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Preconception and Women’s Healthcare: An Interview with Dr. Michael Lu (Part Two)

[Editor's note:  This is part two of an interview series between Science & Sensibility's Walker Karraa and OBGYN/researcher, Dr. Michael Lu.  To read this interview from the beginning, go here.For a list of resources pertaining to this interview series, go here: resources and bibliography_dr lu interview series. ]

Working Smarter: Preconception Care, Part II

 

Walker Karraa: You encourage your colleagues to follow the “every woman, every time” philosophy–to use every visit as an opportunity for pre-conception or inter-conception counseling.  Given the current system of medical care, how can a care provider manage to do preconception counseling, and get reimbursed?

 

Dr. Lu: I’ll give you a short answer and then maybe later on I’ll give the broader vision.  The short answer is that everything I read and learn from quality and systems improvement over the last several decades indicates that it’s not just about making individual doctors work harder, it’s really about making the systems work smarter. We’re always asking the OB to do this and do that–often they’re not trained for it.  They don’t necessarily have the time for it.  And they’re not reimbursed for it.

OBs should have an obligation to try to do their best in terms of promoting women’s health, but I think there’s a need to really rethink how we might redesign prenatal care, or how we might redesign women’s health care in general, so that the center of the universe doesn’t revolve around the OB office–which I think is presently poorly equipped to address the totality of the continuum of women’s health across the life course.

Currently the 1.0 system is that you get the OB in either a solo, or small group practice, who is supported by the office clerks, maybe a nurse manager who doubles as a health educator, and maybe an ultrasound tech.

All of the things we’ve been learning about the fetal origins of health –the importance of nutrition, mental health, environmental exposures in developmental and fetal programming, how much of that counseling do you think is actually going on in OB’s office?  And remember most of these OB’s didn’t sign up to be a health educator, to be a nutritional counselor, to be a teratogen information specialist, to do all the things that we know are important in terms of really promoting maternal and infant health.

The public health response over the last couple of decades has been if the OB’s aren’t doing all those things, then let’s create these “wrap-around services”– some kind of the enhanced prenatal care model: I call it the prenatal care 2.0 system.

Ideally it should work better than the 1.0 system, but we all know that there are a lot of holes, a lot of gaps:  If the providers don’t make the referrals, for example. There’s nothing more frustrating to me when I screen somebody positive for peripartum depression and there’s no one on the other end of the referral, or when we screen someone for intimate peripartum violence and there’s no infrastructure at all to help them.  And so the 2.0 system just doesn’t work very well either.

 

OB is not the center of the universe

Dr. Lu cont’d: Many of my colleagues around the country and I have been talking about the need to redesign prenatal care, to move it from the 1.0 or 2.0 system to the 3.0 system where the center of the universe is no longer the OB’s office.  It could be a medical home or better yet kind of a wellness home for women’s health– and let’s make sure all the things that need to get done, actually get done in that home.

For OBs who don’t want to run a medical home, they can be the specialists.  They can run an ultrasound center.  They can be a hospitalist and just do deliveries.  Let them do what they actually enjoy doing.  Don’t ask them to pretend to be a nutritional counselor or health educator –which they never really signed up to do.

We now know health education is critically important.  We know that nutritional counseling is critically important.  We know some component of mental health and social support, etc. is very important.  We know that environmental influences, both looking at the physical and social environment, also play a big role.  Let’s make sure that we actually have a system of supporting this, including reimbursement systems and so forth and actually support this more integrative, more comprehensive system of health care.  This doesn’t have to be just a medical home for prenatal care because now you can have preconception, inter-conception care, family planning, all the things that we know that make that continuum of women’s health care over the life course.  All of that can be happening in this medical home.

 

Walker Karraa: Where do you see childbirth education in the model?

 

Dr. Lu: I think certainly childbirth education needs to be an integral part of that model and that the review and the birth plan–discussing, creating the birthing plan would be important.  Many OBs maybe take 5-10 minutes to sit down with the women and go over some of the components about the birth plan.  They might take some time to explain what an episiotomy is, the risk and benefits and alternatives to analgesic use during labor, and they might talk about the different modes of delivery, the vaginal, versus instrumental, versus caesarean.  But that’s about it.  They may address some questions that the couple has, but I don’t think it usually goes any further than that.

And that’s what I’m saying in terms of we can’t just ask the OBs to work harder.  We’re training our OB residents about the importance of nutrition and mental health, etc. and we can ask them to screen for more and more…and I think we should do that; but on the other hand, the system just doesn’t work very well.  When they’re thrown into a private practice setting, or when they’re thrown into a clinic where they’re seeing two OB patients every fifteen minutes–it just doesn’t happen.

 

So we’ve got to work a lot smarter than that.

 

[Editor's note:  In tomorrow's installment of this interview series, you will read Dr. Lu's thoughts on how childbirth educators can expand their curricula to include inter-conception information, as well as what our culture can do to better support fathers.]

Preconception Care, Research, Series: Preconception Care, Uncategorized , , , ,

  1. avatar
    Emily
    July 17th, 2011 at 06:23 | #1

    Why are they seeing 2 OB patients every 15 minutes? Anyone who sees clients should know you can’t explain anything moderately complex in 15 minutes.

  2. avatar
    Walker Karraa, MFA, MA, CD
    July 19th, 2011 at 09:34 | #2

    Emily,
    Exactly! Thank you for the comment. Dr. Lu points out that the limited amount of time for an OB with patient is caused by the system we have in place, not by the individual OB–and that isn’t what the OB signed up for. The vision and implementation of the medical home, or wellness home model (3.0) addresses the system, and is an invitation for other care providers, like childbirth educators, or doulas, to have a place in the system, in the medical home. Tomorrow he addresses some of the things Lamaze, and all childbirth professionals, can do to expand our own work in this way for the benefit of healthy women, children, families, and society as a whole.

  3. avatar
    Katharine Hikel, MD
    July 19th, 2011 at 13:45 | #3

    This is so bad it isn’t even wrong.

    Here’s a wonderful, awful example of women’s health care from a perspective that is institution-centered, not patient-centered, and – dare I say it in 2011 – completely patriarchal. I, for one, am utterly exhausted by men going on & on about what they think about women’s health; the time is long past for this fully and permanently to stop. Shame on Lamaze for colluding in this ongoing travesty.

  4. avatar
    Anton
    July 19th, 2011 at 15:30 | #4

    @Katharine Hikel, MD
    Dr. Hikel, It seems to me that a response like this is neither well thought out, nor helpful in promoting a positive dialog on women’s health care. You point out nothing specific in your comment that warrants the label of “completely patriarchal”. In fact, it seems more as if you had a predetermined opinion about the information presented based only on the gender of its origination. A good idea is a good idea. If we deem an idea bad based solely on the aforementioned criterion, and prevent a potentially helpful idea from reaching fruition, then upon whom shall the shame be heaped?

  5. avatar
    Walker Karraa, MFA, MA, CD
    July 19th, 2011 at 16:41 | #5

    “So we’ve got to work a lot smarter than that.”

  6. avatar
    Katharine Hikel, MD
    July 19th, 2011 at 17:31 | #6

    @Walker Karraa, MFA, MA, CD
    Preconception care may be a good idea; but having the boys of ACOG run it most assuredly is not. Anyone who can posit a birth scenario where ‘the hospitalist’ shows up for ‘the delivery’ has clearly not been paying attention to what’s been happening in best evidence & best outcomes. One bit of glaring evidence is that not once in Dr. Lu’s discussion has he mentioned the word ‘midwife’. Nor did he once mention seeking or receiving – nor did he cite – any input from the very women he is seeking to push this new ACOG program onto. A thorough exploration of the ACOG web site is enlightening research on the context of the problem of men governing women’s health. (Pay special attention to the gender balance of ACOG’s regional directors.) Yes it is a problem, because these guys’ concerns and priorities are not, and never will be, ours; and if that is sexist, or biased, it also happens to be true, as a review of ACOG statements, legislative activities, and publications – particularly with regard to women’s choices in birth – will tell you.

  7. July 20th, 2011 at 10:08 | #7

    I, too, would like to point out that midwives are specialists in the antenatal, intrapartum, and postpartum care of healthy childbearing women. They are logical candidates for providing preconception health advice as well, and many also provide wholistic well-woman gyne care. It is surprising that Dr. Lu could understand so well the systemic problems in the provision of maternity care without seeing that the obvious solution is to make midwives the primary providers of women’s reproductive health especially when those problems largely derive from putting surgical specialists in the pathology of women’s reproductive organs in charge of it.

  8. avatar
    Walker Karraa, MFA, MA, CD
    July 20th, 2011 at 10:48 | #8

    Dr. Lu works extensively with midwives (UCLA has a full staff of them) and has throughout his lifetime of dedication to women’s health. This was part II of a five part interview, and I encourage you to read the entirety of his thoughts, and familiarize yourselves with a little of the body of his work, some of which is listed in the consolidated bibliography provided in the introduction. He has published over 200 articles, including advocating for doulas, midwives, etc. And researched areas many of us have not yet gone, for example, racism, homelessness, etc. As a matter of fact, one of his early studies, if you look, is about childbirth education and disparity of attendance.

    He agreed to take two hours and sit down in person with me…a doula, and representative of S&S. That should speak to his understanding of the import of all maternal care providers. Looking for one word you don’t find and then judging a person’s career, intention, and motive, is a surprising and disappointing demonstration of how we often fail to read the 800 words, and actually digest their meaning.

    While the 15 pages of transcribed interview could not be offered in this venue, the material for these interviews shares that there is no doubt–to everyone more familiar with more complex systems approaches, and public health, that the concept is inclusive of every care provider.

    And as a die hard feminist myself, I learned from hearing Dr. Lu speak, reading his book, 15 of his articles, and speaking with him personally that this man has dedicated his life to the welfare of women, and I could learn a great deal from setting aside the usual knee jerk reactions that limit my ability to rethink old paradigms no longer serving women (of all color, class, and socioeconomic status).

    I would also like to remind everyone that the Secretary of Health and Human Resources, who appointed Dr Lu the chair of the committee on infant mortality—is a woman…Kathleen Sebelius.

  9. avatar
    Nicole B
    July 20th, 2011 at 11:33 | #9

    I find it fascinating that the Care 3.0 model looks almost exactly like what we have here in Canada – with a Family Physician or midwife in the middle, where Dr. Lu has put “medical home”. The model he describes seems to me to look precisely like what family medicine has always been about – the generalist who serves as the link to all the other specialist services as needed.

  10. avatar
    Walker Karraa, MFA, MA, CD
    July 20th, 2011 at 11:52 | #10

    Hi Nicole,
    I was wondering if the model in Canada follows a life course model as well? The idea that a woman’s health over the life span, rather than a disconnected set of reproductive events (birth, menarche, childbirth, menopause, etc.). The other thing that Canada demonstrates is a dedication, and core belief, that all care providers should be compensated, and specialize in what they do best–rather than one individual doctor trying to be a nutritional counselor, screen for mental health, screen for IDV, etc.

    I wonder do you think the childbirth education and doula orgnizations in Canada are more open to expanding their work to preconception counseling? Here is a citation for more systems reform in perinatal health care in America:

    Lu MC. (2010). We can do better: improving perinatal health in America. J Womens Health (Larchmt).19(3):569-74.@Nicole B

  11. avatar
    Nicole B
    July 21st, 2011 at 17:09 | #11

    Hi Walker,
    I would say yes, I think family physicians are following a “life course model” – in that the idea is to be the primary care giver for someone over the course of their life. Now, I may be challenged on that in how the model works in the big cities, as life in general in large urban areas is so disconnected. I am basing my comments on my life, which was growing up in a small town, where my dad was the town doctor… so I probably see it as being more connected than some might.
    To your second questions – do i think childbirth education and doula organizations are more open to including preconception work? Not sure about organizations, as we tend to simply import American ones (I trained with Lamaze and ICEA) however – in my job, as a childbirth educator for our health region (3 hospitals in a big city) we offer a preconception class, that I teach…

  1. October 22nd, 2011 at 17:17 | #1