Care After Pregnancy Study (CAPS): Engaging Women in Postpartum Care
Condition: Postpartum Care
Study type: Interventional

Summary: 
      The overarching hypothesis of our research agenda is that an intervention that engages
      economically disadvantaged women in personalized postpartum care will promote equality in
      maternal child health. As a first step to test our hypothesis the investigators propose the
      following aims:

      Specific Aim 1: Measure the impact of Healthy Beyond Pregnancy on key components of
      postpartum care, including use of effective contraception at three and six months postpartum
      and breastfeeding duration at three and six months.

      Specific Aim 2: Determine if Healthy Beyond Pregnancy improves adherence to health screening
      and linkage to follow-up care for women with cardio-metabolic complications of pregnancy.
    

Detailed description: 
      There are profound economic inequalities in a wide range of important maternal and child
      health outcomes ranging from neonatal death to maternal morbidity and mortality. The
      overarching scientific premise for our proposal is that these inequalities stem in part from
      poor engagement in postpartum care by economically disadvantaged women. The investigators
      hypothesize that an innovative intervention grounded in empirically derived tenets of
      behavioral economics that includes the critical components of the American College of
      Obstetricians and Gynecologists (ACOG) new vision for postpartum care will narrow gaps in
      important maternal child health outcomes.

      Women of lower socioeconomic status are at significantly increased risk of unintended
      pregnancies, short inter-pregnancy interval and short duration of breastfeeding. The
      consequences of untimed pregnancies and short duration of breastfeeding for the health of
      mothers, infants and children are well documented. In addition to significant health
      implications, these inequalities have important economic ramifications. The cost of births
      from unintended pregnancies in 2006 was estimated at $11 billion in maternity and infant
      care. This does not include cost of abortion care, lost productivity, and government
      assistance.

      Providers have effective postpartum strategies to reduce the risk of poorly timed pregnancies
      and low breastfeeding rates.

      Short interval or poorly timed pregnancies: Women have a range of effective contraceptive
      options, however, not initiating contraception postpartum remains common. The provision of
      long-acting reversible contraception (LARC) including intrauterine devices (IUDs) and
      hormonal implants has been shown to decrease short interval pregnancies and the associated
      risk of preterm birth. Importantly, given the array of contraceptive options available to
      women, it is important to make LARC accessible while empowering women to choose a method that
      is effective and acceptable to them. This highlights the need for solutions to engage women
      in patient centered comprehensive contraceptive decision-making in the postpartum period.

      Short Breastfeeding Duration: A number of strategies have been shown to increase
      breastfeeding success. Most relevant to our proposal is that efforts to educate women about
      the benefits of breastfeeding, weekly text reminders in the immediate postpartum period, and
      access to a lactation consultant have all improved both duration and exclusivity of
      breastfeeding. Importantly, three recent trials demonstrated significant increases in
      exclusive breastfeeding from eight weeks to six months postpartum among women who received
      weekly-automated text message breastfeeding support. These interventions may be particularly
      relevant to our target population, as low-income, non-Hispanic Black women between 18-29
      years send and receive text messages more frequently than any other demographic.

      There are important high-risk subgroups of women who benefit uniquely from postpartum care
      given the need to link these women to primary or specialty health care providers in
      postpartum period.

      Gestational diabetes (GDM): GDM complicates roughly 6-9% of pregnancies, but
      disproportionately burdens those with lower socio-economic status. Women with GDM are at
      increased risk of type 2 diabetes, metabolic syndrome, and cardiovascular disease after
      delivery. These findings are present as early as 3 months postpartum with the absolute risk
      of Type 2 diabetes approaching 5% a year postpartum. Professional societies recommend
      screening women for diabetes 4-12 weeks after delivery and linking women to primary care to
      improve long-term maternal health. In 2016, only 14% of economically disadvantaged women who
      received prenatal care at the Magee-Womens Hospital outpatient clinic returned for their
      postpartum screening. This is slightly better than national trends, which suggest roughly 6%
      of women with GDM had recommend postpartum screening and 13.8% had a primary care visit
      within a year.

      Hypertensive disorders of pregnancy: Hypertensive disorders of pregnancy occur in roughly
      6-8% of pregnancies and low SES is an independent risk factor. Women with hypertensive
      disorders of pregnancy, either gestational hypertension or preeclampsia, are more than twice
      as likely to develop hypertension or prehypertension in the 12 months after delivery. They
      are also at increased risk for cardiovascular disease. Given this, women with a hypertensive
      disorder of pregnancy should have early postpartum follow up for a blood pressure and
      establish care with a primary care physician within a year of delivery.

      Recognizing the importance of the postpartum period for the health of women and children
      across their lifespans, ACOG recently proposed a new paradigm for postpartum care. In their
      new vision for postpartum care ACOG emphasized the following: 1) Postpartum care should be an
      on-going process rather than a single encounter 2) The content of postpartum care should be
      tailored to a woman's individual needs 3) The timing of the postpartum visit should be
      individualized for a woman. How to implement and scale this model of postpartum care and
      whether it will improve health outcomes for women and children has not been investigated.

      Despite considerable maternal morbidity and mortality in the postpartum period, attendance
      rates for the postpartum visit are markedly lower for women with limited resources
      contributing to economic health disparities. While women with Medicaid receive excellent
      prenatal care, only 50% of them return for their postpartum visit. These parallel national
      trends, where 60% of women with Medicaid insurance return for a postpartum checkup compared
      with over 82% of women with private insurance. Medicaid programs serve pregnant women who are
      particularly vulnerable to poor health outcomes and thus this gap is critical. These data
      demonstrate that our current care model does not engage all women in quality postpartum care
      and is disproportionately failing our most vulnerable moms and babies.

      Existing interventions to improve adherence with the postpartum visit have not been
      rigorously evaluated, would be difficult to scale, and do not reflect the new vision for
      postpartum care outlined by ACOG.

      Empirically derived concepts from behavioral economics can be leveraged to design
      interventions that support patient's engagement in their health. The field of behavioral
      economics acknowledges that people do not make exclusively rational choices. In fact,
      immediate (rather than future) needs, cognitive and psychological biases, and social norms
      profoundly influence decision-making. Insights from the field of behavioral economics have
      begun to influence the health sciences as researchers seek more effective health
      interventions and health policy.

      Healthy Beyond Pregnancy incorporates tenets of behavioral economics that address two
      powerful drivers of behavioral change-- awareness and willingness. Awareness has three parts:
      1) an awareness of how one's behavior affects oneself 2) an awareness of how one's actions
      impact others and 3) an awareness of social norms around the given behavior. Awareness alone,
      however, is insufficient to alter behavior. People must be willing to change their behavior.
      Designing health interventions that address both awareness and willingness are more likely to
      lead to behavior change.

      In the current proposal the investigators focus on four tenets of behavioral
      economics-bounded rationality (information overload), status quo bias (valuing the present
      self over the future self), hovering (limited attention), and framed incentives-- that
      address both awareness and willingness and have been successfully used to tackle stubborn
      health problems such as smoking and obesity. Both bounded rationality and hovering address
      awareness, while status quo bias and framed incentives address willingness.

      In summary, this proposal is significant because it will evaluate the impact of an innovative
      program built on empirically derived concepts of behavioral economics on health
      decision-making in the postpartum period- a critical window for maternal child health. Our
      program directly mirrors the new vision for postpartum care outlined by ACOG. Additionally,
      it targets low-income women who are at risk for not participating in postpartum care to
      promote equality in maternal child health.
    

Intervention name(s): Healthy Beyond Pregnancy; Pre-Scheduled Postpartum Visit; Attention Control
Intervention type(s): Behavioral; Behavioral; Other
Intervention description(s): Web-based application grounded in tenants of behavioral economics.; Participants will have their postpartum visit scheduled while they are still in the hospital after delivery.; Participants will receive texts related to infant care to mirror the attention participants receive in the Healthy Beyond Pregnancy intervention.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Health Services Research
Keywords: contraception; postpartum care; breast feeding; interconception care