key: cord-0871427-5u3ygbwm
authors: Sakowicz, Allie; Matovina, Chloe N.; Imeroni, Sidney K.; Daiter, Maya; Barry, Olivia; Grobman, William A.; Miller, Emily S.
title: The association between the COVID-19 pandemic and postpartum care provision
date: 2021-08-14
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2021.100460
sha: 59d2faef65ca30efa49e7ff0122575b84e6cfe3d
doc_id: 871427
cord_uid: 5u3ygbwm

BACKGROUND: : The COVID-19 pandemic led to a rapid transformation of the healthcare system in order to mitigate viral exposure. In the perinatal context, one change included altering the prenatal visit cadence and utilizing more telehealth methods. Whether this approach had inadvertent negative implications for postpartum care, including postpartum depression screening and contraceptive utilization, is unknown. OBJECTIVE: : To examine whether preventative health service utilization, including postpartum depression screening and contraceptive utilization, differed during the COVID-19 pandemic as compared to a pre-pandemic period. STUDY DESIGN: : This retrospective cohort study included all pregnant patients who underwent prenatal care within five academic obstetric practices and who delivered at Northwestern Memorial Hospital either before (delivery 9/1/2018-1/1/2019) or during (delivery 2/1/2020-5/15/2020) the COVID-19 pandemic. Completion of postpartum depression screening was assessed by reviewing standardized fields for documentation of this screening within the electronic health records. The method of contraception was ascertained from the postpartum clinical documentation. Patients were classified as initiating long-acting reversible contraception (LARC) if they received Nexplanon or an intrauterine device (IUD) during the delivery hospitalization or within three months following delivery. Bivariable and multivariable analyses were performed. RESULTS: : Of 2375 pregnant patients included in this study, 1120 (47%) delivered during the COVID-19 pandemic. Pregnant patients who delivered during the COVID-19 pandemic were significantly less likely to have postpartum depression screening performed (45.5% vs 86.2%, p<0.01); this association persisted after adjusting for potential confounders (aOR 0.13, 95% CI 0.11-0.16). Pregnant patients who delivered during the COVID-19 pandemic also were significantly less likely to initiate LARC methods within three months of delivery (13.5% vs 19.6%, aOR 0.67, 95% CI 0.53-0.84). CONCLUSION: : The onset of the COVID-19 pandemic is associated with decreases in the completion of postpartum depression screening and fewer overall patients receiving LARC methods for contraception. These data can inform adaptations in healthcare delivery in the midst of the ongoing COVID-19 pandemic.

Background: The COVID-19 pandemic led to a rapid transformation of the healthcare system in order to mitigate viral exposure. In the perinatal context, one change included altering the prenatal visit cadence and utilizing more telehealth methods. Whether this approach had inadvertent negative implications for postpartum care, including postpartum depression screening and contraceptive utilization, is unknown. 

The Coronavirus disease 2019 (COVID-19) pandemic has dramatically altered public health and healthcare delivery both in the United States and globally. 1 Specifically, healthcare systems have instituted many changes in healthcare delivery in order to minimize the risk of COVID-19 transmission to healthy patients and healthcare workers. Such changes in the obstetric setting include paring down frequency of antenatal visits and shifting visits to telehealth, including for postpartum care. While this approach is necessary to limit viral spread, these health systems changes may have negative implications for postpartum care, including depression screening and initiation of contraception.

The pandemic is expected to have significant negative effects on mental health given widespread stay-at-home orders, potential social isolation, stress over unemployment, fear of contracting or transmitting COVID-19, or grief over loss of loved ones. 2 In the perinatal context, the pandemic has been associated with an increased risk of postpartum depression and other mood disorders. 3 Postpartum depression affects up to one in seven patients and is a leading cause of maternal morbidity and mortality. 4, 5, 6, 7 Early recognition of postpartum depression through the use of validated screening tools is critical in order to initiate prompt treatment, but such tools may be used less frequently in a context with more remote care. 8 With the increased prevalence of postpartum depression during the pandemic, early recognition and treatment is ever more important for public health.

Further, with the decline of in-person visits and shift to telehealth delivery during the pandemic, there have been increased barriers to accessing desired services such as long-acting reversible contraception (LARC). 9 LARCs are the most effective reversible method of contraception and are especially valuable in the pandemic setting due to their low failure rate and reduced need to return to the office or pharmacy for refills. 10, 11 However, unless LARCs are placed during the delivery hospitalization, patients must attend an additional appointment for placement. Indeed, many inperson appointments for contraception have been delayed as a result of not being considered essential. 12 Thus, limitations to in-person postpartum outpatient care caused by the pandemic could potentially lead to changes in LARC utilization.

Understanding how the COVID-19 pandemic is associated with preventive health services in the postpartum period is vital in order to ensure targeted, effective, and patient-centered care. The objective of this study was to examine whether preventative health service utilization, including postpartum depression screening and contraceptive utilization, differed during the COVID-19

pandemic as compared to a pre-pandemic period.

This retrospective cohort study included all pregnant patients who received prenatal care with one of five academic obstetric practices and delivered at Northwestern Memorial Hospital's Prentice Women's Hospital either before or during the COVID-19 pandemic. The academic obstetrical practices include those staffed by obstetrician-gynecologist specialists, maternal-fetal medicine subspecialists, and certified nurse midwives. Obstetric clinicians at these practices collectively perform approximately 3,500 deliveries per year.

Pregnant patients were divided into two cohorts: those who delivered prior to the pandemic and those who delivered during the pandemic. Patients in the pre-pandemic cohort were included if they delivered between September 1, 2018 and January 1, 2019. This time period was chosen because it is when the postpartum depression screening rate reached a stable level of approximately 85% after institutional implementation of screening protocols. Patients in the pandemic cohort were included if they delivered between February 1, 2020 and May 15, 2020, as their six-week postpartum visits fell after the date when SARS-CoV-2 was declared a pandemic by the World Health Organization 13 and our health system began to offer patients the option to convert postpartum visits to telehealth. This time period was chosen in order to fully capture our intended cohort, including those patients that delivered at the beginning of the pandemic.

Attendance at the postpartum visit (either in-person or by telehealth), as well as completion of postpartum depression screening, was assessed by reviewing standardized fields within the electronic health record. Performance of the Patient Health Questionnaire-9 (PHQ-9) 14 , a validated self-reported measure of depressive symptomatology, is standard of care at every postpartum visit at our institution. For postpartum visits completed via telehealth during the pandemic, the PHQ-9 could be completed either over the phone or sent to patients via a secure web-based portal to complete and return. In some cases, patients returned their PHQ-9 screening via the web-based portal but did not attend a postpartum visit. Our electronic health record allowed for PHQ-9 screening results to be entered into the relevant field regardless of whether it was completed in-person or electronically, and thus we were able to use results from all methods of screening in our analysis. All obstetric practices included in these analyses utilized a single centralized electronic health record for both inpatient and outpatient care.

The chosen method of contraception was ascertained by reviewing the clinical documentation.

Patients were classified as initiating LARC if they received Nexplanon or an IUD either during the delivery hospitalization or within three months following delivery. Other contraceptive utilization was categorized according to either the prescription provided (e.g., oral contraceptive pills) or by patient-reported intention of use (e.g., condoms). For patients who initiated LARC, the timing of placement was dichotomized by whether the LARC was placed during the delivery hospitalization or during an outpatient visit.

Electronic health records were reviewed for all patients meeting inclusion criteria. Demographic and clinical data included maternal age, self-reported race or ethnicity, marital status, insurance status, body mass index (BMI) at delivery, tobacco use, and any identified pre-existing comorbidity (e.g., pre-pregnancy diabetes, chronic hypertension, asthma). Obstetrical data included parity, pregnancy complications (e.g., gestational diabetes and hypertensive disorders of pregnancy), gestational age at delivery, and route of delivery. Data on any positive SARS-CoV-2 test during pregnancy or at delivery were also abstracted. Data were entered into the research electronic data capture system (REDCap; Vanderbilt University) 15 , and missing or out of range data were re-reviewed.

Bivariable analyses were performed to examine whether delivery during the COVID-19

pandemic was associated with a change in postpartum depression screen completion or types of contraception utilization. Variables that were statistically significantly different in bivariable analyses (p<0.05) were considered for inclusion in multivariable models as potential confounders.

Multivariable logistic regressions were performed for the outcomes of postpartum depression screen completion and LARC utilization.

Two planned sensitivity analyses were done. The first sensitivity analysis excluded patients who did not attend a postpartum visit (either virtually or in-person), and the second excluded patients who tested positive for SARS-CoV-2 during pregnancy or at delivery. Mann-Whitney U tests were used for continuous variables, and chi-square tests were used for categorical variables. Data were analyzed with Stata (version 15, StataCorp LLC, College Station, TX). This study was approved by the Northwestern University Institutional Review Board with a waiver of consent prior to its initiation.

Of the 2375 pregnant patients included in this study, 1120 (47%) delivered during the COVID-19 pandemic. Compared to pregnant patients who delivered before the pandemic, those who delivered during the pandemic were less likely to attend a postpartum visit, either in-person or via telehealth (87.7% vs 90.4%, p=0.036). During the pandemic, 702 (71.6%) visits were conducted by telehealth and 278 (28.4%) were in-person.

Demographic and clinical characteristics of patients included in this study are displayed in Table   1 . Compared to pregnant patients who delivered before the pandemic, those who delivered during the COVID-19 pandemic were less likely to be married or have diabetes (either pre-existing or gestational) and more likely to be obese or have a hypertensive disorder of pregnancy. There were no differences in any other sociodemographic or clinical characteristics (Table 1) .

Pregnant patients who delivered during the COVID-19 pandemic were significantly less likely to have postpartum depression screening (45.5% vs 86.2%, p<0.01) performed. This association persisted after controlling for potential confounders (Table 2 ). These data persisted in sensitivity analyses excluding patients who did not attend a postpartum visit (51.8% vs 95.4%, p<0.01, aOR 0.05, 95% CI 0.04-0.07) and excluding patients who tested positive for SARS-CoV-2 during pregnancy or at delivery (45.5% vs 86.2%, p<0.01, aOR 0.13, 95% CI 0.10-0.16).

Distributions of contraceptive plans comparing pregnant patients who delivered before versus during the COVID-19 pandemic are shown in Table 3 . Significant differences were identified in the distribution of contraception utilized (p=0.004) and so comparisons were made in each individual contraceptive plan.

After controlling for confounders, pregnant patients who delivered during the COVID-19 pandemic were significantly less likely to use LARC methods within three months of delivery (aOR 0.67, 95% CI 0.53-0.84) ( Table 4 ). These data also persisted in sensitivity analyses excluding patients who did not attend a postpartum visit (15.1% vs 19.8%, p<0.01, aOR 0.67, 95% CI 0.53-0.85) and excluding patients who tested positive for SARS-CoV-2 during pregnancy or at delivery (13.3% vs 18.0%, p<0.01, aOR 0.67, 95% CI 0.53-0.84). Of the patients who received a LARC method during the pandemic, 24% were placed during the delivery hospitalization, as compared to 11% prior to the pandemic (p<0.01).

These results demonstrate that the COVID-19 pandemic was associated with a decrease in screening for postpartum depression, as well as changes in postpartum contraception utilization, with fewer patients receiving LARC methods. These findings may have occurred as a result of health services changes during the pandemic.

Our findings underscore the degree to which the pandemic has health implications far beyond those immediately related to viral-related illness. Reproductive healthcare has become a frequent topic of debate when it comes to defining services as essential, oftentimes leading to restrictions on reproductive autonomy. 16 Given their increased need for both mental health and contraceptive care, pregnant and postpartum patients represent a particularly vulnerable population during the COVID-19 pandemic.

The COVID-19 pandemic has been shown to increase rates of symptoms of depression and anxiety both in the general population and in a pregnant and postpartum population. 17, 18, 19 Prior to the onset of the COVID-19 pandemic, it was estimated that only 50% of pregnant and postpartum patients with depressive symptoms would be diagnosed. 20 Since the onset of the pandemic, rates of both depression and anxiety during the perinatal period have more than doubled compared to pre-pandemic values. 20 This study was conducted in a state which legislatively mandated postpartum depression screening in 2008 21 , thus we would expect that this observed dip in screening rates during the COVID-19 pandemic is likely to be more pronounced in areas without mandated screening. Given the increased prevalence of perinatal mental health conditions during the pandemic, screening for postpartum depression becomes increasingly important in order to accurately identify patients and initiate appropriate treatment. The COVID-19 pandemic was also associated with fewer patients initiating LARC for postpartum contraception. While LARC methods are highly effective and reversible, placement requires an in-person encounter with a provider. Our results demonstrate that while rates of LARC placement decreased overall during the pandemic, patients who did receive a LARC during the pandemic had a higher chance of having it placed during the delivery hospitalization as compared to before the pandemic. The American College of Obstetricians and Gynecologists recommends that immediate postpartum LARC placement be offered to patients as a way to increase access to contraception. 26 Immediate postpartum LARC placement may also benefit patients who are unable or unwilling to return for a postpartum visit, especially in the setting of a global pandemic when in-person visits are limited. However, as a result of challenges with insurance coverage and reimbursement, many hospitals around the United States do not offer this as an option for patients. 27 In addition, with changes in the cadence of prenatal visits, opportunities for antenatal education on contraceptive modalities may be more limited. During a global pandemic, increasing access to immediate postpartum LARC placement represents an opportunity to expand access to reliable contraception.

An important strength of this study is the large and diverse population of patients who sought care at midwifery-, perinatologist-, and obstetrician-based practices. However, this study is not without limitations. First, the time period of this study spans February to May 2020, the latter part of which was a period of rapid viral dissemination and stringent lockdown measures in Chicago and throughout the country. Thus, these data may not necessarily be transposable to later time periods during the pandemic, especially as healthcare organizations adjusted to changes in healthcare delivery and re-expanded access to in-person visits. Second, the inclusion criteria for the pandemic cohort were selected to include patients who would have been scheduled for their postpartum visit during the COVID-19 pandemic. Though changes in healthcare behaviors as a result of the pandemic, including inpatient LARC utilization, would not have been expected to occur prior to March 2020, our inclusion of these cases of LARC utilization would bias toward the null. Next, this study was conducted at a single quaternary care institution, with protocols for health services responses to the pandemic catered to the local pandemic epidemiology and care delivery context. Accordingly, our results may not be generalizable to other settings. Finally, our study is limited by the fact that we were unable to stratify our analyses by postpartum visits conducted in-person versus via telehealth, which may be useful information to better determine the impact of telehealth on postpartum care provision. 

Understanding how changes to postpartum care delivery may impact preventative health services utilization, including postpartum depression screening and contraceptive utilization, can inform ongoing adaptations in healthcare delivery in the midst of the COVID-19 pandemic. Accordingly, these data can inform policies to maintain access to important postpartum services. 

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