Abstract
Objective
To study postpartum follow-up rates, as well as counseling opportunities, among Queen Emma Clinic patients before and after the implementation of the Queen Emma Clinic Postpartum Follow-up Initiative.
Methods
This was a retrospective chart review of 221 women who received prenatal care at the Queen Emma Clinic and gave birth between April 2006 and April 2008. In April 2007 the postpartum initiative was started. The primary outcome was the number of postpartum follow-up visits. Secondary outcomes included breastfeeding, contraceptive use, depression screening and referral, follow-up screening for patients with gestational diabetes and subsequent pregnancy.
Results
Postpartum follow-up rates were signifificantly higher after the Postpartum Follow-up Initiative (86.1% compared with 71.7%, P=.012). When comparing timing of follow-up, the first postpartum visit occurred approximately one week sooner in the post intervention group (2.96 weeks compared with 3.73 weeks, P= 0.38) with no difference in timing of the second postpartum visit (6.62 weeks compared with 6.42 weeks, P=.72). In the post intervention group there were more patients breastfeeding at the first postpartum visit (28.7% compared with 16%, P=.015), as well as the second postpartum visit (28.7% compared with 12.3%, P= 0.01). There were also more women using contraception in the post intervention group (84.3% compared with 71.7%, P=.009). There was no difference in depression screening or referral, follow-up screening for gestational diabetes, or timing of subsequent pregnancies.
Conclusion
The Postpartum Follow-Up Initiative improved postpartum follow-up rates, as well as breastfeeding, and contraceptive use.
Introduction
The postpartum time period lasts from delivery of the placenta until six to eight weeks after delivery. While the postpartum period is uncomplicated for most women, approximately 3% of women who have a vaginal delivery and 9% of women who have a cesarean section will experience a complication that either requires prolonged hospitalization after delivery or readmission to the hospital.1 Outpatient postpartum visits allow clinicians to address problems with bowel and bladder function, pain, and vaginal bleeding. They also allow clinicians to assess breastfeeding, postpartum depression, infant bonding, resumption of sexual intercourse, and contraception.2
While there is no specific research that has established the optimal timing for outpatient postpartum visits, early postpartum care by health care providers has been associated with reduced maternal and infant morbidity3 and improved patient satisfaction.4 However, women can experience several obstacles to complying with postpartum care. Transportation to and from a medical facility can be challenging. Childcare, particularly if a woman is caring for other children, can also present an obstacle. Thus, in many settings, compliance with postpartum visits is suboptimal.
This study compares postpartum follow-up rates before and after initiation of the Postpartum Follow-Up Initiative. This program was instituted at Queen Emma Clinics (QEC) in Honolulu, Hawai‘i on April 1, 2007 to increase compliance with postpartum care. The Postpartum Follow-Up Initiative was comprised of two main interventions. The first involved providing women with the time and date of their first postpartum appointment while the patient was still in the hospital. At this time, women received an appointment card as well as a congratulatory letter. If the entire in-patient postpartum course took place over the weekend when clinic staff was not available to schedule the first postpartum visit, the patient received a phone call or letter detailing the time and date of the first postpartum appointment. The second intervention took place at the patient's first and second postpartum visit. At the first postpartum visit, a picture was taken of the patient and her baby. This was then presented to the patient in a photo album with the hospital's logo when she returned for her second postpartum visit.
Methods
A retrospective chart review was performed at QEC in Honolulu, Hawai‘i. QEC is located at Queens Medical Center, a non-profit, Joint Commission on Accreditation of Healthcare Organizations accredited acute care health facility which includes a labor and delivery suite. Ambulatory care services are provided at QEC by residents and University of Hawai‘i faculty physicians. QEC serves a diverse population which includes both the insured and uninsured as well as underserved residents of Oahu who may have difficulty accessing health care due to socioeconomic factors and immigration status that precludes state sponsored healthcare coverage.
Patients were included in this study if they received prenatal care at QEC and gave birth between April 2006 and April 2008. Patients were divided into two groups, those who delivered before April 1, 2007, prior to implementation of the postpartum initiative, and those who delivered after April 1, 2007, after the initiative had been started. Exclusion criteria included patients with no prenatal care or those who received prenatal care outside of QEC.
Data was collected on demographics and the patient's obstetric course including age, insurance status, gravidity and parity, and mode of delivery. The primary outcome was the number of postpartum follow-up visits. Secondary outcomes included the timing of postpartum visits, breastfeeding, contraceptive use, depression screening and referral, postpartum glucose tolerance testing for patients with gestational diabetes, and the timing of subsequent pregnancy. The different contraceptives were grouped in order of effectiveness with sterilization and intrauterine devices falling in the “most effective” category, oral contraceptive pills, the contraceptive patch, the contraceptive ring, and depo medroxyprogesterone acetate falling in the “effective” category, and no method and barrier methods falling in the “least effective” category. The single rod contraceptive implant was not available during the time period studied.
Descriptive statistics were generated to compare demographic information using t-tests for continuous variables and chi-square tests for categorical variables. The primary outcome, postpartum follow-up, was analyzed using a chi square test. Secondary outcomes were also analyzed using chi square tests. Multiple logistic regression and model building were performed to control for potential confounders.
Sample size calculations were based on an expected difference of 25% in postpartum follow-up rates before and after the initiative. To address this hypothesis, a total of 70 subjects in each arm of the study were needed to have 80 % power with a significance level of p=0.05. This study was approved by the Queens Medical Center Institutional Review Board.
Results
A total of 221 women met inclusion criteria, 106 in the pre-intervention group and 115 in the post-intervention group. The demographics for the study population are presented in Table 1. The pre-intervention and post-intervention groups were similar in terms of age, insurance status, gravidity and parity. Participants in both groups had a mean age of 26 years and the majority of patients both before and after the intervention had some form of health insurance.
Table 1.
Demographics of the Study Population
| Pre-intervention % (n) | Post-intervention % (n) | p value | |
| Age | 26.5 (106) | 26.1 (115) | 0.570 |
| Gravidity | 0.193 | ||
| 1 | 26.4 % (28) | 28.7% (33) | |
| 2–3 | 45.3% (48) | 33.9% (39) | |
| 4 or more | 28.3 % (30) | 37.4% (43) | |
| Parity | 0.104 | ||
| 1 | 39.7% (41) | 34.8% (40) | |
| 2–3 | 45.3% (48) | 37.4% (43) | |
| 4 or more | 16.0% (17) | 27.8% (32) | |
| Insurance | 0.365 | ||
| Yes | 89.6% (95) | 93.0% (107) | |
| No | 10.4% (11) | 7.0% (8) | |
Postpartum follow-up rates are presented in Table 2. Women were significantly more likely to follow-up in the postpartum period following implementation of the Postpartum Follow-up Initiative (86.1% compared with 71.7%, P= 0.012). Women were also more likely to come in for 2 postpartum visits following implementation of the initiative with 56.6% of subjects coming in for both postpartum visits following the initiative compared to 39.6% of subjects prior to the initiative.
Table 2.
Number of Follow-up Visits Before and After Implementation of the Postpartum Follow-up Initiative
| # of follow-up visits | Pre-intervention % (n) | Post-intervention % (n) | p value |
| None | 28.3% (30) | 13.9% (16) | 0.012 |
| One | 32.1 % (34) | 29.6% (34) | |
| Two | 39.6% (42) | 56.6% (65) |
When the timing of follow-up was compared, the first postpartum visit occurred approximately one week sooner in the post intervention group (2.96 weeks compared with 3.73 weeks, P= 0.38) with no difference in timing of the second postpartum visit (6.62 weeks compared with 6.42 weeks, P= 0.72). The proportion of subjects who followed up in a timely manner are presented in Table 3 with subjects being significantly more likely to follow-up within 3 weeks for their first visit and within 7 for their second postpartum visit following initiation of the Postpartum Follow-up Initiative.
Table 3.
Timing of Postpartum Visit 1 and Visit 2 Before and After Implementation of the Postpartum Follow-up Initiative
| Pre-intervention % (n) | Post-intervention % (n) | P value | |
| Postpartum Visit 1 | 0.014 | ||
| No follow-up | 28.3% (30) | 13.9% (16) | |
| Visit within 3 weeks | 47.2% (50) | 64.3% (74) | |
| Visit more than 3 weeks | 24.5% (26) | 21.7% (25) | |
| Postpartum Visit 2 | 0.025 | ||
| No follow-up | 60.4% (60) | 44.3% (51) | |
| Visit within 7 weeks | 34% (36) | 41.7% (48) | |
| Visit more than 7 weeks | 5.7% (6) | 13.9% (16) | |
Rates of breastfeeding, contraception use, depression screening and referral, postpartum glucose tolerance testing for patients with gestational diabetes, and timing of subsequent pregnancy are presented in Table 4. In the post intervention group there were more documented instances of breastfeeding at the first postpartum visit (28.7% compared with 16.0%, P=.015) and the second postpartum visit (28.7% compared with 12.3%, P= 0.01). There were also more documented instances of patients using contraception in the post intervention group (84.3% compared with 71.7%, P= 0.009). There was no difference in depression screening or referral, glucose tolerance testing for gestational diabetes, or timing of subsequent pregnancies. Various confirmatory analyses including multiple logistic regression with the inclusion of potential demographic confounders did not change relationships.
Table 4.
Rates of Breastfeeding, Contraceptive Use, Depression Referral, Screening for Diabetes and Timing of Subsequent Pregnancy Before and After Implementation of the Postpartum Follow-up Initiative
| Outcome | Pre-intervention % (n) | Post-intervention % (n) | p value |
| Breastfeeding at Visit 1 | |||
| No | 53.8% (57) | 54.8% (63) | 0.015 |
| Yes | 16.0% (17) | 28.7% (33) | |
| Unknown | 30.2% (32) | 16.5% (19) | |
| Breastfeeding at Visit 2 | |||
| No | 25.5% (27) | 22.6% (26) | 0.010 |
| Yes | 12.3% (13) | 28.7% (33) | |
| Unknown | 62.3% (66) | 48.7% (56) | |
| Contraception Use | |||
| None, barrier | 28.3% (30) | 15.7% (18) | 0.009 |
| Pills, patch, ring, DMPA | 34.9% (37) | 49.6% (57) | |
| Sterilization or IUD | 11.3% (12) | 19.1% (22) | |
| Unknown | 25.5% (27) | 15.7% (18) | |
| Referral for Depression | |||
| No | 4.7% (5) | 1.7% (2) | 0.427 |
| Yes | 1.9% (2) | 2.6% (3) | |
| Unknown | 93.4% (99) | 95.7% (110) | |
| Gestational Diabetes | |||
| Screened with 2 hr GTT* | 1.9% (2) | 5.2% (6) | 0.155 |
| Not screened with 2 hr GTT* | 2.9% (3) | 5.2% (6) | |
| Not a gestational diabetic | 84.8% (89) | 85.2% (98) | |
| Unknown | 10.5% (11) | 4.3% (5) | |
| Subsequent Pregnancy | |||
| Conception < 6 months postpartum | 5.7% (6) | 7.8% (9) | 0.373 |
| Conception 6–12 months postpartum | 9.4% (10) | 6.1% (7) | |
| Conception > 12 months postpartum | 12.3% (13) | 7.0% (8) | |
| Unknown | 72.6% (77) | 79.1% (91) | |
Refers to the 75 gram 2 hour glucose tolerance test
Discussion
This study documents the implementation of an innovative, low-cost project to increase postpartum compliance in a population with traditionally low postpartum follow-up rates. Following implementation of the Postpartum Follow-Up Initiative, postpartum follow-up rates increased to 86.1% with 56.6% of subjects coming in for two postpartum visits compared to 39.6% prior to implementation. Higher rates of postpartum follow-up allowed for more opportunities to reinforce the importance of breastfeeding and provide contraception.
The first part of the initiative moved the responsibility of scheduling the first postpartum visit from the patient to clinic personnel. This took relatively little time for clinic personnel to accomplish and did not require them to work outside of scheduled clinic hours as patients who delivered and were discharged over a weekend or holiday received a letter or phone call during scheduled clinic hours. This practice alone decreased non-compliance with the first postpartum visit from 28.3% to 13.9%. The second portion of the initiative involved incentivizing care by giving patients a photo album with the mother and infant's picture. This practice decreased non-compliance with the second postpartum visit from 60.4% to 44.3%. Though very different in their approach, both practices improved postpartum follow-up rates to a similar degree.
Patients were also more likely to come in for their first postpartum visit within 3 weeks. This time frame is important because women who do not breastfeed or achieve lactational amenorrhea can ovulate as soon as 25 days after delivery and will require contraception within this time frame to prevent ovulation.5,6
The American College of Obstetricians and Gynecologists recommends postpartum follow-up 4 to 6 weeks after delivery for uncomplicated patients. A visit 7 to 14 days after delivery is recommended for women who are at high-risk for complications or for women who had cesarean deliveries.7 Most pregnant patients who receive care at QEC are considered high risk, if not because of medical comorbidity, because of socioeconomic factors that can place them at a higher risk for adverse outcomes. Low rates of postpartum follow-up are a problem for many clinical sites, particularly those sites which serve a similar population.8 For many hospitals and health care organizations, the postpartum visit has also been used as a national standard by which to measure health care quality.9 However, there have been few studies to examine ways to improve compliance with postpartum care. This study documents that a low-cost project can significantly improve postpartum follow-up rates.
This study was powered to detect differences in postpartum follow-up. However, perhaps the more important question is whether our intervention led to differences in our secondary outcomes which included clinical outcomes such as glucose tolerance testing for gestational diabetics and referrals for postpartum depression. We did not have a large enough sample to detect statistically significant differences in these types of outcomes. Also, secondary outcomes in this study included documented instances of a particular clinical outcome such as breastfeeding or contraceptive use. However, we did not have information on these outcomes for women who did not follow-up postpartum. Thus, if a woman was breastfeeding but did not follow-up, she would have been placed in the unknown category rather than the breastfeeding category. While this may have contributed to the difference we noted in breastfeeding, other outcomes, such as contraceptive use, are unlikely to be due to differences in reporting as physician intervention was necessary for use of the most reliable contraceptive methods. Also, it is important to note that this study took place in an urban clinic in Honolulu, Hawai‘i and may not be applicable to other populations.
In summary, this is one of the only published studies to specifically explore ways to improve postpartum follow-up. While this study describes an intervention that is low-cost and could easily be adopted to improve compliance in other clinics, it is far from perfect. Nearly 14% of women did not return for any postpartum visits following implementation of the initiative. Thus, more strategies are needed to further improve postpartum compliance, particularly in patients at high-risk for adverse outcomes.
Footnotes
Financial disclosure/conflicts of interest: none reported
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