This project is ongoing and does not have results.
The Patient-Centered Outcomes Research Institute (PCORI) is partnering with the Agency for Healthcare Research and Quality (AHRQ) to develop a systematic evidence review on postpartum care for women up to one year after birth. The American College of Obstetrics and Gynecology (ACOG) plans to use this systematic evidence review to develop related clinical guidelines.
Over the past few decades, maternal mortality and morbidity has increased steadily in the United States, with large, persistent disparities by race and ethnicity, particularly among Black and American Indian/Alaska Native women. Half of the more than 700 annual deaths related to pregnancy or pregnancy complications are considered preventable. In addition, as many as 60,000-70,000 US women experience some type of severe maternal morbidity annually; furthermore, it has been estimated that these women have a twofold increase in mortality in the postpartum period and beyond compared to women who experience no complications. The Centers for Disease Control and Prevention and Maternal Mortality Review Committees estimate that over half of maternal deaths occur postpartum: 1-6 days postpartum (19 percent), 7-42 days postpartum (21 percent), and 43-365 days postpartum (12 percent). Despite the increased risk of postpartum mortality and morbidity, a surprisingly large number of women (40 percent to 50 percent), regardless of whether they experienced complications of pregnancy or not, do not receive routine care after birth from a medical provider.
Postpartum care encompasses a range of important maternal health needs, including recovery from childbirth, health maintenance, follow-up on pregnancy complications, management of chronic health conditions, counselling for healthy birth spacing, access to contraception, and addressing mental health conditions. The extent of postpartum care may vary significantly, depending on where a woman receives it (e.g., access to high quality care, social and political policies, healthcare institutions, and birth setting), who provides it (e.g., education, training, practice, implicit bias, and communication), or her level of healthcare coverage (e.g., Medicaid, private, uninsured). Although postpartum care has traditionally centered around one clinical visit six to eight weeks after delivery, the paradigm has recently shifted to acknowledge that postpartum care is ongoing rather than a one-time event and best when tailored to each woman’s needs. Current recommendations from ACOG suggest an interaction with the obstetrician/gynecologist or other obstetric care provider within the first three weeks postpartum, followed up with ongoing care as needed, and concluding with a comprehensive postpartum visit no later than 12 weeks after birth. Furthermore, ACOG recommends that women with chronic medical conditions (e.g., hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders) be counseled regarding the importance of timely follow-up with their obstetrician/gynecologists or primary care providers for ongoing coordination of care. These recommendations have been endorsed by several other professional colleges and societies including the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Academy of Breastfeeding Medicine.
To date, no systematic review has comprehensively assessed whether strategies around postpartum healthcare delivery increase appropriate postpartum healthcare utilization and maternal well-being. A handful of reviews has focused on specific aspects of postpartum healthcare delivery, including predictors of postpartum healthcare utilization among minority populations; face-to-face interactions between healthcare providers and postpartum women with low-risk pregnancies; schedules for home visits in the early postpartum period among women with low-risk pregnancies; and the impact of collaborative care models on women with depression, including pregnant and postpartum women. None of these reviews, however, has sought to synthesize the totality of the evidence on this topic. The goal of this review is to identify and describe studies and strategies which seek to improve utilization of postpartum care and maternal health outcomes in the United States.
Draft Key Questions
1. What strategies for healthcare delivery increase appropriate postpartum healthcare utilization within one year of birth?
- What is the optimal timing for the postpartum visit for improving attendance?
- Which strategies increase appropriate healthcare utilization within 60 days of birth? Does this relationship differ by timing of death in relation to pregnancy, specifically 1-6 days postpartum, 7-42 days postpartum, or 43-60 days postpartum?
- Which strategies increase appropriate healthcare utilization between 60 days and 1 year postpartum?
2. What strategies for healthcare delivery improve maternal (and infant) health outcomes within one year of birth?
- What is the optimal timing for the postpartum visit for reducing adverse maternal (and infant) health outcomes?
- Do these strategies reduce adverse maternal health outcomes within 60 days of birth? Does this relationship differ by timing of death in relation to pregnancy, specifically for 1-6 days postpartum, 7-42 days postpartum and 43-60 days postpartum?
- Do these strategies reduce adverse maternal health outcomes between 60 days and 1 year postpartum?
3. Does expansion of health care or better healthcare coverage result in increased healthcare utilization or better maternal health outcomes?
For all key questions, how do the findings vary by women with high and low risk of postpartum complications, by specific complications or disorders of pregnancy (such as hypertensive and cardiovascular disorders of pregnancy, gestational diabetes, etc.) and subgroups defined by patient and hospital characteristics (i.e., by race, socioeconomic status, type of coverage, hospital patient population and volume, and in rural areas, etc.).
Contextual Question: What additional evidence is needed (e.g., research gaps) to assess the value of extending postpartum care to one year after pregnancy?
Draft Key Questions
Posted for public comment (on the AHRQ Effective Healthcare website)