Respondents
Of the 600 surveys sent to providers (200 per specialty subgroup), 50 were excluded from analysis (twenty-nine surveys were returned to sender as an undeliverable address and twenty-one recipients returned an uncompleted survey due to being retired or having a non-relevant specialty). A total of 20 surveys were returned with no explanation. These 20 surveys were categorized as refusals and were not excluded.
Based on eligible responses, the overall response was rate 43% (236/550). The majority - 72% (170/236) - returned the survey by mail. Table 1 provides respondents’ demographic data and their characterization of their patient population by provider specialty. Region was determined from the respondent’s reported primary practice zip code.
Table 1. Provider Respondent Characteristics and Patient Population
Characteristics
|
Frequency (%)
|
|
All respondents
(n = 236)
|
Nurse-Midwives
(n=106)
|
Family Medicine
(n=63)
|
OB-GYN
(n=62)
|
Mean years in practice
|
25.0 ± 11.8
|
22.8 ± 12.7
|
28.8 ± 9.7
|
24.1 ± 11.2
|
Actively treating postpartum patients
|
214 (90.7%)
|
98 (92.5%)
|
52 (82.5%)
|
60 (96.8%)
|
Gender
|
|
|
|
|
Female
|
159 (67.4%)
|
104 (98.1%)
|
28 (44.4%)
|
26 (41.9%)
|
Male
|
75 (31.8%)
|
1(0.9%)
|
34 (54.0%)
|
36 (58.1%)
|
Race
|
|
|
|
|
Asian
|
12 (5.1%)
|
1 (0.9%)
|
4 (6.3%)
|
6 (9.7%)
|
Black / African American
|
11 (4.7%)
|
5 (4.7%)
|
1 (1.6%)
|
5 (8.1%)
|
Hispanic / Latino(a)
|
8 (3.4%)
|
2 (1.9%)
|
2 (3.2%)
|
4 (6.5%)
|
Native American
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
Mixed race, Other
|
5 (2.1%)
|
0 (0%)
|
3 (4.8%)
|
2 (3.2%)
|
White / Caucasian
|
197 (83.5%)
|
97 (91.5%)
|
51 (81.0%)
|
45 (72.6%)
|
Did not respond
|
3 (1.3%)
|
1 (0.9%)
|
2 (3.2%)
|
0 (0%)
|
Region of Practice
|
|
|
|
|
Northeast
|
39 (16.5%)
|
26 (24.5%)
|
3 (4.8%)
|
10 (16.1%)
|
Midwest
|
72 (30.5%)
|
23 (21.7%)
|
29 (46.0%)
|
17 (27.4%)
|
South
|
68 (28.8%)
|
33 (31.1%)
|
13 (20.6%)
|
21 (33.9%)
|
West
|
53 (22.5%)
|
21 (19.8%)
|
17 (27.0%)
|
14 (22.6%)
|
Proportion of patients on Medicaid
|
42.9 ± 29.4
|
50.9 ± 30.1
|
37.7 ± 28.0
|
35.7 ± 27.5
|
Postpartum care attendance
|
|
|
|
|
Schedule care
|
90.4 ± 14.1
|
90.1 ± 13.2
|
87.7 ± 20.4
|
93.0 ± 8.6
|
Attend care
|
79.4 ± 18.8
|
79.1 ± 18.4
|
75.6 ± 23.7
|
82.2 ± 14.9
|
Characterization of Care
Providers largely favored earlier care with 37.7% preferring a single visit within 1 to 3 weeks postpartum and 19.5% wanting both earlier and more frequent care. Many (31.4%) responded that the traditional 6-week postpartum visit was most effective. Only a small percentage specified that a later than 6-week visit would be most effective (8.9%) or indicated a postpartum visit only be required if specific concerns needed to be addressed (2.1%).
Providers reported an average of 24.4 ± 11.7 minutes spent with each patient at their postpartum visit. An ANOVA identified significant differences in time allotted depending on specialty; Nurse-Midwives (28.1 ± 12.7 minutes) and Family Medicine providers (25.1 ± 10.9 minutes) reported more time than OB-GYNs (17.6 ± 6.9 minutes), F (2, 216) = 17.51, P <.001.
A chi-squared analysis identified that the nature of care provision differed significantly by provider type, according to reports from each, X2 (8, N = 224) = 19.89, p=.002. Almost all respondents actively provided postpartum care (>90%). Nearly half of OB-GYNs saw those patients routinely throughout their pregnancy (46.8%); more than half of Family Medicine providers had an ongoing (primary care and obstetric care) relationship with their pregnant patients (58.6%); whereas about one third of nurse-midwives provided routine pregnancy care only (37.5%), with the same number providing ongoing gynecologic care in addition to pregnancy care (36.5%).
Priorities for care
Table 2 shows the mean Likert-scale–rated priorities for each postpartum care item compared with mean reported frequency of practice of that item across provider types. It also shows the effect size of the difference in priority and practice (Cohen’s d), which appropriately adjusts for non-normal distribution.
Table 2. Cohen’s d of Importance-Rank Difference for Postpartum Care Categories
Categories
|
Importance
Mean (SD)*
|
Frequency
Mean (SD)†
|
Cohen’s d‡
|
Clinical Items
|
|
|
|
C-section birth complications
|
4.51(.73)
|
4.70(.68)
|
0
|
Vaginal birth complications
|
4.47(.77)
|
4.74(.64)
|
0
|
Pregnancy-related complications
|
4.32(.80)
|
4.57(.75)
|
.1
|
Chronic health conditions
|
3.76(.91)
|
3.98(.93)
|
.1
|
Transitioning to primary care
|
3.39(1.17)
|
3.33(1.35)
|
.1
|
Physical/pelvic exam
|
3.28(1.10)
|
4.08(1.05)
|
.7§
|
Behavioral
|
|
|
|
Depression
|
4.78(.41)
|
4.90(.46)
|
.1
|
Intimate partner violence
|
4.32(.78)
|
3.90(1.05)
|
.6
|
Substance use
|
4.19(.88)
|
3.78(1.17)
|
.5
|
Smoking
|
4.13(.85)
|
4.01(1.11)
|
.2
|
Maternal sleep
|
3.98(.81)
|
3.92(.99)
|
.2
|
Diet and weight trajectory
|
3.53(.92)
|
3.62(.97)
|
0
|
Family planning
|
|
|
|
Family planning counsel
|
4.63(.61)
|
4.89(.49)
|
.2
|
Contraceptive provision
|
4.52(.68)
|
4.59(.81)
|
.1
|
Resuming sexual activity
|
3.96(.85)
|
4.70(.65)
|
.8§
|
Infant Health
|
|
|
|
Breast health, breastfeeding and other infant feeding issues
|
4.45(.71)
|
4.66(.66)
|
.1
|
Infant safe sleep
|
3.70(1.10)
|
3.38(1.30)
|
.3
|
Notes
* Importance scale ranged from “1 = not at all” to “5 = extremely,” with a midpoint of “3 = moderately.”
† Frequency scale ranged from “1 = never” to “5 = always,” with a midpoint of “3 = sometimes.”
‡ Cohen’s d calculations were performed on differences between importance and frequency on normalized scales. Medium (Cohen’s d values > .5) or Large (Cohen’s d values > .8) differences highlighted in bold.
- Indicates item is performed more frequently than it is valued.
In terms of specific aspects of care, there was generally high correspondence between valued and performed care. For example, depression screening was an item that was both highly valued and frequently performed, as was birth-related and pregnancy-onset complications. There were, however, a few large inefficiencies in care: the pelvic exam, counseling regarding resumption of sexual activity, and intimate partner violence screening. The first two items were performed more frequently than the level at which they are valued. Intimate partner violence screening, on the other hand, was performed less often than would be expected considering its value.
There were also some consistent differences in care provision and valued care by provider type. Several items were valued and performed differently depending on provider type. For example, an ANOVA identified that, on a 5-point Likert scale, Family Medicine physicians and Nurse-Midwives both valued infant safe sleep care provision (4.07 ± 0.96 and 3.79 ± 1.10, respectively) more highly than OB-GYNs (3.31 ± 1.05) , F (2, 224) = 8.03, P <.001, and performed it more frequently, F (2, 2224) = 20.23, P <.001. While there were no significant differences in the high value placed on opioid and other substance use counseling across provider types, it was more routinely provided by Family Medicine physicians (4.17 ± 1.02), than by Nurse-Midwives (3.77 ± 1.18) or OB-GYNs (3.5 ± 1.19), F (2, 209) = 5.18, P <.01.
Figure 1 illustrates Likert-scale–rated priorities for postpartum care compared with reported frequency of practice broken down by provider type for (a) OB-GYN (b) Family Medicine and (c) Nurse-Midwife respondents.
Items that show equivalent values for importance but differ in performed frequency can be conceptualized as opportunity costs under time constraints, whereby some aspects of care are routinely “traded-off” against other forms of care. Identifying such tradeoff items can lend insight into prioritization and distribution of postpartum care. As mentioned above, counseling regarding the resumption of sexual activity can be broadly considered inefficient. For Nurse-Midwives, it was performed more frequently than equivalently valued maternal sleep assessment and smoking cessation counseling. For OB-GYNs, on the other hand, it was performed more frequently than equivalently valued smoking cessation counseling, opioid and other substance use assessment, and intimate partner violence screening. In the case of Family Medicine physicians, it was performed more frequently than equivalently valued discussions about transitioning to primary care and discussion of chronic health conditions. By the same token, screening for intimate partner violence was consistently underperformed relative to its value. For both Family Medicine physicians and Nurse-Midwives, this was specifically in contrast with vaginal birth and C-section complications, which were both performed more frequently.
Additional postpartum care items that were seen as important by all provider types (based on coding of open-ended text reports of care) largely fell into a category that could be called, “Transition to Parenthood.” This included certain aspects involved in evaluating the social, emotional, and tangible support available to patients as they transition to motherhood, including family relationships and their work environment. Providers also identified items such as infant bonding and vaccine schedules, as well as reviewing a woman’s birth experience and planning for future pregnancies. Inter-rater reliability analysis found moderate agreement between the two raters after the first round of coding for this open-ended response (Kappa= 0.79, P <.001).
The mean appointment attendance rate was 75% for patients of providers who supported telemedicine approaches, and 81% for patients of providers who did not, (t(198) = 1.97, P = .05), illustrating that those with lower postpartum attendance rates, tend to report higher support for telemedicine. As one provider noted, “There is benefit to human touch and contact. There are also many nonverbal cues that could be missed when not viewing the total person. However, telemedicine beats no visit at all.”