This is a guest article by Silvio Aladjem MD.
Prenatal care, as we know it today, is a newcomer to the world of pregnancy care. Until the beginning of the 20th century, a pregnant woman never saw a midwife or a doctor before labor started. It was not until 1900 that midwives and physicians in Boston started establishing clinics so that pregnant women could come and be seen during pregnancy. Their goal was reducing maternal mortality by the early detection of severe pregnancy complications, like pre-eclampsia, which could kill a mother and the baby. Slowly, this new approach to maternal care spread throughout the country, and the world, and the idea of prenatal care was established as a corner stone in the care of pregnant women.
This new approach reduced maternal mortality, which in the US was 850/100,000 births in 1900 to 12.5/100,000 births by the end of the 20th century. A dramatic improvement. The entire 20th century, was a period of learning. From 1950 on, an explosion of knowledge, knowhow and technology followed and changed the practice of obstetrics forever. The scope of the begining years of prenatal care was early diagnosis of potential pregnancy complications. This was followed in the second half of the 20th century by our technical ability to visualize and approach the fetus thanks to the advent of ultrasonography. A new branch of medicine was born: Fetal Medicine. The unborn was now approachable and intrauterine transfusions, intrauterine surgery, prenatal diagnosis, prenatal cardiology and so forth, unthinkable just 50 years ago, became standards of care.
Have we reached the pinnacle of maternal and fetal care?. I don’t think so. We are barely at the dawn of what the future will bring us.
In an ideal world, we would like to entirely eliminate maternal deaths, no matter how low it is now. No woman should have to die in childbirth. Unfortunately, that is never going to happen. But we can strive to reach what is known as an irreducible minimum. By that we imply that we will not be able to eliminate all deaths. Some are inevitable by their very nature. But we can strive to reduce it to the level of an “irreducible minimum” and would like for that to be as low as humanly possible. I believe that this will come, sooner or later. Equally important, we would like to be able to reach the day where pregnancy will rarely have any complications. An irreducible minimum will be found here as well. There will always be some complications. We are still not even close to an irreducible minimum for complications.
Where do we start? I think that we should start where we started in 1900: Prenatal Care, only different. By that I mean, Prenatal Care before conception, otherwise known as Preconceptional Prenatal care.
Is this an oxymoron? The answer is a definite no.
Pregnancy is not something that happens in a vacuum. Two individuals, a man and a woman, first must decide to have a baby. They are both young and appear healthy. Not a worry in the world. Well….., Let’s look at this a little bit closer.
Both of them will bring to the pregnancy. their genetics, past and present. Both of them, before they were born, may have been exposed to various influences , external or internal, which may or may not have modified their genetic potential. An external influence would be smoking or alcohol for example. An internal influence would be, for example, maternal diabetes. There is more, however. For example, a cousin may have some disease.. An aunt had a stillborn. The grand-grand mother of the woman came from the Mediteranean area where certain chromosomal abnormalities are common. In the man’s family other health histories may be plaguing his background. As you can see, they do not start with a clean slate. No one does.
Preconceptional prenatal care may be able to put all this history in some sort of order with resultant valuable information upon which the couple will be able to make important decisions. Based on a medical evaluation of their background, they may be able to avoid some complications or the physician can make care plans appropriate for this couple.
If the prospective parents had children before, or if in-between pregnancies their health was modified as compared to previous pregnancy, a reevaluation of the changes need be taken into account.
Last but not least, if the mother had a complication during the last pregnancy, much can be done to avoid or harness the problem this time. A typical example is diabetes. Controlling a known diabetic before conception, can modify if not avoid, the complication this time around.
Such an approach would, in the long run, decrease complications of pregnancy. Just as in the case of maternal mortality, there will always be an irreducible minimum. But just like maternal mortality was dramatically reduced in the 20th century, now is the time to look into reducing complications.
Easier said than done. Preconceptional Prenatal care would not serve, of course, in cases of unplanned pregnancies. It is no secret that many are. Furthermore, I recognize that it will be a hard sell to people of reproductive age as a whole. We will have to spend effort, time and money to educate the public on the advantages of such an effort. Really, not different than when the concept of prenatal care was being developed. As late as 1955, I remember distinctly as a medical student, when a woman told me that “My mother had 7 kids and had no prenatal care and did just fine!!!”
Persistence and perseverance, however, will eventually educate and succeed. Hopefully it will not take another full century.
SILVIO ALADJEM MD, an obstetrician/gynecologist and Maternal Fetal Medicine (high risk obstetrics) specialist, is Professor Emeritus in obstetrics and gynecology at Michigan State University, College of Human Medicine, in Lansing, MI. He is the author of “10,000 babies: my life in the delivery room” now available on Amazon, Barnes and Noble and other book stores. Dr. Aladjem published extensively in Scientific Medical Journals and wrote several textbooks in the specialty. He can be reached through his website, www.drsilvio.com.