|
|
 |
 |
 |
|
|
|||
|
||||
|
||||
summary of Prenatal Care Meeting (fwd)From: Robert J. Woolley (wooll005@gold.tc.umn.edu)Mon Jun 30 20:20:07 1997
Forwarded with no permission whatsoever (but asking forgiveness in advance). ------------ Forwarded Message begins here ------------ From: "Joseph B. Stanford" <stanford@MSSCC.MED.UTAH.EDU> Date: Mon, 30 Jun 1997 18:42:11 -0700 (MST) To: FAMDEL@pgh.auhs.edu Subject: summary of Prenatal Care Meeting the following is my totally unofficial brief summary of the AHCPR-funded meeting held at Harvard School of Public Health, entitled "The Effectiveness of Prenatal Care: New Evidence, New Paradigms" June 26-27, 1997 this posting is about three pages long. there were about 180 attendees. it was "sold out" with a waiting list. faculty included many of the research experts in prenatal care, including Robert Goldenberg, Lorraine Klerman, Mark Klebanoff, Milton Kotelchuck. Alas, no family physicians on the faculty, and I didn't meet any other family docs (besides myself) at the meeting. reflecting this blind spot, everything was stated in terms of obstetrics and pediatrics. briefly, some highlights from the meeting: the first day was devoted to the evidence (or lack thereof) that prenatal care influences fetal outcomes. the consensus is that there is no evidence that prenatal care has any overall effect on the rate of low birth weight (LBW) or preterm delivery (PTD). many participants at this conference did not believe this conclusion which was held by all of the expert presenters- they (the participants who were still true believers despite the evidence) stated that prenatal care is highly variable and that this issue has not been adequately studied. nevertheless, there are many studies (both observational and interventional- the latter with various types of intensive prenatal care with increased social services, home visits, continuity, counselling, etc., etc.), all of which have shown no effect with regard to low birth weight, after controlling for confounding variables. paradoxically, it is likely that prenatal care actually increases low birth weight among one subgroup of patients- those who have intrauterine fetal compromise or maternal complications (eg IUGR, PIH) and therefore have a medically indicated induction before term, resulting in a LBW baby (and reducing the stillbirth rate). there is also no good evidence that psychosocial support has anything to do with PTD and LBW as outcomes. on the other hand, all agreed that there is overwhelming evidence, albeit ecological rather than experimental, that prenatal care has lowered the stillbirth rate and perinatal mortality rate significantly. the intervention which would be most likely to reduce LBW/PTD if it could be incorporated into prenatal care would be smoking cessation. about 50% of women who become pregnant stop smoking on their own (and about 50% of those relapse after pregnancy). the other 50% who don't stop on their own are probably "harder cases" and it is not clear what the most effective approach in prenatal care to get them to stop smoking is. one lead for the future is bacterial vaginosis (BV), which in some studies has been highly correlated both with PTD (especially very early PTD) and positive cultures of the membranes. a couple of small intervention trials have shown decreased rates of PTD in groups screened for and treated for BV. BV could also help explain racial disparity for PTD, since it is much more prevalent among African Americans. (It is probably not an STD.) However, it is premature to recommend adoption of this in clinical practice until large trials are done to confirm that there are not unexpected negative outcomes of this approach. Another interesting link suggested in some preliminary studies is between peridontal disease and PTD. Some of the same organisms have been cultured from amniotic membranes as were in the mouth. This however is very preliminary and requires much more study. other factors suggested as having enough data to justify further research as to their potential effect on PTD/LBW include psychosocial stress, iron deficiency anemia, vitamin C, folate, cocaine, and physical activity. bed rest, a commonly prescribed treatment for PTD, bleeding, PIH, has shown no benefit in RCTs for any condition of pregnancy and there is some suggestion that it may cause harm. prenatal care may also decrease the prevalence of birth defects at birth- by increasing the use of folate, and by increasing the detection of fetuses with abnormalities who are then subsequently aborted. the RADIUS study took a beating from several (not all) of the obstetricians on the panel who objected to its low rate of detection of anomalies and stated that the only thing the study proved was that all prenatal ultrasound should be done in tertiary care centers. (quite an ivory tower viewpoint) increased capacity for prenatal genetic diagnosis is rapidly being developed (for example, by extracting fetal cells from maternal blood) which will raise a whole host of new ethical questions. the second day focused on the effect of prenatal care on women's health. it was pointed out that the original reason for prenatal care (to detect PIH early) had very little to do with fetal outcome and much to do with maternal outcome. again, prenatal care has been successful at lowering maternal morbidity/mortality (though the evidence for this is ecological). other potential maternal benefits from prenatal care include plugging into social services (eg WIC), health education during a time of high receptivity, long-term smoking cessation, and contraceptive/family planning services to prevent later unintended pregnancy. these are unproven and it may be that prenatal care may need to be restructured to improve upon these outcomes. prenatal care should optimally be viewed as a continuum with women's primary and preventive health care. often, however, this doesn't happen. for example, how often is the prenatal form (which includes all kinds of info about medical hx and health habits) even looked at after the delivery? we need to know what we currently do that doesn't work, so that we can channel resources into things that do work. I understand that proceedings from this conference will be published, but I have no idea when. Possibly the following contact might know:
> For additional information: posted by Joe Stanford
-- ========================================================= Joseph B. Stanford,MD,MSPH *stanford@msscc.med.utah.edu Dept. Family & Prev. Med. *voice: 801-581-7234 x359 50 N. Medical Drive *fax: 801-581-2771 U.of Utah, SLC, UT 84132 USA =========================================================
|
|
Return to
|
Mail a New Message to the Forum: ob-gyn-l@obgyn.net Forum Administrator: geffrey.klein@obgyn.net Report Technical Problems: webmaster@obgyn.net Last Updated: Mon Nov 2 05:22:21 2009 |
The American Medical Association is no longer designating CME hours for AMA Category II CME credit. However, physicians themselves may self designate learning activities as Category II CME credit hours if they feel it is of sufficient educational merit and meets the formal definitions of continuing medical education. OBGYN.net believes these interaction in this forum meets these criteria. For further information see the AMA web site.