Neglected Research and the Administration of Tdap During Pregnancy

 

On October 24 of last year (2012), the ACIP voted 14 to 1 in the recommendation of administering a pertussis booster (Adacel or Boostrix) during every pregnancy regardless of vaccination history, preferably after 20 weeks gestation.[*][*][*]
 
This over ruled the earlier suggestion of the administration of just one booster during the first pregnancy because antibody levels were found to wane substantially during the first year after vaccination. Hence, leading the ACIP to conclude a single dose of Tdap at one pregnancy would be insufficient to provide protection for subsequent pregnancies.[*]
 
In the post below, I will provide published literature as to why this particular approach is not well-founded on actual science or research. I will also provide some information on the relevant risks of pertussis during infancy, the safety concerns of administering Tdap during pregnancy and the modification of pertussis epidemiology due to the current vaccination program.
 
 
Problematic Ambitions in Administering Tdap During Pregnancy
 
The underlining goal in this particular vaccination strategy (according to the CDC) is twofold:[*]
 
Mainly (1) “reduce the burden of pertussis in infants by providing some protection until they are old enough to be vaccinated themselves” [*]
 
Secondly (2) “protect the mother from pertussis around the time of delivery, making her less likely to become infected and transmit pertussis to her infant.” [*]
 
Let us address these individually with published data…
 
 
Reducing the burden of pertussis in infants
 
The goal of reducing pertussis infection within the infant population via vaccination is ambitious and nothing new (Clinical Infectious Diseases 1990).[*][*][*] 
 
Decades of research examining newborn vaccination against pertussis has been amassed; none of which has been enough to implement a national recommendation from the ACIP…until now, with a twist.
 
The CDC now feels strongly that this particular new approach, vaccinating women late term during pregnancy, will provide the protection they are hoping for.
 
Unfortunately, relying on transplacental antibodies to provide protection against pertussis in infants is not based on published evidence.
 
In fact, the very board that recommended Tdap during pregnancy (ACIP) states the effectiveness of maternal anti-pertussis antibodies in preventing infant pertussis is not yet known (ACIP 2011, CDC 2011).[*][*]
 
This is one of two major concerns the ACIP voiced, acknowledging the complete “lack of evidence evaluating that transplacental maternal antibodies induced by Tdap in the protection of infants against pertussis” (Journal of Perinatology 2010).[*]
 
Even if data reflects an increase in infant antibodies to pertussis via maternal vaccination, because there is currently no correlate of protection in pertussis infection, it is uncertain whether this increase could be considered clinically protective (The Pediatric Infectious Disease Journal 2011).[*]
 
This is significant since the transfer of antibodies against pertussis to the offspring is influenced by various factors and determining a benchmark for correlation would aid in establishing if any protection is conferred. (Current known factors that influence transplacental antibodies: the age of women at delivery, mothers’ vaccination history, mothers’ immune response and ability to generate IgG immunoglobulins).[*- Tdap in risk groups 2012]
 
In fact, it is becoming more evident that the (aP) pertussis vaccines do not yield any correlation between antibody levels and protection against pertussis.[* source 17]
 
Currently, I am aware of two completed published studies (as mentioned by the CDC in 2011) providing data that evaluates antibody levels in newborns whose mothers received tdap during pregnancy, neither produce confirmation of protection against infection.[*][*][*]
 
What is certain is the evident “need for larger studies with longer follow-up to help understand the immunologic responses in pregnant women and the consequences on neonatal immunity” (Clinical Infectious Diseases 2013).[*]
 
 
Interference with Infant Immune Response to Primary DTaP Vaccination
(also known as blunting)
 
Data to consider, several studies have suggested that maternal pertussis antibodies can inhibit active pertussis-specific antibody production after administration of DTaP vaccine to infants of mothers vaccinated with Tdap during pregnancy, referred to as blunting (CDC 2011).[*] 
 
In fact, the ACIP states that this phenomenon known as blunting could result in an increase in pertussis susceptibility to children under 12 months (Journal of Perinatology 2010).[*] 
 
The ACIP assumes that maternal pertussis antibodies might reduce an infant's risk for  infection in the first few months of life, but neglects to apply actual data illustrating an increase in risk for disease after receipt of primary DTaP doses (CDC 2011).[*]
 
Instead, the ACIP applies data used in naturally acquired maternal pertussis-specific antibodies, stating that one study completed shows little or no interference between naturally acquired transplacental antibodies and the DTaP series (Clinical Infectious Diseases 2012).[*] 
 
No published literature is available yet for review examining vaccine-induced transplacental antibodies.
 
Based on data that has been completed, blunting does occur, we just don’t know to what degree and what the effects may be.
 
The theorized benefit of vaccinating pregnant mothers is a decline in risk for disease and death in infants aged <3 months, but the trade-off is a potential increase in the occurrence of pertussis in older infants (CDC 2011).[*]
 
According to the ACIP, the potential benefit of protection from maternal antibodies in newborns outweigh the potential risk for shifting disease burden to later in infancy (CDC 2011, The Pediatric Infectious Disease Journal 2011).[*][*]
 
Worth noting, two clinical trials are currently underway (one in Canada, the other in the USA) to evaluate the assess the immune response of infants receiving DTaP immunization at ages 2, 4, and 6 months whose mothers received Tdap during the third trimester of pregnancy (Vaccine 2012).[*][*- Tdap in risk groups 2012]
 
It is unfortunate (and, in my opinion, inappropriate) that this data was not completed prior to recommendation .
 
 
Evidence for Safety
 
Although in prelicensure evaluations, the safety of administering a booster dose of Tdap to pregnant women was not studied. The ACIP Pertussis Vaccines Work Group declares safety and expresses it as well established (CDC 2011).[*]
 

What does ‘well established’ mean exactly….

 
The data that is used to established safety which resulted in the ACIP’s recommendation was collected from:

Vaccine Adverse Event Reporting System (VAERS)

Sanofi Pasteur pregnancy registry

GlaxoSmithKline pregnancy registry

 

 
The ACIP asserts that no data collected suggests any elevated frequency or unusual patterns of adverse events in pregnant women who received Tdap (CDC 2011, Can Fam Physician. 2013).[*][*]
 
It is worth noting, all three are passive surveillance programs which have several limitations which include: unverified reports, underreporting, inconsistent data quality and absence of an unvaccinated control group (Drug Safety 2008).[*] 
 
 
Data Evaluated From VAERS:
 

-Only 130 reports met safety research criteria (AJOG 2012).   [*] 

 

-The data was collected before Tdap was routinely recommended in pregnancy (AJOG 2012). [*]

 

-Only 3% of women were administered the vaccine in the recommended third trimester (77% in the first trimester, 19% second trimester, 3% third trimester) (AJOG 2012). [*] 

 

The most frequent pregnancy-specific adverse event was spontaneous abortion occurring in 16% of reports (AJOG 2012). [*] 

 
 
GlaxoSmithKline Registry:

From GSK pregnancy registry: “The safety of Boostrix (tdap) during pregnancy has not been established, and no adequate human studies have been performed. [*]

“None of these products, except RETROVIR® (zidovudine, AZT) after the first trimester, is approved for use during pregnancy.”[*] 

 
 
Sanofi Pasteur Registry:
 

From the Sanofi Pasteur pregnancy registry: “This is a company-run, passive, pregnancy surveillance system designed to collect and analyze the outcome of vaccination.” [*]

“There are no adequate and well-controlled studies of Adacel in pregnant women and data are limited. Sanofi Pasteur does not recommend the use of Adacel vaccine in any manner other than that described in the package insert.”[*][*][*]

 
 
From a safety perspective, ACIP adds that administration of Tdap after 20 weeks' gestation is preferred in the hope to minimize the risk for any low-frequency adverse event and the possibility that any spurious association might appear causative.[*]
 
 
Risk of pertussis infection

In all honesty, when it comes down to it – expecting mothers are going to make the decision to get the Tdap booster if the perceived benefits outweigh any risk.
 
One could read 30 peer reviewed publication arguing for (and against) Tdap during pregnancy, but it always comes down to perceived risk.
 
To estimate risk and the potential impact of Tdap administered during pregnancy, let us evaluate the data and statistics from 2010-2011.
 
Using the National Notifiable Diseases Surveillance System during 2000–2011, the annual mean of pertussis cases in infants aged <12 months was 2,746 cases - with deaths equaling to 18.[*]
 
Using the 2010 birth rate (4,007,000 live births) and this data, we can determine the following risk assessment for 2010:[*]

Without Vaccination:

Risk pertussis infection under 12 months = 0.007%

Risk of death = 0.000004%

 

With Vaccination:

Risk of pertussis infection under 12 months = 0.005%

Risk of death = 0.000002%

 
 
Not to make light of pertussis infection, but more people died of being struck by lightning (count = 29)  then babies dying of pertussis infection in 2010.[*]
 
Yet, I’m pretty sure mothers perceive the risk of pertussis as more glaring then being struck by lightning.
 

Changing epidemiology due to vaccination and the increased risk to infants
 
 
Everyone is quick to  proclaim the benefits of herd immunity when vaccinating, yet not so many are so swift as to declare its faults (such as protecting some while placing others at greater risk).
 
The implementation of a vaccine against pertussis infection, with decreasing natural boosting,  has changed the epidemiology of infection to the disease.[*]
 
The resurgence of pertussis in the post-vaccination era has been widely documented. In fact, it is the chief reason for the ACIP recommendation in vaccinating pregnant mothers. 

The overall incidence of pertussis has been increasing steadily
 since 2007 and has now surpassed peak rates observed
 during 2004-2005. source

Yet, a shift of cases from school-age children to adolescents, adults and children under 1 year of age has been described in the last decade. As a consequence, pertussis circulating in these new populations is considered  being the source of infection for infants and newborns (The Pediatric Infectious Disease Journal 2011, BMC Infectious Diseases 2013). [*][*]
 
One study that examined the increase of pertussis in California between 2006 and 2011, demonstrated decaying protection against pertussis during 5 years after a child’s fifth dose of the Tdap booster. The authors state this waning might be one of the causes of reported increased infection in adolescents which increases the risk of transmission to infants (Can Fam Physician 2013).[*]

source here - CDC

 
The solution for a severely limited booster vaccine? Cocooning.
 
Unfortunately, this strategy of cocooning (vaccinating pregnant women immediately postpartum and all other close contacts of infants with Tdap) to reduce the risk for transmission of pertussis to infants is an insufficient strategy (CDC 2011).[*]
 
The ACIP recognizes this as well as the CDC(CDC 2011).[*]
 
The solution for this latest failing strategy and inadequate vaccine? Simply, vaccinate during pregnancy. 

 

Which to choose

 
If you still regard the risk of pertussis infection to outweigh any known and unknown risks of vaccinating during pregnancy, then consider this: Please request the Adacel vaccine.
 
The Adacel vaccine contains antigens that intend to elicit antibodies against fimbriae (types 2 and 3) which play a critical role in the attachment of the bacteria to the respiratory cells (which would, in theory, make a mother less likely to transmit the disease to her child).[*][*][*]
 
Boostrix contains mainly antigens that intend to modify and lessen symptoms of disease, which would make a mother more likely to become an asymptomatic carrier of the disease, which places her child more at risk.[* sources 3-8]
 
Information on Tdap boosters:

Boostrix contains: pertussis antigens (inactivated pertussis toxin [PT] 361 and formaldehyde-treated filamentous hemagglutinin [FHA] and pertactin). also  - contains aluminum hydroxide as adjuvant (not more than 0.39 mg aluminum by assay), 4.5 mg of sodium chloride, ≤100 mcg of residual formaldehyde, and 387 ≤100 mcg of polysorbate 80 (Tween 80).

 

Adacel contains: 2.5 mcg detoxified pertussis toxin (PT), 5 mcg filamentous hemagglutinin  (FHA), 3 mcg pertactin (PRN), 5 mcg fimbriae types 2 and 3 (FIM). Also dose includes 1.5 mg aluminum phosphate (0.33 mg aluminum) as the adjuvant, ≤5 mcg residual formaldehyde.

 
 
I would also encourage you to read more about pertussis infection here: CDC Pinkbook Pertussis.

Similar posts:
 
The Perfect Storm - How the increase in pertussis vaccine usage is causing an 'epidemic'

5 Prenatal Practices Low-Risk Moms Should Reconsider

I’d like to start out by stating two important points: (1) this is absolutely not a complete dismissal of the following prenatal treatment in women (2) nor is this a blanket condemnation of the women who choose to elect them during their prenatal care.

Only you and your practitioner can decide what is right for your care in your pregnancy.

Below is my interpretation based on my experience and data I’ve gathered up until this point – of which, I apply to low-risk situations. I encourage all women to learn more about the influence of their role in prenatal care and the effectiveness of such prenatal care in the United States (start by checking this gem out).

Cervical Checks in Late Pregnancy

There is a myth that seems to have been perpetuated in most medical schools in the US: that vaginal exams at the end of a pregnancy (36+ weeks) are beneficial. 

Yes, vaginal exams can help measure certain things - such as dilation, ripeness, effacement, and station...however, these are NOT good predictors of when labor will start.

You may already know that cervical exams don't provide reliable information for when to expect labor to begin – and to that, you might say "So what, it is nice to know how I am dilating”.

If this is case - you may be surprised to find that there are valid reasons to NOT have a routine vaginal exam: increase risk of infection (pushing bacteria found in the vagina upwards toward the cervix) and risk of rupturing the membranes.

It is common during late-term cervical checks that some practitioners routinely sweep the membranes or separate the bag of waters from the cervix to stimulate production of prostaglandins and to 'help' labor begin, however research has not shown this intervention to be effective.

There are, of course, times when cervical checks are helpful - when preterm labor is suspected (unusual bleeding/cramping), uncertain presenting part (unsure if the baby is head down), the need to determine the most effective method for induction (due to medical complications). The results and information gathered from routine vaginal exams prior to 41 weeks have not been found to change the management of pregnancy.[*] 

Gestational Diabetes Screening

Preface: I was NOT initially going to include this here, but the more I read about GD screening/testing/treatment I found it overtly necessary.

…another Preface: I believe there is a basic rule of thumb that should be applied to most screening tests (whether prenatal or otherwise): that no matter what test you are considering, you should ask yourself "what will I do if the results are positive?". If you eat a terrible diet, you don't exercise and you are over weight - then the results of a positive diagnosis for GD would be a powerful catalyst for you to make important changes in your lifestyle which would carry great benefits to your baby and your health - if this is the case, then I definitely would consider a gestational diabetes screening/testing to be of great benefit that may carry improved the outcomes for you and your baby.

Effective medicine that includes diagnosis and treatment of a disease should satisfy 3 criteria:

1. Diagnosis accurately classifies those who have the disease between those who don’t

2. Treatment is effective

3. Benefits of diagnosis outweigh the risks

A Quick Brief on Diagnosis

Prenatal practitioners recommend a blood test known as a glucose challenge test (GCT) between 24-28 weeks of pregnancy (or earlier if considered higher risk-but we are only addressing low risk here in this post).

You are asked to drink a glucose solution called glucola. One hour later, you have blood drawn to measure your blood sugar level.  A level below 130-140 mg/dL is considered ‘normal’, although this widely varies by practitioner.  If your level is higher than the threshold held by your doctor, you take a second test to confirm the diagnosis. 

For the follow-up test, you are required to fast overnight. You then drink another glucola solution with an even higher concentration of glucose. Following that, your level is checked every hour for 3 hours. When both of the readings are higher than ‘normal’ you are then diagnosed with gestational diabetes (GD or GDM).

Is Gestational Diabetes a Disease? 

Is gestational diabetes a disease-a consensus on that has yet to be determined.

All women experience metabolic changes during pregnancy which lowers their tolerance for glucose – for most women (@ 96%) this is a normal physiologic process.

Because glucose intolerance increases naturally during pregnancy, the determination of screening in the 24-28 week gestation is peculiar.  There is no evidence that this is the optimal time to identify women who would benefit from treatment.[*]

There are some pregnant mothers (@4%) that experience “too much” glucose intolerance which becomes the problem we understand to be 'gestational diabetes’. The most significant risk factors are: increasing age, higher BMI and previous GD diagnosis.[*]

I emphasize here the term “too much” because the diagnosis window in which a medical professional determines if a woman has GD or not is not black and white as one might presume.

The false positive rate is over 80%, so you may need to fast then ingest the syrupy solution again during a 3-hour test....just to find out that you are indeed ‘normal’.

It is critical to mention that nearly 1 out of 4 women diagnosed with GD (with the gold standard 100-gram GTT test) would have inconsistent results just one week later if retested!![*]

Out of the expected mothers screened and diagnosed with gestational diabetes, the majority will deliver healthy babies. There are some risks associated in the 4% of women with gestational diabetes such as a higher risk in c-section, pre-eclampsia, jaundice, and premature delivery – however, there is no association between infant deaths and gestational diabetes.[*]

Despite no strong recommendations in favor of universal screening from the American College of Obstetricians and Gynecologists (ACOG), 94% of medical professionals working with pregnant mothers report performing universal screening anyway.[*][*]

The largest benefit of screening is the avoidance of macrosomia (a birth weight of over 9lbs). As a pregnant mother’s glucose level increases over her pregnancy, extra glucose crosses the placenta which prompts the fetus to produce extra insulin – leading to larger babies.

GD diagnosis is a poor predictor of macrosomia. Only babies over the 90^th percentile have been seen to correlate with glucose level and birth weight which characteristically embody those mothers with true diabetes (many of which were not diagnosed until becoming pregnant). Material weight, race, age and number of previous pregnancies are much better factors at calculating the risk of having a large baby.

Despite the lack of evidence for association, most women diagnosed with gestational diabetes will be induced or plan a caesarean section because of the fear of delivering a large baby. [*]

“Despite the increasingly common diagnosis and treatment of Gestational Diabetes, birth outcomes have not improved as a result of these efforts. No more mothers or babies are saved with current treatment of GD than without. Death rates, birth injury rates, and congenital anomaly rates have all remained consistent.”[*]

Let’s recap -

-The timing in which screening is held is completely arbitrary.[*] 

-Screening and diagnosis are not accurate.[*]

-All women experience metabolic changes during pregnancy which lowers their tolerance for glucose which is a normal physiologic process...there is lacking evidence that universal screening decreases risk to low risk babies/mothers[*][*][*][*]

It may be of great benefit to make actions as though the test did come back positive.

Schedule a visit to a Nutritionist/Dietician. Not only will this help with addressing complication of your metabolic changes in pregnancy but it will also help expecting mothers to become more knowledgeable about how to get the best nutrition during pregnancy. Did you know that just by switching 5% of your food intake from red meat to fish/vegetable protein you lower the risk of GD by 51% - That’s amazing![*]

Prenatal Vitamins

The great world of prenatal nutrition and supplement advice…

Believe it or not, it is entirely possible for a woman to obtain everything she needs from her diet to yield a healthy pregnancy. Visiting a nutritionist, in my opinion, should be on top of the prenatal ‘to-do’ list for every mother.

The risk of relying on prenatal vitamins to supplement and provide the daily dose of minerals and vitamins is three fold. 

One: prenatal vitamins do NOT take the place of healthy eating. A mother taking supplements may be more lenient in unhealthy eating choices or, worse yet, completely forego a healthy pregnancy strategy!

Two: Prenatal vitamins do NOT contain protein, fiber or omega-3s (in some cases you end up taking ANOTHER supplement for these as well)…can you name some healthy foods that contain these instead?

Three: Prenatal vitamins do not impart one smidgen of education/understanding of a healthy diet – of which is advantageous to have not only in pregnancy but also when breastfeeding and raising a child.

If a mother can’t afford to consult a nutritionist then there are some benefits in picking up a book and reading about the subject of nutrition – or better yet, you can check out Fit and Healthy Pregnancy Guide (FHP) which, written by a registered dietitian and exercise physiologist, is an online resource for healthy pregnancy options (it even includes prenatal exercises!).

Should a mother forego prenatal vitamins entirely? Of course not – but I would have her consider two points: (1) Please consider nutrition as paramount in a healthy pregnancy (2) consider an organic liquid prenatal vitamin which is more gentle on digestion and more readily absorbed (Rainbow Light and New Chapter have a few options to choose from).

The Flu and Tdap vaccine

I’m going to keep this short and to the point because in all honesty there isn’t too much to say about this one.

In 2010, the ACIP adopted an ‘evidence-based’ process (make you wonder what they were basing their recommendation on before) in making its recommendation to the CDC for whom and when a vaccine is administered…if this was truly the case then neither the influenza nor the Tdap booster should be administered to pregnant mothers. [*]

Influenza

The influenza vaccine is suggested during all trimesters of pregnancy. Yet, there is no confirming evidence in the effectiveness of the administration of this vaccine in pregnancy. In fact, a large (N=49,585) study completed by Kaiser Permanente in collaboration with the Vaccine Safety Datalink Workgroup provided evidence that there is no statistically significant difference in illness rates among those pregnant moms who were vaccinated and those who weren’t (this even factored in women with asthma who are at higher risk for influenza complications).  The assessment of risk/safety of the vaccine during pregnancy is completely absent.[*]

Even at a theoretical level, the safety-benefit of the influenza vaccine in a pregnant population should not tolerate any risk to unborn babies.   

Tdap

Although the US is experiencing the highest rate of vaccination against pertussis containing vaccines then ever before, the CDC states that the reported level of whooping cough is the highest its been in the last 50 years. [*]

Not only that – but the rate has double in just the last year. [*]

These numbers/reports would make any concerned parent-to-be apprehensive.

To remedy the concern, the CDC now recommends (2013) that during each and every pregnancy, a pregnant mother must be administered the Tdap vaccine during her 3rd trimester.

This recommendation is neither recommended by manufacturers of the vaccines nor approved by the FDA. However, doctors do not need FDA approval to recommend and administer the vaccine repeatedly to pregnant women. [*][*]

In fact, there is no data at all to support repeat administration of Tdap in any population, especially pregnant women.[*][*]

To date, one safety trial was completed which incorporated pregnant mothers and a pertussis-containing vaccine. The results are not published or available for review. The trial consisted of 48 pregnant woman and 32 non pregnant women. Both groups received a combination vaccine. Now, don't get me wrong, I'm not a clinical researcher - but the assessment of safety seems mute if both groups are receiving a vaccine with one not even pregnant to begin with?! [*]

Need further reason to give more thought to this recommendation (other then the lack of safety/efficacy/approval) – once the vaccine is administered, mothers are more likely to exhibit sub-clinical/asymptomatic signs of pertussis infection. What that mean in laymen’s terms: vaccinated individuals become reservoir for mild infection – a mother will only think she has a slight cold and may continue to keep in close contact with her newborn when in fact she has pertussis![*][*][*][*][*][*]

Ultrasound

Prenatal ultrasound can be a valuable diagnostic tool when abnormalities are suspected – in this case, I hold no reservations.

However – routine prenatal ultrasound is questionable in its necessity and effectiveness in improving outcomes in pregnancy.

Today, routine ultrasounds are used for several reasons: predict due date, determine sex, detect abnormalities, and/or identify placenta previa.

The accuracy in using ultrasound to determine the estimated due date in the early stages of pregnancy is sound, however calculating the estimated due date based on the menstrual cycle is just as accurate (both accurate to plus or minus 3-4 days).

When detecting abnormalities routine ultrasound can detect 35% up to 80% of significant abnormities at birth. This wide range reflects the peculiar reliance on the ultrasound technician (their proficiency in operating the equipment and their ability to determine the best imagines to be reviewed by the physician) and the physicians themselves (aptitude in interpreting ultrasound results/pictures).  False positives do occur; although this occurrence is small – it is significant (1 in 200 babies aborted for supposed major abnormalities, the diagnosis post mortem revealed less severe expectations of which the termination was unjustified).[*] 

Ultrasound is effective in accurately identifying placenta previa, however almost all women will experience the placenta move up prior to labor. The detection of placenta previa by ultrasound is no more safe than detection during labor.[*][*] 

Due to the above mentioned – ACOG recommends ultrasound use for specific reasons only – NOT routine examination of low risk mothers.[*] 

Routine prenatal ultrasound does NOT improve birth outcomes nor does it hold significant benefits.[*][*][*][*]

Instead, routine prenatal ultrasound holds potential harm – physiological and psychological (of which the psychological stress/anxiety is converted to real physical changes in both mom and baby).[*][*][*][*][*]

From the 2010 Cochrane review:[*]

Subjecting a large group of low-risk patients to a screening test with a relatively high false positive rate is likely to cause anxiety and lead to inappropriate intervention and subsequent risk of iatrogenic morbidity and mortality.

The routine prenatal screening in low risk mothers for potential abnormalities in pregnancy can very well become a self-fulfilling prophecy.

Final Thoughts

The bizarre thing about pregnancy in our modern era…it is as if all pregnancies are treated to be abnormal until proven otherwise.

Before the implementation and development of our universal prenatal screening/testing/care the fetus and mother was assumed to be healthy…unless data existed pointing to the contrary. Today, this balance shifts towards having to prove the health of the baby – in some extreme cases a doctor will end care if a woman refuses routine screenings!

Ultimately, prental care should be address by both parties involved. Women and babies would be best served when they take an active part in their care.  By revisited research on the recommendations for routine screenings during pregnancy, a woman is not only taking an active role but also insisting on better care.

Two great books for prenatal care:

Thinking Woman's Guide to A Better Birth - Henci Goer

 Reviews the true risks and benefits of interventions during birth as well as discusses topics to prepare women on their journey into motherhood.

Obstetric Myths Versus Research Realities - Henci Goer

 If you are looking for a detailed, analytical approach to pregnancy then this is the book for you!