Nearly four years ago, Cassie Calderone strapped her newborn into a carrier to take the El from Andersonville to the Loop for her first postpartum checkup, just six days after giving birth.
Calderone experienced heavy blood loss during delivery and was still passing large blood clots even after several days at home. When she made it to the hospital after the hour-long commute, her midwife told her that she needed to go on bedrest for a week.
Initially, Calderone was happy to hop on the train for a follow-up appointment, but started to feel nervous about exposing her newborn to germs on public transit. “[And] after I saw my midwife and she put me on bedrest, that was when I had the ‘What am I doing out here?’ thought,” Calderone remembered.
Until recently, post-delivery care was not considered as significant as prenatal care. But with new studies showing that the maternal mortality rate rose 26 percent in the United States between 2000 and 2014, and that more than half of maternal deaths occur postpartum, medical practices and opinions are starting to shift.
But nationwide, 40 percent of women don’t make it to their standard six-week postpartum checkup, according to the American College of Obstetricians and Gynecologists. That could be because of many barriers to access, including transportation, poor weather or lack of childcare—and it means these women don’t get the essential information they need to care for themselves after childbirth.
That’s why public health and maternal health experts across the country are advocating for home visits: sending nurses to moms who are at high risk for postpartum medical complications or who cannot travel to their postpartum appointments.
In October 2018, as part of its first report on the maternal mortality crisis in Illinois, the Illinois Department of Public Health recommended that the state increase its home-visit nurse and doula services for both pregnant and postpartum moms to prevent deaths that occur after delivery.
Now, with the help of a state block grant, the Chicago Department of Public Health is expanding its home-visit services to reach about 5,000 families by 2020.
Helping high-risk women
Home care for pregnant women and new mothers is nothing new; there are examples of home-visit services for low-income women as far back as the mid-1900s in Chicago.
The Chicago Department of Public Health has provided home-visit services for mothers and children for decades, though many of its current programs focus on newborn health over maternal health.
Jacqueline Hoskins Wroten, a public health nurse with the CDPH who has done home visits for pregnant women and new moms for more than 30 years, is helping to coordinate two of the city’s newer home-visit services for moms, funded by the Illinois Department of Public Health.
The first, which launched in September 2018, is for new moms with hypertension, a high blood pressure condition that puts pregnant women and moms at risk of having strokes, heart attacks or blood clots after birth.
Wroten estimated that so far 40 hypertensive women have received home visits through referrals from Cook County Hospital Network and the University of Illinois Hospital Network.
At these visits, nurses check mothers’ blood pressure and make sure that they’re taking their medication. They may also provide lactation and other parenting guidance, as well as connection to local health and childcare resources. They also try to emphasize to partners and families the importance of mom not exerting herself, Wroten said.
Expanding to universal care
CDPH’s second—and much larger—initiative is a pilot for a universal, short-term postpartum home-visit service called Family Connects. It could reach as many as 5,000 families through five hospitals when it launches later this year, according to CDPH chief program officer Jen Vidis.
The service, which was designed for the city of Durham, North Carolina, by Duke University, has been shown to reduce rehospitalization and emergency visit rates for families during the postpartum period, increase show rates for follow-up appointments and reduce emergency health care costs by $3.02 for every dollar invested.
Data is limited about how home-visit services impact health outcomes for women in Illinois—especially Black women, who are six times more likely to die from a pregnancy-related condition than white women in the state. But health care experts agree that expanding home-visit care will not only improve outcomes for new moms and babies, but will also help improve the city agency’s understanding of what families need in the postpartum period.
Hospitals often lose sight of patients after they’re discharged from the hospital, Vidis said. A universal service can change that.
Once it’s up and running, regional community boards will meet on a regular basis to review data, so they can see what resources those families need. That information will help both hospitals and home-visit nurses to better serve their patients.
“We’ll be more likely to find families that have other needs that are not on our radar and not being met,” Vidis said. “We’ll do a better job at connecting with those families at risk and creating a better safety net.”
Providing equitable postpartum care
Home visits are one way to provide sustained support and education to women who are likely to experience health care disparities because of their race, income, age or housing status.
Implicit bias in the health care system means that women of color often find themselves stereotyped or have their concerns about their care or symptoms dismissed. Studies have shown, for instance, that doctors prescribe less pain medication to Black patients than white patients with the same reported pain levels due to a mistaken stereotype that Black people are better at withstanding pain than people of other races.
In the context of pregnancy-related issues, the dismissal of an ache or pain after delivery could lead to a preventable death. But having a nurse or home visitor around can help at-risk women to better prepare for these risks and to advocate for themselves.
That’s especially true for younger mothers. “People see young moms as more being told, not really seeing them as being able to make decisions for themselves,” said Luecendia Reed, assistant director of family supports for New Moms, an Austin-based nonprofit that provides housing, job training and perinatal support for moms between the ages of 16 and 24.
In Austin, the rate of teen births is nearly double the citywide rate, according to Chicago Health Atlas. Home visits can “help them to have those conversations with their providers,” she said.
New Moms uses Healthy Start, an initiative funded by the Illinois Department of Public Health, and one of a number of home-visit programs available to groups in Chicago, to provide home care to their moms from pregnancy up to their child’s fifth birthday. New Moms’ home-visit service also includes a doula through pregnancy and the first two months postpartum.
“Black families don’t get the same [maternal health] education as their counterparts, white families,” Reed said. “Most times [our moms have] already been told they’re already gonna get an epidural, and even though it’s really subtle, what if they don’t want an epidural? No one really gave them an option that they could do these things.
“I think that’s one of the biggest things families get out of a home-visiting program,” Reed said, “is that they get options and they’re well informed.”
Shirley Scott, who is the administrator of the perinatal network at the University of Illinois at Chicago, and who helps to run CDPH’s hypertension home-visit service, said that home visits can help bridge that gap in information. “There’s a whole lot of information that’s given and received during pregnancy during the postpartum period. And the ability for individuals to digest that information varies, especially if you are not a native English speaker,” Scott said. With home visiting, moms benefit from longer visits and sustained relationships with home visitors.
Still, access to longterm postpartum care is a challenge. Many hospital-based programs only offer visits up to seven or eight weeks postpartum.
But cardiomyopathy, one of the leading causes of death for Black women after birth, commonly leads to death between seven weeks and one year postpartum—and it’s difficult to detect early on.
Paying it forward
After experiencing how difficult and frightening the postpartum recovery process can be for women of color, Cassie Calderone wanted to help others through the process. She started her doula training to become a birth doula when her son was three months old, and she trained to become a postpartum doula the following year.
With home visits, Calderone thinks doulas and home visitors have the ability to communicate the risks women face during pregnancy and the postpartum period to women of color more sensitively than in a medical setting. There’s a way to do it gently and efficiently, she said, and not just in a “scary numbers way.”
“I didn’t know that as a Latina I should automatically be scared for my health,” Calderone said, referencing the fact that Black and Latina women are at highest risk of dying during delivery or facing serious birth-related health issues. “I wish someone had told me all the things I was at risk for.”
Looking back on her own experience as a new mom, Calderone thinks that she would have benefited physically and emotionally from a home visit.
“I think that having a nurse or midwife come to the home after discharge would be so beneficial,” she said. “Postpartum bleeding can pick up again with even minimal activity,” she said. “A home visit would encourage more time to rest.”
This story was produced by City Bureau, a civic journalism lab based in Woodlawn. Learn more and get involved at www.citybureau.org.
Read all stories in our special Maternal Health Issue here.