Abstract
Introduction:
Despite the existence of guidelines on optimal postpartum care from the American College of Obstetricians and Gynecologists, gaps in their implementation persist, particularly for high-risk patients. This case study explores provider perspectives on barriers and facilitators to postpartum care for high-risk patients and reflections on a specialized postpartum clinic’s strategies to address them.
Methods:
Ten months after launching a specialized clinic in the United States for high-risk postpartum patients, we conducted semi structured interviews (April-July 2023) with 7 key providers involved in implementation and care delivery. Data were analyzed using thematic analysis with themes mapped to a social ecological framework.
Results:
Providers cited individual-level barriers to postpartum care, such as traumatic birth experiences, complex social needs, and medical mistrust. Organizational factors, such as poor communication with patients and between providers, were identified as contributors to poor transitions of care and loss to follow up. The community health worker (CHW) from the postpartum clinic was viewed as an effective resource in building trust and addressing logistical challenges, like childcare and transportation.
Conclusions:
Providers viewed a multidisciplinary care model with CHW support as a promising strategy to reduce barriers to high-quality postpartum care for high-risk patients.
Introduction
The postpartum period is a critical period for supporting the long-term health of individuals with recent high-risk pregnancies. 1 It involves many challenges, including physical recovery, caregiving demands, infant feeding issues and mental health concerns. Notably, over 50% of pregnancy-related deaths occur during this period. 2 Recognizing the potential of the postpartum period as a unique opportunity to prevent poor outcomes and promote lifelong health, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines for optimal postpartum care, including: routine clinical care, lactation support, mental health and social needs screening, reproductive life planning, chronic disease management, preventative care, counseling on pregnancy complications, and linkage to community resources. 1
Despite these guidelines, delivery of optimal postpartum care, especially for those with high-risk pregnancies, remains difficult. Scheduled postpartum care is often fractured and underutilized. Nearly 30% of patients do not attend a postpartum visit within 12 weeks and up to 50% of patients with a medically complicated pregnancy do not see a primary care provider in the year after delivery.3 -5 Even when visits occur, key services such as mental health and social needs screening are often missed.6,7
In June 2022, our institution launched the PHOENIX (Postpartum High-Risk Optimization, Empowerment and Networking Experience) clinic as a strategy to address these gaps and implement ACOG guidelines for high-risk patients’ postpartum care. 8 Drawing on evidence that community health workers (CHWs) and care coordination improve postpartum visit attendance and chronic disease outcomes,9 -11 the clinic’s core innovation is the provision of care coordination by a CHW under the supervision of a high-risk obstetrician. The team holds weekly half-day sessions in a Federally Qualified Health Center serving a predominantly non-White, publicly insured population.
Maternal health care providers, who deliver frontline care to patients with high-risk pregnancies, have unique insights into the systemic gaps they encounter, making their perspectives essential for designing care models that effectively address these shortcomings. Yet few studies explore provider perspectives on delivering postpartum care to high-risk patients. In this paper, we apply a social ecological lens to examine providers’ views of the specialized clinic described above for high-risk postpartum patients, 8 focusing on perceived barriers and strategies to improve care.
Methods
Study Design
We used a case study approach. The case was bounded by organizational and temporal context: a single postpartum program, the PHOENIX clinic, within an academic center in the Bronx, NY during its first year of operation. This design allowed for contextualized understanding of the complexities in delivering optimal postpartum care for high-risk patients. Details of the PHOENIX clinic’s workflow has been previously published. 8
Participants and Sampling
Between April and July 2023, we conducted semi-structured interviews with providers directly involved in the implementation and/or the day-to-day operations of the PHOENIX clinic. Eligible participants included obstetricians (N = 6) or physician assistants (N = 3) who see patients through or refer patients to the PHOENIX clinic, the clinic’s community health worker (N = 1), primary care physicians (N = 4) who commonly see PHOENIX patients after delivery, and lactation consultants (N = 1) and mental health professionals (N = 3) who provided care in close coordination with the PHOENIX clinic. Because the pool of eligible providers was limited to those engaged in these roles, all such providers were invited to participate. The final number of interviews by provider type is reported in the Results Section. We used a convenience sample based on provider availability, but our approach sought to capture the full range of perspectives from providers most directly connected to the clinic’s implementation.
Reflexivity
Reflexivity was an integral component of the study given the dual role of primary author KV as the primary implementor of the PHOENIX clinic and one of the participants interviewed. While this position provided valuable contextual knowledge, it also introduced potential bias in framing the research questions and interpretation of the data. To address these concerns and enhance trustworthiness, the interview guide was developed with a co-investigator external to the clinic (DL). Data analysis was conducted iteratively with team members who were not involved in the clinic’s implementation (RH, TL, CM, and DL).
Data Collection and Ethical Considerations
Semi structured interviews were conducted using an interview guide that included open-ended questions on barriers and facilitators to postpartum care, experiences with the PHOENIX clinic, and recommendations for improvement. Probes were used to encourage elaboration while minimizing bias. The complete guide is provided in the Appendix. All participants provided informed consent. The study was approved by the Montefiore-Einstein Institutional Review Board (IRB protocol # 2022-14176). Authors RH, TL, and CM conducted the interviews virtually using video conference technology. All interviews were audio-recorded and lasted approximately 30 min.
Data Analysis
We used a thematic analysis approach. 12 Interviews were transcribed, de-identified, and thematically coded using Dedoose®. Four researchers (KV, RH, TL, and CM) independently reviewed transcripts to identify key themes and patterns. They collaboratively identified both commonalities and discrepancies in their understanding and application of codes. Through iterative discussion, they found consensus on final coding and a cohesive set of themes. These themes were organized at the individual, interpersonal, and organizational levels of the social ecological model. The social ecological model, grounded in community psychology, offers a framework for understanding and improving care delivery for high-risk postpartum patients by accounting for influences at the individual, interpersonal, and organizational levels.13 -16 These can include family dynamics, healthcare environments, and community resources.
The study followed the Standards for Reporting Qualitative Research (SRQR) to enhance methodological transparency and rigor.
Results
Between April and June 2023, a total of 18 providers were approached for semi structured interviews. We interviewed 7 providers involved in the PHOENIX clinic. Participants included the core team—the high-risk obstetrician (KV), the outpatient medical director (n = 2 of 6), and the CHW (n = 1 of 1)—as well as a referring physician assistant (n = 1 of 3) from the inpatient high-risk obstetrics team, lactation consultant (n = 1 of 1), primary care physician (n = 1 of 4), and reproductive psychiatrist (n = 1 of 3). Providers described challenges and facilitators to postpartum care delivery. Themes are summarized in Table 1.
Thematic Analysis by Social Ecological Level of Maternal Care Providers’ Perspectives of Challenges of and Strategies to Providing Optimal Postpartum Care.
Barriers to Optimal Postpartum Care
Individual Patient Factors
Providers highlighted how adverse birth experiences shaped fear and trauma that affected care-seeking behaviors (Table 1, Theme 1). The inpatient physician assistant noted a particular patient’s experience,
There was a patient that had a significant postpartum hemorrhage that wound up going into cardiogenic shock . . . and she was so traumatized by the experience . . . she was afraid of going to sleep. She was afraid of dying.
Similarly, the high-risk obstetrician commented on the fear that highlighted another patient’s experience,
There’s one patient who . . . got admitted 3-4 days after delivery and had a pulmonary embolism . . . she was just so devastated by what happened . . . she would say, ‘I am so afraid I am going to die.’
The primary care physician noticed how these difficult birth experiences can affect patient identity and family expectations (Table 1, Theme 1),
. . . For a few of the people of the people that I have seen, their lives have drastically changed . . . the way they’re envisioning their families and their lives have changed . . . this connection to birth and how that feels for people’s identities . . . I think that has really impacted them a lot.
Logistical and psychosocial barriers also impede engagement (Table 1, Theme 2). The CHW observed,
Usually it’s not so much the medical [barriers] that prevent them from . . . getting care. It’s usually, ‘I don’t have childcare, I don’t have transportation, or I have all these legal issues.’ These things are usually the ones that stress them out to the point that the last thing they are thinking about is coming to the doctor’s office.
Medical mistrust was a recurring theme (Table 1, Theme 3). The high-risk obstetrician noted that,
. . . patients are really afraid that people are going to see them as unfit mothers and that they are going to call child protective services and so they will not engage with mental health care because they are worried.
Interpersonal Factors
Providers noted that patients want to feel safe and have a reliable way to access care (Table 1, Theme 4). The inpatient physician assistant commented on how,
Patients want quality care. They want to be able to have someone to go to, as opposed to just going to the emergency room, for issues that can be managed with a phone call or an email . . . they want to feel safe.
Others remarked on how the clinic team should do more to assist with care navigation; the high-risk obstetrician mentioned that
so much of what is needed for postpartum care is emotional and social support . . . following up with patients and doing all that ‘in-between’ visit work.
Poor inter-provider communication further disrupted continuity (Table 1, Theme 4). The reproductive psychiatrist noted,
I don’t know that . . . my recommendations or notes are read . . . often I’ll see things in the notes that the patient is continuing to follow with me but the patient hasn’t come to any of their appointments.
Not only are providers unaware of other providers’ plans or follow up, but they sometimes do not know their role during the postpartum period (Table 1, Theme 4). The primary care doctor reflected,
What role am I playing in this immediate postpartum period versus [the obstetrician]? And then also, if I have an acute concern, who do I reach out? That has always kind of been a stressor for me.
Organizational Factors
Staffing shortages and siloed systems lead to unreliable pathways of communication (Table 1, Theme 5). The physician assistant remarked,
Our system right now is not at its best . . . there are not enough people to make appointments and there are a lot of systems that do not communicate with each other . . . sometimes patients are not able to communicate with the office.
The outpatient clinic director explained that gaps in transitions of care during the postpartum period lead to patients getting lost to follow up care (Table 1, Theme 6),
[The postpartum period is a] time where patients fall through the cracks . . . everybody has to navigate transitions into prenatal care . . . and . . . to and from postpartum care and to and from regular care, which for many women doesn’t actually exist.
This is particularly true for patients with chronic medical conditions. She noted,
. . . we’re seeing them like 3 times a week by the end of pregnancy, and then . . . they deliver. And it’s like they fall off a cliff . . . there is a real contrast between the level of beautiful care we provide antepartum and the complete absence of care postpartum.
Provider Perspectives on Strategies to Address Barriers to Postpartum Care
Providers described the importance of providing emotional and social support to patients (Table 1, Theme 7). The lactational consultant emphasized the power of consistent support,
At a time when [patients’] attention might be so divided between . . . worry, desperation, fear, grief and their own health, having really consistent, almost relentless . . . warm support might make the difference between their life and death.
She described how the PHOENIX clinic model’s inclusion of the CHW supported patients,
I was really moved and inspired by the gentle support [given by the CHW] and also encouragement to the woman to continue to come to visits and take care of herself . . . And it’s that kind of really loving, frequent attention that can make the difference between people’s healing and lack of healing.
Providers also agreed that patient navigation by the clinic team is helpful for patients to feel secure and trusting in the care that they receive after delivery (Table 1, Theme 8). The inpatient physician assistant felt,
having [the CHW] is a big part of [good care] because . . . there is someone aside from the physician [for patients] to be able to say, ‘Okay, I have someone that I can bring my concerns to,’ so that they feel secure in the postpartum period.
She also noted that within the PHOENIX care model,
[the CHW] is very responsive in a timely fashion and this builds trust in the patient.
Providers noted that patient navigation by the clinic helps to address patients’ complex needs during the postpartum period (Table 1, Theme 9). A complex patient case described by the high-risk obstetrician highlighted how coordinated services were successfully arranged:
A patient had a postpartum hemorrhage, hysterectomy and systolic heart failure . . . we connected her with psychiatry and social work, and we’ve seen her five times through the PHOENIX clinic. We got her connected with a primary care doctor, a cardiologist and also the breastfeeding medicine doctor . . . [the CHW] also got her transportation for all of these appointments.
The importance of the CHW as a team member who can address social needs and relate to patients in a different way than other members of the medical team was also emphasized during the interviews (Table 1, Theme 10). The CHW herself noted,
It’s important to [the patients] . . . like somebody having an argument with their landlord . . . helping them through that process of knowing that they’re not going to get evicted and knowing their rights. That alone is a lot for them and makes them feel good that somebody’s actually listening and helping them. And I know that women of the Bronx specifically have not always been heard or listened to.
The high-risk obstetrician observed how patients trust the CHW,
I think [the CHW] can talk to patients on a level that I cannot . . . she was born and raised and lives in the Bronx . . . I think [the patients] . . . see themselves in her and so I think sometimes they are more open with her than they are with me . . . so she has been really helpful in reinforcing some of the things that I recommend.
Lastly, providers highlighted that good communication between the various providers involved in postpartum care optimizes care delivery (Table 1, Theme 11). The primary care doctor appreciated that the good communication provided through the PHOENIX clinic helped her better take care of patients. She noted,
I think it was a nice supportive transition into primary care, and it felt like a collaborative team where, ‘We all care about you (the patient).’ And even if we don’t work directly together . . . that experience does set up their partnership by proxy.
She also reflected that,
having a very thorough note . . . that made plans for a transition care is really useful . . . it helps set the visit up for success . . . and then you can jump in without having to spend the extra time . . . to put the pieces together yourself.
Providers in this study identified barriers to postpartum care for high-risk patients at the individual (eg, traumatic birth experiences, complex social needs, medical mistrust), interpersonal, and organizational factors (eg, poor communication pathways and care transition gaps). They also emphasized the value of strategies implemented by the PHOENIX clinic, including care navigation, the CHW’s role as a trusted team member who can address unmet social needs, and strong communication with patients and across care teams. Table 1 summarizes the elucidated themes and shows how they align with approaches already embedded in the PHOENIX clinic. The “Challenges” column reflects provider-identified barriers, the “Strategies” column reflects suggested solutions raised during interviews, and the final column highlights PHOENIX-specific strategies that directly map to these themes.
Discussion
Providers in this study described challenges such as fear after adverse birth experiences, medical mistrust, logistical, and social barriers that limited follow-up, poor communication across specialties, and gaps in care transitions. At the same time, they emphasized the value of strategies embedded in the PHOENIX clinic, CHW-supported care coordination, and strong communication within and across care teams. These themes add to the literature by situating barriers and facilitators within a social ecological framework and by highlighting how a multidisciplinary clinic model may help address persistent gaps.
Our findings align with prior literature, which has highlighted provider-noted barriers such as childcare, language, limited family support, medical mistrust, and care continuity—especially for low-income patients. 17 Suggested facilitators from past studies include education, telemedicine, enhanced communication through the electronic health record, and patient navigation. 17 Similarly, providers in our study underscored care coordination and the CHW’s role as central to improving care. Previous studies also show that high-risk patients themselves cite medical mistrust and lack of resources, education, and standardized follow-up as barriers to postpartum care, while recognizing the value of social support and care coordination. 18
This study was novel in gathering perspectives from multidisciplinary providers serving high-risk, largely non-White, publicly insured patients. It not only highlights barriers to postpartum care but also reflects on strategies that have been trialed by a specific clinic at our institution. Applying a social ecological lens helped contextualize barriers and facilitators across individual, interpersonal, and organizational domains. This framework, supported by prior research,14 -16 emphasizes the interconnectedness of people, systems, and the flow of resources, and can inform more responsive postpartum care models, particularly in complex urban environments like the Bronx.
Limitations of our study include the single-institution scope and convenience sample. Perspectives may not reflect the full spectrum of provider experiences or align with patients’ lived realities. Provider perceptions may not capture all relevant barriers or accurately identify effective strategies from the patient perspective.
This study highlights provider views on barriers and facilitators to postpartum care for high-risk patients. It underscores the value of the strategies employed by the PHOENIX clinic—particularly care coordination via CHWs and improved communication. Further research should elevate high-risk patients’ voices, rigorously evaluate CHW-led models, such as the PHOENIX clinic, on clinical outcomes and explore generalizability across health systems. Our findings suggest that CHW-led care coordination represents a promising approach to reducing barriers to postpartum care.
Footnotes
Appendix
Acknowledgements
Not applicable.
Ethical Considerations
This study was approved by the Albert Einstein College of Medicine Institutional Review Board under IRB # 2022-14176.
Consent to Participate
All participants provided consent to participate in the study.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through CTSA award number K12TR004411. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data generated and analyzed during this study are available from the corresponding author on reasonable request.