As obstetricians we have always stressed the importance of prenatal care. The Centers for Disease Control and Prevention reported that delayed entry into prenatal care was associated with adverse outcomes for the mother and baby. We also know that the earlier in the pregnancy that a patient receives prenatal care, the better the chance for the obstetrics caregiver to establish the gestational age, address the issues that can affect the pregnancy such as preexisting medical diseases or issues related to previous pregnancies, avoidance of teratogenic medications, and modification of lifestyle issues such as smoking, drugs, alcohol, and excessive weight gain. It also allows the provider of care to develop and implement an obstetrics treatment plan best suited to the patient. Prenatal care has always been assumed to start when the pregnant mom is first examined by her obstetrics provider. Unfortunately in many cases, this “start” is after organogenesis has occurred and is too late to avoid adverse outcomes for the mother and fetus.

We know that organogenesis starts 2 weeks after conception. We also know that some medications, diseases like diabetes mellitus, and toxin exposure like cigarette smoke during the first 12 weeks of pregnancy can result in not only an increased risk of miscarriage but also an increased risk of congenital anomalies. For these reasons, it is distressing to see the data reported by Nettleman et al , which indicates that, even in a commercially insured married population, prenatal care is delayed for 25% of pregnant women for >4 weeks. This timeframe is after many organs have formed or interventions that could minimize risk to the fetus should have been initiated. The study also shows that other than information relating to the form of insurance that the patient has, no other information was asked for in >90% of the patients. In fact, only 67% of the office staff asked for the date of the last menstrual period; 14% of the staff asked whether the patient had a previous pregnancy, and <5% of the staff asked about the general well-being, medication use, hypertension, diabetes mellitus, history of pregnancy complications, or smoking. No practice asked the patient about alcohol use.

This study points out the “missed opportunities” that occur in medicine and that the system of providing prenatal care is flawed. The first encounter with the patient (ie, scheduling of an appointment) is handled as a “nonevent” when in actuality it should be used as an effective educational and triaging opportunity. Multiparous women with no medical problems could be given an appointment at the convenience of the office, but first-time pregnant women and those with medical or lifestyle issues should be effectively triaged and given appointments without delay. It is clear that obstetrics care is initiated at the convenience of the provider’s office as opposed to the individual needs of the pregnant patient. This opportunity to “triage” patients when they call for their first prenatal appointment has the potential to improve prenatal care significantly and decrease some very important morbidities.

Imagine an office that trained the front office to ask the following simple questions when the patient called for her obstetrics appointment:

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  When was your last menstrual period?

  
  
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  Have you had any problems in a previous pregnancy?

  
  
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  Do you have diabetes mellitus?

  
  
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  Do you take any medicines other than prenatal vitamins?

  
  
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  Do you have any chronic medical problems?

  
  
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  Are you taking prenatal vitamins with folic acid?

  
  
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  Are you drinking alcohol now that you know that you are pregnant?

  
  
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  Do you think there is any reason that the doctor/midwife should see you as soon as possible?

These questions would take approximately 60 seconds to ask but could result in the ability to triage patients effectively. Those women who need to be seen right away could be accommodated, and those women who could be seen in 3, 4, or 6 weeks could wait, as appropriate. It would allow the obstetrician/midwife to provide the care to patients who are in most need of early evaluation and treatment in pregnancy appropriately and delay appointments for patients who are routine.

If this approach to care based on individual need rather than who calls first were adopted, as well as adopting scheduling of prenatal care visits for routine patients that results in fewer visits, providers could actually provide better care for those who need it and decrease the number of traditional visits offered to those who do not have any risk factors. The traditional prenatal care schedule for low risk patients (ie, 8, 12, 16, 20, 24, 28, 30, 32, 34, 36, 37, 38, 39, and 40 weeks ) has been shown to not be necessary for low-risk women. The scheduling of visits at 8, 12, 16, 24, 28, 32, 36, 38, and 40 weeks for a Kaiser Permanente group compared with the traditional scheduling of prenatal visits resulted in no differences in perinatal outcome and the use of diagnostic prenatal testing or the use of other medical services. “Group” prenatal care has also been studied and has been shown to be another method that results in equal or improved perinatal outcomes with less physician involvement.

By instituting individualized prenatal care first appointments and using reduced scheduled appointments or group prenatal care for low-risk patients, obstetrics care providers could use their time and efforts more effectively to improve prenatal care, rather than just provide prenatal care. Nettleman et al have shown that we have opportunities to significantly improve the provision of early prenatal care. By combining this information with the adoption of other proven methods of providing prenatal care to the low-risk population, I believe we can establish a win for the patient and a win for the obstetrics providers. To do this though, we each must ask ourselves what the barriers are in my practice to the implementation of this type of care and find ways to overcome them.