By Christopher Guadagnino, Ph.D.

Published November 2008

HH: Even before I was sworn in as commissioner last January, this was an issue I was very interested in. Last year, the National Women’s Law Center had come out with a report card that graded states on a number of issues, and we had received a failing grade in this area. New Jersey ranked 40^th in terms of access to early prenatal care. I found these statistics to be unacceptable, particularly in a wealthy state like New Jersey, and I wanted to find out why we were doing so poorly and what we could do to reduce the barriers that pregnant women are facing. Early prenatal care is critical to a healthy pregnancy and contributes to reducing mortality. I decided to focus on this as one of my top issues, as commissioner. I created a task force with a wide range of experts. We have a number of physician members, including ob/gyns and pediatricians, nurses and a nurse midwife, as well as representatives of hospitals, primary care, family planning and child health advocacy groups. We also have representatives from the state’s six maternal and child health consortia, as well as a number of other state departments.

HH: The panel was charged with examining the barriers and circumstances that contribute to women, especially African-American and Latino women, not getting first trimester prenatal care, and then make recommendations to make care more accessible. The group also reviewed current best practices in order to identify programs that have successfully increased early entry into prenatal care. We formed three subcommittees to look at issues in depth: educating patients and the general public, examining the prenatal care system capacity and identifying barriers, and measuring program quality. The task force reviewed a variety of state and federal data. We used data from New Jersey’s Pregnancy Risk Assessment Monitoring System (PRAMS), which is a joint research project between the Department of Health and Senior Services, Rutgers University and the CDC. PRAMS includes data on pregnancy intention, insurance status, timing of entry into prenatal care and other pregnancy-related issues.

HH: We found that health insurance coverage is critically important. Women with no insurance during their pregnancy had the lowest rate of first trimester prenatal care – only 73 percent, while 96 percent of women with health insurance were accessing prenatal care in the first trimester. This is yet one more reason we need to push toward universal health care, which is something that Gov. Corzine and I are very committed to. We found that, in some parts of the state, women are waiting six to eight weeks for a prenatal care appointment. Those most at risk for poor birth outcomes – and therefore most in need of early access to prenatal care – are teens, unmarried women, uninsured women and minorities. We also found that the state should be promoting family planning, because those services can reduce unintended pregnancies and serve as a point of entry for women into early prenatal care. In fact, nearly one-third of pregnancies in New Jersey are unintended or mis-timed, so it’s very important that all women get access to good pre-conception care, so that they are healthy when they become pregnant. We had real geographic variation. In some parts of the state there was nearly total access to early prenatal care, and in other parts of the state there was a real lack of access. As policymakers, it is important for us to see this variation so that we can focus our resources on the places where the risks are the greatest, and where we know the waiting times are the longest.

HH: It is a variety of issues on the provider front. Hospitals in the state are facing severe financial problems that, in some cases, are exacerbating the access issues, where we’ve had hospital closures. It can also be that there are too few providers in the area, and greater concentrations of uninsurance. We’ve seen the problem across the state of ob/gyns dropping the obstetrical part of their practice, so it may be too few ob/gyns. It may be that the clinics in the area have hours that are not sufficient.

HH: There are concerns about provider capacity, and that we need to address the supply of obstetricians, especially in underserved areas. We’re exploring the use of appropriate incentives that may increase the supply of obstetricians in those underserved areas. In addition, we’re going to be examining the issue of medical malpractice insurance and tort reform, especially in the area of obstetrics. We’re working with partners from the task force to continue to provide quality continuing education for the physician community. For example, one of the recommendations suggests that we raise awareness of the factors impacting first trimester prenatal care as a standard measure of quality of health care services, so that when ob/gyns are talking to women in a pre-conception context, they are talking about the importance of entering a pregnancy in a healthy state, and of entering prenatal care early. We’re also looking into sharing best practices from top performers in prenatal care with other doctors, nurses and health care providers. We have six regional maternal and child health consortia that bring together hospitals and providers for educational work, and we would be looking to partner with them.

HH: We want to look at all options. We had a representative of the American College of Obstetricians and Gynecologists (ACOG) on the task force. We currently have a program of malpractice insurance assistance for certain high-risk specialties in New Jersey, so one of the things we want to look at is how that’s working. We also have loan forgiveness programs for providers who enter into underserved areas. Of course, all of these conversations need to be had in the context of the state’s very difficult budget situation. We have fewer tools than we might like to have, given how tough the state’s budget is, but we need to look at what programs we are already doing, how effective they are, and what more we could be doing. What’s exciting about this report is that it’s the start of the conversation. Now that we’ve highlighted the issues and know what the problems are, we have a lot of work ahead of us, with many stakeholders, to operationalize the recommendations.

HH: There was a lot of discussion about Federally Qualified Health Centers and how to use them. The budget this year included $5 million for capacity expansion at the FQHCs, and one of the priority areas that we’re going to highlight in our request for application is to increase capacity for ob/gyn services. We want to work with our sister agency, the Department of Human Services, to look at the type of incentives that might be possible through Medicaid managed care providers. We’ve heard a lot of concern about Medicaid managed care networks not being sufficient, in terms of access to ob/gyn, so we want to work with the Medicaid program on that. We clearly need to do a better job promoting women’s health issues and improving the coordination among different state agencies. We want to apply for a federal family planning waiver, which would allow us to expand access to family planning services in the state and hopefully would help us reduce the number of unintended pregnancies, and also ensure that women have access to good health care and are entering pregnancies in their optimal health state. We’ll be working with the Department of Education as they revise their core curriculum standards for health and physical education, which includes family life education. The Department of Children and Families will be promoting early and regular prenatal care though its home visitation programs for pregnant women and new parents. We’ll be looking at how to better direct existing funds we have to support the report’s recommendations. We have, by region, a risk index, so we know what parts of the state are at higher risk.

We’ve been facing significant distress in our hospital systems, and eight hospitals have closed in the last 18 months. One of the challenges of the Department of Health and Senior Services has been to manage those closures in such a way as to preserve access to critical health care services. One example has been the closure of Barnert Hospital in Patterson – they were a big provider of prenatal care. The state gave a grant to a local Planned Parenthood organization to move into that area and start offering prenatal care services to fill the gap that had been left by the closure of Barnert. So, with each closure we’re looking very specifically at maintaining services that might have been provided at the hospital that closed, and making sure that they remain in the community. We are also implementing an early warning system, where our goal is to catch the signs of hospital distress earlier in the process so that we can intervene earlier. For far too long we’ve operated in a culture of crisis management, and we want to move to one of strategic planning, where we’re better able to manage the process.

HH: We’re in the lead, but we’re going to be working with our partners within the state government, as well as private partners and advocates – the March of Dimes, ACOG, the Academy of Pediatrics, nursing organizations, and the maternal child health consortia. Some of the recommendations are administrative in nature, which the department can do on its own: the initiative to target money to expand services at FQHCs; the Department of Human Services’ family planning application to the federal government. For some recommendations, I’ve heard great interest from members of the Legislature, including expanding access to health care, generally. There’s always interest in the overarching finding that lack of health insurance is a key barrier.

We’re going to be prioritizing which of the recommendations can be done in a short time frame, and which are longer; which ones require funding – which we may not be able to undertake immediately, given the state’s finances, and which ones don’t require funding. A key recommendation of the task force was to increase education and promote awareness of early entry into prenatal care and pre-conception health. I’m going to be going around the state to talk about these issues to raise awareness, to work with our partners, and to coordinate better among our sister agencies. Commissioner Velez of the Department of Human Services joined me at the kick-off event where we released the task force’s report, so we have a strong partnership there. The governor himself has expressed support for our strategies, and wants to be helpful. I’ve committed to the members of the task force that we would convene a year from now to report on the progress we’ve made. We are going to take this very seriously and don’t want this to be a report that sits and gathers dust.