New mothers can ‘fall through the cracks’ in health care. Researchers suggest a different approach

When people are pregnant, they get a lot of attention from the health care system. But that attention fades after the baby is born.

This dropoff in care — which researchers call the “postpartum cliff” — comes as sleep-deprived parents are learning how to care for a newborn baby, often while managing health conditions of their own.

New research from Harvard and Massachusetts General Hospital suggests some small changes could make a big difference during the postpartum period. In a study published this week in JAMA Network Open, researchers found that scheduling medical appointments for patients and sharing information by text message nearly doubled the chances that the patients received primary care in the postpartum months.

The study included 360 patients in the Boston area, who were pregnant and had a condition such as anxiety, depression, hypertension, diabetes or obesity. Forty percent of those who received help scheduling appointments saw their primary care provider four months after giving birth, compared with 22% of study participants who did not receive help making appointments.

Jessica Cohen is the senior author of the study and an economist at the Harvard T.H. Chan School of Public Health specializing in behavioral economics and maternal health. Cohen spoke with WBUR about the research.

This interview has been edited and condensed for clarity: 

Tell me about the postpartum cliff — what is it, and why does it exist? Why is there so little follow-up for people postpartum?

Cohen: There’s a really stark contrast between how carefully pregnant people are monitored — [during pregnancy] there’s chronic disease monitoring, mental health monitoring, infectious disease monitoring, weight, hypertension, diabetes, all of those things. And following delivery, there’s typically just one routine visit with the pregnancy care provider. But many people have no postpartum health care visit at all.

The status quo is just to advise people to follow up with their primary care provider or a mental health provider. There’s no assistance navigating that transition. Records are not shared, there’s no communication between the [obstetrician] and the primary care doctor.

Why does this exist? I think it reflects our valuation of birthing people largely as vessels for delivering, rather than their overall health and wellbeing.

We know from previous studies that a lot of pregnancy-related complications and deaths happen in the postpartum period, right?

Cohen: Exactly. More than half of the deaths happen postpartum, some of them months into the postpartum period. And many of them are addressable through high-quality primary care.

I’d say the main thing is really just about having eyes on the person. Not letting people fall through the cracks. Conditions can get really severe if no one feels accountable for you or responsible for you.

Describe the intervention you studied. Sounds like it was mainly setting up appointments, and then text messaging to let people know about those appointments?

Cohen: The first thing we did was schedule their annual health maintenance appointment for them with the primary care provider four months after their expected delivery date. We called it their ‘pregnancy-to-primary care transition appointment.’ It gives it a purpose.

And then we used the best language from mega-studies in behavioral economics about how to motivate health behavior. And that was that ‘an appointment has been reserved for you.’ They’ve done these studies, if you say ‘this flu shot’s been reserved for you,’ it maybe increase vaccination by a few percentage points compared to if you say ‘it’s a good idea to get a flu shot.’ So we used motivating language through the [online patient portal] and text messaging.

How would you summarize the main findings of this work? The big takeaway seems to be that people who received help scheduling appointments were about twice as likely to actually see their primary care provider in the postpartum period. What else?

Cohen: In addition to that, we found significant improvements in the rate of having a primary care provider conduct recommended screenings — mood screenings, blood pressure screenings, providing a contraception plan.

We see a giant impact of the intervention on the chances that postpartum people with depression are on medication. And I think that that stands to reason. If you see a primary care doctor, they can prescribe you an SSRI [selective serotonin reuptake inhibitor]. And now there are these newer medications for postpartum depression.

How big of a lift is it to do this, to actually schedule the appointments and send these messages. What are the resources involved?

Cohen: It was very low-resource. I mean, sending messages through [an online patient portal] is pretty much automatic. We have a research coordinator who scheduled the appointments for most people. It just took a few minutes. There could obviously be some cases where they had to leave a message and call back, but it was very low-resource.

If it doesn’t take a lot of resources, if it’s not a huge change, why isn’t it happening already?

Cohen: My impression is that pregnancy care providers, for the most part, don’t see that as their job. And the whole structure — the front desk staff, the nurses — don’t really see that as part of their job.

There’s also just not that much time to do kind of counseling about the [postpartum] period. The more immediate needs are the pregnancy.

Do you have funding to continue this research?

Cohen: We applied. I’m hopeful. I think it’s going to work. It helped a lot of people [in the study], knowing that you have a person, knowing that someone is accountable for you, that you have a reliable person to go to.