rising assessment before conception VERSUS THE DECLINE OF HEALTH CARE IN PREGNANCY
After February 23, 2002
When we know how prematurity and low birth weight increase mortality, morbidity and disability in the lifetime, you can not imagine a major study published by the SF Olsen and NJ Secher in her British Medical Journal (1), the February 23, 2002. Eight thousand seven hundred twenty-nine (8729) Danish pregnant women were questioned about their habits dietary, and classified according to their fish consumption. Prematurity Levels ranged from 1.9% in the group who ate fish at least once a week up 7.1% in the group that ate no fish! Similar results were obtained for low birthweight babies given birth.
In a subsequent appearance of the British Medical Journal (2), stressed the obvious practical question that emerges from this study: Should we routinely encourage all pregnant women to consume, or increase consumption of marine fish?. I would remind you that during 1991-92, in prenatal care at Whipps Cross Hospital in East London, we encourage randomly selected of 499 pregnant women (less than 20 weeks) to increase the consumption of marine fish (3). Each woman was confronted with another control group would have the same parity. We could not detect any significant effect with our dietary recommendations during the perinatal period relating to baby weight or length of pregnancy. We repeated similar studies in three different contexts: the French University Hospital (Rennes), a Dutch team of midwives (Boxtel) and another hospital in East London (Newham). We encourage you to continue these studies because, once again, no significant effects were detected in the perinatal period.
remarkable thing is that Olsen and Secher recorded dietary habits before the onset of pregnancy. It is probable that dietary recommendations in antenatal clinics are given too late to have detectable effects in the perinatal period.
Many people associate the word with fish pollution. This may explain why these studies are little known and why are most often recommend fish oil capsules that own fish to pregnant women. However, small fish that live the high seas (and are at the top of the food chain) are not contaminated and are rich in omega 3. These include sardines, herring, anchovies, kippers, etc., all uncontaminated (and cheap). We must also emphasize that eating fish is not the same as taking fish oil capsules. It's more than eating a long chain of amino acids, omega 3. It also provides high quality protein and a good balanced supply of minerals. Many of these minerals (eg selenium and zinc), are increasingly rare in the terrestrial food chain. Also, when you eat fish, it automatically reduces the contribution of other food (as opposed to what happens with supplements.) In interpreting the apparent contradiction between the results of Danish and results of our studies, it highlights the relative importance of routine medical care during pregnancy compared with prepregnancy advice.
it worth ROUTINE MEDICAL CARE DURING PREGNANCY?
routine in many countries control is of 10 visits. Each visit offers the opportunity to practice a battery of tests. These traditional patterns of medical care based on the belief that more prenatal visits mean better results. This is not based on scientific data.
Review of routine medical care concept
British studies have failed to find a relationship between a late onset of prenatal care (more than 28 weeks gestation) and any maternal or neonatal adverse outcome (4), or between the number of visits and the onset of eclampsia (5). This casts doubt on the effectiveness of such protocols. Within the Britsh National Health Service (NHS UK), number of visits is not as directly related to socioeconomic status as it is in the U.S. This makes the results of British studies comparatively easier to interpret than the American studies (6.7). However, it is worth examining the report of the CDC's Morbidity and Mortalily Weekly, dated December 6, 2002 (CDC Centers for Disease Control and Prevention) in USA. There appears that women who were born outside the United States are more likely than their counterparts in race and ethnicity were born in USA, to start late prenatal monitoring, or not following any antenatal care. However (or perhaps because of it ?) Women born in Sweden, are more likely than their counterparts born outside the United States to give birth prematurely (11 '9% versus 10.5 %), or giving birth to underweight babies (7.9% versus 6.4%).
fruitful also analyze studies comparing the different programs of prenatal visits. One of them took place in California, the Kaiser Permanente Medical Center (8). A second study in South London, included 2794 women (9). The third, conducted by WHO, involved 53 centers in Thailand, Cuba, Saudi Arabia and Argentina (10). None of these studies showed some benefit from conventional programs compared to programs with fewer visits.
One might ask whether women are a greater number of antenatal visits give birth more easily than those who do not make any visits. For obvious reasons it is impossible to conduct a randomized study. A study on the effects of cocaine in the progress of labor, so unexpected suggested otherwise (11). The researchers realized that a third of consumers had not taken cocaine prenatal versus 4% of nonusers. For this reason it was essential to determine the average expansion at the time of admission among non-users of cocaine who had not followed prenatal care. It appeared that the average expansion at the time of admission in this group was 5.4 cm, while among those who had more than four antenatal visits was 3.8 cm (the average was between 4'63 using cocaine). Reconsideration
the content of prenatal visits
Until recently the main reason for the first prenatal visit was to confirm the diagnosis of pregnancy and to determine their age. Since pregnancy tests are safe and can be purchased without a prescription, most women confirm their pregnancy before seeing a health professional and reliable manner known date of conception. Knowing that pregnancy lasts about nine months from conception, we can calculate the expected date of delivery. So we can say that the primary reason for early control and pregnancy has gone.
The routine ultrasound during pregnancy has become the symbol of modern control pregnancy. It is also one of the most expensive. A number of studies comparing the effects of routine ultrasound versus selective use of ultrasound on birth outcomes.
One of these randomized studies, published by the New England Journal of Medicine, includes 15,151 pregnant women (12). The last statement of the article is clear: Whatever proposed interpretation, the results of this study clearly indicate that ultrasound screening does not improve perinatal outcomes in daily practice in the United States .
is this time, an article in the British Medical Journal (13) compared data from other four randomized similar (meta-analysis). The authors concluded that: The routine ultrasound screening does not improve pregnancy outcomes in terms of increasing the number of live births or reduce perinatal morbidity. The routine use of ultrasound can be effective and useful as a detector of malformations. However, the use for this purpose should be explicit and take into account the risk of false positive diagnoses and ethical factors .
is possible that in the future, a new generation of studies (within the structure of the Primal Health Research) would call into question the absolute safety of exposure Repeated ultrasound for fetal life. The selective use would have the effect of greatly reducing the number of scans, especially in the early and most vulnerable stage of pregnancy.
Even among the group of high-risk pregnancies, the use of ultrasound is not as necessary as people think. The evidence from randomized trials suggests that the ultrasonography of intrauterine growth retardation does not improve outcomes despite increased medical surveillance (14,15). In pregnancies with diabetes, has shown that ultrasound measurements are no better than clinical examination to identify babies macrosoma (16). This recalls the title of a memorable editorial British Journal of Obstetrics and Ginaecology: Guess the weight of the baby (Guess the baby's weight).
In most countries, the number of red blood cells (hemoglobin), is routinely monitored during pregnancy. There is widespread belief that this test can effectively detect anemia and iron deficiency. But this test can not diagnose iron deficiency, because it is assumed that the blood volume of pregnant women increases dramatically. Therefore hemoglobin concentrations than indicated in the first place is the degree of blood dilution resulting from placental activity. In a large British study about 153,602 pregnancies (17), was the highest average birth weight was between the group of women with hemoglobin concentrations between 8.5 and 9.5. And yet, when the hemoglobin remains above 10.5 in the last weeks of pregnancy increases the risk of low birth weight, premature delivery and pre-eclampsia. The unfortunate result of a routine evaluation of the hemoglobin level is that, worldwide, millions of pregnant women are mistakenly reports that are anemic should take iron supplements. There is a tendency to ignore the side effects of iron (constipation, diarrhea, heartburn, etc.) and to forget that iron inhibits the absorption of other important factors for development such as zinc (18). In addition, iron is an oxidizing substance which can exacerbate the lipid peroxidation (free radicals), which always involves an increased risk of pre-eclampsia (19).
In some countries, another routine screenings are helpful in diagnosing called gestational diabetes. For this reason the test is used glucose tolerance. If blood glucose (rate of glucose in the blood) is considered too high after the absorption of sugar, the test is positive. This diagnosis is useless because it simply reinforces the simple recommendations to be made to todas las mujeres embarazadas, tales como: evitar azúcares puros (incluyendo los refrescos, las bebidas gaseosas, etc.), elegir carbohidratos integrales (pasta, pan, arroz, etc.); hacer suficiente ejercicio físico. Un amplio estudio canadiense demostró que el único efecto de los tests de tolerancia a la glucosa era informar de que el 2,7% de las mujeres embarazadas tienen diabetes gestacional (20). El diagnóstico no cambió los resultados del parto.
También la rutina de medición de la presión sanguínea durante el embarazo debe ser reconsiderada. Originalmente, esta propuesta servía para detectar signos preliminares de pre-eclampsia, especialmente hacia el final del primer embarazo. Pero el increased blood pressure without protein in the urine, is associated with good perinatal outcomes (21,22,23,24). The prerequisite for diagnosing pre-eclampsia is the presence of more than 300 mg of protein in urine for 24 hours. Therefore, it is easier to use special reactive strips periodically urinalysis can be bought at the pharmacy. Under these conditions, the taking of blood pressure is not essential.
What can he offer the doctor? Once
questioned the true purpose of routine medical care in pregnancy and after evaluating the content of the visits 'antenatal' We explore the issue from a third perspective. We may ask, once conceived the baby, what can the physician to improve results. Since prematurity is a major concern, let me focus on what they can offer medical care to reduce the incidence of births before term. Recently, much research focuses on the potential for antibiotic prophylaxis. A large randomized multicenter trial of 6,295 women, was not favorable to the use of antibiotics (25). Besides the treatment of vaginal infections in early pregnancy does not reduce the risk of incidence of preterm birth (26). Cervical cerclage has been widely used to reduce the risk of preterm delivery, especially in cases of short neck or cervix incompetent. Indeed, data on the validity of this technique are conflicting and show that doubles the risk of postpartum fever (27). Medical interventions do not reduce the risk of birth of children with growth retardation. Often the bed rest is useless and even harmful.
From the point of view of the expecting mother, the first question should be: What can the doctor do for me and my baby if I know I'm pregnant and feel like the baby is growing? . The doctor must respond with humility No too much, too little, apart from detecting a large anomaly and provide abortion. COUNCIL BOOST
Preconception
While we have data indicating how medical care in pregnancy represent a vast waste of time and money, we feel urgency to focus attention on what can be done before conception. Today it is clear that the prevention of abnormalities such as spina bifida, is effective before conception: Almost everyone has heard about folic acid. In terms of nutrition we emphasize the factors revealed by a comparative study of Danish and our own studies on fish consumption. Large amount of data from a variety of medical disciplines indicates what should be considered a priority for the health of generations not designed: intrauterine pollution by soluble synthetic chemicals accumulated over the years in the adipose tissue. The establishment of a preconceptional program as our accordion method could reduce the overhead of synthetic pollutants body before conceiving a baby (28). It is the same data concerning prospective parents from developing the concept of development toxic male mediation: it is known today that certain diseases or developmental disorders occur more frequently when the man has been exposed to certain contaminants.
The good news is that there is already a part of the population (especially women) who, on the one hand, they know the limits of medicine in pregnancy and on the other hand, they recognize the enormous potential of preconception preparation. Thanks to his motivation and generosity, Primal Research Center is now able to conduct a long-term study to answer a simple question: What is the effectiveness of the method accordion?
THE FUTURE How
time will develop an interest in health generations are not designed?. If we had the answer to this question could anticipate how long it will be necessary to balance the important relationship between preconception counseling and prenatal care. Recent studies indicate the extent of our responsibility for the health of future generations. Some researchers have collected data on food available during a certain period of poverty in Sweden (1890), compared with the more opulent times (1905, 1920). The conclusion is that the risk of dying from diabetes is significantly higher if the paternal grandfather was exposed to excessive eating during childhood (29). We do not want to conclude by saying
there is no absolute need for medical visits during pregnancy: we can not make a comprehensive list of all the reasons why a woman may need consultation or assistance of a qualified health professional before giving birth. It is the word routine which should be discarded. It is easy to explain why current practices are a waste of time and money is even easier to explain why they are potentially dangerous. It is dangerous to misinterpret the results of a routine test and tell a healthy pregnant woman who is anemic and need iron supplements. It is dangerous to make a decision rather high voltage isolation, as bad news. It is dangerous to say to a pregnant woman who has gestational diabetes .
Generally, this is the style used in prenatal care, which constantly focuses on potential problems with a strong nocebo effect (30,31,32).
The decline of routine prenatal medical care should be followed by the rediscovery of the basic needs of the pregnant woman. I remember with pleasure the happy atmosphere that accumulated during the evening by singing the Pithiviers Maternity Hospital in France. These sessions and cato probably had more positive effects on developing babies in the womb that the series of scans. Pregnant women need to socialize and share experiences. It's easy to create chances for it, swimming, practice yoga, prenatal workouts, ... Let us dream about the potential for future parents restaurants! Michel Odent
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