Variation in Guideline-Based Prenatal Care in a Commercially Insured Population.

Abstract Background Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether receiving more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients’ clinical and sociodemographic characteristics has also not been studied. Objective To measure receipt of guideline-based prenatal care among pregnant patients and to describe the association of guideline-based prenatal care with the number of prenatal visits and other patient characteristics. Study Design This is a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016-2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs® Data Warehouse. We identified eight components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists as well as other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, TDAP vaccine, and group B streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care by patient age, comorbidities, high deductible health plan enrollment, and their county’s rurality, health professional shortage area status, racial composition, median income, and educational attainment. Results The 176,092 pregnancy episodes were mostly among patients ages 25-34 (63%), with few pregnancy comorbidities (81%), and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least four prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of TDAP vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income. Conclusion In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.