# Use and Out-of-Pocket Costs of Antenatal Fetal Surveillance for Patients With Chronic Conditions

## TL;DR

This study shows that the use and costs of antenatal fetal surveillance vary widely among pregnant patients with chronic conditions, even within commercial insurance plans.

## Contribution

The study reveals significant disparities in access and financial burden of fetal surveillance for high-risk pregnancies.

## Key findings

- 15.9% of patients with chronic hypertension and 12.3% with pregestational diabetes received no antenatal fetal surveillance.
- One-quarter of patients faced out-of-pocket costs of $264 or more for these tests.
- Geographic and demographic factors, such as rural areas and race, were linked to lower use and higher costs.

## Abstract

This study documents wide variation in use and cost of antenatal fetal surveillance in a commercially insured sample of pregnancies with chronic hypertension or pregestational diabetes.

To measure variation in use and out-of-pocket costs for antenatal fetal surveillance (AFS) among commercially insured patients with chronic hypertension or pregestational diabetes.

This was a cross-sectional analysis of pregnancies of at least 20 weeks of gestation between 2017 and 2022. We used administrative enrollment and health insurance claims data from the Health Care Cost Institute, which includes commercially insured pregnancies nationwide. Our sample included patients with chronic hypertension or pregestational diabetes. Our outcomes were the number of days with AFS testing during pregnancy, the out-of-pocket costs for those tests, and those costs as a proportion of all out-of-pocket costs during pregnancy. We used linear regression models to compare variation in these outcomes by health plan type, patient factors (age, clinical characteristics), and geographic factors (rurality, maternity care access, and area-level income and race distributions).

Our sample included more than 150,000 pregnancies with chronic hypertension or pregestational diabetes. Patients with chronic hypertension received a median of five AFS tests, and those with pregestational diabetes received a median of six. There was significant variation in the number of AFS tests received, with 15.9% of patients with chronic hypertension and 12.3% of those with pregestational diabetes receiving no AFS tests during pregnancy. Receiving no AFS was most common for patients in areas that were rural or low income or had a higher concentration of Black individuals. One-quarter of patients with chronic conditions faced out-of-pocket costs for AFS of $264 or more or $301 or more for one-quarter of patients with pregestational diabetes. Patients in point-of-service or preferred provider organization plans, in rural areas, and in areas with a higher concentration of White people had higher costs.

Antenatal fetal surveillance is the primary tool for stillbirth prevention, yet we found wide variation in AFS use and costs in this commercially insured population of high-risk pregnancies, including many patients who receive no AFS.