Significance

These findings support the need for innovative models for postpartum mother-infant care during and beyond the pandemic to provide dyadic care and material support. Ongoing studies of community outreach efforts like the MMC, which focus on dyadic care, can evaluate comparative effectiveness of maternal and infant outcomes.

Introduction

Postpartum maternal and neonatal health care schedules, endorsed by American College of Gynecology (ACOG) and American Academy of Pediatrics (AAP) guidelines, respectively, promote the health and well-being of birthing persons and the nearly 4 million infants born annually in the US (“ACOG Committee Opinion No. 736,” 2018; Hagan et al., 2017; Martin et al., 2019; McInerny et al., 2016). Assessments of mothers and infants provide critical opportunities to screen for and detect postpartum depression and health-related social needs (HRSN) affecting families (“ACOG Committee Opinion No. 736,” 2018; McInerny et al., 2016).

In 2018, the ACOG Committee on Obstetrics Practice substantially shifted its recommendations for maternal postpartum care from a single visit at 4–6 weeks to earlier, frequent, individualized care during the first 12 weeks postpartum—“the fourth trimester”—a period that lays the groundwork for healthier futures for women and families. These recommendations evolved from the United States’ unacceptably high maternal mortality rate, which has more than doubled since 1990 (World Health Organization, 2019). For women with pregnancy complications, short-interval follow-up can mitigate the risk of postpartum pregnancy-related deaths, 35% of which occur between 24 h to 6 weeks postpartum (“ACOG Committee Opinion No. 736,” 2018; Kassebaum et al., 2014) and can address the higher lifetime risk of developing cardiovascular disease associated with adverse pregnancy outcomes (Canoy et al., 2016; Grandi et al., 2019; Parikh et al., 2021; Riise et al., 2019; Theilen et al., 2018).

Despite the public health importance of postpartum care for women and infants, there are substantial and longstanding barriers to and disparities in accessing regular and recommended postpartum care. Even though frequent care is indicated for at-risk women, about 40% do not attend the six-week postpartum visit. Attendance rates are lower among women with limited resources, lack of insurance or underinsurance, or individuals with difficulty communicating with their healthcare providers (“ACOG Committee Opinion No. 736,” 2018; Bennett et al., 2014; Bryant et al., 2006; Danilack et al., 2019; Daw et al., 2020). These disparities extend to stark gaps in maternal and infant health outcomes in the US, with significantly high morbidity and mortality among Non-Latino Black women and infants (CDC Infant Mortality, 2020; CDC Pregnancy Mortality Surveillance System, 2020; Howell & Zeitlin, 2017).

As with other disaster-related events (DeYoung & Mangum, 2021), the COVID-19 pandemic exacerbated existing challenges in postpartum care, including economic challenges and interrupted support structures for perinatal care (Barbosa-Leiker et al., 2021; Kinser et al., 2021). Because of uncertainties about transmission and hospital burdens of caring for COVID-19 patients, postpartum stays were shortened, and other services, such as depression screening and lactation support, were limited (DeYoung & Mangum, 2021; Hendrix et al., 2021).

Mobile medical clinic (MMC) strategies can bridge community and medical systems and decrease barriers to accessing care, especially for patients from racial and ethnic minority groups disproportionately impacted by health inequities (Hendel, 2022; Yu et al., 2017). For women who are pregnant or who have recently given birth, MMCs have been associated with improved hypertension management, decreased emergency care utilization, lower cost, and earlier initiation of prenatal care with fewer preterm births (Edgerley et al., 2007; O’Connell et al., 2010; Song et al., 2013).

In light of the many challenges related to accessing care during the COVID-19 pandemic, primary care clinicians at our institution re-purposed an MMC to provide medical care to newborns and women near or outside their homes. The MMC was deployed to respond to both pandemic concerns (related to community transmission of COVID-19 and heightened transportation barriers) and to provide patient- and family-centered postpartum and neonatal care to narrow pandemic-generated health disparities. In this mixed methods study, we describe demographic characteristics and HRSN of families (caregivers and infants) who accessed maternal-infant care through the MMC and explore intervention feasibility (Lancaster & Thabane, 2019), acceptability, perceived benefits, and barriers to care.

Methods

Setting

New Haven, Connecticut, with a population of 130,000, is disproportionately impacted by poverty, unemployment, an elevated infant mortality rate, substance use, and HIV (Data Haven, 2016). To address the HIV and substance use epidemics, a 40-foot MMC has provided free healthcare since 1993 (Gibson et al., 2014; Morano et al., 2013a, 2013b; Morano et al., 2014a, 2014b). Redeployed in April 2020 for maternal-infant care during the COVID-19 pandemic, the MMC, staffed by a Family Nurse Practitioner and a Medical Assistant, offers clinical assessments of newborns (vital signs, growth, limited physical exam, transcutaneous bilirubin when needed) and women (vital signs, wound healing, mood) in safe, accessible, physically distanced, community settings.

Sample Population

Of the 170 caregivers who attended MMC appointments during this period, eight were excluded because a language other than Spanish or English was listed as their primary language in the electronic health record (Fig. 1). Purposive sampling for the concurrent surveys and interviews preferentially included (1) recent attendees and (2) attendees who listed Spanish as their primary language. The study was exempt by our institution’s Internal Review Board, and all respondents provided verbal informed consent to participate and for collection of deidentified chart data.

Fig. 1
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Caregivers who received care at the mobile medical clinic and completed surveys/interviews

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Study Design

We used a convergent mixed methods design (Curry & Nunez-Smith, 2015; Fetters et al., 2013) to conduct and analyze a telephone survey (all respondents) and interview (until thematic saturation) with caregivers whose preferred language in the electronic health records was English and/or Spanish and who received care at the MMC between April and November 2020. Surveys/interviews occurred one to nine months after the MMC encounter.

Survey and Semi-Structured Interview Development

The survey and semi-structured interview guide (Supplemental Table 1), developed and iteratively refined by our research team, included demographic components modeled from the American Community, National Health and Education, and National Immunization Surveys (National Immunization Surveys | CDC, 2021; NHANES—National Health and Nutrition Examination Survey Homepage, 2021; US Census Bureau, 2021) and previously-validated instruments to assess COVID-19 symptoms and exposures, food insecurity, diaper insecurity, anxiety, and means of transportation (Hager et al., 2010; Nelson et al., 2020; Silver et al., 2012; Smith et al., 2013; Spitzer et al., 2006).

Telephone Interviews and Chart Data Collection

Following recruitment and verbal informed consent, English- and/or Spanish-speaking members of the research team conducted both a structured survey and semi-structured qualitative interview with participants. A three-person coding team of a health services researcher, a primary care pediatrician, and a medical student (JR, LS, MB) independently developed codes and created a codebook by consensus. We recorded survey responses in Qualtrics® (Qualtrics, Provo, Utah) and, separately, we recorded contact information to send participants a $20 gift card. All respondents were provided information about additional services and resources for mental health, nutrition, and medical resources at the conclusion of the survey. Semi-structured interview components were audio-recorded, transcribed with the automatic transcription software Trint®, and manually edited. Once we reached thematic saturation, we continued to administer the structured telephone survey without the semi-structured interview components. Full surveys with semi-structured qualitative interviews ranged from approximately 20 to 40 min in duration, while structured surveys alone ranged approximately 10 to 30 min. For all caregiver-infant dyads who consented to participate in the study, we collected the following infant data via medical chart review: number of MMC visits, bilirubin assessments, COVID-19 test results, and vitamin D prescriptions (Supplemental Table 2). For the 66 of 68 postpartum women who were evaluated on the MMC, maternal blood pressure evaluations, maternal follow-up appointment data, and COVID-19 test results were also collected via chart review. Survey data and chart review data were linked and subsequently de-identified.

Mixed Methods Analyses

Descriptive analyses of survey data and chart review using proportions were analyzed using Stata (StataCorp, 2017). Transcripts were analyzed with grounded theory methodology using the constant comparative method in Dedoose® (Corbin & Strauss, 2008). The coding team analyzed all transcripts (with two coders—JR and MB—analyzing Spanish-language transcripts) and discrepancies were resolved through an iterative process. Codes were then sorted into emerging themes and reviewed and modified with the larger research team. Representative Spanish-language quotations were translated after analysis, and original Spanish-language quotations can be found in the Supplement. We used an intervention mixed methods framework to perform connected integration of qualitative and quantitative results (Curry & Nunez-Smith, 2015; Fetters et al., 2013). We followed the COREQ criteria for reporting qualitative research (Tong et al., 2007).

Results

Of the 162 eligible caregivers, we attempted to reach 139 (97 English-preferred and 42 Spanish-preferred) and successfully completed 68 surveys, 27 of which also included qualitative interviews, of caregivers of 69 children (one set of twins) with a 48.9% response rate (Fig. 1).

Sociodemographic Characteristics

Nearly all caregiver respondents were mothers (91.2%). Over half (52.9%) identified as Latino and 33.8% as Non-Latino Black (Table 1). Nearly half (44.1%) lived in multilingual households, 44.1% had education beyond high school, and just over half (52.9%) were married or living with a partner. Most (89.9%) made one or two visits to the MMC (Table 1). Most women had public insurance (63.3%), and many (22.7%) were uninsured (Table 2).

Table 1 Respondent characteristics (N = 68 parents/guardians, N = 69 infants)
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Table 2 Characteristics of women and infants and services received on the mobile medical clinic and in the community (N = 66 mothers, N = 69 infants)
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Infant and Maternal Health Characteristics

Four caregivers (5.9%) reported contact with someone who tested positive for SARS-CoV2, and two mother-infant dyads (2.9%) tested positive after discharge. No women or infants tested positive for SARS–CoV2 during their birth admissions. We found no cases of hyperbilirubinemia requiring phototherapy. Although most (89.9%) reported ever breastfeeding, nearly all (94.2%) had fed formula, and only half (49.3%) were still breastfeeding at the time of the survey (Table 2).

According to chart review, two-thirds of women who were evaluated on the MMC attended an in-person or telehealth postpartum visit, and 16.7% had a documented missed postpartum visit. All women evaluated on the MMC had blood pressure evaluated. Over two-thirds (69.7%) had at least one postpartum blood pressure reading > 120/80 mmHg, and 19.6% had readings elevated enough to require contact with the obstetric provider for further guidance. Follow-up visits with either an outpatient or obstetric provider regarding blood pressure then occurred in 15.2% of mothers, and four (6.1%) required emergent treatment and/or readmission to the hospital for postpartum hypertension detected on the MMC (Table 2).

Health-Related Social Needs (HRSN) of Caregivers

About half of caregivers screened positive for food insecurity (52.9%), diaper insecurity (44.1%), and use of Supplemental Nutritional Assistance Program (SNAP) (55.9%). About one-third of respondents screened positive for mild (16.2%), moderate (8.9%), or severe (1.5%) anxiety. Most respondents were somewhat and/or very worried about contracting COVID-19 and about finances related to COVID-19 (69.1% for both) (Table 3).

Table 3 Health-related social needs and characteristics of caregivers who visited the mobile medical clinic (N = 68)
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One-quarter of respondents reported missing an office appointment because of transportation problems. About one-third (29.4%) reported that they found it “somewhat” or “very” challenging to get to the doctor’s office (Table 3). When asked about transportation, most reported that they typically traveled by driving themselves or obtaining a ride with family and/or friends, while 5.9% reported taking a taxi-like service, 4.4% reported using a bus, and 1.5% reported walking.

Acceptability and Satisfaction

Table 4 demonstrates satisfaction measures from survey responses. Nearly all caregivers reported they were very satisfied and very likely to recommend the MMC to friends (98.5% and 94.1%, respectively), with responses like: “They exceeded my expectations,” and “It was better than expected” (Respondents #4 and #5, respectively). Most (85.3%) had no suggestions for improvement, although some requested additional resources and space (“I'm kind of claustrophobic and it was kind of tight.” –Respondent #2).

Table 4 Satisfaction of caregivers who visited the mobile medical clinic (N = 68 parents/guardians)
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About two-thirds (66.2%) preferred the MMC for future visits over the office location, 7.3% preferred the office, and 26.5% expressed no location preference.

As we discussed the acceptability and satisfaction with caregivers, perceived patient- and family-centered care and respectful interactions were common threads through many responses, with many expressing a desire to expand services.

“Even like if they have this when I was pregnant too. It would have been nice to be able to go down and talk to somebody in a in a situation like this instead of having to go all the way down there, you know, nine months pregnant, you know, risking getting sick and everything. So if you guys have a possibility to expand this, I would go for it.” – Respondent #18

Themes from Qualitative Interviews

Major themes from the qualitative analysis of interviews included (1) patient- and family-centered care, (2) perceived safety, and (3) perceived benefits of dyadic mother-infant care (Table 5).

Table 5 Themes, sub-themes, and representative quotations from qualitative discussions
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Patient- and Family-Centered Care

Perceived delivery of patient- and family-centered care, in which patient/family goals, values, and preferences guide provision of healthcare, was evident in several subthemes related to the patient experience on the MMC. This included patient- and family-centeredness around aspects of convenience, communication, privacy, continuity of care, acceptability and intervention feasibility, and resources provided to address HRSN.

Related to patient- and family-centered convenience, caregivers discussed transportation, childcare, and scheduling as typical burdens and inconveniences of in-person office visits eased by the MMC. One participant noted the convenience of not needing to coordinate travel or childcare for other children while home schooling during COVID-19:

“Because I have two other kids that are toddlers and they do virtual school, so it's hard to go all out once over there. And then also taking the baby out.” – Respondent #11

Many respondents reflected that, in contrast to prior in-office experiences, they faced fewer barriers to communication with MMC staff and had positive interactions during the scheduling process, appointment confirmations, and discussing care for themselves and their newborns:

“I spoke with a person directly and they would always arrange the arrival time and call a day ahead of time to confirm that they were coming, to see if everything was okay with me, and that I didn’t have COVID symptoms and that everything was good.” – Respondent #24

Privacy was appreciated as a component of patient- and family-centered care for providing respectful, personalized interactions with the MMC staff:

“I mean I just like it because you're by yourself. It's private, you're by yourself. Just you and the staff which is nice.” – Respondent #3

Perceived Safety

Perceived safety from exposure to communicable diseases, especially related to COVID-19, was a major theme that emerged from discussions with many caregivers. There was often overlap with patient- and family-centered care and convenience, as the components of the MMC model which provided convenience for transportation, childcare, privacy, ease of scheduling and communication also allowed many caregivers physical space and reassurance around COVID-19 safety during the height of the pandemic in 2020:

“Honestly, the [MMC] is just better, with no other patients on the [MMC]. So I just you know, I'm just scared because people start coughing, don't cover their mouth. At the clinic, that's what I'm worried about. But the [MMC] is literally just you, so you don't have to worry about much.” – Respondent #3

“I would recommend it, since newborn babies leave the hospital without vaccines and are low in defenses and, well, we can avoid exposure for them.” –Respondent #24

Perceived Benefits of Dyadic Care

The final theme reflected the perceived benefits of dyadic care, in which participants expressed how engaging the mother-infant dyad in care together provided opportunities for improved health for both caregivers and their infants.

One woman discussed how the MMC evaluation provided her confidence as she continued to breastfeed:

“Because I can keep track on his weight because I have mastitis. So I was worried he wasn't getting enough nutrients and enough milk, but everything was all good. That's how I can keep track, with the [MMC].” – Respondent #12

This woman, like many, often mentioned her own health as secondary to the health of her child. Similarly, when asking about care for themselves, caregivers would often respond in the context of caring for their children, especially for women recovering from Caesarean sections who had added barriers to care:

“And I was glad that they had that because I can't drive right now because I had a C-section with the boys…It was like a relief for me. You know, I'm going [to the office] all the time…So I was glad when they told me about the [MMC] doing home visits, I was really glad that they had that service available.” – Respondent #13

Furthermore, as noted above, many women had not yet attended a postpartum visit, and yet the MMC clinicians detected many instances of elevated blood pressure and several instances of hypertension requiring urgent or emergent medical management. For one woman who was admitted, her focus remained on her child, only disclosing her own admission after being explicitly asked about her experience with blood pressure checks:

“Because I thought it was only for [my daughter], they were going to check her up and then I realized it was also for me. So when they checked me, I found out that I was with high blood pressure. So then I went back to the hospital for two days with my magnesium and everything.” – Respondent #15

Discussion

In this mixed methods evaluation of a MMC that was emergently repurposed to provide postpartum/postnatal care for women and neonates during the early COVID-19 pandemic, findings suggest high acceptability especially related to perceived safety and feelings that certain transportation and social needs were addressed. Respondents found services acceptable, feasible, and, importantly, patient- and family-centered. In addition, 15% of women had instances of maternal hypertension requiring follow-up with an obstetrician, and 6% of women required emergent evaluation and treatment. The MMC, deployed during the COVID-19 pandemic to address COVID-19 safety concerns, could be one of many dyadic outreach interventions to help to improve patient- and family-centered care and reduce disparities in access to postpartum and neonatal care for underserved populations.

From both qualitative and quantitative responses, we found high levels of satisfaction related to patient- and family-centeredness. Patient-centered care is defined by the Institute of Medicine as, “providing care that is respectful and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (Institute of Medicine (US) Committee on Quality of Health Care in America, 2001). Patient- and family-centered care emphasizes “collaborating with people of all ages, at all levels of care, and in all health care settings” according to the Institute for Patient- and Family-Centered Care (Institute for Patient & Family Centered Care, 2021).

Elements of the six domains of patient- and family-centeredness, described in a 2019 Academy Health report (Sinaiko et al., 2019) and modified in Fig. 2, were addressed through the MMC. The domains include (1) addressing caregiver and provider goals, (2) adjusting to life circumstances, including COVID-19 modifications, (3) respecting values and culture, (4) allowing options for provider care preference, (5) addressing health status and symptoms, and (6) promoting equitable access. All six of these domains were reflected in the qualitative responses, especially as patients shared their experiences with the MMC related to convenience, communication, and privacy. This respectful and responsive care was appreciated by families and, for some, contrasted with the patient experience in usual clinic-based care. Focusing on patient values through patient- and family-centered care must guide initiatives aimed at improving equitable access to health care and decreasing the significant inequities in US maternal and infant health outcomes (CDC Infant Mortality, 2020; CDC Pregnancy Mortality Surveillance System, 2020; Howell & Zeitlin, 2017).

Fig. 2
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Achieving domains of patient- and family-centeredness on the mobile medical clinic

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Beyond offering patient- and family-centered care, the MMC provided hypertension screening for postpartum women. The MMC’s linkage to primary provider and/or specialist referrals resulted in follow-up for many, and in emergent treatment for 6% of women in our study. The US has the highest rate of maternal mortality among high-income countries, with Non-Latino Black women at disproportionately high risk of dying from a pregnancy-related complications (World Health Organization, 2019). Cardiovascular disease and hypertensive disorders of pregnancy are leading causes of maternal mortality (Petersen et al., 2019). One of the greatest shortcomings in the current health system, especially in light of the fractured care and missed visits that have occurred during the pandemic, is a safe transfer of care between the obstetrician and primary care provider for women with known risk (Hendrix et al., 2021; Parikh et al., 2021). The MMC is one possible model to provide frequent and individualized postpartum care that can help identify women with high-risk conditions and facilitate potentially life- and cost-saving follow up during the twelve week postpartum period (“the fourth trimester”) and beyond (World Health Organization, 2019).

Approximately half of the respondents reported HRSNs of food insecurity, diaper insecurity, and/or use of the Supplemental Nutrition Assistance Program. Consistent with prior research, caregivers also expressed substantial anxiety and stress related to the COVID-19 pandemic (Basu et al., 2021; Boekhorst et al., 2021; Chmielewska et al., 2021; Hessami et al., 2020; Liu et al., 2021; Mariño-Narvaez et al., 2021; Mayopoulos et al., 2021; Silverman et al., 2020). Worldwide, the pandemic has been associated with worsened maternal and infant outcomes, including significant increases in stillbirth, maternal death, and postnatal depression (Chmielewska et al., 2021). This pandemic has also worsened many material hardships, with rates of food insecurity doubling nationwide and tripling in families with children (Keith-Jennings et al., 2021). Multiple studies have found maternal stress, anxiety, and loneliness have worsened since the onset of the pandemic, although studies have found varying changes in depression scores (Basu et al., 2021; Boekhorst et al., 2021; Chmielewska et al., 2021; Hessami et al., 2020; Liu et al., 2021; Mariño-Narvaez et al., 2021; Mayopoulos et al., 2021; Silverman et al., 2020). Allaying material hardships such as diaper insecurity is one way to reduce caregiver stress (Smith et al., 2013), and many caregivers we surveyed expressed appreciation for the material items—including diapers and creams—that were provided as part of the MMC outreach efforts. Thus, direct material support through provision of items including diapers and food may continue to be key interventions for health providers’ community outreach efforts, not only to alleviate these direct material hardships but also to mitigate caregiver anxiety and stress.

A key element of this MMC iteration was the provision of dyadic mother-infant care provided by a Family Nurse Practitioner. As highlighted in a framework for maternal-infant dyad care model developed and described by Glazer, et al., applying a dyadic approach is a crucial paradigm shift which can break down silos to address the multifactorial maternal-infant health disparities and accompanying lifelong health outcomes (Glazer et al., 2021). As was noted by the multiple instances of maternal hypertension that were detected and treated through the MMC, even when caregivers were focused on their children, dyadic care offers opportunities for maternal evaluations during the “fourth trimester.” These evaluations, which may have otherwise been missed, may help to meet the mutual goals of both AAP and ACOG postpartum care schedules and reduce morbidity and mortality (“ACOG Committee Opinion No. 736,” 2018; McInerny et al., 2016).

Limitations included a small clinical sample further reduced by time and budgetary restraints which restricted the ability to contact all participating families. Social desirability bias and recall bias may have affected responses, as some respondents were surveyed months after their MMC visit. We tried to minimize social desirability bias by using an independent interviewer and to minimize recall bias by asking questions in a variety of ways to approach the constructs of interest. Furthermore, we conducted this study in English and Spanish, but respondents who spoke other languages were excluded, which constrained the evaluation of language barriers.

Conclusions for Practice

Many caregivers who accessed care on a mobile medical clinic during the COVID-19 pandemic reported a high level of satisfaction, especially related to patient- and family-centered care, and, importantly, the mobile medical clinic clinicians detected multiple instances of maternal hypertension requiring emergent treatment and care. Caregivers identified health-related social needs including food insecurity, diaper insecurity, and use of SNAP and significant anxiety related to COVID-19 transmission. These findings support the need for innovative models for postpartum mother-infant care during and beyond the pandemic to provide dyadic care and material support. Ongoing studies of community outreach efforts like the MMC, which focus on dyadic care, can evaluate comparative effectiveness of maternal and infant outcomes. Sustainability of such programs will require support from hospitals and community-based pediatric practices to support increased patient- and family-centered care initiatives for maternal-infant dyads.