How to Provide Quality Care in High-Risk Pregnancies

By Christopher Cheney

Health systems, hospitals, and physician practices need to step up their efforts to provide care in cases of high-risk pregnancies, an expert at San Diego-based Scripps Health says.

A national study of women aged 18 to 44 showed that complicated pregnancies are growing more prevalent in the United States—they rose by 16.4% from 2014 to 2018. The same study, which looked at 1.8 million pregnancies, revealed that childbirth complications increased by about 14% from 2014 to 2018.

These are high numbers in the span of just four years, says Sean Daneshmand, MD, medical director of the Maternal-Fetal Medicine Program at Scripps Clinic. “The study also found a significant increase in chronic health conditions in women before becoming pregnant—issues such as high blood pressure and obesity have become much more common, which can make pregnancy a challenge to manage. Also on the rise are conditions that begin during pregnancy such as hypertensive-related crises, which are better known as pre-eclampsia, and gestational diabetes. These conditions increased by 19% and 16%, respectively.”

A significant percentage of pregnancies involve medical challenges, he says. “While 80% of women have healthy pregnancies and deliveries, the others have one or more risk factors that can cause serious complications. These could be stemming from heart disease, hypertensive-related crises, diabetes, obesity, and depression and anxiety. For babies, there can be genetic or chromosomal abnormalities, structural defects such as heart or spine defects, and pre-term birth.”

Health systems and hospitals should have integrated care teams to provide services for women with high-risk pregnancies, Daneshmand says. “One of the major failings of our country’s healthcare system is, too often, we do not have the right team in place to provide the best care for high-risk pregnancies. We need to make sure that the physical and mental health of pregnant women are addressed. A major problem in caring for high-risk patients is inadequate access to mental health services. There was a recent report from USAFacts, which is a clearinghouse for U.S. government data, that showed 37% of Americans live in areas with shortages of mental health professionals. The nation needs nearly 6,400 mental health professionals to fill in the gaps.”

Depression and anxiety among women during and after their pregnancies can have a negative impact on their babies, he says. “There was a recent study published in JAMA Pediatrics that suggested maternal depression and anxiety during the perinatal stage spanning from conception to the baby’s first year of life is associated with negative developmental outcomes in the offspring through adolescence, including deficits in language and motor development. What happens during pregnancy can impact a child in a positive or a negative way.”

Scripps’ approach to high-risk pregnancies

Daneshmand says Scripps Health has several key elements in place for care of high-risk pregnancies, including helping patients manage health issues before they become pregnant, close collaboration between various subspecialties such as cardiology and endocrinology, and pre-conception counseling. The health system has recently taken two vital steps, he says.

“One is creating a complex care coordinator—better known as a patient navigator—to help keep patients from falling into dangerous spirals. Scripps added this new role to our Maternal-Fetal Medicine Program in October 2021. The complex care coordinator role is seen more commonly in cancer and organ transplant clinics. We also have expanded access to mental health therapists. Scripps recently began a unique collaboration with a local nonprofit organization to expand access to mental health therapists for high-risk moms, with the goal of identifying these new mothers and delivering care to them within a 72-hour period after diagnosis. We can screen these patients but getting them help in a timely fashion is a challenge for most healthcare professionals.”

The two recent initiatives are adding value to Scripps’ high-risk pregnancy care, Daneshmand says. “By embedding a complex care coordinator inside our clinic and teaming with a community partner for additional mental health resources, we are building a bridge to connect vulnerable patients to more of the care they need.”

Complex care coordinator

Adding a complex care coordinator to the Maternal-Fetal Medicine Program has improved care for high-risk pregnancies, he says. “With our complex care coordinator, we have someone who has clinical experience who is emotionally intelligent and compassionate. We have embedded this role within the clinic, so that when the patient sees me and has an abnormal finding, they can have a consult with the complex care coordinator and follow-up visits with the complex care coordinator.”

The complex care coordinator has become a crucial care team member, Daneshmand says. “The complex care coordinator is available for every one of our high-risk patients, making sure they are receiving necessary testing and follow-up care as well as answering questions. She plays a critical role in determining which patients need additional help. She keeps an eye out for warning signs that may emerge between screenings because early intervention is important for issues such as depression and anxiety.”

The complex care coordinator is like a consultant, he says.

“For example, a woman could come in at 20 weeks of her pregnancy, have an ultrasound, and we suspect the baby has a heart defect. This patient is then referred to pediatric cardiology to get a fetal echocardiogram and referred to our complex care coordinator. The complex care coordinator either sees the patient immediately or within 48 hours. The patient is also scheduled for an appointment within a week for mental health screenings to assess whether they are exhibiting any signs of depression or anxiety. From that point forward, care depends on the diagnosis and whether the complex care coordinator feels the patient should be seen more frequently. If the patient exhibits any signs of depression or anxiety, the complex care coordinator refers the patient to a program called My Brain & My Baby.”

Improving care for high-risk pregnancies

Daneshmand offered advice for other health systems seeking to improve care for high-risk pregnancies. “First, we need to recognize that complicated pregnancies are becoming more common. Secondly, we need to move beyond the status quo and find ways to improve care for these vulnerable moms and their children. Putting an integrated care team in place to surround and support these patients is important. For example, this can ensure that mothers-to-be who need mental health services receive care in a timely fashion—this is one of the main challenges in our country.”

The stakes are high, he says. “We have a responsibility to provide the care that is desperately needed by these moms and their babies. This impacts entire families—it is not just the mother who struggles with depression or other complications. The fetus can be impacted, as well as other children, the woman’s partner, and the workplace. Their future hangs in the balance.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.