Postpartum Visit Attendance Research Articles

Integrated group antenatal and pediatric care in Haiti: A comprehensive care accompaniment model.

The J9 Plus (J9) maternal-child accompaniment program is based on four pillars: group antenatal care (GANC), group pediatric care, psychosocial support, and community-based care. We aimed to evaluate the impact of the J9 model of care on perinatal outcomes. We conducted a convergent mixed methods study of maternal-newborn dyads born in 2019 at Hôpital Universitaire de Mirebalais. Quantitative data was collected retrospectively to compare dyads receiving J9 care to usual care. A secondary analysis of qualitative data described patient perspectives of J9 care. Antenatal care attendance was significantly higher among women in J9 (n = 524) compared to usual care (n = 523), with 490(93%) and 189(36%) having >4 visits, respectively; p <0.001, as was post-partum visit attendance [271(52%) compared to 84(16%), p<0.001] and use of post-partum family planning methods [98(19%) compared to 47(9%), p = 0.003]. Incidence of pre-eclampsia with severe features was significantly lower in the J9 group [44(9%)] compared to the usual care group [73(14%)], p <0.001. Maternal and neonatal mortality and low birth weight did not differ across groups. Cesarean delivery [103(20%) and 82(16%), p<0.001] and preterm birth [118 (24%)] and 80 (17%), p <0.001] were higher in the J9 group compared to usual care, respectively. In the qualitative analysis, ease of access to high-quality care, meaningful social support, and maternal empowerment through education were identified as key contributors to these outcomes. Compared to usual care, the J9 Plus maternal-child accompaniment model of care is associated with increased engagement in antenatal and postpartum care, increased utilization of post-partum family planning, and lower incidence of pre-eclampsia with severe features, which remains a leading cause of maternal mortality in Haiti. The J9 accompaniment approach to care is an empowering model that has the potential to be replicated in similar settings to improve quality of care and outcomes globally.

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

BackgroundBlack 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. MethodsTo 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). DiscussionThrough 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 registrationThis trial was registered on ClinicalTrials.gov (NCT05430815) on June 23, 2022.

Report from a text-based blood pressure monitoring prospective cohort trial among postpartum women with hypertensive disorders of pregnancy

BackgroundHypertensive disorders of pregnancy are a main cause of maternal morbidity and mortality in the United States and worldwide, and it is estimated that approximately 60% of maternal deaths in the United States occur during the postpartum period. The utilization of telehealth modalities such as home blood pressure monitoring has shown improvement in blood pressure control and adherence with follow up visits. Our study sought to determine if standardized education improved patient hypertension knowledge and if this when combined with home blood pressure telemonitoring increased participants’ postpartum self-blood pressure monitoring and postpartum visit attendance.MethodsThis is an Institutional Review Board approved prospective cohort study conducted at the University of Mississippi Medical Center. Women with a hypertensive disorder of pregnancy who met the inclusion criteria and provided written informed consent to participate were enrolled. Participants received a baseline pre-education questionnaire designed to assess their knowledge of their hypertensive diagnosis, hypertension management, and postpartum preeclampsia (PreE). Participants then received standard education, a blood pressure monitor, and were scheduled a follow-up visit during the first 10 days following discharge. Remote home blood pressure monitoring was performed via text messages and voice calls for 6-weeks postpartum. At the conclusion of the study, participants repeated their original questionnaire.Results250 women provided informed consent to participate in the study and were included in this analysis. Relative to the baseline survey, there was a significant increase (p = 0.0001) in the percentage of correct responses. There was not an association between study engagement and percentage of correct responses on end of study questionnaire (p = 0.33) or postpartum visit attendance (p = 0.69). Maternal age was found to drive study engagement, even when adjusted for community-level distress (p = 0.03) and maternal race (p = 0.0002).ConclusionImplementing a standardized postpartum education session was associated with improvement in patient’s knowledge. Further studies are needed with more longitudinal follow up to assess if this program would also result in improved long-term outcomes and decreased hospital readmission rates.Trial registrationNCT04570124.

Improving Equitable Postpartum Care in an Urban Private Clinic with Predominantly Black Patients.

Maternal health disparities based on race, ethnicity, and socioeconomic factors exist in the United States, with Black women experiencing significantly worse outcomes. With much of perinatal morbidity and mortality attributed to the postpartum period, attention to equitable postpartum care is necessary for addressing this disparity. A rapid-cycle quality improvement initiative was implemented in an urban clinic serving predominantly Black, Medicaid-insured clients. Although baseline data indicated 95% of clients experienced comorbidities, only 65% attended a comprehensive postpartum visit (PPV). The project's goal was to improve equitable postpartum care by increasing PPV attendance and quality of postpartum care to 90% in 8 weeks. The clinical team was engaged throughout to promote organizational change within the clinic. A provider checklist was implemented to improve PPV care metrics, and shared decision-making was initiated surrounding contraception and mood disorders. A care log tracked clinical practice guideline adherence with regular feedback informing the change process. Postpartum care improved across a variety of factors studied over 8 weeks. The provider checklist prompted a 78% documentation rate of PPV care metrics, and care log tracking reflected an ending PPV attendance rate of 93%. Client satisfaction with postpartum care education was measured using a Likert scale of 1 to 5 (1 = dissatisfied and 5 = satisfied) with a noted improvement from a baseline score of 4.3 to an overall mean of 4.8. This quality initiative addressed a key factor in health equity for a predominantly Black, Medicaid-insured population in an urban clinic by raising PPV attendance rates above national standards of 90% and improving client satisfaction and the quality of care received during these visits. The project was low cost and created sustainable systems for maintaining evidence-based equitable care. Limitations included the coronavirus disease 19 pandemic, clinic staff turnover, and staff and client biases. Continued innovative research targeted at improving health equity is needed.

Continuous Medicaid Eligibility During the COVID-19 Pandemic and Postpartum Coverage, Health Care, and Outcomes

Pursuant to the Families First Coronavirus Response Act (FFCRA), continuous Medicaid eligibility during the COVID-19 public health emergency (PHE) created a de facto national extension of pregnancy Medicaid eligibility beyond 60 days postpartum. To evaluate the association of continuous Medicaid eligibility with postpartum health insurance, health care use, breastfeeding, and depressive symptoms. This cohort study using a generalized difference-in-differences design included 21 states with continuous prepolicy (2017-2019) and postpolicy (2020-2021) participation in the Pregnancy Risk Assessment Monitoring System (PRAMS). State-level change in Medicaid income eligibility after 60 days postpartum associated with the FFCRA measured as a percent of the federal poverty level (FPL; ie, the difference in 2020 income eligibility thresholds for pregnant people and low-income adults/parents). Health insurance, postpartum visit attendance, contraceptive use (any effective method; long-acting reversible contraceptives), any breastfeeding and depressive symptoms at the time of the PRAMS survey (mean [SD], 4 [1.3] months postpartum). The sample included 47 716 PRAMS respondents (64.4% aged <30 years; 18.9% Hispanic, 26.2% non-Hispanic Black, 36.3% non-Hispanic White, and 18.6% other race or ethnicity) with a Medicaid-paid birth. Based on adjusted estimates, a 100% FPL increase in postpartum Medicaid eligibility was associated with a 5.1 percentage point (pp) increase in reported postpartum Medicaid enrollment, no change in commercial coverage, and a 6.6 pp decline in uninsurance. This represents a 40% reduction in postpartum uninsurance after a Medicaid-paid birth compared with the prepolicy baseline of 16.7%. In subgroup analyses by race and ethnicity, uninsurance reductions were observed only among White and Black non-Hispanic individuals; Hispanic individuals had no change. No policy-associated changes were observed in other outcomes. In this cohort study, continuous Medicaid eligibility during the COVID-19 PHE was associated with significantly reduced postpartum uninsurance for people with Medicaid-paid births, but was not associated with postpartum visit attendance, contraception use, breastfeeding, or depressive symptoms at approximately 4 months postpartum. These findings, though limited to the context of the COVID-19 PHE, may offer preliminary insight regarding the potential impact of post-pandemic postpartum Medicaid eligibility extensions. Collection of longer-term and more comprehensive follow-up data on postpartum health care and health will be critical to evaluating the effect of ongoing postpartum policy interventions.

Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People with Gestational Diabetes.

We aimed to evaluate uptake of the glucose tolerance test performed during delivery hospitalization as part of routine clinical care. This is a retrospective cohort study of people with GDM at a tertiary center. We collected 9 months of postimplementation data after the in-hospital ("early") glucose tolerance test was adopted as a routine screening option. Adherence was compared between those who elected early glucose tolerance testing versus those who deferred testing to the standard postpartum period. Bivariable statistics including demographics, care team, and postpartum testing/visit attendance were compared between those who received early testing and those who did not using chi-square, Fisher's exact, and t-tests. A total of 681 patients with GDM delivered during the study period. Of those who had an early glucose tolerance test ordered (n = 408), 340 (83.3%) completed the test. Among those who did not complete an early glucose tolerance test (ordered and not completed or never ordered), only 104/341 (30.5%) completed any postpartum glucose testing in the first 12 months of postpartum. There were significant differences in characteristics in terms of race/ethnicity, insurance, type of gestational diabetes (A1GDM vs. A2GDM), diabetes medications, obstetric care provider, and delivery mode. Among those who completed early testing, 43.7% of participants had impaired glucose metabolism and 6.5% had values concerning for overt diabetes mellitus. Among those who deferred testing to the standard 6- to 12-week period, 24.0% had impaired glucose metabolism and none had overt diabetes. Those who completed an early glucose tolerance test had a lower rate of postpartum visit attendance compared with those who deferred (75.6 vs. 91.5%, p < 0.01). In this cohort, when the early glucose tolerance test is offered in clinical practice, adherence rates are higher than when the test is deferred until the postpartum visit. · Adherence rates with the early glucose tolerance test (GTT) are higher than if the testing is deferred.. · Those who completed an early GTT had a lower rate of postpartum visit attendance compared with those who deferred.. · Offering an in-hospital postpartum GTT can help address low rates of glucose testing postpartum..

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis.

To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov . We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09). Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. PROSPERO, CRD42021279233.

Association Between State Paid Family and Medical Leave and Breastfeeding, Depression, and Postpartum Visits.

To evaluate the association of state paid family and medical leave policies with the likelihood of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit. This was a cross-sectional study that used 2016-2019 data from PRAMS (Pregnancy Risk Assessment Monitoring System) for 43 states and Washington, DC. We describe the association of state paid family and medical leave generosity with rates of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit. Logistic and Poisson regression models tested the significance of state paid family and medical leave coverage generosity after controlling for individual respondent sociodemographic characteristics, with sensitivity analyses for respondents with deliveries covered by Medicaid insurance. Of the 143,131 respondents, representative of an estimated 7,426,725 population, 26.2% lived in eight states and DC with the most generous paid family and medical leave, 20.5% lived in nine states with some paid family and medical leave, and 53.3% lived in 26 states with little or no paid family and medical leave. Overall, 54.8% reported breastfeeding at 6 months or at time of the survey, ranging from 59.5% in the most generous paid family and medical leave states to 51.0% in states with the least paid family and medical leave coverage. Postpartum depression symptoms varied from 11.7% in the most generous states to 13.3% in the least generous states (both P<.001). State differences in postpartum visit attendance rates (90.9% overall) did not differ significantly. After adjusting for respondent characteristics, compared with states with the least paid family and medical leave, breastfeeding was 9% more likely (adjusted incidence rate ratio [aIRR] 1.09, 95% CI, 1.07-1.11) in states with the strongest paid family and medical leave coverage and 32% more likely (aIRR 1.32, 95% CI, 1.25-1.39) in analyses limited to respondents with deliveries covered by Medicaid insurance. A more generous state paid family and medical leave policy was significantly associated with a lower likelihood of postpartum depression symptoms compared with states with the least paid family and medical leave (adjusted odds ratio 0.85, 95% CI, 0.76-0.94) and a modest but significant increase in postpartum visit attendance (aIRR 1.03, 95% CI, 1.01-1.04) among respondents with deliveries covered by Medicaid insurance. Respondents from states with strong paid family and medical leave had a greater likelihood of breastfeeding and had lower odds of postpartum depression symptoms, with stronger associations among respondents with deliveries covered by Medicaid insurance. Despite major potential health benefits of paid family and medical leave, the United States remains one of the few countries without federally mandated paid parental leave.

Association of Antenatal Housing Instability with Perinatal Care Utilization and Outcomes.

Background: Social determinants of health are important contributors to maternal and child health outcomes. Limited existing research examines the relationship between housing instability during pregnancy and perinatal care utilization. Our objective was to evaluate whether antenatal housing instability is associated with differences in perinatal care utilization and outcomes. Materials and Methods: Participants who were surveyed during their postpartum hospitalization were considered to have experienced housing instability if they answered affirmatively to at least one of six screening items. The primary outcome was adequacy of prenatal care measured by the Adequacy of Prenatal Care Utilization index. Maternal, neonatal, and postpartum outcomes, including utilization and breastfeeding, were also collected as secondary outcomes. Multivariable logistic regression models were adjusted for sociodemographic and clinical covariates. Results: In this cohort (N = 490), 11.2% (N = 55) experienced housing instability during pregnancy. Participants with unstable housing were more likely to have inadequate prenatal care (17.3% vs. 3.9%; odds ratio [OR] 5.11, 95% confidence interval [CI] 2.15-12.14, p < 0.001), but findings were not significant after adjustment (aOR 1.72, 95% CI 0.55-5.41, p = 0.35). Similarly, postpartum visit attendance was lower for individuals with unstable housing (79.6% vs. 91.2%), but there was no difference in the odds of the postpartum visit attendance after adjustment (OR 0.69, 95% CI 0.29-1.66, p = 0.14). Conclusions: There were no statistically significant association with the maternal, neonatal, and other postpartum secondary outcomes. Housing instability appears to be a risk marker that is related to other social determinants of health. Given the range of housing instability experiences, future research must account for specific types and degrees of housing instability and their potential perinatal consequences.

Group prenatal care for pregnant women with opioid use disorder: Preliminary evidence for acceptability and benefits compared with individual prenatal care.

The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not. This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described. G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology. Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes.

Postpartum Family Planning in Pediatrics: A Survey of Parental Contraceptive Needs and Health Services Preferences.

Infant well-child visits are increasingly being explored as opportunities to address parental postpartum health needs, including those related to reproductive health. To inform potential pediatric clinic-based interventions, this study assessed postpartum contraceptive needs and health services preferences. We surveyed postpartum individuals attending 2 to 6-monthwell-child visits at three Northern California pediatric clinics (2019-20). We examined unmet contraceptive needs; the acceptability of contraceptive education, counseling, and provision at well-child visits; and sociodemographic and clinical correlates. We conducted univariate and multivariable regression modeling to assess associations between sociodemographic and clinical variables, the status of contraceptive needs, and acceptability measures. Study participants (n=263) were diverse in terms of race and ethnicity (13% Asian, 9% Black, 37% Latinx, 12% Multi-racial or Other, 29% White), and socioeconomic status. Overall, 25% had unmet contraceptive needs. Unmet need was more common among participants who had delivered more recently, were multiparous, or reported ≥1 barrier to obtaining contraception; postpartum visit attendance, education, race, and ethnicity were not associated with unmet need. Most participants deemed the following acceptable in the pediatric clinic: receiving contraceptive information (85%), discussing contraception (86%), and obtaining a contraceptive method (81%). Acceptability of these services was greater among participants with unmet contraceptive needs, better self-rated health, and private insurance (all P<.05). A quarter of participants had unmet contraceptive needs beyond the early postpartum period. Most considered the pediatric clinic an acceptable place to address contraception, suggesting the pediatric clinic may be a suitable setting for interventions aiming to prevent undesired pregnancies and their sequelae.

Variation in Outpatient Postpartum Care Use in the United States: A Latent Class Analysis.

Despite efforts to improve postpartum health care in the United States, little is known about patterns of postpartum care beyond routine postpartum visit attendance. This study aimed to describe variation in outpatient postpartum care patterns. In this longitudinal cohort study of national commercial claims data, we used latent class analysis to identify subgroups of patients (classes) with similar outpatient postpartum care patterns (defined by the number of preventive, problem, and emergency department outpatient visits in the 60days after birth). We also compared classes in terms of maternal sociodemographics and clinical characteristics measured at childbirth, as well as total health spending and rates of adverse events (all-cause hospitalizations and severe maternal morbidity) measured from childbirth to the late postpartum period (61-365days after birth). The study cohort included 250,048 patients hospitalized for childbirth in 2016. We identified six classes with distinct outpatient postpartum care patterns in the 60days after birth, which we classified into three broad groups: no care (class 1 [32.4% of the total sample]); preventive care only (class 2 [18.3%]); and problem care (classes 3-6 [49.3%]). The prevalence of clinical risk factors at childbirth increased progressively from class 1 to class 6; for example, 6.7% of class 1 patients had any chronic disease compared with 15.5% of class 5 patients. Severe maternal morbidity was highest among the high problem care classes (classes 5 and 6): 1.5% of class 6 patients experienced severe maternal morbidity in the postpartum period and 0.5% in the late postpartum period, compared with less than 0.1% of patients in classes 1 and2. Efforts to redesign and measure postpartum care should reflect the current heterogeneity in care patterns and clinical risks in the postpartum population.

Effect of prenatal counseling on postpartum follow-up and contraceptive use in women with gestational diabetes mellitus: a randomized controlled trial

Postpartum visit attendance for glucose screening and uptake of effective contraception is crucial after a pregnancy with gestational diabetes mellitus (GDM). Although postpartum women with recent GDM are generally advised in the early postnatal period to attend postpartum visits, data have shown suboptimal rates of postpartum glucose testing and highly effective contraceptive use in these women. Compared to the early postnatal period, the antenatal period is when women and healthcare providers have more contact. This may facilitate a better relationship between the pregnant woman and her healthcare providers, thereby improving the women's trust in the providers' counseling. This study aimed to investigate whether adding prenatal counseling to routine early postnatal counseling increases the rates of glucose screening and contraceptive use by 6 weeks postpartum in pregnant women with GDM. A randomized controlled trial including 280 women diagnosed with GDM was conducted. Participants were randomly allocated (1:1, stratified with a permuted block method) to the intervention group (receiving prenatal counseling at 35-36 weeks of gestation plus routine early postnatal counseling) or the control group (receiving only routine early postnatal counseling). The two primary outcomes were glucose screening and highly effective contraceptive uptake by 6 weeks postpartum. The secondary outcome was the use of any contraceptive by 6 weeks postpartum. Data were analyzed according to the intention-to-treat principle. The rate of postpartum glucose screening was 86.4% (121/140) in the intervention group, which was significantly higher than the 50.7% rate (71/140) in the control group (adjusted relative risk [RR], 1.70; 95% confidence interval [CI], 1.27-2.28). The uptake of highly effective contraceptive methods was increased in the intervention group compared to that in the control group (59.3% vs 30.7%; adjusted RR, 1.90; 95% CI, 1.31-2.74). The uptake of any contraceptive method by 6 weeks postpartum was reported by 122 of 140 participants (87.1%) in the intervention group and 77 of 140 participants (55.0%) in the control group (adjusted RR, 1.58; 95% CI, 1.19-2.10). Adding prenatal counseling to routine early postnatal counseling significantly increased the rates of glucose screening and contraceptive use by 6 weeks postpartum in pregnant women with GDM. Given that incorporating counseling regarding postpartum glucose testing and effective contraceptive use into standard prenatal care requires minimal increases in expenditure and manpower, implementation of this counseling strategy in clinical practice seems advisable.

Effect of the COVID-19 pandemic on racial disparities in postpartum visits at a Texas level IV maternal center

Background The primary aim of our study was to determine the attendance of postpartum visits stratified by race and if the COVID-19 pandemic affected racial disparities in postpartum visit attendance. Methods We searched our labor and delivery records from July 1, 2019 to December 31, 2019 and from July 1, 2020 to December 31, 2020 and included patients who delivered liveborn infants. The final analysis was restricted to patients who identified as White or Caucasian only, Black or African American only, or Hispanic. We then performed joint tests on the logistic regression with an interaction term of race and year of delivery to determine the final model. Results The odds ratio of Black or African American and Hispanic patients attending a postpartum visit was 0.589 (95% CI 0.456, 0.760; P < .001) and 0.836 (95% CI 0.676, 1.034; P = 0.099), respectively, compared to White or Caucasian patients. The interaction term of race and year of delivery was not statistically significant. Conclusion Black or African American patients at our hospital had a clinically and statistically significant lower utilization of postpartum visits compared to White or Caucasian patients and this disparity was not exacerbated by the COVID-19 pandemic.

Health Insurance Coverage and Postpartum Outcomes in the US

Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People With Gestational Diabetes [ID: 1375592

INTRODUCTION: The 2-hour glucose tolerance test (GTT) performed during delivery hospitalization is as predictive of postpartum dysglycemia as the 4- to 12-week test. Our objective was to assess test uptake as part of routine care rather than a research protocol. METHODS: This is a retrospective cohort study of patients with gestational diabetes mellitus (GDM) at a high volume center. The in-hospital (“early”) GTT began being offered in early 2021 as postpartum glucose screening option, and we collected 6 months of postimplementation data. Adherence to the GTT was compared between those who elected an early GTT versus those who deferred testing. Descriptive characteristics including demographics, care team characteristics, and postpartum testing/visit attendance were compared between those who received an early GTT and those who did not. Institutional review board approval was waived. RESULTS: Six hundred eighty-one patients with GDM delivered during the study period, and 340 (50%) received the early GTT. Of those who had an early GTT ordered (n=408), 83.3% completed the test. Among those who did not receive an early GTT, only 104 (30.5%) completed any postpartum glucose testing. There were significant differences in demographic characteristics among those who completed the early GTT compared to those who did not. When postpartum visit attendance was assessed, those who completed an early GTT had a lower rate of attendance compared to those who deferred (75.6% versus 91.5%, P&lt;.01). CONCLUSION: When an early GTT is offered in clinical practice, adherence rates are still significantly higher than when the test is deferred until the postpartum visit.

Healing at Home: Impacting Postpartum Outcomes Utilizing Clinical Practice Changes and Augmented Intelligence [ID: 1379350

INTRODUCTION: The fourth trimester is a time of great physical and emotional challenge. To help patients navigate this period, we created the Healing at Home (H@H) program, which combined expedited discharge with a 24/7 bidirectional postpartum support chatbot. METHODS: Clinical outcomes, abstracted from medical record and patient report via text message, were evaluated for patients enrolled in H@H (March 2020 to September 2021) compared to patients delivering prior to program implementation (July to December 2019). Enrolled patients had a full-term singleton vaginal delivery of a non-small-for-gestational-age infant without postpartum hemorrhage (&gt;1,000 cc), a low-risk sepsis risk score, a low- to intermediate-risk bilirubin, and lack of significant maternal comorbidities (eg, preeclampsia, preexisting diabetes). Institutional review board waiver for this quality improvement study was obtained. RESULTS: There were 490 patients enrolled in H@H versus 309 in preintervention group. The groups were similar in parity, race, ethnicity, and insurance status. There was no difference in the primary outcome, postpartum visit attendance (76.9% versus 76.1%, P=.77). H@H patients had a shorter postpartum length of stay (33.3 versus 46.7 hours, P&lt;.001), higher rates of exclusive breastfeeding at 1 week (59.2% versus 57.0%, P=.02), and a higher rate of contraceptive use (55% versus 44%, P=.01), with no difference in maternal unscheduled visits or hospital readmissions. CONCLUSION: This innovative postpartum program was associated with a shorter length of stay and improvement in contraceptive acceptance and breastfeeding without increasing unscheduled visits. Future studies should evaluate the cost-effectiveness of this program and expansion to higher-risk patients including those with cesarean delivery and medical comorbidities.

Postpartum Titration of Antihypertensives in Patients With Hypertensive Disorders of Pregnancy [ID: 1380430

INTRODUCTION: Postpartum hypertension is observed in up to 20% of patients within 6 weeks of delivery. While blood pressure evaluation is an integral component of prenatal care, effective blood pressure follow-up postpartum is uncertain. The objective of this study was to evaluate the use of antihypertensive medications and subsequent dosage adjustments in the postpartum period. METHODS: This was a retrospective qualitative observational study of patients with hypertensive disorders of pregnancy who delivered at a single quaternary care safety net hospital from July to December 2021. Patients with at least one of the following diagnoses: chronic hypertension (cHTN), gestational hypertension (gHTN), and/or severe preeclampsia (SPE), were included. Data collected included initiation and/or titration of antihypertensives during delivery admission, postpartum visit attendance, outpatient antihypertensive dose adjustments, and emergency department visits. RESULTS: From July to December 2021, 1,232 pregnancies were complicated by hypertensive disorders: gHTN only, 577 (46.8%); both gHTN and cHTN, 34 (2.8%); both gHTN and SPE, 499 (40.5%); and all three, 122 (9.9%). Of these, 256 (20.8%) required initiation and/or titration of antihypertensives during delivery admission with over 90% of these complicated by SPE. Of the 197 (77.0%) attending at least one follow-up, medication was stopped in 26 (13%), increased in 9 (5%), decreased in 22 (11%), and continued unchanged in 140 (71%). The majority of medication adjustment occurred in the first 2 weeks postpartum. CONCLUSION: Postpartum hypertensive therapy management occurs predominantly within 2 weeks postpartum, with nearly one-fourth decreasing and only 5% requiring increased medication.

An assessment of postpartum contraception rates with evolving care during the COVID-19 pandemic

ObjectiveThe COVID-19 pandemic presented new care delivery obstacles in the form of scheduling procedures and safe presentation to in-person visits. Contraception provision is an indispensable component of postpartum care that was not immune to these challenges. Given the barriers to care during the initial months of the pandemic, we sought to examine how postpartum contraception, sterilization, and visit attendance were affected during this period.Study Design.We performed a retrospective chart review to examine contraception initiation, sterilization, and postpartum virtual and in-person visit attendance rates during the first six months (March 15 to September 7, 2020) of the COVID-19 pandemic compared to the rates in the same period in the year prior at a single tertiary academic care center. We abstracted data from the first prenatal visit through twelve weeks postpartum. ResultsWith the initiation of virtual appointments, postpartum visit attendance significantly increased (94.6 % vs 88.4 %, p < 0.001) during the pandemic with no difference in overall contraception uptake (51 % vs 54.1 %, p = 0.2) or sterilization (11.0 % vs 11.5 %, p = 0.88). During the pandemic, contraception prescribed differed significantly with a trend towards patient-administered methods including pills, patches, and rings (21 % vs 16 %, p = 0.02). In both periods, there was a significantly younger mean age (p < 0.001), higher proportion of non-White and non-Asian race (p < 0.001), public insurance (p = 0.003, 0.004), and an established contraceptive plan prenatally (p < 0.001) in the group that received contraception. ConclusionAs virtual postpartum visits were instituted, contraception initiation and sterilization were maintained at pre-pandemic rates and visit attendance rose despite the obstacles to care presented by the COVID-19 pandemic. Provision of virtual postpartum visits may be a driver to maintain contraception and sterilization rates at a time, such as early in the COVID-19 pandemic, when patient care is at risk to be disrupted by social distancing, isolation, and avoidance of medical campuses.