Every day is different and every pregnant woman is unique. Pregnancy is a dynamic process in which the mother’s physical state changes daily from the moment of conception until many weeks after delivery. The hormonal, physiologic, and immunologic changes that occur account for the common complaints of pregnancy (e.g., “morning sickness”), the common complications of pregnancy (e.g., gestational diabetes) and account for the more serious, though still common, problems associated with pregnancy (e.g., preeclampsia). These changes determine the success of pregnancy from the time of implantation through delivery. If you already have medical problems, they may worsen, improve, or have no effect during a pregnancy. Previously undiagnosed medical conditions may surface only during the pregnancy and sometimes only after the baby is born in the postpartum period. And occasionally the fetus may put both the mother and the pregnancy at risk.
As an obstetrician, I am always mindful of a woman’s desire to have a “normal” pregnancy while being constantly vigilant for evidence of maternal and fetal complications. When problems are recognized, I try to be straightforward and truthful, yet remain sensitive and empathic. Explanations regarding complications, particularly those related to the baby’s well-being, demand careful forethought. Balancing these issues can make pregnancy an emotional roller coaster for both the family and the healthcare providers who care for them.
We have seen remarkable advances in medicine over the past three decades, but progress in obstetrics has been painfully slow and spotty.
For instance, the survival of newborn infants born at less than 27 weeks, almost unheard of in the 1970’s, has jumped to 30-50% when born between 23-24 weeks and with access to neonatal intensive care units. During the same time period however, preterm labor rates have actually increased from 8% in 1979 to more than 13% (15-17% in certain high risk groups, depending on geographical location and ethnic group), in the U.S. today, adding billions of dollars to healthcare costs in both the short- and the long-term care of these children.
When the new technologies of electronic fetal monitoring and real-time ultrasonography were introduced in the 1970’s, we hoped that these would improve both maternal and fetal outcomes. Yet, despite their widespread use, there has been essentially no impact of fetal monitoring on the incidence of cerebral palsy, 90% of which has been found to occur prior to the onset of labor, and limited success of interventions during the pregnancy for fetal abnormalities detected by ultrasound.. Indeed, some would argue, albeit simplistically, that the greatest impact of these interventions has been to increase cesarean delivery rates from 12-16% during the 1970’s (6.5% in 1965) to more than 30% at many hospitals across the nation today.
Not all has been to the downside. It is true that today infertile women and women with serious medical conditions, who could never have conceived in the past, are achieving pregnancies with the help of sophisticated assisted reproductive technologies. But, with that has come a whole new set of challenges and ethical considerations (as well as job security for me!).
Perhaps my greatest source of frustration is the low priority that is given to pregnant women in terms of health care and research dollars. Despite the universal proclamations that “our children are our greatest resource,” this statement has not been backed by the support, financial and political, that is required to make sure that every fetus really has the best start on life. This is in stark contrast to the megabucks handed out for patient care and research related to midlife medical conditions such as cardiovascular disease.
Admittedly, things improve for care after the fetus becomes an actual newborn, but we have already learned, as demonstrated by the success of folic acid supplementation of foods, that the best prenatal care begins prior to conception.