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Increasing Access to Prenatal Care: Disease Prevention and Sound Business Practice Karline Wilson-Mitchell

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Midwifery Education Program , Ryerson University , Toronto , Ontario , Canada Accepted author version posted online: 14 Jun 2013.Published online: 02 Aug 2013.

To cite this article: Karline Wilson-Mitchell (2014) Increasing Access to Prenatal Care: Disease Prevention and Sound Business Practice, Health Care for Women International, 35:2, 120-126, DOI: 10.1080/07399332.2013.810221 To link to this article: http://dx.doi.org/10.1080/07399332.2013.810221

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Health Care for Women International, 35:120–126, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2013.810221

Increasing Access to Prenatal Care: Disease Prevention and Sound Business Practice KARLINE WILSON-MITCHELL Downloaded by [University of Chicago Library] at 00:50 20 November 2014

Midwifery Education Program, Ryerson University, Toronto, Ontario, Canada

Following our study of birth outcomes for uninsured new immigrant and refugee women in Toronto, we discovered clinically significant numbers of women with hypertension and diabetes. As this population ages and prevalence increases, the expense of treating uncontrolled chronic illness increases. Prudent health policy change, a reduction in treatment delays, and equitable access to care will decrease clinical risk and limit the financial burden on the health care system. This unanticipated finding supports the argument for establishing government-funded maternity care insurance for all women. Such policies could prevent perinatal complications and decrease the rate of uncontrolled chronic illness later in life. A retrospective study of newcomers to Toronto, Canada, was undertaken to determine whether access to an exclusionary health insurance plan had an effect on health status or birth outcomes (Wilson-Mitchell & Rummens, 2013). There is a common assumption that most newcomers are essentially healthy upon emigration (Ray et al., 2007) and so will likely have less need for health care services. Clinically significant numbers of women with hypertension and diabetes, however, were observed. We concluded that the provision of universal maternity health insurance to all women might improve key perinatal outcomes. Such health policy could function as an effective strategy for both health promotion and chronic illness prevention. These measures could decrease the funds expended on acute care for the sequelae of uncontrolled chronic disease. Recently, legislators have been demanding that health care providers and hospitals adopt corporate models of fiscal restraint (Collier, 2008). In this economic climate, it would seem counterproductive to divert

Received 26 September 2012; accepted 28 May 2013. Address correspondence to Karline Wilson-Mitchell, Midwifery Education Program, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada. E-mail: [email protected] gwemail.ryerson.ca 120

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ever-scarcer health care dollars toward acute care of uncontrolled chronic illness. Instead, greater investment in preventative prenatal care may ultimately decrease the costs of chronic illness care. Immigration and health policies are closely interrelated. Approximately 2.5% of the world’s population has emigrated from their country of origin (Martin, 2009). The promise of increased human capital makes integration of migrants desirable, although uniquely challenging for each country (Wiesbrock, 2011). Following the 2010 United Nations summit in Canada, G8 politicians pledged $5 billion toward reduction of maternal and child mortality globally (Dearing, 2010). As developed countries seek to address the millennium developmental goals, health care access during international migration and settlement processes warrants closer examination.

COMPLICATED BIRTHS AMONG NEW IMMIGRANTS AND REFUGEES Both the insured and uninsured groups in the quantitative study consisted primarily of newcomers to Canada, with large proportions of Caribbean and South Asian women. Key study findings revealed that the number of prenatal visits reported for the uninsured group (mean = 6.03) was significantly lower (t = −6.173, α = 0) than for their insured peers (mean = 8.76). In fact, four out of five uninsured women received less than adequate prenatal health care; 6.5% received no prenatal care at all. Due to the small sample size in the pilot study, there was no significant difference seen in preterm birth rate, small for gestational age rate, low birth weight rate, and neonatal intensive care admissions. The uninsured women, however, required significantly more caesarean sections for abnormal fetal heart rates and their newborns required more resuscitations (9.7% vs. 4.3% with χ 2 = 5.174, α = 0.023; Wilson-Mitchell & Rummens, 2013). Although care of all the newborns was covered by provincial health insurance because their mothers were Ontario residents, the mothers’ care was not covered. Not surprisingly, the uninsured’s maternal hospital stay was significantly shorter (t = −6.11, α = 0) than their insured counterparts’. It is noteworthy that many of the uninsured women experienced significantly less time under the care and surveillance of maternity care providers both prenatally and postnatally.

CHRONIC ILLNESS AMONG NEW IMMIGRANTS AND REFUGEES Surprisingly, the study revealed significant numbers of pregnant women with gestational hypertension (4.2%) and gestational diabetes (4.0%), regardless of insurance status. In this study, mild gestational diabetes and hypertension did not contribute to a higher risk of preterm birth, but they could lead to sequelae in pregnancy if untreated. Perinatal complications or sequelae

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of gestational hypertension include newborn asphyxia, fetal death, placental insufficiency, abnormal fetal growth, stroke, pulmonary edema, hepatic failure, jaundice, seizures, placental abruption, and acute renal failure (Society of Obstetricians and Gynecologists of Canada [SOGC], 2011). A small number of newcomer women in the study presented with chronic conditions such as asthma, diabetes, mild chronic hypertension, hypothyroidism, and lifestyle changes such as smoking. The incidence of smoking tends to increase as the length of residence for newcomers increases (Booth et al., 2010; Creatore et al., 2010; Magnussen, Vatten, Smith, & Romundstad, 2009; Shah, Ray, Taback, Meffe, & Glazier, 2011). A lack of access to insurance, therefore, could limit early detection, treatment, and prevention of sequelae of these conditions following birth as well (Magnussen et al., 2009). It is unknown how many uninsured newcomer women are lost to follow-up and later present for urgent or expensive emergency care in Ontario. The tendency is for the incidence of diabetes and hypertension to increase with age (Magnussen et al., 2009). Early intervention prevents the development of complications in the postpartum period. In fact, the older insured mothers in the pilot study experienced higher rates of medical perinatal interventions. Normally, however, uninsured women lack warning about the importance of these interventions until the clinical need arises with the onset of pregnancy complications. Consequently, they often hesitate and delay expensive obstetrical consultations and procedures (Gagnon et al., 2010; Simich, Wu, & Nerad, 2007). Restriction of access to these clinical treatments through lack of insurance would affect perinatal morbidity. It would also increase the risk of long-term maternal morbidity. In an effort to minimize the risk of infant morbidity and mortality, medical interventions such as induction or augmentation of labor and caesarean section are more likely with a pregnancy complication such as diabetes or hypertension. During the postpartum period, uninsured women may be lost to long-term follow-up if they lack a primary care provider despite the increased risk of developing chronic hypertension and adult-onset diabetes. It is not unreasonable to imagine that their chronic hypertension or diabetes would go untreated indefinitely. Ultimately, it may be the practitioners who staff urgent care centers, walk-in clinics, community health centers, volunteer clinics, and emergency rooms who will bear the brunt of the clinical management of advanced complications of chronic Illness in those whose illness has long gone undetected. Heart disease and diabetes mellitus are leading preventable causes of death and disability amongst women in Canada. In 2004, cardiovascular disease caused 32% of female deaths (Bierman, Shack, & Johns, 2012). In 2007, 126.1 per 100,000 deaths were related to heart disease among women (Milan, 2011). While the overall prevalence of diabetes in Canadian women is 8.4% and 2.7% in childbearing women (Booth et al., 2010), it has a relatively high prevalence in women of South Asian and Caribbean descent (Creatore

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et al., 2010). Uninsured pregnant women who lack prenatal care and early intervention have an increased risk of developing sequelae to hypertension and diabetes later in life. The subsequent costly medical complications have implications both for these women’s health and for the health care system itself.

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HEALTH PROMOTION, ILLNESS PREVENTION, AND COST CONTAINMENT Health promotion and illness prevention strategies would be invaluable to newcomers and provide a cost-saving measure for health care delivery. O’Brien, Patrick, and Caro (2003) estimated that an acute myocardial infarction cost the government as much as $18,635 Canadian in 2003. Current rates of inflation could easily drive up these costs, not to mention the cost of end-stage renal failure (over $63,045). These are only some of the expenses that should be estimated in regard to the long-term sequelae of uncontrolled diabetes and hypertension. Cost–benefit analyses of government expenditures on preventative treatment versus acute hospital care would also be helpful. Maternity care providers have a unique opportunity to engage in research that promotes equitable care for migrating families. This issue has come into the forefront with the passage of Bill C-31, which restricts medical care for refugees and refugee claimants (Parliament of Canada, 2012). The challenge remains that an important subsample of uninsured individuals, namely, those with precarious migration status, rarely wish to be discovered or involved in research studies. Comprehensive databases that allow quick access to data and facilitate the analyses of perinatal outcomes would be helpful. Demographic data such as insurance status, ethnic heritage, or years of residence would be useful in helping to target health care services and resources for marginalized and socially high risk groups such as refugees.

EQUAL ACCESS TO HEALTH CARE AS A QUALITY ASSURANCE BENCHMARK Extending health care insurance to pregnant refugees and immigrants would be a significant step toward disease prevention. The recently published Project for an Ontario Women’s Health Evidence-Based Report, or POWER Study (Bierman, Shack, & Johns, 2012), pointed to the importance of targeting research to identify the socioeconomic and ethnoracial factors that influence women’s health. Bierman, Shack, and Johns (2012) identified 12 of 27 health equity indicators that address chronic illness and three indicators that are linked to access to ambulatory services. These indicators included

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potentially avoidable emergency department visits and hospitalizations, diabetes complications, and depression care. They further demonstrated that the presence of these indicators not only prevents disparity in access to health resources, but it also decreases emergency room (ER) usage. Expensive ER usage could be cut substantially (30%) if chronic obstructive lung diseases, diabetes, asthma, and heart failure could be managed in the community (Bierman et al., 2012). It is pivotal for health care providers to support universal health insurance coverage for pregnant newcomer women due to the primacy and ethical soundness of preventative medicine (Simich et al., 2007). Current fiscal restraints also present clinicians with the responsibility for sound management of provincial health care dollars (Collier, 2008; Ministry of Health and Long Term Care, 2012).

CONCLUSION Globally, the number of immigrants traveling and resettling in our countries will continue to rise. Access to health care is an important element in the integration of a migrant woman to her new home. Also, health policies that make maternity care more accessible to pregnant migrants is clinically and economically sound practice. The discovery of clinically significant hypertension and diabetes amongst pregnant new immigrants and refugees in a Toronto community was a surprising finding. It challenges previous assumptions about the health status and needs of migrant women. Health care providers have a key role to educate newcomers on the importance of prenatal care and to make prenatal care more accessible for women in an effort to avert the potential long-term complications of diabetes and cardiovascular disease. It is possible that early prenatal care could be an important health promotion and chronic disease prevention strategy. Even more so, provision of health insurance to our newest residents would ultimately lead to substantial cost containment in the health care system.

REFERENCES Bierman, A. S., Shack, A. R., & Johns, A. (2012). Achieving health equity in Ontario: Opportunities for intervention and improvement (Chapter 13). In Project for an Ontario Women’s Health Evidence-Based Report (POWER Study) (vol. 2). Toronto, Ontario: St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences. Retrieved from http://powerstudy.ca/power-report/volume2/ achieving-health-equity-in-ontario/ Booth, G. L., Lipscombe, L. L., Bhattacharyya, O., Feig, D. S., Shah, B. R., Johns, A., . . . Bierman, A. S. (2010). Diabetes. In Project for an Ontario Women’s Health Evidence-Based Report (POWER study) (vol. 2). Toronto, Ontario: St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences. Retrieved from http://powerstudy.ca/power-report/volume2/diabetes/

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Collier, R. (2008). Activity-based hospital funding: Boon or boondoggle. Canadian Medical Association Journal, 178, 1407–1408. Retrieved from http://www.cmaj. ca/content/178/11/1407.full Creatore, M., Moineddin, R., Booth, G., Manuel, D., Des Meules, M., McDermott, S., & Glazier, R. H. (2010). Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada. Canadian Association Medical Journal, 182, 781–789. Dearing, S. (2010, June 28). The accomplishments of the G8, G20 Canda summit meetings, politics. The Digital Journal. Retrieved from http://digitaljournal.com/ article/293964#ixzz1Yp2gc2v0 Gagnon, A., Carnevale, F., Saucier, J. F., Clausen, C., Jeannotte, J., & OxmanMartinez, J. (2010). Do referrals work? Reponses of childbearing newcomers to referrals for care. Journal of Immigrant and Minority Health, 12, 559–568. Magnussen, E. F., Vatten, L. J., Smith, G. D., & Romundstad, P. R. (2009). Hypertensive disorders in preganncy and subsequently measured cardiovascular risk factors. Obstetrics and Gynecology, 114, 961–970. Martin, S. F. (2009). Heavy traffic: International migration in an era of globalization. The Brookings Review, 19(4), 41–44. Milan, A. (2011). Mortality: Causes of death. In Statistics Canada (Ed.), Report on the demographic. situation in Canada. Ottawa, Ontario, Canada: Statistics Canada. Retrieved from http://www.statcan.gc.ca/pub/91-209-x/2011001/article/11525eng.htm Ministry of Health and Long Term Care. (2012). Frequently asked questions: How are hospitals funded and administered by the province? Retrieved from http://www.health.gov.on.ca/english/public/contact/hosp/hospfaq_dt.html O’Brien, J. A., Patrick, A. R., & Caro, J. J. (2003). Cost of managing complications resulting from type 2 diabetes mellitus in Canada. BMC Health Services Research, 3(7). Retrieved from http://w02.biomedcentral.com/content/pdf/14726963-3-7.pdf Parliament of Canada. (2012). House Government Bill C-31: An act to amend the immigration and refugee protection act, The balanced refugee reform act, the marine transportation security act and the department of citizenship an immigration act. Retrieved from http://www.parl.gc.ca/HousePublications/Publication. aspx?Language=E&Mode=1&DocId=5581460 Ray, J. G., Vermeulen, M. J., Schull, M. J., Singh, G., Shah, R., & Redelmeier, D. A. (2007). Results of the recent immigrant pregnancy and perinatal longterm evaluation study (RIPPLES). Canadian Medical Association Journal, 176, 1419–1426. Shah, R. R., Ray, J. G., Taback, N., Meffe, F., & Glazier, R. H. (2011). Adverse pregnancy outcomes among foreign-born Canadians. Journal of Obstetrics and Gynaecology Canada, 33, 207–215. Simich, L., Wu, F., & Nerad, S. (2007). Status and health security: An exploratory study of irregular immigrants in Toronto. Canadian Journal of Public Health, 98(5), 369–373. Society of Obtetricians and Gynecologists of Canada (SOGC). (2011). Chapter 13: Hypertensive disorders of pregnancy. In SOGC (Ed.), Advances in labour and risk management (18th ed., pp. 1–13). Ottawa, Canada: Author.

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Wiesbrock, A. (2011). The integration of immigrants in Sweden: A model for the European Union? International Migration, 49(4), 48–66. Wilson-Mitchell, K., & Rummens, J. A. (2013). Perinatal outcomes of uninsured immigrant, refugee and migrant mothers and newborns living in Toronto, Canada. International Journal of Environmental Research and Public Health, 10, 2198–2213; doi:10.3390/ijerph10062198

Increasing access to prenatal care: disease prevention and sound business practice.

Following our study of birth outcomes for uninsured new immigrant and refugee women in Toronto, we discovered clinically significant numbers of women ...
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