Pregnancies are usually characterized into high-risk and low-risk categories. The ‘high-risk’ pregnancies are those that have documented and accepted risk factors for poor outcomes. They include concerns like anatomical and genetic abnormalities in the baby, multiple gestation pregnancies, pre-eclampsia, gestational diabetes, and some maternal health conditions. These pregnancies are often co-managed by a maternal-fetal medicine specialist and are followed using a protocol that involves additional testing and more frequent monitoring. The ‘low-risk’ pregnancies are any that don’t meet the criteria.
The stillbirth rates for ‘high-risk’ pregnancies are a fraction of what they are for ‘low-risk’ pregnancies.
According to the Society for Maternal Fetal Medicine, incorporation of this proactive care can decrease the rate of perinatal mortality from 8.8 to 1.3 deaths per 1000 births (Society for Maternal Fetal Medicine, 2010). The current US stillbirth rate is 6.1 deaths per 1000 births. That seems backwards because the label implies the higher rate would be in the ‘high-risk’ group. I believe there are many ‘low-risk’ pregnancies that could/should be managed by this same protocol.
There are many, many known risk factors for stillbirth and other poor pregnancy outcomes that don’t qualify for high-risk care. Included in that list are: maternal obesity, advanced maternal age, non-Hispanic black race, first pregnancy, maternal drug use, use of IVF or other reproductive technologies, umbilical cord or placental abnormalities, pregnancies over 40 weeks gestation, and a mother who had a previous poor pregnancy outcome (such as stillbirth, preterm birth, neonatal death). These women are not routinely given the opportunity to benefit from a higher level of care. We hear from women every week who are in these categories, yet they are reassured that there is no reason to be concerned. We also hear from women with these characteristics that are turned down as patients by maternal-fetal medicine specialists because they don’t qualify for that level of expertise.
Even more concerning are the women who have several of these ‘soft’ risk factors. A 40 year old, obese, African American woman who used IVF to conceive should make every obstetrician or midwife nervous. Yet, most will consider her ‘low-risk’. We don’t have a magic study that tells us how to prevent all poor outcomes for these women – but we can use common sense and take advantage of the tools available to try. At the very least, we can have an honest conversation with the family about these risk factors and work together to identify a plan that makes sense to those most involved and affected. One of the options would be to offer them a high-risk pregnancy management plan.
I am also concerned that the current management of many of these risk factors is to prevent them from being true. Of course – it would be great if every woman could choose to be pregnant before they are 35 years old, be an ideal weight, not need fertility treatments, and not use recreational drugs. But these aren’t always practical. And even so, not considering those issues as risk factors once a pregnancy is a reality for these women is unethical. We have to have a better approach to managing these risk factors, even if they are modifiable.
For the women who are managed as high-risk, the classification can also be challenging because their management is often centered on the one piece that earned them that status. A woman with gestational diabetes will be seen more often with diligent monitoring of her blood glucose levels, but may not have any attention paid to the effects on the placenta, be asked about her baby’s movements, or consider that this is her first pregnancy, she is 38 years old, and she is at 40 weeks gestation. These women often have a false sense of security because they know they are getting a higher level of care and assume that care is comprehensive.
The number one comment I receive during these conversations is this: “If we consider the entire list of risk factors, every pregnancy would be classified as ‘high-risk”. YES.
There is no such thing as a low-risk pregnancy.
Every mother, every baby, every pregnancy, and every family deserves the best we have to offer. Comprehensive, high-risk care protocols should be offered to every pregnant woman. The education about all those risk factors and an honest discussion about the options should be automatically provided for each pregnancy. Each family will decide how aggressive they want to be – and that is what medicine is all about. But keeping that information and those options from large numbers of women is not doing anyone any favors.
This is not to say that I believe this care will prevent all stillbirths or other poor outcomes. It won’t. And I don’t expect our health professionals to be super heros with super-human talents. I just want them to give their patients credit for being rational, intelligent people who simply want what is best for themselves and their babies. And that will look different for each patient. That is where the art of medicine comes into play. Having all the information doesn’t scare pregnant women – it empowers them.
Yes – there is a financial cost associated with much of this. However, it is impossible to put a dollar amount on the life of a baby and the grief experienced by a family if that baby does not get to go home with the family as planned.
I want our health professionals to worry about our HEALTH first, and our wealth second.
This is part of the conversation, but families need to know their risks and have information about the pros and cons of proactive care (including costs) in order to make those decisions.
If it were up to me, every woman would be offered what is currently considered ‘high-risk’ care, but it would also be comprehensive and include multiple discussions with the families about any and all risk factors that are present and the options available to manage them. I hope our health providers would want to do this because it is utilizing the technology, intelligence, and ethics of 21st Century health care.