Abstract
Background:
Short inter-pregnancy interval (IPI) is associated with adverse health outcomes for women and infants, and low-income women experience disproportionate rates of short IPI. An essential solution is providing postpartum (PP) women with timely contraceptive care. However, patient-centered approaches for facilitating care access are needed.
Objective:
To explore Community Health Center (CHC) staff and provider perspectives on the implementation of a clinical trial offering co-scheduled well-infant/maternal contraceptive care for women with infants 0 to 6 months at the Well-Baby Visit (WBV).
Method:
Eighteen participants (providers, staff, and administrators) representing 7 diverse CHC sites in 2 U.S. states completed semi-structured telephone interviews. Audio-recordings were transcribed and analyzed using hybrid thematic analysis.
Results:
Offering co-scheduled visits was perceived as beneficial for facilitating timely PP contraception, convenient care access, and encouraging family planning considerations during the PP period. However, provider and staff discomfort with initiating family planning and contraceptive care conversations at the WBV emerged as a salient barrier.
Conclusion:
Paired approaches to well-infant/maternal contraceptive care may promote increased access to timely contraception for PP women, possibly reducing unintended short IPI. Comprehensive training, ongoing support, and patient-centered implementation strategies tailored to context and developed with care team input are needed to ensure competency and comfortability with facilitating contraceptive care conversations at the WBV.
Keywords
Introduction
Pregnancies conceived within 18 months of a prior delivery (termed short inter-pregnancy interval [IPI]) place mothers and infants at high risk for poor health outcomes including pre-eclampsia, anemia, preterm birth, low-birth weight, and congenital abnormalities.1 -3 Despite these negative health consequences, nearly 27% of pregnancies in the United States are short IPI pregnancies. 3 While the percentage of total short IPI has decreased in recent years, numbers among racial/ethnic minority women have increased, and women with household incomes below the federal poverty level compromise over 30% of all short IPI pregnancies. 3 Thus, there is an urgent need for patient-centered approaches to address these health disparities, and decrease rates of unintended short IPI pregnancies toward improved health outcomes for low-income and underserved women and infants.
An essential approach to reducing short IPI is providing postpartum (PP) women at risk for unintended pregnancy with timely access to effective contraception, a key reproductive health goal outlined by the U.S. Department of Health and Human Services (HHS) Healthy People 2030. 4 Traditionally, contraceptive counseling is routinely provided as part of the 4 -to- 6 week PP visit. However, many women resume sexual activity prior to 6 weeks PP,5,6 and many women, particularly low-income and racial/ethnic minority women, do not present for the visit.7 -9 Although many women do not attend the PP visit, receiving contraceptive counseling throughout the maternity continuum, both antenatally and PP, has been associated with greater uptake of postpartum contraception. 10 In addition, research supports that many women are interested in receiving contraceptive care earlier in the PP period, prior to the first PP appointment.8,11 -13
Well Baby Visits (WBV), beginning 3 to 5 days post-hospital discharge and re-occurring at least 6 other times throughout the first year (ie, 1, 2, 4, 6, 9, and 12 months) may provide valuable opportunity for reaching women at risk for unintended pregnancy early in the PP period to address their reproductive health needs. 14 Paired approaches (eg, co-located and co-scheduled) maternal contraceptive care and WBV visits have demonstrated feasibility and acceptability within urban academic health centers.14 -17 However, these models have not yet been widely implemented or evaluated within Community Health Centers (CHCs), which service an estimated 24% of all low-income women of childbearing age in the United States. 18 Thus, the present research qualitatively explores staff and provider perspectives on the implementation of the Linking Inter-professional Newborn and Contraception Care (LINCC) trial, a co-scheduling program pairing maternal contraceptive care with a WBV in diverse CHC settings.
Method
The LINCC Trial
This qualitative study is a planned component of the LINCC trial, an effectiveness-implementation trial that employs mixed methods and a stepped wedge design. The trial began in 2021, and the co-scheduling program has since been fully implemented within 7 CHCs and 14 individual CHC sites in Illinois, Hawaii, and New York. All components of the trial, including the present research, were approved by the Institutional Review Boards of participating universities.
The LINCC co-scheduling program was developed with input gathered from CHC providers and PP patients at implementing sites during an earlier phase of the trial. With the aim of increasing access to timely PP contraceptive care, LINCC offers women with infants 0 to 6 months co-scheduled appointments for contraceptive counseling and/or services (with a women’s health provider) at the same time as a future scheduled WBV. To offer these appointments, staff and providers engage with PP women about their family planning and contraceptive care needs at a WBV, including facilitating a co-scheduled appointment for contraceptive counseling (or procedures) at the time of a future WBV.
In this model, conversations about contraceptive care planning are initiated at the WBV by the infants’ provider (eg, a pediatric or family medicine provider), while support staff are primarily responsible for coordinating co-scheduled maternal and infant appointments. Aligned with the principles of reproductive justice and a person-centered approach to contraceptive counseling, 19 providers were trained to present contraceptive appointments as entirely optional, tailored to the patients’ expressed desires regarding family planning and choice of contraceptive methods—including the choice to not use any method of contraception—and to avoid emphasizing any one particular method of contraception over another in their conversations. PP women who decline a contraceptive appointment but indicate openness to contraception at a later timepoint are offered LINCC at each subsequent WBV until 6 months.
Aims and Research Questions
In this qualitative study, we aimed to understand staff and provider experiences with the LINCC program, to inform the development and implementation of similar paired approaches to maternal contraceptive care and well-baby care. Our study was guided by the following research questions:
(1) What are CHC staff and providers perspectives on the acceptability and appropriateness of LINCC for their clinical settings and patient populations?
(2) How have CHC staff and providers experienced offering LINCC to PP women and families?
(3) What barriers and facilitators have been identified?
Recruitment and Data Collection
Purposive sampling methods were used to recruit staff, providers, and administrators who were involved with the trial at their CHC sites. One trained research assistant (AZ; female, medical student) contacted the clinical coordinators of each participating health site via email to invite them to participate in an interview, and to provide a list of other staff and providers involved with trial implementation. Thirty-one potential participants were contacted via email; 18 participants responded to the email invitation and completed an interview.
All interviews (12-55 min) were facilitated by AZ, using a semi-structured interview guide developed collaboratively with research team members AZ, SH, and RC. Interview guides were informed by the Consolidated Framework for Implementation Research (CFIR). 20 The CFIR is an implementation determinants framework that describes factors associated with implementation outcomes across 5 domains: (eg, Outer setting, Inner Setting), and is used to predict or describe barriers and facilitators to implementation. 21 Interviews were conducted by phone and audio-recorded, apart from one interview that was completed via email per respondent request. Interviews took place between August 2022 and September 2023, ranging from 6 to 12 months after the initial implementation of LINCC at each site. Participants received a $25.00 Amazon gift card for their participation.
Data Analysis
Interview audio-recordings were transcribed verbatim. ATLAS.ti.22 22 software was used for data organization and management, and to facilitate initial coding. Informed by the principles of grounded theory, including a constant comparison across data units, analytic and reflective memoing, simultaneous data collection and analysis, and an iterative analysis process, 23 AK (Female, Assistant Professor, PhD) reviewed and analyzed interview audio-recordings and interview transcripts applying both inductive and deductive coding and categorization strategies. 24 Inductive codes applied consisted largely of “in-vivo” codes (ie, codes that use the participants’ own language, such as “Awkward,” “Not my role,” “Great opportunity”). In-vivo codes are utilized to elevate the participant voice and maintain proximity to participant language throughout the process of data analysis. 25 Deductive codes were derived primarily from the CFIR domains and constructs and were applied to root the data in the context of implementation barriers and facilitators across the 5 CFIR domains. Deductive codes incorporated CFIR domains and constructs using domains as code stems (eg, Inner Setting: Mission Alignment or Outer setting: Access barriers). Reflective summary memos 25 were completed for each interview and used in the process of thematic development. Emergent themes were presented and discussed with research team members AZ, SH, and RC at multiple timepoints throughout the analysis process, and subsequently restructured to form the final themes.
Findings
Participants were medical assistants or other front-desk staff (8), pediatricians and pediatric nurse practitioners (8), and clinic administrators (2) from 6 diverse CHC sites in Illinois and 1 rural site in Hawaii (See Table 1). In this section, experiential themes are presented with embedded quotations; a list of all themes each with accompanying illustrative quotations may be found in Table 2.
Sample Characteristics by Clinic Role (n = 18).
Study Themes With Additional Illustrative Quotes.
Views on Addressing Contraception at the WBV
Participants shared their perspectives, observations, and experiences with initiating contraceptive care planning topics in the early days PP. Staff and providers across sites noted an observed tendency for newly PP women to prioritize the needs of the infant and “forget” about their own health—inclusive of their reproductive health— during the first several weeks post-delivery. For some, discussing the LINCC program functioned as a “reminder” for PP women, families, and pediatric providers to actively consider a woman’s healthcare needs in the early PP, and served as an opportunity for providers to offer encouragement and support toward addressing those needs.
LINCC is definetely helping me better understand the population I serve. Many [mothers] have no plan, they tend to miss their appointments, and they don’t understand the importance of the appointments for themselves. They tend to focus only on the infant. . .they forget about themselves. . .sometimes, I [forget about them] too. . . (P2, CHS #3) I just asked if they wanted to link their postpartum care to their baby’s care, because it might simplify things for them. [I say] we’re doing this project to see if we can link the baby’s care to the mother’s care. And its just to make sure that moms get the postpartum care they need. That’s what I say. And I would say the majority of women, lots of women, are interested. . .(P2, CHS #2)
For others, offering LINCC was valued as an opportunity to deliver needed information and address myths and misconceptions about postpartum pregnancy—a recognized need.
It’s important for [women] to know that they can get pregnant before they thought they could. . .it’s really important to tell them, you can get pregnant before your period. . .they tell them to wait 4-6 weeks [before sexual intercourse]. They may not wait that long. . .they think, “oh, I just had a baby, I can’t get pregnant.” (P1, CHS #1)
However, some participants viewed the earliest WBVs—the newborn visit in particular— as an inopportune time to broach the topic of maternal contraception. In addition to concerns about time constraints in an already “lengthy” visit, the views that PP women were not actively considering their contraception, or not “ready” to consider family planning, resulted in hesitation toward offering LINCC at the earliest WBVs:
Some of the women are [interested] but most of the time, they are not ready. . .Sometimes I ask them if they’re thinking about family planning. Most of them say, “I don’t know. We don’t have that plan yet”, but they will schedule an appointment with us. Some will say, “What? I just delivered. We are not thinking about it” (S2, CHS #4)
While participants held differing views about introducing LINCC during the newborn visit, the opportunity to offer co-scheduled care at multiple later timepoints (corresponding with the WBV schedule), was regarded as helpful, insofar as it served as a reminder for women and families to proactively consider their family planning needs, even if they declined to make a co-scheduled appointment:
Some parents were resistant [to talk about family planning] initially. If we [mentioned contraception] more consistently on the second, third, fourth visit, then it was easier for them to talk about. They were more prepared, and they had thought about it. . .they had a plan. (P2, CHS #3)
Perceived Benefits and Challenges of Co-Scheduled Care
When asked if the LINCC program made it easier for PP women to meet their contraceptive care needs, virtually all respondents responded affirmatively. The co-scheduling element was regarded as convenient, and helpful in reducing barriers common among their patient populations, such as difficulty accessing or paying for transportation or childcare:
It’s very convenient because I know sometimes parents forget or don’t have someone to take care of the baby. I feel like [co-scheduling] helps them out. (S2, CHS#1) Most of our parents are really great about bringing their babies in, especially the first few months for their health visits. So, if they’re coming in for that, you know, it’s much easier for them to attend their own appointment as well. (P1, CHS #2)
Most (but not all) participants experienced the process of implementing LINCC (ie, initiating questions, co-scheduling appointments) to be straightforward, requiring minimal “extra” time. However, some participants at high-volume sites shared logistical barriers including limited appointment slots, limited provider availability, and unpredictable wait times that complicated the process on the health system side.
It requires coordination between the OB and the peds side. . . . So in an ideal world, yes, it would make [meeting contraceptive care needs] easier. But logistically, sometimes things get backed up, so it can make things a little bit more difficult, because now you not only have one one patient appointment that might be late or that you have to reshuffle, now you have two and those are tied together (P, CHS #6)
Experiences of Discomfort With Family Planning and Contraceptive Care Conversations
While LINCC was well-supported on a conceptual level, initiating contraceptive care planning conversations emerged as the most salient barrier. Participants in diverse roles across sites used words such as “awkward,” “uncomfortable,” “inappropriate,” and “leery” to describe experiences with these interactions (or the idea of them). The reasons for discomfort were multi-factorial, with considerable variation between and within CHC sites. Within this larger theme, 3 subthemes emerged:
Concerns about role boundaries
For some, discomfort offering LINCC was related to a belief that broaching contraceptive care topics fell outside the scope of their professional role and/or training. While providers acknowledged that asking questions about the mother’s health (eg, postpartum depression) was common, many felt uncomfortable inquiring about the topic of contraception, in particular.
Because I am a pediatrician, sometimes I feel like it’s a little awkward because I’m obviously dealing mostly with the baby. Sometimes I just feel weird. . .asking the mom if she is on contraception, or wants to be on contraception. . .I’m not the mom’s doctor. . . .sometimes I feel uncomfortable. . .it’s not really my place. (P2, CHS #1) I think in my role as a medical assistant, I cannot just discuss family planning with them. [I’m] not comfortable enough or knowledgeable enough for this kind of topic. (S2, CHS #4)
Concerns about PP women’s comfortability
For other participants, discomfort was not necessarily experienced due to their own confidence or comfortability with discussing contraception, but was more associated with anticipation of a PP women or families’ potential discomfort (or negative response) related to the introduction of these topics at the WBV. One provider reflected:
It’s a little awkward to ask about contraception at the newborn visit, because it’s very exciting they have a baby, and I don’t want to discredit that. I feel like [its saying], “now, no more babies!” (P1, CHS #3)
Notably, while acknowledging their own discomfort, none of the pediatric providers interviewed experienced women and families’ actual responses to the introduction of contraceptive care planning topics as a significant barrier: Some were a little taken aback, but some were fine talking about [contraception]. Most were happy and fine to talk about it. (P1, CHS #3)
However, a few staff members who were tasked with making co-scheduled appointments perceived that any mention of contraception (inclusive of asking about interest in scheduling an appointment) might be better coming from “someone else,” such as a clinical provider, to enhance patient comfortability.
[I’m not] always comfortable [asking if someone needs a contraception appointment] because people are not always willing to share that with you. . . .Sometimes they are ok with it, sometimes they are not okay with it. Sometimes they don’t really want to discuss it with you. Some patients don’t feel comfortable talking to us about it. . . .they’re more open to talk to the provider. I just think. . . maybe they are uncomfortable discussing it with. (S1, CHS #2)
Notably, staff member comfort with engaging patients about making contraceptive care appointments varied widely, both between and within health sites:
I felt very comfortable, it’s not an awkward position that we’re in. It’s just talking to a mom like, “Do you have an idea if you want to do birth control? Do you want to schedule an appointment with a provider to see what your options are?” I feel confident in talking to the patient about that. (S2, CHS #1)
Concerns about privacy
Another subgroup of respondents (both providers and staff) expressed that they felt comfortable discussing contraception with PP women who presented for their appointments alone, but became uncomfortable when another adult was also present, which was perceived as common at WBVs.
Especially those early visits, it’s not always just mom in the room. Sometimes mom will be there with her mom, or mom is with dad. . .and I always get a little nervous about asking—I don’t want to ask the mom, specifically—if they’re on contraception when there are other adults in the room. I just don’t feel that is appropriate. (P1, CHS #2) I: How comfortable are you asking mom if they need a healthcare visit for contraception? P: It’s uncomfortable if the husband is standing right next to her. . .its not uncomfortable if the husband is not standing right next to her. . .you’re like, “I don’t know how to ask this person this.” [laughter]. I don’t want the husband to be like, “what did you just ask her?” What can you say if the husband is standing right next to her? (S1, CHS #1)
Recognizing Need, Reimagining Role
As interviews occurred several months into the implementation of the LINCC trial, participants often shared how their perceptions had shifted over time. Despite initial feelings of hesitation, awkwardness, and discomfort, nearly all respondents affirmed that offering LINCC became “easier” with time. In part, participants attributed increasing ease to observations and interactions that led to new insights about the needs of the PP women and families—including educational needs, support needs, and willingness to discuss contraception at the WBV:
You know, once you do it a few times, you realize people don’t hesitate to talk about contraception. Sometimes because it’s not an OB/GYN, they might not want to talk about it. But, if they’re willing to talk about their [reproductive] health with me. . .then yeah, that’s a good thing. (P, CHS #7)
Some participants reflected on the perceived benefits of LINCC for PP women and families, as well as their own professional practice:
They build relationships with us and sometimes we even offer to take care of the baby while she’s getting a procedure done, or a Nexplanon insertion, “no worries, you focus on the procedure, we’ll take care of the baby.” They trust us. . . .yes, they trust us to take care of their babies. I feel like LINCC is going great and that it helps us build better relationships with our patients. (S2, CHS #1)
For one provider, implementing the LINCC program prompted an introspective process, including the acknowledgment of misconceptions and knowledge gaps which in turn facilitated a significant attitudinal shift and re-imagining of her role as a pediatric care provider:
I think I had to overcome my own prejudice where I felt if they were pregnant, they knew how to get pregnant and how not to get pregnant. That was a misconception. Another misconception I uncovered was that I felt that someone was already doing it for them, someone [else] was on top of that. It’s not the role of me, a pediatrician, to discuss it. . . . . .Now, after doing it a while, I think I could actually be a facilitator. You really start to focus on the fact that it is not just one isolated pregnancy. It’s a family. It’s a unit. I used to feel it was intrusive. Now I don’t think it is intrusive. Now it’s more an act of kindness, an act of actual, complete care. (P2, CHS #3)
Discussion
Providing contraceptive care services co-scheduled with a WBV may promote timely access to needed PP healthcare for low-income, underserved women who have historically experienced the lowest rates of PP care utilization7,8,26 and remain at high-risk for unintended pregnancy and short IPI.3,4 While CHCs serve a large proportion of childbearing low-income women in the United States and are well-positioned to offer comprehensive contraceptive care, 18 paired approaches to maternal/well-infant care have not yet been evaluated within these settings. In this exploratory qualitative study of the LINCC trial, we sought to understand CHC staff and providers experiences with introducing co-scheduled maternal contraceptive care and well-infant visits.
Overall, participants viewed LINCC as an acceptable, 27 worthwhile program, relevant to the needs of PP women served by their organizations. Despite clinic-level logistical challenges at some sites, the opportunity to link maternal contraceptive care/WBV visits was perceived as convenient, and ameliorative of structural access barriers such as accessing childcare. Further, exposure to the offer to schedule contraceptive care at each subsequent WBV was perceived as an important, recurring “reminder” for PP mothers to consider their own healthcare needs during a time when infant care is prioritized, even if they chose not to co-schedule. While responses varied, a majority perceived that “some” or “most” of the PP women they interacted with (who did not already have a contraceptive care plan) were interested in learning about co-scheduling options. While based on providers’ perceptions, this finding is aligned with previous research findings that women desire opportunities for contraceptive care counseling prior to the 6-week PP visit11,13,14 and that many PP women are agreeable to receiving contraceptive counseling or services paired with WBVs.12,14 -17
However, despite strong conceptual support, some participants questioned the appropriateness 27 of introducing topics related to family planning and maternal contraception in the WBV context. For many staff and providers, initiating these conversations initially felt uncomfortable, awkward, or inconsistent with their understanding of their professional role and responsibilities. For some, attitudes about contraception as a “private” matter overlapped with attitudes about role boundaries, compounding the sense of discomfort. Notably, variation in reported comfortability was experienced by participants within the same employment category (eg, providers, support staff) and between and within CHC sites, perhaps suggesting that relative comfortability was rooted more in individual-level beliefs and lived experiences versus organizational or population-specific factors. For example, one provider credited her lengthy experience serving adolescent patients with unintended pregnancies as contributing to her comfort with initiating family planning discussions. Additionally, a few participants reported feeling “very comfortable” with initiating contraceptive care conversations.
In our study, providers and staff supported the aims of LINCC, but discomfort and perceptions of awkwardness with family planning and contraceptive care topics at the WBV emerged as a significant barrier. Interestingly, during a formative pre-implementation assessment of capacity and anticipated barriers, comfortability with family planning was not identified as a significant concern, possibly suggesting that staff and providers may not have been previously aware of their discomfort. Yet, the salience of the experience of discomfort is noteworthy, as it was perceived to directly impact implementation: “In the beginning, it was hard to ask those questions. I think that’s why my team wasn’t asking, because they didn’t feel comfortable.” (P/A, CHS#6). When asked about their preparedness to offer LINCC, most participants reported satisfaction with the training received, and felt technically well-prepared. However, one provider viewed the training she received as not especially helpful, because, “I think it’s just your own comfort of how you have to do it with patients” (P1, CHS#3). Another participant expressed a desire for additional, more substantive training and resources on how to ask questions, respond to questions, and engage women and families in conversations about contraception and family planning needs and desires: “For me, there must be more fliers or instructions for us, written instructions. What are some good questions we need to say to the patients or good answers regarding family planning topics?” (S3, CHS#4).
Importantly, virtually all study participants reported that offering LINCC became easier over time, with increased exposure and shifting attitudes and perceptions. For some, feelings of discomfort and inappropriateness faded or disappeared altogether as they reconsidered how integrating maternal contraceptive care planning could be compatible with the needs of their patient populations, and with their roles as care team members. When considering the implementation of similar paired approaches to maternal contraceptive and WBV care, clinic leadership and implementation teams should provide interactive training opportunities to promote competence and comfortability in discussing contraception with pp women and families in a manner aligned with the principles of reproductive justice and person-centered contraceptive care. 19 Specifically, attention should be placed on striving to understand a PP woman’s family planning needs, values, and contraceptive care choices in the context of her lived experience, providing needed information while emphasizing autonomy and choice. 19 Teams should encourage feedback and discussions on the alignment of the approach with the care team members understanding of their roles, the identified needs of the patient population, and the missions of their community health organizations. Throughout the process of implementation, dialog on experienced challenges and proposed solutions should be invited, and access to ongoing support provided.
Limitations
We acknowledge that our study has several limitations. First, we were unable to interview a representative from every implementing health site, or from every targeted role within health sites (eg, administrators). Further, all clinical providers interviewed were pediatric providers. A larger sample with more diverse roles (eg, family medicine providers) may have yielded unique perspectives and contributed additional nuance to our findings. While patient interviews occurred earlier in the trial period to inform program development, we did not conduct interviews with patients who had been offered LINCC, and are therefore missing that key perspective in these data. Finally, the inclusion of quantitative data, such as attitudinal scales at multiple timepoints throughout the trial, may have bolstered our findings related to changing attitudes—a consideration for future research.
Conclusion
Offering opportunities for patient-centered maternal contraceptive care co-scheduled with WBVs may facilitate timely family planning and access to contraceptive healthcare in the early PP, potentially reducing unintended pregnancy with short IPI. In our study, staff and providers in diverse CHC settings found co-scheduled maternal contraception /infant well care acceptable, convenience-promoting, and highly relevant to the needs of their patient populations. However, initial discomfort with introducing the topic of contraception was experienced as a widespread challenge. When implementing similar paired approaches, the provision of comprehensive training and ongoing support tailored to expressed needs and experiences of providers, staff, and PP women should be prioritized
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health [R01 HD097171]
Ethical Approval and Informed Consent Statement
The Institutional Review Board at the University of Chicago and Rush University approved this research. Participants provided verbal informed consent prior to completing interviews.
