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OCR for page 21
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
OCR for page 23
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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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
Representative terms from entire chapter:
pregnant women
