Postpartum Patient Navigation and Postpartum Weight Retention

"A Wake-Up Call": A Mixed-Methods Analysis of Barriers to Type 2 Diabetes Prevention After Gestational Diabetes Mellitus

Background

Individuals who have gestational diabetes mellitus (GDM) are advised to engage in physical activity and healthy eating behaviors in the postpartum period to prevent type 2 diabetes. We aimed to understand individual perspectives on incorporating such lifestyle choices during the first postpartum year.

Methods

This was a mixed-methods analysis of data from individuals with GDM who completed surveys and in-depth interviews at 4-12 weeks and 11-13 months postpartum as part of their participation in a feasibility randomized controlled trial on postpartum patient navigation. Participant attitudes were elicited with surveys (structured items with Likert-scale responses) and interviews that focused on barriers to postpartum type 2 diabetes prevention. We used a concurrent, triangulation design to jointly analyze survey data alongside interview data.

Results

Of 40 participants, 39 provided data about their type 2 diabetes prevention activities. Interview themes triangulated with survey results to yield consistent insights about attitudes regarding physical activity and healthy eating. The majority of participants reported that caring for a new baby and family responsibilities made it much harder to be physically active; fewer participants identified cost of exercise, accessing a safe area to exercise, or breastfeeding as barriers. The most common barriers to healthy eating included caring for a new baby, family responsibilities, and work/school schedules. Although proximity and transportation to healthy food sources were uncommon barriers, when they did occur, they were experienced as major burdens.

Conclusion

Individuals who had GDM reported many barriers to implementing recommended postpartum lifestyle choices. Recognizing these unique needs may enhance provision of guidance for type 2 diabetes prevention postpartum.

Patient navigation in women's health care for maternal health and noncancerous gynecologic conditions: a scoping review

PURPOSE

This study investigated the scope of patient navigation studies on women's health care for maternal health and noncancerous gynecologic conditions and aimed to report the characteristics of the identified patient navigation programs.

METHODS

A scoping review was conducted following Arksey and O'Malley's framework. Five electronic databases were searched for relevant studies published in English: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo. There were no restrictions on the publication date and the search was completed in July 2023.

RESULTS

This scoping review included 14 studies, which collectively examined seven patient navigation programs. All selected studies were related to maternal health issues (e.g., perinatal health problems and contraception for birth spacing). Close to two-thirds of the patient navigation services were provided by women (n=9, 64.3%) and half by lay navigators (n=7, 50.0%). The majority incorporated the use of mobile health technologies (n=11, 78.6%). All of the patient navigation programs included in the review coordinated the necessary clinical and social support services to improve women's access to care.

CONCLUSION

Patient navigation appears to be in its nascent phase in the field of maternal health. The results of this study suggest that the implementation of patient navigation services could potentially improve access to care for socially disadvantaged women and families. Furthermore, providing patient navigation services that are specifically tailored to meet women's needs could improve the quality of maternity care.

Obstetric Provider Perspectives on Postpartum Patient Navigation for Low-Income Patients

BACKGROUND

Patient navigation programs have shown promise for improving health but are not widely used in obstetric care. Our objective was to understand obstetric provider perspectives on how to implement patient navigation to optimize care during the postpartum period for low-income patients.

METHOD

Focus groups were conducted with obstetric physicians, nurses, and social workers who care for low-income pregnant and postpartum patients in an academic medical center. Semistructured interview guides were developed to elicit conversations about the potential value of patient navigators, recommendations for navigator training, and how navigators could be most effective in improving postpartum care. Analysis of themes was based on the constant comparative method.

RESULTS

Twenty-six obstetric providers (six focus groups) discussed elements for a successful obstetric navigation program. Successful implementation themes included selecting navigators with appropriate interpersonal attributes, arranging navigator training, and identifying the most valuable services navigators could render. Desirable navigator attributes included persistence in patient advocacy, consistency, relatability, and a supportive manner. Training recommendations included learning the health care system, identifying where to obtain health system and community resources, and learning how be effective health educators. Suggested services were broad, ranging from traditional care coordination to specific educational and resource-driven tasks.

CONCLUSIONS

Obstetric providers perceive patient navigation to be a potentially beneficial resource to support low-income patients and offered recommendations for navigation implementation. These included suggestions for patient-centered navigators, with specific training and services focused on promoting care continuity and coordination.

Mobilizing the fourth trimester to improve population health: interventions for postpartum transitions of care

Birthing people in the United States, particularly those from marginalized communities, experience an unexpectedly high rate of morbidity and mortality. Optimal postpartum care is an opportunity to address immediate maternal health concerns while providing a connection to further high-value primary care. However, postpartum care in the United States is fragmented and incomplete. In response to this failure, the American College of Obstetricians and Gynecologists has called for obstetricians to develop individualized care plans that facilitate transitions from obstetrical to primary care after delivery. In this clinical opinion, we review previous interventions that have aimed to increase postpartum care engagement and bridge gaps in care. Although numerous interventions have been trialed, few have been both successful and scalable. We provide recommendations on ways to reimagine equitable and effective postpartum care interventions with multidisciplinary collaboration.

Primary Care Clinician Perspectives on Patient Navigation to Improve Postpartum Care for Patients with Low Income

Background

Birthing individuals experience significant physical and psychosocial transitions during the postpartum period. Despite amplified health needs, many individuals do not successfully transition from obstetric to primary care. Patient navigation provides a patient-centered solution that has been applied to other health care specialties resulting in improved care coordination and patient engagement for populations in greatest need. Our objective was to understand primary care clinician perspectives regarding the role of navigators in improving postpartum care for individuals with low income.

Methods

In this qualitative investigation, we conducted focus groups with primary care clinicians from family and internal medicine specialties. Semistructured interview guides addressed clinician perceptions of navigator roles during the postpartum period and recommendations for navigator training. Focus group discussions were digitally recorded, transcribed, and analyzed via a constant comparative method.

Results

Twenty-eight primary care clinicians, including 26 physicians and 2 advanced practice registered nurses, participated in 8 focus groups. Participants reported favorable attitudes toward implementation of a postpartum patient navigation program. Themes regarding useful navigation services included streamlining obstetric to primary care transition, enhancing visit effectiveness, creating personalized postpartum care, and providing patient- and clinician-focused education. Recommendations for navigator training included education on basic medical concerns that are common in the postpartum period, health information privacy and electronic health record use, health care systems, and community resources.

Clinical Trial Registration number: NCT03922334.

Conclusions

Primary care clinicians were highly receptive to the concept of patient navigation as a process to improve health in the postpartum period through enhanced care coordination and improved patient knowledge, engagement, and self-efficacy.

Mental health after childbirth and the impact on postpartum weight retention and body composition. Data from the INTER-ACT randomized controlled trial

OBJECTIVE

To study the evolution of maternal mental health during the first year after childbirth in women with previous excessive gestational weight gain, and the relationship with postpartum weight retention and body composition.

METHODS

Anthropometric and mental health data of 505 women of the INTER-ACT RCT control group were collected and assessed using descriptive statistics and mixed model analyses.

RESULTS

At 6 weeks postpartum 28% of women reported depressive symptoms, 46% anxiety, 47% low sense of coherence and 48% low quality of life. From 6 weeks to 12 months postpartum there was a monthly increase (+0.38, p = .003) in anxiety and a monthly decrease (-0.39, p = .008) in quality of life. High levels of depressive symptoms at 6 weeks postpartum predicted higher body fat (+0.9%, p = .01) and higher waist circumference (+1.3 cm, p = .02) in the first year postpartum. High sense of coherence at 6 weeks postpartum predicted lower body fat (-0.8%, p = .01) the first year postpartum.

CONCLUSIONS

In women with a history of excessive gestational weight gain, the first year after childbirth is characterized by a high prevalence of mental health problems in which levels of anxiety and quality of life deteriorate over time. Moreover, high levels of depressive symptoms and low sense of coherence in the first weeks postpartum predict unfavourable body composition outcomes in the year after childbirth.

Gestational Weight Gain: Achieving a Healthier Weight Between Pregnancies

Rates of obesity continue to be a cause of morbidity and mortality, requiring intervention. Excessive gestational weight gain is related to postpartum weight retention and subsequent development of obesity, which translates into higher risk of adverse maternal and neonatal outcomes in future pregnancies and long-term excess cardiovascular disease and cancer for the mothers. Limiting gestational weight gain to within recommended limits prevents postpartum weight retention. This article provides an overview of methods and practices aimed at helping women achieve a healthy weight between pregnancies by improving gestational weight gain. These interventions include lifestyle behavioral changes, diet and exercise, and motivational interviewing.