Primary Care

Programs to improve timely prenatal care should not focus solely on uninsured and Medicaid-insured women

Recent efforts to improve prenatal care in the United States have focused on expanding Medicaid maternity care programs for poor "special needs" mothers. Health care planners have often assumed that programs to improve prenatal care use are needed only by the public sector and by providers serving large numbers of uninsured or Medicaid-insured women. Yet a new study shows that low income, even among privately insured women, is strongly associated with untimely prenatal care (first visit after the first trimester or no prenatal care), and that a substantial proportion of privately insured childbearing women are poor.

In one of the largest and most comprehensive population-based studies of childbearing women to date, Paula Braveman, M.D., M.P.H., of the University of California, San Francisco, and her colleagues conducted a State-wide survey of women giving birth in California during 1994 and 1995. Their work was supported in part by the Agency for Health Care Policy and Research (HS07910). They compared prenatal care use among women in different income groups and income-insurance subgroups and explored barriers to prenatal care.

The researchers found that nearly two-thirds (65 percent) of the women delivering babies in California during this time had low incomes. As expected, nearly all women (96 percent) with Medi-Cal (California's Medicaid program) had low incomes, but one-third (35 percent) of privately insured women also had low incomes. Most of the women in both groups received their prenatal care at private-sector sites.

Overall, 32 percent of low-income women had untimely prenatal care. Among poor women (0 to 100 percent of the Federal poverty level), 38 percent insured by Medi-Cal and 25 percent with private coverage had untimely prenatal care. Among the near poor (101 to 200 percent of the Federal poverty level), 24 percent of women with Medi-Cal and 14 percent with private insurance had untimely care. Among privately insured, moderate-income women, only 8 to 12 percent had untimely care.

These findings clearly indicate that low-income women are the mainstream maternity population, notes Dr. Braveman. Thus, programs and policies aimed at improving the timely use of prenatal care should include all low-income women, not only those who are uninsured or Medicaid-insured women.

See "The prevalence of low income among childbearing women in California: Implications for the private and public sectors," by Dr. Braveman, Susan Egerter, Ph.D., and Kristen Marchi, M.P.H., in the June 1999 American Journal of Public Health 89(6), pp. 868-874.

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