Prenatal Care Discrepancies within Grand Rapids

By: Tyler Oatmen and Sarah Loveland, Frederick Meijer Honors College, Grand Valley State University

First article in a three-part series

When I walked into the Baxter Community Center on Grand Rapids' southeast side for the first time during my sophomore year of college, I was simply looking for volunteer hours that are required for many students seeking acceptance to graduate level programs.  It was very early, and I was headed to Baxter’s Dental Clinic to meet Registered Dental Hygienist Katie Hudson.  Katie was an original member of the dental clinic’s staff and worked on the grant to start Baxter’s “Brush Up For Baby” program in 2006. Katie has been working with pregnant mothers by providing oral hygiene care and oral health education.  She explained that the clinic started in light of literature correlating periodontal disease and preterm pregnancies.[1]  The clinic’s goal was to provide targeted care to at risk pregnant or inter-conceptional mothers within Grand Rapids in order to reduce the number of preterm pregnancies, a common indicator of poor birth outcomes. By providing dental care to mothers, The Baxter Dental Clinic and many other healthcare providers hope to lower statistics indicating poor birth outcomes within Grand Rapids.  "Prenatal care" is a term that encompasses many aspects of health, and potential mothers can be overwhelmed with the abundant areas of concern.  But what is not confusing is the obvious need within Grand Rapids for more mothers to seek out and receive prenatal care.

In 2005, with a rate of 7.9 per 1,000 live births, Michigan ranked 40th in the nation in overall infant mortality.[2]  Overall pregnancy outcomes are most commonly measured by two indicating statistics: the infant mortality rate and percentage of low birthweight babies born.  Birthweight is a strong indicator of the health and possible complications within a newborn.  A study in 2005 by the Lancet Neonatal Survival Steering Team stated, “Preterm birth complications cause 27% of newborn deaths, and between 60 and 90% of newborn deaths occur in low birthweight babies.”[3]  Low birthweight babies are more likely to die of infection, have trouble breathing, or survive pregnancy complications.[4]

Grand Valley State University’s Johnson Center for Philanthropy runs a Community Research Institute that gathers community level data throughout the state of Michigan to identify social issues.  The Center’s 2006 report on prenatal care states that the percentage of Michigan mothers having low birthweight babies (8.2%) exceeds the national average of 7.9%.[5]  While Michigan seems to have an overarching problem with poor pregnancy outcomes, Grand Rapids in particular has a more serious problem.  The city of Grand Rapids had a higher percentage of low birthweight babies than the state average in 2005, and also posted a higher percentage of extremely low birthweight babies (1.9%) than the Michigan average in 2006.[6,7]  Another study in the summer 2007 edition of The Michigan Journal of Public Health “geomapped” the number of mothers receiving adequate prenatal care within Grand Rapids and the surrounding areas. The areas with the least amount of adequate prenatal care were within the inner city areas of Grand Rapids (Baxter, Madison, South East Community, Heartside).[5] 

These are glaring statistics that point to a serious health issue within the state of Michigan, and a more acute problem within the city of Grand Rapids.  Michigan health organizations have convened to tackle the problem, such as the Michigan Department of Community Health.  In May 2008 the MDCH and Blue Cross Blue Shield of Michigan co-sponsored ‘The Summit’ in Lansing, bringing together health specialists to discuss lessons from the field concerning infant mortality.  One of the goals of many health organizations is to further awareness through answering the question, "What is encompassed within the term ‘prenatal care’?

Prenatal care is the healthcare and consideration that pregnant women should adhere to in order to increase the likelihood of a successful pregnancy outcome.  Proper clinical care should integrate evidence and practitioner recommendations in order to reach a shared decision between a mother and her physician.  Ideally, prenatal care begins at the thought of pregnancy, and may incorporate counseling and screenings for risks due to maternal health.  Once pregnant, proper prenatal care begins with regular doctor’s appointments.  Prenatal visits are effective in providing support and reducing the common problem of postpartum depression.  The Nurse Family Partnership of Grand Rapids, an organization that provides at-home weekly visits from nurses, provides pregnant women a menu which has a number of different conversation options during every visit, including personal health, nutrition, preparing for the baby, relationships, etc.  These talks aid in monitoring and sustaining the mental health of the mother throughout the pregnancy. 

The initial visit is the most important visit because it establishes an accurate timeline for the pregnancy.  Within the first prenatal appointment, the mother should be informed about common issues that will affect the fetus during the pregnancy and an accurate estimated date of delivery should be established.  The mother should also be made aware that the first 12 weeks of pregnancy are considered the time of organgenesis (organ forming) and that the fetus will experience heightened vulnerability. [8]

Some common suggestions can be made concerning air travel, exercise, medications, alcohol consumption, smoking, illicit drugs, and workplace environments.   Certain exercises should be avoided that put mothers at risk for falls or abdominal injuries.  Alcohol use can cause Fetal Alcohol Syndrome, and there exists no safe amount of alcohol consumption while pregnant.  Screening for drug use is important, as the use of Methadone therapy for opiate-addicted women could save the baby’s life.[8]  Along with these considerations, information concerning nutrition, healthy weight gain, and possible infections should be discussed.  This is only a sampling of counseling issues; a list of research-based recommendations can be found at http://www.aafp.org/.

There are many contributing factors and social patterns that contribute to the exceptionally high infant mortality rate seen in the Grand Rapids area.  Baxter Clinic, Mothers Offering Mothers Support (MOMS), Nurse Family Partnership (NFP) and Cherry Street Health Services are all programs based in the Grand Rapids area which have all identified at least some of these social risk factors, through their own research, to be contributors to the high-risk pregnancies seen in Grand Rapids. A detailed look at these organizations and their goals can be found in our companion Rapidian article, “Prenatal Care Programs and Resources within Grand Rapids”.  Some identifiable social patterns are a lack of social support, lack of transportation, domestic violence, severe mistrust for healthcare providers, and unstable basic needs.

Mothers identified as ‘high risk’ within these programs tend to have similar backgrounds.  NFP reports that 94% of the women who come through their program are unmarried and that the median age of the mothers is 17.  This same trend is also seen in the Cherry Street programs.  The fact that the majority of these women are unmarried and young contributes to their lack of social support and experience.

The lack of social support increases stress, which can lead to low birth weight complications.  Stress is also increased because most of these women live in poverty.  Lack of sufficient funds leads to unstable housing and inadequate nutrition.  These patterns of stress and poverty all work together to create a vicious cycle.

If poverty is an issue, then these women should qualify for government assistance under Medicaid.  According to Kristin Batts of Cherry Street Health Services, Medicaid is not only available, but many pregnant women qualify for it.  Women applying for Medicaid can do so right in the Cherry Street Health Services Building.  Pregnant women who are citizens and qualify for Medicaid receive a long list of benefits.  All medical care, even if they have to see a specialist, is covered. Dental care, support programs, labor and delivery, and the option to have their fallopian tubes tied or an IUD inserted after birth are all covered under Medicaid.  If these women have these kinds of resources available to them, why are they still not utilizing them?  Part of the problem lies in the fact that many doctors will not accept Medicaid patients because the government does not reimburse them as well as privately insured patients.

Again, much of the reluctance to utilize these available resources lies in social patterns.  Staff at most pre-natal programs mentioned several reasons for why women are not taking advantage of these resources.  The lack of social support experienced by most of these women and the lack of involvement by most of the fathers, along with the mothers’ past experiences, results in a great mistrust for authority figures and the medical community in general.  The young age of most mothers may also decrease willingness to seek care due to the social stigma associated with teen pregnancy.  With this knowledge and awareness, how are these prenatal programs working to diminish these factors and patterns and to ultimately break the cycle?