Patient navigation in women’s health care for maternal health and noncancerous gynecologic conditions: a scoping review

Purpose This study investigated the scope of patient navigation studies on women’s health care for maternal health and noncancerous gynecologic conditions and aimed to report the characteristics of the identified patient navigation programs. Methods A scoping review was conducted following Arksey and O’Malley’s framework. Five electronic databases were searched for relevant studies published in English: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo. There were no restrictions on the publication date and the search was completed in July 2023. Results This scoping review included 14 studies, which collectively examined seven patient navigation programs. All selected studies were related to maternal health issues (e.g., perinatal health problems and contraception for birth spacing). Close to two-thirds of the patient navigation services were provided by women (n=9, 64.3%) and half by lay navigators (n=7, 50.0%). The majority incorporated the use of mobile health technologies (n=11, 78.6%). All of the patient navigation programs included in the review coordinated the necessary clinical and social support services to improve women’s access to care. Conclusion Patient navigation appears to be in its nascent phase in the field of maternal health. The results of this study suggest that the implementation of patient navigation services could potentially improve access to care for socially disadvantaged women and families. Furthermore, providing patient navigation services that are specifically tailored to meet women’s needs could improve the quality of maternity care.


Introduction
Patient navigation provides person-centered care designed to improve patient's access to health care services across the continuum of care.The first patient navigation service was introduced in 1990 for breast cancer patients, primarily low-income Black women in Harlem, New York, United States [1].The patient navigation services provided low-cost breast examination services and addressed each patient's unique challenges (e.g., finan- [3,4].Within women's health care, the need for improving access to care has been strongly emphasized by many researchers and health professionals.For example, the United Nations highlighted the high global level of maternal mortality from pregnancy and childbirth-related causes that are mostly preventable if timely prenatal care is provided [5].Even worse, current statistics reveal greater maternal mortality rates in lower-income countries and among Black women, indicating disparities in the degree to which women receive prenatal care [6].Additionally, limited access to care persists until the postpartum period despite significant mortality and morbidity rates after childbirth [7].According to the American College of Obstetricians and Gynecologists (ACOG), about 40% of women did not attend postpartum checkups that were usually scheduled between 4 to 6 weeks postdelivery [8].The ACOG also pointed out that current postpartum care often fails to address common health-related problems in new mothers, such as emotional well-being, breastfeeding, infant care issues, sleep or fatigue, urinary incontinence, and contraception.A recent systematic review has identified a range of individual factors that act as barriers to prenatal and postpartum care.These include lack of transportation, financial or insurance challenges, long waiting times, difficulties in finding childcare, late awareness of pregnancy, and disrespectful attitudes from providers, among others [9].Expanding access to perinatal care is closely related to reducing maternal mortality rates and health disparities worldwide.Thus, integrating patient navigation within women's health care should be considered.
Patient navigation may also be a suitable intervention for wom-en seeking contraception, which is known as an effective strategy to reduce maternal morbidity and mortality rates [10].Control over birth can empower women to avoid unintended pregnancies, which are linked to pregnancy-related deaths, unsafe abortion, and sexually transmitted infections.However, access to contraception is also limited by several individual barriers, including lack of knowledge, costs, religious or cultural beliefs, and misconceptions [11][12][13].Similar to prenatal care access, these barriers are more common among low-income and minority women, causing disparities in women's health [11].In order to improve access to contraception, barriers should be tackled in a way that is tailored to each woman's needs.As noted by the ACOG, patient-centered counseling may promote contraception use [14].Despite the potential benefits of patient navigation, its use in women's health care has not been as widespread as in other patient populations.While there are some studies on patient navigation for women, these have primarily focused on breast and gynecologic cancers [15,16].A literature review by McKenney et al. [17] highlighted the potential role of patient navigation in women's health by examining existing programs within various health care settings and identifying current gaps in access to women's health care.To the best of the author's knowledge, no recent studies have systematically reviewed the scope and status of patient navigation in the context of maternal or noncancerous gynecologic care.Therefore, this scoping review aimed to explore patient navigation studies that evaluated the impact of these programs on women with maternal and noncancerous health issues, and to describe the characteristics of the identified patient navigation programs.

Summary statement
• What is already known about this topic?
Patient navigation programs have been implemented in various health care settings, including for patients with cancer and many other chronic illnesses.Aside from breast and gynecologic cancers, however, little is known about the scope of these programs related to maternal and noncancerous women's health issues.

• What this paper adds
The patient navigation programs identified in this study all applied to maternal care settings (perinatal care and family planning).Lay navigators were the main providers, and the majority of programs involved the use of mobile health technologies.All the patient navigation programs attempted to link women to relevant clinical or social services related to maternity care.
• Implications for practice, education, and/or policy Implementing patient navigation programs could improve access to perinatal care services and promote contraception use.Patient navigation for women with noncancerous health may be a suitable area for clinicians aiming to improve continuity of care, since such programs have yet to be widely implemented.

Methods
Ethics statement: As this study was a review of existing literature, the author did not request Institutional Review Board approval.
This scoping review was conducted using the five stages proposed in Arksey and O'Malley's methodological framework [18] to ensure the rigor of the research process: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results.The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews) guidelines [19] were utilized to report all pertinent information related to conducting a scoping review.

Stage 1: Identifying the research questions
This scoping review aimed to answer the following research questions: 1) What progress has been made in the literature on the impact of patient navigation on women's health care for maternal health and noncancerous gynecologic conditions?2) What are the characteristics of these patient navigation programs?Within the domain of cancer care, the National Navigation Roundtable has defined patient navigation as "individualized assistance provided to patients, families, and caregivers to help overcome health care system barriers and facilitate timely access to quality health and psychosocial care, from pre-diagnosis through all phases of the cancer experience" [20].However, the delivery of patient navigation services currently varies due to the absence of a universally accepted definition.Furthermore, in the literature, the terms "patient navigation," "case management," and "care coordination" are often used interchangeably.This is due to overlap in the services provided by these interventions, which include individual needs assessment, care coordination, and the provision of psychosocial support.To differentiate "patient navigation" from similar terms, it is defined for the purposes of this study as a service that addresses patients' barriers to care on an individual basis.This involves a reactive approach, resolving a patient's problems as they arise, rather than a proactive approach [3,21].For instance, patient navigation services may also provide needs assessment, care coordination, or psychosocial support, similar to case management or care coordination programs.However, as long as the services were provided with the aim of resolving each patient's barriers to care using an individualized and reactive approach, the program was defined as patient navigation.

Stage 2: Identifying relevant studies
Five electronic databases were searched: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo.There were no restrictions on the publication date or language of the studies during the initial search and the final search took place in July 2023.The primary search terms were "patient navigation," "care coordination," "case management," "women's health," "women," "maternal," "obstetrics," "gynecology," "family planning," "reproductive health," and "infertility."The specific search strategy used for each database can be found in Supplementary Table 1.

Stage 3: Study selection
The inclusion criteria for this scoping review were studies that (1) included women who were older than 18 years, (2) conducted patient navigation programs to facilitate access to maternal and noncancerous gynecologic care services, (3) reported any quantitative or qualitative outcomes related to patient indices, and (4) were published in English.Studies were excluded if they: (1) focused solely on transgender women, homeless women, or women younger than 18 years of age; (2) delivered patient navigation programs across the continuum of breast cancer or gynecologic cancer care (including prevention, early detection or screening, diagnosis, treatment, and palliative care), substance abuse care, malaria care, or general chronic disease care (e.g., heart disease or diabetes); (3) conducted patient navigation programs that were not barrier-focused or individualized, did not adopt a reactive approach to patients' barriers to care, or did not clearly state intervention descriptions; (4) reported effects of patient navigation outcomes only related to health care providers' indices; (5) were intervention developmental studies, protocols, literature reviews, case reports, theses, commentaries, or conference abstracts, or (6) were not published in English.
To select the studies, the author initially retrieved pertinent studies from electronic databases, eliminated any duplicates using Endnote (Clarivate Analytics, Philadelphia, PA, USA) and screened the titles and abstracts to exclude any studies that did not meet the eligibility criteria.For the studies that remained, the author obtained the full texts to determine the final selection of included studies.Throughout the screening process, the author consulted a second reviewer whenever there was uncertainty about a study's inclusion.The final 14 studies were included following consultation with this independent reviewer.

Stage 4: Charting the data
Data from the included studies were extracted and organized into a predetermined Excel table, which was developed by the author.The extracted data included the author, publication year, country where the study was conducted, study design, sample size, participants, women's health care continuum, recruitment settings for women, types of services delivered by patient navigation interventions, patient navigator background, use of mobile health (mHealth), comparison, and patient-related outcomes.The author initially charted the data independently.If any data were not clearly reported in the study, the author emailed the corresponding author to ensure the accuracy of the information.Any uncertainties that arose during the data charting process were discussed with a second reviewer.An example of corroboration with the second reviewer was charting family planning separately from perinatal care within the women's health care continuum.

Stage 5: Collating, summarizing, and reporting the results
The charted data were compiled and summarized in two tables (Tables 1 and 2) through a process of comparison and contrast of the extracted information.Initially, the author summarized the details of the selected studies (Table 2), and while closely adhering to the research questions, the author arranged the results according to specific themes (Table 1) that effectively represented the characteristics of the selected patient navigation studies.The process of compiling, summarizing, and reporting the results was iterative.

Study selection process
The results of study selection are presented in Figure 1.In total, 5,742 records were identified from the five electronic databases.After removing 2,160 duplicate records, 3,582 records underwent title and abstract screening.During this initial screening, 3,323 records were removed due to being case management studies or including women who were receiving cancer care.The remaining 259 studies underwent full-text screening.Of these, 122 studies were excluded, as they did not align with the patient navigation definition set for this scoping review.Thirty-one other studies were excluded because the patient navigation services delivered were not related to maternal or noncancerous gynecologic care.Of the remaining studies, 84 were not original interventional studies (protocols, literature reviews, case reports, theses, commentaries, and conference abstracts), five did not report the effects of patient navigation outcomes, and three were not published in English.Thus, 14 studies [22][23][24][25][26][27][28][29][30][31][32][33][34][35] were finally included.
Each study included in this review specifically focused on women or families with unique socioeconomic and obstetric statuses.The majority of these studies involved participants with low incomes (n = 8) [24-26,30-34], followed by those from ethnic minority groups (n = 4) [22,23,29,35].One of the remaining studies focused on women living on islands far removed from well-equipped mainland medical centers [28], while another study included women who had an unplanned cesarean section during delivery [27] (Table 1).
The outcomes could be classified into several categories (Table 1).The most frequently reported outcome category in quantitative studies was the completion rates of care services or referred services (n = 7) [22,25,26,29,30,33,35], which included attending prenatal or postpartum visits, receiving perinatal care services (e.g., screening for postpartum depression, glucose tolerance tests, or influenza vaccination), or using preferred contraception methods.Only two studies reported waiting times were reported [22,28].Two studies also reported patient satisfaction with navigation services, measured quantitatively [27,31].Health-related patient outcome indices (physical health [24,26,29,32], mental health [25], healthy behavior changes [25,29,30]), such as women's weight gain, birth outcomes, anxiety, or initiation of breastfeeding, were reported in six studies.The most commonly reported qualitative outcomes were participants' positive perceptions of the patient navigation services they received (n = 3) [23,27,31].

Discussion
Research question 1: What progress has been made in the literature on the impact of patient navigation on women's health care for maternal health and noncancerous gynecologic conditions?The 14 patient navigation studies encompassed seven different patient navigation programs, all conducted for women during the perinatal period and up to 15 months post-childbirth.These programs were designed to facilitate access to either perinatal care or family planning services.Although this study also aimed to include participants with noncancerous gynecological issues, no such patient navigation programs were found.The range of publication years suggests that patient navigation programs have been relatively recently introduced into the maternity care setting.This is in contrast to the findings of a systematic review [36] that examined care coordination programs conducted in maternity care settings since the late 1980s.This review found that the majority of the studies were observational and conducted in the United States, which may have been due to the fact that patient navigation programs first emerged in the United States.More than half of the studies reported the impact of patient navigation outcomes through a secondary analysis of the data collected in their primary studies, and most reported outcomes using quantitative data.

Research question 2: What are the characteristics of these patient navigation programs?
The patient navigation programs included in this study primarily targeted socially disadvantaged women and families, aiming to facilitate their access to perinatal care or family planning services.Given that many previous patient navigation programs have been implemented to eliminate health disparities [37], conducting such programs in maternity care settings could potentially increase social equity.Notably, a study specifically targeted Latina mothers in a pediatric care setting to provide contraceptive care [35].Mothers, who are typically the primary caregivers for their children, frequently visit pediatric care facilities for well-child visits, but not maternal health facilities after childbirth.This provides an opportunity for pediatric health providers to reach mothers to provide contraceptive care for birth spacing.Our study's findings suggest a need for close collaboration between maternal and pediatric care providers.Patient navigation services could be instrumental in bridging these two specialty areas to promote contraceptive care.
The majority of patient navigation programs conducted in mahttps://doi.org/10.4069/whn.2024.03.15 Oh J • Patient navigation for women's health ternity care settings involved the use of mHealth technologies, reflecting the recognition that information and communication technologies are potentially cost-effective means of delivering efficient, person-centered care [38].The use of advanced technologies enables patients to connect with health care providers from the comfort of their homes, thereby increasing their access to care and promoting communication between interdisciplinary health care providers.Researchers and health care professionals planning to implement patient navigation services in maternity care settings might consider using mHealth applications.
The patient navigation services provided were similar to those previously implemented in other health care settings [3,39], yet with different health topics.The most frequently identified service in this scoping review was the integration of maternal care services with other clinical (e.g., neonatal or mental health care) and social support services (e.g., public transportation, childcare assistance programs, and financial support services).The findings of this study suggest other possible clinical and social support services that can collaborate with maternity care services.The application of patient navigation in a postpartum care setting could prove beneficial.The postpartum period is a time of transition for women, both relative to their pre-pregnancy state and parenthood.However, these developmental transitions are often overlooked by health professionals in real-world clinical settings.To address this, the ACOG [8] recently urged health professionals to increase the frequency of postpartum visits and improve the quality of discussions during these encounters.The ACOG also highlighted the need for care coordinators within a postpartum care team who could link postpartum women and their families to the multiple clinical and social services they need.In this scoping review, two of the included patient navigation programs [27,30] focused on postpartum women, either to boost postpartum visit attendance [30] or to address common postpartum concerns (e.g., breastfeeding, infection, pain, postpartum depression, sleep, fatigue, or infant care) that are often neglected during routine postpartum visits.In light of the findings of this scoping review, the application of patient navigation programs in postpartum care settings could be beneficial for addressing the needs of many women following childbirth.
A notable finding regarding types of patient navigation services was the presence of slight differences in types of services among countries.In Guatemala and Kenya, the services were mainly focused and limited to increasing access to care by arranging emergency transportation and providing educational information about safe births.However, in addition to these services, the patient navigation programs in the United States arranged neonatal or mental health care along with childcare assistance services, coordinated or provided follow-up on clinical appointments, and offered psychosocial support.According to the World Health Organization [40], over 99% of global maternal deaths occur in low-and middle-income countries.These statistical data clearly explain the differences in the types of navigation services delivered between Guatemala and Kenya (upper and lower-middle income countries according to the World Bank) versus the United States (high-income country in the World Bank classification).Therefore, patient navigation services should be delivered carefully considering the existing maternal issues within the countries.
The primary focus of researchers was to measure the influence of patient navigation programs on the completion rates of provided care services.McKenney et al. [17] proposed a set of outcome measures that could be used to assess the impact of patient navigation services in maternal care settings.However, only two studies actually evaluated waiting times until the use of appropriate care.A significant number of the included studies were designed to measure the effects of patient navigation on patient health outcomes (physical or mental health, or changes in health behavior) in conjunction with completion rates of appropriate care services.Despite the set of outcome measures suggested by McKenney et al. [17], a more robust core set of outcomes that can be measured in maternity care settings may be necessary.

Limitations
Despite being the first study to review patient navigation programs in women's care, a limitation of this study is that it did not include the gray literature.Although this aligns with the author's intention to identify studies that have fully and accurately reported their methods and outcomes, as noted in one of the selected studies in this scoping review [27], there may be additional ongoing patient navigation studies for women with maternal or noncancerous gynecologic health issues.Therefore, it is recommended that future reviews include the gray literature.

Implications for nursing practice and research
The findings of this scoping review offer valuable information for both nursing practitioners and researchers.For practitioners, this study presents a framework for creating new patient navigation programs in maternity care settings.For example, patient navigation programs could be delivered within perinatal or postpartum care settings in collaboration with other clinical (neonatal or mental health care) or social support services (child assistance, transportation, or financial support programs), provide educa-tional or psychosocial support for women and families, or encourage postpartum visits.Additionally, in family planning care settings, patient navigation programs could provide contraceptive care to hard-to-reach mothers by integrating maternal and pediatric care providers.Furthermore, since no patient navigation programs were identified for women with noncancerous gynecologic issues, practitioners might contemplate implementing a patient navigation program for these women.
This scoping review provides information on baseline outcomes for patient navigation studies conducted in the field of maternity care.However, synthesizing the evidence of the effects of patient navigation programs on maternal health through a systematic review may not yield high-quality evidence due to the scarcity of studies employing rigorous study designs.To validate the effects of patient navigation on maternal health, researchers should first conduct primary studies using robust study designs.
This scoping review presents information on the characteristics of patient navigation programs implemented in maternity care.The findings suggest that patient navigation services have not been as widely applied in maternal health as they have in other health care settings.However, the introduction of patient navigation services in maternal health could potentially reduce health disparities among socially disadvantaged women and families and improve the quality of postpartum care.This study, in conjunction with previous research, suggests a potential role for patient navigators in maternity care settings, and the application of patient navigation services could benefit many women by offering care tailored to their specific needs.

Figure 1 .
Figure 1.Flowchart of the study selection process.

Table 1 .
Characteristics of the included studies (N=14) (Continued on the next page)

Table 2 .
Details of the included studies

Table 2 .
Continued(Continued on the next page) https://doi.org/10.4069/whn.2024.03.15 Cont, Control group; Exp, experiment group; GTT, glucose tolerance test; His cont, historical control group; HPV, human papillomavirus; mHealth, mobile health; Post, post-implementation group; RCT, randomized controlled trial; TBA, traditional birth attendant; WIC, the special supplemental nutrition program for women, infants, and children; WHO, World Health Organization.† Primary study.‡ Secondary study of Austad et al. [22].§ Secondary study of Blake-Lamb et al. [24].ǁ Secondary study of an unpublished study.¶ Secondary study of Yee et al. [30].# Demonstrated statistically significant and favorable outcomes compared to the comparison group in a study.