Prenatal Care Visit Frequency: The Patient Perspective

Prenatal care models worldwide seek to reduce negative neonatal outcomes and maternal morbidity and mortality, making prenatal care a priority in preventive healthcare. The current model of the prenatal care visit schedule as recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists consists of a base schedule of one visit every four weeks until week 28, biweekly visits until week 36, and weekly visits thereafter until delivery, for an average of 14 visits.(1) This model appears to be based largely on convention, and has been the subject of several studies that seek to investigate the benefits of alternative schedules.

Several previous studies have sought to evaluate the efficacy of an alternative schedule of prenatal care that involves a reduced number of visits in low-risk expectant mothers. These studies have indicated that there is no significant change in neonatal and maternal outcomes with reduced visit schedules.(2-5) Prior research also has displayed mixed evidence on patient satisfaction with reduced visit schedules and demonstrated diverse reasons for potential dissatisfaction, ranging from too little time spent with providers to barriers such as transportation, insurance, childcare, and missed work.(3,6) Other current studies are evaluating the efficacy of telemedicine in filling the gaps previously identified.(7,8)

To better understand the patient viewpoint on alternative prenatal care schedules, we performed a comprehensive review of women’s perspectives on their prenatal care and the possibility of a reduced schedule. We hope these data guide future models of prenatal care that keep both clinical outcomes and maternal interests in mind. Ultimately, by identifying areas of redundant care, we hope to inform models that prioritize higher-risk patients and eventually contribute to a more individualized prenatal care schedule and reduced maternal morbidity and mortality.

The objectives of this study were as follows:

• To critically assess patient views of their prenatal care experience;

• To identify patient priorities in relation to their prenatal care; and

• To describe the ideal prenatal care plan from the patient perspective.

We hypothesized that low-risk expectant mothers would look favorably on a reduced prenatal care visit schedule.

Materials and Methods

Subjects were recruited face-to-face from the Texas Tech Physicians OB/GYN Clinic in Lubbock, Texas. After informed consent was given and women were screened for inclusion/exclusion criteria, they were invited to participate in the project. Data were collected via a written survey of 20 questions and an open interview of 4 questions. Each subject completed both components. The written survey was filled out by subjects independently, with a researcher present to answer any questions. The open interview was conducted by the investigator using a script to avoid any inconsistency, and was audio recorded. The investigator did not view the results of the written survey before conducting the interview. Data from the recorded interview was transcribed and grouped in units representing themes of discussion, and these themes were evaluated based on frequency.

The written survey incorporated demographic information, background, obstetric history, and a Likert scale evaluating opinions on matters of frequency and quality of prenatal care visits. The Likert scale ranged from 1, “strongly disagree,” to 5, “strongly agree.” No items were switched, so a higher numerical value was always indicative of a stronger level of agreement. This survey was filled out on paper and completed independently by the subject.

The open interview, consisting of four items, was designed to obtain a more thorough view of women’s attitudes and opinions on prenatal care quality and frequency. Subjects were interviewed by researchers TJGW or RJM. The interview was recorded using a digital recorder and later transcribed independently by two researchers. Any discrepancies in the transcript were settled by consensus. To preserve subjects’ privacy, all subjects were completely deidentified, and all audio recordings were deleted as soon as transcription was completed. Transcripts were not returned to subjects for comment or correction. Transcripts were analyzed using the MAXQDA 12 software and coded based on themes of discussion. This was completed as a continuous process as more transcripts were obtained to result in a final codebook of themes that were to be analyzed. Lastly, coded segments were analyzed based on frequency to determine which items were most important to women regarding their prenatal care. Data were collected from 145 subjects. This protocol was approved by the Institutional Review Board of Texas Tech University Health Sciences Center (#L18-175). Statistical analysis was performed using chi-squared and Fisher’s exact test, and significance was set at 0.05. For display purposes, common discussion themes were arranged in a word cloud sized according to frequency, with larger words occurring more frequently.

Results

Using mixed-methods analysis of both the survey and interview data, there were no differences when survey responses were analyzed against age, ethnicity, number of prior pregnancies, number of living children, marital status, or level of education. The average Likert scale scores are summarized in Table 1. Additionally, the median value reported by participants to be their ideal number of prenatal care visits was found to be 12, which is relatively consistent with the current standard schedule.

The words “baby,” “healthy,” and “knowledge” were among common key words subjects used to describe their priorities relating to prenatal care

The qualitative data obtained from the surveys revealed several primary concerns that women have when seeking prenatal care and when contemplating a reduced visit schedule. The words “baby,” “healthy,” and “knowledge” were among common key words subjects used to describe their priorities relating to prenatal care (Figure 1). Subjects used the words “anxiety,” “nervous,” and “reassurance” to describe their concerns with a reduced visit schedule (Figure 2).

Figure 1. Relative frequency of keywords discussing priorities sought in prenatal care visits as told by low-risk expectant mothers. Words are sized by frequency, with larger words representing more frequent themes of discussion.

Figure 2. Relative frequency of keywords discussing concerns about reduced prenatal care visit schedules as told by low-risk expectant mothers. Words are sized by frequency, with larger words representing more frequent themes of discussion.

Fifteen subjects reported having barriers that made it difficult to seek prenatal care when asked this question directly, and in the course of the entire interview, 28 total subjects revealed that they did have obligations that made seeking prenatal care difficult. The most common barriers mentioned by subjects were “school,” “transportation,” and “work” (Figure 3).

Figure 3. Relative frequency of key words discussing barriers to seeking prenatal care as told by low-risk expectant mothers. Words are sized by frequency, with larger words representing more frequent themes of discussion.

When asked whether or not they would be amenable to cutting down the number of prenatal care visits, assuming no added risk to them or the baby, women responded primarily with a “no.” Of our sample size of 145 subjects, 97 participants (66.9%) responded “no,” 36 participants (24.8%) responded “yes,” and 12 participants (8.3%) responded “unsure.”

Discussion

Our hypothesis that low-risk patients would look favorably on a reduced number of prenatal care visits was not supported by these data. The results as presented showed that low-risk pregnant women do not wish to reduce the number of prenatal care visits they receive, across all demographics. In certain demographics, such as college-educated women, women who work full time, and women with multiple previous pregnancies, no statistical difference was shown in preference of the current versus a reduced prenatal care schedule. It is interesting to note that this applies despite increased outside time constraints through working and childcare.

This study was limited to our clinic population, and aspects of that demographic may have affected the results of this study. For example, there was an inherent form of selection bias in polling women who were already successfully attending their appointments. Women who were keeping their appointments and were willing to stay longer to participate were inherently less likely to report barriers to their healthcare than women who missed their appointments or declined due to time constraints. It also must be considered that our population was choosing to receive care at a resident clinic versus a private office setting. It is possible that differences in socioeconomic factors between these two settings could have affected the priorities or attitudes of women seeking prenatal care. Additionally, we were unable to include non–English-speaking women in our study. Given that the language difference alone might have been a “barrier” to healthcare for these women, we feel that they may have expressed valuable opinions that English-speaking mothers did not.

The qualitative portion of our study had its own limitations. One such limitation was in the wording of one of our interview questions: “Are there any barriers that prevent you from seeking prenatal care, and if so, what are they?” The vast majority of our subjects said they did not have any barriers. However, over the course of the interview, many times the subject would reveal that they did have obligations that made it difficult to schedule and/or keep their appointments, such as a difficult job schedule, several kids at home, or a long commute. Subjects seemed to associate the word “barrier” with socioeconomic or insurance issues, whereas the intent was to explore any factors that made it difficult to make and/or keep appointments. In future research on this topic, we may want to consider expanding on the term “barrier” for more precise communication.

Areas for Future Research

This study was conducted in 2018, long before the term COVID-19 was a part of our collective vocabulary; therefore, we believe that the results of this study could potentially be very different given the current climate. With many clinics now using telemedicine for the first time or with increased frequency due to the need for “social distancing,” we believe women might look more favorably on a reduction in the number of in-person prenatal care visits in order to reduce exposure risk. We think, therefore, it would be worthwhile to recreate this study to see how low-risk pregnant women’s priorities and opinions of their prenatal care schedule have changed in light of the pandemic.

Additionally, the stated maternal priority of hearing fetal heart tones found during this study raises an interesting question about the use of home fetal Dopplers. These devices are readily available on Amazon, and are relatively simple to use in many cases. However, in some cases, heart tones can be difficult to find even by an experienced provider. Would use of these devices provide comfort to mothers when successful, or lead to an increase in anxiety and potentially even emergency care visits if mothers were unable to find heart tones on their own? This could prove an interesting avenue for future study, especially in the era of COVID-19.

Practice Implications

Based on presented data, we believe that the distribution of prenatal visit appointment time for low-risk pregnant women should allow for time to be spent on issues of maternal priority, including healthy behaviors, knowledge about the pregnancy, and the future health of the baby. Providers should make a concerted effort to get to know their patients and be aware of barriers and specific concerns in order to decrease the burden on the patient. Additionally, when scheduling, administration should focus on working with patients on factors that reduce compliance, such as childcare, work, school, and transportation.

Conclusion

Our hypothesis that low-risk patients would look favorably on a reduced number of prenatal care visits was not supported by these data. Overwhelmingly, women of all demographics did not want the frequency of their prenatal care visits to be reduced. Despite various levels of employment, single-parent status, or other childcare responsibilities, the vast majority of subjects do not express that they have any barriers inhibiting them from attending appointments and would not reduce the number of visits, even if they believed it to be safe. Regardless of the frequency schedule, women claim that they enjoy coming to prenatal visits to obtain information about their pregnancy, to get answers to their questions, to hear fetal heart tones, and to seek reassurance from their physicians. They even expressed concerns with the idea of reducing the current number of visits, including their own anxiety amassing between visits, timely problem detection, and inadequate care for themselves or their babies.

Acknowledgment: The authors thank the TTUHSC Clinical Research Institute, the staff of the TTUHSC OB/GYN Clinic, and the Institutional Review Board for their support in this project.

References

1. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 7th ed. Washington, DC; American College of Obstetricians and Gynecologists:2012;106-107.

2. Carroli G, Villar J, Piaggio G, et al. WHO systematic review of randomised controlled trials of routine antenatal care. The Lancet. 2001;357(9268):1565-1570. DOI: 10.1016/s0140-6736(00)04723-1.

3. Sikorski J, Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trial comparing two schedules of antenatal visits. Obstet Gynecol Surv. 1997;52:334-335. DOI: 10.1097/00006254-199706000-00004.

4. Partridge CA, Holman JR. Effects of a reduced-visit prenatal care clinical practice guideline. J Am Board Family Med. 2005;18:555-560. DOI: 10.3122/jabfm.18.6.555.

5. Mcduffie RS. Effect of frequency of prenatal care visits on perinatal outcome among low-risk women. JAMA. 1996;275:847. DOI: 10.1001/jama.1996.03530350029030.

6. Mazul MC, Ward TCS, Ngui EM. Anatomy of good prenatal care: perspectives of low income African-American women on barriers and facilitators to prenatal care. J Racial Ethn Health Disparities. 2016;4(1):79-86. doi: 10.1007/s40615-015-0204-x.

7. Ridgeway JL, Leblanc A, Branda M, et al. Implementation of a new prenatal care model to reduce office visits and increase connectivity and continuity of care: protocol for a mixed-methods study. BMC Pregnancy Childbirth. 2015;15:323. doi: 10.1186/s12884-015-0762-2.

8. Barbour KD, Nelson R, Esplin MS, Varner M, Clark EA. 873: A randomized trial of prenatal care using telemedicine for low-risk pregnancies: patient-related cost and time savings. Am J Obstet Gynecol. 2017;216(1) Suppl:S499. doi: 10.1016/j.ajog.2016.11.782.