Achieving Better Postpartum Care
The year after giving birth is an important one for mothers and their infants. Care delivered during this period is critical to improving mother and infants’ long-term health and reducing future health risks. However, a recent study shows that all too often, this is a missed opportunity to deliver important preventive care to adult women.
In the study published in Medical Care, Emily Gregory, Alexander Fiks, Scott Lorch, and colleagues examined the health care use of nearly 600,000 mother-infant pairs who were eligible for Medicaid for at least 11 of the 12 months following birth in 12 geographically diverse states. They found that 38% of mothers on Medicaid had no adult preventive visits one year postpartum.
All mothers were between the ages of 12-55 and had a live birth between 2007-2011. The authors looked at preventive health care utilization in both adult and pediatric settings, since studies have shown that some mothers receive preventive care during their infants’ well baby visits—such as screening for depression and tobacco use.
In the year after birth, mother-infant pairs had a median of 1 adult preventive visit and 3 pediatric preventive visits. However, nearly 40% of the sample lacked any adult preventive visits and 10% lacked any pediatric preventive visits. Most mother-infant pairs had more visits in pediatric settings than adult settings, suggesting that offering maternal care during the infant’s doctor’s visit may be an effective strategy for increasing postpartum care. Mothers with maternal health risks (i.e., maternal cardiovascular risk and depression) were more likely to report having at least one adult preventive visit than their counterparts without health risks. However, pairs with a preterm or low-birth weight infant had lower odds of receiving an adult preventive visit than pairs with a full-term infant. Race and ethnicity also affected postpartum utilization, as Latinx pairs were 43% less likely to have an adult preventative visit than non-Latinx white pairs.
This study reveals several important action areas for policymakers. Expanding health insurance coverage is an important first step in addressing gaps in postpartum care, but is not the only step. All mother-infant pairs in the study were eligible for continuous health insurance coverage through Medicaid, which is not universally true in the United States. One study found that 47% of pregnant women on any type of insurance from 2005-2013 experienced a period of uninsurance in the six months after delivery. Even after the Affordable Care Act’s Medicaid expansion, women are still not experiencing continuous health coverage after giving birth. This insurance “churn”—or switching between different types of health insurance or no insurance—poses a threat to maternal health, as interrupted health coverage could cause women to skip needed care, encounter barriers to accessing medication, and experience interruptions in seeing their regular health care providers.
In addition to expanding postpartum coverage, payment policies must also support better care integration and alignment of preventive services for mothers and infants. Gregory and colleagues point to colocation of services, care coordination, and previsit planning as strategies to foster alignment between pediatric and adult preventive visits. For instance, states have the option to cover maternal depression screening under Medicaid’s Early and Periodic Screening, Diagnostics, and Treatment (EPSDT) benefit. The authors also suggest that states may benefit by aligning preventive services delivered outside the health care setting, such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and home visiting.
However, the authors acknowledge several issues in integrating maternal care into pediatric services. First, care integration may create trade-offs for pediatric care providers if they lack the time or resources to incorporate both maternal and pediatric preventive care into one visit. Second, incorporating maternal care into a pediatric visit may be duplicative if the mother is already receiving regular maternal care. And lastly, preventive care is particularly important for women who have specific clinical and demographic risk factors. In this study, Latina women and women who experienced a preterm birth were most likely to have no preventive visits, suggesting the need to tailor solutions for certain at-risk groups.