According to a recent study published in JAMA Network Openmore comprehensive health insurance increases the prevalence of postpartum visit attendance.
A significant increase in maternal morbidity and mortality has been observed in the United States. In 2020, the highest maternal mortality rate among industrialized countries was reported, at 23.8 per 100,000 live births.
Over 80% of pregnancy-related deaths have been estimated as preventable, and over 65% in the United States have been reported within 1 year after giving birth. Factors such as racism, lack of coordination among practitioners, ineffective treatment, and poor knowledge about warning signs have been attributed to postpartum death.
Routine postpartum care is given to less than half of US individuals, and those with access may experience barriers from existing payment models. Postpartum care may be improved through global reimbursement models where practitioners with any number of postpartum visits receive bundled payments for postpartum care.
Medicaid only provides coverage for postpartum care up to 60 days, preventing long-term postpartum care from reaching more individuals. The American Rescue Plan Act of 2021 allowed for state-wide extensions for Medicaid up to 1 year.
To determine if extended coverage is associated with improved postpartum care and maternal outcomes, investigators conducted a systematic review using guidelines from the Agency for Healthcare Research and Quality (AHRQ). Diverse groups of clinical and mythological experts were consulted to refine research questions, eligibility criteria, and planned methods.
Databases consulted include Medline, Embase, the Cochrane Central Register of Controlled Trials, and Cumulative Index to the Nursing and Allied Health Literature. Unpublished studies with results reported in ClinicalTrials.gov were also eligible for the review. Searches were current as of November 16, 2022.
Titles and abstracts were screened by 8 independent researchers using Abstrackr, with discrepancies resolved through full-team discussion or consultation with an additional investigator. Studies of postpartum individuals, defined as live birth, still birth, or induced abortion at 20 weeks of gestation or more in the United States were included.
Studies with healthy postpartum individuals and postpartum individuals at risk of complications were reviewed, and the focus of studies could be on general postpartum care or specific aspects of postpartum care. Randomized control trials with at least 10 participants and prospective or retrospective studies with at least 30 participants were eligible for inclusion.
Risk of bias assessment and data extraction was performed by a single investigator, while a second investigator verified extractions. Risk ratios were evaluated for dichotomous outcomes, and net mean differences or mean differences for continuous outcomes. A high risk of bias was found in 9 studies, with 19 rated as moderate risk of bias.
Strength of evidence (SoE) was evaluated based on the AHRQ Methods Guide. SoE was rated either high, moderate, low, or insufficient.
There were 28 studies in the final analysis, all of which were nonrandomized comparative studies published from 2008 to 2022. Of the studies, 15 were focused on general postpartum care and 13 on contraceptive care. There were 3,423,781 postpartum individuals between the studies, with racial diversity observed between participants.
Various comparisons were made between studies. Of studies comparing outcomes with different types of health insurance, 2 compared private insurance with Medicaid, 1 compared continuous Medicaid eligibility with pregnancy-only Medicaid eligibility, and 1 compared an insurance plan providing full antepartum coverage with one including an annual deductible.
Other studies analyzed the impact of policy changes improving insurance coverage. Of these, 9 evaluated Medicaid expansions, 1 evaluated unbundling, 1 evaluated a law requiring long-acting reversible contraception as an option, 1 evaluated the transition from a pilot expansion providing contraceptive care for all, and 1 evaluated the Families First Coronavirus Response Act.
When analyzing the association between health insurance status and postpartum visit attendance, studies found a more comprehensive health insurance was associated with greater attendance. The mean number of postpartum visits by month also increases with more comprehensive health insurance.
Unplanned health care utilization was analyzed by only 1 of the 28 studies. The study found a lower rate of preventable admissions and emergency department visits by one and a half months postpartum associated with Florida’s Mandatory Medicaid Managed Care policy.
Studies displayed inconsistent results on depressive symptoms with some reporting no change in outcomes based on coverage while others reported reduced symptoms in states with improved coverage.
Overall, the evidence on the impact of coverage on other health outcomes was insufficient. Investigators recommended further studies to evaluate the impact of comprehensive health insurance on health outcomes beyond increased postpartum visit attendance.
Saldanha IJ, Adam GP, Kanaan G, et al. Health insurance coverage and postpartum outcomes in the US: A systematic review. JAMA Netw Open. 2023;6(6):e2316536. doi:10.1001/jamanetworkopen.2023.16536