Nevada ranked second-worst in prenatal care

Thursday, Jan. 30, 2003 | 11:15 a.m.

It came as no surprise to some local physicians when a new study released this week ranked Nevada second-worst in the nation when it came to mothers who received late or no prenatal care in 2000.

The problem, they say, can be attributed to any number of factors, including the difficulty low-income pregnant women have getting Medicaid, accessing prenatal care programs and finding obstetricians to handle their pregnancies.

Nevada's dubious ranking -- ahead of only New Mexico -- was contained in a report on birth trends in 2000 that was prepared by Child Trends in Washington and Kids Count, an initiative funded by the Annie E. Casey Foundation in Baltimore.

In a ranking of the 50 states and Washington, D.C., Nevada also rated poorly when it came to under-educated and unwed mothers and pregnant teenagers who had children.

"This is not surprising to us," Dr. John Nowins, president of the Clark County OB/GYN Society, said Wednesday. "This is why we met with the governor on Sept. 18 to discus HMO/Medicaid."

The report revealed that 8.5 percent of Nevada mothers received late or no prenatal care two years ago, more than double the national average of 3.9 percent. Nevada had been 45th in that category in 1990 at 8.1 percent, compared with a national average of 6.1 percent.

But while the percentage of mothers with late or no prenatal care has been on a steady decline nationally, Nevada's 2000 percentage rose sharply from the 6.7 percentage rate the state logged in 1999, when it ranked 48th. Las Vegas likewise saw its ranking plummet among the nation's 50 largest cities in the same category, from 33rd and 5.9 percent in 1999 to 41st and 7.5 percent in 2000. The top 50-city average in 2000 was 5.3 percent.

Part of the problem with prenatal care in Nevada is that many pregnant women do not know how to access the medical system or programs such as the state-sponsored Baby Your Baby referral service. So says Janice Vandenbergen-Smith, director of the Center For Healthy Families at Sunrise Hospital and Medical Center.

"Getting the word out is a problem," she said. "There are a lot of things we could help with if they knew we were here. We can help teens who don't know how to access the system.

"We have husbands who come to this state with jobs but their insurance won't kick in for three months. With the medical malpractice issue there are a number of doctors who won't take clients late in their pregnancy because of the increased liability."

Charles Duarte, Nevada's administrator of health care financing, conceded that the poor ranking in prenatal care has much to do with the state's stringent eligibility requirements for Medicaid, a medical insurance program for low-income recipients that relies on state and federal funds. In many cases, it takes pregnant women up to 90 days to gain eligibility, making it too late for them to receive adequate prenatal care.

In 2001, the Nevada Legislature approved funding that would have allowed more pregnant women to become Medicaid-eligible and would have made it easier for them to prove their eligibility instead of forcing them to dig up paperwork on their assets. But then the state was hit with a budget crisis and the money was not spent.

Duarte said Gov. Kenny Guinn's budget proposal for the next biennium includes $1.17 million for fiscal 2004 and $2.78 million for fiscal 2005 to expand Medicaid eligibility while also making it easier for applicants to prove their income levels.

"The current policy is probably the single biggest factor in delayed prenatal care for our recipients," Duarte said. "The Legislature has already stated its intent. The only issue is money. I'm hopeful this will be implemented, but it boils down to dollars."

But Nowins and fellow Las Vegas obstetrician Dr. Robert Comeau said that another big hurdle is the Medicaid health maintenance organization program the state launched in Clark County in 1997, which now has an enrollment of 1,300 pregnant women. The state, which has contracted with Sierra Health Services and Nevada Care Inc. to run the HMOs, launched the program to save money.

Nowins and Comeau said, however, that they and many other obstetricians who used to deal with Medicaid patients directly refuse to participate in the county's two Medicaid/HMOs because they say it is a struggle to get pre-authorization from the insurers to perform various tests and services. They also said the HMOs force patients to see particular doctors and go to certain hospitals, which also restricts access to care.

"Because of the Medicaid/HMOs the access to prenatal care has gotten worse," Comeau said. "The ideal thing would be for doctors to participate in the care of the underserved through regular Medicaid like it was done in the past.

"The OB/GYN Society has been trying to warn state officials for four years that poor prenatal care would occur if they ignored us."

Comeau said he was particularly perturbed that the state appears to want to save money on the front end through the Medicaid/HMO system.

"Every dollar spent on prenatal care saves $2 to $10 in neonatal care," he said.

But Duarte said the state has 67 obstetricians enrolled in one Medicaid/HMO and 63 in the other program -- some doctors serve both HMOs -- and has not experienced a shortage of prenatal care for its pregnant recipients.

"One of our primary goals is to make prenatal care more readily available but it's not a Medicaid/HMO problem," Duarte said. "It's a Medicaid eligibility problem."

The March of Dimes planned today to kick off a new, five-year, $75 million Prematurity Campaign to educate women about the symptoms of births that occur before the 37th week of pregnancy and to increase research to identify causes of premature births. The March of Dimes, a national volunteer health agency, reported that the annual rate of babies born prematurely has risen by 27 percent nationally since 1981.

Among the scheduled speakers at the announcement at Sunrise Hospital were Ward and Laurie Travis of Las Vegas, parents of 22-month-old twin boys who were born nine weeks premature. Laurie Travis said she received good prenatal care and that her doctors don't know why her sons were born premature.

But she said that she and her husband, both of whom serve as federal probation officers, have good jobs and health insurance plans that pregnant teenagers and single parents often don't have.

"If you don't have good insurance, it's hard to get good prenatal care," Travis said. "If you're a single mom, you may not have the time to take off work to go to an appointment for prenatal care."

Another scheduled speaker, Dr. Philip Reidel, medical director of the Sunrise Neonatal Intensive Care Unit, said that other problems that contribute to poor prenatal care in Clark County include lack of transportation and day care for low-income pregnant women.

Reidel said that many premature births are caused by poor prenatal care.

"There are some poor, unmarried females who live in parts of town where they don't have the means to get to a clinic," Reidel said. "Sometimes you have a teen who is pregnant who can't come to a clinic because they have no child care."

Of the eight categories ranked in the Child Trends study, Nevada's ranking improved from 1999 to 2000 in only one category, the percentage of births of less than 5.5 pounds. The state saw no change in its ranking in three other categories and ranked worse in four others.

Among the top 50 cities, Las Vegas' ranking improved slightly in the categories of low-birthweight babies and percentage of preterm births, but declined in six other areas.

Among other categories in the study:

Las Vegas ranked 29th among cities in 2000 in the same category, 27.7 percent compared with 27.4 percent nationally. The city ranked 26th in 1999.

Las Vegas also dropped in rank from 20th in 1999 to 28th in 2000. In 2000, 23.8 percent of teen births in the city were to women who were already mothers, compared with a 50-city average of 22.7 percent.

Las Vegas fell from 14th in 1999 to 17th in 2000 but at 37 percent was below the top 50-city average of 43.4 percent.

Las Vegas fell from 11th to 14th but at 12.1 percent was below the top 50-city average of 13.8 percent.

Las Vegas slipped from 25th in 1999 to 27th in 2000 in the same category. The city had 10.5 percent of its births to mothers who smoked during pregnancy, higher than the top 50-city average of 9.6 percent.

Las Vegas moved up one notch to 30th in 2000 from 31st in 1999 among the nation's top 50 cities. But at 12.9 percent in 2000, Las Vegas was still above the top 50-city average of 12.7 percent in this category.

Las Vegas also improved to 14th in 2000 after ranking 15th in 1999. In 2000, 7.2 percent of the births in Las Vegas involved low-birthweight babies, compared with 8.7 percent among the top 50 cities.

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