Maternal morbidity and mortality are major public health concerns in the United States.¹ There are significant racial and ethnic disparities in pregnancy-related death that persist regardless of age, education level, or geographic location.^2-4 The leading underlying causes of pregnancy-related death varied by race and ethnicity and are cardiac and coronary conditions among non-Hispanic Black persons, mental health conditions (including overdose related to substance use disorders) among Hispanic and non-Hispanic White persons, and hemorrhage among non-Hispanic Asian persons.⁵ More than half of pregnancy-related deaths happen in the postpartum period (i.e., 1 week to 1 year after pregnancy), and 84% of pregnancy-related deaths were preventable.⁵

Efforts to identify and address the immediate health care needs for a person during the pregnancy and postpartum periods are critical for long-term health and well-being.⁶ These efforts include helping health care providers make informed decisions for the care of the patient, supporting maternal care coordination and care provision, and developing data and clinical care quality improvement initiatives to improve the standardized documentation and follow-up of pregnancy and postpartum care services. Despite the importance of data to successfully identify, treat, and follow up with patients, critical data on pregnancy status and pregnancy outcomes are not standardized across electronic health records (EHRs). Efforts to develop standards in maternal health in the US Core Data for Interoperability (USCDI) and USCDI+ are occurring but not yet being implemented.^7-9

In 2018, the Centers for Disease Control and Prevention (CDC), in partnership with the National Association of Community Health Centers (NACHC), began a 6-year initiative to build capacity in Federally Qualified Health Centers (FQHCs) to (1) improve the infrastructure for perinatal care management and measurement of perinatal care quality for health center patients to ultimately inform strategies to (2) use perinatal care measures to identify and address gaps in care around provision of clinically recommended postpartum services and transitions of care in community health centers.

Health centers are an important setting for implementing quality improvement¹⁰ and supporting the interoperability of EHRs to improve the care of pregnant persons.^7,11-13 The Health Resources and Services Administration (HRSA) Health Center Program supports nearly 1,400 FQHCs that provide comprehensive primary health care to ~30.5 million patients at more than 15,000 service sites across the United States, including maternity services to more than 500,000 prenatal care patients.¹⁴ Health centers are often located in areas where economic, geographic, or cultural barriers limit access to health care and serve as a critical safety net for certain populations, including those uninsured or insured by Medicaid and Medicare, migrant and agricultural workers, people experiencing homelessness, residents of public housing, and veterans.¹⁵ NACHC, the national association dedicated to the support of community-based health centers and health care access for the medically underserved and uninsured, provides numerous supports to health centers and networks, including improvement of quality of care and using informatics and Health Information Technology (HIT) systems to improve data standardization for structured documentation and electronic measurement of quality improvement.^16,17

In this project, NACHC worked across three partner Health Center-Controlled Networks (HCCNs) to build health center capacity to integrate evidence-based recommendations into the clinic workflow and use HIT systems to improve standardized documentation and measurement of quality improvement for the provision of postpartum care. In Year 1, activities focused on advancing the adoption of contraception clinical guidelines, developing a systems approach to identify and manage gestational diabetes, and understanding clinic and data workflows to improve pregnancy-related EHR data collection in health centers. Based on these initial experiences, in Years 2 and 3, the activities merged, and focus shifted to standardizing data capture, streamlining data extraction, and maximizing data output on postpartum care for clinical care quality improvement. NACHC developed a public health informatics data dictionary and built a cloud-based data infrastructure using HIT for data aggregation, data quality improvement, and innovation and implemented decision support tools to improve data quality and standardization. Two partner HCCNs, AllianceChicago and OCHIN, implemented strategies to document the pregnancy episode, a record linking encounters during the period of care from when the pregnancy is identified through the pregnancy outcome, and to integrate the delivery data from the delivery hospitalization into the EHRs at the health center. The analysis of extracted data and information was used to evaluate on demand data extraction, high-quality data capture, and use of data by health centers to drive clinical care quality improvement. In Years 4 and 5, the initiative expanded its scope to a broader spectrum of pregnancy-related care services associated with adverse pregnancy and postpartum outcomes and an additional HCCN joined the project. The efforts were focused to identify pregnancy episodes and expand the measurement of a broader range of perinatal care measures based on clinical and public health guidance and recommendations, including an initial postpartum visit, postpartum management of gestational diabetes mellitus (GDM), postpartum contraception counseling, management of hypertensive disorders of pregnancy and related outcomes, and postpartum depression screening and follow-up. In Year 6, the initiative is refining the implementation strategies to improve the quality of postpartum care, standardizing pregnancy-related data elements with EHR vendors, and developing a dissemination plan involving a communication strategy, learning communities, and collaboration with key partners to ensure sustained improvements in postpartum care quality.

This CDC report describes the initiative’s efforts to standardize perinatal care measures and to use the measures to identify and address gaps in postpartum care. We describe data quality improvement efforts to extract data from the EHR, establish baseline data, and identify and address interoperability challenges within health centers. We also highlight health centers’ clinical care quality improvement efforts to identify gaps and improve postpartum care. Lessons learned are reported, emphasizing the potential for adaptation and scale-up of HIT tools in other health center networks. This initiative aligns with public health efforts for a comprehensive postpartum quality care approach in outpatient settings and activities to improve the care for hypertension in pregnant and postpartum persons.^18,19 Ensuring quality care for all pregnant and postpartum persons is a strategy for addressing pregnancy-related deaths and related disparities.^20,21

Between January 2020 and December 2022, 90,876 patients and 96,919 pregnancies were identified and included in the dataset, respectively (Table 2). About one-third of pregnancies (34.4%) occurred in people aged 15–24 years, 28.2% in people 25–29 years, and 37.3% in people 30–44 years. More than half of the pregnancies occurred in people identified as Hispanic/Latino (62.3%), followed by Black/African American (14.7%), White (12.5%), and Asian (4.5%). In total, 42.4% of the pregnancies occurred in people whose preferred language was one other than English. There was significant missingness of financial (23.8%) and insurance data (20.3%); however, at least 52.1% of pregnancies occurred in people who lived at or below 100% of the federal poverty level, and 65.3% were insured by Medicaid.

Project partners convened multidisciplinary teams of clinicians, data analysts, and informaticists to identify local challenges and determine which recommended quality improvement activities could be implemented, focusing on HIT systems improvement efforts to support improving postpartum care (Table 3). Some activities focused on improving data quality for perinatal care measures, such as closing out open pregnancy episodes and development of new registries to support postpartum follow-up. Other clinical care quality improvement activities focused on addressing gaps in postpartum care, such as delivering text messages to patients with reminders to schedule postpartum care appointments and implementing a standard protocol for postpartum depression screening.

In general, the longitudinal capture of perinatal care measures shows overall improvement over time. Data capture and extraction of several measures were incomplete at the start of the project, but over time data missingness was improved for measures through data validation and clinical support interventions (Table 4). Contraceptive counseling and provision and screening for gestational diabetes were the initial measures, and data capture for these measures was higher at the beginning of the measurement period. In contrast, data capture for postpartum depression screening and treatment, gestational hypertension, and aspirin therapy, which were later added as measures, was much lower but increased the most over the duration for the project. The combination of targeted clinical support and data extraction adjustments improved the postpartum depression screening measure from 0% (no data) in 2020 to 22.8% (8,316) in 2022, based on EHR records. Similarly, the postpartum depression treatment measure increased from 7.8% in 2020 to 15.2% in 2022, gestational hypertension screening from 2.3% to 40.0%, and aspirin therapy from 0.1% to 10.5%, according to EHR records. Other measures, such as postpartum visits within 8 weeks after delivery, contraceptive counseling, and the identification of persons with high-risk hypertensive outcomes, were steady across the project period.

Because the US maternal health crisis continues to have persisting health disparities and worsening health outcomes, there is renewed focus on supporting patients and care teams in improving health outcomes and reducing disparities.^1,20 Existing efforts to improve quality maternal health care, such as the Perinatal Quality Collaborative program⁴² and the Alliance for Innovation on Maternal Health,⁴³ have focused primarily on health care quality at the delivery hospitalization. It is important to support postpartum care, when more than half of pregnancy-related death occurs, particularly for populations with the greatest disparities.^5,44

This project assessed opportunities to improve the quality of postpartum care in the outpatient setting of health centers. At the initiation of the project, NACHC and its partners identified several pregnancy-related data elements underreported or absent from the EHR, making it difficult to calculate accurate measures and implement and monitor quality improvement activities in postpartum care. Our project partners reported that the current support available for maternal quality and care coordination is inadequate to provide the care team with an effective clinic workflow and the information to close care gaps. By Year 5, NACHC’s partners demonstrated that collection of perinatal-related data elements into EHR structured fields was feasible, which enabled them to more accurately assess the quality of the selected postpartum areas of concern and implement activities to improve service delivery. However, the absence of requirements for pregnancy data standards in EHRs remains a barrier. Specifically, current EHR systems lack interoperability and standards designed for managing information related to pregnancy, childbirth, and postpartum care. Such deficiency leads to poor data completeness, low standardization, and a lack of functionality to support optimal postpartum care in outpatient obstetric settings. NACHC and health center partners continue to support the advancement of these standards in HIT products.^7-9 However, informatics and data strategies to convert electronic and paper-based records (i.e., nonstructured data) to automatically import relevant information to mapped, structured data fields linked to standard terminology codes within a data warehouse, and the EHR system could reduce the burden on local teams to reinput and abstract these data and allow for messages and dashboards to alert care teams to inpatient encounters and deliveries through a clinical decision support system.

In addition, there are remaining gaps owing to the intentional absence of nonstructured documentation, which was not collected owing to data privacy risks. The accuracy of some of the metrics cannot be fully accounted for without this nonstructured data. However, data gaps that could be resolved with structured data were addressed by providing feedback to the partners and expanding the requested data elements and value sets. Ongoing work to identify relevant data elements and improve extraction and consolidation may impact the results. NACHC, the HCCN partners, and subject matter experts collaborated to determine extensions of the clinical content of the measures and the addition of new measures.

Using a quality improvement strategy that includes better collection of pregnancy data, the capture of perinatal care measures increased progressively in some areas, demonstrating the value of continuous data quality improvement in reaching better outcomes. It also demonstrates how the implementation of clinical care quality improvement efforts can drive improvements in documentation and data capture. A best practice at the initiation of this activity was to have a multidisciplinary team, with a shared goal of aligning processes and measures and identifying clinic workflow and data challenge points.

Our findings suggest that focusing initially on a subset of target measures, including process measures focused on documentation of actual delivery dates to indicate when postpartum follow-up should occur, can create a foundation to track real improvements in care and close data quality gaps. For example, an estimated rather than actual delivery date would shift the measurement timeframe of the numerator criteria and may mask patients who satisfied the measure otherwise. Additional effort in the documentation and extraction of the clinical data elements and measure refinement would likely increase performance of the selected measures. Identifying an initial clinical quality measure set can be led by the multidisciplinary team and include consideration around local patterns of pregnancy-related comorbidities, challenges identified by care team members, and data on maternal mortality available from state Maternal Mortality Review Commissions.^20,38 Identifying pilot sites helps reduce the initial level of effort and allows improvements to be implemented with less burden on the organization. Creating clinical dashboards to guide care teams in their progress is a best practice which supports other staff who provide care coordination to do additional patient outreach and supports measure validation activities (e.g., chart reviews). Health equity goals, such as reducing disparities or addressing health-related social needs, can be included in the monitoring of stratified measure results to ensure new processes reduce inequity instead of reinforcing it.

Furthermore, initial and ongoing training is pivotal for the effective use of pregnancy and postpartum modules in the EHR, facilitating ongoing feedback and allowing adjustments to clinic workflows. Some care gaps require the addition of patient outreach and support. Efforts such as targeted text messaging using EHR data elements can enhance patient outreach, whereas prenatal and postpartum navigators can play a vital role in educating patients, filling data gaps, and facilitating comprehensive care, including social needs coordination. As new measures are onboarded, clinical efforts to support care coordination and train and equip care teams with tools can be implemented in phases until goals are met and sustained. Quality improvement frameworks can also be used to support the delivery of high-quality patient care and improved patient outcomes.⁴⁵

Ongoing monitoring of these measures is key to identifying new gaps in the data or care process that may occur after the initial monitoring period. In our data, despite the general trend of improvement over time, there were measures and periods of time where the capture of performance measures decreased. Our findings reinforce the importance of supporting ongoing monitoring of measures longitudinally, including reviewing patient volume by site, performing chart reviews, and following-up with training and care coordination activities.⁴⁶

The findings in this report are subject to several limitations related to the completeness and accuracy of reported perinatal measures. First, interoperability challenges impact data capture in the pregnancy and postpartum period. Hospital-level information from the delivery encounter is seldom electronically transmitted to the health center’s system in structured data. This results in the care team redocumenting paperwork data or manually verifying the delivery by contacting the patient or hospital. EHR systems also lacked effective tools for documenting and linking multiple encounters within a single pregnancy episode. These data challenges and existing clinical workflows led to inconsistencies in critical pregnancy data, causing patients to have multiple estimated delivery dates close to each other. NACHC addressed this by developing an algorithm to prioritize reported delivery dates, selecting the most recent estimated date if unavailable, and excluding additional dates within months of the final accepted date. In addition, health centers reported building workflows to assist care team members in documenting and closing pregnancy episodes to address this gap. Second, significant missing data may arise from unstructured information (e.g., progress notes), as extracting structured data from such sources is not a routine practice in electronic health care documentation. Third, metrics for the project focused on postpartum care delivery and were calculated across unique pregnancies that ended with a live birth; women experiencing a stillbirth or pregnancy loss may still need postpartum care services. Finally, this analysis is limited to data that were available to NACHC and may not reflect the full extent of data available to the partners directly.

Our findings highlight the challenges to measure and improve postpartum care in outpatient health center settings. However, health centers are key partners for implementing quality improvement activities that align with evidence-based clinical guidance and recommendations. HIT is an integral part of these activities, with priority on documenting the pregnancy episode in the EHR and supporting users providing postpartum care with EHR systems tailored for dedicated clinical decision support. Documentation of pregnancy episodes and outside data from inpatient delivery sites that automatically populate delivery dates and delivery outcomes can support the outpatient care team to close the pregnancy episode and initiate follow-up to patients who should receive postpartum care services. Incomplete pregnancy-related data in outpatient settings continues to limit care and coordination. Health organizations who choose to make incremental, longitudinal actions to monitor these data can see improvements over time in their quality measure performance and care team effectiveness.⁴⁷ The infrastructure and strategies used in this project may translate to other areas of health care and provide value for organizations moving toward value-based care.⁴⁸ The multidisciplinary approach to data and clinical care quality improvement yields the opportunity to align organizational goals and improve the delivery of postpartum care in settings that serve communities disproportionately impacted by poor outcomes.