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. The resulting publication, reviewed below, outlines “the new MiPATH recommendations and to provide practical guidance on implementing them in routine practice.”

Methodology and Goals

• 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 | Telemedicine | Ability of patient to utilize services

Key Recommendations with Average Risk Patient 

• Average risk patients
  • Defined as those who could be cared for without preexisting complications
  • May include those with mild hypertension or social issues such as food insecurity based on location
• New Recommendations for Prenatal Visits
  • 7 to 10 weeks: First OB ultrasound and risk assessment
  • ≥13w6d to 27w6d (first and second trimester): Every 4 to 6 weeks
  • 28w0d to 35w0d (early third trimester): Every 2 to 4 weeks
  • >36 week: Every 1 to 2 weeks
• Consider use of telehealth and home devices to supplement care

Note: In the new MiPATH recommendations, there are only 4 mandatory face-to-face visits: first prenatal visit | 28 weeks | 36 weeks | 39 weeks

Patients With Preexisting High-Risk Conditions

• Medical conditions including
  • HTN | Diabetes | History of early pregnancy loss | HDP or GDM
• Monitoring of condition (e.g., blood pressure or finger sticks) considered more essential than face to face encounter
• If high quality monitoring and pathway for provider contact cannot be established then visits should be in person
• Later diagnoses in pregnancy such as HDP and GDM should move toward traditional schedule/ current guidelines for specific conditions

Patients with Adverse SSDoH

• Assess possible needs in the following areas
  • Material: Food insecurity | Financial
  • Psychological: Mental health | Cognitive ability
  • Social: Relationships | Discrimination | Community role
  • Demographics: Age | Education | Race | Immigration status
• Resources for help do not need to be actual provider but can be support groups in office, social workers, community support
  • Consider telehealth options
  • Exceptions to decreased in person contact include
    • Low health literacy |  Pregnancy-related anxiety | Intimate partner violence
  • Team-based care offers promising guidance for future shaping of proposed restructuring of care
• If practices do not routinely address SSDoH, select from assessment tools that match population
• Positive screens may provide challenges to practices that do not have mechanisms in place to connect patients to resources

Other Considerations 

• Telemedicine
  • 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)
• Home devices            
  • Panel does not provide recommendations on which to use but most models include home BP cuff
  • Other devices i.e. fetal heart tone tracker or fundal height measurement tools involve shared decision making
  • 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

Future Research and Policy Directions 

• Additional research
  • To determine impact of change in proposed frequency of visits and use of new modalities of care on pregnancy outcomes, patient satisfaction, access to care and disparities
• Regulatory and payment policies
  • Will need to adapt to cover flexible models of care as well as coverage of telemedicine services and at-home use of products
• Authors acknowledging these new guidelines will put strain on existing maternity care packages
  • Listening tours nationally being planned to address model with key stakeholders to identify essential needs and support to implement proposed changes

KEY POINTS:

• COVID pandemic changed prenatal care delivery with possible beneficial additions that may improve type of access to care
• MiPATH clearly states role is not to impact provision of care but instead how that care is best delivered
• Major components are
  • Flexible scheduling | Incorporation of routine monitoring | Use of telemedicine | Incorporation of SSDoH analysis into care
• Average risk patient has 4 required in person visits with flexibility to accommodate other issues as they arise in pregnancy
• Higher risk patients have proposed supplemental assessments that may not be necessarily in person
• Plans to continually convene to incorporate new data and obstacles to implementation
• Considered as initial steps in ongoing assessments of care delivery

Learn More – Primary Sources

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