Prenatal Care: Is Earlier Better?

Abstract & Commentary

By John C. Hobbins, MD, Professor, Department of Obstetrics and Gynecology, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.

Dr. Hobbins reports no financial relationship to this field of study.

Synopsis: Despite the standard admonition that patients should be scheduled for prenatal care as early as possible in pregnancy, this study shows that often this does not occur.

Source: Nettleman MD, et al. Scheduling the first prenatal visit: Office-based delays. Am J Obstet Gynecol 2010;203:207.e1-3.

For many years we have been pushing the concept that the earlier that prenatal care is initiated, the better will be the outcome. Since there are certainly data proving that late enrollment makes for worse outcomes, this "the-earlier-the-better" mantra has almost attained bumper sticker status.

To see if we back up our recommendations with action, a group of investigators from Michigan State University went undercover. A research assistant attempted to call all OB/GYN offices in Michigan and got through to 239. Posing as a prospective patient who, 2 days past her missed period, had just found that she was pregnant via a home pregnancy test, she asked when she could come in for her first visit.

The response from the office staff varied from "immediately" (4 weeks) to 11 weeks, with a mean of 6.4 weeks. Fifty percent recommended a first appointment to be at < 6 weeks, 66% at < 7 weeks, and 75% at < 8 weeks. Of the 118 offices offering visits at > 6 weeks, only once was a request honored for an earlier visit. During 27% of the interactions, the staff did not ask about last menstrual period (LMP), and only 14% of the time the research assistant was asked whether this was her first pregnancy. Not surprisingly, 91% of offices asked the woman about her insurance status. However, information regarding inter-current conditions, medications, or smoking was requested during only 5% of the calls.

The authors' major point was that patients, especially in their first pregnancies, need to receive some guidance regarding their individual needs as early as possible during the vulnerable first trimester. In lieu of an immediately scheduled office visit, they make a pitch for some type of easily accessed, updated, evidence-based resource to be available on-line that would provide advice about smoking cessation, vitamins, medications to avoid, etc.

Commentary

One can agree to a point with the authors' perspective. However, I guess one has to weigh delving too deeply into a patient's life during the first telephone contact with the need to obtain important information regarding who needs to be seen immediately. In a companion editorial in the same issue of the American Journal of Obstetrics & Gynecology, Arnold Cohen, MD, laid out some suggestions that a trained individual could ask1:

  1. When was your last menstrual period?
  2. Have you had any problems in the previous pregnancy?
  3. Do you have diabetes?
  4. Do you take any medicines other than prenatal vitamins?
  5. Do you have any chronic medical problems?
  6. Are you taking prenatal vitamins with folic acid?
  7. Are you drinking alcohol now that you know that you are pregnant?
  8. Do you think there is any reason that the doctor/ midwife should see you as soon as possible?

While pushing for a selective approach toward very early appointments, Cohen addressed another important issue concerning how often low-risk patients should be seen during their pregnancies. The standard timetable generally involves office visits being scheduled at 8, 12, 16, 20, 24, 28, 30, 32, 34, 36, 37, 38, 39, and 40 weeks. In a Kaiser system study it was found that, using a more pragmatic and cost-efficient schedule of 8, 12, 16, 24, 28, 32, 36, 38, 40 weeks for low-risk patients, resulted in equivalent outcomes.2 From a public health standpoint skipping five visits per patient translates into substantial cost-savings and an approach that leans far more toward enhanced patient convenience.

References

  1. Cohen AW. Scheduling the first prenatal visit: A missed opportunity. Am J Obstet Gynecol 2010;203:192-193.
  2. McDuffie RS Jr, et al. Does reducing the number of prenatal office visits for low-risk women result in increased use of other medical services? Obstet Gynecol 1997;90:68-70.