Pregnant Women

The author of this paper reviews evidence about the health care resources currently available to children and pregnant women in the United States. The data reveal that the overall supply of physicians has grown steadily in recent years. However, as a result of factors such as physicians’ preferences for metropolitan practice locations, rising malpractice premiums, and physicians’ reluctance to accept Medicaid patients, the increase in supply has not improved access for many underserved women and children. At the same time, there has been a significant decline in the number of organized settings—hospital clinics, public health clinics, and migrant and community health centers—on which many of the underserved rely. Further, the capacity of remaining facilities has been greatly diminished by reductions in support for public programs. Even if the supply of health care resources is adequate to meet the needs of most women and children, the persistent maldistribution of maternal and child health care providers will continue to pose a serious threat to health care access for the women and children at greatest risk for adverse pregnancy outcomes and morbidity and mortality during childhood. Policy strategies suggested to maintain and improve the availability of maternal and child health resources include: bolstering the supply of family physicians; reducing the problems related to medical professional liability; supporting the National Health Service Corps (NHSC) scholarship and loan repayment programs; increasing participation of physicians in serving Medicaid-eligible women and children; developing systematic data to evaluate the supply of maternal and child health care available in organized settings; and enhancing the capacity of organized settings to meet the needs of underserved children and pregnant women. D uring the past decade, strides have been taken toward lowering financial barriers to the health care needed by children and pregnant women. Private third-party payers have begun to cover more of the costs of children’s preventive and primary care, and Medicaid financing is available not only for the care of poor children and pregnant women but also for many women and children living in families with incomes above the federal poverty level. As financial barriers to care are lowered, problems in the supply and distribution of health care resources become more important than ever before. This paper reviews evidence about health care resources currently available to children and pregnant women in the United States and concludes that, while the supply and distribution of these resources may be adequate to meet the needs of most women and children, those who are black, poor, and/or residents of rural and inner city communities remain underserved. The problem of maldistribution of maternal and child health care resources is not new; however, data reviewed here demonstrate that the dimensions of this problem have changed in recent years. The overall supply of physicians (and the supply of medical and surgical subspecialists, in particular) has grown; but as a result of factors such as physicians’ preferences for metropolitan practice locations, rising malpractice premiums, and physicians’ reluctance to accept Medicaid patients, this increase in supply has not necessarily meant improved access for underserved women and children. At the same time, data reviewed here document that there have been significant declines in the supply of the organized settings on which many of the underserved rely—hospital clinics, public health clinics, and migrant and community health centers—and that the capacity of remaining facilities has been greatly diminished by reductions in support for various public programs. The available evidence suggests that, to the extent that maldistribution of maternal and child health care persists, it will pose a serious threat to the usefulness of third-party coverage in enabling access to health care for the very women and children who are at greatest risk for adverse pregnancy outcomes and morbidity and mortality during childhood. Health Care Resources for Pregnant Women The Supply, Distribution, and Accessibility of Maternity Care Physicians and Certified Nurse Midwives Most maternity care in the United States is provided by obstetrician-gynecologists, family physicians and general practitioners, and certified nurse midwives. Factors influencing the supply, distribution, and accessibility of these health professionals figure prominently in women’s access to maternity care. These factors include (1) the tendency for these professionals to locate in metropolitan areas, (2) the high cost of medical liability insurance for these providers and physicians’ perceptions about the risks of being sued by obstetric patients, and (3) the reluctance of these professionals to serve Medicaid patients. Obstetrician-Gynecologists According to the American Medical Association Masterfile, the most complete source of information about the supply of physicians, there were 31,364 obstetrician-gynecologists in the United States in 1986. The supply of obstetrician-gynecologists is growing, and the future is likely to bring increasing competition for patients. Projections indicate that the population of obstetrician-gynecologists will grow to a total of 40,000 to 44,600 by the year 2000. Using an adjusted needs-based model developed in 1980 by the Graduate Medical Education National Advisory Committee (GMENAC)—a quasi-governmental body charged with making recommendations