Mapping the Postpartum Experience Through Obstetric Patient Navigation for Low-Income Individuals

Abstract

Background:

Although the postpartum period is an opportunity to address long-term health, fragmented care systems, inadequate attention to social needs, and a lack of structured transition to primary care threaten patient wellbeing, particularly for low-income individuals. Postpartum patient navigation is an emerging innovation to address these disparities.

Methods:

This mixed-methods analysis uses data from the first year of an ongoing randomized controlled trial to understand the needs of low-income postpartum individuals through 1 year of patient navigation. We designed standardized logs for navigators to record their services, tracking mode, content, intensity, and target of interactions. Navigators also completed semistructured interviews every 3 months regarding relationships with patients and care teams, care system gaps, and navigation process. Log data were categorized, quantified, and mapped temporally through 1 year postpartum. Qualitative data were analyzed using the constant comparative method.

Results:

Log data from 50 participants who received navigation revealed the most frequent needs related to health care access (45.4%), health and wellness (18.2%), patient-navigator relationship building (14.8%), parenting (13.6%), and social determinants of health (8.0%). Navigation activities included supporting physical and mental recovery, accomplishing health goals, connecting patients to primary and specialty care, preparing for health system utilization beyond navigation, and referring individuals to community resources. Participant needs fluctuated, yielding a dynamic timeline of the first postpartum year.

Conclusion:

Postpartum needs evolved throughout the year, requiring support from various teams. Navigation beyond the typical postpartum care window may be useful in mitigating health system barriers, and tracking patient needs may be useful in optimizing postpartum care.

Clinical Trial Registration:

Registered April 19, 2019, enrollment beginning January 21, 2020, NCT03922334, https://clinicaltrials.gov/ct2/show/NCT03922334

Introduction

Despite being a prime opportunity to address long-term health,^1–4 the postpartum period is characterized by dramatic disparities in health care access and outcomes.^5–8 Financial barriers and fragmented health systems prevent individuals from accessing optimal care, while social needs compromise one's ability to dedicate time to both postpartum health and transitions of care.^9–11 Given that nearly 30% of birthing individuals overall and nearly 40% of individuals with Medicaid do not attend a postpartum visit¹² and many do not successfully transition to primary care,¹³ health systems are in need of mechanisms to improve health during this time.

Improving postpartum care through the first 12 weeks, commonly called the “fourth trimester,” has been addressed in many programs and initiatives.^14,15 Yet, less is known about longer-term postpartum needs. As new federal policy allows for states to expand postpartum Medicaid coverage to 1 year after delivery, a better understanding of the experiences of postpartum individuals through this period could provide evidence of patient needs through the duration of expanded coverage.¹⁶

Patient navigation, a patient-centered, individualized intervention, often provided by a trained layperson,¹⁷ has been implemented in a variety of specialties to identify and address barriers to care within and outside the ambulatory setting.^18–21 The comprehensive nature of navigation is a unique lens to holistically view the postpartum period within and beyond the health care system. Although multiple studies have sought to identify patient needs in the initial postpartum period,^2,22,23 few have done so for extended periods, and none through the lens of navigation. This study aimed to identify the needs and experiences of low-income individuals through 1 year postpartum in the context of a patient navigation program.

Materials and Methods

This is a mixed-methods planned analysis of data from an ongoing randomized controlled trial (RCT) of patient navigation for low-income birthing individuals, defined as those enrolled in Medicaid during antenatal care. The RCT, Navigating New Motherhood 2 (NNM2), implemented following a pilot observational study (Navigating New Motherhood) of postpartum patient navigation,²⁴ seeks to enroll 400 publicly insured pregnant or postpartum individuals to receive either 1 year of postpartum patient navigation or usual care.²⁵ This analysis examines qualitative and navigator activity data from the first 50 participants enrolled and randomized to navigation. This data collection occurred over the first 18 months of the trial. The primary outcome of the ongoing trial is a composite measure of participant health; no clinical outcome or comparative data are presented herein.

The study took place within an obstetric and gynecologic (ob/gyn) ambulatory setting at an urban academic medical center. Participants in NNM2 randomized to navigation received individualized support from a patient navigator. Navigators (two for majority of study and one substitute for temporary coverage of a leave) were lay individuals extensively trained in postpartum patient navigation.¹⁷ All navigators identified as women, and the two primary navigators were bilingual (English and Spanish) and identified as Hispanic/Latinx. Navigators performed support activities throughout the first year postpartum, including checking in with participants, responding to social or health care needs as needed, and meeting with participants during or after care appointments.²⁶ To track navigation activities, we designed a standardized log in which navigators documented interactions with participants, care teams, and community organizations (Fig. 1A).

FIG. 1.

(A) Empty entry illustrating format of standardized navigator log. Navigators tracked all interactions with patients and care team members, including mode of communication and issue addressed. Navigators also recorded notes to narrate tasks and interactions. (B) Sample entry with coding and quantification of patient need categories. Notes were coded, quantified, and entered into REDCap for data management. REDCap, Research Electronic Data Capture.

Navigator notes in logs allowed for quantification of navigator tasks by topic addressed (example in Fig. 1B). Navigators also recorded the care team members with whom they interacted, if applicable, as well as the mode of communication used (in-person, text, phone, or email). Thus, logs quantified mode, topic, and intensity (number of tasks required to address a patient need) of communications. Data were entered into Research Electronic Data Capture (REDCap), a secure web application for managing data,²⁷ and analyzed quantitatively. We stratified log entries by participant and postpartum week and subsequently analyzed the care team member with whom an interaction occurred, if pertinent, the mode of communication, and topic of navigator task.

Topics of navigator tasks were grouped into five a priori participant needs categories generated to organize our analysis: health care access, social determinants of health, health and wellness, parenting, and relationship building between patient and navigator (definitions located in Table 1). Although health care access is considered a social determinant of health,²⁸ for this analysis, it was considered separately from other social determinants, given the central role of navigators in promoting health care access. Across 50 participants, we calculated the average number of navigator tasks addressing each need category per postpartum month.

Table 1.

Overarching Participant Need Categories and Corresponding Topic Areas for Navigator Log Analysis

Participant need category	Topic areas and definitions
Health Care Access	Appointments and Access (scheduling and rescheduling appointments, appointment reminders, connecting patients to care team members, connecting patients to primary care) Insurance (facilitating patient coverage, ensuring clinic services were covered, connecting uninsured patients to care) Transportation (scheduling transportation services to attend appointments, assisting with parking logistics or payment at site of care)
Health and Wellness	Healthy Living (counseling on weight loss, counseling on blood glucose readings, facilitation of routine care e.g., dental services) Mood and Mental Health (connecting patients to mental health resources, providing psychosocial support) Recovery/Physical (providing information regarding contraception, discussing blood pressure monitoring, addressing patient concerns regarding nonpostpartum health issues)
Relationship Building	Relationship Building (pre-scheduled check-ins with participants, non-health related discussions to build participant-navigator bond)
Parenting	Breastfeeding/Infant Feeding (connecting patients to breastfeeding resources, connecting patients to WIC for formula, addressing individuals' breastfeeding issues) Citizenship/Legal Aid (assisting patients with obtaining babies' birth certificates and social security cards, facilitating insurance coverage for new baby) Parenting, Childcare, Family (connecting patients to a pediatrician, facilitating car seat acquisition, addressing issues with childcare, providing support and resources for adjustment to parenting, providing support and resources for domestic issues with family members)
Social Determinants of Health	Housing, Utilities, Food (connecting patients to community resources) Work, Education, Finances (connecting patients to community resources, providing assistance finding or returning to employment and/or school)

WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Study protocol specified navigators were to check in with participants at least biweekly for postpartum months 1–6, and at least monthly for postpartum months 6–13. All additional interactions were a direct result of patient need. Thus, the number of navigator tasks in an area correlated to the level of participant need, and this frequency indicates patterns of needs over the postpartum year. We further assessed navigator interactions with care team members per postpartum month for all participants. As a clear pattern of health care and social needs emerged after 50 participants, investigators agreed findings had achieved saturation for this mixed-methods analysis.

We also conducted five semistructured interviews with each navigator every 3 months for a total of 10 interviews, pre-planned as a component of study protocol, using appropriate reporting standards.²⁹ One substitute navigator, who was hired for temporary coverage of one navigator's leave, participated in a single interview. Interviews lasted approximately 1 hour and focused on navigator experiences, relationships with participants and care teams, participant needs, and gaps in the health care system. Interviews were audio-recorded, transcribed, and coded using the constant comparative method using Dedoose (www.dedoose.com), a data management and analysis application for qualitative research. The first set of interviews yielded an initial codebook, which was refined through an iterative team-based process. While codebook creation included navigators, all coding was completed independently by investigators. To maximize reliability, a codebook was finalized, agreed upon by all investigators, and applied to subsequent transcripts.

Log and interview data were integrated to yield a comprehensive overview of the needs of the first postpartum year for low-income individuals. We developed a “heat map” demonstrating the intensity of each patient need category (and corresponding topics of navigator tasks, representing the types of activities for each category) across time, as well as a dynamic timeline of the first postpartum year. The NNM2 study was approved by the appropriate institutional review board. Investigators received signed consent forms for all participants and verbal consent from navigators at the start of each interview.

Results

Most of the 50 participants in this analysis self-identified as non-Hispanic Black (56%) or Hispanic/Latinx (42%). Over half disclosed a household income of <$25,000 per year (64%) and nearly three-quarters (74%) reported education less than a bachelor's degree (Table 2).

Table 2.

Demographic Information for Navigated Participants (n = 50)

Demographic	Value	Frequency	% of patients
Race	American Indian/Alaskan Native	0	0
	Asian	1	2
	Native Hawaiian or Other Pacific Islander	1	2
	Black	28	56
	White	8	16
	None of the above	18	36
Hispanic/Latinx	Yes	21	42
	No	29	58
Household income	Under $10,000	16	32
	$10,000–$25,000	16	32
	$25,001–$50,000	6	12
	$50,001–$100,000	2	4
	Don't know	9	18
	No answer	1	2
Education level	Some high school or less	3	6
	High school graduate	16	32
	Associate's degree or some college	18	36
	College graduate	8	16
	Graduate degree or greater	2	4
	Other	3	6
Relationship status	Single/unpartnered	20	40
	Living with a partner	21	42
	Married	8	16
	Other	1	2
Current work situation	Unemployed	25	50
	Part time or temporary work	8	16
	Full time work	10	20
	Student	4	8
	Other	3	6
Total pregnancies (including navigated)	1	9	18
	2	16	32
	3 or more	25	50

Demographic characteristics for n = 50 patients randomized to navigation. Frequencies in race category sum to above 50 due to ability to check multiple identifiers.

Navigator actions to address participant needs

Navigator workload, as recorded in logs, was highest in the first 2 months postpartum (averaging 22.2 ± 14.4 and 21.6 ± 11.5 tasks per participant, respectively). Workload tapered throughout the year and rose during month 13 as navigators prepared participants to exit the study (Fig. 2).

FIG. 2.

Heat map displaying the intensity of navigator tasks across participant need categories for all 50 participants per month postpartum. Darker red indicates a higher number of navigator tasks, as quantified through navigator logs.

Table 1 presents the topics of navigation activities related to each participant need category. For example, the participant need category “health care access” consisted of topics such as “appointments and access,” “insurance,” and “transportation.” “Health and wellness,” task topics were related to “healthy living,” “mood and mental health,” and “recovery/physical.” “Relationship building” focused on navigator check-ins with participants throughout the postpartum year. These conversations centered on participants' nonhealth-related personal events, strengthening the participant-navigator bond. Navigators assisted participants with “parenting” by addressing topics such as “breastfeeding/infant feeding,” “citizenship/legal aid,” and “parenting, childcare, family.” Finally, the category “social determinants of health” consisted of navigator work addressing topics “housing, utilities, food,” and “work, education, finances.”

The largest proportion of navigators' time (45.4%) was spent assisting participants with health care access, including accessing postpartum, primary, specialty, and mental health care. In descending order, the patient needs that consumed the next largest proportions of navigators' time were as follows: health and wellness (18.2%), patient-navigator relationship building (14.8%), parenting (13.6%), and social determinants of health (8.0%). Given navigation's goal of addressing social needs, it may be expected for the social determinants need category to consume more of navigators' time. Our analysis, however, separates social barriers to accessing care (e.g., transportation, which is included in health care access) and psychosocial support (e.g., mood and mental health, included in health and wellness) from the overall social determinants of health category.

Over the course of the year, the relative proportions of navigator tasks dedicated to these categories fluctuated, demonstrating the time-varying nature of different postpartum needs (Fig. 2).

Navigator interactions with care team members

Navigators' logs demonstrated that, throughout the year, they interacted with a variety of care team members, including ob/gyn physicians, nurses, social workers, clinic administration, and primary care team members. As navigators were considered members of the patient care team, they had access to participant protected health information and were able to directly contact other care team members as needed to discuss participant health care. Although navigators logged a high number of interactions with all ob/gyn team members during the first two postpartum months, the highest number of care team interactions (n = 69) occurred during the second postpartum month with ob/gyn physicians (Table 3). Interactions with ob/gyn clinicians tapered throughout the year as participants transitioned out of obstetric care.

Table 3.

Total Navigator Interactions with Care Team Members per Month Postpartum

Care team member	Postpartum month
	1	2	3	4	5	6	7	8	9	10	11	12	13
MD (OBGYN)	54	69	11	20	13	3	7	4	4	7	2	0	1
Nurse (OBGYN)	43	8	6	2	6	2	0	2	1	0	1	1	0
Social worker	40	27	10	2	6	4	0	4	2	2	8	1	0
OB clinic admin	27	24	6	10	9	3	6	3	2	1	4	0	2
PCP team	1	15	10	11	9	6	2	14	10	12	6	20	16

Data are the total number of navigator interactions with various care team members per month postpartum.

OB, obstetric; OBGYN, obstetrics/gynecology; PCP, primary care provider.

To facilitate transitions between postpartum and primary care, navigators maintained interactions with participants' primary care teams throughout the year. Although some participants' longitudinal health care involved specialists (e.g. endocrinologists), this was a less frequent occurrence, and data from navigator interactions with specialty teams are not presented herein.

Navigator interaction with primary care team members was infrequent during the first month postpartum but increased during three periods: postpartum months 2–4, 8–10, and 12–13. As noted above, this last period was when participants prepared to exit the program and, with navigators' assistance, finalized their care transition.

Mapping the postpartum year

Qualitative analysis of navigator interviews yielded themes such as physical and mental recovery, accomplishing goals, connection to ongoing care, preparing for health system utilization beyond navigation, and referrals to community resources (Table 4).

Table 4.

Quotations from Navigator Interviews and Log Notes Demonstrating Patient Needs

Patient need	Navigator quotation
Physical and mental recovery
Recovery from birth	“Needs to talk to doctor about a cut and leakage/discharge on her c-section incision”a
Short-term postpartum clinical care	“When we do the postpartum care plan, there's a section where there's this long list of things that you may want to talk to your provider about…it's important to read through every single one of those…”b
Postpartum depression care/screening	“I checked in…and she's like, ‘I'm not feeling well, I'm feeling really anxious…’ I told her that because she was postpartum…[was it] okay for me to reach out to the social worker?…She got an appointment with [mental health services]”b
Accomplishing goals
Breastfeeding initiation/maintenance	“…patients are already given a lot of support…but having someone that works more closely with the patient [is beneficial]. Like, the doctor's telling you you need a breast pump, but is the doctor helping you fill out the prescription form?”b
Contraception uptake	“a patient reached out to me…like… ‘Do I get birth control? I'm really interested. I wanna get this Nexplanon, but maybe I can just get the pills.’”b
Weight loss	“When we met for her appointment, we put weight loss was a challenge she was facing…we talked about the importance of losing weight …then when I met with her she was like, ‘Oh by the way…I haven't had McDonalds in a while… My mom actually brought it up and [said] ‘You haven't gone to McDonalds' and she's like ‘Yeah, I had a deep conversation with my patient navigator, and I guess it…just put some things into perspective.’”b
Connection to ongoing care
Receipt of preventative care	“Reminded about pending pap smear the doctor has recommended her to get”c
Retention in care	“Some patients would not have…established primary care…if they didn't have a patient navigator…One of my patients who recently exited [said], ‘Thanks for helping me connect with the doctor because I didn't know how to do it and I would have been like, ‘Forget it.’’”b
Communication of obstetric events to primary care	“One of my patients transitioned over to primary care…she did have GDM when she was pregnant…and when I reached out to the primary care clinic, I felt like there was so much disconnect in what they knew and what they didn't know.”b
Preparing for health system utilization beyond navigation
Fostering patient activation	“Helped prepare her questions to provider so she has a thorough [clinical] examination”d
Promoting self-efficacy	“I tell them, ‘No you've got this. You know how to make your own appointments, you already have this set up, if you need assistance with or you have a concern, like a health issue, you already have a primary care doctor.’ Just letting them know that even though I'm not gonna be with them [after the program ends], I know they can do it on their own and giving them confidence.”b
Developing health system knowledge	“Many patients don't know that primary care is important…like ‘Oh so I can set up with a doctor, and I can just always go back to them?’ Like yeah! Even if you don't need them. So that's always a good feeling, just to know that they're learning more about how to navigate the health care system.”b
Health education	“One of [my patients was] concerned about bleeding…she got an IUD [and]…was experiencing bleeding…she was really worried that something was wrong…it was so much more than I think she expected.”b
Anticipatory guidance for future care	“I remind them before they exit, ‘These are still the appointments you need to follow up with…Do you need assistance scheduling the appointment?’ And I also make sure they're…aware of how to schedule appointments…anywhere…Always reminding them of checking on their insurance and making sure they still have coverage.”b
Referrals to community resources	“Patient texted me to ask if I knew of any programs that helped pay utility bills. Provided patient information on CEDAe program, called CEDA program…provided information to ComED assistance programs and encouraged patient to call…”f

^a Quotation excerpted from navigator log at postpartum week 10.

^b Quotation excerpted from navigator interview.

^c Quotation excerpted from navigator log at postpartum week 16.

^d Quotation excerpted from navigator log at postpartum week 8.

^e The CEDA provides financial assistance to low-income individuals in the county.

^f Quotation excerpted from navigator log at postpartum week 25.

CEDA, Community and Economic Development Association; ComED, Commonwealth Edison Company; GDM, gestational diabetes mellitus; IUD, intrauterine device.

Navigators reported that the initial period of the postpartum year, from birth to month 5, focused on physical and mental recovery from birth. One navigator reported a participant “always had questions about what was normal” in recovery. To anticipate and address such needs, before the 6-week postpartum visit, navigators and participants completed a Postpartum Care Plan that systematically identified concerns to raise with clinicians, ensuring clinical encounters addressed pertinent recovery issues. Navigator efforts to address physical and mental recovery also included monitoring for postpartum depression and anxiety. According to one navigator, one patient claimed to be doing well mentally, but “deep down I knew something was wrong…she reached out…told me what was going on and…I was able to connect her to the providers.”

Later in the postpartum period, although with some overlap to the recovery period, navigators addressed participant goals, including breastfeeding, contraception, and weight loss (Table 4). Navigators noted they facilitated acquisition of breast pumps, weighed contraception options with participants, and helped achieve weight loss goals through motivational interviewing and connection to healthy eating resources. Navigators reported that achieving these goals, particularly linkage to contraception, extended beyond the traditional postpartum care period, recounting, “it's kind of surprising to me. I'm like, ‘Oh wow, you're like four to five months out.’”

The middle portion of the postpartum year was dedicated to connecting participants to ongoing primary and specialty care (Table 4). Navigators completed a Primary Care Transition plan with participants, which they sent to the primary care team, to facilitate “a smooth transition where [providers were] very appreciative of the information.” Occasionally, navigators would accompany participants at primary care appointments, serving as advocates by participating in appointments. Navigators noted, however, that fragmented health care institutions challenged this transition when primary care was established outside the hospital system in which the study was situated.

In the final portion of the postpartum year, navigators related how they prepared participants for health system usage beyond the navigation period by fostering patient activation and promoting self-efficacy (Table 4). Emphasizing the importance of engagement in longitudinal care was a primary feature. One navigator reported “letting [patients] know, ‘You can ask questions…please keep asking until you understand.’” Throughout the year, navigators gradually handed off responsibilities to build participant capabilities. Toward the end of the study, navigators emphasized, “You know how to make an appointment…check your insurance…contact transportation…”

Alongside these time-dependent activities, navigators described how they consistently connected participants to community resources (Table 4), which ameliorated stress caused by high social needs and thus supported care access. When participants expressed a social need or barrier to care, navigators provided them with community resources or reached out to organizations directly: “I…dedicate[ed] almost an entire day finding [housing resources] in her area…We both made a bunch of calls.” Navigators connected participants to resources to assist with finances, childcare, furniture acquisition, and diaper provision, among other areas. Navigators consistently cited unstable housing as one of the biggest barriers to care as it causes “so much stress that they're not…focusing on their health.”

Navigator interactions with care team members helped identify shifts in participant engagement with teams throughout the postpartum year (Fig. 3). In the first half of the year, obstetric and psychosocial support teams within the obstetric clinic provided most health care for participants as they focused on physical and mental recovery and accomplishing postpartum goals. Navigators worked collaboratively with obstetric providers as “…they provide [us] information… [saying] ‘This is how you can help her…’ It makes me feel integrated and part of the team.”

FIG. 3.

Graphic depicting optimized care for the first postpartum year, including evolving postpartum care initiatives and pertinent care teams over the course of the year.

Beginning around the second postpartum month, primary care teams became more prevalent. Navigators worked in tandem with these teams, especially for patients with chronic conditions, “finding out what things my patient should reach out for, who's gonna manage her diabetes…[The primary care provider] reached back out and was like, ‘She should really go to endocrinology for that…she has a lot of needs so it's good that you're here.’” Shifts in care teams were dynamic and varied depending on ease of transition and individual needs.

Integration of data from qualitative interviews with navigator logs resulted in a timeline of needs and relevant care teams during the first postpartum year for low-income individuals, as presented in Figure 3.

Discussion

Understanding the needs and experiences of low-income individuals through patient navigation elucidated a comprehensive picture of the postpartum year. Immediately following birth, navigation focused on participant needs related to physical and mental recovery, such as screening for postpartum depression. Focus then shifted toward goals such as breastfeeding, contraception, and weight loss. Next, participants required assistance transitioning to long-term care, although this transition was often challenged by fragmented care systems and lack of communication between care teams.³⁰ Throughout the year, navigators attempted to build participant self-efficacy and enhance activation to increase effective long-term health systems usage.³¹ We also identified a persistent high level of social needs well past the fourth trimester.

These data yielded a heat map depicting the intensity of postpartum health and social needs experienced by this population over time (Fig. 2), as well as an integrated model of care needs through 1 year postpartum (Fig. 3). While the final rise in patient need level we observed in month 13 likely reflects study activities, a high level of need persisted throughout all 12 postpartum months, particularly in accessing care. Identifying shifts in patient needs may help various teams optimize postpartum care for individuals, ensuring appropriate needs are addressed beyond the traditional 6-week postpartum window.

Results in the context of what is known

These data corroborate findings from prior recommendations focused on optimizing postpartum care.² Our study also described barriers to a smooth transition to longitudinal care (insurance challenges, fragmented care systems with limited communication between teams), which have been elucidated in prior studies.^12,29,32,33 These prior studies on postpartum needs, however, have lacked temporality and scale, and thus have been insufficient to model a fully optimized postpartum care experience.³⁴

Tracking the activities of patient navigators also revealed the care teams that were most engaged throughout periods of the postpartum year. Unsurprisingly, obstetric teams and psychosocial support teams provided most care for the first portion of the year. After the postpartum visit, patient care transitioned to primary care teams, with transition time varying for each individual. Prior literature has uncovered low rates of transition from postpartum to primary care, particularly for low-income and minority individuals.^14,32 Navigators' high workload facilitating this transition for participants corroborates these findings and highlights a need for further interventions to streamline this transition.³⁵

Clinical and research implications

Understanding longer-term patient needs and experiences may help care teams engage patients beyond the early postpartum period and ensure long-term health systems usage, although additional research is needed for more targeted interventions. Our findings also support the rationale for states to expand Medicaid coverage through 1 year postpartum, as we identified many needs well beyond the federally mandated coverage window of 60 days postpartum.

Further work is needed to understand health outcomes as a result of this postpartum patient navigation intervention, which we expect will be generated from the primary trial. The needs of postpartum individuals could be further elucidated by studies that stratify patients across various characteristics to better understand how needs vary between demographic groups. Such research could be integral in developing systems to provide optimized postpartum care for specific populations.

Strengths and limitations

Patient navigation, a multilevel intervention operating within and outside the care system, offers a unique lens for comprehensively viewing the postpartum period. The trusting relationship navigators revealed they developed with patients over time also allows for more vulnerable expression, and thus a more realistic and complex picture, of patient needs than is typically gathered at care visits or from administrative or survey data.¹⁹ Navigation provides additional context and depth for identifying the temporality and intensity of postpartum needs. This study also mapped a longer follow-up period than other studies of postpartum needs.^2,14,36,37

A limitation of this study is its sample size, although detailed logs and interviews demonstrated adequate information power upon analysis.³⁸ This population of patients, who resided within one city and visited one academic medical center, may not be generalizable. Barriers to care and the navigator-identified participant needs in this study, however, are similar to those found in prior work focused on low-income patients.^39–43 Relationship building, a participant need identified in this study, may not be a core need of the postpartum period for individuals outside a navigation program. However, it may serve as a proxy for the benefit of relationship maintenance and nonhealth-focused interactions between postpartum individuals and care team members.

Furthermore, navigators' individual styles in recording tasks (particularly with more complex tasks) and interacting with participants and care teams also may have varied, although we believe such variation reflects real-world implementation of patient navigation.²⁶ Variation was also minimized through standardized training, standardized logs, and regular check-ins with navigators.¹⁷

Conclusions

As an individualized, comprehensive approach to optimizing health care, patient navigation was a unique lens to identify the needs of low-income individuals through 1 year postpartum. This analysis of navigator activities during the postpartum year highlights the wide spectrum of new parents' needs that are unaddressed by traditional postpartum care, including not only physical recovery but also acclimation to parenthood, access to a fragmented health care system, and connection to community resources. This understanding of postpartum health and social needs calls attention to the importance of engagement that extends beyond the typical postpartum period.

Data Sharing

Due to the sensitive nature of qualitative data, which may reveal participant identity, individual data cannot be shared. Additional data are unavailable as the trial is ongoing. Qualified researchers who meet criteria for access to qualitative data may contact the authors and receive contact information for the institutional review board.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development R01 HD098178 (PI: L.M.Y.).