Rhogam. The biological, economical, social, religious, and political.

So, what's up with Rhogam? I find this to be one of the most complicated things to discuss with women who show up with a negative blood type, and I'm trying to make it simpler each time I talk about it. And by simpler I mean understandable to most audiences, including patient populations who read at a fifth grade level, but need to understand their healthcare and be properly consented just like everyone else. Let's give this a try.For some midwives, the conversation may start out as simple as a statement like:Your blood type is A-negative, so for moms with negative blood types, we give you a shot of Rhogam late in pregnancy and after you have the baby.And some women may jump on board with that. I'm a little more type-A (by blood, but not by blood type, ay-o!), so here's an attempt at what I say:Most people have a positive blood type: O+, B+, A+, AB+. Few people have a negative blood type: O-, B-, A-, AB-. You and your partner may have the same or different blood types, including the positive or negative types. In pregnancy, the positive or negative matters more than the letter. Depending on the blood type of your partner, your pregnancy may have a blood type similar to yours, or different. The positive type outweighs the negative type in the genetics battle, so if one partner has a positive type, and one has a negative type, the pregnancy will likely have a positive blood type. If the mother is the person with the negative blood type, and we assume the baby has a positive blood type (since most people do), then those are two conflicting bloods in one person's, the mother's, body. The mother's blood, since there's more of it, will develop a defense system against the baby's blood once they're exposed to each other, usually during a miscarriage, abortion, or birth. So a woman's first pregnancy isn't usually a problem, because the baby is exiting at the time the mother's blood figures out what's going on. However, the mother's blood keeps that defense system forever, and it's reactivated for all future pregnancies with opposite blood types. This can cause problems for future pregnancies, including blood cell diseases and repeat miscarriages. So, Rhogam is a blood product we give women with a negative blood type at two different times in their pregnancy, at 28 weeks and within 72 hours postpartum, to keep the woman's defense system from activating. It's  a shot that goes in the arm and hurts like the flu vaccine. Like any blood product it has the risk of carrying blood-borne diseases, but it is screened at high levels to rule out those infections.NB: I would love any feedback people have about what they include or don't include in this conversation. Now, Rhogam is scientifically way, way more complicated than that. The laudable Anne Frye, CPM has a comprehensive description of all diagnostic tests in pregnancy, including that for determining blood type and sensitizations, in her book "Understanding Diagnostic Tests in the Childbearing Year: A Holistic Approach." Her writing is thorough, straightforward, a bit thick, but ineffably complete. Worth as much time as you can dedicate to it in one sitting. Translation: it's worth it's weight in caffeine. Also, if you order any books from Anne, you get to speak with her directly on the phone. And Anne's pretty famous in the midwife community. AND, if you're a student midwife at the time, possibly in celebrity shock on your cell phone, you might get a little breathless while giving her your credit card number. I'm sure she gets that all the time.Anne brings up some really awesome points in this section. Providers should be able to answer more specific questions about risk, such as:

• If both partners are a known negative blood type, does the woman needs Rhogam? (No, she doesn't, but a conversation should happen around ensuring paternity, genetic mutations, and past exposure risks.)
• What is the risk of an Rh-D negative woman developing antibodies after a miscarriage? (2%)
• What about after an induced abortion greater than 8 weeks and up to 20 weeks gestation? (4-5%)
• What about for a first pregnancy carried to term, what percentage of Rh-D negative mothers develop antibodies with their first Rh-D positive baby? (10%. Also translated as 90% of women do not develop antibodies in their first Rh-D positive pregnancy. That's a lot.)
• If my next baby is Rh-negative, will they be affected if I didn't get the shot in my first pregnancy with an Rh-positive baby? (Nope)
• Are there side effects? (Yes, for the woman receiving the shot. For the baby? Unknown, but there are studies out there and curious minds.)

What if, at delivery, we discover that the woman had scant prenatal care and never received Rhogam during the pregnancy? At that point there's a concern for how much of the baby's blood mixed with the mother's blood. The Kleihauer-Betke test determines how much of the baby's blood mixed with mom's, and then how much Rhogam the woman should receive postpartum to stave off those antibodies.Now, is that all there is to know about Rhogam? Absolutely not. Including the social, religious, political, and economical weight of it. Here, I quote Anne Frye:

(p. 145)

"RhIG is not given for the direct benefit of the recipient or even her current fetus. The only beneficiary will be an RhD-positive fetus during a subsequent pregnancy (although the woman would also benefit in the event of a wrongly typed transfusion during the time of birth). Furthermore, prenatal prophylaxis unnecessarily exposes the 35% of fetuses who are RhD-negative to RhIG. These babies are at no risk of RhD sensitization. RhIG is completely unnecessary when a baby is the last child in the family.In the absence of clear answers to these pressing questions, the routine use of RhIG assumes that the birth process for RhD-negative women is inherently flawed. Moreover, no differentiation is made between physiological birth and births that have been interfered with in ways that may promote maternofetal transfusion. In fact, some now routine interventions may enhance the risk of blood mixing. Normal birth, to the contrary, may be protective."

Well said.Economical: How much does Rhogam cost? Free on medicaid or state insurance programs. Seems like insurance plans charge anywhere from $100-$500. That's a lot of money for something that is potentially given for the benefit of the doubt.Social: Firstly, while working at a Planned Parenthood, a woman post-procedure had been counseled on Rhogam, and declined it in the recovery room because she knew her husband's blood type was negative. There was an uproar among the staff, as to whether they thought she could decline, what the big deal was in taking it, and multiple providers came in to counsel her on it. Quite the social stigma for a woman educated to make her own decision.Secondly, since this is such a difficult topic to explain to anyone, let alone individuals who have limited scientific understanding, a full consent process is difficult. I find Rhogam to be one of those things that people consent to, more or less, based on as much information they can understand, because it's really complicated. Provider discretion that it's important, and then they agree, and then they get the shot. Hm.Thirdly, a woman waiting in OB triage at the hospital where I work visited two different pharmacies and sat in the triage waiting room for over 3 hours waiting for someone to give her the shot, and couldn't get the pharmacy to fill it or a nurse to administer it due to logistical protocols. So for a woman who wanted it, the system still failed her. Not because of the Rhogam itself, but it was wrapped up in the social situation.Religious: Rhogam is a blood product, specifically derived from human blood plasma. Thus, people of certain belief systems, such as Jehovah's Witnesses, may choose to refuse Rhogam in their pregnancy. Similarly, Christian Scientists may refuse Rhogam on prophylactic medicine reasons. Anne Frye has great advice on strengthening the placental bed to decrease the amount of blood mixing during labor, good for all women, but also in situations where Rhogam is declined. These suggestions include a healthy diet and Vitamin C, among some cool others.Political/Economical: In The Gambia, West Africa, the situation is incredibly complex. Assuming women have received prenatal care, and assuming that it is through a clinic that can do blood typing, she may know her blood type. However, Rhogam  is not available anywhere in the country. An entire country without Rhogam. That's incredible to me. Women must travel into Senegal to receive the medication, which, depending on where they live in The Gambia, can be a very long and expensive trip. And on top of that, they must purchase the Rhogam in Senegal and bring it back: it is not free. Nigeria recently celebrated a Rhesus Factor Day to enhance public knowledge of blood types to educate on needs during childbirth and blood transfusions. Needless to say, where I was working, blood wasn't regularly available at the hospital due to lack of donations, and many women did not know their blood type in pregnancy. So for many women, repeated miscarriages and neonatal deaths might be a mystery, blamed on them socially as individuals responsible for growing the family, or not regarded as concerning for future pregnancy attempts.Many issues to ponder about Rhogam. Like anything, women should be fully consented and given all positives and negatives. But, like anything, it's never just as simple as that.