Postpartum navigators missed the main goal of a 405-person trial but nearly doubled primary care follow-up

A trial in Chicago gave 203 pregnant people with low incomes a personal guide to the health system for a year after birth, and compared them with 202 who received the usual care. On the measure the researchers chose in advance, the guides made no detectable difference. On three of the six pieces that make up that measure, and on what happened a year later, they made a clear one.

The guides are called patient navigators. With one, 96% of new mothers came back for their postpartum visit, against 80% without. A year after the birth, 57% had seen a primary care clinician, against 30%. The trial was published on October 2 in JAMA Health Forum by a team at Northwestern University.

What the trial measured was care received. It did not measure whether anyone ended up healthier, and it ran at one hospital.

What a postpartum patient navigator does

A patient navigator is a trained staff member who is not a doctor or a nurse. The job is to find out what stands between a patient and their care, and to remove it. Patient navigation is already widely used in cancer care and is even funded by Medicaid, the public insurance program for people with low incomes in the United States, said Lynn Yee, the trial’s lead researcher.

In this program, people assigned to navigation received individualized services that were designed to overcome postpartum-specific barriers to care. The work was practical. Navigators identified social needs, coordinated health care appointments, assisted with insurance, provided health education, and served as patient advocates. Navigators attended appointments in person with participants.

They also sat inside the clinic. Navigators were embedded in the clinical care team and could book obstetric appointments directly in the electronic medical record. The paper sets that apart from outside helpers such as community health workers, who often lack that access.

Northwestern’s news release describes one case. A pregnant patient with chronic conditions was about to miss an appointment for lack of reliable transport and childcare, and navigator Viridiana Carmona-Barrera arranged both.

How the postpartum navigation trial worked

The trial enrolled English- or Spanish-speaking pregnant people 16 years or older with Medicaid insurance. From January 2020 to June 2023, the study team approached 598 potentially eligible participants, and 405 agreed to take part. Half were non-Hispanic Black and 41% were Hispanic. Their average age was 28.

Each person was assigned at random to a navigator or to usual care, which is what makes the comparison fair: the two groups differed only by chance at the start. The program used 2 full-time, bilingual lay patient navigators. Support ran from late pregnancy through the first year after delivery.

The main measure was strict. It was the receipt of 6 care elements considered to be essential to optimal postpartum care by 12 weeks postpartum. The six were a full postpartum visit, counseling on all the topics a new mother is meant to hear about, a chosen birth control method, screening for depression with follow-up if needed, breastfeeding, and all indicated vaccinations. A participant counted as a success only with all six.

That list follows the American College of Obstetricians and Gynecologists (ACOG), the professional body for the specialty in the United States. In 2018 it said postpartum care should become an ongoing process, rather than a single encounter. It recommended contact within the first 3 weeks postpartum and a comprehensive postpartum visit no later than 12 weeks after birth. The ACOG statement calls these months the fourth trimester.

The main result: complete postpartum care stayed rare

Very few people in either group received all six parts. It happened for 19 of 203 with a navigator, or 9.4%, and 16 of 202 with usual care, or 7.9%. The frequency of the primary outcome was similar between the groups, the primary outcome being the main measure chosen in advance.

The researchers had planned for something different. When they worked out how many people to enroll, they estimated that 50% of participants receiving usual care would achieve the primary outcome. The real figure was under 8%. With so few successes on either side, this study was underpowered to detect the hypothesized difference in the primary outcome, the authors write, meaning the trial could not reliably show the difference the researchers had planned for, even if it exists.

They read the low figure as a result in its own right. All six parts together, they suggest, may reflect an ideal but rarely obtained outcome.

Where patient navigation changed postpartum care

Counted another way, the groups did differ. On average, people with a navigator received 71% of the six parts and people without one received 64%. Three components drove this difference.

Part of postpartum care by 12 weeks	With a navigator	Usual care
Attended the postpartum visit	195 of 203 (96%)	161 of 202 (80%)
Counseled on all recommended topics	131 (65%)	104 (51%)
Screened for depression, with follow-up if needed	174 (86%)	145 (72%)
All six parts	19 (9.4%)	16 (7.9%)

The counseling in the second row has a clinical name, anticipatory guidance, which means telling a patient in advance what to expect and what to watch for. People with a navigator were more often counseled on mental health, social needs, sleep, physical recovery and family planning.

Two parts did not move. Receipt of a desired family planning method by 12 weeks was frequent and similar between groups. And although navigators were trained to support breastfeeding, there was no difference in breastfeeding frequency, meaning the share of mothers who were breastfeeding.

One year after birth: primary care and screening

The widest gap opened later. At 11 to 13 months, people in the navigator group were more likely to have attended a primary care appointment, 115 of them (57%) against 60 (30%). That is a rate 1.9 times as high, with a plausible range of 1.5 to 2.4.

The hand-off from pregnancy care to a regular doctor is where many new mothers leave the health system. As few as 60% of individuals with Medicaid return for postpartum care at all, the paper notes. In this trial 37% of participants had been uninsured before pregnancy.

Other services followed the same pattern at one year. More of the navigator group were using their chosen birth control method, 65% against 43%. Among people who had developed diabetes during pregnancy, known as gestational diabetes, those with a navigator were more likely to have had any diabetes screening afterward. The numbers were small: 15 of 16 against 6 of 15.

Preventive testing rose too. By one year, the shares who had been checked were higher with a navigator for blood pressure (85% vs 62%), lipids (28% vs 13%) and glucose (31% vs 16%). Lipids are blood fats such as cholesterol, and glucose is blood sugar. The navigator group was also more likely to have received recommended vaccines by then.

Yee described why the first year matters. “Pregnancy and the postpartum periods are complex, and people often deprioritize themselves, particularly if they don’t have much support or have complex social needs,” Yee said.

Co-author Joseph Feinglass said the clinic staff gained as well. “One of the goals of navigators was not just to help patients, but to help clinicians too, and doctors were happy at how much more efficient and engaged patients were,” Feinglass said.

Where this fits: what earlier postpartum studies found

The same Northwestern group had tested a shorter version of the idea before. That work was a prospective observational study of women enrolled in a patient navigation program compared with women receiving care before the program. Return for postpartum care was more common among women in the program, 88.1% compared with 70.3%. A before-and-after comparison cannot rule out that something else changed in the clinic over the same period, which is why a randomized trial was the next step.

Independent evidence is thinner and points in a slightly different direction. A team at Johns Hopkins ran a randomized trial comparing a joint visit for mother and newborn with separate appointments. It enrolled 116 women, of whom 76.7% were Latina immigrants. The joint visit made no difference: almost all study participants attended their postpartum visit, 94.0% in each group. What the two groups shared was that the visit had been booked before they left the hospital. Both were more likely to attend the postpartum visit than historical controls, meaning earlier patients at the same clinic, of whom 69.7% had attended. The authors concluded that postpartum appointment scheduling before hospital discharge could increase postpartum visit attendance.

That result matters for reading the new trial. Booking an appointment for someone is one of the things a navigator does, and it may account for part of the attendance gain. The Chicago trial was not designed to separate the pieces of the navigator’s work.

A wider review looked at every way of delivering postpartum care that had been compared in the United States or Canada. The reviewers found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480), N being the total number of participants. Some approaches helped with specific things. Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing, a check for diabetes. Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month. Their overall verdict was cautious: various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health.

On breastfeeding the two bodies of evidence part ways. Peer support aimed at breastfeeding was linked to higher rates in the earlier studies, and a general navigator was not.

Limits of the navigation trial

The trial counted services, not health. It did not report whether blood pressure, depression, later pregnancies or deaths differed between the groups, so the link from better-attended care to better health is assumed here and not shown.

The setting was narrow. The study was conducted in a single academic medical center in an urban Midwest location. The authors add that the intervention is highly context dependent, which may make it hard to copy. Two navigators did all the work.

Some of the measured gain could be a matter of record-keeping. Outcomes came from medical records, and it is possible that not all elements of anticipatory guidance were documented. The staff who read the records knew which group each person was in.

The timing was unusual. Enrollment began in January 2020, and pandemic-related changes in health care may have contributed to the null primary outcome, the lack of a difference on that main measure.

The paper does not report what the program cost, and the authors list cost-effectiveness among the questions for future work. They are now running a second trial of navigation that starts earlier in pregnancy.

The stated aim of the program was for patients not to need it. “Their goal was to put themselves out of business, to be able to get to the end of the year and say, ‘You don’t need me anymore,’” Yee said.

A year of navigation got more low-income mothers to their postpartum visit, to depression screening and to a primary care doctor at one Chicago hospital, while complete recommended care stayed below 10% in both groups and health itself was not measured.