Matching risk and resources in high-risk pregnancies

Abstract

Objective. To evaluate the joint impact of pregnancy risk and the timing of referral of high-risk pregnancies from obstetricians to maternal fetal medicine (MFM) sub-specialists on gestational age (GA) at delivery.

Methods. For the period 1992–2002, 2567 consecutive deliveries from pregnancies of at least 23 weeks gestational age (GA) from a community-level sub-specialty perinatal center were studied. A multiple regression model was developed specifying the impact of various risk factors and referral timing.

Results. Prior pregnancy risk was inversely related to GA at birth. Referral timing, operationalized as a continuous variable, did not have a significant additive impact on GA at birth, but several dummy-variable interaction effects combining risk factors and referral before 20 weeks as a dichotomy were significant.

Conclusion. There are identifiable risks that occur either before the pregnancy or early into it that should lead to early referral to a sub-specialist because of their impact on GA at birth. Early referral is an important tactic in a larger preterm prevention strategy, but it needs to be embedded in a broader maternal-fetal health initiative in which both generalists and sub-specialists play important roles.

Keywords:

• Prenatal risk
• prematurity
• prenatal care
• specialist–generalist collaboration
• gatekeeper model
• matching risk and resources