Despite current mammography recommendations, screening rates among African-American women are suboptimal. The purpose of this case-control study was to identify the psychological, demographic, and health care system barriers to screening mammography use among low-income African-American women. A total of 574 women with screening mammogram appointments at an urban hospital were interviewed to determine the predictors of mammogram appointment noncompliance. Predictor variables included: demographics; breast cancer knowledge, attitudes, beliefs, and screening practices; and type of health care provider making the referral. Age was inversely related to mammogram appointment noncompliance. Relative to women 40 to 49 years old, women 70 years of age and older were the least likely to miss their appointments (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2, 0.5). Women referred for mammography by a physician's assistant or nurse practitioner were less likely to miss their appointments than women referred by a physician (OR, 0.3; 95% CI, 0.1, 0.8). Embarrassment, lack of breast symptoms, and forgetfulness also contributed to noncompliance. Key demographic, attitudinal, and health care system factors hinder low-income African-American women from obtaining screening mammograms. These findings have significant health education and policy implications for health care delivery to women in this population.