Am Fam 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.)
| Outcome group | Outcome | Intervention and comparison | Number of studies (participants) | Overall effect | Strength of evidence |
|---|---|---|---|---|---|
| Clinical | Contraception | Earlier interventions vs. later interventions | Eight (829) | Comparable intrauterine device continuation rates at three and six months postpartum Greater implant continuation at six months postpartum | • • ○ • • ○ |
| Adherence to testing | Reminders vs. no reminders | Three (783) | Greater adherence to glucose tolerance testing up to one year postpartum but not random glucose or A1C testing | • • ○ | |
| Breastfeeding | Lactation consultant vs. no lactation consultant | Seven (1,993) | Higher rates of breastfeeding at six months but not at one or three months postpartum | • • ○ | |
| Peer support vs. no peer support for breastfeeding | Nine (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 use | Telephone and home visits vs. clinic-based care | Two (673) | Comparable depression and anxiety symptoms | • ○ ○ | |
| Breastfeeding care at the pediatric clinic vs. home care | Four (3,917) | Comparable depression and anxiety symptoms | • ○ ○ | ||
| Integrated care vs. non-integrated care | Three (842) | Comparable depression and anxiety symptoms and substance use | • ○ ○ | ||
| Use of care | Preventable emergency department visits and hospital readmissions | More comprehensive insurance | One (1,454,699) | Fewer preventable emergency department visits and hospital readmissions | • ○ ○ |
| Breastfeeding care at the pediatric clinic vs. home | Four (3,917) | Comparable emergency department visits and hospital readmissions | • ○ ○ | ||
| Likelihood of attending postpartum visits | More comprehensive insurance | 11 (580,852) | Increased likelihood of attending postpartum visits | • • ○ |
Practice Pointers
In 2020, the United States had the highest maternal mortality rate of industrialized countries, with disease burden disproportionately affecting non-Hispanic Black women.1 More than one-half of maternal deaths occur after delivery, making postpartum medical care an important intervention toward decreasing maternal mortality.2 Rather than focusing on the traditional recommendation of a six-week postpartum visit, the American College of Obstetricians and Gynecologists (ACOG) recommends that postpartum care should be individualized to each patient's needs. Ideally, this care should include a telehealth or in-person visit within three weeks and then a comprehensive wellness visit within 12 weeks of delivery.3 ACOG also recognizes that social circumstances, chronic medical conditions, and insurance status may affect timing and frequency of post-partum care, as well as the most effective delivery modality. An American Family Physician review of postpartum care made similar recommendations.4 Furthermore, most states have recognized the importance of health care access during this period through their extension to make Medicaid coverage more comprehensive to provide coverage to women up to one year postpartum, a move also endorsed by the American Academy of Family Physicians.5,6
A 2023 Agency for Healthcare Research and Quality (AHRQ) report on postpartum care up to one year after delivery reviewed 92 studies (50 randomized controlled trials and 42 observational studies).1 Conclusions were limited because of the wide range of postpartum care aspects examined, limited availability of patient-reported outcomes, inconsistency of the studied interventions and outcomes, and limited data reporting by population subgroups. Therefore, no data or insufficient data were available to assess many identified outcomes. Additionally, most conclusions were based on studies that enrolled mainly healthy postpartum individuals.
The AHRQ report highlights five findings based on moderate strength of evidence.
Compared with later care, earlier contraception interventions probably lead to comparable continued intrauterine device use at three and six months but higher rates of implant use at six months postpartum (eight studies).
Reminders are probably associated with greater adherence to glucose tolerance testing up to one year postpartum (three studies).
Peer support for breastfeeding is probably associated with higher rates of any breastfeeding at one month and three to six months and exclusive breastfeeding at one month postpartum (nine studies).
Support from a lactation consultant is probably associated with higher rates of any breastfeeding at six months postpartum but not at one month or three months (seven studies).
More comprehensive insurance probably increases the likelihood of attending postpartum medical visits (11 studies).
The AHRQ report also highlights four findings with low strength of evidence.
Telephone or home visits may result in comparable depression or anxiety symptoms compared with clinic-based care (two studies).
Breastfeeding care provided at the pediatric clinic or home may result in similar depression and anxiety symptoms (four studies).
Integrated care, compared with nonintegrated care, may result in comparable depression and anxiety symptoms and substance use (three studies).
More comprehensive insurance resulted in fewer preventable emergency department visits and hospital readmissions (one study).
More research is needed to identify postpartum care delivery models with the most targeted effect on positive health outcomes. This will necessitate studies examining participant subgroups, including those most vulnerable to disparate outcomes such as Black women and those with chronic conditions. Future research must also focus on patient-reported and patient-centered outcomes for all interventions studied.
Editor's Note: American Family Physician SOR ratings are different from the AHRQ Strength-of-Evidence ratings.
