Our Bodies, Ourselves (81 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
All prenatal care is not alike. Some prenatal care providers, especially midwives who practice in home and birth center settings, offer long visits with plenty of time to answer questions, address concerns, celebrate joys, and explore fears. We may be encouraged to participate in aspects of our visits, such as taking our own blood pressure or writing our weight in our own medical records.
My 6-year-old daughter, Lucia, often came to my appointments with me, and I think it was an important part of making her the great big sister that she is. Our midwife, Elizabeth, was really patient with all of Lucia's questions, let her try all of her tools, and always had a doll for her to hold that was the same size as our growing baby. After Savina was born, Lucia was really sad that we couldn't go visit Elizabeth anymore
.
Some provider visits are brief and emphasize tests and procedures. While most of us have one-on-one appointments with a care provider, more women are participating in supportive group prenatal care with other women due around the same time. Be prepared to take a proactive role to get the most out of your visits. For more information, see
Chapter 23
, “Navigating the Health Care System.”
In the first trimester, prenatal visits to your health care provider are recommended every four to six weeks. The timing of your visits may vary depending on your individual needs. Visits will typically include measuring your weight and blood pressure, listening to the baby's heartbeat (after ten to twelve weeks), and measuring his or her growth by feeling the uterus or placing
a measuring tape on your abdomen. Ideally, you will have enough time to talk about any concerns, review test results if tests were done, and discuss future plans.
© Judith Elaine Halek
If you participate in group prenatal care with other women, your visits will also include time to learn together the information you will need to make informed choices about your care. If you have traditional one-on-one prenatal visits, you will likely benefit from childbirth education classes, including early pregnancy and breastfeeding or parenting classes, especially if your care provider offers relatively brief prenatal visits (less than thirty to sixty minutes with the midwife or doctor). For more information see
“Childbirth Classes.”
If your first prenatal visit is the first time you will meet your care provider, come with questions that will help you decide if she or he is a good fit for you. (See
suggested questions.
) If possible, bring your partner, other family member, or a friend for support.
At the first visit, you will be asked about your health history and your family's history, your background, your occupation, and what support you have at home. You will talk about your diet, exercise, and drug and alcohol use. The purpose of this visit is to help you identify any problem areas, such as physical and psychological concerns. If you are experiencing physical or sexual abuse, consider telling your midwife or doctor.
He or she may be able to help by giving you referrals and scheduling more frequent visits if needed.
CENTERING PREGNANCY: A MODEL OF GROUP PRENATAL CARE
Some doctors and midwives follow a model for group prenatal visits called Centering Pregnancy. At each prenatal visit, the provider facilitates learning and discussion among a group of pregnant women. In addition, the provider gives individualized private care to each woman at every meeting. Studies of Centering Pregnancy suggest that it lowers the likelihood of preterm birth and low-birth-weight infants, and increases breastfeeding rates and satisfaction with prenatal care experiences.
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For more information, visit centeringhealthcare.org
Another important goal of the first prenatal visit is to establish a reliable estimated due date (EDD). Your EDD is thirty-eight weeks from the day you conceived the pregnancy. If you don't know when you conceived, you can determine your EDD by reviewing your menstrual cycle. If you have regular, twenty-eight-day menstrual cycles, your EDD is forty weeks from the beginning of your last menstrual period. Many women, however, don't have regular menstrual cycles, or their cycles are longer or shorter than twenty-eight days. If this is true for you, tell your provider how long your menstrual cycles usually are, whether they are regular, and whether you have recently been on a hormonal birth control method or breastfeeding (these can both alter your menstrual cycle.)
Pregnancies usually last about thirty-seven to forty-two weeks, with most women giving birth between thirty-nine and forty-one weeks. Your EDD is merely the middle of that window. Most babies will not actually be born on their due date.
Some doctors' offices and clinics have ultrasound machines and use them at this first visit to see the fetal heartbeat and estimate how far along you are. However, office ultrasounds are not routine in all settings or necessary for most pregnant women. The quality of the pictures produced by ultrasound machines is unlikely to provide useful information about your baby's well-being.
At the first prenatal visit, your doctor or midwife may ask you to get undressed. The examination typically includes a pelvic exam to collect specimens for testsâwhich may include a Pap test and gonorrhea and chlamydia culturesâand to feel the size of your uterus. If you want to see your vagina and cervix, ask for a mirror. (For more information on pelvic exams, see
“The Gynecological Exam”.
) If it is ten to twelve weeks after your last period, you may be able to hear the baby's heartbeat with an electronic Doppler (ultrasound wave device). Later in pregnancy, the baby's heartbeat can be heard with a simple device called a fetoscope.
Before leaving, ask when to return, what to expect from future visits, and where and whom to call with problems and concerns. The practitioner should provide you with any other information you may need, such as written materials and referrals to classes and nearby resource centers. You should leave feeling listened to and well cared forâoff to a good start. If you don't think this person is a good fit for you, seek a different provider, if possible.
Your subsequent visits will generally be shorter than the first one. Your care provider will check your weight, blood pressure, and
urine; measure your belly to evaluate the baby's growth and position; and listen to the fetal heartbeat. You will occasionally have other tests or procedures, which your care provider should discuss with you ahead of time. All prenatal visits should include plenty of time to talk about your pregnancy, discuss plans for labor and birth, and get your questions answered.
CARE FOR PREGNANT WOMEN WITHOUT HEALTH INSURANCE
Finding appropriate medical care and services can be difficult if you do not have health care insurance. Some women who lack health care insurance become eligible for Medicaid coverage after becoming pregnant. Eligibility requirements in all states are expanded for pregnant women, and there is a special program called “presumptive eligibility” that pays for medical care for pregnant women whose Medicaid applications have not yet been approved. To find out if you are eligible for Medicaid, visit benefits.gov. To see if your state has a presumptive eligibility program, go to statehealthfacts.org and search for “presumptive eligibility.”
In 2014, as a result of new health care legislation, many more of us will become eligible for federal subsidies to purchase health care insurance, and all plans will be required to cover maternity and childbirth services as part of an “essential health benefits” package defined by the federal government. Medicaid will also cover many younger adults who currently lack coverage, enabling women to have insurance before becoming pregnant. These insurers will not be allowed to charge women who are pregnant higher rates.
Your local medical assistance, welfare, social services, or public health office can help you find a clinic that will offer you care or refer you to an insurance program that is available to you.
One program available everywhere in the United States is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC provides milk, fruit, vegetables, whole grains, juice, cheese, and eggs and offers some prenatal and breastfeeding education. The program may be housed in the local health department, schools, or free clinics. It is available to everyone and is often the best place to start when you're looking for affordable prenatal care. People in the WIC office can refer you to health care providers and other programs and services that are available to you during pregnancy. The WIC website (fns.usda.gov/wic) lists toll-free phone numbers for WIC agencies in each state.
If you aren't able to find insurance coverage, you might consider working with a midwife at home or at a birthing center. These midwives often provide the most affordable care; your out-of-pocket costs will likely be lower than those at a hospital or ob-gyn office. For more information about finding low-cost care or accessing Medicaid, see
Chapter 23
, “Navigating the Health Care System.”
Some prenatal tests give information about the mother's health, while other tests provide information about the characteristics of the developing fetus. While some tests are routine and generally helpful, every test does not make sense for every woman. Ideally, tests will be selected based on your individual circumstances and personal preferences.
Prenatal tests that provide information about your health, such as blood testing to find out if you are anemic or are HIV-positive, are important because they detect conditions that often can be treated.
Your state health department may require certain tests, such as blood tests for syphilis or HIV. If you do not want certain tests, you may have options for refusing them in most states, although states differ in procedures for refusing such tests.
After your first prenatal visit, blood tests are not needed at each visit. In your sixth month, a blood test that measures the level of sugar in your blood is routine in many practices. The blood is drawn one hour after you drink a measured amount of sugar (glucose). If your blood sugar level is higher than normal after you've drunk the sugar solution, you will be asked to do a second, three-hour test to determine if you have gestational diabetes. Some women find that the testing makes them feel nauseous, light-headed, or weak. Blood tests before and after a high-carbohydrate meal may be an appropriate alternative way to screen. Gestational diabetes occurs in about 4 to 7 percent of women and is associated with higher rates of cesarean section and larger babies. It also puts you at increased risk for developing diabetes later in life.
About a month before your estimated due date, your care provider will offer you a vaginal culture for group B streptococcus (GBS). GBS is not an infection; it is one of the bacteria that can be found normally in the vagina. Ten to 30 percent of pregnant women carry this bacterium. Because in rare cases a baby will become ill from GBS infection contracted during birth, your practitioner may test you for GBS and recommend treatment during labor to prevent your baby from becoming sick. Women with GBS are usually given intravenous penicillin during labor.
There is controversy in the obstetrical community about the value of recommending screening for GBS to all women. The test is not offered routinely in many other countries. That's because the downstream effects of the testsâsuch as the use of antibiotics and separation of mothers and babies after birthâcan be harmful, and many women need to be screened and exposed to these interventions to prevent a single newborn illness or injury.
Ever since the 1970s, it has been possible to get some information during pregnancy about the characteristics of the developing baby. In recent years, the number of tests available to pregnant women has multiplied, allowing increased scrutiny of the fetus for specific disorders. Women may choose prenatal testing to learn about health problems, diseases, or disabilities that might occur. If you learn through prenatal testing that your baby will likely be born with a correctable, treatable, or lifelong impairment, you may want to make special plans before the child's birth. Or you may decide to end the pregnancy if you know that your future child would have a disabling condition or be unlikely to survive after birth.
Though prenatal tests may offer useful information,
they also raise concerns if the report is false-positive. Most of the noninvasive tests (blood tests and ultrasounds) are screening exams that are not perfect, and they can indicate a problem that with further testing will turn out not to be there. Invasive tests such as amniocentesis or chorionic villus sampling (CVS) can give you a 100 percent true answer about some genetic conditions, but these tests involve drawing fluid out of the amniotic sac by inserting a needle through the abdomen or vagina. These tests carry a small risk of miscarriage. Even when they do not cause medical problems, tests can create anxiety and expense and add to the medicalization of pregnancy and birth.