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Prenatal Care for the Poor:

Is our community positioned to meet the need?

by Rodney Berry & Kathy Strobel



Private care, public care

Approximately 1,400 babies are born in Daviess County each year. An estimated 900 pregnant women (63 percent) receive prenatal care through eight local obstetricians in private practice. Until recently, the 500 remaining women (37 percent) received prenatal services from two midwives at the Green River District Health Department. In any given month, the health department caseload was 250 to 300 pregnant women and another 40 to 50 new pregnant women turned to the department for care.

Absorbing the cost of care

Most of the women served by obstetricians are insured through private insurance plans. Most who sought care at the health department were insured through Medicaid, a health care program funded by state and federal governments. To qualify for Medicaid, their annual incomes could not exceed 185 percent of the federal poverty level*. The health department also provided prenatal care for women who did not qualify for Medicaid but could not afford health insurance.

Problems in caring for the poor

Some obstetricians in private practice do not accept Medicaid and uninsured patients because their caseloads are already full and reimbursements from the Medicaid program are substantially less than reimbursements from insurance companies. Medicaid and uninsured patients also tend to miss appointments more often and are at high risk for complications. Poor women are more likely to smoke, not follow directions during pregnancy, and have substance abuse problems. And the language barrier, with an increasing number of immigrants here, is a hurdle to care.

Medical supervision required

Birth Data (2003)
Daviess County
Number of live births 25-bed acute care facility
Crude birth rate (per thousand) 25-bed critical access facility
Infant deaths 410-bed
Low birth weight 365-bed
Births to single unmarried women 116-bed
Births to mothers under 18 216-bed

Source: Kentucky Cabinet for Health and Family Services, 2003-Vital Reports http://chfs.ky.gov/dph/vital/2003vitalreports.htm

Government regulations require that the midwives at the health department be supervised by an obstetrician. Obstetricians claim that they must assume too much liability when providing oversight for health department midwives, and that drives up their already high malpractice insurance premiums.

Forced to cut the program

This year, health department officials were unable to reach an agreement with local obstetricians to provide supervision. So in September 2006, under pressure from state regulators and insurance carriers, the health department eliminated much of its prenatal care program, including prenatal exams. The health department continues to provide various programs and services for pregnant women – nutrition counseling, Women, Infants and Children program, Building Stronger Families program, etc.

Health department reaches out to obstetricians

Concerned that hundreds of pregnant women may not have access to prenatal care, health department officials approached local obstetricians to accept its Medicaid referrals. If patients do not qualify for Medicaid and are unable to pay, the health department offered to reimburse obstetricians the Medicaid rate by using a $70,000 state grant and $47,000 from local health taxes. Seven obstetricians agreed to accept established health department patients during their current pregnancy and four agreed to take new patients. A month into this referral system, 269 pregnant women patients had been accepted by local obstetricians.

Different setting could be good or bad

Assigning pregnant women to obstetricians in private practice ensures continuity of care through delivery. It establishes a relationship between the doctor and patient that can benefit both the pregnant woman and her child. It creates a central location for medical records and ongoing care. However, some are concerned that Medicaid and uninsured pregnant women will feel less welcome in private practice settings.

Essential questions

Given the volume and unique challenges in serving Medicaid and uninsured patients:

  • Can four obstetricians absorb all the new patients who need prenatal care?
  • Should they be expected to absorb this burden?
  • If there are not enough obstetricians, where will these patients go for care?
  • One alternative suggested is Madisonville’s Trover Clinic (nearly an hour’s drive, much of which is on poor roads), which provides medical oversight for three midwives. Is that the best service we can provide in Daviess County?
  • Why can we not provide medical oversight for midwives in Daviess County while being satisfied to send our patients to another community that provides care through midwives?
  • Should our community and health care providers develop a better plan?

Without proper prenatal care, babies are more likely to be born preterm, putting them at high-risk for health problems and learning disabilities. The pregnant women who are most vulnerable are poor, single mothers and immigrants.

* Federal poverty level for single women without children: $10,160
* Federal poverty level for single women with two children: $15,735

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