Health Insurance Coverage and Postpartum Health | Photo credits: © Grooveriderz – © Grooveriderz – stock.adobe.com.
According to a recent study published in the JAMA Network Open, having more comprehensive health insurance increases the frequency of attending postpartum visits.
A significant increase in maternal morbidity and mortality has been observed in the United States. In 2020, it reported the highest maternal mortality rate among developed countries, at 23.8 per 100,000 live births.
It is estimated that over 80% of pregnancy-related deaths are preventable, and in the United States over 65% have been reported within a year of delivery. Factors such as racism, lack of coordination between doctors, ineffective treatment and a lack of knowledge of the warning signs have been attributed to death after birth.
Less than half of all Americans receive routine postpartum care, and those who have access may face obstacles due to existing payment models. Post-natal care can be enhanced through global reimbursement models where physicians receive pooled post-natal care payments with any number of post-natal visits.
Medicaid only covers postpartum care for up to 60 days, preventing long-term postpartum care from reaching more people. The American Rescue Plan Act of 2021 allowed up to one year of statewide extensions for Medicaid.
To determine if expanded coverage is associated with improved postpartum care and maternal outcomes, researchers conducted a systematic review using Agency for Healthcare Research and Quality (AHRQ) guidelines. Various groups of clinical and mythological experts were consulted to refine research questions, selection criteria, and planned methods.
Databases consulted include Medline, Embase, the Cochrane Central Register of Controlled Trials and the Cumulative Index to the Nursing and Allied Health Literature. Unpublished studies with results reported on ClinicalTrials.gov were also eligible for review. The searches were as of November 16, 2022.
Titles and abstracts were reviewed by 8 independent researchers using Abstrackr, with discrepancies resolved through team-wide discussion or consultation with an additional researcher. Studies of postpartum subjects defined as live birth, stillbirth, or induced abortion at 20 weeks gestation or more in the United States were included.
Studies in healthy postpartum subjects and postpartum subjects at risk for complications were reviewed, and the studies could focus on general postpartum care or specific aspects of postpartum care. Randomized control studies with at least 10 participants as well as prospective or retrospective studies with at least 30 participants could be included.
The risk of bias assessment and data extraction were performed by a single researcher, while a second researcher verified the extractions. Risk rations were assessed for dichotomous outcomes and net mean differences or mean differences for continuous outcomes. A high risk of bias was identified in 9 studies, with 19 rated as having a moderate risk of bias.
The level of evidence (SoE) was assessed based on the AHRQ Methods Guide. SoE was rated as either high, medium, low, or insufficient.
There were 28 studies in total, all of which were non-randomized comparative studies, published from 2008 to 2022. Of the studies, 15 focused on general follow-up and 13 on contraceptive care. Between studies, there were 3,423,781 postpartum subjects, with racial diversity observed between participants.
Various comparisons between the studies were carried out. Of the studies that compared the outcomes of different types of health insurance, two compared private insurance to Medicaid, one compared continuous Medicaid eligibility to Medicaid eligibility only during pregnancy, and one compared an insurance plan with full prenatal coverage to an insurance plan with an annual deductible.
Other studies analyzed the impact of policy changes on improving insurance coverage. Of these, 9 assessed Medicaid expansion, 1 unbundling, 1 an act mandating reversible long-term contraception as an option, 1 moving from a pilot expansion to contraceptive coverage for all, and 1 the Families First Coronavirus Response Act.
When analyzing the association between health insurance status and attendance at postpartum visits, studies found that more extensive health coverage was associated with higher attendance. The average number of postpartum visits per month also increased with more comprehensive health insurance.
Unplanned use of health services was only analyzed in one of the 28 studies. The study found that a month and a half after birth, there was a lower rate of avoidable admissions and emergency room visits related to Florida’s mandatory Medicaid managed care policy.
Studies have shown inconsistent results on depressive symptoms. Some reported no change in outcomes based on coverage, while others reported a reduction in symptoms in states with improved coverage.
Overall, the evidence on the impact of coverage on other health outcomes was insufficient. The researchers recommended further studies to assess the impact of comprehensive health insurance on health outcomes beyond increased attendance at postpartum visits.
Saldanha IJ, Adam GP, Kanaan G, et al. Health Insurance Coverage and Postpartum Outcomes in the United States: A Systematic Review. JAMA Netw Open. 2023;6(6):e2316536. doi:10.1001/jamanetworkopen.2023.16536