Prenatal Care Does Not Improve Outcomes

"Much of what passes for prenatal care in this country is unduly expensive, unnecessarily high-tech, and serves no beneficial purpose, consisting of little more than a string of pointless, largely ceremonial clinic visits, which infrequently avert the conditions we want our babies to avoid." With this quote, Thomas H. Strong, Jr., MD, an obstetrician/gynecologist, sums up the premise of his new book, Expecting Trouble: The Myth of Prenatal Care in America (New York and London: New York University Press, 2000).

Dr. Strong has reviewed the last 20 or so years of prenatal care research and put it into a readable form for parents and policy makers. The scientific evidence shows virtually no benefit to the routine tests and monitoring activities central to prenatal care--listening to fetal heart rate, uterine measurement, urinalysis, etc. Occasionally, laboratory testing can identify treatable illnesses, such as HIV infection.

American women have come to accept, even demand, the usual 14 doctor visits as the means of insuring the good health of their babies. By all measures, however, the care provided by doctors throughout the pregnancy seems to have little benefit. A considerable amount of research shows that it does not improve the rates of miscarriage, fetal anomaly, cesarean, fetal death, or maternal death. To determine whether the number of prenatal visits has any import, researchers looked at the European countries where fewer visits are the norm. Their infant mortality rates are lower than that of the U.S. Nevertheless, the high number of visits continues to be important to Americans, despite the fact that the majority of low-birthweight babies (under 5.5 pounds and usually preterm) in the U.S. are born to women with adequate or better prenatal care.

Curiously, obstetricians often ignore the studies that show a common practice to be useless; for example, long-term oral drugs thought to prolong the pregnancies of women in premature labor are ineffective and associated with undue risks. That was over 15 years ago; yet they continue to be as popular as ever. Corticosteroid drugs were proven to improve the outcomes of premature infants over 20 years ago in seven well-designed studies, but these drugs continue to be underused.

In the old days, before the advent of modern obstetrics, pregnancy used to be considered a normal physiological event. Today, pregnancy is defined by the insurance companies as a disability; and it is managed by obstetricians trained to view it as a disaster waiting to happen. To be sure, maternal and child mortality used to be high, but the author contends that obstetrics had little to do with the improvements in maternal and child health that began in the early 20th century. Most of this progress, he writes, was accomplished by such low-tech strategies as child-spacing, housing, hygiene, and nutrition. Maternal mortality rates began to drop well before the creation of antibiotics, blood banks, or obstetric committees on maternal mortality rates.

The book proposes that obstetricians be reserved for the small number of women with medical problems like diabetes that complicate their pregnancies. They are overtrained for the 70-90% of all pregnancies that are entirely normal. Low-risk pregnancies should be attended by certified-nurse midwives who tend to spend more time with their patients, provide health counseling, and generally get higher satisfaction ratings than doctors. Studies show they are skilled in identifying problems that should be referred to physicians.

Our medical system is structured to put fetal interest ahead of maternal interest, observes Dr. Strong, noting that in many arenas, the health of reproductive-age women is considered only to the degree that it affects their babies. In the most provocative critique of his own specialty, Dr. Strong finds it ludicrous that obstetrics/gynecology has positioned itself--with women's complicity--as primary care givers. The shrinking health care dollar and growing recognition that the U.S. is oversupplied with specialists have caused federal funds to be redirected to primary care. To keep the federal money coming and to gain broader access to patients, the American College of Obstetricians and Gynecologists has managed to have its field of expertise designated as primary care. Quite a stunning feat for a surgical specialty without much training in the health of women unrelated to pregnancy and gynecology.