Respondents
Of the 600 surveys sent to providers (200 per specialty subgroup), 50 were excluded from analysis. Of the 50 excluded, 29 surveys were returned to sender as an undeliverable address (55% were from the AMA list, 21% were from the ACNM list, and 24% were from the AAFP list) and 21 recipients returned an uncompleted survey due to being retired or having a non-relevant specialty (over 50% of these were from the AAFP list). A total of 20 surveys were returned uncompleted and in their original envelope with no explanation. To be conservative, these 20 surveys were categorized as refusals, rather than undeliverable, and were included in response rate analyses.
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.
Priorities for care
Table 2 shows the mean Likert-scale–rated priorities for each postpartum care element compared with mean reported frequency of practice of that element 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.
In terms of specific elements of care, there was generally high correspondence between prioritized and performed care. For example, depression screening was an element that was both highly prioritized and frequently performed, as was addressing birth-related and pregnancy-onset complications. There were, however, a few large potential discrepancies in care across all specialties, identified by calculated normalized differences in priority and practice: the pelvic exam, counseling regarding resumption of sexual activity, and intimate partner violence screening. The first two elements were performed more frequently than the level at which they were prioritized, pointing to inefficiencies in care. Intimate partner violence screening, on the other hand, was performed less often than would be expected considering its perceived importance, perhaps pointing to a potential tradeoff being made given competing demands on time.
Several elements were prioritized 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 prioritized infant safe sleep education 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 priority 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.
Elements that show equivalent numeric ratings for priority but differ in performed frequency can be conceptualized as competing demands under time constraints, whereby some elements of care are routinely “traded-off” against other forms of care. Identifying such tradeoff elements 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 prioritized maternal sleep assessment and smoking cessation counseling. For OB-GYNs, on the other hand, it was performed more frequently than equivalently prioritized 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 prioritized 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 judged priority. 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 elements, not included in current guidelines, but 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 other important care elements, 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).
Characterization of Care
Providers largely favored earlier care with 37.7% preferring a single in-person 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%). A small percentage (11.4%) provided open-ended comments about their postpartum timing preference. From these comments, the primary reasons offered for earlier postpartum appointments were timelier intervention for delivery-related complications, mental health, breastfeeding, and contraceptive needs, all of which may present challenges to the patient earlier than 6-weeks’ postpartum. Some also mentioned providing schedule flexibility to patients (e.g. allowing patients to coordinate the postpartum visit with their infant’s first well-visit).
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 routinely provided postpartum care (>90%). Nearly half of OB-GYNs saw those patients 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%).
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.”