Uninsured Pregnant Patients: Where Do We Begin?

Pregnant immigrant women without medical insurance often receive inadequate prenatal care. They are more likely to present late in their pregnancy for care, to receive less prenatal testing, and to receive inadequate prenatal follow-up. There is a documented association between inadequate prenatal care and poor birth outcomes, including preterm delivery and low birth weight. Caring for uninsured women causes stress for physicians and health care teams. A standardized approach to caring for uninsured pregnant women has the potential to improve access to care while providing a framework to healthcare providers that may decrease the tensions that arise within health care teams caring for these patients. We believe that giving uninsured women and the physicians who care for them a voice in constructing a system to address barriers to care is essential.

Perspectives of family physicians on the care of uninsured pregnant women.

OBJECTIVE: No official provisions are made for the medically uninsured under provincial public health programs in Canada. Studies have shown that uninsured pregnant women have inadequate access to prenatal and obstetrical services that favour healthy maternal and child outcomes. This qualitative study aimed to explore the perspectives of family physicians who provided care to uninsured pregnant women. METHODS: Eight family physicians affiliated with two Montreal-based primary-care clinics and one tertiary care hospital between 2004 and 2007 were interviewed using a semi-structured interview guide. Data were assessed using thematic analysis. RESULTS: Uninsured pregnant patients were characterized by physicians as socially vulnerable, with precarious immigration status that limited their access to health services. Uninsured patients were thought not to benefit from the same standard of perinatal care as their insured counterparts. Care of uninsured women was generally thought to be a professional obligation, regardless of the woman's ability to pay. Caring for this population was considered by family physicians to be challenging, engendering psychological stress, increased workload, and occasional tensions with other health care providers. CONCLUSION: In the present context, family physicians are left to negotiate the health care system in an attempt to provide adequate perinatal care for uninsured pregnant patients. This situation has repercussions for physicians, for patients and, ultimately, for infants. Leadership is required to ensure that all pregnant women in Canada have access to appropriate health care during the perinatal period.

Objectif : Il n'existe aucune disposition officielle en ce qui concerne les personnes qui ne sont pas couvertes par les régimes publics d'assurance-maladie provinciaux au Canada. Des études ont démontré que les femmes enceintes non assurées ne disposent pas d'un accès adéquat aux services prénataux et obstétricaux qui favorisent l'obtention de résultats maternels et infantiles sains. Cette étude qualitative avait pour but d'explorer les points de vue de médecins de famille ayant offert des soins à des femmes enceintes non assurées. Méthodes : Des entrevues semi-structurées ont été menées auprès de huit médecins de famille affiliés à deux cliniques montréalaises de soins primaires et à un hôpital de soins tertiaires de la même région entre 2004 et 2007. Les données ont été évaluées au moyen d'une analyse thématique. Résultats : Les patientes enceintes non assurées ont été caractérisées, par ces médecins, comme étant des personnes vulnérables sur le plan social dont le statut précaire en matière d'immigration limitait leur accès aux services de santé. Ces médecins estimaient que les patientes non assurées ne bénéficiaient pas du même standard de soins périnataux que leurs homologues assurées. D'ordre général, ils estimaient que l'offre de soins aux femmes non assurées constituait une obligation professionnelle, sans égard à la capacité de payer. Les médecins de famille considéraient que l'offre de soins à cette population était une activité complexe, qu'elle engendrait du stress psychologique, qu'elle entraînait une augmentation de la charge de travail et qu'elle donnait occasionnellement lieu à des tensions dans leurs relations avec d'autres fournisseurs de soins de santé. Conclusion : Dans le contexte actuel, les médecins de famille sont laissés à eux-mêmes dans leurs efforts visant à utiliser le système de santé pour tenter d'offrir des soins prénataux adéquats aux patientes enceintes non assurées. Cette situation a des répercussions pour les médecins, les patientes et, en bout de ligne, les enfants. Les décideurs doivent faire preuve de leadership pour s'assurer que, au Canada, toutes les femmes enceintes obtiennent accès à des soins de santé appropriés au cours de la période périnatale.

Retrospective review of prenatal care and perinatal outcomes in a group of uninsured pregnant women.

OBJECTIVE: To assess the adequacy of prenatal care and perinatal outcomes for uninsured pregnant women at two primary care centres in Canada. METHODS: We conducted a retrospective case comparison study of uninsured women presenting for prenatal care between 2004 and 2007 (n = 71). Control subjects (n = 72) were chosen from provincially insured women presenting for prenatal care during the same period. A modified Kotelchuck Index was used to assess adequacy of care. Frequency of routine prenatal testing (blood tests, ultrasound, cervical swabs, Pap testing, and genetic screening) was compared. Perinatal outcomes assessed included gestational age and birth weight. RESULTS: Uninsured pregnant women presented for initial care 13.6 weeks later than insured women (at 25.6 weeks vs. 12.0 weeks, P < 0.001). Uninsured women had fewer blood tests (93.7% vs. 100%, P = 0.045), ultrasound screenings (82.5% vs. 98.4%, P = 0.003), cervical swabs (69.8% vs. 85.2%, P = 0.04), Pap tests (38.1% vs. 75.4%, P < 0.001), genetic screenings (12.7% vs. 44.3%, P < 0.001), and visits with health care providers (6.6 vs. 10.7, P = 0.05). Using a modified Kotelchuck Adequacy of Prenatal Care Utilization Index, uninsured women were more likely to be categorized as receiving "inadequate care" (uninsured 61.9% vs. insured 11.7%, P < 0.001). CONCLUSION: This study begins to document the care of uninsured pregnant women in Canada. Women in this category presented late for prenatal care, were less likely to have adequate screening tests, and were more likely to receive "inadequate care" as defined by the modified Kotelchuck Index. This information may be valuable in helping to plan programs to improve access to timely and adequate medical care for uninsured pregnant women.

Undocumented pregnant women: what does the literature tell us?

The present literature review was conducted to determine what information has been published on the topic of undocumented pregnant migrants. Scientific databases and gray literature sources were searched for articles published between January 1967 and September 2010. Eighty-seven articles met the inclusion criteria and were reviewed. A final sample of 23 articles was included in the review. Existing evidence suggests that pregnant undocumented migrants living in Western societies tend to be younger, unmarried, and more likely to be employed in the domestic sector than documented migrants and permanent residents. They have less access to prenatal care and consult later in pregnancy than controls. Findings concerning delivery and birth outcomes are conflicting and subject to several biases. Little has been published on programs to address the needs of undocumented pregnant women living in Western countries. More research on the particular health and social issues faced by these women is needed.

Evaluation of an evidence-based peer teaching assessment program.

OBJECTIVE: To determine faculty perceptions about an evidence-based peer teaching assessment system. METHODS: Faculty members who served as instructors and assessors completed questionnaires after year 1 (2002-2003) and year 4 (2005-2006) of the peer assessment program. Factors were evaluated using a Likert scale (1 = strongly disagree; 5 = strongly agree) and included logistics, time, fostering quality teaching, diversifying teaching portfolios, faculty mentoring, and value of structured discussion of teaching among faculty members. Mean responses from instructors and assessors were compared using student t tests. RESULTS: Twenty-seven assessors and 52 instructors completed survey instruments. Assessors and instructors had positive perceptions of the process as indicated by the following mean (SD) scores: logistics = 4.0 (1.0), time = 3.6 (1.1), quality teaching = 4.0 (0.9), diversifying teaching portfolios = 3.6 (1.2), faculty mentoring = 3.9 (0.9), and structured discussion of teaching = 4.2 (0.8). Assessors agreed more strongly than instructors that the feedback provided would improve the quality of lecturing (4.5 vs. 3.9, p < 0.01) and course materials (4.3 vs. 3.6, p < 0.01). CONCLUSION: This peer assessment process was well-accepted and provided a positive experience for the participants. Faculty members perceived that the quality of their teaching would improve and enjoyed the opportunity to have structured discussions about teaching.