A Long Road to Prenatal Medical Care

In a cramped Palmdale apartment, Andrea Williams wakes at 6 a.m. for a 10 a.m. doctor’s appointment. Her destination is Olive View-UCLA Medical Center in Sylmar, 40 miles and a bus and shuttle ride away. It is an all-day ordeal for Williams, who is eight months pregnant and who lost part of her leg to cancer as a child.

Because her pregnancy is high risk, she couldn’t find a doctor in the Antelope Valley willing to take her as a patient.

“I don’t like having to come to Olive View,” Williams, 21, said recently before setting off from her home in a wheelchair for the county-run facility. “But it’s the only choice I have. It’s the only way to check up on the baby and know he’s fine.”

Williams is not alone. More than anyplace else in Los Angeles County, pregnant women in the Antelope Valley confront hurdles that make it difficult to obtain high-quality care. As a result, authorities say, these women suffer disproportionate numbers of problem pregnancies, and their babies are nearly twice as likely to die in their first year as those in the county as a whole.

The problems are especially acute among African American women. Health officials are trying to pinpoint factors in the black community that might contribute to the higher rate of deaths, and have initiated outreach and education programs to improve babies’ chances.

The desert communities of Palmdale and Lancaster -- urban outposts in a region that stretches more than 2,200 square miles to the Kern County border -- are two of the fastest-growing cities in Los Angeles County. But the neat rows of new middle-class housing developments mask pockets of poverty, joblessness and crime.

Outside of those cities, the Antelope Valley is sparsely populated, with fewer than 250 people per square mile. The state considers the region rural for purposes of health planning, but the federal government recently reclassified it as urban, an action that renders it ineligible for federal healthcare dollars designated for rural areas.

County health officials say it is exactly this rural nature -- with the lack of convenient transportation and paucity of maternal medical services -- that is feeding high infant mortality. The Antelope Valley also has some of the highest rates in the county of tobacco use, obesity, adult and childhood asthma, and hypertension.

Studies show that poverty and being a minority heighten the risks of infant mortality. But experts also say that environmental and social conditions -- geographic isolation from family and friends, loneliness, brutally long commutes, few amenities such as grocery stores -- are taking a toll on pregnant women in the Antelope Valley.

“It’s really worrisome what’s going on up there,” said Michael Lu, a UCLA assistant professor who studies infant health. “We’re beginning to look at place-based studies: What is it about a neighborhood or community that promotes healthy births or increases the risk of premature birth? There are some studies linking the quality of air and water to bad outcomes. For some, though, it could be the lack of social support, social isolation.”

This is Williams’ first pregnancy. She and her boyfriend have been staying with a friend because they cannot afford their own place.

The apartment, on a rough west Palmdale street dotted with older, rundown houses, is crowded with roommates and offers little privacy, she said.

“Sometimes I pray, sometimes I cry,” she said. “Other times I try to not even be bothered with it, I try not to think about it.”

She is not sure what will happen after the baby is born. The couple have applied for low-income housing but have been told to expect to wait several months. Her mother, who lives with her grandmother and cares for Williams’ younger siblings, can offer little help.

Because it was hard for her to find prenatal care, Williams went four months without a checkup, which left her anxious. She is at high risk for complications because of her history of cancer and use of anti-cancer drugs.

Doctors have told her that her pregnancy is proceeding normally. But getting to and from the clinic has its own problems. She recently set out about 7 a.m. for an appointment three hours later in Sylmar and did not return home until after 2 p.m.

She took a shuttle that could accommodate her wheelchair from the hospital to Lancaster City Park and then had to catch a city bus home. During her appointment, Williams learned that Olive View will provide door-to-door transportation for her remaining clinic visits because she is a high-risk patient.

“It’s hard being on a bus and being eight months pregnant,” she said. “It’s definitely stressful. But there’s not a lot I can do to change things right now.”

The Antelope Valley’s infant mortality rate in 2003, the most recent year for which data were available, was 9.7 deaths per 1,000 live births, compared with 10.6 deaths in 2002. The countywide rate was 5.4 deaths per 1,000 live births, down slightly from 5.5 in 2002.

Forty-eight Antelope Valley infants died in their first year in 2003. The numbers are provisional, and health officials have not yet had time to study the circumstances of the deaths.

A review by the county Department of Health Services of the 53 infants who died in 2002 found that in 27 cases, babies were under 3 pounds and less than a month old at death. Six were born with infections, and 18 died because they were premature and not fully developed.

Nine of the mothers of these tiniest babies started prenatal care after their 12th week, and 17 reported feeling their neighborhoods were unsafe, feeling less happy during pregnancy or other stressful conditions.

“It seems to be an issue that women [in the Antelope Valley] are getting prenatal care later than other women in the county,” said Cynthia Harding, director of Maternal, Child and Adolescent Health Programs for the county.

Antelope Valley Hospital, in Lancaster, is the only hospital for 40 miles that has labor and delivery services and a level two (out of four) neonatal intensive care unit, meaning it can care for newborns who are delivered at 35 weeks or later. But because there are no higher-level neonatal units nearby, the hospital frequently delivers babies of fewer than 35 weeks’ gestation.

About 400 babies are born there each month, and about 20% of the pregnancies are high risk, meaning women are more likely to deliver preterm or low birth-weight babies.

About 30 women arrive each month to give birth having received no prenatal care, said Teresa Huester, administrative director of women’s and children’s health services at the hospital. Sometimes that’s because newcomers are looking for doctors late in their pregnancies, she said.

At Edwards Air Force Base, Huester said: “People may transfer into the area farther along in their pregnancy and may have difficulty getting a new physician. Many doctors don’t want to pick up a woman in the sixth month of pregnancy because they don’t know what might have gone on. High risk is so lawsuit-oriented.”

The hospital, a nonprofit institution funded by user fees and donations, has started building a women and infant center that will increase capacity from eight labor and delivery rooms to 15. It also is building private rooms for patients, adding obstetricians and gynecologists, and increasing educational services.

“We’re looking forward to a new concept in the Antelope Valley,” Huester said. She said the area has a fair number of women who travel to Los Angeles for prenatal care and to deliver, “mainly because of the nicer touches and amenities available.”

Linda Bowling has been a health outreach worker in the Antelope Valley for 15 years and has known many women to forgo prenatal care.

“Can you imagine the temperature is about 110 degrees and you’ve got to go see a doctor, and you’ve got to get on a bus? Come on,” she said.

Bowling works for the Black Infant Health Program, a county-funded Antelope Valley group created to support African American parents and pregnant women such as Williams, who is enrolled. The group is working to organize churches to use their vans to help women get health services.

One of Bowling’s jobs is to impress upon clients that such things as smoking, diabetes and hypertension may put their pregnancies at risk.

“Reality has not set in,” she said. “They are not making healthy choices and planning when they move up here and see how remote it is.

“Because the housing prices are rising in Palmdale and Lancaster, many move out to Lake Los Angeles, which is another 15 miles east, and there is nothing out there. When they go into labor, they have to call 911. Quite a few of my girls have had their babies in an ambulance.”

Audrey Price feared that might be her fate. When she had early labor pains while attending a community health forum in Littlerock, it took 25 minutes for an ambulance to reach her in the remote community east of Palmdale, and 20 minutes more to get to Antelope Valley Hospital. After being examined, she was released. On May 26 she gave birth to a baby girl at Antelope Valley Hospital.

Price, who has been homeless and in foster care, lives in Palmdale with her husband and his family, which includes three foster children. The couple receive welfare while her husband trains to become an emergency medical technician.

She has a 1-year-old daughter who was born with jaundice, and Price had a bacterial infection that put her baby at risk of infection or death during delivery.

“They definitely need more hospitals, more clinics,” she said, adding that she must often walk nearly half a mile from her house to the bus stop.

Ramin Samadi is the Antelope Valley’s lone perinatologist, a specialist in high-risk pregnancies. Women with diabetes, hypertension and infections, those who use drugs or smoke, as well as women older than 35, are at increased risk of going into labor early.

Samadi sees 25 or more patients a day, three days a week, at the low-slung bungalow at Antelope Valley Hospital that houses the perinatal unit.

Many women have had no prenatal care before stepping through his doors late in their terms, Samadi said.

But he is optimistic. Pointing to the bulletin board filled with snapshots of smiling mothers and children, he said more problems are being detected early, and more mothers are delivering healthy babies.

“It’s such a great feeling,” he said, “a fantastic feeling knowing that someone who has lost baby after baby now is able to carry to full term.”