The Communicable Disease Impact of Eliminating Publicly Funded Prenatal Care for Undocumented Immigrants

Objectives: In 1996, California proposed regulations to eliminate publicly funded prenatal care for undocumented immigrants. Prenatal treatment of sexually transmitted infections (STIs) can prevent STI-related adverse outcomes of pregnancy (AOP). The study assessed the STI-related health and economic impact of the proposed regulations in Los Angeles County (LAC). Methods: We modeled excess STI-related AOPs and associated costs that would occur in LAC as if the regulations were implemented in 1995. Using attributable fractions in the exposed for five STIs and their associated AOPs, we calculated excess STI-related AOPs and their costs that would result from the regulations and the degree to which excess morbidity would offset gross savings. Results: The model indicates that, depending on regulatory level, 74, 110, or 132 excess AOPs would occur subsequent to the regulations, representing lost prevented morbidity. These excess AOPs would cost $5.1, $7.6, or $9.2 million dollars in direct medical expenses, offsetting anticipated savings by 19.2%, 29.0%, or 34.9%. This analysis does not include other costs of these STIs or costs associated with non-STI-related sequelae of diminished prenatal care, all of which could further offset anticipated savings. Conclusions: The proposed regulations would likely lead to increased STI-related morbidity and costs, thereby offsetting anticipated savings. Health departments are in a special position to promptly respond to policy issues affecting vulnerable populations. The development of a practical and rational framework for local-level policy assessment can be important for encouraging good scientific approaches that respond to calls for reductions in basic preventive health services.     

Risk Factors for Late or No Prenatal Care Following Medicaid Expansions in California

Objectives: To describe the characteristics and risk factors of women with only third-trimester (late) or no prenatal care. Methods: A statewide postpartum survey was conducted that included 6364 low-income women delivering in California hospitals in 1994 and 1995. Results: The following factors appeared most important, considering both prevalence and association with late or no care: poverty, being uninsured, multiparity, being unmarried, and unplanned pregnancy. Forty-two percent of women with no care were uninsured, and uninsured women were at dramatically increased risk of no care. Over 40% of uninsured women with no care had applied for Medi-Cal prenatally but did not receive it. Risks did not vary by ethnicity except that African American women were at lower risk of late care than women of European background. Child care problems were not significantly associated with either late or no care, and transportation problems (not asked of women with no care) were not significantly related to late care. Conclusions: Lack of insurance appeared to be a significant barrier for the 40% of women with no care who unsuccessfully applied for Medi-Cal prenatally, indicating a need to address barriers to Medi-Cal enrollment. However, lack of financial access is unlikely to completely explain the dramatic risks associated with being uninsured. In addition to eliminating barriers to prenatal coverage, policies to reduce late/no care should focus on pre-pregnancy factors (e.g., planned pregnancy and poverty reduction) rather than on logistical barriers during pregnancy.Dr. Nothnagle was a medical student at the University of California, San Francisco when most of the work for this study was done     

The Influence of Site of Care on the Content of Prenatal Care for Low-Income Women

Objective: To assess whether site of prenatal care influences the content of prenatal care for low-income women. Design: Bivariate and logistic analyses of prenatal care content for low-income women provided at five different types of care sites (private offices, HMOs, publicly funded clinics, hospital clinics, and other sites of care), controlling for sociodemographic, behavioral, and maternal health characteristics. Participants: A sample of 3405 low-income women selected from a nationally representative sample of 9953 women surveyed by the National Maternal and Infant Health Survey, who had singleton live births in 1988, had some prenatal care (PNC), Medicaid participation, or a family income less than $12,000/year. Outcome Measures: Maternal report of seven initial PNC procedures (individually and combined), six areas of PNC advice (individually and combined), and participation in the Women Infant Children (WIC) nutrition program. Results: The content of PNC provided for low-income women does not meet the recommendations of the U.S. Public Health Service, and varies by site of delivery. Low-income women in publicly funded clinics (health departments and community health centers) report receiving more total initial PNC procedures and total PNC advice and have greater participation in the WIC program than similar women receiving PNC in private offices. Conclusions: Publicly funded sites of care appear to provide more comprehensive prenatal care services than private office settings. Health care systems reforms which assume equality of care across all sites, or which limit services to restricted sites, may foster unequal access to comprehensive PNC.     

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995–2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.     

Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High-Value Model of Care

Policy Points

• Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients.
• Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks.
• Addressing the barriers identified in this study would promote birth centers’ participation in Medicaid, leading to better outcomes for Medicaid‐covered mothers and newborns and significant savings for the Medicaid program.

ContextMidwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth centers’ experiences participating in Medicaid, and identify policies that influence Medicaid beneficiaries’ access to midwives and birth centers.MethodsWe analyzed data from more than 200 key informant interviews and 40 focus groups conducted during four case study rounds; a phone‐based survey of Medicaid officials in Strong Start states; and an Internet‐based survey of birth center sites. We identified themes related to access to midwives and birth centers, focusing on influential Medicaid policies.FindingsMedicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, or in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid enrollees currently have less access to birth centers than privately insured women. Many birth centers have difficulty contracting with managed care organizations and participating in Medicaid value‐based delivery system reforms, and birth center reimbursement rates are sometimes too low to cover the actual cost of care. Some birth centers significantly limit Medicaid business because of low reimbursement rates and threats to facility sustainability.ConclusionsMedicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts. Medicaid policy barriers prevent some birth centers from serving more Medicaid patients, or threaten the financial sustainability of centers. By addressing these barriers, more Medicaid beneficiaries could access care that is associated with positive birth outcomes for mothers and newborns, and the Medicaid program could reap significant savings.     

Unplanned Pregnancy as a Major Determinant in Inadequate Use of Prenatal Care

Background.Previous reports have stressed the importance of social class and education in prenatal care use. Unplanned pregnancy as a determinant of prenatal care use has been insufficiently studied. The objective of this report was to assess whether unplanned pregnancy is an independent predictor of inadequate use of prenatal care.Methods.A 5% sample of women delivering at a hospital (409 women in the study population) was selected. Data on pregnancy were obtained by personal interview and from clinical charts. Prenatal care was considered inadequate according to the Kessner index. Relative risk (RR) and 95% confidence intervals (CI) were estimated. Stepwise logistic regression analysis was applied to select the independent predictors of inadequate prenatal care use.Results.Prenatal care use was inadequate among 16.4% of the women. Pregnancy was unplanned among 42.8% of the women. Twenty-two percent of women with an unplanned pregnancy used prenatal care inadequately, while 12% of those with planned pregnancies used prenatal care inadequately (RR = 1.9, 95% CI = 1.2–2.9). In crude analysis, inadequate prenatal care use was also related to lower social class, lower education level, no employment outside the home, and multiparity. After adjustment was made for other predictors that were included in a stepwise logistic regression model (maternal education, social class, maternal occupation, parity, and pregnancy-induced hypertension), unplanned pregnancy was a significant risk factor for inadequate use of prenatal care (odds ratio = 2.1, 95% CI = 1.2–3.7) and it was an independent predictor for a delayed first prenatal care visit and for a reduced number of visits.Conclusions.The results suggest that unplanned pregnancy is a major determinant for inadequate use of prenatal care.     

过期妊娠妇女产前保健服务利用的影响因素分析

目的了解过期妊娠发生的产前保健服务利用因素。方法研究对象为嘉兴市在1993—2000年间分娩单胎活产的妇女16033人,其中过期妊娠1008人。采用t检验和χ2检验比较不同人群计量和计数资料的差异,应用两分类多元Logistic回归模型分析过期妊娠妇女产前保健服务利用的影响因素。结果孕早期没有接受早孕检查妇女的过期妊娠发生率(9.1%)高于进行早孕检查的妇女(5.3%)。过期妊娠妇女第一次产前检查孕周[(11.8±6.1)周]晚于足月产组[(10.1±4.9)周]。孕晚期接受产前保健服务妇女的过期妊娠发生率最高(14.0%),其次是孕中期组(9.4%)、孕早期组(5.7%)。妇女职业和丈夫生育年龄是过期妊娠妇女产前保健服务利用的影响因素。结论孕早期没有接受早孕检查、接受产前保健服务晚的妇女发生过期妊娠的风险高,影响过期妊娠发生的产前保健服务利用因素是妇女的职业和丈夫的生育年龄。     

Impact of recent welfare and immigration reforms on use of Medicaid for prenatal care by immigrants in California

This study investigates the impact of the recent welfare and immigration changes on the use of Medicaid by low-income pregnant immigrant women in California. The study presents findings from interviews with government officials, safety-net prenatal care providers, and immigrant advocates who serve low-income pregnant Asian and Latina immigrants at the national, state, or local levels. These informants spoke of policy actions that affect immigrants' abilities to use Medicaid for coverage of prenatal care. These actions include (1) the sharing of information between the California Department of Health Services and the federal Immigration and Naturalization Service, (2) the slow and confusing implementation of the reforms, and (3) the intimidating Medicaid eligibility process. The findings demonstrate how the policies changed the immigrant women's relationship with safety-net prenatal care providers, and sparked intense actions on the part of their advocates to sustain the women's access to perinatal care.     

The Affordable Care Act and Long-Term Care: Marginal Advancement on the Status Quo

The purpose of this analysis is to evaluate the sufficiency of the Long-Term Services and Supports (LTSS) provisions contained within the Patient Protection and Affordable Care Act (ACA). Beyond the ambitious but fatally flawed Community Living Assistance Services and Supports Act, the ACA’s LTSS changes represent only marginal advances over the status quo. Moreover, the impact of the ACA’s strategies varies with the extent to which the federal and state governments opt to invest in them, through funding, implementing, and enforcing the modest changes enacted. The ACA’s LTSS provisions, while welcome, are unlikely to result in the major changes necessary to meet both current and future demand for care.     

Prospective Recruitment of Women Receiving Prenatal Care from Diverse Provider Arrangements: A Potential Strategy

Objectives: This study describes the use of a Medicaid managed care list to prospectively recruit into a research project pregnant women receiving care from a variety of providers. Method: A list of women enrolled in Medicaid managed care was used to recruit pregnant African-American and Latina women into a study of prenatal care satisfaction. Due to privacy concerns, the researchers were not able to directly access names from the list. Instead, a managed care contract agency sent recruitment letters to 1009 pregnant African-American and Latina Medicaid recipients. Response rates by ethnicity and several other key variables are calculated. The biases associated with this method of recruiting pregnant women from a variety of providers are discussed. Results: Thirty-five percent of the women contacted returned consent forms and agreed to have researchers approach them; the response rate for African-American women was 43% and for Latinas was 29% (p < 0.0001). Respondents were younger and later in their pregnancies than nonrespondents, but did not differ from them by zip code of residence. The women recruited into the study obtained prenatal care from a diverse group of providers. Conclusions: While the use of a prospectively generated list of pregnant Medicaid recipients to recruit low-income pregnant women into a research study may be associated with some selection bias, the potential cost savings, decreased effort, and diminished recall bias may make their use a feasible sampling alternative, particularly when the researcher desires to recruit women seeking care from a variety of provider arrangements.     

Women's Voices: Prenatal Diagnosis and Care for the Disabled

The development and implementation of prenataldiagnosis has changed the experience of pregnancy for many women. How women make decisions about prenatal diagnosis PD is an important question that challenges us both individually and as a community. The questionof care is central to many women's decision-making process. How much care a child will require, how much care a woman feels confident to provide, and the level of care available for children with genetic conditionsand families from their communities all impact on women's decisions to undertake prenatal diagnosis as well as how to use the information available from testing. Interviews with women making these decisions explored, among otherthings, the role that caring and access to care played in women's ethical deliberations. Before PD can widen women's reproductive choices and counter criticisms that its use is eugenically oriented, the central role that provision of, and access to, care holds for participants in PD programmes must be acknowledged and addressed.     

武汉市黄陂地区农村已婚育龄妇女人工流产原因分析

目的:了解黄陂地区已婚育龄妇女流产原因。方法:采用结构式问卷对2006年8月～2007年10月到黄陂区、乡两级计划生育服务站做终止妊娠手术的农村已婚育龄妇女进行问卷调查。结果:被调查者受教育水平以初中为主72.95%,有近50%的妇女认为流产引产对身体没有什么影响(23.41%)或者说不清(21.89%)。流产次数最高可达9次(2人),未采取避孕措施而流产的有1302人次,占46.60%。避孕失败的原因中有30.14%是因使用宫内节育器失败,有25.16%是使用避孕套失败。流产原因中因未计划妊娠有1997人次,占71.81%,政策不允许669人次,占24.06%。结论:应提高妇女的科学文化素质,加强避孕知识的普及和宣传,提高农村妇女的避孕使用率,提高正确选择和使用避孕工具的比率,通过这些措施来降低黄陂地区已婚育龄妇女的流产率。     

Abortion services for sex workers in Uganda: successful strategies in an urban clinic

Sex workers' need for safe abortion services in Uganda is greater than that of the population of women of reproductive age because of their number of sexual contacts, the inconsistent use of contraception and their increased risk of forced sex, rape or other forms of physical and sexual violence. We sought to understand sex workers' experiences with induced abortion services or post-abortion care (PAC) at an urban clinic in Uganda. We conducted nine in-depth interviews with sex workers. All in-depth interviews were audiotaped, transcribed, translated, computer recorded and coded for analysis. We identified several important programmatic considerations for safe abortion services for sex workers. Most important is creating community-level interventions in which women can speak openly about abortion, creating a support network among sex workers, training peer educators, and making available a community outreach educator and community outreach workshops on abortion. At the health facility, it is important for service providers to treat sex workers with care and respect, allow sex workers to be accompanied to the health facility and guarantee confidentiality. These programmatic elements help sex workers to access safe abortion services and should be tried with all women of reproductive age to improve women's access to safe abortion in Uganda.     

Individual and Community Level Correlates of Prenatal Care in California

This event history analysis of the Perinatal Substance Exposure Study investigates individual and community level correlates of the timing of first prenatal care among pregnant women in California. Data were collected anonymously at the time of delivery and include demographic information from hospital records and urine samples which were tested for a battery of substances. Zip-code level data from the 1990 census were appended to each record to assess absolute community effects. A discrete-time hazard rate was estimated for each trimester in six nested models using logistic regression. Results suggest that: poor, non-White, younger, native born, Spanish-speaking, substance-using women in poorer neighborhoods were least likely to receive prenatal care. While a positive urine test for alcohol was not associated with prenatal care initiation; overall drug positives and tobacco positives (self-report) were. The optimal model, with interactions, estimates that women in poorer communities were less likely to receive prenatal care in the first trimester, but more likely to receive care in the third trimester. This pattern is similar for most of the time-varying covariates in that non-Whites, English speakers and younger women were less likely to receive first trimester care, but more likely to receive second and third trimester care.