Health Equity Efforts Help Moms Newly Home from the Hospital

New mothers and their babies typically leave the cocoon-like environment of the hospital maternity floor within a few days of delivery. Their discharge marks the end of a particularly intense nine months of medical support: from the monthly, then biweekly, then weekly obstetric exams during pregnancy to the 24/7 access to nurses in the hospital. Once they return home after giving birth, most new parents will not be seen by a medical professional for the next month and a half, until the typical six-week postpartum appointment with their obstetrician.

But for the unlucky few, early postpartum problems can quickly develop into much more serious complications. Of the approximately 1,000 childbirth-related deaths in the United States each year, about one in every five occurs between one week and six weeks postpartum. “It’s not a complicated delivery or somebody who is very sick,” said Mario DeMarco, MD, an associate professor of Clinical Family Medicine and Community Health in the Perelman School of Medicine at the University of Pennsylvania and director of Family Medicine Obstetrics. “It’s someone who gets discharged from the hospital and experiences some sort of symptom. It could be cardiomyopathy or preeclampsia or stroke. It could be suicide, homicide or a drug overdose. For them, a six-week visit wouldn’t have been helpful.”

For this reason, addressing risks in those first few weeks postpartum is a key part of Penn Medicine’s comprehensive, system-wide effort to reduce maternal morbidity and mortality, and in particular to eliminate inequities in which Black patients and other racial and ethnic minorities disproportionately experience poor outcomes. Some of the core principles underlying the efforts include standardizing patient care during key moments in pregnancy and childbirth to reduce opportunities for racial bias, centering equity as a goal, and wielding influence across the city and nation to extend the innovations proven at Penn Medicine to help new families in more places.

The First Six Weeks Postpartum

In the first six weeks before a new parent’s typical first postpartum checkup, the elation of new motherhood is often mixed with a great deal of stress. New mothers are still recovering from childbirth, dealing with pain and soreness, heavy vaginal bleeding and urinary incontinence. Those who had C-sections are bracing their incision site with a pillow during every laugh or sneeze to prevent the stitches from reopening. As many new mothers struggle with breastfeeding, their newborns wail for milk every two to three hours. Faced with what can feel like an endless day of round-the-clock feedings and diaper changes, punctuated by precious little sleep, a whopping 80 percent of new parents report experiencing “baby blues” during the first few weeks postpartum.

But, DeMarco said, while Penn Family Care hopes to lead others to adopt the three-week postpartum visit through their example, the six-week visit remains the typical standard in most health systems. To bridge the gap in these crucial early weeks, Penn Medicine rolled out several initiatives that leverage technology to make it easier for patients to access postpartum care.

Texting Buddies for Triage

Healing at Home is a text messaging program for low-risk postpartum patients who delivered at the Hospital of the University of Pennsylvania. It covers the period from hospital discharge to the six-week postpartum visit, keeping patients engaged in their health through interactions with “Penny,” an AI-augmented conversational agent. Penny sends personalized messages with anticipatory guidance, such as “your baby’s umbilical stump will fall off soon,” and can also answer most patient questions on breastfeeding, constipation and more.

“I see Healing at Home as a triage for which patients need extra support,” said Kirstin Leitner, MD, an assistant professor of Clinical Obstetrics and Gynecology and the Penn Medicine physician who created the program. “It offers [providers] the potential to say, ‘This patient keeps asking questions, or is screening high on her postpartum depression screening or is still having elevated blood pressures. She might be a patient worth bringing in for a [two-week] visit versus a patient who has had her third baby and is smooth sailing.’”

Text messaging is more accessible to people with fewer resources, Leitner said, such as those who don’t have internet at home, since most do have a cell phone plan with unlimited text messaging. Since its launch in March 2020, Healing at Home has had more than 1,800 participants. Of the top 10 percent of highest-engagement users—that is, participants who asked a lot of questions, followed up with Penny and used emojis and pleasantries with the conversational agent—90 percent were Black women. Patients who are breastfeeding their baby and patients having their first baby are more likely to engage in the platform. Not only is engagement higher, but there are some improved outcomes such as high rates of contraceptive acceptance and higher rates of exclusive breastfeeding at one week of life.

Penn Medicine’s system-wide commitment to reducing maternal morbidity and mortality for Black women has been important to Healing at Home’s success. “I can’t tell you how many times I’ve written in a paper or proposal on the awful rates of maternal mortality in the U.S. compared to other countries,” Leitner said. “To have leadership emphasize this [problem] has been hugely helpful to allow us to bring solutions to people.”

With a grant from the City of Philadelphia, Leitner is now working on starting a non-English version of the program.

Because of efforts at the Hospital of the University of Pennsylvania to boost hypertension screening during pregnancy, most patients enrolled in Healing at Home already own and use a blood pressure cuff. With hypertension a concern for many postpartum women, even those without a previous diagnosis, Leitner added regular self blood pressure checks to Healing at Home in 2021; this has helped connect patients with additional support and intervene sooner. A patient who screens severely high once or mildly high twice is enrolled in a program that is one of Penn Medicine’s longest-established and widest-reaching success stories in using text messaging technology to save lives: Heart Safe Motherhood.

A Success Story in Preventing Postpartum Complications

Heart Safe Motherhood, a text-based, remote blood pressure monitoring program, was established in 2014 in response to poor attendance rates at a postpartum blood pressure clinic for high-risk new mothers, said Adi Hirshberg, MD, director of obstetrical services at the Hospital of the University of Pennsylvania and an associate professor of Clinical Obstetrics and Gynecology, who co-founded the program with Sindhu Srinivas, MD, MSCE, a professor and vice chair for quality and safety in the department. Black patients reported significant barriers to accessing in-person health care, including transportation, childcare and cost. But they were also the group who needed this postpartum health monitoring the most: Black women are more likely to suffer from preeclampsia, a serious condition in pregnancy and postpartum characterized by high blood pressure.

Heart Safe Motherhood provides patients with a blood pressure cuff and educates them on how to use it. Once discharged from the hospital, postpartum patients receive text-message reminders to conduct twice-daily blood pressure readings at home, for 10 days, and report the readings to their providers via reply message. A 2019 study of the program found that vastly more patients—more than 90 percent overall—submitted blood pressure readings via text, versus the number of patients not in the program who attended the in-person clinic. The effect for Black patients in particular was most dramatic, rising to 93 percent submitting readings via text vs. only 33 percent who were checked in person. (By comparison, among non-Black patients, 70 percent had their blood pressure checked in person.)

Penn Medicine’s system-wide focus on maternal health disparities has positive benefits for all pregnant and postpartum patients, said Elizabeth Howell, MD, MPP, chair of the Department of Obstetrics and Gynecology in the Perelman School of Medicine and the Harrison McCrea Dickson, MD President’s Distinguished Professor, who has spearheaded Penn Medicine’s overall efforts with Srinivas.

And while the earliest weeks after returning home with a new baby may be the most vulnerable, the opportunity to help new parents sustain lifelong health does not end there, and Penn Medicine is also connecting with these patients to support their ongoing care in the months and years after their child’s birth.

“We are seizing a unique opportunity to meet the moment at a transformational point in our patients’ lives,” Howell said. “It’s so important. Healthy moms, healthy babies, and families are the foundation of healthy communities.”