UNDERSTAFFED N.C. CLINICS BLAMED FOR BABY DEATHS
Tuesday, January 2, 1990
Section: MAIN NEWS
Page: 1A
By PAM KELLEY And BRUCE HENDERSON, Staff Writers
Inadequate staffing at public health clinics is a major reason North Carolina has the worst infant mortality rate of the 50 states, according to a new study. ``We found that medical staffing of family planning and prenatal care clinics is woefully inadequate,`` said Dr. Bret Williams, a doctor who conducted the study as a post-doctoral project at the UNC-Chapel Hill School of Public Health. ``I knew it was going to be bad. I knew how brisk the increase in demand had been, but it was worse than I thought.`` Williams surveyed public health clinics in North Carolina`s 100 counties about the prenatal and family planning services they offer poor women. He found that 12 county health departments offered no services and that 85 percent of the clinics devoted less than 10 hours of doctors` time a week to such care. Many, especially in rural counties, offered their services only three or four hours a week. ``Hardly ever are they open evenings. There`s only one or two in the state to serve working women,`` he said. ``The message is that indigent care is underfunded,`` Williams said. Though his study doesn`t examine funding, Williams speculated funding should rise by a third or a half to accommodate the demand for prenatal care. The volume of prenatal care patients using N.C. public clinics has risen 30 percent in the past four years, he said.
Preliminary figures for 1988 - the most recent year available - show North Carolina`s infant death rate of 12.7 deaths per 1,000 live births is the highest in the 50 states. That was the second straight year North Carolina`s rate rose. Only the District of Columbia has a higher rate, with 22.8 deaths per 1,000 live births. In December, Gov. Jim Martin appointed a a 27-member commission to attack the problem. ``We cannot and will not let our babies continue to die,`` he vowed. Williams said he hopes to give that committee his findings. His study was paid for by the nonprofit N.C. Poverty Project, based in Greensboro. He says policymakers have tried to tackle infant mortality by increasing Medicaid money. But that tactic is ineffective, he said, because many private doctors won`t accept Medicaid patients.
In 25 of North Carolina`s public clinics, pregnant women must wait three to eight weeks for an appointment. That figure alone understates the problem, Williams said. If more women were educated about the need for prenatal care, he said, ``those clinics would be twice as crowded.`` Though health officials know patient education should be a priority, many clinics have too few employees to attempt it. ``That`s really a sad state of affairs,`` Williams said.
The Mecklenburg County Health Department staffs half-day prenatal clinics each week at seven sites around the county. Department officials are working on a chronic problem - that it takes much longer to get an appointment at some clinics than at others. That wait can take as long as four or five weeks at the Billingsley Road clinic, said the department`s Rebecca Oliver, or as short as two weeks at the Huntersville clinic. To cut the waiting time, the department plans to start adding nurses to pregnancy testing times at the Billingsley and Beatties Ford road centers, she said. The nurses could immediately begin work-ups - such as blood tests and medical histories - of pregnant women instead of forcing them to return for separate appointments. ``Our goal is that at all clinic sites, we reduce the waiting period to no more than 10 working days,`` Oliver said. Oliver heads the department`s maternity care coordination, a five-member staff of nurses and social workers who help pregnant women with day-to-day problems that indirectly affect prenatal care - finding transportation and child care, buying a crib. ``What we`re doing is looking at this whole area to see what we can do,`` health Director Betty Snow said. Williams, the study`s author, advocates increasing education and generally making it easier for pregnant women to get to the clinics - by offering free transportation, several clinic locations and evening hours, for instance. ``I feel very strongly there are good people in public clinics working hard,`` he said. ``The problem is not that they`re inadequate. Their numbers are inadequate.``
The 12 N.C. counties that don`t offer prenatal clinics are Alleghany, Chatham, Clay, Durham, Forsyth, Graham, Harnett, Hyde, New Hanover, Pamlico, Pender and Transylvania. However, four of those - Chatham, Durham, Forsyth and Harnett - are home to other low-cost clinics.
Clinics In The Piedmont
N.C. Health Departments:
Alexander County: (704) 632-9704. Prenatal appointments available within a week.
Anson County: (704) 694-5188. Prenatal appointments available in one to two weeks.
Burke County: (704) 433-4250. Prenatal appointments available within two weeks.
Cabarrus County: (704) 786-8121. Financial eligibility screening required in person, 8-10
a.m. and 1-3 p.m. weekdays.
Prenatal appointments available in three weeks.
Caldwell County: (704) 396-3163 in Granite Falls, (704) 757-1219 in Lenoir. Prenatal
appointments available within two weeks.
Catawba County: (704) 328-2561. Prenatal appointments available within three weeks.
Charlotte Memorial Hospital Maternity Clinic: (704) 355-2192 for financial eligibility
interview. Once qualified, (704) 355-2186 for prenatal appointment, available within a
week.
Cleveland County: (704) 484-5150. Prenatal appointments available in three to four weeks.
Gaston County: (704) 853-5001. Prenatal appointments available in seven to eight weeks,
although high-risk patients would be worked in sooner.
Mecklenburg County: (704) 336-6500. Prenatal appointments available in two to six weeks,
depending on which of seven clinics you choose.
Iredell County: (704) 878-5314 or (704 )873-7291, or from Mooresville, (704) 663-1163.
Appointments required for financial eligibility screening, available within a
week. Prenatal appointments available three weeks later.
Lincoln County: (704) 735-3001. Prenatal appointments available within four to five weeks,
but only after women have qualified for Medicaid, a process that can take 45 days.
Rutherford County: (704) 287-6100. Appointments for eligibility screening available in a
day or two. Once qualified, prenatal appointments available in two weeks.
Stanly County: (704) 982-9171. Prenatal appointments available in two to four weeks.
Union County: (704) 283-3815. Prenatal appointments available in two to three weeks.
S.C. Health Departments:
York County: (803) 324-7521. Prenatal appointments available in four weeks.
Lancaster County: (803) 286-9948. Prenatal appointments available within two weeks.
Chester County: (803) 385-6152. Prenatal appointments available within a week of calling.
Chesterfield County: (803) 632-2117 in Chesterfield, (803) 537-2113 in
Cheraw, and (803) 672-6561 in Pageland. Prenatal appointments available within 10 days of
calling.
A $4.5 MILLION GOOD START EXPANDING MEDICAID COVERAGE WILL HELP SAVE BABIES
Sunday, January 14, 1990
Section: EDITORIAL
Page: ED
Gov. Jim Martin`s proposal to expand state Medicaid coverage for pregnant poor women is a smart investment that the General Assembly will surely endorse.
By investing $4.5 million from the state and $800,000 from the counties, North Carolina can get an additional $10.7 million in federal Medicaid funds. That`s a $16 million boost to this state`s struggle to reduce its infant mortality rate - the nation`s worst. The expanded program would enable an estimated 3,800 women under age 21 to buy prenatal services.
There is no silver lining without a cloud, of course. One reason many women who are pregnant and poor don`t get prenatal care is lack of money. But another is lack of services, and expanding Medicaid benefits won`t necessarily expand services. The task of serving women covered by Medicaid falls primarily on county health clinics because most private physicians won`t accept Medicaid patients - particularly pregnant Medicaid patients. Why not? Because fears of malpractice suits and other concerns have sharply reduced the number of N.C. physicians who will deliver babies. And Medicaid doesn`t pay as much as most doctors usually charge for deliveries. So the job falls to the public clinics, and they don`t adequately serve the women they`re seeing now - at least that`s what the people who run them say.
Dr. Bret Williams of the UNC School of Public Health recently surveyed the state`s 100 county health departments and found that three out of four clinic directors believe the prenatal care they offer is inadequate. In about a fourth of the counties, women have to wait at least three weeks for their first prenatal appointment. ``If you have to wait a month, it`s easy for your first appointment to fall in the second trimester of pregnancy,`` Dr. Williams said. ``That alone establishes that the care is inadequate.``
Ironically, many clinic directors say they have increased prenatal services by cutting family planning services. If the number of women seeking prenatal care increases, and the number of providers doesn`t, the inadequacy will be even worse. And that will make it even less likely that the clinics will be out searching for women who are truly medically needy - those who now get no prenatal care at all. Many of the 1,227 N.C. babies who died before the first birthday in 1988 (the most recent statistics available) were victims of poverty, ignorance and isolation. The infant mortality rate, in fact, is an indicator of the woeful inadequacy of health services for many of our citizens, old and young, particularly the rural poor. Solving those problems will take money and ingenuity from all levels of government and the public over a long period of time. But it`s important to begin by doing what can be done now. Expanding Medicaid to cover more pregnant women is a good start.
FOR BETTER PRENATAL CARE, SUBSIDIZE FAMILY DOCTORS`INSURANCE
Thursday, February 8, 1990
Section: VIEWPOINT
Page: 17A
By CHRIS HOOD, Special To The Observer
The malpractice insurance problem - which results in physicians trained for but unable to provide prenatal and birth services - forces pregnant women in rural North Carolina to choose between long-distance health care or none at all. Doctors` insurance costs, which have risen six-fold in six years, are the reason why. The result is that 40 percent of our state`s qualified family physicians have quit the battle against infant mortality and associated post- birth medical problems.
A November 1989 report by UNC-Chapel Hill`s Health Services Research Center identifies 22 rural counties that until recently completely lacked physician- provided prenatal care. Those counties were helped by a $730,000 state-funded, three-year insurance subsidy for doctors enacted by the N.C. General Assembly. But the approved funding, under the N.C. Rural Obstetric Care Incentive Act (ROCI), helped only 52 doctors last year, ROCI`s first. And more physicians applied than could be covered. Those not receiving aid were willing to practice in 20 more needy, rural counties. That gap between funds and need is called by Dr. Tom Ricketts, co-author of the UNC report, ``a cut in the expectation that the funding could entice physicians to resume their obstetrical practice.``
The original subsidy bill requested three times the amount the legislature eventually adopted. Ricketts and his co-author, Richard Langholz, stated that to succeed an insurance incentive needed sufficient funding and a long-term commitment from the state. Thus, the ROCI response to the malpractice insurance problem in rural counties, like its effect on infant mortality in those counties, will be partial at best. Moreover, ROCI provided no aid for women and their doctors in the rest of the state, where an overburdened obstetric care system adds to North Carolina`s infant mortality crisis.
Proposals for solving the statewide problem, such as Gov. Jim Martin`s $16 million prenatal-care plan for teenage mothers, do not address the needs of hundreds of family physicians who were forced out of the baby business by high insurance costs and who won`t receive subsidy aid under current ROCI funding. Family physicians, whose specialty is treating all family members, not just pregnant women, earn the lowest incomes of all doctors. So high insurance costs strike them hardest, and first, and in nonrural as well as rural areas. Obstetricians, who specialize in prenatal and birth services, won`t fill the rural-urban gap, because they cannot practice where lower doctor incomes make their insurance unaffordable. Rural practice pays much less than urban practice, and not enough obstetricians are available even in urban areas. But family physicians sidelined in the pregnancy-care crunch could join the fight against infant mortality if we helped them. Urge your legislators to expand ROCI. An insurance subsidy for family physicians throughout the state would increase access to obstetric care and make it more affordable. And save the rest of us money, too. Proof for those benefits comes first from N.C. Insurance Commissioner Jim Long. In addition to grim infant death statistics, Long explained in 1988, the lack of prenatal care also results in health problems in surviving babies who burden public and private health insurance systems, many for the rest of their lives. Gov. Martin also made that point in his recent proposal.
Next, the governor`s own call for increasing Medicaid coverage for teen mothers would be made more effective. Dr. Bret Williams, author of the definitive study of the infant mortality problem, recently stated: ``It doesn`t matter if a pregnant teenager has insurance if she has no place to go.`` Teens need access to care the same as pregnant women in rural areas, and Williams` report shows that both teens and adult women across our state find obstetric care hard to come by. And as an expanded insurance subsidy provides access to Medicaid patients, it would lower costs for other pregnant women, those privately insured, who choose the family physician for treatment. Obstetricians are more expensive. Finally, a comprehensive subsidy would require less money than Gov. Martin`s $16 million plan. Obstetric insurance for as many as three family physicians in each of the 78 counties not currently receiving aid would add less than $5 million to ROCI`s current cost. Taxpayers spend hundreds of millions on patient insurance coverage, Medicaid and private combined, and doctor training at state medical schools. So why not spend a little more on an inexpensive plan to make available the cost-effective obstetric care family physicians can provide? Our abysmal infant mortality ranking would improve in the bargain.
Chris Hood is a senior at UNC-Chapel Hill majoring in interdisciplinary studies and is an intern in the office of Sen. Terry Sanford.
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