Re-examining Prenatal Care

Antepartum and Intrapartum Management Conference No Disclosures San Francisco, CA

Kate Frómeta, CNM Assistant Professor Department of Obstetrics and Gynecology UCSF

Prenatal Care Prenatal Care Visit Schedule for Low-Risk Women Urine Dips

74% 58% A. Q 4 weeks until 28 A. at every visit Q 2 weeks until 36 B. at the first visit only weekly C. with elevated BPs only B. More Frequent Visits 23% 23% D. No urine dips C. Less Frequent Visits 4% 9% 9%

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1 Prenatal Care History of Prenatal Care Integration of Support Services

A. Routinely have women see a provider 73% who is not an OB or Midwife or Family . Adolphe Pinard and midwife Madame Bequet Practice MD/NP. - Refuge de L'Avenue du Maine B. Only see another type of provider if 27% 1892 indicated

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History of Prenatal Care History of Prenatal Care: US

. First models out of Europe in early 20th century

. Children’s Bureau started in 1912 . By 1930: UK ministry of health Focused on preventing infant mortality - PNV at 16, 24, 28, then q 2 w until 36 then weekly - Promotion of the idea of prenatal care - Measure fundal height at 32 and 36 weeks - in the European model - Fetal heart rate monitoring and urine testing q visit

. “More Ritualistic than Rational”

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2 Reasons for PNC Our Failures

. Decrease LBW through nutrition/substance abuse intervention . Identifying infectious disease . US Obstetric care is the most expensive in the world . Identify Rh negative mothers and give Rhogam as needed . Identification and rectification of breech presentation . One of the highest rates of both infant and maternal mortality of . Identification of preeclampsia to decrease eclampsia industrialized countries . Identification and treatment of severe anemia . Assure appropriate delivery setting . Major opportunities for improvement - Anomalies, breech, preterm . Build trust, anticipatory guidance

ETC. ETC. ETC.

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Difficulty of Assessing Prenatal Care Quantity: Schedule of Visits . Never studied before implementation . Considered standard of care therefore RCT are not a Possibility . US standard: - First visit in 1st trimester . Relationship between care seeking and other positive health behaviors - f/u q 4 weeks until 28 then q2 until 36 then weekly (13-14) - ACOG “frequency of obstetric visits should be individualized” . Measuring quantity vs quality . NICE guidelines: - content, provider, setting - First visit before 10 weeks - f/u at 16, 25 , 28, 31,34, 36,38,40,41 . WHO (2016) - 8 visits = adequate prenatal care - first 12 weeks - f/u at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation.

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3 UCSF Schedule Of Prenatal Care Visits US Expert Panel on Prenatal Care (1989)

. First visit in 1st trimester . 8 visits for multip, 10 for primip . Q 6 weeks until 28 weeks - Including preconception visit . Q 4 weeks until 36 weeks . More integration of support services “team approach” . Q 2 weeks

. * Individualized to risk status* . Antenatal Testing . Eliminate “Visits that are not meaningful are counterproductive” . 9-10 visits

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Quantity Of Visits: Quantity Of Visits: Standard vs. Reduced Visit Schedule Standard vs. Reduced Visit Schedule

. McDuffie et al. (1996) JAMA . RCT N=2764 . Binstock and Wolde-Tsadik (1995) and Walker and Koniak-Griffin . 9 for primips, multips 8 (+ 1 phone call at 12 weeks) vs. 14 (1997) - No difference: - Smaller sample sizes (n=549, 81), both in CA, homogenous populations . PTB - White, highly educated, women . LBW - Latina women on Medicaid attending a birth center . PreE - ~8 visits vs. 11-14 . C/S - No change in perinatal outcomes . Satisfaction (reduced more likely to rate # of visits as “just right”) - greater satisfaction with reduced visits

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4 Quantity Of Visits: Quantity Of Visits: Standard vs. Reduced Visit Schedule Standard vs. Reduced Visit Schedule . Sikorski et al (1995) - n=2794 (reduced =6-7 vs 13) . 2015 Cochrane Review randomized/cluster-randomized - Fewer ultrasounds and antenatal admissions . 7 trials, n=60,000 Reduced vs Standard PNC - Less suspicion of IUGR (no difference in diagnosis of IUGR) . High, medium and low-income countries - No change in perinatal outcomes (PreE, IOL, C/S, SGA, PPH etc) . High Income - Less satisfaction - Reduced = 8-12 visits (13-14 in regular schedule ~ 3 less) . Low and middle income - Reduced = 4-5 visits (regular schedule about 7 ~2-4 less)

Dowswell et al. (2015)

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Quantity of Visits: Quality Of Visits: Standard vs. Reduced Visit Schedule Components of Prenatal Care

. No difference between groups . BP - Maternal mortality . Fundal Height - Hypertensive d/o . FHR auscultation - PTB . Urine Dip - SGA . Warning signs . Perinatal mortality . Questions/Anticipatory - Associated with reduced visits in low and middle income countries Guidance - No difference in high income countries

. Satisfaction

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5 Fundal Heights Fundal Heights

. Vasilly Sutugin St. Petersberg 1875 . Sparks et al, 2011 - Fundal height to determine gestational age/length - Retrospect cohort - N=3627, u/s for abnormal fundal height = 448 . Alfred Baker Spalding, Stanford 1904

“Measure….the height of the fundus above the symphysis in . Sensitivity LGA (>90%) 16.6% SGA (<10%) 17.3% cm….and add two to measurements between 22 and 26 cm, - Lower for overweight/obese women three to measurements between 26 and 30, four to measurements between 30 and 32 and five to measurements - Higher for multips above 32, which sum will equal the probable week of . Specificity 94.9-95.4% LGA and SGA 92.4-93.1% pregnancy” - Outcomes occurred about 10% of the time

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Assessing Fetal Growth Fundal Height

WHO 2016 . ? 3rd trimester u/s - Sensitivity 46-93% for SGA and 6.7-89% for LGA . Replacing abdominal palpation with . NICE says no 3rd trimester u/s for LGA in “low-risk” population. symphysis-fundal height (SFH) . Customized growth charts measurement for the assessment of fetal growth is not recommended to improve - (GROW software – UK, endorsed by RCOG) perinatal outcomes. A change from what - Ethnic/racial and gender differences (NICHD, WHO) is usually practiced (abdominal palpation . Deter-Rossavik model or SFH measurement) in a particular rd nd setting is not recommended - Base 3 tri growth on 2 tri growth (u/s)

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6 Fetal Heart Rate Auscultation Urine Dips

. Protein . In the US is standard of care at every visit (appropriate to - Proteinuria common in pregnancy 10-40% (≥+1) gestational age) - Protein dipstick has ppv of PreE of 2-11% - High false positive when compared to 24 hr urines . NICE (UK) recommends against fhr auscultation at routine visits . New Guidelines place less emphasis on proteinuria - “Auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have any predictive value and routine listening is therefore not recommended.” . Glucose - False positive 11: 1 - Glucose loading test much better Alto, W (2005)

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Urine Dips

. “The time-honored inclusion of routine urine dipstick assessment for all pregnant women can be modified…In the absence of risk . factors….there has not been shown to be a benefit in routine urine dip- stick testing” - ACOG GUIDELINES FOR PERINATAL CARE, 2017

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7 Innovations Innovations OB Nest (HCD) . Centering Pregnancy http://centerforinnovation.mayo.edu/files/2016/05/ob-nest-experiment-report.pdf - CHI . Butler Tobah et al, (2016) . Expect with me - RCT, N=150 - United Health . 8 office and 6 RN phone visits vs. 12 office visits . BabyScripts - RN moderated online community - Home weight and BP monitoring . Nest = greater satisfaction, . OB Nest less pregnancy-related stress - Mayo Clinic . No difference: - Maternal/fetal outcomes - Unplanned visits - Perceived quality of care

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Innovations Thank You OB Nest Now Go Innovate!

. Self-Monitoring (home and drop-in) . Telemedicine . Text-based communication . Online community

“The intent behind the design is (to)...anticipate (patients’) needs and provide access to reassurance in a way that fits patients’ lives. The place of care becomes home based instead of clinic based, and the pregnant woman is no longer a passive recipient of care but instead an engaged partner”

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