Overwhelmed Health Clinics Struggle to Serve the Pregnant

On Thursday morning, the Van Nuys Health Center reluctantly played its own version of a radio call-in contest.

The first 56 pregnant women who got through were scheduled for a prenatal visit with a physician at the Los Angeles County clinic in July.

At least that many women were turned away. But they can check back again on the last Thursday in July to try to book an appointment for August.

“We’re not proud of this, but of all the choices we have it seems to be the best,” said Bernie Nelson, the Van Nuys public health clinic’s nursing supervisor.

To cope with a growing demand for prenatal services, the county’s clinics in Van Nuys and Canoga Park recently began limiting the number of new patients. They accept appointments only once a month, on a first-come, first-served basis. In two hours, the next month’s appointments are filled.

No Solutions in Sight

Although many county health clinics are chronically overcrowded and under-funded, nowhere is the crunch more severe than in the area of prenatal care and family-planning services. The problem became so critical that the county formed a Prenatal Appointment Backlog Task Force two years ago. But, for the most part, solutions have proved elusive.

County health centers in the San Fernando Valley and elsewhere are handling the endless stream of pregnant patients in different ways. In many cases, officials say, the result is similar to bailing out a sinking boat with a small bucket.

“It’s overwhelming,” said Dr. Dorris Harris, chief physician of the clinics in the San Fernando and Santa Clarita valleys. “I will tell you it’s extremely frustrating.”

The demands placed upon the county’s prenatal services have increased dramatically in recent years, especially in the San Fernando Valley. From 1980 to 1984, for instance, prenatal visits to county health clinics in the Valley rose 45%, while the countywide average increased by 9%.

Various factors have figured into the clinics’ baby boom. The clinics are heavily patronized by immigrant women who have neither private insurance nor Medi-Cal coverage. As their numbers have risen, so has the demand. In addition, more and more obstetrician-gynecologists are abandoning the baby-delivering business because of expensive malpractice insurance premiums.

The consequences of this patient boom are far-reaching, health experts said. Pregnant women who never see physicians or see them late in their pregnancies risk medical complications for themselves and their babies. These infants are more likely to be born underweight or to start their lives in intensive-care units.

“There are many undetected conditions that can go on in pregnancy that have serious consequences for the mother and the baby if you don’t see them on time or not at all,” said Dr. Angela Murphy, chief physician for the North Hollywood Health Center.

8% Get Late or No Care

In the county, about 8% of all mothers receive late prenatal care or none, according to a recent report issued by the Southern California Child Health Network. At the same time, the number of high-risk women requiring early care--including those over 35 and under 18--is increasing and now represents 20% of the births in the state.

Valley women who do get prenatal appointments are spending less and less time with physicians. At some clinics, doctors are seeing far more prenatal patients a day than the county’s medical guidelines recommend.

The county suggests that a physician should ideally see no more than 18 pregnant women in a four-hour session. The guidelines caution physicians not to exceed 25 exams during that period. That equals one woman every 9 1/2 minutes.

At the Van Nuys clinic, however, physicians are typically examining 26 to 30 pregnant women in a four-hour session. The number is similar at the North Hollywood clinic. Last month, Pacoima physicians saw an average of 26 patients during four-hour sessions. By contrast, the Valencia clinic averaged 15 women a session in May.

“If we’re seeing 25 prenatal patients per session that’s tops,” said Dr. Lionel Cone, who oversees the clinics in Pacoima, San Fernando, Valencia and the Antelope Valley. “If it’s more, there’s a danger of practicing dangerous medicine.”

The prenatal clinics are a far cry from the quiet, wallpapered offices filled with child-care magazines that many women visiting private obstetricians are accustomed to. In the summer, the clinics are often hot and the drinking water warm. At the North Hollywood clinic, where the fans are frequently broken, women sometimes faint in line.

At the busier health centers where three or four women are interviewed simultaneously by nurses in a small room, the nurses worry that patients do not divulge parts of their medical history because others can overhear them.

“I think the worst part is we don’t have the privacy, the time and space to talk to a patient in a nice, calm manner,” said Flor Chavarria, a registered nurse who manages the prenatal clinic at North Hollywood. “It’s rush, rush, rush. Sometimes I don’t even look at their faces.”

Some Bright Spots

There have been some bright spots in prenatal care at the county clinics. The two Valley clinics devoted exclusively to women’s care--in Pacoima and Burbank--have a wait of only one week for first-time prenatal patients. Pacoima has been devoted to family planning and prenatal services since the 1970s; Burbank was converted from an all-purpose clinic two years ago to handle the prenatal demand.

The county’s clinics have the most moderate prices in Los Angeles, though critics insist that charging anything at all discourages some women from seeking medical help. Pregnant women pay $25 for each visit in a series of seven appointments, any treatment after that is free.

Meanwhile, staff members at the Canoga Park and Van Nuys clinics worry about the pregnant patients they must turn away.

Said Ruth Woods, district nursing director for the two clinics: “We just know we are the last resort. When we can’t take them, it’s anybody’s guess where they go.”