S.D. County Faces a Crisis of Fewer Services for More Needy Pregnant Women

Every month in San Diego, about 225 women in active labor take the longest walk of their lives--the one where they will discover if they are too late to give their babies a fighting chance at a good life.

For, instead of being full of the promise of a cuddly newborn, the babies may be entering the world too soon, and will spend weeks attached to tubes in an intensive care unit. They may be brain-damaged because their oxygen supply was cut off during early, unattended labor. Or they may have birth defects, preventable if their mothers had seen a physician during pregnancy.

It is a problem that is getting worse in San Diego County, not better, said Kim Warma, coordinator of the Regional Perinatal System sponsored by three area hospitals. She confirmed the thrust of a statewide report issued Tuesday by the Southern California Child Health Network, but said she has seen indications recently that women are having more difficulty finding doctors.

“San Diego, next to L.A. County, really has the worst access problem in the state, because we don’t have enough providers” of care for poor, pregnant women, Warma said. “What’s happening is we’re getting more and more people and we don’t have more and more services.”

Numbers Are Increasing

From May, 1987, through January, 2,011 babies were born in the county to women who had received no prenatal care, according to figures kept by Warma. The monthly number of such mothers increased from 180 in May to 242 in January.

“That in itself says something is changing. I can definitely see a trend. And now we’re heading into summer, which is our busiest time for babies. So I’m a little concerned that we’re going to hit 300 a month,” Warma said.

A 1984 UC San Diego Medical Center study of such babies showed they are 2 1/2 times more likely to spend time in the intensive care unit than babies born to women who have been cared for by a physician throughout their pregnancy.

Costs for such stays can run into tens of thousands of dollars--contrasted with about $1,500 for prenatal care--Warma said.

The Child Health Network study reported that the number of San Diego obstetricians willing to care for Medi-Cal patients dropped from 37 in 1984 to 14 in 1987. Yet there are about 8,000 such women annually who need prenatal care, Warma said. They just can’t find doctors who will care for them, she said.

In 1987, an estimated 5,000 pregnant women were

turned away from San Diego County prenatal care clinics, according to the study.

“The two-class system that’s developing is going to get worse,” Warma predicted. “Right now, if you’re wealthy you have a range of providers; you can go anywhere you want. If you’re poor and you can’t find someone, you’re just plain out of luck.”

The problem, said Dr. Ira Goldstein, is that doctors simply can’t afford to take Medi-Cal patients. Goldstein chairs the county Health Services Advisory Board.

Medi-Cal will pay $657 for a woman’s prenatal care, delivery and a follow-up visit, Warma said. But doctors need $1,200 to $1,300 to cover their own rapidly rising costs, so they are dropping out of the Medi-Cal field, Goldstein said.

One of the largest costs of being an obstetrician is medical malpractice insurance, which has risen from an average of $10,946 in 1982 to $37,015 in 1987, according to a survey by the American College of Obstetricians and Gynecologists. Faced with such bills, one out of every eight obstetrician/gynecologists has stopped delivering babies altogether, not just those of poor women, the group reported earlier this month.

Pressed also by more stringent rules in other reimbursements, such as from Medicaid and private insurers, doctors no longer can bail out the state by providing free care for poor mothers-to-be, said Dr. Nathan Harrison, president of the San Diego Gynecological Society.

Yet everyone agrees that women need such care if they are to have healthy children, he said.

“The travesty is that it’s morally not right--and that no one on the government side has done anything about it,” Harrison said. “The government has to decide that it’s going to provide the care, or figure out how to provide it without paying for it.”

Not solving the problem is economically short-sighted, Warma said, because society’s costs don’t necessarily stop when a baby who was born in distress is released from the hospital. She noted that such children can end up with lifelong learning disabilities that don’t show up until they get to school.

“Are those kids going to be happy, healthy, functioning members of society, or are they just going to be a drain to their families and their community because we couldn’t be progressive enough to say pregnancy is a condition for which everybody should have care?” she asked.

She and the physicians said the problem could be solved in two ways: by increasing Medi-Cal reimbursement rates and by somehow capping the awards that parents can get in malpractice cases when something goes wrong during a delivery.

The Child Health Network study found that San Diego County rates of newborn deaths and deaths of children in the first year of life were slightly below the state average, but Warma warned against taking comfort in those figures. They were based on 1985 statistics, she noted, and the number of pregnant women without medical care has increased since then.