Use of Maternal-Fetal Medicine Subspecialist Services by Commercially Insured Pregnant People

Abstract

Importance: Improving access to high-quality maternity care and reducing maternal morbidity and mortality are major policy priorities in the US. Previous research has primarily focused on access to general obstetric care rather than access to high-risk pregnancy care provided by maternal-fetal medicine subspecialists (MFMs).

Objective: To measure access to MFM services and determine patient factors associated with MFM service use, including MFM telemedicine.

Design, setting, and participants: This cohort study identified pregnancies in commercial health insurance claims from the Health Care Cost Institute from 2016 to 2021. More than 2.1 million pregnancies were included, where age at delivery was 18 years or greater and people were continuously enrolled for the duration of their pregnancy. The association of patient and pregnancy covariates with MFM involvement in care was analyzed using logistic regression; and rates of telemedicine for pregnancies in urban and rural areas were reported over time. Data were analyzed from June 2022 to March 2024.

Main outcomes and measures: Primary study outcomes included whether a pregnancy ever had a service from an MFM, the type of MFM services provided, and whether MFM care occurred via telemedicine.

Results: There were 2 169 026 pregnancies among 1 968 091 unique people (1 325 212 [61.2%] aged 25 to 34 years). Among 1 625 237 pregnancies at risk for conditions that might require MFM involvement, 838 493 (51.6%) had an MFM service. Rates of MFM involvement in care varied considerably by geography, with pregnancies in rural areas having lower use than urban areas. Use of telemedicine-enabled MFM care increased in 2020 and 2021 but remained low: in 2021, 2.7% of urban pregnancies (7535 of 276 599) and 1.7% of rural pregnancies (550 of 32 949) received telemedicine-enabled MFM care.

Conclusions and relevance: In this cohort study, access to MFM services varied across geography, even among pregnancies at risk for conditions that might require MFM involvement. These results suggested a need to improve access to MFM care for at-risk pregnancies and to further explore expanded access via telemedicine.

Figure 1.. Odds of Maternal-Fetal Medicine Subspecialist (MFM) Involvement in Pregnancy Care

Results show the odds ratios (ORs) and 95% CI for coefficients from logistic regression, adjusted for age, pregnancy risk, driving distance to nearest MFM, delivery year, pregnancy number in sample, and the Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Model estimated on 2 163 687 pregnancies. SVI was reported with its 4 defined groups: socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation. Model includes state fixed effects, standard errors clustered at the state level.

Figure 2.. Predicted Probability of Maternal-Fetal Medicine Subspecialist (MFM) Involvement in Care of At-Risk Pregnancies by Hospital Service Area (HSA)

Map of the US is color-coded to show the predicted probability of pregnancies with MFM service utilization by HSA. Model estimated on 1 625 237 pregnancies. Predicted probabilities from a logistic regression adjusted for age, pregnancy risk, driving distance to nearest MFM, delivery year, pregnancy number in sample, and Centers for Disease Control and Prevention Social Vulnerability Index. Model includes HSA fixed effects, standard errors clustered at the HSA level. HSAs with 10 or fewer pregnancies were excluded due to Health Care Cost Institute privacy requirements.

Figure 3.. Comparison of In-Person and Telemedicine Maternal-Fetal Medicine Subspecialist (MFM) Utilization From 2016 to 2021 by Geographic Location

Telemedicine use was identified via procedure codes, procedure code modifiers, and place-of-service codes (eTable 2 in Supplement 1). Rural or urban location was determined by the Rural Urban Commuting Area (RUCA) for the person’s zip code. RUCA codes were grouped into 2 standard categories: urban (codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1), and rural (codes 4.0, 4.2, 5.0, 5.2, 6.0, 6.1, 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, 9.2, 10.0, 10.2, 10.3, 10.4, 10.5, and 10.6). Values for only-telemedicine MFM visit during pregnancy were censored prior to 2020, when they did not meet the Health Care Cost Institute requirement for number of observations.