Tailored Prenatal Care

• Who is considered an “average-risk” pregnant patient?

  Average-risk pregnant people include those without significant medical, pregnancy, or mental health conditions who can be cared for by obstetrician–gynecologists or other maternity care professionals. This definition is inclusive of patients with common chronic and pregnancy conditions (eg, chronic hypertension, gestational diabetes mellitus), as tailored options may improve their access to evidence-based services and experience of care. The definition is flexible as there are:

  • Limitations in current risk stratification scores that assess pregnancy and childbirth morbidity and mortality risk
  • Variations in practice by region, group, or clinician
• Who is considered a “greater-than-average-risk” pregnant patient?

  The term “greater-than-average-risk” refers to individuals with medical comorbidities or pregnancy complications that require greater intensity of follow-up and potential referral for subspecialist care, including maternal–fetal medicine care. Care for these patients is not covered by this sample schedule. Of note, principles of tailored care, including screening and addressing social drivers of health and considering care modality to accomplish treatment goals, can be applied to this population, which is not covered by this sample schedule.

Tailored Visit Schedules

• How do I reassure my patient that tailored prenatal care visits are not “less” care?

  Tailored care does not mean less care. Patient assessments, including medical and social risk factors, as well as visit planning, require more time in early pregnancy than with prior prenatal care models. Furthermore, 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. Patients should have access to a clinician to ask questions or triage concerns between visits, particularly with longer intervals between scheduled contacts.

  Clinicians may also consider establishing or referring patients to childbirth education and peer support programs to increase contacts with the health system, opportunities for information sharing, and social support. Clinicians interested in building a virtual online education and support program can refer to the online implementation website section on “Stay Home, Stay Connected.” Future work is needed to assess the effects of new care models on operational efficiency and access to care.

• What are the advantages and disadvantages of offering patients the option of tailored prenatal care delivery?

  Tailored prenatal care, including visit schedules and modality (eg, telemedicine, group care) may provide advantages for individual patients, such as an improved care experience, patient autonomy and trust in the health care system, and reduced travel, time accessing care, and associated costs while supporting the completion of evidence-based services. For health systems, adjusting the number of appointments for average-risk individuals can improve availability for patients with more complex needs. In observational studies, not all patients preferred telemedicine care to in-person visits. Studies of the models of care were heterogeneous (one to six telemedicine visits), the quality of evidence was low, and studies were underpowered to detect rare outcomes. Tailored care patient assessments necessary for tailoring care, including medical and social risk factors, as well as visit planning, may require more time than with prior prenatal care models.

• How should I determine which prenatal care options are right for an individual patient?

  Individuals’ preferences for prenatal care delivery may be shaped by their prior health care experience, cultural norms, and social drivers of health, such as employment, transportation, and caregiving responsibilities. Tailoring prenatal care may optimize individuals’ access to services, care experience, and, ultimately, health outcomes while improving operational efficiency for health systems. As pregnancy progresses, the plan of care can be adjusted based on current medical needs and patient preferences. Evidence is lacking for how to best engage patients, including the timing of care-planning conversations (eg, first prenatal visit), the preferred team member to lead conversations (eg, community health worker, nurse, maternity care professional), and optimal supporting tools (eg, handouts, videos). Clinicians may consider adapting the tools available on the implementation website, including patient handouts, videos, and shared decision-making grids for supporting tailored care in their practice.

• How should a patient’s risk stratification be performed to guide appropriate visit schedule selection?

  Tailored visit schedules that adjust the number and frequency of prenatal visits based on risk and parity have been supported by several organizations and peer nations for over two decades. The use of a targeted visit schedule (eight to nine visits) for patients without chronic or pregnancy conditions is supported by three systematic reviews. Tailoring prenatal care requires the incorporation of patients’ preferences and needs for services throughout pregnancy using shared decision-making. This includes discussion about the risks and benefits of preference-sensitive care options in light of the person’s values and priorities. As pregnancy progresses, the plan of care can be adjusted based on current medical needs and patient preferences. Evidence is lacking for how to best engage patients, including the timing of care planning conversations, the preferred clinician to lead conversations, and optimal supporting tools.

• Will a tailored prenatal care visit schedule result in more visits to the emergency room or obstetric triage?

  All patients should have access to a clinician to ask questions or triage concerns between visits. Future work is needed to assess the effects of new care models on operational efficiency and access to care.

• Could additional capacity created by tailored visit schedules result in higher patient volume and increased staff burden?

  For health systems, adjusting the number of appointments for average-risk individuals can improve the capacity for additional visits. Health systems may utilize this additional capacity in a variety of ways: creating more available appointments for patients with more complex needs, increasing patient volume for less complex pregnant patients, or shifting volume to gynecologic care. Health systems should ensure that staffing is sufficient for patients to have a clinician to ask questions or triage concerns between visits, particularly with longer intervals between scheduled contacts. Future work is needed to assess the effects of new care models on operational efficiency and access to care.

• How do we prevent payers’ response to tailored visit schedules from resulting in lower payments?

  Tailored care does not mean less care; patient assessments, including medical and social risk factors, as well as visit planning, require more time than with prior prenatal care models, although screening and adjustment may prevent later unscheduled care. Indeed, the amount of care, including patient evaluation, counseling, education, and interventions, as indicated, is at least the same, if not more, than traditionally delivered prenatal care models. Furthermore, 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.

• Should a longer visit time be used in tailored visit schedules?

  Tailored care patient assessments, including medical and social risk factors, as well as visit planning, require more time than with prior prenatal care models. Furthermore, 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.

• What should I do if my patient presents after the recommended time for the first prenatal visit?

  The timing of the intake or initial visit depends on when the individual presents for care. There is limited research on the optimal timing of prenatal care initiation. It is reasonable to offer an initial prenatal assessment before 10 weeks from the last menstrual period or within a reasonable timeframe after discovery of pregnancy. More rapid assessment and evaluation by an obstetrician–gynecologist or maternity care professional may be appropriate for individuals who have medical or mental health conditions, poorly controlled pregnancy symptoms, unmet social needs, or risk factors for ectopic pregnancy, or who desire abortion care. A risk assessment as early in pregnancy as possible can facilitate opportunities to address risk factors and share important information and anticipatory guidance. Patients who present after the ideal timing for the initial prenatal appointment should be seen as quickly as possible to accomplish these goals.

• Can a patient’s care option change throughout their pregnancy?

  As pregnancy progresses, the plan of care can and should be adjusted based on evolving medical and social needs, as well as patient preferences.

Social Needs Screening and Management

• What if my practice does not routinely screen for social and structural determinants of health?

  Many medical, social, and structural factors are correlated with perinatal health. An early risk assessment for all patients in pregnancy can facilitate opportunities to mitigate the adverse effects of these risk factors and to share important information and anticipatory guidance. Social and structural drivers of health should be included in patient-completed intake questionnaires and expanded medical history questions and integrated into electronic medical records prompts. Screening for social and structural determinants is recommended by several national organizations to improve care access and outcomes.

• How do I train my staff to deliver trauma-informed, culturally competent, and patient-centered screening?

  A team-based and system-wide approach is important for overcoming social and structural issues. Many professional organizations have documents discussing the provision of trauma-informed, culturally competent care specific to the role and scope of their membership.

  The following resources offer helpful implementation information:

  • Social Interventions Research & Evaluation Network (SIREN): Social Needs Screening Tool Comparison Table
  • Health Leads–Boston Medical Center Screening Tool
  • The Health Leads Social Needs Screening Tool Kit
  • Centers for Medicare & Medicaid Services: A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool: Promising Practices and Key Insights

  Additional implementation resources and information can be found below. Additional relevant ACOG documents include ACOG Committee Statement No. 11: Addressing Social and Structural Determinants of Health in the Delivery of Reproductive Health Care and ACOG Committee Opinion No. 825: Caring for Patients Who Have Experienced Trauma.

• Which types of staff members in the practice should screen for the social needs of patients?

  Assessments and screening may be completed by any trained clinical staff (eg, medical assistants, community health workers, nurses) who have received proper training in assessing medical, mental health, and social needs under the supervision of an maternity care professional.

• What resources are available to perform social needs screening of my patients?

  There are many reliable and valid screening tools available for a variety of needs and tested in various populations. Some tools are available in multiple languages.

  ACOG Committee Statement No. 11: Addressing Social and Structural Determinants of Health in the Delivery of Reproductive Health Care discusses many available tools.

  The Social Interventions Research & Evaluation Network (SIREN) has information about a wide range of screening tools in their evidence and resource library.

• How do I reassure my patients that social needs screening is not meant as surveillance particularly in the absence of resources?

  Clinicians may consider a “resource-first” approach to screening, where reasons for screening and available support are presented before asking screening questions. Health care professionals should counsel patients that social and structural determinants of health are important contributors to health and well-being, and that information is being collected to help best support the patient through connection to resources and modifying care to be more accessible.

  It is critical that health care professionals use patient-centered, evidence-based, where possible,  approaches to address unmet social needs; many patients referred to social interventions never use them due to factors such as fear of discrimination, cost concerns, and lack of availability during times that work for their family schedule. Patients are more likely to engage with social interventions if they believe they will benefit from them, the referral is presented in an acceptable way that matches their preferences, and the activity is accessible. Patients in need may feel less inhibited from using assistance programs when the obstetrician–gynecologist or other health care professional frames the referral letter to the community assistance program as a prescription, for example, to promote a healthy pregnancy. Closed-loop referrals, where the community organization provides feedback on services rendered and the outcome, can help ensure social needs are effectively addressed.

• If I screen for the social needs of my patients, how do I identify infrastructure to support social needs services?

  Each community has different types of assistance available through public infrastructure (such as WIC or SNAP), health systems assistance, and private nonprofits (eg, food banks, religious organizations). Health systems often have local experts available, such as community health workers or social workers, to assist in identifying relevant resources. When these care team members are not available, ACOG’s Districts and Sections, regional partnerships, resource lists, and national resources such as 2-1-1 or subscriptions to social needs-prescribing programs may be used.

• After identifying a patient’s social need through screening, how do I ensure that patients’ social needs are appropriately addressed? What are my obligations as the patient’s clinician?

  Assistance for unmet social needs may take many forms and will often be specific to the need identified. Referral to other professionals (eg, social workers), where available, can provide a central point for care coordination. When these care team members are not available, regional partnerships, resource lists, and national resources such as 2-1-1 or subscriptions to social needs-prescribing programs may be used. Although maternity care professionals may not manage social needs directly, they should remain aware of the status of unmet social needs and how they affect individuals’ ability to access health care services. Maternity care professionals may consider adjusting prenatal care (ie, modifying care delivery to be more accessible) through shared decision-making with the patient. For example, for patients with transportation barriers, maternity care professionals may work with social workers to identify ride share vouchers (assistance) and discuss a targeted visit schedule and telemedicine (adjustment). See Table 2 of ACOG Clinical Consensus No. 8: Tailored Prenatal Care for Pregnant Individuals for potential examples of unmet social needs matched with possible assistance and adjustment.

  Occasional follow-up on needs during prenatal visits can be helpful to assess the state of unmet social needs and determine if the patient has been able to access services. These check-ins, even in the absence of available resources, may help patients feel more supported by their prenatal team. The ACOG Task Force report Implementing Team-Based Care provides an overview of team-based care, including guiding principles and implementation, including regulatory considerations.

• How should the prenatal schedule be adapted for patients with adverse social and structural determinants of health?

  Care adjustments are modifications to care delivery to improve accessibility. Adjustment may be used to temporarily meet needs (eg, a patient with transportation barriers awaiting ride vouchers), address ongoing social needs (eg, an hourly employee cannot afford to forgo wages), or provide adjustment in light of patient preferences for care delivery. Maternity care professionals should recognize the social and structural drivers of health that affect patients’ ability to make or maintain prenatal appointments and be prepared to offer care adjustments. Potential care adjustments include 1) tailored visit schedules (versus traditional) streamlined around needed education and services; 2) telemedicine (versus in-person care) where possible to reduce travel burden, need for childcare, or time away from work; and 3) group prenatal care (versus individual care, ideally in the individual’s native language) to address social isolation and low health literacy. Adjustments should incorporate the individual’s medical and social risk factors and ensure the timely provision of evidence-based services.

Telemedicine and Self-Monitoring

• Can telemedicine or selfmonitoring lead to a delayed diagnosis in a pregnancy?

  Telemedicine can improve access to services, reduce patient and health system costs, and improve patient experience. If access to care is increased through telemedicine visits, perinatal outcomes are equivalent to or improved when compared to in-person visits. One systematic review demonstrated equivalent maternal and neonatal outcomes and an overall positive care experience with telemedicine, although the number of telemedicine visits differed (one to six) and studies were underpowered to detect rare but serious outcomes.

  Multiple studies support the safety, feasibility,and acceptability of selfmonitoring of blood pressure when patients are properly trained on how to complete measures and have an appropriate device.

• How do I determine as a clinician whether telemedicine and self-monitoring are acceptable/preferable to my patients?

  Ambulatory practice preparation for the implementation of telehealth, including attention to workflow, educational content of visits, and adequate allotment of time for the visit, may improve the experience of telehealth for patients and clinicians. It is important that patients have access to necessary equipment with audio or video if planning telemedicine care; infrastructure such as broadband internet or reliable cell service with adequate bandwidth is also needed for successful communication. There is no evidence that video visits are superior to audio-only encounters. Video visits may support rapport building, communication, and insight into the patient’s home setting or be seen by patients as surveillance and an invasion of privacy.

• What if my practice does not have available telemedicine infrastructure?

  The American College of Obstetricians and Gynecologists and the Plan for Appropriate Tailored Healthcare in Pregnancy (PATH) panel recommended four key in-person visits but, beyond those visits, emphasized flexibility in prenatal care delivery based on the medical needs, social and structural risk factors, and preferences of the individual. Telemedicine can take many forms depending on the needs of the patient, including audio-only telephone calls, and does not require extensive clinic infrastructure. ACOG Committee Opinion No. 798: Implementing Telehealth in Practice provides additional guidance on implementation. 

• What home devices are required for patients receiving telemedicine prenatal visits?

  Although routine measurement of key parameters, including maternal blood pressure, weight, fundal heart, and fetal heart tones, is traditional in prenatal care, little is known about the optimal frequency of these measures. Monitoring of routine parameters in pregnancy is increasingly available outside of clinical settings, such as local pharmacies, through home visiting programs, or by remote self-monitoring. Evidence demonstrates the feasibility, acceptability, and accuracy of self-monitoring of blood pressure and weight. Less data is available on self-monitoring of obstetric assessments, including fetal heart tones and fundal height. Self-measurement of routine parameters is reasonable if the patient 1) desires self-monitoring; 2) has adequate training to accurately complete the measurement; 3) can access necessary, appropriate, and reliable equipment; 4) is aware of abnormal parameters; and 5) has means to obtain help with abnormal results.

Changes in Obstetric Billing: What Providers and Payers Need to Know

ACOG is leading efforts to modernize obstetric payment structures, advocating for CPT code updates and refined billing practices. Stay informed on evolving reimbursement strategies and their impact on prenatal and postpartum care.

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