For prenatal care, more doesn’t necessarily mean better

Most pregnant people receive prenatal care today in much the same way their mothers or grandmothers would have decades ago: 12 to 14 one-on-one visits in a doctor’s office over the course of their pregnancy.

That’s more than the number of visits pregnant people make in France or the Netherlands or other countries. These visits can add up to almost one full week of missed work or child care. This model is so ingrained that doctors and researchers measure the quality of a person’s prenatal care by whether they had all of these visits.

The wisdom of this approach is coming into question.

In new research we conducted with colleagues at OptumLabs with support from the Robert Wood Johnson Foundation, recently published in final form in the American Journal of Obstetrics and Gynecology, we found that many pregnant patients are not receiving the most basic care recommended by clinical guidelines even when they follow their regimented visit schedules.

In our sample of nearly 180,000 pregnancies covered by a commercial insurer between 2016 and 2019, pregnant people received an average of six of the eight guideline-based services we studied. These services — urine cultures, ultrasounds, screening for gestational diabetes, Tdap (“whopping cough”) vaccination, and the like — are important to ensuring healthy pregnancies and newborns (though they amount to just a fraction of what is supposed to happen during prenatal care). As might be expected, those with a minimal number of prenatal visits received fewer of the recommended services. But even those who had many prenatal visits still had major gaps in receiving recommended care.

In fact, there was no meaningful difference in the number of guideline-based services received by pregnant people whether they had five prenatal visits or 15. In other words, more frequent prenatal visits do not automatically equal better care.

As the U.S. works to address glaring inequities throughout the health care system, and specifically in maternal health, our research showed that receiving guideline-based care varies by demographics. Younger mothers, those who have more pregnancy complications, and those living in rural areas were less likely to receive at least six of the eight guideline-based services. Lower numbers of guideline-based services were also seen among mothers in counties with a high proportion of Black non-Hispanic or Hispanic residents, or those in counties with lower median incomes.

The historical focus on the number of prenatal visits, rather than what actually happens during those visits, is a classic example of quantity-equals-quality thinking in health care. Our results show major gaps in quality of care across just these eight services. The larger picture of variation in prenatal care quality has yet to be revealed.

The fundamental goals of prenatal care are to promote healthy outcomes for mother and child and to foster trust between expectant mothers and their care providers. Developing measures of prenatal care quality that capture whether the health care system is providing the care needed to meet these goals is a crucial first step toward accountability.

The Covid-19 pandemic has forced clinicians to rethink the traditional in-person visit model and has accelerated momentum to finding alternative ways to provide prenatal care, including combinations of in-person and virtual visits. The way patients engage with the health care system and medical innovations in obstetrics have changed dramatically since the 1940s; the structure of prenatal care has not. A colleague of ours, Alex Peahl, is leading path-defining work on how to right-size prenatal care so it identifies and focus on patients’ unique needs.

Alternative models of care, including incorporating group visits that provide extra social support and virtual support that removes the need for physical proximity, bring prenatal care into the 21st century. These models deliberately upend the number of in-person visits, so trying to measure their quality based on visit count doesn’t make sense — and probably never did.

The structure of prenatal care should center patients’ goals for their health and the support they need in preparing to start or grow their families. Those working to redesign care also need to ensure that the system for caring for pregnant people is guided by evidence and designed to be more equitable. This underscores the need for more meaningful measures of prenatal care quality that capture whether patients’ medical and psychosocial needs are met, rather than just how many times they visit their provider.

Rebecca A. Gourevitch is a doctoral candidate in health policy at Harvard University. Neel Shah is the chief medical officer of Maven Clinic, an OB-GYN at Beth Israel Deaconess Medical Center, and an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.