‘Mom-Mobile’ for Obstetric Care Faces Funding Obstacle

LA HABRA —  Cradling her baby in her arms, 31-year-old Celia Barrera waited in the parking lot to see the pediatrician.

On a gray December day, she and a dozen other low-income parents were bringing their children to a St. Jude Hospital and Rehabilitation Center pediatric health-mobile that comes here once a week. Motioning to her swelling girth, Barrera said she too could use a checkup. More than three months’ pregnant, she had not yet seen a doctor.

“Si, problemas, “ Barrera sighed. With no money, no car and with 6-month-old Maria to care for, she didn’t know how she would ever get to an obstetrician--that is, if she could find one.

She would not find obstetric care here at the pediatric van. But it is here that a plan was hatched that could end up helping hundreds of mothers like Barrera.

Drawing on two years’ success with the pediatric van, St. Jude’s wants to outfit a second van with medical equipment, putting a nurse and obstetrician on board and offering free prenatal exams in the North County’s low-income neighborhoods.

The hospital’s plan has been endorsed and propelled by state and county agencies and community groups, but it has hit a roadblock in efforts to get federal money.

Each year, here and around the state, thousands of poor women get prenatal care late in pregnancy--or not at all. The impact, health experts say, is measured in children’s lives: babies born premature, some too sick to make it, by mothers whose first contact with an obstetrician comes in the emergency room.

The idea of a “mom-mobile,” as some call it, has broad appeal.

Nine of the hospital’s 12 obstetricians agreed to take turns in the van. And St. Jude’s vowed that all 240 women who would be served in the van’s first year could have their babies at the Fullerton hospital.

Impressed, county officials last summer gave St. Jude’s $250,000 from the new state tax on tobacco to start the project. And state Medi-Cal officials sang its praises, saying that if the “mom-mobile” worked, other California hospitals would consider similar vans.

But federal officials say they cannot reimburse St. Jude’s for prenatal care offered off hospital grounds. Under federal regulations that govern Medi-Cal, outpatient clinics can be reimbursed for off-site care, but not hospitals.

County, state and St. Jude’s officials call this shortsighted and wrong.

“This is extremely arbitrary and has no basis, from our interpretation of federal regulations,” said Janet Toney, chief of benefits analysis for Medi-Cal’s policy division.

Describing the federal response as “ludicrous,” Toney noted that a medical van would address two major barriers to prenatal care in California--lack of transportation and lack of child care.

“A woman may have a couple of toddlers, and she doesn’t want to drag them around on a bus and wait three hours. And if we can help them (with a van), we should,” Toney said.

After months of saying “no,” federal officials say they are “reconsidering” their position.

Acknowledging that poor women in Orange County have great difficulty finding obstetrical care, Larry McDonough, San Francisco regional administrator of the U.S. Health Care Financing Administration, called the prenatal care van “a good idea.”

“We’d like to see if we can find some way within our regulations to see if these services could be reimbursed,” McDonough said. “If we can do it within the rules, we will. And if we can’t, we might have to seek a change.”

Charles Woffinden, another official in the same office, noted that “the western regional office supports the concept” of a van and has asked lawyers in the Baltimore headquarters to consider a new interpretation allowing a van. “We expect it will be changed,” Woffinden said Thursday.

He and McDonough said they expect a decision on the “mom-mobile” in January. “I can assure you this is a priority,” McDonough added. “I’ve personally been down to Los Angeles County, Orange County . . . I’m very concerned about the access problem in obstetrics.”

Joan Furman, the soft-spoken community activist who directs St. Jude’s Care for the Poor Program and who came up with the concept of a prenatal van, is excited about the shift in federal views.

“That’s really good news,” Furman said. “At least if it’s moving in that direction, it’s OK with me.”

Although experience with prenatal care vans is limited, a few communities around the country report success, said Dottie Andrews, director of community affairs for Orange County’s March of Dimes chapter.

Health agencies use vans to bring women to prenatal appointments in Philadelphia and Washington, D.C., Andrews said. And in Indianapolis, the Indiana University School of Nursing this year started a Maternity Outreach Mobile Project--or MOM Project--in low-income black neighborhoods where infant mortality rates were soaring--up to 24.5% in 1989, more than double the 10.7% mortality rate for white babies.

In that project, a public health nurse and community workers visit the neighborhoods, offering counseling, prenatal exams and ultrasound exams aboard a 35-foot motor coach.

A six-month review of that program, presented Oct. 2 to the American Public Health Assn., showed that mothers seen by its team were less likely to have low-weight babies. Only four--or 7.4%--of 54 MOM-Project babies were underweight, contrasted with 14% babies born underweight in that neighborhood.

Also, Mom-Project leaders reported, four of the women they visited in the first three months were in pre-term labor and had had no prenatal care. The project’s nurse got them immediate care, and all delivered, healthy full-term babies. Andrews called St. Jude’s difficulties with federal regulations unfortunate--a situation in which state and federal officials were “passing the buck” about approving the project for Medi-Cal. (State officials provide half the financing for Medi-Cal, federal officials the rest.)

Meanwhile, St. Jude’s is using its tobacco tax money to provide free prenatal care to Medi-Cal patients who must visit the hospital for care. Since the program began in late October, six women have come, usually taking the bus with young children in tow, Furman said.

She expects the program, dubbed Healthy Beginnings, will get “up to steam by January.”

And Furman still expects to use a new van--not for prenatal exams, but rather as an educational tool, to travel to community centers and churches in low-income neighborhoods, offering information on prenatal nutrition, social services, baby care.

Furman and her colleagues at St. Jude’s are convinced that they would reach more women in need if they could provide mobile prenatal care.

“For so many women, their barrier to prenatal care is transportation,” Furman said. “A lot of them don’t have money to take the bus. And they may have to take themselves and five other children. If the van was in the community, they could walk to the van.”

One week after Celia Barrera’s visit with her little girl, the health-mobile was back in La Habra again. Only this day it was raining. Outside in the cold, parents huddled under a pine tree, wrapping their toddlers and babies--some sick with ear infections, persistent coughs--in baby blankets to try to keep them dry.

As the crowd thinned and the van prepared to leave, Barrera again boarded the bus.

This time little Maria was home with relatives. And this time, when she mentioned she was pregnant and had not yet seen a doctor, Furman probed for details.

Yes, Barrera said she had a pregnancy test and tested positive. No, she was not getting prenatal care at any clinic.

Told of St. Jude’s hospital prenatal program, Barrera said she would try to come. But again, she had no transportation. There was a bus, she said, but she didn’t know how to use it.

Furman consulted with others on the van, and as Barrera waited, they devised a plan. If she could meet the van next Wednesday at the end of its La Habra run, she could ride it to St. Jude’s and see a doctor. Later someone would show her how to take a municipal bus the four miles home.