Prenatal Care and Income

Shy Chwen Ni, Bryan Mesina, Janice Guzman, Pak-Hun Chan, Charleen Bondoc

• 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.

Background

Too many women under the Federal Poverty Level of

0-100% receive late or no prenatal care.

The Problem

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

Why should we care?

SOURCE: Institute of Medicine. Preventing Low birthweight. National Academy Press, Washington, D.C., 1985.

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

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%

Poverty Rates

National Statistics on Women in Poverty receiving late/no prenatal care

2004 2005 20061250

1300

1350

1400

1450

1500

1550

1600

1650

1605

1388 1396

National Statistics of Women Receiving late/no PNC to Poverty Level

Years

per

100,0

00 w

om

en

National Crude Rates

Year Rate

2004 518,557/4,112,052

2005 448,499/4,138,349

2006 451,068/4,265,555

SOURCE: DATA2010 (2006), National Vital Statistics System – Prenatal Care, CDC, NCHSAdjusted 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

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

California vs. Arizona

2004 2005 20060

500

1000

1500

2000

2500

3000

3500

1674

1431 1396

31202942 2938

California vs. Arizonapoverty adjusted to no/late PNC

CalifornaLinear (Californa)ArizonaLinear (Arizona)

Years

per

100,0

00 p

regnant

wom

en

Crude Rate Year California Arizona

2004 0.12688 0.236392005 0.10838 0.228882006 0.10575 0.22259

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

2004

Age GroupsLate/No PNC Rate

Poverty-Adjusted, Late/No PNC Rate(Per 100,000)

Under 15 0.486 6468

15-19 0.238 3159

20-24 0.166 2208

25-29 0.114 1519

30-34 0.087 1156

35-39 0.088 1167

40-44 0.101 1343

45-49 0.101 1341

50-54 0.108 1430

Average 0.127 1689

Under 15

15-1920-24

25-2930-34

35-3940-44

45-4950-54

Averag

e0

1000

2000

3000

4000

5000

6000

7000

Age Groups

Poverty-Ad-justed,

Late/No PNC Rate

(Per 100,000)

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

Under 15

15-1920-24

25-2930-34

35-3940-44

45-4950-54

Averag

e0

1000

2000

3000

4000

5000

6000

Age Groups

Poverty-Ad-justed,

Late/No PNC Rate

(Per 100,000)

2005

Age Groups

Late/No PNC Rate

Poverty-Adjusted, Late/No PNC Rate (Per 100,000)

Under 15 0.414 5506

15-19 0.250 3319

20-24 0.175 2321

25-29 0.122 1626

30-34 0.091 1215

35-39 0.088 1165

40-44 0.104 1389

45-49 0.122 1625

50-54 0.040 536

Average 0.133 1772

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

Under 15

15-1920-24

25-2930-34

35-3940-44

45-4950-54

Averag

e0

1000

2000

3000

4000

5000

6000

7000

Age Groups

Poverty-Ad-justed,

Late/No PNC Rate

(Per 100,000)

2006

Age Groups

Late/No PNC Rate

Poverty-Adjusted, Late/No PNC Rate (Per 100,000)

Under 15 0.487 6474

15-19 0.261 3477

20-24 0.183 2439

25-29 0.128 1699

30-34 0.095 1262

35-39 0.092 1220

40-44 0.108 1432

45-49 0.113 1502

50-54 0.096 1277

Average 0.140 1860

County-Level Analysis

2004 2005 20060

1000

2000

3000

4000

5000

6000

7000

8000

Merced vs FresnoPoverty-Adjusted, Late/No PNC Rates

MercedFresno

Year

Poverty-Ad-justed, Late/No

PNC Rate(Per 100,000)

2004 2005 20060

1000

2000

3000

4000

5000

6000

7000

8000

Merced vs FresnoPoverty-Adjusted, Late/No PNC Rates

MercedFresno

Year

Poverty-Ad-justed

Late/No PNC Rate

(Per 100,000)

•PNC rates obtained from the CDC National Vital Statistics•Poverty rates obtained from the US Census Bureau

Merced FresnoYear Late/No PNC Rate Late/No PNC Rate2004 0.314 0.1322005 0.328 0.1362006 0.335 0.140

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.

Trend

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)

Social Determinants

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/ )

Structural Violence

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

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

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 ScrimshawUniversity of California, Davis. 1993

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

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.

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