Care After Pregnancy Study (CAPS): Randomized Controlled Trial of Patient Engagement After Pregnancy

There are profound economic inequalities in a wide range of important maternal and child health outcomes ranging from neonatal death to maternal morbidity and mortality. The overarching scientific premise for our proposal is that these inequalities stem in part from poor engagement in postpartum care by economically disadvantaged women. The investigators hypothesize that an innovative intervention grounded in empirically derived tenets of behavioral economics that includes the critical components of the American College of Obstetricians and Gynecologists (ACOG) new vision for postpartum care will narrow gaps in important maternal child health outcomes.

Women of lower socioeconomic status are at significantly increased risk of unintended pregnancies, short inter-pregnancy interval and short duration of breastfeeding. The consequences of untimed pregnancies and short duration of breastfeeding for the health of mothers, infants and children are well documented. In addition to significant health implications, these inequalities have important economic ramifications. The cost of births from unintended pregnancies in 2006 was estimated at $11 billion in maternity and infant care. This does not include cost of abortion care, lost productivity, and government assistance.

Providers have effective postpartum strategies to reduce the risk of poorly timed pregnancies and low breastfeeding rates.

Short interval or poorly timed pregnancies: Women have a range of effective contraceptive options, however, not initiating contraception postpartum remains common. The provision of long-acting reversible contraception (LARC) including intrauterine devices (IUDs) and hormonal implants has been shown to decrease short interval pregnancies and the associated risk of preterm birth. Importantly, given the array of contraceptive options available to women, it is important to make LARC accessible while empowering women to choose a method that is effective and acceptable to them. This highlights the need for solutions to engage women in patient centered comprehensive contraceptive decision-making in the postpartum period.

Short Breastfeeding Duration: A number of strategies have been shown to increase breastfeeding success. Most relevant to our proposal is that efforts to educate women about the benefits of breastfeeding, weekly text reminders in the immediate postpartum period, and access to a lactation consultant have all improved both duration and exclusivity of breastfeeding. Importantly, three recent trials demonstrated significant increases in exclusive breastfeeding from eight weeks to six months postpartum among women who received weekly-automated text message breastfeeding support. These interventions may be particularly relevant to our target population, as low-income, non-Hispanic Black women between 18-29 years send and receive text messages more frequently than any other demographic.