At the beginning of my second trimester in late March, I was contacted by my obstetrician’s office. They told me to come alone for my next ultrasound. At the appointment, I learned that my next appointment would be almost two months later, leaving me angry.
During my first pregnancy four years ago, I had 12 in-person appointments. This pregnancy, I may see a doctor for seven appointments, even though I’m now in a higher-risk category as a 35-year-old with a “geriatric pregnancy.”
What if something important goes unchecked with our baby? But my doctor’s desire to limit my exposure to the coronavirus trumped her need to personally check my baby more regularly. She referred to this period as “D.I.Y. pregnancy.”
Medical practices across the country have made similar calculations, with some low-risk expectant parents going 10 weeks between in-person appointments. What we learn about adapting to a new schedule may affect prenatal care in the United States well beyond the pandemic and into the endemic era. So how different will be pregnancy in the Covid pandemic era? Let's take a look.
Frequent Visits May Be Less Crucial Than We Think
There has never been uniformity in visit schedules in the US. Until recently, the American practice of 11 to 14 prenatal visits reflected a guideline from 1930. Its prevalence reflected patient preference, as well as providers delivering care in the ways they’ve been trained, said Dr Alex Peahl, MD, an ob-gyn at Michigan Medicine who has been working on redesigning that university’s prenatal care policies during the pandemic.
The practice of frequent visits was not motivated by financial incentives; most practices charge a flat fee per pregnancy regardless of the number of visits. And the standard schedule can affect patients negatively, Dr Peahl said. The extended visit schedule could require patients to spend an average of 40 hours getting to and from their appointments.
The family planning at Stanford University.
And while we spend more per pregnancy than any other country, our infant and maternal death rates are among the highest of industrialised nations.
Is it safe to be pregnant during Covid?
Against the setting of the Covid-19 pandemic, new guidelines from the American College of Obstetricians and Gynecologists suggest that clinicians group vaccinations and screenings together to reduce the overall number of in-person visits.
They recommend four ultrasounds - between 11 and 13 weeks, then at 20, 32 and 36 weeks. In addition to the virtual appointments that many practices are now scheduling, the group suggests remote follow-ups for monitoring diabetes control, hypertension, mood disorders and other conditions.
A new federal change inspired by the coronavirus provides the ability to bill patients’ insurance plans for telehealthcare, which physicians said represents a major change. It also represents a primary source of revenue at a precarious financial moment when many private practices, major institutions and community health centres have been threatened with shutdown.
Pregnancy in covid pandemic for Millennial parents
Dissuaded from visiting clinics, many pregnant women are learning to self-monitor. They now have blood pressure cuffs, foetal heart rate Doppler monitors and smartphones.
For many parents-to-be, it’s the first time we have been involved in collecting our own data or had direct communication with our care teams outside of face-to-face appointments. For some, collecting information about their pregnancy symptoms, blood pressure, weight and fetal heart rates can be oddly empowering at this uncertain time. But only if a person has the resources to do it properly.
Niha Zubair, a data scientist, signed up for a TeleOB program through the University of Washington School of Medicine that provides a blood pressure cuff and fetal monitor, along with instructions, to the participating expectant mothers.
Even before the Seattle area was hit hard by the coronavirus, women regularly met their doctors and midwives on video-conferencing calls between their in-person appointments.
"It’s a huge time saver. I have a full-time job and two small children, and it means not having to drag kids to an appointment if I don’t have child care," Zubair said.
But TaNefer Camara, a lactation consultant based in Oakland, California, says she was disappointed to have one of her prenatal appointments moved to Zoom recently and to learn that her midwife would limit most in-person meetings to one per trimester.
"Regular prenatal care in this country already feels like it lacks connection. Already it feels so impersonal," says Camara. She adds that as a health care provider herself, she understands the need to limit in-person visits. But other women may not have the level of access and information she has, she says.
The Danger For People Whose Pregnancies Were Already Risky
Dr Peahl says that the country’s less advantaged institutions and patients would probably miss out on some opportunities that higher-income patients have. Many blood pressure cuffs start at $25 and foetal heart rate monitors are not covered by Medicaid.
Dr Jennifer McLeland, MD, an obstetrician with Vivi Women’s Health in Fort Worth, said that without opportunities to meet in person or access to tools to self-monitor, some conditions might be missed in financially vulnerable expectant mothers, particularly in their third trimesters.
She said patients in this population already experience higher rates of preeclampsia, a potentially fatal condition that can be indicated by changes in blood pressure, protein in the urine, swelling and other symptoms. Individualising care for people in these higher-risk categories and with underlying medical conditions is crucial, Dr McLeland adds.
Monica McLemore, Ph.D, is a family health care nursing professor at the University of California, San Francisco. She says, "We have already seen things we never expected. Let’s maintain that orientation. We must work together to fix this system for people with the capacity for pregnancy."
Pregnancy in covid pandemic: regular self-monitoring required
She suggests mental health check-ins and regular self-monitoring. Because successful telemedicine requires access to a device, internet connectivity and technical savviness that not all patients have, Dr McLemore, suggests that clinics or philanthropic foundations provide devices and data plans not just for providers but also for patients who need them.
This pandemic is highlighting myriad existing health care gaps, whose roots include systemic racism and classism. And that will be the biggest change in pregnancy in endemic.
For some marginalised individuals, lack of visits, scans and sonograms is nothing new. Dr McLemore says that longtime health disparities compounded to form the lack of universal coverage for pregnancy care. This includes a higher rate of diabetes and hypertension among low-income people who may lack access to private insurance.
They’re often the same people who don’t have access to midwifery without paying out of pocket. "Risk is not equally shared," Dr McLemore said. "We’ve always had two, three, four-tier allocations of care based on insurance."
The Internet Is Not Your Doctor
"Just because you are talking to your doctor on the internet doesn’t mean the internet is your doctor," says Dr Cahill.
For several millennial parents, it might seem the safest to make fewer visits to the doctor right now. Expectant parents and their loved ones feel an increased sense of uncertainty. Mummy blogs are not new but people with time and internet access may find themselves pulled in by questionable guidance. It can feel like an information vacuum. Providers worry that their patients are getting bad advice online.
In Texas, Dr McLeland said she saw false information about pregnancy and the Covid-19 virus spread via Facebook groups and Reddit.
"Misinformation is vast and scary. People are preying on a vulnerable population during this time," she says.
Dr McLeland tries to share accurate information on social networks and via a texting app that protects patient privacy. Many universities and practices have also expanded free access to webinars and other guidance through their websites, email lists and YouTube.
Prenatal Care Might Change For Good
Gynaecological care, contraception and abortion access remain threatened during the pandemic. This might be the case during the endemic as well. Yet when it comes to pregnancy and the weeks immediately afterwards, providers do see some cause for optimism.
In addition to rethinking in-person visit schedules, pregnancy in endemic could motivate creating a central set of resources for prenatal care. Doctors suggest that postnatal care schedules may change from in-person appointments six weeks after delivery to tele-visits 2-3 weeks post-birth.
It’s a change that could stick and lead to better postpartum experiences for parents and babies.
Finally, the normalisation of telehealth might help people in rural and remote locations as well as hourly wage workers. Dr Peahl says tele-visits will have an advantage in the long run. Patients won’t have to miss work or will be able to have kids in their lap."
Many clinicians speak about this time as an invitation to redesign maternal health infrastructure. "We could rebuild this differently. Some of the decisions in the pandemic could be permanent," says Dr McLemore.
Dr Cahill has no doubts, “Prenatal care will change after Covid.”
"Prenatal Care May Look Very Different After Coronavirus" by Emily Goligoski © 2020 The New York Times Company
Emily Goligoski directs audience research at The Atlantic and was formerly on the staff of The New York Times.
This story was originally published on 28 April 2020 in NYT Parenting.
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