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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Postpartum Visit.

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Strategy. Quality Improvement Initiatives

Approach. Promote hospital quality improvement initiatives designed to increase the rate of postpartum visit attendance

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Overview. Quality improvement (QI) projects initiated by healthcare teams can increase postpartum visit attendance and facilitate follow-up care. Whether conducted within a clinic, hospital, or state agency, QI projects can help ensure the continuation of maternal care beyond birth. They can help postpartum women schedule appointments, whether virtual or in person, and monitor and manage conditions such as postpartum hypertension.[1,2,3,4] Specific QI approaches vary and may include appointment reminders and patient education; provider education on the importance of the postpartum visit; changes to payment and billing policies; or team-based care using case managers, care coordinators, and community health workers.[5] Evidence suggests that such initiatives are designed to standardize processes and improve care over time and appear to be effective in increasing postpartum visit attendance.[6]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work. They often have a growing body of recent, but limited research that documents effects. However, further study is needed to confirm effects, determine which types of health behaviors and conditions these interventions address, and gauge effectiveness across different population groups. (Clarifying Note: The WWFH database calls this "mixed evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Collaboration (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

Examples from the Field. There are currently no ESMs that use this strategy. As Title V agencies begin to incorporate this strategy into ESMs, examples will be available here. Until then, you can search for ESMs that have similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of healthcare systems, hospitals, and clinics that implement quality improvement (QI) initiatives focused on increasing postpartum visit attendance. (Measures the adoption and spread of the strategy)
  • Number of healthcare providers, staff, and teams trained and engaged in QI initiatives to improve postpartum visit attendance. (Measures the workforce development and participation in the strategy)

OUTCOME MEASURES:

  • Number of postpartum patients who attend their scheduled postpartum visits as a result of the QI initiatives. (Measures the effectiveness of the strategy in achieving its primary goal)
  • Number of postpartum patients who receive comprehensive care, including screening, education, and referrals, during their postpartum visits as a result of QI initiatives. (Assesses the quality and continuity of care outcomes of the strategy)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of QI initiatives to increase postpartum visit attendance that adhere to evidence-based practices, such as using data to drive improvement, engaging patients and families, and applying systems thinking. (Measures the fidelity and quality of the QI approach)
  • Percent of postpartum patients who receive culturally and linguistically appropriate outreach, education, and support through the QI initiatives to increase their postpartum visit attendance. (Measures the equity and patient-centeredness of the strategy)

OUTCOME MEASURES:

  • Percent increase in postpartum visit attendance rates within healthcare systems, hospitals, and clinics implementing QI initiatives, compared to baseline or control groups. (Measures the impact and effectiveness of the strategy)
  • Percent of postpartum patients who report high satisfaction, perceived value, and positive care experiences related to their postpartum visits attended as a result of QI initiatives. (Measures the patient-centeredness and acceptability of the strategy)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of cross-sector partnerships and collaborations established to support the design, implementation, and evaluation of QI initiatives to increase postpartum visit attendance. (Measures the collective action and systems approach of the strategy)
  • Number of policies, guidelines, and reimbursement models developed to incentivize and sustain the implementation of QI initiatives focused on postpartum visit attendance. (Measures the enabling environment and infrastructure for the strategy)

OUTCOME MEASURES:

  • Number of healthcare systems, payers, and policymakers that adopt and integrate QI initiatives to increase postpartum visit attendance as a standard of care and accountability measure. (Measures the institutionalization and policy impact of the strategy)
  • Number of QI leaders, champions, and advisors emerged who continue to drive and mentor others in improving postpartum visit attendance and maternal health outcomes. (Assesses the leadership and sustainability of the strategy)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • Percent of QI initiatives to increase postpartum visit attendance that actively engage and support postpartum patients and families as co-designers, advisors, and evaluators. (Measures the patient and family engagement in the strategy)
  • Percent of QI initiatives to increase postpartum visit attendance that embed continuous learning, adaptation, and improvement process based on real-time data and feedback. (Assesses the agility and resilience of the strategy)

OUTCOME MEASURES:

  • Percent of postpartum individuals, particularly those from communities that have experienced economic or social marginalization, who report feeling respected, supported, and valued in the QI initiatives to increase their postpartum visit attendance. (Measures dignity and humanity in the strategy)
  • Percent reduction in structural and systemic barriers to accessing and attending postpartum visits, such as transportation, childcare, and insurance coverage, as a result of the QI initiatives and their policy and advocacy efforts. (Measures the systems change and social determinants impact of the strategy)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] Rowland, P., & Kennedy, C. (2022). Implementing effective care by improving attendance to the comprehensive postpartum visit in an urban hospital practice. Nursing forum, 57(6), 1606–1613. https://doi.org/10.1111/nuf.12796.
[2] Hirshberg, A., Downes, K., & Srinivas, S. (2018). Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial. BMJ quality & safety, 27(11), 871–877. https://doi.org/10.1136/bmjqs-2018-007837.
[3] Hauspurg, A., Lemon, L. S., Quinn, B. A., Binstock, A., Larkin, J., Beigi, R. H., Watson, A. R., & Simhan, H. N. (2019). A Postpartum Remote Hypertension Monitoring Protocol Implemented at the Hospital Level. Obstetrics and gynecology, 134(4), 685–691. https://doi.org/10.1097/AOG.0000000000003479.
[4] Kuster, A., Lee, K. A., & Sligar, K. (2022). Quality Improvement Project to Increase Postpartum Clinic Visits for Publicly Insured Women. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN, 51(3), 313–323. https://doi.org/10.1016/j.jogn.2022.01.002].
[5] Centers for Medicare and Medicaid Services (CMS). (2019). Improving postpartum care: State projects conducted through the Postpartum Care Action Learning Series and Adult Medicaid Quality Grant Program. CMS Issue Brief August 2019. https://www.medicaid.gov/sites/default/files/2020-03/postpartum-als-state-projects.
[6] Centers for Medicare and Medicaid Services (CMS). (2024) Quality Measurement and Quality Improvement https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-#:~:text=Quality%20improvement%20is%20the%20framework,%2C%20healthcare%20systems%2C%20and%20organizations.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.