Doctor Who?

In many Twin Cities clinics, continuity of prenatal care is a thing of the past.

When Bridget Malisow realized she was pregnant last spring, she called an Edina obstetrician recommended by a friend. Bridget liked the idea of seeing this highly regarded surgeon for her first pregnancy. "I felt comfortable that if something went wrong during the delivery, she would be right there and could handle everything," Bridget says.

At Bridget's first prenatal visit, though, her new doctor said she could not guarantee her own presence for the delivery and explained that another doctor may be present instead. As it turned out, when Bridget went into labor, her doctor was not on call and did not attend the birth.

But by that time, Bridget didn't much care if her doctor was there or not. "Out of about twelve prenatal visits, I saw my doctor for maybe four of them," she says. "Sometimes she was at the hospital delivering a baby. Other times her schedule was too full and I couldn't get in with her. Other times she was out for health reasons." Over the course of her pregnancy, Bridget saw three different physicians and one nurse practitioner.

The doctor-roulette continued when she arrived at Fairview Southdale Hospital to deliver. Three physicians "popped in and out" during her sixteen-hour labor, none of whom she had met before. The third doctor was in the room for about forty-five minutes before Bridget's daughter was born.

Certainly, this scenario bears no resemblance to the cherished image of the concerned, kindly doctor assisting a woman through pregnancy, childbirth, and postnatal care. Many first-time mothers who expect to form a trusting relationship with a medical professional who will share their childbirth experience are disappointed to find that, in many Twin Cities clinics, continuity of care is a thing of the past.

While mother-newborn bonding is a hot topic, little is heard these days about mother-caregiver bonding. How important to pregnant women is continuity of health-care provider during prenatal care? Does a mother care whether she knows the person who delivers her baby? Are medical outcomes affected when strangers deliver strangers?

Continuity of prenatal care

The first pregnancy can be overwhelming for many women. Full of doubts and questions about her own and her baby's health, a mother-to-be needs consistent answers and a good deal of reassurance. One 1995 study found that pregnant women find continuity of provider, clear explanations, and accessibility of care important in prenatal care, with the provider relationship having the greatest influence on their satisfaction.

Nationally, most childbirths are handled by physicians; about five percent are supervised by certified nurse midwives (CNMs). Physician and nurse-midwife groups in the Twin Cities have distinct styles and policies regarding continuity of prenatal and maternity care.

Many local physicians try to adhere to the traditional model of seeing a woman consistently for all nine to fourteen of her prenatal visits. The nine OB-GYNs who practice at HealthEast's clinics in Shoreview and Woodbury, for example, make every effort to see their own patients. At the HealthPartners clinics, a pregnant woman can expect to see her chosen doctor alternating with a nurse midwife, who will perform the more educational aspects of prenatal care. At Hennepin County Medical Center's (HCMC) resident continuity clinics, a pregnant patient is scheduled to be seen by the same resident for each visit.

At other metro-area clinics, seeing the same doctor prenatally is possible but the patient has to bend her schedule to fit her doctor's. When Bridget was in her seventh month of pregnancy, her clinic suggested that she schedule her prenatal visits far in advance to help in getting appointments with her own doctor. "I wish I had known that earlier," Bridget says.

In a recent study conducted at the University of Exeter in the United Kingdom, virtually all of the 116 women surveyed wanted to be cared for throughout their pregnancy by one practitioner whom they knew well. But some women have priorities other than continuity of care, like getting an appointment at a particular time or scheduling their visits when an interpreter will be present, says Virginia Lupo, M.D., director of maternal-fetal medicine at HCMC. "The overriding concern is what is most convenient for the patient at the time," she says. "With a second pregnancy, for example, you're living with a toddler and there's just no time to think about being pregnant. You get in there for those prenatal visits and get out. You're not going to let a doctor's schedule run your life."

The stranger in the delivery room

While some physicians promise continuity during prenatal care, rare is the doctor who assures a woman that he will attend her delivery. Virtually every Twin Cities hospital has a call group of ten to thirty obstetricians, and whoever happens to be on call when a woman shows up in labor will attend the birth. The reason, of course, is that if physicians promised to attend all their patients' births, they would be on call twenty-four hours a day, 365 days a year. And the smaller the call group, the more time each doctor spends on call.

"There are a lot fewer physicians in this world [than before] who are willing to make their time totally available to their patients many nights a week," Dr. Lupo says. "It's an unlivable lifestyle. You can't have a carte blanche on your life every other night when you have a family and kids. More and more women and men in medicine are finding their voice and saying, 'No, I'm not going to work ninety hours a week after residency.'"

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