ACOG Committee Opinion No. 736: Optimizing Postpartum Care

Linking Inter-professional Newborn and Contraception Care (LINCC) trial: Protocol for a stepped wedge cluster randomized trial to link postpartum contraception care with routine Well-Baby Visits

BACKGROUND

Pregnancies conceived within 18 months of a prior delivery (termed short inter-pregnancy interval [IPI]) place mothers and infants at high risk for poor health outcomes. Despite this, nearly one third of U.S. women experience a short IPI.

OBJECTIVE

To address the gap in the current model of postpartum (PP) contraception care by developing and implementing a novel approach to link (co-schedule) PP contraception care with newborn well-baby care to improve access to timely PP contraception.

METHODS

The LINCC Trial will take place in seven clinical locations across five community health centers within the U.S. PP patients (planned n = 3150) who are attending a Well-Baby Visit between 0 and 6 months will be enrolled. The LINCC Trial aims to leverage the Electronic Health Record to prompt providers to ask PP patients attending a Well-Baby Visit about their PP contraception needs and facilitate co-scheduling of PP contraception care with routine newborn care visits. The study includes a cluster randomized, cross-sectional stepped wedge design to roll out the intervention across the seven sites. The outcomes of the study include receipt of most or moderately effective methods of contraception by two and six months PP; and rate of short IPI pregnancies. Implementation outcomes will be assessed at baseline and 6 months after site enters intervention period.

CONCLUSIONS

The LINCC Trial seeks to evaluate the effectiveness and feasibility of a linked care model in comparison to usual care.

Identification of postpartum symptom informedness and preparedness typologies and their associations with psychological health: A latent class analysis

BACKGROUND

Birthing parents, defined as postpartum women and people with various gender identities who give birth, commonly experience challenging postpartum symptoms. However, many report feeling uninformed and unprepared to navigate their postpartum health.

OBJECTIVE

To identify typologies of postpartum symptom informedness and preparedness using latent class analysis (LCA) and to examine the associated patient and healthcare characteristics.

METHODS

We used survey data from a large, multi-method, longitudinal research project Postnatal Safety Learning Lab. Participants were recruited using convenience sampling and enrolled between November 2020 and June 2021. LCA was used to identify subgroups of birthing parents with different symptom informedness and preparedness using 10 binary variables (N = 148). Bivariate analysis was conducted to examine the association between characteristics and each typology.

FINDINGS

The 3-class models had better fit indices and interpretability for both informedness and preparedness typologies: High, High-moderate, and Moderate-low. The sample characteristics were different by typologies. In the modified discrimination in medical settings assessment, we found higher discrimination scores in the moderate-low informedness and preparedness typologies. The moderate-low preparedness typology had a higher percentage of birthing parents who did not have private insurance, underwent cesarean section, and planned for formula or mixed infant feeding. The median PHQ-4 scores at 4 weeks postpartum were lower among those in high informedness and preparedness typologies.

CONCLUSION

In our sample, 18 to 21 % of birthing parents were in the moderate-low informedness or preparedness typologies. Future research and practice should consider providing tailored information and anticipatory guidance as a part of more equitable and supportive care.

Adolescents' Intention to Use Long-Acting Reversible Contraception Postpartum

STUDY OBJECTIVE

Multiparous teens, compared to primiparous teens, are at increased risk for adverse neonatal and maternal outcomes. Long-acting reversible contraception (LARC) is infrequently used among postpartum teens. This study identifies predictors of teens' intentions to use LARC postpartum when it is widely available.

METHODS

Colorado teens who were patients during their pregnancy in an adolescent-centered clinic where all common methods of contraception were easily accessible were surveyed in clinic during their third trimester and following delivery regarding life circumstances (relationships, stress, and family function) and intended method of postpartum contraception. Multinomial logistic regression analyses were used to examine predictors of intended postpartum contraceptive method: LARC, non-LARC effective (condoms, birth control pills, shot, patch, or ring), or low-effective method or no contraception (abstinence, no method, or undecided).

RESULTS

A total of 1203 patients were enrolled. Greater life stress was associated with greater likelihood of intending to use low-effective contraception versus LARC postpartum. Teens in a longer relationship with their baby's father (versus those never in a relationship with the baby's father) were less likely to intend to use low-effective contraception or non-LARC effective methods and more likely to intend to use LARC postpartum.

CONCLUSION

When structural barriers are minimized, non-clinical factors such as relationship context and life stress are most associated with postpartum LARC use intentions. Health care providers can help teen patients obtain the postpartum contraception the patients believe is best by employing developmentally appropriate, person-centered care that is sensitive to life stressors and relationship context.

Factors Associated with the Uptake of Long-Acting Reversible Contraception and Contraceptive Use in Postpartum People with HIV at a Single Tertiary Care Center

OBJECTIVE

 This study aimed to elucidate factors contributing to uptake of highly effective contraception, including permanent contraception, and no contraceptive plan among postpartum people with HIV (PWHIV).

STUDY DESIGN

 A retrospective cohort analysis was conducted to correlate postpartum birth control (PPBC) with sociodemographic and biomedical variables among postpartum PWHIV who received care at The Ruth M. Rothstein CORE Center and delivered at John H. Stroger, Jr. Hospital of Cook County in Chicago, from 2012 to 2020.

RESULTS

 Earlier gestational age (GA) at initiation of prenatal care, having insurance, and increased parity are associated with uptake of highly effective contraception. Meanwhile, later GA at presentation increased odds of having no PPBC plan.

CONCLUSION

 Early prenatal care, adequate insurance coverage, and thorough PPBC counseling are important for pregnant PWHIV.

KEY POINTS

· Contraceptive use among PWHIV is poorly understood.. · Having insurance and increased parity are associated with long-acting reversible contraception use.. · Earlier GA at first prenatal care visit is associated with increased PPBC uptake..

Perinatal care among Hispanic birthing people: Differences by primary language and state policy environment

OBJECTIVE

The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment.

DATA SOURCES AND STUDY SETTING

Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions.

STUDY DESIGN

Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline-recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five-year waiting period for pregnant immigrants to access Medicaid.

DATA COLLECTION/EXTRACTION METHODS

Survey responses from 35,779 postpartum individuals with self-reported Hispanic ethnicity who gave birth during 2016-2020.

PRINCIPAL FINDINGS

Compared to English-speaking Hispanic people, Spanish-speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage-point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage-point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish-speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage-point lower prenatal care adequacy, but 1.3 (95% CI:-1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage-point higher postpartum care quality than English-speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage-points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage-points higher.

CONCLUSIONS

Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish-speaking and English-speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth.

The Relationship Between Provider and Patient Racial Concordance and Receipt of Postpartum Care

Access to postpartum care (PPC) varies in the US and little data exists about whether patient factors may influence receipt of care. Our study aimed to assess the effect of provider-patient racial concordance on Black patients' receipt of PPC. We conducted a cross-sectional study analyzing over 24,000 electronic health records of childbirth hospitalizations at a large academic medical center  in Alabama from January 2014 to March 2020. The primary outcome variable was whether a Black patient with a childbirth hospitalization had any type of PPC visit within 12 weeks after childbirth. We used a generalized estimating equation (GEE) logistic regression model to assess the relationship between provider-patient racial concordance and receipt of PPC. Black patients with Black main providers of prenatal or childbirth care had significantly higher adjusted odds of receiving PPC (adj. OR 2.26, 95% CI 1.65-3.09, p < .001) compared to Black patients with non-Black providers. White patients who had White providers did not have statistically significantly different odds of receiving PPC compared to those with non-White providers after adjustment (adj. OR 0.88, 95% CI 0.68-1.14). Although these results should be interpreted with caution given the low number of Black providers in this sample, our findings suggest that in one hospital system in Alabama, Black birthing people with a racially concordant main prenatal and delivery care provider may have an increased likelihood of getting critical PPC follow-up.

Trajectory of Postpartum Cervical Remodeling in Women Delivering Full-Term and Spontaneous Preterm: Sensitivity to Quantitative Ultrasound Biomarkers

OBJECTIVE

Women with a history of spontaneous preterm birth (sPTB) face an increased risk of recurrence. Yet, the factors contributing to the increased risk are unknown, hampering the development of targeted interventions. Noninvasive quantitative ultrasound (QUS) has been validated in the characterization of cervical tissue and has the potential to provide information about postpartum cervical remodeling. The objective of this study was to determine the postpartum cervical remodeling trajectories of women over 12 mo post-delivery and to determine whether there were differences between women who delivered full-term and spontaneous preterm that were sensitive to QUS biomarkers.

METHODS

Data were collected prospectively from 55 women: 41 who delivered full-term and 14 who delivered spontaneously preterm at 6 wk, 3, 6, 9 and 12 mo (±2 wk) postpartum. Data from QUS biomarkers: Attenuation Coefficient; Backscatter Coefficient; Shear Wave Speed; and Lizzi-Feleppa Slope, Intercept and Midband were analyzed from the acquired radiofrequency data using a Siemens S2000 ultrasound system with a transvaginal MC 9-4 MHz probe. The biomarkers were analyzed using descriptive statistics and linear mixed-effects models.

RESULTS

QUS biomarkers, Backscatter Coefficient and Lizzi-Feleppa Intercept showed significant differences during the year after delivery between women who had a full-term birth and sPTB (p < 0.05), suggesting that there are differences in the cervical remodeling trajectories between the two groups. All QUS biomarkers demonstrated significant variations between the full-term birth and sPTB groups over time (p < 0.05), indicating ongoing cervical remodeling for both groups during the 12-mo postpartum period.

CONCLUSION

QUS biomarkers identified cervical microstructure differences and trajectories in the year after delivery between women who delivered full-term and spontaneous preterm.

A systematic review of postpartum psychosis resulting in infanticide: missed opportunities in screening, diagnosis, and treatment

PURPOSE

Impacting 1 in 1000 women, untreated postpartum psychosis is associated with a 4% infanticide rate. This systematic review aims to identify factors that are associated with infanticide resulting from psychosis in the puerperal period and pinpoint areas of missed opportunity for intervention.

METHODS

A systematic literature review was conducted in accordance with PRISMA guidelines to identify and synthesize cases of maternal infanticide among perinatal females with evidence of postpartum psychosis. Four independent reviewers screened 231 articles identified in searches of three databases (PsycInfo, PubMed, and Web of Science) for studies conducted from 2013 to 2023.

RESULTS

Twelve studies were included in the final review. Findings indicate that those experiencing puerperal psychosis have increased incidence of infanticide suggesting missed opportunities for intervention and treatment. Common factors in mothers who committed infanticide as a result of delusions and/or hallucinations associated with PMADs were identified, including lack of standardized screening tools, preference for traditional and/or cultural healing practices, and access to care.

CONCLUSION

The current body of evidence supports developing and evaluating clinical interventions aimed at improving maternal mental health outcomes and infant outcomes in perinatal women experiencing puerperal psychosis.

Building Capacity of Community Health Centers to Improve the Provision of Postpartum Care Services Through Data-Driven Health Information Technology and Innovation

Maternal morbidity and mortality remain significant challenges in the United States, with substantial burden during the postpartum period. The Centers for Disease Control and Prevention, in partnership with the National Association of Community Health Centers, began an initiative to build capacity in Federally Qualified Health Centers to (1) improve the infrastructure for perinatal care measures and (2) use perinatal care measures to identify and address gaps in postpartum care. Two partner health center-controlled networks implemented strategies to integrate evidence-based recommendations into the clinic workflow and used data-driven health information technology (HIT) systems to improve data standardization for quality improvement of postpartum care services. Ten measures were created to capture recommended care and services. To support measure capture, a data cleaning algorithm was created to prioritize defining pregnancy episodes and delivery dates and address data inconsistencies. Quality improvement activities targeted postpartum care delivery tailored to patients and care teams. Data limitations, including inconsistencies in electronic health record documentation and data extraction practices, underscored the complexity of integrating HIT solutions into postpartum care workflows. Despite challenges, the project demonstrated continuous quality improvement to support data quality for perinatal care measures. Future solutions emphasize the need for standardized data elements, collaborative care team engagement, and iterative HIT implementation strategies to enhance perinatal care quality. Our findings highlight the potential of HIT-driven interventions to improve postpartum care within health centers, with a focus on the importance of addressing data interoperability and documentation challenges to optimize and monitor initiatives to improve postpartum health outcomes.

Extended postpartum outcomes with systematic treatment of and management of postpartum hypertension program

OBJECTIVE

The purpose of this study was to examine the long-term effect of a quality improvement initiative at one-year post delivery.

STUDY DESIGN

This was a retrospective study of 1480 patients who delivered between October 2018 and June 2020 at the study institution and were enrolled in the Systematic Treatment and Management of PostPartum Hypertension Program (STAMPP). Patients received standardized cuffs, education, and follow-up. At the six-week postpartum follow-up, patients were again given instructions to establish follow-up.

MAIN OUTCOME MEASURES

The primary outcome was a visit with a primary care physician (PCP) or cardiologist between 6 weeks and 1 year postpartum.

RESULTS

A total of 939 (63 %) patients had some follow-up within twelve months. Of these, 113 (12 %) and 175 (19 %) had follow-up with cardiology and primary care providers, respectively. Patients with no follow-up were more likely to have public aid (73.9 % vs 60.3 %; p < 0.001). 77 % identified as Black, with only 12 % of this cohort following up with cardiology and 13 % with a PCP.

CONCLUSIONS

Despite specific counseling about long term follow-up, a minority of patients completed one year follow-up, notably amongst Black patients and those with public insurance. Further work is needed to optimize long-term follow-up after HDP to reduce the prevalence of cardiovascular disease, especially amongst high-risk patients.

Clinical Outcomes Associated With a Remote Postpartum Hypertension Monitoring Program

OBJECTIVE

To evaluate differences in health care utilization and guideline adherence for postpartum individuals with hypertensive disorders of pregnancy (HDP) who are engaged in a remote monitoring program, compared with usual care.

METHODS

This was a retrospective cohort study of postpartum individuals with HDP who delivered between March 2019 and June 2023 at a single institution. The primary exposure was enrollment in a remote hypertension management program that relies on patient home blood pressure (BP) measurement and centralized nursing team management. Patients enrolled in the program were compared with those receiving usual care. Outcomes included postpartum readmission, office visit within 6 weeks postpartum, BP measurement within 10 days, and initiation of antihypertensive medication. We performed multivariable logistic and conditional regression in a propensity score matched cohort. Propensity scores, generated by modeling likelihood of program participation, were assessed for even distribution by group, ensuring standardized bias of less than 10% after matching.

RESULTS

Overall, 12,038 eligible individuals (6,556 participants, 5,482 in the control group) were included. Program participants were more likely to be White, commercially insured, be diagnosed with preeclampsia, and have higher prenatal and inpatient postpartum BPs. Differences in baseline factors were well-balanced after implementation of propensity score. Program enrollment was associated with lower 6-week postpartum readmission rates, demonstrating 1 fewer readmission for every 100 individuals in the program (propensity score-matched adjusted risk difference [aRD] -1.5, 95% CI, -2.6 to -0.46; adjusted risk ratio [aRR] 0.78, 95% CI, 0.65-0.93). For every 100 individuals enrolled in the program, 85 more had a BP recorded within 10 days (propensity score-matched aRD 85.4, 95% CI, 84.3-86.6), and six more had a 6-week postpartum office visit (propensity score-matched aRD 5.7, 95% CI, 3.9-7.6). Program enrollment was also associated with increased initiation of an antihypertensive medication postpartum (propensity score-matched aRR 4.44, 95% CI, 3.88-5.07).

CONCLUSION

Participation in a postpartum remote BP monitoring program was associated with fewer postpartum hospital readmissions, higher attendance at postpartum visits, improved guideline adherence, and higher rates of antihypertensive use.

Moving the needle: Quality improvement strategies to achieve guideline-concordant care of obstetric patients with severe hypertension

OBJECTIVES

To improve timely treatment and follow-up of birthing individuals with severe hypertension.

STUDY DESIGN

A quality improvement (QI) initiative was implemented at an academic tertiary care center in the United States of America for individuals with obstetric hypertensive emergencies. Statistical process control charts were utilized to track process measures and interventions tested through plan-do-study-act cycles. Measures were disaggregated by race and ethnicity to identify and improve disparities.

MAIN OUTCOME MEASURES

Treatment of hypertensive events within 60 min, receipt of blood pressure (BP) device at discharge and completed postpartum follow-up BP check within 7 days of discharge.

RESULTS

All process measures showed statistically significant improvements. The primary process measure, timely treatment of hypertensive emergencies, improved from 29 % to 76 %. Receipt of BP device improved from 37 % to 91 % and follow-up BP checks from 58 % to 81 %. No racial or ethnic disparities were noted at baseline or after interventions. Readmission rates within 6 weeks of delivery increased from 2.3 % to 6.1 % for the cohort with no severe morbidity or mortality events after discharge. Strategies associated with improvement included project launch with establishment of the "why," telehealth, simulation, a video display of quality metrics on the birthing unit, promoting BP cuff access, and automated orders.

CONCLUSIONS

This comprehensive QI initiative provides novel improvement strategies for the management of individuals with severe hypertensive disorders of pregnancy for the timely treatment of severe BP, attainment of home BP devices, and follow-up after discharge. Quality improvement methodology is practical and essential for achieving guideline-concordant care.

Patient perceptions of remote patient monitoring program for hypertensive disorders of pregnancy

PURPOSE

The utilization of remote patient monitoring (RPM) with home blood pressure monitoring has shown improvement in blood pressure control and adherence with follow-up visits. Patient perceptions regarding its use in the obstetric population have not been widely studied. The aim of this study was to assess patients' knowledge about hypertensive disorders of pregnancy and perceptions and satisfaction of the RPM program.

METHODS

Descriptive analysis of survey responses of patients with PPHTN enrolled into the RPM program for 6 weeks after delivery between October 2021 and April 2022. Surveys were automatically administered at 1-, 3-, and 6-week postpartum. Responses were further compared between Black and non-Black patient-reported race.

RESULTS

545 patients received the RPM program. Of these, 306 patients consented to data collection. At 1 week, 88% of patients that responded reported appropriately that a blood pressure greater than 160/110 is abnormal. At 3 weeks, 87.4% of patients responded reported they were "very" or "somewhat" likely to attend their postpartum follow-up visits because of RPM. At 6 weeks, 85.5% of the patients that responded were "very" or "somewhat" satisfied with the RPM program. Responses were not statistically different between races.

CONCLUSIONS

Majority of postpartum patients enrolled in the RPM program had correct knowledge about hypertension. In addition, patients were highly satisfied with the RPM program and likely to attend postpartum follow-up based on responses. Further research is warranted to validate these findings and to address any barriers for patients who did not utilize the program.

Diversity, Equity, and Inclusion: Obstetrics and Gynecologist Hospitalists' Impact on Maternal Mortality

Obstetrics and gynecology hospitalists play a vital role in reducing maternal morbidity and mortality by providing immediate access to obstetric care, especially in emergencies. Their presence in hospitals ensures timely interventions and expert management, contributing to better outcomes for mothers and babies. This proactive approach can extend beyond hospital walls through education, advocacy, and community outreach initiatives aimed at improving maternal health across diverse settings.

Financial Toxicity in Relation to Childbirth

OBJECTIVE

To measure change in financial toxicity from pregnancy to the postpartum period and to identify factors associated with this change.

DESIGN

Longitudinal survey.

SETTING

Obstetric clinics at an academic medical center in Massachusetts between May 2020 and May 2022.

PARTICIPANTS

Obstetric patients who were 18 years of age or older (N = 242).

METHODS

Respondents completed surveys that included the COmprehensive Score for financial Toxicity tool during pregnancy and in the postpartum period. We collected additional medical record data, including gestational age, birth weight, and cesarean birth. We used paired t tests to assess changes in financial toxicity before and after childbirth and one-way analysis of variance to compare average change in financial toxicity by demographic and medical variables.

RESULTS

The mean current financial toxicity score was significantly lower after childbirth (M = 19.0, SD = 4.6) than during pregnancy (M = 21.8, SD = 5.4), t(241) = 13.31, p < .001. Concern for future financial toxicity was not significantly different after childbirth (M = 8.5, SD = 2.9) compared to during pregnancy (M = 8.2, SD = 3.0), t(241) = -1.80, p = .07. Individual-level sociodemographic variables (e.g., racial/ethnic category, insurance, employment) and medical factors (e.g., cesarean birth, preterm birth) were not associated with change in financial toxicity.

CONCLUSION

Among respondents, financial toxicity worsened after childbirth, and patients are at risk regardless of their individual socioeconomic and medical conditions.

Clinical and Demographic Characteristics of Patient-Initiated Encounters Before the 6-Week Postpartum Visit

OBJECTIVE

To identify characteristics associated with a higher likelihood of patient-initiated encounters with a health care professional before the scheduled 6-week postpartum visit.

METHODS

We performed a retrospective cohort study of postpartum persons who received prenatal care and delivered at a single academic level IV maternity care center in 2019. We determined associations between maternal sociodemographic and obstetric characteristics and the likelihood of patient-initiated early postpartum encounters with χ2 tests for categorical variables and Wilcoxon rank sum tests for continuous and ordinal variables.

RESULTS

A total of 796 patients were included in our analysis, and 324 (40.7%) initiated an early postpartum encounter. Significantly more postpartum persons who initiated early postpartum encounters were primiparous persons (54.3%) than multiparous (33.8%) persons (P < .001). Postpartum persons who desired breastfeeding or who had prolonged maternal hospitalization, episiotomy, or cesarean or operative vaginal delivery were also significantly more likely to initiate early postpartum encounters (all P≤.002). Of postpartum persons who initiated early encounters, 44 (13.6%) initiated in-person visits, 138 (42.6%) initiated telephone or patient portal communication, and 142 (43.8%) initiated encounters of both types. Specifically, 39.2% of postpartum persons initiated at least one early postpartum encounter for lactation support, and nearly half of early postpartum encounters occurred during the first week after hospital discharge.

CONCLUSION

Early postpartum encounters were more common among primiparas and postpartum persons who were breastfeeding or had prolonged hospitalization, episiotomy, cesarean delivery, or operative vaginal delivery. Future studies should focus on the development of evidence-based guidelines for recommending early postpartum visits.

Understanding VA Maternity Care Coordinators Interactions and Collaboration With Primary Care Providers

INTRODUCTION

Maternal morbidity is higher among the Veteran population in part because of high rates of chronic medical and mental health conditions. To improve care for pregnant Veterans, the Department of Veteran Affairs created the position of the Maternity Care Coordinator (MCC) to provide care coordination during a Veteran's pregnancy. Maternity Care Coordinators must work with primary care providers (PCPs); yet, little is known about their collaboration and interaction. The objective of this work is to better understand how MCCs interact with PCPs.

METHOD

Between March and May of 2021, we conducted qualitative interviews with 30 MCCs using a semi-structured interview guide to learn about their role and interactions with PCPs.

RESULTS

We identified 3 main themes in interactions between MCCs and PCPs, which correlated to times during the Veteran's pregnancy: initial interactions, care coordination during the pregnancy, and end of pregnancy transitions of care. Most MCCs indicated a positive and collaborative relationship with PCPs. There was significant variability in how closely MCCs worked with PCPs. MCCs reported that PCPs were not always comfortable caring for pregnant Veterans.

DISCUSSION

Although MCCs generally indicated a positive and collaborative interaction with PCPs, our data suggest that there are opportunities to improve communication between PCPs and MCCs and to educate PCPs on knowledge of maternity benefits, the role of the MCC, and how to care for pregnant and postpartum Veterans. The Veteran Affairs MCC can also serve as a model for other health systems aiming to improve care coordinator among pregnant patients.

Birthing parent postpartum acute care use: Multilevel opportunities for strengthening healthcare

BACKGROUND

Three-quarters of pregnancy-related deaths occur from 1 day to 1 year after birth, and medical complications frequently occur after birth. Postpartum health concerns are often urgent, requiring timely medical care, which may contribute to a reliance on acute care. One approach to improving postpartum health is to investigate birthing parents' accounts of acute care use in the months after birth, which is what we did in this study.

METHODS

This mixed-methods study included questionnaire responses, semi-structured interviews, and chart review of 18 English-speaking individuals who used acute care in the 90 days after birth in the southeastern United States. Interviews were conducted remotely, recorded, and professionally transcribed. Qualitative data were inductively coded to iteratively develop categories and themes with respect to contributors and barriers to postpartum acute care use.

RESULTS

Birthing parents engaged in complex decision-making processes to decide where and when to seek postpartum acute care in response to their urgent health concerns. Many described fear and uncertainty about their postpartum health. Most participants contacted a healthcare practitioner before using acute care, followed their guidance, and were treated or otherwise reassured at the acute care visit.

DISCUSSION

These findings suggest multilevel opportunities for strengthening healthcare systems, including better-preparing individuals for the postpartum period and structuring care to accommodate birthing parents and include their support systems. The insights from this study can inform multilevel strategies for strengthening healthcare so that birthing parents are safe and well postpartum.

County-level Structural Vulnerabilities in Maternal Health and Geographic Variation in Infant Mortality

OBJECTIVE

To evaluate whether community factors that differentially affect the health of pregnant people contribute to geographic differences in infant mortality across the United States.

STUDY DESIGN

This retrospective cohort study sought to characterize the association of a novel composite measure of county-level maternal structural vulnerabilities, the Maternal Vulnerability Index (MVI), with risk of infant death. We evaluated 11,456,232 singleton infants born at 22 0/7 through 44 6/7 weeks' gestation from 2012 to 2014. Using county-level MVI, which ranges from 0-100, multivariable mixed effects logistic regression models quantified associations per 20-point increment in MVI, with odds of death clustered at the county level and adjusted for state, maternal, and infant covariates. Secondary analyses stratified by the social, physical, and health exposures that comprise the overall MVI score. Outcome was also stratified by cause of death.

RESULTS

Odds of death were higher among infants from counties with the greatest maternal vulnerability (0.62% in highest quintile vs 0.32% in lowest quintile, [p<0.001]). Odds of death increased 6% per 20-point increment in MVI (aOR: 1.06, 95% CI 1.04, 1.07). The effect estimate was highest with theme of mental health and substance use (aOR 1.08; 95% CI 1.06, 1.09). Increasing vulnerability was associated with six of seven causes of death.

CONCLUSIONS

Community-level social, physical, and healthcare determinants indicative of maternal vulnerability may explain some of the geographic variation in infant death, regardless of cause of death. Interventions targeted to county-specific maternal vulnerabilities may reduce infant mortality.

A rapid review of telehealth in women with recent de novo hypertensive disease of pregnancy

Hypertensive disorders of pregnancy pose significant risks to both maternal and fetal health. Postpartum hypertension, a common complication, often leads to emergency room (ER) visits or hospital readmissions. Despite the prevalence of these complications, there is a paucity of studies that focus on blood pressure monitoring in postpartum patients with de novo hypertensive disorders of pregnancy. This review aimed to address the gap by evaluating available evidence to compare telehealth monitoring with in-person visits in preventing ER visits and hospital readmissions among postpartum patients with de novo hypertensive disorders of pregnancy. The study identified relevant studies by conducting a rigorous search strategy (Medline/OVID, the Cochrane Library, Scopus, and research registries such as the International Clinical Trials Registry Platform [ICTRP] and clinical trials) directed by the clinical information specialist. Two reviewers independently screened titles and abstracts, resolving discrepancies with the assistance of a third reviewer. Data extraction followed standardized protocols, and risk of bias assessments were conducted using appropriate tools. This rapid review synthesized evidence from 11 studies on telehealth for women with recent de novo hypertensive disorders of pregnancy. Findings highlighted that telemonitoring led to earlier blood pressure documentation and intervention, reduced disparities in blood pressure measurement, decreased hypertension-related readmissions, higher rates of postpartum antihypertensive treatment initiation, and increased patient satisfaction. Telehealth emerges as a promising tool for managing postpartum hypertension among women with recent de novo hypertensive disorders of pregnancy.

Severe Hypertension in Pregnancy: Progress Made and Future Directions for Patient Safety, Quality Improvement, and Implementation of a Patient Safety Bundle

Hypertensive disorders of pregnancy account for approximately 5% of pregnancy-related deaths in the United States and are one of the leading causes of maternal morbidity. Focus on improving patient outcomes in the setting of hypertensive disorders of pregnancy has increased in recent years, and quality improvement initiatives have been implemented across the United States. This paper discusses patient safety and quality initiatives for hypertensive disorders of pregnancy, with an emphasis on progress made and a patient safety tool: the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Future patient safety and quality directions for the treatment of hypertensive disorders of pregnancy will be reviewed.

Preventive Primary Care in the Postpartum Year: The Role of Medicaid Delivery System Reform

INTRODUCTION

Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year.

METHODS

The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024.

RESULTS

Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation.

CONCLUSIONS

Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse.

Postpartum Ambulatory Blood Pressure Patterns Following New-Onset Hypertensive Disorders of Pregnancy

Importance

After a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for ongoing hypertension and associated outcomes have not been well characterized.

Objective

To identify risk factors and characterize outcomes for individuals with ongoing hypertension and severe hypertension following hospital discharge post partum through a hospital system's remote blood pressure (BP) management program.

Design, Setting, and Participants

This cohort study involved a population-based sample of individuals with a new-onset hypertensive disorder of pregnancy (preeclampsia or gestational hypertension) and no prepregnancy hypertension who delivered between September 2019 and June 2021. Participants were enrolled in a remote BP monitoring and management program at a postpartum unit at a referral hospital. Data analysis was performed from August 2021 to January 2023.

Exposure

Inpatient postpartum BP categories.

Main Outcomes and Measures

The primary outcomes were readmission and emergency department visits within the first 6 weeks post partum. Logistic regression was used to model adjusted odds ratios (aORs) and 95% CIs.

Results

Of 2705 individuals in the cohort (mean [SD] age, 29.8 [5.7] years), 2214 (81.8%) had persistent hypertension post partum after hospital discharge, 382 (14.1%) developed severe hypertension after discharge, and 610 (22.6%) had antihypertensive medication initiated after discharge. Individuals with severe hypertension had increased odds of postpartum emergency department visits (aOR, 1.85; 95% CI, 1.17-2.92) and hospital readmissions (aOR, 6.75; 95% CI, 3.43-13.29) compared with individuals with BP normalization. When inpatient postpartum BP categories were compared with outpatient home BP trajectories to inform optimal thresholds for inpatient antihypertensive medication initiation, there was significant overlap between postdischarge BP trajectories among those with inpatient systolic BP greater than or equal to 140 to 149 mm Hg and/or diastolic BP greater than or equal to 90 to 99 mm Hg and those with systolic BP greater than or equal to 150 mm Hg and/or diastolic BP greater than or equal to 100 mm Hg.

Conclusions and Relevance

This cohort study found that more than 80% of individuals with hypertensive disorders of pregnancy had ongoing hypertension after hospital discharge, with approximately 14% developing severe hypertension. These data support the critical role of remote BP monitoring programs and highlight the need for improved tools for risk stratification and consideration of liberalization of thresholds for medication initiation post partum.

Patterns of Antihypertensive Medication Use in the First 2 Years Post Partum

Importance

Women who had a hypertensive disorder of pregnancy (HDP) have a well-documented risk of chronic hypertension within a few years of delivery, but management of postpartum hypertension among these women remains inconsistent.

Objective

To assess the incidence of initiation of antihypertensive medication use in the first 2 years after delivery by HDP status and antenatal antihypertensive medication use.

Design, Setting, and Participants

This Danish register-based cohort study used data from women with at least 1 pregnancy lasting 20 or more gestational weeks (only the first pregnancy in the period was considered) who delivered from January 1, 1995, to December 31, 2018. Statistical analysis was conducted from October 2022 to September 2023.

Exposure

Hypertensive disorders of pregnancy.

Main Outcomes and Measures

Cumulative incidences and hazard ratios of initiating antihypertensive medication use within 2 years post partum (5 postpartum time intervals) by HDP status and antenatal medication use.

Results

The cohort included 784 782 women, of whom 36 900 (4.7% [95% CI, 4.7%-4.8%]) had an HDP (HDP: median age at delivery, 29.1 years [IQR, 26.1-32.7 years]; no HDP: median age at delivery, 29.0 years [IQR, 25.9-32.3 years]). The 2-year cumulative incidence of initiating postpartum antihypertensive treatment ranged from 1.8% (95% CI, 1.8%-1.8%) among women who had not had HDPs to 44.1% (95% CI, 40.0%-48.2%) among women with severe preeclampsia who required antihypertensive medication during pregnancy. Most women who required postpartum antihypertensive medication after an HDP initiated use within 3 months of delivery (severe preeclampsia, 86.6% [95% CI, 84.6%-89.4%]; preeclampsia, 75.3% [95% CI, 73.8%-76.2%]; and gestational hypertension, 75.1% [95% CI, 72.9%-77.1%]). However, 13.4% (95% CI, 11.9%-14.1%) of women with severe preeclampsia, 24.7.% (95% CI, 24.0%-26.0%) of women with preeclampsia, 24.9% (95% CI, 22.5%-27.5%) of women with gestational hypertension, and 76.7% (95% CI, 76.3%-77.1%) of those without an HDP first filled a prescription for antihypertensive medication more than 3 months after delivery. Women with gestational hypertension had the highest rate of initiating medication after more than 1 year post partum, with 11.6% (95% CI, 10.0%-13.2%) starting treatment after this period. Among women who filled a prescription in the first 3 months post partum, up to 55.9% (95% CI, 46.2%-66.1%) required further prescriptions more than 3 months post partum, depending on HDP status and antenatal medication use.

Conclusions and Relevance

In this cohort study of postpartum women, the incidence of initiation of postnatal antihypertensive medication use varied by HDP status, HDP severity, and antenatal antihypertensive medication use. Up to 24.9% of women initiated antihypertensive medication use more than 3 months after an HDP, with up to 11.6% initiating treatment after 1 year. Routine postpartum blood pressure monitoring might prevent diagnostic delays in initiation of antihypertensive medication use and improve cardiovascular disease prevention among women.

Does reversible postpartum contraception reduce the risk of pregnancy condition recurrence? A longitudinal claims-based study from Maine

PURPOSE

To estimate the effect of reversible postpartum contraception use on the risk of recurrent pregnancy condition in the subsequent pregnancy and if this effect was mediated through lengthening the interpregnancy interval (IPI).

METHODS

We used data from the Maine Health Data Organization's Maine All Payer Claims dataset. Our study population was Maine women with a livebirth index pregnancy between 2007 and 2019 that was followed by a subsequent pregnancy starting within 60 months of index pregnancy delivery. We examined recurrence of three pregnancy conditions, separately, in groups that were not mutually exclusive: prenatal depression, hypertensive disorders of pregnancy (HDP), and gestational diabetes (GDM). Effective reversible postpartum contraception use was defined as any intrauterine device, implant, or moderately effective method (pills, patch, ring, injectable) initiated within 60 days of delivery. Short IPI was defined as ≤ 12 months. We used log-binomial regression models to estimate risk ratios and 95 % confidence intervals, adjusting for potential confounders.

RESULTS

Approximately 41 % (11,448/28,056) of women initiated reversible contraception within 60 days of delivery, the prevalence of short IPI was 26 %, and the risk of pregnancy condition recurrence ranged from 38 % for HDP to 55 % for prenatal depression. Reversible contraception initiation within 60 days of delivery was not associated with recurrence of the pregnancy condition in the subsequent pregnancy (aRR ranged from 0.97 to 1.00); however, it was associated with lower risk of short IPI (aRR ranged from 0.67 to 0.74).

CONCLUSION(S)

Although initiation of postpartum reversible contraception within 60 days of delivery lengthens the IPI, our findings suggest that it does not reduce the risk of prenatal depression, HDP, or GDM recurrence. This indicates a missed opportunity for providing evidence-based healthcare and health interventions in the intrapartum period to reduce the risk of recurrence.

Women utilisation, needs and satisfaction with postnatal follow-up care in Oman: A cross-sectional survey

BACKGROUND

In Oman, there is a lack of data on utilisation, needs and women's satisfaction with care and information provided during postnatal follow-up period.

AIM

To investigate postnatal follow-up care utilisation and women's needs; level of postnatal information received and satisfaction with services.

METHODS

A purposive sample of women (n = 500), recruited in the immediate postnatal period at one metropolitan and one regional birthing hospital in Oman. An electronic survey link was sent to participants at 6-8 weeks postnatally. Quantitative variables were analysed as frequencies and chi-squared test.

RESULTS

A total of 328 completed surveys were received; a response rate of 66 %. Most respondents were located in the metropolitan area (n = 250) and between 20 and 39 years (n = 308). Utilisation was low as women reported no need or no benefit in attending. Women's information needs were not sufficiently met by HCPs, requiring women to seek information from family and the internet to meet their needs. Satisfaction with services was mostly neither satisfied nor dissatisfied (30 %) or satisfied (30 %).

CONCLUSION

Postnatal follow-up care utilisation in both metropolitan and regional areas is less than optimal and not utilised as there was no advice to attend or no appointment date/time given, no benefit experienced previously, no need and information needed sourced from family or the internet. The information provided by postnatal follow-up care consumers can be used to enhance service delivery, inform future updates to the national maternity care guidelines, and provides a baseline for future evaluation and research.

Planning for the forgotten fourth trimester of pregnancy: A parallel group randomized control trial to test a postpartum planning intervention vs. standard prenatal care

BACKGROUND

Black and brown birthing people experience persistent disparities in adverse maternal health outcomes, partially due to inadequate perinatal care. The goal of this study is to design and evaluate a patient-centered intervention for obstetric patients with one or more cardiometabolic risk factors for severe maternal morbidity [gestational diabetes, diabetes mellitus, hypertensive disorders of pregnancy (chronic hypertension, preeclampsia, eclampsia, or gestational hypertension), or preconception obesity (BMI > 30)] to promote postpartum visit attendance.

METHODS

To address identified unmet needs for postpartum support and barriers to postpartum care, we developed 20 thematic postpartum planning modules, each with corresponding patient educational materials, community resources, care coordination protocols, and clinician support tools (decision aids, electronic medical record prompts and fields). During prenatal care encounters, a research coordinator delivers the educational content (in English or Spanish), facilitates the participant's planning and shared decision-making, provides the participant with resources, and documents decisions in the electronic medical record. We will randomize 320 eligible patients with a 1:1 ratio to the intervention or standard prenatal care and evaluate the impact on postpartum visit attendance at 4-12 weeks and secondary outcomes (postpartum mental health, perceived future maternal and cardiometabolic risk, contraceptive use, primary care use, readmission, and patient satisfaction with care).

DISCUSSION

Through engagement with patients and community stakeholders, we developed a guideline-based, locally tailored intervention to address drivers of engagement with postpartum care for high-risk obstetric patients. If demonstrated to be effective, the educational materials and electronic medical record based-tool can be adapted to other settings.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov (NCT05430815) on June 23, 2022.

Primary Care After Pregnancy Survey: Patient Preferences, Health Concerns, and Anticipated Barriers

Despite recommendations for ongoing care after pregnancy, many individuals do not see a primary care clinician within the first postpartum year, missing a critical window to engage reproductive-age individuals in primary care. We administered an anonymous, cross-sectional, trilingual survey at a large urban safety-net hospital to assess postpartum individuals' preferences, health concerns, and anticipated barriers to primary care during the year after pregnancy. While 90% of respondents preferred a visit within one year, most individuals - including those with complicated pregnancies - did not recall a primary care recommendation from their pregnancy care team. Respondents reported a variety of primary care-amenable health concerns, and many social and logistical barriers to care. Preference for virtual care increased if self-monitoring tools were hypothetically available, indicating virtual visits may improve primary care access.

Racial and ethnic disparities in severe maternal morbidity from pregnancy through 1-year postpartum

BACKGROUND

Previous studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period.

OBJECTIVE

To examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization.

STUDY DESIGN

We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined "SMM cases added" by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The "SMM cases added" represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included.

RESULTS

Among 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance.

CONCLUSION

Racial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities. El resumen está disponible en Español al final del artículo.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Clinician care priorities and practices in the fourth trimester: perspective from a California survey

BACKGROUND

Professional societies such as the American College of Obstetricians and Gynecologists (ACOG) promote the idea that postpartum care is an ongoing process where there is adequate opportunity to provide services and support. Nonetheless, in practice, the guidelines ask clinicians to perform more clinical responsibilities than they might be able to do with limited time and resources.

METHODS

We conducted an online survey among practicing obstetric clinicians (obstetrician/gynecologists (OB/GYNs), midwives, and family medicine doctors) in California about their priorities and care practices for the first postpartum visit and explored how they prioritize multiple clinical responsibilities within existing time and resources. Between September 2023 and February 2024, 174 out of 229 eligible participants completed the survey, a 76% response rate. From a list of care components, we used descriptive statistics to identify those that were highly prioritized by most clinicians and those that were considered a priority by very few and examined the alignment between prioritized components and recommended care practices.

RESULTS

Clinicians were highly invested in the care components that they rated as most important, indicating that they always check these components or assess them when they perceive patient need. Depression and anxiety, breast health/breast feeding issues, vaginal birth complications and family planning counseling were highly ranked components by all clinicians. In contrast, clinicians more often did not assess those care components that infrequently ranked highly among the priority listing, consisting mainly of social drivers of health such as screening and counseling for intimate partner violence, working conditions and food/housing insecurity. In both instances, we found little discordance between priorities and care practices. However, OB/GYNs and midwives differed in some care components that they prioritized highly.

CONCLUSIONS

While there is growing understanding of how important professional society recommendations are for maternal-infant health, clinicians face barriers completing all recommendations, especially those components related to social drivers of health. However, what the clinicians do prioritize highly, they are likely to perform. Now that Medi-Cal (Medicaid) insurance is available in California for up to 12 months postpartum, there is a need to understand what care clinicians provide and what gaps remain.

Planning, Implementation, and Evaluation of a Postpartum Nurse Home Visit Service to Improve Health Equity

OBJECTIVE

To describe how a college of nursing and urban academic medical center partnered with the local health department to plan, implement, and evaluate a universal nurse home visit service to improve health equity in the postpartum period.

DESIGN

Evidence-based practice.

SETTING/LOCAL PROBLEM

Wide health disparity in rates of maternal and infant morbidity and mortality in Chicago, Illinois.

PATIENTS

All patients who gave birth at the medical center and lived in Chicago.

INTERVENTION/MEASUREMENTS

A nurse home visit was offered after birth to all eligible patients beginning in March 2020. We used data from a Web-based platform to determine key performance indicators for the program and examined patient demographics to determine equitable delivery of the service for all visits provided in 2022.

RESULTS

There were 1,488 patients eligible for a home visit and 714 who received a home visit. The average contact rate was 76%, the scheduling rate was 63%, the completion rate for scheduled visits was 76%, and the population reach was 48%. Sixty-eight percent of families visited were from high-economic-hardship zip code areas of the city. Eighty-one percent of visits resulted in at least one referral to meet a family's need, and 98% of patients surveyed rated their visit as "very helpful."

CONCLUSION

The successful implementation of this public-private partnership was due in part to an organizational culture that supports health equity initiatives, the inclusion of system-wide stakeholders, having a process in place to monitor outcomes, and hiring a diverse team of nurses who prioritize respectful patient-centered care.

Incorporating Maternal Blood Pressure Screening Into Routine Newborn Clinic Visits

BACKGROUND AND OBJECTIVES

In the immediate postpartum period, mothers often prioritize newborn care over postpartum follow-up. There is an increasing contribution of hypertensive disorders of pregnancy (HDP) to maternal morbidity and mortality. In this feasibility study, we sought to implement maternal postpartum blood pressure (BP) screening in a newborn clinic.

METHODS

We conducted a non-randomized, prospective feasibility study to evaluate the application of maternal BP screening at newborn clinic visits. An elevated BP was defined as a systolic pressure (SBP) of ≥140 mmHg or a diastolic pressure (DBP) of ≥90 mmHg. BPs were triaged with a standardized algorithm, utilizing support and expertise of on-call maternal subspecialists.

RESULTS

We screened 72 postpartum individuals, with a mean SBP of 130±19 mmHg and DBP 86±12 mmHg. Most were publicly insured (78%) and self-identified as Black (69%). Of the 31 (43%) with an elevated BP, 13 (42%) did not have a known HDP. Of those without known HDP, 4 were diagnosed with postpartum preeclampsia and 2 with postpartum hypertension. One individual diagnosed with new-onset postpartum preeclampsia was triaged to the emergency department. Only 56% of women attended a obstetrics appointment within 12 weeks after delivery.

CONCLUSIONS

This study demonstrates the feasibility of an innovative maternal postpartum BP assessment in a racially and socioeconomically diverse pediatrics clinic. Through collaborative care, individuals were able to be safely triaged, thus providing an opportunity to identify at-risk individuals who could benefit from earlier identification and management of hypertension. Pediatricians have a unique opportunity to contribute to postpartum maternal health.

Risk factors for postpartum readmission: a prediction model in Iranian pregnant women

BACKGROUND

Postpartum readmissions (PPRs) are an important indicator of maternal postpartum complications and the quality of medical services and are important for reducing medical costs. The present study aimed to investigate the risk factors affecting readmission after delivery in Imam Ali Hospital in Amol, Iran.

METHODS

This retrospective cohort study was conducted on the mothers who were readmitted after delivery within 30 days, at Imam Ali Hospital (2019-2023). The demographic and obstetrics characteristics were identified through the registry system. Univariate and multivariate logistic regressions with odds ratios (ORs) and 95% CIs were carried out. To identify the most important variables by machine learning methods, a random forest model was used. The data were analyzed using SPSS 22 software and R (4.1.3) at a significant level of 0.05.

RESULTS

Among 13,983 deliveries 164 (1.2%) had readmission after delivery. The most prevalent cause of readmission after delivery was infection (59.7%). The chance of readmission for women who underwent elective cesarean section and women who experienced labor pain onset by induction of labor was twice and 1.5 times greater than that among women who experienced spontaneous labor pain, respectively. Women with pregnancy complications had more than 2 times the chance of readmission. Cesarean section increased the chance of readmission by 2.69 times compared to normal vaginal delivery.

CONCLUSION

The method of labor pain onset, mode of delivery, and complications during pregnancy were the most important factors related to readmission after childbirth.

Implementation of a Cell-Enabled Remote Blood Pressure Monitoring Program During the Postpartum Period at a Safety-Net Hospital

BACKGROUND

Postpartum hypertension is a risk factor for severe maternal morbidity; however, barriers exist for diagnosis and treatment. Remote blood pressure (BP) monitoring programs are an effective tool for monitoring BP and may mitigate maternal health disparities. We aimed to describe and evaluate engagement in a remote BP monitoring program on BP ascertainment during the first 6-weeks postpartum among a diverse patient population.

METHODS AND RESULTS

A postpartum remote BP monitoring program, using cell-enabled technology and delivered in multiple languages, was implemented at a large safety-net hospital. Eligible patients are those with hypertensive disorders before or during pregnancy. We describe characteristics of patients enrolled from January 2021 to May 2022 and examine program engagement by patient characteristics. Linear regression models were used to calculate mean differences and 95% CIs between characteristics and engagement metrics. We describe the prevalence of patients with BP ≥140/or >90 mm Hg. Among 1033 patients, BP measures were taken an average of 15.2 days during the 6-weeks, with the last measurement around 1 month (mean: 30.9 days), and little variability across race or ethnicity. Younger maternal age (≤25 years) was associated with less frequent measures (mean difference, -4.3 days [95% CI: -6.1 to -2.4]), and grandmultiparity (≥4 births) was associated with shorter engagement (mean difference, -3.5 days [95% CI, -6.1 to -1.0]). Prevalence of patients with BP ≥140/or >90 mm Hg was 62.3%, with differences by race or ethnicity (Black: 72.9%; Hispanic: 52.4%; White: 56.0%).

CONCLUSIONS

A cell-enabled postpartum remote BP monitoring program was successful in uniformly monitoring BP and capturing hypertension among a diverse, safety-net hospital population.

Severe maternal morbidity from pregnancy through 1 year postpartum

BACKGROUND

Few recent studies have examined the rate of severe maternal morbidity occurring during the antenatal and/or postpartum period to 42 days after delivery. However, little is known about the rate of severe maternal morbidity occurring beyond 42 days after delivery.

OBJECTIVE

This study aimed to examine the distribution of severe maternal morbidity and its indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery and to estimate the increase in severe maternal morbidity rate and its indicators after accounting for antenatal and postpartum severe maternal morbidity to 365 days after delivery.

STUDY DESIGN

This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008 to 2020. This study examined the distribution of severe maternal morbidity, nontransfusion severe maternal morbidity, and severe maternal morbidity indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery. Subsequently, this study examined "severe maternal morbidity cases added," which represent cases among unique individuals that are included by considering the antenatal and postpartum periods but that would be missed if only the delivery hospitalization cases were included.

RESULTS

A total of 64,661 (2.5%) individuals experienced severe maternal morbidity, whereas 37,112 (1.4%) individuals experienced nontransfusion severe maternal morbidity during antenatal, delivery, and/or postpartum hospitalization. A total of 31% of severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery, whereas 49% of nontransfusion severe maternal morbidity cases were added after accounting for nontransfusion severe maternal morbidity occurring during the antenatal or postpartum periods. Severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 12% of all severe maternal morbidity cases, whereas nontransfusion severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 19% of all nontransfusion severe maternal morbidity cases.

CONCLUSION

Our study showed that a total of 31% of severe maternal morbidity and 49% of nontransfusion severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery. Our findings highlight the importance of expanding the severe maternal morbidity definition beyond the delivery hospitalization to better capture the full period of increased risk, identify contributing factors, and design strategies to mitigate this risk. Only then can we improve outcomes for mothers and subsequently the quality of life of their infants.

The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents

BACKGROUND

Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood.

OBJECTIVES

We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care.

METHODS

B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health.

IMPLICATIONS

If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Maintaining A Long-Term Practice of Daily Pelvic Floor Muscle Exercises: What Do Childbearing Women Think?

INTRODUCTION

To be effective, pelvic floor muscle therapy (PFMT) exercises should be intense, be practiced consistently, and include clinical support. Many women do not adhere to a consistent PFMT program, compromising the resolution or prevention of urinary incontinence (UI). This study aimed to answer 2 key questions: What prevents women from performing PFMT long term, and what can health care providers do to support women to perform them?

METHODS

Postpartum women from 4 sites in the United States completed a questionnaire about experiences with PFMT or Kegel exercises during and after pregnancy. This study focused on one of the 7 open-ended questions: What would prevent you from performing Kegels lifelong? Thematic analysis was implemented via an inductive approach using Braun and Clarke's 6-phase process.

RESULTS

Three salient themes emerged that help explain factors that prevent women from adhering to a daily PFMT routine: (1) life gets in the way, (2) inadequate PFMT education and instruction, and (3) disconnect exists about long-term consequences. The sample included 368 participants.

DISCUSSION

The themes were congruent with the limited body of qualitative literature on experience with PFMT exercises. This study was able to identify areas of need in the US maternal health care system to help childbearing people adopt daily PFMT, such as (1) inadequate parental leave and childcare support, (2) no formalized education related to UI and PFMT and a lack of pelvic health promotion, (3) lacking prioritization of long-term PFMT, and (4) the need to dispel the acceptance that UI postbirth is normal. Health care providers should prioritize interactive education, emphasizing how to correctly perform PFMT and the importance and effectiveness of integrating clinical support. To adequately encompass pelvic floor health care and education up to one year postbirth, changes are needed to the US perinatal health care system, providing sufficient insurance reimbursement and parental social support programs.

Cardio-obstetrics de novo: a state-level, evidence-based approach for addressing maternal mortality and severe maternal morbidity in Georgia

Georgia has a higher rate of severe maternal morbidity and mortality when compared with the rest of the United States. Evidence gained from the Georgia Maternal Mortality Review Committee identified areas of focus for high-yield clinical initiatives for improvement in maternal health outcomes. Cardiovascular disease, including cardiomyopathy, coronary conditions, and preeclampsia with or without eclampsia, is the most common cause of pregnancy-related death in non-Hispanic Black women in Georgia. The development of a cardio-obstetrics program is an initiative to advance health equity by decreasing cardiovascular morbidity and mortality. This report describes the following: (1) state-level advocacy for improving maternal health outcomes with funding gained through the legislative process and partnership with a governmental agency; (2) cardio-obstetrics program development based on evidence gained from the maternal mortality review process; and (3) implementation of a cardio-obstetrics service, beginning with a focused approach for capacity building and understanding barriers to care.

Choice and factors associated to the use of contraceptive methods among postpartum women: A prospective cohort study

OBJECTIVES

To assess women's contraceptive preferences in the immediate postpartum period and identify factors associated with use of their desired contraceptive method six months later.

MATERIAL AND METHODS

This prospective cohort study included women ≤48 h after delivery at a single public Brazilian hospital. The women's interview took place in two different momentsbefore hospital discharge (in-person interview) and six months after delivery (by telephone contact). For data collection and management, we used the REDCap electronic tool. Univariate and multivariate analyses (unadjusted and adjusted Odds Ratio and 95 % confidence intervals) were used to identify factors associated with higher use of their desired contraceptive method six months after delivery.

RESULTS

A total of 294 women (166 adolescents) were included. Initial contraceptive preferences were especially intrauterine devices (IUDs) (39.1 %), implants (33.0 %) and injectable hormonal contraceptives (17.0 %). Six months later, 42.5 % (n = 125) were using their desired contraceptive method. Younger age, white race and contraceptive initiation prior to hospital discharge were associated with use of their desired contraceptive at six months.

CONCLUSION

Long-acting reversible contraception (LARC) methods were the most desired contraceptives among women after delivery. Providing and initiating free contraception prior to discharge from a birthing unit is important with regard to use of their desired method.

A review of public health guidelines for postpartum physical activity and sedentary behavior from around the world

BACKGROUND

The period following pregnancy is a critical time window when future habits with respect to physical activity (PA) and sedentary behavior (SB) are established; therefore, it warrants guidance. The purpose of this scoping review was to summarize public health-oriented country-specific postpartum PA and SB guidelines worldwide.

METHODS

To identify guidelines published since 2010, we performed a (a) systematic search of 4 databases (CINAHL, Global Health, PubMed, and SPORTDiscus), (b) structured repeatable web-based search separately for 194 countries, and (c) separate web-based search. Only the most recent guideline was included for each country.

RESULTS

We identified 22 countries with public health-oriented postpartum guidelines for PA and 11 countries with SB guidelines. The continents with guidelines included Europe (n = 12), Asia (n = 5), Oceania (n = 2), Africa (n = 1), North America (n = 1), and South America (n = 1). The most common benefits recorded for PA included weight control/management (n = 10), reducing the risk of postpartum depression or depressive symptoms (n = 9), and improving mood/well-being (n = 8). Postpartum guidelines specified exercises to engage in, including pelvic floor exercises (n = 17); muscle strengthening, weight training, or resistance exercises (n = 13); aerobics/general aerobic activity (n = 13); walking (n = 11); cycling (n = 9); and swimming (n = 9). Eleven guidelines remarked on the interaction between PA and breastfeeding; several guidelines stated that PA did not impact breast milk quantity (n = 7), breast milk quality (n = 6), or infant growth (n = 3). For SB, suggestions included limiting long-term sitting and interrupting sitting with PA.

CONCLUSION

Country-specific postpartum guidelines for PA and SB can help promote healthy behaviors using a culturally appropriate context while providing specific guidance to public health practitioners.

Society for Maternal-Fetal Medicine Position Statement: Extending Medicaid coverage for 12 months postpartum

Position: The Society for Maternal-Fetal Medicine supports federal and state policies that expand Medicaid eligibility and extend Medicaid coverage through 12 months postpartum to address the maternal morbidity and mortality crisis and improve health equity. Access to coverage is essential to optimize maternal health following pregnancy and childbirth and avoid preventable causes of maternal morbidity and mortality that extend throughout the first year postpartum. The Society opposes policies such as work requirements or limitations on coverage for undocumented individuals that unnecessarily impose restrictions on Medicaid eligibility.

Mapping the Postpartum Experience Through Obstetric Patient Navigation for Low-Income Individuals

Background: Although the postpartum period is an opportunity to address long-term health, fragmented care systems, inadequate attention to social needs, and a lack of structured transition to primary care threaten patient wellbeing, particularly for low-income individuals. Postpartum patient navigation is an emerging innovation to address these disparities. Methods: This mixed-methods analysis uses data from the first year of an ongoing randomized controlled trial to understand the needs of low-income postpartum individuals through 1 year of patient navigation. We designed standardized logs for navigators to record their services, tracking mode, content, intensity, and target of interactions. Navigators also completed semistructured interviews every 3 months regarding relationships with patients and care teams, care system gaps, and navigation process. Log data were categorized, quantified, and mapped temporally through 1 year postpartum. Qualitative data were analyzed using the constant comparative method. Results: Log data from 50 participants who received navigation revealed the most frequent needs related to health care access (45.4%), health and wellness (18.2%), patient-navigator relationship building (14.8%), parenting (13.6%), and social determinants of health (8.0%). Navigation activities included supporting physical and mental recovery, accomplishing health goals, connecting patients to primary and specialty care, preparing for health system utilization beyond navigation, and referring individuals to community resources. Participant needs fluctuated, yielding a dynamic timeline of the first postpartum year. Conclusion: Postpartum needs evolved throughout the year, requiring support from various teams. Navigation beyond the typical postpartum care window may be useful in mitigating health system barriers, and tracking patient needs may be useful in optimizing postpartum care. Clinical Trial Registration: Registered April 19, 2019, enrollment beginning January 21, 2020, NCT03922334, https://clinicaltrials.gov/ct2/show/NCT03922334.

Optimizing Postpartum Care in Rural Communities: Insights from Women in Arizona and Implications for Policy

OBJECTIVES

Optimal postpartum care promotes healthcare utilization and outcomes. This qualitative study investigated the experiences and perceived needs for postpartum care among women in rural communities in Arizona, United States.

METHODS

We conducted in-depth interviews with thirty childbearing women and analyzed the transcripts using reflexive thematic analysis to gauge their experiences, needs, and factors affecting postpartum healthcare utilization.

RESULTS

Experiences during childbirth and multiple structural factors, including transportation, childcare services, financial constraints, and social support, played crucial roles in postpartum care utilization for childbearing people in rural communities. Access to comprehensive health information and community-level support systems were perceived as critical for optimizing postpartum care and utilization.

CONCLUSIONS FOR PRACTICE

This study provides valuable insights for policymakers, healthcare providers, and community stakeholders in enhancing postpartum care services for individuals in rural communities in the United States.

Predictive modeling of postpartum blood pressure spikes

BACKGROUND

Hypertensive disorders of pregnancy are one of the leading causes of maternal morbidity and mortality worldwide. Management of these conditions can pose many clinical dilemmas and can be particularly challenging during the immediate postpartum period. Models for predicting and managing postpartum hypertension are necessary to help address this clinical challenge.

OBJECTIVE

This study aimed to evaluate predictive models of blood pressure spikes in the postpartum period and to investigate clinical management strategies to optimize care.

STUDY DESIGN

This was a retrospective cohort study of postpartum women who participated in remote blood pressure monitoring. A postpartum blood pressure spike was defined as a blood pressure measurement of ≥140/90 mm Hg while on an antihypertensive medication and a blood pressure measurement of ≥150/100 mm Hg if not on an antihypertensive medication. We identified 3 risk level patient clusters (low, medium, and high) when predicting patient risk for a blood pressure spike on postpartum days 3 to 7. The variables used in defining these clusters were peak systolic blood pressure before discharge, body mass index, patient systolic blood pressure per trimester, heart rate, gestational age, maternal age, chronic hypertension, and gestational hypertension. For each risk cluster, we focused on 2 treatments, namely (1) postpartum length of stay (<3 days or ≥3 days) and (2) discharge with or without blood pressure medications. We evaluated the effectiveness of the treatments in different subgroups of patients by estimating the conditional average treatment effect values in each cluster using a causal forest. Moreover, for all patients, we considered discharge with medication policies depending on different discharge blood pressure thresholds. We used a doubly robust policy evaluation method to compare the effectiveness of the policies.

RESULTS

A total of 413 patients were included, and among those, 267 (64.6%) had a postpartum blood pressure spike. The treatments for patients at medium and high risk were considered beneficial. The 95% confidence intervals for constant marginal average treatment effect for antihypertensive use at discharge were -3.482 to 4.840 and - 5.539 to 4.315, respectively; and for a longer stay they were -5.544 to 3.866 and -7.200 to 4.302, respectively. For patients at low risk, the treatments were not critical in preventing a blood pressure spike with 95% confidence intervals for constant marginal average treatment effect of 1.074 to 15.784 and -2.913 to 9.021 for the different treatments. We considered the option to discharge patients with antihypertensive use at different blood pressure thresholds, namely (1) ≥130 mm Hg and/or ≥80 mm Hg, (2) ≥140 mm Hg and/or ≥90 mm Hg, (3) ≥150 mm Hg and/or ≥ 100 mm Hg, or (4) ≥160 mm Hg and/or ≥ 110 mm Hg. We found that policy (2) was the best option with P<.05.

CONCLUSION

We identified 3 possible strategies to prevent outpatient blood pressure spikes during the postpartum period, namely (1) medium- and high-risk patients should be considered for a longer postpartum hospital stay or should participate in daily home monitoring, (2) medium- and high-risk patients should be prescribed antihypertensives at discharge, and (3) antihypertensive treatment should be prescribed if patients are discharged with a blood pressure of ≥140/90 mm Hg.

Comparison of a person-centered pregnancy prevention question and One Key Question to assess postpartum contraceptive needs

OBJECTIVES

To explore the relevance of pregnancy intention as a screen for contraceptive needs among postpartum individuals.

STUDY DESIGN

We surveyed 234 postpartum individuals to assess the alignment between pregnancy intentions in the next year and current desire to prevent pregnancy.

RESULTS

Most individuals (87%) desired pregnancy prevention now, including 73% of individuals who desired or were ambivalent about pregnancy in the next year.

CONCLUSION

A majority of individuals considering pregnancy in the next year desired pregnancy prevention now. Directly assessing current desire to prevent pregnancy may be more specific for contraceptive needs in postpartum individuals.

IMPLICATIONS

Our ability to ensure that all individuals who want to prevent pregnancy have access to contraception depends on the use of effective screening questions. These findings prompt consideration of broader clinical implementation of screening for desire to prevent pregnancy in lieu of questions about pregnancy intention in the next year.