Download PDF
Am J Perinatol
DOI: 10.1055/a-2559-7261
Original Article

Evaluating Risk-Adjusted Associations between Prenatal Care Utilization and Obstetric Outcomes in a Commercially Insured Patient Population

Adina R. Kern-Goldberger 
1   Division of Maternal-Fetal Medicine, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic Foundation, Cleveland, Ohio
2   Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
,
Natalie E. Sheils
3   Optum Labs, Minnetonka, Minnesota
,
Rachell Vinculado
3   Optum Labs, Minnetonka, Minnesota
,
Ana Jane A. Paderanga
3   Optum Labs, Minnetonka, Minnesota
,
David A. Asch
4   Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
,
Sindhu K. Srinivas
5   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
› Author Affiliations Funding A.K.-G. was supported by the National Institutes of Health T32 training grant (number: T32-HD007440) in Perinatal Epidemiology at the University of Pennsylvania at the time of this study.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective

Office prenatal care has followed a similar structure for the past century. It is largely unknown whether attendance at routine outpatient antenatal visits prevents major adverse maternal outcomes. This study examined associations between prenatal care utilization and adverse obstetric outcomes including severe maternal morbidity (SMM), preterm birth, and stillbirth in a large, commercially insured US patient population.

Study Design

This is a retrospective cohort study using an insurance claims database evaluating associations between prenatal care utilization and obstetric outcomes over 4 years (2017–2020). Prenatal care utilization was characterized based on the adequacy of prenatal care utilization (APNCU) index. The primary outcome was SMM (as per Centers for Disease Control). Secondary outcomes included preterm birth <37 weeks and stillbirth. Associations between exposure and outcome were investigated using logistic regression models in designated “low” and “medium” maternal risk groups, defined based on obstetric co-morbidity index (OB-CMI) scores modeled at the time of the first trimester and at delivery.

Results

A total of 297,453 patients were included: 78,100 in the sub-group who remained low-risk throughout pregnancy and 49,920 in the sub-group who remained medium-risk. The largest number of patients overall (29.9%) received “adequate plus” care, as defined by the APNCU index, while a plurality of low- and medium-risk patients received “intermediate” care (35.6 and 29.9%, respectively). One point seventy seven percent of patients experienced SMM, 8.63% delivered preterm, and 0.88% had stillbirth. Adjusted analysis comparing volume of prenatal care with these outcomes demonstrated no statistically significant associations, with the exception of preterm birth, which was positively associated with “adequate” and “adequate plus” care in low- and medium-risk patients. “Inadequate care” was not associated with any of the studied outcomes.

Conclusion

Overall volume of prenatal care was not associated with a reduction in adverse obstetric outcomes. Clinical quality improvement and health policy efforts to improve prenatal care delivery models may need to bypass adherence to established guidelines in terms of gross visit number as a key metric and instead work to revise practices based on more meaningful clinical outcomes.

Key Points

  • It is unknown whether receipt of routine prenatal care is associated with better pregnancy outcomes.

  • There were no associations between amount of prenatal care and SMM or stillbirth.

  • Preterm birth was associated with “adequate” and “adequate plus” care in low- and medium-risk patients.

  • Likely suggesting higher utilization in the setting of concerning symptoms.

  • “Inadequate” care was not associated with any of the studied adverse outcomes.

Keywords

care delivery - health services - prenatal care - preterm birth - severe maternal morbidity - stillbirth

Supplementary Material



Publication History

Received: 01 March 2025

Accepted: 16 March 2025

Accepted Manuscript online:
17 March 2025

Article published online:
08 April 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Peahl AF, Howell JD. The evolution of prenatal care delivery guidelines in the United States. Am J Obstet Gynecol 2021; 224 (04) 339-347
    Search in Google Scholar
  • 2 American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 8th. ed. American Academy of Pediatrics; American College of Obstetricians and Gynecologists; 2017
    Search in Google Scholar
  • 3 Gourevitch RA, Natwick T, Chaisson CE, Weiseth A, Shah NT. Variation in guideline-based prenatal care in a commercially insured population. Am J Obstet Gynecol 2022; 226 (03) 413.e1-413.e19
    Search in Google Scholar
  • 4 Osterman MJK, Martin JA. Timing and adequacy of prenatal care in the United States, 2016. Natl Vital Stat Rep 2018; 67 (03) 1-14
    Search in Google Scholar
  • 5 Kogan MD, Martin JA, Alexander GR, Kotelchuck M, Ventura SJ, Frigoletto FD. The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices. JAMA 1998; 279 (20) 1623-1628
    Search in Google Scholar
  • 6 Chawanpaiboon S, Vogel JP, Moller A-B. et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Health 2019; 7 (01) e37-e46
    Search in Google Scholar
  • 7 Geller SE, Koch AR, Garland CE, MacDonald EJ, Storey F, Lawton B. A global view of severe maternal morbidity: moving beyond maternal mortality. Reprod Health 2018; 15 (Suppl. 01) 98
    Search in Google Scholar
  • 8 Optum Labs. Accessed August 1, 2022 at: https://labs.optum.com/
  • 9 Leonard SA, Kennedy CJ, Carmichael SL, Lyell DJ, Main EK. An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity. Obstet Gynecol 2020; 136 (03) 440-449
    Search in Google Scholar
  • 10 Kotelchuck M. An evaluation of the Kessner adequacy of prenatal care index and a proposed adequacy of prenatal care utilization index. Am J Public Health 1994; 84 (09) 1414-1420
    Search in Google Scholar
  • 11 Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012; 120 (05) 1029-1036
    Search in Google Scholar
  • 12 Lentine KL, Schnitzler MA, Garg AX. et al. Race, relationship and renal diagnoses after living kidney donation. Transplantation 2015; 99 (08) 1723-1729
    Search in Google Scholar
  • 13 AHRQ. Creation of New Race-Ethnicity Codes and Socioeconomic Status (SES) Indicators for Medicare Beneficiaries. Accessed 2008 at: https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.233.6403&rep=rep1&type=pdf
  • 14 Peahl AF, Gourevitch RA, Luo EM. et al. Right-sizing prenatal care to meet patients' needs and improve maternity care value. Obstet Gynecol 2020; 135 (05) 1027-1037
    Search in Google Scholar
  • 15 Peahl AF, Zahn CM, Turrentine M. et al. The michigan plan for appropriate tailored healthcare in pregnancy prenatal care recommendations. Obstet Gynecol 2021; 138 (04) 593-602
    Search in Google Scholar
  • 16 Peahl AF, Turrentine M, Barfield W, Blackwell SC, Zahn CM. Michigan plan for appropriate tailored healthcare in pregnancy prenatal care recommendations: a practical guide for maternity care clinicians. J Womens Health (Larchmt) 2022; 31 (07) 917-925
    Search in Google Scholar
  • 17 Homer CS, Oats J, Middleton P, Ramson J, Diplock S. Updated clinical practice guidelines on pregnancy care. Med J Aust 2018; 209 (09) 409-412
    Search in Google Scholar
  • 18 NICE. Antenatal care. Accessed 2012 at: https://www.nice.org.uk/guidance/qs22
  • 19 Gourevitch RA, Peahl AF, McConnell M, Shah N. . Understanding the impact of prenatal care: improving metrics, data, and evaluation. Health Affairs Forefront. Accessed January 1, 2025 at: https://www.healthaffairs.org/content/forefront/understanding-impact-prenatal-care-improving-metrics-data-and-evaluation
  • 20 Baer RJ, Altman MR, Oltman SP. et al. Maternal factors influencing late entry into prenatal care: a stratified analysis by race or ethnicity and insurance status. J Matern Fetal Neonatal Med 2019; 32 (20) 3336-3342
    Search in Google Scholar
  • 21 Krukowski RA, Jacobson LT, John J. et al. Correlates of early prenatal care access among u.s. women: data from the pregnancy risk assessment monitoring system (PRAMS). Matern Child Health J 2022; 26 (02) 328-341
    Search in Google Scholar
  • 22 Debiec KE, Paul KJ, Mitchell CM, Hitti JE. Inadequate prenatal care and risk of preterm delivery among adolescents: a retrospective study over 10 years. Am J Obstet Gynecol 2010; 203 (02) 122.e1-122.e6
    Search in Google Scholar
  • 23 Partridge S, Balayla J, Holcroft CA, Abenhaim HA. Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: a retrospective analysis of 28,729,765 U.S. deliveries over 8 years. Am J Perinatol 2012; 29 (10) 787-793
    Search in Google Scholar
  • 24 Raatikainen K, Heiskanen N, Heinonen S. Under-attending free antenatal care is associated with adverse pregnancy outcomes. BMC Public Health 2007; 7: 268
    Search in Google Scholar
  • 25 Heaman MI, Newburn-Cook CV, Green CG, Elliott LJ, Helewa ME. Inadequate prenatal care and its association with adverse pregnancy outcomes: a comparison of indices. BMC Pregnancy Childbirth 2008; 8 (01) 15
    Search in Google Scholar
  • 26 Heaman MI, Martens PJ, Brownell MD, Chartier MJ, Derksen SA, Helewa ME. The association of inadequate and intensive prenatal care with maternal, fetal, and infant outcomes: a population-based study in Manitoba, Canada. J Obstet Gynaecol Can 2019; 41 (07) 947-959
    Search in Google Scholar
  • 27 McDuffie Jr RS, Beck A, Bischoff K, Cross J, Orleans M. Effect of frequency of prenatal care visits on perinatal outcome among low-risk women. A randomized controlled trial. JAMA 1996; 275 (11) 847-851
    Search in Google Scholar
  • 28 Dowswell T, Carroli G, Duley L. et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2015; 2015 (07) CD000934
    Search in Google Scholar
  • 29 Carter EB, Tuuli MG, Caughey AB, Odibo AO, Macones GA, Cahill AG. Number of prenatal visits and pregnancy outcomes in low-risk women. J Perinatol 2016; 36 (03) 178-181
    Search in Google Scholar
  • 30 Chappell LC, Tucker KL, Galal U. et al; BUMP 2 Investigators. Effect of self-monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension: the BUMP 2 randomized clinical trial. JAMA 2022; 327 (17) 1666-1678
    Search in Google Scholar
  • 31 Tucker KL, Mort S, Yu LM. et al; BUMP Investigators. Effect of self-monitoring of blood pressure on diagnosis of hypertension during higher-risk pregnancy: the BUMP 1 randomized clinical trial. JAMA 2022; 327 (17) 1656-1665
    Search in Google Scholar