Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Continuity of Care (Caseload), Midwifery, Home Visit (caregiver),

Intervention Description: A model pilot program was established in South Australia to address the ongoing closure of regional maternity services and bring sustainable birthing services to the area with the aim of keeping birthing as close to home as safely possible. This Midwifery Caseload Model of Care (MMoC) model was an all-risk model or care whereby 12.9 full-time equivalent midwives were employed to work in collaboration with general practitioners (GP)/obstetricians across five birthing sites (Port Pirie, Crystal Brook, Wallaroo, Clare and Jamestown). In the MMoC all pregnant women in the region could be referred to the program and allocated to a known midwife once pregnancy had been confirmed. Care was then provided by the MMoC midwife and an obstetric GP or obstetrician. The service delivery model prioritized choice and interdisciplinary care. An anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period.

Intervention Results: Most women (97%) received a postnatal visit from a MMoC midwife and 84.1% reported the MMoC midwives were their main postpartum care provider. Shared care GP/MMoC midwives accounted for 8.9% (n = 17) and 6.9% (n = 13) indicated they had “other” postnatal care such as child and family health nurse, midwives and nurses at the birth hospital, and midwives at referral hospital due to baby’s prematurity. Overall women had an average of four postnatal visits. Close to a third of women (32.5%) had six or more visits. Most women (77%) reported receiving their visit in their home or a combination of home and not at home (20%). Only 3.2% of visits were not conducted at home. In addition to midwifery visits, most women (approximately 80%) also used community supports, the most frequently being child and family health nurses.

Conclusion: In this regional/rural MMoC, women were able to receive quality continuity and components of care as have been previously benchmarked against the QMNC Framework. Women embraced the new MMoC, established strong relationships with their midwives and were able to maintain good collaborative arrangements with their local GPs. The generalisability of these results should be considered for other regions which offer maternity services and have GP obstetrician support. These findings are consistent with existing evidence that supports midwifery continuity of care for women and adds to the growing body of evidence for midwifery caseload outside of metropolitan areas

Study Design: Mixed methods design using qualitative and quantitative methodologies

Setting: Five birthing sites in South Australia (Port Pirie, Crystal Brook, Wallaroo, Clare and Jamestown).

Population of Focus: Pregnant women in regional/rural areas

Sample Size: 205

Age Range: 16-42 years

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation (Assistance), Concurrent Infant/Mother Checkups

Intervention Description: The Mother-Infant dyad postpartum primary care program was part of Ohio Gestational Diabetes Postpartum Care Quality Improvement Collaborative, a multi-year initiative sponsored by the Ohio Departments of Health and Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The Dyad program evaluation was conducted in the context of a quality improvement (QI) initiative aimed at increasing postpartum type 2 gestational diabetes (T2DM) screenings during the 4–12 week postpartum period and also increasing postpartum visit attendance with a prenatal provider. Women were eligible for the Dyad program if they lived in central Ohio and had a diagnosis of gestational diabetes mellitus (GDM) during the most recent pregnancy or condition suggesting previous undiagnosed GDM. Following delivery, Dyad program appointments occurred concurrent with the infant’s well-check visits and allowed mothers to access comprehensive postpartum care services including but not limited to postnatal screening for T2DM, health and wellness education, breastfeeding support, and referrals to specialty services if indicated. An on-site patient navigator contacted mothers by phone in advance of the visit to address barriers to care including transportation and childcare. Reminders were also sent via phone and electronic health record (EHR) patient portal to con- firm attendance. The Dyad program facilitated postpartum obstetrics to primary care hand off to improve longitudinal care engagement for disease management and prevention.

Intervention Results: Women who participated in the Dyad program were more likely to complete a postpartum visit and receive type 2 diabetes mellitus (T2DM) screenings than women who did not participate. In addition, fewer women who participated in the program experienced new T2DM diagnoses (17%) than those in the comparison group (29%), yet a greater proportion of Dyad program participants experienced new predia- betes diagnoses (12%, p<.001) than those in the com- parison group (6%, p<.001).

Conclusion: The Mother-Infant Dyad postpartum primary care program improved type 2 diabetes mellitus screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program partici- pants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.

Study Design: Analysis of patient surveys, claims data, and administrative records

Setting: Midwestern academic medical center internal medicine and pediatrics primary care clinic

Population of Focus: Postpartum patients with a previous diagnosis of gestational diabetes mellitus

Sample Size: 75 mother-infant dyads

Age Range: Mean age 30.75

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits, Access,

Intervention Description: Family Connects is a short-term nurse home visiting approach designed to deliver brief education and intervention, assess family needs, and connect families to community resources for ongoing support. Impact evaluation compared outcomes for families of infants born in the months immediately prior to program launch (comparison group n = 360; Feb. 1, 2014–July 31, 2014) to families of infants born during the FC implementation period (intervention group n = 1068; Sept. 1, 2014-Dec. 31, 2015). Outcomes were assessed for both groups via a 30-min telephone interview when the infants were 6 months old.

Intervention Results: No group differences were found in total emergency care utilization for birthing parents (see Table 3). FC parents reported making more ED and urgent care visits for themselves than did comparison group parents (95% CI = 0.04, 0.51; effect size = 0.14) and (non-significantly) fewer hospital overnight stays. FC parents reported greater perceived social support relative to comparison group parents (95% CI = 0.01, 0.14; effect size = 0.13). No differences were observed for maternal 6-week postpartum health-check completion or endorsed symptoms of depression or anxiety.

Conclusion: Results from this quasi-experimental field trial indicate that FC effectively engages families living in high-poverty rural counties during the postpartum period with broad reach and high program fidelity, leading to positive population impacts on family health and well-being. Implementation findings indicate FC had broad community reach, high nurse reliability and fidelity to the manualized protocol, and nurse-family referral connection rates that exceeded rates observed in prior trials (Dodge et al., 2014, 2019). The findings provide compelling evidence that FC can be disseminated through rural public health departments with high quality. The high completion rate (65% of all eligible families) suggests that the FC is well suited for rural contexts.

Study Design: Quasi-experimental design

Setting: Four rural Eastern North Carolina counties

Population of Focus: Families living in high-povery rural counties

Sample Size: 392 intervention group families and 126 families with infants born between Feb. 1, 2014–July 31, 2014 (natural comparison group).

Age Range: Reproductive age (≥Teenage)

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, EMR Reminder,

Intervention Description: With assistance from the clinical informatics department, a postpartum-specific note template was created in the electronic health record (EHR) to increased adherence with counseling guidelines recommended by the American College of Obstetrics and Gynecology (ACOG). The template addressed birth spacing, breastfeeding, contraception, depression, and sleep/fatigue, as well as comorbidities requiring follow-up (abnormal Pap smear, gestational diabetes mellitus, and pre-eclampsia). Patients were seen in a resident-run clinic: 100 consecutive visits occurred prior to implementation of the template, while 100 consecutive visits occurred post-implementation with use of the template.

Intervention Results: In visits that occurred without use of the template, counseling was charted as low as 1.0% for birth spacing to as high as 86.0% for contraception. With use of the template, counseling was charted as 100% in all visits for each of the recommended counseling guidelines (all p < 0.001).

Conclusion: A postpartum specific EHR note template shows improvement in adherence with recommended postpartum counseling. We propose that managers in hospitals and clinical practices create OBGYN-specific EHR note templates for clinical use to potentially improve documentation quality. This may increase adherence to documentation of postpartum counseling, with the ultimate goal of increasing adherence to evidence-based counseling guidelines.

Study Design: Retrospective cohort study

Setting: Resident run clinic, Nassau University Medical Center

Population of Focus: Postpartum patients

Sample Size: 200

Age Range: Mean age 30

Intervention Components (click on component to see a list of all articles that use that intervention): Technology-Based Support, Patient Reminder/Invitation, Text Messaging,

Intervention Description: As part of an ongoing quality improvement project, the hospital implemented a remote hypertension monitoring protocol for postpartum women with a diagnosis of chronic hypertension, superimposed preeclampsia, gestational hypertension, preeclampsia, or postpartum hypertension. After identification by an obstetric care provider, women with access to a text messaging-enabled smartphone device are enrolled in the 6-week postpartum program, which is automatically indicated in the electronic medical record. Participants are trained on the use of a blood pressure device (obtained through insurance, patient purchase or hospital provision) by a nurse educator before discharge from the hospital. After discharge, participants are prompted to check their blood pressure 5 days per week and are prescribed an antihypertensive medication from a call center physician if clinically indicated. Women with blood pressures exceeding the goal who are asymptomatic are encouraged to keep their postpartum office visit.

Intervention Results: Among women enrolled in the program, 360 (88%) attended a 6-week postpartum visit, compared with a historical background rate of 60% attendance among all deliveries and 66% attendance among women with a hypertensive disorder of pregnancy in the year before implementation of the program (2017). Compliance with the program was high. Based on the protocol, 177 (43%) women did not require the previously scheduled in-office blood pressure check at 1-week postpartum, the majority (112; 63%) were in the no medication group. Of the 232 women who required a blood pressure check based on the protocol, 198 (85%) women attended the visit. Of the 409 women who have completed the program to date, 340 (83%) continued the program beyond 3 weeks postpartum and 302 (74%) continued the program beyond 4 weeks postpartum. An ongoing goal of the program is to bridge care from obstetricians to primary care physicians; currently 87 (21%) participants have established care with a primary care physician postpartum, with an additional 42% reporting that they have scheduled an appointment with their primary care physician.

Conclusion: In this study, we detail results from an ongoing remote blood pressure monitoring program. We demonstrate high compliance, retention, and patient satisfaction with the program. This is a feasible, scalable remote monitoring program connected to the electronic medical record.

Study Design: Quality improvement project

Setting: University of Pittsburgh medical center

Population of Focus: At risk postpartum women

Sample Size: 499

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Technology-Based Support, Patient Reminder/Invitation, Text Messaging,

Intervention Description: The intervention involved a text-based surveillance arm, where women were given an automatic Omron blood pressure cuff and instructed on its use. Patients were enrolled into a texting program platform developed through Way to Health, a web-based platform within the institution, with secure technological infrastructure developed for research. Patients received reminders to text message their blood pressures twice daily for 2 weeks postpartum, and immediate feedback was provided to the patient based on a preprogrammed automated algorithm. The primary investigator was alerted with specified severe range blood pressure values via text message or email, and care was escalated as needed based on the outpatient algorithm used in the office

Intervention Results: The study found that text-based monitoring was more effective in obtaining blood pressures and meeting current clinical guidelines in the immediate post-discharge period in women with pregnancy-related hypertension compared with traditional office-based follow-up.

Conclusion: Text-based monitoring is more effective in obtaining blood pressures and meeting current clinical guidelines in the immediate postdischarge period in women with pregnancy-related hypertension compared with traditional office-based follow-up.

Study Design: Randomized control trial

Setting: Two prenatal practices within a single medical sytem

Population of Focus: Health care providers; postpartum patients with pregnancy-related hypertenion

Sample Size: 206 women with pregnancy-related hypertension

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): Consensus Guideline Implementation, Note-Taking (caregiver),

Intervention Description: Four core interventions were created for this project. The population health management registry tracked postpartum patients for early postpartum follow‐up. Patients who were 1–3 weeks postpartum were placed on the registry. Two providers (nurse‐midwife and OB/ GYN physician) called patients to ensure they were progressing as expected, with complications referred for either an in‐person office visit or for urgent evaluation in Labor & Delivery or the Emergency Department. The electronic postpartum note template guided review and documentation of ACOG's recommended visit components for postpartum visits. Clinic staff and providers were educated regarding the use of the tools. No incentive was provided for tool use.

Intervention Results: The project aimed to increase the frequency of effective postpartum care visits from 0% to 80% in 8 weeks. The frequency of effective postpartum care visits was 88% by the end of PDSA Cycle 4. The PRATs increased patient postpartum warning sign knowledge, with a project mean risk factor knowledge score of 6 (Goal = 5). The population health registry drove right care by ensuring early postpartum patients were recovering as expected, as seen by a project mean right‐care score of 16 (Goal = 12). The note template increased the effectiveness of postpartum visits, with a mean effective postpartum care score of 10 (Goal = 10).

Conclusion: The Postpartum Readiness and Awareness Tools (PRAT), population health registry, and note template tools improved quality and postpartum care effectiveness over 8 weeks. It is suggested that the PRAT and note template be sustained to increase anticipatory guidance and adherence to postpartum counseling guidelines. It is also recommended that pre‐scheduled telemedicine visits be implemented for early postpartum follow‐ up. Continued tool utilization can increase patient knowledge of postpartum warning signs, early postpartum follow‐up, and comprehensive 6‐week postpartum visits. Further studies are needed to examine the impact of the interventions on clinic‐ specific patient postpartum morbidity and mortality and differ- ences by race.

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

Setting: Ob/gyn practice in a large academic hospital in the eastern U.S.

Population of Focus: Postpartum patients

Sample Size: 188 patients

Age Range: Childbearing age

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): Mobile Programs, Concurrent Infant/Mother Checkups

Intervention Description: Implementation of a mobile postpartum clinic, known as the Dyadic Care Mobile Units program, at Boston Medical Center

Intervention Results: 1. Increased Attendance Rates: The mobile clinic achieved a high appointment attendance rate of 97%, which contrasts with the 60% attendance rate for postpartum parents coming into the traditional healthcare institution. 2. 2. Improved Access to Care: The mobile clinic program addressed structural determinants of health by overcoming barriers of transportation access and clinic wait times, thereby increasing safety and ease for new families to access care. 3. Improved Patient Outcomes: The high-touch postpartum care provided by the mobile clinic team was associated with improved patient outcomes, particularly related to hypertensive disorders of pregnancy and depression. Multiple patients were readmitted directly to the postpartum unit from the van in acute hypertensive crises.

Conclusion: The mobile clinic succeeded in increasing attendance rates, improving access to care, and addressing unmet material needs for participating patients.

Study Design: Descriptive program evaluation

Setting: Obstetrics and Gynecology Department’s Midwifery Service and the Pediatric Department at Boston Medical Center (BMC), a tertiary care hospital in Boston

Population of Focus: Postpartum patientnewborn dyads; health professionals

Sample Size: 347 postpartum patients; 364 newsborns

Age Range: <20--35+ (maternal age range)

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Workers (CHWs), Home Visits,

Intervention Description: The Baby Love program, administered by the Social Work Division of the University of Rochester Strong Memorial Hospital, pairs licensed, master’s-prepared social workers with community health workers (CHWs) to address barriers to health for high-risk pregnant and parenting women and infants as part of an interdisciplinary, perinatal health care team. The program serves participants by (1) increasing linkage with health and community support services, (2) educating participants on perinatal- and parenting-related topics along with stress-reduction strategies, and (3) providing support and advocacy for participants. The CHW serves as the primary Baby Love service provider, completing regular home visits and forming supportive relationships throughout the course of a women’s pregnancy and for one year postpartum. To facilitate integrated care, all interventions are documented in the participant’s medical record.CHWs are trained based on the Family Development Credential Program, a strengths-based approach of partnership between the family and CHW that is focused on achieving identified service goals.

Intervention Results: During the study period, Baby Love participants had fewer adverse outcomes than did nonparticipants, including lower rates of preterm birth. Neonatal intensive care unit (NICU) admission rates were 16% among participants compared with 21% among nonparticipants. The odds of NICU admission, preterm birth, and low birth weight were all lower among Baby Love participants than nonparticipants, whereas the odds of attending a postpartum visit within 60 days and attending at least four well-child visits within six months after births were higher.

Conclusion: The societal imperative to improve perinatal outcomes continues to pose a public health challenge. Well-structured CHW-supported home-visiting programs are a promising tool to more fully address the needs of a broader population of diverse and socioeconomically disadvantaged pregnant women. The Baby Love program’s effectiveness at improving perinatal outcomes and addressing social determinants of health from its integrated placement within the health delivery system positions this program as a valuable contributor to a fully integrated care delivery system

Study Design: Retrospective cohort study

Setting: Social Work Division of the University of Rochester Strong Memorial Hospital

Population of Focus: At-risk pregnant women

Sample Size: 353 enrolled with Baby Love;102 in comparison group

Age Range: Childbearing age

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

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation, Concurrent Infant/Mother Checkups

Intervention Description: Following randomization, participants in the mommy-baby visit arm were scheduled for a co-located, co-timed postpartum/well-child visit at 4 weeks after delivery designed through a partnership between obstetrics and pediatrics. The pediatricians performed the infant's checkup either in the same patient room as the mother's obstetric visit or in the adjacent pediatric practice immediately before the postpartum visit. Women randomized to the control group received usual postpartum care, separate maternal and child visits. Their usual care was “enhanced” in that study staff scheduled participants' postpartum visits before hospital discharge.

Intervention Results: One hundred sixteen women, of whom 76.7% (n = 89) were Latina immigrants, were enrolled postdelivery and randomized to a mommy-baby visit (n = 58, 49.5%) or to enhanced usual care (n = 58, 50.4%). Almost all study participants attended their postpartum visit (n = 109, 94.0%). There was no significant difference in postpartum visit attendance rate by randomization assignment (91.4% of mommy-baby vs. 96.6% of enhanced usual care participants). Study participants, mommy-baby intervention and enhanced usual care arms combined, were significantly more likely to attend the postpartum visit than historical controls (94.0% vs. 69.7%, respectively, p < 0.001).

Conclusion: In a randomized controlled trial, we showed postpartum visit attendance rates were high for participants in both the mommy-baby and enhanced usual care arms. Postpartum visit scheduling assistance was provided to all participants and may have increased postpartum visit attendance and thereby attenuated the effect of the intervention. It is encouraging that a low-cost, low-tech, low-touch intervention, that is, postpartum appointment scheduling before hospital discharge, could increase postpartum visit attendance.

Study Design: Randomized control trial

Setting: Large academic hospital in Baltmore

Sample Size: 116 low-income postpartum women with limited English-langauge proficiency

Age Range: >18

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits, Access, Patient Navigation,

Intervention Description: The implementation of clinical-community linkages to engage Medicaid-insured pregnant women in underutilized home visiting services for enhanced prenatal care coordination.

Intervention Results: Clinical-Community Linkages: The Impact of Standard Care Processes that Engage Medicaid-Eligible Pregnant Women in Home Visiting. When compared with similar women from the rest of the state, the Federally Qualified Health Center observed a 9.1 absolute percentage points (APP; 95% confidence interval [CI], 8.1–10.1) increase in MIHP participation and 12.5 APP (95% CI, 10.4–14.6) increase in early first trimester enrollment. The obstetrics and gynecology residency practice experienced increases of 4.4 APP (95% CI, 3.3–5.6) in overall MIHP participation and 12.5 APP (95% CI, 10.3–14.7) in first trimester enrollment. Significant improvements in adequate prenatal care, emergency department use, and postpartum visit completion were also observed.

Conclusion: Clinical–community linkages can significantly improve participation of Medicaid-insured women in an evidence-based home visiting program and other prenatal services. This work is important because health providers are looking for ways to create clinical–community linkages

Study Design: Quasi-experimental design

Setting: A Federally Qualified Health Center (FQHC) and a hospital-based obstetrics and gynecology residency practice

Population of Focus: Medicaid-insured pregnant women; healthcare pracitioners

Sample Size: 1,017 (Combined FQHC and Ob/Gyn residency practice)

Age Range: n/a

Intervention Components (click on component to see a list of all articles that use that intervention): Mobile Programs, Concurrent Infant/Mother Checkups

Intervention Description: A mobile medical center was emergently repurposed to provide postpartum/postnatal care for women and neonates (caregiver-infant dyads) during the early COVID-19 pandemic.

Intervention Results: Two-thirds of women who were evaluated on the mobile medical center (MMC) attended an in-person or telehealth postpartum visit, and 16.7% had a documented missed postpartum visit. All women evaluated on the MMC had blood pressure evaluated. Over two-thirds (69.7%) had at least one postpartum blood pressure reading > 120/80 mmHg, and 19.6% had readings elevated enough to require contact with the obstetric provider for further guidance. Follow-up visits with either an outpatient or obstetric provider regarding blood pressure then occurred in 15.2% of mothers, and four (6.1%) required emergent treatment and/or readmission to the hospital for postpartum hypertension detected on the MMC. Nearly all caregivers reported they were very satisfied and very likely to recommend the MMC to friends (98.5% and 94.1%, respectively)

Conclusion: In this assessment of caregivers who accessed the MMC-a rapidly-developed COVID-19 pandemic response-insights from caregivers, predominantly people of color, provided considerations for future postpartum/postnatal service delivery. Perceptions that the MMC addressed health-related social needs and barriers to traditional office-based visits and the identification of maternal hypertension requiring urgent intervention suggest that innovative models for postpartum mother-infant care may have long-lasting benefits.

Study Design: Mixed methods observational study

Setting: Mobile medical center in New Haven, Connecticut

Population of Focus: Caregiver-infant dyads

Sample Size: 139 caregiver-infant dyads contacted

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital), Patient Reminder/Invitation,

Intervention Description: The project team created four interventions to address gaps and increase attendance to the 6‐week comprehensive postpartum visit: a schedule log, postpartum telehealth check‐in visit, administering the EPDS within 6 weeks postpartum (during the telehealth check‐in visit), and a team engagement plan. Appointments for a telehealth check‐in visit and a comprehensive postpartum visit were scheduled for each postpartum patient and tracked using the log. Schedulers served as a patient navigator and scheduled both appointments. The nurse practitioners, physician, and midwife performed telehealth check‐in visits 1– 3 weeks postpartum. Providers used a four‐item checklist, created by the team, and placed the text in the summary of their notes. The four items included the EPDS, inquiring about breastfeeding and any issues, discussing the importance of postpartum visits, and asking about needs for community resources.

Intervention Results: The number of people who attended comprehensive postpartum visits increased to 56.8% (up from 27% prior to the intervention). The team performed a χ2 test of independence to determine the statistical significance of outcomes when compared with the baseline data. The outcome shows a statistically significant result, χ2(1, N=228) = 18.05, p=.000022. During the project, the balancing measure, team efficiency, improved as measured by anonymous surveys to team members.

Conclusion: Overall, this project proved to be low cost with high value for patients and the medical department. The initiative improved care by increasing attendance at comprehensive postpartum visits, identify- ing concerns early, detecting postpartum depression or anxiety in six patients, and identifying a surgical site infection during check‐in visits. The team's success would be intriguing to most practices that provide obstetrical care, given that the national postpartum return rate is only 60%. Recommendations for spread and sustainability include dedicated postpartum patient navigators, who would handle the schedule log, continuation of a check‐in visit, electronic EPDS, and ongoing staff education. Further study could show the efficacy of this model in other settings. Given the increased postpartum attendance and early identification of complications, the team successfully improved effective care to postpartum families in North Philadelphia.

Study Design: Quality improvement initiative

Setting: Einstein Medical Center, a large academic hospital in North Philadelphia

Population of Focus: Postpartum patients

Sample Size: 147 patients

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Patient-Centered Medical Home, Concurrent Infant/Mother Checkups

Intervention Description: Jointly scheduling PP visits and the 2-month well infant visits.

Intervention Results: Of the 74 patients enrolled, 41.9% were Hispanic and 17.6% were Black, mean age was 31.6 years, and 58.1% delivered vaginally. Attendance at the 6-week PP visit was 68.9%, and attendance at the infant visit was 55.1%. PP glucose testing was ordered for 76.5% of attendees at the PP visit, and of those ordered, 43.6% of attendees completed testing. All patients had joint visits requested, though only 70.3% of visits were scheduled jointly. Among those who were jointly scheduled, 71.2% of women attended, 57.7% of infants attended, and 7.7% of pairs attended on the same day. The PP visit attendance rate was not significantly different than the prior attendance rate (p = 0.84)

Conclusion: This study was unable to improve PP visit attendance among women with GDM by jointly scheduling the 6-week PP visit and the 2-month well-infant visit. Future research could be directed toward a shared space where both women and children can be seen to attempt to increase PP visit attendance and monitoring for women with GDM.

Study Design: Cohort study

Setting: New York City-based publicly insured hospital clinic

Population of Focus: Patients with gestational diabetes (GDM)

Sample Size: 74

Age Range: Reproductive age

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Concurrent Infant/Mother Checkups

Intervention Description: The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network, a family medicine maternal child health learning collaborative of the Family Medicine Education Consortium, created a model of intercconception care (ICC) that addresses barriers to care by screening women during well-child visits (WCVs). The IMPLICIT Network develops, implements, evaluates, and optimizes new and existing models of care focused on improving birth outcomes and the health of women, infants, and families. In this model, clinicians assessed pregnancy status, intent, and current method of contraception and offered counseling and interventions. Mothers were also screened for depression. Clinicians screened mothers at well-child visits from 2 to 24 months. Mothers received screening and advice regardless of whether or not she received primary care from the same provider or practice. A variety of services were available to the participating clinicians on site, including case management, social workers, community health workers, substance abuse counselors, and office-based pharmacists. Each family medicine practice offered patients access to mental health counseling, with 6 of the 11 sites reporting availability of colocated, integrated behavioral health models.

Intervention Results: Mothers accompanied their babies to 92.7% of WCVs. At more than half of WCVs (69.1%), mothers were screened for presence of ICC behavioral risks, although significant practice variation existed. Risk factors were identified at significant rates (tobacco use, 16.2%; depression risk, 8.1%; lack of contraception use, 28.2%; lack of multivitamin use, 45.4%). Women screened positive for 1 or more ICC risk factor at 64.6% of WCVs. Rates of documented interventions for women who screened positive were also substantial (tobacco use, 80.0%; depression risk, 92.8%; lack of contraception use, 76.0%; lack of multivitamin use, 58.2%).

Conclusion: Based on the findings of this study and the clinical experiences of participating sites with the IMPLICIT ICC model, several key recommendations can be offered to clinical practices seeking to implement this model for interconception care. Practices should develop standardized screening protocols, tools for point-of-care intervention for women who screen positive in any of the four key behavior risk areas, such as patient education materials and clinical management algorithms, and linkages with local community agencies so they may refer women needing additional resources not offered on site, such as depression care or contraception access. Practices should also strive to use quality improvement techniques to improve both screening and intervention rates. Practices that serve populations with limited resources such as uninsured, undocumented, or immigrant communities would gain particular benefit from implementing IMPLICIT ICC as a way to reach women not seeking care. Based on their particular population's needs, clinical practices might consider expanding the IMPLICIT ICC model to include additional risk factors for poor birth outcomes, such as domestic violence, food insecurity, obesity, or substance abuse. However, adding additional screening targets could limit the feasibility of screening and intervention in the context of the well-child visit. The use of the WCV is one of many strategies that providers may use to deliver the full breadth of comprehensive interconception care that women should receive. Future effectiveness studies are needed to assess rates of prematurity and other birth outcomes in populations who received interconception care through the IMPLICIT ICC model, especially at sites who have implemented the model for several years, to inform the growing literature on preconception care.

Study Design: Descriptive statistics; Feasibility study

Setting: Eleven eastern US family medicine residency programs

Population of Focus: Mothers accompanying their babies at well-child checkups

Sample Size: Varies across sites

Age Range: <15--≥24

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation, Text Messaging,

Intervention Description: Navigating New Motherhood (NNM) was a patient navigation program that sought to increase the frequency of postpartum care attendance in a tertiary care center practice serving predominantly low-income, minority women. The NNM program provided postpartum appointment scheduling assistance, appointment reminders, assistance with logistical barriers, and social support to mothers. In accordance with patient preference, the NNM program relied predominantly on SMS text message communication between patient navigators and women enrolled in the program.

Intervention Results: While the program was in place, the majority of enrolled women (88.1%) returned for their postpartum visits at an average of 6.2 weeks postpartum. More frequent and multidimensional communication was associated with follow-up in a postpartum patient navigation program. Most women (98.2%) communicated with navigators via text message. Women who completed postpartum follow-up sent and received more texts than women who did not (7.8 vs. 3.7, p<0.001 and 11.5 vs. 8.0, p<0.05, respectively); exchange of ≥6 messages was associated with greater odds of follow-up (adjusted odds ratio 2.89, 95% CI1.13–7.41). Lack of patient response was also associated with lack of follow-up (p<0.001). Four categories of message themes were identified: Rapport-building, Postpartum Care Coordination, Maternal Health, and Motherhood. Message threads with more Rapport-building or Maternal Health messages were associated with more frequent patient follow-up (p<0.01 and p<0.05, respectively), as was average number of emoticons per message thread (2.1 vs. 1.2, p=0.01).

Conclusion: Findings illustrate that certain communication characteristics, including more frequent exchange of messages and greater use of rapport-building- or maternal health-oriented messages, are associated with an improved likelihood of return. Message frequency and message content appear to be critical communication features of effective patient navigation. Rapport-building messages were the most frequently observed type of communication across all message threads, and they were significantly more frequent among patients who ultimately completed follow-up. These results are consistent with previous studies emphasizing the importance of relational qualities and the ability to build trust within the patient navigation model

Study Design: Mixed methods secondary analysis

Setting: University tertiary care center in Chicago

Population of Focus: Women enrolled in public insurance receiving prenatal care

Sample Size: 218 women

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation, Text Messaging,

Intervention Description: The patient-centered Navigating New Motherhood program hired one full-time patient navigator who was experienced navigating low-income women through women's health cancer screening and treatment. The navigator coordinated with clinic staff to schedule the patient's six-week postpartum appointment as well as any earlier visits recommended by the medical team. Appointment times were communicated in person or by phone, text, or email, per patient preference. Reminders were sent by the navigator one week after delivery, one week prior to appointment, and one day prior to the appointment. The navigator offered additional services as needed, including connection to health care providers for maternal or neonatal clinical concerns, psychosocial support, appointment and logistical support, assistance with social work needs (such as identifying food or transportation resources), or connection to mental health care providers. Additionally, during the postpartum hospitalization, the navigator offered brief written and verbal counseling about the benefits of and options for contraception and breastfeeding.

Intervention Results: The primary outcome, return for postpartum care, was more common among women in Navigating New Motherhood (88.1% compared with 70.3%, P<.001), a difference that persisted after adjustment for potential confounding factors. Women in Navigating New Motherhood were also more likely to receive a WHO Tier 1 or 2 contraceptive method, postpartum depression screening, and influenza and human papillomavirus vaccination.

Conclusion: Implementation of a postpartum navigation program was associated with improved retention in routine postpartum care and frequency of contraception uptake, depression screening, and vaccination.

Study Design: Prospective observational study

Setting: Medicaid based university clinic

Population of Focus: Patients receiving prenatal care

Sample Size: 218 in intervention group; 256 in historic cohort

Age Range: ≥18 (29 mean age)