THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION Sarah Beth Verbiest, Master of Social Work and Master of Public Health A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctorate in Public Health in the Department of Health Policy and Management. Chapel Hill 2008 Approved by: Ned Brooks, DrPH (Chair) Shoou-Yih Daniel Lee, PhD Milton Kotelchuck, PhD, MPH Larry Mandelkhr, MBA, CPHQ Merry-K Moos, MPH, FNP, FAAN ABSTRACT SARAH VERBIEST: The Postpartum Visit: An Overlooked Opportunity for Prevention (Under the direction of Edward Brooks) Women’s postpartum health needs affect the woman, her ability to care for her infant, and the health of babies she may have in the future. The postpartum visit provides an opportunity to help women transition from pregnancy to well-woman care, playing an important role in continuity of health services. This dissertation included a comprehensive literature review of the postpartum visit. Using the data from key informant interviews, surveys, and a chart review, this study examined factors that impact the postpartum visit provided by the University of North Carolina’s Obstetric Program, including: a) the health care system; b) provider attitudes and practice; c) the content of care; and d) the woman’s medical needs and access to care. The study found that certain populations of patients are less likely to receive a postpartum visit and when they do receive a visit they receive fewer services than other mothers. The content of the visit is variable and not as complete as it could be. Postpartum screening for conditions such as gestational diabetes and hypertension warrants further attention. Communication among providers across the system is incomplete. Low-income mothers are likely to leave their postpartum visit without a plan in place for follow up services. The research determined that there are things that could be done within the UNC Obstetric Clinic to improve the postpartum visit and the care new mothers receive. ii Eight recommendations for improvements were generated from this study, including: 1) developing a comprehensive interconception care initiative; 2) building a University-wide research consortium; 3) marketing the postpartum visit to mothers; 4) improving postpartum visit compliance by strengthening the continuity of care given by providers; 5) improving the information available about mothers at the postpartum visit by adopting an electronic prenatal medical record; 6) enhancing the quality of the postpartum visit by implementing improvement initiatives; 7) expanding the information mothers receive at the postpartum visit by increasing the number of educational materials they receive; and 8) linking low- income mothers back to local health departments and clinics after their postpartum visit. The postpartum visit is key in the journey toward improved interconception care for mothers. iii DEDICATION This work is dedicated to my husband Dirk and our amazing children Kylie and Tai. Together we can do anything. It is also dedicated to Maureen Darcy and the staff of the Women’s Birth and Wellness Center who helped me become a healthy and happy new mother. iv ACKNOWLEDGEMENTS I would like to thank the members of my dissertation committee for their time, instruction, guidance and support. I would also like to thank my parents, David and Patricia Zuber for their ongoing love and encouragement across all of my academic pursuits. I also owe a debt of gratitude to my grandparents, John and Pearl Tatko, for their gift, which allowed me to have the funds to matriculate into this program. I could not have achieved this goal without many friends and family including: Amy Zuber, Susan Kimberly, Nichelle Perry, Carole Boudreau, Cheryl Cistuilli, Amy Mullenix, Anna Bess Brown, Susan Auger, Linda Kay Stone, Kathy Hodges, Barbara Beaman, Selden Holt, and my friends and colleagues in cohort 1. I am also grateful for the support and encouragement of all of the members of the Center for Maternal and Infant Health Team. I am also grateful to the following friends and colleagues for their technical assistance, resources, and advice: Laura Baron, Peter Bernstein, MD, Melissa Burns, MA, Alice Chuang, MD, Kelly Felton, MHA, CPHQ, Janice French, CNM, MS, Kim Hamden, CNM, Joe Holliday, MD, MPH, Tina Inman, PhD, Tom Ivester, MD, MPH, Virginia Johnson, Bonnie Jones, MSPH, MSW, Juli Kidd, Alvina Long-Valentine, RN, MPH, Paul Mihas, Jeanette Moore, RN, Sarah Parvanti, MPH, Dennis Rodriguez, MS, Suzanne Shores, CNM, MSN, Sara Smith, MSW, MPH v TABLE OF CONTENTS LIST OF TABLES …………………………………………………………………….. xii LIST OF FIGURES …………………………………………………………………….. xiv CHAPTER I. INTRODUCTION, STUDY AIMS, OBJECTIVES, AND SIGNIFICANCE ……... 1 Introduction………………………………………………………………………… 1 Definitions…………………………………………………………………………..3 Conceptual Framework……………………………………………………………. 5 Study Aims and Objectives……………………………………………………….. 7 Significance……………………………………………………………………….. 10 II. LITERATURE REVIEW…………………………………………………………... 14 Maternal Health Needs…………………………………………………………..… 14 Utilization of Postpartum Care……………………………………………………. 32 Postpartum Visit Services…………………………………………………………. 36 Health Care Provider Attitudes and Practices……………………………………... 41 Health Care System Impact on Postpartum Care………………………………….. 48 Programs and Recommendations Focused on Improving Care……………………. 52 Summary…………………………………………………………………………… 58 III. METHODOLOGY………………………………………………………………… 61 Operational Definitions……………………………………………………………. 61 vi Study Design………………………………………………………………………. 61 Study Population…………………………………………………………………… 62 Data Collection: Patient Chart Review……………………………………………. 63 Key Informant Interviews…………………………………………………………. 69 Provider Survey……………………………………………………………………. 72 Recommendations…………………………………………………………………. 75 Confidentiality…………………………………………………………………….. 79 IV. CHART REVIEW RESULTS…………………………………………………….. 80 Patient Characteristics………………………………………………………………81 Aim 1: Postpartum Visit Utilization……………………………………………….. 82 Aim 2: Services Receive at the Postpartum Visit………………………………….. 84 Aims 1 & 2: Postpartum Visit Utilization and Services for High-Risk Mothers….. 94 Aim 4: Health Care System Factors that Affect Utilization and Services - Resident and Faculty Service Comparison………………………………………………….. 100 Supplement to Aim 2: Observation of the Utilization of Care at UNC in the First Year Postpartum…………………………………………………………………………. 103 Discussion………………………………………………………………………….. 106 V. KEY INFORMANT INTERVIEW RESULTS……………………………………. 109 Informants………………………………………………………………………….. 109 Analysis……………………………………………………………………………. 110 Aim 4a: Health Care System Factors that Influence Utilization…………………… 113 Aim 4b: Health Care System Factors that Influence the Services Provided……….. 119 Aim 4c: Health Care System Factors that Influence Provider Care……………….. 134 vii Aim 5a: Gaps that Should be Addressed…………………………………………... 141 Aim 5: Recommendations to Enhance the Postpartum Visit………………………. 145 Aim 5b: Elements Required to Address gaps and Promote Change……………….. 155 Examples of Good Practice………………………………………………………… 158 Roles and Perceptions of Postpartum Care for New Mothers at UNC…………….. 160 Discussion………………………………………………………………………….. 162 VI. HEALTH CARE PROVIDER SURVEY RESULTS……………………………... 167 Provider Background………………………………………………………………. 168 Provider Responses………………………………………………………………… 169 Discussion………………………………………………………………………….. 180 VII. DATA SYNTHESIS, LIMITATIONS, AND DISCUSSION……………………. 184 Data Synthesis……………………………………………………………………… 185 Limitations…………………………………………………………………………. 188 National and State Issues…………………………………………………………... 192 Discussion………………………………………………………………………….. 196 VIII. RECOMMENDATIONS……………………………………………………….. 207 Recommendation #1: Develop a Unified, Comprehensive Interconception care Initiative at UNC………………………………………………………………….. 209 Recommendation #2: Build a Research Consortium at UNC to Improve Knowledge about Postpartum and Interconception Health and Health Care for Women……… 213 Recommendation #3: Market the Postpartum Visit to Women…………………… 216 viii Recommendation #4: Improve Postpartum Visit Compliance by Strengthening the Continuity of Care Given by Providers……………………………………………. 222 Recommendation #5: Improve the Information that is Available about Mothers at the Postpartum Visit by Adopting an Electronic Prenatal Record…………………….. 230 Recommendation #6: Enhance the Quality of the Postpartum Visit by Implementing Improvement Initiatives…………………………………………………………….238 Recommendation #7: Expand the Information Mothers Receive at the Postpartum Visit by Increasing the Number of Educational Resources They Receive………… 243 Recommendation #8: Link Low-Income Mothers Back to Local Health Departments and Community Clinics After the Postpartum Visit……………………………….. 248 Discussion………………………………………………………………………….. 255 Summary…………………………………………………………………………… 259 Final Word………………………………………………………………………… 261 APPENDIX A……………………………………………………………………………… 263 APPENDIX B……………………………………………………………………………… 269 APPENDIX C……………………………………………………………………………… 276 APPENDIX D……………………………………………………………………………… 279 REFERENCES…………………………………………………………………………….. 280 ix LIST OF TABLES TABLES 1. General Characteristics of Women Who Delivered at UNC in 2006…………. 63 2. UNC Faculty & Resident Clinic Health Care Providers 2007…………………. 74 3. Summary of Study Inclusion and Exclusion Criteria…………………………. 75 4. Comparison of Study Sample Population to Total Population………………….81 5. Patient Characteristics and Postpartum Visit