Preventing Low Birthweight (1985) / Chapter Skim
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7. Ensuring Access to Prenatal Care
7. Ensuring Access to Prenatal Care
Pages 150-174
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From page 150... ...
. Efforts to reduce ache nation' s incidence of low birthweight must include a commitment to enrolling all pregnant women in prenatal care, particularly because many of the women who r eceive inadequate prenatal care are those at greater than average risk of a low birth- weight delivery.
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From page 151... ...
Who Receives Inadequate Prenatal Care? The Advance Report on the 1981 nasality statistics3 states that prenatal care almost 24 percent of all births were to women who began after the first trimester of pregnancy.
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From page 152... ...
The Oregon Center for Health Statistics' analysis of inadequate prenatal care (no care, care begun in the third trimester, or less than five prenatal visits) showed that the marked improvement observed throughout the 1970s had been reversed.~° The increase in inadequate care was greatest among teenagers, unwed mothers, and blacks.
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From page 153... ...
There are several possible reasons why an individual woman does not enroll in prenatal care early or at all, but the literature that could help in understanding this problem is not extensive. From those studies and programs reviewed, however, the committee has def fined several types of barriers related to the poor utilization of prenatal care: · f financial constraints, including inadequate insurance or public funds such as Medicaid to purchase adequate prenatal care; · inadequate availability of maternity care providers, particularly providers willing to serve socially disadvantaged or high-risk pregnant women; · insufficient prenatal services in some sites routinely used by high-risk populations such as Community Health Centers, hospital outpatient clinics, and health departments; · experiences, attitudes, and beliefs among women that make them disinclined to seek prenatal care; · transportation and child care services that are poor or absent; and · inadequate systems to recruit hard-to-reach women into care.
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From page 154... ...
Many of them stress decreases in Medicaid eligibility. Some descr ibe declines in private insurance coverage because of unemployment; others note increasingly restr ictive eligibility or increased cost-sharing requirements in health department clinics and Community Health Centers.
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From page 155... ...
Medicaid mothers living in Missouri had a 75 percent greater low birthweight rate than the state's overall low birthweight rate.20 While these data may not be generalizable to other states, they do highlight the high-risk characteristics of many Medicaid-eligible women. Another body of data indicates the cost-effectiveness of Medicaid maternity benefits.
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From page 156... ...
And because participation in prenatal care is associated with improved birthweight, efforts to expand and strengthen the Medicaid program should be part of a comprehensive program to reduce the nation's incidence of low birthweight. Decreasing the participation of pregnant women in the Medicaid program by such means as changing welfare or Medicaid eligibility criteria serves only to undermine the purpose of the program and, among other things, threatens appropriate use of prenatal care and increases costs for low birthweight infant care.
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From page 157... ...
Pregnant women enrolled in the program often are at elevated risk of a poor pregnancy outcome, including low birthweight, and may need more frequent prenatal visits and care of a more specialized, intense nature than low-risk women. To reflect the hiqh-risk status of many Medicaid-eliaible pregnant women, the number of prenatal visits a Med~caid-eligible woman may have, and reimbursement rates should reflect the fact that such women of ten need more services and more specialized care than lower isk women.
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From page 158... ...
is managed nurse midwives, nurse practitioners, and public health Nonetheless, in this section only two of the provider groups are discussed: obstetrician- gynecologists, who offer the ma jor ity of prenatal services, and a combined group consisting of certified nurse-midwives and obstetr ical nurse practitioners, because they often care for socioeconomically disadvantaged women who are at elevated risk of low birthweight. many of which involved a substantial amount of by nurses.
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From page 159... ...
Finally, in some states, the entire Medicaid fee goes to the health professional attending the delivery, whether or not that individual provided the ma jor Sty of the prenatal care. Thus, the incentives are directed more toward managing the deliver ies of Medicaid-eligible women than toward their prenatal care.2 ~ Consistent with such findings, Mitchell and Schurman reported that factors that appeared to increase physician participation in Medicaid included higher Medicaid fees, more efficient processing of Medicaid claims, and fewer benefit restrictions, such as pr for author ization and service limitations e In short, one reason that prenatal care is not fully accessible to poor populations is the relative lack of pr ivate obstetr ical services for women relying on Medicaid.
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From page 160... ...
In Norway, almost 96 percent of pregnant women receive prenatal care and delivery services from midwives; in England, 70 percent do.30 Nurse practitioners (NPS) , quite similar in most respects to nurse-midwives, do not manage intrapartum and immediate postpartum care; their training places greater emphasis on gynecology, but they also provide substantial amounts of prenatal care.
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From page 161... ...
The discontinuation of the program after 3 years was associated with a reversal of these trends, even though more physicians had by then moved into the area, thereby alleviating the earlier deficit in care prov~ders.35 With specific regard to low birthweight, Piechnik and Corbett found a signif icantly lower incidence of low birthweight among the infants of pregnant ados escents cared for by a multidisciplinary team (medicine, nurse-midwi fery, nutrition, social work, and nursing, with CAMS managing the case load and seeing each patient at every prenatal visit) , than among a matched control group who received prenatal care through state-supported maternal and child care clinics.
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From page 162... ...
Other sections of this chapter and portions of Chapters 6 and 8 discuss the significance of such expanded prenatal services for low birthweight prevention. Unfortunately, information is lacking on the extent of prenatal services in such settings.
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From page 163... ...
But it should not be assumed that in all instances, greater reliance on health departments will be the preferred way to fill gaps in services. In some communities, additional support of Community Health Centers, Maternity and Infant Care Projects, hospital outpatient departments, or related settings may be a better way to provide an adequate network of prenatal services.
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From page 164... ...
In particular, a perceived lack of "caring" in prenatal care, especially as provided to poor and socially disadvantaged women, may be an important cause of late registration, poor continuation In care, unsuccessful communication with providers, and, consequently, heightened risk for a poor pregnancy outcome. This.has been confirmed by numerous studies of reasons given for not seeking prenatal care, including those of Her zog and Bernstein,40 the Perinatal Association of Mich~gan,4~ and Chao et al.
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From page 165... ...
A personal, caring environment has been a key ingredient of several prenatal care programs designed specifically to reduce low birthweight and infant mortality In high-risk groups, especially teenagers.4 9 Although programs differ, some common elements of a scaring environments can be def ined and should be incorporated into prenatal services to make them more accessible, particularly for socioeconomically disadvantaged women: . · respect for patients -- their questions, their problems, and their time; conveyance of the expectation that they can, with support and education, assume increasing responsibility for their own health and that of their babies; · accessibility -- institution of a system by which patients can always reach a provider who is known to them and who will respond to their concerns; this involves an increased capacity for telephone consultation;
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From page 166... ...
For the poor, distance appears to be a significant deterrent to seeking preventive care.s° Where health care services exist but are difficult or impossible to reach because people lack adequate transportation, transportation services are a necessary component of care. Further, many women who would seek prenatal services have difficulty in arranging babysitting for other children at home and may put off getting care except in acute or emergency situations.
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From page 167... ...
Both costs and effectiveness should be considered. Outreach Through Program Links Bringing hard-to-reach women into care also can be accomplished by forging strong referral relationships between prenatal services and other programs that are in touch with potential clients.
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From page 168... ...
The federal government has long been on record as supporting prenatal care and urging that all women secure such care early in pregnancy. ThiS support must be accompanied by specific actions: · providing funds to state and local agencies in amounts sufficient to remove financial barriers to prenatal care (through channels such as the Maternal and Child Health Services Block Grants, Medicaid, health departments, Community Health Centers, and related systems )
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From page 169... ...
Th is would involve the state in: · assessing unmet needs -- e.g., surveying existing prenatal services and identifying the localities and populations that have inadequate prenatal services; · serving as a broker to contract with private providers to fill gaps In services; and · in some instances, providing prenatal services directly through facilities such as Community Health Centers and health department clinics. In addition, the committee suggests that In each community a single organization be designated by the state as the "residual guarantor" of prenatal services.
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From page 170... ...
Lack of sufficient and timely data hamper efforts to emeOnitOr maternal and child health on a population basis and, in particular, to assess the impact of public programs such as Medicaid and various private initiatives on specific health outcomes. Efforts such as the Child Health Outcomes Project of the University of North Carolina are important in addressing this concern and in helping to increase available data.
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From page 171... ...
They also may threaten the roles traditionally played by health departments, nurse-midwives, Community Health Centers, and hospital outpatient departments. Thus, where such changes in the delivery of care are introduced, the committee urges that adequate resources be made available to monitor the access to and adequacy of care, particularly prenatal care, provided under the new arrangements.
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From page 172... ...
11. Lazarus W: Right From the Start: Improving Health Care for Ohio' s Pregnant Women and Their Children.
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From page 173... ...
28. Committee to Study the Prevention of Low Birthweight: The role of Medicaid in deliver sing prenatal care to low income women.
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From page 174... ...
Government Printing Off ice, 1981. Feldman PH and Mosher BA: Preserving Essential Services: Effects of the MCH Block Grant on Five Inner City Boston Neighborhood Health Centers.
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