Objective: To determine maternal fetal medicine (MFM) referral trends in a Medicaid population over time. Study design: Sixteen clinical guidelines and 23 clinical conditions were identified where co-management/consultation with MFM specialist is recommended. Linked Medicaid claims and birth certificate data for 2001-2006 were used to identify pregnancies with these conditions and whether they received co-management/consultation from a MFM specialist. Results: Between 2001 and 2006, there were 108,703 pregnancies with delivery of 110,890 neonates. Forty-five percent had one or more of the conditions identified for co-management/consultation. Overall pregnancies receiving MFM contact remained unchanged at 22.2 % in 2001 and 22.1 % in 2006. However, face to face contacts decreased from 14.6 % (2001) to 8.7 % (2006) while telemedicine consults increased from 7.6 % (2001) to 13.3 % (2006). Health departments were most likely and family practitioners least likely to refer to MFM (p < 0.001). Pregnancy complications leading to MFM referrals include cardiac complications, renal disease, systemic disorders, PPROM, suspected fetal abnormalities, and cervical insufficiency. Conclusion: Referral of high-risk pregnancies to MFMs varies with the level of expertise at the primary prenatal site. Increased contact between MFMs and local providers increased MFM referrals. © 2012 Springer-Verlag.