Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, Quality Improvement, Shortened Appointment Interval

Intervention Description: The addition of a 2-3 week postpartum visit in addition to a 6 week visit, in keeping with guidelines from the American College of Obstetricians and Gynecologists (ACOG. This quality improvement (QI) project was guided by the Quality Implementation Framework, a process model with a systematic and practical approach to implementation. The model has four phases: initial considerations regarding the host setting, creating a structure for implementation, ongoing structure once implementation begins, and improving future applications by learning from experience. The intervention is based on the assumption that adding an earlier prescheduled postpartum appointment would increase the likelihood that women would attend at least one postpartum appointment.

Intervention Results: During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation.

Conclusion: Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings.

Study Design: Quality improvement project consisting of four rapid Plan-Do-Study-Act (PDSA) cycles

Setting: Small nurse practitioner maternity care clinic in an academic health center

Population of Focus: Publlicly-insured women

Sample Size: 25

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation (Assistance), Patient Reminder/Invitation, Participation Incentives, Shortened Appointment Interval

Intervention Description: Women were randomized to receive 3–4 and 6–8 weeks postpartum appointments and were followed for 18 months. Study participants were recruited from the VCUMC in-patient postpartum unit by using Electronic Health Records (EHR) to monitor deliveries. Eligible women were contacted within 48 h of delivery and informed about the study. Women who agreed to participate were asked to sign the informed consent form, which authorized research staff to access participants' EHR to enhance tracking of postpartum visit attendance. Study participants were interviewed in person at baseline (within 48 h of delivery) and at the postpartum visit. Participants were compensated $25 for completing the baseline interviews and $30 for completing the postpartum interviews. Follow-up assessments were administered via telephone at 3, 6, 9, 12, and 18-months post-delivery to evaluate secondary outcomes including contraceptive use, infant feeding practices, pregnancy status, stress and social support, and socio-demographic and medical information. Each of the follow-up assessments lasted approximately 10–15 min, and participants were compensated $10 per follow-up assessment. To reduce loss to follow-up, participants' contact information, as well as contact information for at least three persons who would know the participants' whereabouts and could get messages to them, were collected from the patients. To compensate study subjects for their participation and encourage follow-up assessment compliance, thank you letters along with appointment reminders and additional $10 checks were mailed to each participant monthly. This was especially important for hard-to-track women who did not have working phone numbers and did not return for postpartum visits. Additionally, per study protocol, participants received appointment reminder SMS text messages and/or emails 1 day before their scheduled follow-up phone interviews. If participants could not be reached, up to four attempts were made to contact the participant on different days and times of the day, in an effort to schedule the interviews.

Intervention Results: The overall postpartum visit adherence rate was generally high in the study. However, the adherence rate was observed to be relatively lower in the 3–4 weeks group (71%) compared to the 6–8 weeks group (90%). One reason that may explain this finding is that participants may have been more familiar with the traditional 6–8 weeks postpartum visit and thus, may have had some inertia or difficulty in attending a 3–4 week postpartum visit. A large proportion of women were retained in the study as demonstrated by the high completion rates at the 18-month follow-up interview (Total sample: 87.6%; 3–4 weeks group: 88.0%; 6–8 weeks group: 87.3%). Similarly, high adherence to the protocol-directed postpartum visit schedule was reported in the overall study sample (79.7%), as well as in the 3–4 (70.5%) and 6–8 (90.0%) week postpartum groups.

Conclusion: In this trial, we successfully maintained high completion rates throughout the course of the study. This is important given that the study population included hard-to-track women who typically do not return for postpartum visits [12]. Due to economic challenges, underserved women may not have permanent addresses or phone numbers. By utilizing a participant tracking form, we obtained contact information from at least three persons who generally knew the participants' whereabouts and could contact them. This provided multiple avenues for reaching participants and enhanced retention. Additionally, monthly communication and incentives provided the opportunity to maintain participant engagement.

Study Design: Prospective, open-label randomized control trial

Setting: Virginia Commonwealth University Medical Center

Sample Size: 364 women

Age Range: 18-43

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation (Assistance), Shortened Appointment Interval

Intervention Description: Participants were randomized with 1:1 allocation to 2 arms. In the control arm, participants were instructed to schedule their routine visit at 6 weeks after delivery (defined as 29–56 days after delivery). Participants in the intervention arm were instructed to schedule a visit at 2 weeks after delivery (8–28 days after delivery) in addition to 6 weeks after delivery.

Intervention Results: The attendance at 1 or more postpartum visits was not significantly different among the control and intervention arms (58% vs 70%; P=.065). The 2-week visit had an attendance rate of 41% (51 of 125), and the 6-week visit had an attendance rate of 60% (151 of 250). After adjusting for confounders, significant predictors of postpartum visit nonattendance included younger age, multiparity, and being a patient from the high-risk obstetrical clinic. The rate of emergency department visits was similar between the control and intervention arms (8% vs 6%; P=.635). However, more patients in the control arm come to the clinic for nonroutine visits (30% vs 16%; P=.010). In response to a patient satisfaction survey on the optimal timing of the postpartum visit, most respondents (59%) would have preferred both the 2- and 6-week visits.

Conclusion: The addition of a 2-week postpartum visit to the 6-week postpartum visit did not increase the likelihood of attendance of patients in a routine visit but did decrease the number of urgent clinic visits.

Study Design: Parallel, randomized, nonblinded trial

Setting: Publicly insured clinic in a tertiary academic medical center

Population of Focus: Postpartum patients

Sample Size: 250

Age Range: ≥18