Prenatal Care Reaching Mothers, Reaching Infants (1988) / Chapter Skim
Currently Skimming:
2. Barriers to the Use of Prenatal Care
2. Barriers to the Use of Prenatal Care
Pages 54-87
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From page 54... ...
Four categories of obstacles are discussed: 1. a set of financial barriers ranging from problems in private insurance and Medicaid to the complete absence of health insurance; 2.
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From page 55... ...
gaps in private insurance coverage for maternity services; (2) the role of Medicaid in helping some, but not all, poor women secure prenatal care; and (3)
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From page 56... ...
As a result, many more private plans now include maternity coverage. In 1977, only 57 percent of employees with new health insurance policies had maternity care benefits, but by 1982 the number had increased to 89 percents Many women do not have access to employer-based group coverage because they or their spouses are unemployed or work for employers who do not offer health benefits.
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From page 57... ...
The Pregnancy Discrimination Act of 1978, which mandates that private insurance plans provide coverage of routine maternity care, does not apply to employers of fewer than IS persons, and not at} states have enacted remedial legislation of their own to close this gap. Furthermore, such state laws, where applicable, do not apply to employers who self-fund their insurance coverage.
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From page 58... ...
and 1980 show significant improvements in the use of prenatal care shortly after Medicaid was enacted and 11 years later, as evidenced by increases in the proportion of pregnant women seeking care in the first trimester (Table 1.11~. Since 1980 there has been little improvement, as discussed in Chapter 1.
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From page 59... ...
Second, Medicaid-insured women rely more heavily on clinics for prenatal care than do women with private insurance, and in many communities these clinics are overburdened and unable to schedule appointments promptly.20 Also, the number of physicians accepting Medicaid-enrolled pregnant women has always been limited and in some areas it is decreasing. (These issues of system capacity are taken up later in
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From page 60... ...
Given these attributes of the Medicaid population, health insurance alone is unlikely to close the gap between their use of health services and that of more affluent women with private coverage.
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From page 61... ...
For example, a 1986 survey of 517 births in Rhode Island found that 84 percent of women with private insurance, 70 percent of uninsured women, and 57 percent of Medicaid-insured women obtained adequate prenatal care.2i By contrast, a General Accounting Office (GAO) study of 1,157 pregnancies found that both Medicaid-enrolled and privately insured women began care earlier in pregnancy and saw a provider more frequently than did women with no insurance.22 Hadley examined the use of prenatal care by pooling data from the 1978, 1980, and 1982 Health Interview Surveys.
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From page 62... ...
The 1987 law permits states to expand eligibility even further for poor children (up to age 1) and for pregnant women with incomes up to 185 percent of the federal poverty level.
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From page 63... ...
Although expansions of Medicaid will help finance care for some portion of uninsured women, the problem of absent health insurance has outstripped the remedial steps taken thus far. To sum up, three major themes emerge from the extensive data on the relationship between use of prenatal care and the availability of private insurance, Medicaid, or no insurance.
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From page 64... ...
These settings include hospital outpatient departments, Community Health Centers and Migrant Health Centers, public health departments, Maternity and Infant Care projects, and school-based prenatal services. Several national surveys confirm that these settings are important sources of care for poor women and for young, unmarried, black, or Hispanic women the same groups at risk for inadequate use of prenatal care.
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From page 65... ...
Finally, some data indicate that pregnant women in these settings begin prenatal care earlier and receive more visits than comparable groups of pregnant women using other systems of care.35 Several data sources suggest that there is a growing demand for prenatal services in clinics a picture consistent with the increasing number of women of reproductive age without adequate private health insurance and the decreasing number of private providers caring for Medicaid-enrolled and other low-income women (see below)
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From page 66... ...
Maternity Care Providers Capacity also hinges on the distribution and practice patterns of providers. Obviously, maldistribution of physicians can affect a woman's ability to secure adequate, timely prenatal care.
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From page 67... ...
have fewer than four obstetricians per 100,000, and 38 of the 577 areas have no obstetrician at all.47 Even in communities with an adequate supply of providers, poor and uninsured pregnant women may not have access to care unless providers are willing to accept their form of payment. Large numbers of obstetricians in particular do not accept Medicaid as payment, and many more will not take patients who are uninsured.
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From page 68... ...
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. Indeed, the case could be made that, because many pregnant women enrolled in Medicaid are at high risk, reimbursement for their care should be greater than average fees.
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From page 69... ...
communities, particularly those with poorer populations and no teaching or public facilities, obstetrical care may be disappearing entirely. A closely related effect of the malpractice situation is that publicly financed clinics and health centers are finding it more difficult to obtain liability insurance and to find providers willing to serve in the clinics, thus contributing further to the reduced availability of subsidized maternity care for poor and uninsured women.
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From page 70... ...
Moreover, the programs may rely on different providers. In some states, public health clinics and CHCs are not certified as Medicaid providers, thereby limiting the choices available to pregnant women enrolled in Medicaid.
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From page 71... ...
Numerous studies have documented greater use of prenatal care among women who regularly use a health care facility than among those who, for example, rely on emergency rooms for episodic care or have no regular health care provider.68 Such studies suggest that women who have only a marginal connection to the health care system are not likely to establish one during pregnancy. Medicaid Application Procedures As described earlier, the Medicaid program is the major source of payment for care obtained by poor pregnant women, yet actual enrollment rates among eligible women are low and vary across states.
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. Investigators from the Alan Guttmacher Institute found, for example, that applications run from 4 to 40 pages long, the average length being 14.
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From page 73... ...
Moreover, if the actual Medicaid card is not sent with the letter notifying a woman she has been found eligible, additional delays in obtaining prenatal care may occur, because some health care providers are reluctant to accept the letter as evidence of enrollment. A recent provision in federal Medicaid law permits states to authorize certain health care providers to make preliminary determinations of Medicaid eligibility for pregnant women and to be reimbursed for providing services to them for 45 days or until eligibility is actually determined so-called presumptive eligibility.
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From page 74... ...
Studies that ask women about reasons for delayed or no prenatal care confirm that responsibility for other children can interfere with keeping appointments.79 Accessibility problems created by long distances to care, inadequate transportation, and lack of child care are compounded by limited clinic hours. Most prenatal services are offered during "normal" working hours (that is, weekdays from, 9:00 a.m.
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From page 75... ...
Though designed to provide prenatal care only to women whose pregnancies have progressed beyond the first few weeks when miscarriage often occurs, this policy obviously causes delays in onset of care for the majority of pregnant women who do not miscarry. Use of care can also be influenced by the attitudes and styles of providers, including poor communication about procedures, failure to answer questions, seeing a different provider at each visit, and hurried or otherwise depersonalized care.
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From page 76... ...
A study of several New York City prenatal clinics noted that there are usually too few chairs in the waiting rooms, leaving patients to stand in corridors.89 Finally, lack of easily available, widely disseminated information about where exactly to go for prenatal services can be an obstacle to care. Studies report that 5 to 18 percent of patients who had obtained little or no care did not know where to seek services.9~92 Given the relatively poor accessibility of clinic telephone numbers, it is not surprising that this barrier can be significant.
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From page 77... ...
Previous, unsatisfying experiences with prenatal services may also act as a deterrent. The provider practices and clinic policies outlined above no doubt leave some women with a negative view of prenatal care, reluctant to seek it out in subsequent pregnancies.
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From page 78... ...
Among some cultures, pregnancy is regarded as a healthy condition not requiring medical treatment or a physician's advice.~02 Furthermore, the perception of what constitutes a health problem may vary between patient and provider. In one study, for example, low-income, primarily black women characterized high-risk behavior as not taking prenatal vitamins and catching the flu, but having more than five children or a previous low birthweight infant were not viewed as conditions constituting risk.~03 Fear as a barrier deserves special comment.
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From page 79... ...
A CHC pediatrician in Los Angeles County reported that the fear generated by the proposal led to an immediate decrease of SO percent in the number of children attending his clinic.~° Pregnant women who are aware that their life-styles place their health and that of their babies at risk may also fear seeking care because they anticipate sanction or pressure to change such habits as drug and alcohol abuse, heavy smoking, and eating disorders. Substance abusers in particular may delay care because of the stress and disorganization that often surround their lives, and because they fear that if their use of drugs is uncovered, they will be arrested and their other children taken into custody.
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From page 80... ...
For some women, the pressures of daily life are such that prenatal services are of low priority. A study of more than 2,000 women in Massachusetts found that women with inadequate care were significantly more likely than women with adequate care to report being very worried or upset during the pregnancy due to lack of money, problems with the baby's father, housing difficulties, lack of emotional support, and related burdens.~9 Such factors as depression and, in particular, denial have also been associated with poor use of prenatal care.
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From page 81... ...
Absence of either Medicaid or private insurance coverage of maternity services Inadequate or no maternity care providers for Medicaid-enrolled, uninsured, and other low-income women (long wait to get appointment) Inadequate transportation services, long travel time to service sites, or both Difficulty obtaining child care Poor coordination between pregnancy testing and prenatal services Inadequate coordination among such services as WIC and prenatal care Complicated, time-consuming process to enroll in Medicaid Availability of Medicaid poorly advertised Inconvenient clinic hours, especially for working women Long waits to see physician II.
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cit. Also published by the Alan Guttmacher Institute as a companion volume is The Financing of Maternity Care in the United States.
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Hughes DC, end Johnson D Maternal and child health services for medically indigent children and pregnant women.
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Provider participation in public programs for pregnant women and children. Washington, D.C.: National Governor's Association, 1988, p.
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Pregnant Women and Newborn Infants in California: A Deepening Crisis in Health Care. Summary of Hearings held March-April, 1981.
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From page 86... ...
Ethical issues in the delivery of quality care to pregnant women. In New Approaches to Human Reproduction, Social and Ethical Dimensions, Whiteford L and Poland ML, eds.
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From page 87... ...
Use of prenatal services by women of Mexican origin and descent in Los Angeles. Los Angeles: University of California at Los Angeles, 1985.
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