Pregnant People Guide

Timeliness of prenatal and postpartum care is important because it can improve the health outcomes and well-being of both pregnant people and infants and their families. Prenatal care is the healthcare that someone receives during pregnancy, and postpartum care is the healthcare that someone receives for the 12 months after giving birth. Perinatal is a term often used to describe this time during and after birth. For the purposes of this guide, “pregnant people” refers to pregnant and postpartum individuals up to 12 months postpartum, which aligns with extended coverage for Medi-Cal eligibility up to 365 days postpartum as well as Department of Health Care Services, Birthing Care Pathway Initiative, Enhanced Care Management Birth Equity Population of Focus and transitional care services for pregnant and postpartum individuals up to 12 months postpartum.

According to the Centers for Disease Control (CDC), timely and adequate prenatal and postpartum care can prevent more than 80% of all pregnancy-related deaths, as well as reduce the risks of complications, infections and low birth weight.^[1] Such adverse health outcomes are largely preventable, but are exacerbated by variation in quality healthcare, underlying chronic conditions, structural racism and implicit bias.^[2] These factors disproportionately impact people from racial and ethnic minority groups.

Racial and ethnic disparities in maternal health outcomes persist and increase as women age, as reported by the CDC. As of 2021, non-Hispanic white pregnant people died from pregnancy-related causes at a rate of 26.6 per 100,000 live births, while Black pregnant people died at a rate of 69.9 per 100,000 live births. American Indian and Alaska Native pregnant people also have higher risk of maternal mortality than white pregnant people, according to the CDC.^[3] A study of maternal mortality in California found that provider-dependent factors, such as delayed response to clinical warning signs, were the most common contributor to maternal deaths.^[4] This is particularly disturbing given the racial disparities in providers ignoring or refusing requests for help from women of color. Prenatal and postpartum care can also provide essential information and support to pregnant people and their families, such as nutrition, breastfeeding, family planning and emotional well-being. By ensuring that people have access to equitable prenatal and postpartum care, we can improve the health outcomes and quality of life for pregnant people and infants.

The work to ensure that pregnant people receive all recommended care is a continuous effort and we still have much to learn. This document uses existing evidence, bright spots and examples from the field to offer practical guidance on improving care for pregnant people, keeping in mind that it will be adapted to your practice’s unique context.

Key activities in this guide are organized into three categories:

• Foundational activities: Activities that all practices should implement as part of their prenatal and postpartum care protocol.
• Going deeper activities: More advanced activities that build off of the foundational activities and that help ensure your practice can achieve equitable improvement in your prenatal and postpartum care.
• On the horizon activities: Additional activities, including ideas worthy of testing that include the latest ideas and thinking on prenatal and postpartum care.

Where to Start: While we recommend following the sequence of the key activities in this guide, the activities can be used individually or adapted to fit your practice’s priorities.

Trying it Out then Making it Habit: For each activity, we provide guidance on how to plan, try, and implement the activity along with links to other resources, technology considerations and examples. Consider trying different versions of the action steps and roles with a smaller group before fully implementing at your practice.

Maintaining Progress: Ongoing review and continual improvement is important for your practice to maintain your progress in population health management and help you stay nimble in adapting to changing patient demographics, new clinical best practices, new payment policies, workforce changes and other changes at your practice. For many activities we have provided tips for periodically reviewing and making improvements to key workflows even after initially implementing the change.

If you implement the Foundational Activities in this guide, your practice should be able to achieve the following objectives:

1. Engage patients served by your practice to validate any of your proposed process improvements and to propose alternative methods to improve quality in your focus area.
2. Analyze core and supplemental quality measures to identify improvement opportunities for achieving timely access to prenatal and postpartum care for attributed patients. Ensure that any analyses of your quality measures are stratified by key patient demographic characteristics to identify disparities in quality performance for specific attention.
3. Use care gap reports or registries to identify all prenatal and postpartum patients due for care.
4. Develop a process for screening pregnant and postpartum people for depression using evidence-based tools.
5. Integrate behavioral health follow-up services as needed (e.g., for positive depression screens).
6. Create an outreach protocol to reach and engage all attributed patients due for care.
7. Create a health-related social needs screening process that informs patient treatment plans.
8. Assess current capabilities and develop a plan for ongoing improvement in data utilization, care team workflows and efficiency that includes sustainable health information technology (HIT) strategies and continuous staff training on technology.

This guide also includes sections on measurement, equity, social health, behavioral health integration and an appendix including helpful tools and resources. We have included information about California Medi-Cal covered benefits and services that were up-to-date at the time of publishing, but benefits and billing guidance change over time. Nothing in this guide should be considered formal guidance, and anyone using this guide should check with the appropriate authorities on benefits and billing guidance.

This is a living document and will change based on continued learning on this topic and may include additional activities, examples, resources and sections in the future.

Additional Information can be found in Getting Started: Introduction to the PHMI Implementation Guides, and Aligning PHM Principles with Community Health Clinic Strategic Planning.

Improving the health of a population impacts everyone in a practice. Critical roles needed to engage in the work outlined in this guide and support practice change include:

• Quality improvement leadership, like a director of quality improvement (QI), to support cultural changes.
• Coaches or practice facilitators who are partnered with teams to help identify areas for improvement and support change through change management strategies.

PHMI’s approach emphasizes four foundational areas for PHM: a reimagined care team, empanelment, the business case, and data quality and reporting (DQ&R). These areas provide the foundation for the sustainable delivery of person-centered, population-based care and improving outcomes for a population of focus; see Building the Foundations for Population Health Management: Talking Points for Engagement for a concise overview and talking points for why these areas are important.

In addition, practices can reference specific Building the Foundations key activities to go deeper into specific challenges related to advancing equity, social health, behavioral health integration, and access and outreach for their population of focus:

Equity

• Business Case Guide: Advancing Equity Through Your Business Case
• Empanelment Guide: Advancing Equity Through Empanelment
• Data Quality and Report Guide: Advancing Equity Through Data Quality and Reporting
• Care Teams and Access Guide: Advancing Equity Through Care Teams and Workforce
• In this guide: Key Activity 5: Use a Systematic Approach to Decrease Inequities within the Population of Focus and Key Activity 20: Strengthen a Culture of Equity

Social Health

• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure
• In this guide: Key Activity 9: Use Social Needs Screening to Inform Patient Treatment Plans

Behavioral Health

• People with Behavioral Health Conditions Guide
• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure and Key Activity 2: Identify gaps in staffing and decide how to address them
• In this guide: Key Activity 10: Implement Behavioral Health Screening, Including Postpartum Depression

Access and Outreach

• Empanelment Guide: Going Deeper: Connecting Empanelment with Patient-Centered Access
• Care Teams and Workforce Guide: Key Activity 2: Identify Gaps in Staffing and Decide How to Address Them
• In this guide: Key Activity 7: Proactively Reach Out to Patients Due for Care