Dr. Steven Bruner receives a phone call from Lawrence Memorial Hospital's emergency room. A pregnant woman is in labor, and she hasn't received any care until now because she's poor and an immigrant, which means she is not eligible for Medicaid assistance.
Bruner, who is on call, doesn't know the medical history of the baby or the woman. There have been no tests, no monitoring and no education, and now he needs to deliver the baby.
"It was a really bad situation," Bruner said, of the deliveries he faced a decade ago.
Fortunately, he said, the Lawrence-Douglas County Health Department stepped up to address the growing problem. "I think this is one of the best things they ever did."
The health department started what it calls a rotation system, where Lawrence obstetricians take turns providing prenatal and postpartum care and delivering the babies. The health department facilitates the system and finds volunteer interpreters to go to all of the appointments because most of the women do not speak English. The health department also makes sure the women fill out paperwork once the babies are born because they do qualify for emergency care under Medicaid for the delivery. By filling out the paperwork, the doctors receive some reimbursement for their services.
"It's really a win-win situation," said Bruner, of Lawrence Family Medicine and Obstetrics. "They get better care and hopefully better outcomes, and we get paid something instead of nothing."
When the rotation system started in 2003, there were four patients. In 2011, there were 33, a 700 percent increase. There currently are 10 women in the system.
"It's important to have prenatal care and to start it relatively early, and that simply wasn't happening at all until the health department came up with this idea," Bruner said.
When it comes to prenatal care, Bruner said he typically sees a patient once a month for seven months and then every two weeks for two months. During the last month of pregnancy, he monitors the mother and baby every week. He said the visits allow him to monitor the growth of the baby, making sure he or she is developing and functioning correctly. He also screens the mother for diseases or other complications that can develop during pregnancy. Additionally, the prenatal visits allow him to educate the mother about nutrition and exercise.
"It gives us the opportunity to counsel women about the do's and don'ts of pregnancy and how to avoid alcohol and tobacco and drugs and X-rays and medications that aren't cleared," he said.
Between 2003 and 2011, the rotation system provided care for 207 immigrants.
Lawrence resident Aida Hernandez has volunteered to be an interpreter for the Spanish-speaking women for the past six years.
She goes to every doctor's visit and if lab work needs to be done, she goes to those appointments too. Sometimes, the patients develop gestational diabetes, and so she goes with them to get nutritional information.
And she's there for the delivery. She gives them ice chips, holds their hands, breathes with them and prays with them. If they need a cesarean section, she explains the procedure. If they are in pain, she lets the medical staff know.
"I love it," she said, with a big smile. "I love it because you have been working with them during the whole pregnancy and then experiencing the birth of a new baby is wonderful. It's amazing."
Hernandez said the most difficult hurdle is the first meeting when she has to earn the woman's trust.
"It is very, very important to establish a good rapport with these women because they do not speak English and they are really, really afraid and going through a lot of issues."
Hernandez said these women are from poor, rural areas in Mexico. Most of them are single, and, if they are in a relationship, it's often not a good one. She said they work tirelessly at low-paying jobs and then send money home to loved ones.
"They've left everything behind — family and sometimes children — and stay here for many years. It is a very difficult situation for them to leave," Hernandez said, adding that many suffer from depression. "They come here for the American dream."
Hernandez said when she meets them, she assures them of confidentiality and lets them know that she, too, is from Mexico.
"When you open this window, then they feel really comfortable, and they are willing to talk about other things," she said. "These women are great warriors."
Hernandez estimates that she's helped 25 women, from ages 17 to 29. She said many do not know medical terms, and some have never had an examination.
"I am really happy that this program is happening in Lawrence," she said. "I am glad they are helping women from my country."
While the system is helping uninsured immigrants, health department leaders fear many low-income women are not receiving prenatal care because of the lack of affordable services in Douglas County.
Kim Ens, director of clinical services, said, these could be women who earn too much to qualify for Medicaid but too little to afford private insurance or a doctor's services.
"I do feel there is a gap. I think it is something that our community really needs to discuss," she said.
Lawrence has two safety net clinics, Health Care Access and Heartland Community Health Center, but they do not provide prenatal care, and neither does the health department. Leaders with the organizations said they do not have the funding, staff or equipment to provide such services.
However, the Leavenworth County Health Department offers a Maternal Infant Program, which provides prenatal care, referrals for clients who need high-risk care and delivery services. They are able to provide the care through a partnership with Kansas University Medical Center and KU Hospital. The care is provided by resident physicians.
Last year, 29 Douglas County residents participated in the program: 26 from Lawrence, two from Eudora and one from Baldwin City. Twelve Douglas County residents are in the program now.
Ens said those numbers are concerning because Douglas County women are needing to seek care elsewhere and finding transportation is not easy for low-income residents.
"We want to look at this gap in services in our community and see what we can do about it," Ens said. She gave a presentation about the issue at a recent health department board meeting, and members asked what the solution might be.
Director Dan Partridge said one possible solution would be for Heartland Community Health Center, located in the east end of the Riverfront Mall, to become a Federally Qualified Health Center or FQHC. If it did, Heartland would receive a $625,000 annual grant, enhanced Medicaid and Medicare reimbursements and federal tort coverage. They likely would be able to offer the full spectrum of services, including prenatal care.
Heartland applied for the status last year and was denied in August because of lack of government funding. New federal funding has become available, and Heartland leaders have their fingers crossed once again. They expect to hear in June about whether they've been accepted.
In the meantime, the health department plans to seek resources to fill the gap, which was brought to light during its community health assessment. Assessment results will be discussed during public forums next month.
"Prenatal care is going to result in healthier babies. Without such care, they may end up with birth defects and fighting illnesses, and we don't want that," Ens said.
PUBLIC HEALTH FORUMS
The Lawrence-Douglas County Health Department will be hosting a series of public forums to discuss the findings of a community health assessment. They will be:
• May 9 — 3:30 p.m., Lawrence's Community Health Facility, 200 Maine.
• May 15 — 7 p.m., Eudora Community Center, 1630 Elm St.
• May 16 — 7 p.m., Baldwin City Library, 800 Seventh St.
• May 17 — 7 p.m., Lawrence's Community Health Facility, 200 Maine.