Bulletin - The measure of excellence : Canadian early childhood ...

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SPECIAL FEATURE ON RESEARCH: PRENATAL CARESTUDY QUESTIONS CURRENT MODEL OF PRENATAL CAREPrenatal care is one of the mostcommon and least scrutinizedforms of medical care. In standardpractice, pregnant women are toldto visit a health care provider oncea month during the first six monthsof their pregnancy, then every twoto three weeks for a period of twomonths and once a week during themonth before their delivery date.This model has been in place forages, but until now it had not beenscientifically evaluated.But recently, the World HealthOrganization (WHO) tested a newmonitoring model for prenatal carethat involved fewer, less frequent visitsto health care providers. Conducted inclinics across Argentina, Cuba, SaudiArabia and Thailand, the WHO programmodel focused on three key elements:a) screening for health conditions likelyto cause problems during pregnancy,birth or the immediate postpartumperiod; b) interventions shown toimprove pregnancy outcomes such asproviding iron and folate supplements;and c) information on handling andresponding to emergency situations.Over a two-year period, 24,678 womenwere enrolled in the study. Forthose who followed the new monitoringmodel, the median number of visits tohealth care providers was five comparedwith eight for the current, standardmodel. When researchers examined theincidence of low birthweight, severepostpartum anemia and urinary trackinfections, they found no significant differencesbetween the two groups. Thewomen enrolled in the new programhad marginally (but non-significantly)higher rates of pre-eclampsia andeclampsia, even though the new modelgroup received better quality, more frequentdetection tests (including urineprotein tests at each visit), while womenin the standard program were generallytested only during their first visit or ifthey showed signs of suffering from highblood pressure.Women and health care providers inboth groups were very satisfied with thecare provided. In some clinics, the newmodel reduced the cost of providingprenatal care.However,some women inthe new model group expressed concernabout the infrequency of visits.Sharon Dore, an AdvancedPractice Nurse in Women's Health atHamilton Health Sciences and aSection Chair for the Association ofWomen's Health, Obstetric andNeonatal Nurses (AWHONN), praisesthe study for breaking importantnew ground. "We're socialized to thestandard practice, and in this studythe researchers are rightly trying toassess what we've been doing on arote basis." While commending thestudy's methodology and scope,Dore notes, "They didn't stratify forwomen having their first baby andwomen having a second or subsequentbaby. That information isimportant," she adds, "as multiparouswomen (who give birth more thanonce) often feel more comfortablewith the pregnancy process and maybe satisfied with fewer visits withhealth practitioners."Dore says that the study also pointsto the need for further work with pregnantwomen to identify why they seemto prefer more frequent visits. "Whatwas it that women needed that madethem feel the gap between visits wastoo long? Did they want the reassuranceof the fetal heart rate? Did theyneed other information? What kind ofinformation?" Dore noted that practitionersare asked to provide pregnantwomen with physical assessments aswell as education, support and anticipatoryplanning (dealing with issuessuch as pain relief in labour and breastfeeding,for example). She suggestedthat researchers begin to evaluatewhether information and supportmight be available from other sourcessuch as family or community resources.Ref.: J. Villar et al. "WHO AntenatalCare Randomized Trial for theEvaluation of a New Model of RoutineAntenatal Care." The Lancet. Vol. 58.April 2001.PAGE 4 - BULLETIN OF THE CENTRE OF EXCELLENCE FOR EARLY CHILDHOOD DEVELOPMENT VOLUME 1, N O 3 - DECEMBER 2002
SPECIAL FEATURE ON RESEARCH: BIRTHDOES LOW BIRTHWEIGHT INCREASETHE RISK OF DEVELOPING CORONARY HEART DISEASE?A fetus with restricted growth willweigh less at birth and may potentiallyface a daunting array ofhealth and developmentalproblems. In the past decades,researchers thought that low birthweightincreased the risk ofdeveloping coronary heart diseaselater in life. However, as a team ofSwedish and Canadian researchersnoted in an article published in TheLancet, these results may have beeninfluenced by factors such asgenetics and early environment.Using data drawn from the SwedishTwin Registry, which includes informationon twins born in Swedenbetween 1886 and 1958, the researchteam undertook a case-control studyto investigate the association betweenbirth characteristics (birth weight,birth length and head circumference)and acute myocardial infarction (AMI).The researchers selected 132 samesexedco-twin pairs in which one twinhad suffered from AMI while the otherhad not. AMI subjects were also comparedwith 118 individually matchedexternal twins (the researchers wereunable to match external twins for all132 AMI subjects).When twin subjects were comparedwith unrelated control twins,lowbirthweight, birth length and head circumferencewere associated with anincrease in AMI,a result consistent withprevious studies. However, when thesesubjects were compared with theirhealthy co-twins on the above-mentionedbirth characteristics, nodifferences were found. The study'sresearchers concluded that, althoughthere is an association between lowbirthweight and AMI, "our findings donot support a direct effect betweenfetal growth and AMI. The result suggeststhat genetic, maternal and environmentalfactors during childhoodand adolescence associated with fetalgrowth may have influenced thepreviously reported associationsbetween birthweight and AMI."John LeBlanc, Assistant Professor ofPediatrics, Psychiatry, CommunityHealth and Epidemiology at DalhousieUniversity called the study, "very wellconstructed" and praised the two-partstructure whereby researchers usedboth related twins and co-twins ascontrols. "The main finding is in thestudy's second part, where twins withAMI were compared with their healthytwin partners. If there is a risk factor forAMI in the early uterine environment,itis something that appears to be independentof restricted birthweight andmust somehow affect one twin only."LeBlanc added that understanding therole of intrauterine growth in terms of aperson's overall lifetime health has animpact on health programs and policies."This kind of research helps sortout where to put our priorities in termsof prevention programs," he said.More research in this area is critical,added Robin Walker, Professor ofPediatrics at the University of Ottawaand Chief of Neonatology at theChildren's Hospital of Eastern Ontario."This is a very preliminary finding. Youneed more studies and you need largersample numbers," he said.However, doing this research is essential,Walkernoted: "Fetal health, geneticsas well as the child and adolescentenvironment may all be profoundlyaffecting adult health. We need toknow more about these factors."Ref.:A.Hübinette,S.Cnattingius,A.Ekbom, P. Lichtenstein, U. de Faire andM. S. Kramer. "Birthweight, EarlyEnvironment, and Genetics: A Studyof Twins Discordant for AcuteMyocardial Infarction." The Lancet.Vol. 357. June 2001.VOLUME 1, N O 3 - DECEMBER 2002 BULLETIN OF THE CENTRE OF EXCELLENCE FOR EARLY CHILDHOOD DEVELOPMENT - PAGE 5
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