Postpartum during a pandemic: Challenges of low-income individuals with healthcare interactions during COVID-19

Experiences Receiving and Delivering Virtual Health Care For Women: Qualitative Evidence Synthesis

BACKGROUND

Persisting sex- and gender-based disparities in access to high-quality, personalized health care in the United States can lead to devastating outcomes with long-lasting consequences. Strategic use of virtual resources could expand equitable health care access for women. However, optimal approaches and timing for individualized, virtually delivered health care for women are unclear.

OBJECTIVE

This study aims to conduct a detailed analysis of the current literature to answer the following question: "According to women and their health care teams, what are the reported successes and challenges in accessing, delivering, and participating in synchronous virtual health care for women?"

METHODS

We conducted a qualitative evidence synthesis using a best-fit framework approach based on the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework and concepts from the Public Health Critical Race Praxis. We searched MEDLINE, Embase, and CINAHL from January 1, 2010, to October 10, 2022, using a combination of database-specific, relevant, controlled vocabulary terms and keywords; this search was updated in MEDLINE through January 2024. Additional citations were identified through handsearching. Our eligibility criteria were developed using the Sample, Phenomenon of Interest, Design, Evaluation, Research type tool to identify qualitative studies addressing synchronous virtual care for women. Citations were screened in duplicate, and eligible articles were abstracted. An iterative thematic synthesis approach was used to identify descriptive themes related to the successes and challenges related to delivering high-quality virtual care. Data reduction was performed using inductive and deductive reasoning. Quality assessment was conducted using the Critical Appraisal Skills Program and certainty of evidence using Confidence in the Evidence from Reviews of Qualitative Research approaches.

RESULTS

Of 85 eligible articles, we sampled 51 (60%) for data extraction based on representation of patient and clinician perspectives, marginalized voices, and relevance to a variety of clinical contexts. We identified themes across NASSS domains, including difficulty building rapport and emotional connections in the virtual setting, the amplification of barriers for women with preexisting challenges (eg, language barriers, limited transportation, and family and social commitments), and differing perceptions of privacy and safety related to virtual care depending on patient home context. Themes found to have high confidence included the value of convenience and cost savings offered by virtual care, the importance of patient choice in visit modality, the potential for negative impact on user well-being, considering the clinical context of modality choice, the importance of technology usability, and the value of virtual care for women located in regions without adequate supply of clinical offerings.

CONCLUSIONS

The benefits of virtual care for health care access may be more acutely felt by women, especially those with preexisting challenges. Strategic incorporation of virtual modalities into health care delivery for women could improve equitable access to high quality, patient-centered care.

TRIAL REGISTRATION

PROSPERO CRD42021283791; https://www.crd.york.ac.uk/PROSPERO/view/CRD42021283791.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1089/heq.2023.0089.

Change in Postpartum Visit and Contraception Rates Pre-COVID-19 to Post-Lockdown in Six U.S. Federally Qualified Health Centers

Background: Postpartum care, including contraception, benefits maternal health and decreases mortality, which increased in the United States with COVID-19. Pandemic disruptions to postpartum health care access in vulnerable populations are not well understood. We utilize electronic health record (EHR) data for prenatal patients (n = 2,265) at six urban Federally Qualified Health Centers (FQHCs) from one year prepandemic (January 1, 2019) through one year after the first stay-at-home orders ("lockdown") (March 31, 2021). Objective: We investigated (1) changes in rates of postpartum visit (PPV) and postpartum contraception receipt in the post-lockdown versus prepandemic periods and (2) characteristics predictive of differential changes in PPV and contraception rates. Materials and Methods: Visit and prescription records from EHR were used to classify if patients received PPV and most/moderately effective contraception within 60 days postpartum, analyzed separately and as a composite variable: PPV and contraception, PPV only, or no PPV. Risk differences comparing post-lockdown with pre-COVID-19 pandemic were estimated using binomial regression and generalized logistic regression models adjusted for age, race/ethnicity, language, and clinical site. Effect modification by sociodemographic and clinical covariates was examined. Results: Total patient volume fell 21% in the post-lockdown versus pre-COVID-19 period. Rates of PPV decreased in absolute terms by 9.6 (95% confidence interval: -13.6, -5.6) and contraception by 8.1 (-13.3, -2.8) percentage points. After adjustment, PPV and contraception decreased by 9.3 percentage points (-13.1, -5.4), while PPV only was stable (-0.4 [-4.3, 3.6]). Conclusions: These findings suggest a substantial impact of the COVID-19 pandemic on postpartum care in FQHCs and community health centers. Supply and demand drivers require further examination to inform strategies to improve postpartum care access and subsequent maternal health outcomes.

Uncertainties and contradictions experienced by women with COVID-19 during childbirth/birth and the postpartum period

OBJECTIVES

to understand experiences and meanings attributed to childbirth/birth and postpartum by women affected by COVID-19.

METHODS

qualitative study in light of complexity, conducted through interviews with 15 women in university hospital reference for infected and high-risk pregnant women in tenth Health Region of Paraná, Brazil, between December 2021 and April 2022. Data were analyzed using thematic analysis.

RESULTS

childbirth/birth and postpartum experiences different from what was desired and planned, permeated by uncertainties, unpredictability and contradictions, especially regarding maternal and neonatal outcomes, were identified. Experiences full of meanings and emotions caused suffering and compromised mental health, particularly related to prematurity, newborn separation, absence of companion and isolation in COVID-19 unit. Mother-baby bond, self-care and breastfeeding damage, and antagonistic professional actions were observed, with a setback in obstetric practices.

FINAL CONSIDERATIONS

there is a need to respect the rights guaranteed by law and designate professionals trained for maternal and child care.

Experiences of Midwestern obstetric clinicians during the Coronavirus disease 2019 pandemic

Background

The Coronavirus disease 2019 (COVID-19) pandemic led to healthcare system changes aimed at minimizing disease transmission that impacted experiences with obstetric healthcare.

Objective

To explore experiences of clinicians providing obstetric care during the COVID-19 pandemic.

Study Design

Qualitative, in-depth, semi-structured interviews were conducted with five nurse practitioners and 16 obstetrical physicians providing a mix of outpatient and inpatient obstetric care during the COVID-19 pandemic in a mid-sized, Midwestern city in the United States. Interviews elucidated challenges and facilitators of obstetric care provision and vaccination of pregnant patients against COVID-19 during the pandemic. Transcripts were coded inductively then deductively using the Health Equity Implementation Framework (HEIF), which integrates a disparities framework and implementation framework to highlight multilevel factors that influence obstetric care. Thematic analysis was conducted, and thematic saturation was reached.

Results

We interviewed 21 clinicians. Clinicians recounted personal challenges such as social isolation and burnout that could be countered by social support. Challenges within the clinical encounter included implementation of infection mitigation efforts, vaccine counseling, and limitations of telehealth. However, when successfully implemented, telehealth facilitated care and circumvented barriers. Clinicians cited challenges at the healthcare system level such as rapidly evolving knowledge and recommendations, restrictive visitor policies, personnel shortage, and inadequate institutional resources to support pandemic-related stressors. However, interdisciplinary care and guidelines available for clinicians facilitated care. Clinicians reported that challenges at the societal level included financial strain, lack of childcare, medical mistrust, politicization of medicine, misinformation, and racism. Societal-level facilitators included insurance access, community outreach, positive policy changes, and fostering trust in medicine.

Conclusion

The pandemic produced unique stressors and exacerbated existing challenges for clinicians providing obstetric care. Applying the HEIF to the findings emphasizes the influence of societal factors on all other levels. Identified facilitators can inform interventions to address stressors in obstetric care that have resulted from the changed sociopolitical landscape of the pandemic.

Optimising digital clinical consultations in maternity care: a realist review and implementation principles

OBJECTIVES

The COVID-19 pandemic has led to increased use of digital clinical consultations (phone or video calls) within UK maternity services. This project aimed to review the evidence on digital clinical consultations in maternity systems to illuminate how, for whom and in what contexts, they can be used to support safe, personalised and equitable care.

DESIGN

A realist synthesis, drawing on diverse sources of evidence (2010-present) from OECD countries, alongside insights from knowledge user groups (representing healthcare providers and service users).

METHODS

The review used three analytical processes (induction, abduction and retroduction) within three iterative stages (development of initial programme theories; evidence retrieval and synthesis; validation and refinement of the programme theories).

RESULTS

Ninety-three evidence sources were included in the final synthesis. Fifteen programme theories were developed showing that digital clinical consultations involve different mechanisms operating across five key contexts: the organisation, healthcare providers, the clinical relationship, the reason for consultation and women. The review suggests that digital clinical consultations can be effective and acceptable to stakeholders if there is access to appropriate infrastructure/digital resources and if implementation is able to ensure personalisation, informed choice, professional autonomy and relationship-focused connections. The review found relatively less evidence in relation to safety and equity.

CONCLUSIONS

Due to the complexity of maternity systems, there can be 'no one-size fits all' approach to digital clinical consultations. Nonetheless, the review distills four 'CORE' implementation principles: C-creating the right environment, infrastructure and support for staff; O-optimising consultations to be responsive, flexible and personalised to different needs and preferences; R-recognising the importance of access and inclusion; and E-enabling quality and safety through relationship-focused connections. Service innovation and research are needed to operationalise, explore and evaluate these principles, particularly in relation to safety and equity.

PROSPERO REGISTRATION NUMBER

CRD42021288702.

Characteristics and influencing factors of caregivers' healthcare preferences for young children under COVID-19 lockdown: a cross-sectional study in Shanghai, China

BACKGROUND

Missed or delayed child healthcare caused by the COVID-19 lockdown has threatened young children's health and has had an unpredictable influence on caregivers' child healthcare preferences. This study investigated caregivers' child healthcare preferences and the factors that influence them among families with young children (0-3 years) during the lockdown in Shanghai.

METHODS

Participants in this cross-sectional study were enrolled through random encounter sampling. Questionnaires were distributed online from June 1 to November 10, 2022, in Shanghai. A total of 477 valid questionnaires were received. The demographics of caregivers and their families, children's characteristics, COVID-19-related information, and caregivers' healthcare preferences were analyzed. The statistical analyses included frequency and percentage, chi-square tests, and multinomial logistic regression.

RESULTS

Caregivers preferred child healthcare professionals in the community health service system (CHS; 47.6%) followed by hospital pediatricians (40.0%) during lockdown. Caregivers with the following characteristics preferred CHS: those with an annual household income of CNY 200,000-300,000, those whose youngest children were aged 8-12 months, and those who experienced early childhood physical development issues. Caregivers preferred hospitals if they had experienced healthcare-seeking-related difficulties in accessing professional guidance from hospital pediatricians.

CONCLUSIONS

During pandemic lockdowns, policymakers should allocate more resources to CHS to meet caregivers' childcare demands. Moreover, special attention should be given to the healthcare needs for CHS among families with specific demographics.

TRIAL REGISTRATION

Approval was obtained from the Ethics Committee of Shanghai Jiao Tong University School of Medicine School of Public Health (SJUPN-202,109; June 1, 2022).

"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.

Pandemic stressors and vaccine hesitancy among young, pregnant Black people: A qualitative study of health disparities during a global pandemic

BACKGROUND

The novel coronavirus 2019 (COVID-19) pandemic exacerbated existing health inequities in the United States, but no studies have focused on the lived experiences of younger Black birthing people. The goal of this qualitative study was to center the experiences of younger pregnant and birthing Black and Biracial people during the pandemic.

METHODS

We recruited 25 Black and Biracial pregnant and birthing people ages 16-23 for individual semi-structured interviews. Participants were asked about experiences with the healthcare system during the pandemic, and interviews were transcribed verbatim and coded for qualitative analysis using nVivo. We adhered to the Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

Participants identified pandemic-related stressors such as fears about infection, lack of support, and pressure to get vaccinated. Reasons for vaccine hesitancy included mistrust in the government and racism experienced during reproductive healthcare. Provider appeals highlighting patient autonomy and science were more effective in encouraging vaccine uptake than emotional appeals that made participants feel guilty about potentially infecting loved ones.

CONCLUSIONS

Restrictions on children and support people created barriers to timely prenatal care and reduced tangible support for young Black and Biracial birthing people during the pandemic. Their vaccine hesitancy was related to mistrust, concerns that the vaccines had not been tested enough prior to roll-out, and possible side effects of the vaccine including infection with the virus and pregnancy loss. Obstetric providers need to understand and recognize the ongoing impact of obstetric and scientific racism on health communication with younger Black and Biracial patients.

Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings

Perinatal mental health has garnered significant attention within obstetrics over the last couple of decades as the long- and short-term morbidities of untreated perinatal mental health disorders on both the mother and fetus/neonate have become increasingly apparent. There have been major strides in increasing screening for perinatal mental health disorders, clinician comfort with prescribing common psychiatric medications, and integrating mental health professionals into prenatal care via health services approaches such as the collaborative care model. Despite these advances, however, gaps still remain in the tools used for screening and diagnosis, obstetric clinician training in diagnosis and management of perinatal mood and anxiety disorders, as well as patient access to mental health care during pregnancy and especially postpartum. Herein we review the state of perinatal mental health from the perspective of the obstetric provider and identify areas of ongoing innovation.

Association Between the Coronavirus Disease 2019 (COVID-19) Pandemic and National Disparities in Postpartum Visit Attendance

This study used data from PRAMS (Pregnancy Risk Assessment Monitoring System) between 2016 and 2020 and found that postpartum visit attendance declined by 5.8 (95% CI -6.4 to -5.2) percentage points in the first 9 months of the coronavirus disease 2019 (COVID-19) pandemic. The greatest declines occurred among non-Hispanic Black individuals (-9.9, 95% CI -11.6 to -8.1 percentage points), individuals aged 19 years or younger (-9.9, 95% CI -13.5 to -6.2 percentage points), and individuals without postpartum insurance (-11.4, 95% CI -14.5 to -8.3 percentage points). Although the pandemic was associated with a decrease in reporting common barriers to attendance, including lack of transportation and not being able to leave work, it introduced new barriers that potentially contributed to widened disparities in postpartum care. A combination of health policy and health system approaches are needed to increase postpartum visit attendance and reduce disparities in use.

The Stress of Parenting in the Postpartum Period During the COVID-19 Pandemic

Background

The COVID-19 pandemic produced a major shift in parental roles, which disproportionally exacerbated existing challenges for low-income new parents. Our objective was to identify pandemic-related parenting challenges experienced by low-income postpartum individuals in the context of the early months of the COVID-19 pandemic.

Methods

Semistructured interviews with 40 low-income postpartum individuals were conducted within 10 weeks after giving birth in April 2020-June 2020. Interviews addressed maternal health and well-being, parental stress, including COVID-related barriers to providing for children, and access to essential services. Interview themes were developed using the constant comparative method.

Results

Half (n = 20) the participants identified as non-Hispanic Black and 38% (n = 15) as Hispanic; 75% (n = 30) were parents of multiple children. Parenting-related themes included challenges of parenting multiple children, barriers to maintaining self-care, and novel barriers to providing for children. Participants discussed handling new roles as educators, struggles with entertaining, allocating time among children, and effects of the pandemic on older children. Participants frequently described their lack of alone time, changes in self-care and coping strategies due to continuous parenting, and effects on maternal mental health like increased anxiety. Many participants reported lack of communal support, financial stress, and difficulty accessing services.

Conclusions

New burdens introduced by the pandemic challenged low-income individuals' health and well-being. Understanding these psychosocial stressors and developing interventions to ameliorate these burdens may be key to promoting family health during difficult times; one potential solution for preventing postpartum depression is offering continual social services. Clinical Trial No.: NCT03922334.

Experiences Navigating the Pregnancy Care Continuum During the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic led to unprecedented changes in care delivery across the pregnancy care continuum. Our primary objective with this research was to characterize the range of ways that the early months of the COVID-19 pandemic affected pregnancy, childbirth, and postpartum care experiences.

METHODS

Pregnant and recently pregnant patients (n = 20) from obstetrics and gynecology clinical sites associated with Massachusetts General Hospital were interviewed about their experiences with prenatal care, childbirth, and postpartum care during the first wave of the COVID-19 pandemic. Interview transcripts were analyzed for emergent themes.

RESULTS

This sample included 20 pregnant and postpartum people, including 11 individuals who tested positive for COVID-19 during pregnancy or postpartum and nine with suspected infection. The ways in which COVID-19 or suspected COVID-19 affected experiences of prenatal care, childbirth, and postpartum care were complex and varied. Three themes were identified across narratives of pregnancy, birth, and postpartum care: patient perceptions of diminished access to care, stigma due to COVID-19 infection, and limited capacity of providers to honor patient preferences.

CONCLUSIONS

A better understanding of pregnant and recently pregnant people's experiences during the early months of the COVID-19 pandemic can inform infection control policies and clinical care delivery practices that are more congruent with the needs and values of pregnant, birthing, and postpartum people as institutions craft responses to future pandemics. Approaches that maximize meaningful access across the pregnancy care continuum, center patients' priorities within adapted care models, and honor patient preferences as much as possible are important aspects of an appropriate response to future waves of COVID-19 and other pandemics.