Society for Maternal-Fetal Special Statement: Transforming the maternity care team model

Abstract

In the last decade, the healthcare system has changed due to circumstances such as a codification of accountable care organizations and a pivot to telemedicine during the COVID-19 pandemic. Due to increased gaps in care, pregnancy-related complications, and mistrust in the healthcare system, it is important that pregnancy care be centered around specific patient health values and needs. The Society for Maternal-Fetal Medicine proposes a list of potential maternity care team members to care for patients during the prepregnancy, pregnancy, and postpartum periods. We believe that the incorporation of a comprehensive maternity care team can help inform patient-centered policy, parallel the pace of medical advancement, mitigate health inequities, and enhance patient trust.

1 |. REDEFINING THE MATERNITY CARE TEAM MODEL

Since the Society for Maternal-Fetal Medicine (SMFM) published a special report on maternal-fetal medicine (MFM) subspecialists’ role in 2014 [1], the healthcare ecosystem has significantly shifted. From the codification of accountable care organizations [2] and a shift toward team- and hospitalist-based care to the accelerated implementation of telemedicine in response to the COVID-19 pandemic, [3] maternity care teams and care delivery methods have transformed over the past decade. In this SMFM Special Statement, we review several changes that have affected the practice of MFM and call for redefining the maternity care team model.

First, there is a growing divide between the urban and rural healthcare experience, and the number of maternity care deserts is increasing amid rising closures of rural hospitals [4]. Maternity care deserts are “counties where there are no hospitals offering obstetric care and no obstetric providers.” [5] In 2022, 36% of US counties, primarily rural, qualified as maternity care deserts [4]. This represents a 2% increase since 2020 and affected 2.2 million reproductive-aged persons [4]. Only 7% of maternity care providers, the majority of whom are not MFM subspecialists, currently practice in rural areas [4]. As a result, the MFM subspecialist’s role has expanded to provide obstetric care at greater distances via telemedicine. This shift has increased access, but 20% of US counties still have suboptimal internet access, impeding participation in virtual visits [5]. Additionally, while telehealth can be a vital tool, it does not replace in-person care for pregnant people. For those seeking in-person care, transportation remains a significant barrier, and the interaction between geography and social determinants of health (SDOH) in maternity care deserts contributes to poor obstetric outcomes in an already vulnerable population. For instance, the proportion of birthing individuals living in counties below the national median household income is twice as high in maternity care deserts compared to full access counties (90.1% vs. 45.2%), and reproductive-age individuals in these areas are more likely to suffer from asthma, hypertension, tobacco use, and preterm birth [6]. One way of bridging the urgent divide between urban and rural communities is to expand the maternity care team.

The current obstetric population, as compared to 10 years ago, is more acutely and chronically ill, with increasing rates of pregnancy-related complications, maternal mortality, cesarean delivery, preexisting conditions, and mental health needs [7]. Among reproductive-age individuals in 11 countries, US residents were the least likely to have a primary care clinician. Additionally, they were more likely to report difficulty affording medical care and to delay or defer care [7]. Concurrently, as patients are more complex yet experience social, economic, and political barriers to care, there is increasing demand for subspeciality care. Advancements in our field offer new opportunities to intervene in maternal and fetal conditions and may improve perinatal outcomes. Examples include innovation in medical device technology [8], surgical approaches [9], fetal intervention [10], and genetic screening and diagnostic options [11] —many of which did not exist 10 years ago. Thus, an updated understanding of the maternity care team is necessary to delineate the varying roles of the MFM subspecialist and care partners.

Lastly, there is rising awareness of mistrust surrounding healthcare systems and health information, which was exacerbated by the COVID-19 pandemic [12]. Medical mistrust may stem from individual negative experiences with healthcare as well as historical injustices against marginalized groups [13]. MFM subspecialists care for a diverse population, but this diversity is not reflected in the demographic composition of our physician workforce [14]. Incorporating trained professionals providing culturally concordant support during pregnancy, delivery, and post-partum, such as through doula services, is an important strategy for maternity care teams to regain and promote patient trust [15–18].

For all these complex and evolving reasons, and because each patient has a different set of healthcare values and needs, care is best optimized when provided by a coalition of dedicated maternity care team members. The core maternity care team and proposed additional members are listed in Table 1.

TABLE 1.

Core maternity care team and additional members.

Maternity care teama
Previously included members1	Additional members
• Certified nurse midwives and certified midwives • Family physicians • Maternal-fetal medicine (MFM) subspecialists • Nurse practitioners • Obstetrician gynecologists • Obstetric-gynecologic hospitalists • Physician assistants	• Anesthesiologists • Community healthcare workers • Diabetes educators (dieticians, nutritionists) • Doulas • Genetic counselors • Mental healthcare providers • Other subspecialists in obstetrics gynecology (complex family planning, reproductive endocrinology and infertility, gynecology oncology) • Patient navigators • Neonatologists • Referral networks for abortion care • Registered nurses and other nursing staff • Safety training, simulation, risk, and quality personnel • Social workers • Sonographers

^aTeams will vary based on patient needs and may only include some of the members mentioned above. Certain roles may not be fulfilled in regions with limited resources or legislative restrictions.

Several essential tenets contribute to the maternity care team functioning effectively. These include pregnant people having timely access to care and appropriate risk assessment. Additionally, the members of the care team must have well-defined roles in the patient’s care, collaborative spirit, clear communication, and explicit policies explaining criteria for consultations, co-management, and transfer of care [1]. Members of the team should also be active in the postpartum transition from maternity care to primary and specialty care.

The role of the MFM subspecialist in collaboration with the entire maternity care team is important for patients and policymakers, particularly as past policy efforts have included a limited subset of providers [19, 20]. We outline the full team of clinicians and allied health professionals that should be supported in the care of high-risk patients in the prepregnancy, pregnancy, and postpartum periods. Full recognition of this transformed maternity care team is an intentional step toward achieving reproductive justice for pregnant and birthing persons. Any policies that seek to improve health outcomes for pregnant individuals should attempt to incorporate the full maternity care team. Examples of advocacy include allotting funding for non-traditional members of the maternity care team and expanding a diverse workforce beyond obstetricians and gynecologists to include social workers, nurses, and interdisciplinary colleagues. SMFM proposes that our society, healthcare systems, and individuals recognize additional members of the maternity care team so that policies fulfill our patients’ needs. In addition to improving care outcomes, a complete and seamless maternity care team informs patient-centered policy, parallels the pace of medical advancement, mitigates health inequities, and enhances patient trust.