In December 2018, Congress passed a bill authorizing $60 million in funding over the next five years to support and create maternal mortality task forces in all 50 states. The goal of their research is to prevent maternal morbidity across the United States, one of only two developed countries with rising maternal death rates.
The passage of this bill is an important step on the path toward improving pregnancy outcomes and marks a good time to revisit the major problems facing pregnant mothers in the United States and solutions for lowering risk.
While maternal death can occur at any time during pregnancy up to a year postpartum, studies have shown that one key factor in improving outcomes is directly tied to prenatal care. To take one example, mothers who have received no prenatal care have a higher risk of death from preeclampsia or eclampsia than women who have received any level of prenatal care.
For patients with high socioeconomic risk (PDF), this can prove a death knell, as many Medicaid and low-income patients do not receive adequate prenatal care—yet these are the patients who need it most. Early prenatal care is essential for women who are at elevated risk of poor birth outcomes, such as women who smoke, are low-income, have poor nutritional status, are HIV-positive, or have other serious health problems prior to pregnancy—situations which, while not exclusive to the Medicaid population, are often more pervasive in these patients.
Reformers and innovators have primarily focused on providing these patients with easier access to care—with the no-show rate for appointments considerably higher for Medicaid patients. Some practices report no-show rates up to 40%, making it an obvious contributor to poor outcomes. However, in focusing efforts on this one particular problem, there is a danger of losing sight of other equally important factors contributing toward Medicaid disparities, such as quality of visits and access to useful information.
Imagine a Medicaid mother who has overcome all of the obstacles to receiving prenatal care—she’s taken two or three buses to an appointment, found childcare for children at home or taken them with her, maybe she’s suffered a loss of income or possibly a job from missed work hours. She’s overcome all of these obstacles only to spend a short time with her doctor, receive a thumbs-up and then sent on her way. She might do this 12 to 14 times over the course of her pregnancy.
This isn’t a hypothetical. Medicaid mothers are overcoming these challenges on a daily basis in order to give their children the best care available, and in Washington, D.C., where 85% of the Medicaid population is black, the problem can often be further compounded by implicit racial bias.
Tanazia Matthews, a young African-American mother from Washington, D.C., confronted all of these obstacles as a pregnant teenager and never missed a prenatal appointment. Now in her work as a caregiver at the Healthy Babies Project, she advises young mothers to travel whatever distance necessary to receive proper obstetrical care.
Time for a new model of care?
For mothers such as Matthews and the teens she advises, the no-show rate is not the problem. We need to focus on what happens when these mothers do show up to their appointments. How effective is access to prenatal care if providers are wedded to an outdated model?
The status quo, a 14-visit model recommended by the Institute of Medicine in the 1970s, has long been due for an overhaul, but while studies have shown that a decrease in the number of visits has no negative effect on outcomes, the rates of patient satisfaction go down with the number of visits—a reality that is continuing to wed systems to an outdated template against recommendations.
And how can the standard, one-size-fits-all visit offer enough time for a provider to understand all of the obstacles that Medicaid mothers are encountering in their daily lives? There is no room for conversations about clinical issues, no time for understanding the psychological challenges that low-income patients may be experiencing.
Yet when the greatest challenge to use of prenatal care is building women’s trust, a relationship between provider and patient is of paramount importance—it can be the difference between attendance and a no-show.
Imagine a model of prenatal care where there are fewer visits but higher quality visits. A model that meets people where they are—that doesn’t disrupt their lives for the simple purpose of checking a box. This model is the only way to address the diverse patient population.
Nancy D. Gaba, M.D, professor and chair of obstetrics and gynecology at the George Washington School of Medicine and Health Sciences, is a longtime advocate for tailoring prenatal care to the needs of the patient, with a goal of improving the patient’s sense of value and quality of care. “Patients need to know that we are committed to partnering with them to provide safe, evidenced-based obstetrical care,” Gaba said. “We need to be willing to change our traditional model to meet the needs of women. This means not only providing information and medical treatments but also making time to really listen and address their issues and concerns.”