Prenatal care is one of the most commonly used preventive care services in the United States. Of the 3.86 million women who give birth each year, more than 98% will establish prenatal care with a maternity provider, resulting in more than 18 million visits annually.1 Current recommendations for prenatal care include 12–14 office-based prenatal visits for low-risk women, in addition to routine laboratory work and ultrasound scans. Recent national recommendations suggest a comprehensive approach to postpartum care,2 but many guidelines continue to endorse one postpartum visit.3,4
Although robust data are available for medical components of prenatal care such as administration of folic acid5 and screening for complications such as aneuploidy6–9 and gestational diabetes,10 evidence is limited for outcomes related to prenatal care delivery such as visit number. Similarly, although evidence supports the safety and efficacy of alternative care models such as reduced visit schedules,11 pregnancy medical homes,12,13 and group care,12,14 head-to-head trials with comparative outcomes are not available. Therefore, current recommendations for prenatal care delivery are based on expert opinion.15 In areas of limited evidence for a particular delivery method, incorporating patient preferences is important for improving adherence and patient-centered outcomes.16,17
As part of a quality-improvement initiative to optimize patients' experience with outpatient maternity care, we conducted a survey of postpartum women's preferences for prenatal and postpartum care delivery. In this manuscript, we present our findings on care delivery preferences, including visit frequency, visit type, and between-visit contact, and patient characteristics associated with those preferences, to inform future efforts to redesign prenatal care.
We conducted a single site cross-sectional survey of postpartum women to evaluate patients' prenatal and postpartum care preferences. Our overarching aim was to inform a larger quality-improvement initiative to align care delivery with patient preferences. We recruited a convenience sample of women admitted for childbirth and postpartum recovery between May 7, 2019, and June 28, 2019. We planned to recruit 300 patients—the average number of women who deliver in our hospital in a typical month—to capture a representative sample of patient perspectives.
At the study site, attending and resident physicians function as a group practice to deliver standardized prenatal care across nine outpatient clinics, coordinated through electronic check-lists in the electronic medical record. The majority of women receive individual prenatal care from a general obstetrician–gynecologist (ob-gyn) (59%), maternal–fetal medicine specialist (15%), family medicine physician (7%), or certified nurse-midwife (19%). A small number of patients (less than 1%) participate in a Centering Pregnancy pilot program (group prenatal care). Most clinics have access to a social worker who provides referrals for Women, Infants, & Children services and addresses other social needs. For prenatal education, patients receive 1) anticipatory guidance during their standardized prenatal intake with a nurse, 2) handouts printed with the after-visit summary, 3) health care provider discussions during visits, 4) a booklet and class for third-trimester teaching, and 5) a hospital-sponsored website with patient resources. Women within a 30-mile radius of the hospital are offered a home nurse visit postpartum; about half participate. To ensure high postpartum follow-up rates, several institutional workflows facilitate appointment scheduling. An appointment for postpartum care is created during the third trimester. When its timing needs to be adjusted for actual delivery, hospital staff help to facilitate appointment scheduling before discharge. All women receive automated reminders and a phone call from a clinic staff member the day before the appointment, and all “no-shows” are contacted to reschedule. Most women (88%) present for a postpartum appointment in the office 4–6 weeks after delivery.
For this study, patients were identified from the electronic medical record by a research assistant if they were at least 12 hours postpartum and had a liveborn neonate. We included all women who are at least 18 years old and were able to read and write in English. Women were approached in their postpartum room by a research assistant and invited to participate in the study. Patients were considered unavailable and not invited to participate if they were 1) with a member of their care team (eg, health care provider, nurse, lactation consultant), 2) sleeping, or 3) were not in the room (eg, visiting their newborn in the neonatal intensive care unit). Two attempts were made to reach patients who initially were not available. This study received exempt status as a quality-improvement project by the University of Michigan Institutional Review Board (HUM00159247).
We used Qualtrics software to develop and administer our survey. As there is no validated survey querying patients' preferences for prenatal care delivery, a team was assembled to design the survey. We included three experts in survey methodology (V.K.D., J.B., M.H.) in our survey design. The survey was then reviewed by a multidisciplinary group of women's health professionals who currently serve on the patient education committee (including ob-gyns, midwives, nurses, prenatal education specialists, and administrators). The committee's feedback was incorporated into the survey and reviewed a final time. The survey was pilot tested with three postpartum patients to confirm readability, comprehension, and length, and was iteratively revised.
The survey content was developed specifically to explore potential options for prenatal care delivery redesign. We conducted a literature search and interviewed prenatal care leaders across the United States to identify prenatal care models with evidence of safety and feasibility for pregnant patients. Care delivery includes how patients participate in prenatal care: visit frequency (number of prenatal and postpartum visits), visit model (eg, individual, group, pregnancy medical home [Table 1]), between-visit contact (desire for contact between visits, scheduled vs unscheduled contact, mode of contact including phone and text messaging, and preferred contact person), and comfort with remote monitoring skills (measuring weight, blood pressure, and fetal heart tones).
To assess preferences for visit number, we asked women, “if you were given a choice, how many prenatal care visits would you prefer in pregnancy?” For alternative visit models, women were specifically asked how likely they would be to participate in each of the models (extremely unlikely to likely) and how many of their prenatal care visits they would want with this model (none, a few, half, most, all). For between-visit contact, we asked whether patients would “want contact with your care team between your prenatal visits,” and, if so, the kind of contact (eg, phone, text message, online portal), with whom (eg, health care provider, nurse), and scheduled or unscheduled. To assess comfort with home monitoring skills, we asked patients, “if a nurse showed you how to, how comfortable would you be checking your weight, blood pressure, and fetal heart tones (baby's heartbeat)?” (very uncomfortable to very comfortable). Additionally, we included validated items assessing patients' demographic characteristics (from the U.S. Census),18 pregnancy history,19,20 and pregnancy experiences. We assessed overall satisfaction by asking, “how satisfied were you with your prenatal care?” Prior work has demonstrated that the majority of patients report high satisfaction with their prenatal care.21–23 We defined maternity care provider broadly to include ob-gyns, family medicine physicians, and certified nurse-midwives.
Data were summarized using descriptive statistics. Missing data were less than 5% for all questions and were not imputed. We analyzed patients based on their preferred visit number in comparison with prenatal care recommendations as currently outlined by the American College of Obstetricians and Gynecologists, which recommends that low-risk women see a health care provider individually in a clinic or hospital 12–14 times during pregnancy.15 We therefore examined three groups: patients who preferred fewer than 12 visits, 12–14 visits, or more than 14 visits. Comparisons between these groups were made using χ2 for categorical variables and analysis of variance for continuous variables. Analyses were performed using STATA-IC 15. Statistical significance was set at P<.05 with two-sided tests.
Of the 590 births over the study period, 253 (43%) women were unavailable for the survey. Of the remaining 337 women, five (1%) did not speak English, leaving 332 eligible women. Of those eligible for the survey, 300 agreed to participate, for a response rate of 90% (Fig. 1).
The mean age of participants was 30.4±5.3 years. Most patients were white, had private insurance, and were married. The majority of patients were low-risk primiparous women who had a vaginal birth. Almost all patients were satisfied with their prenatal care experience (Table 2).
The median desired number of prenatal care visits over the course of pregnancy was 10 (interquartile range 9–12). When compared with the recommendations for 12–14 total prenatal care visits during pregnancy, most patients desired fewer visits, though almost a quarter desired the same number of visits, and a few desired more visits (Fig. 2). A higher proportion of patients with private insurance preferred fewer than 12 visits (fewer than 12: 76%, 12–14: 62%, more than 14: 63%). Preference for visit number differed by race and insurance type, but there were no differences in preference for visit number by age, parity, relationship status, number of high-risk patients, antepartum hospitalization, delivery type, or prenatal care satisfaction between groups (Table 2).
The majority of patients preferred to have contact with their care teams between prenatal visits (84%, 95% CI 79–88%). Most women desired either scheduled contact between visits (40%, 95% CI 26–37%), or a combination of scheduled and unscheduled contact (39%, 95% CI 34–45%). Patients preferred contacts between visits be conducted by phone or through the electronic medical record portal more than text messages or home visits. Most patients preferred between visit contact be completed with a nurse (n=225 [75%], 95% CI 70–80%) or health care provider (n=168 [56%], 95% CI 50–61%). There were no differences in desired between-visit contact by patient preference for number of prenatal care visits (Table 3).
Patients were most likely to use individual care models (94%), but more than half of patients would also consider using pregnancy medical homes (72%) and home visits (69%) for prenatal care. Though most patients expressed a preference for having the majority of their visits be individual (88%), some patients would consider alternative care models for the majority of their prenatal visits, including pregnancy medical homes (44%), home visits (37%), group visits (28%), telemedicine (24%), and peer support (23%) (data not shown). Patients who desired more than 14 prenatal visits were less likely to prefer traditional visits than patients who desired 12–14 visits or fewer than 12 visits. There were no other differences in visit type by desired visit number or patient characteristics including age, race, insurance, parity, or satisfaction with prenatal care (Table 3).
Many patients reported comfort with remote monitoring skills, including measuring weight (91%) and blood pressure (82%) and checking fetal heart tones (68%). There were no differences in remote monitoring comfort by desired visit number or patient characteristics including age, race, insurance, or parity (Table 3).
The majority of patients (91%) preferred at least two postpartum visits after delivery, with 44% of patients desiring at least three postpartum visits. Most patients (81%) preferred the first postpartum visit to be scheduled within 3 weeks after delivery—28% desired a visit within 1 week after discharge and 53% (n=159) desired a visit 1–3 weeks after discharge. Only 19% of patients preferred their first visit be 4–6 weeks after delivery, and no patients preferred a visit 6 weeks after delivery. Although a similar number of patients desired an individual visit (57%) or home visit (55%) for their first postpartum visit, most preferred individual visits with their health care provider (69%) for subsequent visits, with fewer women desiring home visits (39%) or other alternative visit types after the initial visit. Primiparous women desired more postpartum visits than multiparous women (three vs two, P=.02). There were no other significant differences by age, race, insurance status, or delivery type. Patients who desired more antepartum visits also preferred a higher median number of postpartum visits (more than 14 visits: 3 [interquartile range 2–5]; 12–14 visits: 2 [interquartile range 2–3]; fewer than 12 visits: 2 [interquartile range 2–3]).
Our study suggests that current outpatient prenatal and postpartum care does not reflect some patients' preferences. Specifically, most women in our cohort reported a preference for fewer scheduled prenatal care visits, with additional between-visit contact points. Many women would consider alternative prenatal visit types for some of their visits, but prefer the majority of their care to be delivered through individual visits. Finally, more than 90% of women reported a desire for multiple postpartum visits, sooner after delivery.
Our study population was from a single, suburban academic center and included predominantly white, privately insured patients. Given the homogenous demographics of our sample, it is possible that even greater variation in patient preferences exists across the country. Future work is needed to define the preferences of various populations, all of which should be incorporated into prenatal care redesign.
Patient preferences should be integrated into care delivery guidelines; however, safety, (ie, ensuring patients' medical and social needs are adequately met) must also be considered. Though guidelines for prenatal and postpartum care were developed without supporting evidence,24 studies have since demonstrated the safety and acceptability of reduced prenatal visit schedules and alternative care models.11,22,25–27
Although the majority of patients in our study preferred fewer antenatal visits, two other groups emerged in our study: those who desired 1) the same number and 2) more prenatal visits than currently recommended. Patients who desired more antenatal care also desired more postpartum visits, suggesting some patients may be high users throughout pregnancy. Few other identifiable differences existed between groups aside from slight, clinically insignificant variation by race and insurance status, making it difficult to identify these women a priori. Many elements of prenatal care delivery lack sufficient evidence to support one single approach. Rather than suggesting a one-size-fits-all prenatal care plan for women, we believe tailored approaches that incorporate women's preferences with medical and social needs through shared decision-making can optimize costs, outcomes, and patient experience.
Delivering care that does not improve outcomes is by definition low-value.28 Given the established safety of reduced visit schedules, and that the majority of patients prefer fewer visits, current prenatal care delivery recommendations for 12–14 visits are likely low-value for patients, health care providers, and health systems. Unnecessary prenatal care is an opportunity cost for patients who must miss work or find childcare, and may reduce access by taking appointments away from patients who need them. Still, comprehensive definitions of value must also include patient-centered outcomes, including care satisfaction. For the 37% of patients in our study who prefer more frequent antenatal visits, additional contact points may provide needed support and improve adherence to recommended services.
Flexible care models may be important for maintaining patient satisfaction. More than 80% of patients in our survey desired contact with their care team between visits. The majority of patients also reported comfort with remote monitoring for weight, blood pressure, and fetal heart tones. These findings are consistent with the OB Nest connected care model,29 which includes a reduced visit schedule, remote monitoring, and nurse care coordination. A randomized controlled trial of OB Nest compared with usual care demonstrated equal pregnancy outcomes with higher patient satisfaction.22 Still, this trial was conducted in a homogenous patient population, emphasizing the need for future studies in diverse groups. Other modalities such as telemedicine, community health workers, and group prenatal care may offer similar flexibility for patients with different needs and preferences (Srinivas SK, Durnwald C, Line L, Patti M, Bucher M, Cunningham S, et al. “Safe Start”: a community health worker program that improves perinatal outcomes in high risk women [abstract]. Am J Obstet Gynecol 2019;220(suppl):S208; Barbour KD, Nelson R, Esplin MS, Varner M, Clark EAS. A randomized trial of prenatal care using telemedicine for low-risk pregnancies: patient-related cost and time savings [abstract]. Am J Obstet Gynecol 2017;216(suppl):S499).12,30 Early data suggest that these models are both preferred by patients and reduce costs, providing a rare “double win” for health care finances and patient-centered outcomes.
Finally, our findings of postpartum care preferences are consistent with recent American College of Obstetricians and Gynecologists recommendations for comprehensive postpartum care, including more frequent postpartum visits, sooner after delivery.2 Most women in our study, regardless of age or parity, desired at least two visits beginning before 3 weeks postpartum. Still, a single postpartum visit at 4–6 weeks remains standard at many institutions.3,4 Home visits, which were acceptable for the first postpartum visit for the majority of patients in our study, may be a promising modality for improving postpartum support without increasing the clinical burden of outpatient clinics or stress on new moms and families. These programs have been successfully implemented in the United States for patients with Medicaid and private insurance, but are not yet considered standard of care.31 Our findings should be interpreted in light of the high postpartum follow-up rate in our hospital system: 88% compared with the national average of 60%.32,33 Postpartum preferences in our population may differ if higher attendance is because patients desire more care, have fewer barriers to postpartum care, or perceive the care delivered to be particularly valuable. Understanding how these preferences extrapolate to populations with poorer attendance and different demographics can guide efforts to support the most vulnerable patients.
Our study has several limitations. First, the survey was conducted at a single suburban academic center, where the majority of patients are white, have private insurance, and are married. Understanding how urban or rural location, insurance, marital status, and racial and ethnic identities affect preferences will be an important part of tailoring care across a variety of settings beyond our institution. Including underserved women and women of racial or ethnic minority groups will be particularly important given the disparities in care access and outcomes seen in our current system.1,2 Additionally, our survey instrument has not been previously validated. As no other available instrument was available, we based our questions on existing literature and expert opinion, and used rigorous methods including review by multiple survey experts and piloting with patients to mitigate potential biases. We were unable to collect demographic information on the women who were unavailable for our survey; however, as our sampled group matches the general characteristics of our hospital's patient population, we believe we have a representative group. Finally, we collected limited sociodemographic data in the setting of this quality-improvement work. Future studies should explore social determinants of health that may influence patient preferences.
Future work will explore how to best capture the preferences and medical and social needs of diverse patients to design tailored prenatal and postpartum care plans. Right-sizing prenatal care—matching patients' needs with services delivered—will be an important next step in preventing both overutilization of unnecessary services and underutilization of valuable care. Next steps will also need to incorporate providers' perspectives, including barriers and facilitators to adopting more flexible care models. Considering that more than 98% of the 4 million women who give birth each year receive prenatal care, improving prenatal care delivery has huge implications for women's health, patient-centered outcomes, and health expenditures across the country.1 By abandoning a “one-size-fits-all” approach to maternity care, we can ensure every patient has access to high-value, patient-centered care that works in the context of their lives and communities.
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