Limited or No Prenatal Care at Term
The essential elements of care for the pregnant woman at term who presents to the obstetric triage unit or emergency department with late or no prenatal care (PNC) is reviewed. The goals of such a visit include establishing maternal and fetal well-being; determining the gestational age of the pregnancy, number of fetuses, fetal presentation, and labor status; and addressing immediate needs. If a woman is not admitted to the hospital, enrollment into PNC needs to be expedited. The U.S. Department of Health and Human Services (DHHS) defines late or no PNC as births that occur to mothers in the third trimester with no documentation of PNC, or documented no PNC on the child’s birth certificate (DHHS, 2015). This population includes a wide range of women, who for a variety of reasons experience barriers to obtaining PNC.
U.S. statistics from 2014 represent the most recent published data on this population. In that year, there were 3,988,076 live births (Centers for Disease Control and Prevention [CDC], 2014). Four to eleven percent of all reported births were to women with late or no PNC (DHHS, 2015). In 2014 American Indian and Alaska Native women were the most likely to receive late or no PNC (11%), followed by Black (10%) and Hispanic women (8%). On the other end of the spectrum during the same year, 6% of births among Asian or Pacific Islander women, and 4% of births among White women, received late or no PNC (DHHS, 2015). Young women in their teens are the least likely to receive timely PNC. In 2014 25% of births to females under age 15, and 10% of births to teens ages 15 to 19 were to those receiving late or no PNC (DHHS, 2015). In addition, women who have unplanned births are less likely to recognize pregnancy early or to receive adequate PNC (Guttmacher Institute, 2015). Almost 40% of the annual births in the United States result from an unintended pregnancy (Guttmacher Institute, 2015). These represent a large number of pregnant women who may present to the emergency department for a first and/or only PNC visit. Infants born to mothers who receive no PNC are three times more likely to be born with low birth weight, five times more likely to die (DHHS, 2015), and have twice the risk of preterm birth (Cunningham et al., 2014) than those whose mothers received PNC.
140WHY WOMEN DO NOT SEEK PRENATAL CARE
Pregnant women may not seek PNC for a variety of social, economic, and medical reasons. Analysis of birth certificate data by the CDC found that risk factors for inadequate PNC included ethnicity, socio-economic status, age and method of payment for services (CDC, 2014; Every Mother Counts, 2014), undocumented status (Guttmacher Institute, 2016a), or other problems (Guttmacher Institute, 2016a). Common reasons cited were that a woman did not know she was pregnant, lacked money or insurance, and had no transportation (DHHS, 2013, 2015). The most recent statistics from 2015 show a marked decrease in the number of uninsured women of childbearing age (ages 15–44) in the United States from 19.6% in 2012 to 13.3%. This is largely due to the Affordable Care Act (Shartzer et al., 2015). Although this is an improvement, it still leaves approximately 530,400 women annually without insurance. Uninsured women are less likely to access PNC (Schartzer et al., 2015). Still, lack of money or insurance remains the second most likely reason for a woman to delay or not obtain PNC, the most common being late identification of pregnancy (Cunningham et al., 2014, p. 167). Access to care for minors can be a complicating factor (Guttmacher Institute, 2016b). Compared with women having planned births, those who have unplanned births are less likely to recognize pregnancy early, to receive early PNC or to breastfeed, and are more likely to have low-birth-weight babies (Guttmacher Institute, 2015). National trends toward restrictive access to abortion services can create a situation where a woman does not desire a pregnancy yet cannot terminate it (Guttmacher Institute, 2015). The 6.4 million women of reproductive age who are not U.S. citizens are much less likely to be insured, especially those who live in poverty and are often barred from Medicaid (Guttmacher Institute, 2016a). Still other barriers may include social pressures such as undocumented legal status, relocation, drug abuse, fear of interacting with “the system”, difficulty with assessing care, or being a woman who has experienced intimate partner violence or reproductive coercion (Guttmacher Institute, 2016c). Social services often available in the emergency setting provide vital assistance in identifying/assessing barriers and expediting the process to obtain necessary documentation, insurance, mental health assessment, and referrals to appropriate agencies.
EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT
The Emergency Medical Treatment and Active Labor Act (Centers for Medicare & Medicaid Services [CMS], n.d.) mandates a medical screening exam (MSE) for any pregnant woman, regardless of age, who presents to obstetric triage with uterine contractions, or who might be in active labor (CMS, n.d.). The examination includes, at a minimum, assessment of vital signs, fetal heart tracing (FHT) status, frequency and intensity of uterine contractions, fetal presentation, cervical dilatation, status of membranes, and rapid assessment of the presenting complaint (CMS, n.d.). The MSE examination must be performed by a “qualified medical examiner” (QME; CMS, n.d.). The QME must be someone who is credentialed to perform this function within this setting and who meets hospital credentialing requisites, as well as state rules and regulations for practice (CMS, n.d.). The QME may include physicians, certified nurse midwives, nurse practitioners, physician assistants, or RNs (CMS, n.d.). Nurses 141must be credentialed to perform the MSE within their respective hospitals, and in addition, they must meet individual state rules and regulations for nursing practice (CMS, n.d.).
CARE OF MINORS
State law is superseded by EMTALA in the case of pregnant minors who are pregnant and contracting (CMS, n.d.). In the case of a minor who is pregnant but not contracting, regulations differ by state. The great majority of states and the District of Columbia currently allow a minor to obtain confidential PNC, including regular medical visits and routine services for pregnancy (Guttmacher Institute, 2016b). State by state information is available at www.guttmacher.org (Guttmacher Institute, 2016b).
EXAMINATION OF THE WOMAN WITH LATE OR NO PRENATAL CARE AT TERM
Even when a woman is obviously pregnant, the presenting complaint may not include pregnancy (Minnerop, Garra, Chohan, Troxell, & Singer, 2011). The history alone is not a reliable method of confirming pregnancy. Key questions for a relevant pregnancy history are summarized in Exhibit 13.1.
Key Questions to Ascertain Relevant Pregnancy History
1. When was your last menstrual period?
2. Do you know when your due date is?
3. Were you using contraception?
4. What number pregnancy is this for you?
5. What happened with your previous pregnancies?
a. Were they term?
b. Were they normal vaginal deliveries or cesarean sections?
6. Have you received any prenatal care anywhere? If so, where?
7. Do you have any medical problems?
8. Do you take any medications? Any drug usage?
9. Do you have any allergies?
10. Do you feel fetal movement?
11. Do you have vaginal bleeding?
12. Are you having contractions, if so, how frequently?
13. Have you noticed leaking of fluid?
14. Intimate partner violence or control screening questions
15. Travel history and corresponding symptomology including specific questions regarding areas where Zika, Ebola, or tuberculosis are endemic
16. Drug and alcohol screen questions
Sources: Adapted from CDC (2016) and Cunningham et al. (2014).