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Clinician care priorities and practices in the fourth trimester

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How are clinicians balancing the demands of postpartum care with limited resources, and what gaps do they face in adhering to professional guidelines during the critical fourth trimester?

Image courtesy of interviewee. November 19, 2024

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In the fall of 2023 and early 2024, a study was conducted through an anonymous online survey targeting obstetricians, midwives, and family medicine physicians in California. The survey aimed to explore two main topics: how clinicians prioritize various clinical responsibilities within their time and resource constraints and the degree to which they adhere to guidelines from the American College of Obstetrics and Gynecology (ACOG) regarding postpartum care.

The study was motivated by rising concerns over maternal mortality and morbidity rates, as well as significant disparities in maternal health. ACOG provided recommendations in 2018 to improve care in the first 12 weeks postpartum, outlining 26 components of care that clinicians should follow. The survey results indicated that while clinicians rarely perform all recommended components of postpartum care, they prioritize certain aspects such as mental health (depression and anxiety), breast health, vaginal birth complications, and family planning, which they tend to check consistently.

Conversely, components related to social health drivers, such as diet monitoring and screening for intimate partner violence, were less prioritized, suggesting room for improvement in adherence to ACOG guidelines. The study highlighted challenges faced by clinicians, including time constraints and patient readiness to discuss complex issues during early postpartum visits. Additionally, it was noted that years of practice experience impacted clinicians' ability and willingness to address social and behavioral health issues.

The findings emphasized the need for better collaboration among healthcare professionals to address comprehensive postpartum care and highlighted strategies such as enhancing awareness of social determinants of health, integrating community resources, and improving guideline accessibility in clinical settings.

Notably, obstetricians and midwives displayed different priorities in care components based on their practice settings and patient needs. Midwives tended to spend more time with patients, focusing more on social and emotional support, whereas obstetricians emphasized clinical complications. The study concluded that a collaborative model of care involving both midwives and obstetricians could better meet the diverse needs of postpartum patients.

Lastly, the study participants advocated for extending Medicaid coverage to 12 months postpartum to ensure continuity of care, which could enhance support for chronic conditions and improve overall maternal health outcomes. The California Department of Healthcare Services is also working on initiatives to transform maternal health services, aiming for better coordination of care.

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Here are five key points from the video:

1. **Survey Overview and Purpose**: In fall 2023 and early 2024, an anonymous online survey was conducted with obstetricians, midwives, and family medicine physicians in California to understand how they prioritize clinical responsibilities within time and resource constraints, and to examine adherence to the American College of Obstetrics and Gynecology (ACOG) recommendations for postpartum care.

2. **ACOG Recommendations and Prioritized Care Components**: ACOG issued recommendations addressing postpartum care components in response to rising maternal mortality and morbidity rates. The study identified 26 care components, discovering that clinicians prioritized four key components: anxiety assessment, breast health, vaginal birth complications, and family planning counseling, with most clinicians reporting they address these during postpartum visits.

3. **Adherence Challenges**: The study revealed that adherence to ACOG guidelines was only at a median score of 62%, indicating significant room for improvement. Factors affecting adherence included clinicians feeling overwhelmed by time constraints, patients being unprepared to discuss multiple issues during their first postpartum visit, and concerns about the stigma attached to discussing sensitive social and behavioral issues.

4. **Collaboration and Support**: Findings indicated that more experienced clinicians are better at addressing social and behavioral components of care, likely due to increased confidence and collaborative relationships with other healthcare providers. Strategies to enhance care include encouraging multidisciplinary teamwork, making guidelines more accessible at the point of care, and providing appropriate referrals tailored to patient preferences.

5. **Insights on Practice Differences and Future Care**: The study highlighted differences in practice between midwives, who prioritize social drivers of health and provide longer visits, and obstetricians, who focus on medical complications often within shorter appointment times. The potential for collaborative care models was noted as beneficial in addressing diverse patient needs, alongside discussing policy changes like extending Medi-Cal postpartum coverage to enhance continuity of care and improve maternal health outcomes.

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Here are some key quotes and summarized points from the video:

1. **Purpose of the Study**
- "We really wanted to understand two issues: How do clinicians prioritize multiple clinical responsibilities within their existing time and resource constraints? And second, we also wanted to examine the recommendations of the American College of Obstetrics and Gynecology (ACOG) issued in response to rising concerns about increasing rates of maternal mortality and morbidity in the US."

2. **ACOG Recommendations**
- "ACOG issued multiple recommendations to optimize care in the first 12 weeks postpartum... Altogether, we identified 26 care components that ACOG recommends, and we focused on those for our study."

3. **Findings on Clinician Prioritization**
- "We found that clinicians rarely performed all the postpartum care components recommended by ACOG."
- "Of the 26 care components, anxiety, breast health, vaginal birth complications, and family planning counseling rank highly as the top priorities for the first postpartum visit."

4. **Adherence to ACOG Guidelines**
- "The median score of adhering to ACOG guidelines is 62%. That is, 50% or more of clinicians will complete 62% while the other 50% will do less than that."

5. **Challenges in Addressing Care Components**
- "Aside from assessing anxiety and depression, other mental health and social issues might just be too time intensive to approach... Patients might be reticent to discuss social and behavioral issues because of perceived stigma."

6. **Factors Influencing Adherence**
- "Years of practice as a clinician is associated with better follow-through with the social and behavioral care components."

7. **Recommendations for Improvement**
- "Strategies to help prioritize the social components include encouraging collaboration with multidisciplinary teams and understanding the social structure of cultural drivers that affect health."
- "Making guidelines more accessible at the point of care or computerized clinical decision supports can help remind clinicians to screen and monitor key components."

8. **Role Differentiation Between Midwives and Obstetricians**
- "Midwives and obstetricians perform under different settings, different models of care... A collaborative model of care in which midwives and OB GYNs work in partnership may be the way to balance different patient needs in the postpartum."

9. **Benefits of Extended Care**
- "Extension of Medi-Cal allows for continuity of care, which can improve breastfeeding support, chronic disease management, and preventive care."

10. **Recruitment and Study Participation**
- "We cast a wide net across the state and enlisted the help of leaders from several professional organizations... Prior to launching the survey, we sharpened the focus with support from the ACOG Public Health Committee."

These quotes and insights encapsulate the main themes of the study, including the challenges facing postpartum care, the prioritization of different care components by healthcare professionals, and recommendations for increasing adherence to guidelines and improving care delivery.

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In the fall of 2023, early 24,

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we conducted an, an anonymous online survey

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of practicing obstetricians, midwives

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and family medicine physicians in California.

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We really wanted to understand two issues.

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How do clinicians prioritize

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multiple clinical responsibilities within their existing

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time and resource constraints?

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And second, we also wanted to examine to

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what extent do clinicians follow AOC guidelines?

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That is the American College of Obstetrics

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and Gynecology, which issued,

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multiple recommendations

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to optimize care in the first 12 weeks postpartum

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in 2018, they were doing this, in response

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to rising concerns about increasing rates

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of maternal mortality

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and morbidity in the US as well

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as large inequalities in maternal health

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and growing behavioral health problems.

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So the wide ranging recommendations that ACOG issued

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include, many different kinds of elements,

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clinical care components, family planning,

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infant health, social

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and social drivers of health, behavioral health,

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as well as planning for future care.

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Altogether, we identified 26 care components

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that AOK recommends, and we focused on those for our study.

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We found that clinicians rarely performed

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all the postpartum care components recommended by acog.

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However, what clinicians did prioritize highly,

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they were likely to perform of the 26 care components,

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we found that depression

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and anxiety, breast health, including breastfeeding issues,

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vaginal birth complications,

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and family planning counseling,

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those four components rank highly

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as the top priorities for the first postpartum visit.

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We also found that the majority of clinicians reported

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that they always check these four components

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or check them when the patient needs it.

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But in contrast,

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and this is our fourth finding care components,

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that very few clinicians consider the top priority

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more often went and checked,

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and such was the case, for instance, for diet

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and weight monitoring

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and many care components that constitutes social drivers

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of health, such as screening

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and counseling for intimate partner violence, food

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and housing insecurity, substance abuse,

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the, the adverse childhood health experiences,

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as well as assessment of the work environment,

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including maternity leave.

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We have been doing a follow-up, study on adherence

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to the AOP guidelines,

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and we're finding that the median score of, following

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through on these components is 62%.

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That is 50%

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or more of clinicians will complete 62%

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of the components,

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whereas the other 50% will do less than that.

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So obviously there is room for improving,

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adherence to performing ACO components.

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A quality of care is to improve.

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Let's start with the challenges.

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Um, aside from assessing anxiety

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and depression, as I said,

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which are two prevalent conditions in the postpartum

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that are often reimbursed by health plans,

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other mental health

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and social issues might just be too in time intensive

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to approach, and

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therefore clinicians might be ask skewing them.

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Alternatively, I think clinicians may be determining

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that patients may just not be ready to absorb

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multiple messages at that first postpartum visit.

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When they're just beginning to recover from delivery,

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they're sleep deprived

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and they're transitioning to the new demands

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that a new infant, brings at home.

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Uh, from another standpoint, patients might be reticent

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to discuss social and behavioral issues

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because of perceived stigma

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or maybe fear of negative consequences, such as,

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bringing forth social services involvement,

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child protective services, which is not something

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that they would look forward to

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or else they might be, concerned about costs.

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We have in our study been studying specific factors

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that might be a associated with adherence

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to the ACO guidelines.

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And we're finding, interestingly that years of practice

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as a clinician is associated with better follow through

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with the social and behavioral care components.

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I guess that with more years of experience come more skills,

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more confidence and efficiency

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and maybe this allows clinicians

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to feel comfortable facilitating difficult conversations

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with their patients to address their social needs.

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More years of clinical practice, it turns out,

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is also associated with better

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or more collaboration with other providers,

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such that through evolved networks, they might be able

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to address, these social needs

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and behavioral guidelines.

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So for instance, collaboration with doulas

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and lactation consultants, nutritionists, psychologists,

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social workers, these are all, collaborations

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that might better cover the spectrum of,

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postpartum care.

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I think that strategies that

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and can help, prioritize the social,

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behavioral needs, is

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one, just what I said, encourage collaboration

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with multidisciplinary teams

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and interaction with community resources.

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We have to understand that many clinical practices are under

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resourced to tackle complex social

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and behavioral health needs, so that better integration

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of community health resources

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and promotion of teamwork can be really, really be helpful.

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Second, I think that clinicians should be made aware

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and understand the social structure of cultural drivers

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that affect health

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and that promote inequities in practice settings.

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And I think that clinicians must also be helped

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to feel comfortable screening their patients

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through appropriate questions.

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Another strategy to consider

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is making guidelines more accessible at the point of care

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through either electronic medical records

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or computerized clinical decision supports.

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These reminds the clinician to screen

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and monitor key components.

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Uh, fourth strategy would be to provide referrals

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to appropriate agencies.

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And these referrals really need

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to be presented in acceptable way that both matches

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patients' preferences and enables them to access care.

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And finally, I think clinicians could consistently assess

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working mother's work environment

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and support them to get paid maternity leave

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and maternity leave extinctions something

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that's not easily done in the us

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and also help support them

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with work accommodations in the workplace if needed.

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As we said, there were these four components that,

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all clinicians regardless of type really prioritize highly

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and therefore they perform.

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But there are others that are perhaps more favored

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or unique to obstetricians

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and some that are favored by midwives.

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So for instance, c-section,

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birth complications meaning cesarean, birth complications

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and pregnancy related complications.

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When there are complications related to let's say diabetes

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or hypertension, were ranked highly by the obstetricians,

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but not by midwives.

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And probably because these elements are at the core of what,

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the expertise is of obstetricians, that's

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what they're asked to do.

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Um, in contrast, social

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and emotional support, focusing on the physical recovery

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after labor and maternal sleep

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we're more ha highly ranked by midwives.

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I guess midwives are trained in relationship centered models

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of care, and that might help explain differences.

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Midwives support the innate capabilities of birthing people

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during labor and delivery with breastfeeding

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and attachment buildings.

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That is one explanation, but it also might be

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because it might be related to patients expectations.

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Midwives either select

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or end up with different types

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of patients than obstetricians,

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and they also practice in different types of settings.

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Midwives in our sample, for instance, were much more likely

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to practice in community clinics, community hospitals,

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and in private practice, while obstetricians tended

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to practice in university and academic settings.

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Now, a really interesting finding in our study was

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that despite midwives spending an average

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of 60 minutes with their patients compared with an average

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of 20 minutes by obstetricians at

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that first postpartum visit, midwives were not more likely

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to prioritize the components of so social drivers of health.

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Um, perhaps they do so in subsequent visits.

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We know that midwives are more likely to hold,

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follow-up visits, with their patients compared

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with OBGYNs.

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Obstetricians in our study, reported,

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that often they did not offer more than one

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postpartum visit to their patients.

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In fact, 46% reported that they only offered

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that single visit.

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So we conclude that midwives

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and obstetricians perform under different settings,

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different models of care, and

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therefore a collaborative model of care in which midwives

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and OB GYNs work in partnership may be the way

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to balance different patient needs in the postpartum.

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In the USO,

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obstetrician gynecologists outnumber midwives

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in many European countries, Australia, New Zealand,

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it's the reverse and midwives there are considered the

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backbone of the reproductive healthcare system.

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So there's certainly a dearth of midwives in California.

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Our study participants, men mentioned several Ben benefits

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of extending medical to the F fall 12 months

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after childbirth because many postpartum conditions

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or a cure much beyond the six to eight week window of

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that traditional postpartum care, visit.

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So extension of Medi-Cal allows

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for continuity of care,

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and as our participants may mention, continuity

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of of care allows for better breastfeeding support,

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better assessment, monitoring

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and support for conditions such as depression and anxiety.

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It improve, it allows for improved management

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of chronic diseases and other high risk conditions,

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and also empowers mothers

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to continue learning about their neuros

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as, mothers.

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Many women do not have a primary care provider

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and do not seek care outside of pregnancy.

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So extending care can also allow for more preventive care.

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Very quickly at the more at the policy level,

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the California Department of Healthcare Services

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is transforming Medi-Cal

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to enhance maternal health services.

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It is working on a birthing pathway initiative

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from conception through 12 months of postpartum care.

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And that should lead to less fragmentation

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and better coordination of care.

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So we're hopeful that those policy recommendations,

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which are due to come any time this year will be helpful

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to the extension of medical coverage.

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I think it happened because we put a big emphasis on

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recruitment by casting a wide net across the state.

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We listed the help of leaders

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from several professional organizations such as acog,

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California chapter,

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the California Maternal Quality Control

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Collaborative, which is a very distinguished,

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group here in California, March of Dimes.

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And also we enlisted collaboration from the California

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Department of Public Health.

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And all these folks were really excited

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to see the STU Study launched.

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One my colleague at Stanford University

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put effort into recruiting at Stanford.

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I cast a large network through my contacts at UCSF,

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school of Medicine

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and uc, Davis, as well as uc, Berkeley, where I,

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I'm part of our champions personally communicated

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with their contacts and sent a written announcement that

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provided a good description

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and linked to the survey requesting that they participate

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and several actual participants gave us

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feedback saying that they found the survey, enjoyable

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to fill out, and they were also very eager to be helpful.

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Prior to launching the survey,

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we conducted three focus groups with mem members

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of the Acco Public Health Committee in California,

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and they helped us sharpen the focus of the survey.

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They also became staunch supporters

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and dedicated their efforts to help us recruit.

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We all also offered some soft financial incentives in the

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way of a hundred dollars gift cards that we raffled out

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to those who had completed data collection.

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And I think we got reliable responses, partly

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because the survey was anonymous, completed online,

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and our consent form alerted clinicians

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that they could skip any question

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that they did not want to answer.

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Fortunately, there weren't many of those.

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However, we must acknowledge

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that ours was a convenient sample

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that may represent motivated clinicians who strive

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to improve the quality of postpartum care

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and also might have strong opinions about

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the delivery of healthcare.

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And we're very grateful to those participants

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for giving us insight into

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what is happening in the postpartum care from the

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clinician's point of view here in California.

Examining Postpartum Care Prioritization Among California Clinicians

00:00:00 - In the fall of 2023, early 24, we conducted an, an anonymous online survey of practicing obstetricians, midwives and family medicine physicians in California. We really wanted to understand two issues. How do clinicians prioritize multiple clinical responsibilities within their existing time and resource constraints? And second, we also wanted to examine to

00:00:37 - That is the American College of Obstetrics and Gynecology, which issued, multiple recommendations to optimize care in the first 12 weeks postpartum in 2018, they were doing this, in response to rising concerns about increasing rates of maternal mortality and morbidity in the US as well

00:01:07 - and growing behavioral health problems. So the wide ranging recommendations that ACOG issued include, many different kinds of elements, clinical care components, family planning, infant health, social and social drivers of health, behavioral health,

Prioritization of Postpartum Care Components by Clinicians

00:01:38 - Altogether, we identified 26 care components that AOK recommends, and we focused on those for our study. We found that clinicians rarely performed all the postpartum care components recommended by acog. However, what clinicians did prioritize highly, they were likely to perform of the 26 care components,

00:02:08 - and anxiety, breast health, including breastfeeding issues, vaginal birth complications, and family planning counseling, those four components rank highly as the top priorities for the first postpartum visit. We also found that the majority of clinicians reported that they always check these four components or check them when the patient needs it.

00:02:40 - and this is our fourth finding care components, that very few clinicians consider the top priority more often went and checked, and such was the case, for instance, for diet and weight monitoring and many care components that constitutes social drivers of health, such as screening and counseling for intimate partner violence, food and housing insecurity, substance abuse,

Challenges in Postpartum Care Adherence

00:03:17 - as well as assessment of the work environment, including maternity leave. We have been doing a follow-up, study on adherence to the AOP guidelines, and we're finding that the median score of, following through on these components is 62%. That is 50% or more of clinicians will complete 62%

00:03:47 - whereas the other 50% will do less than that. So obviously there is room for improving, adherence to performing ACO components. A quality of care is to improve. Let's start with the challenges. aside from assessing anxiety and depression, as I said, which are two prevalent conditions in the postpartum

00:04:19 - other mental health and social issues might just be too in time intensive to approach, and therefore clinicians might be ask skewing them. Alternatively, I think clinicians may be determining that patients may just not be ready to absorb multiple messages at that first postpartum visit. When they're just beginning to recover from delivery,

Barriers to Discussing Postpartum Care

00:04:47 - and they're transitioning to the new demands that a new infant, brings at home. from another standpoint, patients might be reticent to discuss social and behavioral issues because of perceived stigma or maybe fear of negative consequences, such as, bringing forth social services involvement, child protective services, which is not something

00:05:19 - or else they might be, concerned about costs. We have in our study been studying specific factors that might be a associated with adherence to the ACO guidelines. And we're finding, interestingly that years of practice as a clinician is associated with better follow through with the social and behavioral care components.

00:05:51 - more confidence and efficiency and maybe this allows clinicians to feel comfortable facilitating difficult conversations with their patients to address their social needs. More years of clinical practice, it turns out, is also associated with better or more collaboration with other providers, such that through evolved networks, they might be able

Enhancing Postpartum Care through Collaborative Strategies

00:06:23 - and behavioral guidelines. So for instance, collaboration with doulas and lactation consultants, nutritionists, psychologists, social workers, these are all, collaborations that might better cover the spectrum of, postpartum care. I think that strategies that and can help, prioritize the social,

00:06:55 - one, just what I said, encourage collaboration with multidisciplinary teams and interaction with community resources. We have to understand that many clinical practices are under resourced to tackle complex social and behavioral health needs, so that better integration of community health resources and promotion of teamwork can be really, really be helpful.

00:07:25 - and understand the social structure of cultural drivers that affect health and that promote inequities in practice settings. And I think that clinicians must also be helped to feel comfortable screening their patients through appropriate questions. Another strategy to consider is making guidelines more accessible at the point of care

Enhancing Postpartum Care: Strategies for Support and Referral

00:07:56 - or computerized clinical decision supports. These reminds the clinician to screen and monitor key components. fourth strategy would be to provide referrals to appropriate agencies. And these referrals really need to be presented in acceptable way that both matches patients' preferences and enables them to access care.

00:08:28 - working mother's work environment and support them to get paid maternity leave and maternity leave extinctions something that's not easily done in the us and also help support them with work accommodations in the workplace if needed. As we said, there were these four components that, all clinicians regardless of type really prioritize highly

00:08:59 - But there are others that are perhaps more favored or unique to obstetricians and some that are favored by midwives. So for instance, c-section, birth complications meaning cesarean, birth complications and pregnancy related complications. When there are complications related to let's say diabetes or hypertension, were ranked highly by the obstetricians,

Contrasting Care Approaches: Obstetricians vs. Midwives

00:09:30 - And probably because these elements are at the core of what, the expertise is of obstetricians, that's what they're asked to do. in contrast, social and emotional support, focusing on the physical recovery after labor and maternal sleep we're more ha highly ranked by midwives. I guess midwives are trained in relationship centered models

00:10:05 - Midwives support the innate capabilities of birthing people during labor and delivery with breastfeeding and attachment buildings. That is one explanation, but it also might be because it might be related to patients expectations. Midwives either select or end up with different types of patients than obstetricians, and they also practice in different types of settings.

00:10:37 - to practice in community clinics, community hospitals, and in private practice, while obstetricians tended to practice in university and academic settings. Now, a really interesting finding in our study was that despite midwives spending an average of 60 minutes with their patients compared with an average of 20 minutes by obstetricians at

Collaboration Between Midwives and Obstetricians in Postpartum Care

00:11:11 - to prioritize the components of so social drivers of health. perhaps they do so in subsequent visits. We know that midwives are more likely to hold, follow-up visits, with their patients compared with OBGYNs. Obstetricians in our study, reported, that often they did not offer more than one

00:11:41 - In fact, 46% reported that they only offered that single visit. So we conclude that midwives and obstetricians perform under different settings, different models of care, and therefore a collaborative model of care in which midwives and OB GYNs work in partnership may be the way to balance different patient needs in the postpartum.

00:12:14 - obstetrician gynecologists outnumber midwives in many European countries, Australia, New Zealand, it's the reverse and midwives there are considered the backbone of the reproductive healthcare system. So there's certainly a dearth of midwives in California. Our study participants, men mentioned several Ben benefits of extending medical to the F fall 12 months

Enhancing Postpartum Care Through Medi-Cal Expansion

00:12:47 - or a cure much beyond the six to eight week window of that traditional postpartum care, visit. So extension of Medi-Cal allows for continuity of care, and as our participants may mention, continuity of of care allows for better breastfeeding support, better assessment, monitoring

00:13:20 - It improve, it allows for improved management of chronic diseases and other high risk conditions, and also empowers mothers to continue learning about their neuros as, mothers. Many women do not have a primary care provider and do not seek care outside of pregnancy. So extending care can also allow for more preventive care.

00:13:52 - the California Department of Healthcare Services is transforming Medi-Cal to enhance maternal health services. It is working on a birthing pathway initiative from conception through 12 months of postpartum care. And that should lead to less fragmentation and better coordination of care. So we're hopeful that those policy recommendations,

Collaborative Efforts in Expanding Medical Coverage

00:14:27 - to the extension of medical coverage. I think it happened because we put a big emphasis on recruitment by casting a wide net across the state. We listed the help of leaders from several professional organizations such as acog, California chapter, the California Maternal Quality Control Collaborative, which is a very distinguished,

00:14:57 - And also we enlisted collaboration from the California Department of Public Health. And all these folks were really excited to see the STU Study launched. One my colleague at Stanford University put effort into recruiting at Stanford. I cast a large network through my contacts at UCSF, school of Medicine and uc, Davis, as well as uc, Berkeley, where I,

00:15:31 - with their contacts and sent a written announcement that provided a good description and linked to the survey requesting that they participate and several actual participants gave us feedback saying that they found the survey, enjoyable to fill out, and they were also very eager to be helpful. Prior to launching the survey,

Engaging Clinicians for Improved Postpartum Care

00:16:02 - of the Acco Public Health Committee in California, and they helped us sharpen the focus of the survey. They also became staunch supporters and dedicated their efforts to help us recruit. We all also offered some soft financial incentives in the way of a hundred dollars gift cards that we raffled out to those who had completed data collection.

00:16:32 - because the survey was anonymous, completed online, and our consent form alerted clinicians that they could skip any question that they did not want to answer. Fortunately, there weren't many of those. However, we must acknowledge that ours was a convenient sample that may represent motivated clinicians who strive to improve the quality of postpartum care and also might have strong opinions about

00:17:11 - And we're very grateful to those participants for giving us insight into what is happening in the postpartum care from the clinician's point of view here in California.

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