Postpartum women with commercial health insurance use substantially more inpatient and outpatient care than nonpostpartum women, particularly in the first 2 months after giving birth, according to a retrospective cohort study published in the May 2021 issue of Obstetrics & Gynecology.
“These findings are consistent with previous studies that have documented elevated postpartum ED and hospitalization rates, and we contribute new evidence that indicates postpartum healthcare utilization rates are significantly higher than rates of healthcare utilization in the general population of reproductive aged women when they are not pregnant or postpartum,” Maria W. Steenland, ScD, of Brown University, Providence, Rhode Island, and colleagues wrote. “Most notably, postpartum women were more than three times more likely to have an ED visit and eight times more likely to be hospitalized than nonpostpartum women in the early postpartum period.”
Approximately one third of maternal deaths occur between 1 week and 1 year postpartum, the authors noted in their background information. The overall US maternal mortality rate was 17.4 per 100,000 live births in 2018, according to the Centers for Disease Control and Prevention.
“This study underscores the importance of access to healthcare for women, in particular in the postpartum period,” Iris Krishna, MD, MPH, an assistant professor of maternal-fetal medicine at Emory University, Atlanta, said in an interview. “Maternal mortality is a public health crisis. The majority of maternal deaths are preventable and occur up to 1 year postpartum. Studies such as these are needed as the postpartum period is a critical time in the care of reproductive age women that is often overlooked.”
Using data from a large national commercial claims database, the researchers analyzed data from 149,563 women aged 18-44 years who gave birth in 2016 and from 2,048,831 women who were neither pregnant nor postpartum during the same study period. In postpartum women, the researchers specifically looked at hospitalization, preventive visits, problem visits, and ED visits during three periods for postpartum women: early postpartum, defined as within 21 days of giving birth; postpartum, defined as 21-60 days after birth; and extended postpartum, defined as 61 days to 1 year after birth. These data were then compared with equivalent periods in nonpostpartum women.
“For the comparison group, we created a random start date of follow-up by generating a random variable between 0 and 365 and adding this integer to Jan. 1, 2016,” the authors explained. “These start dates correspond to the range of possible follow-up start dates among postpartum women who gave birth in 2016.”
The groups differed in age composition: 62% of the postpartum women were between 25 and 34 years old while the nonpostpartum women were more evenly distributed across the age range. A higher proportion of nonpostpartum women had a chronic disease, but median income and geographic region were similar between the groups. Just over a third of the postpartum women (36%) had a cesarean delivery, higher than the 2016 national average of 32%.
Nearly a quarter (23.7%) of postpartum women had a problem visit in the early postpartum period, compared with one in five (19.7%) nonpostpartum women in the equivalent period. This 4-point difference increased to a 4.8-point difference after adjustment for age group, chronic disease, geographic region, income, and month when follow-up began.
Postpartum women were also three times more likely to have an ED visit (3.2%) in the early postpartum period than nonpostpartum women (1%). Postpartum women’s problem visits and ED visits were most prevalent in the first 2 weeks after childbirth: 12.4% in the first week and 10.4% in the second. Complaints for these visits primarily included urinary tract infections and other genitourinary issues, hypertension, breast or breastfeeding issues, and respiratory issues, such as shortness of breath or chest pain. Hospitalization rates were also higher in the early postpartum period for postpartum women (0.8%) than nonpostpartum women (0.1%).
Problem visits showed a similar pattern during the postpartum period from 21 to 60 days after birth: 39.4% of postpartum women, compared with 30.2% of nonpostpartum women. Rate differences were narrower for ED visits (2% postpartum vs 1.9% nonpostpartum) and hospitalization (0.3% postpartum vs 0.2% nonpostpartum), but the differences remained significant, and ED visits were still 0.3 points higher after adjustment.
The biggest differences between the groups in the first 2 months occurred with preventive care. In the early postpartum period, 15% of postpartum women had a preventive visit, compared with 3.3% of nonpostpartum women. Similarly, the rates were 28.2% in postpartum women and 6.5% in nonpostpartum women in the postpartum period.
Differences between the groups evened out in the extended postpartum period, when postpartum women had slightly fewer preventive visits (42.5%) than nonpostpartum women (42.7%). ED rates (11.2% postpartum vs 11.1%) and hospitalization rates (1.4% postpartum vs 1.6%) were similar, but postpartum women were significantly more likely to have problem visits (79.2%) in the year after childbirth than nonpostpartum women (72.8%).
“Compared with postpartum women overall, postpartum women with chronic disease, pregnancy complications, and cesarean births were more likely to receive healthcare of all types in the early postpartum period,” the researchers reported. “Of the three subgroups, healthcare use was highest among postpartum women with chronic disease, among whom 35% had at least one outpatient problem visit, 5% had an ED visit, and 1.3% were hospitalized within the first 20 days of childbirth.”
These findings as a whole point to an increased need for healthcare not only in the first 3 weeks after women give birth but “beyond the traditional 6-week postpartum period, which adds to the argument that the way we care for women in the postpartum period should be revised,” Krishna said.
The American College of Obstetricians and Gynecologists updated their postpartum recommendations in 2018 to advise that all postpartum women have a follow-up visit in the first 3 weeks after birth.
Krishna reiterated that postpartum patients should ideally have an initial follow-up within 3 weeks of giving birth, which the rapid expansion of telehealth has made more viable for both clinicians and mothers.
The authors similarly noted that telehealth and home visits “are promising options to promote early and consistent healthcare contact and reduce known barriers to postpartum care seeking such as fatigue, lack of transportation, and child care.” Predischarge guidance may also help meet postpartum patients’ healthcare needs.
“Healthcare professionals also may be able to reduce the escalation of common early postpartum problems identified in this study (eg, respiratory problems, pain, urinary tract infections) with anticipatory postpartum counseling and care before hospital discharge such as ensuring that women have inhalers at home, developing a pain management plan, and screening for signs of urinary tract infection,” the authors wrote.
Krishna also pointed out the need to address racial inequalities in healthcare and material mortality.
“Black women have a maternal mortality rate two times the rate of non-Hispanic white women,” Krishna said. “One way to address health disparities between commercially insured and uninsured women is improving access to healthcare through Medicaid expansion for at least 1 year postpartum. States that participated in the Affordable Care Act’s Medicaid expansion have noted improvement in maternal mortality and a decrease in racial/ethnic inequities.”
The research was funded by the Robert Wood Johnson Foundation and the National Institutes of Health. Data was provided by Aetna, Humana, Kaiser Permanente and UnitedHealthcare. The authors and Krishna reported no disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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