Health Care Delivery

Mamas on Bedrest: Early Prenatal Care Lowers the Risk of Preterm Birth

December 13th, 2013

Early initiation of progesterone prophylaxis is associated with a reduction in spontaneous preterm births among women with a history of preterm delivery, a new retrospective cohort study shows.

So Begins a recent study published by Kara B. Markham, MD, from the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University. Interestingly, the more important piece of the article is,

Special efforts to promote timely access to care and initiation of progesterone treatment are likely needed to lower the rate of prematurity.

For me, this is the crux, the real nugget of truth to this article. When prenatal care is initiated early, many necessary treatments can be initiated at times when they may actually be effective.

So let’s look at the article.

The investigators analyzed data on women with a history of preterm birth attending the Prematurity Clinic at The Ohio State University Wexner Medical Center between January 1, 1998, and June 30, 2012. Clinicians started in 2004 to offer high-risk women routine progestin prophylaxis, delivered as weekly injections provided by a clinic staff member, and, starting in 2008, women could opt for daily, self-administered vaginal suppositories..The greatest reductions in preterm deliveries were observed in birth rates before 37 and 35 weeks of gestation. No significant difference was seen in the odds of birth at less than 32 weeks’ gestation, although the study was not statistically powered to detect a difference at that point in pregnancy.

According to the authors, Our report suggests that progestin prophylaxis can reduce the rate of recurrent spontaneous preterm birth when barriers to care and treatment are aggressively removed and that the gestational age at initiation may affect the success of progestin prophylaxis.”

This is great. Yet it has already been esstablished the progesterone therapy is effective in the prevention of preterm labor. (see our previous blog posts on 17OHP/Makena Injections) But the real gem of this article isn’t the progesterone therapy, but the realization by the authors that if prenatal care is initiated early, progesterone therapy can be initiated early and effectively prevent preterm births.

According to this publication, many of the women at risk for preterm delivery were Medicaid recipients. Because of the laws governing Medicaid in Ohio, there is a lag time between when a women is approved to receive Medicaid and eligible to receive Medicaid benefits (i.e. about to go for prenatal care). So in 2008,

the clinic started a program designed to identify and address obstacles to the timely initiation of progestin therapy, such as delayed entry to prenatal care, late identification of patients most in need of progestin prophylaxis, barriers to obtaining insurance, and safe administration of progestin injections. 

This action resulted in

the mean gestational age at the first clinic visit dropped from 19.6 weeks in 1998 to 2003, to 17.4 weeks in 2004 to 2008, and to 15.5 weeks after 2008, a statistically significant reduction (P < .01 for trend)Compared with the period from 1998 to 2007, the odds ratios of preterm birth in 2008-2012, adjusted for race, cerclage, smoking, and number of prior preterm births, were 0.75 at less than 37 weeks’ gestation (95% confidence interval [CI], 0.58 – 0.97), 0.70 at less than 35 weeks’ gestation (95% CI, 0.52 – 0.94), and 1.21 at less than 32 weeks’ gestation (95% CI, 0.83 – 1.76).

The authors note that the reduction in preterm births could be attributed to some unknown factor, but from what they observe, aggressively getting women (who need it) approved for Medicaid and in for their first prenatal visit early greatly enhanced the likelihood that they would start progesterone therapy at a time when it would be most effective.

This is truly remarkable work. Not only did the researchers find Progesterone therapy effective in preventing preterm births, they also found that early prenatal care also plays a role in reducing preterm births. Since women were seen and evaluated earlier, if any medical treatments or interventions were needed, they were started sooner rather than later.

Early intervention is the crux of most medical therapies; breast cancer campaigns, infant vaccination programs, diabetes treatments….Is it any wonder, then that early intervention is also beneficial when it comes to prenatal care? I was unaware that iniital prenatal visits have been pushed out to 10 weeks and beyond. It seems to me that earlier is better-allowing time to get baseline laboratories and to educate mamas on much needed prenatal information.

In my opinion, this is another example of how insurance coverage-money- is dictating medical care. And once again, this is proving to be an inappropriate standard by which to practice medical care. What is it going to take for us, as a society, to understand that sometimes faster, cheaper, leaner isn’t better? It certainly isn’t the case when it comes to health care and it most certainly isn’t best when it comes to prenatal care. We now have “evidence” to this, so in this era of “evidence based medicine”, isn’t it time to practice what we preach?

Reference

Markham, Kara B. MD; Walker, Hetty RNC-OB, CCRC; Lynch, Courtney D. PhD, MPH; Iams, Jay D. MD “Birth Rates in a Prematurity Prevention Clinic After Adoption of Progestin Prophylaxis”  Obstetrics & Gynecology., POST AUTHOR CORRECTIONS, 6 December 2013.

 

 

 

Mamas on Bedrest: Game ON!

October 4th, 2013

Wendy Davis is running for Governor of Texas!! The image of her on the cover of Texas Monthly shows her with her now trademark sneakers and the tagline, “Game On”.

Okay, what does this have to do with Mamas on Bedrest you may be asking? It means that women will once again get a chance to receive medical care that has long been denied here in Texas.

Texas has some of the worst records when it comes to women’s health. According to Cecile Richards, The President of Planned Parenthood,

“Over the past two years, 76 women’s health centers have been forced to close their doors and stop providing affordable, lifesaving cancer screenings, birth control, STD testing, and basic preventive care. And when Governor Perry and his allies ended the Texas Women’s Health Program, more than 130,000 women were shut off from accessing the health care they need, purely because of politics.”

In addition, in Texas, many health insurance plans do not offer maternity coverage. Yup. You read me right. Health insurance policies are not required to cover maternity care, and many of the carriers who cover Texas women don’t provide coverage for maternity services as part of their standard insurance plans. What they do is offer women “the opportunity to purchase an additional rider for maternity care.” In other words, if your insurance policy doesn’t include maternity coverage, you must pay for the rider or wing it and hope that you don’t incur ANY complications for which you will be responsible. I know many women who have fared just fine in this system. They receive their care from excellent midwives and many have home or birthing center births. But for those of us who are high risk, or for those of us who become high risk, not having maternity coverage and developing a complication during pregnancy can cause catastrophic financial damage.

Now, we all need to take a breath. Wendy Davis has simply announced that she is running for governor. She has not yet won. But for Texas women, this is the best news to come in a really long time. The fact that there is even a potential that someone may become an elected official that actually CARES about women’s health and is willing to take a stand for it and demand it on behalf of thousands of women is great new indeed.

Some people see Davis as purely an abortion rights advocate. If you only see her in that light, you are missing the much larger picture. Davis stands for women, children and those which many call “the underserved”. She is a champion or education, something desperately needed as Texas schools rank near the bottom in the country on per pupil spending. She has fought against education cuts 2 years ago and was able to get reinstated $3billion dollars of the $5billion cut in education.  It’s going to be a tough battle. Davis is going up against a strong “good ole boy” establishment and a strong candidate in Gregg Abbott. Many of the “status Quo” are not taking her campaign too seriously. They feel that while there is a lot of national attention focused on Davis, within Texas, she’s not going to be able to make the impact necessary to win the election.

I hope that they are wrong.

The Texas Department of State Health Services reports that the infant mortality rate overall in Texas is 6.1/1000 live births. However, black infants die at a rate of 11.4/1000 live births. Additionally, the Maternal mortality rate overall is 24.6/100,000  births with black women having a maternal mortality rate of 53.9.  Analysts from the state and the US Centers for Disease Control and Prevention attribute these numbers to lack of access to quality medical care.

Now Wendy Davis, if elected governor of Texas won’t be able to change all that is wrong with Texas women’s health care overnight. She will still have to contend with the “good ole boy” network and the very conservative right which is a large segment of the electorate in Texas. However, the demographics have changed alot over the years and there are substantial numbers of women and ethnic minorities able to vote. We will all have to see if these changing demographics are enough to turn the tide on the electorate, to elect Wendy Davis governor and to positively effect access to quality, comprehensive Women’s health care in Texas.

Mamas On Bedrest: Got a Medical Question? Tap into HealthTap for Answers

June 3rd, 2013

Mamas,

When you have medical questions, where do you go for answers? Do you ask your OB? Do you ask a friend? Relatives? How do you handle those pressing medical questions that plague you late at night?

Nagging questions can be burdensome, and often times a simple answer can put your mind to rest. But who do you call when it’s 2 am and your mind is running amok with all sorts of scenarios and “what ifs”?  Which websites should you view? How should you search? And how reputable is the information that you find?

HealthTap LogoMamas, I’d like to introduce you to HealthTap. HealthTap is a health information website with over 40,000 physicians in 3000 cities in all 50 states and 128 specialties. You can post a question and several physicians will  answer, or, you can search the archives for answers to similar questions.  According to Forbes and The New York Times, this immediate access to health information is the wave of the future.

I had the opportunity to hear the founder and CEO, Ron Gutman, speak at Austin’s South by Southwest a couple of years ago when HealthTap was in its development phase. It’s really an interesting concept. For patients, there is an incredible amount of information available right at your fingertips, anytime, day or night. For physicians, there is  a wide reaching platform from which to share expertise nationwide and with consumers otherwise out of reach. HealthTap has the potential to catapult a physician onto the worldwide stage; a physician shares his/her expertise, a syndication or publication sees them and boom-overnight fame, success, the potential to be the next “Dr. Oz. It truly is the interactive wave of the future.

However, there are limitations. While you can ask “personal” questions, most of the physicians cannot offer specific medical advice as they are unable to see you and learn the specific nuances of your situation. So much of the information you’ll receive is general in nature. But at 2 am to be able to calm feelings of anxiety, its a good thing! Also, the information provided is strictly medical in nature. I don’t believe that you are going to get a lot of holistic advice. These are board certified physicians and as is customary, the psycho-social aspects of medicine are left to the consumer.

HealthTap-Smartphone-Member-AppOn May 30, 2013, HealthTap rolled out its app, AppRx. AppRx is an app that recommends the most helpful health apps-per the physicians in the network. While this is a useful service if you are looking for very specific medical information, i.e. what are the best websites/apps for tracking blood sugars, it may not be the best place to look for information on best places to give birth. I don’t know that you are going to get a lot of pro home birth information or information on how to choose a doula. So the app and the website have their limitations. The app is available for both smartphones and tablets.

Like all new technology, there are good things and not so good things. I think that HealthTap is a useful website for people to use to learn more about their health and medical conditions. AppRx is a good tool to use to start a search for medical information. However, I also believe that there is more to health and healing than medical procedures and interventions, and while you will get great medical information, you won’t likely get the information you’ll actually need to really “live” with your condition day by day. I think that consumers should investigate HealthTap and the AppRx and use them as the information tools they are intended to be. Additionally, I think consumers need to be savvy and examine all aspects of their health care conditions and integrate necessary health and wellness practices along with medical treatment for a comprehensive approach to their situation.

On this week’s Wednesday Video, I’ll download and go through the AppRx.