The real cost of pregnancy for the uninsured

By Cristina Fernandez Pereda 

TheUnited States is one of the most medically and economically advanced countries in the world. However, almost three women die every day here from pregnancy complications, according to the Association of Maternal and Child Health Programs.Medical associations link the risk of mortality among pregnant women to their lack of health insurance. One of the most prominent bills pending in Congress this session has been the State Children Health Insurance Program (SCHIP) bill, designed to extend health coverage to uninsured children in the United States. The SCHIP bill, vetoed for the second time by President Bush on Dec. 12, includes a provision that aims to extend coverage also to uninsured pregnant women.The American Medical Association estimated last August that 45 million Americans lacked health insurance. Of those, 12.6 million women of childbearing age are uninsured, making up 25 percent of the uninsured in the United States.

Photo by La Clinica del Pueblo.
Dr. Meredith Joseph works with women at
the Community Health Center La Clinica del
Pueblo, in Washington, D.C.

According to World Health Organization estimates, in 2004 the U.S. maternal mortality ratio was 13.1 deaths per 100,000 live births. The rate has been increasing since 1982: around 1,000 American women are dying of pregnancy-related complications such as diabetes, hypertension, hemorrhages and infections.

Most of these deaths are preventable: pregnancy-related maternal mortality is 3-4 times higher among women who receive no prenatal care compared to women who receive it, as found by the American College of Obstetricians and Gynecologists.

Uninsured women who become pregnant often have no coverage options other than public programs. Individual health insurance rarely includes maternity coverage, and when it does, it often excludes services related to the pregnancy, such as prenatal care or delivery, or requires the purchase of an expensive health policy.

One of the alternatives for uninsured pregnant women is access to Medicaid. However, too many women fall in the gap of making more money than the limit required to be eligible, but still too little to be able to pay for coverage and/or medication they need through pregnancy.

The college of obstetricians supports the need for prenatal care because it helps prevent low birth weight and reduce incidence mortality among infants and mothers.

“Prenatal care has shown very effective so far, but there is an important lack of insurance among women in maternal age that increases for both the mother and the baby their likelihood of dying,” said Tara Straw, Manager of Government Affairs at the American College of Obstetricians and Gynecologists.

Photo by La Clinica del Pueblo.
La Clinica del Pueblo
provides health services
in the Latino Community.

Whether or not a mother has health insurance also affects the future of the child. “There is a direct link between women without insurance during pregnancy and the behavior when, for example, taking their child to the doctor regularly. It’s very important to create the health link from the beginning,” Straw said.

Women with access to medical care in their first trimester of pregnancy are more likely to stay healthier and have healthier babies. Uninsured women are less likely to have access to it and may never have access to peri-natal or postpartum care.

How the delivery is performed is also decisive. The risk of Caesarean infections has increased by 41 percent in the last two years. “Doctors are more inclined to do them because it saves from different complications, but also women choose this practice when they want to have their baby on a specific date,” said Sarah Fahey, Women and Perinatal Health Program Associate.

For the families, the cost of delivery, excluding prenatal care, varies between $7,000 and $10,000, according to the March of Dimes Foundation. On the other hand, a study by The Institute of Medicine found in 2000 that every dollar in prenatal care saved more than three dollars in postnatal care and long-term morbidity costs. This makes half of the hospital charges for infants: $18 billion of $37 billion.

In order to improve the situation of uninsured pregnant women, the SCHIP bill pending in Congress, last vetoed on Dec. 12, 2007 by President Bush, includes a provision to cover them. This provision will affect 1.2 million women in the United States who are going into the program as soon as it is extended and will potentially reduce the number of uninsured.

SCHIP is a joint state-federal effort that currently covers the health expenses of more than 6 million people, mostly children. Democrats in control of Congress have been pushing an extension to this program adding $35 billion to the program and therefore cover 4 million more children. But President Bush will only allow a $5 billion increase in funding. The provision to cover pregnant women will have to wait until Democrats and Republicans reach an agreement that will override any presidential veto.

Recently, experts have highlighted some shortfalls in the SCHIP program. The current set-up might not allow more people into the program and thereby create waiting lists. To address this particular problem, some states may have to create new eligibility rules or expand Medicaid.

Despite the extensive media coverage of the political showdown between President Bush and Democrats in Congress over the SCHIP bill, the provision to extend coverage to pregnant women hasn’t garnered much public interest.

“This provision hasn’t been included in the public debate because it is not actually considered a big issue. This is helpful; it is good that it’s not controversial. We are happy that they don’t want to change it,” Straw said.

Women’s advocacy groups agree that they want the bill to pass and stay as close as possible to the first agreements reached in Congress. They are also sure that the provision to cover pregnant women has a good chance of success.
However, this provision will only cover pregnant women who are U.S. citizens. Legal immigrants and undocumented women will not be eligible. “There has been some discussion about extending it to legal immigrants, whether after five years in the country they would be eligible for health care, but this hasn’t been discussed anymore after the first veto, and this issue won’t be accomplished by this bill,” Straw said.

Women in this situation have three alternatives: premature care at community health centers, coverage exclusively for the delivery or assistance at free clinics whenever they think there is a complication. Regarding insurance, the National Women’s Law Center states that low-income pregnant women may be eligible for health coverage in four ways:

• Pregnant women qualify for health care coverage through Medicaid if they meet certain income qualifications. According to the Kaiser Family Foundation, 70 percent of those covered by Medicaid are women.
• State programs that use only state dollars to cover populations the federal Medicaid program does not.
• State waivers from the SCHIP program.
• State plan amendments implementing the SCHIP ‘unborn child’ regulation, already approved in the states of Michigan, Illinois, Rhode Island, Massachusetts and Minnesota.

Out of these choices, the current coverage by SCHIP programs offers each state the alternative called the ‘unborn child’ extension, which gives coverage to the fetus and their pregnant mothers who are not themselves eligible. “This creates a problem for doctors when trying to know what kind of treatment they can provide to make sure that their patient is O.K., because some standard treatments are still not included,” Straw said.

According to a statement by the National Women’s Law Center released in March, 2007, the SCHIP ‘unborn child’ regulation has not accomplished its objective to expand coverage for thousands of low-income pregnant women. It requires states “to give services to the ‘unborn child’ and not the pregnant woman; the full range of recommended pre- and post-natal services are not always paid by SCHIP, and are not provided by every state that is participating.”

Photo by La Clinica del Pueblo.
Dr. Joseph attends one of her patients
at La Clinica del Pueblo.

Uninsured pregnant women also go to Community Centers such as La Clínica del Pueblo, in Washington, D.C., with programs that provide them and their children with health care. “We have a very small program, we practice between 40 and 50 deliveries a year, but we created it to answer a big necessity and provide help when it’s needed,” said Dr. Meredith Joseph of La Clínica del Pueblo.

This organization has an agreement with Howard University, also in Washington, to provide coverage according to the families’ income. “Howard is happy for this. Their students can do their practice for free here and we provide care to pregnant women,” Joseph said.

Alternatives such as La Clínica del Pueblo have become the only choice for women who fall between the gaps of legislation and insurance companies’ eligibility requirements but need to ensure their children’s health and their own. Uninsured pregnant women in the United States will have to wait for now until the approval of this SCHIP extension gives them a new possibility.

This story was published on the American Observer on Jan. 23, 2008.

Work raids and children

By Cristina Fernández Pereda 

Children pay the price of immigration raids with their well-being and emotional stability, the non-profit organization La Raza’s research concluded on the consequences of enforcement actions against undocumented workers. Work raids by the U.S. Immigration and Customs Enforcement Department have become increasingly common to apprehend undocumented immigrants.

“The impact is both inevitable and underappreciated, destabilizing children, their families, their schooling and their social networks,” said Rosa Maria Castaneda, research associate at the Urban Institute.

The report “Paying the Price: The Impact of Immigration Raids on America’s Children,” was released Wednesday by the non-profit advocacy groups National Council of La Raza (NCLR) and The Urban Institute. The study took place at three different locations with an increase of work raids: Greely, Colo.; Grand Island, Neb.; and New Bedford, Mass.

“Children are increasingly at risk because these worksite raids are becoming a more common and important enforcement tool for the federal government,” Randy Capps, senior research assistant at The Urban Institute, said. He reported that 4,000 people have been arrested so far this year during work raids, while five years ago there were just a few hundred.

There are approximately 5 million U.S. children with at least one undocumented parent. The report concluded that for every two people arrested, one child is left behind. Work raids can end up with the arrest, from a few days to months, of undocumented workers, their immediate deportation or criminal charges against them.

“I believe the politics of ‘no child left behind’ are good. But I would submit that the politics of the raids left a whole lot of kids behind,” Steve Joel, Superintendent of Grand Island School District, Neb., said

The research concluded that the proceeding and detention procedures lack sensibility to parents’ responsibilities and children’s needs, with cases in which arrested parents could not use a phone to let their family what had happened. “How the raids are conducted is the most important factor affecting children’s safety and well-being,” Castaneda said.

The researchers found that psychological problems the children experience when one of their parents is arrested go from anxiety to emotional distress to depression to feelings of abandonment. “It may be years before we know the full impact of these actions on children and on the communities in which they live,” Janet Murgia, president and CEO of NCLR, said.

The researchers interviewed families, teachers, lawyers, non-profit organizations and social services agencies to measure the impact of these enforcement activities. The children’s extended families become their new support system, suffering the economic consequences of the raids: having one more member to take care of adds costs to the families, which sometimes need social services agencies for resources.

The report ends with recommendations drawn from the study, such as a call to Congress to make the situation of children affected by work raids a priority, to the Immigration and Customs Enforcement department to assume that there will always be children affected by the arrests, and to schools to develop systems to ensure that children have a safe place to go in the event of a raid.

“We are asking that Congress takes a good hard look on this issue as soon as possible and do what is necessary to and provide guidance and support to agencies in order to protect children,” Murgia said.

Rev. E. Roy Riley of the New Jersey Synod Evangelical Lutheran Church in America added a different suggestion: “We need a report on how we got this way. We are an immigrant nation, virtually built entirely by immigrant people. We need to know how we lost side of our most democratic family values: the protection of the most vulnerable among us,” he said.

From work to school

By Cristina Ferández Pereda

No nation in the world can presume that there are no child laborers among its people.

More than 240 million children work every day instead of going to school. They load rocks and sand, handle explosives, crawl in tunnels of mines or work in water. Many times they use dangerous tools, breathe dust or are in contact with toxic products. This situation will cause them life-long health problems.

They are millions from countries that signed the Convention on the Rights of the Child. From 1989, it forces governments to protect children from “economic exploitation and from undertaking any work that might be dangerous or interfere with education, or that is harmful to their physical, mental or spiritual health or for their social development.”

In Latin America, more than 18 million children work on the streets, in mines or on plantations. Ten years ago the International Labour Organization and the Spanish Agency of International Cooperation and other international organizations and ONG, began fighting to send child workers to school. Thanks to their collaboration, 100,000 minors attended high school.

Their work is based on the International Program for the Eradication of Child Labor. IPEC aims to combine national policies with projects that will compel various countries to ban child labor.

The first accomplishments of the Program have demonstrated that it is possible to end child labor through the application of a series of measures. It’s necessary to help the mining communities of these countries organize themselves into cooperatives, acquire legal rights, improve security measures in the workplace and secure certain essential services in health, education and hygiene in the workplace.

However, these organizations cannot replace the governments. The aim is to give a model to the countries in which child labor is most prevalent. Afterwards, the national governments must, once they have acknowledged the necessity to educate children, secure the defense of their rights and prevent their return to the streets, plantations or factories.

As Gillermo Dema, the coordinator of IPEC for Central America, Panama and the Dominican Republic, says, “we are convinced that the fight against child labor is a long-term effort. This program aims to help the countries that have this problem, but we must understand that it is the affected nations that must eliminate it. We help and give tools.”

UNICEF distinguishes between two types of child labor: the work of children in peasant or artisan families, who, due to the level of poverty, require the cooperation of the youngest, and the exploitation of children for a company or employer outside the family. In this last case, the child cannot fit in school time in their work schedule.

The general rule in child labor is the greater the poverty, the more kids work. The alphabetization programs for minors like IPEC are conscious that one of the first steps is to combine work with education. Behind every working child, there is a family that counts on his salary, no matter how small. Acknowledging the importance of education may be the first step for them to learn another job and leave the vicious cycle of poverty.

No country in the work can presume that there aren’t any working children among its people. The majority of them are found in Africa, Asia and Latin America. With projects like IPEC a growing number of children are leaving the labor market to enter school, to build a better future.