Strategies to improve postpartum engagement in healthcare after high-risk conditions diagnosed in pregnancy: a narrative review

Transition from antepartum to postpartum care is important, but often fragmented, and attendance at postpartum visits can be poor. Access to care is especially important for individuals diagnosed antepartum with conditions associated with longer-term implications, including gestational diabetes (GDM) and hypertensive disorders in pregnancy (HDP). Strategies to link and strengthen this transition are essential to support people to attend recommended appointments and testing. This narrative review evaluates what is known about postpartum transition of care after higher-risk antepartum conditions, discusses barriers and facilitators to uptake of recommended testing, and outlines strategies trialled to increase both postpartum attendance and testing. Barriers to attendance frequently overlap with general barriers to accessing healthcare. Specific postpartum challenges include difficulties with transport, coordinating breastfeeding and childcare access. Systemic challenges include inadequate communication to women around implications of health conditions diagnosed in pregnancy, and the importance of postpartum follow up. Uptake of recommended testing after a diagnosis of GDM and HDP is variable but generally suboptimal. Strategies which demonstrate promise include the use of patient navigators, focused education and specialised clinics. Reminder systems have had variable impact. Telehealth and technology are under-utilised in this field but offer promising options particularly with the expansion of virtual healthcare into routine maternity care. Strategies to improve both attendance rates and uptake of testing must be designed to address disparities in healthcare access and tailored to the needs of the community. This review provides a starting point to develop such strategies from the community level to the population level.


Current recommendations for postpartum care
The postpartum period begins at birth and is defined as the first 6 [1] to 12 [2] weeks after delivery, sometimes referred to as the fourth trimester.Postpartum review with a healthcare practitioner plays a significant role in supporting those with immediate health needs including contraception, breastfeeding, peripartum mental health, and wound care [1,3].Most guidelines recommend this visit takes place at or prior to 6 weeks' postpartum [1].
Despite this recommendation, documented low attendance rates at the postpartum visit suggest that many people do not receive this important review in a timely manner [4].Contributing factors to this include inconsistently defined care pathways supporting people in the transition from antepartum to postpartum care, fragmented communication between healthcare providers and competing priorities.
Many pregnant people are diagnosed for the first time with a medical condition during pregnancy.Conditions such as gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) have implications for longer term health and ongoing engagement in healthcare and postpartum testing is recommended following these diagnoses.GDM, defined as the first presentation of hyperglycaemia in pregnancy, affects 14% of pregnancies worldwide [5] and is predictive of an increased risk of metabolic disorders including a seven-to ten-fold risk of type 2 diabetes within 10 years [6].An oral glucose tolerance test (OGTT) is recommended for those with a diagnosis of GDM within the first 12 weeks' postpartum [2] and at regular intervals thereafter to provide opportunity for early diagnosis and treatment of type 2 diabetes mellitus.
The spectrum of HDP includes gestational hypertension, pre-eclampsia, eclampsia, chronic hypertension and preeclampsia superimposed on chronic hypertension [7].Global prevalence is estimated at 116 cases per 100,000 women of childbearing age, with the highest rates seen in low-income countries at 286 cases per 100,000 compared with 70 cases per 100,000 in high-income countries [8].HDP are associated with long-term cardiovascular, cerebrovascular and renal disease [9,10], and blood pressure review is recommended in the first 7-10 days postpartum [7].Testing for persistent hypertension, markers of organ dysfunction (e.g.urinalysis for proteinuria, renal and liver function testing), ambulatory blood pressure monitoring, metabolic screening with fasting glucose, lipid profile and body mass index measurement, within 3-6 months is advised, and at regular intervals thereafter [11].
Both chronic medical illness [12] and new antepartum diagnoses of medical conditions [13] are associated with poorer peripartum mental health.Those with GDM have a significantly increased risk of postpartum depressive symptoms, with an estimated pooled relative risk of 1.32 [14].Pre-eclampsia has been identified as a risk factor for depression both during the postpartum period, and beyond [15].The relationship between other HDP and poor peripartum mental health is less clear, but trends towards increased risk of depression, anxiety and post-traumatic stress disorder have been reported [16].Postpartum review provides an important opportunity for screening and support for peripartum mental health disorders.
This state of the science review summarises what is known about rates of postpartum engagement in care both nationally and internationally, as defined by attendance at the 6-week postpartum visit, and uptake of recommended testing in those with medical diagnoses of GDM and HDP during pregnancy.We outline the strategies trialled to date to improve attendance at postpartum visits and improve adherence to recommended testing; the barriers and facilitators to uptake of recommended testing; and discuss gaps in the literature for future research.

Attendance postpartum: what is known?
Attendance rates for postpartum care vary significantly between different cohorts, countries, and healthcare systems.Whilst a 6-week appointment is recommended, few studies report attendance rates at this time point.Attendance rates of 42% at the maternal 6-week check have been reported in the United Kingdom (U.K.) by 6-8 weeks postpartum, increasing to 62% by 12 weeks [17].In the United States (U.S.), reported rates vary from 54% in the first year postpartum amongst veterans [18], to 72% in a recent systematic review [4], and to more than 80% by 90 days postpartum amongst women with funded postpartum care [19].In Australia, 81% attendance at a general practitioner visit was reported in a South Australian cohort in the first 9 months postpartum [20].Disparities in attendance rates exist within these countries, with significantly lower attendance rates in the U.S. among those of Black/African American (52%), Asian (45%) and Hawaiian/other Pacific Islander (48%) race and ethnicity [18].Similarly, in Australia attendance was lower (48%) amongst Aboriginal and Torres Strait Islander people attending rural health services [21], suggesting multiple factors contributing to non-attendance.Access to health insurance in countries such as the U.S. also impact on attendance at postpartum visits, with Medicaid-insured women less likely to attend than those with private insurance [4].Concurrent existence of a chronic condition has also been found to reduce the likelihood of attending the postpartum visit [4].

What strategies have been trialled to increase postpartum attendance?
A variety of strategies have been trialled in different settings to increase postpartum attendance.The different types of approaches are discussed by Phillips et al. [22] in their recent review of postpartum transition of care, and strategies trialled to date were described by Stumbras et al. [23] in their 2016 narrative review.As these summaries provide an excellent overview of strategies to improve postpartum transition of care, an in-depth analysis is not repeated in our review.For the purposes of understanding what has been identified to date, Table 1 summarises these strategies with examples of their use to increase postpartum attendance.
Patient incentives, patient education and home visits have generally shown mixed success at increasing attendance.Patient navigator systems appear more successful at increasing attendance as well as other parameters including vaccination uptake and screening for depression [33].This may be due to the ability to tailor such strategies towards individual needs.A systematic review and meta-analysis by Bowden et al. [34] of strategies in high-income countries and their impact on antepartum and postpartum care found that people who received enhanced support with individualised care were significantly more likely to attend their postpartum visit.This conclusion was based on aggregate data using two very different strategies: patient incentives [27] and patient navigators [29].The use of administrative Pilot mHealth programme (New Jersey, U.S.): text-based two-way messaging system for 6 weeks postpartum with daily six-item questionnaire.'Yes' responses triggered telephone follow-up by provider [32] assistance such as pre-discharge appointment scheduling has also been associated with promising results [24] but has yet to be trialled prospectively as a strategy in its own right.More recently, the use of technology has allowed the opportunity to expand strategies beyond reminder-based messaging alone, for example to incorporate remote blood pressure monitoring [35], and education delivery [32].Use of technology within the postpartum setting to specifically increase attendance rates has yet to be explored definitively particularly in high-income settings.Preliminary findings from a series of qualitative interviews for people who received text-based messaging from their postpartum healthcare provider indicated that this approach was viewed positively by participants [32].
Many programmes combine two or more of these approaches within their postpartum care set-up.For example, Health Beyond Pregnancy [30] used text-based reminder systems to prompt postpartum follow-up, with additional motivational messaging via video and text, and also used a cash incentive which was provided to those who attended their visit.This multi-approach focus may be helpful in broadening the reach of individual programmes; however, there is insufficient evidence to identify which combinations of approaches are most likely to be successful in increasing attendance rates.Feasibility assessment and economic evaluation of these combined approaches are also an essential part of service evaluation and data remains sparse on this topic.

Uptake of postpartum testing: what is known?
Recommended postpartum testing for those with GDM includes an OGTT within the first 12 weeks [2], and for those with HDP, a blood pressure measurement within 7-10 days [7], followed by more comprehensive testing with proteinuria analysis, ambulatory blood pressure testing and metabolic screening [11].However, postpartum testing rates after antepartum diagnoses such as GDM and HDP are frequently suboptimal.
A systematic review of studies analysing postpartum testing rates after GDM identified aggregate rates of 48% [36], with a further systematic review focusing on studies published in the U.S. setting since 2011 finding testing rates of 58% at best, and frequently lower, by 3 years postpartum [37].Analysis from a large university-insurance collaborative data repository in the U.S. identified much lower testing rates after GDM diagnosis with just 6% undergoing any type of glucose testing by 8 weeks postpartum, 22% by 1 year and 51% by 3 years [38].Blood pressure screening within 6 weeks of delivery after HDP also varies, with observational studies from the U.S., reporting ranges from 33.5% [39], to 52% [40].A further evaluation of women attending a 3-month study visit found that despite high rates of blood pressure testing (98%) in this group, far fewer (< 60%) had further testing with lipid screening [41].National data in other high-income settings is sparse.
In Australia, those diagnosed with diabetes are encouraged and assisted to register with the National Diabetes Services Scheme (NDSS); registrants are invited to being contacted for research purposes using an opt-in model of consent [42].A survey of responses among those registered to the NDSS with GDM identified that 73% underwent postpartum diabetes testing, but of these, only 27% underwent OGTT prior to 8 weeks' postpartum [42].Lower rates were reported in more remote regions of Australia, with 14% of Indigenous people, and 28% of non-Indigenous people undergoing OGTT by 6 months postpartum [43].Health inequities in this study were identified beyond testing rates, with Indigenous people experiencing significantly longer times to any postpartum glucose test [43].A large retrospective study reviewed the follow up of over 10,000 women with GDM from an estimated 12 weeks' postpartum, until over 4 years postpartum, and found that 29% had not been assessed for diabetes [44].This study excluded the postpartum period in order to highlight practices of long-term screening, finding that longer term follow-up also remains suboptimal [44].The authors also found that 6% of the whole cohort received a new diagnosis of diabetes within this timeframe, highlighting the importance of testing in the postpartum period and beyond [44].In terms of follow up of HDP in the postpartum period, 94.5% of a group of women with diagnosis of pre-eclampsia in the previous 2 years reported blood pressure measurement since birth, but screening for metabolic abnormalities occurred in less than half [45].

Factors associated with adherence to recommended testing
In order to identify why some strategies work better than others, it is essential to understand the facilitators and barriers for uptake of testing.Several individual, sociodemographic and systemic factors contribute to the ability and prioritisation of engagement in care (Table 2).
Many of the identified barriers are frequently associated with worse health outcomes across the life course, and often co-exist with each other.For example, people with GDM of high socioeconomic status are more easily able to overcome financial barriers to undergoing oral glucose tolerance testing [53], and those who live rurally [52], or in an area of deprivation [47], are more likely to experience barriers to uptake of testing.Black and Hispanic individuals are over-represented among people with the diagnosis of GDM and HDP [54] yet have lower rates of uptake of postpartum testing [55].The presence of structural racism within policy and institutional practices may exacerbate such disparities [54].There is a need to provide tailored, culturally sensitive strategies which factor in social determinants of health.
For many, the logistics of attending for testing present barriers, for example accessibility issues for those requiring childcare and breastfeeding facilities [49], and the time involved in undergoing an OGTT [50].There is conflicting data on the relationship between undergoing postpartum testing, and factors such as maternal age [28,36,37,40,42,47], requirement for insulin for GDM management [36,46,47,56], and the timing of first presentation for antepartum care [37,51].

What strategies have been trialled to improve postpartum testing rates in higher-risk groups?
Table 3 presents an overview of strategies trialled within the antepartum and postpartum periods with the aim of increasing postpartum testing after GDM and HDP.
A limited number of strategies have been implemented in the antepartum period with the aim of improving postpartum testing rates.These include focused antepartum education [55], and use of care co-ordinators [46,57], and in all studies have improved testing rates.Strategies implemented postpartum have been more widely trialled.[37] Raised body mass index at GDM diagnosis [37,46] Increased gestational weight gain [28] Past history of GDM [46] Not breastfeeding [47] Readmission to medical care (woman or baby) [48] Concurrent diagnosis of pre-eclampsia [37] Individual: Health-seeking behaviours Time constraints [49,50] Household emergency [48] Need to breastfeed at testing centre [49] Need to care for other children [48,50] Busy looking after their infant [50] Attendance at postpartum visit [36,51] Individual: Health literacy and beliefs Belief that conditions no longer exist postpartum [49] Inadequate healthcare education [49] Increased awareness of need for testing [49] Higher level of health literacy [41]
Other successful approaches include the use of postpartum patient care co-ordinators and patient navigators.These roles may overlap: we define care co-ordination as a role that focuses on the provision of individualised care such as co-ordinating appointments and following up to ensure attendance, but which does not necessarily extend to in-person assistance; whereas patient navigators provide longitudinal care, often attending appointments with women, and provide a more culture-specific service.Both these strategies have been found to increase postpartum GDM testing [28] and early surveillance in people with chronic hepatitis B infection, another condition frequently diagnosed antepartum requiring long-term co-ordination of care [59].
Administrative assistance in booking testing and appointments has not been trialled extensively and understanding of the potential benefits of this approach remain limited.One study found improvement in testing rates in a small population with GDM when this approach was combined with patient incentives [58].Specialist postpartum clinics have been trialled in those with HDP to facilitate transition to ongoing primary care follow-up, with financial viability and attendance rates of 85% demonstrated in one clinic providing intensive monitoring in the early postpartum period, including provision of home blood pressure monitoring resources [48].Another multidisciplinary clinic providing both inperson and virtual care to women at a median of 11 weeks postpartum, had attendance rates of 80%, and included blood pressure testing for all attendees at the time of the visit, and lipid panel testing forms provided for metabolic screening [64].Uptake of lipid testing for clinic attendees was low, at 53%, although no baseline rate was available for comparison [64].No difference was identified in clinic attendance rates, nor postpartum lipid testing between those who attended virtually versus face to face [64].Finally, models of care which integrate parent and infant postpartum visits into the same appointment have demonstrated variable success in improving rates of postpartum glucose testing [65,67].
The use of Telehealth provides opportunities for flexible modalities of service delivery.As discussed, a hybrid clinic found no difference in either uptake of clinic use as measured by attendance rates, nor in metabolic screening, between participants who received virtual versus face to face care [64].Use of remote monitoring of blood pressure has also been trialled for people with HDP, with successful outcomes in early testing [35] but not 6-week visit attendance [66].Integration of technology as part of multi-approach programmes may enhance overall outcomes and is deserving of further attention.

Tailoring strategies to optimise adherence to testing
Higher adherence to testing recommendations were seen with strategies which personalised healthcare, provided education and addressed individual barriers, such as through use of patient navigators, provision of environments which supported childcare and breastfeeding, and reduced time burden of testing [49].This suggests that consumers are motivated to engage in healthcare when they are supported to do so according to their individual needs.Personalised healthcare, for example by use of a patient navigator to support individual needs, can also address a number of the barriers to accessing care, and care can be tailored in a way that allows equitable access.
Telehealth provides an opportunity to overcome the time and financial burden associated with travel and childcare, but introduces risk of further inequity via the digital divide if cost of technology and device access is placed on the individual [69].For women who do not speak English, the logistics of ensuring adequate access to interpreters within the telehealth setting can add another layer of complexity.Furthermore, there may be unintended consequences of telehealth appointments including missed opportunities for screening, vaccination and physical examination.Care must be taken when designing and evaluating initiatives to ensure that unintended consequences that widen gaps in healthcare access do not occur.
Limited qualitative data exists on what consumers of postpartum care want and need after diagnosis of highrisk conditions to enable them to access recommended testing.A cross-sectional telephone survey of people with GDM in Australia explored the barriers to post-partum screening in detail [49].Logistic challenges such as the time burden of doing a two-hour OGTT and childcare access featured prominently.These concerns were echoed in an earlier study which also identified that many participants either perceived they were 'healthy' or were fearful about receiving a diagnosis of type 2 diabetes after postpartum glucose testing [70].With any programme designed to improve engagement in healthcare, it is essential to understand the needs and wishes of the intended consumers.Involvement of consumers in the developmental stages of such programmes, and feedback from those who receive care as part of an evaluation process, are recommended.

Key findings
The postpartum period, or the 'fourth trimester', provides a unique healthcare opportunity, when otherwise mostly healthy people access healthcare regularly.Many pregnant people will receive an antepartum diagnosis associated with potential longer-term adverse health outcomes.Primary prevention can be implemented to reduce these risks and/or delay onset.However, this must be provided equitably and address disparities in healthcare access within the highest risk populations.
Despite several different strategies trialled in a wide variety of populations, there is not conclusive data on the best method to improve attendance at postpartum appointments and to engage those with high-risk conditions in longer-term follow-up.
Strategies that have shown promise include: focused antepartum education, for example with a diabetes educator [55], nutritionist, or with education booklets [57]; use of patient care co-ordinators providing assistance with booking testing appointments and following up those who did not attend to arrange in-home testing [28,46]; and patient navigators providing individualised assistance with education, co-ordination of testing, and assistance to attend [59].
In addition, creating environments for postpartum testing which support the unique needs of parents with young infants, such as provision of breastfeeding-friendly spaces with options for childcare, may help reduce inequities in access [49].Systems which facilitate remote testing opportunities, for example blood pressure measurements, can help reduce geographical and transport barriers.The expanding field of telemedicine has yet to be fully realised in this area of healthcare but has potential to enhance systemic provision of care.

Avenues for future research
Several gaps have been identified requiring further research.Firstly, the data around both rates of postpartum follow-up at the routine postpartum check and uptake of recommended testing in those at higher risk of long-term conditions is limited to a small number of geographical areas and does not capture national rates.Estimations of the scale of these issues are essential to healthcare and resource planning.
Secondly, careful thought is required about how to provide effective, scalable strategies to support people at this uniquely challenging time, and which provide an opportunity to empower them in managing their immediate and longer-term health.Thirdly, many programmes employ nursing and allied health practitioners such as social workers and administrative staff to provide education and care, with most of these based within the hospital system.Integration with existing community services beyond primary care practitioners may help broaden access, such as through community pharmacists and pathology testing centres.
Further, the role of telemedicine requires further exploration particularly in settings with geographical barriers to care and for those with challenges to in-person attendance such as childcare needs.The potential for remote monitoring, for example with blood pressure and blood glucose level testing, are areas of promise.
Finally, the needs of populations with specific health, cultural and equity imbalances must be reviewed in depth, and consumers from these groups included in co-design and evaluation of strategies.

Quick points
• Postpartum pathways of care are poorly defined and attendance at recommended visits is often suboptimal • Uptake of recommended testing after high-risk conditions including gestational diabetes and hypertensive disorders of pregnancy is low • Barriers to uptake of testing include individual, sociodemographic and systemic factors which often overlap with drivers of inequity in access to healthcare in general • Strategies to improve adherence to recommended testing include specialist postpartum clinics, patient education and the use of patient navigators • Further research into engagement with healthcare, and optimal strategies to support postpartum populations including through a culturally sensitive and equitable lens are urgently required

Table 1
Strategies to increase postpartum engagement, with examples of use clinic visits set up within combined Internal Medicine/Paediatric settings, with primary care provider and in-clinic access to nursing, social work, lactation, psychiatrist and obstetrician-gynecologist support Telehealth Use of text, mobile application or web-based technology.Often used in tandem with other strategies e.g.education, reminder system

Table 2
Factors associated with uptake of testing and non-uptake of postpartum testing after high-risk conditions GDM and HDP GDM gestational diabetes mellitus, OGTT oral glucose tolerance test, U.K. United Kingdom, U.S. United States Factors associated with non-uptake of testing Factors associated with uptake of testing Individual: Clinical factors Mental health disorders in pregnancy

Table 3
Interventions to increase attendance at postpartum testing in those diagnosed antepartum with conditions associated with longer-term morbidity