Lack of Prenatal Care Is Putting Poor Mothers’ Babies at Risk

The baby inside was telling Maria Velasquez that its moment had arrived. As the pain of her labor grew more intense, friends at the factory where she worked eased her into a car for the trip to UC San Diego Medical Center’s emergency room.

She was admitted to the hospital, taken upstairs to the second floor and examined by a doctor. Except for a trip to the same emergency room during false labor two days earlier, it was the first time since her pregnancy had been confirmed that Velasquez had seen a physician.

“I had called (during the pregnancy) and asked how much to see the doctor, and they said $250,” Velasquez, 26, explained through an interpreter just hours after her son was born Wednesday at UCSD. “I came to this hospital and they asked me to give $250. I couldn’t get all that money together.”

Instead, Velasquez became one of the estimated 2,000 to 4,000 San Diego County women who this year will deliver children without prenatal care--a growing population that now amounts to 5% to 10% of the county’s new mothers.

Although a few are transients and drug addicts who treat their unborn fetuses as cavalierly as they treat themselves, most of the “no-cares,” as doctors call them, are patients like Velasquez--poor and low-income women shunned by private obstetricians and turned away by the county’s overburdened health clinics.

More frequently than mothers who receive prenatal care, they will give birth to underweight, premature infants who run a greater risk of developing lung disease, cerebral palsy, mental retardation, visual handicaps and neurological problems.

Because they do not receive the routine tests given to most women during pregnancy, they also have a better chance of carrying their children while suffering from poor nutrition, syphilis, hepatitis or drug addiction.

Each mother and infant will, on average, cost the UCSD hospital about $2,200 more than women who received prenatal care in publicly subsidized clinics, according to a 1985 study conducted at UCSD.

Ironically, greater availability of less expensive prenatal care would prevent the need for costly post-partum medical attention and reduce a debt that is often borne by private patients and taxpayers, hospital officials said.

“There is no question that there is a lot of (infant) illness here at the hospital that is preventable. That’s the sad part of this,” said Dr. Thomas Key, director of perinatal medicine at UCSD.

“It’s awful,” said Pam O’Neil, an aide to county Supervisor Brian Bilbray, who is part of a county task force examining the no-care problem. “It’s sad for the taxpayer. It’s terribly sad for the woman. It’s terribly sad for the infant. It’s just a terribly sad situation.”

Velasquez was one of the lucky ones. A social worker in her native Mexico, she knew enough to eat well and rest often. Her son, Oscar, was born at a healthy 7 pounds, 5 ounces. His only discernible difficulty is a heart murmur, which often clears up during infancy.

But two floors below Velasquez’s bed are some no-care infants who aren’t as fortunate, babies who spend their first days attached to tubes, monitors and ventilators in UCSD’s Infant Special Care Center.

They are infants like Bobby, born at 2 pounds, 13 ounces after 28 weeks of gestation, whose ruptured intestine required major surgery. In his three months of life, Bobby has endured a serious infection and respiratory distress syndrome.

“He has been very, very sick the last couple of weeks,” said Dr. Marva Evans, an attending neonatologist in the center. “He has tried to die three or four times on us.

“You don’t know that (prenatal) care would have helped. But certainly he would have come in in better condition,” she said.

Nearby is Carolina, whose mother gained no weight during her pregnancy but sought no medical attention. Carolina’s growth was retarded; she weighed just 4 1/2 pounds at birth. She had an abnormal heart rate and aspirated meconium (fetal excrement) at birth, a problem more common among newborns who are under stress because of inadequate prenatal care, Evans said.

“The baby’s probably going to be all right,” Evans said, but there is “some evidence . . . of brain damage.”

Oscar, Bobby and Carolina are children of the ‘80s. As obstetricians’ costs have soared here and throughout the nation in recent years--mostly as a result of skyrocketing malpractice insurance premiums--more and more of them began to refuse poor and uninsured patients or women relying on the state’s Medi-Cal system to pay their bills, health officials said.

With Medi-Cal paying them just $657 for nine months of care, the number of San Diego County obstetricians accepting Medi-Cal patients dropped from 97 in 1984 to fewer than a dozen today, said Kim Warma, director of the Regional Perinatal Program for San Diego and Imperial counties. One review showed that just four of the county’s 250 obstetricians are accepting Medi-Cal payments, she said.

At the same time, San Diego was becoming California’s fastest-growing urban area. The 40,000 to 42,000 children expected this year will make up 8% of the state’s total births, Warma said.

Because of their proximity to the border, county hospitals deliver the children of countless undocumented immigrants and Mexican residents who cross the border to deliver their babies on American soil so that the infants automatically become American citizens, UCSD medical authorities said.

“They are no-cares from Tijuana. They tell us that’s where they come from,” said Mitzi Disnard, staff nurse in the UCSD labor and delivery unit. “I have had patients say to me, ‘Well, they don’t put you in jail here if you don’t pay your bills like they do in Mexico.’ ”

The demand for places in prenatal care programs for the indigent is unrelenting. The largest network, the 13-clinic Comprehensive Perinatal Program staffed by UCSD’s nurse-midwives, serves 1,500 women annually. In December and January alone, the clinics turned away 1,246 women seeking medical attention, director Ann Bush said.

Bush’s clinics could handle more women, but the program is limited by UCSD’s inability to handle the tide of deliveries. Even with 360 monthly openings, 60 of them devoted to no-cares, UCSD sometimes leaves women to labor in the corridors, said Dr. Chris Lafferty, a second-year resident in reproductive medicine.

None of the county’s 15 other maternity hospitals is willing to accept the clinics’ indigent clients for delivery because they lose substantial amounts of money on each patient who cannot pay her bills, Bush said. Under an arrangement with the county, UCSD receives a subsidy for handling indigent women’s births, but it still loses money on the deal.

The county has several other clinics, but all are in the same predicament. Planned Parenthood, which offers health education and the services of a nurse-practitioner to about 200 low-income women annually, turns away about the same number, said spokeswoman Lenore Lowe. The organization recently closed a clinic in National City--leaving it with just two centers, in Escondido and El Cajon--because it could not find an obstetrician willing to handle its clients.

Overall, 4,800 San Diego county women are turned away from publicly subsidized prenatal programs each year, according to a study released this month by the Southern California Child Health Network and the Children’s Research Institute of California.

As a result, 10% of the 205 women who gave birth in local hospitals during a two-day period in January received no prenatal care, according to a survey conducted throughout the state. That figure is 43% higher than the state average, Warma said.

According to the Southern California Child Health Network study, the percentage of mothers receiving late or no prenatal care here was 5.3% in 1984, compared to a statewide average of 7.1%. The county ranked 12th out of 38 counties in that category.

“Even if (the rate is) 5%, we have 2,000 women who aren’t getting care,” Warma said. “And if we . . . look at the worst-case scenario, that’s 4,000 women who aren’t getting care. That’s a whole raftload of moms and babies.”

Velasquez knew that she should see a doctor, but she was working as many hours as possible to raise the cash. “It was because I was working too many hours, and it was too late after work to see a doctor,” she said.

Instead of breast-feeding, Velasquez immediately started Oscar on a bottle so that she could return to work, she said. She has no idea how she will pay her hospital costs, although a county program generally absorbs them in cases like hers.

Nowhere is the no-care situation more staggering than at UCSD. The two-day survey revealed a 26.3% no-care rate at the hospital, highest among the county’s maternity hospitals. Key said that the no-care rate averages at least 22% a year.

“We have no way of regulating the no-care population,” Key said. “We can’t control that group. We are at their mercy. If they show up, we are not going to turn them away.”

No one is quite sure why UCSD receives such a huge share of no-cares, but it is generally accepted that an informal grapevine has created something of an underground railroad in San Diego’s Latino neighborhoods and in Tijuana. First and last stop--UCSD’s emergency room.

Approximately 85% of UCSD’s no-cares are undocumented immigrants or Mexicans, Key said. Many women expecting a difficult delivery or a Caesarian section routinely head north from Tijuana. Among them are the wives of Mexican physicians, Key said.

When Velasquez went into labor, friends brought her straight to UCSD, though there was at least one other maternity hospital nearby.

“I told them how I was feeling and they told me to come to this hospital,” she said. “I don’t know why they brought me here. I hadn’t even thought about what hospital to go to.”

According to health authorities, taxis regularly bring Latino women to UCSD; some claim the same address.

“It’s very well known that there are taxi pools,” said one health official. “Patients have shown up in certain emergency rooms with maps of how to get there. We have copies of the maps.

“I sometimes wonder how these people hear. I don’t know how anyone knows,” the official said.

Key and other UCSD doctors suspect that other hospitals, seeking to cut costs, send no-cares from their emergency rooms to UCSD, which turns away women only when there is no room and never turns away women who are in labor. The photocopied maps that the women carry are a clue that other hospitals are pointing the way to UCSD.

“I think that happens to a large degree,” Key said. “I don’t know the extent. I’ve tried to refrain from finding out.”

When they arrive, the women become the responsibility of doctors like Lafferty, the easy-going resident who is resigned to the tide of no-cares. “It’ll never go away,” he said recently. “It would be very difficult to solve the problem.”

No-cares present Lafferty with an unwanted challenge: delivering a baby without much of the background information that guides his efforts. A battery of extra tests is performed to re-create medical history that should be in the woman’s charts.

“You have to start from square one,” Lafferty said. “You have no idea where she is in her pregnancy. Is she (full) term? Is she pre-term? What sort of medical problems does she have? And then, what is the status of the baby?”

No-cares, lacking knowledge of the signs of labor, often show up at UCSD’s door late in the labor process. If they are too far along, doctors cannot administer drugs often used to stop a pre-term delivery and have more difficulty with complications such as infection or abnormal heartbeat.

Health problems inevitably result. The Southern California Child Health Network study showed that California, once ranked seventh-best in the nation in preventing infant mortality, has fallen to 14th place largely because of the increasing number of women receiving late or no prenatal care.

San Diego county’s infant mortality rate was 9.5 per 1,000 births in 1984, slightly higher than the state average of 9.4 per 1,000. The county also averages a low birth-weight rate of 5.8%.

In UCSD, women who have prenatal care deliver pre-term about 5% of the time, Key said. Women without the care deliver 32% of their babies before they are due. Pre-term deliveries account for about 80% of the hospital’s newborn deaths and most infant illnesses, he said.

They also cost UCSD an average of $5,168, nearly $2,200 more than the $2,974 spent to care for infants and mothers who received prenatal care, according to a study in which Key and three other doctors compared 100 no-cares with 100 patients from the Comprehensive Perinatal Program.

Almost all of the extra money is spent on the children, who suffer far more damage than children of mothers who have received prenatal care. In contrast, mothers from both groups fared about equally well medically, the study showed.

“We are a problem-oriented society,” Key said. “We seek health care when there’s a problem, when there’s a crisis, when there’s an illness. That’s an expensive way to operate.”