Pregnant women in the United States have greater maternal morbidity and death rates than in other high-income nations, requiring governmental initiatives for improving maternal health care. Despite these efforts, there are still large gaps, particularly in “maternity care deserts” that lack birthing facilities, midwives, or obstetricians. An important yet often overlooked component of perinatal care is offered by maternal-fetal medicine subspecialists (MFMs), who manage high-risk pregnancies and contribute to improved maternal and neonatal outcomes, such as decreasing the cesarean section rate and perinatal mortality. However, MFM care access is limited, especially in the regions that are outside the metropolitan areas.
This cohort study, was exempted from informed consent by Harvard University and the study adhered to the strengthening of the reporting of observational studies in epidemiology (STROBE) recommendations. It assessed MFM care access and telemedicine use among pregnant beneficiaries across over 2 million pregnancies from the Health Care Cost Institute (HCCI) from 2016 to 2021. Pregnancies were defined using a validated algorithm, and those without insurance coverage, with gaps in coverage, or missing zip codes were excluded from the study.
Primary outcomes included MFM involvement in patient care, types of MFM services provided, and telemedicine usage based on taxonomy codes and service classifications such as evaluation and management (EM) visits and ultrasounds. Covariates were age, pregnancy risk, defined using Antenatal and neonatal guidelines, education, and learning systems (ANGELS) and other parameters, urban/rural classification, and sociodemographic characteristics.
The statistical analyses used logistic regression, matched for both patient characteristics and area characteristics, along with sensitivity tests where patients’ covariate data was exchanged. The data was analyzed using R statistical software, with a level of significance of P < 0.05.
A recent study included 2,169,026 pregnancies in 1,968,091 women, and 61.2% of them were 25 to 34 years of age. The majority of the pregnancies (88.7%) were among women from the urban regions while 11.3% were among rural women. Patients in rural locations were farther from MFM specialists, with 56.6% residing 21-60 miles from the nearest specialist.
Of all pregnancies considered as being at risk (74.9% of the participants), 51.6% of them engaged in MFM service. Conversely, 24.4% of non-high-risk pregnancies involved MFM. MFM services included ultrasound procedures, evaluation and management services, antenatal fetal surveillance, delivery services, and other related services. At-risk pregnancies received higher MFM care services with 95.8% of the clients receiving an ultrasound and 53.0% receiving EM services.
The improvement of attention toward MFM care was another finding done in the study showing that involvement had significantly improved over time and was higher in urban regions. Telemedicine also grew more popular, especially during the coronavirus disease (COVID-19) pandemic, and was a vital service for pregnancies in remote regions.
The study revealed that MFM involvement in at-risk pregnancies was seen in less than half of them and MFM services emphasize ultrasound rather than the emergency visits or any other kind of care. There were clear geographical disparities, with access being considerably worse in rural regions and for individuals who lived further away from MFMs. Although more MFM practices participated in 2021 than in 2016, the use of telemedicine, traditional during the COVID-19 pandemic, was still not widely used. This highlights the need to expand the availability of MFM care, particularly in rural areas through telemedicine.
To alleviate the crisis on maternity health in the U.S., it is recommended that policymakers work on increasing access to physicians such as the MFMs as these specialists deal with complicated pregnancies. Telemedicine has the potential to overcome these access barriers, but its utilization is still low including during the current COVID-19 crisis. A more detailed study is needed to identify the obstacles and policies that could enhance safe and evidence-based MFM telemedicine extension is required.
References: Sullivan HK, Armstrong JC, Fox K, Cohen JL, Sinaiko AD. Use of maternal-fetal medicine subspecialist services by commercially insured pregnant people. JAMA Netw Open. 2025;8(1):e2454565. doi:10.1001/jamanetworkopen.2024.54565
