Efficient prenatal care: fewer visits, fewer sonograms.

In this issue of ecp, Evidence Matters focuses on obstetric care and how it might be done more efficiently. The goal of prenatal care is to ensure delivery of a healthy baby to a healthy mother. The standard regimen of care that most obstetric providers have been trained to use is intense—14 visits during a 40-week pregnancy and a myriad of screening tests. Many recommended aspects of prenatal care have not been shown in clinical trials to improve outcomes, but more tests and visits must be better, right? The studies presented in this issue of ecp show the opposite—that more visits and, at least in the case of routine ultrasonography, more tests are not necessarily better. Neither increases the number of healthy babies delivered to healthy mothers. The first study presented here was designed to put the recommendations of the Expert Panel on the Content of Prenatal Care1—a multidisciplinary panel convened by the Public Health Service—to the test of a randomized, controlled trial. This trial, conducted in the Colorado region of Kaiser Permanente, found that reducing the number of prenatal visits had no adverse effects on outcome or patient satisfaction. That the intensity of prenatal care can safely be reduced has been confirmed by randomized trials in Britain2 and Zimbabwe.3 By paying attention to what we do in fewer prenatal visits, we can improve the efficiency of prenatal care while satisfying our patients and maintaining excellent pregnancy outcomes. Obstetric providers can use the results of these randomized trials to safely reduce the intensity of routine prenatal care and continue to deliver healthy babies to healthy mothers. Performing ultrasonography at least once and often twice or more during pregnancy has seemingly become routine. This practice was based on the belief that such screening would improve outcomes. However, the RADIUS trial, presented here and in another paper4 examining the impact of routine screening ultrasonography on maternal management and outcomes, demonstrated that routine ultrasonography does not reduce adverse perinatal outcomes or obstetric interventions. Keeping in mind the caveat that these trials examined care given to low-risk obstetric patients, it seems clear that in prenatal care, more is not necessarily better. Indeed, when equivalent or better outcomes result from less intense care, resources become available for use elsewhere. To me that means that less—not more—is better.