About one in five Colorado babies didn’t get timely care before birth in 2024, raising risks for both the children and their mothers.
The Colorado Department of Public Health and Environment tracks data for each live birth in the state, including when mothers started prenatal care. The department doesn’t ask those who started late or skipped care why they didn’t receive the recommended prenatal visits, but state officials and nonprofits focused on infant and maternal health believe lack of access to care is a major factor.
The vast majority of Colorado has a shortage of prenatal care providers, requiring families in some rural areas to drive an hour or longer for routine pregnancy visits, according to the state health department.
Last year, 19% of babies in Colorado were born to mothers who didn’t receive first-trimester care, including 2.2% who arrived without any prenatal care. (The share of mothers without timely care may be slightly different than the share of babies, because of twins and other multiple births.)
Typically, during the first prenatal visit, the provider performs an ultrasound to verify that only one embryo is present and that it implanted in the uterus. Twin pregnancies need closer observation because of an increased risk of complications, and embryos that implant in a fallopian tube require removal before the tube ruptures.
Providers also test for infections that could pass to the embryo and for conditions that could make pregnancy less safe for the birthing parent, such as anemia and kidney problems.
The first trimester visits are an opportunity to address risk factors such as smoking, poor nutrition or medications from before pregnancy that carry a risk of birth defects, said Toni Sarge, health policy director at the Colorado Children’s Campaign.
While it may not seem like much is happening before the woman starts to show, most of the embryo’s body parts form in the first trimester, making it a vulnerable time for chemical exposures.
In Colorado, teens were more likely to start care late or miss it, as were parents who identified as Hispanic, Black, American Indian or Pacific Islander. Women with less education and lower incomes also were less likely to get first-trimester care.
All those groups, except Hispanic women, also had above-average rates of maternal mortality as of 2020, which was the most recent year with data.
Rates of late or absent prenatal care were higher in rural counties.
Rural populations, on average, have lower incomes and education levels than urban ones, and the small number of births means that a few women starting care late have an outsized impact. But another factor is that access to prenatal care has been “slowly declining” in rural areas for years, particularly in the southeastern counties, said Chelsea Andrews, a spokeswoman at the state health department.
Arkansas Valley Regional Medical Center and Delta Health both stopped performing deliveries in the past year, though Delta Health will still offer prenatal care.
About 98.6% of Colorado residents live in an area with a prenatal care shortage under the state’s definition, meaning the number of visits available with providers within a 20-minute drive is less than the number of visits needed for the expected number of births. The radius increases to an hour-long drive in rural areas.
The model assumes 12 visits for a typical pregnancy and 15 for mothers who are under 20 or over 35.
Obstetric care is “one of the first programs or services to go” when rural hospitals are struggling, and parents who already have a child may not see early prenatal care as a priority when it would require taking off work or finding a babysitter, Sarge said. While someone who has been through pregnancy before will know more about what to expect, having one healthy pregnancy doesn’t guarantee that the next one will be uncomplicated, she said.
“Every pregnancy and every child is extremely different,” she said.
Access is a problem across the country, particularly as some obstetrician-gynecologists move away from delivering babies because they decide the cost of malpractice insurance is too high, said Ashley Stoneburner, director of applied research and analytics at the March of Dimes.
Increasing the number of providers isn’t easy, particularly in rural areas without a birthing hospital.
University of Colorado’s College of Nursing is planning to open a program to train midwives who don’t have a nursing degree, with the goal of accepting its first class in 2026. The first group will include five students, gradually increasing to 15 per year, said Shannon Pirrie, director of the midwifery education program.
As is, the state’s midwife training programs produce roughly enough graduates to replace those who are retiring or moving to other states, so the additional students will help gradually expand the workforce, she said.
“At the end, 15 midwives a year will be a big impact,” she said.
Midwives can practice independently and assist with deliveries in any setting, but won’t be able to replace the loss of a hospital maternity unit or birthing center, Pirrie said. Still, even if patients face a long drive for the birth, having someone nearby for their prenatal and postpartum care is an important improvement in access, she said.
Other models, such as sending people who aren’t clinicians to conduct home visits or scheduling group prenatal care so a traveling provider can see all the pregnant patients while swinging through town, could partially fill gaps, Sarge said. But in some rural areas, even those methods won’t be feasible because of the low number of births and the significant distances between towns, she said.
The situation isn’t entirely hopeless, though — forced innovation during the pandemic managed to improve access to prenatal care, despite all the disruption to the health system. In 2021, the share of babies without timely prenatal care in Colorado hit its lowest point for the decade, at about 16.2%. The pattern is similar nationwide, Stoneburner said.
The expansion of telehealth may have made it easier for mothers to start care promptly, Sarge said. While some care, such as ultrasounds, needs to happen in person, some visits could be virtual if the patient has guidance to monitor their blood pressure and weight, she said.
“They kind of made it work and pivoted” during the pandemic, she said.
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