Toward the Codification of an Innovative Model of Postpartum Healthcare: A Qualitative Assessment

Background and Purpose: The United States is facing a maternal health crisis with unacceptable rates of severe maternal morbidity and mortality. Mental health disorders are the leading cause of pregnancy-related deaths, and almost all deaths are potentially preventable. Improving maternal health requires innovative health care delivery mechanisms that address both the physical and mental health needs of postpartum women. To address maternal health needs and promote health equity, we developed a novel Two-Generation Clinic Model as part of a federal maternal health innovations grant. Implemented in 2020, the model combines a dyadic strategy for simultaneous maternal postpartum and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social care needs of families.

Promising health innovations frequently fail when integrated into novel contexts. To prepare for implementation of similar models into novel healthcare settings (i.e., community health centers) we engaged in a multi-step process to identify and describe core components and implementation determinants within the program’s original context—an urban, academic, primary care outpatient setting serving a predominately publicly insured patient population.

Methods: Twelve in-depth, semi-structured interviews (30-80 minutes) were conducted with a purposive sample of transdisciplinary care team members, including primary care physicians, clinical social workers, care navigators, a psychiatrist, and program administrators. Interviews were transcribed verbatim and analyzed per the principles of Applied Thematic Analysis, incorporating inductive and deductive processes. Four analysts independently coded all transcripts toward the generation of descriptive themes, which were then collaboratively refined in a series of debriefing sessions. Inductively identified core components were categorized as “philosophy/value”, “structural element”, or “practice” to facilitate their description and interaction with other components and contextual factors. The Consolidated Framework for Implementation Research (CFIR) constructs were applied as deductive categories to identify and describe experienced implementation barriers and facilitators.

Findings: Team members elevated components categorized as “value/philosophy” as essential elements of the model. A family-centered, “whole-person” orientation was emphasized, along with a flexible, adaptable program structure. Leadership support for modifying care practices to address emergent patient needs was perceived as necessary to the success of the model, as was provider willingness to engage in practices which may be deemed unconventional in other health settings (e.g., texting with patients after hours to facilitate timely care for postpartum mental health issues).

We identified factors affecting implementation effectiveness across three levels of the Inner Setting domain of the CFIR (organization, clinic, transdisciplinary team). Implementation barriers were primarily structural (e.g., limited physical space, fixed operating hours within the larger health system) while facilitators were primarily cultural—related to perceived quality of interprofessional communication and a unifying commitment to person-centered care.

Conclusion and Implications: Extending beyond logic models, engaging in qualitative research with original program implementers to identify and comprehensively define program elements and contextual factors experienced as meaningful to the success of a given innovation may assist potential adopters in assessing the fit of a health program for their own unique settings and contexts prior to implementation.