IS THE LACK OF HEALTH-INSURANCE THE MAJOR BARRIER TO EARLY PRENATAL-CARE AT AN INNER-CITY HOSPITAL

The reasons for delayed or no prenatal care are multifactorial and ran ge from poor access to many socioeconomic factors. Therefore, it is li kely that even with health insurance available to all patients, many w ill not present for early prenatal care. Prenatal care is considered a dequate when it begins in the first trimester of pregnancy and continu es on a regular basis every 4 weeks until 28 weeks, then every 2 weeks until the 36th week, and then weekly thereafter.(1) The amount of pre natal care should vary depending on the risk status of the pregnant wo man.(2) In the United States, approximately 5-6% of all pregnant women do not seek prenatal care until the 3rd trimester or obtain no care.( 3) Another study showed that in 1988, 24% of women did not receive pre natal care in the first trimester of pregnancy; specifically for black women, 40% did not receive care in the first trimester, and 11% recei ved little or no care during pregnancy. Inadequate prenatal care is as sociated with poor pregnancy outcome and with a greater number of mate rnal and fetal complications.(4) A strong association has been found b etween poor prenatal care and low birth weight infants, neonatal morbi dity, and infant mortality. The infant mortality rate of the United St ates ranks 21st among industrialized countries.(5) Low birth weight (< 2,500 g) is a major determinant of infant mortality. This is a major h ealth burden as each low birth weight infant can cost $400,000 over a lifetime. Every delivery of a low birth weight newborn that is prevent ed would save the U.S. health care system $14,000-$30,000.(6) Prenatal care is also cost effective; ''for every dollar spent on care for low -income, poorly educated women, $3.38 direct medical expenditures can be saved from caring for low birth weight infants during their first y ear of life.''(7) It is therefore apparent that the key to decreasing infant mortality rates lies in early prenatal care. Cramer reported th at the infant mortality rate is higher in teenagers, unwed mothers, an d mothers of low socioeconomic status.(4) To target this group for bet ter prenatal care, the question must be addressed: What are the barrie rs to early prenatal care in these groups? Brown organized three main categories: sociodemographic, system related, and attitudinal. Sociode mographic categories consisted of minority status, poverty, age, marit al status, education, area of residence, high parity, and being non-En glish speaking. System-related factors included health system provider s and such factors as under-funded public health departments, lack of transportation, and being unable to find health providers who accept M edicaid. Attitudinal factors included such factors as unplanned pregna ncy, indifferent attitude toward prenatal care, inadequate social supp orts or personal resources, failure to notice the signs of pregnancy, and fear of parental discovery.(3) However, Young et al stated that in ability to accept the pregnancy was the most frequently reported reaso n for delayed care.(8) Other reasons included lack of knowledge about pregnancy, misguided attitudes, and drug abuse, which were equally as important as access to prenatal care services.(7) Haas et al showed th at access to prenatal care actually declined in Massachusetts over the 5-year period of their study despite wide provision of health insuran ce to the poor.(9) They therefore concluded that financial access to c are is not the only answer to surmount the multiple problems and issue s of poverty. The goal of this study was to determine if the availabil ity of health insurance as reported by women who delivered at an inner -city hospital is the major barrier to early prenatal care, as compare d to other barriers.