Erin Clark presented an overview of the evolution and future of prenatal care as part of the CCTS-supported Foundations in Personalized Health Care course, which was designed to introduce students to many facets of this emerging field.
Today, it is unusual to associate pregnancy with risk. “Maternal mortality has fallen 100-fold, but prenatal care has changed very little in the past 100 years,” began Erin Clark, MD assistant professor of obstetrics and gynecology at the University of Utah Health.
The history behind current prenatal practices is illustrated by the dramatized death of a fictional early-20th century aristocratic English woman. Lady Sybil, a lead character in the TV show Downton Abbey, succumbed to eclampsia following the birth of her first child. The dramatic turn on the show highlighted a critical gap in health care for women.
“To watch a woman die of eclampsia was heart-wrenching thing, and people said we need to prevent this,” Clark said. Eclampsia is caused by high blood pressure during pregnancy that can result in deadly seizures. In response to this need, obstetricians developed a regimented series of prenatal appointments that would identify high blood pressure early to prevent seizures and death.
Today, regular prenatal care consists of about 12 face-to-face visits, which Clark concedes are mostly for the purposes of education and counseling. “Outside of some additional tests and screening, the prenatal care that I administer has not changed much in the past 100 years,” she said. Standard prenatal care uses a one-size-fits all approach, but the world is changing. The numerous visits can be a burden, trying to find time off from work, additional cost for multiple visits, and even long commutes to the doctor’s office.
Almost 30 years ago, the U.S. Department of Health and Human Services suggested a revision to standard pre-natal care. The agency proposed reducing the frequency of prenatal visits for low-risk women — women in their 20–30s who previously gave birth without complications ¾ from 12 to 8 face-to-face visits. This recommendation was based on randomized studies that showed fewer doctor visits produced no difference in perinatal or maternal morbidity or mortality.
Despite these findings, prenatal care has not changed.
“People get really uncomfortable when we stray from something we have done for a really long time,” said Clark. “Any shift in prenatal care requires that you take baby steps.”
Clark thought personalized health care offered a new approach to modernize prenatal care. “I look at risk factors that are non-genetic to manage populations through the lens of an obstetrician,” she said.
She developed a randomized trial for low-risk women where the number of visits did not change, but the style of visit did. “We shifted some of the visits to tele-medicine,” she said.
The trial consisted of two groups of low-risk women. One group received the traditional number of in-clinic prenatal visits. The second group received five scheduled in-clinic visits set at specific times during the pregnancy. The remainder of the visits was conducted through web-based teleconference. “People did visits from home, work, even airplanes,” she said.
Patients in the second group took common vital signs, like blood pressure and temperature, and entered the information into their electronic medical records that were shared with the doctor using a HIPPA-compliant web-based appointment platform. This information was discussed during the web-based teleconference.
Participants who attended fewer in-person visits responded positively to the new approach. “We found it was the number of physician contacts that were most important for patient satisfaction,” Clark said.
Clark pointed to other important benefits from this approach. “By reducing the number of in-clinic visits, we could reduce disparities in care, by extending our reach as obstetricians to rural areas,” she said. She also pointed to cost-saving for the patient.
Despite the benefits, Clark cautions that adherence to the traditional approach may be harder to overcome despite the decreased time, energy, and cost for this low-risk population. An eye toward modernization means giving patients a choice. “In the future, I see it as a menu of evidence-based strategies for prenatal care that the patient can select from,” she said.