Barriers to Prenatal Care
Dr. Naomi Newton, an Emergency Department doctor, wrote a good article for MedPage on “Prenatal Care Shouldn’t Begin in the ED.” As an obstetrician who has been in the emergency room more times than I can count over the past 45 years, I can tell you that Dr. Newton is correct. Prenatal care also should not end in the emergency room (ER). How does prenatal care get buried in the ER?
Dr. Newton describes a young woman she saw in the ER for vaginal bleeding and severe pelvic pain. Dr. Newton learned that the patient had recently found out she was pregnant, but was unable to afford prenatal care. Dr. Newton was surprised to hear the patient had been evaluated in another ER a week earlier. All she learned from the previous ER visit was that the patient had been reported to have been in her “first trimester,” a very vague description of her stage of her pregnancy. The ER should have been able to estimate how many weeks pregnant she was. Dr. Newton found out the patient had been “discharged without obstetric follow up because she was uninsured.”
Pregnant women without access to healthcare for lack of insurance are standing in the middle of a healthcare glut which payers, including our federal government, attempts to control the cost of healthcare by depriving patients of needed care. This attitude is grand folly on many levels. In the first place, it doesn’t save money. What’s worse, the denial of access to healthcare for a large portion of pregnant women contributes to the dubious distinction of the U.S. having the highest maternal mortality rate of any developed country. Many other developed countries have maternal mortality rates of 1 or 2 per 100,000 births. You might ask how this could be.
First, many pregnant women are uninsured and therefore surrounded with this glut of healthcare they cannot access. If a pregnant woman has insurance and can access prenatal care, the second problem is to connect with competent, considerate, appropriate medical care. Many areas of the U.S. are obstetric deserts. A competent obstetrician may be over a 100 miles away. Then there is now the shadow of state abortion laws hovering over every physician treating miscarriages. So, when you throw these three situations into the mix, patient care suffers.
Dr. Newton is correct. Pregnancy-related care should not be so difficult to find. When I was a resident 45 years ago, the emergency department doctors were required to call gynecologisgts to the emergency room for all female problems.
When a woman was released from the ER, necessary pregnancy care follow-up was provided. There were obvious advantages to following up a visit to the ER by a pregnant woman. Certainly, the first one was to get an accurate diagnosis and correct treatment. The most likely diagnosis for the patient Dr. Newton describes was probably an intrauterine infection associated with a late first trimester or early second trimester of pregnancy. This infection, which could be treated at the time of the ER visit, could develop into a miscarriage if left untreated.
Appropriate treatment might have been able to not only save the baby, but also to safeguard the mother’s health. Early and timely intrauterine infections are hard to identify and that’s precisely the reason you should call the on-call obstetrician when a patient with these symptoms appears in the ER. In order to achieve this diagnosis and treat it correctly, you need to have a high index of suspicion and many times you have to place more emphasis on the mother’s history and presentation then on the actual pelvic examination.
There would be some lab signs of the infection problem. These could be an elevated sedimentation rate or an elevated C-reactive protein (CRP), as well as possibly an elevated white count. The correct diagnosis and treatment at the time of the first ER visit by an on-call obstetrician might have saved the baby.
The patient is in the ER, but it is unreasonable to send this patient home with no follow-up plan. Having no insurance is no excuse not to provide needed care. The “treat and street” ER mentality has no place with pregnant women who appear in the ER. And although healthcare might not be as simple or work as well as it did 45 years ago, it shouldn’t mean the patients must walk the “medical plank” at the time of discharge from the ER.
Today, many hospitals have a hospitalist obstetrician available 24/7. The obstetric hospitalist should be able to arrange follow up obstetric care and connect the patient with social services to get Medicaid. Most pregnant women who enter the ER uninsured are eligible for Medicaid. Connection with a social service agent to arrange for Medicaid could be done either by by the obstetric hospitalist, someone in the ER, or a call to the social worker.
If the pregnant woman in the ER has no insurance, someone in the ER should start arranging for Medicaid coverage. If the pregnant woman in the ER has an obstetrician, call the obstetrician and ask them to come in to see the patient. I presented thousands of times to the ER to see my patients. That way they got somebody who knew their history, knew of their ER visit, and could provide follow up. If this kind of care doesn’t exist in our healthcare environment today, it should. This worked well for the patient and saved an enormous amount of healthcare dollars by preventing unaddressed medical problems from becoming very expensive complications later on.
The healthcare world I practiced in years ago had no shortage of doctors who felt they were called to medicine, called to taking care of people much in the same way that priests feel they are called to work. Our environment was full of doctors who felt they had a moral and ethical responsibility to establish a patient relationship, to respect it, to guard it, and to maintain it. We had layers of ethically driven healthcare providers who would pick up the pieces, even if the first provider failed to do so.
As much as I have a love affair with the past, I can remember a particular group of doctors who did not want to see their obstetric patients before 12 weeks of pregnancy because they didn’t want to go through the work of starting a new chart at six weeks if the patient was going to miscarry at eight weeks. I caught a lot of those patients as a result of their attitude. I saw every newly pregnant patient as soon as they called and that was precisely so that if they miscarried, I could be there with them. I have always recognized the soul-wrenching anguish associated with pregnancy loss at any time. I wanted to be there with them to guide them through the darkest hours.
Prenatal care needs to begin when pregnancy begins.
No excuses.