home or to pair them with arranged rides. That is where the next module's priority-setting should begin.
References
Kozhimannil, K. B., Hung, P., Henning-Smith, C., Casey, M. M., & Prasad, S. (2018). Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA, 319(12), 1239-1247. https://doi.org/10.1001/jama.2018.1830
Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030, U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health
Syed, S. T., Gerber, B. S., & Sharp, L. K. (2013). Traveling towards disease: Transportation barriers to health care access. Journal of Community Health, 38(5), 976-993. https://doi.org/10.1007/s10900-013-9681-1
Wolfe, M. K., McDonald, N. C., & Holmes, G. M. (2020). Transportation barriers to health care in the United States: Findings from the National Health Interview Survey, 1997-2017. American Journal of Public Health, 110(6), 815-822. https://doi.org/10.2105/AJPH.2020.305579
How this NUR 4043 Module 2 example is structured
NUR 4043 Module 2 typically moves to determinants, linking housing, transport or income figures to a health indicator; your classroom's instructions set the aggregate, the indicator and the format. This example names the indicator first with its source and time window, because a determinant cannot be linked to an outcome that has not been defined. It then places each determinant within a recognized framework, gives its figure and source, and traces the pathway from that determinant to the indicator. A separate section weighs the strength of each link and names what the data cannot show, and the conclusion states which determinant a nursing response should target first.
NUR4043 Module 2 questions, answered
What does NUR4043 Module 2 usually ask for?
NUR4043 Module 2 typically asks students to link social determinants of health, such as housing, transportation or income, to a specific health indicator for their aggregate. Most versions expect real figures with sources rather than general statements. Your classroom's instructions decide the aggregate, the number of determinants and whether a framework such as Healthy People 2030 is required.
How do I link a social determinant to a health outcome in a paper?
Define the outcome with its source and time window, give the determinant a figure and a source, and then describe the pathway: how the determinant plausibly produces the outcome in daily life. Support the pathway with at least one study, and state what your county-level data cannot prove, since area comparisons do not show individual causes.
Where can I find county-level data for a determinants paper?
The American Community Survey covers income, poverty, vehicle access and housing. CDC WONDER provides birth and death data by county. County Health Rankings and state health department dashboards bring many measures together. Pool several years when numbers are small, and always report the years and the source alongside each figure.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official American College of Education document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.