Reverb Effect Season 3, Episode 2 Transcript

[Reverb Effect Introduction]

Alex Peahl: Good morning Ms. Jones. Thanks so much for coming in today. I’m Dr. Peahl. How are you doing?

Mrs. Jones: I’m fine. Pretty tired though. I’m getting so big and my two-year-old daughter won’t give me a break. She’s always running around.

Alex Peahl: They will do that! But I’m glad to hear you’re doing ok. It looks like you are at 35 weeks and 4 days today, which means you’re a few weeks into the third trimester! Your last ultrasound we did a few months ago looked perfect... and the blood tests from a few weeks ago look good too—your blood count is great and you don’t have diabetes in pregnancy. Let’s check the baby’s heartbeat and measure your belly to make sure the baby is growing well. 

Alex Peahl: Everything sounds great! Can you hear it?

Mrs. Jones: Yes!

Alex Peahl: I wanted to check in with you about the past few weeks— it looks like you have missed a few appointments? 

Mrs. Jones: I know, doctor. I’ve been trying, but it’s hard to get here. The first one, my ride canceled, and I couldn't find anybody else to take me. Plus, my boss gets mad when I leave for a medical appointment, and if I don't work I don’t get paid. Me and my daughter gotta eat, you know? 

Alex Peahl: That sounds really tough.

Mrs. Jones: And, I can feel this baby moving ALL the time. I know from my first pregnancy that nothing much happens in those visits. The nurse checks a few things, you come in, listen to the baby, and we’re done in less than 10 minutes. That’s it. I already knew that everything is OK. Why spend all that time getting to you when it’s not gonna help anything? 

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Alex Peahl: I saw this same sequence happen over and over again for my pregnant patients: At the first prenatal visit we would give every patient the same schedule of appointments, once per month for the first 28 weeks of pregnancy, every two weeks up to 36, and then weekly until the baby is born. That usually comes to about 12-14 visits. Everyone got the same schedule. And that’s just how we did things. 

People would usually show up to have a routine ultrasound taken at 20 weeks of pregnancy—who doesn’t want to see their baby? But soon after that the pregnant people began to question the value of the brief, ten-minute prenatal visits, and some simply didn’t show up. When I finally did see them and asked why they had missed those appointments, they usually explained that “I knew everything was fine.” 

And they were usually right. They were weighing the benefits of prenatal visits with the costs of missed wages, childcare and travel expenses: the benefits simply did not outweigh the costs. Though patients were making a seemingly logical decision, they sometimes got punished for it: if Child and Family Services became involved in the patient’s care, these missed appointments could be used as evidence of their fitness for parenthood and threaten their ability to take their baby home.

It became clear to me that the prenatal appointment schedule didn’t necessarily line up with the lived experiences and perceived needs of my patients, and could be in fact harmful to them. I began to wonder what was the evidence for our recommended schedule of visits. So I did a little digging. 

When I turned to the national guidelines for people who practice obstetrics I was shocked to find no reference to support the current prenatal visit schedule. As I read more I learned this schedule was first recommended almost a century ago, around 1930. And I started to ask some questions: Why do we have the schedule that we use today? Where did it come from? And, most importantly, why hasn’t it changed over all these years?

Allie Goodman: Welcome to season 3, episode 2 of Reverb Effect, a podcast brought to you by the University of Michigan Department of History. I’m your host, Allie Goodman. You just heard a recreation of a patient visit with Dr. Alex Peahl, an assistant professor in Obstetrics and Gynecology at the University of Michigan, and the chair of the American College of Obstetricians and Gynecologists Redesigning Prenatal Care Initiative. In this episode, Alex will be joined by Joel Howell, a professor specializing in the history of medicine and technology in the University of Michigan Department of History, and professor of Internal Medicine and Health Management and Policy. Together, Alex and Joel’s research considers the implications of the history of the prenatal visit schedule on modern families, how that schedule came to be, and possibilities for future care. 

Joel Howell: To get to the bottom of the origins of the prenatal visit schedule, we have to go back to the nineteenth century United States. Medical care then was very different.

There were no licensing laws, which meant that anyone could claim the title of “physician” (and many people did). As a result, most physicians had very little formal medical training, sometimes as little as a few weeks of apprenticeship and no medical school. Even those who did have formal training learned relatively little about pregnancy and childbirth. Women were initially barred from attending medical schools, and then, starting in the second half of the nineteenth century, accepted at a few schools, but only in very small numbers. 

Moreover, the predominately rural landscape and difficulty of transportation meant that health care advice was often delivered by laypeople, with no professional medical training, frequently relying on widely read popular texts. Regular visits to what we would today consider a “professional” provider were neither recommended nor likely to be an option. This meant that most prenatal care remained in the domain of other women in the family. And those women were likely close at hand, since most people lived near relatives. 

Pregnancy and childbirth were common experiences—at the turn of the nineteenth century the average woman could look forward to giving birth to seven children during her lifetime. The networks of women who advised each other had considerable experience. Pregnancy was seen as a natural event, not a medical one. The circle of female relatives and friends collected and shared expertise with each other through apprenticeship and lore, and the experience of pregnancy and childbirth was a central feature of domestic culture.

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Abby: I wasn’t sure what was happening, but the pains are coming more regularly ... I’m sure I’m starting labor! It sure is nice to have you around.

Betsy: Of course—what are sisters for?! You do remember I’ve been through this myself—five times!

Abby: I know. But this is my first—and even though you’re here with me, I’m still worried.

Betsy: I know that having Mom there for my deliveries made me feel a whole lot better ... Now, try to breathe through the pain [Abby deeply breathing through a contraction . That’s it. [Breathing becomes less intense, gradually slows.] Good, now try to rest in between. Save your strength for the next one. And Clara, please run into the kitchen and get your aunt some water to drink and a cool cloth for her forehand.

Abby: That makes me feel so much better. 

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Alex Peahl: Pregnant women could look forward to the support of their family and community, with ample advice on managing common discomforts of pregnancy and navigating birth. While much of the advice for routine care was good, without an understanding of the pathophysiology of disease, management of complications was extremely limited, and maternal and infant mortality in pregnancy, birth, and the postpartum period was high. 

Today one of the key reasons to see pregnant individuals throughout pregnancy is to prevent some rare but serious complications that can happen. When we see pregnant people we confirm their due date, do ultrasounds, and measure the patient’s belly to ensure the baby is growing well. We check blood pressure frequently to detect diseases like preeclampsia (high blood pressure of pregnancy) and prevent more serious sequelae like seizures and kidney failure. The sooner we detect these complications, the sooner we can intervene, leading to better outcomes for mom and baby.

Joel Howell: People realized as early as the ancient Greeks that convulsions in pregnancy could be an ominous sign. At first, medical care was primarily done using only the unaided senses of the caregiver. But physicians and scientists came to see laboratory science as providing useful information. For example, analyzing someone’s urine. 

In the 1850s, physicians in Europe developed the tools necessary to measure substances found in the urine. They connected the presence of a specific type of protein found in the urine—albumin—to pregnant people who suffered from convulsions. Other types of technology were developed, such as tools with which one could measure blood pressure. Elevated blood pressure, like albumin in the urine, is an early indicator of problems in pregnancy. If we can identify the problem, often we can intervene early, before the disease advances far enough to put the patient at risk.

Alex Peahl: Starting around the turn of the twentieth century, American medicine began to change in profound ways. States started to require a medical license to practice. Medical schools became more selective and started to base education on emerging ideas in science and technology. The public at large increasingly came to see the value of science and its growing role in “common” events and experiences. Innovations such as anesthesia and discoveries such as the germ theory of disease also helped to increase the effectiveness and status of physicians. 

At the same time, more and more people moved into cities and away from their extended families. This, combined with innovations in transportation such as the automobile, along with inventions in communication such as the telephone, meant that it was easier for patients who wanted to consult a licensed physician to do so, including pregnant women. 

But not all pregnancies went well. Leading physicians at the time emphasized the precariousness of health in pregnancy.

J. Whitridge Williams: “It is apparent that the border-line between health and disease is less clearly marked during gestation, and derangements … may readily give risk to pathological conditions which seriously threaten the life of mother, child, or both.” 

Alex Peahl: That was J. Whitridge Williams, who was an obstetrician at Johns Hopkins University. In his 1914 presidential address to the American Association for Study and Prevention of Infant Mortality, Williams presented a massive study of 10,000 consecutive admissions of pregnant women, with 705 fetal deaths. He concluded that 40 percent of infant deaths could be prevented. 

Based on his findings, Williams believed a more comprehensive prenatal care plan was needed to prevent maternal and infant deaths:

J. Whitridge Williams: “I believe that too narrow a view is ordinarily taken of the scope of prenatal care, which is regarded … as a side issue in the propaganda for breast feeding … If ideal results are to be obtained, neither view is correct, and if the consideration of the facts which I have presented you has served its purpose, it will have convinced you that broad-minded prenatal care has an immense scope and can be carried out effectively only under the auspices of a well-regulated obstetric department which can command enthusiastic cooperation of carefully trained obstetricians, social service workers and prenatal and outdoor obstetric nurses, and at the same time is in close affiliation with a children’s clinic with its corps of organized workers …” 

Alex Peahl: In this ideal care plan all pregnant people would present for an early prenatal visit and receive a full physical exam and Wasserman test (for syphilis). He suggested that a nurse visit everyone in her home to assess her “social situation,” and that women return one month prior to delivery to decide if the baby should be delivered at home or in the hospital. 

Of note, Williams stressed the much worse outcomes for African American mothers, a racial disparity in infant mortality that has persisted into the twenty-first century. 

Women’s groups were becoming a political force during this time, in what historians call the Progressive era. They worked to pass the 19th Amendment to the U.S. Constitution in 1919, which gave women the right to vote. They also focused reform efforts on women’s and prenatal health, pushing for passage of the Sheppard-Towner Bill in 1921, which funded prenatal care centers, public health nurses, and community distribution of educational materials. This funding was discontinued in 1929 following lobbying by the American Medical Association, which contended that this was a “step towards socialized medicine.” 

Despite the AMA’s position, high infant mortality rates increasingly captured public attention—as did the ability of prenatal care to influence both infant and maternal outcomes. 

Another Progressive-era reform, the Federal Children’s Bureau, published national guidelines for prenatal care in 1930. 

The Children’s Bureau detailed a specific schedule for prenatal physicians. Depending on how early a pregnancy was diagnosed, they recommended 12-14 visits during pregnancy.

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1930 Imagined Pregnant Person: Thanks again, doctor. My husband and I really appreciate all the advice. And I do feel reassured knowing everything is ok after the physical examination. When should I come back and see you?

1930 Imagined Physician: Well, let’s just do what the Children’s Bureau suggests. I’ll see you once a month for the first six months of your pregnancy, then twice a month for a couple of months, and then every week until you deliver. How does that sound?

1930 Imagined Husband: Sounds like a plan! I’ll bring her back and see you in a month. 

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Alex Peahl: The Children’s Bureau did not provide any evidence supporting the recommended visit schedule, nor did it specify how or if the schedule should be modified for specific patients, such as those with additional risk factors. 

Joel Howell: And there the schedule sat, while the world changed. Health care moved increasingly out of the home and into the hospital, where surgeries became routine and fancy, expensive machines such as X-ray machines became used for routine patient care. The medical profession became more respected, and more lucrative. Clinical practice became seen as being based on a ideology of “science” and a training to which the lay public simply did not have access. As part of this process, pregnancy became medicalized. By around 1940 about half of all births took place in a hospital, a percentage that only continued to rise. The profession of obstetrics became increasingly specialized. 

New groups, such as the American Congress of Obstetrician-Gynecologists, issued recommendations for the care of pregnant people in a 1959 document that reflected the many changes in medical practice that had taken place in the three decades since the original schedule of prenatal visits took shape. 

By the 1970s, ultrasounds and fetal heart monitoring revolutionized the landscape for people in their reproductive years. In the 1980s, inexpensive home pregnancy tests gave people access to detection of pregnancy outside of the office, earlier than ever before. Genetic screening became widely available. 

Yet, still, even as many other aspects of medicine, health care, and society changed dramatically, the core schedule and number of recommended visits for a pregnant woman remained remarkably unchanged—and largely unquestioned—over the years.

But not everyone in America experienced pregnancy and the medical system in the same way.

US Surgeon General Julius Richmond: “In recent years, we have made considerable progress in the reduction of infant mortality ... Although this progress is dramatic and encouraging, the mortality rates for black infants twice the rate for whites is unacceptable in our society. It is time to take an inventory and for that reason this workshop was organized to bring to bear expertise and competence on the subject of parental and infant health.”

Joel Howell: With these words, US Surgeon General Julius Richmond opened a 1980 workshop on maternal and infant health. 

Alex Peahl: Perhaps prompted by this meeting, a series of high-level medical groups convened to discuss recent advances in the care of pregnant women. In 1989, the United States Public Health Service assembled a panel to consider the best content for effective, equitable prenatal care. 

The panel recommended a more flexible series of prenatal visits than the original Children’s Bureau did in 1930, accounting for patients’ specific medical and social risk factors. People having their first child would be advised to come in more often, as would pregnant people with medical or social risk factors. People who already had children and who were in good health would be advised to come in less often. The panel also recommended a variety of social and mental health services designed to support the pregnant patient. In other words, the panel suggested a more flexible schedule for prenatal visits, one that would reflect the specific social and medical needs of the mother. 

As reasonable as this may sound, leaders of the field such as Duane Alexander, Director of the National Institute of Child Health and Human Development, made a prediction: 

Duane Alexander: “These changes will be fought by a lot of people.”

Joel Howell: And that prediction turned out to be accurate. Physicians’ organizations noted, correctly, that if the new recommendations were widely adopted, physicians would see fewer visits from pregnant people. And many physicians were still being reimbursed based on each patient visit. Opponents of change noted the lack of solid evidence supporting the new schedule—at the same time, failing to note the lack of solid evidence supporting the original schedule. The result? Physicians went on using the same schedule of prenatal visits that had first been suggested back in 1930.

Alex Peahl: Meanwhile, researchers continued to study how many prenatal visits were actually needed. During the 1990s and early 2000s, clinical trials studied reduced visits for people who were pregnant but at low-risk, and more intensive services—often known as “enhanced prenatal care”—for those at higher risk of preterm birth and low birthweight. 

One analysis, which looked at more than 5000 patients from the United States and other high-income countries, demonstrated no difference in outcomes for moms or babies when visits for low-risk patients were reduced from 12-14 to nine. The World Health Organization recommended an eight-visit schedule. They also suggested shifting components of prenatal care such as education and monitoring pregnancy symptoms to community-based health workers to improve access and patient experience, particularly in low-resource settings. They additionally recommended the use of patient-held case notes, putting patients’ medical information in their own hands. The idea was to improve communication between prenatal care and delivering providers—to begin to shift the power inherent in control of information.

Over the past few decades, the United States has seen the introduction of still more innovative prenatal care delivery models. Modern patients can choose from a variety of prenatal care delivery options such as group prenatal care or virtual care. And new technologies offered by the private sector are available to help them navigate pregnancy. Here’s what this might look like for two fictional pregnant people: 

Alli: “ I’m a first-time mom, I graduated high school three years ago and just moved to Detroit for a new job so I can provide better for my baby. All of my family is on the west side of the state, so I don’t have a lot of support here. The other people in my pregnancy group are going through the same things I am and they can give me advice on things I’m having trouble with like good foods when I’m feeling like I’m going to throw up or where to get a free car seat.”

Alex Peahl: Group prenatal care, which includes enhanced education and relationship building, started in the 1990s, has recently enjoyed greater popularity. Studies have documented improved patient outcomes, particularly for patients facing complex challenges. These could be medical challenges, such as diabetes, or congenital heart disease, or social challenges, such as adolescence, or substance abuse. 

Emma: "I just turned 35, and this is my third baby—I have two little ones at home, ages three and five. I’m a hairstylist, and I’m lucky my mother-in-law is down the street and can help with the kids when I have a late client. I already have to cancel clients sometimes to take care of my kids, so I was really excited when my doctor offered me virtual prenatal visits. I can save so much time just logging into my virtual visit rather than going all the way to the clinic!”

Alex Peahl: For patients who have to balance work and childcare obligations, virtual visits offer a convenient solution. And the addition of home monitoring devices, like blood pressure cuffs, puts care back into patients’ homes and hands. Though many specialties, such as dermatology and psychiatry, implemented telehealth in the 1990s, virtual prenatal care was not available until 2014, when the University of Utah and the Mayo Clinic piloted new virtual prenatal care programs. The outcomes were the same, but with lower costs and high patient satisfaction. 

In spite of these innovations, most major U.S. maternity care organizations maintained the same visit schedule originally proposed in 1930. Nothing changed. Until …

[Interlude, Centers for Disease Control: This program is presented by the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention is working to help keep you and your community safe from Covid-19. Take the following everyday steps to protect yourself and others: Get a Covid-19 vaccine as soon as you can. If you are not fully vaccinated, wear a mask in indoor, public places. Children under the age of two should not wear a mask…] 

Joel Howell: Suddenly, everything changed. Hospitals were cleared out for Covid patients. Outpatient clinics were shut down. People were urged not to go out, and not to go to the doctor unless absolutely necessary. Concerns about transmission were everywhere.

Suddenly, that routine prenatal visit to the doctor no longer seemed quite so routine. 

Alex Peahl: And very suddenly, obstetricians had no choice. They had to change guidelines that had sat unchanged for 90 years. Clinic visits were limited to appointments where in-person services like laboratory testing and ultrasounds had to be delivered. This meant fewer visits for lower risk pregnant people, and more visits using virtual technology. Even patients with medical and pregnancy conditions experienced changes in care, with increased use of telemedicine and reduction in non-essential appointments. Some patients purchased devices to check their blood pressure and the fetal heart rate, bringing essential elements of prenatal care back to the home in ways that had not been seen in over a century. 

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Alex Peahl: Hi Ms. Jones. Can you hear me? I can see you. Did you have any trouble connecting?

Ms. Jones: Hi Dr. Peahl, I can hear you. It’s good to see you! It was easy today now that I have done a few of these. I’m so glad not to have to leave the house right now. It’s scary out there. I’ve been staying home all the time … I want to keep me and this baby safe. 

Alex Peahl: I’m glad y’all are being careful. Before we get started, did you check your blood pressure before the visit?

Ms. Jones: Yes I did—it was 126 for the top number and 74 for the bottom—which I think is good.

Alex Peahl: You got it. I would want you to call if the top number is 140, or the bottom number is 90… 

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Alex Peahl: The pandemic changed health care—and prenatal care—as we know it. However, as is often the case when any system comes under stress, it also highlighted problems that had started long before COVID. The long-standing emphasis on using science as the underlying basis for health care all too often meant that social support is left well down on the list of priorities—if it’s on the list at all. Technology worked great, if you had it. But often patients who already faced the greatest barriers to care were precisely those who had the greatest difficulty accessing the new technology.

COVID raised psychosocial stressors, too: economic instability, isolation, and increased anxiety. While new prenatal care models with reduced visit schedules and virtual visits decreased patients’ risk of viral exposure, for some patients they also exacerbated feelings of isolation and anxiety. New models of care developed during the pandemic are an important evolution in prenatal care delivery, but they require careful attention to ensure they promote equity and a positive patient experience. 

Joel Howell: And what next?

The pandemic persists, but the widespread availability of vaccines gives us hope. 

Some changes generated by COVID aren’t going away. While people in general have had quite enough of Zoom meetings and much too much of remote schooling, we will doubtless think twice in the future about whether it makes sense to physically travel to each and every meeting, or whether some tasks can be done more efficiently remotely.

Virtual visits have exploded. Michigan Medicine transitioned from not offering any virtual prenatal visits at all, to—essentially overnight—completing 40 percent of prenatal visits virtually.

Alex Peahl: Another change is that we are seriously rethinking the best schedule for prenatal visits. We may finally move away from the one originally proposed in 1930. In fact, in November 2020 the University of Michigan and the American College of Obstetricians and Gynecologists led a panel of 21 maternity care experts to reconsider prenatal care delivery in light of changes made during the COVID-19 pandemic. The panel composition ensured that diverse voices were included in deliberations: it included not only professional experts in maternity care, but also patient advocates, too. And, unlike the people who wrote the guidelines from the 1930s, over 70 percent of panelists were women. 

The panel recommended less intense care for low-risk patients, judicious incorporation of telemedicine, and tailoring of care to patients’ needs and preferences. 

For the first time since 1930, prenatal care guidelines have been redesigned for patients with patients’ input. The flexibility and individualization inherent in new guidelines reflects the unique lived experience of every pregnant patient, which cannot be reduced to a simple algorithm of visits. 

A couple of centuries ago, women gathered together to help each other deliver babies. Some of the advice they gave could be repeated today: eat a good diet, exercise in moderation, wear comfortable clothes, get plenty of sleep. But over the centuries physicians used new technology to play an important role in the care of people who are pregnant, tools used to measure urine chemistry, check blood pressure, and, now, provide care at a distance over the Internet. The best care will be provided when physicians and patients work together to arrive at a care plan that considers the specific social circumstances and takes into account the specific needs of every person involved. 

Difficult questions still remain. Will the very ease of virtual communication lead to increased, inappropriate use? In a world in which we hear almost daily about some electronic system being hacked, how do we ensure the privacy of patients’ medical records? What can we do for patients who lack secure access to the Internet? Or for those patients who lack other basic essentials of a healthy life—food, shelter, safety from partner violence? Telemedicine is not a panacea for the many problems that confront marginalized Americans. Yet, COVID-19 has demonstrated at least some of what virtual visits can do. What remains to be seen is how we ensure every patient has access to care that meets their needs and preferences. 

Allie Goodman: Thanks for listening, and a special thank you to our segment producers for this episode, Alex Peahl and Joel Howell. Another thank you to voice actors in order of appearance Taylor Sims, Audrey udrey Tieman, Hayley Bowman, Andrew Johnston, and Joshua McCurry. Our editorial board is Professor Henry Cowles, Alexander Clayton, Christopher DeCou, and Hannah Roussel. Gregory Parker is our executive producer, and I’m your season producer, Allie Goodman. I hope you’ll join us for our next episode, for more stories about how the past reverberates in the present. This is Reverb Effect.