Prenatal Care and Income

1. Prenatal Care and Income Shy Chwen Ni, Bryan Mesina, Janice Guzman, Pak-Hun Chan, CharleenBondoc

2. Background • Late prenatal care is considered a mother starting prenatal care after her first trimester. • Mothers who fall between the Federal Poverty Level (FPL) of 0-100% receive $10,830 or less based on FPL of 2010.

3. The Problem Too many women under the Federal Poverty Level of 0-100% receive late or no prenatal care.

4. Why should we care? • Women with no PNC are 3 times more likely to give birth to low-birth weight babies • PNC not only saves babies lives, it is cost effective • every dollar spent on prenatal care for high-risk pregnant women saves U.S. $3.38 in medical care • $600 for PNC vs $1000 per day in Neonatal ICU • The emotional costs of having a high-risk infant are more difficult to measure. • In 1987, 6.6 maternal deaths per 100,000 and now in 2006 13.3 deaths per 100,000 deaths per birth SOURCE: Institute of Medicine. Preventing Low birthweight. National Academy Press, Washington, D.C., 1985.

5. Why is income a factor? 7-9% Low-income women have high levels of very late or no PNC Only 2% of nonpoor women initiate late/no pnc SOURCE: National Natality Survey

6. Poverty Rates US poverty rate – 13.2% California poverty rate – 13.3% Arizona poverty rate – 14.7% Merced County poverty rate – 21.5% Fresno County poverty rate – 22.1%

7. National Statistics on Women in Poverty receiving late/no prenatal care SOURCE: DATA2010 (2006), National Vital Statistics System – Prenatal Care, CDC, NCHS Adjusted National data to no/late prenatal care to CENSUS 2000 population. Source U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, Census of Population and Housing, Small Area Income and Poverty Estimates, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits, Consolidated Federal Funds Report Last Revised: Thursday, 22-Apr-2010

8. California vs. Arizona SOURCE: DATA2010 (2006), National Vital Statistics System – Prenatal Care, CDC, NCHS Source U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, Census of Population and Housing, Small Area Income and Poverty Estimates, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits, Consolidated Federal Funds Report Last Revised: Thursday, 22-Apr-2010

9. California 2004 Poverty-Adjusted Rates by Age Groups • PNC rates obtained from the CDC National Vital Statistics • Poverty rates obtained from the US Census Bureau

10. California 2005 Poverty-Adjusted Rates by Age Groups • PNC rates obtained from the CDC National Vital Statistics • Poverty rates obtained from the US Census Bureau

11. California 2006 Poverty-Adjusted Rates by Age Groups • PNC rates obtained from the CDC National Vital Statistics • Poverty rates obtained from the US Census Bureau

12. County-Level Analysis • PNC rates obtained from the CDC National Vital Statistics • Poverty rates obtained from the US Census Bureau

13. Trend • National Level: From 2004-2006, there is decreasing trend in late/no PNC. It has decreased about 13.02% of people from 04’ to 06’. • State Level: California’s low-income women are receiving are twice as more PNC than Arizona. Both states show a slight decrease between the years 2004 and 2006. • County Level: Both Merced and Fresno County show an increase in women that receive no/late PNC. However, Merced county shows 2x more women receiving no/late PNC than Fresno county.

14. Social Determinants • Many low-income women depend on public transportation • Reports have found that the shortage of health care professions in rural areas in inner cities also contributed to the problem. Many people lack transportation and available time to visit far away clinics (Source: Doerter, Deadly Delivery Summary, 2010)

15. Structural Violence High Cost of healthcare insurance • Inadequate Services Provided by Medi-cal • “For those 42% of births that are covered by Medicaid, women often face significant delays in prenatal care because of the messy bureaucratic requirements. “ • Welfare reform in 1996 “restrictions on eligibility for cash assistance have translated into decreased access to pre-pregnancy Medicaid coverage for low-income women. “ • Women have to be pregnant first in order to get the coverage. Medi-cal gap • Women have to pay out of pocket for prenatal care • Even though medical covers PNC, they are very restricted on PNC vitamins. • Newer study: Health people 2010 low income women begin at the 1st trimester but there has no goal set to reduce the problem in relation on late PNC and income. (SOURCES: http://wphr.org/2010/allison-doerter/homegrown-human-rights-violation/)

16. Individual behavioral intervention • A study at Oregon Health Sciences University investigated women, regardless of risk profile showed that there was a coorelation between low birthweight due to late/no PNC due to psychosocial factors. • -Pyschosocial factors – Maternal behavior (timing, participation in PNC ), Depression, Drug use • Studies showed that women who received more than 45 min of psychosocial services decreased the rate of low birth weights of infants, regardless of the womens risks factors. Even after controlling for number of PNC visits, having pshychosocial services still lowered the amount of low birth weights. SOURCE: Low birthweight in a public prenatal care program: Behavioral and psychosocial risk factors and psychosocial intervention By Melanie J. Zimmer-Gembeck and Mark Helfand; Oregon Health Sciences University, Biomedical Information Communication

17. Individual behavioral intervention • A study at Oregon Health Sciences University investigated women, regardless of risk profile showed that there was a coorelation between low birthweight due to late/no PNC due to psychosocial factors. • -Pyschosocial factors – Maternal behavior (timing, participation in PNC ), Depression, Drug use • Studies showed that women who received more than 45 min of psychosocial services decreased the rate of low birth weights of infants, regardless of the womens risks factors. Even after controlling for number of PNC visits, having pshychosocial services still lowered the amount of low birth weights. SOURCE: Low birthweight in a public prenatal care program: Behavioral and psychosocial risk factors and psychosocial intervention By Melanie J. Zimmer-Gembeck and Mark Helfand; Oregon Health Sciences University, Biomedical Information Communication

18. Community behavioral Intervention After a study by UCDavis of why low income women receive late/no PNC, 4 topics were identified as the most relevant to communicate to the community: -Health services use -The mother's weight gain -Nutrition and anemia -Symptoms of high-risk complications during pregnancy. A poster, a calendar, a brochure, and two radio songs were produced and pretested in focus groups with low-income women. Each medium included one or more messages addressing informational, attitudinal, or behavioral needs, or all three, of the target population. SOURCE: Designing prenatal care messages for low-income Mexican women. By R Alcalay, A Ghee, and S Scrimshaw University of California, Davis. 1993

19. Organizational behavioral Intervention A study by The American College of Obstetricians and Gynecologists found that even when affordable care was available to many low income women did not make themselves available to them. Even though many women knew the importance of PNC, there were sociodemographic factors, system barriers, and cultural or personal barriers that caused them to not seek PNC. • To address these issues regarding the barriers between organizations and individuals, in 1994 the state of Tennesee implemented TennCare - Provided mandatory managed-care coverage for Medicaid and uninsured populations. Additionally they wanted to understand the barriers for people to did not receive adequte PNC care. -Conducted interviews with women of reproductive age to collect information about women who wished to enter health services, and how they could address any barriers. SOURCE: Prenatal Care for Low-Income Women Enrolled in a Managed-Care Organization. By GAZMARARIAN, JULIE A. MPH, PhD et al. 1999

20. Recommendations • Organizational level: Extend the regular business hours and work day to weekends of clinics that benefit low income women. (these type of clinics would provide low-income women with PNC, information, and one-on-one sessions with other mothers) • Community level: Having the government make a policy to extend these hours • Individual level: this would remove any time barriers of women who can’t go to clinics due to work related interferences. Hopefully this would increase low-income women to go seek PNC without any time restraints.