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Health care access and utilization among pregnant adolescents
JOURNAL OF ADOLESCENTHEALTH 1997;21:253-258
ORIGINAL ARTICLE
Health Care Access and Utilization Among Pregnant Adolescents ALISON A. GALBRAITH, B.A., JODY STEVENS, M.S., R.N.C., AND JONATHAN D. KLEIN, M.D., M.P.H.
Purpose: To assess access to and use of health care by adolescents prior to their b e c o m i n g pregnant. Methods: A n interviewer-administered questionnaire was completed by all pregnant adolescents (n = 65) entering the Rochester Adolescent Maternity Program (RAMP) b e t w e e n January and June 1994. Questions addressed access and utilization issues i n c l u d i n g routine care and other services used, and existence of a regular source of care prior to pregnancy. Results: Sixty-one adolescents (94%) completed questionnaires. A l m o s t all (93%) had made a doctor or clinic visit, and 77% had had a checkup in the prior year. Most had Medicaid (85%) or private insurance (13%). The median n u m b e r of visits to a regular source of care was 2.0 (range 0-10). Most frequently reported sources of regular care were hospital clinics (43%), c o m m u n i t y health centers (26%), and private physician offices (15%). Two-thirds (66%) reported having used multiple sources of care. Of those w h o used other sources in addition to a primary care source, 40% used reproductive health clinics. Adolescents w h o s e primary care source was a traditional physician's office were more l i k e l y to also use reproductive health clinics than those w h o reported using more comprehensive primary care sources. Conclusions: Most pregnant adolescents in this sample had previously used routine primary care, usually in hospital clinics or health centers. Many of these adolescents also use multiple sources of care, most often for reproductive services. Access to reproductive health services does not seem to have been a problem for these
From the Rochester Adolescent Maternity Program, Department of Pediatrics, Division of Adolescent Medicine, University of Rochester Medical Center; and University of Rochester School of Medicine and Dentistry, Rochester, New York. Address reprint requests to: Dr. J.D. Klein, Department of Pediatrics, Division of Adolescent Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642. Manuscript accepted 15 February 1997.
adolescents prior to their pregnancies. © Society f o r A d o l e s c e n t Medicine, 1997 KEY WORDS:
Adolescent pregnancy Health care access Primary care Adolescents
Adolescents w h o engage in early u n p r o t e c t e d sex and w h o become p r e g n a n t are at risk for adverse outcomes. Early initiation of sexual activity has been linked to substance abuse, cigarette smoking, p o o r school performance, and delinquency (1-4). In 1993, 53% of American high school students reported that they were sexually active (5), and, in 1990, 22% of sexually active high school girls reported not using contraception at their last intercourse. (6). The median delay for adolescent girls in seeking contraceptive care from a clinic was 9-12 monffts after initiating sexual activity (7). The 1991 U.S. p r e g n a n c y rate for girls ages 15-19 was 115.8/1000 and the 1992 birth rate was 60.7/1000 (8). In M o n r o e County, N e w York, the site of this study, 10% of pub]Lic high school students reported either that they had been p r e g n a n t or that they have i m p r e g n a t e d someone (9). M a n y adolescents do not have access to ongoing health care. Adolescents are a m o n g those most likely to be uninsured, and adolescents are ~Lheage g r o u p with the lowest rate of p r i m a r y care use (10,11). Several studies have addressed adolescents' health care access and use in general (9,12-17), for family planning services (7,18,19), and for prenatal care (20). H o w e v e r , previous studies have not looked at prior access to or use of care a m o n g adolescents w h o
© Societyfor AdolescentMedicine,1997 Published by ElsevierScienceInc., 655 Avenueof the Americas,New York,NY 10010
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b e c o m e pregnant; thus, it is not k n o w n w h e t h e r most p r e g n a n t y o u t h have ever received care designed to reduce risky behaviors or to p r o m o t e healthy ones (21). To assess w h e t h e r adolescents had access to and used health care prior to becoming pregnant, we s u r v e y e d adolescents in the Rochester Adolescent Maternity P r o g r a m (RAMP) at Strong Memorial Hospital at the University of Rochester.
Methods The Rochester Adolescent Maternity Program is a hospital-based program that provides prenatal care and social services to pregnant adolescents under the age of 19 years regardless of insurance status or ability to pay (22,23). RAMP serves approximately 10% of all pregnant teens who deliver babies in Rochester and Monroe County. Between 1993 and 1994, the mean age of patients in RAMP was 16 years (range 12-19); 67% were African-American, 21% were white, and 11% were Hispanic. Most (66%) of the adolescents lived with a single mother, 26% in a two-parent home, 4% with relatives, 2% with a single father, and 2% in other situations. The mean gestational age at entry into RAMP was 16 weeks. Adolescents in RAMP face a number of psychosocial problems: Between 1990 and 1995, 30% of all RAMP patients reported having used counseling, 8% reported having attempted suicide, 23% reported a history of sexual abuse, and 22% reported physical abuse. More than 1 in 4 had been involved with child protective services, 35% had run away from home, 27% had dropped out of school, and 18% had been in foster care. The majority of patients (85%) are insured by Medicaid, 13% are covered by private insurance, and only 2% are uninsured. Referrals to RAMP come from clinicians, clinics, schools, and social service agencies. In general, among RAMP clients, 14% of RAMP patients' pregnancies were planned, 21% were unplanned but not unwanted, and 65% were unplanned and unwanted according to clients' intake interviews. Questionnaires about prior health care use were administered d u r i n g patients' regular intake interviews b y RAMP staff nurses and social workers. We interviewed all patients entering RAMP b e t w e e n January and June 1994. Each adolescent was asked w h e n she last visited a doctor or clinic (aside from a visit for a p r e g n a n c y test), w h e n she last had a regular checkup or physical examination, and whether she had any chronic illnesses requiring regular care. She was also asked w h e n and where her last visit was, her usual source of care, and use of other sources of care. Adolescents w h o identified
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Table 1. Pregnant Adolescents' Health Services Use ~ Site Type Hospital clinic Community health center Adolescent clinic Private physician's office Foster care clinic Hospital ED Planned parenthood clinic
Last Visit RegularSource of Care (n = 61) (n = 53) 43% (26) 43% (23) 21% (13) 26% (14) 15% (9) 11% (6) 10% (6) 15% (8) 5% (3) 4% (2) 5% (3) 0% (0) 2% (1) 0% (0)
Percentages may not add to 100% owing to rounding.
two or more care sites were considered to lhave used multiple sources of care. To categorize other sources of care, we defined as " r e p r o d u c t i v e health clinics," Planned P a r e n t h o o d facilities and two adolescent health centers that provide confidential family planning. We also defined " c o m p r e h e n s i v e " sources of care as clinics or p r o g r a m s having services; available on site to address physical health, mental health, preventive health, social services, and health education (24). These included several c o m m u n i t y health centers, two hospital clinics, two adolescent health centers, and a specialized foster care clinic. Traditional physicians' office practices were considered "less comprehensive," as they generally do not provide the same range of services onsite. Statistical analyses were done using StatView 4.01 (25). Statistical significance of proportions and means were d e t e r m i n e d using chi-square test and Fisher's exact test. We also used nonparametric statistics-specifically, the M a n n - W h i t n e y test (for two group comparisons) and the Kruskal-Wallis test (for three or more group comparisons), as health care visits are not normally distributed. An alpha level of 0.05 was considered significant in these analyses.
Results Sixty-five adolescents entered RAMP b e t w e e n January and June 1994. Of these, 61 (94%) patients completed usable questionnaires. Almost all ]La~MP adolescents s u r v e y e d (93%) reported having m a d e at least one visit to a doctor or clinic in the past year prior to pregnancy. Most of these visits were to hospital clinics and c o m m u n i t y health centers (Table 1). Most respondents (77%) also r e p o r t e d having had a regular checkup in the past year, and an additional 18% had h a d a checkup within 2 years. Most adolescents (88%) were able to identify a place they used for regular care, usually a p r i m a r y care provider (Table 1). The average n u m b e r of visits to a regular
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HEALTH CARE ACCESS AND UTILIZATION IN PREGNANCY
255
Table 2. Source of Regular Primary Care % Reporting Last visit in past year Last checkup in past year Multiple sources of care Reproductive clinic as an alternate source M e a n / m e d i a n visits last year
Doctor's Office (n = 8)
Health Center (n = 14)
Hospital Clinic (n = 23)
Adolescent Clinic (n = 6)
Foster Care Clinic (n = 2)
p Value
75% 50% 75% (6) 75% (6)
86% 77% 50% (7) 7% (1)
100% 78% 70% (16) 17% (4)
100% 100% 83% (5) 33% (2)
100% 100% 50% (1) 50% (1)
0.139 0.224 0.550 0.007
1.0/1.0
2.91/2.0
3.45/2.5
3.0/3.0
1.5/1.5
0.031/NA
source of care over the past year was 2.4 (median, 2.0). Twenty-two percent reported one visit, 19% reported two visits, 17% three visits, and 22% four or more visits in the past year. Those who had a regular source of care and those who did not were equally likely to have visited a doctor or clinic in the past year (92% vs. 100%), to have had a regular checkup (77% vs. 71%), and to have used multiple sources of care (66% vs. 57%). Only 34% of these adolescents reported using a single source of care. Although 8% of respondents reported a chronic health problem for which they saw a doctor on a regular basis, these patients were no more likely to use multiple source of care than those without chronic illnesses (60% vs. 65%). In addition, there were no significant differences in the number of visits made in the past year between those with and without chronic illness. Adolescents using different settings for regular primary care were equally likely to have reported having health care visits or checkups in the prior year (Table 2). However, the number of visits in the past year varied for those using different sources of care. Those reporting hospital clinics and adolescent clinics as their regular care source had the highest average number of visits (3.45 _+ 0.61 and 3.0 _+ 0.32, respectively), followed by those using health centers (2.9 + 0.81), a county foster care clinic (1.5 + 0.5), or private doctors' offices (1.0 _+ 0.33) (p = 0.03). The proportion of adolescents using multiple sources of care did not differ by the type of primary care sites adolescents identified (Table 2). Among those who had used other sources in addition to their primary care source, 40% reported using reproductive health clinics. Seventy-five percent of those using private doctors' offices for primary care had also used a reproductive health clinic, compared with only 18% of those using more comprehensive sources of primary care (p = 0.003). A similar proportion of those who used multiple sources reported having had a checkup in the past year compared with those who had used only a single source of care
(79% vs. 71%, respectively). The mean number of visits in the past year was also similar for those with multiple sources compared to those reporting only a single source (2.62 vs. 2.06; p = 0.31), although those who used multiple sources had a higher median number of visits than those reporting l~aving used a single source of care (2.0 vs. 1.0, respectively).
Discussion In this study, most of these high-risk adolescents had access to health care and had used primary care services prior to their pregnancies and before initiation of prenatal care. In Monroe County, 12% of all adolescents (9), and nationally, 10% of adolescents (17) cannot identify a regular source of: primary care. Although poor and minority adolescents in other studies have been less likely to identify a regular source of care (9,13,16,17), our population was as likely to identify a regular care source as adolescents in the general population. It cannot be determined from our data whether this is owing to a referral bias influencing which pregnant adolescents get their care at RAMP, or to other differences in Rochester adolescents' access to services. Nonetheless, this population's utilization rates suggest tThatthese teens may have some remaining barriers to care. Nationally, adolescents average 3 visits/year (17,26), whereas RAMP patients made an average of 2.4 visits in the past year. This is consistent with data showing that poor adolescents tend to have higher rates of health problems (27,28) but fewer physician contacts than nonpoor adolescents (29). The proportion of adolescents in RAMP that had a routine checkup or examination in the past year (79%), while high, is similar to other adolescent girls in Monroe County (9). However, the existence of these routine visits suggest that some of these youth may have had opportunities to receive preventive health care during the months before they became pregnant. Preventive content may be ]Lessrelevant to
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the proportion of adolescents whose failure to use contraceptives is due to wanting a baby (31,32). However, 65% of RAMP clients reported their pregnancy was unintended, and another 21% had ambivalent feelings about being pregnant. Thus, many of these adolescents had opportunities to receive services able to help prevent unintended pregnancies. We cannot know from this study whether the adolescents' utilization was adequate in quality, because we do not have data on the content of their visits. While much adolescent care is brief and problem oriented (30), these adolescents may have had opportunities to receive services able to prevent unintended pregnancy. Further research is needed to evaluate the content of adolescents' visits prior to pregnancy, and to determine whether differences in health care access and utilization exist between those adolescents whose pregnancies were unintended, and those whose were not. Rochester Adolescent Maternity Program adolescents used hospital clinics and health centers more often than private physicians' offices. Only 15% of RAMP adolescents used office-based physicians for their regular care, compared to 60% of Monroe County adolescents (9). There may be a bias toward prior use of hospital sources, because our study population were patients in a hospital-based prenatal program. The discrepancy may also be due to differences in race and ethnicity (13,15,16), socioeconomic status (16), or insurance status (16). Prior access to private physicians may have been difficult, either because of low physician participation in Medicaid (14,33,34) or because these adolescents were uninsured and did not become Medicaid-eligible until they became pregnant. The majority of adolescents used multiple sources of care, even those with a regular source of care. Use of multiple sources was not related to chronic illness; however, some adolescents likely used sources other than their primary care provider for reproductive health needs. A large proportion of adolescents who used doctors' offices as their primary care sources also used a reproductive care source, while fewer adolescents who used more comprehensive sources of primary care did so. More comprehensive sources of care are more likely to address confidential reproductive needs of adolescents (11); thus, adolescents may use family planning clinics because they have a real or perceived lack of confidentiality with their primary care physician, or because of problems using services that are dependent on their parents' insurance (18,29,35). Many primary care providers address sexual or reproductive health issues at rela-
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tively low rates and many adolescents report wanting to discuss these issues with their doctors but do not do so (12,36,37). The use of multiple sources of care may also provide necessary access to services for thi,; high-risk population with multiple medical and psychosocial problems (1-4,38,39). Although having a single source of care has been shown to be beneficial for both children and adults (40-42), not all adolescent care sources provide comprehensive services at a single site. Further research is needed to assess how well adolescents' health care visits prior to pregnancy provided reproductive health care or pregnancy prevention content, and how one versus multiple sources of care affects whether comprehensive services are delivered and whether they are effective at changing adolescents' behavior (43). It would be important to know how adolescents choose their care sources and whether their prior sources of care influenced their time of entry into prenatal care or other risk factors at entry to care. If confirmed in larger, more representative studies, our results suggest important policy implications. If at-risk adolescents depend on hospital clinics, health centers, and reproductive health clinics in addition to primary care providers, health plans and adolescent health programs targeting at-risk adolescents must actively include these sources of care in their service plans. If these needs are not planned for, adolescents would have to pay out of pocket for care, or, more likely, more of these routine care needs will go unmet. Our research had a number of limitations. This was a small study on a population that may not be representative of other adolescents, pregnant or not. We did not evaluate the length or content of visits, barriers to access, or whether adolescents' health problems had gone untreated. In addition, although our instruments had face and content va].idity, we were unable to validate adolescents' reported responses. Our study also may be biased with regard to which adolescents were referred to RAIvIP. Also, our respondents were adolescents who received prenatal care; adolescents were able to enroll in RAMP right up to the time of their delivery, and our population had relatively early entry into prenatal care for high-risk adolescents. However, they do represent a population of youth in care, and thus potentially are more easily reached by interventions. More information is needed to know whether the policy emphasis should be on making other primary care health services more comprehensive, or on improving the preventive content of existing pri-
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HEALTH CARE ACCESS AND UTILIZATION IN PREGNANCY
mary care and reproductive health services. Nonetheless, our findings suggest that preventive care opportunities do exist prior to conception among pregnant adolescents. The authors thank the staff and patients of the Rochester Adolescent Maternity Program for their help with data collection, and Dr. Elizabeth McAnarney for her thoughtful comments. This study was supported in part by a grant from the J. M. Kaplan Fund. Dr. Klein is a recipient of a Generalist Faculty Scholars Award from the Robert Wood Johnson Foundation.
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17. Butler JA, Winter WD, Singer JD, Wenger M. Medical care use and expenditure among children and youth in the United States: Analysis of a national probability sample. Pediatrics 1985;76:495-507. 18. Chamie M, Eisman S, Forrest JD, Orr MT, Torres A. Factors affecting adolescents' use of family planning clinics. Fam Plann Perspect 1982;14:126-39. 19. Zabin LS, Hirsch MB, Smith EA, Street R, Hardy JB. Evaluation of a pregnancy prevention program for urban teenagers. Fam Plann Perspect 1986;18:119-26. 20. Cartwright PS, McLaughlin FJ, Martinez AM, et al. Teenagers' perceptions of barriers to prenatal care. S Med J 1993;86:737-41. 21. Irwin CE, Millstein SG. Biopsychosocial correlates of risktaking behaviors during adolescence. J Adolesc Health Care 1986;7:825-965. 22. McAnarney ER, Roghmann KJ, Adams BN, Tatelbaum RC, Kash C, Coulter M, Plume M, Charney E. Obstetric, neonatal, and psychosocial outcome of pregnant adolescents. Pediatrics 1978;61:199-205. 23. Fuller SA, Engerman JR, Sprik M, Eisinger SZ, Jefferson JA, Martin SA, Thompson-Scott HM. Information on a shoestring: A practical database at an adolescent pregnancy, program. Pediatric Nurs 1991;17:539-45. 24. Ducey AL, Klein JD, Loda FA, Vitaglione T. Adolescent health services in North Carolina's local health departments. J. Adolesc Health 1993;14:307-13. 25. Sager S. StatView. Berkeley, CA: Abacus Concepts, Inc., 1992. 26. Gans GE, McManus PM, Newacheck PW. Adolescent Health Care: Use, Costs, and Problems of Access. Chicago, IL: American Medical Association; 1991:9-21. AMA Profiles of Adolescents Health, No. 6. 27. Brindis CD, Lee PR. Public policy issues affecting the health care delivery system of adolescents. J Adolesc Health 1990;11: 387-97. 28. National Center for Health Statistics, Examination and Health History Findings Among Children and Youths, 6-17 years, United States. Washington, DC: U.S. Government Printing Office, 1973; DHEW Pub. No. (HRA) 74-1611. 29. Newacheck PW. Improving access to health services for adolescents for economically disadvantaged families. Pediatrics 1989;84:1056-63. 30. Klein JD, Slap GB, Elster AB, Schonberg SK. Access to Health for Adolescents: A position paper of the Society for Adolescent Medicine. J Adolesc Health Care 1992;13:162--70. 31. Panzarine S, Kubis J, Elster A, McAnaraney ER. Motivated adolescent pregnancies. J Current Adolesc Med 1979;1:57-9. 32. Stevens-Simon C, Kelly L, Singer D, Cox A. Why pregnant adolescents say the}, didn't use contraceptives prior to conception. J. Adolesc Health 1996;19:48-53. 33. Davidson SM, Perloff JD, Kletke PR, Schiff DW, Connelly JP. Full and limited Medicaid participation among pediatricians. Pediatrics 1983;72:552-9. 34. Perloff JD, Kletke PR, Neckerman KM. Recent trends in pediatrician participation in Medicaid. Med Care 1986;24:749-60. 35. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: A survey of knowledge, perceptions and attitudes a m o n g high school students. JAMA 1993;269: 1404-7. 36. Russell NK, Boekeloo B, Raft IZ, Rabin DL. Unannounced simulated patients' observations of physicians' STD / HIV prevention activities. Am J Prev Med 1992;8:23.5-40. 37. Lewis CE. Health Services Research in Prevention. Primary Care Research: An Agenda for the 90's. Rockville, MD: Department of Health and H u m a n Services; 1990:87-92.
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38. Marks A, Malizio J, Hoch J, Brody R, Fisher M. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. J Pediatr 1983;102:456-60. 39. Stiffman AR, Earls F, Robins LN, Jung KG, Kulbok P. Adolescent sexual activity and pregnancy: socioenvironmental problems, physical health, and mental health. J Youth Adolesc 1987;16:497-509 40. Gordis L. Effectiveness of comprehensive care programs in
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preventing rheumatic fever. NEJM 1973;289:331-5. 41. Alpert J, Robertson L, Kosa J, Heagarty M, Haggerty R. Delivery of health care for children: report of an experiment. Pediatrics 1976;57:917-30. 42. Starfield B. Primary Care: Concept, Evaluation and Policy. New York, NY: Oxford University Press, 1992. 43. Earls F, Robins LN, Stiffman AR, Powell J. Comprehensive health care for high-risk adolescents: an evaluation study. Am J Public Health 1989;79:999-1005.
ORIGINAL ARTICLE
Health Care Access and Utilization Among Pregnant Adolescents ALISON A. GALBRAITH, B.A., JODY STEVENS, M.S., R.N.C., AND JONATHAN D. KLEIN, M.D., M.P.H.
Purpose: To assess access to and use of health care by adolescents prior to their b e c o m i n g pregnant. Methods: A n interviewer-administered questionnaire was completed by all pregnant adolescents (n = 65) entering the Rochester Adolescent Maternity Program (RAMP) b e t w e e n January and June 1994. Questions addressed access and utilization issues i n c l u d i n g routine care and other services used, and existence of a regular source of care prior to pregnancy. Results: Sixty-one adolescents (94%) completed questionnaires. A l m o s t all (93%) had made a doctor or clinic visit, and 77% had had a checkup in the prior year. Most had Medicaid (85%) or private insurance (13%). The median n u m b e r of visits to a regular source of care was 2.0 (range 0-10). Most frequently reported sources of regular care were hospital clinics (43%), c o m m u n i t y health centers (26%), and private physician offices (15%). Two-thirds (66%) reported having used multiple sources of care. Of those w h o used other sources in addition to a primary care source, 40% used reproductive health clinics. Adolescents w h o s e primary care source was a traditional physician's office were more l i k e l y to also use reproductive health clinics than those w h o reported using more comprehensive primary care sources. Conclusions: Most pregnant adolescents in this sample had previously used routine primary care, usually in hospital clinics or health centers. Many of these adolescents also use multiple sources of care, most often for reproductive services. Access to reproductive health services does not seem to have been a problem for these
From the Rochester Adolescent Maternity Program, Department of Pediatrics, Division of Adolescent Medicine, University of Rochester Medical Center; and University of Rochester School of Medicine and Dentistry, Rochester, New York. Address reprint requests to: Dr. J.D. Klein, Department of Pediatrics, Division of Adolescent Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642. Manuscript accepted 15 February 1997.
adolescents prior to their pregnancies. © Society f o r A d o l e s c e n t Medicine, 1997 KEY WORDS:
Adolescent pregnancy Health care access Primary care Adolescents
Adolescents w h o engage in early u n p r o t e c t e d sex and w h o become p r e g n a n t are at risk for adverse outcomes. Early initiation of sexual activity has been linked to substance abuse, cigarette smoking, p o o r school performance, and delinquency (1-4). In 1993, 53% of American high school students reported that they were sexually active (5), and, in 1990, 22% of sexually active high school girls reported not using contraception at their last intercourse. (6). The median delay for adolescent girls in seeking contraceptive care from a clinic was 9-12 monffts after initiating sexual activity (7). The 1991 U.S. p r e g n a n c y rate for girls ages 15-19 was 115.8/1000 and the 1992 birth rate was 60.7/1000 (8). In M o n r o e County, N e w York, the site of this study, 10% of pub]Lic high school students reported either that they had been p r e g n a n t or that they have i m p r e g n a t e d someone (9). M a n y adolescents do not have access to ongoing health care. Adolescents are a m o n g those most likely to be uninsured, and adolescents are ~Lheage g r o u p with the lowest rate of p r i m a r y care use (10,11). Several studies have addressed adolescents' health care access and use in general (9,12-17), for family planning services (7,18,19), and for prenatal care (20). H o w e v e r , previous studies have not looked at prior access to or use of care a m o n g adolescents w h o
© Societyfor AdolescentMedicine,1997 Published by ElsevierScienceInc., 655 Avenueof the Americas,New York,NY 10010
1054-139X/97/$17.00
PI[ $1054-139X(97)00124-9
254
GALBRAITHET AL.
b e c o m e pregnant; thus, it is not k n o w n w h e t h e r most p r e g n a n t y o u t h have ever received care designed to reduce risky behaviors or to p r o m o t e healthy ones (21). To assess w h e t h e r adolescents had access to and used health care prior to becoming pregnant, we s u r v e y e d adolescents in the Rochester Adolescent Maternity P r o g r a m (RAMP) at Strong Memorial Hospital at the University of Rochester.
Methods The Rochester Adolescent Maternity Program is a hospital-based program that provides prenatal care and social services to pregnant adolescents under the age of 19 years regardless of insurance status or ability to pay (22,23). RAMP serves approximately 10% of all pregnant teens who deliver babies in Rochester and Monroe County. Between 1993 and 1994, the mean age of patients in RAMP was 16 years (range 12-19); 67% were African-American, 21% were white, and 11% were Hispanic. Most (66%) of the adolescents lived with a single mother, 26% in a two-parent home, 4% with relatives, 2% with a single father, and 2% in other situations. The mean gestational age at entry into RAMP was 16 weeks. Adolescents in RAMP face a number of psychosocial problems: Between 1990 and 1995, 30% of all RAMP patients reported having used counseling, 8% reported having attempted suicide, 23% reported a history of sexual abuse, and 22% reported physical abuse. More than 1 in 4 had been involved with child protective services, 35% had run away from home, 27% had dropped out of school, and 18% had been in foster care. The majority of patients (85%) are insured by Medicaid, 13% are covered by private insurance, and only 2% are uninsured. Referrals to RAMP come from clinicians, clinics, schools, and social service agencies. In general, among RAMP clients, 14% of RAMP patients' pregnancies were planned, 21% were unplanned but not unwanted, and 65% were unplanned and unwanted according to clients' intake interviews. Questionnaires about prior health care use were administered d u r i n g patients' regular intake interviews b y RAMP staff nurses and social workers. We interviewed all patients entering RAMP b e t w e e n January and June 1994. Each adolescent was asked w h e n she last visited a doctor or clinic (aside from a visit for a p r e g n a n c y test), w h e n she last had a regular checkup or physical examination, and whether she had any chronic illnesses requiring regular care. She was also asked w h e n and where her last visit was, her usual source of care, and use of other sources of care. Adolescents w h o identified
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Table 1. Pregnant Adolescents' Health Services Use ~ Site Type Hospital clinic Community health center Adolescent clinic Private physician's office Foster care clinic Hospital ED Planned parenthood clinic
Last Visit RegularSource of Care (n = 61) (n = 53) 43% (26) 43% (23) 21% (13) 26% (14) 15% (9) 11% (6) 10% (6) 15% (8) 5% (3) 4% (2) 5% (3) 0% (0) 2% (1) 0% (0)
Percentages may not add to 100% owing to rounding.
two or more care sites were considered to lhave used multiple sources of care. To categorize other sources of care, we defined as " r e p r o d u c t i v e health clinics," Planned P a r e n t h o o d facilities and two adolescent health centers that provide confidential family planning. We also defined " c o m p r e h e n s i v e " sources of care as clinics or p r o g r a m s having services; available on site to address physical health, mental health, preventive health, social services, and health education (24). These included several c o m m u n i t y health centers, two hospital clinics, two adolescent health centers, and a specialized foster care clinic. Traditional physicians' office practices were considered "less comprehensive," as they generally do not provide the same range of services onsite. Statistical analyses were done using StatView 4.01 (25). Statistical significance of proportions and means were d e t e r m i n e d using chi-square test and Fisher's exact test. We also used nonparametric statistics-specifically, the M a n n - W h i t n e y test (for two group comparisons) and the Kruskal-Wallis test (for three or more group comparisons), as health care visits are not normally distributed. An alpha level of 0.05 was considered significant in these analyses.
Results Sixty-five adolescents entered RAMP b e t w e e n January and June 1994. Of these, 61 (94%) patients completed usable questionnaires. Almost all ]La~MP adolescents s u r v e y e d (93%) reported having m a d e at least one visit to a doctor or clinic in the past year prior to pregnancy. Most of these visits were to hospital clinics and c o m m u n i t y health centers (Table 1). Most respondents (77%) also r e p o r t e d having had a regular checkup in the past year, and an additional 18% had h a d a checkup within 2 years. Most adolescents (88%) were able to identify a place they used for regular care, usually a p r i m a r y care provider (Table 1). The average n u m b e r of visits to a regular
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Table 2. Source of Regular Primary Care % Reporting Last visit in past year Last checkup in past year Multiple sources of care Reproductive clinic as an alternate source M e a n / m e d i a n visits last year
Doctor's Office (n = 8)
Health Center (n = 14)
Hospital Clinic (n = 23)
Adolescent Clinic (n = 6)
Foster Care Clinic (n = 2)
p Value
75% 50% 75% (6) 75% (6)
86% 77% 50% (7) 7% (1)
100% 78% 70% (16) 17% (4)
100% 100% 83% (5) 33% (2)
100% 100% 50% (1) 50% (1)
0.139 0.224 0.550 0.007
1.0/1.0
2.91/2.0
3.45/2.5
3.0/3.0
1.5/1.5
0.031/NA
source of care over the past year was 2.4 (median, 2.0). Twenty-two percent reported one visit, 19% reported two visits, 17% three visits, and 22% four or more visits in the past year. Those who had a regular source of care and those who did not were equally likely to have visited a doctor or clinic in the past year (92% vs. 100%), to have had a regular checkup (77% vs. 71%), and to have used multiple sources of care (66% vs. 57%). Only 34% of these adolescents reported using a single source of care. Although 8% of respondents reported a chronic health problem for which they saw a doctor on a regular basis, these patients were no more likely to use multiple source of care than those without chronic illnesses (60% vs. 65%). In addition, there were no significant differences in the number of visits made in the past year between those with and without chronic illness. Adolescents using different settings for regular primary care were equally likely to have reported having health care visits or checkups in the prior year (Table 2). However, the number of visits in the past year varied for those using different sources of care. Those reporting hospital clinics and adolescent clinics as their regular care source had the highest average number of visits (3.45 _+ 0.61 and 3.0 _+ 0.32, respectively), followed by those using health centers (2.9 + 0.81), a county foster care clinic (1.5 + 0.5), or private doctors' offices (1.0 _+ 0.33) (p = 0.03). The proportion of adolescents using multiple sources of care did not differ by the type of primary care sites adolescents identified (Table 2). Among those who had used other sources in addition to their primary care source, 40% reported using reproductive health clinics. Seventy-five percent of those using private doctors' offices for primary care had also used a reproductive health clinic, compared with only 18% of those using more comprehensive sources of primary care (p = 0.003). A similar proportion of those who used multiple sources reported having had a checkup in the past year compared with those who had used only a single source of care
(79% vs. 71%, respectively). The mean number of visits in the past year was also similar for those with multiple sources compared to those reporting only a single source (2.62 vs. 2.06; p = 0.31), although those who used multiple sources had a higher median number of visits than those reporting l~aving used a single source of care (2.0 vs. 1.0, respectively).
Discussion In this study, most of these high-risk adolescents had access to health care and had used primary care services prior to their pregnancies and before initiation of prenatal care. In Monroe County, 12% of all adolescents (9), and nationally, 10% of adolescents (17) cannot identify a regular source of: primary care. Although poor and minority adolescents in other studies have been less likely to identify a regular source of care (9,13,16,17), our population was as likely to identify a regular care source as adolescents in the general population. It cannot be determined from our data whether this is owing to a referral bias influencing which pregnant adolescents get their care at RAMP, or to other differences in Rochester adolescents' access to services. Nonetheless, this population's utilization rates suggest tThatthese teens may have some remaining barriers to care. Nationally, adolescents average 3 visits/year (17,26), whereas RAMP patients made an average of 2.4 visits in the past year. This is consistent with data showing that poor adolescents tend to have higher rates of health problems (27,28) but fewer physician contacts than nonpoor adolescents (29). The proportion of adolescents in RAMP that had a routine checkup or examination in the past year (79%), while high, is similar to other adolescent girls in Monroe County (9). However, the existence of these routine visits suggest that some of these youth may have had opportunities to receive preventive health care during the months before they became pregnant. Preventive content may be ]Lessrelevant to
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the proportion of adolescents whose failure to use contraceptives is due to wanting a baby (31,32). However, 65% of RAMP clients reported their pregnancy was unintended, and another 21% had ambivalent feelings about being pregnant. Thus, many of these adolescents had opportunities to receive services able to help prevent unintended pregnancies. We cannot know from this study whether the adolescents' utilization was adequate in quality, because we do not have data on the content of their visits. While much adolescent care is brief and problem oriented (30), these adolescents may have had opportunities to receive services able to prevent unintended pregnancy. Further research is needed to evaluate the content of adolescents' visits prior to pregnancy, and to determine whether differences in health care access and utilization exist between those adolescents whose pregnancies were unintended, and those whose were not. Rochester Adolescent Maternity Program adolescents used hospital clinics and health centers more often than private physicians' offices. Only 15% of RAMP adolescents used office-based physicians for their regular care, compared to 60% of Monroe County adolescents (9). There may be a bias toward prior use of hospital sources, because our study population were patients in a hospital-based prenatal program. The discrepancy may also be due to differences in race and ethnicity (13,15,16), socioeconomic status (16), or insurance status (16). Prior access to private physicians may have been difficult, either because of low physician participation in Medicaid (14,33,34) or because these adolescents were uninsured and did not become Medicaid-eligible until they became pregnant. The majority of adolescents used multiple sources of care, even those with a regular source of care. Use of multiple sources was not related to chronic illness; however, some adolescents likely used sources other than their primary care provider for reproductive health needs. A large proportion of adolescents who used doctors' offices as their primary care sources also used a reproductive care source, while fewer adolescents who used more comprehensive sources of primary care did so. More comprehensive sources of care are more likely to address confidential reproductive needs of adolescents (11); thus, adolescents may use family planning clinics because they have a real or perceived lack of confidentiality with their primary care physician, or because of problems using services that are dependent on their parents' insurance (18,29,35). Many primary care providers address sexual or reproductive health issues at rela-
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tively low rates and many adolescents report wanting to discuss these issues with their doctors but do not do so (12,36,37). The use of multiple sources of care may also provide necessary access to services for thi,; high-risk population with multiple medical and psychosocial problems (1-4,38,39). Although having a single source of care has been shown to be beneficial for both children and adults (40-42), not all adolescent care sources provide comprehensive services at a single site. Further research is needed to assess how well adolescents' health care visits prior to pregnancy provided reproductive health care or pregnancy prevention content, and how one versus multiple sources of care affects whether comprehensive services are delivered and whether they are effective at changing adolescents' behavior (43). It would be important to know how adolescents choose their care sources and whether their prior sources of care influenced their time of entry into prenatal care or other risk factors at entry to care. If confirmed in larger, more representative studies, our results suggest important policy implications. If at-risk adolescents depend on hospital clinics, health centers, and reproductive health clinics in addition to primary care providers, health plans and adolescent health programs targeting at-risk adolescents must actively include these sources of care in their service plans. If these needs are not planned for, adolescents would have to pay out of pocket for care, or, more likely, more of these routine care needs will go unmet. Our research had a number of limitations. This was a small study on a population that may not be representative of other adolescents, pregnant or not. We did not evaluate the length or content of visits, barriers to access, or whether adolescents' health problems had gone untreated. In addition, although our instruments had face and content va].idity, we were unable to validate adolescents' reported responses. Our study also may be biased with regard to which adolescents were referred to RAIvIP. Also, our respondents were adolescents who received prenatal care; adolescents were able to enroll in RAMP right up to the time of their delivery, and our population had relatively early entry into prenatal care for high-risk adolescents. However, they do represent a population of youth in care, and thus potentially are more easily reached by interventions. More information is needed to know whether the policy emphasis should be on making other primary care health services more comprehensive, or on improving the preventive content of existing pri-
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HEALTH CARE ACCESS AND UTILIZATION IN PREGNANCY
mary care and reproductive health services. Nonetheless, our findings suggest that preventive care opportunities do exist prior to conception among pregnant adolescents. The authors thank the staff and patients of the Rochester Adolescent Maternity Program for their help with data collection, and Dr. Elizabeth McAnarney for her thoughtful comments. This study was supported in part by a grant from the J. M. Kaplan Fund. Dr. Klein is a recipient of a Generalist Faculty Scholars Award from the Robert Wood Johnson Foundation.
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