Before the COVID-19 pandemic, made steady but small changes to the practice of obstetrics and gynecology. The advent of the pandemic forced, by necessity, many in-person ob/gyn appointments to be suddenly and markedly shifted to online messaging or virtual video appointments. This rapid innovation was necessary for patient safety, but it also highlighted a retrospective examination of the fact that the prenatal care journey in obstetrics had remained largely unchanged since its . In 1930, the Children's Bureau published a booklet recommending monthly prenatal care visits until 28 weeks, then biweekly visits until 36 weeks, and then weekly visits until delivery. However, there was no evidence supporting this visit schedule, nor did it address how or if the schedule should be modified for patients with additional risk factors.
In 2021, we have an incredible opportunity to rethink what a better, more evidenced-based, more patient-centered, and outcomes-analytic approach to prenatal care might look like.
We know the current prenatal visits and schedule are often beset by the following: long waits in doctor's offices; short visits of 9 to 12 minutes that don't always address all of a patient's medical complications of pregnancy; insufficient time for mental health concerns, education and anticipatory guidance, birth and delivery planning, assistance with diabetic education, discussion about preparation for postpartum, breastfeeding planning support, barriers to prenatal or postpartum care, language needs, and many other concerns. So how do we do all of that in the current system? And is the ob/gyn or the certified nurse-midwife (CNM) the only one to deliver this prenatal care? What would a virtual platform that complements in-person care look like and how would we measure that impact?
Telehealth has taught us that such a platform can care for pregnant women beyond the walls of an office, that we can reach women in communities who may not have experts available in-person, and that there are many different kinds of experts who can contribute time, knowledge, and care to a pregnancy journey.
Take, for example, a woman newly diagnosed with gestational diabetes. A complement to her ob/gyn care could include: mental health , as show that women with medical complications of pregnancy often face increased , which can exacerbate pregnancy outcomes. Diabetic with a certified educator, given that dietary changes actually begin in the grocery store, extend to cooking and meal preparation, and may include understanding the impact of diabetic meal preparation on other family members. If applicable, a weight management who can help design activity plans to mitigate the risks of in pregnancy to mother and fetus. Nice-to-haves might include real-time messaging with an expert to help answer questions such as, "Why was my fasting blood glucose this morning 120?" Or a call from an expert when her glucometer reads a one-hour postprandial of 204 after breakfast. Or, a class facilitated by a diabetic educator in which she finds community, peer support, and expert advice. This wrap-around care for women in pregnancy and postpartum addresses many of their current unmet needs for experts, community, and real-time engagement.
When considering the ideal way to deliver prenatal care, we also need to reexamine how we measure quality in prenatal care design, given the most widely used measures of prenatal care quality solely ask: When did care start and how many times did it happen? Other questions we should ask enable us to measure quality more holistically, taking into consideration key drivers including access to evidence based care, racial or other social determinant of health disparities, patient engagement and education, and outcomes and cost. Examples of these questions include:
1. Is the care being offered utilized, and are patients engaged with the care?
2. Is the care equitable across all populations?
3. Did the care follow evidence-based guidelines?
4. Is shared decision-making a key component of the care?
5. Is the care provided with an anti-racism lens and does it address systemic racism and bias in the healthcare delivery system?
6. Do patients have access to the specialists they need?
7. Does the care provide the necessary psychosocial support and are there experts in trauma-informed care?
8. Does the care produce the outcomes we desire?
9. Are we delivering prenatal care that uses economic resources wisely?
10. Does the patient and her support system feel educated and prepared about her plans for birth, breastfeeding, and postpartum parenting?
In order to answer those questions and others about the nature and design of prenatal care, we must listen to patients first and then to other, and newer, experts in the field. There are incredible researchers in obstetrics and gynecology, from who writes about a 21st century prenatal care design to who recently provided a comprehensive redesign of a more patient-centered postpartum care delivery. The list goes on.
It's an incredible time to read and listen to these experts, rewrite our own mental models, imagine how care could be different in our own community, and change the way we connect birthing women with resources. Patients want safety for themselves and their pregnancies and newborns, they want convenience and peace of mind around the questions that are keeping them up at night -- and they want to feel listened to by their providers.
Jane van Dis, MD, is a board-certified obstetrician/gynecologist and works as an OB Hospitalist in La Cañada, California. As an early adopter of telehealth, van Dis now serves as Medical Director at Maven Clinic, the world's largest virtual clinic for women's and family medicine, and she is co-founder of TIMES UP Healthcare and Equity Quotient.