- Shopping Bag ( 0 items )
Reaching Mothers, Reaching Infants
Copyright © 1988 National Academy of Sciences
All right reserved.
In 1985, 76.2 percent of all U.S. infants were horn to women who began prenatal care in the first trimester of pregnancy, 18.1 percent to women who delayed care until the second trimester, 4.0 percent to women who obtained care only in the third trimester, and 1.7 percent to mothers who had no prenatal care at all. When vital statistics are analyzed to determine rates of adequate care rather than trimester of onset, a slightly different picture emerges. In 1985, only 68.2 percent of all women obtained adequate prenatal care, 23.9 percent had an intermediate level of care, and 7.9 percent of all pregnant women had inadequate care.
Trends in the use of prenatal care from 1969 to 1980 show steady improvement in the percentage of births to mothers obtaining prenatal care in the first trimester of pregnancy. Since 1980, however, this percentage has remained stable or decreased. Among black women, declines in early use of prenatal care were registered in 1981, 1982, and 1985.
More troubling is that since 1980, there has been an increase in the percentage of births to women with late or no prenatal care. Although this trend applies to all races, the increase is more pronounced among black women. In 1981, 8.8percent of births to black women were in this category; by 1985, 10.3 percent were.
These trends present important challenges to public policy and to the health care system for several reasons. First, there is widespread agreement that prenatal care is an effective intervention, strongly and clearly associated with improved pregnancy outcomes; moreover, available evidence suggests that prenatal care is especially important for women at increased medical or social risk, or both. Second, prenatal care is cost-effective. In a 1985 report, for example, the Institute of Medicine calculated that each dollar spent on providing more adequate prenatal care to low-income, poorly educated women could reduce total expenditures for direct medical care of their low birthweight infants by $3.38 during the first year of life; the savings would result from a reduced rate of low birthweight. Finally, the importance of prenatal care is confirmed by international comparisons. Many other countries (particularly Japan and most Western European countries) provide prenatal care to pregnant women as a form of social investment, with minimal barriers or preconditions in place. As a consequence, very high proportions of women in these countries begin prenatal care early in pregnancy.
Faced with evidence of prenatal care's value and cost-effectiveness, and with data revealing poor and declining use of this key service, in the summer of 1986 the Institute of Medicine convened an interdisciplinary committee, the Committee to Study Outreach for Prenatal Care, to study ways of drawing more women into prenatal care early in pregnancy and of sustaining their participation until delivery. The Committee was asked to focus particularly on outreach as a means for increasing the use of prenatal services. In keeping with conventional understanding, outreach was defined in the study to include various ways of identifying pregnant women and linking them to prenatal care (casefinding) and services helping them remain in care once enrolled (social support).
The Committee's work, however, and the resulting report were not confined to outreach. It became evident early in the study that this service cannot be studied in isolation from the larger maternity care system within which it occurs and that, as a result, the study had to embrace aspects of the surrounding environment. The Committee's conclusions and recommendations are not limited to outreach, therefore, but also touch on issues of maternity care financing and organization. The report's major sections cover demographic risk factors, barriers to the use of prenatal care, women's perceptions of barriers to care, providers' opinions about the factors that account for delayed care, multivariate analysis of predictors of prenatal care use, and lessons learned from a variety of programs that attempt to improve utilization of this basic health service.
DEMOGRAPHIC RISK FACTORS
Several demographic risk factors are closely associated with insufficient prenatal care:
Among white women giving birth in 1985, 79.4 percent began care in the first trimester of pregnancy and 4.7 percent received late or no care. Black women were far less likely than white women to begin care early (61.8 percent) and twice as likely to receive late or no care (10.1 percent versus 4.7 percent). Hispanic mothers are substantially less likely than non-Hispanic white mothers to begin prenatal care early and are three times as likely to obtain late or no care. Moreover, Hispanic mothers as a group are more likely than non-Hispanic black mothers to begin care late or not at all. American Indian women are more likely than either white or black women to obtain late or no care.
Young mothers are at high risk of obtaining late or no prenatal care, with the greatest risk for the youngest mothers, those under 15. Mothers age 40 and over are less likely than mothers age 25 to 39 to begin care in the first trimester and more likely to obtain care late or not at all.
Timing of the first prenatal visit correlates highly with educational attainment. In 1985, 88 percent of mothers with at least some college education began care early in pregnancy, compared with 58 percent of mothers who had less than a high school education. The probability that a pregnant woman will obtain care late or not at all decreases steadily as her educational level increases.
The more children a woman has had, the more likely she is to obtain insufficient care or none at all. In 1985, nearly 5 percent of both first and second children were born to mothers who obtained late or no care. About 6 percent of third births fell into this category, however, and the numbers increased to 9 and 14 percent for fourth and fifth children, respectively.
Unmarried mothers are more than three times as likely as married mothers to obtain late or no prenatal care (13.0 and 3.4 percent, respectively, in 1985). Unmarried white mothers are almost four times as likely as married white mothers to obtain late or no care; and unmarried black mothers are twice as likely as married black mothers to obtain late or no care. Among unmarried mothers, women of Hispanic origin are most likely to obtain late or no care, followed by white non-Hispanic and then black non-Hispanic mothers. The correlation of unmarried status with insufficient prenatal care has become more salient in recent years as childbearing among unmarried women has increased, reaching an all-time high of 828,000 births (about 22 percent of all births) in 1985.
Poverty is one of the most important correlates of insufficient prenatal care. Women below the federal poverty level consistently show higher rates of late or no care and lower rates of early care than women with larger incomes. Given that one-third of all U.S. births are to women with incomes less than 150 percent of the federal poverty level, the consistent correlation of low income with insufficient prenatal care is of major importance and forms the basis of many Committee recommendations.
Insufficient prenatal care is concentrated in certain geographic areas, most often inner cities and isolated rural areas. States vary in their rates of early and late entry into care, and great diversity in use of prenatal care can exist within states, counties, cities and even neighborhoods.
BARRIERS TO THE USE OF PRENATAL CARE
Four categories of obstacles to full participation in prenatal care can be described: (1) a set of financial barriers ranging from problems in private insurance and Medicaid to the complete absence of health insurance; (2) inadequate capacity in the prenatal care systems relied on by many low-income women; (3) problems in the organization, practices, and atmosphere of prenatal services themselves; and (4) cultural and personal factors that can limit use of care.
Women with private health insurance are more likely to obtain adequate prenatal care than uninsured or Medicaid-enrolled women, but many women do not have access to employer-based group coverage (the most common means of obtaining private insurance). Even when such coverage is available, the cost to the employee may be too high to enroll or coverage may not include maternity care or require substantial cost sharing.
The Medicaid program is the largest single source of health care financing for the poor and is believed to be primarily responsible for the increased use of medical services by low-income individuals since its enactment in 1965. Natality data from 1969 (shortly after Medicaid was enacted) and 1980 show significant increases in the proportion of pregnant women seeking care in the first trimester. Medicaid has been particularly important in increasing minority access to prenatal care.
Despite such favorable trends, data also show that women covered by Medicaid do not obtain prenatal care as early in pregnancy or make as many visits to providers as women with private insurance. At least three reasons have been offered for this differential. The Medicaid enrollment process is so time-consuming that a woman may be well into her pregnancy before her eligibility is established. Second, Medicaid-insured women rely more heavily on clinics for prenatal care, and these clinics are often overburdened and unable to schedule appointments promptly; similarly, the number of physicians accepting Medicaid-enrolled pregnant women has always been limited and in some areas is decreasing. Finally, women on Medicaid are characterized by numerous demographic factors associated with insufficient prenatal care, including being unmarried, having less education, being under 20, and being in fair or poor health. 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.
A substantial proportion of the poor is not covered by Medicaid. In fact, in 1988, the average income eligibility ceiling for Medicaid was only 49 percent of the federal poverty level. In addition, the proportion of the poor covered by Medicaid has decreased: it is estimated that in 1976, 65 percent of the poor were covered by Medicaid; in 1984, the comparable figure was 38 percent. Congress has expanded Medicaid eligibility for pregnant women through numerous laws passed in the mid-1980s. One of the most important reforms in these laws severs the link between Medicaid and AFDC (that is, Aid to Families with Dependent Children-welfare). Thus, some women may now become eligible for Medicaid even if they are not eligible for AFDC, and states have the opportunity to increase Medicaid eligibility for targeted subgroups, and to receive federal matching funds, without increasing AFDC program costs.
Between the group covered by private insurance and the group enrolled in Medicaid are the uninsured. By the mid-1980s, more than 37 million Americans were completely uninsured, and women of childbearing age are disproportionately represented among them. An estimated 26 percent of women of reproductive age (14.6 million) have no insurance to cover maternity care, and two-thirds of these (9.5 million) have no health insurance at all. Of poor women, 35 percent are completely uninsured.
Women with no insurance face significant obstacles to obtaining prenatal services and must rely on free or reduced-cost care from willing private physicians or from health department clinics and other settings usually financed by public funds. Unfortunately, the proportion of women age 15 to 44 who are uninsured is likely to grow.
Inadequate System Capacity
Numerous reports document inadequate numbers of, and long waiting times for appointments at, such facilities as Community Health Centers and health department clinics-settings that have traditionally provided prenatal care to those unable or unwilling to use the private care system. Similarly, there appears to be 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. Adequate or even excess capacity can exist for affluent women in the same geographic area as inadequate capacity for low-income women.
Limited availability of maternity care providers is a major contributor to the capacity problem. Many areas of the country have few or no obstetricians in practice. Large numbers of obstetricians will not take patients who are uninsured, and many do not accept Medicaid clients. An important reason for this disinclination is that Medicaid reimbursement rates are often very low and represent only a fraction of cost or of privately reimbursed fees. The increase in malpractice insurance premiums and a growing concern about the risk of malpractice litigation are also associated with the increasing number of providers who have discontinued or appreciably reduced their obstetrical practice. In some communities, particularly those with poorer populations and no teaching or public facilities, obstetrical care may be disappearing entirely.
Organization, Practices, and Atmosphere of Prenatal Services
Use of prenatal care can also be limited by the way services are organized and provided at the delivery site. Common barriers include inadequate coordination of services (such as poor links among health department clinics, private physicians, and such other service systems as welfare and housing); problems in securing Medicaid (the application and enrollment process can often be time-consuming and difficult, and eligible women may know little about the program or how and where to apply); and a host of classic access barriers well known to limit use of not only prenatal care but also health services generally (including transportation problems, difficulties in arranging child care, service hours that do not accommodate the schedules of women who work or go to school, long waits in clinics, communication problems between providers and clients, language and cultural barriers, unpleasant surroundings, and lack of easily accessible information about where to go for prenatal care).
Cultural and Personal Barriers
Use of prenatal care can be limited by a woman's attitudes toward her pregnancy and toward prenatal care, her cultural values and beliefs, a variety of other personal characteristics often called life-style, and certain psychological attributes. Attitudes toward pregnancy that may influence efforts to seek prenatal care include whether the pregnancy is planned or unplanned and whether the woman views her pregnancy positively or negatively. These are particularly important issues because more than half of all pregnancies in the United States are unplanned. In addition, not all women believe that prenatal care is important and worth the effort to seek it out. Some believe that care is needed only if a pregnant woman feels ill; among some cultures, pregnancy is regarded as a healthy condition not requiring medical treatment or advice from a health care provider. A few women may actually be unaware of what prenatal care is or what the signs of pregnancy are. Previous, unsatisfying experiences with prenatal services may also act as a deterrent.
Excerpted from PRENATAL CARE Copyright © 1988 by National Academy of Sciences. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.