By Deborah Stokol
Images by P. Kim Bui
As long as she is pregnant, a woman living in the United States may receive medical care. So even the homeless, the undocumented, “the tired [and] poor,” may visit a doctor while expecting.
Yet for the inhabitants of Los Angeles County, health continues to accompany wealth. L.A.’s southernmost areas sustain the highest rates of premature births, gestational diabetes and hypertension in the county.
Every pregnant woman residing there may attain prenatal care, but for many, that is either not enough to reverse years’ worth of physical negligence, its acquisition still does little to provide them with the attention they need or they do not seek that care in the first place.
The number of preterm births in the country has increased 20 percent since 1990.
While older women using In Vitro fertilization and overweight women are at high risk for early labor, African American women are most likely to give birth prematurely. That likelihood increases for those African Americans living in lower income areas like those in South L.A.
Many have disputed the reasons behind this phenomenon.
Some academics fault society, calling institutionalized racism the leading factor behind the stress and destitution adversely affecting these women’s pregnancies.
Others claim pollution insidiously complicates “confinement.”
Certain public health workers pin it on the difference in quality between the care a woman on Medi-Cal receives and the one she would have with Kaiser or with private insurance.
But while hospital and clinic doctors may have little reason to question or criticize the prenatal care given these women, they have joined the city’s public health department in citing other culprits.
They say it’s not necessarily the quality of care these women face that compromises their health or their baby’s, but such malaises as chronic poverty-wrought stress, non-compliance with medical schedules, family structure or the lack thereof, sexually transmitted diseases and poor nutrition.
In order to have a healthy baby, then, they say a woman must attend to her physical well-being long before she becomes pregnant because care, while incredibly important, comes too late.
:::: Care Received: More Functionally Analogous than Irrevocably Different?
(Click into the image to play with the numbers)
Medi-Cal is California’s branch of Medicaid, the health program the country provides for low income, low resource families.
Both the Centers for Medicare and Medicaid and the California State Department of Health Care administer Medi-Cal.
And under the program’s “Presumptive Eligibility for Pregnant Women,” any woman pregnant, with an annual income below roughly $11,000 may receive walk-in prenatal care and any prescription drugs needed as a result of her pregnancy.
Presumptive Eligibility does not include labor and delivery, and those do not have Medi-Cal but wishing to attain it—those uninsured and/or undocumented—must fill out an application for the service.
Once the applicant has submitted the form, the program sends her a temporary Medi-Cal card, good for two months. Medi-Cal requires this step that a women believing herself pregnant see a doctor in order to receive a pregnancy test.
Should she test positive, she must then present her results to Medi-Cal, after which the program will verify that she is financially eligible to use its services. Once its representatives have done so, they will send her an official Medi-Cal Beneficiary Identification Card (BIC) to use while pregnant.
But Watts Health Care Center’s Chief of Obstetrics & Gynecology’s Dr. Deirdre Logan said that “many of the woman do not open their mail and miss the 60 day cut off.
“Even with an extension,” she added, “a lot of women…who are on welfare and are otherwise uninsured…still don’t apply.”
A Federally Qualified Health Center (FQHC) located on Compton Avenue, Watts Health Center receives financial support from the government under the section 330 grant of the Public Health Service Act. FQHC’s Web site explains the grant exists in order to fund organizations “provid[ing] care to underserved populations.”
The clinic’s health educator, Marcela Rodriguez, explained that those who do apply and receive the Medi-Cal-sponsored prenatal care for which they are eligible, may visit the doctor once a month for the first six months of the pregnancy.
During the given woman’s third trimester, Rodriguez continued, she may see a doctor twice in the seventh and eighth months and once a week during her ninth. Medi-Cal’s prenatal care plan grants its subscribers health education, prenatal vitamins, lab work, diabetes testing, screening for birth defects and ultrasounds.
Clinica Monsenor Oscar A. Romero has three branches and is also a Federally Qualified Health Clinic. One site situated in East L.A. directly across from L.A. County Hospital, its doctors attend to those generally uninsured and only able to speak Spanish.
Sandra Rivera, its prenatal case manager, said Oscar Romero turns no one away.
“If they come in,” she said, “they won’t be denied. Even if a woman comes in 36 weeks pregnant and has received no other care, we’ll see her.”
In a sense, hospitals adhere to the same M.O. as does the clinic.
Even though Medi-Cal and its Presumptive Eligibility do not cover labor and delivery, and many of these women have no other insurance, no hospital may refuse care to a woman in labor.
But most women neither know that nor feel it their best option. Clinics such as Oscar Romero and the Watts Health Center match their patients to hospitals nearest the women (such as L.A. County, UCLA Harbor or St. Francis Hospitals), or those that maintain a partnership with the clinic and offer these women care (e.g. Inglewood’s Centinela Hospital).
- Using Kaiser, then Private Insurance
Sarah Tuttle-Singer, 27, a pregnant woman with one young child who lives in West L.A., used both Los Angeles’ and Oakland, Calif.’s Kaiser for her first pregnancy and now has Blue Cross.
During her first pregnancy, she “had a lot of complications early on with a lot of bleeding, and I was at risk for preterm labor.
“[But with Kaiser,] you can’t just call up the doctor for the appointment,” she said. “You need to call the appointment line, and they assess whether you need to be seen. And the nurse was very good about getting me an urgent care appointment.”
She explained that Kaiser held an element of inconsistency she did not find unpleasant.
“You didn’t always see the same doctor—which was not a problem for me,” she said. “But it might be for others.”
When stepping into the waiting room, she felt “it was a very egalitarian process that includes difference ethnicities and levels of affluence.
“From what I could tell,” she continued, “we were all receiving good care. Kaiser is fantastic, but there is a different kind of attention you get with private insurance.”
She said she found the waiting room of the physician she now visits tending toward the homogonous Caucasian. She explained how it is “more expensive than with Kaiser as there is now an 80/20 co-pay.
She has received the results of every one of her tests the same day, while “the draw back with Kaiser is that there’s a longer wait time for results.
“We had a 4D video taken of the baby and could see his face and watch him moving like a real person,” she added. “You don’t get that with Kaiser as far as I know.”
:::: Other Factors
Map: Premature births and prenatal care by county. Click in to play with the numbers.
Health Center professionals and the U.S. Department of Health and Human Services indicated that while prenatal care was invaluable to these women and their unborn children, attending to such factors as stress, STD’s, nutrition and the pursuit of the care were as, or more, important.
Both Watts Health Center’s Dr. Logan and St. John’s Dr. Laura Reynard explained that stress could lead a woman to deliver early. And women living in Watts, Logan said, are under a lot of stress.
Many of these women single mothers and many of those on welfare, Logan also said “they’re worried about killings and drive-by-shootings, and all that [concern] can induce preterm labor.”
She said sexually transmitted diseases and infections could lead to preterm birth as well.
And in 2006, the U.S. Department of Health and Human Services released a study titled “Healthy People 2010 Midcourse Review,” breaking down the various areas within Los Angeles by such topics as respiratory disease, obesity, sexually transmitted diseases, cardiovascular disease and food consumption, among others.
The study named each general area a “service planning area” or SPA, and Watts belonged under the heading of SPA 6. Glancing at the charts revealed Watts embodied the gravest level of every category.
Thirty-nine percent of the Watts, Compton population is younger than 17, while 37 percent of the area’s “population lives below the Federal Poverty level.” Of that number, 44 percent are younger than 17-years-old.
Though L.A. County sustains 315 chlamydia cases per 100,000 people, Watts sees 1,022. While L.A. County encounters 74 gonorrhea cases per 100,000 people, Watts faces 407.
Within the area, 28.9 percent of children in fifth, seventh and ninth grade are obese, while 35.4 percent of the adults are as well. Consuming sugar-rich fast foods, 12.3 percent of SPA6 has diabetes, 37.9 percent of who die from the condition.
Eating inexpensive foods with too much salt can lead to hypertension, or high blood pressure. And 29 percent of SPA 6 have been diagnosed with hypertension. It may lead to both heart disease and stroke, 217.6 SPA 6 inhabitants per 100,000 die each year from the first, 51.9 from the second.
Nearly 75 percent of any given 1,000 births in the area come from girls within the ages of 15 and 19; for any given 100 live births, 8.5 percent concern infants with a low weight (less than 2,500 grams). Fourteen percent of babies born to African American women in the area have a low weight. Most of the infants survive, but they are far less healthy than they would otherwise be.
All of these numbers indicate that these situations are the worst in the county.
The statistics describing nutritional habits and smoking are concerning as well.
More than half of SPA 6’s children eat fast food “at least once a week;” more than half of the adults “drink at least one soda or sweetened drink a day” and more than half of the children do the same. Nineteen percent of the adults smoke cigarettes as well.
And 11.8 percent of SPA 6 live births come from mothers who received late prenatal care—or none at all.
:::: Look not for Blame Elsewhere (i.e. On-Paper Care Standards may be Deceiving)
But Cordelia Hanna-Cheruiyot said she felt the care women on Medi-Cal received sup-par, and no on-looker should be misled by what may seem like otherwise “standard care” and lofty principles.
A Pasadena Public Health Department Black Infant Health Program community service representative, Doula, certified childbirth educator, certified birth assistant, assistant midwife, certified health education specialist and masters in public health and health education and Promotion/Maternal Health, Cheruiyot said “the comprehensive Medi-Cal program seems like a very good program in design, in theory and on paper, but how it is [put to use] leaves a lot to be desired.”
She emphasized “people think good care means measuring vitals and the growth of the baby and having the visits, but that’s only adequate in one sense—in terms of the physical care of the women. A holistic model includes the optimal wellbeing of the body, mind and spirit…the patient’s psychological well-being.”
Cheruiyot explained that she felt the women had been robbed of the opportunity to make pregnancy-related choices.
“One of the greatest differences between the types of care I saw while working at a Medi-Cal clinic is that the patients did not receive informed consent,” she said.’’
In medicine, informed consent means a physician will give the patient necessary facts about a certain test or treatment, and that patient must then knowingly decide whether he or she wishes to undergo the test or treatment based on that information.
Informed consent exists that patients have the right to make decisions regarding their own bodies and health. But leaving the patient the option to make that decision without first explaining the stakes only arms that individual halfway. He or she could make the choice, but it would not be an informed one.
“The greatest disparity I saw between the types of care,” Cheruiyot said, “is that women on Medi-Cal didn’t even know they had the right to ask questions.
“The providers aren’t taking the time to fully educate someone about the pro’s and cons, advantages and disadvantages, risks and benefits [of a procedure]—based on the patient’s values and needs,” she continued. “The woman must be allowed to make an informed choice, free from coercion, free from bias, in language and terms she can understand, and that doesn’t happen very often there.”
In Cheruiyot’s estimation, calling the patients non-compliant and making a decision for them is an “excuse. That gives [care-givers] carte-blanche to do what [they] want, and that’s unethical in my point of view. A vaginal birth, for example, is 99 percent safer for the mother and the baby, yet doctors have convinced many of the patients to have Caesarians.
“Some doctors at small clinics will tell their patients ‘you’ll go to the hospital for your induction,’ but she’s at 37 weeks, and they’re sending her to be induced? Why is it not safe for her [to wait]?” She said. “There’s no reason given, and these women on Medi-Cal are disempowered, ignorant and don’t have the information they need to prevent their care-givers from taking advantage of them.”
One of the richest countries in the world, the United States ranked No. 30 in 2005 for its rate of infant survival.
“We get this idea that childbirth is perilous, and we need highly trained specialists to help that,” she said. “But the way we conduct childbirth in this country perpetuat[es] that.
“You can literally take a perfectly healthy woman, put an epidural and pitocin in too early, keep her in the bed, and you’ve created a ripe environment for fetal distress,” she continued. “Fetal distress would not [otherwise] be common on its own.”
But Cheruiyot says many take such measures because they want to speed the birthing process up for convenience purposes.
“The doctors in hospitals are seeing a large volume of patients as well, and these are 15 minute prenatal care [sessions],” she said. “It’s a baby factory. They get pushed through the system, and the clock [keeps] ticking.”
Yet even with her criticisms of the care women using all forms insurance receive, Cheruiyot emphasized the most important way to ensure healthy birth outcomes was to keep the women healthy before they became pregnant.
“You get [the patient]—at best—for seven months, and you see her nine times,” she explained, “that’s not enough to make an impact. She needs to have [less stress] before she gets pregnant.”
:::: Pollution as Malefactor: Yes, Care: No
This year, UC Irvine Epidemiology Department Assistant Professor in Public Health Jun Wu joined five other university researchers in publishing a study that showed women living near traffic hubs sustained a higher risk of preeclampsia and of delivering their babies early than did those living in areas with less air pollution.
Titled “Association between Local Traffic-Generated Air Pollution and Preeclampsia and Preterm Delivery in the South Coast Air Basin of California,” the study looked at 81,000 people living in such southern state areas as Los Angeles County and Orange County.
It found that whether wealthy or impoverished, in possession of private or public health insurance, Caucasian, Hispanic or African American, women residing in those areas had 42 percent higher chance of preeclampsia and preterm birth.
The study’s supplemental materials divide the researcher’s subjects by race (Hispanic, White, African American, Asian and Other), insurance type and socioeconomic background, among other lines.
The majority of those living in the study area were White and possessed private insurance (e.g. 2,175 Whites v. 891 African Americans in one graph and 3,990 individuals using private insurance compared to 2,481 with public in another).
But Wu said that despite the “larger sample size,” statistically speaking, the “results overlapped if [the researchers] do data analysis by public or private insurance.
“There are not many differences [between the two],” she added, clarifying that what affected the study women’s health was not the type of insurance they had or prenatal care they received but whether they lived near fume-rich thoroughfares.
:::: Next in Line: Education
Toward the beginning of November, the Los Angeles Times published an article stating Kaiser planned to open a 15,000-square-foot building in South L.A. within the next two years.
The $10 million structure would provide “primary care, specialty care and other services” to the “80,000 members of the healthcare organization in the area.”
The Times wrote many of South L.A.’s inhabitants greeted the announcement with enthusiasm, celebrating Kaiser’s increased presence in the area with a gospel choir performance.
In addition to what should be more robust site-specific healthcare, L.A. Best Babies Network and within it its Best Babies Collaboratives, links 100 or so individuals to “caregivers” seeking to improve women’s health in between pregnancies as well as during.
But if poor care comprises only one part of the potential factors behind unhealthy births, and if it may not be the factor most influential, Dolores Magana and others in her position will have their hands full.
Assistant Principal at Watts-bound Los Angeles Thomas Riley school, Magana watches over 180 pregnant teenagers.
Along with McAlister and Ramona High Schools, Thomas Riley offers a high school curriculum to high school-aged girls who are pregnant. All three of them LAUSD schools, Magana states the “only difference between our school and others’, generally speaking, is that we cater to [the students] because of their condition.”
She added “we have parenting classes, but most schools have that too.”
Though neither Magana, the school’s nurse nor its teachers could force the students to seek proper prenatal care, eat healthfully and take the precautions that would prevent their catching STD’s, she said they do their best by “forcing the students to bring proof of pregnancy” in with them before enrolling.
Magana explained the school requires that proof because it lets her, the nurse and the teacher know that the girl had to go to a doctor to acquire the note and that she had begun to “receive medical care.”
Just across the street, Watts Health Center presents a convenient healthcare station for the students. After that initial proof of pregnancy and a doctors slip OK-ing or not OK-ing PE class, Magana said the schools begs “no [further] documentation, but the teachers are constantly asking them about their ‘appointments,’ and the nurses are too.”
She added that dearth of prenatal care posed a far smaller problem than did the girls’ nutrition and their health—unrelated to the pregnancy.
“A lot of them have health issues like STD’s, asthma and kidney infections,” she began, “yet…in my experience, most of the girls take care of business and follow up on their appointments. But my belief is that the majority of the girls don’t comply with eating the right things.”
She said the school does what it can, but even that action does little by way of health benefits. And a balanced diet will need to be a point of concentration.
“We provide them with the basic LAUSD school lunch, and we have to adhere to the nutritional guide provided by the government. But a lot of that food is high in fat and low in nutritional value.”
She said the girls—some of who have their own health insurance, others of who receive their own Welfare or that of their parents’—“are healthy in the sense that they look healthy, but their [diet] leads to high blood pressure.
“A lot of them load up on salt: potato chips, Cup of Noodles, Gatorade,” she said. “They think that’s healthy.”