KEY INFORMANT INTERVIEW RESULTS
The questions posed to key informants focused on the UNC health care system, its influence on utilization and services, the gaps in care that may exist, and potential solutions. The interviews were structured to respond to the research questions in Aims 4 and 5 by collecting two kinds of data: 1) factual information about services, policies, and processes at UNC, and 2) opinions and ideas about the system and services themselves. Approximately half of the questions for each interview were developed specifically for the individual being interviewed based on his/her area of expertise and influence. The information shared in these interviews reflects the knowledge and opinions of the informants about the current state of postpartum services at UNC.
Informants
A total of 19 individuals were interviewed, reflecting a diverse group of UNC staff and faculty. The participants represented a number of disciplines including nurses,
administrators, nurse midwives, social workers, genetics counselors, and physicians. The areas of influence include:
Leadership within the Prenatal Clinics
In-Patient Education for NC Women’s Hospital Lactation
Center for Maternal and Infant Health Prenatal Genetics
OB/GYN Telephone Call Center Maternal Fetal Medicine
Administration for NC Women’s and Children’s Hospital Administration for the Department of OB/GYN
Analysis
The interview data were typed into word documents, cleaned, and uploaded into an Atlas.ti 5.2 program. During the first analysis, 13 different codes were used to classify the data. During the second review, several codes were associated with each other and eight themes began to emerge. These themes facilitated the interpretation and initial understanding of the data. The number of statements per theme gives a sense as to where the informants focused their thoughts and responses during the interview. The themes and number of statements made within those areas are described in Table 13.
Table 13: Key Informant Themes and # Statements Coded Per Theme
Themes # Statements
System Challenges 74
Service Gaps 66
Available Services 43
Ideas for Service Improvement 52
Quality Indicators / Improvement 16 Opinions about the Postpartum Visit 19
Areas for Further Exploration 10
The statements made by informants most commonly reflected system challenges and
services gaps at UNC. Comments in the system challenges category focused on denoting specific problems and issues faced around the care women receive. Comments in the service gaps category were specific to areas where services were needed but not present. While system challenges many times lead to gaps in care, the statements in these sections were specific in their focus on what was working and what was not. Many respondents followed up statements about challenges or concerns with ideas for improvement and areas for further exploration. Statements included in the available services theme largely provided specific information about postpartum care and related services at UNC. These comments were particularly useful in explaining some of the consistencies or inconsistencies discovered during the chart review. They also helped piece together a better picture of the overall system of care around postpartum care in general at UNC.
The informants had a large number of ideas for ways to improve the postpartum visit and care for new mothers in general. These suggestions were captured in the Ideas for Service Improvement category. The data in this section reflected opinions about service improvement across almost all of the 19 job functions covered by the informants. It was interesting that regardless of whether this specific question was asked or not, most informants had ideas to share for improvement. This may in part reflect the type of people that are in leadership positions at UNC. While they can identify problems, they also can describe ways to address them. Lack of resources was commonly cited as a barrier to implementing the ideas mentioned. Of the thoughts offered about service improvement, some were very specific and pragmatic while others were ambitious and less practical. Many informants had
ideas that they were able to share instantly which suggest they had given them some prior thought. Others had to take some time to think about what they would do to change care.
While quality improvement could be considered part of the service improvement
category, there were enough comments around quality improvement that they merited a separate category. Further, while quality improvement often leads to improved care, it also involves a closer tracking and analysis of data, particularly around service delivery. There were a number of comments shared that reflected individuals’ opinions about the postpartum visit. Many related to the timing and number of visits. Items coded under exploration
included issues that the informant wanted to personally explore or areas he/she recommended that the study consider investigating in more depth. Good practice examples described
programs or systems that were working well – at UNC or another institution.
All of the informants were very receptive to the interview and to answering the questions. At the same time that they were willing to share the system issues and problems in the interview, they were also eager to share ideas for ways to address those gaps. In a few cases, informant statements refuted each other in terms of service delivery or protocol at UNC. For example, there were differing opinions as to whether or not mothers in the resident clinic were matched with specific providers, such as the one who may have delivered their baby, for their postpartum visit. These inconsistencies are a finding as they demonstrate that policies and knowledge about services delivered may not be universally known, accepted or believed.
After a review of all the data based on these themes, the data were reviewed based on the research aims that they were to answer. The various statements within the themes were organized to fall into five larger groupings as they addressed research questions 4a, 4b, 4c,
5a, and 5b. They are reported in this dissertation from this perspective along with a summary of opinions about good practices and the postpartum care new mothers receive. The most challenging segment of data to describe were the many ideas listed in the service
improvement category. The responses were so varied and rich that presenting them in list format was selected as the best way to initially share the results.
In the sections below, the information collected through the interviews is presented, often broken into smaller subcategories within each aim. Efforts have been made to preserve the informants’ voices are reflected below. The comment sections reflect the voice of the interviewer from a broader perspective and synthesis of the data.
Aim 4a: Health Care System Factors that Influence Utilization Appointments
A number of informants were asked about the process of scheduling postpartum visits at UNC. For UNC Obstetric Clinic patients, the nurse at the front desk schedules the
postpartum visit appointment. She reviews the daily delivery log generated by labor and delivery and makes the appointment. She also cancels any planned prenatal appointments that will no longer be needed. The patients are then given their postpartum visit appointment date when they are discharged from the hospital. An appointment reminder is mailed to the woman’s home and the automated call system leaves a reminder message for her two days prior to the appointment. Since the clinic has a backlog, it can be difficult for the mother to reschedule a missed or inconvenient appointment.
Women are given two 15-minute clinic slots to make time for 30-minute postpartum visits. However, several informants suggested that it is likely that some of the postpartum visits end up being only 15 minutes. Patients with Medicaid and Private Insurance now
receive equal time for their postpartum visit. This was not always the case in the past, when these patients were only allocated a 15-minute postpartum visit time slot. There are some exceptions to the postpartum scheduling system. A few patients may be seen in the family planning clinic in the postpartum period, particularly those who wish to have an IUD or be sterilized. This visit to the family planning clinic for some women may double in the system as their postpartum visit. Mothers who received services through the Center for Maternal and Infant Health during their pregnancy have additional follow up from their care coordinators. The coordinators check the schedule and make sure that these mothers have a visit scheduled and do what they can to facilitate the mothers receiving that care. These mothers often have infants who have serious congenital anomalies or who may have died following birth. Beginning in June 2007, the Center also works with mothers in the intensive care nursery to encourage them to schedule their postpartum appointments. These mothers, however, may have received care from outside of the UNC Obstetric Clinic system. This new service was not in effect for the period of time from which the chart data were reviewed. Thinking beyond the postpartum visit to the mother’s annual well-woman examination, the clinic does not have the capacity to schedule a woman’s future appointment at her postpartum visit. They also do not send reminder cards to patients to encourage them to schedule their annual well-woman examination.
Information about the Postpartum Visit
Questions were asked to a number of informants regarding the information given to pregnant and new mothers about the postpartum visit. All of the respondents noted that they did not give women any specific information about the postpartum visit. Several said they would distribute this information if they had it. All women receive a postpartum care guide,
which is distributed at hospital discharge. This guide provides new mothers with information about self-care and infant care during the first two weeks after giving birth. It does not contain information about the follow up postpartum visit at 6-weeks nor a reminder to attend that visit. A great deal of effort was put into the development of the booklet and informants suggested that not including this information in the booklet was not because it was
unimportant rather it was an oversight. None of the websites for mothers and infants at UNC (including the OB/GYN Department pages, the Center for Maternal and Infant Health, and the Women’s Health Information Center) contain information about postpartum health concerns. With the exception of postpartum depression, there are not any patient education sheets available on this topic either.
A number of informants noted that they did not provide good information about the postpartum visit, did not encourage women to come, and could do more to improve the care they give during the visit. One person felt that there was an assumption that women would come back for the visit because they need signed consent to return to work. Another person refuted that statement by saying that many companies were no longer requesting such a form. A different informant noted that there are problems in getting some moms to return to the clinic for repeat visits once they have received a prescription for medication, particularly antidepressants. In some cases the women need to return in two weeks to be seen in order to ensure that medication is appropriate. When they don’t return their refills can’t be given. No one has looked into the reasons why these mothers do not return although one informant noted it is likely that some of them no longer have health coverage to pay for the cost of the drugs. Other mothers who receive services in the resident high-risk clinic often come from a distance to UNC. They may not come back for the postpartum visit because of the cost of
gasoline, the difficulty in traveling far with an infant, and not knowing why they need the visit. Overall, informants suggested that UNC is not effectively marketing or promoting the postpartum visit at this time.
One informant noted that she felt worried about some groups of mothers when they were discharged from the hospital. Her responses were focused on the larger population of women delivering at UNC, not only those seen in the UNC clinic. She didn’t know if certain groups of mothers received needed follow up care. The patients whom she felt were at-risk and in need of more care in her opinion were teen mothers, complex families with children already in the DSS system, and breastfeeding moms and babies who don’t quite have it “right” yet. The informant’s main concern for these mothers is that they did not have the support postpartum that they needed. She also had specific concerns for the many Hispanic mothers who deliver at UNC with Emergency Medicaid but leave the hospital with no further access to care and support. She noted that if something wasn’t quite right with mom or the baby, she wasn’t sure if these dyads were able to get the care they needed post discharge. The informant noted that mothers who are identified as having substance use programs are
routinely referred to the Horizon’s Program. These referrals do receive follow up by the clinic. This program provides follow up contact and care to mothers during pregnancy as well as after the birth of the baby. The Center for Maternal and Infant Health provides follow up for mothers who have babies born with congenital anomalies, including visits while their babies are in the intensive care nursery. The Center also schedules and facilitates postpartum visits for its patients. These programs were considered to be helpful for the mothers they served. There was a desire expressed that more mothers could receive this kind of care.
Clinic Capacity
According to several informants, there is currently limited visit capacity in the UNC OB clinic, with a backlog of several hundred patients. The OB/GYN clinics also have a high “no show” rate estimated at almost 60%. One informant provided more detail about the booking challenges faced by the UNC OB clinic. Health departments may make several appointments with various providers in an attempt to get the earliest visit they can. However, they may not go back and cancel the appointments they don’t need. They are moving to a different referral process to try to address this issue. Two informants noted that there is a UNC Healthcare system effort known as PACE (Patient Access and Efficiency Initiative) which has been taking a very close look at clinic flow and function. They are studying everything about the systems with the goal of improving efficiency and patient satisfaction.
Further, it is difficult for the clinic to follow up on missed appointments, as many telephone numbers provided by the women while they are pregnant are no longer accurate postpartum. One informant estimated this to be the case for one-third of the women. Language is a barrier for follow up calls.
Comment
According to the chart review, UNC does better than the national average in
postpartum visit utilization. UNC doesn’t, however, appear to have any particular system in place that would explain this slightly higher than normal return rate. There are not any outreach efforts employed to encourage women to return for this visit. The staff work hard to be sure that a woman doesn’t leave the hospital without a scheduled appointment. The hospital also provides two separate reminders about the visit. The problems in rescheduling
the visit for women who need to do so are more concerning. However, this is part of a larger scheduling issue in the clinic that is being addressed by administrators.
Some comments made by informants suggest some disparities in care at UNC. The fact that all postpartum visits are now of the same length of time for both faculty and resident clinics also suggests that there was a time when patients seen by residents received shorter visits. Informants also implied that at present not all women receive a full 30-minute appointment. With so many services to offer at this visit, it is concerning that the length of visit isn’t consistently at least 30 minutes for all mothers. Further, respondents raised concerns about gaps in postpartum services for Hispanic women. Many of these women are low-income and speak limited English. As such, their access to care after they have a baby may be limited. At the same time that the institution’s ability to provide linguistically and culturally appropriate care is also limited. The system at UNC does not seem well suited to meet the postpartum needs of these patients. Linking these mothers as well as other low- income women back to a public health clinic setting for postpartum care and family planning services may be one way to improve care. At a minimum it might address respondent
concerns about follow up for mothers who start a contraceptive method or a medication and then do not return to UNC for needed care.
Pamphlets, booklets, or other patient education materials about the postpartum visit are not currently available at UNC. However, an online search of professional websites and patient education agencies only found a single fact sheet about the visit at only one site. So access to easily distributable information about this visit isn’t readily available for purchase and use by the clinic. Augmenting the information available about the postpartum visit and a woman’s physical and mental postpartum adjustment may be instructive for patients as well
as the providers who develop these products. Information describing the reason for the postpartum visit and its content might help improve utilization.
Aim 4b: Health Care System Factors that Influence the Services Provided Prenatal, In-Patient, and Postpartum Services Available
Many informants were asked questions about the various services and education available for pregnant and new mothers at UNC. There is a wide range of educational services available to pregnant women at UNC. These include: breastfeeding classes, new father “boot camp” training, prenatal yoga classes, tours of labor and delivery, pet adjustment to new baby class, new baby preparation classes, and childbirth education classes. None of these classes are offered free of charge. The vast majority of these classes are taught only in English. One informant noted that only a portion of mothers who receive prenatal services at UNC attend childbirth classes. The OB clinic offers a class in Spanish for mothers with