prenatal visit schedule aafp

TYLER S. ROGERS, MD, MBA, FAAFP, AND BRENDAN LUSHBOUGH, DO, Martin Army Community Hospital, Fort Benning, Georgia

Am Fam Physician. 2023;107(2):187-190

Author disclosure: No relevant financial relationships.

Key Clinical Issue

What are the risks and benefits of less frequent antenatal in-person visits vs. traditional visit schedules and televisits replacing some in-person antenatal appointments?

Evidence-Based Answer

Compared with traditional schedules of antenatal appointments, reducing the number of appointments showed no difference in gestational age at birth (mean difference = 0 days), likelihood of being small for gestational age (odds ratio [OR] = 1.08; 95% CI, 0.70 to 1.66), likelihood of a low Apgar score (mean difference = 0 at one and five minutes), likelihood of neonatal intensive care unit (NICU) admission (OR = 1.05; 95% CI, 0.74 to 1.50), maternal anxiety, likelihood of preterm birth (nonsignificant OR), and likelihood of low birth weight (OR = 1.02; 95% CI, 0.82 to 1.25). (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.) Studies comparing hybrid visits (i.e., televisits and in-person) with in-person visits only did not find differences in rates of preterm births (OR = 0.93; 95% CI, 0.84 to 1.03; P = .18) or rates of NICU admissions (OR = 1.02; 95% CI, 0.82 to 1.28). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) There was insufficient evidence to assess other outcomes. 1

Practice Pointers

Antenatal care is a cornerstone of obstetric practice in the United States, and millions of patients receive counseling, screening, and medical care in these visits. 2 , 3 There is clear evidence supporting the benefits of antenatal care; however, the number of appointments needed and setting of visits is less understood.

The American College of Obstetricians and Gynecologists recommends antenatal visits every four weeks until 28 weeks' gestation, every two weeks until 36 weeks' gestation, and weekly thereafter, which typically involves 10 to 12 visits. 4

Expert consensus and past meta-analyses have favored fewer antenatal care visits given similar maternal and neonatal outcomes. In 1989, the U.S. Public Health Service suggested a reduction in the antenatal visit schedule based on a multidisciplinary panel and expert opinion in conjunction with a literature review; however, the American College of Obstetricians and Gynecologists has not updated its guidelines, and practices have not changed. 5 A 2010 Cochrane review found no differences in perinatal mortality between patients randomized to higher vs. reduced antenatal care groups in high-income countries, and a 2015 Cochrane review showed no difference in neonatal outcomes for women in high-income countries. 6 , 7

The Agency for Healthcare Research and Quality (AHRQ) review showed moderate- and low-strength evidence and did not find significant differences between traditional and abbreviated schedules when looking at many outcomes, such as gestational age at birth, low birth weight, Apgar scores, NICU admission, preterm birth, and maternal anxiety. The review was limited by a small evidence base with studies that are difficult to compare. The randomized controlled trials that were eligible were adjusted for confounding, whereas the nonrandomized controlled studies were not adjusted and were at high risk for confounding.

Telemedicine, defined as the use of electronic information and telecommunication to support health care among patients, clinicians, and administrators, is a new option for antenatal care delivery. 8 Televisits, the real-time communication between patients and clinicians via phone or the internet, are the specific interactions that encompass telemedicine. Recent literature suggests that supplementing in-person visits with televisits in low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction scores. 9 The AHRQ review found no significant differences between rates of preterm births or NICU admissions for a hybrid model of televisits and in-person visits compared with in-person visits only. The review was limited due to the lack of adjustments for potential confounders in the study. For example, some of the studies were conducted during the COVID-19 pandemic, which adds multiple confounders and potential for bias.

The AHRQ review offers limited opportunity for conclusions to suggest changes in current practice. The current evidence supports past evidence, suggesting that fewer visits are not associated with neonatal or maternal harm, and televisits may have a role in antenatal care. Many of the other outcomes of interest had insufficient evidence to generate conclusions.

Editor's Note:   American Family Physician SOR ratings are different from the AHRQ Strength of Evidence ratings.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, the U.S. Department of Defense, or the U.S. government.

For the full review, go to https://effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/cer-257-antenatal-care.pdf .

Balk EM, Konnyu KJ, Cao W, et al. Schedule of visits and televisits for routine antenatal care: a systematic review. Comparative effectiveness review no. 257. (Prepared by the Brown Evidence-Based Practice Center under contract no. 75Q80120D00001.) AHRQ publication no. 22-EHC031. Agency for Healthcare Research and Quality; June 2022. Accessed October 1, 2022. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-257-antenatal-care-evidence-summary.pdf

Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: part I. General prenatal care and counseling issues. Am Fam Physician. 2005;71(7):1307-1316.

Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014;89(3):199-208.

Kriebs JM. Guidelines for perinatal care, sixth edition: by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. J Midwifery Womens Health. 2010;55(2):e37.

Rosen MG, Merkatz IR, Hill JG. Caring for our future: a report by the expert panel on the content of prenatal care. Obstet Gynecol. 1991;77(5):782-787.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2010(10):CD000934.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2015(7):CD000934.

Fatehi F, Samadbeik M, Kazemi A. What is digital health? Review of definitions. Stud Health Technol Inform. 2020;275:67-71.

Cantor AG, Jungbauer RM, Totten AM, et al. Telehealth strategies for the delivery of maternal health care: a rapid review. Ann Intern Med. 2022;175(9):1285-1297.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ’s summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

This series is coordinated by Joanna Drowos, DO, MPH, MBA, contributing editor. A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq .

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INTRODUCTION

This topic will discuss the initial prenatal assessment (which may require more than one visit) in the United States. Most of these issues are common to pregnancies worldwide. Preconception care, ongoing prenatal care after the initial prenatal assessment, and issues related to patient counseling are reviewed separately.

● (See "The preconception office visit" .)

● (See "Prenatal care: Second and third trimesters" .)

● (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs" .)

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Prenatal care: 1st trimester visits

Pregnancy and prenatal care go hand in hand. During the first trimester, prenatal care includes blood tests, a physical exam, conversations about lifestyle and more.

Prenatal care is an important part of a healthy pregnancy. Whether you choose a family physician, obstetrician, midwife or group prenatal care, here's what to expect during the first few prenatal appointments.

The 1st visit

When you find out you're pregnant, make your first prenatal appointment. Set aside time for the first visit to go over your medical history and talk about any risk factors for pregnancy problems that you may have.

Medical history

Your health care provider might ask about:

• Your menstrual cycle, gynecological history and any past pregnancies
• Your personal and family medical history
• Exposure to anything that could be toxic
• Medications you take, including prescription and over-the-counter medications, vitamins or supplements
• Your lifestyle, including your use of tobacco, alcohol, caffeine and recreational drugs
• Travel to areas where malaria, tuberculosis, Zika virus, mpox — also called monkeypox — or other infectious diseases are common

Share information about sensitive issues, such as domestic abuse or past drug use, too. This will help your health care provider take the best care of you — and your baby.

Your due date is not a prediction of when you will have your baby. It's simply the date that you will be 40 weeks pregnant. Few people give birth on their due dates. Still, establishing your due date — or estimated date of delivery — is important. It allows your health care provider to monitor your baby's growth and the progress of your pregnancy. Your due date also helps with scheduling tests and procedures, so they are done at the right time.

To estimate your due date, your health care provider will use the date your last period started, add seven days and count back three months. The due date will be about 40 weeks from the first day of your last period. Your health care provider can use a fetal ultrasound to help confirm the date. Typically, if the due date calculated with your last period and the due date calculated with an early ultrasound differ by more than seven days, the ultrasound is used to set the due date.

Physical exam

To find out how much weight you need to gain for a healthy pregnancy, your health care provider will measure your weight and height and calculate your body mass index.

Your health care provider might do a physical exam, including a breast exam and a pelvic exam. You might need a Pap test, depending on how long it's been since your last Pap test. Depending on your situation, you may need exams of your heart, lungs and thyroid.

At your first prenatal visit, blood tests might be done to:

• Check your blood type. This includes your Rh status. Rh factor is an inherited trait that refers to a protein found on the surface of red blood cells. Your pregnancy might need special care if you're Rh negative and your baby's father is Rh positive.
• Measure your hemoglobin. Hemoglobin is an iron-rich protein found in red blood cells that allows the cells to carry oxygen from your lungs to other parts of your body. Hemoglobin also carries carbon dioxide from other parts of your body to your lungs so that it can be exhaled. Low hemoglobin or a low level of red blood cells is a sign of anemia. Anemia can make you feel very tired, and it may affect your pregnancy.
• Check immunity to certain infections. This typically includes rubella and chickenpox (varicella) — unless proof of vaccination or natural immunity is documented in your medical history.
• Detect exposure to other infections. Your health care provider will suggest blood tests to detect infections such as hepatitis B, syphilis, gonorrhea, chlamydia and HIV , the virus that causes AIDS . A urine sample might also be tested for signs of a bladder or urinary tract infection.

Tests for fetal concerns

Prenatal tests can provide valuable information about your baby's health. Your health care provider will typically offer a variety of prenatal genetic screening tests. They may include ultrasound or blood tests to check for certain fetal genetic problems, such as Down syndrome.

Lifestyle issues

Your health care provider might discuss the importance of nutrition and prenatal vitamins. Ask about exercise, sex, dental care, vaccinations and travel during pregnancy, as well as other lifestyle issues. You might also talk about your work environment and the use of medications during pregnancy. If you smoke, ask your health care provider for suggestions to help you quit.

Discomforts of pregnancy

You might notice changes in your body early in your pregnancy. Your breasts might be tender and swollen. Nausea with or without vomiting (morning sickness) is also common. Talk to your health care provider if your morning sickness is severe.

Other 1st trimester visits

Your next prenatal visits — often scheduled about every four weeks during the first trimester — might be shorter than the first. Near the end of the first trimester — by about 12 to 14 weeks of pregnancy — you might be able to hear your baby's heartbeat with a small device, called a Doppler, that bounces sound waves off your baby's heart. Your health care provider may offer a first trimester ultrasound, too.

Your prenatal appointments are an ideal time to discuss questions you have. During your first visit, find out how to reach your health care team between appointments in case concerns come up. Knowing help is available can offer peace of mind.

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• Lockwood CJ, et al. Prenatal care: Initial assessment. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
• Prenatal care and tests. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests. Accessed July 9, 2018.
• Cunningham FG, et al., eds. Prenatal care. In: Williams Obstetrics. 25th ed. New York, N.Y.: McGraw-Hill Education; 2018. https://www.accessmedicine.mhmedical.com. Accessed July 9, 2018.
• Lockwood CJ, et al. Prenatal care: Second and third trimesters. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
• WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/. Accessed July 9, 2018.
• Bastian LA, et al. Clinical manifestations and early diagnosis of pregnancy. https://www.uptodate.com/contents/search. Accessed July 9, 2018.

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Prenatal care checkups

Prenatal care is medical care you get during pregnancy. at each prenatal care visit, your health care provider checks on you and your growing baby., call your provider to schedule your first prenatal care checkup as soon as you know you’re pregnant., getting early and regular prenatal care can help you have a healthy pregnancy and a full-term baby., go to all your prenatal care checkups, even if you’re feeling fine..

What is prenatal care and why is it important?

Prenatal care is medical care you get during pregnancy. At each visit, your health care provider checks on you and your growing baby. Call your provider and go for your first prenatal care checkup as soon as you know you’re pregnant. And go to all your prenatal care checkups, even if you’re feeling fine.

Getting early and regular prenatal care can help you have a healthy pregnancy and a full-term baby. Full term means your baby is born between 39 weeks (1 week before your due date) and 40 weeks, 6 days (1 week after your due date). Being born full term gives your baby the right amount of time he needs in the womb to grow and develop.

Don’t be afraid to talk to your provider about personal things. Your provider needs to know all about you so she can give you and your baby the best care. She asks lots of questions about you, your partner and your families. Your medical information and anything you tell her are confidential. This means she can’t share them with anyone without your permission. So don’t be afraid to tell her about things that may be uncomfortable or embarrassing, like if your partner hurts or scares you or if you smoke , drink alcohol , use street drugs or abuse prescription drugs .

Who can you go to for prenatal care?

You can get prenatal care from different kinds of providers:

• An obstetrician/gynecologist (also called OB/GYN) is a doctor who has education and training to take care of pregnant women and deliver babies. The American College of Obstetricians and Gynecologists  can help you find an OB in your area. 
• A family practice doctor (also called a family physician) is a doctor who can take care of every member of your family. This doctor can take care of you before, during and after pregnancy. The American Board of Family Medicine can help you find a family practice doctor in your area. 
• A maternal-fetal medicine (also called MFM) specialist is an OB with education and training to take care of women who have high-risk pregnancies. If you have health conditions that may cause problems during pregnancy, your provider may want you to see a MFM specialist. The Society for Maternal-Fetal Medicine can help you find a specialist in your area.
• A certified nurse-midwife (also called CNM) is a nurse with education and training to take care of women of all ages, including pregnant women. The American College of Nurse-Midwives  can help you find a CNM in your area.
• A family nurse practitioner (also called FNP) or a women’s health nurse practitioner (also called WHNP). A FNP is a nurse with education and training to take care of every member of your family. A WHNP is a nurse with education and training to take care of women of all ages, including pregnant women. The American Association of Nurse Practitioners can help you find these kinds of nurse practitioners in your area.   

Think about these things to help you choose a provider:

• Is the provider licensed and board certified to take care of you during pregnancy, labor and birth? Licensed means the provider can legally practice medicine in a state. To have a license, a provider has to have a certain amount of education and training and pass certain tests to make sure he can safely take care of patients. Board certified means that a provider has had extra training in a certain area (called a specialty).
• Is the provider covered by your health insurance ? 
• Have you heard good things about the provider? Is she recommended by your friends or family? How does your partner feel about her as your prenatal care provider?  
• Would you rather see a man or a woman provider? How old to you want the provider to be? Does he explain things clearly? 
• Is the office easy to get to? Do the office hours fit into your schedule? Is the office staff friendly and helpful? 
• Who takes care of phone calls during office hours? Who handles them after hours or in an emergency? Do you have to pay if your provider spends time with you on the phone? 
• Is the provider in group practice? If yes, will you always see your provider at prenatal care checkups? Or will you see other providers in the practice? Who will deliver your baby if your provider’s not available when you go into labor? 
• What hospital or birthing center does the provider use? What do you know about it? Is it easy for you to get to?  

How often do you go for prenatal care checkups?

Most pregnant women can follow a schedule like this:

• Weeks 4 to 28 of pregnancy. Go for one checkup every 4 weeks (once a month).
• Weeks 28 to 36 of pregnancy. Go for one checkup every 2 weeks (twice a month).
• Weeks 36 to 41 of pregnancy. Go for one checkup every week (once a week).

If you have complications during pregnancy, your provider may want to see you more often.

Your partner or support person (a friend or someone from your family) is welcome at your prenatal checkups.

How can you get ready for your first prenatal care checkup?

Be ready to talk with your provider about:

• The first day of your last menstrual period (also called LMP). Your provider can use this to help find out your baby’s due date .
• Health conditions you have, like depression , diabetes , high blood pressure , and not being at a healthy weight . Conditions like these can cause problems during pregnancy. Tell your provider about your family health history . This is a record of any health conditions and treatments that you, your partner and everyone in your families have had. Use the March of Dimes Family Health History Form and share it with your provider. If you have a record of your vaccinations , take it to your checkup.  A vaccination is a shot that contains a vaccine that helps protect you from certain harmful infections. 
• Medicines you take, including prescription medicine , over-the-counter medicine, supplements and herbal products . Some medicines can hurt your baby if you take them during pregnancy, so you may need to stop taking it or switch to another medicine. Don’t stop or start taking any medicine without talking to your provider first. And tell your provider if you’re allergic to any medicine. You may be allergic to a medicine if it makes you sneeze, itch, get a rash or have trouble breathing when you take it.
• Your pregnancy history. Tell your provider if you’ve been pregnant before or if you’ve had trouble getting pregnant. Tell her if you’ve had any pregnancy complications or if you’ve had a premature baby (a baby born before 37 weeks of pregnancy), a miscarriage or stillbirth . Miscarriage is when a baby dies in the womb before 20 weeks of pregnancy. Stillbirth is when a baby dies in the womb after 20 weeks of pregnancy.
• Smoking, drinking alcohol, using street drugs and abusing prescription drugs. All of these can hurt your baby. Alcohol includes beer, wine and liquor. Street drugs are illegal to use, like heroin and cocaine. Abusing prescription drugs means you use them differently than your provider tells you to. This means you take more than your provider says you can take, you take it with alcohol or other drugs or you use someone else’s prescription drugs.
• Stress you feel. Stress is worry, strain or pressure that you feel in response to things that happen in your life. Talk to your provide about ways to deal with and reduce your stress. High levels of stress can cause complications during pregnancy.
• Your safety at home and work. Tell your provider about chemicals you use at home or work and about what kind of job you have. If you’re worried about abuse during pregnancy and ask about ways you can stay healthy and safe at home and work.

What happens at your first prenatal care checkup?

Your first checkup is usually the longest because your provider asks you lots of questions about your health. At your first prenatal care checkup, your provider:

• Gives you a physical exam and checks your overall health. Your provider checks your weight and height to figure out how much weight you should gain during pregnancy.
• Checks your blood, blood pressure and urine. Blood tests can tell your provider if you have certain infections, like syphilis , hepatitis B and HIV. Your provider also uses a blood test to find out your blood type and Rh factor and to check for anemia. Anemia is when you don't have enough healthy red blood cells to carry oxygen to the rest of your body. Rh factor is a protein that most people have on their red blood cells. If you don’t have it and your baby does, it can cause Rh disease in your baby. Treatment during pregnancy can prevent Rh disease. Blood pressure and urine tests can help your provider diagnose a serious condition called preeclampsia . This is a kind of high blood pressure that can happen during pregnancy. Having too much protein in your urine may be a sign of preeclampsia. Urine tests also can tell your provider if you have a kidney or bladder infection or other conditions, like diabetes.  
• Gives you a pelvic exam and a Pap smear. Your provider checks the pelvic organs (pelvis and womb) to make sure they’re healthy. For the Pap smear, your provider collects cells from your cervix to check for cancer and for infections, like chlamydia and gonorrhea. The cervix is the opening to the uterus (womb) that sits at the top of the vagina.
• May give you vaccinations, like a flu shot. It’s safe to get a flu shot any time during pregnancy. But some vaccinations are best at certain times and some aren’t recommended during pregnancy. Talk to your provider about what’s best and safe for you and your baby.
• Tells you your due date. Your provider usually uses your LMP to figure out your due date. But you may get an early ultrasound to confirm that you’re pregnant and help your provider figure out your baby’s age. An ultrasound uses sound waves and a computer screen to show a picture of your baby inside the womb.
• Prescribes a prenatal vitamin. This is a multivitamin made for pregnant women. Your prenatal vitamin should have 600 micrograms of folic acid in it. Folic acid is a vitamin that every cell in your body needs for healthy growth and development. If you take it before pregnancy and during early pregnancy, it can help protect your baby from birth defects of the brain and spine called neural tube defects (also called NTDs), and birth defects of the mouth called cleft lip and palate .
• Talks to you about prenatal tests. These are medical tests you get during pregnancy. They help your provider find out how you and your baby are doing. You may want to have certain tests only if you have certain problems or if you’re at high risk of having a baby with a genetic or chromosomal condition , like Down syndrome . If your provider thinks you’re at risk for having a baby with one of these conditions, he may recommend that you see a genetic counselor . This person has training to help you understand about genes, birth defects and other medical conditions that run in families, and how they can affect your health and your baby’s health.

What happens at later prenatal care checkups?

Later prenatal care checkups usually are shorter than the first one. At your checkups, tell your provider how you’re feeling. There’s a lot going on inside your body during pregnancy. Your provider can help you understand what’s happening and help you feel better if you’re not feeling well. Between visits, write down questions you have and ask them at your next checkup.

At later prenatal care checkups, your health care provider:

• Checks your weight and blood pressure. You also may get urine and blood tests.
• Checks your baby’s heartbeat. This happens after about 10 to 12 weeks of pregnancy. You can listen, too!
• Measures your belly to check your baby’s growth. Your provider starts doing this at about 20 weeks of pregnancy. Later in pregnancy, she also feels your belly to check your baby’s position in the womb.
• Gives you certain prenatal tests to check you and your baby. For example, most women get an ultrasound at 18 to 20 weeks of pregnancy. You may be able to tell if your baby’s a boy or a girl from this ultrasound, so be sure to tell your provider if you don’t want to know! Later in pregnancy, your provider may use ultrasound to check the amount of amniotic fluid around your baby in the womb. Between 24 and 28 weeks, you get a glucose screening test to see if you may have gestational diabetes . This is a kind of diabetes that some women get during pregnancy. And at 35 to 37 weeks, you get a test to check for group B strep . This is an infection you can pass to your baby.
• Asks you about your baby’s movement in the womb. If it’s your first pregnancy, you may feel your baby move by about 20 weeks. If you’ve been pregnant before, you may feel your baby move sooner. Your provider may ask you to do kick counts to keep track of how often your baby moves.
• Gives you a Tdap vaccination at 27 to 36 weeks of pregnancy. This vaccination protects both you and your baby against pertussis (also called whooping cough). Pertussis spreads easily and is dangerous for a baby.
• Does a pelvic exam . Your provider may check for changes in your cervix as you get close to your due date.

How can you get free or low-cost prenatal care?

If you don't have health insurance or can't afford prenatal care, find out about free or low-cost prenatal care services in your community:

• Call (800) 311-BABY [(800) 311-2229]. For information in Spanish, call (800) 504-7081.
• Visit healthcare.gov to find a community health center near you. Community health centers can provide low-cost prenatal care.

Last reviewed: June, 2017

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Prenatal Care via Telehealth

During the COVID-19 pandemic, providers and patients explored the use of telehealth on a wide and rapid scale. Reflecting on how prenatal providers and pregnant patients used telehealth during the pandemic and afterward, we review existing and new lessons learned from the pandemic. This article summarizes international and national guidelines on prenatal care, presents practice examples on how telehealth and remote patient monitoring were used during the COVID-19 pandemic, and offers lessons learned and suggestions for future care.

• • Prenatal care can be provided through many modalities, including virtual care.
• • Remote monitoring is a tool to use with virtual prenatal care visits and results in similar patient satisfaction as in-person care.
• • When prenatal complications arise, the care team can transition back to in-person care. Better data and guidelines will be needed to improve the virtual management of pregnancy complications.
• • Virtual care is growing as technology evolves for this population.

Introduction/background

The primary goal of prenatal care is the birth of a healthy infant while minimizing maternal morbidity and mortality. The current model of prenatal care for a low-risk pregnancy in the United States includes a recommended 12 to 14 in-person visits throughout a 40-week pregnancy, typically with visits every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, and weekly thereafter. 1 Despite significant medical and technological advances, this schedule has remained largely unchanged since its inception in the early twentieth century, when it was developed primarily for the early detection of preeclampsia. 2 This coincided with physicians taking primary responsibility for prenatal care and the transition of more births to a hospital setting; before this development, prenatal care was provided primarily by nurses and community midwives, with births taking place primarily in the home. 2

There are growing data to support fewer prenatal visits for low-risk pregnancies. A 2015 study examined two groups of patients: those with fewer than 10 prenatal visits and those with 10 or more prenatal visits. There was no difference in neonatal outcomes between the two groups, but patients with more visits were more likely to undergo induction of labor and had a higher rate of cesarean delivery. 3 Further, guidelines for prenatal care delivery vary significantly around the world. In a comparison of the United States to peer countries, there was little variation in prenatal care guidelines for educational topics and psychosocial services, but significant variation in visit frequency. Of eight peer countries, all but one recommended fewer visits throughout pregnancy. More than half recommended a total of 7 to 10 visits, and most recommended a longer interval between visits in the third trimester. 4

There are ongoing efforts to optimize and enhance prenatal care, including the incorporation of telehealth modalities. Telehealth has been investigated both as an adjunct to routine care and the basis of a full redesign of the prenatal care paradigm. Telehealth has been well established in obstetric care to improve access to specialty care and ultrasound interpretation for patients in rural settings. 5 In some rural areas deemed maternity-care deserts due to lack of access to care, telemedicine has been used to supplement routine prenatal care and postpartum care. 5 Telemedicine has also been used to support rural providers. The University of Arkansas for Medical Sciences has implemented state-wide educational campaigns around hypertension and hemorrhage management for rural hospitals, as well as 24-h access to educational materials, a high-risk pregnancy call center, and maternal–fetal medicine consultation. 5 Text-message-based educational interventions have improved smoking cessation in pregnancy and breastfeeding rates at 6 months postpartum. 6 A telephone-based lifestyle intervention decreased weekly gestational weight gain in patients at risk for excessive gestational weight gain. 7 Smartphone applications for mood tracking have demonstrated improved identification and service delivery for patients with perinatal symptoms of depression. 8

Other groups have studied reduced in-person care models supplemented with telehealth. In 2019, the Mayo Clinic published their work on the OB Nest model, which consists of eight in-person physician appointments, six virtual visits with a nurse, and access to an online community of other pregnant people. Patients were supplied with a home blood pressure (BP) cuff and fetal Doppler. 9 Compared with usual care, OB Nest patients had higher satisfaction, decreased pregnancy-related stress, and increased duration of breastfeeding, with no differences in perceived quality of care, adherence to the American College of Obstetricians and Gynecologists (ACOG) guidelines, and clinical maternal and fetal outcomes. 9 The study authors postulated that the increased satisfaction and decreased pregnancy-related stress could be due to receiving care from the comfort of home, access to an online community for support throughout pregnancy, and access to home monitoring devices for fetal heart rate and BP. 9 Another study assessed patient satisfaction with a hybrid model, in which prenatal patients during the COVID-19 pandemic had the option to receive routine care with 12 to 14 in-person visits, or with one-third of the visits as virtual visits. Both groups were highly satisfied with their care, but those who had opted for virtual care had significantly higher mean satisfaction scores. 10 This was thought to be due to a shared desire to limit in-person care during the pandemic. 10 An additional study assessed patient comfort with the use of technology and telemedicine for weekly blood glucose review, as opposed to in-person visits, in pregnancies complicated by gestational diabetes. Patients generally were satisfied with this care, believed it to be safe, and appreciated the convenience, but noted some discomfort with the use of the technology such as a home BP cuff and fetal Doppler. 11

Guideline summary

The American College of Obstetricians and Gynecologists 1 : ACOG recommends that obstetric visits be individualized ( Table 1 ). They do recommend that women with known medical problems, complications with prior pregnancies, or those who had fertility treatment should be seen as early as possible. They acknowledge that although a typical pregnant patient is seen every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, then weekly after that, there are women that may need more or fewer visits depending on their circumstances.

Box 1

2016 world health organization antenatal care model schedule.

• Contact 1: up to 12 wk
• Contact 2: 20 wk
• Contact 3: 26 wk
• Contact 4: 30 wk
• Contact 5: 34 wk
• Contact 6: 36 wk
• Contact 7: 38 wk
• Contact 8: 40 wk

Table 1

Summary of national and international prenatal care guidelines

The American Academy of Family Physicians (AAFP ) 12 : The AAFP has no guidelines for the frequency of prenatal visits, but acknowledges that 7 to 12 visits are typical in developed countries.

The National Institute for Health and Care Excellence (NICE) 13 : NICE recommends 10 routine antenatal appointments with an OB provider for nulliparous women and 7 routine antenatal appointments with an OB provider for parous women. See the schedule timing in Table 2 .

Table 2

National Institute for Health and Care Excellence Antenatal Care schedule

World Health Organization (WHO) 14 : The 2016 WHO Antenatal Care Model recommends a minimum of 8 antenatal care “contacts” during the pregnancy to reduce perinatal mortality and improve women’s experience of care. See the schedule in Table 2 . They prefer the word “contact” to “visit,” as it implies an active connection between a pregnant woman and a health care provider that is not implicit with the word “visit.” The term “contact” can be adapted to local contexts.

Evolution of Telehealth in Prenatal Care

The novel coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China, in December 2019. By January 30, 2020, the WHO declared COVID-19 a public health emergency, and it was officially classified as a pandemic by the WHO on March 11, 2020. 15 This led to rapid changes in health care delivery throughout the world to limit viral exposure to patients and health care staff, as well as conservation of personal protective equipment. For some fields, this included canceling and postponing nonurgent care and procedures; for prenatal care, this led to creative reimaginings of care delivery and, in many cases, the incorporation of telehealth.

For the average low-risk pregnant patient, the goal at many institutions was to plan in-person visits around necessary in-person care and supplement with virtual visits. 16 , 17 , 18 , 19 This typically included in-person visits for:

• • The initial maternity care intake for a dating ultrasound and prenatal laboratories
• • 20 weeks for the anatomy ultrasound
• • 28 weeks for glucose tolerance testing, repeat complete blood count (CBC), administration of the tetanus, diphtheria, and pertussis (TDaP) vaccine, and Rhogam administration if indicated
• • 36 weeks for a collection of the Group B streptococcal swab and determination of fetal presentation
• • 39 weeks through delivery

Further modifications were required for high-risk pregnancies (eg, gestational diabetes, gestational hypertension, preeclampsia, and abnormal anatomy ultrasound) requiring closer monitoring, including pregnancies requiring more frequent ultrasounds, diagnostic procedures, and antenatal testing, which have limited options for conversion to telehealth.

Models of telehealth in prenatal care

Columbia University Irving Medical Center (CUIMC) in New York City examined the uptake of telehealth during the 5-week period from March 9 to April 12, 2020. Approximately, one-third of the 4248 total visits in the study period took place via telehealth, with an increase in the proportion each week to a peak of 50% to 60% of visits (via telehealth) by week 5, depending on the practice setting. 20 The CUIMC still attempted to limit exposure by clustering the scheduling of required in-person services to the same day. 21 They began recommending cell-free fetal DNA for aneuploidy screening to avoid multiple visits for blood draws and ultrasound for nuchal translucency. 21 They also published guidelines for modifications of virtual care models for high-risk pregnancies. 22 These guidelines included modified in-person visit schedules, recommendations for home equipment such as home BP monitoring, and modified antenatal testing schedules, depending on the high-risk feature. As an example, for hypertensive disorders of pregnancy, they recommend access to a home BP cuff for all patients and recommend in-person visits after 36 weeks gestation. Similar modifications are detailed for conditions including maternal cardiovascular disease, maternal neurologic conditions, gestational and non-gestational diabetes mellitus, history of preterm birth and stillbirth, fetal conditions such as intrauterine growth restriction (IUGR), multiple gestation, and congenital anomalies. 22 Providers surveyed during a 5 week period from March to April 2020 felt that telehealth increased access (97%), provided adequate care (92%, definition of “adequate care” not published), and that they would continue to use the technology after the pandemic (89%). Providers were divided on whether they felt there was any change in preparation time before the appointment (50%), documentation time (56%), and patient rapport (53%). 20

The University of Michigan developed the “4-1-4 prenatal plan” which included four in-person visits (at 8 weeks, 28 weeks, 36 weeks, and 39 weeks), one antenatal ultrasound at 20 weeks, and four virtual visits (at <8 weeks for counseling, 16 weeks, 24 weeks, and 32 weeks). 17 They encouraged home monitoring of BP and fetal heart rate. 17 Patients were surveyed and a majority felt that the conversion to telehealth improved access to care (68.8%), believed the care to be safe (53.3%), and reported satisfaction with care (77.5%). 23 However, only 45.5% of patients felt that the quality of virtual care was the same as the quality of in-person care, and only 40.3% of patients reported willingness to continue with virtual visits after the pandemic. 23 Patients identified decreased provider continuity and relationship building as a driver behind these findings. 23 Providers felt that telehealth improved access (96.1%), believed the care to be safe (62.1%), and reported satisfaction (83.1%). In contrast to patients, 92.2% of providers reported a willingness to continue this care model after the pandemic. 23 Barriers that providers identified to successful prenatal telehealth care were difficulty with interpreter services, difficulties for patients accessing and using the technology, the additional training required for staff and physicians, as well as a concern that differential access to technology and the Internet may lead to inequitable access to care. 20 , 23

Multiple studies demonstrated that the no-show rate did not increase after the transition to telehealth. 20 , 23 The Perinatal Experiences and COVID-19 Effects (PEACE) study also found that most of the women reported being very, extremely, or moderately satisfied (71.4%) with their virtual experiences, although 89.9% preferred in-person care in non-pandemic conditions. Satisfaction scores decreased with increased pandemic duration. 24 Given this discrepancy between patient and provider satisfaction, more research is needed to determine the drivers of these lower satisfaction scores. It will be important to continue to monitor patient satisfaction and experience to inform the future evolution of telehealth prenatal care.

Of note, utilization of telehealth for prenatal care and satisfaction of care via telehealth was not consistent across all patients. One study at NYU Langone Medical Center in New York City examined differential uptake of telehealth across demographics and found that patients with public insurance were less likely to have at least one telehealth visit when compared with patients with private insurance (60.9% vs 87.3%, P <.0001). 25 In addition, an inner-city safety-net hospital in New York City assessed patient satisfaction scores in patients who had at least one virtual visit and one in-person visit from March 2020 to May 2020. Although all scores were in the “satisfied” range, the satisfaction scores were lower in all categories for virtual visits. 26 Although telehealth has the potential to improve access to care in some settings, these data raise the concern that a transition to telehealth has the potential to deepen preexisting disparities in prenatal and maternity care. More data are needed on the implementation of telehealth prenatal care in public insurance and safety-net populations to ensure appropriate care delivery.

Example practices

Example practice 1: uchealth (university of colorado) family medicine residency program, denver, colorado, af williams family medicine center: mixed in-person and virtual visits.

AF Williams Family Medicine Center introduced a schedule displayed in Table 3 , composed of decreased in-person visits with a combination of virtual visits. For those patients with high-risk pregnancies, patients were only offered virtual visits with the approval of the provider. Each patient was given a home BP cuff for monitoring. In addition, patients were offered monthly group informative sessions via Zoom (Zoom Video Communications, Inc, San Jose, CA) based on trimester. These sessions were helpful to patients but not well attended (around 25%–50% attendance) and eventually ceased after 4 months. Over time, pregnant patients preferred to be seen in-person over virtual visits, and the clinic eventually stopped scheduling regular virtual visits once in-person visits increased. AF Williams still has virtual visits available to pregnant patients if they have issues with scheduling or coming to the clinic, but these visits have become rare.

Table 3

AF Williams Family Medicine Center schedule

Example Practice 2: UCHealth Family Medicine Practice Located in the Denver, Colorado Metropolitan Area

Westminster family medicine: virtual group prenatal care.

To decrease the loneliness and isolation many pregnant women were experiencing during the pandemic for fear of contracting COVID while pregnant, UCHealth Westminster Family Medicine began virtual group prenatal visits ( Table 4 ). The format consisted of six sessions, meeting once per month, which repeated continuously starting in January 2021. Patients started at any point in the curriculum, creating a group spanning all gestational ages. The project received funding from a Colorado Medicaid Upper Payment Limit Grant and purchased home Doppler monitors and BP cuffs for patients to use. Once monthly, a 2-hour block was used on the provider’s schedule to see each of up to six patients in 10-min individual appointments, with a 1-hour talk from an external speaker and questions answered as a group. For most of the first year, the patients and speakers all met via Zoom. During the brief individual check-in, the provider was able to have the patient use the Doppler to auscultate fetal heart tones and check BP. Any upcoming laboratories were coordinated with the supporting medical assistant/project manager before or after the provider saw the patient. Patients were generally seen in person at least once per month, so patients occasionally end up having slightly more appointments in the first half of pregnancy. Ten prenatal patients participated in the program between January 2021 and October 2021. One notable complication arose where, due to inability to measure fundal heights, a patient had a presumed delay in diagnosis of sizes less than dates and subsequent concern for IUGR. Despite this concern, the baby was appropriate for gestational age at birth. Of note, the evidence to support the routine use of fundal height measurements as a screening tool to identify IUGR is inconclusive, although commonly still practiced as the standard of care. 27

Table 4

Westminster Family Medicine: Proposed telehealth hybrid prenatal care schedule a

After the COVID-19 vaccine became available to patients, they were given the option to attend class in person, which after September 2021 all patients chose to do. The class is ongoing and maintains social distancing and masking in a large conference room with speakers still on Zoom. The curriculum topics (and presenter types) include peripartum mood changes (psychologist); normal vaginal delivery/non-pharmacologic pain management (doula); pharmacologic pain management (anesthesiologist); complications of pregnancy (maternal–fetal medicine provider [MFM]); C-sections, assisted delivery, the COVID vaccine in pregnancy (MFM); and breastfeeding (lactation consultant).

Example Practice 3: Web Application

Babyscripts 28 is an application that allows maternity providers to enroll their patients. The cost is several hundred dollars per patient. The patient receives a Bluetooth scale and BP monitor which synchronizes with the application. The patient checks in weekly with the application to review topics about her current stage of pregnancy, weigh herself, and check her BP. In addition, patients attend in-person appointments every 8 weeks until 32 weeks, then at 34, 36, 37, 38, and 39 weeks. In a study of 88 women, 47 were assigned to the “Babyscripts” group and 41 to the control group (standard care). Patients were allocated via quasi-randomization based on whether they had an iPhone. Although not powered to detect a difference in perinatal outcomes, the study showed a reduction in in-person visits in the Babyscripts group compared with the control group, and no statistically significant difference between patient or provider satisfaction. 29

Using telehealth for prenatal care is still an evolving field, in which the COVID-19 pandemic has accelerated its use. There remain discussions on the appropriate number of prenatal visits for low-risk patients, with some evidence that not only does patient and provider satisfaction improve, fewer visits may also improve maternal outcomes such as fewer inductions of labor and cesarean sections without any differences in neonatal outcomes.

Virtual visits can be a valuable tool to improve access to prenatal care, especially in cases where clinics may limit in-person visits because of safety concerns or in more remote rural settings where access to maternity providers may be limited. Developing a hybrid model of care which includes a mix of in-person and virtual visits to include group visits can be an effective way to provide prenatal care and education. In low-risk pregnancies, as few as four in-person visits can be accomplished with the rest of the visits conducted virtually with remote BP and fetal heart tone monitoring. However, the most effective process to develop this workflow is still not clear. Prenatal patients have expressed satisfaction with virtual prenatal care, especially to limit in-person care to limit infection risk during the pandemic. However, when there were opportunities to be seen in person, especially as the COVID pandemic continued and in-person care returned, many patients choose to be seen in person.

Many questions remain with virtual prenatal care. There is no clear guidance on how to address pregnancy complications, which will usually result in converting virtual visits to in-person assessments. Concerns still exist on missing important complications that in-person visits may catch compared with virtual visits, such as growth restrictions, gestational hypertension, or preeclampsia. There is limited evidence on how to best use home monitoring such as blood pressure (BP) cuffs and fetal Doppler monitoring. Many barriers to this aspect of virtual care remain. Patients who received access to home fetal Dopplers may potentially have higher satisfaction with virtual care, but it is not known the true effect of home monitoring on satisfaction or outcomes. Lack of access to the technology to complete virtual visits, including home monitoring, may limit the effectiveness of virtual visits and widen health care disparities between patients. Other routine care such as assessing fetal growth with fundal heights is another challenge that may need more evidence to determine the appropriate frequency and accuracy of fundal heights, especially in later gestation.

Last, as we view virtual prenatal care as a way to improve access to care, caution is needed to assure virtual care does not cause a greater gap in health care disparities. Access to the technology required for successful virtual visits, such as appropriate Internet bandwidth, may be more available for some patients and less available to others. In addition, access to and comfort with the use of remote monitoring equipment is another factor that could add to health care disparities.

Clinics care points

• • For patients with low-risk pregnancies, we recommend following the World Health Organization guidelines to include a minimum of 8 touchpoints during pregnancy, with additional touchpoints based on provider and patient comfort (see Table 4 ).
• • After 24 to 28 weeks, home Doppler and home blood pressure cuffs can support a more robust virtual care model.
• • Patients need more education regarding when an in-person visit might be more appropriate if they choose to do more visits virtually. This can be done via an registered nurse (RN) educator, medical assistant (MA) educator, or prenatal education class model.
• • Consider the impact of your virtual care model on disparities. For large volume practices, we recommend a quality improvement infrastructure during implementation to ensure you are not exacerbating existing disparities.

None of the authors report any disclosures.

• Pregnancy Classes

Your First Prenatal Visit

If you did not meet with your health care provider before you were pregnant, your first prenatal visit will generally be around 8 weeks after your LMP (last menstrual period ). If this applies to you, you should schedule a prenatal visit as soon as you know you are pregnant!

Even if you are not a first-time mother, prenatal visits are still important since every pregnancy is different. This initial visit will probably be one of the longest. It will be helpful if you arrive prepared with vital dates and information. This is also a good opportunity to bring a list of questions that you and your partner have about your pregnancy, prenatal care, and birth options.

What to Expect at Your First Pregnancy Appointment

Your doctor will ask for your medical history, including:.

• Medical and/or psychosocial problems
• Blood pressure, height, and weight
• Breast and cervical exam
• Date of your last menstrual period (an accurate LMP is helpful when determining gestational age and due date)
• Birth control methods
• History of abortions and/or miscarriages
• Hospitalizations
• Medications you are taking
• Medication allergies
• Your family’s medical history

Your healthcare provider will also perform a physical exam which will include a pap smear , cervical cultures, and possibly an ultrasound if there is a question about how far along you are or if you are experiencing any bleeding or cramping .

Blood will be drawn and several laboratory tests will also be done, including:

• Hemoglobin/ hematocrit
• Rh Factor and blood type (if Rh negative, rescreen at 26-28 weeks)
• Rubella screen
• Varicella or history of chickenpox, rubella, and hepatitis vaccine
• Cystic Fibrosis screen
• Hepatitis B surface antigen
• Tay Sach’s screen
• Sickle Cell prep screen
• Hemoglobin levels
• Hematocrit levels
• Specific tests depending on the patient, such as testing for tuberculosis and Hepatitis C

Your healthcare provider will probably want to discuss:

• Recommendations concerning dental care , cats, raw meat, fish, and gardening
• Fevers and medications
• Environmental hazards
• Travel limitations
• Miscarriage precautions
• Prenatal vitamins , supplements, herbs
• Diet , exercise , nutrition , weight gain
• Physician/ midwife rotation in the office

Possible questions to ask your provider during your prenatal appointment:

• Is there a nurse line that I can call if I have questions?
• If I experience bleeding or cramping, do I call you or your nurse?
• What do you consider an emergency?
• Will I need to change my habits regarding sex, exercise, nutrition?
• When will my next prenatal visit be scheduled?
• What type of testing do you recommend and when are they to be done? (In case you want to do research the tests to decide if you want them or not.)

If you have not yet discussed labor and delivery issues with your doctor, this is a good time. This helps reduce the chance of surprises when labor arrives. Some questions to ask include:

• What are your thoughts about natural childbirth ?
• What situations would warrant a Cesarean ?
• What situations would warrant an episiotomy ?
• How long past my expected due date will I be allowed to go before intervening?
• What is your policy on labor induction?

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• A 26-year-old G1P0 woman presents to the obstetrician for her first prenatal visit. An ultrasound is performed (See image). She is estimated to be approximately 8 weeks gestation. She notes that she has experienced increased fatigue and occassional nausea but no major complaints. The patient is a recent immigrant from Mexico and has no immunization records with her and does not recall her vaccination history. She is sexually active with only her husband and has no history of sexually transmitted infections. The obstetrician takes a thorough medical history, performs a physical examination, informs her about the course of pregnancy, and explains details of the laboratory studies that will be performed at the current visit and subsequent visits.
• accurate estimation of gestational age
• identify pregnancies at ↑ risk for maternal or fetal morbidity/mortality
• prevent morbidity during pregnancy
• provide a transition to a healthy labor and birth
• earlier if at risk for ectopic pregnancy
• every 4 weeks for the first 28 weeks
• every 2-3 weeks until 36 weeks gestation
• every week after 36 weeks gestation
• initial history and physical exam
• family medical history
• genetic history
• general examination to confirm pregnancy
• assess for tobacco, alcohol, and/or drug use
• screen for domestic violence
• screen for depression
• provide prescriptions for prenatal vitamins and iron supplementation
• inform about expected course of pregnancy
• avoid contact sports or activities with high fall risk
• discuss routine lab studies and testing
• cystic fibrosis carrier screening
• hemoglobinopathy screening for individuals of African, Southeast Asian and Mediterranean descent
• discuss high-risk conditions
• blood type and screen
• complete blood count (CBC)
• platelet count
• hepatitis B surface antigen (HBsAg)
• syphilis screening test
• pre-pregnancy BMI ≥ 30 kg/m
• previous history of gestational diabetes
• HIV screening test
• urine dipstick for protein and glucose levels
• asymptomatic bacteriuria should be treated in pregnant women
• chlamydia screening
• previous sexually transmitted infection
• new or multiple sex partners
• inconsistent condom use
• commercial sex work
• MMR (measles, mumps, and rubella) is a live vaccine
• during pregnancy, ↑ circulating levels of thyroxine-binding globulin (TBG), and ↑ plasma volume ↑ demand for T4
• inactivated influenza vaccination
• vital signs
• fetal assessment, beginning after 10 weeks gestation
• uterine size assessment (see Table below)
• domestic violence screening
• assessment of tobacco use and exposure
• education about breastfeeding
• offer option of chorionic villus sampling or 2nd trimester amniocentesis
• anatomic survey ultrasound at 18-20 weeks
• maternal serum alpha-fetoprotein (MSAFP)
• if Rh negative, administer Rh immunoglobulin
• screen for gestational diabetes
• discuss postpartum contraception
• syphilis, HIV, gonorrhea, and chlamydia
• determine fetal position
• group B strep screening
• provide information about labor
• discuss postpartum contraception again
• discuss labor induction   
• - Prenatal Care

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Establishing a Positive Pediatrician-Family Relationship, a Crucial Part of the Patient-Centered Medical Home

Information from the prenatal and family history, anticipatory guidance and enhanced parenting skills; social determinants of health, positive parenting, connections to community resources, delivery and nursery routines, thoughts on feeding the newborn infant, circumcision, infant visit routines and care offered at the office, emotions in the newborn infant, emotions in the parents, decreasing the risk of serious illness and effective response to medical problems should they occur, information sharing with the family, types of prenatal visits, the full prenatal visit, the brief visit to get acquainted, the basic contact or telephone call, no prenatal contact, recommendations, examples of questions to use in the prenatal visit 66  , lead authors, committee on psychosocial aspects of child and family health, 2015–2016, the prenatal visit.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Michael Yogman , Arthur Lavin , George Cohen , COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH , Keith M. Lemmon , Gerri Mattson , Jason Richard Rafferty , Lawrence Sagin Wissow; The Prenatal Visit. Pediatrics July 2018; 142 (1): e20181218. 10.1542/peds.2018-1218

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A pediatric prenatal visit during the third trimester is recommended for all expectant families as an important first step in establishing a child’s medical home, as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition . As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow general pediatricians to establish a supportive and trusting relationship with both parents, gather basic information from expectant parents, offer information and advice regarding the infant, and may identify psychosocial risks early and high-risk conditions that may require special care. There are several possible formats for this first visit. The one used depends on the experience and preference of the parents, the style of the pediatrician’s practice, and pragmatic issues of payment.

As the medical specialty that is entirely focused on the health and well-being of the child, embedded in the family, pediatric care ideally begins before pregnancy, with reproductive life planning of adolescents and young adults, and continues during the pregnancy, with an expectant mother and father of any age. This clinical report is an updated revision of the original clinical report from the American Academy of Pediatrics (AAP) on the prenatal visit. 1 Although survey results show that 78% of pediatricians offer a prenatal visit, only 5% to 39% of first-time parents actually attend a visit. 2 The prenatal visit offers the opportunity to create a lasting personal relationship between parents and the pediatrician, one of the most important values in all ongoing pediatric care. The AAP has put forward the rationale and standards for the prenatal visit for pediatricians in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition (Bright Futures), 3 as well as for parents and families ( www.healthychildren.org ). 4 This clinical report augments these approaches to making the prenatal visit an important part of the practice of pediatrics.

Less than 5% of urban poor pregnant women see a pediatrician during the prenatal period although they are at higher risk of adverse pregnancy outcomes; pregnant women in rural areas may have even more difficulty accessing a prenatal visit. 5 , 6 To attempt to reduce disparities in pregnancy outcomes, encouraging nonresident prospective fathers to attend the prenatal visit along with expectant mothers is particularly important, albeit challenging. 7  

Prenatal contact with a pediatrician may begin with a contact from a prospective parent to the pediatrician’s office to ask whether the practice is accepting new patients and to inquire about hours, fees, hospital affiliation, health insurance accepted, and emergency coverage. These questions may be answered by a member of the office staff or the pediatrician, and this exchange establishes an initial relationship between the office and the parent. During this conversation, the expectant parent can be encouraged to schedule a prenatal visit with the pediatric health care provider, and both parents can be encouraged to attend. The prenatal visit can be enhanced if the parents come prepared with questions. Optimally, this visit should occur at the beginning of the third trimester of pregnancy.

A prenatal visit with the pediatrician is especially important for first-time parents or families who are new to the practice; single parents; women with a high-risk pregnancy or who are experiencing pregnancy complications or multiple gestations; and parents whose previous pregnancies had a complication such as preterm delivery, an infant with a congenital anomaly, a prolonged course in the NICU, or a perinatal death. Same-sex couples and parents expecting via surrogacy may have questions unique to their circumstance. This visit also can be particularly valuable to parents who are planning to adopt a child, because they may have had previous experience with pregnancy complications and/or be sensitized to special vulnerabilities in their infant (see the AAP clinical report The Pediatrician’s Role in Supporting Adoptive Families at http://pediatrics.aappublications.org/content/130/4/e1040 ). If adoption occurs or is to occur across states or internationally, review of records, need for waiting periods, scheduling of initial visits, concerns about potential fetal exposure (eg, maternal substance use or fetal alcohol spectrum disorders), and additional recommended screenings and/or tests can be discussed. 8 , 9 If needed, pediatricians can consult experts in international adoption or the AAP Council on Foster Care, Adoption, and Kinship Care. 10  

The most comprehensive prenatal visit is a full office visit, during which a trusting relationship can be established and expectant parents can have time to express their needs, interests, and concerns and receive initial anticipatory guidance. Most pediatricians believe that the prenatal visit is helpful in establishing a relationship with families that is essential for the medical home. Because they may not be able to initiate these visits, pediatricians can discuss the concept with referring obstetricians, family physicians, and internists, who can, in turn, encourage their patients to contact pediatricians for a prenatal visit. Office Web sites and social media can also be used to advertise this service to expectant parents.

The following objectives for a prenatal visit are suggested as important topics to be addressed. 2 The actual range of topics covered can be determined by the preference of the provider, the interest of the expectant parent(s), or the presence of an existing complication with the pregnancy or the fetus. Topics not covered prenatally can be presented to parents during the newborn or first postnatal visit.

To provide a foundation on which to build a positive family-pediatric professional partnership, a crucial part of the patient-centered medical home.

To access pertinent aspects of the past obstetric and present prenatal history; to review family history of genetic or chromosomal disorders and to review fetal exposure to substances that may affect the infant.

To introduce anticipatory guidance about early infant care and infant safety practices.

To identify psychosocial factors (eg, perinatal depression) that may affect family function and family adjustment to the newborn (eg, social determinants of health, adverse child experiences, and promoting healthy social-emotional development and resiliency).

The prenatal period is an ideal time to start building the health care alliance that may last for many years, commonly until the patient reaches adulthood. 11 The prenatal visit often is an opportunity for the family to determine whether their relationship and their mutual philosophies will form the basis of a positive relationship.

The prenatal visit is also an opportunity for parents to invite other supportive adults, including grandparents, 12 , 13 to establish a relationship with the pediatrician and to encourage them to come to future visits and support the new parent(s). A prenatal visit can be used to introduce parents to the concept of a medical home for the child’s health and development needs. Parental familiarity with the pediatric health care provider prenatally may be helpful if a referral or transfer of care occurs because of perinatal complications or the newborn infant’s medical condition. 14 Adolescent parents 15 and older first-time parents may benefit from the opportunity to share their specific concerns with a knowledgeable professional.

Gathering information about pregnancy complications, parental depression, and family medical and social history (especially social determinants of health) is helpful as a background to the context of the pregnancy. This inquiry also conveys to parents an interest in the broader psychosocial environment of the infant, including areas in which support would be most useful, especially if there is any risk of domestic violence. 16 , – 18 Answering parents’ questions about the approach to pediatric care also is helpful. This is a good opportunity to review how the practice uses the tools of social media and e-mail to communicate with families.

Additional topics that may be addressed include:

developmental dysplasia of the hip, early urinary tract infections, asthma, lipid disorders, cardiac disease, sickle cell disease, substance abuse, psychiatric illness, domestic violence, chronic medical conditions, and ongoing medications;

plans for feeding, circumcision, child care, work schedules, and support systems;

parents’ plans regarding child care and expectations about work-life balance;

cultural beliefs, values, and practices related to pregnancy and parenting;

concerns regarding tobacco, alcohol, and other drug use 19 , 20 and exposure to environmental hazards; and

parents’ attitudes about and use of complementary and alternative medications and health care.

If there are other children in the family, pediatricians can provide helpful advice about managing the older sibling’s adjustment. Managing parental expectations about their child is important in laying the foundation for positive attachment. Questions useful to consider as the pediatrician approaches the prenatal visit are listed in the chapter on the prenatal visit in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition . 3  

The prenatal visit offers an opportunity to discuss a range of concerns that may be of great interest to the expectant parents and pediatric provider. The following areas for discussion are meant to be a helpful reference. The conversation, the specific concerns of the parents, and time allowed will define which of these issues are discussed at the prenatal visit. The prenatal visit also offers an opportunity for assessment of family risk factors and connections to key evidence-based and other early learning, health, and development programs in the community.

One of the pediatrician’s tasks is to provide guidance to mothers, fathers, and other supportive adults to become more competent caregivers. This can begin with discussion of the parents’ concerns, planned strategies, and cultural and family beliefs and values. Advice can be offered about shared roles in parenting, such as diapering, bathing, nighttime care, and helping with feeding. Pregnancy and delivery make the central importance of the mother in the newborn infant’s life clear, but it is important to talk about the special role fathers and same-sex partners play in good outcomes for children as well. 21 A key goal of positive parenting is the reliable provision of the infants’ basic needs—food, shelter, love, and care—and in doing so, fostering the development of trust. 22 , 23 The adverse effects of poverty on child health have been well documented. 22 , 24 Optimal use of supports and resources (eg, the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]) can be discussed and information about access can be provided. Positive parenting also includes providing a steady emotional climate in which reasonable expectations are sustained consistently. 25 Avoiding and/or buffering adverse childhood experiences, such as parental postpartum depression, increasingly is seen as an evidence-based part of pediatric care, and this can begin by identifying prenatal risk factors. 26 It is important to share evidence-informed online information sources and other local resources about parenting and child development for families. Many excellent resources are available, such as the Building “Piece” of Mind program from the Ohio chapter of the AAP ( http://ohioaap.org/tag/parenting/ ), the Zero to Three program ( http://www.zerotothree.org/child-development/ ), the Triple P Positive Parenting Program ( http://www.triplep-parenting.net/glo-en/home ), and the Talk, Read, Sing tool kit available from the Clinton Foundation (Too Small to Fail [ www.toosmall.org ]).

The pediatrician can share with parents the knowledge that children, at an early age, can learn through playful serve-and-return interactions with adults and that playing with and daily reading, singing, and talking to children from birth onward are recommended, as is providing a language-rich environment and minimizing media exposure.

Office materials and Web sites can demonstrate provider awareness of key early childhood resources in the community, from home visiting, Early Head Start, child care resource and referral agencies, quality child care settings, local libraries, and parent support groups, as well as cardiopulmonary resuscitation courses. A discussion of the types of child care typically available (family care, in-home baby-sitting, family day care, child care centers) is helpful.

A discussion of the hospital routines around delivery and nursery care may include: who will be in the delivery room and how new infants behave in the first hours and days; qualifying who will provide newborn care in the hospital and what will happen if there is (1) an unanticipated urgent delivery away from the expected hospital, (2) a home birth, or (3) an admission to a special care nursery is also helpful. This discussion might include the newborn infant’s ability to seek and attach to the mother’s breast right after delivery, the related concept of skin-to-skin care, and the 12-hour postdelivery sleep phase after the adrenaline rush of labor. Mothers often choose to have the infant with them continuously during the entire hospital stay, which aids successful lactation.

This is an appropriate teaching moment for describing to both parents the many advantages of exclusive breastfeeding and how it improves outcomes for both the mother and infant. 27 , 28 Special breastfeeding training of expectant fathers or partners has been shown to increase their support of breastfeeding mothers as well as the duration of breastfeeding. 29 For parents living with food insecurity, breastfeeding offers economic advantages as well. Rooming in and avoiding unnecessary supplementation can be mentioned as ways to support nursing.

The benefits of breastfeeding can be reviewed if there are no contraindications, and lactation support services can be discussed. 30 , – 33 However, ultimately, decisions about feeding the infant are made by the parents. If formula feeding is the parents’ choice, they can be supported in their decision and given advice on formula type and preparation and proper bottle use. Ultimately, the goal is a growing, healthy infant and parents who enjoy feeding so that they can be supported in whatever decision they make. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) also is available to help with nutrition discussion and support prenatally, and mothers can be referred to determine whether they are eligible for a nutrition package during pregnancy, if not already participating in the program.

Parental expectations can be shaped so that parents do not become overly concerned if infants take a few days to learn to latch to the breast and lose some weight before the mother’s milk comes in. Infants commonly lose weight for a few days before the mother’s milk comes in but typically regain birth weight at or before 2 weeks of age. If mothers who plan to breastfeed are taking any medication, a helpful reference for the pediatrician to evaluate safety is the LactMed Drugs and Lactation Database ( http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm ). 34  

Screening for various infections and conditions that can affect the fetus is an important part of pregnancy, delivery, and birth. The prenatal visit is an excellent time to discuss the benefit of screening and the specific screening tests prospective mothers will experience. For example, the mother is regularly screened by her obstetrician to assess fetal growth and development and may have fetal testing for genetic diseases and chromosomal abnormalities. In addition, the mother may be screened for conditions that may affect the fetus, such as gestational diabetes, pregnancy-induced hypertension, and the presence of infectious agents, such as hepatitis B, cytomegalovirus, group B streptococci, and HIV.

For the infant, the main universal screening programs are used to detect metabolic diseases, sickle cell disease, cystic fibrosis, newborn jaundice, critical congenital cardiac disease, and hearing impairments. Parents may seek more information about risk factors for the management of newborn jaundice. Some discussion of these conditions can be helpful to many families so they understand what is being looked for, how the tests are performed, and what the response to test results will be. Family history may have led to detailed genetic testing and counseling and may warrant special discussion. 35 , – 38 Routine postpartum care can be discussed. The rationale for routine recommendations for vitamin K to prevent gastrointestinal or cerebral hemorrhage, eye ointment to prevent eye infection leading to blindness, and the birth hepatitis B vaccine can be explained.

Discussion of circumcision, including benefits, risks, the surgical process, and analgesia, can be presented at this visit, with particular attention to the family’s religious, personal, and cultural views. 39  

Most parents are interested in understanding what to expect for a routine pediatric visit as well as information about office and telephone hours, the appointment scheduling process, and coverage for night, weekend, and emergency care. The prenatal visit also is a good time to establish the pediatrician’s expectations of the family and explain the use of electronic communications during and after routine office hours, including billing for this service. The routine periodic schedule of well-child care visits from Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition 3 can be shared with the parents ( http://brightfutures.aap.org/clinical_practice.html ), along with information from Bright Futures about behavior, development, and the importance of social determinants of health.

The prenatal visit also is a good time to ask parents about their preferred approach to communication with the office, clarifying office policies on the availability of telephone and electronic communications. Preferred Web sites (HealthyChildren.org) for sharing information and other helpful resources and books can be recommended.

Safety is an important topic to discuss with the parents, particularly advice on “safe sleep” 40 and the importance of proper bedding, 40 , 41 proper holding of the infant, water temperature during bathing, the proper use of a pacifier, and hand washing. Encouraging a good family diet, regular checkups with the family physician or obstetrician 42 and dentist, 43 , 44 and appropriate rest and exercise also is important. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) increasingly emphasize attention to oral health and smoking cessation during pregnancy, and pediatricians can reinforce these recommendations during the prenatal visit. 45 , 46 Specific safety issues to discuss include the use of car seats, gun safety in the home, smoke detectors and carbon monoxide monitors, and reducing exposures to toxins such as mold and lead.

For many families, including those with other children, the unique emotional life of a newborn infant is unfamiliar and can be challenging. It is key to manage expectations and raise parental awareness about the range of temperaments infants can have as well as the strengths and challenges of them. There can be some discussion on how crying can be a normal mode of communication, explaining that a common peak typically occurs during the evening hours at 6 weeks of age and giving advice on how best to respond to it. Parents can be given techniques for soothing fussy infants, such as holding, including cuddling and skin-to-skin contact 47 ; rocking; singing; talking quietly; and dimming lights and playing soft music.

The prenatal visit provides an opportunity to discuss how to recognize when crying is an indicator of actual pain or illness. It is important to establish strategies for parental coping with the stress of an infant crying and the demands of infancy, including setting clear plans for strategies to deal with stress.

The experience of enhanced, powerful emotions of a wide variety is likely universal to most parents during and after delivery. Even if no serious difficulties with emotions emerge, it is helpful for expectant parents to be aware of the special power of both positive and negative emotions that surround a new person being born and entering their life.

It is also important for all expectant parents to be aware that it is common for many mothers, as many as 10% to 20%, 48 and some fathers to experience depression before, during, and/or after delivery. Postpartum depression is largely unappreciated, because stigma prevents a majority of parents from being identified and accessing services. 48 Several states have recommended universal postpartum depression screening by pediatricians, and insurers are increasingly paying for these screens. The prenatal visit offers mothers a valuable opportunity to become aware of the facts about depression so they know to call for help from their primary care physician or their obstetrician if they experience significant persistent sadness, which can be compounded by fatigue from lack of sleep. 49 , – 51  

The pediatrician can instruct parents that infants usually awaken to feed every 3 hours during the night until approximately 3 months of age, when brain maturation enables one longer sleep stretch in every 24-hour cycle. To shape this longer stretch to the dark hours, parents can wake infants every 3 hours to feed during the day, keep the lights dim after dark to entrain circadian rhythms, and schedule a bedtime feeding at 11:00 pm right from birth so that the longer sleep stretch after 3 months of age begins then.

At the prenatal visit, pediatricians can listen for and make note of fathers’ or partners’ feelings about lack of parenting skills and decreased marital intimacy. This is an opportunity to lay the groundwork for pediatric providers to be available to fathers as well as mothers after the birth of the infant.

The prenatal visit is a good time to review family history of any illnesses or congenital diseases or any concerns the parents have had during the pregnancy. Adolescent parents often benefit from more guidance than more experienced parents, and older-than-usual parents also feel stressed and insecure. Single parents may not have family or other support systems and may benefit from postpartum referral to social service agencies, evidence-based home visiting programs, or parenting programs (Incredible Years, Triple P) in local communities, if available, for help. The absence of the father, parental conflict, a chronic parental physical condition or concern about mental health, and preterm birth or a birth defect in the infant may require additional medical visits and involvement of specialists 52 , – 55 and can present physical, emotional, and financial burdens for the parents. Many expectant parents wish to discuss the value of cord blood banking and the relative merits of private– versus public–cord blood donation. 56  

During the pregnancy, maternal obesity and maternal drug use 8 , 9 are risk factors for labor complications, birth defects, and/or developmental impairment. 57 , – 59 Maternal diet is important, and ACOG recommendations about the weight gain during pregnancy can be emphasized.

New data are increasingly available about the adverse health effects of environmental toxins during pregnancy (eg, mercury and fish), and pediatricians can work with obstetricians and the ACOG to knowledgably respond to parents’ questions on this topic. 60 , – 63 Pediatric providers may want to request direct contact with obstetric providers and request obstetric records to clarify prenatal complications, particularly regarding abnormalities detected on prenatal ultrasonography that may require postnatal follow-up. New understanding of the relationship between environmental toxins and epigenetic modifications have provided a stronger evidence-based recommendation highlighting the fetal programming of adult diseases. 64  

The prenatal visit also is a good time to give parents guidelines about the timing of taking their newborn infant out in crowded public places or inviting visitors/relatives to their home. With regard to preventing infections, this is a good moment to discuss and encourage parents and family members to be immunized against pertussis and, if during the right season, influenza. Tetanus-diphtheria-acellular pertussis (Tdap) immunization is recommended for every pregnant woman after 20 weeks’ gestation, for every pregnancy, and for fathers as well. 65 Underimmunized siblings at home also present a risk to a newborn infant, and expectant parents can be encouraged to ensure siblings are fully immunized before the delivery.

Many parents have questions about the recommended schedule of immunizations. The prenatal visit is a valuable opportunity to discuss the value of immunizations and the reason for the recommended schedule. It is an opportunity to listen to any parental concerns well before the infant is born, and the decision is on the family. It is also important for the pediatric provider to outline office immunization policy with regard to parents who wish to alter the standard immunization schedule.

Although the volume of information and advice may seem overwhelming to expectant parents, they can be given appropriate handouts to supplement and reinforce information provided at the prenatal visit. A follow-up visit or telephone call can be offered if they still have questions. A Web page can be a good source of information and can include parent questionnaires for subsequent visits.

The most comprehensive form of prenatal visit is a scheduled office visit with both expectant parents. Nurse practitioners can have a significant role in conducting prenatal visits. The objectives listed previously are accomplished through an in-person discussion with the provider. Discussion can include office and telephone hours; fees; office staff; hospital affiliations; coverage for night, weekend, and emergency care; arrangements for newborn care after delivery both at the hospital the pediatricians visit and at a hospital where the pediatrician is not on the staff; and the pediatrician’s expectations of the family. A handout containing this information can be helpful for the family, including information on how and when to schedule the first visit after newborn discharge and how to retrieve the discharge summary if care was provided by a hospitalist. This type of visit is most important for first-time parents, for adolescent and other young parents, when pregnancy complications or newborn problems are anticipated, or when parents are unusually anxious for any reason. The establishment of a mutual commitment to a sound and rewarding family-physician relationship usually results from the visit.

If women with high-risk pregnancies require bed rest, there may be a need for a prenatal visit with only 1 parent and/or telephone calls. These contacts can include the same content as the full prenatal visit. The outcome should be the same mutual commitment as from the full prenatal visit in the office. If an infant is born prematurely, before a prenatal visit could occur, it is often helpful to meet with the parents in a modified prenatal visit before the infant is discharged from the NICU. In the tragic circumstance of a pregnancy loss after a prenatal visit, a follow-up expression of sympathy by the pediatric provider can feel supportive.

Some pediatricians may offer a less formal prenatal visit than a full consultation, and some parents also may prefer this option. A meet-and-greet session, individually or in a group, can include meeting key staff members such as the practice manager, taking a short tour of the office, and receiving other administrative information and handouts. This type of visit may be appropriate for parents before deciding on scheduling a full prenatal visit. Other models include group visits at the maternity hospital as part of a prenatal class or at community events for expectant parents.

The initial prenatal contact often is an expectant parent’s call to the pediatrician’s office. The staff member can offer a brief description of the practice, basic information including a source of referral, expected delivery date, and type of insurance and can be invited to make an appointment for a full prenatal visit. An office information handout may be sent to the expectant parents, if requested.

If no prenatal contact has been made, the objectives and discussion of the prenatal visit can be presented to the parents in the newborn visit or first postnatal visit. Because of other priorities, the parents may not absorb some of this discussion; therefore, a handout containing pertinent information may be used at this type of visit. At the infant’s first office visit, parents should be encouraged to have an additional family member accompany them to care for the infant while the parents and pediatrician confer.

Pediatricians or office staff can discuss with parents whether the visit will be covered by the expectant parent’s insurance and whether a referral will be required. A discussion of insurance plans that the practice accepts may be included. Payment for a prenatal visit often requires advocacy with third-party payers, both individually and through pediatric councils. Both the recommendations of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition 3 and this clinical report can provide further support for advocacy. Pediatric providers may seek advice from AAP coding resources and may review acceptable codes with their health plans.

A prenatal visit is an important first step to help expectant families (especially first-time parents) establish their child’s medical home. The visit is a unique opportunity to address the relationship between the family and practice and for the bidirectional sharing of information between the parents and pediatric provider.

Pediatric practices can effectively incorporate prenatal visits into their routine. Services can be flexible and designed to meet the needs of expectant parents. A full prenatal visit is preferred, if feasible.

Payment for full prenatal visits is supported by the evidence in Bright Futures and this report. State chapters of the AAP (as through pediatric councils) and pediatric practices can advocate to payers the short-term and long-term benefits of prenatal visits on the health outcomes of infants and their parents.

Pediatricians can share their established practices on prenatal visits with local obstetricians, internists, and family physicians, and with expectant parents.

Pediatric residents can effectively be taught during residency about the content and importance of the prenatal visit.

Increased partnerships with colleagues in obstetrics and gynecology, who are now routinely screening mothers for perinatal depression, are encouraged. Whenever risk factors are identified, obstetric and gynecologic colleagues can be encouraged to refer expectant parents for prenatal pediatric visits so that postpartum family care is optimized.

A comprehensive review of this topic with suggested questions and specific suggestions for expectant parents can be found in the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition . 3  

Parents can find resources of value during the prenatal period at www.healthychildren.org . 4  

What kinds of previous experience with infants have you had?

Are you working? Are you planning to return to work after delivery?

How are the siblings adjusting to the pregnancy?

Have you attended prenatal classes, and have they been helpful?

What kind of relationship did you have with your parents when you were growing up?

Are you planning to rear your infant in a manner similar to or different from the way your parents reared you?

What expectations do you have about this infant?

What worries and concerns do you have?

What are your plans about feeding the infant (offer support, whether for breast or formula feeding)?

To specifically engage the father/partner, when appropriate, address at least one question to just the father/partner, for example, if the infant is a boy, do you plan to have him circumcised?

Was this a convenient time for you to be pregnant?

How do you cope when you are stressed?

American Academy of Pediatrics

American College of Obstetricians and Gynecologists

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

Michael Yogman, MD, FAAP

Arthur Lavin, MD, FAAP

George Cohen, MD, FAAP

Michael Yogman, MD, FAAP, Chairperson

Keith M. Lemmon, MD, FAAP

Gerri Mattson, MD, FAAP

Jason Richard Rafferty, MD

Lawrence Sagin Wissow, MD, MPH, FAAP

George J. Cohen, MD, FAAP

Sharon Berry, PhD – Society of Pediatric Psychology

Terry Carmichael, MSW – National Association of Social Workers

Edward R. Christophersen, PhD, FAAP (hon) – Society of Pediatric Psychology

Norah Johnson, PhD, RN, CPNP – National Association of Pediatric Nurse Practitioners

L. Read Sulik, MD – American Academy of Child and Adolescent Psychiatry

Stephanie Domain, MS

Competing Interests

Re: the prenatal visit.

We commend Drs. Yogman, Lavin and Cohen and the AAP Committee on Psychosocial Aspects of Child and Family Health on their recent clinical report, The Prenatal Visit (1), for drawing attention to the value of the third trimester in establishing a child’s medical home.

As the authors note, most pediatricians offer a prenatal visit, recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition (2), but most parents do not attend one. Pediatricians and families may never make up for this opportunity to address the most fundamental factors affecting the child’s health: their psychosocial risk factors and the social determinants of their health.

Prenatal visits are even less likely to take place for the urban poor, rural and minority families who may most need early intervention and anticipatory guidance. Achieving health equity demands extra efforts to pull in at-risk families and close the gap in access to the prenatal visit, especially as the rate of return on interventions is highest in the prenatal and earliest years (3).

Moreover, given how frequently this visit is skipped, we must remain attentive to the health of both the caregiver and child at the ‘postnatal’ well-child visits, especially for at-risk families. While caregivers may not access their own health care provider often, they visit their pediatrician four times a year on average (4). Providers can use these visits to provide guidance on healthy changes that will benefit the whole family – and they can bill for it.

Bright Futures sets periodicity schedules for screenings for substance and tobacco use and exposure; parental depression; and poverty, housing and food insecurity. These screenings are reimbursed by Medicaid under the Early and Periodic Screening, Diagnostic and Treatment services (EPSDT) benefit and by most private payers. Some states and health care systems have started successfully billing a child’s health insurance for caregiver health risk assessments that benefits the child. Effective January 1, 2017, providers can report CPT code 96161 for caregiver-focused, standardized health-risk assessments that can benefit the child (5).

The post-natal well-child visit, like the prenatal visit, offers critical, longitudinal, reimbursable opportunities for pediatricians to screen children for health-related social needs and caregivers for health risks. These opportunities are too important and costly to overlook.

References: 1.Yogman M, Lavin A, Cohen G. The Prenatal Visit. Pediatrics. 2018;142(1):e20181218 2. Hagan JF, Shaw JS, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017 3. Heckman Econ Inq. 2008:46(3): 289-324 4. Newacheck PW, Stoddard JJ, Hughes DC, Pearl M. Health Insurance and Access to Primary Care for Children. N Engl J Med 1998; 338:513-519 5. AAP News. AAP Division of Health Care Finance. May 24, 2017. Update on use of, payment for new health risk assessment codes. http://www.aappublications.org/news/2017/05/24/Coding052317

In their recent revision of the prenatal visit for pediatricians, Drs. Yogman, Lavin and Cohen and the Committee on Psychosocial Aspects of Child and Family Health (Yogman M, Lavin A, Cohen G. The Prenatal Visit. PEDIATRICS. 2018, 142(1):e20181218) state in the beginning,”As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow general pediatricians to establish a supportive and trusting relationship with both parents, gather basic information from expectant parents, offer information and advice regarding the infant and may identify psychosocial risks early and high-risk conditions that may require special care”, yet it seems as if more could have been included to guide the general pediatrician in making the most of the prenatal visit to accomplish the above mentioned psychosocial objectives. The prenatal visit can be an excellent time for the pediatrician to discuss the innate capacities and capabilities of the infant, the concept of infant-parent (or infant) mental health, the role of the parent and pediatrician in helping to support the infant/parent dyad in promoting positive infant mental health, how early experiences/interactions with the parent play a major role in determining not only the psychosocial health of the infant (later child and adult) but in fact sculpt, shape, modify the developing infant’s physiologic regulatory and system functions. To accompany this, the general pediatrician could discuss when in the hospital seeing the newborn he could demonstrate these capacities and capabilities for the parents, and so in the process help establish or enhance a positive attachment relationship by utilizing the late T. Berry Brazelton’s Newborn Behavioral Observations. As recent literature has shown parenting neurobiology, circuitry and interactions are negatively affected by conditions that can have their origins in the parent’s early life experiences, and beyond screening for substance (drugs, alcohol, tobacco) or present domestic violence, screening using the ACEs questionnaire may provide for the pediatrician a more complete picture of a parent’s need for early supportive care to improve their reflective capabilities and capacities and so enable improved infant-parent interactions and outcomes. Perhaps the time has come for a new AAP committee that focuses on integrative and translational aspects of parenting and infant-parent mental health.

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