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21 ENSURING ACCESS TO PRENATAL CARE Efforts to reduce the nation's incidence of low birthweight must include a commitment to enrolling all pregnant women in prenatal services early in pregnancy. Ironically, many of the women who now receive inadequate prenatal care are those who would benefit the most from such services- those at greater than average risk of a low birthweight delivery. In addition, recent evidence suggests that the trend throughout the 1970s toward im- proved use of prenatal services, particularly by high-risk women, may have come to a halt. National, state, and local data indicate that the proportion of mothers beginning prenatal care in the first trimester of pregnancy increased steaclily from 1970 to 1980, but that this trend has levelled off or possibly reversed since 1981. The committee views with deep concern the possibility that the nation's progress in extending prenatal benefits to all women has been ctisrupted. The committee believes that full access to prenatal care will require a fundamental assumption of responsibility by the public sector for making such services available. Federal leadership will be critical to achieving this policy goal, but states also must attach high priority to prenatal care. At both levels, full support of the private sector and a greater commitment of public funds will be required. Defining the Problem If prenatal care is to become available to all pregnant women, the popula- tion of women receiving inadequate or no prenatal care must be defined, circumstances analyzed to reveal why these women receive insufficient care, and then ways founc! to remove the barriers. After reviewing numerous studies, the committee concluded that the major barriers to early receipt of prenatal care fall into the following six categories: financial constraints such as inadequate insurance or lack of Meclicaid funds to purchase care; limited 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 dis- inclined to seek prenatal care; poor or absent transportation and child care services; and inadequate systems to recruit hard-to-reach women into care. Financial Constraints Numerous studies have shown that the availability of funds to cover the costs of prenatal care influences women's decisions about seeking such services. Efforts to eliminate financial barriers can take many forms, includ ing making private health insurance more affordable for those without coverage who do not qualify for Medicaid, increasing support for public

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22 agencies that serve socioeconomically disadvantaged groups, and improv- ing Medicaid coverage of prenatal care. The committee chose to focus on the Medicaid program, the largest public program financing prenatal care. Medicaid Coverage The Medicaid program is a crucial element in reducing the occurrence of low birthweight, partly because of its capacity to reduce financial barriers to care generally and thereby to increase the proportion of low-income women seeking prenatal care. The program is also of great significance because of the characteristics of Medicaid recipients themselves. Medicaid-eligible pregnant women are typically poor and single and often have other risk factors as well, such as low weight for height and short intervals between pregnancies. Medicaid prenatal benefits have also been shown in a few studies to be cost-effective. For example, in California, extending an improved set of Medicaid prenatal benefits to selected low-income women between 1979 and 1982 was found to be cost-effective because it was associated with savings in the costs of caring for low-weight infants.16 Support of the Medicaid program should be part of a comprehensive effort to reduce the nation's incidence of low birthweight. Changes in the program, a topic of considerable controversy in both Congress and state governments, should be dedicated to enrolling more eligible women in the program and to providing them with early and regular, high-quality prenatal care. The Health Care Financing Administration (HCFA), in collaboration with the Division of Maternal and Child Health (DMCH), should establish a set of generous eligibility standards that maximize the possibility that poor women will qualify for Medicaid coverage and thus be able to obtain prenatal care. All Medicaid programs should be required to use such standards. In particu- lar, eligibility standards should provide Medicaid coverage for pregnant, indigent women, regardless of their family composition or the employment status of the chief breadwinner in the family unit. Further, Medicaid policies and reimbursement rates should reflect the high-risk nature of the Medicaid-eligible population. Program policies should not set a limit on the number of prenatal visits, because these women may require more frequent visits and more specialized care than Tow-risk women. DMCH should develop a model of prenatal care for use in publicly financed facilities; the model should be adopted by all Medicaid programs and be used to help structure reimubrsement policies. HCFA and appropri- ate state agencies should monitor adherence to this standard of care. Maternity Care Providers Assessing whether there are enough prenatal care providers is a compli- cated task, in part because several different groups are involved. Although obstetrician/gynecologists perform the majority of deliveries, family physi- `-i~n~ ~n`1 ~n~r~1 nr~rtition~r~ perform almost 20 percent, and about 2 percent are managect by cert~ect nurse-m~aw~ves. Moreover, a substantial amount of prenatal care (as distinct from deliveries) is provided by nurse- midwives' nurse practitioners, and public health nurses. The committee limited its investigation to two provider groups: obstetrician/gynecologists, because they offer the majority of maternity services, and a combined group . . . . --by o ~- rip r . . .. a. . . . . ) J

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23 consisting of certifier! nurse- midwives and obstetrical nurse practitioners, because they often care for so- cioeconomically clisad- vantaged women who are at elevated risk of low birth- weight. Obs te tricia n/Gyneco logis is The number of private physi- cians providing prenatal care is inadequate in many parts of the country; of equal con . .. ,. ~ . .. . .. MARCH OF DIMES BIRTH DEFECTS FOUNDATION cern Is the toning that the participation rate of obstetrician/gynecologists in Medicaid is relatively low and may be decreasing. This limits the number of private practitioners available to care for high-risk, low-income women. To overcome this problem, the committee recommends that HCFA de- velop a series of demonstration/evaluation projects aimed at increasing the participation of obstetrician/gynecologists in Medicaicl. Approaches should include reducing delays in reimbursement, increasing reimbursement rates, and increasing the number of prenatal visits reimbursed by MecTicaid. The results of these projects should be vigorously disseminated to policy leaders. To the extent that provider attitudes are found to impede Medicaid partici- pation, local and national professional societies, including the American College of Obstetricians and Gynecologists, should undertake appropriate education to urge members to increase their Medicaid patient loads. Nurse-Midwives and Obstetrical Nurse Practitioners Certified nurse- midwives and obstetrical nurse practitioners have been shown to be particu- larly effective in managing the care of pregnant women who are at high risk of Tow birthweight because of social and economic factors. These health care providers tend to relate to their patients in a nonauthoritarian manner and to emphasize education, support, and patient satisfaction. For example, sever- al studies have shown that women served) by nurse-midwives are more likely to keep appointments for prenatal care and to follow specified treatment regimens. 17 The committee recommends that more reliance be placed on nurse- midwives and nurse practitioners to increase access to prenatal care for hard-to-reach, often high-risk groups. Maternity programs designed to serve high-risk mothers should increase their use of these providers; and state laws should be supportive of nurse-midwifery practice and of collaborations between physicians and nurse-midwives/nurse practitioners. Insufficient Prenatal Care Services Closely related to the issue of financial barriers and poor provider availabil- ity is the evidence that in some communities there is an inadequate number of organized facilities, particularly publicly financed ones, providing prena- tal care to pregnant women who are unable or unwilling to use the private care system. Often these are women who traditionally have relied for care on

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24 facilities such as Community Health Centers, Maternity and Infant Care Projects, hospital outpatient departments, and health departments. The importance of such facilities derives not only from their capacity to provide prenatal care to groups often outside of the private practice system, but also from the fact that there are populations that may be better served by public facilities offering a range of services than by physicians in private practice, who traditionally provide only medical care. The poor and the very young, as well as those not yet part of the mainstream culture, such as recent immigrants, may benefit especially from the outreach activities, social work, and nutritional counseling often provided in such settings. The committee emphasizes the important function of these organized facilities, especially local health departments, in the effort to increase access to prenatal care. Health departments are singled out for cletailed discussion in the main report because virtually every person in the United States lives in an area that is served by one, and because they are known to be active providers of prenatal care. in fact, national and state data indicate that reliance on health departments for maternity care has increased in the 1980s. To acIdress the unmet needs for prenatal care, health departments should be given increased resources. Every community is different, however, and in some it may be more appropriate to provide additional support to Communi- ty Health Centers, Maternity and infant Care Projects, hospital outpatient departments, or related settings. Women's Experiences, Attitudes, and Beliefs Access to prenatal care also is affected by a pregnant woman's perceptions of whether care is useful, supportive, and pleasant; by her general knowI- edge about prenatal care; and by her cultural values and beliefs. Some women may fait to seek prenatal care early because they lack information about the symptoms of pregnancy, the facilities that could assist them, or the importance of early care in averting the complications of pregnancy. Other women may resist seeking prenatal care because of a language barrier, because of cultural beliefs that women should receive prenatal care only from other women, because of conflicts over the life-st,vIe changes required to maintain a healthy pregnancy (e. g., reducing smoking and heavy drinking), because of a desire to conceal the pregnancy, or because of previous unfortunate experiences with the health care system. Two major strategies exist to overcome these barriers: general education about prenatal care anc! the development of a personal, caring environment in which to offer prenatal services, especially for socioeconomically dis- advantaged women. The following attributes should be built into this environment: (~) respect for patients their questions, problems, and time; (2) accessibility, including easy availability of telephone consultations; (3) continuity of care in the patient-provider relationship; (4) small size or decentralization to avoid the feeling of a large, impersonal bureaucracy; (5) responsiveness to the concerns that are most salient to women in early pregnancy, such as first trimester nausea and recognition of the need for emotional support and acceptance; (6) flexibility in the definition of services encouraging providers to help women obtain nonmedical be- nefits; and (7) an unclerstanding of cultural barriers.

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25 Transportation and Child Care Provision of transportation and child care services should be viewed as an integral part of prenatal care for low-income populations. Distance and difficulty in arranging babysitting for other children can lead women to put off seeking care unless an emergency occurs. Increasing the Capacity for Outreach Sometimes health care programs must do more than provide an open door. They must take the initiative to find and educate women about the importance of care. Two strategies employed to accomplish this task involve the use of outreach personnel and the fording of ref~rr~1 r~:~tinnchir~c ~A,ith other service systems. ~o^-~o ~^ ~ ~ ~ ~^ ~ ~A ~ ~1~ Lath 1~71 ll}J~ VV 1 L1 I Outreach Personnel In the field of maternity services, outreach personnel generally perform one or more of the following tasks: identifying women requiring services and enrolling them in prenatal care, acting as an in- termecliary between these women and the provider system to ensure access to needed services, and establishing ties to other social services to address the nonmedical neecis of pregnant women. The committee believes that the use of outreach workers is an effective way to improve access to care for difficult-to-reach populations. More research is needed, however, on the comparative advantages of different case-finding approaches, the costs of different outreach systems and their effectiveness, anc! the types of person- ne! best suited to various program goals and target groups. Program Links Bringing hard-to-reach women into care also can be accom ~ . . . . . . p~snecl by forging strong referral relationships between prenatal services and other programs that are in touch with potential clients. The Special Supplemental Food Program for Women, Infants and Children (W]:C) is a good example of a program that can lead to increased use of prenatal care. WIC prenatal participants must document their pregnancy status, which can lead to entry into a prenatal care network. Also, WIC sites are often located in neighborhood or county health centers, adjacent to prenatal care clinics, and WIC personnel actively encourage prenatal care during nutritional counsel- ing. A System of Accountability The committee believes that although many different factors contribute to the problem of inadequate access to prenatal care, an underlying cause is the nation's patchwork, nonsystematic approach to making prenatal services available. Although numerous programs have been developed in the past to extend prenatal care to more women, no institution bears responsibility for ensuring that such services are available to those who need them. Without a structure of accountability, gaps in care will remain and efforts to expand prenatal services will continue to face major organizational and administra- tive difficulties. The committee recommends that federal and state govern- ments take specific actions to assume such responsibility.

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26 Government Actions The federal government has long been on record as supporting prenatal care. For example, the 1980 Public Health Service report Promoting Health/ Preventing Disease: Objectives for the Nation sets specific goals for reducing the number of women who receive inadequate prenatal care and for eliminating variations among groups in access to such services. ~ To meet or exceed these goals, the committee believes that the federal government should take the following specific actions: provide sufficient funds to state and local agencies to remove financial barriers to prenatal care (through channels such as the Maternal and Child Health Services Block Grants, Mecticaid, health departments, Community Health Centers, and related systems); provide prompt, high-quaTity technical consultation to the states on clinical, aclministrative, and organizational problems that can impede the extension of prenatal services; define a model of prenatal services for use in public facilities providing maternity care; and fund demonstration and evaluation programs and Hart training and research in these areas. -wry ~ States should take a complementary leadership role in extending prenatal services. This could be accomplished by designating one organization probably the state health department- as responsible for ensuring that prenatal services are available and accessible in every community. Through . . .. sucn an organization, each state should: and assess unmet needs for prenatal care; serve as a broker to contract with private providers to fill gaps in services; where necessary or preferable, provide prenatal services directly through facilities such as Community Health Centers and health department . . c 1nlcs. In addition, the state shouIcT designate a local organization in each commu- nity to be the "residual guarantor" of services to arrange for care for pregnant women who still remain outside of the prenatal care system. In many areas, the local health department would logically fill this role. System Development To begin the development of a functioning system of responsibility and accountability, the committee recommends that the Secretary of the Depart- ment of Health and Human Services convene a task force charged with defining a system for making prenatal services available to all pregnant women. Such a group must include representatives from Congress, the Public Health Services, HCFA, state governments and health authorities, maternity care providers, and consumers. This task force should focus on four specific issues: (1) how to bring together the knowledge and general goals of maternal and child health programs with the "financial power" of the Medicaid program; (2) what can