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5. Prenatal Care: Having Healthy Babies
Pages 96-125

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From page 96...
... In 1987, the most recent year for which there are data, the United States ranked nineteenth among industrialized countries in infant mortality, behind such nations as Spain, Singapore, and Hong Kong, where infant mortality rates were 9 per 1,000 births. The lowest newborn death rates are 6 per 1,000 births, found in Japan, Finland, and Sweden.
From page 97...
... A number of factors contribute to low birthweight: low socioeconomic status, a low level of education, childbearing very late or very early in the reproductive years, poor nutrition, medical problems, and substance abuse. By providing necessary medical care and helping pregnant women improve their general health, prenatal care programs play an important role in alleviating risk factors and improving pregnancy outcomes, particularly if the care is adequate and obtained early.
From page 98...
... MATERNAL AND INFANT HEALTH THE PICTURE TODAY Key measures of the health of an industrialized society are its rate of infant mortality, its percentage of low birthweight newborns, and what proportion of its pregnant women receive prenatal care. From the mid1960s to the 1980s, the United States made considerable improvement in these areas.
From page 99...
... LOW BIRTHWEIGHT AND INFANT MORTALITY Birthweight came to be viewed as an measure of fetal growth early in this century; a low birthweight was seen as an indicator of inadequate intrauterine growth or prematurity and the baby was not expected to live. Forty years ago the World Health Organization (WHO)
From page 100...
... Major advances in improving infant mortality have been achieved through saving the lives of premature infants, not in reducing the prevalence of low birthweight. In the late 1960s sophisticated monitoring and treatment methods were developed for premature infants whose undeveloped lungs did not function properly.
From page 101...
... Some analysts believe one factor in the current slowdown of the infant mortality decline may be this difference in managing and reporting extremely immature births, rather than a real deterioration in the health of pregnant women. POVERTY AND INFANT MORTALITY Others concerned with the rate of infant mortality in this country believe that an important factor in infant mortality rates is the progressive "dis-insurance" of the working poor, the increase in the proportion of women and infants living in poverty, and the shrinking in real dollars of subsidized health services for pregnant women and children.
From page 102...
... Committee to Study the Prevention of Low Birthweight, convened in 1982, found that many of these babies are at increased risk for a number of health problems, which in turn engender financial and family stresses. In its 1985 report, Preventing Low Birthweight, the committee notes "this increased risk has implications for health services, and possibly for educational services and family function as well." Health Problems Neurodevelopmental Handicaps The most obvious side effect of low birthweight is the substantial prevalence in these youngsters, as they grow, of such neurodevelopmental handicaps as cerebral palsy, seizure disorders, and other neurologically based deficits.
From page 103...
... The increased incidence of problems experienced by low birthweight babies means a greater use of health care services. In its report on these infants, the IOM committee said: The length of hospital stay in the neonatal period for infants who survive to the first year of life averages 3.5 days for normal birthweight infants, but is much longer for smaller infants: 7 days for those between 2,001 and 2,500 grams at birth; 24 days for those between 1,501 grams and 2,000 grams; 57 days for those less than 1,500 grams; and 89 days for those less than 1,000 grams.
From page 104...
... A large proportion of low birthweight infants are born to families living in poverty and to teenage mothers who do not qualify for Medicaid under individual state criteria. In many of these cases the cost of care for
From page 105...
... As a result, the cost of caring for low birthweight babies is borne by the public. PREVENTING LOW BIRTHWEIGHT: THE ROLE OF PRENATAL CARE Studies demonstrate that infant mortality and low birthweight can be alleviated if the pregnant mother receives sustained, quality medical care beginning early in her pregnancy, so that incipient problems can be detected and corrected before they affect the fetus.
From page 106...
... health care system saves between $14,000 and $30,000 in expenses for newborn hospitalizations and long-term health services. For the savings to outweigh the costs, between 133 and 286 low birthweight births would have to be averted nationally among the newly eligible Medicaid users of early prenatal care.
From page 107...
... For the IOM study on the prevention of low birthweight, analysts calculated how fiscal outlays for the medical care for low birthweight infants might be reduced if expenditures for prenatal care for high-risk pregnant women were increased. They estimated that each $1 spent on prenatal care might save over $3 in medical care for such infants, if increasing the amount of prenatal care decreased the rate of low birthweight from the current 11.5 percent to the 9 percent level, the Surgeon General's 1990 goal for high-risk women.
From page 108...
... Almost 14 percent of all the low birthweight infants born in the United States in 1986 were born to adolescents under age 15, and 9.3 percent were born to adolescents aged 15 to 19. Unmarried Women Childbearing by unmarried women is on the increase in the United States.
From page 109...
... Differences in local health care systems, language, and ethnic attitudes toward such care may keep them from obtaining prenatal services. The Poorly Educated The IOM Committee to Study Outreach for Prenatal Care, which began its work in 1986, found that education was an important factor in receiving prenatal care.
From page 110...
... A review of the data from the 1980 National Natality Survey shows that women whose incomes were at or below 150 percent of the federal poverty level were three times more likely to receive no prenatal care or late care than women whose incomes were equal to or above 250 percent of the poverty level. An analysis of data from the 1982 National Survey of Family Growth found that only one-half of women living below the federal poverty level obtained maternity care in their first trimester of pregnancy.
From page 111...
... Furthermore, young wage earners seldom have enough savings to cover gaps in their insurance. The Alan Guttmacher Institute found that in 1985 a total of 14.6 million women of childbearing age had no insurance coverage for maternity care.
From page 112...
... After 1981, however, the number remained static. After a survey of 51 Title V Maternal and Child Health agency officials in 1986, Sara Rosenbaum and her fellow researchers observed: As private insurance coverage of the poor has ebbed, the growing deficiencies of the Medicaid program, the nation's largest public financing system for low income families, have grown more glaring.
From page 113...
... The 1988 Medicare Catastrophic Coverage Act required that all states extend their Medicaid coverage to this level by mid-1990. Furthermore, the 1987 OBRA gives states the option of providing maternity care benefits to all pregnant women and infants whose family incomes are at or below 185 percent of the federal poverty level.
From page 114...
... The presence of an adequate number of practitioners, however, does not make maternity care more accessible to poor and uninsured pregnant women, unless the physicians are willing to accept Medicaid or to reduce their fees for women who have no maternity coverage at all. Among primary care physicians, obstetricians have been the least likely to accept Medicaid patients, according to an early 1980s study of physician access.
From page 115...
... In addition, the IOM prenatal care study committee reported: The problem of low Medicaid reimbursement is exacerbated by the high proportion of Medicaid women who are high-risk patients. Because of multiple health and social problems, these women often need more frequent and comprehensive maternity care than more affluent women' and such extra care can be time-consuming and expensive to provide.
From page 116...
... As Sara Rosenbaum and Dana Hughes of the Children's Defense Fund point out: Even though both Community Health Centers and nurse midwives have very low malpractice claims profiles compared to other providers of obstetrical care, their rates have risen dramatically.... At one center in Florida, malpractice coverage for prenatal care services is $4,000 annually per staff member.
From page 117...
... The lack of a direct relationship does not help women whose pregnancy tests are positive to make an appointment for the important first-trimester evaluation. Close ties to prenatal care clinics would expedite appointments, making it easier for clients to start maternity care.
From page 118...
... Although the committee noted that Congress and the states have taken steps recently to broaden Medicaid eligibility, it also observed that the program remains limited in its ability to draw low-income women into prenatal care promptly and with a minimum of bureaucratic harassment. Other Barriers The traditional obstacles to receiving early and regular care continue to hinder women from receiving necessary services.
From page 119...
... Staf/: Attitudes The use of prenatal care can also be influenced by the way clinic staff treat patients. Seeing a different doctor each time, receiving hurried or impersonal care, and dealing with rude or indifferent appointment clerks or receptionists discourage patients from continuing prenatal care.
From page 120...
... This is particularly true of first-time pregnant women, especially those still in their teens. "Not knowing I'm pregnant" also is a form of denial, a marker of an unintended and usually unwanted pregnancy.
From page 121...
... Substance Abuse Pregnant women who are aware that their life-styles risk their health and the health of their babies may also be afraid to seek care because they expect pressure to change such habits as heavy smoking, eating disorders, or the abuse of drugs or alcohol. Substance abusers, especially, may avoid seeking prenatal care because of the disorganization and stress in their lives.
From page 122...
... Even if they give up cocaine after the first trimester, these women remain at high risk for miscarriage. If they continue to use cocaine throughout their pregnancy, they increase their risk of having a preterm delivery and a low birthweight infant or of having a full-term baby who is smaller than normal.
From page 123...
... RESEARCH NEEDS Although many agencies and programs help provide health care to pregnant women and young children, increasing numbers of pregnant women do not receive maternity care until the third trimester or obtain no care at all. Health care professionals have suggested several approaches for drawing into care those low-income women who are at elevated risk for poor pregnancy outcomes.
From page 124...
... Several factors are implicated in this leveling off of infant deaths: a deepening of poverty in the United States; a more careful reporting of extremely low birthweight infants who die almost immediately, which in the past would have been reported as fetal deaths or would have gone unreported altogether; a continuation of the large proportion of births to teenagers and unmarried women, who often have low birthweight babies; and an increase in the percentage of women receiving prenatal care late or not at all. The effect of these factors has been exacerbated by an increase in the number of women, particularly young women, who are not covered by maternity insurance, by the difficulty and the delays that pregnant women experience when they try to enroll in Medicaid, by a decline in the number of physicians accepting low-paying Medicaid patients, and by a lack of coordination among clinics.
From page 125...
... 1985. Preventing Low Birthweight.


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