SUMMARY:

The number and timing of prenatal visits has remained unchanged since 1930. The original 12 to 14 weeks schedule was implemented to address preeclampsia. During the pandemic, new approaches were taken to address scope of prenatal care and these changes have been viewed as sustainable. In 2020, ACOG collaborated with the University of Michigan and convened maternity care, public health, and pediatric experts as well as patient representatives to address care models for average risk patients (MiPATH). The outcome of this project determined that individualized plans based on individually assessed medical, social and structural determinants of health (SSDoH) were considered to be ideal. An ACOG clinical consensus document was created based on this process and has been endorsed my multiple organizations including SMFM. Note that a ‘Sample Schedules for Prenatal Care Services and Visit Frequency’ is provided as well as additional support and suggestions regarding meeting unmet social needs (see ‘Learn More – Primary Sources’ below)

Methodology and Goals of MiPATH Project

• Participants included maternity care providers | Public Health representatives | Pediatrics | Equity Experts
• Recommendations were created using RAND-UCLA appropriate method that uses systematic review of evidence and expert opinion to fill gaps (Delphi approach)
• Goals were to determine
  • Importance of how to tailor average risk visits
  • How to assess and incorporate SSDoH into care plan using alternate methods including
    • Home care | Telehealth | Ability of patient to utilize services

Initial Prenatal Needs Assessment

• Should be performed <10 weeks
• May be completed by via telehealth
• May be done by trained clinical staff (e.g., nurses or medical assistants) “who have received proper training”
• Components
  • Ob and/or Gyn (e.g., previous and current history)
  • Medical (e.g., chronic health conditions)
  • Family history (e.g., prior birth defects or familial conditions)
  • SSDoH (e.g., demographic characteristics associated with marginalization)
• Prenatal care may be tailored based on the needs assessment of the individual patient including
  • Prenatal care delivery
  • Frequency and and monitoring schedule

Key Recommendations with Average Risk Patient 

• Average risk patients
  • Defined as those who could be cared for without preexisting complications
• New Recommendations for Prenatal Visits (suggested based on ‘Sample Schedule’ however flexibility is encouraged based on particular patient needs)
  • 10 weeks: In-person with physical exam components based on gestational age and patient individual risk factors
  • 16 weeks: In-person
  • 22 weeks: Any accessible care modality
  • 28 weeks: In-person
  • 32 weeks: Any accessible care modality
  • 36 weeks: In-person including fetal presentation if relevant to mode of birth
  • 39 weeks: In-person

Note: Any accessible care modality refers to what is accessible to the patient (e.g., telehealth or group Ob care)

Patients With High-Risk Conditions

• Medical conditions including
  • HTN | Diabetes | History of early pregnancy loss | HDP or GDM
• Focus on monitoring of condition (e.g., blood pressure or finger sticks)
• New Recommendations for Prenatal Visits (suggested based on ‘Sample Schedule’)
  • 10 weeks: In-person with physical exam components based on gestational age and patient individual risk factors
  • 14 weeks: In-person
  • 18 weeks: In-person
  • 22 weeks: Any accessible care modality
  • 26 weeks: Any accessible care modality
  • 28 weeks: In-person
  • 30 weeks: Any accessible care modality
  • 32 weeks: Any accessible care modality
  • 34 weeks: Any accessible care modality
  • 36 weeks: In-person including fetal presentation if relevant to mode of birth
  • 37 weeks: Any accessible care modality
  • 38 weeks: Any accessible care modality
  • 39 weeks: In-person
• If high quality monitoring and pathway for provider contact cannot be established then visits should be in person
• Later diagnoses in pregnancy such as FGR, HDP and GDM should be managed regarding frequency and intensity of care based on current guidelines for specific conditions

Other Considerations 

• Telehealth
  • Can assist in flexibility even without preexisting platform in office
  • Offer flexible visits and phone time as well
  • ACOG Committee Opinion 798 addresses further considerations (see ‘Learn More – Primary Sources’ below)
• Implementation
  • Social needs
    • Referral to other healthcare professionals (e.g., social work)
    • If other professionals not readily accessible, “regional partnerships, resource lists, and national resources such as 2-1-1 or subscriptions to social needs–prescribing programs may be used”
  • Care adjustments may include
    • Tailor visits around needs (e.g., specific services)
    • Telehealth to reduce travel time
    • Group prenatal care that may be of benefit to “address social isolation and low health literacy”
• Time demands on ObGyns
  • Tailored approach may result in additional professional time demands
  • “Health systems can consider increasing visit length for patients receiving tailored visit schedules to maintain the overall time patients spend with their maternity care professional, even though the overall number of visits may be decreased”
• Home monitoring devices
  • Self-measurement may be reasonable if
    • There is patient interest
    • Patient has adequate training
    • Monitoring equipment is accessible
    • Patient is aware of normal vs abnormal ranges and results
    • Patient can access help as needed
  • Insurance coverage varies and may need to consider this could widen equity gap, however possible options to obtain devices include
    • medical equipment benefits | health savings account | personal purchase

KEY POINTS:

• COVID pandemic changed prenatal care delivery with possible beneficial additions that may improve type of access to care
• Major components are
  • Shared decision making | Flexible scheduling | Use of telehealth | Incorporation of SSDoH analysis into care
• For average risk patients, evidence exists that 6 to 10 targeted visits vs traditional 12 to 14 in-person visits has been associated with good outcomes
• For high-risk patients, other approaches such as telehealth may be incorporated into care delivery model

Learn More – Primary Sources

ACOG: Sample Schedules for Prenatal Care Services and Visit Frequency

ACOG Clinical Consensus 8: Tailored Prenatal Care Delivery for Pregnant Individuals

ACOG Prenatal Care Resource Center

ACOG Prenatal Care FAQs

ACOG Committee Statement 11: Addressing Social and Structural Determinants of Health in the Delivery of Reproductive Health Care

Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations: A Practical Guide for Maternity Care Clinicians

The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations (Research Plan)

ACOG Committee Opinion 798: Implementing Telehealth in Practice

MiPATH: Pregnancy and Postpartum Patient Resources

Related ObG Topics:

Antenatal Fetal Surveillance: Indications and Timing

What is the SARS-CoV-2 Transmission Risk Associated with Prenatal Visits?

STI Screening in Pregnancy: CDC Recommendations

Managing an Obstetric Office Practice During COVID-19

What Do You Really Need to Know About Your Patient’s Family History?

Chronic Hypertension in Pregnancy: Evaluation and Management