Pregnant People - Key Activity 9

KEY ACTIVITY #9:

Conduct Postpartum Planning and Care


 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

 

Overview

This activity provides guidance on conducting effective postpartum planning and care. Postpartum care is a critical part of the reproductive healthcare continuum.[1] The postpartum period is a vulnerable time for patients from both physical and mental health perspectives: most pregnancy-related deaths in California occur during the postpartum period[2], and pregnancy-associated mood disorders are the most common comorbid conditions in the perinatal period[3]. Optimal postpartum care should be an ongoing process with, at minimum, two visits completed by three and 12 weeks after birth. The timing and frequency of postpartum visits should be tailored to a patient’s individual health concerns and needs[4] (e.g., adding a visit in the first seven days for a blood pressure check, modifying the schedule to allow for contraception method initiation, or increasing the frequency of follow-up visits for a mood concern).

Care during the postpartum period should include other preventive health screenings and services a patient might be due for, such as depression screening, substance use screenings, cancer screenings and immunizations. Additional elements of optimal postpartum care include screening for social needs and linkage to specialty care and services; certifying paid family leave; management of pregnancy-specific health conditions; anticipatory guidance addressing the transition to parenthood and well-person care; comprehensive contraceptive services; and interconception counseling. Postpartum visits present a good opportunity to discuss interconception care[5]; the provider and patient can reflect on any birth complications and discuss modifiable risk factors that might improve subsequent birth outcomes (e.g., monitoring for recurrence of preterm birth and aspirin to prevent recurrent preeclampsia). Although the postpartum period begins after birth, the postpartum transition may be experienced for six months or more; therefore, planning for this important period, or “fourth trimester,” should begin during pregnancy.[6]

Maternal mortality in the United States is far higher than in other developed nations, and it continues to rise. In California, maternal deaths are disproportionately high in the birthing population insured by Medicaid.[7] In addition, significant racial disparities in health outcomes exist for pregnant and postpartum patients. More than 50% of pregnancy-related deaths occur one week to one year after pregnancy, and more than 80% of pregnancy-related deaths are deemed preventable. Currently, up to 40% of birthing people do not attend a routine postpartum visit, and few receive all recommended elements of postpartum care. The postpartum period provides an important opportunity to support birthing persons and their families, as it is often a time of increased patient motivation, engagement and access to insurance. Intervention in the postpartum period can contribute to long-lasting maternal health and family benefits. It is therefore critical to ensure that birthing persons receive comprehensive care and support during the postpartum period.

These strategies are equity-based interventions.

Developing your postpartum care pathway presents an opportunity to improve equitable health outcomes. For example:

  • When you stratify your quality performance data on postpartum visit completion, you might find lower performance in certain subpopulations. Consider focused outreach strategies or creative ways of reaching these patients to schedule and confirm postpartum visits.
  • Certain serious pregnancy and postpartum complications disproportionately affect patient subpopulations experiencing marginalization (e.g., hypertensive disorders of pregnancy among individuals who identify as Black or African American). Focusing postpartum process improvements on these conditions and subpopulations may close disparity gaps in process measures while meaningfully supporting safer births (e.g., ensuring all patients with hypertensive disorders in pregnancy have early postpartum visits and medical equipment for close blood pressure monitoring).
  • Ensure that your clinic’s postpartum visit scheduling processes do not create unintentional obstacles to accessing contraception (e.g., requiring separate visits for contraceptive placement procedures).
  • Breastfeeding has well-established health benefits for postpartum individuals and their infants. Rates of breastfeeding initiation and continuation may be lower in your practice among certain already marginalized groups. Ensure that proactive lactation education and supplies are provided in these groups.

Good equity-based interventions attend to patient and family needs and are whole-person centered. The postpartum visit lends itself well to administering a comprehensive social needs screening as discussed earlier in this implementation guide. There are specific focus areas and activities you can consider to attend to some common social needs specific to the postpartum population:

  • Postpartum patients and their families may qualify for nutrition support through state and federal programs. Ensure that linkages to these programs are automatically provided for eligible patients.
  • Job protections and income support are key during the postpartum period. Ensure that your patient, if eligible, applies for paid family leave. Train staff on this benefit and ensure they are ready to provide certification.
  • Refer interested and eligible clients to programs that provide holistic postpartum support: home visiting, doula services, and community health worker services.
  • Link to ongoing social needs, including access to transportation, childcare and dyadic services.

This activity relies on similar capabilities as care gap management, utilizing population views and registries to track patients who have delivered and should be scheduled for a postpartum visit. These registries can be utilized to generate outreach lists for appointment schedulers and/or care managers and other care team members who might be tasked with contacting patients. Many EHRs are capable of storing next appointment data that can also be used to generate lists and may link to automated appointment outreach workflows. Patient-facing outreach and engagement technologies can be utilized to deliver appointment reminders and for patient self-scheduling.

Postpartum care planning can be supported by the following technologies: clinical decision support, registries, care gap reports, screening data (BH, social needs, etc.), external referral reports and hospital delivery records. Equity data can be leveraged to identify patients at higher risk for postpartum complications.

Action steps and roles

These action steps were adapted from Postpartum Discharge Transition Change Package. Institute for Healthcare Improvement. 2022

Readiness

 

1. Develop and maintain a set of referral resources and communication pathways.

Suggested team member(s) responsible: Clinic manager and referral coordinator.

Referral and communication pathways between obstetric providers, hospitals, community-based organizations, and state and public health agencies can enhance access to and utilization of services and supports for pregnant and postpartum families.

Making referrals encompasses a spectrum of potential information-giving and supportive behaviors ranging from providing information on specific services to follow-up on service utilization and outcomes and assessment of the quality of referrals.[8] “Cold” and “warm” are often used to describe referral behaviors at two points along this spectrum.[9] A cold referral means providing information to the client about another agency or service, and it is then the client’s responsibility to contact the agency or service.[10] A warm referral involves contacting another agency or service provider on the client’s behalf. This entails calling and making an appointment for the client, providing support to overcome barriers to care, and following up to determine if the appointment has been kept.[11]

Agency policies should indicate the type of referral that is usually most appropriate for each service. Referral type may also depend on the client’s individual circumstances, so providers should use their best judgment.

Establish technology-based partnerships to allow staff at Community Health Centers (CHCs) to access hospital discharge summaries and other relevant inpatient records.

2. Ensure resource lists are available in languages representative of the populations in the health center service area.

Suggested team member(s) responsible: Translation staff.

Review resource lists to ensure availability in preferred languages spoken in the community and, when possible, refer patients to resources and services that are available in their preferred language.

3. Collaborate on the development of a patient-facing discharge summary form.

Suggested team member(s) responsible: Outpatient clinicians, prenatal assistants, hospital staff.

Wherever possible, postpartum appointments should be made prior to discharge from the birth facility for your patients. Discharge summaries can serve as a mechanism for patient and family member engagement and postpartum education. Convene an interdisciplinary team of inpatient and outpatient providers to develop a standard patient-facing discharge summary form that highlights risk factors, complications or diagnoses, necessary follow-up, and health system contact information. Engage people with lived experience in development of patient-facing discharge summary documents to ensure they are clear, understandable and meet patient needs.

4. Educate clinicians and staff on optimizing postpartum care.

Suggested team member(s) responsible: Medical director or designates, clinic manager.

Providing multidisciplinary staff education on optimizing postpartum care, including why and how to screen for life-threatening postpartum complications and how to engage family members and caregivers in discharge education and planning will ensure that any encounter birthing people and family members have with health center staff is an opportunity for prevention or early intervention.

The schedule of postpartum visits encourages the postpartum person to see their provider at three weeks, six weeks and 12 weeks after birth. It is important to remember that postpartum recovery can take approximately six months or longer. By engaging in whole-person care, health centers will engage the postpartum pen and their support network to ensure optimal health outcomes and any identified concerns can be mitigated.

5. Support professional development opportunities on trauma-informed practice and protocols.

Suggested team member(s) responsible: Medical director or designates.

Developing trauma-informed protocols and trainings to address healthcare team member biases enhances quality of care. See resource: Trauma-Informed Population Health Management)

6. Educate clinicians and staff on how to use a standardized discharge summary form.

Suggested team member(s) responsible: Informatics team, EHR IT.

Clinicians and staff ability to effectively review patient data ensures that recommendations made for postpartum care follow-up and community services and resources have been carried out. Health centers will review the mechanisms that are in place to share delivery and discharge information with obstetrician (OB) or midwife and primary care provider (PCP), with consideration for situations where the delivery hospital is not part of the same system as the OB, midwife or PCP.

Ensure clinicians and staff recognize that patients and family may be the primary source of information at the time of visit, if outside records are not available.

Recognition and prevention

 

7. Discuss reproductive desires during prenatal visits and revisit at postpartum visit.

Suggested team member(s) responsible: Providers and clinic staff.

Prenatal visits should include discussion about the birthing person’s reproductive desires, including the desire for and timing of any future pregnancies, and include in postpartum care plans. Offer appropriate resources, including access to a full range of contraceptive options in accordance with safe therapeutic regimens.[12] A birthing person’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.

At the postpartum visit, re-assess previously stated contraception preferences and provide relevant services.

8. Provide anticipatory guidance during pregnancy with the development of a postpartum care plan that addresses the transition to parenthood and well-person care.

Suggested team member(s) responsible: Providers and clinic staff.

Providing anticipatory guidance during prenatal visits optimizes postpartum care and can help to inform the development of a postpartum care plan.4 Co-design postpartum care plans that emphasize patient and family needs and wishes by engaging in open, transparent and empathic communication. Encourage the participation, as appropriate, of the support network in the development of a postpartum care plan.

The American College of Obstetricians and Gynecologists (ACOG) suggests components of the postpartum care plan include care team member names (inclusive of family and friends) and contact information; time, date and location of postpartum visits; infant feeding plan; reproductive life plan; pregnancy complications and follow-up; and anticipatory guidance regarding signs and symptoms of perinatal depression or anxiety. See ACOG Committee Opinion Number 736: Optimizing Postpartum Care. May 2018 for a complete list of suggested components for postpartum plans.

9. Establish a system for scheduling the postpartum care visit and needed immediate specialty care visit or contact (virtual or in-person visit) prior to discharge or within 24 hours of discharge.

Suggested team member(s) responsible: Clinic manager and prenatal assistants.

All postpartum people should have contact with a perinatal care provider within the first three weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. The timing of these visits should be individualized and person-centered. Attempt to schedule the patient with their preferred perinatal care provider who they saw during their pregnancy.

10. For primary care or other non-OB/GYN settings, assess and document if a patient presenting is pregnant or has been pregnant within the past year.

Suggested team ”ember(s) responsible: Providers and clinic staff.

Include the question, "Have you been pregnant in the last year?" in standard intake scripts in EHR, and ensure gender inclusivity in assessment. If they answer yes, assess for need for prenatal or postpartum services. Screen for postpartum risk factors and provide linkage to community services and resources.

Response

 

11. Conduct a comprehensive postpartum visit for at least 30 minutes.

Suggested team member(s) responsible: Providers and clinic staff.

The comprehensive postpartum visit should include a full assessment of physical, social and psychological well-being.4 This is also an opportunity to engage the postpartum patient in discussions around elements of postpartum self-care. Consider scheduling needs to allocate sufficient time in the provider’s schedule.

12. Engage the birthing person’s support team.

Suggested team member(s) responsible: Providers, social workers, clinic staff.

Encourage the presence of a designated support person (e.g., doula, CHW, partner, friend, family member) during all instances of care as desired and particularly when teaching or education occurs. Connect the patient with local birth centers and peer support groups for additional community building and postpartum support, like lactation support or new parenting groups.

Reporting and systems learning

 

13. Develop and systematically utilize a standard comprehensive postpartum visit template.

Suggested team member(s) responsible: EHR IT, clinic manager, providers, clinic staff.

Engage a multidisciplinary team to create and test a standard postpartum visit template. Include patients in the development of the template to ensure the visit components meet their needs.

14. Identify and monitor postpartum quality measures.

Suggested team member(s) responsible: QI and implementation team.

Review all process and outcome data disaggregated by race, ethnicity and language to assess for inequities. Engage clinicians and staff in the review and discussion of the data. Engage leaders in messaging about destigmatizing discussion and identification of inequities to ensure diverse populations have access to respectful, whole-person, quality care. Include patient-facing surveys or other feedback options.

15. Monitor data related to completed postpartum comprehensive visits.

Suggested team member(s) responsible: QI and implementation team.

Disaggregate postpartum comprehensive visits by race and ethnicity, at a minimum, to evaluate disparities in rate of follow-up visit completion and identify strategies for improvement. Consider sharing data on postpartum visit attendance with hospital systems where patients deliver and identify strategies to improve referral and scheduling processes.

Respectful, equitable and supportive care

 

16. Include each pregnant or postpartum person and their identified support network as respected members of and contributors to the multidisciplinary care team.

Suggested team member(s) responsible: Providers and clinic staff.

By facilitating open conversations with the pregnant or postpartum person helps to ensure that concerns are adequately addressed, and there is opportunity to investigate possible causes when patients express that something is "off." Having a member or members of the birthing person’s support network present during these conversations may help to unearth concerns as well as ensure the appropriate support is in place when the patient returns home. During these conversations providers should consider ways in which implicit bias and structural racism may influence response to patient concerns and response to pain.

17. Promote life-long learning among clinicians and staff.

Suggested team member(s) responsible: Leadership team, including medical director and clinic manager

Educate clinicians and staff on providing respectful care by engaging in the lifelong learning of cultural humility, understanding that individuals cannot learn all aspects of any culture, including their own.

Review local resources and benefits available to pregnant and postpartum clients to increase staff and provider knowledge of such services. See more in Key Activity 17: Continue to Develop Referral Relationships and Pathways and Key Activity 18: Strengthening Community Partnerships.

FIGURE 15: POSTPARTUM VISIT TOPIC CHECKLIST


Checklist Domain

Checklist Item

General

  • Date of delivery and delivery report, if available.
  • Weeks postpartum.

Postpartum problem list

Pregnancy conditions requiring follow-up (e.g., anemia, GDM, latent TB, immunization status, depression).

Vitals and physical exam

  • Weight.
  • Blood pressure.
  • Breast exam, if indicated.
  • Abdominal exam/wound check after cesarean.
  • Pelvic exam, if indicated.

Screenings

  • Social determinants of health screening.
  • Depression and anxiety.
  • Tobacco or other substance use.
  • Reproductive desires and contraception initiation.
  • Cervical cancer screening (Pap smear).

Other topics

  • Support systems.
  • Breastfeeding/chest feeding.
  • Sleep and fatigue.
  • Resumption of physical exercise and intercourse.
  • Nutrition.

Referrals, if indicated

  • Lactation support.
  • Nutrition support (Supplemental Nutrition Program for Women, Infants, and Children (WIC)).
  • Dyadic services.
  • Social work.
  • Counseling.

 

Evidence base for this activity

Alliance for Innovation on Maternal Health (AIM) Patient Safety Bundles: Postpartum Discharge Transition.

Endnotes

  1. Improving Postpartum Care https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/maternal-infant-health-care-quality/postpartum-care/index.html 
  2. The California Pregnancy Mortality Surveillance System [Internet]. www.cdph.ca.gov. Available from: https://www.cdph.ca.gov/Programs/CFH/DMCAH/Pages/CA-PMSS.aspx 
  3. Maternal Mental Health [Internet]. Ca.gov. 2019. Available from: https://www.cdph.ca.gov/Programs/CFH/DMCAH/Pages/Communications/Maternal-Mental-Health.aspx 
  4. The American College of Obstetricians and Gynecologists. Optimizing Postpartum Care [Internet]. www.acog.org. 2018. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care 
  5. Interpregnancy Care [Internet]. www.acog.org. Available from: https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/01/interpregnancy-care 
  6. Romano M, Cacciatore A, Giordano R, La Rosa B. Postpartum period: three distinct but continuous phases. J Prenat Med. 2010 Apr;4(2):22-5. PMID: 22439056; PMCID: PMC3279173. 
  7. Pregnancy-Related Mortality — 2018–2020 [Internet]. www.cdph.ca.gov. [cited 2024 Jan 2]. Available from: https://www.cdph.ca.gov/Programs/CFH/DMCAH/Pages/Health-Topics/Pregnancy-Related-Mortality.aspx 
  8. Reproductive Health National Training Center. Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers 
  9. Reproductive Health National Training Center. Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers 
  10. Reproductive Health National Training Center. Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers 
  11. Reproductive Health National Training Center. Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers 
  12. ACOG Committee Opinion Number 736: Optimizing Postpartum Care. May 2018