Correspondence

Review of Expecting Trouble: The Myth of Prenatal Care in America

N Engl J Med 2001; 344:459-460February 8, 2001

Article

To the Editor:

In her review of my book, Expecting Trouble: The Myth of Prenatal Care in America (Oct. 12 issue),1 Dr. Klerman correctly asserts that one benefit of tocolysis is that it may delay premature delivery until corticosteroids have been administered. However, the type of tocolysis to which she refers is short-term, intravenous tocolysis (≤48 hours). In my book, however, I explicitly refer to the ineffectiveness of long-term, oral tocolysis (which is initiated after intravenous tocolysis has halted preterm uterine contractions and the corticosteroids have exerted their full effect on the fetus).

Contrary to the reviewer's statement, I do speak to the issue of how prenatal care is isolated from (and venerated above) other aspects of women's health, sometimes to the detriment of pregnancy outcomes. Indeed, this is the whole point of the section of my book entitled “The Primary Care Scam.”

Thomas H. Strong, Jr., M.D.
Phoenix Perinatal Associates, Phoenix, AZ 85006-2768

1 References

1. 1

   Klerman LV. Review of: Expecting trouble: the myth of prenatal care in America. N Engl J Med 2000;343:1126-1126
   Full Text

Author/Editor Response

Dr. Klerman replies:

To the Editor: I regret that some of the comments in my review may have been misinterpreted. Dr. Strong correctly notes that his statements about the ineffectiveness of tocolytic drugs refer to their oral administration after intravenous use has halted preterm contractions. I believe, however, that Dr. Strong should have mentioned the potential value of intravenous tocolysis in connection with corticosteroids, because the difference between these two applications of the same drugs might not be known to most of the pregnant women who read this book.

With regard to care for women's health when they are not pregnant, my only suggestion is that Dr. Strong should have discussed the possible value of care during periods before conception and between conceptions. Again, professionals might understand that such care is referred to in “The Primary Care Scam” section where Dr. Strong states that “non-pregnant women are nearly invisible to prenatal researchers and policymakers.” But this section, largely devoted to reasons why obstetrics should not be considered a primary care specialty, might not make women who are planning a pregnancy realize that they could benefit from the advice of an obstetrician, nurse midwife, or primary care physician before becoming pregnant. Such advice could be particularly important for women who have had medical complications or a miscarriage during a prior pregnancy or have delivered an infant with health problems.

I hope that my few suggestions for additions that might have strengthened this book will not deter professionals, policymakers, and the public from reading this thought-provoking book.

Lorraine V. Klerman, Dr.P.H.
University of Alabama at Birmingham, Birmingham, AL 35294