According to a recent article in Cosmopolitan, the potential repeal of the Affordable Care Act means that a flood of poor women will be going to jail – deliberately – to get prenatal care.   The author claims that prior to the implementation of the ACA, for many women, prison was their main provider of prenatal care, and should the ACA be repealed, it will be so again. http://www.cosmopolitan.com/politics/a8672870/obamacare-repeal-will-send-poor-pregnant-women-jail-prenatal/  

Of course, the ACA does not really mean all women have access to prenatal care.  It simply means that they have insurance. Insurance does not always equate to health care.  Health care, for most people, carries additional costs and fees beyond the amount insurance covers.  The amount of money I had to pay out of pocket for my pregnancy and birth in 2009 vs. my pregnancy and birth in 2012 more than doubled in only 3 years.  Our insurance paid a lower percentage of my prenatal care post-ACA. Since the price we paid for our monthly insurance also went up significantly at the same time, it certainly didn’t translate to affordable care for us, anyway.  If we hadn’t been able to afford the money for the co-pay, our insured status would not have equated to prenatal care for me. But I digress.

The author of the Cosmo piece never exactly proves that because the women received prenatal care in prison, that it was really their REASON for being in prison, nor does she establish that the women in question tried very hard to get prenatal care outside of prison, either.  And even before the implementation of the ACA, there were social programs that offered free health care to people below a certain income available for the taking – no need for poor women to go to jail to get prenatal care. But let’s take the claim at face value. For the sake of argument, we’ll agree that at least some women are willing to deliberately subject themselves to prison to access prenatal care.  Some would argue that adequate prenatal care is so important to the good of the country that so we should provide it for free to everyone. Let’s accept that as a given, too. As a caring, empathetic society, we should ensure that everyone has access to some basic level of food, water, air, and prenatal care. But what adequate prenatal care should entail is hard to pin down, exactly.   “Adequate” is a pretty amorphous term. What does it really mean?

Women’s magazines and medical experts universally agree that adequate prenatal care is very important for the health of women and their unborn babies.  Without adequate prenatal care, terrible things can happen. But as most women who have had a baby will testify, the bulk of prenatal care involves an afternoon taken off work, finding a sitter for your other children or dragging them along if you can’t, a stressful drive into heavy traffic, paying for parking in a crowded parking garage, waddling into a building full of sick and possibly contagious people, waiting an interminable length of time for a nurse to check your pee sample/take your blood pressure/measure your stomach/weigh you and scold you for the amount you’ve gained, be it too much or too little, and then waiting another interminable length of time for the doctor to show up.  The doctor shakes your hand and glances at your paperwork and tells you to return in a month, 2 weeks, a week, or a few days, depending on how far along you are. Sometimes you get to listen to your baby’s heartbeat on the Doppler, which is fun.

Quite frankly, a good percentage of prenatal care is bullshit.  You lose an entire afternoon, if not a full day, to see a nurse for a few minutes and a doctor for fewer.  Somebody behind the scenes dips a test strip into your pee. It’s basically an excuse to listen to your baby’s heartbeat.  Lots of appointments, lots of ultrasounds, lots of tests, lots of weighing and measuring and poking and prodding, but most of it is only window dressing.    

If you have concerns about aches or pains they are usually played off as inconsequential.  If you have minor pregnancy complaints, they are easily fixed. If you have heartburn, take Tums.  If you are constipated, take a stool softener. Varicose veins, put your feet up. If you’re nauseous, try soda crackers.  But adequate prenatal care should not mean going to the doctor for advice about soda crackers and footstools and reassurance over cramps.  It should mean that which is minimally adequate for a healthy pregnancy. Adequate means good enough, not best of the best. Yet women are sold a bill of goods where if they don’t have it done exactly as the OBGYN suggests, their uterus will implode, taking out everyone within a 5 yard radius.  

Things can and do go wrong in pregnancy.  But most of what pregnant women receive when they get prenatal care is useless.  It isn’t preventative, it’s a placebo. A lot of hassle for a lot of nothing. Most of the patients OBGYNs see in the office are not having emergencies and most who are having emergencies are well aware they are having them.  In fact, developing emergencies are sometimes missed during prenatal visits when doctors and nurses write off concerning symptoms as minor complaints, lulling women into a false sense of security that everything is ok when it actually isn’t.

Most serious problems in pregnancy (that are able to be corrected by doctors, that is) show up towards at the end of pregnancy.  Gestational diabetes and pre-eclampsia rarely develop before the 5th month and usually much later. Problems during the first trimester of pregnancy are almost always terminal.   If you’re losing a pregnancy before 26 weeks (more realistically, 32 weeks) there is usually little they can do to save your baby. Despite this, some doctors will have women come in every 2-3 days day at the beginning of a pregnancy for something called “betas”.  Betas are blood tests to check the level of pregnancy hormones in a woman’s blood. They’re done repeatedly to see how fast they’re rising. Slow rises can mean a pregnancy is not developing normally. But fast rises, while encouraging, do not guarantee a pregnancy is developing normally.  Betas are largely pointless, but women love them anyway. They will obsess over their betas. Women whose doctors won’t do betas lament over not having their beta numbers. But betas are totally useless because if the pregnancy is ending at the earliest stage of gestation, there is nothing doctors can do about it anyway.   Betas are a huge waste of valuable medical dollars that could be spent more wisely on about a million other things.

Some other things that doctors like to do in early pregnancy:

Prescribe really expensive prenatal vitamins, but prenatals are readily available over the counter for a much lower price and prenatals have never been shown to do anything to help a pregnancy anyway.  https://www.statnews.com/2016/07/11/prenatal-supplement-unnecessary/  Folic acid has, but most foods are fortified with folic acid now, and it’s also readily available over the counter at a fraction of the price as the prescription brand.  Vitamin D may also be a good idea, but again it’s available in fortified foods and also over the counter.

Prescribe progesterone supplements which data indicates are no better than placebos and do not help maintain any pregnancy that isn’t developing normally http://www.health.harvard.edu/blog/9829-201606229829

Pressure women over 35 into having amniocentesis or CVS tests that carry a risk of miscarriage even though there are now non-invasive blood tests that do the same thing for a much, much lower cost and without risk to the pregnancy http://www.whattoexpect.com/pregnancy/pregnancy-health/noninvasive-prenatal-testing

Send women for “dating ultrasounds” which involve something called a transvaginal ultrasound wand (just as pleasant as it sounds) to verify when the woman got pregnant.   Even when the woman knows exactly when she got pregnant, many doctors insist upon the “dating ultrasound” even though it is of no proven medical benefit. They are also very unreliable and many times women end up highly stressed out when a technician can’t see a baby on the screen because they are not far enough along.

Insist upon doing Pap smears and other preventative vaginal exams “because they won’t be able to do them later in pregnancy.”  But Pap smears only need to be done every 3-5 years https://www.cancer.org/cancer/cervical-cancer/prevention-and-early-detection/cervical-cancer-screening-guidelines.html

Put women on bed rest or pelvic rest even though these things have never been shown to help sustain pregnancy and bed rest even make matters worse by causing blood clots in the legs.  https://www.fitpregnancy.com/pregnancy/pregnancy-news/experts-call-bed-rest-be-discontinued

Things that doctors DON’T like to do in early pregnancy:

Check thyroid levels of women with a history of thyroid problems.  Thyroid problems are known to cause or contribute to miscarriage and yet some women have to fight tooth and nail for their doctors to do these tests and adjust their medication even when they’re experiencing troubling symptoms.  https://www.endocrineweb.com/news/reproductionsexuality/15793-untreated-low-thyroid-function-during-pregnancy-can-lead-trouble

Properly investigate severe cramping and spotting.   One true medical emergency that does occur in early pregnancy is a pregnancy that occurs in the Fallopian tubes (ectopic pregnancy).  The tubes can rupture and cause potentially fatal internal bleeding. It’s rare, but worthy of a thorough investigation, not only to be sure an ectopic pregnancy has not occurred, but also to avoid medical mismanagement where a viable pregnancy is terminated.  There is a strange dichotomy wherein ectopic pregnancies are both frequently missed http://onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.1996.tb03282.x/full but at the same time viable pregnancies are terminated wrongfully http://commonhealth.legacy.wbur.org/2013/10/ectopic-pregnancy-misdiagnosed-methotrexate

Investigate unexplained fevers.  Women occasionally go into their doctor with an unexplained fever during pregnancy.  Yes, usually it’s viral. But occasionally a woman develops a bladder or kidney infection during pregnancy or even an infection in the uterus.  Because doctors often assume fevers are benign in cause, infections may be left untreated until a woman is very ill. If the infection is in the uterus, the pregnancy cannot withstand it.  Invasive procedures like Pap smears and transvaginal ultrasounds (as in, those things that some doctors like to do without cause in early pregnancy) during pregnancy may raise the risks of uterine infections, due to a lack of sanitization of equipment, the medical provider, or contamination of the gel products used during the procedure when technicians reuse the same container of gel again and again rather than opening a new sterile package for each patient.   https://www.cdc.gov/hicpac/Disinfection_Sterilization/3_1deLaparoArthro.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3973690/

http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm299409.htm

The argument for Mercedes-level prenatal care is that “If it saves one life, it’s all worth it”.  But the problem is, when every patient is treated as a ticking time bomb in need of intense scrutiny, it makes it much more likely the minority who really ARE developing a complication will be missed.   It’s like a reverse form of the needle in a haystack. Doctors and nurses are so busy dealing with all the pieces of straw, they can’t spot the needle even though it’s shiny. If a doctor’s office is so busy doing “dating ultrasounds” that it doesn’t have the capability to quickly and thoroughly investigate a woman who is actually having symptoms of an ectopic pregnancy, then they’re doing it wrong.  And if they’re so busy doing those “dating ultrasounds” that employees can’t even clean their equipment properly, wash their hands, or even open a sterile container of ultrasound goo, then they’re making even more needles to lose in the stack.

Some doctor’s office do early pregnancy right.  They refuse to see patients (without cause) until the start of the second trimester.  This allows them to better focus on their patients who are experiencing real problems and those later along in pregnancy and at higher risk of developing complications.  It also prevents temptation for doctors to cave in to their patients, who often demand interventions like dating ultrasounds, beta testing, and progesterone supplements when they are not medically indicated.  Unfortunately these non-interventionist doctors have to compete with the offices that are willing to do unnecessary intervention, so the pressure is on everyone to provide more and earlier care.

Prenatal care is likely even being overused even into the second trimester.  Most serious, life threatening pregnancy complications do not start to occur until the 5th month of pregnancy, and even then it’s only a tiny percentage which gradually grows to a still-small percentage by the 9th month.  So why do ALL women have to come in for numerous appointments even when their risk of complications is miniscule? Is this the best of use of our medical time and dollars? It probably isn’t, and any woman who is experiencing weird symptoms and is terrified and wants to come in right away only to be told “we can squeeze you in next Tuesday at 3” wants to tear her hair out knowing that most of the people in the doctor’s office are only there to listen to their baby’s heartbeat on the Doppler.  

Did I mention how fun that is?   It’s pretty fun. Fun enough to justify wildly inflated medical bills?  Nah. Fun enough to justify having to wait days for true medical emergencies?  Definitely not.

There are some very clear markers for gestational diabetes and preeclampsia that are easy to spot.  Increasing blood pressure, sugar and protein in urine, and excessive weight gain are early signs. Why not allow pregnant women to take their own blood pressure, check their own urine with dip sticks to check for sugar and protein, weigh themselves, and call for an immediate appointment if anything seems off?  Maybe come to the lab a couple times for a blood test at the start of the second trimester and the start of the 3rd to rule out anemia, gestational diabetes and a few other rare complications? A woman wouldn’t even need to see the doctor for that, if everything came out ok. It would give doctors and nurses more time to answer the mundane questions about heartburn and support stockings via email.

Some women won’t do those things, of course.  But I’ll wager that most if not all of the women who aren’t willing to take their own blood pressure and check their urine for glucose and protein once a month are also the ones who weren’t going to prenatal exams anyway.  And that’s not meant as a slam on them. If you don’t have reliable transportation and someone to watch your children, it becomes a massive ordeal to go to the doctor’s office once every 2 weeks or even once a month. If you work a non-professional job, and are expected to work 9-5 M-F, it’s undoable.   And knowing that you’ll face judgement from the nurses and receptionists if you miss an appointment or two makes it that much harder to show up at the visits you can. Who can blame them for wanting to stay away? I actually suspect we’d see better compliance with a do-it-yourself approach than with traditional prenatal exams.

Articles about women going to jail to get adequate prenatal care are nonsensical because no one is even questioning what that even means.  No one is calling for “good enough, get the job done” prenatal care. They’re calling for an unnecessary amount of prenatal care that most do not need, which puts huge burdens onto the backs of poor and working-class women (whether or not they have insurance).   Prenatal care as it exists here and now, America 2018 is NOT adequate. It’s a fun and reassuring life experience for women who can afford it and have the luxury of being able to get to the appointments. But a lot of women don’t want a fun and reassuring life experience, they want adequate prenatal care.  Truly adequate. They want a healthy pregnancy and a healthy baby and I believe we can do that with far fewer visits.

No one needs to go to jail for “adequate” prenatal care.  We need to start giving women the option of a basic level of care.  This isn’t harming women, it’s helping them. If doctors weren’t stretched so thin, they’d be better able to serve all their customers.  They may even be better able to help the women and babies who truly require medical intervention by decluttering the doctor’s schedules and making it easier to spot the needle in the haystack.  It would very likely be more affordable as well – an important consideration given the recent debates over health care. And nobody would have to go to jail to get it.