are prenatal doctor visits considered preventive

Well-Women Visits and Prenatal Care under the ACA’s Women’s Health Amendment

By: Susan Berke Fogel

Executive Summary

The Affordable Care Act (ACA) recognizes that preventive health services in general, and women’s preventive health services in particular, are critical to individual and community health, and that cost is often a barrier to accessing needed preventive care. In addition to the Essential Health Benefits requirement to cover maternity care and preventive services, the ACA adds § 2713(a)(4) to the Public Health Service Act (the Women’s Health Amendment) to require coverage of women’s health preventive services, including prenatal care, without cost sharing.

The Affordable Care Act (ACA) recognizes that preventive health services in general, and women?s preventive health services in particular, are critical to individual and community health, and that cost is often a barrier to accessing needed preventive care. In addition to the Essential Health Benefits requirement to cover maternity care and preventive services, the ACA adds § 2713(a)(4) to the Public Health Service Act (the Women’s Health Amendment) to require coverage of women’s health preventive services, including prenatal care, without cost sharing.

The ACA Requires Coverage of Preventive Services for Women

• Items or services that have a rating of A or B in the recommendations of the U.S. Preventive Services Task Force,
• The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommended vaccinations,
•  Preventive care and screenings for infants, children, and adolescents, as provided for in guidelines supported by the Health Resources and Services Administration (HRSA),
• Additional women’s health preventive care and screenings, to fill in the gaps and supplement the U.S. Preventive Services Task Force recommendations, and as provided for in guidelines supported by HRSA’s the Women’s Health Amendment.[2]

The recommended content of the [well-woman prenatal care] visit includes specific tests and procedures (e.g., blood pressure, weight, urine test, uterine size and fetal heart rate assessment, glucose tolerance testing, and screening for specific sexually transmitted infections and genetic or developmental conditions), as well as topics for counseling and guidance (e.g., tobacco avoidance and nutrition).[6]

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Preventive Care: What's Free and What's Not

Thanks to the Affordable Care Act , health insurers in the U.S. have to cover certain preventive health care without requiring you to pay a deductible , copayment, or coinsurance . That rule applies to all non- grandfathered major medical plans in both the individual/family and employer-sponsored markets.

This article will explain how the preventive care rules work, what services are covered, and what you need to be aware of in terms of potential costs when you go to the doctor for a check-up.

So, what exactly counts as preventive care? Here’s the list of preventive care services for adults that, if recommended for you by your healthcare provider, must be provided free of cost-sharing .

Children have a different list , and there's also an additional list of fully covered preventive services for women .

As long as your health plan isn't grandfathered (or among the types of coverage that aren't regulated by the Affordable Care Act at all, such as short-term health insurance or fixed indemnity plans ), any services on those lists will be fully covered by your plan, regardless of whether you've met your deductible or how long you've been enrolled.

But keep in mind that you'll need to use an in-network medical provider in order to obtain zero-cost preventive care.

Preventive care is one of the ACA's essential health benefits (EHBs). But it's the only one that has to be covered with no cost-sharing . And it's the only one that has to be covered by large group health plans ; the rest of the EHBs only have to be covered on individual/family and small group health plans (although most large employer plans do tend to include all of the EHBs).

Covered preventive care includes:

Cancer prevention measures:

• Colorectal cancer related : for adults age 50 to 75, including screening colonoscopies, removal of polyps discovered during a screening colonoscopy, and anesthesia services required to perform the screening colonoscopy. Note that people do sometimes report being charged for polyp removal during a regular screening colonoscopy, but that is not allowed under federal rules. However, if the colonoscopy is being done in conjunction with any sort of symptoms, or if it's being done more frequently than the normal schedule, it will be considered diagnostic rather than preventive, which means regular cost-sharing rules would apply. For example, if a colonoscopy is being done as a follow-up to a previous colonoscopy in which a polyp was found; doctors sometimes recommend a follow-up after three years, which would generally not be covered by health insurance, since that's outside the regular screening guidelines of once per decade. It's a good idea to thoroughly discuss colonoscopy coverage with your health insurer in order to make sure you fully understand what is and isn't covered under the screening guidelines.
• Breast cancer related : including screening mammograms every 1-2 years for women over 40, BRCA genetic testing and counseling for women at high risk, and breast cancer chemoprevention counseling for women at high risk. As is the case for colonoscopies, mammograms are only covered with zero cost-sharing if they're done purely as a screening measure. If you find a lump in your breast and your healthcare provider wants a mammogram to check it out, your health plan's regular cost-sharing (deductible, copay, and/or coinsurance) will apply, since this will be a diagnostic mammogram rather than a screening mammogram. This will be true even if you've never had a mammogram before, or even if you're due for your regularly-scheduled screening mammogram.
• Cervical cancer related : screening covered once every three years from ages 21 through 65; human papillomavirus DNA testing can instead be done in conjunction with a pap test once every five years.
• Lung cancer related : screening for smokers or those who’ve quit smoking within the last 15 years and are between the ages of 55 and 80

Infectious disease prevention measures:

• Hepatitis C screening one time for anyone born 1945-1965 and for any adult at high risk.
• Hepatitis B screening for pregnant women at their first prenatal visit, and for any adults considered at high risk.
• HIV screening for anyone between ages 15-65, and for others at high risk.
• Syphilis screening for adults at high risk and all pregnant women.
• Chlamydia screening for young women and women at high risk.
• Gonorrhea screening for women at high risk.
• Sexually transmitted infection prevention counseling for adults at increased risk.
• Routine immunizations as recommended by age for
• COVID-19 ( recommendation was added in December 2020 )
• Hepatitis A
• Hepatitis B
• Herpes Zoster(shingles)
• Human Papillomavirus
• Influenza (flu)
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Tetanus, Diphtheria, Pertussis (lock-jaw and whooping cough)
• Varicella (chickenpox)
• Obesity screening and counseling.
• Diet counseling for adults at high risk for chronic disease.
• Recommended cardiovascular disease-related preventive measures, including cholesterol screening for high-risk adults and adults of certain ages, blood pressure screening, and aspirin use when prescribed for cardiovascular disease prevention (and/or colorectal cancer prevention) in adults ages 50 to 59.
• Diabetes type 2 screening for overweight adults age 40 to 70
• Abdominal Aortic Aneurysm screening one time for men who have ever smoked

Recommended substance abuse and mental health preventive care:

• Alcohol misuse screening and counseling
• Tobacco use screening and cessation intervention for tobacco users
• Depression screening
• Domestic violence and interpersonal violence screening and counseling for all women

Woman-Specific Preventive Care

• Well-woman visits for women under 65 (note that most Americans transition to Medicare at age 65, and Medicare has its own preventive care coverage).
• Osteoporosis screening for women over 60 based on risk factors.
• Contraception for women with reproductive capacity as prescribed by a healthcare provider. This includes all FDA-approved methods of female contraception, including IUDs, implants, and sterilization. The Supreme Court ruled in 2020 that employers with a "religious or moral objection" to contraception can opt out of providing this coverage as part of their group health plan. But the Biden administration has proposed a rule change that would eliminate the moral objection, and that would ensure access to zero-cost contraception for women whose employers have a religious objection. (Note that although male contraception is not a federally-mandated benefit, some states do require state-regulated health plans to cover vasectomies; state-regulated plans do not include self-insured plans , which account for the majority of employer-sponsored coverage. )
• Preventive services for pregnant or nursing women, including:
• Anemia screening
• Breastfeeding support and counseling including supplies
• Folic acid supplements for pregnant women and those who may become pregnant
• Gestational diabetes screening at 24 and 28 weeks gestation and those at high risk
• Hepatitis B screening at first prenatal visit
• Rh incompatibility screening for all pregnant women and follow up screening if at increased risk
• Expanded tobacco counseling
• Urinary tract or other infection screening
• Syphilis screening

Who Determines Which Preventive Care Benefits Are Covered?

So where did the government come up with the specific list of preventive services that health plans have to cover? The covered preventive care services are things that are:

• Rated “A” or “B” in the current United States Preventive Services Task Force recommendations. (In 2023, a federal judge overturned the requirement that health plans cover preventive services recommended by the USPSTF since 2010. But that ruling has been put on hold while the case is appealed, so health plans must continue to cover these services. )
• Provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA updated its recommendations for women's preventive services in 2019; the updated guidelines are available here ).
• Recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention

All of the services listed above (and on the lists maintained by HealthCare.gov ) meet at least one of those three guidelines for recommended preventive care. But those guidelines change over time, so the list of covered preventive care services can also change over time. For example, COVID vaccines were added to the list of covered preventive care in December 2020.

If there's a specific preventive care treatment that you don't see on the covered list, it's probably not currently recommended by medical experts. That's the case with PSA screening (it's got a "C" or a "D" rating, depending on age, by USPSTF).

Vitamin D screening is another example of a preventive care service that isn't currently recommended (or required to be covered). For now, the USPSTF has determined that there's insufficient evidence to determine whether to recommend Vitamin D screening in asymptomatic adults. But they do note that more research is needed, so it's possible that the recommendation could change in the future.

It's also important to understand that when you go to your healthcare provider for preventive care, they might provide other services that aren't covered under the free preventive care benefit. For example, if your healthcare provider does a cholesterol test and also a complete blood count, the cholesterol test would be covered but the CBC might not be (it would depend on your health plan's rules, as not all of the tests included in the CBC are required to be covered).

And some care can be preventive or diagnostic, depending on the situation. Preventive mammograms are covered, for example, but your insurer can charge you cost-sharing if you have a diagnostic mammogram performed because you or your health provider find a lump or have a specific concern that the mammogram is intended to address.

Or if you need a follow-up screening sooner than the regular recommended screening guidelines (due to an issue that was found on the last screening test, for example), the follow-up may have your plan's regular cost-sharing. If in doubt, talk with your insurer beforehand so that you'll understand how your preventive care benefits work before the bill arrives.

Preventive Care Related to COVID-19

The COVID-19 pandemic gripped the world starting in early 2020. There's normally a lengthy process (which can last nearly two years) involved with adding covered preventive services through the channels described above.

But Congress quickly took action to ensure that most health insurance plans would fully cover the cost of COVID-19 testing, although that only lasted through the end of the COVID public health emergency, which ended in May 2023.

And the legislation that Congress enacted in the spring of 2020—well before COVID-19 vaccines became available—ensured that once the vaccines did become available, non-grandfathered health plans would cover the vaccine nearly immediately , without any cost-sharing.

ACIP voted in December 2020 to add the COVID-19 vaccine to the list of recommended vaccines, and non-grandfathered health plans were required to add the coverage within 15 business days (well before the vaccine actually became available for most Americans).

That continues to be the case, even after the public health emergency has ended. Recommended COVID vaccines continue to be fully covered by non-grandfathered health plans, just like other recommended vaccines.

Obviously, the medical costs related to COVID-19 go well beyond testing. People who need to be hospitalized for the disease can face thousands of dollars in out-of-pocket costs, depending on how their health insurance plan is structured. Many health insurance companies opted to go beyond the basic requirements, temporarily offering to fully cover COVID-19 treatment , as well as testing, for a limited period of time. But those cost-sharing waivers had mostly expired by the end of 2020.

When Your Health Plan Might Not Cover Preventive Care Without Cost-Sharing

If your health insurance is a grandfathered health plan, it’s allowed to charge cost-sharing for preventive care. Since grandfathered health plans lose their grandfathered status if they make substantial changes to the plan, and can no longer be purchased by individuals or businesses, they’re becoming less and less common as time passes.

But there are still a substantial number of people with grandfathered health coverage; among workers who have employer-sponsored health coverage, 14% were enrolled in grandfathered plans as of 2020. Your health plan literature will tell you if your health plan is grandfathered. Alternatively, you can call the customer service number on your health insurance card or check with your employee benefits department.

If you have a managed care health plan that uses a provider network , your health plan is allowed to charge cost-sharing for preventive care you get from an out-of-network provider. If you don’t want to pay for preventive care, use an in-network provider.

Also, if your health plan is considered an "excepted benefit," it's not regulated by the Affordable Care Act and thus not required to cover preventive care without cost-sharing (or at all). This includes coverage such as short-term health plans , fixed indemnity plans , healthcare sharing ministry plans , and Farm Bureau plans in states where they're exempted from insurance rules.

Preventive Care Isn’t Really Free

Although your health plan must pay for preventive health services without charging you a deductible, copay, or coinsurance, this doesn’t really mean those services are free to you. Your insurer takes the cost of preventive care services into account when it sets premium rates each year.

Although you don’t pay cost-sharing charges when you receive preventive care, the cost of those services is wrapped into the cost of your health insurance. This means, whether or not you choose to get the recommended preventive care, you’re paying for it through the cost of your health insurance premiums anyway.

Under the Affordable Care Act, certain preventive care has to be covered in full (ie, without a deductible, copay, or coinsurance) on all non-grandfathered major medical plans. Covered preventive care includes a long list of services that are recommended by medical experts, although it does not include all medical care that's considered preventive. And some services, such as mammograms, pap test, or colonoscopies—can be fully paid for by the health plan or not. Coverage will depend on whether they're done at regular screening intervals without any symptoms, or to diagnose a problem or follow-up after a previous test returned abnormal results.

A Word From Verywell

Your health plan likely covers a wide range of preventive services at no cost to you, and it's in your best interest to take advantage of these benefits. But to avoid being surprised by an unexpected medical bill, you'll want to be sure you understand the details prior to receiving preventive care. Make sure you use a provider who is in your health plan's network, and make sure you understand exactly what tests or services will be provided during the visit. If you decide to go beyond what your health plan will cover, that's perfectly fine and is a decision you'll make with your medical provider.

U.S. Centers for Medicare & Medicaid Services.  Preventive care benefits for adults .

Centers for Medicare and Medicaid Services. Affordable Care Act Implementation FAQs - Set 12 (See Q5) .

Rovner, Julie. Kaiser Health News. High Court Allows Employers To Opt Out of ACA's Mandate On Birth Control Coverage .

U.S. Center for Medicare and Medicaid Services. Coverage of Certain Preventive Services Under the Affordable Care Act: Proposed Rules . January 30, 2023.

Rakoczy, Christy. lendedu. Does Health Insurance Cover the Cost of a Vasectomy?

Kaiser Family Foundation. 2021 Employer Health Benefits Survey .

American Cancer Society. Patient Groups Applaud Circuit Court Ruling That Largely Stays Remedy in Braidwood Management v. Becerra . June 13, 2023.

Health Resources and Services Administration. Women's Preventive Services Guidelines .

Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) .

U.S. Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening .

U.S. Preventive Services Task Force. Vitamin D Deficiency in Adults: Screening .

Pollitz, Karen. Kaiser Family Foundation. Private Health Coverage of COVID-19: Key Facts and Issues .

America's Health Insurance Plans. Health Insurance Providers Respond to Coronavirus (COVID-19) .

Kaiser Family Foundation. 2020 Employer Health Benefits Survey .

By Elizabeth Davis, RN Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.

Call or Text the Maternal Mental Health Hotline

Parents: don’t struggle alone

The National Maternal Mental Health Hotline provides free, confidential mental health support. Pregnant people, moms, and new parents can call or text any time, every day.

Start a call: 1-833-TLC-MAMA (1-833-852-6262)

Text now: 1-833-TLC-MAMA (1-833-852-6262)

Use TTY: Use your preferred relay service or dial 711 , then 1-833-852-6262 .

Learn more about the Hotline

Women’s Preventive Services Guidelines

Affordable care act expands prevention coverage for women's health and well-being.

The Affordable Care Act (ACA) – the health insurance reform legislation passed by Congress and signed into law by President Obama on March 23, 2010 – helps make prevention services affordable and accessible for all Americans by requiring most health insurance plans to provide coverage without cost sharing for certain recommended preventive services. Preventive services that have strong scientific evidence of their health benefits must be covered and plans can no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider.

Under the ACA, most private health insurers must provide coverage of women's preventive health care – such as mammograms, screenings for cervical cancer, prenatal care, and other services –with no cost sharing. Under section 2713 of the Public Health Service Act, as modified by the ACA, non-grandfathered group health plans and non-grandfathered group and individual health insurance coverage are required to cover specified preventive services without a copayment, coinsurance, deductible, or other cost sharing, including preventive care and screenings for women as provided for in comprehensive guidelines supported by HRSA for this purpose.

The law recognizes and HHS understands the unique health needs of women across their lifespan. The purpose of WPSI is to improve women’s health across the lifespan by identifying preventive services and screenings to be used in clinical practice and, when supported by HRSA, incorporated in the Guidelines.

HRSA-Supported Women's Preventive Services Guidelines: Background

The HRSA-supported Women’s Preventive Services Guidelines (Guidelines) were originally established in 2011 based on recommendations from a Department of Health and Human Services' commissioned study by the Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM).

Since the establishment of the Guidelines, there have been advancements in science and gaps identified in clinical practice. To address these, in 2016, the Health Resources and Services Administration (HRSA) awarded a five-year cooperative agreement, the Women’s Preventive Services Initiative (WPSI), to the American College of Obstetricians and Gynecologists (ACOG) to convene a coalition of clinician, academic, and consumer-focused health professional organizations to conduct a scientifically rigorous review to develop recommendations for updated Guidelines in accordance with the model created by the NAM Clinical Practice Guidelines We Can Trust. The American College of Obstetricians and Gynecologists (ACOG) formed an expert panel, also called the WPSI, for this purpose.

In March 2021, ACOG was awarded a subsequent cooperative agreement to review and recommend updates to the Guidelines. Under ACOG, WPSI reviews existing Women’s Preventive Services Guidelines biennially, or upon the availability of new evidence, as well as new preventive services topics. New topics for future consideration can be submitted on a rolling basis at the Women’s Preventive Services Initiative website .

HRSA-Supported Women's Preventive Services Guidelines

HRSA supports the Women’s Preventive Services Guidelines (Guidelines) listed below that address health needs specific to women. 

In December 2022, HRSA approved updates to the Guidelines for two listed preventive services:  Screening for Gestational Diabetes Mellitus (to be retitled as “Screening for Diabetes in Pregnancy”) and Screening for Diabetes Mellitus after Pregnancy (to be retitled as “Screening for Diabetes after Pregnancy”). The Guidelines are provided in the table below. 

Updated Guidelines

Current guidelines, implementation considerations.

While not included as part of the HRSA-supported guidelines, the Women's Preventive Services Initiative, through ACOG, also developed implementation considerations, available at the Women's Preventive Services Initiative website , which provide additional clarity on implementation of the guidelines into clinical practice. The implementation considerations are separate from the clinical recommendations, are informational, and are not part of the formal action by the Administrator under Section 2713.

* Non-grandfathered plans and coverage (generally, plans or policies created or sold after March 23, 2010, or older plans or policies that have been changed in certain ways since that date) are required to provide coverage without cost sharing consistent with these guidelines beginning with the first plan year (in the individual market policy year) that begins on or after December 30, 2022. Before that time, non-grandfathered plans are generally required to provide coverage without cost sharing consistent with the guidelines as previously updated in 2019.

** (I)(a) Objecting entities—religious beliefs.

(1) These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to a group health plan established or maintained by an objecting organization, or health insurance coverage offered or arranged by an objecting organization, and thus the Health Resources and Service Administration exempts from any Guidelines requirements issued under 45 CFR 147.130(a)(1)(iv) that relate to the provision of contraceptive services: (i) A group health plan and health insurance coverage provided in connection with a group health plan to the extent the non-governmental plan sponsor objects as specified in paragraph (I)(a)(2) of this note. Such non-governmental plan sponsors include, but are not limited to, the following entities: (A) A church, an integrated auxiliary of a church, a convention or association of churches, or a religious order; (B) A nonprofit organization; (C) A closely held for-profit entity; (D) A for-profit entity that is not closely held; or (E) Any other non-governmental employer; (ii) An institution of higher education as defined in 20 U.S.C. 1002 in its arrangement of student health insurance coverage, to the extent that institution objects as specified in paragraph (I)(a)(2) of this note. In the case of student health insurance coverage, section (I) of this note is applicable in a manner comparable to its applicability to group health insurance coverage provided in connection with a group health plan established or maintained by a plan sponsor that is an employer, and references to “plan participants and beneficiaries” will be interpreted as references to student enrollees and their covered dependents; and (iii) A health insurance issuer offering group or individual insurance coverage to the extent the issuer objects as specified in paragraph (I)(a)(2) of this note. Where a health insurance issuer providing group health insurance coverage is exempt under this paragraph (I)(a)(1)(iii), the plan remains subject to any requirement to provide coverage for contraceptive services under these Guidelines unless it is also exempt from that requirement.

(2) The exemption of this paragraph (I)(a) will apply to the extent that an entity described in paragraph (I)(a)(1) of this note objects to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage, payments, or a plan that provides coverage or payments for some or all contraceptive services, based on its sincerely held religious beliefs. (b) Objecting individuals—religious beliefs. These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to individuals who object as specified in this paragraph (I)(b), and nothing in 45 CFR 147.130(a)(1)(iv), 26 CFR 54.9815–2713(a) (1)(iv), or 29 CFR 2590.715-2713(a)(1)(iv) may be construed to prevent a willing health insurance issuer offering group or individual health insurance coverage, and as applicable, a willing plan sponsor of a group health plan, from offering a separate benefit package option, or a separate policy, certificate or contract of insurance, to any individual who objects to coverage or payments for some or all contraceptive services based on sincerely held religious beliefs.

(II)(a) Objecting entities—moral convictions.

(1) These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to a group health plan established or maintained by an objecting organization, or health insurance coverage offered or arranged by an objecting organization, and thus the Health Resources and Service Administration exempts from any Guidelines requirements issued under 45 CFR 147.130(a)(1)(iv) that relate to the provision of contraceptive services: (i) A group health plan and health insurance coverage provided in connection with a group health plan to the extent one of the following non-governmental plan sponsors object as specified in paragraph (II)(a)(2) of this note: (A) A nonprofit organization; or (B) A for-profit entity that has no publicly traded ownership interests (for this purpose, a publicly traded ownership interest is any class of common equity securities required to be registered under section 12 of the Securities Exchange Act of 1934); (ii) An institution of higher education as defined in 20 U.S.C. 1002 in its arrangement of student health insurance coverage, to the extent that institution objects as specified in paragraph (II)(a)(2) of this note. In the case of student health insurance coverage, section (I) of this note is applicable in a manner comparable to its applicability to group health insurance coverage provided in connection with a group health plan established or maintained by a plan sponsor that is an employer, and references to “plan participants and beneficiaries” will be interpreted as references to student enrollees and their covered dependents; and (iii) A health insurance issuer offering group or individual insurance coverage to the extent the issuer objects as specified in paragraph (II)(a)(2) of this note. Where a health insurance issuer providing group health insurance coverage is exempt under this paragraph (II)(a)(1)(iii), the group health plan established or maintained by the plan sponsor with which the health insurance issuer contracts remains subject to any requirement to provide coverage for contraceptive services under these Guidelines unless it is also exempt from that requirement.

(2) The exemption of this paragraph (II)(a) will apply to the extent that an entity described in paragraph (II)(a)(1) of this note objects to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage or payments for some or all contraceptive services, or for a plan, issuer, or third party administrator that provides or arranges such coverage or payments, based on its sincerely held moral convictions. (b) Objecting individuals—moral convictions. These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to individuals who object as specified in this paragraph (II)(b), and nothing in § 147.130(a)(1)(iv), 26 CFR 54.9815–2713(a) (1)(iv), or 29 CFR 2590.715-2713(a)(1)(iv) may be construed to prevent a willing health insurance issuer offering group or individual health insurance coverage, and as applicable, a willing plan sponsor of a group health plan, from offering a separate policy, certificate or contract of insurance or a separate group health plan or benefit package option, to any individual who objects to coverage or payments for some or all contraceptive services based on sincerely held moral convictions.

(III) Definition. For the purposes of this note, reference to “contraceptive” services, benefits, or coverage includes contraceptive or sterilization items, procedures, or services, or related patient education or counseling, to the extent specified for purposes of these Guidelines.

See Federal Register Notice: Religious Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act (PDF - 474 KB)

*** General Notice On July 29, 2019, the District Court for the Northern District of Texas issued an injunction preventing the enforcement of “the Contraceptive Mandate, codified at 42 U.S.C. § 300gg–13(a)(4), 45 C.F.R. § 147.130(a)(1)(iv), 29 C.F.R. § 2590.715–2713(a)(1)(iv), and 26 C.F.R. § 54.9815–2713(a)(1)(iv), against any group health plan, and any health insurance coverage provided in connection with a group health plan, that is sponsored by an Employer Class member[,]” to the extent that such coverage conflicts with the Employer Class member’s sincerely held religious objections to such coverage, in connection with DeOtte v. Azar, No. 4:18-CV-00825-O, 2019 WL 3786545 (N.D. Tex. July 29, 2019). The injunction also prevents the enforcement of “the Contraceptive Mandate” to the extent it requires an "Individual Class member[] to provide coverage or payments for contraceptive services" to which the individual objects based on sincerely held religious beliefs, if a health insurance issuer and, if applicable, a sponsor of a group health plan, is willing to offer the Individual Class member a separate policy or plan that omits such contraceptive coverage. On December 17, 2021, the Fifth Circuit vacated the injunction in DeOtte v. Nevada, No. 19-10754 (5th Cir. Dec. 17, 2021). However, as of the date of this publication, the Fifth Circuit has yet to issue a mandate in connection with its order, and the injunction remains in place.

**** Education and counseling includes all methods of contraception, including but not limited to, hormonal, devices, surgical, barrier, and fertility-based awareness methods, including lactation amenorrhea.

***** FDA's Birth Control Guide This refers to  FDA’s Birth Control Guide  (PDF - 450 KB) as posted on December 22, 2021 with the exception of sterilization surgery for men, which is beyond the scope of the WPSI.

****** Notice This sentence, included at the end of the "Contraception" section of the previous Guidelines, remains at the conclusion of the "Contraception" section of the 2021 Guidelines per a Final Order issued on December 6, 2022, in Tice-Harouff v. Johnson, Eastern District of Texas (Tyler Division), Case No. 6:22-cv-201-JDK. This is consistent with footnote **** above, which indicates that education and counseling within the "Contraception" section of the 2021 Guidelines includes fertility awareness-based methods, including lactation amenorrhea.

[email protected] .

• HRSA/MCHB Preventive Guidelines and Screening for Women, Children, and Youth
• Historical Files
• 2019 Guidelines
• 2016 Guidelines
• Institute of Medicine:  Clinical Preventive Services for Women  (2011)
• Bright Futures
• Advisory Committee on Heritable Disorders in Newborns and Children

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Prenatal Care

(medical care during pregnancy), should i see a doctor before i try to get pregnant, what happens at my first doctor visit, what medical care will i need during my pregnancy.

Prenatal care is medical care you get before you give birth. Prenatal care includes routine doctor visits and routine tests. The doctor checks your health and the health of your developing baby.

Routine visits and tests let your doctor find problems before they cause symptoms

Problems you had before, like high blood pressure or asthma, may need to be treated differently when you're pregnant

Your doctor will tell you how to take care of yourself, including your diet and what vitamins you need

You'll see your doctor once a month in the beginning of pregnancy and more often as you get closer to delivery

Doctors check your weight, your urine, and your blood pressure at each visit

It's a good idea to see a doctor before you get pregnant. The doctor can make sure your pregnancy will be as safe as possible and help you prepare to get pregnant. Your doctor will:

Talk to you about how pregnancy might affect any diseases you have

Give you any immunizations Overview of Immunization You're immune to an infection when your body's natural defenses have learned how to fight it off. You can become immune naturally after you're exposed to germs such as bacteria or viruses. Or... read more you need

Ask you about risk factors for diseases that could be passed to your baby (inherited)

If you have risk factors for inherited diseases, the doctor may recommend doing blood tests as part of genetic screening Genetic Counseling and Genetic Testing Before Pregnancy Genetic disorders are caused by abnormalities in one or more genes or chromosomes. Some genetic disorders are hereditary and others are spontaneous. Hereditary genetic disorders are passed down... read more . The tests look to see if you or your partner carry genes for diseases you could pass on to your child. Some doctors do these tests on everyone because people don't always have risk factors.

If you decide to try to get pregnant, do the following to give your baby the best chance of being healthy:

Take a multivitamin with at least 400 micrograms of folic acid Folate Deficiency Folate deficiency is common. Because the body stores only a small amount of folate, a diet lacking in folate leads to a deficiency within a few months. Not eating enough raw leafy vegetables... read more every day (you can find the amount of folic acid on the label)

Don’t use tobacco or be around someone who is smoking

Don’t drink alcohol

Avoid scooping used kitty litter or touching cat poop—this can transmit a disease, toxoplasmosis Toxoplasmosis Toxoplasmosis is infection caused by the protozoan parasite Toxoplasma gondii . Infection occurs when people unknowingly ingest toxoplasma cysts from cat feces or eat contaminated meat... read more , that damages your baby

You’ll see your doctor once you're about 6 to 8 weeks pregnant. The weeks of pregnancy are counted from the first day of your last menstrual period.

At this visit, your doctor will:

Estimate your due date Pregnancy Tests and Due Dates Pregnancy begins with fertilization (when a sperm enters an egg) and ends with delivery (when the baby is born). Pregnancy lasts about 9 months. You should suspect you’re pregnant if: Your period... read more (the day your doctor expects your baby to be born, usually 40 weeks after the first day of your last period)

Measure your height, weight, and blood pressure

Ask about your health, your medicines, and details about any earlier pregnancies

Check your ankles for swelling

Do a pelvic (internal) exam to check for diseases or other problems

Do a Pap test (a test to check for cancer in your cervix), if you haven't had one in the recommended time period

Take samples of blood and urine for testing

Test for sexually transmitted infections Overview of Sexually Transmitted Infections STIs are infections that are passed from person to person through sexual contact, including oral sex. STIs may be caused by different types of germs, including chlamydia, gonorrhea, HIV, and... read more

You'll see the doctor more often as your pregnancy goes along. After the first visit, you’ll see your doctor:

Every 4 weeks until 28 weeks of pregnancy

Every 2 weeks until 36 weeks

Then once a week until delivery

At each visit, your doctor will:

Take your blood pressure

Look at your ankles for swelling

Measure your uterus

Check your baby’s heartbeat

Check a urine sample for sugar

At about 16 to 20 weeks, your doctor will do an ultrasound to check your fetus's:

Size and growth

The ultrasound can also tell:

Whether you're pregnant with twins or multiples

Whether your fetus has any possible issues, including birth defects or problems with the placenta (the organ that feeds your fetus)

Depending on the ultrasound results, your doctor may do more ultrasounds later in your pregnancy.

At about 24 to 28 weeks, your doctor will do a blood test to check for high blood sugar ( gestational diabetes Diabetes During Pregnancy Diabetes is a disease in which your blood sugar (glucose) levels are too high. Blood sugar is your body’s main source of energy. Your body breaks down all types of foods, including bread, fruit... read more ).

X-rays aren't a regular part of pregnancy care. If you need an x-ray, you can get one safely by using a lead apron to shield your belly.

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Prenatal care

Prenatal care is the health care you get while you are pregnant. 

What is prenatal care?

Prenatal care is the health care you get while you are pregnant. Take care of yourself and your baby by:

• Getting  early  prenatal care. If you know you're pregnant, or think you might be, call your doctor to schedule a visit.
• Getting  regular  prenatal care. Your doctor will schedule you for many checkups over the course of your pregnancy. Don't miss any — they are all important.
• Following your doctor's advice.

Why do I need prenatal care?

Prenatal care can help keep you and your baby healthy. Babies of mothers who do not get prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care.

Doctors can spot health problems early when they see mothers regularly. This allows doctors to treat them early. Early treatment can cure many problems and prevent others. Doctors also can talk to pregnant women about things they can do to give their unborn babies a healthy start to life.

I am thinking about getting pregnant. How can I take care of myself?

You should start taking care of yourself  before  you start trying to get pregnant. This is called preconception health. It means knowing how health conditions and risk factors could affect you or your unborn baby if you become pregnant. For example, some foods, habits, and medicines can harm your baby — even before he or she is conceived. Some health problems also can affect pregnancy.

Talk to your doctor before pregnancy to learn what you can do to prepare your body. Women should prepare for pregnancy before becoming sexually active. Ideally, women should give themselves at least 3 months to prepare before getting pregnant.

The five most important things you can do before becoming pregnant are:

• Take 400 to 800 micrograms (400 to 800 mcg or 0.4 to 0.8 mg) of  folic acid  every day for at least 3 months before getting pregnant to lower your risk of some birth defects of the brain and spine. You can get folic acid from some foods. But it's hard to get all the folic acid you need from foods alone. Taking a vitamin with folic acid is the best and easiest way to be sure you're getting enough.
• Stop smoking and drinking alcohol. Ask your doctor for help.
• If you have a medical condition, be sure it is under control. Some conditions include  asthma ,  diabetes ,  depression ,  high blood pressure ,  obesity , thyroid disease, or  epilepsy . Be sure your vaccinations are up to date.
• Talk to your doctor about any over-the-counter and prescription medicines you are using. These include dietary or herbal supplements. Some  medicines  are not safe during pregnancy. At the same time, stopping medicines you need also can be harmful.
• Avoid contact with toxic substances or materials at work and at home that could be harmful. Stay away from chemicals and cat or rodent feces.

I'm pregnant. What should I do — or not do — to take care of myself and my unborn baby?

Follow these do's and don'ts to take care of yourself and the precious life growing inside you:

Health care do's and don'ts

• Get early and regular prenatal care. Whether this is your first pregnancy or third, health care is extremely important. Your doctor will check to make sure you and the baby are healthy at each visit. If there are any problems, early action will help you and the baby.
• Take a multivitamin or prenatal vitamin with 400 to 800 micrograms (400 to 800 mcg or 0.4 to 0.8 mg) of folic acid every day. Folic acid is most important in the early stages of pregnancy, but you should continue taking folic acid throughout pregnancy.
• Ask your doctor before stopping any medicines or starting any new medicines. Some medicines are not safe during pregnancy. Keep in mind that even over-the-counter medicines and herbal products may cause side effects or other problems. But not using medicines you need could also be harmful.
• Avoid x-rays. If you must have dental work or diagnostic tests, tell your dentist or doctor that you are pregnant so that extra care can be taken.
• Get a flu shot. Pregnant women can get very sick from the flu and may need hospital care.

Food do's and don'ts

• Eat a variety of healthy foods.  Choose fruits, vegetables, whole grains, calcium-rich foods, and foods low in saturated fat. Also, make sure to drink plenty of fluids, especially water.
• Get all the nutrients you need each day, including iron. Getting enough iron prevents you from getting anemia, which is linked to  preterm birth  and  low birth weight . Eating a variety of healthy foods will help you get the nutrients your baby needs. But ask your doctor if you need to take a daily prenatal vitamin or iron supplement to be sure you are getting enough.
• Protect yourself and your baby from food-borne illnesses, including  toxoplasmosis  (TOK-soh-plaz-MOH-suhss) and  listeria  (lih-STEER-ee-uh). Wash fruits and vegetables before eating. Don't eat uncooked or undercooked meats or fish. Always handle, clean, cook, eat, and store foods properly.
• Don't eat fish with lots of mercury, including swordfish, king mackerel, shark, and tilefish.

Lifestyle do's and don'ts

• Gain a healthy amount of weight. Your doctor can tell you how much weight gain you should aim for during pregnancy.
• Don't smoke, drink alcohol, or use drugs. These can cause long-term harm or death to your baby. Ask your doctor for help quitting.
• Unless your doctor tells you not to, try to get at least 2 hours and 30 minutes of moderate-intensity aerobic activity a week. It's best to spread out your workouts throughout the week. If you worked out regularly before pregnancy, you can keep up your activity level as long as your health doesn't change and you talk to your doctor about your activity level throughout your pregnancy. Learn more about  how to have a fit pregnancy .
• Don't take very hot baths or use hot tubs or saunas.
• Get plenty of sleep and find ways to control stress.
• Get informed. Read books, watch videos, go to a childbirth class, and talk with moms you know.
• Ask your doctor about childbirth education classes for you and your partner. Classes can help you prepare for the birth of your baby.

Environmental do's and don'ts

• Stay away from chemicals like  insecticides , solvents (like some cleaners or paint thinners), lead, mercury, and paint (including paint fumes). Not all products have pregnancy warnings on their labels. If you're unsure if a product is safe, ask your doctor before using it. Talk to your doctor if you are worried that chemicals used in your workplace might be harmful.
• If you have a cat, ask your doctor about  toxoplasmosis . This infection is caused by a parasite sometimes found in cat feces. If not treated toxoplasmosis can cause birth defects. You can lower your risk of by avoiding cat litter and wearing gloves when gardening. 
• Avoid contact with rodents, including pet rodents, and with their urine, droppings, or nesting material. Rodents can carry a virus that can be harmful or even deadly to your unborn baby.
• Take steps to avoid illness, such as washing hands frequently.
• Stay away from secondhand smoke.

I don't want to get pregnant right now. Should I still take folic acid every day?

Yes! Birth defects of the brain and spine happen in the very early stages of pregnancy, often before a woman knows she is pregnant. By the time she finds out she is pregnant, it might be too late to prevent those birth defects. Also, half of all pregnancies in the United States are not planned. For these reasons, all women who are able to get pregnant need 400 to 800 mcg of folic acid every day.

How often should I see my doctor during pregnancy?

Your doctor will give you a schedule of all the doctor's visits you should have while pregnant. Most experts suggest you see your doctor:

• About once each month for weeks 4 through 28
• Twice a month for weeks 28 through 36
• Weekly for weeks 36 to birth

If you are older than 35 or your pregnancy is high risk, you'll probably see your doctor more often.

What happens during prenatal visits?

During the first prenatal visit, you can expect your doctor to:

• Ask about your health history including diseases, operations, or prior pregnancies
• Ask about your family's health history
• Do a complete physical exam, including a pelvic exam and  Pap test
• Take your blood and urine for lab work
• Check your blood pressure, height, and weight
• Calculate your due date
• Answer your questions

At the first visit, you should ask questions and discuss any issues related to your pregnancy. Find out all you can about how to stay healthy.

Later prenatal visits will probably be shorter. Your doctor will check on your health and make sure the baby is growing as expected.  Most prenatal visits will include:

• Checking your blood pressure
• Measuring your weight gain
• Measuring your abdomen to check your baby's growth (once you begin to show)
• Checking the baby's heart rate

While you're pregnant, you also will have some routine tests. Some tests are suggested for all women, such as blood work to check for anemia, your blood type, HIV, and other factors. Other tests might be offered based on your age, personal or family health history, your ethnic background, or the results of routine tests you have had. Visit the pregnancy section of our website for more details on  prenatal care and tests .

I am in my late 30s and I want to get pregnant. Should I do anything special?

As you age, you have an increasing chance of having a baby born with a birth defect. Yet most women in their late 30s and early 40s have healthy babies. See your doctor regularly before you even start trying to get pregnant. She will be able to help you prepare your body for pregnancy. She will also be able to tell you about how age can affect pregnancy.

During your pregnancy, seeing your doctor regularly is very important. Because of your age, your doctor will probably suggest some extra tests to check on your baby's health.

More and more women are waiting until they are in their 30s and 40s to have children. While many women of this age have no problems getting pregnant, fertility does decline with age. Women over 40 who don't get pregnant after six months of trying should see their doctors for a fertility evaluation. 

Experts define infertility as the inability to become pregnant after trying for one year. If a woman keeps having miscarriages, it's also called infertility. If you think you or your partner may be infertile, talk to your doctor. Doctors are able to help many infertile couples go on to have healthy babies.

Where can I go to get free or reduced-cost prenatal care?

Women in every state can get help to pay for medical care during their pregnancies. This prenatal care can help you have a healthy baby. Every state in the United States has a program to help. Programs give medical care, information, advice, and other services important for a healthy pregnancy.

To find out about the program in your state:

• Call 800-311-BABY (800-311-2229). This toll-free telephone number will connect you to the Health Department in your area code.
• For information in Spanish, call 800-504-7081.
• Contact your local Health Department.

Did we answer your question about prenatal care?

For more information about prenatal care, call womenshealth.gov at 800-994-9662 (TDD: 888-220-5446) or contact the following organizations:

• American College of Obstetricians and Gynecologists Phone:  202-638-5577
• American Pregnancy Association Phone:  972-550-0140
• Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, HHS Phone:  800-370-2943 (TDD: 888-320-6942)
• March of Dimes Phone:  914-997-4488
• National Center on Birth Defects and Developmental Disabilities, CDC, HHS Phone:  800-232-4636 (TDD: 888-232-6348)
• John W. Schmitt, M.D., Associate Professor of Clinical Obstetrics and Gynecology, University of Virginia Medical School
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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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What types of preventive care services are available for women?

By HealthSherpa

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As a woman, figuring out your healthcare options and understanding the services available to you is a vital part of your preventive care. Thankfully, an important provision of the  Affordable Care Act  (ACA) requires that Marketplace plans cover certain preventive services for American women. This includes check-ups and routine screenings, as well as specialty services for pregnant women. As of 2012, these types of preventive services must be free, even for  non-grandfathered health plans . This means if you go to the doctor for anything related to your reproductive healthcare, you should not have to pay a copay or receive a bill later on. However, there are some stipulations, especially related to an employer’s religious objections, so it’s important for you to check with your network provider before receiving any preventive health services.

What is preventive care?

Preventive care is the healthcare that helps a person manage and maintain their health before a condition or illness becomes serious. For everyone, preventive care includes routine tests and screenings, vaccines, and annual checkups with your doctor. For women, preventive care can also include mammography screenings to check for breast cancer, cervical cancer screenings, testing for sexually transmitted infections, and information about contraceptive methods. And for pregnant women, preventive care also includes most routine prenatal visits and screenings, including gestational diabetes screenings. If you or a family needs these services, the ACA’s provision makes it easy and affordable for you to receive them.

Which women’s health services are considered preventive care?

Below are a few women’s preventive services that the majority of women will access and benefit from within their lifetime. Marketplace plans guarantees these services, with no copay or cost sharing. This set of preventive services may differ depending on your health plan. Therefore, it’s a good idea to check with your health insurance provider to see which preventive services are covered for you.

Well-woman visit

The Department of Health and Human Services recommends that women over 18 have an annual preventive check-up in order to receive an overall wellness assessment and any recommendations for future care. A well-woman visit will typically consist of a routine physical and, depending on sexual activity and age, could also include screening for sexually transmitted infections and patient education, a pelvic exam/pap smear, a mammography screening, and screenings for reproductive capacity for women who want to become pregnant. Well-woman can happen at your primary care physicians office, or at a women’s health clinic, depending on your insurance.

Contraception

Contraception with an approval by the Food and Drug Administration (FDA) is generally free for women. This includes contraceptive methods such as birth control pills and implant devices. Note: There are some exceptions for employers who cite religious objections. Read the full list of  covered contraceptive methods  here.

Sexually transmitted infection screening and counseling

Sexually active women can receive annual screening and counseling on sexually transmitted infections. This includes but is not limited to the human papillomavirus (HPV), chlamydia, and gonorrhea. This can also included HIV screenings and syphilis screenings.

Domestic violence screening and counseling

All adolescent and adult women can receive domestic violence screenings and counseling. The CDC notes that 1 in 3 women will experience intimate partner violence in their lifetime. Annual screenings to identify the signs of domestic violence and abuse can help prevent it in the future.

Unless otherwise noted by your health insurance plan, all women can receive some additional preventive services with the following benefits at no cost.

• Breast cancer prevention, including genetic testing for women who may be at high risk, like women with the BRCA gene. This also includes mammograms every 1-2 years for women over 40, and chemo-prevention counseling for women who are high risk.
• Osteoporosis screening for all women over 60. One in two women will experience complications (often a broken bone) from osteoporosis in their lifetime, making this an invaluable free service.
• Diabetes screening for women who have been diagnosed with gestational diabetes who have never had type 2 diabetes and aren’t currently pregnant.
• Tobacco use screening and interventions, as smoking can increase the risk of certain illnesses for women.
• Colorectal cancer screenings.
• Blood pressure screenings.

Like we discussed above, sexually transmitted infection prevention, screenings, and counseling are available for sexually active women, as well as the following:

• Birth control methods including diaphragms, sponges, birth control pills, vaginal rings, IUDs, and other implants.
• Cervical cancer screenings every three years in combination with a pap smear for women between 21-65.
• Screening for sexually transmitted infections, including chlamydia, gonorrhea, HPV, syphilis, and more.
• HIV screening and counseling.

Women who are pregnant or are trying to become pregnant require specific care. Therefore, these women receive additional preventive services through their Marketplace plan.

• Marketplace plans and private health insurance plans must cover maternity and childbirth. Medicaid and Child Health Insurance Program (CHIP) also cover maternity and childbirth. Although coverage varies from state to state, so it’s important to check your state’s guidelines and benefits regularly.
• Anemia screening throughout pregnancy.
• Other screenings will occur at different stages of pregnancy. Women will receive tests for Hepatitis B and have an Rh incompatibility screening at the first prenatal visit. They will also test for gestational diabetes between 24-28 weeks.
• Breastfeeding education, counseling, and supplies.
• Sterilization procedures.
• Folic acid supplements.
• Testing for infections of the urinary tract (UTIs).
• Follow-up visits with their healthcare provider.

Medicaid plans cover pregnancy and childbirth. And if you were pregnant before you enrolled in your current health plan, you cannot be charged more or penalized.

It’s important to raise awareness around all of the free preventive services available to women with Marketplace plans. After all, there are common misconceptions that free preventive healthcare for women begins and ends with the “well-woman visit.” In reality there are actually many more health resources available throughout a woman’s life. As always, you should speak with your health plan provider for more information regarding specific preventive coverage. Factors such as age and risk factor may affect co-payment, cost-sharing, or coinsurance for certain services.

Originally published on Feb 13, 2018.

I am pregnant – six weeks. I am starting a new job. They are offering me a MEC wellness preventative benefit in addition to my fixed indemnity medical insurance plan. Should I pick up this MEC plan? Will it help to cover my health visits throughout my pregnancy? Please advise

Hi there! Give us a call at (872) 228-2549 to talk through your options.

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SARAH INÉS RAMÍREZ, MD, FAAFP

Am Fam Physician. 2023;108(2):139-150

Related AFP Community Blog:   Practice Ancestry-Based Medicine, not Racial Essentialism

Related editorial:   Perinatal Care of Transgender Patients, Adolescent Patients, and Patients With Opioid Use Disorder

Author disclosure: No relevant financial relationships.

Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater satisfaction, and lower pregnancy-associated morbidity and mortality. Care initiated at 10 weeks or earlier improves outcomes. Identification and treatment of periodontal disease decreases preterm delivery risk. A prepregnancy body mass index greater than 25 kg per m 2 is associated with gestational diabetes mellitus, hypertension, miscarriage, and stillbirth. Advanced maternal and paternal age (35 years or older) is associated with gestational diabetes, hypertension, miscarriage, intrauterine growth restriction, aneuploidy, birth defects, and stillbirth. Rh o (D) immune globulin decreases alloimmunization risk in a patient who is RhD-negative carrying a fetus who is RhD-positive. Treatment of iron deficiency anemia decreases the risk of preterm delivery, intrauterine growth restriction, and perinatal depression. Ancestry-based genetic risk stratification using family history can inform genetic screening. Folic acid supplementation (400 to 800 mcg daily) decreases the risk of neural tube defects. All pregnant patients should be screened for asymptomatic bacteriuria, sexually transmitted infections, and immunity against rubella and varicella and should receive tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), influenza, and COVID-19 vaccines. Testing for group B Streptococcus should be performed between 36 and 37 weeks, and intrapartum antibiotic prophylaxis should be initiated to decrease the risk of neonatal infection. Because of the impact of social determinants of health on outcomes, universal screening for depression, anxiety, intimate partner violence, substance use, and food insecurity is recommended early in pregnancy. Screening for gestational diabetes between 24 and 28 weeks is recommended for all patients. People at risk of preeclampsia, including those diagnosed with COVID-19 in pregnancy, should be offered 81 mg of aspirin daily starting at 12 weeks. Chronic hypertension should be treated to a blood pressure of less than 140/90 mm Hg.

Family physicians provide family-centered care for individuals and families before, during, and after the birth of a child. Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater care satisfaction, improved perinatal outcomes, and mitigates pregnancy-associated morbidity and mortality. 1 Family physicians are uniquely positioned to address social determinants of health while ensuring quality of care.

Prenatal Care Visits

Initiation of care between six and 10 weeks allows for identification of preexisting conditions that negatively affect maternal-fetal outcomes (e.g., diabetes mellitus, hypertension, obesity) 2 ; however, 22% of pregnant patients do not receive care during this time. 2 The COVID-19 pandemic resulted in a reevaluation of the number of physician visits needed, with an emphasis on increased flexibility, allowing for a combination of virtual and in-person visits depending on risk. 3 Table 1 outlines the components of prenatal care. 1 , 4 – 22 Table 2 provides opportunities for educating pregnant patients during prenatal care visits. 6 , 8 , 14 – 19 , 23 – 29

PHYSICAL EXAMINATION

Weight, height, and blood pressure should be measured at the first prenatal visit. Early identification of periodontal disease and treatment decreases adverse pregnancy outcomes. 7 Treatment may be performed in the second trimester, and emergent treatment may be completed at any time during pregnancy. 7 A bimanual pelvic examination has poor predictive value for clinical pelvimetry and screening for disease (i.e., sexually transmitted infections and cancer) but may be used as a diagnostic aid in patients with a discrepancy between uterine size and gestational age, which warrants ultrasonography assessment. 30 A pelvic examination is also useful in a symptomatic patient for evaluating spontaneous labor (e.g., cervical dilation, rupture of amniotic membranes). The clinical breast examination is a diagnostic aid in the symptomatic patient and addresses breastfeeding concerns or barriers but does not demonstrate benefit in patients already receiving screening mammograms and does not decrease mortality. 31 – 33

MATERNAL WEIGHT GAIN AND NUTRITION

A prepregnancy body mass index (BMI) greater than 25 kg per m 2 is associated with preterm delivery, gestational diabetes, gestational hypertension, and preeclampsia. A BMI greater than 30 kg per m 2 is also associated with an increased risk of miscarriage, stillbirth, and obstructive sleep apnea. 6 Prepregnancy BMI informs the timing of fetal surveillance, nutritional counseling, and goals for gestational weight gain. Table 3 lists general dietary guidelines for pregnant people. 8 , 17 , 34 , 35 For Black and Hispanic people, a prepregnancy BMI greater than 25 kg per m 2 and the associated poor outcomes are worse compared with non-Hispanic White people. 36

PARENTAL AGE AT CONCEPTION

Advanced maternal and paternal age (35 years and older) is associated with poor outcomes (i.e., aneuploidy, birth defects, gestational diabetes, hypertension, intrauterine growth restriction [IUGR], miscarriage, and stillbirth). Activities focused on improving perinatal outcomes for this group, such as a detailed fetal anatomic screening on ultrasonography, may decrease morbidity and mortality. 37

PREGNANCY DATING AND ULTRASONOGRAPHY

Accurate gestational age estimation is critical to quality care because it enables more precise timing of interventions (e.g., aspirin for preeclampsia prevention, steroids for fetal lung maturity), screening tests, and delivery. Up to 40% of people estimate their last menstrual period incorrectly; therefore, ultrasonography is recommended if uncertainty exists and for patients with irregular menstrual cycles, irregular bleeding, and discrepancy between uterine size and gestational age. 1 , 38 Ultrasonography before 24 weeks decreases missed multiple gestations and post-term inductions. 39 Although routine third-trimester ultrasonography may increase detection of IUGR, it does not improve outcomes. 40 If malpresentation is suspected on physical examination, confirmation with ultrasonography is recommended. 4

ALLOIMMUNIZATION

For patients who are RhD-negative and carrying a fetus who is RhD-positive, the alloimmunization risk is 1.5% to 2% in the setting of spontaneous abortion and 4% to 5% with dilation and curettage. The risk is decreased by 80% to 90% with anti-D immune globulin. 41 Testing for the ABO blood group and RhD antibodies should be performed early in pregnancy. A 300-mcg dose of anti-D immune globulin is recommended for RhD-negative pregnant patients at 28 weeks and again within 72 hours of delivery if the infant is RhD-positive. 41

Iron deficiency anemia increases the risk of preterm delivery, IUGR, and perinatal depression. The U.S. Preventive Services Task Force found insufficient evidence to assess the benefits and harms of screening for anemia in pregnancy. 42 Screening is recommended by the American College of Obstetricians and Gynecologists early in pregnancy, with iron treatment if deficient. 43 Intravenous iron should be considered for patients who cannot tolerate oral iron or in whom oral iron has been ineffective at correcting the deficiency. 43 Patients with non–iron deficiency anemia, or if iron repletion is ineffective within six weeks, should be referred to a hematologist for further evaluation. Iron supplementation in the first trimester decreases the prevalence of iron deficiency. 43

INHERITED CONDITIONS

Pregnant patients should be counseled and offered aneuploidy (extra or missing chromosomes) screening in early pregnancy, regardless of age. 44 In the United States, 1 in 150 infants has a chromosomal condition, the most common being trisomy 21 (Down syndrome). 44 Table 4 compares screening tests for Down syndrome. 1 , 45 , 46 If a screening test is positive, amniocentesis at 15 weeks or more or chorionic villous sampling between 11 and 13 weeks is recommended. Both procedures have similar rates of fetal loss. 47 At 35 years of age, the risk of Down syndrome (1 in 294 births) is similar to that of fetal loss from amniocentesis. 47 Serum and nuchal translucency testing can screen for other trisomies, including 13 and 18, the protocols for which have lower sensitivities and higher specificities compared with screening protocols for trisomy 21 because they are rarer. 47

Additional genetic screening should be based on maternal and paternal personal and family histories. Race is a social construct, necessitating a shift in genetic risk stratification from race-based to ancestry-based. Sickle cell disease affects up to 100,000 people in the United States, but its inheritance pattern (1:10) is based on people with African ancestry, which includes much of the world. 48 Cystic fibrosis is inherited mainly by people of European ancestry (1:25), but ignoring the possibility of European ancestry in certain racial and ethnic groups results in an underestimation of its prevalence: African (1:61), Hispanic (1:40), and Mediterranean (1:29). 49

NEURAL TUBE DEFECTS

In the United States, neural tube defects affect approximately 2,600 infants per year, with the highest prevalence in Hispanic populations. 35 , 50 All pregnant patients should be counseled and offered screening with maternal serum alpha fetoprotein. 35 Folic acid, 400 to 800 mcg daily, started at least one month before conception and continued until the end of the first trimester, decreases the incidence of neural tube defects by nearly 78%. 35 Patients taking folic acid antagonists (e.g., carbamazepine, methotrexate, trimethoprim) or who have a history of carrying a fetus with a neural tube defect should take 4 mg of folic acid daily, starting at least three months before conception. 35

THYROID DISORDERS

There is no evidence that screening for thyroid disorders improves pregnancy outcomes. Thyroid-stimulating hormone levels should be measured if there is a history of thyroid disease or symptoms of disease. If the level is abnormal, a free thyroxine test helps determine the etiology. 51 Hypothyroidism complicates 1 to 3 per 1,000 pregnancies and increases the risk of fetal loss, preeclampsia, IUGR, and stillbirth. Hyperthyroidism occurs in 2 per 1,000 pregnancies and is associated with miscarriage, preeclampsia, IUGR, preterm delivery, thyroid storm, and congestive heart failure. 51 The effect of subclinical hypothyroidism on a child's neurocognitive development is not well understood, and the effectiveness of treatment with levothyroxine is unproven. 51

CERVICAL CANCER

Intervals for cervical cancer screening are based on patient age, cytology history, and history of the presence of high-risk human papillomavirus (HPV). Routine screening for people at average risk of cervical cancer should begin at 21 years of age. Screening can be performed with either cytology alone every three years, HPV screening alone every five years, or cytology plus HPV screening every five years starting at 25 years of age. Screening is not indicated for people 65 years and older with negative screening in the previous 10 years, and no history of cervical intraepithelial neoplasia grade 2 or higher in the past 25 years. 52 Colposcopy is indicated when the risk of cervical intraepithelial neoplasia grade 3 is greater than 4%. Surveillance of high-grade lesions should be performed every 12 to 24 weeks. 52 , 53 Although colposcopy and cervical biopsy can be safely performed during pregnancy, endocervical sampling should be deferred until postpartum. 53

Infectious Disease

Bacteriuria.

Asymptomatic bacteriuria complicates up to 15% of pregnancies in the United States, 30% of which progress to pyelonephritis if untreated. 54 All pregnant patients should be screened for bacteriuria at the first prenatal visit. 54 A culture from a midstream or clean-catch sample with greater than 100,000 colony-forming units per mL of a single pathogen is considered positive and treated to decrease the risk of pyelonephritis and subsequent preterm delivery. 54

SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections can affect prenatal outcomes. 55 – 57 Table 5 lists routine screening and treatment for sexually transmitted infections in pregnancy. 55 , 56

Rubella immunity screening during the first prenatal visit is recommended. Postpartum vaccination should also be offered if the patient is not immune to prevent congenital rubella syndrome in subsequent pregnancies. 1 , 58 The presence of rubella immunoglobulin G should be interpreted with caution in patients recently migrating from areas where rubella is endemic because this may indicate a recent infection. 58 Rubella is a live vaccine and should not be administered during pregnancy but is safe during lactation after delivery. 59 , 60

Maternal varicella can result in congenital varicella syndrome (i.e., IUGR and limb, ophthalmologic, and neurologic abnormalities) and neonatal varicella; infection can occur from approximately five days before to two days after birth. A negative history of varicella infection or vaccination warrants serologic testing, and if immunoglobulin G is negative, varicella exposure should be avoided. Postpartum vaccination should be offered. 61

Although tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination is recommended for anyone in close contact with the infant, only antenatal maternal vaccination ensures increased protection against neonatal pertussis. 62 Pregnant patients should receive a Tdap vaccine beginning at 27 weeks to maximize time for passive immunity to the fetus through the placental transfer of maternal antibodies; vaccination is recommended in each subsequent pregnancy. 62

INFLUENZA AND COVID-19

Influenza and COVID-19 infection in pregnancy increase the risk of intensive care unit admission, preterm delivery, stillbirth, and maternal death. 63 , 64 COVID-19 infection almost doubles the risk of developing preeclampsia 64 ; therefore, initiating low-dose aspirin (81 mg daily) starting at 12 weeks should be considered. 5 Pregnant patients and their household contacts should be vaccinated for influenza and COVID-19. 63 , 64

GROUP B STREPTOCOCCUS

In the United States, group B Streptococcus (GBS) is the leading cause of infection in the first three months of life; 25% of all pregnant patients are GBS carriers. 65 , 66 Screening with a vaginal-rectal swab for culture between 36 and 37 weeks is recommended. 67 Intrapartum antibiotic prophylaxis decreases neonatal mortality. Antibiotics are recommended when there is GBS bacteriuria with the current pregnancy, a history of a previous infant affected by GBS (e.g., septicemia, meningitis, pneumonia, death), or unknown GBS status and risk factors (e.g., preterm labor, rupture of membranes more than 18 hours before delivery, GBS in previous pregnancy). 67 Patients with GBS bacteriuria in the current pregnancy are assumed to be colonized and do not need subsequent screening. 67

Social Determinants of Health

Social determinants of health represent up to 80% of the factors that directly affect a person's health. 68 Physicians who provide prenatal care play a critical role in mitigating the burden that social determinants of health play on maternal-child health without compromising the quality of care delivered. 69 An increased burden from social determinants of health increases the risk of depression, anxiety, intimate partner violence, substance use, and food insecurity 70 , 71 ; therefore, universal screening is recommended early in pregnancy.

DEPRESSION AND ANXIETY-RELATED DISORDERS

After the COVID-19 pandemic, rates of perinatal depression and anxiety have increased. People who are non-White, 24 years or younger, or who have 12 years or less of education, lower socioeconomic status, or a history of intimate partner violence or sexual trauma are at higher risk. 11 , 72 , 73 If untreated, depression and anxiety-related disorders increase the risk of preeclampsia, preterm delivery, IUGR, substance use, maternal suicide, infanticide, psychosis, and homicide. 11

INTIMATE PARTNER VIOLENCE

Intimate partner–related homicide is the leading cause of death in the United States in pregnancy. Screening is recommended at the first prenatal visit and once per trimester. 13 Intimate partner violence increases the risk of miscarriage, placental abruption, premature rupture of membranes, IUGR, and preterm delivery. 13 Family physicians should be aware of the signs of intimate partner violence (e.g., frequent sexually transmitted infections, repeated requests for pregnancy tests when pregnancy is not desired, fear of asking a partner to use a condom), the effect of violence on health, and the increased risk of child abuse after delivery. 13

SUBSTANCE USE

Substance use during pregnancy increases the risk of IUGR, preterm delivery, stillbirth, fetal malformations, and maternal death. 74 The use of prescription opioids complicates 7% of pregnancies in the United States; of these, 20% of patients report misuse. 75 Opioid use in pregnancy increased by 131% from 2010 to 2017 in the United States, and the incidence of babies born with withdrawal symptoms in that time increased by 82%. 76 Fetal alcohol exposure is the leading cause of preventable neurodevelopmental disorders in the United States. 14 However, 14% of pregnant patients report current drinking, and 5% report binge drinking in the past 30 days. 77 Exposure to cigarette smoking in utero increases the risk of sudden intrauterine and infant death. 15

FOOD INSECURITY

Maternal food insecurity increases the risk of poor outcomes (e.g., IUGR, preterm delivery, gestational diabetes, hypertension, depression, anxiety). However, few patients disclose this due to concerns about social stigma; therefore, a universal approach to screening is encouraged. The Hunger Vital Sign tool may be used. 12

Complications of Pregnancy

Gestational diabetes.

Gestational diabetes complicates up to 14% of U.S. pregnancies, with up to 67% of patients developing type 2 diabetes later in life. 78 Racial and ethnic minorities are at the highest risk. 79 Gestational diabetes is associated with hypertension, macrosomia, shoulder dystocia, and cesarean deliveries. 80 Screening for undiagnosed type 2 diabetes at the initial prenatal visit is recommended for people at increased risk 80 ( Table 6 5 , 80 ) . Universal screening for gestational diabetes should occur between 24 and 28 weeks with a one-hour (50-g) glucose tolerance test and, if results are abnormal, should be followed by a confirmatory, fasting, three-hour (100-g) test. 80

HYPERTENSION

Blood pressure should be monitored at each prenatal visit, and education should be provided on preeclampsia warning signs. 5 Patients at increased risk of preeclampsia should be screened for thrombocytopenia, transaminitis, and renal insufficiency, including proteinuria, during the first or second trimester and started on prophylactic daily low-dose aspirin (81 mg) between 12 and 16 weeks 5 ( Table 6 5 , 80 ) . Screening for proteinuria in isolation has little predictive value for detecting preeclampsia. 5 Chronic hypertension (hypertension before 20 weeks) is treated to less than 140/90 mm Hg. 81

PRETERM DELIVERY

Preterm delivery (between 20 and 37 weeks) is a significant cause of neonatal morbidity and mortality, complicating 10.5% of U.S. pregnancies. 2 Modifiable risk factors include prepregnancy BMI (less than 18.5 kg per m 2 and greater than 25 kg per m 2 ), substance use, and short interval between pregnancies (i.e., less than 18 months). 82 Several options are available for the prevention of preterm labor in a singleton pregnancy. 82 Patients with a previous preterm delivery before 34 weeks should have a cervical length assessment starting at 16 weeks through 24 weeks. 82 These patients should be treated with progesterone supplementation (vaginal or intramuscular). In the asymptomatic patient with a short cervix and without a history of spontaneous birth before 34 weeks, vaginal progesterone (200 mg) started between 16 and 20 weeks and continued through 36 weeks is recommended. 82

POST-TERM DELIVERY

Stillbirth complicates 3 per 1,000 post-term (42 weeks or greater) pregnancies. 20 Antenatal testing should be initiated at 41 weeks; if the results are not reassuring, induction of labor is recommended. 20 , 21

Cultural Considerations

Maternity care improves outcomes; however, vulnerable populations (i.e., racial, ethnic, and religious minorities) are less likely to engage in care if it is not culturally centered, which acknowledges the effect of culture on health conditions (e.g., depression) and enhances patient-physician trust. 83 Addressing cultural needs (e.g., doula, community health workers, interpreters) throughout pregnancy helps mitigate barriers and improves outcomes.

This article updates previous articles on this topic by Zolotor and Carlough 1 ; Kirkham, et al. 17 ; and Kirkham, et al. 84

Data Sources: A search was completed using the key terms prenatal care, COVID-19, oral health, pelvic examination, prepregnancy body mass index, pregnancy dating and ultrasound, maternal and paternal age and impact on pregnancy outcomes, aneuploidy screening, inheritance patterns of sickle cell disease and cystic fibrosis, anemia, cell-free DNA analysis, thyroid disease, cervical cancer screening, management of abnormal cervical cytology, screening guidelines for sexually transmitted infections in pregnancy, group B Streptococcus screening, social determinants of health and prenatal outcomes, intimate partner violence, polysubstance abuse, food insecurity, maternity care deserts, hypertension in pregnancy, progesterone for preterm birth prevention, post-term delivery, and preconception care. Also searched were PubMed, Essential Evidence Plus, the Cochrane database, U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Cancer Society, American Family Physician , and reference lists of retrieved articles. Search dates: July 1, 2022; February 19, 2023; and June 16, 2023.

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Preventive Counseling in Routine Prenatal Care—A Qualitative Study of Pregnant Women’s Perspectives on a Lifestyle Intervention, Contrasted with the Experiences of Healthcare Providers

Associated data.

The datasets used and analyzed in this study are available from the corresponding author on reasonable request.

Maternal lifestyle during pregnancy and excessive gestational weight gain can influence maternal and infant short and long-term health. As part of the GeMuKi intervention, gynecologists and midwives provide lifestyle counseling to pregnant women during routine check-up visits. This study aims to understand the needs and experiences of participating pregnant women and to what extent their perspectives correspond to the experiences of healthcare providers. Semi-structured interviews were conducted with 12 pregnant women and 13 multi-professional healthcare providers, and were analyzed using qualitative content analysis. All interviewees rated routine check-up visits as a good setting in which to focus on lifestyle topics. Women in their first pregnancies had a great need to talk about lifestyle topics. None of the participants were aware of the link between gestational weight gain and maternal and infant health. The healthcare providers interviewed attributed varying relevance regarding the issue of weight gain and, accordingly, provided inconsistent counseling. The pregnant women expressed dissatisfaction regarding the multi-professional collaboration. The results demonstrate a need for strategies to improve multi-professional collaboration. In addition, health care providers should be trained to use sensitive techniques to inform pregnant women about the link between gestational weight gain and maternal and infant health.

1. Introduction

Overweight and obesity are major public health challenges and risk factors for subsequent diseases in both children and adults [ 1 , 2 ]. The foundations for overweight and obesity are established early in life. There is growing evidence that excessive gestational weight gain and the maternal lifestyle during pregnancy can influence the child’s risk of obesity and chronic disease in the long term [ 3 , 4 , 5 ]. Furthermore, excessive gestational weight gain is a risk factor for pregnancy and birth complications, such as preeclampsia, macrosomia, cesarean section, gestational diabetes mellitus (GDM), and Large for Gestational Age (LGA) [ 3 , 4 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ].

Due to this, pregnancy is described as a unique “window of opportunity” for preventive interventions aimed at improving maternal and child health [ 13 ]. Modifiable behavioral risk factors for adverse pregnancy outcomes and lifelong non-communicable diseases include a lack of physical activity, unhealthy diet, alcohol consumption, and smoking during pregnancy [ 14 ]. Even though adopting a healthy lifestyle before pregnancy is beneficial for the health of the mother and child [ 15 , 16 ], the period of pregnancy is discussed as a “teachable moment” and may, therefore, be a favorable time for interventions. This is because pregnant women may be particularly motivated toward ensuring that they are in good health, and the importance of risk factor modification and healthy lifestyles can be reinforced effectively [ 17 , 18 ]. There is evidence that lifestyle interventions can be effective in improving maternal lifestyle and limiting excessive gestational weight gain [ 14 , 19 , 20 , 21 , 22 , 23 ].

The percentage of women experiencing excessive weight gain during pregnancy based on National Academy of Medicine (NAM; formerly known as the Institute of Medicine, IOM) guidelines [ 24 ] ranges from 47 to 68.5% across various studies and countries [ 3 , 7 , 10 , 25 , 26 , 27 , 28 ]. These figures highlight the urgent need for preventive intervention. The International Weight Management in Pregnancy (i–WIP) Collaborative Network published a “statement on tackling obesity in pregnancy”, in which it called for the incorporation of lifestyle counseling into routine prenatal care [ 29 ].

In Germany, lifestyle topics are not discussed consistently in the context of prenatal care [ 30 , 31 ]. Prenatal care in Germany is provided by office-based gynecologists and midwives, and focuses mainly on the early identification of diseases and developmental problems in the fetus [ 30 , 31 ]. While prenatal care can, in principle, be provided by midwives and gynecologists individually, it should preferably be administered in a complementary manner [ 31 ]. Almost all pregnant women in Germany utilize prenatal screening appointments, which are paid for by the Statutory Health Insurance. As a result, they are monitored closely throughout the entire course of their pregnancies [ 31 ]. In addition to this, gynecologists are often the main healthcare providers (HCPs) for women of childbearing age and accompany these women for many years during regular preventive check-ups [ 32 ]. As such, routine prenatal care provides an ideal setting for lifestyle intervention. The GeMuKi intervention (acronym for “Gemeinsam gesund: Vorsorge plus für Mutter und Kind”—Strengthening health promotion: enhanced check-up visits for mother and child), carried out in Germany, uses this setting to address lifestyle topics and to involve multiple HCPs who consistently complement each other [ 33 , 34 ].

In order for lifestyle interventions to be effective and sustainable, they must be adapted to the needs of pregnant women. At the same time, HCPs who implement these in routine care need to find the interventions acceptable and feasible [ 35 ]. A qualitative study conducted in the U.S. showed that most women had a positive attitude toward counseling during pregnancy, while HCPs discussed barriers to counseling, including, among others, a lack of time, lack of patient interest, or inadequate training [ 36 ]. A German study revealed information gaps among pregnant women in the fields of healthy eating and weight gain, as well as the need for information and motivation regarding suitable forms of exercise during pregnancy [ 37 ]. As demonstrated by an integrative review, evidence regarding women’s overall experience with regard to prenatal care is currently limited and further research is needed to enable HCPs to modify their care to more adequately fit women’s needs [ 38 ].

In light of this, this study aims to answer the following research questions: What needs, demands, and experiences do women have with regard to the preventive lifestyle counseling provided in the GeMuKi intervention? How do their perspectives correspond to the experiences of HCPs? The results can be used to develop strategies for adapting and improving prenatal care service structures.

2. Materials and Methods

2.1. backrgound of this study: the gemuki intervention.

This qualitative study was conducted as part of the process evaluation of the GeMuKi trial. The GeMuKi trial implemented a computer-assisted multi-professional intervention in order to address the lifestyle-related risk factors for overweight and obesity in expecting mothers and their infants. The intervention was carried out in five intervention regions of the southern German state of Baden-Wuerttemberg between January 2019 and January 2022 [ 33 , 34 ].

Embedded into regular check-up visits during pregnancy, six additional preventive counseling sessions were provided: four by trained gynecologists and two by trained midwives. All HCPs who delivered the intervention received eight hours of training in advance on lifestyle topics and on motivational interviewing (MI) techniques. MI is a client-centered approach designed to evoke intrinsic motivation for behavioral change [ 39 , 40 ]. The counseling topics were based on the national recommendations for a healthy lifestyle during pregnancy issued by the ‘Healthy Start—Young Family Network’ (“Netzwerk Gesund ins Leben”) [ 41 ]. During each counseling session, the women were asked to choose from the following topics: nutrition, water intake, physical activity, breastfeeding, alcohol, nicotine, and drug use. At the end of each session, the women and HCPs agreed on jointly set SMART (Specific, Measurable, Achievable, Reasonable, Time-Bound) goals for lifestyle changes. The achievement of these goals was then discussed in the next counseling session. The GeMuKi intervention included a novel shared telehealth platform that aids multi-professional HCPs during the counseling process (the GeMuKi-Assist counseling tool) and a corresponding app (the GeMuKi-Assist app) for the women participating in the intervention. One of the features used allowed HCPs to enter each women’s jointly agreed SMART goals into the GeMuKi-Assist counseling tool. After each counseling session, the participants received a reminder (push notification) of their lifestyle goals in their GeMuKi-Assist app. Further details on the GeMuKi trial and the GeMuKi intervention can be found elsewhere [ 33 , 34 , 42 ]. The GeMuKi trial was designed as a hybrid effectiveness–implementation trial, meaning that data on effectiveness and implementation were collected simultaneously [ 43 ]. The results on the effectiveness of the intervention, which was evaluated using a cluster randomized controlled design, are yet to be published.

2.2. Study Design

The report and conduct of this study are based on the ‘COnsolidated criteria for REporting Qualitative research’ (COREQ) ( Figure S1 ) [ 44 ].

Qualitative interviews were conducted alongside the GeMuKi trial as part of the process evaluation during the first year of implementation. In order to answer the research question, an in-depth perspective from both the participating pregnant women and the HCPs was required. The use of qualitative methods appeared to be most appropriate, since this allowed an intensive description of the needs and perceptions of the interviewees.

Ethical approval was obtained from the University Hospital of Cologne Research Ethics committee on 22 June 2018 (ID: 18-163) and from the State Chamber of Physicians in Baden-Wuerttemberg on 28 November 2018 (ID: B-F-2018-100).

The interviews were conducted using semi-structured interview guides, which can be found in the Supplementary Materials ( Table S1 ). To systematize the research interest, the development of the interview guides was informed by theoretical frameworks for the factors that influence implementation. The frameworks included were the ‘Implementation outcomes’ developed by Proctor et al. 2011 [ 45 ] and the ‘Tailored Implementation for Chronic Diseases (TICD) checklist’ [ 46 ], which is based on a synthesis of frameworks and taxonomies for determinants of professional practice. The interview guides contain open-ended questions regarding the procedure and the topics of the counseling sessions, as well as the participants’ satisfaction with the intervention and the needs of the pregnant women and HCPs. Depending on the flow of the conversation, the open-ended questions allowed individuals to bring up topics not covered by the interview guides.

At the end of the interviews, once the closing question had been answered, the pregnant women were asked to answer some questions related to sociodemographic factors and their pregnancy, while HCPs were asked about their professional experience and working environments. The interview guides were tested and discussed with women of childbearing age, experts from professional associations of gynecologists and midwives, and the project’s scientific advisory board.

2.3. Recruitment and Sample

The sample for this study was drawn from women and HCPs who were enrolled in the GeMuKi-trial. HCPs and pregnant women were invited to participate if they had undergone at least two counseling sessions. This applied to 23 gynecologists and their medical assistants from 17 gynecologic practices, 7 midwives, and 59 pregnant women. Pregnant women, gynecologists, and medical assistants were invited by postal mail to participate in the interviews. Letters of invitation were sent out to the women in June 2019, while invitations to the gynecological practices were sent out in October 2019 (in one of the five regions, the recruitment of interviewees was carried out one year later, as the implementation of the intervention in this region started one year later. This involved only one pregnant woman and two medical assistants). Midwives were recruited exclusively via telephone calls in October 2019 due to their limited postal accessibility.

Only two pregnant women and one medical assistant accepted the invitation, while two gynecologists and one medical assistant declined. No response was received from the remaining invitees. Because of this, all of the remaining participants already invited were contacted successively again by phone to ask if they were interested in an interview. While all contacted pregnant women were willing to be interviewed, 18 of the eligible gynecologists and 4 of the eligible midwives either rejected participation due to a lack of time or could not been reached. An appointment was scheduled with all of those who were interested. Once the interview was over, all of the interviewees received a gift (voucher) worth 15–20 euros as a thank you for their participation. After 12 interviews had been conducted with pregnant women, data saturation was discussed by the research team as no new themes emerged in the interviews. This was not possible in the same way for the HCP interviews, as no more HCPs could be recruited for an interview. The final sample consisted of 25 interviewees, of whom 12 were pregnant women and 13 were multi-professional HCPs (five gynecologists, five medical assistants, and three midwives). The sample characteristics are displayed in Table 1 and Table 2 . The participating women were about 33 years old on average, had an average body mass index (BMI) of 25.6, and half of them were first-time mothers. All of the interviews were conducted in the last trimester of pregnancy. The interviewed HCPs were mostly female, and their level of professional experience varied greatly between 4 and 42 years. They all had between 8 and 12 months of experience in implementing the GeMuKi intervention.

Sample description of pregnant women; mean values (minimum; maximum).

Sample description of HCPs; mean values (minimum; maximum).

2.4. Data Collection

The data collection for this study took place between July 2019 and March 2020 (in one of the five regions, the interviews were carried out in October and November 2020, as the implementation of the intervention in this region started one year later. This involved only the interviews with one pregnant woman and two medical assistants. These interviews were conducted during the COVID-19 pandemic. As the GeMuKi-intervention and the interviews for this study could be carried out in the same way as before the pandemic, there were no substantial differences). The first author (L.L.; female), who is a sociologist by training and an experienced qualitative researcher conducted 25 qualitative interviews. The interviewer was part of the evaluation team and had not met the interviewees before. The interviewees were informed in advance that the interviews would discuss their personal perspectives on and experiences of prevention and lifestyle counseling in prenatal care. They knew that their insights were needed to understand if the intervention fit their expectations and to improve the implementation process of the intervention in case of a national rollout. The interviews with the gynecologists were conducted in person in their offices. The interviews with the pregnant women, midwives, and medical assistants were conducted via telephone. All of the interviews were recorded digitally, anonymized, and transcribed verbatim according to the rules published by Dresing/Pehl (2011) [ 47 ]. The interviews with the pregnant women took an average of 21 min. The interviews with the medical assistants lasted a similar amount of time (17 min), whereas the interviews with the midwives and gynecologists took longer ( Table 1 and Table 2 ). A second researcher (F.K. or F.N.) was present during the interview and documented the atmosphere and specifics during the interview in a postscript. They also made sure that all of the aspects of the interview guide were covered.

2.5. Data Analysis

The transcribed interviews were analyzed by two researchers using ‘thematic qualitative text analysis’ as described by Kuckartz (2014), a particular form of qualitative content analysis [ 48 , 49 ]. An inductive–deductive category-based approach was used [ 48 ]. L.L. developed the category system. Initially, only deductive categories derived from the interview guides were applied. In an iterative process, two researchers coded the data and derived inductive categories from the text material. In a final pass, two researchers coded the interviews independently using the elaborate category system. Conflicts in coding were discussed among L.L., F.N., and F.K. until a consensualized version for all analyses was completed. All of the coding and analyzing processes were carried out with the aid of the MAXQDA 18 software (VERBI Software, Berlin, Germany) [ 50 ]. The interviews were conducted and analyzed in German. In order to make the results available to an international audience, two researchers translated the quotes independently into English. The names of the interviewees were pseudonymized. The thematic qualitative text analysis focused on categories relevant to the research questions, which could be grouped into five main themes (see Figure 1 ).

Main themes of the Qualitative Content Analysis.

The results from the interviews are presented here for the five main themes (see Figure 1 ), each of which is discussed below from the perspectives of both the pregnant women and the HCPs. After both perspectives are presented in detail, they are each contrasted in a summary figure at the end of every section (see Figure 2 , Figure 3 , Figure 4 , Figure 5 and Figure 6 ).

Summary of the results in Section 3.1 .

Summary of the results in Section 3.2 .

Summary of the results in Section 3.3 .

Summary of the results in Section 3.4 .

Summary of the results in Section 3.5 .

3.1. Perspectives on Motivation, Acceptance, and Satisfaction Regarding Lifestyle Counseling in Prenatal Care

3.1.1. pregnant women’s perspective.

The women were interested in the intervention, mainly because they expected to receive more extensive counseling for themselves and their babies. Several of the women stated that they believed obesity to be a socially important issue, and that they would like to help to improve care for pregnant women and infants. The first-time mothers were especially interested in receiving more detailed counseling sessions. They often felt uncertain about various issues and were pleased to be given the opportunity to receive extended counseling sessions with HCPs. Some of the women who had already given birth also reported that they were often overstrained, especially during the first pregnancy.

“because when you don’t have a clue at all and you’re at the beginning and..: Hm, yes, what am I allowed to do now, what should I do, what can I NOT do, what would be better for me? At the beginning, you are a bit overwhelmed when you get your first [baby]” (Christine, paragraph 67)

The women who had already had children felt that their first pregnancies had already provided them with all of the information they needed. They stated several times that they felt less need to talk. In addition to this, due to their already busy childcare schedules, they had less time to implement the recommendations on lifestyle changes.

The pregnant women were of the opinion that the opportunity for lifestyle counseling should be available as part of routine care, but women should be able to decide for themselves whether and with whom they would like to address the topics, depending on their needs.

Pregnancy is rated as a good time for lifestyle counseling because it is a time when women report taking greater care of themselves. During check-up visits, almost all of the women wanted to discuss what they were allowed to do and what they should avoid. For example, they expected instructions on what foods or sports they should avoid during pregnancy.

The women were mainly satisfied with their participation in the intervention, as it gave them more time to spend with HCPs.

“I am very pleased. In particular, the additional counseling from the gynecologist was of the main reasons why I participated in this intervention” (Kerstin, paragraph 86)

Nevertheless, some of the women reported that they already knew everything the HCPs had told them during their counseling sessions. Some of the interviewees pointed out that the counseling should always be adapted to each woman’s individual needs, and that maintaining a healthy lifestyle was already important to them before they became pregnant.

Some of the participants found it difficult to assess whether they had changed any aspects of their lifestyle as a result of the counseling sessions. Nevertheless, they noted that a recommendation from a physician had more impact than when an attempted change was driven by self-commitment alone. For example, one participant identified her unhealthy lifestyle patterns, and now wants to pay more attention to them. She felt that a face-to-face conversation strengthened her focus more than simply reading up on recommendations would. Several of the women reported that jointly agreed goals helped them and provided motivation. They also considered it beneficial to discuss the progress of reaching their goals with their gynecologists.

“I have to say I really like that because that gives you a little bit of an extra motivation, because every time when checking the app after visiting the doctor, there is a summary of what we talked about and what we agreed upon. That is an additional reminder and then you simply want to accomplish that [goal].” (Kerstin, paragraph 26)

The pregnant women wanted their counseling goals to realistically fit their daily lives and be easy to implement. Only one of the participants reported that the sessions failed to motivate her at all, and that she already knew everything she was told prior to participating in the intervention.

In summary, minor changes, such as participants eating more fruit or getting up to exercise more, were attributed to counseling. Additionally, some of the women were repeatedly encouraged to exercise by their HCP, even though they had concerns at first.

3.1.2. Healthcare Providers’ Perspective

All of the HCPs interviewed said that their patients generally responded positively to the offer of the intervention. In particular, they reported that the women who were going through their first pregnancies tended to be anxious, and were, therefore, grateful for receiving additional support. Furthermore, some of the women had weight problems during previous pregnancies, and therefore appreciated the counseling sessions.

The HCPs came away with the impression that most of the women were already very well informed prior to the intervention. They often needed reassurance that they were doing things right. When asked, some of the women would also always say that they were doing just fine and did not need the lifestyle advice.

All of the HCPs who were interviewed considered taking the time to provide additional counseling on lifestyle issues to be very worthwhile. They emphasized their intrinsic interest in participating, and noted that they had already dealt with the topics before. Some of the medical assistants stated that they had realized that additional counseling would be beneficial as a result of their own pregnancies. In addition to this, all of the HCPs agreed that there was a need for intervention with regard to overweightness and obesity issues.

Some of the HCPs felt that the counseling had helped the participants. In some cases, awareness was raised regarding the need for change. Sometimes, the help was nothing more than small tips for everyday routines that the patients had not come up with on their own. The HCPs also reported that the joint goal-setting process motivated their patients to give things a try. Some of the HCPs came away with the impression that the women preferred to have their hands held and be given a guideline.

According to one gynecologist, pregnant women are confronted by so many major changes in their life circumstances during pregnancy that they are not able to fundamentally change their diet and exercise if they have not already been eating/exercising adequately. Likewise, this gynecologist believed that women who were already overweight would fail to change their dietary habits, and said that the counseling intervention would thus be unable to help them.

“I think that during pregnancy, women are confronted with so many things, so many changes in life, that it is DIFFICULT for them to put everything into action, to have adequate physical activity, a healthy diet, when they didn’t even manage to do that before. And that’s what I’ve said right from the start: Those who do that ANYWAY, do not need the program, whereas those who weren’t doing it before pregnancy, definitely won’t manage it during pregnancy” (gynecologist 5, paragraph 66)

In addition to this, some of the HCPs believed that there were always some women who thought that they already knew everything. This particularly applied to women in their second or third pregnancy. Likewise, there were certain women who were described as resistant to counseling and who did not value additional counseling. Some of the HCPs noted that these were often overweight women who were unwilling to talk about their lifestyle.

One gynecologist had the impression that the counseling was particularly well received by women who were well-educated and physically active, and thus did not really need it. In contrast, another gynecologist explained that he sometimes had to phrase the information somewhat differently depending on the patient’s socioeconomic status, though he would not necessarily say that the better-off knew a lot more. In his opinion, the counseling sessions always needed to be tailored to the patients’ needs and background. In spite of this, some of the HCPs observed an information leak for women with little formal education.

There was consensus that an established relationship of trust between the woman and the HCP, e.g., due to treatment and consultation during previous pregnancies, improved the readiness of the women to accept the counseling.

3.1.3. Summary and Comparison of Perspectives

A summary of the findings and comparison of the perspectives on the motivation, acceptance and satisfaction regarding the lifestyle counselling in prenatal care is given in Figure 2 .

3.2. Perspectives on Lifestyle during Pregnancy and Topic-Specific Needs for Counseling

3.2.1. pregnant women’s perspective.

All of the women reported that they took more care of themselves during pregnancy. Nearly all of the participants used various pregnancy apps, online searches, and books to obtain information on lifestyle topics. The unborn child motivated them to adopt a healthy lifestyle.

“[…]and I think, for the good of the child, I think every mom would like to contribute something[…]” (Elli, paragraph 97)

“Hm, how can I put it best? It’s about doing my bit to ensure the development of our children” (Frida, paragraph 63)

Nutrition during pregnancy was considered a very important topic, and advice on it was desired by almost all of the participants. Some of the women expected to be educated on foods that were “forbidden” foods during pregnancy, and to receive a list of rules from HCPs.

“Yes, so that she [the gynecologist] simply explains, what I can eat, and what’s good for me and what’s not.” (Christine, paragraph 87)

Some of the participants exercised regularly, but their fitness declined during the course of their pregnancy. The participants were unsure of what activities they were still allowed to do.

During the counseling sessions, nutrition was the most frequently chosen discussion topic. One participant reported that she had more in-depth counseling sessions on nutrition due to her gestational diabetes. Another participant needed specific advice because she wanted to maintain her vegetarian diet. In addition to nutrition, the integration of physical activity into the women’s day-to-day routines was also discussed, as well as sufficient water intake. Smoking and alcohol were not discussed in depth because they were of no concern to any of the women who were interviewed.

One interviewee stated that she knew enough about the topics herself and therefore did not want to waste time receiving counseling on lifestyle issues. She believed that people thought enough about healthy lifestyle choices without the need for further advice. She had gained more weight than she wanted, and considered this to be due to a lack of physical activity.

The women reported that they would also like something to take home after the counseling session, such as an information brochure on the lifestyle topics they had discussed. The participants reported that their minds were often very busy during the counseling sessions, and that it would be great to be able to remind themselves of the conversation using written information the next day.

The predefined topics corresponded to the participants’ expectations. Most of the women felt that, in addition to these topics, they could also address any other issue as necessary. One participant said she would also be open to home visits for counseling sessions on breastfeeding.

3.2.2. Healthcare Providers’ Perspective

The HCPs believed there was a tremendous need for lifestyle counseling, since they provide care to many overweight women. One gynecologist said that the needs of pregnant women varied greatly depending on their initial weight and level of education. One gynecologist said that many women had no idea what healthy food was, and that they stopped exercising the moment they discovered they were pregnant.

”because they simply have no idea at all what is healthy food and what is not. They put themselves to bed: I’m not moving (laughs slightly), that could harm the child (laughs slightly). That’s really blatant” (Gynecologist 3, paragraph 8)

One medical assistant came away with the impression that the women were mostly asking for confirmation on whether they were eating enough and whether their diets were healthy enough.

“I would say that nutrition [is the most important topic for women]. Many are uncertain about this. Am I now eating sufficiently, am I now eating HEALTHY enough? So I always have this feeling, yes.” (Medical Assistant 3, paragraph 44)

The HCPs confirmed that nutrition was the most popular counseling topic, followed by physical activity. They also stated that nutrition was usually particularly important to women during their first pregnancy. One gynecologist said that the participants often had problems with gaining weight or drinking water. Some physicians stated that alcohol and nicotine-related issues were a problem. Smokers often do not manage to quit completely, while alcohol consumption is very taboo and often kept secret. The gynecologists stated that many problems, such as substance abuse disorders, cannot be addressed in regular preventive care, and said that some women also needed psychological support.

One gynecologist reported that it was difficult for the participants to decide which lifestyle topic they wanted to discuss while still in the early phase of pregnancy. During this phase, worries and fears regarding the progress of the pregnancy are still highly prominent. In addition to this, the early stages of pregnancy involve a large number of medical tests and require the women in question to handle a multitude of information.

“the pregnant woman COMES to the determination of the pregnancy, then one determines the pregnancy and then she is OVERCOME first with completely many information. Right? And there are really MANY, MANY, MANY things, so she must first come to terms with the fact that she is pregnant at all, is happy or not happy, is afraid whether the pregnancy will go well or not—you don’t know at the beginning of the pregnancy. Then (clears throat) is the explanation, okay, now maternity care starts. What does prenatal care mean, what do all the examinations that are done in prenatal care mean?” (Gynecologist 4, paragraph 12)

As a result, they cannot remember everything. Due to this, some of their patients expressed disappointment that they did not receive any written information after the counseling sessions. They also noted that pregnant women needed to adjust to their new life circumstances, and did not consider lifestyle issues a priority for this reason.

3.2.3. Summary and Comparison of Perspectives

In Figure 3 , the results on lifestyle during pregnancy and topic-specific needs for counselling are summarized and the perspectives on this main theme are compared.

3.3. Perspectives on Gestational Weight Gain and Needs for Counseling

3.3.1. pregnant women’s perspective.

For the women who participated in the study, weight gain was seen as a normal part of being pregnant. The participants gave the impression that they were not particularly concerned about weight gain, and did not think they could do anything about it anyway. None of the participants associated weight gain with consequences for their own health or that of their child.

“I make sure that it’s not so MUCH [weight], but I/Now if it’s 15, 20 kilos, then that’s just how it is [...] So it’s just pregnancy (laughs lightly), so then you gain weight, right?” (Christine, paragraph 54)

“Actually, it [weight gain] does not matter so much now. What is certain is that you gain weight. I am not exactly the skinniest of the participants. But I’m not worrying about it right now.” (Elli, paragraph 26)

“Well, I mean, you can’t really influence it [weight gain] much, or you shouldn’t really influence it much, by saying: Oh dear, I’m putting on far too much weight, I want to cut back. So I wouldn’t do that, also with regard to the health of the child, that the child would then, I don’t know, suffer any disadvantages in its development.” (Frida, paragraph 28)

Some of the interviewees seemed to be of the impression that they did not need to be counseled regarding weight gain, even if they had already gained a lot of weight or started their pregnancy at a high initial weight. One of the participants explicitly stated that she had gained very little weight, and, therefore, did not need to talk about weight. Some of the women reported that their weight was not discussed with a gynecologist or midwife at all. Others reported that sometimes, after weighing, they had been told that their weight gain was within limits, but that there was no further conversation on the topic afterwards.

Only one of the interviewees reported that her gynecologist had discussed and analyzed her weight gain with her. At the beginning of the pregnancy, she was afraid of gaining the same amount of weight as she had during her previous pregnancy. As a result, she was appreciative of the helpful advice on nutrition during the consultation.

One participant explained that she had gained a lot of weight, but said that she did not need to talk about it because she knew herself what had caused the gain. Her gynecologist advised her to write down her daily meals in spite of this, and she now reports that she is in better control of her weight.

In summary, it seems that none of the women were aware of weight gain recommendations or the risks associated with excessive weight gain.

3.3.2. Healthcare Providers’ Perspective

The HCPs possessed differing views on the relevance of gestational weight gain. There were both midwives and gynecologists in the study who believed that it was not their job to talk about weight, and stated that they had many other important priorities.

“So I think as long as she feels good and does not have any side effects, so if blood pressure is okay, it’s not important for me whether she gains 16 or 18 or 20 kg.” (Gynecologist 1, paragraph 56)

Some midwives even said that they did not want to address weight gain because it felt uncomfortable.

“You just have to be a little bit careful, and when I don’t see the women during the course of the pregnancy, and only at these counseling sessions, I’m just a little bit more cautious about bringing up the subject of weight if it would be extreme in any way.” (Midwife 3, paragraph 24)

Moreover, some of the HCPs reported that they had had difficulty communicating recommendations regarding gestational weight gain to overweight women. One gynecologist believed that to do so would be in conflict with the MI technique, as consultants should not give instructions when using MI. In contrast, one medical assistant said that MI techniques were helpful because they provided a means of approaching the topic of weight gently and sensitively.

On the other hand, there were also gynecologists who said that they always addressed weight, and see regular weighing during check-ups in particular as an opportunity to repeatedly raise awareness. Their impression was that women were more sensitized to the issue of their weight when it was discussed frequently. In their opinion, a combination of regular weighing and information dissemination had the potential to change lifestyles. They, therefore, believed that pregnancy and the close accompanying monitoring can be particularly beneficial in this regard.

“So, of course, all you need is information, and also of course this/We weigh them every four weeks. They’ll never have that again in their lives, right? So then they’re like: (changes voice pitch) Oh, my God, I don’t want to be asked about it again at the gynecologist.” (Gynecologist 3, paragraph 56)

Another gynecologist said that his patients know how strict he is with regard to weight gain. Even outside of pregnancy, he discusses options with obese women or refers them to colleagues.

“and then pregnancy starts, and I say “Yes, you know, weight development, how high it SHOULD be” and then you can see how it develops and that’s good […] So it seems to help if you keep pointing it out.” (Gynecologist 2, paragraph 26)

Another of the gynecologists said that, although she tries to address weight frequently, women have a very different focus and want to know if their child is healthy. Often, her patients are more concerned when they are perceived to not be gaining very much weight.

“The focus is on the child. After that, whether they’ve gained a lot of weight or not is only a minor concern. That’s something that doesn’t really interest them deeply. Funnily enough, it’s more the NOT gaining weight. The significant weight gain shocks them rather less (laughs).” (Gynecologist 4, paragraph 26)

One of the gynecologists noted that, for obese women, body weight is without a doubt an issue before pregnancy and that it should ideally have been talked about beforehand. In contrast, another of the gynecologists explained that she would only discuss lifestyle issues in the context of prenatal care, because, in such scenarios, they also have a direct impact on the health of the child. Outside of pregnancy, she sees no obligation to address the issue, and considers it the responsibility of a general practitioner.

One of the gynecologists was convinced that pregnant women are concerned about their weight because they are constantly being asked about their appearance. Nevertheless, most of her patients were unaware of the recommendation. Practically all of the HCPs observed that the women were not familiar with the recommendations for adequate weight gain during pregnancy.

3.3.3. Summary and Comparison of Perspectives

Figure 4 summarizes the findings on gestational weight gain and needs for counselling and compares the perspectives of pregnant women and HCPs.

3.4. Perspectives on the Appropriateness and Feasibility of Embedding Counseling Sessions into Routine Prenatal Check-Up Visits

3.4.1. pregnant women’s perspective.

In all cases, the women appreciated the fact that the counseling sessions were carried out as part of their routine prenatal care.

“Yes, I think so. Because where else can you go/I think it makes sense when you’re at the gynecologist’s that you also talk about such topics.” (Elli, paragraph 58)

The majority of the participants were opposed to additional appointments outside of their regular check-up visits. The pregnant woman also said they would also only consult other healthcare experts outside of their routine prenatal care setting if problems arose. For example, one participant said she could see herself contacting a lactation consultant if her breastfeeding was not going well.

The women provided highly differing descriptions of their counseling sessions. Some women felt that a lot of time was given to them. Others complained that there was little time for a conversation, and that things were rather hectic. One woman said that she stopped asking questions because everyone in the practice was so stressed. Some women reported that, despite being enrolled in the trial, they had not yet received counseling, nor had their lifestyle issues been addressed. However, the women also found it difficult to distinguish their standard care from the intervention.

Most of the interviewed women received lifestyle counseling at their gynecological practices. In half of the sample, there was no involvement at all from medical assistants in the intervention components. In some cases, they assisted with documentation or with preparing topics for the counseling sessions. For example, some medical assistants attempted to identify the topic the patients wanted to discuss. Two women reported that they had received counseling from medical assistants. Only one of the women who were interviewed received counseling from a trained midwife. The other participants reported that they only saw their midwives at a later stage of their pregnancy.

About half of the women who received counseling sessions chose the counseling topic themselves. The topics for the other half of the sample were predetermined by the respective HCP. From the interviews with the women, it appears that the HCPs often asked questions regarding their behaviors, then offered recommendations in response.

“For example, when it comes to eating behavior, she first asks me what I like to eat or what I eat in general, i.e., whether I eat healthily or not, or when it comes to drinking, what I drink all day, how much I drink and (clears throat) I answer all the questions. Then, if she has any other information that doesn’t match my questions, then she informs me about it.” (Doris, paragraph 12)

3.4.2. Healthcare Providers’ Perspective

All of the HCPs considered prenatal care to be an appropriate setting for preventive counseling. The gynecologists stressed that a gynecological practice is a good setting for preventive counseling because they usually already have a long-standing relationship with their patients and see them regularly. Emphasis was also placed on the fact that prenatal check-up visits at a gynecological practice present a reliable opportunity to speak to women about their health, since all women attend these services. Medical assistants can usually schedule appointments in order to tie the consultations to regular check-up visits.

The gynecologists did not take patient accessibility via midwives as a given, as many women are not in contact with midwives during their pregnancy; in fact, some have no contact with midwives at all. The gynecologists also pointed out that a medical practice provides a safe space where these conversations can take place uninterrupted. The gynecologists usually incorporated their consultations into the regular check-up visits. Some took 5–10 min for the consultation, and others between 15 and 20 min.

On the other hand, all of the gynecologists reported a lack of time due to many other issues relating to regular screening during check-up visits. One gynecologist stressed that gynecologists are mainly responsible for curative matters, and that preventive medicine is not something they generally deal with.

“Preventive medicine in general just basically isn’t something we do, we are basically there for curative issues. But then that’s a contradiction in itself, because there is no curative activity for us to carry out in maternity care. So we definitely need to talk about the extent to which such a practice procedure really offers room for it. But, yes, on the other hand, this is again contrary to the relationship work that one does as a caring doctor.” (Gynecologist 4, paragraph 64)

One gynecologist explained that she needed to educate the women on numerous topics, and suggested that midwives should be made more aware of prevention topics. However, she also pointed out that midwives all have different levels of training. Despite this, the gynecologists stated that breastfeeding was a topic traditionally discussed in midwifery.

Several of the HCPs did not apply the conversational MI technique, deciding instead to stick to their usual conversational approach. One physician stated that he did not consider the technique applicable at all. One of the gynecologists considered MI inappropriate for topics such as breastfeeding.

All of the midwives stressed that they had always provided lifestyle counseling and saw themselves as suitable counselors, since they also assisted families after the birth. Nutrition and breastfeeding have always been topics on which midwives have provided detailed counseling.

Contrary to the study protocol, all of the midwives reported that they always made additional appointments for lifestyle counseling as part of the intervention, as they did not normally see their patients until shortly before birth. The midwives visited the women in their homes and spent about 20 min on counseling. They felt that going to the woman’s home specifically for this purpose gave the consultation special relevance. The midwives also highlighted a number of other advantages to providing counseling in the home environment—there were no interruptions, they were able to take more time for the conversation, and they also gained an insight into the women’s lifestyles in their homes. Nevertheless, they noted that the visits were time-consuming and not very profitable. In terms of scheduling, they said that the facts that they do not have practice offices and that it is difficult to coordinate on-site home visits were problematic. One of the midwives said that they would like a predefined guideline on how to incorporate the counseling sessions into her workflow. On the other hand, another of the midwives expressed concern that gynecologists’ offices are too overburdened, and said that midwives can be more flexible and provide longer counseling sessions on an individual basis.

One gynecologist pointed out that the quality of counseling varied greatly among all colleagues. In addition, he emphasized that, in the gynecological practice, they can only cover the tip of the iceberg and highlight topics. He refers obese women to nutritional counseling and draws their attention to the services offered by health insurance companies.

Another of the gynecologists expressed concern that dedicated and well-educated women would follow the recommendation to see a nutritionist when they were actually the group that least needed to do so.

“So I think that it [the gynecological practice] is the right place, because they will definitely be there. [...] So if we now say that they should all go to a nutrition consultation, then I’ll tell you: All the working women won’t go, they’re happy when they’ve managed to get the appointment here, ok? All those who more or less let everything slide anyway, i.e., the unmotivated ones, they will NOT go either. Then the women you have in the nutritional counseling are the ones who actually don’t really need it, because they’re already quite good anyway.” (Gynecologist 3, paragraph 124)

Some of the HCPs stressed that the program was unable to reach the women who needed to be addressed most urgently. All of the HCPs agreed that there was an urgent need to find a way of conducting good counseling sessions with non-German-speaking women. In addition to this, they said that all of the information materials needed be translated as standard.

Another of the gynecologists reported that most of her patients had a huge need for counseling on childbirth, and many fears and concerns that needed to be discussed. She said that sometimes there was more focus on this than on lifestyle issues. This gynecologist suggested using the counseling time to discuss all of the patient’s fears first, otherwise, the women would not be able to concentrate on lifestyle issues.

One of the gynecologists said that she would like to see general changes in the health care system, and that it was not cost-effective for her to conduct in-depth consultations with her patients. She claimed that HCPs needed more time and adequate compensation. Likewise, the midwives said that they would like to be reimbursed for the consultation in a manner similar to a postpartum visit. In addition to this, it was agreed that regular training should be provided. Some of the gynecologists also suggested that medical assistants should be more closely involved in the consultation process. The medical assistants echoed this preference.

“I have an additional qualification as a nutrition consultant and […] I find it especially interesting in pregnancy and that was my motivation for me. […] I would like to do more personally, but I’m kind of not allowed to. So I think that’s a bit of a shame” (Medical Assistant 1, paragraph 54; 92)

3.4.3. Summary and Comparison of Perspectives

A summary of the findings and comparison of the perspectives on the appropriateness and feasibility of embedding counselling sessions in routine prenatal check-up visits is given in Figure 5 .

3.5. Perspectives on Inter-Professional Cooperation and Receiving Counseling from Different Healthcare Providers

3.5.1. pregnant women’s perspective.

Several of the women liked the idea of receiving lifestyle counseling from multiple HCPs. They felt that the more often they heard the key messages, the better. In addition to this, they believed that it would be a good idea for all of the professions involved to consult on lifestyle topics, as they hoped that this would give them a more comprehensive picture and the opportunity to explore different perspectives. In contrast, one of the women, who had already given birth to several children, said that she would have liked to choose who her counseling session was with, and did not want to have to discuss the topics with everyone.

“I am not sure whether I would be annoyed by this, when visiting all three providers, […] I would say (sighs) one time would be enough. So I think it would be good if you could choose, so everyone offers it and you can decide who you trust the most. But hearing it from everyone, I think that is too much.” (Helga, paragraph 36)

Some of the women said that they only saw their midwives shortly before/after giving birth, or only for a birth preparation class. As a result, they had no counseling sessions with their midwives. In some cases, the women already knew their midwives from previous pregnancies, and said that there was no need to see them early.

The women described a relationship of trust with their HCP as being particularly crucial for counseling. Which HCPs were trusted varied greatly from one woman to the next. Some participants reported that they already had a relationship of trust that had been established during a previous pregnancy. One of the participants felt that the gynecologist was the best person to provide the counseling, but said that she would still like the midwife to be more involved. One participant specifically said that she would prefer to confer with her gynecologist because, unlike the midwife, the gynecologist was someone who would continue to provide her with medical assistance for many years to come.

Some of the participants experienced a close relationship of trust with their midwives, and said that they would particularly like to receive advice from their midwives on breastfeeding. One participant said she would like to discuss all of the topics with her midwife, because she sees the midwife both during and after birth. Another of the women also placed considerable trust in her midwife, as she felt it was safe to assume that the midwife would have a particular interest in ensuring that the birth was free of complications. One of the participants reported that her midwife was available to her at all times and always responded promptly. In contrast, she hardly felt comfortable asking any questions at all at her gynecological practice.

The pregnant women expressed uncertainty regarding the relationship between gynecologists and midwives. Some of the women explicitly requested that the HCPs not contradict each other in counseling. The women were under the impression that midwives and gynecologists do not exchange information with one another and do not have access to the same data. In addition to this, the women assumed that HCPs do not maintain any contact with each other. Some of the participants were highly dissatisfied with the lack of collaboration, saying that there seemed to be a lack of mutual acceptance and respect.

The participants felt torn between their gynecologists their and midwives. They felt that some gynecologists seemed to believe that a midwife was not needed, while the midwife had offered to take over the preventive care.

“My midwife offered to do the usual prenatal care, just like the doctor would do it. That would be my choice, whether seeing the doctor or seeing her. They are both from this village, and she made the remark that my gynecologist is not convinced about letting the midwife do that and said I don’t need a midwife anyway, and that’s why I am thinking there is no cooperation between them.” (Frida, paragraph 46)

“Yes, I would say it [cooperation] is quite bad. I have a midwife who I am visiting for every second prenatal care appointment, because I want to give birth in a birthing center. And it seems like my gynecologist does not accept that. Every time I visit her she keeps saying to me that I should make the next appointment for in about two weeks, and I am not familiar with the legal situation of what is my right, and every time I see my midwife she keeps saying that my gynecologist did too much, and she wasn’t allowed to do that, because it was agreed that my midwife would do that. That is a difficult situation for me.” (Brigitte, paragraph 49–50)

In addition to this, the midwives and the gynecologists offered differing advice on a number of topics. One participant reported a discrepancy between the information she had received from her gynecologist and that from her midwife. For example, the midwife might have recommended something, then the gynecologist would state that the proposed action would not be of any help, and, as a result, the participant would not know what to do. At the same time, some of the women described midwives as peculiar, and said that they were thus hesitant to follow their advice. In this context, the women described their physicians as the authority.

“Midwives are usually kind of a bit, let’s call it ‘special.’ Every one of them has her direction where she’s heading and she is super convinced of that, but I am not sure if they are able to judge objectively. Every one of them has her own, let’s call it ‘style.’ So I would maybe rather lean towards the doctors.” (Frida, paragraph 56)

One participant said that she was more likely to listen to or act on something a doctor might say than a midwife. The women were not generally referred to other health care experts. Unless there was any particular need, they might not think of visiting other experts. Two of the participants were diagnosed with gestational diabetes, and were, therefore, referred to a diabetologist.

3.5.2. Healthcare Providers’ Perspective

All of the HCPs said that there was a need to engage more with their colleagues regarding counseling on lifestyle topics. All of the HCPs also reported that the intervention had not led to any changes with regard to collaboration.

One of the gynecologists has always worked hand-in-hand with midwives in her practice; three midwives rent offices in her practice and the collaboration works very well. The gynecologist carries out the preventive care first, then the women usually go to see the midwife afterwards. The gynecologist in question strongly supports this approach. In her opinion, gynecologists and midwives have different areas of expertise, and, therefore, complement each other well. Nonetheless, she expressed concern that this is not the way things are done in most practices. She believed that legislation has hindered collaboration between midwives and gynecologists, and said that this was bad for all of the parties involved.

“It has also been hindered by the legislation. […] This is not good for the pregnant women, for pregnancy counseling, for the midwife, and not for the doctors either, right? Nobody knows what that was all about. But (...) midwives can do different things to me. And I can do different things to the midwife. And of course I do my regular prenatal care, that’s obvious, that’s also obligatory, that’s how it should be, that’s what the women want. But they come HERE because they read on the Internet that I work with midwives, right? And then that’s exactly how it is: they have their own consultation hours, and then the patients can just go there additionally.” (Gynecologist 3, paragraph 156)

The other participating gynecologists reported that they had no contact with midwives. One gynecologist expressed regret at this, as she believes that messages are received better when they come from different HCPs. She would be open to gynecologists and midwives sharing prenatal care in a better way. For example, gynecologists could focus on more of the technically related matters and midwives could conduct more of the preventive work.

“in this room, the pregnant women are perhaps more receptive […], because they are more focused on getting this information, and if one were to speak the same language and the pregnant women knew, okay, my midwife says this, and my doctor says the same thing, so in that imaginary scenario, okay, it’s my job as a doctor to somehow record the technical points and perhaps then consult with the midwife. Maybe I would advise her to pay a little more attention with one patient, or discuss what could be done with another one, but then I would leave the intervention itself to the midwife.” (Gynecologist 4, paragraph 72)

The remaining gynecologists expressed little interest in working with midwives. One gynecologist explained this by saying that they did not have time to network. Another of the doctors had had bad experiences in the past, and said that midwives had made questionable recommendations he did not agree with. Nevertheless, he recognized that midwives perform an important job and can offer women a closer level of care than a gynecological practice is often able to. Due to the shortage of midwives, the gynecologist in question said that he already advises all newly pregnant women to seek midwifery care as soon as possible.

One of the gynecologists said that he was not interested in networking and discussion because, firstly, he had no further use for other people’s information, and secondly, he did not want to interfere with anyone else.

The medical assistants reported that discussion and collaboration in a large practice is difficult because it is not clear which midwife is in charge of which pregnant woman.

One of the midwives described the nature of the communication between physicians and midwives as old-fashioned: the midwife approaches the physician, but not vice versa.

“We midwives have been thinking about this for a long time, but it’s hard to get the doctors to do it. So we go to them, but they don’t come to us (laughs slightly) […]. I think that’s just an old-fashioned attitude to collaboration in general, which is certainly almost historically conditioned.” (Midwife 2, paragraph 122–124)

One midwife suggested that the lack of discussion was due to tight schedules and the overburdening of both physicians and midwives. In addition to this, competitive thinking could also play a major role. One midwife observed that women were more likely to follow advice from gynecologists than that from midwives.

The midwives in particular indicated that they would like to see an improvement in their collaboration with gynecologists. They all considered joint training to be beneficial, and emphasized the importance of understanding the respective skill sets of each professional group and the way in which each one consults. They saw knowing one another’s faces as important in facilitating the exchange of patient information and further referrals. In addition to this, they advocated for a more holistic approach to counseling during pregnancy.

3.5.3. Summary and Comparison of Perspectives

The results and perspectives on inter-professional cooperation and receiving counseling from different healthcare providers are summarized and compared in Figure 6 .

4. Discussion

The results of this study are valuable for tailoring preventive measures in prenatal care according to the needs and expectations of pregnant women and their HCPs. The findings illustrate the similarities and differences in the expectations and experiences of women and HCPs with regard to the preventive counseling in pregnancy provided in the GeMuKi intervention. This demonstrates the importance of including both patients’ and HCPs’ perspectives when planning and designing implementation.

The pregnant women expressed a need to talk about lifestyle issues, mainly in terms of nutrition and physical activity. The first-time mothers in particular felt a great need for counseling and welcomed the extra time with HCPs. This was reflected by the HCPs in their daily practice as well. Furthermore, the HCPs pointed out a tremendous need for lifestyle counseling, since they provided care to many overweight women.

All of the pregnant women who participated in the study stated that they wanted to strive for a healthy lifestyle in order to benefit themselves and their child. This behavior was not questioned and could represent a form of social desirability. Atkinson et al. (2016) found that women whose pregnancies were not characterized by a sense of vulnerability or anxiety made lifestyle decisions based upon a “combination of automatic judgements, physical sensations, and perceptions of what is normal or ‘good’ for pregnancy” [ 18 ]. Furthermore, Rockliffe et al. (2021) found that women wanted to adopt to the role of the ‘good mother’ by making healthy lifestyle changes, but, at the same time, a lack of understanding with regard to health consequences and low risk perception represented barriers to change [ 51 ].

The interviews emphasized that perspectives on gestational weight gain varied widely. Pregnant women assumed that they could not influence gestational weight gain and did not link it to the health of the child. Although the HCPs described the women as well informed, the HCPs believed that the women were not aware of recommendations for weight gain during pregnancy. Despite this, HCPs differed in how and whether they addressed weight gain, if they did so at all, and what relevance they attached to it. Moreover, some HCPs reported difficulties in communicating gestational weight gain recommendations to overweight women.

This is in line with findings that stated that pregnant women were not aware of the risks associated with gestational weight gain [ 37 , 52 , 53 ]. Pregnant women often base their behavior regarding diet and physical activity on their social and community environment and their peers’ beliefs [ 54 , 55 ]. While risks, such as smoking during pregnancy, are discussed in these contexts, the risks relating to weight gain are often not known and are not talked about [ 55 ]. This further highlights the importance of sharing information on gestational weight gain through HCPs. There is evidence that women who have received information from their gynecologists have a higher level of knowledge with regard to lifestyle-related factors during pregnancy [ 56 ]. Liu et al. (2016) showed that weight gain recommendations made by HCPs are an important predictor of actual weight gain [ 57 ]. Furthermore, Deputy et al. (2018) found that both inadequate and excessive weight gains were more likely in women who had received no recommendation at all [ 58 ]. Research has also indicated that pregnant women assume that weight gain is not a relevant issue if it is never addressed by HCPs [ 59 ]. Additionally, findings illustrate a need for accurate advice from HCPs regarding gestational weight gain recommendations [ 60 ]. Research is needed on appropriate resources and materials to support HCPs in giving consistent weight gain advice [ 36 ].

All of the interviewees agreed that regular check-up visits in prenatal care were a good setting for lifestyle counseling. While the HCPs reported a lack of time due to many other issues related to regular screening, the women appreciated the fact that they did not have to attend additional appointments for lifestyle counseling outside of their normal check-up visits. Embedding additional counseling into routine care was not always feasible for midwives, while it was easy to organize in gynecological practices. While this was not a concern of the interviewed women, some HCPs pointed out that the intervention was unable to reach the women who needed to be addressed most urgently. More research is needed regarding methods to improve outreach to these women and to refer them to experts.

All of the interviewees agreed that joint goal setting and reminders may help pregnant women in making lifestyle changes. Aside from incorporating joint goal setting, the best approach for counseling on lifestyle-related topics remains unclear. The MI technique was not always used and some of the women tended to expect concrete instructions, rather than an open conversation. In contrast, the HCPs stressed that MI techniques had been particularly helpful in enabling them to address difficult and sensitive topics, such as weight. This is in line with other findings, which demonstrated that implementing MI techniques can facilitate openness and create trust, but pose challenges to medical practices due to a lack of time in their daily routine [ 61 , 62 ].

However, it is important to consider that HCPs should be trained in sensitive communication. There is a risk that HCPs who are not trained and not aware of obesity and lifestyle issues may provide discriminatory advice. HCPs, therefore, require additional training to ensure that they do not stigmatize their patients and inadvertently harm the relationship or health outcomes [ 63 , 64 ]. Continuing education on lifestyle counseling could also benefit patients in other stages of life, such as those undergoing hormonal changes during menopause or cancer and cardiovascular disease [ 32 ].

The pregnant women described a relationship of trust with their HCP as particularly crucial for counseling. They were dissatisfied with the collaboration between gynecologists and midwives. Conflicts between the professional groups were sometimes acted out at the patients’ expense, resulting in insecurity. The midwives in particular expressed a desire for improved cooperation, while the gynecologists mostly believed that discussion was only needed if complications occurred. Many women do not receive care from a midwife until the last few weeks before birth. Some of the interviewed gynecologists proposed a better division and coordination of consultations so that each profession could focus on their respective field of expertise. Interdisciplinary stakeholders in health care relating to childbirth in Germany have also called for improved collaboration, for example, through joint education and training, and resolution of legal ambiguities [ 65 ]. Different authors point to the importance of commitment, interpersonal skills, effective communication, respect, and trust among HCPs for successful collaboration [ 66 , 67 , 68 ]. More research is needed to examine the deep-rooted reasons for the difficulties in collaboration between gynecologists and midwives in Germany. Van der Lee et al. (2016) described a combination of exploring contemporary inter-professional practice with a historical perspective on inter-professional collaboration as beneficial to understand problems, and to provide guidance for improving collaboration [ 69 ]. From this, implications for policy and practice could be derived and could enable practitioners to implement actions for improving collaboration.

Strengths and Limitations

One strength of the study was the open and explorative character of the interviews. At the beginning, the women were asked to tell the interviewer about their last counseling session with their gynecologist and/or midwife. This led to an open flow of conversation in which the women were able to decide for themselves what to focus on. Another strength was the study’s ability to incorporate inter-professional perspectives, as it allowed gynecologists, midwives, and medical assistants to share their experiences. The fact that different researchers were involved in the iterative analysis process represents another advantage, as it meant that the results were discussed in depth at various stages and according to the text material.

As shown in an evaluation of the recruitment procedures during the GeMuKi trial, intrinsic motivation was one of the major factors that led to HCPs participating in the GeMuKi trial [ 70 ]. The HCPs who consented to be interviewed were most likely motivated. It was, therefore, reasonable to assume that they did not represent typical HCPs in terms of implementing the intervention. A larger sample of different healthcare providers would have been beneficial. Unfortunately, it was not possible to recruit more healthcare providers for an interview. The interviews did not provide the information required for a comprehensive evaluation of the use of MI techniques. This would have required recurring observations of the counseling sessions, which was unfortunately not possible in practice.

5. Conclusions

Pregnant women and HCPs rated regular check-up visits during pregnancy as a good setting in which to focus on lifestyle topics. In particular, both pregnant women and HCPs reported that the combination of joint goal setting, reminders via push notifications, and feedback sessions helped women to make minor lifestyle changes. Nevertheless, it became apparent that there was a lack of information among pregnant women with regard to the recommendations for adequate gestational weight gain, and that the counseling approaches adopted by HCPs varied greatly. A discussion should be held regarding using sensitive techniques to inform all pregnant women of the risks and consequences of excessive weight gain. In addition to this, strategies should be sought to improve inter-professional collaboration between all of the HCPs involved in regular prenatal care. The results of this study will help to improve health care in pregnancy by taking into account the perspectives of both pregnant women and their HCPs.

Acknowledgments

The GeMuKi project was supported by the Innovation Fund of the German Federal Joint Committee, the G-BA (Project no. 01NVF17014), and was carried out by a consortium of five partners: Plattform Ernährung und Bewegung, Institut für Gesundheitsökonomie und Klinische Epidemiologie Universitätsklinikum Köln, Fraunhofer Institut für Offene Kommunikationssysteme FOKUS, BARMER, and Kassenärztliche Vereinigung Baden-Wuerttemberg. First, we would like to thank all of the interviewees—both the pregnant women and the healthcare providers—for their participation in the study and their openness to sharing their experiences and perspectives with us. We would also like to thank Isabel Lück and the team of study coordinators for their assistance in recruiting the interview participants. Additionally, we would like to thank the whole project team for their efforts and fruitful discussions. In the context of the host trial, the authors would like to thank all participating practices, gynecologists, pediatricians, medical assistants, midwives, pregnant women, and their families for their involvement. We would like to extend our deep thanks to Isabel Lück, Judith Kuchenbecker, Andrea Moreira, Andrea Seifarth, Elena Tschiltschke, Denise Torricella, and Hilke Friesenborg, who coordinated the study in the study regions in Baden-Wuerttemberg and provided essential support for data management in the field, and Anne-Madeleine Bau, GeMuKi project leader, who coordinated the consortium. We would also like to thank Brigitte Neumann and Sonja Eichin for developing and conducting the training in all intervention regions. Furthermore, we acknowledge Stefan Klose, Christian Giertz, Benny Häusler, and Michael John for developing and operating all of the digital intervention components. In addition, we would like to extend our thanks to Karsten Menn, Tobias Weigel, Rüdiger Kucher, and Simone Deininger for their help with the legal and contractual aspects of the project. We also acknowledge the members of the scientific advisory committee: Hans Hauner, Joachim Dudenhausen, Liane Schenk, Julika Loss, and Andrea Lambeck. We also thank Arim Shukri for his assistance with the statistical analyses. Additionally, we would like to thank the following partners, who have had an essential role in the success of the GeMuKi project: Gesund ins Leben—Netzwerk Junge Familie, Berufsverband der Kinder—und Jugendärzte, Berufsverband der Frauenärzte, Hebammenverband Baden-Wuerttemberg, Landesärztekammer Baden-Wuerttemberg, Universität Freiburg, AOK Baden-Wuerttemberg, Techniker Krankenkasse, and all other health insurers participating in the project through GWQ Service Plus. Further, we would like to thank Cornelia Wäscher for her contribution to the grant proposal. Finally, we gratefully acknowledge Thomas Kauth and Ulrike Korsten-Reck for contributing to the initial project idea and for their support during implementation.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph19106122/s1 , Figure S1: COREQ Checklist; Table S1: Interview guides. Table S2: Topics of the interview guide*: Interviews with healthcare providers.

Funding Statement

The Innovation Fund of the German Federal Joint Committee (G-BA), Module 3, funded the trial: Improving communication with patients and promoting health literacy (Project no. 01NVF17014).

Author Contributions

L.L. designed the study, collected and analyzed the data, and wrote the manuscript. F.K. and F.N. assisted in the recruitment of the interviewees and supported the iterative process of data coding. A.A., F.K., F.N., L.L. and S.S. were members of the research team for the host trial. A.A. and S.S. designed the evaluation of the host trial. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki. Ethical approval was received from the University Hospital of Cologne Research Ethics committee on 22 June 2018 (ID: 18-163), and from the State Chamber of Physicians in Baden-Wuerttemberg on 28 November 2018 (ID: B-F-2018-100). The trial was registered in the German Clinical Trials Register (DRKS00013173; date of registration: 3 January 2019). The study data were processed exclusively in a pseudonymized form in accordance with the EU General Data Protection Regulation (GDPR).

Informed Consent Statement

Written informed consent for the interviews and to publish the study was obtained from all the participants.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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What is Preventive Care?

Preventive care helps detect or prevent serious diseases and medical problems before they can become major. Annual check-ups, immunizations, and flu shots, as well as certain tests and screenings, are a few examples of preventive care. This may also be called routine care.

What’s the difference between preventive care and diagnostic care?

Diagnostic care is related to services in which your provider is looking for something specific, often based on the results of a preventive test or screening. For example, a radiologist may ask for a follow-up mammogram for a patient. This follow-up is to check for something that may have been detected during the preventive or routine mammogram. The follow-up mammogram is diagnostic, and not covered as preventive care.

What are preventive care services?

Examples of preventive health services and their frequency:

• Annual check-up (1 per calendar year): This is when your Primary Care Provider (PCP) checks all areas of your health—physical, as well as emotional. This can help detect any health concerns early, before they become major medical problems.
• Flu shot (1 per year): This is typically covered 100% under most health plans and helps protect you from certain strains of the flu virus.
• Mammogram (1 per calendar year, usually after the age of 40): Routine X-rays of breast tissue to check for any signs of cancer or other abnormalities. Some health plans may also cover costs for 3D imaging.
• Colonoscopy (typically 1 per every 10 years, usually after the age of 45): Screening for colon cancer.
• Vaccinations (usually administered during childhood, includes boosters as needed): Vaccinations like measles, mumps, rubella, polio, etc. are covered 100%.

Examples of non-preventive care include:

• Diagnostic tests and screenings: These are not routine tests and screenings. For example, if your radiologist finds something on your mammogram and wants another, it’s considered a diagnostic mammogram and will typically not be covered as preventive care.
• Additional primary care visits: Most health plans will cover you for 1 annual check-up with your doctor. Other visits during the same calendar year will likely not be covered as preventive. For example, let’s say you have flu symptoms and need to see your doctor—that’s not a covered preventive care visit.
• Specialist visits: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular problem are not covered as preventive care.
• Alternative therapies: Services such as chiropractic, massage, acupuncture, and other alternative health services are not considered preventive care.
• PSA blood test: This is a test to check for prostate cancer. Some health plans may cover this as preventive care, but many do not.

Is preventive care free?

Most health plans are required by law to cover eligible preventive care services at 100%. This includes health insurance plans you get through your employer as well as those you may buy on your own through the Health Insurance Marketplace. Your doctor must also be in-network in order to be fully covered.

What are the benefits of preventive care?

Preventive care is intended to help you stay as healthy as possible. Regularly scheduled visits and tests allow your doctor to identify any medical problems before they can become major.

Benefits of preventive care include:

• Most preventive care at no cost to you as part of your health coverage
• Early detection of medical problems, illnesses, and diseases helps your doctor provide proactive care and treatment
• Routine care can help you stay focused on your own health goals

How do you know what preventive care you need and when?

Your PCP can help you coordinate what tests and shots are right for you. They may consider things like family history, age, sex, current health status, and more.

See a complete list of preventive care services

Preventive care is often covered 100% by your health plan and offers many benefits, both in cost and health. If you have questions about what’s covered and not covered, or when you should have certain tests done, make sure to ask your doctor.

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Prenatal Care

(medical care during pregnancy), should i see a doctor before i try to get pregnant, what happens at my first doctor visit, what medical care will i need during my pregnancy.

Prenatal care is medical care you get before you give birth. Prenatal care includes routine doctor visits and routine tests. The doctor checks your health and the health of your developing baby.

Routine visits and tests let your doctor find problems before they cause symptoms

Problems you had before, like high blood pressure or asthma, may need to be treated differently when you're pregnant

Your doctor will tell you how to take care of yourself, including your diet and what vitamins you need

You'll see your doctor once a month in the beginning of pregnancy and more often as you get closer to delivery

Doctors check your weight, your urine, and your blood pressure at each visit

It's a good idea to see a doctor before you get pregnant. The doctor can make sure your pregnancy will be as safe as possible and help you prepare to get pregnant. Your doctor will:

Talk to you about how pregnancy might affect any diseases you have

Give you any immunizations Overview of Immunization You're immune to an infection when your body's natural defenses have learned how to fight it off. You can become immune naturally after you're exposed to germs such as bacteria or viruses. Or... read more you need

Ask you about risk factors for diseases that could be passed to your baby (inherited)

If you have risk factors for inherited diseases, the doctor may recommend doing blood tests as part of genetic screening Genetic Counseling and Genetic Testing Before Pregnancy Genetic disorders are caused by abnormalities in one or more genes or chromosomes. Some genetic disorders are hereditary and others are spontaneous. Hereditary genetic disorders are passed down... read more . The tests look to see if you or your partner carry genes for diseases you could pass on to your child. Some doctors do these tests on everyone because people don't always have risk factors.

If you decide to try to get pregnant, do the following to give your baby the best chance of being healthy:

Take a multivitamin with at least 400 micrograms of folic acid Folate Deficiency Folate deficiency is common. Because the body stores only a small amount of folate, a diet lacking in folate leads to a deficiency within a few months. Not eating enough raw leafy vegetables... read more every day (you can find the amount of folic acid on the label)

Don’t use tobacco or be around someone who is smoking

Don’t drink alcohol

Avoid scooping used kitty litter or touching cat poop—this can transmit a disease, toxoplasmosis Toxoplasmosis Toxoplasmosis is infection caused by the protozoan parasite Toxoplasma gondii . Infection occurs when people unknowingly ingest toxoplasma cysts from cat feces or eat contaminated meat... read more , that damages your baby

You’ll see your doctor once you're about 6 to 8 weeks pregnant. The weeks of pregnancy are counted from the first day of your last menstrual period.

At this visit, your doctor will:

Estimate your due date Pregnancy Tests and Due Dates Pregnancy begins with fertilization (when a sperm enters an egg) and ends with delivery (when the baby is born). Pregnancy lasts about 9 months. You should suspect you’re pregnant if: Your period... read more (the day your doctor expects your baby to be born, usually 40 weeks after the first day of your last period)

Measure your height, weight, and blood pressure

Ask about your health, your medicines, and details about any earlier pregnancies

Check your ankles for swelling

Do a pelvic (internal) exam to check for diseases or other problems

Do a Pap test (a test to check for cancer in your cervix), if you haven't had one in the recommended time period

Take samples of blood and urine for testing

Test for sexually transmitted infections Overview of Sexually Transmitted Infections STIs are infections that are passed from person to person through sexual contact, including oral sex. STIs may be caused by different types of germs, including chlamydia, gonorrhea, HIV, and... read more

You'll see the doctor more often as your pregnancy goes along. After the first visit, you’ll see your doctor:

Every 4 weeks until 28 weeks of pregnancy

Every 2 weeks until 36 weeks

Then once a week until delivery

At each visit, your doctor will:

Take your blood pressure

Look at your ankles for swelling

Measure your uterus

Check your baby’s heartbeat

Check a urine sample for sugar

At about 16 to 20 weeks, your doctor will do an ultrasound to check your fetus's:

Size and growth

The ultrasound can also tell:

Whether you're pregnant with twins or multiples

Whether your fetus has any possible issues, including birth defects or problems with the placenta (the organ that feeds your fetus)

Depending on the ultrasound results, your doctor may do more ultrasounds later in your pregnancy.

At about 24 to 28 weeks, your doctor will do a blood test to check for high blood sugar ( gestational diabetes Diabetes During Pregnancy Diabetes is a disease in which your blood sugar (glucose) levels are too high. Blood sugar is your body’s main source of energy. Your body breaks down all types of foods, including bread, fruit... read more ).

X-rays aren't a regular part of pregnancy care. If you need an x-ray, you can get one safely by using a lead apron to shield your belly.

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What exactly is preventive care?

It may seem counterintuitive to go see your doctor when you’re feeling well. But a yearly checkup is one of the best ways to help stay as healthy and vibrant as possible.

Most health plans cover annual wellness visits. These yearly checkups are what’s known as preventive care. Preventive care also covers screening tests and advice from a primary care provider (PCP). 1 It’s how providers focus on keeping people healthy and catching illnesses earlier, before they progress and become larger problems. And it’s one of the best ways to help improve your well-being.

Routine wellness visits may be different for everybody. Some include common screening tests. Other tests and advice will depend on your health and age. A PCP can help you focus on the preventive measures that will be most effective for you, says Jay W. Lee, M.D., a member of the board of directors of the American Academy of Family Physicians and an associate professor of family medicine at the University of California, Irvine.

Here’s a closer look at each part of preventive care and how each plays a role in keeping you healthier.

Routine checkups: preventing chronic conditions

Roughly 60% of adults in the United States have a chronic disease, such as diabetes, cancer, or heart disease, according to the Centers for Disease Control and Prevention (CDC). 2 While not all conditions can be avoided, seeing a PCP regularly can go a long way to preventing certain illnesses.

Early visits are a good way for a PCP to check in on any screening tests you may need that year. They can also review your records to see if you are up to date on shots. PCPs typically take time to talk to people about their daily habits. This includes talking to you about a balanced diet and regular physical activity. Both are effective ways to help prevent chronic conditions like diabetes and heart disease. 3

When Dr. Lee talks to his patients about healthy living, he often focuses on diet and exercise, as well as sleep, “which is critical for maintaining good brain function as we age,” he says. He also brings up the importance of mental health and social connections. “There’s an increasing body of evidence showing how unhealthy social isolation can be,” he says. 4

These lifestyle tweaks can help boost your health and longevity.

Screening tests: finding a disease in its earliest stage

Preventive care also includes the recommended screenings you’ll get throughout your life. Some, such as blood pressure checks, you’ll get often. Others you may only need every few years.

The goal is to catch things early, while they’re easier to treat and less likely to cause health complications. “It’s remarkable how many times a screening test catches something early enough that we can cure it or get way ahead on treatment,” Dr. Lee says.

Routine screening tests may include: 5

• Monitoring height and weight
• Blood pressure checks
• Blood tests to check cholesterol and blood sugar levels
• Screening for cancers, such as breast cancer (mammogram), prostate cancer, cervical cancer (pelvic exam and Pap smear) and colon cancer (colonoscopy)
• Checking for sexually transmitted infections
• Testicular exams
• Prostate checks
• Bone density scans
• Dental exams
• Full-body skin checks

Some of these screening tests will be done at the PCP’s office. Others, such as screening for cancers and dental exams, will be done by other providers. A PCP can help you keep on top of these tests.

PCP counseling: managing conditions

“Ultimately, as family physicians, our goal is to prevent you from getting sick,” says Dr. Lee. “But if you do develop a chronic illness like diabetes or high blood pressure, our goal is to prevent those diseases from further damaging your body,” he says.

At the annual wellness visit, a PCP may ask you about the medicines you take and other providers you see. PCPs can also order additional tests if they suspect a problem based on family or health history. 6

In that way, PCPs help manage your condition and reduce your risk of longer-term complications such as blindness, kidney failure, heart attack or stroke. It’s important to follow your treatment plan, and you should never hesitate to ask questions if you’re confused about any part of the plan, says Dr. Lee.

If you’re one of the many Americans who are behind on their doctor visits, 7 “Now’s the time to reach out, schedule those appointments, and get back on track,” he says.

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The Full Prenatal Care Guide

Getting good healthcare during your pregnancy is important for both you and your baby.

Prenatal care helps boost your chances of having a full-term pregnancy and delivering a healthy baby. Plus, having regular visits to your healthcare provider offers a great opportunity to get answers to any questions you have about your pregnancy and the birth of your baby.

You have lots of choices when it comes to your prenatal care. This guide can help you understand what types of prenatal care may be offered to you, and describes some of the options you may have.

Read on to find out why prenatal care is important, how to choose a good prenatal healthcare provider, what happens during your prenatal care visits, what tests might be recommended to you as part of your prenatal care schedule, and more.

What Prenatal Care Is and Why It’s Important

Prenatal care, as the name suggests, is the healthcare you get during your pregnancy. It consists of regular medical checkups that may include various types of tests and exams, along with a chance to discuss what might happen when it comes to your pregnancy, labor, and the delivery of your baby.

If you're wondering why prenatal care is important, it’s because it helps keep you and your baby healthy and safe. With prenatal care, your doctor, nurse, or midwife can spot any health problems early and treat them. Another benefit of prenatal care is that you have the opportunity to get guidance from your healthcare provider on how to have a healthy pregnancy.

It’s ideal if you visit your healthcare provider when you first decide you want to get pregnant. Taking care of your health and preparing for a successful conception helps put you on the path to a healthy pregnancy.

If you’ve just discovered that you’re pregnant and you didn’t get a chance to visit your provider beforehand, don’t worry. You’ll certainly still benefit from great prenatal care to help ensure you have a healthy pregnancy.

Once you’ve chosen a prenatal care provider, she will plan your prenatal care schedule, including the timing of your first prenatal checkup.

How to Choose Your Prenatal Care Doctor

Finding a healthcare provider is one of the most important decisions you’ll make in the early stages of your pregnancy.

You’ll want to choose a prenatal healthcare provider with a good reputation, of course, but it’s also crucial that she listens to you, cares about your preferences, and respects you. The key is to choose someone you feel comfortable with.

Another thing to consider as you begin your search for a prenatal healthcare provider is where you want to have your baby. If you’d prefer to have your baby at a specific hospital or birthing center, or if you’re considering a home birth, make sure your provider supports your choice and can deliver your baby in the place you want.

Your current healthcare provider can give you recommendations for a prenatal care provider, and you may also want to ask moms in your circle for their opinions about their prenatal healthcare providers.

Your health insurance provider will also have a list you can check to help you find a prenatal care provider.

As you do your research, you’ll find there are different types of healthcare providers who can give you care during pregnancy, labor, and childbirth. Depending on your pregnancy and preferences, you may end up with one or a combination of the following:

Obstetrician-gynecologists (ob-gyns). These medical doctors specialize in women’s healthcare.

Maternal-fetal medicine specialists. These doctors, also called perinatologists, have the same specialized training as ob-gyns do, plus additional training in high-risk obstetrics. This kind of doctor may be what you need if yours is a high-risk pregnancy.

Family physicians. Family care doctors also have some training in obstetrics. A family physician can care for you if yours is a low-risk, straightforward pregnancy.

Certified nurse-midwives (CNMs) and certified-midwives (CMs). These specially trained practitioners can provide care if you have a low-risk pregnancy. CNMs are registered nurses with a graduate degree in midwifery. CMs have graduated from an accredited midwifery educational program. CMs have completed the same midwifery requirements as CNMs but don’t have the additional training that nurses have. Both usually work with a qualified medical doctor, like an ob-gyn or a family physician, who provides additional support.

Family nurse practitioners (FNPs) or women's health nurse practitioners (WNPs). These nurses receive advanced training in caring for all family members or in caring for women of all ages, including pregnant women.

Doulas. Doulas aren’t medically trained and don’t stand in for a doctor or nurse, but they are trained to help coach you through your labor. Doulas can be supportive for you and your partner during childbirth and postpartum.

Timing of Your Prenatal Checkups

As soon as you find out that you're pregnant, call your healthcare provider's office to set up an appointment. This first prenatal visit might take place as early as 6 to 8 weeks of pregnancy.

If you don’t have any risk factors that complicate your pregnancy, your prenatal care provider may recommend the standard schedule for checkups, which is:

Every 4 weeks until you’re 28 weeks pregnant

Every 2 weeks between 28 and 36 weeks

Once a week from 36 weeks until the birth of your baby.

If yours is a high-risk pregnancy or if a special circumstance arises, your healthcare provider may recommend scheduling additional tests or more frequent prenatal checkups.

Your provider will determine whether your pregnancy is considered high risk by taking into account certain factors, such as if you

are 35 or older, or are 17 or younger

were underweight or overweight before you become pregnant

have high blood pressure, diabetes, depression, or another health issue

are pregnant with twins, triplets, or other multiples

had a previous pregnancy that included problems such as premature labor, or had a child with a birth defect.

What Might Happen at Your Prenatal Care Visits

Most of your prenatal checkups will include:

Checking your weight and blood pressure

Measuring your abdomen to monitor your baby’s growth

Checking your baby’s heart rate.

During each of your visits, your healthcare provider will ask several questions and sometimes offer you various prenatal tests.

Between visits, keep a list of any questions or concerns you have, and be sure to raise them during your next prenatal visit.

Of course, if something is urgent or distressing, or if you experience a pregnancy symptom you think shouldn’t be ignored, you can reach out to your healthcare provider anytime at all.

Types of Prenatal Tests

Prenatal tests are various medical tests you’ll be offered throughout your pregnancy. Some prenatal tests will be done several times during your pregnancy, and some you’ll get only at certain times or under specific conditions.

Two primary types of prenatal tests are screening tests and diagnostic tests:

Screening tests. These standard prenatal tests help determine if there’s a chance of a possible health risk for you or your baby. If screening tests show that you or your baby might be at risk for some kind of health condition, then a diagnostic test may be recommended. Screening tests typically pose no risk to you or your baby. Standard screening tests check things like:

Your blood type

Your blood pressure, which can help determine if you have a blood pressure disorder called preeclampsia

Whether or not you have a health condition such as anemia or gestational diabetes

Whether or not you have an STD or cervical cancer

Your protein levels, signs of infection, or blood sugar levels

Your baby’s size, age, and position in your uterus.

Diagnostic tests. These tests help your healthcare provider confirm whether your baby has a certain health condition. Diagnostic tests are conducted when results from a screening test indicate there might be a risk for you or your baby. Some diagnostic tests carry a slight risk for miscarriage, for example. Your healthcare provider will explain the risks and benefits so that you can make an informed choice about whether you would like such a test.

First Trimester Prenatal Care: Visits and Tests

During your first prenatal care visit, you’ll get a complete physical exam, have blood tests done, and get an estimate of your due date, which will let you know approximately how far along you are.

Your healthcare provider may prescribe you prenatal vitamins, such as a prenatal multivitamin that contains folic acid.

Folic acid is an important vitamin that can help protect your baby from neural tube defects and also from cleft lip and palate.

You might also be offered vaccinations, like a flu shot.

Your first prenatal care visit will include your healthcare provider taking a full health history, and you’ll be asked about your lifestyle and relationships, among other things. Be open and honest, because your answers help your provider determine how to provide you with the best prenatal care possible.

If you don’t feel comfortable sharing openly with your provider, consider finding one you trust.

During your first or second prenatal care visit, you may also have a pelvic exam, a breast exam, and a cervical exam, which includes a Pap test.

Your provider will also check your uterus. Some healthcare providers may do this via an ultrasound exam.

Near the end of your first trimester , your healthcare provider might use what’s called a Doppler to listen to your baby’s heartbeat. This is a thrilling moment as you finally get to hear that wonderful sign of life.

Here are descriptions of some tests and exams your prenatal care provider might recommend during the first trimester:

Early ultrasound. This helps determine how far along you are and also measures the clear space in the tissue at the back of your baby’s neck, called nuchal translucency. This screening test can give your healthcare provider important information about your baby’s health and development.

A blood test. This helps determine, among other things, your blood type and your hemoglobin levels. Low hemoglobin levels can be a sign that you have anemia, which can make you feel extremely fatigued. This test will also be used to check your Rh (Rhesus) factor, a protein on the surface of red blood cells. Most people have this protein, and are what's known as Rh positive. However, if you’re Rh negative and your baby is Rh positive, this Rh incompatibility may sometimes lead to health problems. Your healthcare provider will know how to manage this condition to keep you and your baby healthy.

Carrier screening test. This is a test of your blood or saliva to determine if you’re a carrier of certain genetic conditions that could have an effect on your baby.

Cell-free fetal DNA testing. Sometimes called a noninvasive prenatal screening, this test checks your blood for your baby’s DNA to see if certain genetic conditions may be present. Depending on the result, your healthcare provider may recommend further diagnostic testing, like amniocentesis.

Chorionic villus sampling. Also called CVS, this is a diagnostic test that checks the placental tissue to determine if your baby has a genetic condition like Down syndrome. Your healthcare provider will only recommend this diagnostic test if you have a screening test, such as the cell-free fetal DNA test, for example, that indicates there might be an issue.

Second Trimester Prenatal Care: Visits and Tests

During your second trimester prenatal care visits, your healthcare provider will

check your baby’s movement

monitor your baby’s heartbeat

track your baby’s growth.

Your healthcare provider will also continue to check your weight and blood pressure at every visit.

These prenatal tests, should you choose to have them, might be done during the second trimester:

Quad test. Also called maternal blood screening, this blood test measures four different substances in your blood to screen for things like Down syndrome or Edwards syndrome (trisomy 18). The substances measured in the QUAD test include the protein called alpha-fetoprotein and the pregnancy hormone hCG.

Ultrasound. An ultrasound exam can help your healthcare provider check for birth defects, see the position of the placenta , and track your baby’s growth. It’s also possible in a second trimester ultrasound to determine your baby’s gender.

Glucose screening. This tests to see if you might have gestational diabetes.

Third Trimester Prenatal Care: Visits and Tests

At one of your prenatal visits, your healthcare provider may recommend you start doing kick counts (also called fetal movement counts) to track how often your baby moves. Your provider will explain how to do these, but you may find this Fetal Movement Tracker helpful.

You might be offered a Tdap vaccination, which is a vaccination that protects you and your baby against pertussis (also called whooping cough ), an infection that's very dangerous for newborns, as well as tetanus and diphtheria.

Near the end of your third trimester , at around 36 weeks, , you’ll start having weekly prenatal checkups. Your healthcare provider will continue to check your baby’s heartbeat and movement, as well as your blood pressure and weight gain.

Your healthcare provider will also check the position of your baby. If your baby is not facing head down — for example, if he’s in a breech position — your provider will discuss your options with you.

This prenatal test, should you choose to have it, is done during the third trimester:

Group B strep test. Also called GBS, this tests fluid from your cervix to make sure you don’t have a strep infection that you could pass to your baby during delivery.

Prenatal Care Cost

The extra expense of prenatal care can be overwhelming even if you have health insurance.

Fortunately, every state has a program to help with prenatal care. If you’d like to see what no-cost or low-cost care you’re eligible for, start by contacting the U.S. Department of Health and Human Services or your local Health Department.

You might also find help through

local hospitals or social service agencies

the federal Women, Infants, and Children (WIC) Program

community clinics

places of worship.

Staying healthy during pregnancy, and helping your baby grow and develop, starts with good prenatal care. We hope our prenatal care guidelines have helped you better understand the benefits of prenatal care and given you a rough idea of your prenatal care schedule for the coming weeks, months, and trimesters of your pregnancy.

See all sources

• Mayo Clinic: Prenatal care
• March of Dimes: Prenatal Care
• Healthy Children: Prenatal Care
• CDC Gov: Prenatal care
• Womens Health: Prenatal Care
• Mayo Clinic: Fetal Ultrasound

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