Falling through the cracks: contradictions and barriers to care in a prenatal clinic.

Prenatal care is often cited as a major factor in the prevention of poor birth outcomes. Yet, the social environment of care has been little studied. This paper illustrates how contradictory features in the structure of the health care system create barriers that weaken effective health care delivery. Social relations in a large urban public outpatient clinic are described and analyzed regarding their impact on clinic procedures. The paper focuses on: 1) the division of labor in which work is compartmentalized and power is diffused; 2) the asymmetrical doctor-patient relationship magnified by social class differences; and 3) the training of resident physicians who provide primary prenatal care. Improvements in the quality of care in public clinics cannot come about without an understanding of the effects that contributing factors have on the way care is organized.