Expanding Prenatal Care Options for Low-Risk Patients

Authors: Lauren Demosthenes, MD
Date: June 25, 2018

Clinical Scenario

Mandy is a 31 yo G2P1 female who is newly pregnant. Her last pregnancy was uncomplicated and resulted in a 7#2oz baby girl born vaginally 2 years ago.  She presents to her provider’s office now and asks if she can eliminate some of the routine prenatal appointments that she had last time. She remembers that she often waited for over 30 minutes for a 10 minute appointment where she had her BP checked and her baby’s heart beat listened to.  She has a new job that is about 30 minutes away from her provider’s office and she would like to reduce the number of days that she has to miss or be late for work due to these visits.

Option A

Mandy is told that the standard of care for an uncomplicated pregnancy is to see a provider every 4 weeks until 28 weeks, every 2 weeks until 36 weeks and weekly until delivery (1) but that she could try to schedule her appointments as the first appointment of the morning or the afternoon to minimize the chance of waiting in the office and having to commute from her job to the office.

Option B

Mandy is told that she can be enrolled in a remote monitoring program for prenatal care using a mobile phone app and a wireless connected sphygmomanometer. She is reassured that she will get weekly evidence based educational information delivered to her and that she will have continuous access to prenatal information on the app.  Furthermore, she is reassured that she can take her own BP as often as she would like and that if she should register a “trigger” number, her provider will contact her immediately. She will be able to reduce her routine visits from 12-14 down to 8-9 yet remain in frequent contact with her provider via the bi-directional app.

Discussion Questions

What are the optimal number of prenatal visits for a low risk pregnancy and do more visits result in better outcomes?

The current model of 12-14 visits for an uncomplicated pregnancy has been widely accepted, but studies have shown that this number can be safely reduced. In 1989, the United States Public Health Service convened a multidisciplinary panel which suggested a reduced prenatal visit schedule based on expert opinion and review of the literature. 2764 low-risk women were enrolled in a trial which showed that the reduced schedule women received an average of 2.7 fewer visits with no significant increases in preeclampsia, cesarean delivery, low birth weight or patient satisfaction. (2)In 2012, a Cochrane Review found that in high income countries, there were no differences in perinatal mortality between women randomized to higher vs. reduced prenatal care groups. (3) Lastly, an article from 2015 looked at a cohort of 7256 patients who received either less than or equal to 10 visits vs. > 10 visits during their prenatal care. Low risk women with more than 10 visits had no improvement in neonatal outcomes but did have higher rates of pregnancy interventions including labor inductions and cesarean deliveries.(4) 

Can alternative models of prenatal care delivery be a high value option for patients?

A. Alternative models of prenatal care delivery have been studied and implemented in numerous health systems using mobile technology and self-monitoring devices. Ob Nest, developed by the Mayo Center for Clinical Innovation, is a standard practice at Mayo Clinic ob practices using remote blood pressure and fetal heart monitoring and text based communication. This was designed to offer pregnant women a more flexible care experience while maintaining patient safety, quality of care and satisfaction. With 8 in-person visits per pregnancy, safety and patient satisfaction has been maintained. Patients enjoy the experience of self care and being an engaged partner in care. (5), Babyscripts is a toolkit for tech-enabled prenatal and post partum care that allows obstetric care providers to remotely monitor their pregnant patients progress and health, making access to care easier for the patient and more efficient for providers. 

Can alternative models of prenatal care delivery be a high value option for providers?

In an ob bundle, a fixed payment is provided for all prenatal care so an individual routine obstetric visit is difficult to cost estimate. However, an average reimbursement for a 10 minute and 15 minute gynecologic appointment for a patient outside of a bundled payment is $95.00 and $125.00 respectively. (6) Assuming that the reduced schedule care model opens up extra time in a practice that can be offered to more acute and high risk patients outside of an obstetric  bundle, that could allow the practice to increase access for approximately 4-5 non-bundled gynecologic patients with that accompanying revenue of approximately   $380.00  ( 5 x $125.00) -   $625.00 (5x$125.00). The reduced schedule option could also attract patients who are looking for choice to the practice.  The expense for the remote monitoring service is estimated at approximately $115.00/patient for the sphygmomanometer and enrollment fee.  Understanding that these figures are not exact, it is still very easy to see that a reduced number of visits for a low risk obstetric patient can increase available appointments for non obstetric bundled patients and revenue for a practice, resulting in a positive return on investment in both monetary income and increasing patient choice.

Teaching Moment

Not all women need or want the same type of prenatal care and options for alternative models of care that are more convenient for the patient and more efficient for the health system should be considered. Evidence supports fewer visits for low-risk prenatal care and patients are satisfied with newer alternative models that allow connectivity with their care team through mobile devices that enhance prenatal care with continuous easy access to education.

References

1. Kriebs J.M.: Guidelines for Perinatal Care, Sixth Edition: By the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. J Midwifery Womens Health 2010; 55: 99.e37
2. Rosen MG, Merkatz IR, Hill JG. Caring for our future: a report by the expert panel on the content of prenatal care. Obstet Gynecol 1991; 77(5): 782-787.
3. Dowswell T, Carroli G, Duley L, Gates S, Gulmezoglu AM, Khan-Neelofur D et al. Alternative vs standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2010; (10): CD000934
4. Carter EB, Tuuli MG, Caughey AB, Odibo AO, Macones GA, Cahill AG Number of prenatal visits and pregnancy outcomes in low-risk women. Journal of Perinatology 2016; 36, 178-181.
5. Meylor de Mooij MJ, Hodny, RL, O’Neil DA, Garder, MR, Beaver M, Brown AT, Barry BA, Ross LM, Jasik AJ, Nesbitt KM, Sobolewski SM,
6. Skinner SM, Chaudhry R, Brost BC, Gostout BS, Harms RW. OB Nest: Reimagining Low-Risk Prenatal Care. Mayo Clinic Proceedings, 2018 – 04-01, Vol 93, Issue 4, p. 458-466.
7. Phone conversation business office department of ob/gyn Greenville Health System