Primary Care Clinician Perspectives on Barriers to Postpartum Transition to Primary Care

Abstract

Background:

The transition from obstetric to primary care is often suboptimal, particularly for individuals with barriers to accessing care. We aimed to understand experiences of primary care clinicians regarding provision of care and their perceptions of barriers to the transition of care in this critical period.

Methods:

We conducted focus groups with primary care clinicians recruited from diverse, urban health care settings, including an academic medical center, private practice, and federally qualified health centers. Groups were conducted in person or virtually (December 2019 to February 2021) using a semi-structured approach. Data were analyzed using the constant comparative method to identify themes regarding barriers to providing primary care to postpartum individuals.

Results:

The study included 28 primary care clinicians (26 physicians and two advanced practice providers) who participated in eight focus groups. Clinicians identified multiple barriers to the successful transition from obstetric to primary care in the postpartum period. Clinician-based barriers included the lack of a clear hand-off from the obstetric care team and limited capacity to adequately address social determinants of health. Clinician perceptions of patient-based barriers included adverse social determinants of health such as lack of childcare and financial and transportation limitations, challenges addressing ongoing health needs (such as persistence of postpartum medical conditions), and limited health care engagement.

Conclusions:

Our results illustrate multiple complex and interrelated challenges to providing optimal primary care during and after the postpartum period that are related to a fragmented health care system, suboptimal support for complex social needs, and insufficient communication between obstetric and primary care clinicians.

Introduction

The postpartum period, including the transition of care from obstetric to primary care, is an important period for a birthing person and their newborn. However, this transition is often disjointed, resulting in substandard care. An unsuccessful transition between care teams not only creates challenges for clinicians and patients but also contributes to inadequate treatment of conditions such as postpartum depression and pregnancy-related cardiovascular disease.^1–4 The gap in care is particularly burdensome for individuals with chronic health conditions and those who have primary care access barriers (e.g., loss of insurance coverage);⁵ in both cases, these individuals are disproportionately people of color and/or have low income.^6–10 For example, in a group of postpartum individuals, many of whom identified as African American (44%) and recipients of Medicaid (87%), 40% who had experienced antenatal complications did not attend a primary care visit within 12 months of delivery.^9,11 The importance of care in the year after pregnancy is underscored by the fact that 53% of pregnancy-related deaths occurred 7 to 365 days postpartum, with as many as 30% occurring in the late postpartum period (43–365 days postpartum).¹² Coupled with known disparities in postpartum morbidity, there is an urgent need to optimize health care provision in the postpartum period and decrease missed opportunities for preventive care.^13–15

Optimizing the transition from obstetric care to primary care provides a critical opportunity for improving health services provision for postpartum individuals and requires clarifying which clinicians have primary oversight over a postpartum patient’s management. The American College of Obstetricians and Gynecologists (ACOG) recommends early involvement and communication with primary care clinicians to delineate key aspects of care for both groups.¹⁶ However, literature exploring primary care clinicians’ perspectives regarding the transition from obstetric care to primary care is sparse.¹⁷ We aimed to identify primary care challenges in the postpartum period, specifically focusing on clinician- and patient-based determinants of health care in this transitional period. This study was conducted in preparation for a randomized controlled trial of postpartum patient navigation for low-income birthing individuals¹⁸ with the goal of supporting the needs of a patient population who are disproportionately more likely to experience barriers to care.

Methods

This was a qualitative study to evaluate primary care clinician perspectives on clinician and patient challenges in the transition from obstetric to primary care during the postpartum period, which we defined as the first year after birth, regardless of whether patients had a previously established relationship with a primary care team. Participants were recruited from several health care settings throughout Chicago, Illinois, including federally qualified health centers, private practices, and a large academic center. These sites serve a diverse population of patients receiving primary care, including those transitioning from obstetric to primary care. Attending physicians, trainee physicians (residents and fellows), and advanced practice clinicians who care for primary care patients were invited to participate. Recruitment was conducted via direct contact with individuals as well as through the use of a snowball approach with their contacts.

Eight focus groups were conducted as 60–120-minute sessions with two to six clinicians. Groups were purposefully mixed such that trainee physicians, attending physicians, and advanced practice registered nurses participated together. Numbers of individuals in the groups varied based on participant availability. A semi-structured interview guide (Supplementary Appendix) was designed by our multidisciplinary team, including clinicians and research staff who have experience with this patient population. The guide was informed by prior work exploring obstetrician/gynecologist perspectives on patient navigation and barriers to providing health care in the postpartum period.^19,20 Interview questions focused on clinician perspectives regarding their experiences and care processes for the provision of postpartum care among low-income birthing individuals. The questions were designed to elicit conversations about their perceptions of challenges experienced by both clinicians providing care and patients in need of primary care during the transition to primary care after giving birth. The Institutional Review Board at Northwestern University approved the study.

All focus groups (December 2019 to February 2021) were conducted in English, digitally recorded, and professionally transcribed. The first three focus groups were conducted in person by two trained researchers, and the last five groups were conducted by two to three trained researchers using video conference technology during the COVID-19 pandemic (Zoom, version 4). All interviewers identified as women and had experience with qualitative interviewing; one identified as a person of color. Two interviewers were medical students, and one was a non-clinician research staff member with experience working in maternal health research. “Chats” entered by participants during the video conference session were collected and included in the final transcription. Participants received a $50 gift card for their participation. All participants provided written consent for participation in the study.

Transcripts were uploaded to a secure, web-based software application (Dedoose, www.dedoose.com) that allows qualitative data management and analysis by facilitating collaborative data exploration and identification of themes. The constant comparative method was used by a team of two trained investigators to evaluate transcripts; the iterative coding process included theme identification, modification, and refinement using quotation selection methods.^21,22 The analysis began with two researchers reviewing two focus group transcripts separately to identify and define emerging themes and subthemes. After a collective review, a unified codebook was developed to allow for thematic modification and reclassification. The analysts continued to meet regularly to ensure agreement on themes and conceptual nodes across reviewers and to resolve any discrepancies. The final codebook was applied to all transcripts with exemplary quotations. The shared impact of each theme, including whether clinicians perceived the theme as a challenge for themselves or a challenge for patients, was also evaluated. We further examined the barriers identified by participants through the application of the themes to the Social Ecological Model. The Social Ecological Model describes how environmental, societal, institutional, interpersonal, and individual factors impact and influence the actions and health behaviors of individuals.²³ This model was applied to analysis but was not used to develop the interview guide.

Results

Twenty-eight primary care clinicians participated in eight focus groups, including 26 physicians and two advanced practitioners (Table 1) from both family (n = 13) and internal (n = 13) medicine specialties. Their length of practice experience ranged from one year (resident physicians) to more than 25 years, with 60.7% being trainees (residents or fellows). Clinicians identified both clinician-based and patient-based challenges to the successful transition from obstetric care to primary care, with challenges related to social determinants of health overlapping both domains. We present themes and subthemes (italicized) organized by whether they were clinician- or patient-based challenges (Fig. 1).

Table 1.

Study Participants (n = 28)

Gender (n)
Female	25
Practice Type (n)
Ambulatory practice affiliated with an academic hospital or safety-net county hospital	22
Ambulatory practice affiliated with a community hospital	4
Federally qualified health center	1
Private practice	1
Position
Clinician type	n
Physicians
Family medicine resident	9
Internal medicine resident	7
Public health and preventive medicine fellow	1
Family medicine faculty	2
Internal medicine faculty	7
Advanced practice clinicians
Family medicine advanced practice registered nurse	1
Family medicine adult nurse practitioner	1

FIG. 1.

Clinician-identified challenges with transitions to primary care experienced by clinicians and patients during the postpartum period organized using the Social Ecological Model.

Clinician-based challenges

Clinicians shared multiple challenges they experienced with caring for low-income postpartum patients transferring from obstetric to primary care. Themes regarding clinician-based challenges included a lack of hand-off from obstetric to primary care and limited capacity to address social determinants of health (Table 2).

Table 2.

Primary Care Clinician-Based Challenges Relating to Transitioning from Obstetrics to Primary Care

Theme	Subtheme	Exemplary quotation
Lack of hand-off from obstetric to primary care	Lack of communication with obstetrician	The problem is really just like the patients that get transferred to the obstetrics clinic, yeah, it’s a little unclear when the Obstetrician-gynecologist (OB) will hand them back off to us. Like does the OB want to do that 2-week appointment or do they want to do like the 6-week appointment? It’s a little unclear sometimes.
	Poor access to and quality of medical records	That’s assuming they had their obstetric care here within the (hospital’s EMR) system. If they had it somewhere else, like even if they had it with a (academic hospital) associated person whose notes aren’t visible on (EMR) then like you’re outta luck. You just have to trust the patient.
		If they haven’t delivered within our system, it’s usually either the patient pulls up on their phone their portal, and I look at it and I review what I need to have. Or some of the community health centers have the pregnancy cards, with their like blood pressures and fundal heights and other immunizations on it. And those are the two most reliable ways of getting prenatal records. Because if someone tries to fax to our system, they’re gonna fax it to the central scheduling, which is not where it’s going to end up in my continuity clinic in the community. Which means it doesn’t get to me, even if the patients tried.
	Lack of shared language between specialties	The OB notes tend to be, they’re just written in a different style than what we’re used to and their abbreviations are not things that we’re used to either, so it’s difficult to read for us.
		It’s really difficult to parse together what happened like intra-op, peri-op, from like during a C-section or you know basically what, what the heck was going on because there are a lot of acronyms used that like we haven’t even seen, either since med school or ever. And so that makes it difficult.
Limited capacity to address social determinants	Lack of knowledge of social services	So just things like transportation. I don’t really know how it works and just kind of figuring out who can help us with that. We now have a social worker in our office, which is huge for some of those tasks, but I have one patient in particular who needs help with transportation issues because she is in a wheelchair and just had her second baby and so there’s always some issues that I don’t really know how to help her and it’s very inefficient how I do it and frustrating a little bit.
		There’s not any particular resource I refer them to specifically ... I don’t refer them anywhere and I don’t have any like books or handouts or information to give them.
	Difficulty coordinating services	I think resource coordination is one of the things that takes up a lot of time, especially for patients of lower socioeconomic status and I think we’ve sort of alluded to all these things previously like mental health services, Women, Infants, and Children (WIC) programs, the Family and Medical Leave Act (FMLA) paperwork, particular letters that are needed by employers or daycares or other family members or spouses, a variety of things where you know you act as a social worker. We’re doing more sorts of social work kinds of tasks for patients just because the support isn’t always there.
	Insufficient time for visits	Sometimes those visits when we see people because although they’re new to us, they may not be new to like our preceptors or they may not be new to the system. We may only get a 25-minute visit with them, which is very difficult and so if it is specifically for a postpartum visit, that should be a full hour long, considered a new visit for us.
		I think that the extent of what I’ve done has been like and here is the contact information of a social worker that can help you rather than really having time or going into it very much myself.

Lack of handoff from obstetric to primary care

Lack of hand-off from obstetric to primary care arose from the challenges of transitioning a patient’s medical management from one clinician (or clinical team) and specialty to another during the postpartum period. Subthemes included lack of communication with the obstetrician, poor access to and quality of medical records, and lack of shared language between specialties (Table 2).

Lack of communication with the obstetrician was a common challenge. Participants described having “very little crosstalk” with obstetricians during the transition period, leading to confusion regarding which clinicians were managing specific aspects of the patient’s care and incomplete implementation of recommendations from the obstetricians due to inadequate communication. This lack of communication often contributed to an increased burden on the primary care clinician, requiring extensive review of medical records to obtain information that could have been more efficiently communicated by the obstetrician. One participant stated, “We hardly ever get communication, or anything faxed over to us. It’s just kind of an investigation like going through record and try and tease things out.” Another participant said, “I think that one of the biggest barriers is that there really is no handoff. Like I said, I had one note that had like follow this, follow up on this. And it was still very brief. And I wish that it were more detailed. So, I think that’s one of the biggest problems, were like the lack of communication, that bridge to care.”

Poor access to and quality of medical records further challenges this handoff. This subtheme explores the difficulties many primary care clinicians face in accessing medical records concerning pregnancy and delivery events, especially those from outside of their institutions. This subtheme also conveys the experience of clinicians receiving low-quality records, such as missing records for specific events (e.g., birth hospitalization) or records requiring patient input for clarification. One participant explained, “If the medical records are actually in the system … . we can review the results. If it’s a private¹⁸ or someone who does not use (electronic medical record [EMR] name), it’s very difficult to look or see any results other than maybe lab tests or what happened once they were hospitalized.”

Even when records were available, clinicians spoke about the specialty differences in documentation, including writing style and usage of obstetric jargon or acronyms. This contributed to lack of shared language between specialties. A participant described, “When I was … reading the OBGYN notes, I didn’t even understand them because of the acronyms. Like we just don’t use those acronyms in internal medicine. And so, when I’m reading them, it’s like kind of like a foreign language to me.”

With inadequate inter-clinician communication and medical record access, clinicians felt they often had a suboptimal awareness of pregnancy events such as antepartum hospitalizations, maternal delivery complications, and neonatal birth outcomes. As a result, clinicians described not knowing their patient had been pregnant or not being aware of their pregnancy-related issues and having to rely on the patient’s recall to provide clinical information. As explained by one participant:

“I think… the couple of times that I’ve had a postpartum patient, I actually found out about the birth because… the EMR like pinged me that they had been hospitalized. And then I like look into the hospitalization, I’m like oh wow, I guess she just gave birth. But like I don’t hear from anybody besides that. So, I never received an actual handoff.”

Limited capacity to address social needs

The second theme was clinicians’ limited capacity to address social needs. Clinicians acknowledged that many of their low-income patients have needs beyond medical concerns that are equally important to their health.

Even when social needs were recognized, clinicians revealed a lack of knowledge of social services available to their patients, experienced difficulty coordinating services, and struggled with insufficient time for visits (Table 2). First, participants discussed instances where they were aware of patients’ social needs but had a lack of knowledge of social services to assist their patients; this experience did not appear to differ based on level of clinician experience. One participant described not being aware of the services available at their institution and using valuable clinic time to research options, such as accessing breastfeeding supplies: “… I don’t know even what we have, so I usually just give a phone number that I find. I just Google it along with them, but I don’t yeah, I don’t know. Probably figuring out the, oh my gosh, the breast pump, takes me the most time.”

When services are available and known, difficulty coordinating social services was identified as another challenge. Several clinicians described logistical barriers to connecting patients to social services, such as one clinician describing the complexity of linking patients with resources:

“It’s the access of care, and a lot of social issues. So, helping to navigate that and helping them [patients] to connect them with resources and figure out what they need … .[I]t’s part of the job, but it’s also not. But I think that’s the biggest thing. Is, is trying to find resources and trying to connect them to it.”

Some clinicians discussed how gaining personal knowledge of the social services, having designated social workers, or developing programming within their hospital system ameliorated this challenge. One participant discussed that experience: “So now that we do have a social worker, that already knows the resources and has access to them, I’m sure that will be much easier.” Clinicians also expressed difficulty coordinating social services, coordinating future appointments, and providing patient education due to language barriers and inadequate language-concordant services. For example, one participant stated: “Just even writing an after-visit summary for your patients if they don’t speak English … it’s hard to have moms, to like give them resources if you don’t have it like, have it in their language in their clinic.”

Lastly, clinicians’ abilities to address a patient’s social needs were impacted by insufficient time for visits. With time constraints on each health care visit, any time dedicated to non-clinical tasks reduces time to address the patients’ medical needs. One participant expressed, “As health care providers, we don’t really have that much time to really focus on like what types of social needs they may need. Although we should, but sometimes our, our visits are so quick.” Another participant said, “We may only get a 25-minute visit with them, which is very difficult and so if it is specifically for like a postpartum visit, like that should be a full like hour long, considered like a new visit for us.

Patient-based challenges reported by clinicians

Participants also described the challenges they perceived to be faced by their low-income postpartum patient population. Themes of clinician-reported patient challenges included adverse social determinants of health, challenges addressing ongoing health needs, and limited health care engagement (Table 3).

Table 3.

Clinician-Reported Patient-Based Challenges Relating to Transitioning from Obstetrics to Primary Care

Theme	Subtheme	Exemplary quotation
Adverse social determinant of health	Lack of childcare	I think it’s childcare in so many different ways … so the parent can work, so they can take care of other children, they can come to appointments for themselves. And even just support at home, I think there’s often like great, like supportive families. But I think sometimes it’s hard to find somebody, so the mom can just have a break for herself.
	Financial and transportation limitations	She (previous patient) really was in need of some type of financial assistance. Unfortunately, with COVID and everything, she was unable to work, and put her kids in school. She was living out of a hotel, and the hotel was given to her by a local church. And so, she was having difficulty in finding housing, as well as transportation, and just providing basic needs and food for her children.
	Low health literacy	[I]f they have a lower health literacy they don’t really realize they had preeclampsia or they don’t know that term or they don’t know it’s important to tell people.
Challenges addressing ongoing health needs	Persistence of postpartum medical conditions	I think seeing women with gestational diabetes has been something that’s really a significantly difficult problem to have and how they navigate through what their blood sugar does in their you know prenatal period, around delivery and then definitely how to transition postpartum is something I see a lot of women struggle with.
		In the postpartum period because they felt like that was an issue that was only gonna be during pregnancy and they’re frustrated with the fact that they’re continuing to have high blood pressure or diabetes even after pregnancy, not wanting to be on the medication.
	Unaddressed contraception needs	I think it’s really challenging that we don’t offer Nexplanons or intrauterine device (IUD)s in the hospital. Really the only thing we offer are oral contraceptive pills, and I think we can do Depo-Provera but aside from that there aren’t really any good you know long long-term contraceptives that we can offer at discharge. So for some patients when they follow-up they’re either not following up if they’re from the Federally Qualified Health Center (FQHC) sometimes and then subsequently not able to get that long-term birth control, so it really depends on their insurance picture and I think it’s a disadvantage to all of our patients but particularly those who come from lower socioeconomic status.
	Lack of breastfeeding support and education	I think that as a family doctor we receive training in how to coach for breastfeeding both on the side of the infant and the mother, but I think that that can be a really big challenge for a lot of women and I think that women easily get discouraged.
Limited health care engagement	Unclear rationale for primary care transition	I think a lot of the barriers that typically we face with patients like navigating a change, like a transition between something … About getting hooked in with primary care. Because a lot of young women use their OBGYNs as their primary care doctors, and don’t necessarily have a designated primary care doctor. Which is you know, great if the OBGYN knows that and is like doing labs, but if they don’t know that, they’re not frequently checking things.
		I find that women often don’t know who to ask. Where they might think like alright, am I supposed to ask my OB, am I supposed to ask my pediatrician, am I supposed to ask my internist?
	De-prioritization of self	I think that the issue that’s come up for me the most often is like people struggling with postpartum activity, diet, weight gain, things like that. I’ve seen several patients who have been frustrated by the fact that they’ve put on weight and haven’t been able to lose it, especially in terms of time management with a new child at home and trying to figure out how to balance their lifestyle with this additional human to take care of has been like a major focus a lot of the visit.
		If you have a newborn … you don’t really have the patience or the time to deal with scheduling challenges. Like there’s only you know one appointment on a particular Tuesday that doesn’t fit with your child’s napping schedule.

Adverse social determinants of health

The adverse social determinants of health theme uncovered what clinicians identified as patients’ social and structural barriers to transitioning from obstetric care to primary care. Subthemes included lack of childcare, financial and transportation limitations, and low health literacy (Table 3).

Several clinicians discussed how their patients were not able to attend appointments due to the lack of childcare after giving birth. For example, one participant described, “My patients have other children at home, and especially now, with COVID, we’re limiting how many people can come. So, I think it’s a challenge to find childcare for the ones that need to stay home.” Clinicians also spoke about their patients having financial and transportation limitations, making it difficult for patients to meet their basic needs and attend necessary appointments. Participants verbalized the impact of transportation limitations on low-income patients who have had high-risk pregnancies, who commonly have many postpartum appointments. One clinician reported “the transportation issue … for the frequent visits” was a major challenge to the postpartum care transition. COVID-19 restrictions exacerbated these barriers due to changes in office visit policies and transportation resources.

Participants also identified low health literacy as a major patient barrier. Clinicians addressed the lack of access to health education and the challenges their patients faced with understanding clinical concepts. Summarized by one participant, “I think some of the challenges are low health literacy as far as knowledge about pregnancy, medications that they should and should not be using, you know access to care and access to education.”

Challenges addressing ongoing health needs

The theme challenges addressing ongoing health needs describes barriers patients experience when managing various health needs during the transition between obstetric and primary care. Subthemes included persistence of postpartum medical conditions, unaddressed contraception needs, and lack of breastfeeding support and education (Table 3).

Persistence of postpartum medical conditions needs was observed to be a barrier by many. Clinicians reported many patients believed health conditions developed during pregnancy will resolve completely after giving birth. Clinicians observed patients’ “shock” or frustration when instructed to continue monitoring and treating complications and chronic diseases in the postpartum period; this sub-theme was particularly salient with regard to hypertension surveillance. One participant discussed how a newly postpartum patient developed complications from a pregnancy-related condition: “I even had a patient who you know had eclampsia. She just forgot all about it. It was like a month or two later and her blood pressure was 170/100. Not good.”

Clinicians also noted patient struggles with unaddressed contraception needs due to delayed access and hesitancy of initiation during the postpartum period. A clinician described a patient who had trouble accessing contraception due to cost and limitations with follow-up: “Postpartum long-acting reversible contraceptives, like IUDs and Nexplanons, having those available immediately postpartum would really be quite helpful for many of our patients who struggle with follow-up and … the financial costs.”

Several clinicians observed patients’ experienced a lack of breastfeeding support and education in the postpartum transition period within primary care. This subtheme highlights the numerous difficulties patients experience when initiating and maintaining breastfeeding and acquiring the resources to be successful. One clinician described this sentiment: “I think an obstacle that my patients face is around nursing and breastfeeding and support about that. It’s really hard being … a first-time mother and having to figure that out and then on top of it too also trying to figure out how to get the breast pump too.” Another clinician stated: “A lack of just understanding of … what are the next steps, do I have to breastfeed or are there other options? Is it evil to do formula? Like that kind of thing.”

Limited health care engagement

Finally, the clinician-reported patient-based barrier limited health care engagement describes patients having less involvement with health care during the postpartum period. Subthemes included unclear rationale for primary care transition and de-prioritization of self (Table 3).

Unclear rationale for primary care transition encompassed the idea that postpartum patients are commonly unaware they should transition their health care to primary care clinicians or do not understand why this transition is needed. As a result, clinicians reported this transfer of care as confusing for patients. One participant commented, “I think that people sort of get unclear about who their provider is now, whether they can still go to their primary care doctor or not.” Other participants described scenarios of patients lost to follow-up for several years because of the assumption that their health needs could be managed by their obstetrician, which resulted in missing critical screenings a primary care clinician would provide. For example, one participant from a large academic center said, “I speak to some patients that have lots of resources but don’t understand the division in roles or scope of practice of the OB versus the primary care person. They think it’s perfectly fine just to yearly keep going back to the OB who doesn’t screen for you know basic stuff.”

Clinicians discussed how patients who are transitioning from obstetric to primary care frequently shift their goals and priorities, often placing the well-being of their child(ren) above their own. New responsibilities, evolving health needs, and time constraints, in addition to varied and complex systemic barriers such as lack of paid family leave, can lead to a de-prioritization of self, as described by this participant: “You know how mental health plays a role in, it is really interesting because I think a lot of new moms don’t put a priority on their own health and so that kind of, it keeps them from making that extra effort to overcome the time barrier and the commute barriers to get to the clinic.” Similar sentiments were expressed regarding the theme of weight loss, with clinicians identifying that postpartum patients had little capacity to engage in lifestyle change in the context of competing family and social priorities.

Discussion

A key step in supporting the long-term health of postpartum individuals is the successful transition from obstetric care to primary care. As such, understanding the challenges faced by clinicians and patients during that transition is paramount. The current analysis revealed challenges for clinicians and patients, many of which related to social determinants of health and mapped to multiple levels within the Social Ecological Model. The Social Ecological Model is a framework that describes how environmental, societal (including access), institutional, interpersonal, and individual factors influence the actions and health behaviors of individuals (Fig. 1).²³ Our work identified complex, multi-level barriers experienced both by patients and clinicians, as perceived by clinicians, ranging from environmental- and societal-level barriers (e.g., childcare, transportation) to institutional-level barriers (e.g., insufficient time for appointments) to interpersonal barriers (e.g., lack of shared language, lack of communication with obstetrician) to individual-level barriers (e.g., low health literacy, de-prioritization of self). As noted in Figure 1, many barriers cross multiple levels, thus illustrating the importance of designing multi-level interventions to address this gap.

Our data are consistent with data from other specialties. In one study from Canada, similar challenges faced by clinicians and patients were identified as barriers to the pediatric-to-adult health care transition such as lack of knowledge of social services, difficulty coordinating social services, lack of communal support, and unclear rationale for primary care transition.²⁴ Another study centered around postpartum patients with HIV, a majority of whom were non-Hispanic Black, unemployed, and had other children at home, showed that only 57.1% attended a primary care appointment within 6 months of delivery. Patients in this study identified that challenges included competing responsibilities for time and transportation access, which mirror our findings.²⁵ In one study with newly immigrated women with postpartum depression, both the clinicians and patients had an unclear understanding of the timing to transition from the obstetrician to the primary care clinician, which parallels our themes regarding unclear rationale for primary care transition and persistence of ongoing postpartum medical conditions.⁷

Social needs are often barriers to health care for resource-limited families.^26–28 When patients lack fundamental social needs, such as childcare, transportation, and basic health literacy, it impacts both patients’ ability to access care and the clinician’s ability to provide care. The overlap in clinician and patient challenges regarding social needs was notable in this study; not only did complex social needs limit patients’ access to care, but when care was accessed, the complexity of social determinants of health challenged clinicians’ ability to meet all care needs. In addition, clinicians expressed role strain, emphasizing the importance of knowing and addressing the patients’ social needs but not having the capacity or time to act in a social worker role. As a result, many clinicians experienced significant barriers to providing thorough and appropriate health care for postpartum patients because of the intersections of social determinants of health with postpartum clinical care.

Current literature discusses challenges obstetricians face in the postpartum period and poses potential solutions to enhance care.^19,29 One such potential intervention is patient navigation, or the use of trained team members, to support care coordination and address adverse social determinants of postpartum health. Relatively little literature addresses this topic from the perspective of primary care clinicians. Our prior work suggests primary care clinicians would be receptive to patient navigation to streamline the obstetric-to-primary care transition, enhance visit effectiveness, create personalized postpartum care, and provide patient- and clinician-focused education.³⁰ Other literature outside of the perinatal context supports the use of an electronic discharge summary,³¹ although more work is needed to define the essential information to support patient care and continuity.³² Our findings suggest that direct clinician-to-clinician communication could overcome existing deficits in pregnancy-event communications, although clinicians also acknowledged that such communication extends beyond typical capacity. Our previous work and other studies suggest maternal care coordinators and patient navigators can support these aspects of care coordination^{19,30,33–35} including easing role strain and reducing work duplication.

The fragmentation between obstetric and primary care in the postpartum period is a multi-level issue that requires interventions beyond the inclusion of additional health care team members in the transition process. Although some primary care clinicians lack knowledge of the importance of pregnancy events, even clinicians who employ strategies to optimize long-term cardiovascular health for patients with adverse pregnancy outcomes, for example, cannot do so if patients’ diagnoses have not been clearly communicated. Solutions to improve physician education and systems of care include clinician education about pregnancy and postpartum adverse health events, technology-based patient-facing interventions that support postpartum health (such as virtual reminders and mobile health applications), the creation of transition clinics or postpartum medical homes with a family medicine or multispecialty focus, the development of patient-centered, low-health-literacy education tools, facilitated hand-offs from obstetric to primary care, and the use of EMR-based communication and education tools for clinicians.^15,36

Strengths of this study include its innovative focus on postpartum care for low-income people from the perspective of primary care clinicians. However, we acknowledge limitations to our work. This study was limited to clinicians working in the Chicago area. Furthermore, all challenges discussed originated from the clinicians’ perspective, as patients were not participants in this analysis; further work regarding patient perspectives is needed. In addition, several participants were trainee physicians who may be less familiar with accessing and utilizing resources than more experienced clinicians. However, as trainee physicians provide essential care to many underserved patients, their perspectives remain valuable. Also, it was not evident from our analyses that more experienced clinicians were substantively more comfortable with addressing social needs.

With the charge to decrease health disparities and improve care in the postpartum period, this study provides insights from primary care clinicians on the barriers encountered by clinicians and patients when moving from obstetric to primary care. The Social Ecological Model provides a framework for understanding and contextualizing the multilevel challenges of this period and hypothesizing corresponding multilevel solutions to bridge gaps. Such process improvements may include optimizing the patient hand-off between clinicians, enhancing education regarding the rationale for care, and addressing social needs via the use of other team members such as community health workers/patient navigators. The development and evaluation of such interventions should be prioritized to improve the quality of care for postpartum individuals through this transition.

Authors’ Contributions

K.D.D.: Conceptualization (equal); investigation—data collection (equal); formal analysis (equal); writing—original draft (equal); writing—review and editing (equal); visualization (lead). K.H.: Investigation—data collection (equal); formal analysis (equal); writing—review and editing (equal); visualization (supporting). A.F.: Investigation—data collection (equal); formal analysis (equal); writing—review and editing (equal); visualization (supporting). B.M.D.: Investigation—formal analysis (equal); writing—review and editing (equal). B.R.W.: Writing—review and editing (equal); formal analysis (equal); project administration (lead). J.F.: Methodology (lead); writing—review and editing (equal); supervision (supporting). W.A.G.: Writing—review and editing (equal); formal analysis (equal); M.A.K.: Writing—review and editing (equal); formal analysis (equal); L.M.Y.: Conceptualization (equal); writing—original draft (supporting); formal analysis (equal); methodology (lead); writing—review and editing (equal); funding acquisition (lead); supervision (lead).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development R01 HD098178. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.