1) Philadelphia's infant mortality rate is higher than the national average, which may be due to high rates of preterm births and low birthweight. The closure of 13 obstetrics units has increased demand on the remaining 6 units. 2) The study assessed prenatal care capacity in Philadelphia by surveying providers on appointment availability, wait times, and other access factors. On average, newly pregnant women waited over 10 days for an initial appointment. 3) Recommendations include expanding prenatal care hours, increasing the provider workforce, standardizing scheduling policies, and addressing socioeconomic barriers through partnerships between medical centers and public health.

1. Prenatal Care Capacity Assessment in Philadelphia
Rosie Ganser, Dr. Nathalie A. Bartle, EdD, Jennifer Breaux, DrPH, MPH
Drexel University School of Public Health
Deborah Roebuck, RN, MSN, DrNP(c), Maria Ness, MPH
Philadelphia Department of Public Health
INTRODUCTION AND BACKGROUND
Philadelphia’s infant mortality rate as of 2008 was 10.8 per 1,000 live births , compared to the
national infant mortality rate of 6.7 per 1,000 live births. Potential Contributors to a high infant
mortality rate are the high rate of pre-term births and low birth-weight births. Since 1997,
thirteen obstetrical units have closed in Philadelphia leaving six remaining units to handle
more than 23,000 births annually.
Importance of Prenatal Care
Barriers to Prenatal Care
•Length of wait time at appointment, cost of transportation, obtaining an initial appointment,
patient perception of prenatal care as unimportant, and unintended pregnancy
Disparities in Access and Birth Outcomes
•Factors that influence access to care :
• maternal age, unemployment, current consideration of abortion, inability to pay for
prenatal care, and no interest in personal health status
•Current infant mortality rates are 13.3 infant deaths per 1,000 live births for African
Americans and 5.6 infant deaths per 1,000 live births for whites; CDC refers to the disparity in
infant mortality between African Americans and whites as “the gap”
Life Course Perspective
•Addresses disparities in biological, environmental, psychological, behavioral and social
protective and risk factors
•African Americans are exposed to greater risks and fewer protective factors throughout their
lifespan
PROJECT GOALS
•Primary goal of this study:
• Conduct an assessment to determine the extent of prenatal care capacity in
Philadelphia
•“Prenatal care capacity” refers to the system’s ability to meet the prenatal care needs of
pregnant women through providing an adequate number of appointments within an
acceptable time frame
SPECIFIC AIMS
1)Assess the number of prenatal care appointment slots available in Philadelphia
2)Examine full time work equivalent of providers offering prenatal care
3)Examine the available hours at various designated sites for prenatal care
4)Explore insurance and/or payment methods providers accept for prenatal care
5)Determine the average length of time a newly pregnant woman has to wait for an initial
appointment
6)Review changes in prenatal care in the last five to ten years
Health Benefits
For the Mother Reduced risk for bleeding, anemia, preeclampsia, sepsis, genito-
urinary infection, obstructed labor, gestational diabetes, and
psychosocial benefits
For the Baby Recognition of genetic abnormalities, unusual fetal position or
restricted growth, fetal problems or distress, and reduced risk for
pre-term or low birth-weight
Health Consequences of Late or No Prenatal Care
For the Mother Maternal morbidity and mortality
For the Baby Low birth-weight infants are at higher risk for abnormal
growth rates, sickness, neurodevelopmental issues, late
onset sepsis, and hypertension, diabetes, psychological
distress, and obesity later in life
METHODS
Research Design
•Mixed methods approach with an online questionnaire and qualitative interviews
•Expedited IRB protocol was submitted to Drexel IRB and approved
Quantitative Methods
•Prenatal care provider listings were requested from Medicaid Managed Care Organizations
(MCO’s)
•Query of the online databases of the five most popular commercial insurance plans in
Philadelphia was completed
• Resulted in a combined total of 7, 925 prenatal care provider listings
•Provider listings were managed using Excel
• Sorted for unique listings (first occurrence in the list) and duplicate listings (repeat
occurrence in the list)
• A total of 64 unique prenatal care sites were identified
•Participants in the study include: Site providers or a “point person” who completes the survey
•Full time equivalency (FTE) was calculated by dividing the total number of prenatal care
hours available each week across all provider types by the total number of providers, and
further dividing the quotient by a typical number of hours in a work week, or for the purpose of
this study, 40 hours
Qualitative Methods
•Qualitative interviews were requested with:
• Two OB unit chairs at Philadelphia hospitals
• One nurse practitioner employed by a public health center
• One certified nurse midwife employed by both a Philadelphia hospital and a public
health center
•Theme analysis conducted of transcribed interviews
Community Coalition Action Theory (CCAT)
•Collaboration between Drexel University School of Public Health and the Maternal Child
Family Health Division of the Philadelphia Department of Public Health
Prenatal Care Hours
•Majority of prenatal care hours between 8am and 5pm
•Only 10% of sites provided hours before 8am and only 25% of sites provided hours after
5pm; These sites were all private sites
•No sites reported providing weekend hours
Provider Type
•Total number of providers N=90
•Total number of prenatal care hours N=797.25
•85% of the sites reported having 5 or fewer prenatal care providers
Qualitative Interview Results
• N=4
Payment Type and Insurance Coverage
•100% of sites accept both private insurance and medical assistance
•95% of sites accept self-payment
•40% of sites accept uninsured patients and 35% of sites accept uninsurable patients
•25% of sites cover uninsured patients by signing them up for Medical Assistance and 15%
offer uninsured patients a sliding fee scale
•15% of sites offer uninsurable patients a sliding fee scale and 10% refer them to city health
centers
Prenatal Care Appointments and Wait Time
•918 total prenatal care appointments weekly
•138 total prenatal care appointments for new patients weekly
•Average wait time across all sites is 10.26 days
•Maximum wait time of 32 days and minimum wait time of 1 day
Full Time Equivalency
•Total number of providers N=90, Total number of prenatal care hours per week across all
provider types N=797.25, Number of hours in a typical work week N=40
•FTE across all types of reported providers is .22
•Provider type with the highest FTE is Physician Assistants (.68), followed by Nurse
Practitioners (.38), and OB/GYNs (.23)
Statistically Significant Differences
Between Public and Private Sites
•Private sites N=11
•Public Sites N=9
•*Qualitative interview respondents reported accepting uninsured and uninsurable patients at
their private sites. However, this was not reflected in the quantitative survey results. The
reported private sites that accept uninsured and uninsurable patients did not participate in the
online survey.
Barriers to Providing Prenatal Care Percentage of Sites Reporting This Type of
Barrier at Their Site
Social Support and Educational Needs of Patients 100%
Prior Existing Health Issues 75%
Limited Understanding of Importance of Prenatal
Care
50%
Ambivalent toward pregnancy 50%
Obstacles in initiating care 50%
Facilitators to Providing Prenatal Care Percentage of Respondents Reporting This Type
of Facilitator at Their Site
Six OB Hospitals Collaborating 75%
Provider Competency 25%
Continuity of Providers 25%
Philanthropy 50%
Key Action Steps to Provide Care Percentage of Respondents Recommending
Implementation of This Key Action Step
Place importance on prenatal care 50%
Shared electronic medical record (EMR) 50%
Shared information source among all support
services
25%
Community engagement by academic medical
centers
25%
CONCLUSIONS
•An inadequate number of sites provide prenatal care hours outside of the 8am-5pm Monday-
Friday window
•Provider workforce is inadequate with 85% of sites having 5 or fewer providers and a FTE
workforce of only .22
•An inadequate number of appointments are available for new patients with only 15% of all
appointments available to them
•Wait time for initial prenatal care appointment is inadequate
•Public facilities were more likely to accept uninsured and uninsurable patients than private
facilities, providing a picture for where these patient populations receive their care
•Qualitative results are consistent with literature and support quantitative data conclusions
RECOMMENDATIONS
•Prenatal care hours need to be extended beyond the 8am-5pm Monday-Friday interval
•Provider workforce needs to be increased to meet demand
•Consider the potential for other types of providers to be utilized for prenatal care to meet the
demand for an increase in provider workforce
•Institutional policies for scheduling need to be standardized across prenatal care providers
•The multiple socioeconomic, systemic, and political barriers to providing prenatal care need
to be addressed
•Implementation of an annual city-wide surveillance of prenatal care capacity is necessary
•Partnerships grounded in the Community Coalition Action Theory (CCAT) between the
academic medical centers, the city health centers, and the public health department are
critical to institutionalize change and improve health outcomes
RESULTS
Quantitative Results
•Completed surveys were received from 20 sites N=20
•55% of sites were public and 45% of sites were private
Characteristic of Site Private Sites Public Sites Significance of
Difference
Percentage Accepting
Uninsured Patients
0%* 88% p< 0.001
Percentage Accepting
Uninsurable Patients
0%* 78% p< 0.001
Average wait time in days for
2nd trimester patients
9 days 7 days p= 0.04
Acknowledgements: Maternal Child Family Health Division,
Philadelphia Department of Public Health; Maternal and Child
Health Working Group, Drexel University School of Public
Health; Maternity Care Coalition
Change in Prenatal Care Capacity Percentage of Respondents Reporting This Type
of Change
Increased 75%
Facility and system changes 50%
Hired additional providers 50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage
Provider Type
Percentage of Each Provider Type Across All Sites vs. Percentage of Total Hours of
Care Provided by Each Type Acorss all Sites
Percentage of Total Number of Providers
Percentage of Total Hours of Care Provided