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Why Early Prenatal Care Is Important

Health: The attention is vital for an embryo's health, and it cuts the risk of newborn death. Women are getting the message.

November 27, 1996|KATHLEEN DOHENY | SPECIAL TO THE TIMES

Early prenatal care dramatically cuts the odds of having an ill or low-birth-weight baby, reduces the risk of newborn death, and study after study shows that it has the greatest impact on teens, unmarried and minority women--all at high risk for complications.

In the last few decades, the message about prenatal care has been spread effectively. In 1992, 78% of pregnant U.S. women received medical attention beginning in the first trimester.

But the numbers in California will drop once Gov. Pete Wilson proceeds with his plan to ban illegal immigrants from receiving prenatal care benefits under terms of the new welfare law.

Wilson does not dispute the health benefits of prenatal care, but says state taxpayers cannot afford to pay the annual bill, which is $70 million for about 69,000 women. Critics argue that good prenatal care--no matter what a mother-to-be's citizenship--makes economic sense, saving countless dollars spent caring for ill infants.

What does prenatal care consist of? Here's a timetable of tests, exams and visits deemed ideal for mothers-to-be.

The First Doctor Visit: This should occur as soon as possible after pregnancy is confirmed, according to guidelines on prenatal care issued jointly by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.

A physician or a nurse should establish an "obstetric data base," including information on the last menstrual period, medical and social history, a diet assessment and an estimated date of delivery.

Also recommended: a urinalysis, blood tests to identify blood type, assessment of Rh factor and tests for sexually transmitted diseases such as syphilis. The physician should determine if the woman has had German measles (rubella) and if she has been exposed to hepatitis B.

Tests for HIV and tuberculosis screening are also often done, adds Dr. Leroy Reese, chief of obstetrics and gynecology at White Memorial Medical Center in Los Angeles.

8-18 Weeks: Ultrasound is recommended at this time, according to the ACOG-AAP guidelines. This sonogram, or picture, can help determine the size of the fetus, confirm the due date, detect multiple pregnancies and reveal certain birth defects. "The most accurate ultrasound for dating [the pregnancy] is before 12 weeks," Reese says.

Also recommended during this time frame is amniocentesis for women 35 and older. In this procedure, a small quantity of amniotic fluid surrounding the fetus is removed. The fetal cells are cultured and analyzed for defects in the chromosomes.

Performing amnio earlier within the recommended time frame is a trend, says Dr. John Medders, chief of the department of obstetrics and gynecology at Kaiser Permanente-Woodland Hills Medical Center. Another test for genetic abnormalities--chorionic villi sampling (CVS)--can also be performed.

"Anyone who needs amnio is potentially a patient who would get CVS," Medders says.

16-18 Weeks: Alpha fetoprotein screening should be considered, according to the guidelines. Alpha fetoprotein is a substance produced by the liver of the fetus; the test measures AFP levels in a woman's blood. High levels can indicate neural tube defects such as spina bifida.

26-28 Weeks: Diabetes screening and repeat blood tests are recommended.

32-36 Weeks: Repeat ultrasound is recommended, as well as STD testing and other blood tests as needed.

At each visit: Blood pressure should be taken. Weight, uterine size and heart rate should also be assessed.

The variables: The frequency of follow-up visits depends on a patient's individual health needs and risks. Usually, a woman with an uncomplicated pregnancy should be examined, according to the joint guidelines, every four weeks for the first 28 weeks, every two to three weeks until 36 weeks, and weekly thereafter, although the schedule is not hard and fast.

Women with medical or obstetrical problems need closer follow-up, experts say, while those with no complications may fare well with less medical attention.

Low-risk pregnant women who had an average of eight visits during their pregnancy fared as well as low-risk pregnant women who had the typical 13 visits, according to a study conducted at Kaiser Permanente-Woodland Hills and published last year in the Journal of Reproductive Medicine. On the basis of the study, a less frequent visit schedule might be acceptable for these low-risk patients, says Dr. Mark Binstock, who led the study.

Compliance: Women are more apt to get early care if they are educated about its need and if programs are individualized, physicians agree.

At Kaiser Permanente-Woodland Hills, for instance, pregnant women receive prenatal information sheets. "This supplements the visit," Medders says. The sheet for the 24-25 week appointment, for instance, includes precautions against lying flat (it can cause dizziness), warning signs of premature labor and other details.

Currently, the number of women at Kaiser's Woodland Hills center obtaining prenatal care in the first trimester is about 92%, Medders says. "When we have a no-show, we call the patient."

At White Memorial, Reese says, discounts are offered to cash-paying patients and installment plans are available to encourage women to obtain care. Of the 300 deliveries there a month, he says, "probably two-thirds of those have had prenatal care in our system."

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