Date:   2/3/2004 2:37:09 PM ( 20 y ago)
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URL:   https://www.curezone.org/forums/fm.asp?i=586035

Long-held prenatal beliefs challenged
By Rita Rubin, USA TODAY
Some long-standing tenets of prenatal care are being called into question — from the recommended number of doctor visits to routine screening for diabetes to Down syndrome testing in older mothers.

Not all women need, or get, the same amount of prenatal care.
By Eileen Blass, USA TODAY

Skeptics say much of the one-size-fits-all approach to prenatal care is based more on tradition than science. They point out that premature births in the USA have continued to rise, even though more pregnant women than ever are getting care. (Related item: Group care is birth of a great notion)

"It's not necessarily that prenatal care has failed, but it hasn't been successful enough," says Irwin Merkatz, chair of obstetrics and gynecology at the Albert Einstein College of Medicine and Montefiore Medical Center in New York City.

In 1989, Merkatz served on a government panel that made headlines for suggesting that healthy pregnant women with good insurance get too much prenatal care, and high-risk or poor pregnant women don't get enough. Leaders of the American College of Obstetricians and Gynecologists (ACOG) said the panel's recommendations lacked scientific rigor.

Over the years, though, the panel's finding that more prenatal care isn't necessarily better has been gaining momentum. For example:

• A growing body of research suggests that reducing the number of prenatal visits doesn't compromise the health of mothers or babies and might even improve it. Based on its own study, Kaiser Permanente schedules healthy pregnant women for nine appointments, although ACOG recommends 13 or 14. Another model for prenatal care, called Centering Pregnancy, does away with individual appointments altogether, except for the first. Unless patients have concerns that require privacy, they receive the rest of their care in groups.

• Several recent studies, including one being presented this week, point out the arbitrariness of the decades-old cutoff of age 35 for Down syndrome testing. New blood and ultrasound screening tests can help identify which pregnant women, no matter their age, are at high risk for carrying an affected fetus.

• The U.S. Preventive Services Task Force concluded last year that there wasn't enough evidence to recommend for or against screening for gestational diabetes, which is diagnosed in at least 2% of pregnant U.S. women. Unless there's strong evidence that such a preventive measure is beneficial, "it's probably not a good idea to be doing it routinely," says Alfred Berg, family practice chair at the University of Washington who just stepped down as task force head. A sizable minority of Canadian doctors have stopped screening for gestational diabetes.

• Britain's National Health Service, with the blessing of the Royal College of Obstetricians and Gynaecologists, is implementing guidelines that reduce the number of visits from 14 to 10 for healthy first-time mothers and to seven for healthy pregnant women who already have had a baby. The guidelines do away with routine screening for gestational diabetes and listening to the baby's heartbeat at every visit, unless the mom wants to.

USA vs. Britain

Change is occurring at a slower pace in the USA than in Britain, because the two differ in more ways than how they spell "gynecologist."

"In general, the consumers in this country want us to do much less in terms of intervention and maternity care," says Peter Brocklehurst, the Oxford doctor who led the panel that developed Britain's new guidelines. "They think we do too much, which is why our cesarean section rate is so high."

Although the U.S. C-section rate is even higher, pregnant women in the USA are more likely to think their doctors aren't doing enough. The news that "you're OK; you don't really need to be tested anymore" doesn't usually sit well with American patients, says Jay Iams, chair of obstetrics and gynecology at The Ohio State University and president of the Society for Maternal/Fetal Medicine. "This is the United States of America, where more is always better."

Take doctor's appointments. Kaiser Permanente generally says healthy women need only one during the first trimester. Under ACOG guidelines, women typically would have two or even three, depending on how early their first is.

Instead of scheduling a doctor's visit during the first six or eight weeks, Kaiser offers classes on nutrition and other important pregnancy topics. And at each doctor's visit, patients get an information sheet covering issues relevant to their pregnancy.

"I have girlfriends right now who are in private offices," says Kaiser patient Tanya Campbell, 33, of Millrae, Calif. Her third child is due Feb. 15. "It seems like I'm constantly giving them information I'm getting from my OB-GYN that they're not getting from theirs."

The biggest challenge has been convincing women that they can wait until later in their pregnancy to see a doctor, says OB-GYN Ruth Shaber, Kaiser's director of women's health services in Northern California. "There's not a whole lot of value in coming in earlier, but they want to come in."

'Nothing we can do at six weeks'

Laura Riley, chair of ACOG's obstetric practice committee, suspects some women have sought care elsewhere because she wouldn't see them before they're 10 weeks pregnant. "Frankly, there's nothing we can do at six weeks," says Riley of Massachusetts General Hospital. Riley says she wouldn't mind seeing patients less often during their pregnancy, because some visits aren't much more than social.

Meanwhile, the Centering Pregnancy program, with its 10 group sessions, encourages conversation among patients and between patients and doctors or midwives.

Don't expect ACOG to recommend a schedule change anytime soon. Riley says the next edition of ACOG's pregnancy care guidelines isn't due until 2007.

Even then, says Robert McDuffie, it's doubtful that ACOG will recommend fewer visits, especially in light of growing concerns about liability. "ACOG is a very conservative political organization," says McDuffie, lead author of the 1996 study that spurred Kaiser to reduce its number of prenatal visits. "They don't want to be in the position of endorsing anything that might be less."

No one advocates denying appointments. If patients start out or end up with conditions that increase their risk of complications, they're seen more often. "When problems are identified, you switch gears," says McDuffie, a Kaiser OB-GYN in Denver. "Most common thing would be if a woman develops hypertension."

Nearly 80 years ago, concerns about high blood pressure from a condition called toxemia, or preeclampsia, gave birth to today's prenatal care schedule.

Preeclampsia, a serious complication that affects 5% to 8% of pregnancies, typically occurs late in the second trimester or in the third trimester. That's why office visits traditionally become more frequent as pregnancy progresses. ACOG recommends visits every other week beginning at 28 weeks, and weekly by 36 weeks.

But if a woman is unlikely to develop preeclampsia — she already has had a couple of uncomplicated pregnancies, she has no family history of the condition and she's neither very young nor very old for a new mother — she really doesn't need all those visits, Merkatz says.

She might be better served by a rarely made preconception visit, which he considers one of the most important prenatal visits. That's when she and her doctor could discuss steps toward a healthy pregnancy, such as losing weight or managing chronic health problems.

Screening for gestational diabetes may be another example of how resources could be better spent.

"An entire generation of obstetricians, almost two generations of obstetricians, have bought into the idea that screening for gestational diabetes is important and serves to improve pregnancy outcomes," says Ohio State OB-GYN Mark Landon.

But it's unclear whether treating mild cases, usually with diet, is beneficial, and some research suggests it could have drawbacks, such as an unnecessarily higher rate of C-sections. Landon leads an ongoing, government-sponsored study to determine the effectiveness of treating the condition.

Landmark research being presented Thursday at a Society of Maternal/Fetal Medicine meeting promises to expand women's options as far as screening for Down syndrome. When amniocentesis was introduced in the 1970s, age was the only way to judge whether a woman had an elevated risk of carrying an affected fetus.

At age 35, a woman's risk of having a baby with Down syndrome was thought to equal her risk of miscarrying as a result of undergoing amniocentesis. But more than half of all Down syndrome babies are born to women under 35.

The new study, based on 38,000 women, found that a combination of a special blood test and sonogram in the first trimester is more useful than age in identifying who's at risk for carrying a fetus with Down syndrome.

"It will be our job to present these options to patients and help them make a decision," says Mary D'Alton, a Columbia University OB-GYN who is the study's co-leader. And Merkatz might say that's all the more reason to schedule a preconception visit.

 

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