Currently, the United States has a higher maternal mortality ratio than most other high-income nations, with more than half of maternal deaths occurring postpartum after hospital discharge. The predominant model of care following discharge from delivery is an in-person visit scheduled between four and 12 weeks postpartum. However, there is variation in when visits are scheduled and low visit completion among patients who are rural, low-income and of minority race/ethnicity. Furthermore, most postpartum maternal mortality and morbidity happen within the first six weeks after delivery, with the vast majority within the first two weeks. Therefore, care at 12 weeks may be too late to prevent severe maternal morbidity and mortality.
The American College of Obstetricians and Gynecologists’ (ACOG) released new guidelines in 2018 recommending a first postpartum contact with health care providers within the first one to three weeks, followed by a comprehensive postpartum visit at approximately six weeks postpartum. However, this model has not been widely implemented in large part due to lack of comparative effectiveness data and resource constraints limiting postpartum care providers’ ability to accommodate an additional in-person visit. Telehealth is one feasible strategy for addressing patients’ early postpartum needs, but systematic reviews note that there is insufficient evidence of the impact of postpartum telehealth in rural, low-income and racially/ethnically diverse communities and how models can be integrated into care systems. This study will directly fill these critical gaps in the evidence.
The goal of this study is to conduct a comparative evaluation among 1,500 rural, low-income and racially/ethnically diverse women to compare two postpartum care models: 1) Telehealth Multicomponent Optimal Model (Telehealth MOM) and 2) enhanced standard of care. This study will address critical gaps in knowledge about how best to deliver comprehensive postpartum care that ensures timely identification and treatment of complications and meets the needs and preferences of diverse patients including disproportionately impacted racial groups and rural residents. This hybrid effectiveness-implementation study (Type 1) will address the following aims: aim 1: Compare the effectiveness of A) Telehealth MOM care and B) enhanced standard of care among rural, low-income and racially/ethnically diverse patients on postpartum six-week comprehensive visit completion, early detection of postpartum complications, hospital readmission and emergency department visits within six weeks postpartum and patient satisfaction; aim 2: Explore the impact of A) Telehealth MOM care and B) enhanced standard of care on reproductive life planning and infant feeding; and aim 3: Document barriers and facilitators for implementation and identify feasible and acceptable strategies to support broad implementation of the Telehealth MOM care.
Results from this study have great potential to benefit the quality of postpartum care received by women in the United States. This is confirmed by stakeholders who have indicated that the predominant standard of postpartum care (e.g., the six-week visit) does not meet the needs of patients but that changes to this model recommended by ACOG will not be implemented without stronger evidence on effectiveness and feasibility of implementation. Given the importance of early detection and treatment of complications in the postpartum period for reducing maternal mortality and morbidity, this study fills a critical gap in knowledge for clinical decision making.
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.