Although teen pregnancy and birth rates among all adolescent females has decreased dramatically over the past two decades (Dworsky & Courtney, 2010), multiple national and state specific studies indicate foster youth remain at heightened risk of teen pregnancy and childbearing (Eastman et al., 2019; King et al., 2014, 2019; Oshima et al., 2013; Pecora et al., 2003; Shpiegel et al., 2017, 2021). This is not surprising as a history of sexual abuse and other forms of maltreatment have been linked to adolescent pregnancy risk (Putnam-Hornstein et al., 2013). A range of birth rates have been reported for girls in foster care (16–50%) (Eastman et al., 2019; King et al., 2014; Svobada et al., 2012), more than double the national average of 8.2% birth rate of their non-foster care peers (Dworsky & Courtney, 2010; Pecora et al., 2003). Studies conducted in three midwestern states indicated that by age 19, approximately 30% of young women in foster care give birth to at least one child compared with 12% of 19 year olds in the general population, and 46% of foster youth who had ever been pregnant had experienced more than one pregnancy compared to 34% of youth in the general population (Courtney et al., 2016; Dworsky & Courtney, 2010). By age 23 or 24, approximately 77% of young women in the Midwest foster care study had given birth, with 42% reported being pregnant at least three times (Courtney et al., 2010). Previous literature has established that girls living in nonrelative foster care settings, those in congregate care, and those with a runaway history are an increased risk for pregnancy compared to foster care youth living in other types of placement settings (Eastman et al., 2019; Shpiegel et al., 2021). Greater placement instability has also been found to be associated with higher pregnancy and birth rates (King et al., 2014). The research also indicates an increased risk of unintended pregnancy by race and ethnicity (King et al., 2014; Shpiegel et al., 2021). Specifically, King et al. (2014) reported that Black and Latina girls in foster care are more likely to give birth than their same race non-foster care peers, and Black adolescents, regardless of foster care status, are more likely to give birth than White adolescents. Additionally, Latina foster youth are at the greatest risk of experiencing rapid, repeat pregnancies (Shpiegel et al., 2021). This is important to understand as Black, Indigenous, and other women of color also experience higher rates of pregnancy-related complications than their white and non-foster, more affluent counterparts (Phillippi & Roman, 2013). Additional factors that increase pregnancy complications that foster youth face include higher levels of mental distress, engagement in risk behaviors, and victimization related to exposure to sexual and physical violence (Coleman-Cowger et al., 2011).

In addition to understanding these risk factors, there are also protective factors that must be considered as they are known to decrease early pregnancy and birth rates. Specially, lower birth rates have been observed among girls who have been in foster care five or more years in comparison to girls who entered foster care during adolescence (as opposed to those that entered care during preadolescence) and stayed in care less than one year (King et al., 2014). Reductions in early births have also been associated with remaining in extended foster care past the age of 18 (Shpiegel et al., 2017). Foster care extension affords the opportunity for foster youth to benefit from continued engagement with caring adults that can support them in accessing critical health care resources. Specifically, caregiver connectedness has been associated with increased contraceptive use and decreased odds of pregnancy (James et al., 2009). If youth do experience a pregnancy during their foster care stay, pregnancy-related complications can be mitigated through early access to prenatal care.

Prenatal Care

Prenatal care is not a single intervention but consists of a series of assessments and appropriate treatments for pregnant women. The three basic components of prenatal care include early and continuous risk assessment, health promotion, and medical and psychological interventions and follow up (Fiscella, 1995). Timing and duration of prenatal care is associated with birth outcomes, and lack of prenatal care is associated with pre-term births, as is delayed receipt of prenatal care (Cederbaum et al., 2013). Given the high incidence of first and repeat pregnancies among youth in foster care (Shpiegel et al., 2021), prenatal visits provide opportunities to discuss post-delivery contraceptive options to support pregnancy prevention and spacing. Adequacy of prenatal care (defined by the frequency and timing of visits), has been correlated with positive outcomes and may also confer benefits such as reduced likelihood of post-partum depression and infant injuries (Alexander & Kotelchuck, 2001). Prenatal care is suggested to occur in the following intervals: about once each month during weeks 4–28 of gestation; twice a month during weeks 28–36 weeks, and weekly during weeks 36 through the time of delivery (Office of Women’s Health, 2012).

Important for the health of both teen mothers and their infants, health care providers use prenatal care visits to educate these young parents on health issues such as diet and nutrition, exercise, immunizations, weight gain, and abstaining from drugs and alcohol; educating teen mothers on nutrition for their newborns, breastfeeding, injury and illness prevention; and monitoring for health-compromising conditions and assisting the new parent(s) in preparing for the emotional challenges of caring for an infant (Child Trends, 2015). Not receiving prenatal care endangers both the lives of the mother and the baby. According to the Guttmacher Institute (2021) women who did not receive prenatal care are 40% more likely than those who did to experience a neonatal death.

Unfortunately, research suggests youth in foster care have less understanding on how to access prenatal care services once pregnancy occurs in comparison to their non-foster care peers (Hudson, 2012; Svobada et al., 2012). Lack of understanding and lack of access could be attributed to the fact that there is a lack of protocols and support from case managers, foster parents, health care and other care providers on how to address sexual health development among children in their care, and the health and well-being of pregnant and parenting youth in particular.

Adolescent health care utilization is below suggested rates, regardless of foster care status. When adolescents do try to access health care, they describe negative experiences including long wait times, feeling rushed at appointments, and the perception that their health care providers are too busy for them (Christiani et al., 2008; Harrison et al., 2017). Adolescents are also hesitant to share sensitive health information (including a desire to access contraception or report a pregnancy) with their health care providers for fear of being judged as well as concerns about confidentiality (Harrison et al., 2017). Thirty-seven states have laws regarding minors’ ability to consent to prenatal care; of those laws, thirteen states allow doctors to inform parents when a child is seeking prenatal care (Moore, 2012). Delayed access to the recommended prenatal care services is a barrier to maternal health- approximately 33% of adolescents do not receive prenatal care within the 1st trimester of pregnancy (Harrison et al., 2017). Labor and delivery services also vary considerably with age, and adolescents experience greater fear, pain and lack of control during labor when compared to their adult counterparts (Harrison et al., 2017). Access to judgement-free adolescent health care should not only be available but should be the practice standard across health care disciplines (social work, medical, nursing, and other allied health training programs), hospital settings, and health care clinics that serve foster youth (Possibilities for Change, 2022).

Role of Medicaid

Any improvements in access to prenatal care and labor and delivery services for foster youth will necessarily involve Medicaid, as Medicaid is the main funding source for health care for most children in foster care (Government Accountability Office, 2009) and virtually all children placed in the United States are eligible for this benefit (Allen & Hendricks, 2013). Medicaid regulations require states to provide a comprehensive set of health benefits to children and youth up to age 21 as outlined in the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit (Svoboda et al., 2012). Included are medical screening services: comprehensive health and development history, unclothed physical exam, appropriate immunizations and laboratory tests, and health education. Though no specific language in the EPSDT framework requires coverage of pregnancy prevention or reproductive health care services, language in the State of Michigan Medicaid Manual (the state in which this current study was conducted) suggests that reproductive health care should be included; in fact, there are a number of access points for reproductive health care services within the mandated medical screen (Friedman, n.d.). In addition to the EPSDT benefits, the Medicaid Act specifically requires states cover “family planning services” that include supplies for sexually active minors of childbearing age (Friedman, n.d.). In addition, the Foster Care Independence Act establishes that Medicaid may continue to be available to former foster youth between the ages of 18 and 21 who have aged out of the system, and states that extend foster care to age 21 can serve youth under the program until age 23 (Fernandes-Alcantara, 2019). Finally, The Patient Protection and Affordable Care Act (ACA, as amended; P.L. 111-148) required states, as of January 1, 2014, to provide Medicaid coverage to youth who have emancipated upon reaching the age of 18 (or up to 21 in states that extended foster care) until their 26th birthday (Congressional Research Service, 2018).

Medicaid: HMOs and Fee for Service Plans

Fee for Service models (FFS) have been used by Medicaid programs for decades; they pay participating physicians, clinics, hospitals and other providers, a fee for each service they furnish. Although FFS can lead to volume, regardless of health care outcomes or quality of care, it can also lead to fragmented care, redundancies in care, and gaps in care (DiGiuseppe & Christakis, 2003). As a strategy to control costs and improve quality and access to health care, including prenatal care for all Medicaid recipients, state governments have begun enrolling beneficiaries in health managed care plans (HMOs) (National Council on Disability, 2013). Standards of performance under the HMO model focus on generation of revenue, volume of patients seen, monitoring the utilization of medical technology, and use of specialist consultation and referral (Geese et al., 1999). The HMO model is considered to be beneficial because it shares financial risk for the health care of children in their programs by offering access to primary care providers and a network of specialists that have incentives to provide effective services in an efficient manner at a rate that controls budget predictability (Federal Trade Commission, 2004). Incentives are built into HMOs using prospective payment arrangements for health plans as well as health plan competition (Wynand & Randall, 2000).

Although nationally most children and youth served by Medicaid are enrolled in HMOs, many states have exempted certain populations from managed care, including foster care youth, covering them instead under a Medicaid fee for service (FFS) plan (DiGiuseppe & Christakis, 2003). One reason for this decision is the concern that HMOs may reduce spending by limiting access to needed medical care rather than reducing wasteful care (Palmer et al., 2017). This may be problematic for foster youth because their high levels of health care utilization may be misinterpreted as excessive spending by managed care plans rather than a reflection of greater health needs. In addition, foster youth lack parents who can be considered reliable health care advocates on their behalf, so they may be more likely to be targeted for across-the-board reductions in health care by managed care plans (Palmer et al., 2017). However, research conducted in the state of Washington showed that foster children on FFS plans had less continuous health care than non-foster children who utilized HMOs (DiGiuseppe & Christakis, 2003). In Michigan, enactment of Public Act 131 of 2009 (Section 1772) changed health insurance coverage for foster care youth from FFS to an HMO system (Child Trends, 2015). Michigan’s law requires enrollment of all foster youth in Medicaid within 14 days of opening a foster care case and utilization of Medicaid insurance to support foster youth in need of obtaining prenatal care services (MDHHS, 2018). This law was in place during the entire observation period of this study (including services paid for on behalf of children in both FFS and HMO Medicaid plans). Although covered by Medicaid, contraceptive treatments (including access to birth control) is an excluded category from required, routine, non-surgical medical care services under the child’s health care coordination plan as defined in the Michigan child welfare manual. This means that child welfare workers and foster parents are not required to assist youth in accessing it as part of the case planning process. In Michigan only a married minor under the age of 18 can get a prescription for birth control without a parent’s permission (Guttmacher Institute, 2021).

Current Study

The established literature has provided a solid foundation in identifying the risk and protective factors associated with childbirth among foster care populations, however, there is a dearth of literature that identifies foster youth at the point of pregnancy. What is known about pregnancy is limited to those foster care youth who eventually give birth. To gain a clearer picture of the scope of pregnancy among foster youth, documentation of pregnancy, prenatal health care utilization and subsequent live births is needed. The current study is one of the first of its kind to use linked inter-agency, state-level, administrative data to examine the prevalence of pregnancy and subsequent access to prenatal care and labor and delivery among a population-based sample of foster care youth in one Midwestern state. This study utilizes a natural experiment to provide the field critical information on how insurance type might also impact prenatal care access. Specifically, this descriptive analysis is designed to discover relationships between several key factors associated with pregnancy among a single cohort of youth in foster care in Michigan and utilizes multivariate analysis to determine if a change in health insurance status is predictive of better access to adequate prenatal care for this vulnerable population of teens. The goal of the investigators is for this research to strengthen policy and practice thereby improving the lives of youth in care as well as their young children.

Methods

Design and Population

Investigators conducted an analysis of linked State of Michigan Medicaid claims data and child welfare case records from January 1, 2009, through September 30, 2012. Included in the analysis were female youth in care who turned 14 years of age or older at any time during the study observation period. This means that pregnancy data for youth who were in care prior to age 14 but turned 14 during the observation period were included in the analysis. This age subgroup was targeted for this study as foster youth in care on or after their 14th birthdays have access to Chaffee independent living resources that can be tapped to support youth in planning for their transition to adulthood, which includes case planning around gaining access to health care services. Foster care case records and Medicaid claim records were linked using name, date of birth and Medicaid ID number, and then de-identified for analysis. Human Subjects Review Boards at Wayne State University and Western Michigan University approved the project. A detailed diagram of the study sampling plan is outlined in Fig. 1.

Fig. 1
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Sample selection diagram

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Measures

Delivery was determined by Medicaid procedure and claims codes associated with birth and delivery. Specific procedure and claims codes identified and used in this study are available in Table 1 as well as those codes associated with deliveries. The major dependent variable of interest was adequate prenatal care. Adequate care was defined as receiving at least seven prenatal visits charged to a single provider as one bundled payment. Seven is the highest number of prenatal office visits that can be billed together under Medicaid and as such, this billing code served as proxy for continuous care during pregnancy.

Table 1 Delivery codes used in the study as defined by medicaid procedures and claims
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Characteristics drawn from child welfare administrative data were examined as potential predictor variables when determining a relationship with pregnancy and/or prenatal care included: age in years at time of pregnancy (under 18 or 18 and older) and at time of delivery for those who delivered at least one child during the study period, type of insurance utilized at time of delivery (FFS vs HMO Medicaid), race/ethnicity (non-Hispanic White, non-Hispanic Black or other), number of different living arrangements during the study period (1, 2, 3, 4 or 5 or more), type of living arrangement at time of delivery (three groups: family-based setting, group or residential facility, youth was living without any adult supervision in independent living/away without leave), and geography of the county with jurisdiction of the case at time of foster care entry (Urban vs Rural). 75% of the foster care population living in Michigan reside in Urban areas (Kids Count, 2019). The largest Urban area in Michigan is Wayne County, which includes the City of Detroit, which houses more than 40% of the State’s total foster care population (Kids Count, 2019). These predictors were selected for several reasons. We controlled for age as youth 18 and older can authorize their own care, while those under 18 cannot. We controlled for race as previous research investigating the phenomena of prenatal care access found significance differences based on race (Alexander et al., 2002). We controlled for geography as access to care may prove more difficult in rural areas due to the need to travel further distances to access care, and number of providers available in communities in which youth reside (Lee et al., 2020). We controlled for number of placements as we wanted to understand if placement moves impacted access to prenatal care. We also wanted to explore whether placement moves impact the number of providers a foster youth saw during a single pregnancy episode. Previous research has found that placement instability is associated with poorer physical health outcomes (Rice et al., 2017). We controlled for type of placement as previous research has shown that youth in nonrelative placements and those in congregate care and runaway youth were more likely to experience a pregnancy (Eastman et al., 2019; Shpiegel et al., 2021).

Analysis

We used ArcGIS 10.2 software to map by county of residence the percentage of females who delivered a baby and received adequate prenatal care for their latest delivery across all 83 of Michigan’s counties. To protect the identity of foster youth in the sample, the map only captures data where five or more foster youth were identified in a single county. We used chi-square analyses to examine prenatal care and pregnancy status by variables of interest and potential predictors. A binary logistic regression was estimated to determine if type of insurance billed at time of delivery (FFS vs HMO) was associated with receiving adequate prenatal visits (seven or more bundled visits claimed from a single health care provider) after controlling for certain predictor variables (age, geography, race). The type of health insurance utilized at the time of delivery (FFS vs HMO) was examined to determine if changes occurred in volume of services rendered comparing youth fully enrolled in fee for service (January 2009–September 2010) to those enrolled fully in managed care plans (September 2011 and later). Prenatal care visits, births, and deliveries that occurred during the transition period were excluded from the analysis since it is not clear the specific month in which counties made the switch from FFS to HMO over the transition period (October 2010 through August 2011). All statistical analyses were conducted using R software version 3.2.2.

Results

Out of 4721 eligible females in the study that turned 14 years of age or older at some point during the study period, 808 (17.1%) females had at least one delivery, while another 1002 (21.2%) had a pregnancy-related charge with no delivery during the study period and the remaining 61.7% (n = 2911) had no pregnancy-related charges during the study period (Table 2). From January 2009 through September 2012, 942 deliveries occurred to 808 females; 594 females had one delivery during this time, while 156 had rapid repeat deliveries, with 117 experiencing two deliveries, 26 had three, and nine had four deliveries during the three-year and nine-month study period.

Table 2 Selected factors by number of prenatal visits among pregnant foster care female youth in Michigana, 2009–2012
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The percentage of youth in the study having at least one pregnancy-related Medicaid charge is shown in Fig. 2, with the highest percentage concentrated primarily in the southern, more densely populated, urban portion of the state. Overall, 12 counties had more than 37% of their foster care female youth receive at least one pregnancy-related Medicaid charge during the study period, including the urban centers of Wayne (Detroit), Genesee (Flint and Saginaw), and Kent (Grand Rapids) counties. Wayne County accounted for 751 (49.5% of the females in this study) of the 1810 females overall in the study with a pregnancy-related charge.

Fig. 2
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The percent of female youth in foster care by Michigan County who had at least 1 pregnancy-related Medicaid charge during study period, 1/1/2009–9/30/2012, N = 1810. Note This figure is intended for color reproduction on the Web (free of charge) and black-and-white in print

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Of the 808 females who delivered, 307 conceived and delivered while in an active foster care placement, defined as being in the child welfare system during the 40 weeks prior to labor and delivery (a proxy for pregnancy period) as well as maintaining an active foster care status during the actual delivery date. Of these females, 276 had one delivery, 28 had two, and three had three deliveries during the study period.

When examining whether the pregnant youth received the recommended number of prenatal visits, pregnancy was measured for those youth who experienced pregnancy over a 40 week period and subsequently delivered while in an active foster care placement. Of these 307 youth, 197 (64.2%) met the threshold for having had access to adequate prenatal care. Twelve counties had five or more youth who became pregnant and delivered within this time period; these were included in spatial analysis shown in Fig. 3. The average percent of youth receiving adequate prenatal care among these 12 counties was 74.5%. 100% of the teens in Calhoun County (a more rural county located in the southern portion of the state), received adequate prenatal care visits while the youth in more Urban locations including Macomb, Kent and Wayne counties averaged between 50 and 60% adequate prenatal care, the lowest in the state. Detroit is in Wayne County is strikingly different from the rest of the counties in terms of several important demographic factors. For example, according to 2010 census, Wayne County included about 52% White and 40% Black. On the other hand, in terms of population size, Calhoun County is 13 times smaller than Wayne with 80% White and 11% Black.

Fig. 3
figure 3

The percent of female teens who became pregnant and delivered in foster care between 1/1/2009–9/30/2012 who received seven or more prenatal care visits across Michigan. Note This figure is intended for color reproduction on the Web (free of charge) and black-and-white in print

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Of the 307 teens with pregnancies and deliveries occurring when they were in an active foster care placement, the percentage with adequate prenatal care visits ranged from lows of 55.5% in Wayne County and 59.8% among Black youth to highs of nearly 71% among Whites and those with foster care placements not supervised by a large urban county (see Table 2). In addition to state geography, the type of Medicaid insurance utilized at the time of delivery (HMO vs FFS) appears to have had a statistically significant effect on access to prenatal care visits in the bivariate analysis. Although race was not significantly associated with prenatal care access in the bivariate model, trends were observed that indicated that Black youth were less likely to have access to adequate prenatal care than White youth and youth of other races. Although not statistically significant, trends were also observed that indicated that age (being under the age of 18) was associated with less access to prenatal care than being over the age of 18. Number of placements and placement type (family-based foster care, residential placement, and independent living) were not associated with access to prenatal care.

In determining whether there was a relationship between access to adequate prenatal care and type of Medicaid insurance held at the time of delivery once controlling for predictors, a binary logistic regression was used (See Table 3). The final model, which included county of jurisdiction and type of Medicaid insurance billed at the time of delivery, indicated that type of insurance billed at delivery predicted having access to an adequate number of prenatal care visits. Specifically, there was a 15% higher chance of having adequate prenatal visits under FFS compared to HMO (Adjusted OR 1.15, 95% CI 1.027–1.297). Additionally, urban county residence predicted adequate prenatal visits; those youth supervised under the State’s largest urban county at the start of foster care had lower odds (OR 0.589, 95% CI 0.346–0.997) of receiving an adequate number of prenatal care visits than those with foster care placements supervised outside of Michigan’s largest urban county.

Table 3 Factors associated with having at least seven prenatal care visits for the latest delivery among female youth in foster care in Michigan during their pregnancy and delivery, 2009–2012
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Discussion

The findings of the current study indicate that like many other states, the percentage of female foster youth that become pregnant in foster care (39%) in Michigan is high, as is the number of foster youths who experience rapid subsequent pregnancies (26%). Many pregnant foster youths are not receiving adequate prenatal care. Among the subset of youth who became pregnant and subsequently delivered while in an active foster care placement, only 64% of youth received adequate prenatal care by our definition of having seven or more prenatal care visits from the same provider under one bundled charge. These Michigan findings are similar to another study conducted in Illinois of over 4500 pregnant and parenting teens in foster care which found that although the majority of females received some prenatal care, more than one in five pregnancies involved either no prenatal care or care that didn’t begin until the third trimester (Dworskey & Decoursey, 2009). Challenges identified in the Illinois study indicated difficulties in engagement of foster youth in services and a history of denial of access to prenatal care through Medicaid for subpopulations of foster youth, such as undocumented immigrants.

Although found to not be statistically significant in the bivariate analysis, trends observed related to race and age at time of pregnancy were potentially concerning. Specifically, Black youth were less likely to have access to adequate prenatal care than White youth and youth of other races. Also, younger teens appeared to have less access to prenatal care than older youth. Number of placements and placement type (family-based foster care, residential placement, and independent living) did not appear to impact access to prenatal care.

When all the predictor variables were loaded into the final multivariate regression model, access to adequate prenatal care only varied significantly by geography and insurance type. Michigan’s largest urban county (Wayne) had more difficulty providing their youth access to prenatal care compared to all other the other Michigan counties combined. Only youth supervised by Wayne, the largest urban county, at the time of foster care entry predicted having inadequate prenatal care. This finding runs contrary to another Michigan-based study related to prenatal care that found access to be more problematic in rural vs urban counties (Wendling et al., 2021). The current finding suggests that lack of access to prenatal care in Urban counties for foster care youth may be more related to overwhelmed caseworkers, large caseloads, and lack of follow up with youth rather than a lack of medical providers available in these communities to provide prenatal care services. The percentage of females receiving adequate prenatal care was lower for the years of HMO enrollment compared to the first year when fee for service was still in place. Similar to past evaluations the current study indicates that the availability of managed medical prenatal care for low-income women has generally not improved their likelihood of getting adequate care nor improved their birth outcomes (Government Accountability Office, 1994).

Policy and Practice Implications

Although many child welfare agencies have programs addressing the special needs of pregnant or parenting foster care youth, comparatively little has been done to help them avoid pregnancy (Boonstra, 2011). The Fostering Connections to Success and Increasing Adoptions Act of 2008 (PL 110-351) includes provisions that may help foster youth delay pregnancy and childbearing. Specifically, the Act allows youth to remain in care until the age of 21, which can increase access to evidence-based, reproductive health services and parenting instruction (Finigan-Carr et al., 2015). The Act also requires state public child welfare agencies to coordinate with their Medicaid agency and other health experts for ongoing oversight of health care services, including access to prenatal care for pregnant youth in foster care (Day & Preston, 2013). Additionally, states are eligible for formula grants under the Personal Responsibility Education Program (PREP) to implement evidence-based programs to improve youth reproductive health outcomes that target high risk youth (including those in foster care) (Finigan-Carr, 2015). Moreover, all youth in foster care are, by definition, are eligible for Medicaid. Medicaid provides reimbursement for contraceptive services, prenatal care, labor and delivery, as well as other preventive family planning services if youth are supported to access them.

Targeted Interventions

Prioritizing investments in targeted interventions designed to prevent teen pregnancy among youth in foster care, provide support to participate in adequate and timely prenatal care services once a pregnancy occurs, and engagement in services that prevent rapid, subsequent early births among first time teen mothers is in the best interests of the young parents, infants, and general public. For example, comprehensive pregnancy prevention strategies and support for youth engagement in timely and adequate prenatal care once a pregnancy occurs should be included in training for foster care workers. Child welfare workers are charged with responsibility for connecting foster youth and their caretakers to services and supports, including prenatal care, but many may feel unprepared to talk with youth on their caseloads about sexuality, safe sex, healthy relationships, and how to navigate community resources, like family planning clinics to obtain needed health care services, such as prenatal care (Boonstra, 2011; Svoboda et al., 2012). Child welfare agencies could partner with local health departments and/or family planning clinics to provide this training and expertise. Clear policies are also needed to ensure the full range of services are provided to pregnant youth, including counseling on pregnancy options, prevention of subsequent pregnancies, and prenatal care resources (Svoboda et al., 2012).

For some foster youth, maximizing timely and preventative sexual health care services means the provision of confidential health care services by a primary care physician. Although many adolescent primary care providers believe collaboration with foster parents and caregivers in the health of teens is important, most consistently express concerns about the consequences of involving caretakers in discussions regarding adolescent risk behavior (Hudson, 2012). Foster youth must be seen by a primary care physician at foster care entry and annually thereafter; these visits may be the best time to conduct a complete sexual history, including risk reduction education, access to pregnancy testing, and education on the benefits of and how to access prenatal care without the presence of the foster parent/other legal guardian present. Sexual health and pregnancy prevention programs should target foster care youth who already have children to prevent rapid, repeat births (Shpiegel et al., 2017). Making Proud Choices! is an example of an evidence-based, sex education curriculum that has been developed to delay initial and subsequent births in foster youth (Dworsky, 2015). Another evidence-based program designed to support pregnant and parenting moms during the prenatal care period and has successfully reduced the occurrence of rapid repeat births is the Nurse Family Partnership program, a home visitation program that utilized registered nurses (Finigan-Carr et al., 2015). In addition to these best practices, the American Association of Pediatrics (2021) provides the following additional practice guidelines for medical professionals to follow during prenatal and postnatal care visits: Use a validated tool to screen for postpartum depression and refer to mental health resources when indicated, screen for intimate partner violence and substance use, emphasize the importance of completing high school and pursuing higher education or vocational training, and recognize all forms of parenting, including coparenting, and support the role of the adolescent father or partner.

Adequacy of Prenatal Care

The large percentage of pregnancies observed among this sample of foster care youth and the lack of access to prenatal care services should be a cause for concern. For every dollar spent on prenatal care for women at high risk (which includes teen parents), $3.38 is saved in medical costs associated with low-birth-weight infants, as well as increases in infant mortality (Fiscella, 1995).

Study Limitations and Implications for Future Research

The current study results should be interpreted with the following limitations in mind: this study was conducted in a single state, and as such, the findings may not be applicable to youth in other states. Additionally, as most male foster youth are not likely to bill Medicaid to obtain access to condoms and other contraceptives, it is difficult to use Medicaid claims data to understand the sexual health behaviors of males. Moreover, the dialogue related to pregnancy prevention and sexual activity among youth in care has predominately assumed heterosexuality of youth, consistently overlooking the risks of early pregnancy for youth who identify themselves as lesbian, gay, bisexual, transgender or queer (LGBTQIA+). Although the current study points to important connections for youth in care and pregnancy, further analysis is needed to understand these associations and to make additional recommendations for policy and practice.

We did not have gestational age, so could only examine adequacy of prenatal care by whether the youth received the highest number of possible bundled visits from one provider (at least seven) under one Medicaid charge claim. Previous research also indicates that timing of prenatal care is a predictor of birth outcomes and later maltreatment (Cederbaum et al., 2013). The current study was unable to determine the specific timing in terms of trimesters in which prenatal care visits occurred as the visits were billed to Medicaid under a single claim code. Seven visits is the maximum number of visits that can be billed under a single claim code. Additionally, enrolling adolescent girls in foster care into managed care plans does not ensure they will access prenatal care at the earliest sign of pregnancy, get the services they need, nor have healthy births. Finally, we did not examine birth outcomes and how birth outcomes might be related to prenatal care access nor maternal health outcomes. These are important areas for future research.

Conclusion

The state bears numerous responsibilities to young people in foster care, including ensuring a foster youth’s medical welfare. Pregnancy prevention and access to prenatal care once a pregnancy occurs is a component of medical welfare and long-term well-being. Urban counties that bear responsibility for larger numbers of foster youth, and youth who are dependent on managed care Medicaid plans to access prenatal care are not being adequately served to ensure the health and safety of these expectant mothers and their unborn children. Prenatal care can serve as a vital gateway into the ongoing health care for female foster youth who become pregnant while in placement. For many pregnant, female foster youths, their first comprehensive health assessment may be received during a prenatal care visit. Prenatal care provides an opportunity for foster youth to receive family planning counseling, parenting education, and linkages to community resources, including nutrition and social service programs. States wanting to improve access to prenatal care and improve the health of pregnant teens and their infants in general must focus on making managed care plans accountable for improving the health of these enrolled populations. Two mechanisms exist to do so: using the quality assurance process to monitor health outcomes and taking corrective action when health outcomes are poor by putting performance expectations into managed care contracts to ensure these Medicaid-enrolled populations actually receive the adequate number of prenatal care visits for which the government has already paid. Specifically, The Center for Medicaid and Medicaid Services has developed quality measures as part of their quality assurance process that quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality and timely health care (CMS.gov, 2020). Additional efforts that could be utilized to monitor state child welfare agency efforts related to implementation of pregnancy prevention and prenatal care access include adding these measurements to the federal Child and Family Services Review (Dudley, 2013).