• not qualified to manage her pregnancy. I told her I thought specialty care was valuable, but that I could not assess for her whether she could afford it. She stayed with her HMO. At the delivery, there were problems, which she believes BAPAC could have handled. The baby died a few days after birth, having tested negative by DNA PCR.
  • "Celeste" begged for a C-section [cesarean section] after her bag of waters had been ruptured for over eight hours, but her doctor refused. The baby was born after 22 hours' labor, with two broken bones.
  • "Karen" called me two days after her diagnosis, in the fifth month of pregnancy. She already had her AZT but didn't know what a T-cell was, or the difference between HIV and AIDS. Given her overall lack of understanding of her diagnosis, it is hard to imagine that the decision to start AZT was an informed one.

Specialty Care Does Save Lives, So Why Isn't It Adequately Funded?

For me, all the political debate about testing pregnant women feels disingenuous. During the past couple of years as universal offering of voluntary testing has been implemented in California, BAPAC (the only specialty clinic providing care to HIV-positive pregnant women in Northern California) has undergone cut after cut after cut in their funding. It makes no sense. Here we have a program that we know works, that we know saves lives, that we know has reduced transmission rates to nearly zero, and yet they struggle for funding and staffing.

If the real goal is saving lives, then regional centers such as BAPAC need to be adequately funded and staffed, to provide direct services to HIV-positive pregnant women, and to provide training and consultation to providers of women who choose to stay with their regular obstetrician or perinatologist.

Where Is the Procedural Standard of Care?

Finally we have guidelines on the use of antiretroviral therapy in pregnancy. Women have been clamoring for them (for this reason we published a "translation" in the April 1998 WORLD).* But the guidelines leave much unsaid. What about C-sections? Amniocentesis? Fetal scalp monitors? Rupturing membranes?

I know that the research is confusing and at times contradictory, but this should not justify silence. Providers attempting to care for HIV-positive pregnant women who cannot afford the luxury of being specialists need guidance.

*  

WORLD. HIV and pregnancy: The basics. WORLD Newsletter 84, April 1998.



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