A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting.

PURPOSE: Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. METHODS: The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. RESULTS: At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. CONCLUSIONS: Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Child Care as a Barrier to Perinatal Health Care in Illinois.

PURPOSE: Within a multi-state Collaborative Improvement and Innovation Network addressing the social determinants of health during 2017-2020, the Illinois Department of Public Health led an exploratory project to understand how the availability of child care affects maternal health care utilization. The project assessed whether lack of child care was a barrier to perinatal health care utilization and gathered information on health facility practices, resources, and policies related to child care DESCRIPTION: TWe surveyed (1) birthing hospitals (n = 98), (2) federally qualified health centers (FQHCs) (n = 40), and (3) a convenience sample of postpartum persons (n = 60). ASSESSMENT: Each group reported that child care concerns negatively affect health care utilization (66% of birthing hospitals, 50% of FQHCs, and 32% of postpartum persons). Among postpartum persons, the most common reported reason for missing a visit due to child care issues was "not feeling comfortable leaving my child(ren) in the care of others" (22%). The most common child care resource reported by facilities was "staff watching children" (53% of birthing hospitals, 75% of FQHCs); however, most did not have formal child care policies or dedicated space for children. Fewer than half of FQHCs (43%) discussed child care at the first prenatal visit. CONCLUSION: The project prompted the Illinois Title V program to add a child care-related strategy to their 2021-2025 Action Plan, providing opportunity for further examination of practices and policies that could be implemented to reduce child care barriers to perinatal care. Systematically addressing child care in health care settings may improve health care utilization among birthing/postpartum persons.

Federal Direction + Local Implementation as a Strategy for Improving Infant Health: The Founding and Evolution of the Infant Welfare Society of Evanston.

While the role of the US federal government in improving Maternal and Child Health (MCH) is often seen as a history of opportunities and tensions between the federal bureaucracy and state implementation, less is known about how federal governmental policies to improve MCH have been implemented at the local level, and the nature of the dynamic between local implementation and federal adoption of locally generated strategies. By describing the emergence of the Infant Welfare Society of Evanston in the first part of the 20th century and describing its evolution until 1971, we showcase the forces that shaped the emergence of an MCH institution at the local level in the early part of the history of MCH in the US.  This article highlights the interaction of a progressive maternalistic frame and the growth of local public health infrastructure as fundamental to the basis of action to address infant health during this period. However, this history also highlights the complex relationship of institutions dominated by White women and their relationship to the populations served in the development of the field of MCH and elucidates the need for more explicit attention to understanding the role of Black social institutions in the development of the field of MCH.

The history of Maternal and Child Health (MCH) in the US is often seen through the lens of federal-state relations; however, less is known about how federal governmental policies to improve MCH have been implemented at the local level, and the nature of the dynamic between local implementation and federal adoption of locally generated strategies. To address this gap in our historical knowledge, we tell the story of the Infant Welfare Society of Evanston (IWSE), a community-based organization, whose activities to address infant health beginning in the second decade of the 20th century directly parallel and in some circumstances influenced federal MCH efforts. Examining this history enables us to also explore issues of racial equity in the development of the field of MCH in the US.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity.

OBJECTIVE: This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants. STUDY DESIGN: This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races. RESULTS: The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model. CONCLUSION: This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709). KEY POINTS: · Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

The Critical Value of Maternal and Child Health (MCH) to Graduate Training in Public Health: A Framework to Guide Education, Research and Practice.

INTRODUCTION: In light of persistent health inequities, this commentary describes the critical role of maternal and child health (MCH) graduate training in schools and programs of public health (SPPH) and illustrates linkages between key components of MCH pedagogy and practice to 2021 CEPH competencies. METHODS: In 2018, a small working group of faculty from the HRSA/MCHB-funded Centers of Excellence (COEs) was convened to define the unique contributions of MCH to SPPH and to develop a framework using an iterative and consensus-driven process. The working group met 5 times and feedback was integrated from the broader faculty across the 13 COEs. The framework was further revised based on input from the MCHB/HRSA-funded MCH Public Health Catalyst Programs and was presented to senior MCHB leaders in October 2019. RESULTS: We developed a framework that underscores the critical value of MCH to graduate training in public health and the alignment of core MCH training components with CEPH competencies, which are required of all SPPH for accreditation. This framework illustrates MCH contributions in education, research and evaluation, and practice, and underscores their collective foundation in the life course approach. CONCLUSIONS: This new framework aims to enhance training for the next generation of public health leaders. It is intended to guide new, emerging, and expanding SPPH that may currently offer little or no MCH content. The framework invites further iteration, adaptation and customization to the range of diverse and emerging public health programs across the nation.

Learning from Graduate and Undergraduate Public Health Virtual Internship Experiences with State Title V Agencies During COVID-19, Summer 2020.

BACKGROUND: Since summer 2014, the National MCH Workforce Development Center has placed students from MCH public health graduate (Centers of Excellence and Catalyst) and undergraduate (MCH Pipeline) programs, all funded by the Maternal and Child Health Bureau, in summer internships with state and territorial Title V agencies. In 2020, due to the COVID-19 pandemic the Title V MCH Internship Program was offered virtually. PARTICIPANTS AND METHODS: This manuscript includes quantitative and qualitative data from 2017 to 2020 generated by both Title V MCH Internship student interns (n = 76) and their preceptors (n = 40) with a focus on a comparison between the 2020 virtual year and the 2017-2019 years. RESULTS: Evaluation data from the 2017 to 2020 Title V MCH Internship Program from both students and preceptors revealed the implementation of a robust and successful internship program in which students increased their confidence in a variety of team, mentorship, and leadership skills while gaining direct exposure to the daily work of state Title V agencies. However, students and preceptors identified more challenges during 2020 compared to previous years. CONCLUSIONS: The COVID-19 Pandemic was both a disruption and a catalyst for change in education. While there were clearly some challenges with the pivot to a virtual Title V MCH Internship Program in summer 2020, students were able to participate in meaningful internship experiences. This success can be attributed to the ability of the internship sponsor to engage in best practices, including extensive planning and provision of ongoing support to the students. Going forward, it is recognized that virtual internships may facilitate access to agencies in distant locales, eliminating issues related to housing and transportation. When both virtual and in-person relationships are available, those responsible for internship programs, including the Title V MCH Internship, will need to weigh these type of benefits against the potential missed opportunities students may have when not able to participate in on-site experiences.

A two-generation approach to postpartum care: Building on the well-baby visit.

BACKGROUND: Although postpartum (PP) care is essential for the health and well-being of women and their infants, many women in the United States do not receive PP care. In order to ensure that women's PP needs are met, it is essential to develop delivery models that address their barriers to care. The objective of the current study was to obtain women's feedback and perspectives about delivering women's health care at the well-baby visit (WBV) using a modified mixed-methods approach including open-ended interviews and surveys. METHODS: Twenty brief open-ended interviews were conducted with PP women at a large urban medical center in Chicago. The interviews were recorded, transcribed, and coded following a mixed deductive and inductive approach and analyzed using Dedoose. Following the interview analysis, surveys with 50 immediate PP women and 50 who were 2-4 months PP were conducted. Statistical analyses included frequencies and chi-square tests to determine differences between participants interviewed at the two time periods. RESULTS: Key themes that emerged from the open-ended interviews include the tension between the desire for continuity of care (prenatal to PP) and the desire for convenient care. The surveys found that 86%-94% of women would be interested in receiving PP care at the same clinic site and time as their new baby. CONCLUSIONS: One approach to addressing women's PP health and need for convenient care is the provision of components of women's health care at the WBV. Therefore, we present an innovative two-generation model for PP care focusing on needs of both the woman and infant.

Setting the Agenda for Reproductive and Maternal Health in the Era of COVID-19: Lessons from a Cruel and Radical Teacher.

BACKGROUND: COVID-19 exposes major gaps in the MCH safety net and illuminates the disproportionate consequences borne by people living in low resource communities where systemic racism, community disinvestment, and social marginalization creates a perfect storm of vulnerability. METHODS: We draw eight lessons from the first 8 months of the pandemic, describing how COVID-19 has intensified pre-existing gaps in the MCH support network and created new problems. For each lesson identified, we present supporting evidence and a call for specific actions that can be taken by MCH practitioners, researchers and advocates. RESULTS: LESSON #1: COVID-19 hits communities of color hardest, exposing and exacerbating health inequities caused by systemic racism. LESSON #2: Women experience the most devastating social, economic and mental health tolls during COVID-19. LESSON #3: Virulent pathogens find and exacerbate cracks in our public health and health care systems. LESSON #4: COVID-19 has become a pretext to limit access to sexual and reproductive health care. LESSON #5: COVID-19 has exposed and deepened fault lines in maternity care: over-medicalization, discrimination, lack of workforce diversity, underutilization of collaborative team approaches, and lack of post-delivery follow-up. LESSON #6: The pandemic adds impetus to much-needed Medicaid policy reforms that can have a lasting positive effect on maternal health. LESSON #7: Social and health policy changes, heretofore deemed infeasible, ARE possible under pandemic threat. LESSON #8: Finally, an overarching COVID-19 lesson: We are all inextricably connected. CONCLUSION: COVID-19 is a loud wake up call for renewed action by MCH epidemiologists, policy-makers, and advocates.

Comparing Postpartum Care Utilization from Medicaid Claims and the Pregnancy Risk Assessment Monitoring System in Wisconsin, 2011-2015.

OBJECTIVE: To compare two data sources from Wisconsin-Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) surveys-for measuring postpartum care utilization and to better understand the incongruence between the sources. METHODS: We used linked Medicaid claims and PRAMS surveys of Wisconsin residents who delivered a live birth during 2011-2015 to assess women's postpartum care utilization. Three different definitions of postpartum care from Medicaid claims were employed to better examine bundled service codes and timing of care. We used one question from the PRAMS survey that asks women if they have had a postpartum checkup. Concordance between the two data sources was examined using Cohen's Kappa value. For women who reported having a postpartum checkup on PRAMS but did not have a Medicaid claim for a traditional postpartum visit, we determined the other types of health care visits these women had after delivery documented in the Medicaid claims. RESULTS: Among the 2313 women with a Medicaid-paid delivery and who completed a PRAMS survey, 86.6% had claims for a postpartum visit during the first 12 weeks postpartum and 90.5% self-reported a postpartum checkup on PRAMS (percent agreement = 79.9%, Kappa = 0.015). The percent agreement and Kappa values varied based on the definition of postpartum care derived from the Medicaid claims data. CONCLUSIONS: There was slight agreement between Medicaid claims and PRAMS data. Most women had Medicaid claims for postpartum care at some point in the first 12 weeks postpartum, although the timing of these visits was somewhat unclear due to the use of bundled service codes.

The Effect of Continuous Versus Pregnancy-Only Medicaid Eligibility on Routine Postpartum Care in Wisconsin, 2011-2015.

OBJECTIVE: To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. RESULTS: Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). CONCLUSIONS FOR PRACTICE: Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

A mixed methods study: Midlife African American women's knowledge, beliefs, and barriers to well-woman visit, flu vaccine, and mammogram use.

African American women (AAW) are particularly at risk for deleterious health outcomes that might be mitigated through increased preventive care use. A mixed methods study that examined relationships between knowledge of, beliefs about, and barriers to well-woman visits, flu vaccines, and mammograms was conducted with midlife AAW who participated in an online survey (n = 124) and in-depth interviews (n = 19). Findings showed that greater knowledge of preventive service recommendations and positive patient-provider relationships were associated with greater preventive service use. Flu vaccines were significantly underused. Study implications inform strategies to increase preventive care utilization among AAW and increase capacities to improve health disparities.

Universal Early Home Visiting: A Strategy for Reaching All Postpartum Women.

Objective The objective of this study is to consider the role of universal nurse home visiting in the postpartum period as a potential strategy to promote women's postnatal health. This study was derived from a formative research project aimed at understanding the early implementation of the Illinois Family Connects (IFC) universal postpartum home visiting program as perceived by key informants. Methods Data from eighteen key informant (KI) interviews conducted between January and February 2018 and quantitative data extracted from reports from two IFC pilot counties were analyzed. Qualitative data were analyzed using Dedoose Version 8.0. Results Data suggest that universal postpartum nurse home visiting has appeal as a postpartum women's health strategy. The data also suggest that the success of such a strategy likely depends on: the value women, families, and community stakeholders attach to the program; the appeal of its universality and the support for home visiting by nurses in particular; the processes adopted by the hospitals and agencies implementing the program; strategies for engaging women after leaving the hospital; and, the initial and ongoing marketing of the program, which ultimately may affect women's willingness to participate. Conclusions for Practice Universal early postpartum home visiting is not a substitute for a woman's visit with a medical provider; however, it should be viewed not only as an early childhood program but an important strategy for improving the delivery of postpartum care for women.

Adapting to a Shifting Health Care Landscape: Illinois Breast and Cervical Cancer Program Lead Agencies' Perspectives.

Understanding how safety net programs adapt to systemic health care changes is pivotal for creating feasible recommendations for policy implementation. This study characterizes perspectives of Lead Agency (LA) coordinators of the Illinois Breast and Cervical Cancer Program (IBCCP) in response to sociopolitical changes at state and national levels. Our cross-sectional study included 29 semistructured telephone interviews between December 2015 and January 2016. Respondents indicated some changes in the priority population served, changes in referrals and clinical services, and, a continued commitment to IBCCP. Our findings suggest that IBCCP and other safety net programs will need to be flexible to meet the ongoing needs of historically vulnerable populations in a complex, shifting environment. Implications for public health practice and policy include the need to ensure that program personnel are aware of evidence-based strategies to reach different priority populations and are kept abreast of organizational and system changes that may affect referral patterns as well as the need to educate health care providers working with safety net programs about changes in the delivery and coordination of services.

Innovations in Maternal and Child Health: Pairing Undergraduate and Graduate Maternal and Child Health Students in Summer Practica in State Title V Agencies.

Objective As part of the National MCH Workforce Development Center, an innovative internship program placed MCH undergraduate and graduate students in summer practica in state Title V agencies. Graduate student mentoring of undergraduates and leadership and professional development training and support are key features of the program. The objective of this paper is to report on the results of the evaluation of the MCH Paired Practica Program in its pilot years, 2014-2016. Methods Students completed pre and post internship questionnaires which included closed as well as open-ended questions. In addition, the Title V state health agency preceptors completed a questionnaire at the end of each summer. Results Over the 3-year pilot project, a total of 17 teams participated. Students were from 6 of the 13 graduate Centers of Excellence in MCH programs in Schools of Public Health and two undergraduate MCH Pipeline Programs. There were 11 participating states. After the practicum experience, there was a significant increase in students' confidence in a number of measures related to working in complex, dynamic environments and in their ability to contribute to improvements in MCH population health. Students reported having more confidence in their ability to function effectively as an informal/formal MCH leader (p = 0.02), more confidence in their ability to contribute to improvements in MCH population health (p = 0.04), and being more prepared to enter the workforce after the practicum experience (p = 0.07), although there was no significant change in students' (n = 22) interest in seeking a job in a Title V agency or a community based organization with a MCH focus. Nearly 60% of the students did state at the posttest that they would likely seek additional education in MCH. Overall, the Title V preceptors (n = 14) were very positive about the program although in some instances there was less confidence in the knowledge and skills of the undergraduate students. Conclusion The MCH Paired Practica Program is a unique effort to go beyond the academic training of undergraduate and graduate MCH students to provide them with direct exposure to the field, as well as leadership, mentorship, and professional development training. While some challenges emerged related to differences in skills between undergraduates and graduate MCH students, participating students demonstrated clear improvements in their leadership skills including increased confidence in their ability to take initiative, provide opinions and feedback, to function informally or formally as leaders, and to contribute to improvements in MCH population health.

A Call to Revisit the Prenatal Period as a Focus for Action Within the Reproductive and Perinatal Care Continuum.

Objectives The broad maternal and child health community has witnessed increased attention to the entire continuum of reproductive and perinatal health concerns over the past few years. However, both recent discouraging trends in prenatal care access and utilization and a renewed understanding of prenatal care as a critical anchor of the reproductive/perinatal health continuum for women who do get pregnant demand a new effort to focus on the prenatal period as a gateway for maternal and infant health. Methods This commentary: describes the Medicaid expansions and the momentum for universal access to prenatal care of the 1980-1990s; examines the pivot away from this goal and its aftermath; provides a rationale for why renewed attention to prenatal care and the prenatal period is essential; and, explores the potential focus of an updated prenatal care agenda. Conclusion We conclude that increasing women's access to high quality prenatal care will require substantial effort at the clinical, community, policy, and system levels. Only when attention is paid to all phases of the reproductive/perinatal health continuum with an emphasis on continuity between all periods, and on the social determinants that affect health and well-being, will our nation be able to ensure the health of all women across the life course (whether or not they ever become mothers), while simultaneously fulfilling our nation's promise that all children-no matter their income or race/ethnicity-will have the opportunity to be born well.

Postpartum Health and Wellness: A Call for Quality Woman-Centered Care.

Introduction The first 3 months after giving birth can be a challenging time for many women. The Postpartum Health and Wellness special issue explores this period, one that is often overlooked and under-researched. Methods This issue is designed to bring greater focus to the need for woman-centered care during the postpartum period. Articles in this issue focus on four key areas: (1) the postpartum visit and access to care, (2) the content of postpartum care and postpartum health concerns, (3) interconception care including contraception, and (4) policy, systems, and measurement. Results The submissions highlight deficits in the provision of comprehensive care and services during a critical period in women's lives. The research highlighted in this issue supports the recommendation that Maternal and Child Health leaders collaborate to create woman-centered postpartum services that are part of a coordinated system of care. Conclusion In order to achieve optimal health care in the postpartum period it is becoming more apparent that increased flexibility of services, cross-training of providers, a "no wrong door" approach, new insurance and work-place policy strategies, improved communication, and effective coordinated support within a system that values all women and families is required.

Guidelines and Interventions Related to the Postpartum Visit for Low-Risk Postpartum Women in High and Upper Middle Income Countries.

Objectives A two-part review was undertaken to: (1) summarize current guidelines on the timing and frequency of postpartum follow-up care for generally healthy, non-high risk postpartum women and to delineate the evidence on which these guidelines are based; and, (2) summarize the results of intervention studies focused on increasing utilization of the postpartum visit for generally healthy, non-high risk postpartum women. Methods A review of guidelines from high and upper middle income countries published between 2000 and 2016 in English related to non-high risk postpartum follow-up visits was conducted in 2014-2016 using four databases and additional sources. In addition, articles published between 1990 and 2016 which evaluated interventions from high to upper middle income countries related to increasing attendance at the postpartum visit were gathered using three databases. Results This review located eight guidelines, all of which relied on expert opinion/group consensus as the evidence for their recommendations regarding the timing of the postpartum visit. The review located 19 intervention studies focused on increasing use of the postpartum visit; in 12 there was statistically significant evidence that these approaches improved utilization. However, no intervention strategy was evaluated more than a few times and many of the evaluations were relatively dated. Conclusions Guidelines for the timing of the postpartum visit are variable and are typically based on weak evidence; however, there is support for increased flexibility to meet women's needs. Additionally, while there is a diverse set of promising interventions to increase utilization of the postpartum visit, there is limited evaluative information. Future initiatives should focus on more rigorous evaluation.

A Qualitative Study to Understand Nativity Differences in Breastfeeding Behaviors Among Middle-Class African American and African-Born Women.

Objective To explore nativity differences and the role of attitudes, social norms, and behavioral control perceptions surrounding breastfeeding initiation and duration among middle-class African-American (AA) and African-born (AB) mothers in the US. Methods Semi-structured individual interviews were conducted with 20 middle-class AA and AB mothers in central Ohio from December 2012 to February 2013. Interview questions were developed based on the Theory of Planned Behavior (TPB). Interviews were analyzed for salient themes by TPB constructs. Differences in themes were examined by nativity status. Results All study participants had initiated breastfeeding or bottle-feeding with expressed breast milk, noting the benefits it conferred as well as the persuasive encouragement they received from others. Persistent encouragement was often cited as a factor for sustaining breastfeeding. More AA mothers had discontinued breastfeeding by the time of the interview, which was often attributed to health, lactation, and work challenges. Inconsistent support from health providers, dissuasive remarks from others, ambivalent breastfeeding attitudes, and diminished family support led some mothers to begin formula supplementation. Analysis of maternal narratives revealed nativity differences across sources of encouragement. Specifically, important sources of encouragement were health providers for AA mothers and family, friends, partners and culture for AB mothers. Only AB mothers expressed concerns about difficulty they encountered with breastfeeding due to the lack of proximal family support. Conclusions Findings reveal that both groups of mothers may be susceptible to unsupportive breastfeeding norms in the US and also highlight the need for intervention in health care settings and workplaces to improve AA women's breastfeeding rates.

Healthcare Utilization in the Postpartum Period Among Illinois Women with Medicaid Paid Claims for Delivery, 2009-2010.

Purpose Postpartum care can provide the critical link between pregnancy and well-woman healthcare, improving women's health during the interconception period and beyond. However, little is known about current utilization patterns. This study describes the patterns of postpartum care experienced by Illinois women with Medicaid-paid deliveries. Methods Medicaid claims for women delivering infants in Illinois in 2009-2010 were analyzed for the receipt, timing and patterns of postpartum care, as identified through International Classification of Diseases Revision 9-Clinical Modification and Current Procedural Terminology© codes for routine postpartum care (43.4 % of visits), other postpartum services (e.g., depression screening, family planning), and other office visits for non-acute care. Results Over 90,000 visits to 55,577 women were identified, with 81.1 % of women experiencing any care during the first 90 days postpartum. Approximately 40 % had one visit, while 31 and 29 % had two and three or more visits, respectively. Thirty-four percent had their first visit <21 days postpartum, while 56 % had the first visit between 21 and 56 days postpartum. Compared with non-Hispanic whites, African-Americans had lower rates of receiving any care (73.6 vs. 86.5 %), fewer visits (48.0 vs. 33.5 % with only one visit), and later first visits (13.6 vs. 7.3 %, >56 days). Conclusions for Practice The vast majority of Illinois women with Medicaid-paid deliveries interact with the healthcare system during the first 3 months postpartum, though not always for a routine postpartum visit. Strategies to optimize postpartum health should encourage a higher level of coordination among services and linkage to well-woman care to improve subsequent women and infants' health outcomes.

Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers.

Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women's preferences with respect to postpartum care. Likewise, there is also limited information on providers' practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers' current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women's use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.