How Long Will Mothers Have to Wait for Decent Prenatal Care?

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Janet Golden is Professor of History at Rutgers University—Camden. She co-edited "Healing the World's Children: Interdisciplinary Perspectives on Health in the Twentieth Century" (McGill-Queens, 2008).

Howard Markel, M.D., is the George E. Wantz Distinguished Professor of the History of Medicine and Director of the Center for the History of Medicine at the University of Michigan. He is the author of "An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine" (Pantheon Books/Alfred A. Knopf, 2011).

In 1909 Mrs. William Lowell Putnam, an anti-suffrage activist, philanthropist, sister of poet Amy Lowell and of Harvard President A. Lawrence Lowell and wife of leading Boston Brahmin lawyer William Lowell Putnam Sr., attempted to answer a question:  would providing women with prenatal care lower infant and maternal mortality?  A five-year experiment, involving middle-class Boston women, provided the answer:  Yes.  From then on Mrs. Putnam, in addition to crusading against giving women the right to vote, became a leading public advocate for prenatal care.  In 1918 she became president of the American Association for Study and Prevention of Infant Mortality, the leading social welfare organization uniting physicians and reformers.  Both of Mrs. Putnam’s political endeavors failed.  In 1920, the 19th Amendment was ratified.  Today, in 2011, millions of women lack insurance coverage enabling them to access prenatal care.

Although access to prenatal care expanded in the twentieth century, it never became universally available.  In the Progressive era hospitals and municipalities opened clinics, and promoted it and the federal government increased access to services through the Sheppard-Towner Maternity and Infancy Protection Act, which gave funding to the states from 1921 to 1929.  A 1933 White House Conference on Child Health and Protection identified the lack of prenatal care as one of the two leading causes of maternal mortality.  During World War II, the federal government again stepped in, funding prenatal and maternity care for the wives of servicemen in the four lowest pay grades.

Coverage of maternity services for low-income women became available with the passage of Medicaid in 1965. 

Thanks to the Pregnancy Discrimination Act of 1978, women covered by large group insurance plans (15 or more employees) received guaranteed access to maternity benefits.  And, in 2014 when the Affordable Care Act is fully implemented, maternity coverage will be mandatory for all health insurance plans.

In the meantime, many millions of women are not able to access the prenatal care.  As of January 2010, 18 states, according to the Kaiser Family Foundation’s require small group and individual insurance plans to cover maternity services.  Mrs. Putnam’s home state, Massachusetts, provides coverage, as do Alabama, Georgia, Montana, California and New York, among others.  But 32 do not.  In my own state of Pennsylvania, 11 percent of women have no insurance coverage for prenatal and maternity services.

Of course, the vast majority of women without insurance give birth in hospitals, but their lack of prenatal care prior to delivery can put them and their babies at risk for complications, or worse.  After their deliveries women lacking insurance coverage end up with newborn babies and a bill they cannot afford to pay.  Ultimately, the cost is borne by the hospital and then shifted along to taxpayers and the insured and in the form of higher premiums and Medicaid costs as the hospital attempts to recoup its expenses by raising prices.

In 1912 Mrs. Putnam spoke to the American Society for Study and Prevention of Infant Mortality, demanding, “The time cannot come too soon when every woman shall have care during her pregnancy as surely as she now secures it at the time of her confinement.”  One hundred years have gone by and the implementation of the Affordable Care Act is more than two years away.  Shouldn’t state legislatures get busy mandating coverage for all in the interim?  Mrs. Putnam was wrong about women’s suffrage and we are glad she lost that battle, but her crusade for prenatal care has our vote.

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