Re-evaluating the role of the MFM specialist: lead, follow, or get out of the way.

OBJECTIVE: To assess the effect of sub-specialty prenatal care provided to high-risk obstetrical patients in a community perinatal center as a function of whether consultation and referral to a Maternal-Fetal Medicine (MFM) sub-specialist was at the discretion of the generalist, required by the insurance carrier, or by patient choice.

METHODS: Demographics, management, and perinatal outcomes for high-risk patients managed exclusively by MFM were compared with those managed by generalists who were later referred to MFM after problems arose.

RESULTS: Despite similar demographics, high-risk patients managed exclusively by a single MFM had less prematurity, lower cesarean section rates, fewer low 5-minute Apgar scores (1.3% vs. 5.5%, p < 0.001), and lower perinatal mortality rates (8.0/1000 vs. 47.6/1000, p < 0.001) than those referred at a later date.

CONCLUSIONS: In this setting, earlier MFM care resulted in better outcomes. These data suggest that the 'gatekeeper' model of generalist to MFM might be better the other way around.