Rise in Lack of Prenatal Care Strains Hospital

An ever-increasing number of pregnant women who arrive unexpectedly at UC San Diego Medical Center to deliver babies without benefit of prenatal care is forcing the Hillcrest hospital to consider the unprecedented action of turning some of them away.

UCSD, which delivers by far the largest share of the county’s “no-care” babies, is developing guidelines governing which women will be accepted and which will be turned away to seek medical care elsewhere or wait outside until their labor has progressed, said a hospital official who asked not to be named.

The new policy, which should be completed in about three weeks, is the most dire symptom to date of an ongoing crisis in prenatal care that will cause more than 2,500 low-income women, many of them illegal aliens, to deliver babies this year without seeing doctors.

UCSD’s jammed maternity wards operate far above capacity and hospital officials believe the only way to safeguard the level of care is to reduce the number of deliveries.

Equipped to handle 300 deliveries each month, UCSD handled 357 in September, 354 in August and 386 in July, said Thomas Key, director of perinatal medicine. Women who had received no prenatal care constituted 96 of the deliveries in September, 83 in August, 89 in July, according to figures from the Regional Perinatal System.

“We have a problem. It was a terrible summer, and, just very simply, we don’t have the capacity to continue to give care,” Key said. “We are comfortable at 325. We are pushed at 350, and there’s an element of danger at 380.”

Though the details are not complete, UCSD intends to tighten its definition of an obstetrical emergency in order to reduce the number of “no-cares” by about 25%, one hospital official said. All women will receive an examination before the decision is made to turn them away, the official said.

The possibility of new rules has raised the specter of laboring women sitting in cars or taxis outside UCSD’s emergency room or searching for care in other hospitals, health officials say. Mercy Hospital, which is just five blocks from UCSD and delivered just nine no-care babies in September, may be a primary recipient of those women.

‘Makes Me Sick’

“I think what will happen is that women will just sit out in the parking lot until they’re five centimeters (dilated),” said Ann Bush, director of the Comprehensive Perinatal Program, which runs 13 of the county’s 17 clinics for low-income pregnant women. “Legally, I don’t see how (UCSD) can do this because they have a contract with the county to deliver them. Frankly, it makes me sick.”

The furor over the expected UCSD rules highlights the county’s chronic shortage of prenatal care, a situation that results in higher levels of infant illness and death and greater cost to hospitals that must care for the newborns.

No-care women will give birth more frequently than mothers who receive prenatal care 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, the no-cares 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 UCSD at least $2,200 more than women who receive prenatal care in publicly subsidized clinics, a figure that Key believes has increased since it was calculated in a 1985 study.

Fallout From Insurance Crisis

No-care babies are children of the insurance crisis. As obstetricians’ costs have soared, primarily 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 just $657 for nine months of care, the number of San Diego County obstetricians accepting the state medical insurance payments dropped from 97 in 1984 to 14 in September, said Kim Warma, director of the Regional Perinatal System.

Publicly subsidized clinics accept some of them, but they are inundated with poor women, about 65% to 70% of them illegal aliens, Bush said.

The number of women being turned away from clinics is difficult to determine. Bush’s organization, which runs 13 of the county’s 17 clinics, turned away 1,246 women in December and January, a figure that would total nearly 7,500 annually. Planned Parenthood, which runs two clinics, turns away about 200 annually, said spokeswoman Lenore Lowe.

A study issued in March by two state health organizations estimated that 4,800 women are turned away from publicly subsidized county health clinics each year.

“It is a critical situation for women,” Lowe said. “Instead of getting better, it’s getting worse.”

Bush’s clinics, which see 1,500 women each year, could offer prenatal care to 500 more annually. But under Bush’s agreement with UCSD, the clinics cannot accept a patient unless there is a hospital bed available, and UCSD’s maternity wards are overloaded. UCSD is the only hospital willing to deliver the clinic’s babies.

Emergency Room

The result is that women wait until they go into labor, then head for a hospital emergency room, where overburdened doctors try to create a medical history that should have been gathered over the previous nine months. In all, 227, or 7.4%, of the 3,051 women who delivered in the county’s 13 maternity hospitals in September received no prenatal care.

More than 42% of them found their way to UCSD, the county’s traditional hospital of last resort. Forty-seven had their babies at Tri-City Hospital in Oceanside, and 25 delivered at Scripps-Chula Vista. In contrast, each of the 180 women who gave birth at Scripps-La Jolla had received prenatal care; just one of the 62 women delivering at Coronado Hospital was a no-care.

According to Key’s research, about 70% of the no-cares are illegal aliens. About 28% of all the no-cares came to UCSD directly from Mexico because they wanted their children to be born American citizens or, more frequently, because they did not trust the care they would receive in Mexican hospitals, Key said.

Perhaps more importantly, as many as 40% of the no-cares had been turned away from another county hospital within 24 hours of their arrival at UCSD, Key said.