PU685 Unit 5 Prenatal Care Access Study Example

Eighty-One Percent Within Half an Hour, Sixty-Two Beyond an Hour: A Unit 5 Prenatal Care Access Study Sorting 3,980 Rural Birth Certificates by Drive Time and Payer, and Saying What the Certificates Cannot See

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Purdue University Global

PU685: Issues and Concepts in Maternal and Child Health

Unit 5 Prenatal Care Access Study

[Instructor Name]

[Date]

The five-county region, its births and its drive times are composite; the measures, the data source limits and the research cited are real.

Question and Setting

The region's five counties hold about 61,000 residents and two hospitals with obstetric units, both in the eastern counties. Planners want to decide where to put a satellite prenatal clinic and whether to fund transportation. The study asks how timing and adequacy of prenatal care vary with drive time to the nearest obstetric unit and with payer, among the region's births in 2022 to 2024.

Methods

Data come from 3,980 birth certificates for residents, using the items for the month prenatal care began, the number of visits and the expected source of payment. Drive time from each mother's residential address to the nearest hospital with an obstetric unit was computed with a road network and grouped into under 30, 30 to 60 and over 60 minutes. Two measures were used: first-trimester entry, and the Adequacy of Prenatal Care Utilization index, which combines the timing of entry with the share of recommended visits received for the length of gestation and classifies care as adequate plus, adequate, intermediate or inadequate (Kotelchuck, 1994). Candidly, the source has limits. The month care began is reported at delivery, sometimes by the mother from memory and sometimes from the prenatal record, and completeness varies by hospital; in this region the item was missing for 2.6 percent of births, which were excluded. The certificate also cannot see pregnancies that did not end in a live birth, so women whose pregnancies ended earlier, possibly including some who had no care at all, are outside the study. National reports using the same items describe the same strengths and limits (Osterman & Martin, 2018). Birth certificates measure access only among women who reached a live birth, which means the study's worst figures are probably not the worst ones in the region.

Findings by Drive Time

1. Under 30 minutes: 2,310 births. First-trimester entry 80.9 percent. Care beginning in the third trimester or not at all, 3.1 percent. Adequate or adequate plus by the utilization index, 76.8 percent.

2. Thirty to 60 minutes: 1,090 births. First-trimester entry 73.0 percent. Late or no care 5.4 percent. Adequate or better 68.2 percent.

3. Over 60 minutes: 580 births. First-trimester entry 62.5 percent. Late or no care 9.4 percent. Adequate or better 55.9 percent.

The gradient is steady across all three measures. Women farthest from obstetric care were three times as likely as the closest group to begin care late or not at all.

Findings by Payer

1. Medicaid: 1,830 births, first-trimester entry 66.0 percent.

2. Private insurance: 2,000 births, first-trimester entry 88.1 percent.

3. Self-pay and other: 150 births, first-trimester entry 38.0 percent.

The Two Together

The far counties have more Medicaid births, so a simple comparison by distance partly measures payer and a comparison by payer partly measures distance. Crossing the two separates them. Among Medicaid births, first-trimester entry was 72.4 percent within 30 minutes, 63.0 percent at 30 to 60 and 54.1 percent beyond an hour. Among privately insured births, it was 90.3, 86.2 and 79.0 percent. Distance matters within each payer group, and payer matters at every distance. The lowest group, Medicaid births beyond an hour, began care in the first trimester barely half the time.

Pathways

Travel time. A visit that takes a two-hour round trip costs a working woman half a day, and the region has no public transit. National evidence shows what greater distance can mean: when a rural county lost its last hospital obstetric unit, the following year brought, in counties not adjacent to urban areas saw increases in births in hospitals without obstetric units, in out-of-hospital births and in preterm births (Kozhimannil et al., 2018). Appointment availability. The two obstetric practices report a three-week wait for a new obstetric visit, so a woman who calls at eight weeks may not be seen until eleven. Medicaid enrollment timing. Women who become eligible for Medicaid because of pregnancy often wait for enrollment before booking care. The state allows presumptive eligibility at qualified providers, but neither eastern practice is enrolled as one, and the western counties have no qualified provider at all.

What the Study Suggests

A satellite clinic in the far western county, staffed for prenatal care two days a week, would bring 580 births a year within 30 minutes. Enrolling both practices and the satellite as presumptive eligibility providers would address the enrollment delay. Transportation vouchers would help women who must still travel for ultrasound and delivery. The crossed results suggest the first two together would do more than either alone. Each option also carries a cost the planners can weigh: the satellite needs a clinician two days a week and a lease, enrollment as a presumptive eligibility provider needs mainly staff training, and vouchers cost little but help only women who already have an appointment.

What the Planners Should Watch After a Change

If the region opens a satellite clinic and enrolls presumptive eligibility providers, the same birth certificate measures can track the result, and the study recommends deciding now what success would look like. The clearest signal would be first-trimester entry among Medicaid births beyond an hour rising toward the level of Medicaid births within thirty minutes, from about 54 percent toward 72 percent, over two to three years. A second signal would be a fall in late or absent care in the far group from 9.4 percent toward the nearer groups' figures. Because annual counts in the far group are small, about 190 births a year, single-year changes will be noisy, so the planners should compare pooled two-year periods and report confidence intervals. A third measure, the wait for a first obstetric appointment, can be checked monthly by calling the practices as a new patient would, which gives an early warning long before the birth certificates catch up.

Limits

The study is cross-sectional and cannot show that distance causes later entry. Residential address at delivery may differ from address in early pregnancy. Adequacy indices penalize women whose care began late for reasons other than access, such as an unrecognized pregnancy. Finally, the study cannot count women who sought care and were turned away, which is precisely the experience planners most need to hear about, and a short survey at the region's emergency departments and family planning sites would add that missing view.

References

Kotelchuck, M. (1994). An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. American Journal of Public Health, 84(9), 1414-1420. https://doi.org/10.2105/AJPH.84.9.1414

Kozhimannil, K. B., Hung, P., Henning-Smith, C., Casey, M. M., & Prasad, S. (2018). Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA, 319(12), 1239-1247. https://doi.org/10.1001/jama.2018.1830

Osterman, M. J. K., & Martin, J. A. (2018). Timing and adequacy of prenatal care in the United States, 2016. National Vital Statistics Reports, 67(3). National Center for Health Statistics.