A large number of women in Hawaii aren’t receiving important prenatal care, putting them and their babies at increased risk of health complications. Indeed, the state has ranked last in recent years when it comes to women obtaining adequate care, defined as initiating care in the first four months of pregnancy and making it to an appropriate number of doctors appointments.

Just 62% of women in Hawaii met this benchmark in 2021, according to recently released government data, compared with a national rate of about 75%.

The rates were the worst on Oahu and Hawaii island, where only 60% of women met the adequacy benchmark when averaged over the years 2019-2021, and the best on Kauai, where 86% of women received adequate care. On Maui, 80% of women met this standard, though the island is now facing a crisis in prenatal care as its only private practice that delivers babies phases out its obstetrics services.

Among the more troubling data points: About 1 in 9 infants in Hawaii was born to a mother who either didn’t begin receiving pregnancy care until her third trimester or received no prenatal care at all, according to the survey data, which was analyzed by the March of Dimes, a national nonprofit that works to end preventable health risks for mothers and babies.

That rate, which has hovered at this level since 2018, is nearly twice the national average.

Ideally, prenatal care should begin within the first three months of pregnancy, according to health officials.

The state Department of Health’s Family Health Serv­ices Division has collected the data annually for dec­ades through surveys that become part of the Pregnancy Risk Assessment Monitoring System, a project of the U.S. Centers for Disease Control and Prevention.

A review of the data over the past two decades indicates that Hawaii has been trending in the wrong direction. For example, in 2001 82% of women were beginning prenatal care in the first trimester, a rate that steadily declined to 71% in 2021.

Dr. Ann Chang, an OB-GYN at Kapiolani and Pali Momi medical centers and the associate director of the University of Hawaii John A. Burns School of Medicine’s OB-GYN residency program, said she wasn’t surprised by the numbers.

“My partners and I take care of a lot of women who have barriers to accessing health care,” she said.

Chang said that women may lack health insurance or not have a good understanding of how to navigate the health care system. Sometimes they may not be able to obtain an appointment or even know in the early months that they are pregnant.

“Even if they can access care, they may have work or child care issues and can’t find time for appointments,” she said.

Chang said that certain areas of the state also have limited providers, and while Oahu has a good number of obstetricians, they don’t all take Medicaid, which can pose another barrier to care.

For women who don’t initiate care early or make it to follow-up appointments, risks are higher.

Prenatal checkups can help doctors catch conditions, such as gestational diabetes and preeclampsia, which threaten the health of mothers and their babies. Infants whose mothers didn’t receive any prenatal care are three times more likely to have a low birth weight and five times more likely to die, according to the CDC, while expectant mothers are three to four times more likely to die from pregnancy-­related complications.

Early screenings also can detect infections such as HIV, syphilis and hepatitis that the mother might not know she has. Beginning treatment early can greatly reduce the chances of the diseases being passed on to the developing fetus.

State health officials say that’s more important than ever with syphilis cases in Hawaii increasing more than tenfold over the past decade.

The steep rise in cases in the general population is translating to more babies being infected. Between 2000 and 2019 there were four or fewer cases of congenital syphilis reported annually, according to DOH data. Twelve cases were reported in 2020, 20 cases in 2021 and preliminary data for 2022 that has yet to be finalized indicates that the trend is continuing upward.

“While this may not be a large number of cases, these are disturbing because the increases have been so dramatic and because (congenital syphilis) is both devastating and completely preventable,” said Dr. Diana Felton, chief of communicable diseases and the public health nursing division at DOH, in an email.

Babies infected by their mothers during pregnancy can have physical deformities, anemia, blindness, deafness and meningitis. As many as 40% of babies born to women with untreated syphilis die from the infection.

“Because it is completely preventable it is a perfect example of the dangers of less than adequate prenatal care,” Felton said.

In many of the cases involving congenital syphilis, the mothers didn’t receive adequate prenatal care, had unstable housing or no housing, had a history of substance abuse, and were of Native Hawaiian or Micronesian ancestry.

Felton said that DOH’s Harm Reduction Branch has been working with health partners on increasing testing and treatment in high-risk communities through mobile health vans.

Health officials also have been focused on a shortage of prenatal health care providers on Maui after the island’s only private obstetrics practice announced earlier this year that it would no longer accept new patients as it prepares to stop delivering babies in October.

Maui Lani Physicians and Surgeons, which is continuing its gynecological serv­ices, cited staffing issues, difficulty recruiting physicians and low reimbursement rates as reasons for discontinuing its obstetrics care.

That decision has left pregnant women on Maui scrambling to obtain care, strained the resources of the island’s safety net clinic, Malama I Ke Ola Health Center, and left top health officials seeking solutions to deal with the growing crisis.

“The recent closure by MLP, to be very frank, has put a considerable strain upon the remaining obstetrics services on the island,” Dr. John Vaz, CEO of Malama I Ke Ola Health Center, told the Honolulu Star-Advertiser.

Patients with Kaiser health insurance can still obtain prenatal care through the health maintenance organization’s system of providers. But the only option for residents covered by other insurers is Malama I Ke Ola Health Center. The community health center has long served the island’s most vulnerable population, including the uninsured and those on Medicaid, the public health insurance program for people with low income.

Since Maui Lani Physicians and Surgeons stopped accepting patients, Vaz said the number of prenatal patients at the clinic has increased between 75% and 100%.

He said that part of the challenge is ensuring that the growing caseload doesn’t take away from the care of existing patients.

While Malama I Ke Ola has not turned any prenatal patients away, Vaz said his staff isn’t able to get patients in for appointments as soon as the clinic would like. But he said that the situation has taken the greatest toll on the clinic’s health providers.

“The brunt is being transferred onto our staff, and that is already on a post-­pandemic burnout situation,” said Vaz. “That is where it is being picked up — our staff going into hyperdrive.”

He said the clinic has been in discussions with Maui Memorial Medical Center, the island’s main hospital system, and the Hawaii Medical Service Association, the state’s largest health insurer. Vaz said the clinic hopes to obtain financial support to recruit doctors by October, when Maui will need help delivering babies.