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Postpartum Care Up to One Year After Pregnancy: A Systematic Review and Meta-Analysis

Practice Pointers by Sarah E. Stumbar, MD, MPH,
Suzanne Minor, MD,
Florida International University Herbert Wertheim College of Medicine, Miami, Florida

American Family Physician. 2023;108(5):506-508.

Author disclosure: No relevant financial relationships.

Key Clinical Issue

What are the results of the use of postpartum care and the clinical outcomes of that care up to one year after pregnancy that was affected by alternative strategies for postpartum health care delivery and extension of postpartum health insurance coverage?

Evidence-Based Answer

More comprehensive insurance is probably associated with increased postpartum care–visit attendance. (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented outcomes.) More comprehensive insurance, including during the postpartum period, may be associated with fewer preventable emergency department visits and hospital readmissions. (SOR: B, inconsistent or limited-quality patient-oriented outcomes.) The way that postpartum care is delivered—at home or via telephone—may not affect depression and anxiety symptoms compared with visits in the clinic. (SOR: B, inconsistent or limited-quality patient-oriented outcomes.) Breastfeeding support delivered in the patient's home vs. the pediatrics clinic may not affect depression and anxiety symptoms, hospital readmission rates, and use of unplanned care. (SOR: B, inconsistent or limited-quality patient-oriented outcomes.) Regarding timing of care, earlier vs. later postpartum contraceptive care probably results in similar intrauterine device continuation rates at three and six months and greater implant use at six months. (SOR: B, inconsistent or limited-quality patient-oriented outcomes.) Peer support and lactation consultant care for breastfeeding probably enhance breastfeeding rates in the first six months postpartum, but there was insufficient evidence regarding the impact of who provides care on other clinical outcomes or use of care. (SOR: B, inconsistent or limited-quality patient-oriented outcomes.) Completion reminders probably increase adherence rates to oral glucose tolerance testing.1 (SOR: B, inconsistent or limited-quality patient-oriented outcomes.)

CLINICAL BOTTOM LINE

Summary of the Outcomes of Postpartum Care One Year After Pregnancy
Outcome groupOutcomeIntervention and comparisonNumber of studies (participants)Overall effectStrength of evidence
ClinicalContraceptionEarlier interventions vs. later interventionsEight (829)Comparable intrauterine device continuation rates at three and six months postpartum
Greater implant continuation at six months postpartum		• • ○
• • ○
Adherence to testingReminders vs. no remindersThree (783)Greater adherence to glucose tolerance testing up to one year postpartum but not random glucose or A1C testing• • ○
BreastfeedingLactation consultant vs. no lactation consultantSeven (1,993)Higher rates of breastfeeding at six months but not at one or three months postpartum• • ○
Peer support vs. no peer support for breastfeedingNine (3,162)Higher rates of any breastfeeding at one month and three to six months and exclusive breastfeeding at one month postpartum• • ○
Depression, anxiety, and substance useTelephone and home visits vs. clinic-based careTwo (673)Comparable depression and anxiety symptoms• ○ ○
Breastfeeding care at the pediatric clinic vs. home careFour (3,917)Comparable depression and anxiety symptoms• ○ ○
Integrated care vs. non-integrated careThree (842)Comparable depression and anxiety symptoms and substance use• ○ ○
Use of carePreventable emergency department visits and hospital readmissionsMore comprehensive insuranceOne (1,454,699)Fewer preventable emergency department visits and hospital readmissions• ○ ○
Breastfeeding care at the pediatric clinic vs. homeFour (3,917)Comparable emergency department visits and hospital readmissions• ○ ○
Likelihood of attending postpartum visitsMore comprehensive insurance11 (580,852)Increased likelihood of attending postpartum visits• • ○

Strength of evidence scale

• • • High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

• • ○ Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

• ○ ○ Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

○ ○ ○ Insufficient: Evidence either is unavailable or does not permit a conclusion.

Adapted with permission from Saldanha IJ, Adam GP, Kanaan G, et al. Postpartum care up to 1 year after pregnancy: a systematic review and meta-analysis. Comparative effectiveness review no. 261. AHRQ publication no. 23-EHC010. Agency for Healthcare Research and Quality; 2023. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-261-postpartum-care-executive-summary.pdf, with additional information from https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-261-postpartum-care.pdf.

Address correspondence to Sarah E. Stumbar, MD, MPH, at sstumbar@fiu.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

  1. 1.Saldanha IJ, Adam GP, Kanaan G, et al. Postpartum care up to 1 year after pregnancy: a systematic review and meta-analysis. Comparative effectiveness review no. 261. (Prepared by the Brown Evidence-based Practice Center under contract no. 75Q80120D00001.) AHRQ publication no. 23-EHC010. PCORI publication no. 2023-SR-01. Agency for Healthcare Research and Quality; June 2023. Accessed September 28, 2023. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-261-postpartum-care-executive-summary.pdf
  2. 2.Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 [published correction appears in Lancet. 2014;384(9947):956]. Lancet. 2014;384(9947):980-1004.
  3. 3.American College of Obstetricians and Gynecologists. Committee opinion no. 736: optimizing postpartum care. May 2018. Accessed July 11, 2023. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
  4. 4.Paladine HL, Blenning CE, Strangas Y. Postpartum care: an approach to the fourth trimester. Am Fam Physician. 2019;100(8):485-491.
  5. 5.Kaiser Family Foundation. Medicaid postpartum coverage extension tracker. September 21, 2023. Accessed September 28, 2023. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/
  6. 6.American Academy of Family Physicians. Striving for birth equity: family medicine's role in overcoming disparities in maternal morbidity and mortality. Accessed July 22, 2023. https://www.aafp.org/about/policies/all/birth-equity-pos-paper.html

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ’s summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

This series is coordinated by Joanna Drowos, DO, MPH, MBA, contributing editor. A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

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