In the weeks after having my son, I opened the Notes app on my phone many times to jot down the questions I was saving up for my six-week postpartum visit. I had seen my obstetrician weekly in the month leading up to my son’s birth, but after he was born, I was left waiting for a visit that always felt like it was weeks away.
When the day finally came, the visit was quick and chaotic, my son cried for almost the entire time, and I didn’t make my way through my full list of questions. I left feeling frustrated and let down by this system that was supposed to help me.
In the words of Carrie Bradshaw, “I couldn’t help but wonder…” was this another example of a research-to-practice gap? Was a single postpartum visit enough for most postpartum people? It turns out the answer is probably no. The American College of Obstetricians and Gynecologists recommends that postpartum care is provided as an ongoing process rather than a single visit, but this is rarely the reality in practice.
My research in the field of implementation science focuses on addressing this kind of gap between what the research recommends and what actually happens in practice. When I started my current position as a faculty member and implementation scientist at Brown University, I spent a lot of time conferring with my husband about how to even explain to people what I do. What usually gets people’s attention is when I cite the finding that only 1 in 7 evidence-based interventions make their way into clinical practice. In other words, just because the research exists doesn’t mean your doctor knows or talks about it. And in fact, the process of getting these interventions into clinical practice takes around 17 years. Trying to reduce this research-to-practice gap is the focus of my work.
Why isn’t good evidence always implemented?
Unsurprisingly, the answer to this question is complex and requires us to explore factors across many levels: systems, providers, and patients.
Coming back to my OB experience — I was not alone in being underwhelmed by the limited support provided at my postpartum visit. The evidence-based recommendation that postpartum care be delivered through multiple visits is rarely carried out because of systems-level barriers such as health insurance in the U.S., which typically covers only a single six-week postpartum visit.
At a provider level, limited time with patients and a growing list of what should be covered in one visit make it challenging to implement all evidence-based recommendations. Postpartum visits last an average of 17.4 minutes. In this time, providers have a lot of demands; they are expected to address topics related to physical recovery, mental health, infant care, sleep, sexuality, and medications. It’s no surprise that postpartum visits typically cover only about 50% of these topics, as there’s simply not enough time to address every need. It’s also likely to be difficult for providers to stay up to date with recommendations, given the growing list of topics to address and recommended procedures. A recent study among primary care providers found that they would need nearly 27 hours in a day to do everything that is asked of them. While I haven’t seen a comparable study conducted for obstetricians, I would guess they would need at least as much time, especially given that they are often caring for multiple patients (parent and child) in brief visits. With that many competing demands on their time, we can begin to understand why it’s a challenge to deliver all evidence-based recommendations.
Finally, at a patient level, there may be factors that make it harder for evidence-based recommendations to be carried out. In my case, my obstetrician offered to do a pelvic exam at the end of my postpartum visit, which aligned with evidence-based recommendations, and I declined. Several factors were at play: I didn’t have any symptoms I was concerned about (recovery was going well); my infant was becoming increasingly cranky in the exam room; and we had a long drive home, with traffic worsening by the minute. In this case, my behavior and decisions got in the way, which also goes to show that sometimes there is a conflict between delivering evidence-based care and meeting the needs of patients on a given day. Even as someone whose entire career centers around the delivery of evidence-based recommendations, sometimes other needs come first.
Another example: peanut allergen exposure
Let’s consider another example of a topic that has strong evidence but isn’t always implemented: allergen exposure. There is very clear evidence from the Learning Early About Peanut Allergy (LEAP) study that exposing infants to peanuts from a young age reduces the risk of peanut allergies. At a systems level, there are several influential organizations that publish guidelines in line with the evidence (e.g. the American Academy of Allergy, Asthma, & Immunology and the American Academy of Pediatrics). This means that providers are receiving information about the importance of early allergen exposure.
However, other research suggests that there may be confusion among providers about how to implement these guidelines for infants at high risk of peanut allergies. It’s recommended that those infants receive additional screening prior to introducing peanuts, but the definition of “high risk” is not always clear. This may result in both provider and parent anxiety about an allergic reaction and/or overclassification of infants as high risk, which can lead to unnecessary testing and delayed introduction of peanuts into an infant’s diet. There are also known knowledge gaps on this topic among providers, leading them to advocate for introduction to peanuts later than the guidelines recommend and to provide limited advice on how to introduce peanuts at home.
Among parents, not everyone is aware of the guidelines for early allergen exposure, and those who are may be hesitant to follow these guidelines. Furthermore, compliance with the recommendation for ongoing exposure can be difficult, especially amid the many competing demands of taking care of an infant. It can be hard to find affordable and infant-safe forms of peanuts, to keep track of when you last gave them to your child, and to overcome the anxiety about doing so each time.
Again, challenges at each of these systems, provider, and patient (parent) levels all get in the way of ensuring that findings from the research actually make their way into our daily lives.
So, what can you do?
As a patient, you do have some say in whether the care you receive is evidence-based. Being informed, collaborating with your provider, and advocating for yourself are all things that can help, and this can be hard. It is not easy to question an expert and to learn about topics that are completely new to you. I remember going to a doctor once who encouraged me “not to trust Dr. Google” and I understood the rationale behind that. At the same time, a shared decision-making process between patients and providers is likely to lead to better outcomes. Here are some approaches to consider:
Be informed and ask questions. Sometimes your doctor isn’t aware of the latest research. You can find the latest guidelines through websites like the American Academy of Pediatrics or the professional society for the relevant medical specialty. Bringing your questions and potential knowledge about the research might help them update their knowledge. As an example of this, I recently had a physical and my primary care physician suggested that I get some routine blood work. I mentioned that one of my specialists suggested that I wait at least a year postpartum before repeating that blood work, but I deferred to my primary care physician on what she thought was best. She acknowledged that she was unaware of that guideline and was happy for me to wait. I was fortunate to have a provider who was open to input from me and from her colleagues, and it resulted in delaying unnecessary testing.
Advocate not just for what you think is best, but for a shared decision-making process. Working with your provider should be a collaborative process that honors both their expertise and your own experience. I once met with my immunologist about starting a new medication and told her I was concerned that I might have an allergic reaction to it, given my prior experiences with allergies to new medications. I asked for her thoughts on how to handle this because I valued her opinion. Of course, if she had responded, “Just start the medication and see what happens,” I knew that wouldn’t work for me. Luckily, she was very open to problem solving this together and even pulled up a research article suggesting a protocol to gradually trial the medication. This is shared decision-making at its best!
It doesn’t always go this smoothly, though. People of color, especially Black women, consistently face racism, bias, and health disparities in the process of seeking medical care, and this is particularly true when it comes to maternal health. Although systemic change is what is ultimately needed to address these disparities, resources such as this guide for helping Black women navigate prenatal and postpartum care can support advocacy efforts for people who routinely experience racism and discrimination in the process of seeking care.
Notice your emotions. Doctor’s appointments can be stressful, especially if you get news about your health that is less than positive or if you experience being dismissed. Before a visit, take some time to write down your questions. If you find yourself feeling highly anxious, stressed, frustrated, or any other negative emotion during a visit, check in with and acknowledge that emotion. If you are comfortable with your provider, perhaps you can even share that emotion with them. It may be harder to advocate for yourself or make decisions when you’re feeling intense emotions. If you have the option of a follow-up visit, continue the discussion after you have some time to process the information. Another option is to bring someone with you who can be your advocate when you’re feeling overwhelmed.
The bottom line
Although some barriers may be addressed on an individual level, my job as an implementation scientist focuses on developing scalable strategies to address these barriers. For instance, we might develop systems to give providers feedback on how often they’re using evidence-based interventions or add alerts to patients’ medical records that tell providers about research-based recommendations to use during the visit. Continued work in this area will ultimately increase the likelihood that we benefit from research in our daily lives. In the meantime, if you have experienced receiving medical care that isn’t backed by evidence or felt underwhelmed by a medical encounter, you are not alone.
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