New ACOG Guidance Recommends Transformation to U.S. Prenatal Care Delivery

Washington, D.C.—The American College of Obstetricians and Gynecologists is recommending significant changes to the way prenatal care is delivered in the United States, according to clinical guidance released today. The new, tailored, patient-centered approach could improve outcomes for millions of pregnant patients.

For nearly a century, prenatal care has consisted of 12 to 14 in-person visits regardless of individual risk factors and with limited evidence linking the timing or number of visits to improved outcomes. Prenatal care would typically consist of one appointment every four weeks until the seventh month, one appointment every two weeks until the eighth month, and then weekly thereafter.

However, according to the latest ACOG Clinical Consensus Committee document, Tailored Prenatal Care Delivery for Pregnant Individuals, evidence shows that health care professionals can individualize care delivery for average or low-risk patients so that they have fewer in-person visits and use other care modalities. This new approach would give pregnant patients and their ob-gyns or other maternity care clinicians the ability to develop prenatal care plans based on medical, structural, and social determinants of health and patient preferences rather than using the traditional one-size-fits-all model.

“This new approach to prenatal care is a significant paradigm shift,” said Christopher Zahn, MD, FACOG, ACOG’s chief of Clinical Practice and Health Equity and Quality. “Advancements in technology and evidence-based assessments and interventions in pregnancy have warranted a change to the current model of care for some time. Research has shown that the standard 12 to 14 visits do not ensure that patients receive the recommended prenatal care. In fact, 23% of patients don’t go to their first prenatal care appointment until after the first trimester, and almost half do not receive all the recommended services on time. In order to improve access and outcomes, we have to adjust the system and meet patients where they are.”

The goal of this new guidance is to promote equitable care by focusing on upstream drivers that often contribute to the disproportionate maternal morbidity and mortality rates seen among marginalized populations. ACOG recommends that clinicians screen for social drivers of health, including race, ethnicity, gender identity, education, and employment, and help address them through two key approaches: assistance, which entails providing resources; and adjustment, which entails modifying care delivery to be more accessible. Assistance can take many forms, such as referrals, partnerships with community organizations, and resource lists. Adjustment can include use of streamlined visit schedules, telemedicine, and group care to reduce barriers to care and provide support. The promotion of patient autonomy through shared decision-making can improve patients’ care experience and trust in the health care system, particularly for historically marginalized groups.

While changes to clinical practice are typically slow going, the COVID-19 pandemic accelerated substantial changes to prenatal care delivery and yielded an early U.S. case study, as the public health crisis necessitated a new approach that included targeted visit schedules, telemedicine, and home monitoring of routine pregnancy measures such as blood pressure.

In response, ACOG and the University of Michigan convened an independent panel of maternal care, public health, pediatrics, and equity experts alongside patient representatives to review all the evidence and provide recommendations for prenatal care delivery that would extend beyond the pandemic. The result was the Plan for Appropriate Tailored Healthcare in Pregnancy, or PATH, which served as the basis for ACOG’s new clinical guidance and consists of recommendations for the number and frequency of prenatal care visits; the role of routine monitoring in pregnancy, including maternal blood pressure, weight, and fundal height; the integration of telemedicine, group prenatal care, or other care modalities; and the inclusion of structural and social determinants of health.

ACOG created a framework for a modifiable prenatal care schedule based on a patient’s risk classification. ACOG’s guidance states that an initial comprehensive needs assessment should take place ideally prior to 10 weeks of gestation and include a thorough medical and reproductive history and a discussion of social and structural factors that may affect a patient’s mental health and outcomes. The guidance acknowledges that the new care model does not apply to patients with greater-than-average risk who may require more follow-up and potential referrals for subspecialist care.

“Tailored care does not mean less care,” said Alex Peahl, MD, MSc, FACOG, coauthor of the guidance and assistant professor of obstetrics and gynecology at the University of Michigan. “It means delivering the right care, by the right professional, through the right modality. For example, average-risk patients’ care can be streamlined around needed services known to improve pregnancy outcomes, but these visits may need to be longer. This approach can significantly reduce travel time and burden for patients while maintaining clinician-facing time. Since we implemented tailored prenatal care at my institution over five years ago, patients have consistently reported a positive experience. Many appreciate the flexibility and choice inherent in the model. Whether patients face transportation barriers, a demanding work schedule, or childcare needs, tailored care allows us to build trust with them by identifying and overcoming the real-world barriers to prenatal care together.”

Tailored prenatal care has the potential to help reduce racial health inequities and disparities in care that exist for patients living in rural areas or maternity care deserts. However, certain communities and practices may not have the available resources or staffing to effectively address patients’ unmet social needs, and the current political climate might create barriers for institutions attempting to address structural and social determinants of health and racial health inequities.

Additionally, while telemedicine has been shown to improve access to care and reduce travel burden and the need for childcare or time off from work, some institutions may not have the infrastructure to accommodate telemedicine appointments. Patients in rural areas also may not have access to reliable broadband or cell phone service or the ability to purchase home devices to effectively self-monitor their pregnancies.

“It will take time to address barriers and determine effective strategies that work best for patients, clinicians, and institutions,” said co-author Mark Turrentine, MD, FACOG, “but the goal is to improve access to care while also improving operational efficiency and cost-effectiveness. By streamlining the number of visits for average-risk patients, we can improve availability for higher-risk patients with more complex needs. But future research will be needed to assess the impact of this new approach in real-world settings to fully understand the effect on care delivery and pregnancy outcomes and ensure that there are no unintended consequences for marginalized groups.”

New policies will also need to be explored and enacted to address barriers such as cost, geographic challenges, and inadequate obstetric billing and payment systems to ensure that tailored prenatal care can be implemented optimally.

“This will be a huge systems change that would take years to fully implement,” said Dr. Zahn, “but if we as clinicians are truly focused on eliminating health inequities, improving access to and the experience of prenatal care services must be an essential part of that.”

Additional Resources

• For Patients: Prenatal Care FAQs
• For Physicians: Tailored Prenatal Care FAQs