Prenatal Care Cost Prices the Poor Out; Infant Mortality Up

California, which once ranked seventh best in the nation in preventing infant mortality, has fallen to 14th place largely because of the rising number of women who receive late or no prenatal care, according to a private study released Monday.

An estimated 40,000 California babies this year will die at birth or soon thereafter, or will begin their lives at risk for serious medical problems that are largely preventable through adequate prenatal care, according to the report.

In San Diego County--the fastest-growing urban area in California, with 35,000 births in 1984--the study found that 4,800 low-income women are turned away each year from prenatal care at publicly subsidized programs.

In part as a result of that, the county placed 23rd out of the 38 counties ranked by percentage of low birth-weight babies, a measure of infant health. The county’s percentage--5.8%--had remained virtually unchanged from the three previous years.

But the county’s infant mortality rate had worsened from an average of 9.1% in 1982-4 to 9.5% in 1984. Using a 1984 statewide average of 9.4%, San Diego ranked 10th among the 38 counties with figures large enough to rank.

The percentage of mothers receiving late prenatal care or no prenatal care had also worsened slightly in the county from 5.1% to 5.3%, compared to a 1984 statewide average of 7.1%. The county ranked 12th out of 38 by that standard, according to the study.

The study’s findings came as no surprise to health authorities in San Diego County.

“Traditionally, San Diego County’s infant mortality rate has been lower (than other counties’),” said Kim Warma, director of the regional perinatal program at UC San Diego Medical Center. “But as we see an influx more and more of medically indigent and undocumented workers, that rate is going to start to rise.”

Much of the prenatal care for the indigent in the county is provided by 13 community clinics under contract to UCSD and supported by state funds. Several other clinics provide prenatal care, along with those doctors who are willing to provide maternity care for MediCal patients.

But both Warma and the San Diego County Health Officer, Dr. Donald Ramras, said that fewer and fewer doctors are taking pregnant women because of low MediCal reimbursement rates. Meanwhile, Warma said, the 13 community clinics were forced recently to hold their new patient caseloads to 100 a month each because of a shortage of maternity beds at UCSD Medical Center.

“I think it’s a sad state of affairs in 1987 that we’re seeing this when we know we can prevent a lot of it by a short-term outlay of capital,” said Warma, whose program is a cooperative effort by UCSD, Childrens and Sharp hospitals to try to coordinate services for so-called medically indigent women. Warma said that for every $1 spent on prenatal care, $3 can be saved on care after birth.

Pregnant women who use Los Angeles County’s overburdened public clinics must wait as long as 19 weeks to get an appointment for prenatal care.

The report said that Orange County’s clinics turned away 2,000 indigent patients in 1985 because of “limited resources,” and that public clinics in San Diego County “turned away 1,245 pregnant women during a recent three-month period for the same reason.”

Elsewhere, 14 of California’s 58 counties have no state or federally funded clinics offering prenatal care, the report said.

It blamed the lack of prenatal care in part on high malpractice insurance rates that have caused many obstetricians to stop offering maternal care.

The report said local governments can make maternity care more available by removing fees that discourage early care. For example, since the 1970s Los Angeles County has charged women who have no insurance $20 to $30 for each prenatal care visit up to seven visits.

Such fees “represent a real obstacle to prenatal care (that) clearly is having an impact,” said Dr. Ezra C. Davidson, chief of obstetrics at Martin Luther King Jr. General Hospital in Watts.

He said that many of the uninsured women forgo the prenatal care in order to save their money for the actual delivery, for which the county charges about $800.

The report recommended that California provide financial assistance to encourage health professionals to set up practices in under-served communities, eliminating red tape in the Medi-Cal program that now deters eligible women from seeking care, and expanding health outreach and counseling programs for pregnant women.

The report was issued by the Southern California Child Health Network and the Children’s Research Institute of California, two nonprofit citizens’ groups. The statistics they gathered came from state and county health departments.

Separately on Monday, the California Conference of Local Directors of Maternal, Child and Adolescent Health, a statewide organization of local health officers, issued a statement saying it joined with the report in asking for a “statewide comprehensive perinatal policy and plan which addresses the needs of all women in California.” Such a plan, it said, would require a “massive cooperative effort” between the public and private sectors.

The report said many of the babies who receive late or no prenatal care will face “bleak” consequences. “Many of these babies begin their lives in hospital intensive care units--sick or disabled--at an average cost of $19,000,” the report said. “These babies account for 7% of births, but 20% of the newborn deaths.” About 470,000 babies are expected to be born in California this year.

Between 1970 and 1983, the report said, California fell from 10th in the nation to 29th in the percentage of women receiving prenatal care in the crucial first trimester of pregnancy, and from 12th to 17th on percentage of babies born with a low birth weight. The absence of prenatal care is a major contributor to babies being born underweight.

Entitled “Back to Basics: Improving the Health of California’s Next Generation,” the report, which took 18 months to research, was released at a news conference at Childrens Hospital of Los Angeles.