Prenatal care, or lack thereof, has been a big issue in the country, particularly here in East Texas, where nearly half of pregnant women are estimated to go without care in their first trimester.

This is according to the UT System and UT Health Northeast’s recently released The Health Status of East Texas, which looked at data between 2011 and 2013. Estimates were similar in the 2013 Smith County, Texas Community Health Assessment, stating that only 45.5 percent of women in the county began the onset of prenatal care within their first trimester.

“Late entry into prenatal care is high throughout Texas, but especially in northeast Texas,” said Dr. Eileen Nehme, assistant professor of population health at UT Health Northeast.

Over the three years for which there is data, the percent of births to women in northeast Texas who did not begin prenatal care in the first trimester has increased, Dr. Nehme said.

“More work is needed to understand whether or how the late entry into prenatal care seen in this region relates to the infant mortality rate,” she said. “However, we can say that late entry into prenatal care represents a missed opportunity to support a woman throughout her pregnancy and manage health conditions that can lead to poor birth outcomes.”

Dr. Nehme noted that the Healthy People 2020 target for the proportion of pregnant women who receive prenatal care beginning in the first trimester is 77.9 percent. In 2013, this number was 62.4 percent for Texas, and just 52.6 percent for northeast Texas.


The first trimester, or the first 12 weeks, is critical for the baby. During this time, the placenta, blood cells and circulation develops. By the end of the third month, the fetus is fully developed. The most critical developments take place during these three months and the risk of miscarriage decreases at the end of the first trimester.

Seeing the doctor in the first 12 weeks helps identify problems with the baby or the mother that need to be monitored.

Doctors also educate the mother on what to expect during pregnancy as well as with delivery.

An ultrasound, tests and consultations look for genetic disorders, infections and behaviors that might harm the baby.

“The earlier we get people in if they have medical problems-whether it’s past surgeries or substance abuse problems - we can address them better,” said Dr. Adam Newman, an obstetrician/gynecologist at ETMC-Jacksonville.

Newman estimates about 20 percent of the patients he sees come in later than the first 12 weeks.

There are numerous reasons some women make it to an obstetrician late, most of which has to do with socioeconomic status and access to care.

Chris Taylor, executive director at Cherokee County Public Health District, said he believes factors that lead to a lack of prenatal care include: lack of transportation, low wage jobs that don’t always permit people to leave to access care, a limited number of providers, language barriers, and a high uninsured rate.

Other women simply don’t realize they are pregnant.

“There are certain people who don’t know because they don’t have a regular period,” Newman said. “Others may be in denial. If they don’t have to think about it, they don’t think about it.”

For low-income moms, applying for Medicaid may take some time, as there is a scheduled appointment for eligibility and paperwork to submit. Some programs in some areas will accept pregnant women who have pending Medicaid approval, but others require payment at the time of service.

“There is a process,” said Tecora Smith, director at Women, Infants and Children (WIC) at Northeast Texas Public Health District. “If the mom doesn’t find out until she’s 12 weeks that she’s pregnant and she applies a couple of weeks after, it takes a while.”

Lack of education about the importance of prenatal care is another reason, which health professionals said is more common in younger mothers, particularly teens. Newman said pregnant women should be bombarded with information about prenatal care and services that are available.

“Access is not the problem,” Newman said, noting there are three obstetricians in Jacksonville. “We’re not turning people away. It’s about creating awareness that they need to get in and get in early.”

But for those who work in population health, there’s a different perspective, Taylor said. While the work ETMC obstetricians do in the county fulfills a need, there are still some gaps when accessing care.

“Many women leave our county for prenatal care in other places, such as Tyler, Henderson, and Nacogdoches,” Taylor said. “Based on many of the available data sources and my personal experiences with people in the community, I would have to respectfully disagree that our current provider levels are sufficient. Although I will say that the providers we have here are excellent. The public health perspective is always going to be a little more of a big picture than the health care perspective.”

Taylor also notes that while analyzing available data is a starting point, it may not always be accurate.

“Often, the data does not represent certain populations very well,” he said. “For example, you can have insurance, but if it only covers major medical (costs) and does not include important annual checkups, etc., do you really have good insurance? In short, I think there are teen and other types of pregnancies that do not get properly examined.”


According to County Health Rankings reports, “pregnant teens are more likely than older women to receive late or no prenatal care, have gestational hypertension and anemia, and achieve poor maternal weight gain.” They’re also more likely to have a pre-term delivery and low birth weight baby, which increases the risk of developmental delays, illness and mortality.

In Cherokee County, the teen birth rate is 72 for every 1,000 in population, ages 15-19. It’s higher than any of the eight counties adjacent to Smith, and higher than the state’s rate of 52 per 1,000 births.

But again, Taylor said the data might not always show the complete picture. When teens do not get prenatal care due to shame or social stigma, these statistics may be understated.

“We tend to find that a lot of teens hide the fact, which contributes to not getting care or lacking support,” Taylor said. “When teens don’t get prenatal care, it’s not recorded in the teen pregnancy rate. Many times, they turn to friends, who help them cope, but are unable to provide resources.”


In Smith County, a Healthy Texas Babies grant allows a coalition of health workers to do community outreach to women and men at college campuses, to primary providers and at barber and beauty shops.

They discuss family planning, birth control, nutrition and preparing the body for conception.

“This is the grant we’re using to educate women of child bearing age 18 to 45 and also educating providers about preconception education,” Ms. Smith said.

The initiative encourages primary providers to ask their clients important questions about access to healthy foods, birth control and whether they are considering getting pregnant.

Ms. Smith said they refer clients to clinics with women’s health programs, such as UT Health Northeast or Tyler Family Circle of Care. They also let them know of the services available at the health district’s Center or Healthy Living.

“I don’t think people realize they have a program that they will see if they can qualify for Medicaid,” Ms. Smith said. “It doesn’t help to educate them if they don’t know where to go.”

Securing prenatal care early has been a concern for Cherokee County health officials for a while. The county has demonstrated some of the region’s worst health outcomes, has a high poverty rate, a high uninsured rate, at 29 percent, and doesn’t fare well in other factors that determine health status.

Cherokee County Public Health District is no longer offering primary care, but is partnering with a federally qualified health center -Tyler Family Circle of Care - to help address access to care for the uninsured.

They hope to care for pregnant women who receive care in the emergency room for common complications during pregnancy, such as preeclampsia or diabetes.

They also aim to bring in more community health workers to reach out to the public, help patients navigate their care, find a provider, provide educational information in Spanish and partner with hospitals and organizations for community outreach to ensure continuity of care across the health care system.


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