At the beginning of my second trimester in late March, I was contacted by my obstetrician’s office and was told to come alone for my next ultrasound. At the appointment I learned that my next appointment would be almost two months later. I was incensed.
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 this current crisis.
Frequent visits may be less crucial than we think
There has never been uniformity in visit schedules in this country. 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, M.D., 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 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 World Health Organization and others have found success with models averaging eight appointments. “Most countries in the world have less frequent visits with better outcomes,” said Dr. Erica Cahill, M.D., an assistant professor of obstetrics and gynecology and complex 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 industrialized nations.
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 an anatomy scan around 20 weeks, and many physicians also order ultrasounds between 11 to 13 weeks and later in the third trimester. 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 gives practices the ability to bill patients’ insurance plans for telehealth care, 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 centers are threatened with shutdown.
Dissuaded from visiting clinics but armed with blood pressure cuffs, fetal heart rate Doppler monitors and smartphones, many pregnant women are being taught to self-monitor. 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 participating expectant mothers. Even before the Seattle area was hit hard by the coronavirus, these 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. And now, she also has the benefit of avoiding medical facilities where she could be exposed to the coronavirus, she said.
But TaNefer Camara, a lactation consultant based in Oakland, Calif., said 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,” said Camara, adding 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 said.
The danger for people whose pregnancies were already risky
Dr. Peahl said 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 fetal heart rate monitors are not covered by Medicaid.
Dr. Jennifer McLeland, M.D., 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 urine, swelling and other symptoms. Individualizing care for people in these higher-risk categories and with underlying medical conditions is crucial, Dr. McLeland said.
Monica McLemore, Ph.D., a family health care nursing professor at the University of California, San Francisco, said that “we have already seen things we never expected” because of the coronavirus. “Let’s maintain that orientation. We must work together to fix this system for people with the capacity for pregnancy,” she said. She suggested 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, of course, highlighting myriad existing health care gaps, whose roots include systemic racism and classism.
For some marginalized individuals, lack of visits, scans and sonograms is nothing new. Dr. McLemore said that the lack of universal coverage for pregnancy care was compounded by longtime health disparities, such as higher rates 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, for example. “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
While it might seem safest to go to the doctor less right now, expectant parents and their loved ones feel an increased sense of uncertainty. Mommy blogs are not new, but people with time and internet access may find themselves newly pulled in by questionable guidance amid what can feel like an information vacuum. Providers are worried that their patients are getting bad advice online.
“Just because you are talking to your doctor on the internet doesn’t mean the internet is your doctor,” said Dr. Cahill.
In Texas, Dr. McLeland said that she had seen false information about pregnancy and the coronavirus spread via Facebook groups and Reddit. “Misinformation is vast and scary,” she said. “People are preying on a vulnerable population during this time. These women are terrified.”
Her practice has tried to share accurate information on social networks and via a texting app that protects patient privacy. To combat questionable information, many universities and practices have expanded free access to webinars and other guidance through their websites, email lists and YouTube.
Prenatal care might change for good
Gynecological care, contraception and abortion access are threatened during this pandemic. Yet when it comes to pregnancy and the weeks immediately afterward, providers do see some cause for optimism. In addition to the rethinking of in-person visit schedules, the coronavirus could motivate the creation of a central set of resources on prenatal care. And doctors have suggested that postnatal care schedules may change from in-person appointments six weeks after delivery to televisits two to three weeks post-birth to check in with parents in this high-anxiety period. It’s a change that could stick and lead to better postpartum experiences for parents and babies.
Finally, the normalization of telehealth might help people in rural and remote locations, as well as hourly wage workers. Dr. Peahl said that, in the long term, “reduced-visit models and televisits will be advantageous: 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,” Dr. McLemore said.
Dr. Cahill has no doubts: “Prenatal care will change after Covid.”
Emily Goligoski directs audience research at The Atlantic and was formerly on the staff of The New York Times.