OR WAIT 15 SECS
Dr Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at DrLockwood@ubm.com.
Among high-risk women, apparently there's no improvement in low birthweight when clinicians provide earlier or more intense prenatal care.
Obstetrics represents a major component of total US health-care expenditures. While it is difficult to derive exact figures, based on a 1994 Rand Corporation report, maternity care alone accounts for about 5% of health-care expenditures and about 7% of personal health-care spending by the non-aged population.1 In today's dollars that would amount to over $90 billion dollars per year. And this is likely an underestimate given the rising incidence of prematurity and the increase in the national cesarean delivery rate over the past 12 years. So what can we ob/gyns learn from our UK cousins that can help reduce costs and increase quality of obstetric care?
Does prenatal care improve pregnancy outcomes?
Of course, no one in his right mind would advocate abandoning prenatal care. But among high-risk women, there doesn't seem to be any improvement in low birthweight when clinicians provide earlier or more intense prenatal care.3 Conversely, meta-analyses indicate that among low-risk women, it doesn't seem that fewer prenatal visits adversely affect perinatal mortality, NICU admissions, or the frequency of low birthweight, preterm deliveries, preeclampsia, abruption, anemia, UTIs, postpartum hemorrhage, or rates of cesarean delivery or labor induction.4,5 And there's even evidence to suggest that among low-risk patients, pregnancy outcomes are very similar whether they are cared for by a mid-level provider, general practitioner, or obstetrician.4 This suggests that we need to take a long hard look at how prenatal care is provided.
Are we using an outdated clinical model?
Our current model of prenatal care dates from the 1930s and is organized around the early identification of preeclampsia. The model doesn't differentiate between nulliparas and multiparas-even though the incidence of intrauterine growth restriction (IUGR), preeclampsia, prematurity, and other complications of pregnancy and delivery is substantially higher among the former patients. Moreover, it has not been modified to account for the far greater amount of teaching, screening, and data gathering required in modern obstetric practice.
In 2003, the UK National Institute for Clinical Excellence commissioned an extensive review of the cost-effectiveness of routine prenatal care and made a number of recommendations that US providers would consider startling.6 For example, they recommend abandoning bimanual examination and clinical pelvimetry as they don't accurately predict gestational age, prematurity risk, or cephalopelvic disproportion. They suggest abandoning routine weighing unless "clinical management is likely to be influenced." Also gone are routine auscultation of fetal heart tones, routine monitoring of fetal movements, breast examination, the Edinburgh Postnatal Depression Screen, testing for chlamydia and group B beta-streptococcus and screening for gestational diabetes! The arguments against such tests reflect the absence of evidence-based studies to support their routine use.
Now while it's unlikely that most of these recommendations will gain traction with American obstetricians, particularly given our irrational medicolegal climate, I would argue that we should strongly consider their recommendation concerning the frequency of prenatal visits.
How the Brits view prenatal care
The next visit for all patients would be at 28 weeks and would include repeat labs (e.g., RBC antibodies in Rh-negative women, and repeat CBC). Rhogam is provided, if indicated, and fundal height, blood pressure, and urine protein assessed. The next visit would be at 36 weeks when fundal height, blood pressure, and urine protein are assessed and breech presentation excluded. If the latter is present, external cephalic version is offered. A repeat scan is done if the 20-week U/S indicates a low-lying placenta, otherwise growth scans are reserved for lagging fundal heights. A visit is repeated at 38 weeks for fundal height, blood pressure, and urine protein evaluation. For undelivered patients, a final visit occurs at 41 weeks when the membranes are stripped, fundal height, blood pressure, and urine protein assessed, and an induction offered. If the latter is refused, antenatal surveillance commences with twice-weekly nonstress tests and amniotic fluid volume evaluations.
For nulliparous patients additional visits are scheduled at 25, 31, and 40 weeks to screen for IUGR and preeclampsia with fundal height, blood pressure, and urine protein assessments.
Obviously, this approach to prenatal care would need to be modified according to our standards of care before it could be applied in the US. We would add a breast examination, glucose screening at 28 weeks, group B beta-streptococcus screening at 36 weeks, and probably fetal heart rate auscultation and maternal weight determinations. In addition, all high-risk patients would need to be identified and excluded. (High-risk medical conditions include cardiovascular disease and hypertension; renal disease and autoimmune disorders; insulin-dependent diabetes and poorly controlled thyroid disease; psychiatric disorders under treatment; cancer and hematologic disorders; thromboembolic disorders; severe asthma and pulmonary disease; substance abuse and HIV; BMI > 34 and <19; and age >40 and <18 years. High-risk obstetric conditions would include a history of recurrent IUGR or pregnancy loss; prior preeclampsia; a history or risk factors for prematurity; RBC and platelet antigen alloimmunization; prior uterine surgery; abruption or postpartum hemorrhage ×2; a retained placenta ×2; prior or current fetus with congenital anomaly; and grand multiparity, >6.)
But even with these additions, the UK approach would vastly simplify the provision of prenatal care, reduce costs, and increase the time available for counseling, particularly at first visits. It would also allow more intensive monitoring of higher-risk patients. In an era of ever-spiraling health-care costs, decreased patient and provider satisfaction, and a new emphasis on patient safety, fundamental changes are needed throughout the health-care system. We can start by examining health-care delivery at the very beginning of life!
1. Long SH, Marquis MS, Harrison ER. The costs and financing of perinatal care in the United States. Am J Public Health. 1994;84:1473-1478.
2. Henderson JW. The cost effectiveness of prenatal care. Health Care Financ Rev. 1994;15:21-32.
3. Goldenberg RL, Davis RO, Copper RL, et al. The Alabama preterm birth prevention project. Obstet Gynecol. 1990;75:933-939.
4. Villar J, Carroli G, Khan-Neelofur D. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2001;(4):CD000934.
5. Carroli G, Villar J, Piaggio G, et al.; WHO Antenatal Care Trial Research Group. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357:1565-1570.
6. Antenatal care: routine care for the healthy pregnant woman. Clinical Guideline October 2003. RCOG Press, 27 Sussex Place, Regent's Park, London NW1 4RG.