SAN DIEGO — The baby inside was telling Maria Velasquez that its moment had arrived. As the pain of her labor grew more intense, friends at the factory where she worked eased her into a car for the trip to UC San Diego Medical Center's emergency room.
She was admitted to the hospital, taken upstairs to the second floor and examined by a doctor. Except for a trip to the same emergency room during false labor two days earlier, it was the first time since her pregnancy had been confirmed that Velasquez had seen a physician.
"I had called (during the pregnancy) and asked how much to see the doctor, and they said $250," Velasquez, 26, explained through an interpreter just hours after her son was born Wednesday at UCSD. "I came to this hospital and they asked me to give $250. I couldn't get all that money together."
Instead, Velasquez became one of the estimated 2,000 to 4,000 San Diego County women who this year will deliver children without prenatal care--a growing population that now amounts to 5% to 10% of the county's new mothers.
Although a few are transients and drug addicts who treat their unborn fetuses as cavalierly as they treat themselves, most of the "no-cares," as doctors call them, are patients like Velasquez--poor and low-income women shunned by private obstetricians and turned away by the county's overburdened health clinics.
More frequently than mothers who receive prenatal care, they will give birth to underweight, premature infants who run a greater risk of developing lung disease, cerebral palsy, mental retardation, visual handicaps and neurological problems.
Because they do not receive the routine tests given to most women during pregnancy, they also have a better chance of carrying their children while suffering from poor nutrition, syphilis, hepatitis or drug addiction.
Each mother and infant will, on average, cost the UCSD hospital about $2,200 more than women who received prenatal care in publicly subsidized clinics, according to a 1985 study conducted at UCSD.
Ironically, greater availability of less expensive prenatal care would prevent the need for costly post-partum medical attention and reduce a debt that is often borne by private patients and taxpayers, hospital officials said.
"There is no question that there is a lot of (infant) illness here at the hospital that is preventable. That's the sad part of this," said Dr. Thomas Key, director of perinatal medicine at UCSD.
"It's awful," said Pam O'Neil, an aide to county Supervisor Brian Bilbray, who is part of a county task force examining the no-care problem. "It's sad for the taxpayer. It's terribly sad for the woman. It's terribly sad for the infant. It's just a terribly sad situation."
Velasquez was one of the lucky ones. A social worker in her native Mexico, she knew enough to eat well and rest often. Her son, Oscar, was born at a healthy 7 pounds, 5 ounces. His only discernible difficulty is a heart murmur, which often clears up during infancy.
But two floors below Velasquez's bed are some no-care infants who aren't as fortunate, babies who spend their first days attached to tubes, monitors and ventilators in UCSD's Infant Special Care Center.
They are infants like Bobby, born at 2 pounds, 13 ounces after 28 weeks of gestation, whose ruptured intestine required major surgery. In his three months of life, Bobby has endured a serious infection and respiratory distress syndrome.
"He has been very, very sick the last couple of weeks," said Dr. Marva Evans, an attending neonatologist in the center. "He has tried to die three or four times on us.
"You don't know that (prenatal) care would have helped. But certainly he would have come in in better condition," she said.
Nearby is Carolina, whose mother gained no weight during her pregnancy but sought no medical attention. Carolina's growth was retarded; she weighed just 4 1/2 pounds at birth. She had an abnormal heart rate and aspirated meconium (fetal excrement) at birth, a problem more common among newborns who are under stress because of inadequate prenatal care, Evans said.
"The baby's probably going to be all right," Evans said, but there is "some evidence . . . of brain damage."
Oscar, Bobby and Carolina are children of the '80s. As obstetricians' costs have soared here and throughout the nation in recent years--mostly as a result of skyrocketing malpractice insurance premiums--more and more of them began to refuse poor and uninsured patients or women relying on the state's Medi-Cal system to pay their bills, health officials said.
With Medi-Cal paying them just $657 for nine months of care, the number of San Diego County obstetricians accepting Medi-Cal patients dropped from 97 in 1984 to fewer than a dozen today, said Kim Warma, director of the Regional Perinatal Program for San Diego and Imperial counties. One review showed that just four of the county's 250 obstetricians are accepting Medi-Cal payments, she said.