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Tuesday, June 4, 201912:30 p.m. Eastern

Dial In: 888.863.0985 Conference ID: 9372129

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Speakers

Sarah Jernigan, MSN, ACNP-BC, CSC Patient Advocate

Rachel Urrutia, MD, MSCRAssistant Professor, UNC at Chapel Hill, Department of Obstetrics and Gynecology

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Disclosures

Sarah Jernigan, MSN, ACNP-BC, CSC has no real orperceived conflicts of interest.

Rachel Urrutia, MD, MSCR has no real or perceivedconflicts of interest.

The presenters wish to thank Kate Berrien, MSN for her assistance in preparing the slides.

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Objectives Review the postpartum period as a critical time for

preventive care

Discuss comprehensive models for establishing a smooth transition from maternity to well-woman care Provide examples that will help implement elements of

the Postpartum Care Basics Bundle

Address complications and implementation barriers to promoting postpartum safety

Hear a patient’s postpartum story and understand the importance of personalized care

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What is the Postpartum Period? Begins immediately following delivery

Ends?6 weeks?

− Many biologic parameters return to baseline

12 weeks?− “The Fourth Trimester”

Up to 12 months?− Many musculoskeletal and genitourinary changes return to baseline

When the global billing period ends?− Varies by insurer and mode of delivery up to 90 days

When lactation ends?− Unique metabolic and hormonal changes return to baseline

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Why is this Period so Important? High risk time for mothers

Many long-lasting health changes that are inadequately addressed

Patients care

Image available, CDC https://www.cdc.gov/reproductivehealth/maternalinfanthealth/index.html

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Top 3 causes of pregnancy-related deaths by time—postpartum

Data from Pregnancy Mortality Surveillance System, United States, 2011-2015

CDC, 2019

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Racial/Ethnic Inequities Pregnancy-related mortality ratio 2-3 fold higher in black

and native populations than among white populations Inequity was greater for postpartum deaths Severe morbidity postpartum: 40% higher in black v. white women

Peterson MMWR 2019 Liese J Racial and ethnic health disparities 2019

Image: Jared Rodriguez / Truthout

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Maternal Health Continuum

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Mental Health and Quality of Life Postpartum

89% of new Australian moms report 1 or more sexual health issues in first 3 months postpartum 30% had persistent pain at 12 months 51% low libido at 12 months (versus 42% prior to pregnancy)

1-7% of new moms meet criteria for new onset PTSD after delivery

1 in 9 moms meet criteria for postpartum depressionClapp Am J Ob Gyn 2016, Khajehai J Sex Med 2015, Soderquist BJOG 2009

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Chronic Disease Risk Postpartum

Mean postpartum weight retention at 12 months: 11.8 pounds 75% of women heavier postpartum

US prevalence of pregnancy complications leading to increased cardiovascular risk Hypertensive disease of pregnancy: 9% Gestational Diabetes: 6-9% Preterm Birth: 10%CDC PRAMS and Vital Statistics Data

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Postpartum Visit and Primary Care Postpartum

Postpartum visit rate US: 90% Lower for women with insufficient prenatal care and lower education

Primary care visits within 12 months of delivery Medically complicated, Medicaid: 57% Routine, Medicaid: 52% Medically complicated, Private Insurance: 60% Routine, Private insurance: 50%CDC PRAMS data 2015; Bennett JGIM 2014

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Patient Perspectives Health consequences of pregnancy as perceived by mothers and clinicians, Seattle, Focus

groups, 1998 Insufficient knowledge about postpartum health (both groups) Wanted more maternal health info Concerned about improving their economic status as a way to health

Listening to Mothers, US online survey of over 1000 mothers, 2012 10% no postpartum visit 24% no contact number for health concerns 43% insufficient information about family planning 70% insufficient information about sexuality

Fourth Trimester Project, Stakeholder meeting 2016 Imbalance between intensity prenatal and postpartum care Practice guidelines not aligned with lived experience Comprehensive care difficult to achieve Six important postpartum themes: mood, medications/substances, physical recovery, sleep,

sexuality/reproduction, infant feeding

DeClerq J Pernital Education 2014; Tully Am J Ob Gyn 2017; Kline Ob Gyn 1998.

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Sarah’s Story

Sarah Jernigan, MSN

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#1 “WOW! You have a BIG baby!” Induction at 41-1 Failed epidural during transition Cephalopelvic disproportion- emergency

Csection Complications: Postpartum depression,

postpartum pain/ lower extremity weakness, no milk production, postpartum hypertension

#2 “Placenta what?” 18 week anatomy scan discovered complete

placenta previa and increta 22 weeks of pelvic rest and no exercise Planned c-section at 34 weeks, vertical

incision, uterine embolization, hysterectomy. Witnessed my daughter’s respiratory

arrest/resuscitation in the OR

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Postpartum Recovery: Immediate/EarlyFirst Pregnancy Lower extremity weakness Back pain (meningeal irritation) Delayed bonding Shock/ “Stress”/ depression No milk Postpartum hypertension, 70lb weight gain

Second Pregnancy Pain Allergic reaction to vacuum dressing adhesive,

limited ability to manage pain due to frequent trips to NICU and nowhere for me to rest while spending time there

Prolonged lifting restriction of 6 weeks

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Postpartum recovery: Late2-6 weeks: Exhaustion (slow to heal) Back pain Anxiety Sexual dysfunction/severe

pain

6 weeks- 1 year: Anxiety Sexual dysfunction Back pain/core instability

(3+ diastasis) De Quervaine’s

>1 year: Persistent sexual

dysfunction/low drive, Back and hip pain, Increased anxiety, insomnia,

intrusive thoughts. PTSD diagnosis did not come unit 2 ½ years postpartum

De Quervaine’s release Difficulty losing weight Infertility

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“See you in 6 weeks…”

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Recommendations for Establishing a Smooth Transition Between Postpartum and

Well-Woman Care

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The 4th Trimester Project Recommendations

Continuum of care

Tailored care

Compassionate, culturally sensitive and nonjudgmental communication

Innovative approachesTully J Behav Med 2018; 4thtrimester.web.unc.edu

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ACOG: Redefining the Postpartum Visit

“Ongoing process” versus single encounter Services and support tailored to individual needs

ACOG Committee Opinion 736 2018

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ACOG Provider Guidelines for Transition to Well-Woman Care

Identify provider for ongoing primary care/medical home

Make appropriate referrals

Ensure appropriate communication with primary care provider

Provide written recommendations of the above to patients, the health care team and in the medical record

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CDC Recommendations for Providers

Provide high-quality care for mothers up to one year after birth, which includes communicating with patients about warning signs and connecting to prompt follow-up care.

Help patients manage chronic conditions

Communicate with patients about warning signs

Use tools to flag warning signs early so women can receive timely treatment

Peterson EE, et al., 2019

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Strategies to Improve the Transition from Postpartum to Well Woman Care

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Some easy ways to individualize care… Read your patient’s chart before going in the room!! Be sensitive to secondary infertility. Informed providers are safer providers and inspire confidence in patients.

Ask questions: What are you most concerned about today? How have you processed your difficult your birth experience? Are you feeling shocked or traumatized by your birth?

Postpartum changes in mood (Depression, anxiety, PTSD), sexual dysfunction, energy level, wound healing can last far beyond 6 weeks.

Continuity of care should be available to the high risk/MFM patient beyond the 6 week follow up.

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Individualizing care continued “Common”≠ “normal” Be aware the tendency to become desensitized to things your

patients find distressing (some normal and some abnormal). YOU may be distressed if it was happening to YOU.

There’s no such thing as too much empathy! Be savvy with local resources and what types of help they can offer.

(i.e. postpartum mood disorders, pelvic PT, counseling, support groups, education)

Discuss common early complications of childbirth and when it’s reasonable to pursue additional medical (shock/depression/anxiety/PTSD, incontinence, sexual dysfunction, diastasis recti, back/hip pain, etc)

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Pelvic PT is more than just good kegels…

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Be Aware of and Share Other Resources Research Studies

Local and County Resources

National/International Support groups (facebook, pinterest, google) https://www.hopeforaccreta.org Maternal Near Miss Survivors Facebook 4th Trimester Project (facebook); @4thtrimesterproject (Twitter) Postpartum support international: psichapters.com Multiple Other Links to National Support groups: https://pqcnc-

documents.s3.amazonaws.com/aim/PQCNCOBHPPHResources20180327.pdf

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The North Carolina Experience

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North Carolina: Working to Improve Postpartum Visit Attendance

Successful clinical strategies to improve postpartum visit attendance in the North Carolina Medicaid population: Schedule postpartum visit(s) during late 3rd trimester visits Ensure patients leave hospital with postpartum follow-up scheduled, if not

arranged earlier Bring patients back early

− 1-2 weeks if warranted (high risk of depression, blood pressure check, operative delivery, lactation difficulties)

− 3-4 week comprehensive postpartum visit

Reminder texts, personalized notes, phone calls Quick follow-up for any missed visits

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North Carolina: Working to Improve Postpartum Visit Attendance

Provider-focused strategies to improve postpartum visit attendance: Incentives to providers for timely postpartum follow-up (within

60 days of delivery) with expectations:− Screen for postpartum depression

− Address reproductive life plan, including access to the desired contraceptive method

− Ensure warm hand-off to ongoing source of primary care

Ongoing quality improvement support, including access to timely data, to “hardwire” strategies such as missed visit calls

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North Carolina: Improving quality of postpartum care

Statewide network of “physician champions” – local opinion leaders to offer peer support, educate on best practices and emerging evidence, and bring local feedback to state level

Physician champions representing multiple health systems and practice settings (public/private) collaborate to develop standardized, evidence-based guidance and disseminate best practices (care pathways)

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North Carolina: Developed Pathway for Ensuring a Transition to Well Woman Care

North Carolina Medicaid Managed Care Pregnancy Medical Home created a postpartum care pathway (guideline) for member practices. https://www.communitycarenc.org/what-we-do/clinical-programs/pregnancy-medical-home/pmh-pathways/postpartum-care-and-transition-well-woman-care

Provide all patients with guidance about value and timing of primary care follow-up. Yearly visits for all women More frequent for women with medical complications such as diabetes or hypertension Identify appropriate care setting for continuing primary care outside of pregnancy,

within the current practice or provide referral.

Note: practices should identify and be able to provide a list local safety net providers for those patients with under-/un-insurance (https://www.freeclinics.com/, https://findahealthcenter.hrsa.gov/ )

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Have a Health Equity Lens Ask yourself: “How would your

interventions be modified if you could not claim success without racially equitable outcomes?”

Integrate social determinants into plan

Challenge your own implicit biases Resources:

Implicit Bias Testing: https://implicit.harvard.edu/implicit/takeatest.html

Black Lives Matter: Claiming a space for evidence-based outrage in obstetrics and gynecology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5024373/

Black Mamas Matter Toolkit: https://blackmamasmatter.org/toolkit-download/?download_nonce=24bdb044ef

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Treat the Postpartum Visit as an Opportunity for Well Woman Care

Pap ≠ Well Woman Care Available Resources Women’s Preventive Services

Initiative Table of Recommended Preventive Services: https://www.womenspreventivehealth.org/wp-content/uploads/WPSI_HealthCareChart_10October.pdf

US Preventive Services Task Force Tool: https://epss.ahrq.gov/PDA/index.jsp

ACOG committee opinions on well woman care and postpartum care: https://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co755.pdf?dmc=1&ts=20180924T2222253972and https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co736.pdf?dmc=1&ts=20190222T1814547421

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Chronic Disease Support

Patients may not be transitioning to “well” woman care but to primary care for chronic disease management

Strategies for postpartum women with chronic disease: Early and ongoing postpartum follow-up

Access to a local provider in the patient’s community

Community-based supports, such as care management, pharmacy support, behavioral health, especially for vulnerable populations

Optimize reproductive life planning to align patient’s reproductive intentions with disease management priorities

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Optimize Billing and Advocate for Better Coverage Ideal World 1-14 days: incision check, mood screen, BP monitoring, review of complications,

lactation support 15-60 days: contraception, mood screen 60-90 days: full preventive visit equivalent to annual exam

Routine global fee (59400, 59510), postpartum package (59410/59515) or postpartum only (59430) covers 1-2 clinic visits Problem visits can and should be coded as E&M visits with the appropriate ICD10 even

within the global period (e.g. Mastitis, Postpartum Depression, Pelvic Pain)

Enrollment in Family Planning Medicaid after Pregnancy Medicaid ends in non-expansion states

Disconnect? Advocacy

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Consider Alternate Models: Group Prenatal Care

Long-term (2 years later) changes in behavior related to nutrition, parenting and family communication

Improved postpartum contraception uptake

Improved perception of peer support and improved breastfeeding rates

Hackley J Midwifery Women’s Health 2019; DeCesare J Reprod Med 2017; Chae Arch Womens Mental Health 2017

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Consider Alternate Models: Pregnancy Complications Clinics

Maternal Health Clinic, Ontario Canada Invites all women with gestational diabetes, hypertensive diseases in pregnancy, growth

restriction, preterm birth, and placental abruption Cardiovascular risk screening done at 6 month postpartum appointment Communication provided to primary care doctor Follow-up for high risk women with cardiology, lifestyle recommendations and Cardiac

Rehab

Handbook for Providers who want to implement: Pudwell J, Smith GN. The Postpartum Maternal Health Clinic Handbook. http://www.themothersprogram.ca/after-delivery/postpartum-health/postpartum-maternal-health-clinic-handbook; 2013 Accessed July 2014 [Ref Type: Pamphlet].

Cusimano AJOG 2014

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Consider Alternate Models: Doula Programs Investigational approach to improve birth and postpartum

outcomes especially among women of color Chicago: postpartum home visiting support with doulas

improved some infant safety behaviors New York City Healthy Start: 4 postpartum visits over 6 months

1-2 hours long− “I would’ve had no one there; it was just me and her. If it wasn’t for her,

maybe I wouldn’t even get through it, because she really helped a lot”Hans Mat Child Health J 2018; Thomas Mat Child Health J 2017

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AWHONN developed post-birth warning signs educational tool

Majority of nurses surveyed: “helpful” and “easy to use”

Available in English, Spanish, Arabic and Mandarin: https://www.awhonn.org/page/POSTBIRTH

Identify/Create Educational Tools

Suplee Nursing for Women’s Health 2016

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Conclusions The transition to well woman care has public health and

quality of life importance The transition to well woman care is frequently suboptimal Simple changes can significantly improve quality of care Postpartum care providers should aim for: Excellent communication before and after pregnancy

Patient-centeredness

A health equity lens

Willingness to think outside the box

Advocacy for better coverage

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References• Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality committees.

Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs.• Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for

Prevention, 13 States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;68:423–429.• Callaghan WM, Creanga AA, and Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in

the United States. Obstet Gynecol 2012; 120(5):1029-1036• Liese KL, Mogos M, Abboud S, Decocker K, Koch AR, Geller SE. Racial and Ethnic Disparities in Severe Maternal Morbidity in

the United States. Journal of racial and ethnic health disparities. 2019 Mar 15:1-9.• Belfort MA, Clark SL, Saade GR, Kleja K, Dildy III GA, Van Veen TR, Akhigbe E, Frye DR, Meyers JA, Kofford S. Hospital

readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period. American Journal of Obstetrics and Gynecology. 2010 Jan 1;202(1):35-e1.

• Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. American journal of obstetrics and gynecology. 2016 Jul 1;215(1):113-e1.

• Khajehei M, Doherty M, Tilley PM, Sauer K. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. The journal of sexual medicine. 2015 Jun 1;12(6):1415-26.

• CDC. Selected 2012 through 2015 Maternal and Child Health (MCH) Indicators. Accessed at: https://www.cdc.gov/prams/pramstat/pdfs/mch-indicators/PRAMS-All-Sites-2012-2015-508.pdf (5/19/2019)

• Endres LK, Straub H, McKinney C, Plunkett B, Minkovitz CS, Schetter CD, Ramey S, Wang C, Hobel C, Raju T, Shalowitz MU. Postpartum weight retention risk factors and relationship to obesity at one year. Obstetrics and gynecology. 2015 Jan;125(1):144.

• Bennett WL, Chang HY, Levine DM, Wang L, Neale D, Werner EF, Clark JM. Utilization of primary and obstetric care after medically complicated pregnancies: an analysis of medical claims data. Journal of general internal medicine. 2014 Apr 1;29(4):636-45.

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References• Kline CR, Martin DP, Deyo RA. Health consequences of pregnancy and childbirth as perceived by women and clinicians.

Obstetrics & Gynecology. 1998 Nov 1;92(5):842-8.• Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Major survey findings of listening to MothersSM III: New mothers

speak out. The Journal of perinatal education. 2014 Jan 1;23(1):17-24.• Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J

Obstet Gynecol 2017; 217(1):37-41.• Suplee PD, Kleppel L, Santa-Donato A, Bingham D. Improving postpartum education about warning signs of maternal morbidity

and mortality. Nursing for women's health. 2016 Dec 1;20(6):552-67.• Thomas MP, Ammann G, Brazier E, Noyes P, Maybank A. Doula services within a healthy start program: increasing access for an

underserved population. Maternal and child health journal. 2017 Dec 1;21(1):59-64.• Hackley B, Elyachar‐Stahl E, Savage AK, Stange M, Hoffman A, Kavanaugh M, Aviles MM, Arévalo S, Machuca H, Shapiro A. A

Qualitative Study of Women's Recall of Content and Skills Developed in Group Prenatal and Well‐Baby Care 2 Years Later. Journal of midwifery & women's health. 2018 Nov 1.

• DeCesare JZ, Hannah D, Amin R. Postpartum Contraception Use Rates of Patients Participating in the Centering Pregnancy Model of Care Versus Traditional Obstetrical Care. The Journal of reproductive medicine. 2017;62(1-2):45-9.

• Chae SY, Chae MH, Kandula S, Winter RO. Promoting improved social support and quality of life with the CenteringPregnancy® group model of prenatal care. Archives of women's mental health. 2017 Feb 1;20(1):209-20.

• McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstetrics & Gynecology. 2018 Sep 1;132(3):784-5.

• World Health Organization. WHO recommendations on postnatal care of the mother and newborn. World Health Organization; 2014.

• Eichelberger KY, Doll K, Ekpo GE, Zerden ML. Black Lives Matter: Claiming a Space for Evidence-Based Outrage in Obstetrics and Gynecology. Am J Public Health. 2016 Oct;106(10):1771-2..

• Cusimano MC, Pudwell J, Roddy M, Cho CK, Smith GN. The maternal health clinic: an initiative for cardiovascular risk identification in women with pregnancy-related complications. Am J Obstet Gynecol. 2014 May;210(5):438.

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