Primary Care after Pregnancy Survey: Patient Preferences, Health Concerns, and Anticipated Barriers

Abstract

Despite recommendations for ongoing care after pregnancy, many individuals do not see a primary care clinician within the first postpartum year, missing a critical window to engage reproductive-age individuals in primary care. We administered an anonymous, cross-sectional, trilingual survey at a large urban safety-net hospital to assess postpartum individuals’ preferences, health concerns, and anticipated barriers to primary care during the year after pregnancy. While 90% of respondents preferred a visit within one year, most individuals – including those with complicated pregnancies – did not recall a primary care recommendation from their pregnancy care team. Respondents reported a variety of primary care-amenable health concerns, and many social and logistical barriers to care. Preference for virtual care increased if self-monitoring tools were hypothetically available, indicating virtual visits may improve primary care access.

Introduction

The first postpartum year is an important time for engaging reproductive-age women in primary care. Primary care in the year after delivery can include both diagnosis and treatment of new medical problems, which are reported by a majority of postpartum individuals,(Declercq et al., 2014) as well as preventive (i.e., “well woman”) care, which can be informed by recent pregnancy history.(Murray Horwitz et al., 2021) For instance, many common pregnancy complications are associated with future heart disease; for all individuals with one such adverse pregnancy outcome (APO; defined as a hypertensive disorder of pregnancy, gestational diabetes, intra-uterine growth restriction, small-for-gestational age baby, or preterm delivery), comprehensive heart disease risk screening and counseling is recommended within the first postpartum year.(American College of Obstetricians and Gynecologists, 2018, 2019) In addition, inter-pregnancy care reduces the odds of recurrent pregnancy complications,(Gregory et al., 2022) and may be able to prevent up to 80% of pregnancy-related deaths.(Trost et al., 2022) Unfortunately, only 50–60% of postpartum individuals – including those with recent APOs – have a primary care visit in the year after pregnancy.(Walker et al., 2015) A better understanding of patient perspectives on postpartum primary care is needed to inform more successful care transitions. Therefore, we conducted a survey at our region’s largest safety-net hospital to assess postpartum individuals’ preferences, health concerns, and anticipated barriers to primary care in the year after pregnancy.

Methods

After receiving IRB approval (H-41819), we collected data through an anonymous cross-sectional 22-item trilingual survey between April and July 2022. All data collection occurred after state-based expansion of postpartum Medicaid benefits from 60 days to 12 months post partum.

The survey was developed in English, then translated into Haitian Creole and Spanish by certified translators, and pilot-tested in each language prior to data collection. We collected additional feedback from the first 2 respondents in each language, to inform additional improvements to the survey language and format (see Online Resources 1–3 for final survey forms in 3 languages).

Inclusion criteria were: delivery at our hospital within the past 1–4 months, age ≥18 years, and ability to read or speak English, Spanish, or Haitian Creole. To capture the racial, ethnic, and linguistic diversity of our obstetric population, we conducted multi-lingual, multi-modal, and multi-stage sampling. All recruitment and data collection were conducted in the (prospective) participant’s preferred language. Potentially eligible individuals were identified through the electronic medical record (EMR), then contacted through the EMR before being approached by study staff at scheduled postpartum or well child appointments. Individuals who missed appointments received additional EMR and telephone outreach. Those who were eligible and consented to the study were able to complete the survey in-person, by telephone, or online. In the latter part of the recruitment period, we shifted the recruitment focus away from the Obstetric clinic and toward other settings (i.e., the Pediatric clinic, and virtual outreach for patients who missed their obstetric appointments) in order to capture the perspectives of patients not attending scheduled postpartum visits.

All data were self-reported. Respondents were asked how they identified in terms of race (Black, White, Asian American, Pacific Islander/Native Hawaiian, American Indian/Alaskan Native, Other, and Unknown) and ethnicity (Latino, Not Latino, Other, and Unknown), with options to select more than 1 or to decline to answer. Clinical history (e.g., parity, complications during their most recent pregnancy) was assessed using a sequence of multi-choice followed by free-text responses (see Online Resources 1–3 for survey instrument in 3 languages).

Preferred and recommended timing of primary care follow-up were assessed via multi-choice options (As soon as possible, 3–6 months after delivery, 6–12 months after delivery, >1 year after delivery, Never/only if needed, or Not sure/Don’t know). We also asked respondents if they preferred in-person or virtual care, first in general, and then when presented with a hypothetical scenario in which they had access to a home blood pressure cuff and weight scale. We took several measures to avoid confusion between primary care and postpartum care. First, we introduced the concept of primary care with questions about respondents’ experiences with health care before they were pregnant. Second, we provided the following definition of primary care:

“Your primary care doctor is someone you see regularly or someone you can go to if you have problems. In addition, they usually do things to help you to prevent future health problems, for example by helping you stay up to date on vaccinations and pap smears.”

Finally, prior to asking about timing of primary care follow-up, we reminded respondents that pregnancy-based care continues through 6 weeks post partum:

“In this first year after pregnancy, when would you like to see a primary care doctor? Remember that someone in the pregnancy care team will see you for the first 6 weeks after pregnancy.”

We asked respondents to rate the importance of 10 specific health concerns and 9 specific potential barriers to care, selected based on theory and evidence, (American College of Obstetricians and Gynecologists, 2018; Declercq et al., 2014; Murray Horwitz et al., 2020; Ruderman et al., 2021; Wouk et al., 2020) using 5-point Likert scales (1=Not at all important, 2=A little important, 3=Neutral, 4=Important, 5=Very important). Their responses were dichotomized for analysis, where ≥4 was coded as an affirming response and <4 as non-prioritized.

Subgroup analyses were stratified by parity (≥2/1), APOs (any/none of: hypertensive disorders of pregnancy, gestational diabetes, intra-uterine growth restriction or small-for-gestational age baby, preterm delivery), race (Black or other), ethnicity (Latina or other), and language of survey completion (English or other). We also conducted a subgroup analysis based on location of study enrollment (Obstetrics clinic or other), since presence in the Obstetrics clinic may be a proxy for access to and engagement in health care.

In this descriptive study, target sample size (n=120) was based on half the hospital’s monthly obstetric volume. We conducted exploratory tests for statistical significance using a p-value threshold of 0.05. As our study was designed not to test a hypothesis, but to describe phenomena and generate hypotheses for future work, we did not adjust for multiple testing.

Data were collected in REDCap between April and July 2022, and analyzed in RStudio between July and December 2022.

Results

The study team contacted 256 eligible individuals, of whom 120 (47%) completed the survey. Detailed recruitment methods and results are published elsewhere.(Murray Horwitz, Saradjha Brédy, et al., 2023) Mean age was 31.3 years (standard deviation, SD, 5.4), and all respondents were between 1–4 months post partum (median 2.0, mean 1.9 (SD 0.9); Table 1). A majority self-identified as Black (64%) or Latina (26%). Eighteen percent completed the survey in Haitian Creole and 10% in Spanish. Nearly 2 in 3 were multiparous, and over half reported having ≥1 APO during their most recent pregnancy. Compared with all patients delivering at our hospital,(Murray Horwitz, Prifti, et al., 2023) the survey sample included a greater proportion of individuals identifying as Black or Latina (83% versus 72%), having Haitian Creole as their primary language (18% versus 10%), or reporting a recent APO (53% versus 36%).

Table 1.

Sample demographics and clinical characteristics (n=120)

Characteristic	n (%) unless otherwise specified
Age (years), mean (SD) and median [min, max]	31.3 (5.4)
	31 [21, 42]
Postpartum timing (months) of survey completion, mean (SD) and median [min, max]	1.9 (0.9)
	2 [1,4]
Race
Black	77 (64.2)
White	16 (13.3)
Asian	3 (2.5)
Other/Unknown/Missing	24 (20.0)
Ethnicity
Latina	31 (25.8)
Not Latina	79 (65.8)
Other/Unknown/Missing	10 (8.3)
Primary language
English	76 (63.3)
Haitian Creole	22 (18.3)
Spanish	12 (10.0)
Missing	10 (8.3)
Multiparous	75 (62.5)
Pre-pregnancy medical problems, any	54 (45.0)
Pregnancy or postpartum medical problems
Any	104 (86.7)
Adverse pregnancy outcome (APO)a	64 (53.3)
Method/location of study enrollment
Obstetrics clinic	66 (55.0)
Pediatrics clinic	17 (14.2)
MyChart/mail	31 (25.8)
Flyer	4 (3.3)
Other	2 (1.7)

^aAPOs: hypertensive disorders of pregnancy, gestational diabetes, IUGR or small-for-gestational age baby, and preterm delivery

In the overall sample, half of respondents desired a primary care visit within 3 months postpartum and 90% within 1 year (Figure 1a). However, most were unable to recall a recommendation for postpartum primary care from their pregnancy care team. In subgroup analyses, respondents with APOs more often preferred earlier primary care (e.g., 59% versus 39% within 3 months after pregnancy), however this difference was not statistically significant (p=0.14). Recollections of primary care recommendations were similar between those with and without APOs (Figure 1a). Other subgroup analyses yielded results similar to the overall sample, without significant differences by race, ethnicity, language, or location of study enrollment (see Online Resource 4 for detailed results).

Figure 1.

a. Desired versus recommended timing of first primary care visit after delivery, among 1–4 month postpartum individuals (n=120)

a) ^a

b. Desired versus recommended timing of first primary care visit after delivery, among 1–4 month postpartum individuals with a recent APO (n=64)

b) ^a

Abbreviation: APO, adverse pregnancy outcome

^a When asked what they remembered being recommended by their pregnancy care team

Respondents’ health concerns for the year after pregnancy were individualized but generally amenable to primary care (Figure 2a). When asked about anticipated barriers to health care after pregnancy, social and logistical issues predominated (Figure 2b). In subgroup analyses, few differences emerged, with the most notable differences occurring between language groups. When compared with respondents who completed the survey in English, those who completed it in Spanish or Haitian Creole more often identified “financial problems” and “staying healthy” as health concerns (23% vs 7%, p=0.02, and 34% vs 16%, p=0.04, respectively) and anticipated “cannot afford care” as a barrier to care (32% vs 3%, p<0.01). Multiparous respondents were also more likely to anticipate cost as a barrier to care when compared with their primiparous counterparts (19% vs 4%), although this difference was not statistically significant (p=0.05). All other responses about health concerns and barriers to care were similar by parity, APO status, race, ethnicity, language, and location of study enrollment (see Online Resources 5–6 for detailed results).

Figure 2.

a. Health concerns for the year after pregnancy, among 1–4 month postpartum individuals (n=120)

b. Anticipated barriers to health care in the year after pregnancy, among 1–4 month postpartum individuals (n=120)

When asked about preferences for primary care delivery, 83% favored in-person over virtual visits. Preference for virtual care increased from 9% to 34% with access to a home blood pressure cuff and weight scale. These results were consistent across subgroups.

Discussion

We conducted a cross-sectional trilingual survey in a postpartum sample with a high degree of racial, ethnic, and linguistic diversity. Despite widespread interest in primary care, many respondents were unaware of follow-up recommendations. In addition, most anticipated logistical and financial barriers to primary care after pregnancy. Anticipated financial barriers to care after pregnancy were particularly common among respondents who completed the survey in a language other than English.

Given the importance of postpartum and inter-pregnancy care for optimizing health outcomes and reducing chronic disease risks,(American College of Obstetricians and Gynecologists, 2018) our findings indicate that postpartum patients – especially those with recent APOs, and those with a language preference other than English – may benefit from increased transition counseling, as well as social and logistical support, to access primary care after pregnancy. Patient-centered health care innovations – such as dyadic care models (i.e., integrated maternal and infant care) (Caskey et al., 2021; Frayne & Bennett, n.d.; Handler et al., 2021; Rosener et al., 2016) and patient navigation programs (i.e., systematic individualized needs assessment and connection to resources)(Yee et al., 2017) – have the potential to reduce important barriers to postpartum primary care, as identified in our study. For some postpartum patients, virtual visits with self-monitoring tools may be an acceptable means to improve primary care access.

This single-center study, based in an academic safety-net health care setting in a Medicaid expansion state, may not be generalizable to other settings. In addition, all measures are self-reported and therefore subject to ascertainment, recall, or social desirability bias. Also, it is possible that our survey language did not adequately differentiate between the concepts of primary care and postpartum care. Finally, multiple-choice questions may have constrained participant responses. Further research in other populations, supplemented by electronic medical record or other measured clinical data, and employing qualitative approaches, is needed to validate and expand upon our findings.

Significance.

What is already known on the subject?

The postpartum year is a time of increased health risks, when individuals – especially those with recent pregnancy complications – are likely to benefit from ongoing care. In minoritized and structurally marginalized communities, low rates of postpartum follow-up compound high rates of pregnancy complications, perpetuating health inequities.

What this study adds?

In a racially, ethnically, and linguistically diverse and predominantly low-income sample, most postpartum individuals were unaware of recommendations to connect with primary care in the year after pregnancy, and most anticipated logistical and financial barriers to care. Increased care transition counseling, and logistical and financial support, are needed to help postpartum individuals access ongoing care.

Availability of Data and Material

Surveys are included as supplemental material. De-identified data can be made available upon reasonable request to the corresponding author.

Code Availability

Code can be made available upon reasonable request to the corresponding author.