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Question:

I saw this elsewhere and thought you might all be interested.

USAToday Articles - Long-held prenatal beliefs challenged

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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That was a really interesting article. Thanks for posting!

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Yes! Thank you.

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Thanks....I hate ACOG. :irked:
There was some postive stuff in there, but the idea of group prenatal visits really skeeves me out. :eek I cherish the 90 minutes I spend alone with my midwife every couple of weeks, and value our relationship as an important part of my pregnancy! I can't imagine gathering with a bunch of other couples to get weighed, BP, urine, talking abou birth planes, etc.

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I am with Kaiser and have always thought that the "early pregnancy" and "mid-pregnancy" class are more valuable than most prenatal visits. I didn't do them this time (third pregnancy), but was pretty much told it wasn't a choice with my first. For me the decreased visits works fine. In the third tri for example I had a visit at 33 weeks, 37 weeks and will have one this week at 39 (usually once a week after that).
A friend of mine has Kaiser as well and she was put on an aggressive prenatal schedule due to history of miscarriage, stillbirth and she has some chronic health conditions. I have no problem with the differences in our schedule. I do not have all the risk factors and she does.
People insisting on having visits/procedures/tests (not just in prenatal care, but in all health care) is a big reason for our health care costs being so out of control!

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I just thought the article was interesting. I also had nice crappy MWs last time and the ONLY appointment that was longer than 15 mins was the very first one. They promised extended visits, but didn't deliver and were more like MEDwives.
I like that I haven't just settled this time for just whomever. We fought with the insurance for my care last time and it wasn't worth it. Sigh...
Anywho... I just thought the article was interesting and figure, to each her own.

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That's a great article, and it's soothing to learn that some of these "long-held" beliefs are being revisited. Although I also want to s****** a little -- long-held by whom?
I've been regarded as reckless for it, but I did not seek professional care until my fifth month. There were reasons, and I was also very young, very healthy, and very on top of things. Once I did have a MW, I skipped most of the "routine" tests. No US, no amnio certainly, no diabetes, minimal bloodwork, minimal pelvics. Now, if/when I have #3, I expect it will be planned and I will have it more together, and I will probably seek out that preconception visit and find a midwife early. And I might rethink a few of those tests -- maybe -- but only if I have reason to believe my risk has gone up.
OTH, I can't totally dismiss the value of professional care and tests. An amusing, though embarassing, anecdote: When I was pregnant with #1 I developed an unpleasant, smelly, itchy, heavy discharge. I assumed it was part of pregnancy and didn't even mention it. It happened again with #2 and I still thought it was just something that happens. Then my #2 midwife, who was slightly more medical than #1, actually did a pelvic and a culture and told me that I had a horrible yeast infection! I'd never had one while not pregnant and so I had no idea that's what it was. :innocent And, it could have caused problems. And there was no reason to suffer. And it easily could have been something worse.
Everything in moderation. Including healthcare. :)

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Thanks for your thread. Although, its an infringement of copyright to post the entire article and a mod may ask you to edit. The link was sufficent. Very interesting...:nod
I'm actually in the Centering Program at UNC. I saw the MEDwife once, kicked her off my team and then saw a doc who was more like a MW. Then I went into classes. We have a scale that we step on that's electronic and document our weight, use the wheel (which I think is inaccurate since I charted and do *not* O on day 14 :eyesroll: ) , to put our place in pg, we use a an electronic wrist cuff for our bp and document it on our chart, and then go down to the lab to take our urine. All at the beginning of class. (I assure you we don't pee together) It gives you more control over your care. Then at the other side of the room the provider does belly checks and hb and asks you questions about the progress of your pregnancy. Then we have a class based on subjects each time and we can ask questions that we have. I think it provides you more information, than simply asking questions to your provider one on one. There may be questions folks have or that are brought up based on a subject you are discussing and you might not have thought about it. The composition of the group is veeeeeeeeeeeeeeeery diverse and I don't really feel that I have anything in common except the fact that we are having babies in October, so the premise of bonding is lost there for me. Dh comes with me and there's another couple who comes, the rest of the women are alone. I think one black girl and I might make a little connection some; but, the couple is from a rural area, there's another girl who just joined and a Japanese girl who hardly speaks English....I just don't feel the warm fuzzies, and I'm an outgoing person! :shrug *Our* individual appointments are *not* nixed altogether. We have one at the beginning, the classes start at 20 and at the end we go back to one on one. I think the classes are very informative. I like that there is some rethinking about prenatal care. :thumb

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Katie,
I also love to spend an hour or so with my midwife every month, but just think of all the women who spend only 5 minutes with their OBs and probably come away feeling very disheartened. It might be nice in a situation like that to be around other pregnant women and get to share thoughts, feelings and concerns...
Also, if you hate ACOG, just wait til you read a new VBAC statement put out on the 15th. Im going to post it on the VBAC board ASAP.

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There's a great book by an OB/Gyn called "Expecting Trouble: The Myth of Prenatal Care in America" that is a wonderful look at how we've all been led to believe that prenatal care makes a difference. Well, surprise, surprise. When you spend 6 minutes with a provider, it doesn't really make a difference.
I've loved the ideas of group prenatals for my practice. There's something appealing about gathering four or so women together to palpate each other's bellies and talk about pregnancy. I live in an area where there aren't a ton of homebirthers and I have thought that group prenatals would be a way to create community. Not to mention it would be so nice to have women who have had babies before in the discussion with first-time mamas.
But, I haven't really figured out how to swing it yet. Still working on it!

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I've loved the ideas of group prenatals for my practice. There's something appealing about gathering four or so women together to palpate each other's bellies and talk about pregnancy. I live in an area where there aren't a ton of homebirthers and I have thought that group prenatals would be a way to create community. Not to mention it would be so nice to have women who have had babies before in the discussion with first-time mamas. See, from this pregnant mama's perspective, I just couldn't handle that. I talk about such things as maternal abuse in my childhood and my former eating disorders with her, as a part of our prenatal visits and relationship. I could never do that with other women there. I come away with a sense of just having had a great therapy session with someone who cares warmly, and I really think that element would be lost if I were in a group situation. JMO. :)

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Lucysmama: I think what you are saying makes perfect sense - in the context of midwifery.
But visits with an OB are usually not like that at all. I can see that I would still get what I needed from a group session. My OB is very sweet, but mostly it's a social visit and a chance to hear the heartbeat, something which - now that baby is so active - I really don't need to hear anymore, kwim?
But I did find the article very interesting in highlighting the differences in patient attitudes. I wonder if the "Doctor=God" mentality you find here in the US is the same as elsewhere. People all take their doc's words as gospel, and I don't find it hard to believe that they'd spend every week at the OB's if they could, even in a trouble-free pregnancy. It's a whole societal attitude towards birth as being something you simply couldn't do without doctors, something medical...

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:nod I had a one on one at the beginning about those personal matters. I had no need to address them beyond that, except for the MW issue and I spoke to the peri coord b/c her comments brought body image issues to the surface. I wouldn't want to "share" that information with the group either, especially, like I said, I don't feel any bond with them. Its really just an informative class for me.
:nod folks trip me out that the doc is gospel. I refused to use OTC remedies for a cold I caught trying to keep cool. :eyesroll: My mamas best friend said why did you ask the doctor if you knew so much. :shake

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Thanks for the article! I understand why prenatal visits start after the third month, but it never made sense to me why those first 3 months aren't used to educate mothers on the importance of pregnancy nutrition, exercise, managing morning sickness, etc. My midwife had me catalog everything I ate for 2 days, and then she reviewed it and gave me tips. I'm sure there are many women that aren't aware of how important nutrition is in those first 3 months. It sounds like Kaiser has a great approach.

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See, from this pregnant mama's perspective, I just couldn't handle that. I talk about such things as maternal abuse in my childhood and my former eating disorders with her, as a part of our prenatal visits and relationship. I could never do that with other women there. I come away with a sense of just having had a great therapy session with someone who cares warmly, and I really think that element would be lost if I were in a group situation. JMO. :)
I can see both sides of this... I would absolutely LOVE to have group appointments, especially since this is my first pregnancy and there's such a steep learning curve. (I thought I was well-read going into it, but there's so much I didn't expect!)
But on the other hand, I had an problem with depression a couple of months ago (I quit anti-depressants while TTC), and would have been way too embarrassed/humiliated to admit it in front of a group. As it was, I waited two months before asking for help, because I was embarrassed to ask in front of the student who sits in on our visits (she was new and it was the first time meeting her, and I felt like a big failure at the time).
BTW, misfit, I also had a yeast infection (for 6 weeks!) and didn't mention it because I assumed itching was just another "surprise" of pregnancy I hadn't been warned about! I'd never had one previously and didn't even know it was treatable! :eyesroll

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yeah, I have always believed that the group prenatal thing would be voluntary - and that it wouldn't necessarily be EVERY visit.
Still, I could see how it might keep a midwife and a client from building that relationship of trust. I love the input I've gotten here!