Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Background: Recent paradigm shifts in postpartum care have conceptualized the ''fourth trimester'' as a critical transitional period requiring tailored, ongoing health care. However, this concept presents challenges for providers, especially in low-resource settings. Our objective was to understand providers' perspectives on challenges in postpartum care to highlight strategies for optimizing care. Methods: Focus groups were conducted using a semistructured interview guide to elicit perspectives on barriers and facilitators to postpartum care. Participants included physicians, nurses, and social workers who care for lowincome postpartum individuals. Interviews explored the provider experience of postpartum care, with a focus on barriers experienced by patients and providers, and tools for maintaining engagement. Analysis was performed using the constant comparative method and framed by the Social Ecological Model. Results: Participants (N = 26) all acknowledged the importance of the ''fourth trimester'' but identified multiple barriers to providing optimal postpartum care. Challenges providers perceived for patients and those they perceived for themselves often overlapped, including difficulty with appointment scheduling, insurance limitations, lack of provider continuity, and knowledge gaps. Providers identified ease of referrals to specialists, access to tangible services (e.g., contraception), and enhanced care coordination (e.g., patient navigation) as potential facilitators of improved postpartum care. Conclusions: Obstetric providers recognize the importance of postpartum care yet highlighted significant systems-and patient-based barriers to achieving optimal care. The development and implementation of postpartum care delivery system redesign, such as the use of patient navigators to improve health care utilization and resource attainment, may enhance care during this critical time. Clinical Trial No.: NCT03922334.

Background Patient navigation programs have shown promise for improving health but are not widely used in obstetric care. Our objective was to understand obstetric provider perspectives on how to implement patient navigation to optimize care during the postpartum period for low-income patients. Method Focus groups were conducted with obstetric physicians, nurses, and social workers who care for low-income pregnant and postpartum patients in an academic medical center. Semistructured interview guides were developed to elicit conversations about the potential value of patient navigators, recommendations for navigator training, and how navigators could be most effective in improving postpartum care. Analysis of themes was based on the constant comparative method. Results Twenty-six obstetric providers (six focus groups) discussed elements for a successful obstetric navigation program. Successful implementation themes included selecting navigators with appropriate interpersonal attributes, arranging navigator training, and identifying the most valuable services navigators could render. Desirable navigator attributes included persistence in patient advocacy, consistency, relatability, and a supportive manner. Training recommendations included learning the health care system, identifying where to obtain health system and community resources, and learning how be effective health educators. Suggested services were broad, ranging from traditional care coordination to specific educational and resource-driven tasks. Conclusions Obstetric providers perceive patient navigation to be a potentially beneficial resource to support low-income patients and offered recommendations for navigation implementation. These included suggestions for patient-centered navigators, with specific training and services focused on promoting care continuity and coordination.

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COVID-19 infection increases the risk of maternal and neonatal morbidity in the pregnant population. While data suggest that COVID-19 vaccines are safe and effective during pregnancy, the risk to the fetus is unclear. The aim of this study was to assess the association between COVID-19 vaccination during early pregnancy and the risk of fetal structural anomalies.This was a retrospective cohort study conducted at a single medical center in Chicago. Included were pregnant people with COVID-19 vaccination records, who completed a fetal anatomic survey between March and November 2021. Excluded were pregnancies in which fetal structural anomaly could not be assessed via ultrasound. The teratogenic window was defined as 30 days before conception until 14 weeks of gestation. Pregnant individuals who were vaccinated within this window were compared with those who were unvaccinated or vaccinated outside of the teratogenic window.A total of 3156 individuals met the inclusion criteria, with 1149 vaccinated within the teratogenic window. An anomaly was identified in 5.1% of unvaccinated people versus 4.2% of people who received at least 1 dose of vaccine ( P = 0.35). After controlling for confounders, vaccination within the teratogenic window was not associated with the presence of a fetal structural anomaly identified on ultrasound (adjusted odds ratio, 1.05; 95% confidence interval, 0.72-1.54).These preliminary findings suggest that COVID-19 vaccination was not associated with fetal structural anomalies. These findings may be useful to clinicians who counsel patients considering COVID-19 vaccination during pregnancy. EDITORIAL COMMENT(When I give a lecture on cost-effectiveness analysis, I show the cost-effectiveness quadrants that are positive and negative in costs and positive and negative in outcomes (effectiveness). Although 5 Preconception and Prenatal Care

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