Our clinic day begins at 9 a.m. with “Welcome, how are you?” Smiles may greet us, with excited tales of the baby’s first kicks. Or a stone face may turn away, and our patient questioning of the pregnant mom elicit a story of trouble at home.
Inner City Prenatal Care
I work in a midwifery clinic in the inner city of Portland, Oregon. We serve a diverse population, ranging from highly educated Caucasian women who come to us specifically because they want nurse midwifery care, to teen African American women who come because we are their neighborhood clinic and their sister or mother or friend has had babies with us. We serve quite a few Asian ladies—Laotian, Hmong and Vietnamese—as well as Russian, Native American and Hispanic women. We’ve helped girls as young as 12 have babies, girls who have hidden their pregnancies until they are due. We’ve helped professional women in their 40s have a first, and very longed for, child.
We are able to serve all women who come to us, whether low-risk or high-, because we work closely with consulting perinatologists. This week I conducted a new OB appointment with a woman past her due date who’d had no prenatal care and will be adopting her baby out. In the same afternoon, I saw a couple six weeks pregnant who arrived with a stack of questions about our cesarean section rate (11 percent to 12 percent) and episiotomy rate (almost zero), with specific questions about labor support. When women have medical problems, we provide their prenatal care and often deliver them, while our physicians titrate their insulin doses or perform amniocentesis or determine which hypertensive medications they need.
Having a group practice means the midwives rotate call and clinic responsibilities. For example, I am in clinic typically one to two days a week and work one 24-hour-call shift, assisting women in labor or triaging emergencies. Women are free to choose to make their prenatal appointments with one primary midwife or take potluck, as they prefer. They understand that any midwife may be the one to catch their baby, although occasionally we all “special” certain patients.
Women average about 10 visits with us—we have had as few as one prenatal visit before birth and as many as close to 30 for very high need women. The schedule is usually once a month until seven months, and then twice a month until the last month, when we see them weekly. We schedule an hour-long visit for the first prenatal, which includes a history and physical exam as well as teaching. Twenty-minute slots are common for most return visits, but again, we are flexible and have spent five minutes to hours for repeat visits.
After women check in with the receptionist, they weigh themselves and dipstick their urine. A typical prenatal visit includes discussion of diet, fetal movement; blood pressure, fetal growth an well-being; encouragement of healthy habits; comfort suggestions for common complaints; and checking in about questions or concerns. We have a checklist of teaching appropriate to each visit, and many handouts. We offer lab tests such as the prenatal panel, HIV, sickle cell and Pap, as well as cervical cultures, vaginitis exams, urine cultures, and diabetes and anemia screening. Ultrasounds are offered between 16 to 20 weeks and performed more frequently as needed.
We screen for sexual, physical and emotional abuse, and we are fortunate to have a wonderful social worker in our office who can offer assistance. Some of our patients have substance abuse problems, and we focus much time on trying to help them overcome or minimize their addictions. We have referrals for financial need, with many of our ladies receiving assistance from the Women, Infants & Children Nutrition Program (WIC) or other programs. Our nurses provide a lot of education, give injections and perform other procedures, and our medical assistants room them and do lab procedures such as drawing blood.
In our treatment room we provide IV hydration for women with hyperemesis or perform non‑stress testing and amniotic fluid volume testing for postdates. This saves women unnecessary visits to the hospital, although it is just across the street from our clinic when needed. Lately we have had free lunchtime meetings in our waiting room with our lactation consultants to try to encourage more women to breastfeed.
We work with a nutritionist to whom we refer our diabetic or obese ladies, and occasionally women with severe pica or eating disorders. Everyone is offered a prenatal vitamin supplement, and women who have anemia are also offered iron supplementation. Some women are interested in herbal supplementation and other alternative modalities, and those of us in the office with experience in those areas are happy to discuss, for VBAC women, evening primrose oil near term or red raspberry leaf, etc. But many of our clients cannot afford such supplements or visits to other practitioners, such as chiropractors or acupuncturists, who are not covered by Oregon Health Plan.
Once a week we have consult clinic, during which time our perinatologist and resident come and see our high-risk patients. I have learned a lot about many different conditions from working this clinic. The midwives provide the prenatal care and the doctors the medical care, and the patients benefit from receiving the best of both worlds.
A critical part of our prenatal care is simply listening to women. Many of the women coming to our clinic have complicated lives. They somehow persevere through circumstances that are crushing to their spirit. I know that sometimes I am the first person who has asked them questions like, “Have you ever been a victim of rape, incest or molestation?” Before we start, I say, “I’m going to ask you some nosy questions. We ask these questions of all women who come to us.” Even if they are not ready to talk about some of these traumatic life experiences, at least they know they are not alone in their experiences and that someone cared enough to ask and let them know we are there for them if they need us. We talk about stress in their lives and give suggestions on coping. Sometimes our appointments resemble therapy sessions more than the typical prenatal exam.
Purpose of Prenatal Care
So these are the things that we do as nurse midwives practicing in the inner city today. But what is the purpose of prenatal care? It certainly wasn’t always part of midwifery care through the ages. It evolved primarily in the United States and England in the early 1900s as a screening for toxemia. Do all these appointments really help women have happier pregnancies, or better births, or healthier babies? Do our interventions, both physical and psychological, make a difference? We have so many routines around pregnancy and birth in our culture, rituals that are reinforced by our belief system that are not necessarily evidence-based care.
I recently read a book called Expecting Trouble: The Myth of Prenatal Care in America, by Thomas Strong, MD. It’s a muckraking, thought-provoking book. He addresses the issue of quantity of care versus quality of care, noting that the average number of prenatal visits is less in western European countries, yet they maintain a lower infant mortality rate than does the United States.
Strong emphasizes that the problem of prematurity is not being well addressed by prenatal care. Out of well-meaning fears and concerns, the overuses of technology and interventions by providers have not contributed to the well-being of mothers and babies. Perceiving pregnancy as a disease and medicalizing prenatal care has created its own set of problems, without improving outcomes. He discusses why midwives should be the providers of routine prenatal care, with obstetricians the high-risk specialists. He goes on to state:
Prenatal care should be based on the assumption that each low risk pregnancy is normal until proven otherwise. Pregnancy is not disease—it should not be subjected to the same style of care that the ill must endure. Prenatal visits should be infrequent and deliberate. Ample time should be scheduled for questions and reassurance. Indeed, high‑quality, low frequency prenatal care visits that emphasize the educational and emotional aspects of maternal health would likely produce better compliance and higher levels of maternal satisfaction.
While Dr. Strong presents a well reasoned and researched case for the overhaul of the average three-minute, obstetrician-attended prenatal visit, he does not deny the benefits of educating pregnant women and screening for certain health problems. Although his book provides much food for thought, I continue to believe the prenatal care offered to the women in our neighborhood clinic does benefit them overall, and our excellent statistics certainly support that belief. The best confirmation is when we finish a prenatal, the pregnant woman (and her family) leaves with a lighter step than when she came in, and she eagerly schedules her next appointment.