In search for answers to absent prenatal care in Texas, an open mind proves key

Journalists like answers. When we don’t get them or they’re not what we expected — which happened during the reporting of my project supported by a National Health Journalism Fellowship — we may feel as though we’ve failed. I found, though, that sometimes the lack of answers is part of the story.

As a health reporter at the San Antonio Express-News, the problem of pregnant women not receiving prenatal care came to my attention because of an epidemic of congenital syphilis in Bexar County. Babies were being born with syphilis because their mothers had not had the simple blood test to diagnose sexually transmitted diseases during pregnancy, so they didn’t get the penicillin that would have easily treated the infection. Sometimes their health care provider didn’t give them the test, but other times the pregnant woman never saw a doctor. Of course, congenital syphilis is just one of many consequences — often devastating — that stem from a lack of prenatal care. Premature birth is another, and San Antonio has one of the highest rates of premature birth in the country, according to the March of Dimes.

Examining data on prenatal care from the San Antonio Metropolitan Health District revealed something shocking: The percentage of babies born to women who did not receive prenatal care had increased dramatically in Bexar County over four years — from 2.7 percent in 2011 to 15.4 percent in 2014. And thousands more babies were born to mothers who received late care. In all, nearly 40 percent of babies born in 2014 were born to mothers who got late or no care. So what caused that increase of women getting no care?

The most common reason posited — Texas’ legislative cuts to women’s health care in 2011 — turned out to be a red herring. Over the next several months, I interviewed dozens of experts, including health care providers, public health officials and policy wonks. They could speculate about the increase, but often their speculations weren’t borne out on further investigation.

None knew for certain what was causing the missing care. Not only that, those I spoke to were unaware there was such a significant increase in babies born to mothers who got late or no care before I asked them about it. I even began to wonder if the data was wrong.

My senior fellow, Kate Long, tried to reassure me. Sometimes the story is that we don’t know, she said.

That shift in perspective was a big help. Even without solving the mystery of the increase, the story was an important and compelling one, after all. What’s key is that too many women aren’t getting early prenatal care, which often means health conditions are going untreated and babies are suffering the consequences. And while plenty of health care providers, community organizations and health officials are working on the problem, clearly more needs to be done.

Several months after I had begun researching the story, I sent the Texas state demographer a more detailed, updated data table I had received from the health department. He pointed out something significant: The percentage of women getting no prenatal care rose at the same time the percentage of women whose prenatal care status was unknown fell. In other words, maybe the problem hadn’t gotten worse, but the recording of the information about prenatal care on birth certificates is getting better. It wasn’t a 1:1 correlation, but it might explain at least part of the increase.

Other experts agreed that this theory was plausible. I had a brief moment of panic — there’s no story here! — but came to my senses once my editor and I realized the severity of the problem had been hiding in the data. That was compelling in a different way.

Now the question became, why was the recording of this information improving? Was there some initiative to more accurately report when women had begun seeing a health care provider during her pregnancy? None of the hospitals or other industry sources I asked gave me an answer. A public health official also thought that, on top of changes in recording, there were indeed fewer women getting prenatal care, but he didn’t know why.

The three-story series that ran in the Express-News in January 2016 wasn’t weaker because of those questions. The fact that no one had solid answers just made it more troubling. The series also made the case that more needed to be done to find the answers so the problem could be addressed. In fact, the health department is planning to convene a workgroup to look at barriers to prenatal care and how to address them.

While the finding that there was an increase in the percentage of women getting no care was high up in every story, there was so much more to the project than that. The first story focused on the impacts of insufficient prenatal care. The second story examined common barriers. The third looked at what was being done to address the problem and what more needed to be done.

While experts could point to specific reasons why women received late or no prenatal care — they were waiting for Medicaid approval in a state that refused to expand Medicaid under the Affordable Care Act; they feared deportation; they couldn’t get transportation or time off from work — I also found that even though community resources existed to assist women in obtaining prenatal care, often they weren’t aware of those resources, or chose not to take advantage of them.

What also became clear was that there were many reasons pregnant women didn’t access care — it was a complicated issue with no easy solutions. In that way, it was like my project.

My advice to other journalists exploring similar subjects would be to work closely with any data journalists at your news outlet or elsewhere (William Heisel, contributing editor for the Center for the Health Journalism, also helped me think about data). Don’t let reporting surprises make you question your entire project. Appreciate that there likely won’t be easy answers, and that expert sources may disagree. Realize that projects are complex by their very nature. Understand that often such issues may not be easily parsed, and that’s OK.

Sometimes journalists can’t find all the answers, but they can point to the right questions, and that can be just as important.

[Photo by Lisa Krantz/courtesy San Antonio Express-News]