Timely Diagnosis of Pregnancy
Lack of Sexual and Reproductive Health Information and Awareness
Lack of sexual and reproductive health information and awareness was perceived as an important underlying factor interfering with timely diagnosis of pregnancy and STDs. In Caddo Parish, participants asserted that strong cultural taboos against speaking openly about sex and the state’s abstinence-only sex education policy leave many young women unprepared to recognize the signs and symptoms of pregnancy or STDs. The parish was described as a place where sexual health is rarely discussed, in school or at home, and where health care providers “rarely do anything below the belt.” Consequently, many young women are unaware of measures to prevent either STDs or pregnancy. Young women may not immediately realize they are pregnant and may not be aware of the importance of prenatal care. A local high school visited by the assessment team reportedly had 50 to 60 pregnant students, many of whom were far along in their pregnancies before they initiated care. In a teen mothers’ support group observed by the team, girls aged 13 to 17 years all had children of their own. “No one talks about this thing—no one wants to go there,” said a participant. “People want to talk about bullying, alcohol—that’s hot. But pregnancy and STDs, they’re taboo.”
Discontinuities in Coverage and Lack of Preconception Health Care
Participants described how a patchwork of coverage types, some with varying criteria for eligibility, left some women uninsured and without health care during critical childbearing years. For example, in 2011, female adolescents were covered under Louisiana Children’s Health Insurance Program (LaCHIP); however, this coverage ended at age 19 years, when they “age out” of coverage. “There are gaps in services,” said a participant. “Patients can be on birth control with Medicaid and not have to pay. But then they turn 18 and are off Medicaid, and they can no longer afford it. It is heartbreaking to think they can’t afford US $50 per month for birth control.” Although some women were eligible for reproductive health services under Take Charge, the state’s family planning waiver program, not all providers accepted Take Charge. A participant explained that although women diagnosed as pregnant could become eligible for the state’s LaMOMs program, which provided pregnant women with comprehensive health care, “6 weeks postpartum, they’re completely cut off.” These discontinuities and disruptions in health coverage and care meant that poor women often had no usual source of care and little opportunity for preconception care or pregnancy planning.
Timely Initiation of Prenatal Care
Difficulty and Delays in Finding Prenatal Care Providers
Timely prenatal care is usually defined as care that starts in the first trimester (0–13 weeks). In the best-case scenario, the sooner a pregnancy is diagnosed, the sooner a woman and her provider can begin monitoring her pregnancy. In addition to general lack of awareness about sexual health and lack of a usual source of care, participants reported that finding prenatal care was often challenging for poor women due to a dearth of referral points; a shortage of prenatal care providers accepting Medicaid patients; and a situation that occurs when delay in initiating care escalates into a crisis of being unable to obtain any prenatal care at all.
At one time, Caddo Parish had several public prenatal care clinics, but by 2011, most had closed down due to the loss of block grant funding. The last remaining prenatal care clinic, located at the Parish Health Unit, closed permanently during the week of the assessment. Participants lamented the loss of this clinic because it meant that the only remaining option for poor women was the university medical center clinic, which was repeatedly described as overburdened, with appointment waiting times that routinely stretched for several hours, and waits for appointments that could sometimes take months. Many women, participants said, would forego using this clinic because they were unable or unwilling to endure the long waits and would choose to seek care only during emergencies.
Finding prenatal care providers who accepted Medicaid was also difficult. Even though a provider has seen a woman through one pregnancy, participants explained, this does not mean the provider will be available for subsequent pregnancies. Provider willingness to take Medicaid patients is based on a number of factors, including how well established the practice is, the practice payment mix, or seasonal cycles. Thus, with each pregnancy, a woman must begin her search anew. Although the LaMOMs website maintained a list of prenatal care providers, at least half the names were grayed out at the time of the assessment planning, indicating they were no longer taking Medicaid patients. Further, participants said some prenatal care providers avoid taking patients with serious health issues, meaning that women who suffer from chronic health conditions, such as high blood pressure, diabetes, and obesity, can find it more difficult to find a prenatal care provider than do healthy women.
Difficulty finding a provider is compounded when a woman advances into her second trimester, resulting in what participants referred to as “Catch 22.” Many prenatal care providers, participants explained, “will refer anything after 20 weeks because the pregnancy is too far along,” raising concerns about risks associated with unmonitored pregnancies. For women who have their pregnancies diagnosed late in the first trimester, the window of opportunity for finding a provider begins to close and escalates into a crisis when a woman is unable to obtain any prenatal care at all. One participant recounted her personal experience: “So I was getting farther along in my pregnancy, but the doctors started to say they would not take me because I was too far along…I was trying to find a doctor and I was sick, sick….I literally had to show up at the hospital when my water broke. I said, ‘I need to see someone. I’m having a baby.”
Adequate Prenatal Care
Barriers to Getting Enough Prenatal Care
Adequate prenatal care is defined along 2 dimensions—timing of the initiation of care, and the ratio of the number of prenatal care visits divided by the number of expected visits.16 Participants outlined both psychosocial and structural reasons why women might not receive the recommended number of prenatal visits. Some women are not aware of the importance of prenatal care, or may feel it is unnecessary. “Health care is seen as for crisis management,” explained a participant. “It’s not seen as preventive.” Keeping appointments may be burdensome. Poor women often juggle multiple jobs or shifts, along with child care and other responsibilities. “When you have to block out time, it's a matter of who is going to keep the kids and who will get them home?” said a participant. “A block of time becomes huge.” Housing instability, transportation problems, and food insecurity mean that routine health care appointments, even during pregnancy, may be less of a priority than meeting more immediate needs. Lack of public transportation in Caddo Parish was mentioned often, as well as the long waits in some clinics, both of which could discourage women from keeping appointments.
Syphilis Testing and Treatment
Participants caring for pregnant women also faced challenges that potentially contribute to missed opportunities to prevent CS. Some said that providers lacked information in the form of health alerts, provider visits, or other forms of communication that could have alerted them to the need to more actively screen for syphilis and ensure that women were followed and treated. “[Syphilis increases] should be front page news,” said one. “It’s like they don’t want you to know.”
Participants said that prenatal care providers often lacked sufficient training and expertise to treat syphilis in pregnant women, which requires monitoring and interpretation of titers, multiple injections, and fetal evaluation. These providers may view their role as “diagnosing,” but not “managing” syphilis, which they perceived as the work of a “specialist,” and outside the bounds of routine prenatal care. Participants reported that pregnant women with syphilis were often referred to the Parish Health Unit STD Clinic for treatment, whereas at the same time, some frustrated and overburdened Parish Health Unit staff complained about providers “dumping” their patients on public health.
Cost and administrative barriers also discouraged providers from treating women with syphilis. Some insurance plans required pre-approvals for administering injections with bicillin, the required treatment for syphilis, which was time consuming and required multiple visits from the patient. The state’s Medicaid managed care insurance plans did not adequately reimburse for the cost of injections, which meant that patients were required to bear the cost, which most patients would be unable or unwilling to do.
Finally, few prenatal care practices had bicillin available to treat women. Bicillin is relatively expensive, requires cold storage, comes in lots of 10, and is rarely used to treat anything except syphilis; thus, most practices do not stock it. Some participants reported writing scripts so that patients could pick up the medication, only to learn that it was not available through pharmacies. “When I call pharmacies and they don’t carry it – how can they not carry it? At this time? … It’s a big issue, making sure providers have access to treatment and get reimbursed. We have all the knowledge now, but we’re making it more difficult for patients to get what they need.”
Instead of the “well-structured care pathways”12 needed to prevent CS in Caddo Parish in 2011, participants reported that there were numerous challenges for both pregnant women and their health care providers. Lack of basic information and awareness about sexual and reproductive health, discontinuities in insurance coverage, a dearth of referral points for prenatal care, and difficulty finding providers who accept Medicaid were perceived to contribute to delays in timeliness of prenatal care. The burdens of poverty, costs of co-pays and overcrowded health facilities also deterred some women from obtaining an adequate number of visits during their pregnancies.
In addition, lack of timely information about increases in syphilis and CS morbidity, insufficient training and experience to manage syphilis cases in pregnant women, low Medicaid reimbursement for bicillin injections, and difficulty obtaining and stocking bicillin created barriers for prenatal care providers and likely resulted in treatment delays and patients lost to follow-up.
Changes Subsequent to 2011
After 2011, the Louisiana Department of Health Office of Public Health’s STD/human immunodeficiency virus (HIV) program and its regional partners implemented numerous measures to improve CS prevention pathways. Measures included forming a Caddo Parish Syphilis Prevention Task Force that included individuals associated with local community health, social service, and faith-based organizations. The task force developed a 3-year plan aimed at engaging priority prenatal, primary, pediatric, and dermatology health providers. The plan included intensified provider visitation to inform prioritized providers about syphilis increases in Caddo Parish and encourage adherence to CDC screening and treatment guidelines. The state and local programs also distributed information about syphilis screening and treatment through a variety of channels, including the state’s public health alert system, delivery of grand rounds, and in-service presentations in key practice locations. In addition, the state shifted resources to add staff in Caddo's Parish Health Unit, including a full-time coordinator for the task force.
In 2014, Louisiana also took steps to enhance the Take Charge Medicaid Waiver Program. It increased the number of covered family planning visits for women from 4 to 7 per year, added STD treatment, and coverage of services for men. The state also passed legislation that took effect in 2014, requiring syphilis and HIV testing of all pregnant women in the first and third trimesters of pregnancy, thus strengthening earlier legislation that had only required testing in the first trimester or at first prenatal visit. Improvements to the state’s CS surveillance system were also implemented, in an effort to improve the timeliness and accuracy of CS case identification17 and facilitate more rapid and thorough follow up of pregnant women with syphilis by the STD program.
To facilitate on-site syphilis treatment and reduce the possibility of treatment delay or loss to follow-up, the state negotiated with Medicaid’s 5 managed care plans to remove pre-approval requirements for bicillin injections. The state also worked with qualifying facilities to help them obtain certification needed to purchase bicillin at Health Resources and Services Administration Office of Population Affairs 340B drug pricing, which greatly reduced costs incurred by health providers, and expanded syphilis testing in new locations. In some instances, the state provided bicillin to facilities at Public Health Service pricing, which is higher than 340B, but lower than retail.
The findings in this assessment are based on the data gathered from a small sample of providers and community members in one Louisiana parish (county) over 1 week. Rapid assessments are meant to provide preliminary understanding of a situation. They are appropriate for exploring perceptions, describing processes, and providing insight into issues; they are not meant to determine frequency or magnitude. Due to the resource and time constraints under which this assessment was conducted, we did not specifically target women with syphilis or syphilis case mothers, whose experiences may differ from the women in this assessment. Nevertheless, we feel that the findings from this assessment provide valuable insights into possible barriers experienced by vulnerable women and their providers, and that these barriers may hinder CS prevention. These insights, however, may not be applicable to other state or local jurisdictions.
This assessment helped to identify problems that can occur along CS prevention pathways, especially at the local level. Although maternal psychosocial and behavioral factors certainly contribute to vulnerability to CS, most of the factors identified in this assessment were health system or policy factors beyond the control of individual women and providers. Laudably, state and local health authorities in Louisiana have taken many positive steps in their efforts to create a more enabling environment for CS prevention. As of 2017, however, CS remains a persistent challenge in Louisiana, as well as in other states, and syphilis cases are continuing to increase in the United States. In 2017, the CDC issued a national Call to Action18 to address CS through specific programmatic efforts, many of which Louisiana already had underway. Addressing the challenge of CS in the United States will require a systemic, holistic approach and the sustained efforts of multiple stakeholders at local, state, and federal levels.
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