Tragic Spiral : Prenatal Care: Less Costs More

They are fragile creatures who venture prematurely from the womb into the blazing lights and antiseptic world of the intensive care unit for newborns.

Their hands are as small as pennies, their heads no bigger than tennis balls. When they cry, they make no sound as they grimace and stretch, reaching vainly for the walls of the womb.

Each tiny body is wired to a respirator, heart monitor and a host of life-support apparatus fueled by a dozen electrical outlets. Their beds are the most expensive in the hospital, running about $2,000 a day in Los Angeles County public medical centers.

One in three of these infants could well have been born perfectly healthy--if only Los Angeles County had ensured that their mothers received adequate prenatal care. Instead, the county’s hospitalization costs for such sick infants are spiraling upward, while funds for preventive prenatal care lag far behind the growing need.

And the problem is worsening as more and more babies are being born to mothers in Los Angeles County who receive no prenatal care. Doctors say that good prenatal care consists of between 10 and 13 medical checkups beginning early in the pregnancy and includes tests that monitor the health of the mother and fetus.

At the county’s 39 public health clinics, record numbers of pregnant women are seeking medical attention. And while more than ever are getting checkups, more than ever also have been turned away or kept waiting for weeks for an appointment.

At some clinics, women must spend a whole day on the phone simply trying to get through to make an appointment. Many clinics are booked for weeks--and the wait can be as long as four months, one survey found.

“I know many women who can’t get an appointment until after their due date!” said Kathy West who surveyed 13 clinics for the Southern California Child Health Network.

Tremendous Cost

The tragic result is that more babies than ever are being born needing extraordinary medical attention--at an average cost 20 times higher than the prenatal care that might well have prevented their early arrival in the first place.

“By shifting more resources to prenatal care, it will pay off in reducing these long-term medical problems,” said Dr. Irwin Silberman, director of maternal health and family planning for Los Angeles County. “No one denies you’d save considerable money.”

The Institute of Medicine in Washington estimates that for every $1 spent in prenatal care, $3.38 can be saved in newborn intensive care costs. An additional $6 is saved when all costs associated with caring for permanently disabled children are included, according to other studies.

But political concerns, as much as medical considerations, determine public health funding priorities. And prenatal care has not become a pivotal political rallying point.

Meanwhile, dramatic medical advances are enabling doctors to save infants born as early as the fifth month of pregnancy, weighing little more than a pound.

The cost of rescuing these infants is astronomical. Across the nation, as much as $3.3 billion is spent each year in intensive care for infants, according to a study prepared last year for the American Academy of Pediatrics. The brunt of the expense is borne by the taxpayers. And this is expected to increase as a growing number of medically uninsured women find themselves unable to pay for either prenatal care or their babies’ medical bills.

The situation is especially acute in Los Angeles County, given the county’s financial crunch, its birthrate, which is 18% higher than the national average, its large population of poor women and the increasing percentage of women who receive no prenatal care.

About 10,000 babies a year are born seriously underweight in Los Angeles County, requiring intensive care to survive. At one public hospital in Los Angeles, the cost of keeping an uncommonly small infant on a respirator for 18 months came to $1.5 million. It costs about $36 million a year to operate newborn intensive care units in the county’s three biggest public hospitals. The county has set aside $15 million for prenatal care in its $1.3-billion health care budget.

Since 1981, when the county’s public clinics began charging fees of $25 for prenatal checkups, the number of women receiving absolutely no prenatal care during their pregnancies has almost doubled. And the percentage of women who began their care during the first critical trimester has declined. The sharpest drop--about 13%--has been among black women.

The most recent statistics compiled for the Los Angeles County Department of Health Services illustrate the close connection between poverty, lack of prenatal care and the high risk of babies being born seriously underweight or dead.

In affluent areas such as the Westside and Malibu, more than 80% of the pregnant women in 1985 began prenatal care during the first trimester. But in the poor neighborhoods of South-Central Los Angeles, where women are almost twice as likely to deliver premature or dead babies, less than 60% began prenatal care during their first trimester.

Countywide, about 2,100 women received absolutely no prenatal care during their pregnancies in 1985. And in six out of seven cases, these women delivered their babies at public hospitals, the institutions of last resort for the poor.

Babies born in the public hospitals are 33% more likely to be born dead or die within their first month of life than babies born at private hospitals, county statistics show.

Statewide Crisis

Earlier this year, the Southern California Child Health Network called attention to a statewide crisis in prenatal care, issuing a report that declared: “Babies in California are dying needlessly or being born with preventable health problems because their mothers do not receive adequate health care during pregnancy.”

The 183-page report asserted that providing prenatal care for the poor is “one of the highest-yield investments that taxpayers can make.”

It estimated that California could, conservatively, save up to $22 million a year in newborn intensive care costs by providing prenatal care to the 32,000 pregnant women statewide who now go without it. An annual savings of up to $256 million could be realized if the cost of future care to disabled children was taken into account.

The group pointed out that despite this, an increasing number of women throughout the state are receiving late or no prenatal care. And they linked this development to a recent rise in the number of babies who die during their first year of life. California, which once ranked seventh-best in the nation in preventing infant mortality, has fallen to 14th place, the group reported.

Wendy Lazarus, the director of the Southern California’s Child Health Network, said a recent national survey found that 25 states devoted considerable state resources to improving the health of mothers and babies; California was not among them.

She pointed out that several bills were passed by the Legislature this year that would have improved prenatal care in the state, but they were vetoed by Gov. George Deukmejian. He killed measures that would have provided a $1.8-million boost for health care of pregnant women, would have adjusted Medi-Cal requirements to encourage undocumented workers to seek care; would have eliminated fees at public clinics for medically indigent pregnant women; would have provided financial incentives to doctors for treating pregnant Medi-Cal patients, and would have boosted funding for pregnant teens by $2.5 million.

In veto messages, the governor contended that some of the bills interfered with local decision-making authority and that he was not persuaded that certain prenatal care programs were more deserving of additional funds than other budget priorities.

The head of health services for Los Angeles County, Robert Gates, said that he has not lobbied for state funds specifically earmarked for prenatal care but that he would welcome assistance from any source.

Gates said that a severe budget squeeze has prevented the health department from meeting the county’s mushrooming demand for prenatal care. And he pointed uneasily to forecasts that the birthrate at public hospitals--already operating over capacity--will jump 50%, up to 60,000 a year, by 1991.

Gates said he firmly believes in prenatal care “because it works,” adding that he thinks that it should be as high a health priority as AIDS. He pointed out that the county Board of Supervisors recently showed its support by allocating an extra $1 million to help reduce the backlogs at public clinics that provide prenatal care.

But Gates acknowledged that this money will not be enough to pay for an outreach program that many say is critical to educate thousands of women to the necessity and availability of prenatal care.

Doctors Frustrated

Dr. Carl Hobel, an obstetrician at Cedars-Sinai Hospital who has won acclaim for his pilot prenatal programs that target high-risk poor women, said the county must reach out to get more women into prenatal care. “The county is not interested in outreach,” he said. “But that is what they ought to be interested in.”

Among the doctors who work on the front line in the public hospitals delivering babies and caring for them, there is a good deal of bitterness.

“A week does not go by here . . . that I don’t see a baby whose outcome would not have been significantly improved if the mother had received prenatal care,” said Dr. James Padbury, a pediatrician in the newborn intensive care unit at Harbor-UCLA Medical Center.

An obstetrician at another public hospital said with exasperation: “The county has known for a long time about its deficient prenatal care, and they did nothing about it. The politicians divide the money in a way that gets the biggest bang, the most bucks, the most votes.”

Some prenatal care advocates assert that county leaders have shown a lack of interest, even callousness, toward poor women and their babies. They cite the slow progress made by a special county task force appointed more than two years ago to develop a long-range solution to the prenatal care dilemma. A report the group has been preparing is now long overdue.

Critics point out that the very title of the group betrays an insensitivity to the whole problem at hand. Technically called the Systemic Obstetrical Task Force, it is commonly referred to by members and in minutes as the S.O.B. Task Force.

Gates said, “I didn’t make up the name, but I’m certain no malice was intended.”

As for the impact of the task force so far, Dr. Richard Paul, head of obstetrics at County-USC Hospital, said, “I can’t see that it’s had any (effect) whatsoever.”

Medical experts agree that prenatal care is not a fail-safe guarantee for healthy babies. They say that whether babies live or die depends upon a variety of factors, including the quality of the hospital care during delivery and after birth, as well as the mother’s prenatal care during pregnancy.

They also point out that certain racial groups tend to have better birth outcomes than others. Latino babies born in Los Angeles County, for example, fare substantially better than white babies and much better than black babies, statistics show. Studies conducted over the years have tried to ferret out why, without arriving at hard conclusions. But one thing the studies do confirm is that, overall, prenatal care helps.

Women who get no prenatal care during their pregnancies, studies show, are three times more likely to have seriously underweight babies than those who do. Babies weighing less than 5.5 pounds are 40 times more likely to die during their first month of life and five times more likely to die during their first year, according to the March of Dimes.

It is estimated that about half the 1,400 infants who died last year in Los Angeles County before reaching their first birthday probably succumbed to factors associated with their low birth weight.

Lifelong Handicaps

Of the infants who survive, some suffer from cerebral palsy and mental retardation or other lifelong handicaps, said Dr. Silberman, the county’s maternal health director. “You have thereby acquired a ward of the state for the rest of his life-- and that is not cheap.”

A Children’s Hospital study of infants admitted to neonatal intensive care units throughout California concluded that one-third of the admissions could have been avoided if the mothers had received adequate prenatal care. The study focused on those 10,000 to 13,000 infants during a single year whose bills were paid by Medi-Cal, at an average cost of $19,000 each, and a total annual cost of $70 million.

For several reasons, low birth-weight infants put an especially big strain on the publicly funded Medicaid system.

Mainly, this is because they are most likely to be born to low-income, minority and adolescent women, whose bills are reimbursed, in large part, through Medicaid.

Even if the mothers are not U.S. citizens and therefore technically ineligible for Medicaid, their babies become U.S. citizens at birth, entitled to coverage.

Poor Suffer Brunt

At Cedars-Sinai Hospital in Beverly Hills, which caters mainly to patients with private insurance, a small percentage of the pregnant women who deliver babies there are poor or minorities enrolled either in Medi-Cal or the Cigna Health Maintenance Organization. But their babies make up a disproportionate two-thirds of the preemies in the hospital’s newborn intensive care unit, hospital neonatologist Dr. Jeffrey Pomerance said.

“We’d never fill the NICU (newborn intensive care unit) if we waited around for Beverly Hills babies,” he said. “Beverly Hills women have fewer premature babies, partly because of the superior medical care they undoubtedly receive, better nutrition, and better education about when to suspect a problem and when to intervene.”

The Cigna Health Maintenance Organization has recently tried to improve birth outcomes among its pregnant patients by targeting high-risk patients for intensive prenatal care. Dr. Robert Bragonier, chairman of Cigna’s obstetrical department, said the effort has already paid off by reducing neonatal intensive care costs by $1 million during a one-year period.

“It shows that doing what is right is also cost-effective,” said Bragonier, who formerly worked as an obstetrician for the county health department.

Prenatal care for pregnant women used to be free at the county’s public health clinics. In 1981, the county started charging fees for prenatal visits, and health advocates have tried unsuccessfully since then to get the fees abolished.

County health officials said it is unrealistic during the current budget crunch to expect the fees to be lifted. Also, they insist that there is no proof that fees are a significant deterrent to women needing care. And furthermore, they said, the county’s policy is not to charge those patients who show they are indigent.

But major studies, including a recent report by the General Accounting Office of the Congress, have concluded that for poor women in need of prenatal care, financial barriers are a major obstacle.

Researchers from the UCLA School of Public Health who recently conducted a study of 250 Los Angeles County women who received no prenatal found that “it was mainly an economic reason that they got no care,” project director Lynn Kersey said.

The study pointed out that many women apparently do not know that the fees for prenatal care at county clinics would be waived if they could show they are indigent.

The study focused on women who delivered babies at Los Angeles County-USC Medical Center during a four-month period this year.

According to the study, 46% of the women said economic barriers prevented them from getting prenatal care. Another 32% cited “organizational” difficulties that included trouble in scheduling appointments, not knowing where to go for care, or having no child care for their other youngsters. About 17% displayed “attitudinal problems,” the study reported, including drug or alcohol problems, or lack of knowledge that prenatal care was necessary.

Of the 250 women who received no prenatal care before delivery, more than 13%--or 33 of them--had low birth-weight babies.

It is these small infants, born to mothers without prenatal care, who make up a significant percentage of the babies being treated in the costly newborn intensive care units at the county’s public hospitals.

Impact Is Dramatic

At Martin Luther King Jr. Hospital in Watts, the impact is dramatic.

One in five women who deliver babies there receive no prenatal care, said Dr. Ezra Davidson, head of obstetrics.

One morning last month, 19 infants were under treatment in the newborn special care nursery. Eleven of them had been born to mothers who got no prenatal care.

Dr. Xylina Bean, a hospital neonatologist who has dedicated herself during the last 15 years to saving tiny infants like these, led a tour of the nursery while making blunt, forthright introductions:

“This one here has syphilis. Every organ has been damaged. That one has Down’s syndrome and heart disease. He’ll probably live, but he’ll be a pain. Over there is a leftover triplet. One of them died and another has brain damage. . . . Over there, that one was born at 520 grams with about a 10% chance of survival. It was supposed to be an abortion. Instead we got this. It’s big enough for us to work with. . . .”

Times Medical Writer Harry Nelson contributed to this story.

PRENATAL CARE AND PERINATAL DEATHS These 1985 figures from the Los Angeles County Department of Health Services show by district areas the percentage of women receiving prenatal care and and also the mortality rates for babies born dead or who die within a month. The figures tend to show a correlation between high perinatal death rates and poor prenatal care.

% Who Began Newborn Prenatal Care Deaths Per District in 1st Trimester 1,000 Births 1. Southeast 49% 19.3 2. South 51% 22.0 3. Compton 58% 17.2 4. Southwest 60% 21.6 5. Central 60% 15.4 6. San Antonio 60% 11.6 7. East Los Angeles 66% 9.7 8. Northeast 66% 9.7 9. Hollywood-Wilshire 67% 14.4 10. El Monte 69% 12.6 11. Long Beach 70% 13.1 12. East Valley 71% 12.5 13. Pasadena 71% 10.5 14. Pomona 73% 10.7 15. Inglewood 74% 16.9 16. Bellflower 75% 15.9 17. Whittier 75% 10.0 18. Harbor 76% 14.9 19. San Fernando 77% 11.0 20. Alhambra 77% 15.4 21. Foothill 77% 12.2 22. Glendale 79% 11.0 23. West Valley 80% 11.2 24. Torrance 81% 9.9 25. West 83% 14.2