It is increasingly recognized that women have unique health needs and challenges that require different intervention strategies. Historically, the field of women's health consisted of issues surrounding reproduction and childbirth. However, increasingly, the health care community has come to see women as a distinct patient group that has unique health concerns over a lifetime.

This section of our website will be regularly updated with information pertinent to mobile, underserved women. We will highlight personal accounts, such as the one below, as well as clinical updates and featured resources. If you have questions or resources you would like to call attention to please send us an email.

Providing Pregnancy Care to Migrant Woman

My concern is the following: I saw a patient last week who recently found out that she was pregnant. She was only going to be in my area for 4 more weeks and was concerned about finding perinatal care in the next place she moved to. I need to know how we can make that kind of transition as smooth as possible and make sure she gets the care she needs. (Physician, New York)

The Challenge

Continuity of care is one of the greatest challenges of providing health care services to migrant and mobile underserved patients. When the patient is a pregnant woman, clinicians are especially frustrated by interruptions in care. We strive to see women at prescribed intervals through the entire pregnancy, administering a wide array of examinations, lab tests, and educational and support services, most of which are dictated by the stage of progression of pregnancy. When a woman leaves our care partway through her pregnancy, we are anxious for her to continue with another provider in her new location. Likewise, if she arrives having begun care elsewhere, we want to assure that appropriate assessments are done, while avoiding duplication.

The current standards related to the management of pregnancy care hold providers to some fairly universal guidelines. Liability concerns are of course one of the motivating factors for following those guidelines and for clear documentation of care. Clinicians working with the underserved are also likely to view themselves as advocates for their patients and have their patients' best interests in mind when they work to provide the working poor with the best care the US health care system has to offer.

Not only does mobility represent a challenge and a frustration to those who provide pregnancy care, but the impact on pregnancy outcomes could also be significant. Women who receive early and regular prenatal care are more likely to have healthier infants. This is the assumption on which we base pregnancy management. Although there is evidence that challenges this dictum in the case of Hispanic women, we are faced with the need to assist their migrant patients to receive continuity of care in pregnancy.

What Can Be Done?

The Migrant Clinician's Network is responding to the need for systems designed to improve continuity in the care of mobile patients. MCN's first initiative was TBNet in 1996, which is dedicated to completion of tuberculosis treatment. In 2000, MCN created the Diabetes Track II project for mobile individuals with diabetes, and in 2004, CAN-track was founded as a cancer care coordination mechanism.

We at MCN have been aware of a need to organize a similar system of bridge case management for pregnancy care. In 2001 and 2002, MCN conducted the Prenatal Care Pilot, providing continuity assistance to a small number of pregnant migrant women who initiated care with Florida's DeSoto County Health Department. Since then we have been actively seeking funding for a more expanded project. Our efforts have come to fruition with the initiation of MCN's newest tracking initiative, the Prenatal Health Network Project. It is the goal of this project to facilitate continuity of pre-natal care for pregnant women who are mobile.

A Needs Assessment

In order to obtain input from health care professionals working with pregnant migrant women, a survey was distributed in the summer of 2005 to the MCN constituency by email, through relevant list serves, and at presentations.

If you are involved in providing pregnancy care, we would like to hear from you also. To add your voice to the needs assessment, please answer the 5-question survey.

A total of 28 responses have been received, from 15 different states. Respondents included perinatal nurses, case managers, outreach workers, nurse practitioners, midwives, and physicians. Almost all (93%) reported that they frequently see pregnant women who move during pregnancy. They overwhelmingly (93%) agreed that such moves result in challenges to providing quality of care during pregnancy.

Current systems

When asked whether they had a mechanism for ensuring that pregnant women who move during pregnancy continue to receive care at their new location, only 39% said yes. These mechanisms were exemplified by the following responses:

• Portable record: [CHC] provides a portable OB chart for migrating females. The process is to update the portable OB record at each prenatal visit: weight, FHR, BP, fundal height, UA, labs, and other pertinent information.
• Copy of chart record: We send a copy of the record with the patient with the name of the CHC and address.
• Referrals: If they know where they are migrating to we try to find the name, phone number and location of the new clinic to give to them.

In addition to mechanisms for assuring continuity, the survey also asked whether respondents had a mechanism for transferring records for a pregnant patient who transfers away from or to your care during pregnancy. Of the 28 respondents, 22 (79%) described record transfer systems which included some combination of faxing or mailing records, signing release of information forms, and providing records to hand carry. Some expressed frustration with these methods:

• It is old fashioned. We request the records we need, the client signs a form that allows this, or we request our clients to give written permission for us to send their information. This is usually done through the mail and takes quite a while depending on the clinic we are dealing with.
• Only seemingly endless release of info forms to fill out which are then faxed and then occasionally returned with PNC records, often missing pertinent info while including obscure irrelevant data.
• When new patients come to us, they do not come with patient records, and patients often do not know sufficient information about their previous clinic to access the records; or if they do, it takes time, and in the delay time we often end up repeating costly labs unnecessarily for lack of records.

There were a few unique systems in use, including Heart Fax (just starting it this year) and within the state only EMR [electronic medical record] between CHC's.

Suggestions

The final question of the survey asked participants whether they felt that there is a need for a system available to Migrant Health Centers and their pregnant patients that would assist pregnant migrant women with maintaining continuity of care. Again the vast majority (89%) said yes. When asked to describe how they would envision such a system, a variety of open-ended suggestions were offered, including:

• No idea: I wish I knew of a brilliant solution, but I don't. Anything to streamline the continuity of records would be great!
• No change: Our system seems to be working smoothly over the years. The portable OB record the pt carries.
• A referral network: The system should begin with an easy, standardized referral system between FQHC's. List of providers that work with migrants.
• MCN Health Network model: Similar system to migrant tb net.
• Web-based system: A national online community/migrant health center perinatal tracking system. If there were a way to connect the OB providers online to transfer info that way (without violating HIPAA) that would be great.
• Cautions: It needs to be easy, inexpensive, and not require much staff time. I am concerned about some of the logistical barriers to the mobile record systems I have seen presented.

The responses we have received have confirmed the need for a universal records transfer system for healthcare providers who want to optimize the quality and efficiency of pregnancy care of migrant and mobile underserved women. Not only would such a mechanism reduce headaches for the providers, but as one survey respondent said, The greatest benefit would be ensuring pregnant women actually continue their prenatal care and babies are born healthier.

We want to hear from you!

We continue to seek input from health care workers involved in perinatal care services with migrant populations. Please help

Send us a copy of your portable record. This time-honored mechanism is used worldwide. If you have a card or form that you use and would be willing to share it, please send a copy to the address below and we will post them on our website. 

Send stories and ideas. Your experiences help us to make a case to potential funders.

Candace Kugel, MS, CRNP, CNM
Migrant Clinicians Network
878 N. Allen St.
State College, PA 16803
814-238-6566 (phone and fax)