This week, our In Focus section comes from HMA Community Strategies (HMACS) Senior Associate Diana Rodin and HMA Managing Principal Sharon Silow-Carroll who authored a recent article in the Journal of Women’s Health drawing on data from the recently completed five-year evaluation of the Strong Start for Mothers and Newborns II Initiative to identify promising approaches to support women in Medicaid to attend postpartum visits. Nationally, less than 60 percent of women enrolled in Medicaid or the State Children’s Health Insurance Program attend a scheduled postpartum medical visit, and some states have much lower rates.[1],[2]
Growing Attention to Postpartum Care
Postpartum care, the care provided to women in the months immediately after they give birth, is important for promoting maternal and infant health and well-being. A majority of women report at least one health issue within the year after birth,[3] and postpartum care may be particularly essential when complications such as depression, obesity, hypertension, diabetes, and substance use disorders are present during pregnancy.[4],[5],[6],[7] High-quality postpartum care can aid in detection of cardiac or hypertensive complications or suicidal ideation that can lead to maternal mortality, which is particularly high in the United States.[8],[9] Postpartum visits also offer opportunities for treating ongoing or chronic conditions, addressing complications related to pregnancy or birth, facilitating healthy pregnancy spacing,[10] addressing breastfeeding concerns,[11] and answering health and parenting questions. Timely postpartum care can reduce emergency department visits and hospitalizations.[12]
Strong Start Examined Enhanced Models of Prenatal Care and Identified Promising Postpartum Strategies
Strong Start provided enhanced prenatal care with the goals of reducing rates of preterm birth and low birthweight among Medicaid-enrolled women. It tested three different models of care: Group Prenatal Care (GPC: almost always Centering Pregnancy [Centering] or a close variant);[13] Maternity Care Homes (MCH), similar to a medical home; and Birth Centers, following the midwifery model of care[14] supplemented by support from peer counselors. All models typically focused on relationship-based care and psychosocial support along with referrals and health education. Strong Start offered patient services from 2013 to 2017, with 27 federal grant awardees operating more than 200 sites in 32 states, the District of Columbia, and Puerto Rico. Awardees included health systems, national organizations, community clinics, and private medical practices. As of the end of Strong Start in early 2017, 45,599 women had participated in the program.[15]
Findings: Increasing Care Continuity and Tailoring Strategies to Needs Can Increase Postpartum Visits
Recognizing the importance of providing support after birth, Strong Start awardees emphasized making resources and referrals available postpartum, sharing information about the importance of postpartum care, promoting awareness of and screening for common postpartum issues, and continuing contact with participants after birth—which was often a challenge when Medicaid ended for women after 60 days postpartum. Provider sites generally struggled with postpartum attendance prior to Strong Start, and attendance remained a challenge despite some reported improvements. Both awardees and program participants described a variety of barriers to postpartum visit attendance, but also identified aspects of Strong Start enhancements and other strategies that they perceived to increase access to postpartum care. These barriers and strategies are summarized in Table 1 below:
Table 1: Postpartum Visit Barriers and Strategies
| Barriers | Strategies | |
| Care Continuity |
|
|
Postpartum Information and Linkages |
|
|
| Participant-Level/Logistical |
|
|
| Provider, Payer, and Patient Incentives |
|
|
Continuity of care was the most common factor identified as affecting postpartum visit attendance. Having separate clinicians for prenatal, delivery, and postpartum care services, as well as lack of insurance coverage soon after delivery and lack of transportation were barriers to returning for postpartum care. However, Strong Start programs’ increased emphasis on postpartum visits often prodded awardees to examine how they could improve access. Awardees found success with strategies that were tailored to the causes of attrition in the postpartum period, such as prenatal emphasis on the importance of postpartum visits, scheduling the postpartum visit before a woman left her birth facility, conducting home visits, and linking women to ongoing health care programs or services. Awardees also found success when they were able to target their efforts to meet women’s specific needs (e.g., support for postpartum depression, substance use disorder treatment, or access to desired family planning options), and when they were able to provide a visit with a familiar provider, group of peers, or care coordinator. These findings add to other evidence supporting the effectiveness of continuity of care through consistent providers, care coordinators, home visits, group-based prenatal care, and enhanced education and support. The results of Strong Start identify many strategies that appear effective and are immediately replicable.
For more information, please contact Diana Rodin at [email protected] or Sharon Silow-Carroll at [email protected]. This study was supported by a team from the Center for Medicare and Medicaid Innovation at CMS and the Urban Institute.
[1] Measure Applications Partnership. Strengthening the Core Set of Healthcare Quality Measures for Children Enrolled in Medicaid and CHIP. National Quality Forum, 2017.
[2] de Bocanegra HT, Braughton M, Howell M, Logan J, Schwarz EB. Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program. Am J Obstet Gynecol 2017;217(1):47.e1-47.e7.
[3] Haran C, van Driel M, Mitchell BL, Brodribb WE. Clinical guidelines for postpartum women and infants in primary care–a systematic review. BMC Pregnancy and Childbirth 2014;14(1):51.
[4] American College of Obstetricians and Gynecologists. Optimizing postpartum care. Obstet Gynecol 2018;131(5):e140-e150.
[5] Accortt EE, Cheadle AC, Schetter CD. Prenatal depression and adverse birth outcomes: an updated systematic review. Matern Child Health J 2015;19(6):1306.1337.
[6] Yonemoto N, Dowswell T, Nagai S, Mori R. Schedules for home visits in the early postpartum period. Cochrane Database of Systemic Reviews, 2013.
[7] Rosenbloom JI, Blanchard MH. Compliance with Postpartum diabetes screening recommendations for patients with gestational diabetes. J Womens Health 2018;27(4), 498-502.
[8] Bodnar-Deren S, Klipstein K, Fersh M, Shemesh E, Howel EA. Suicidal ideation during the postpartum period. J Womens Health 2016;25(12):1219-1224.
[9] Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. Pregnancy Mortality Surveillance System. Centers for Disease Control and Prevention 2018.
[10] Cross-Barnet C, Courtot B, Hill I, Benatar S, Cheeks M, Markell J. facilitators and barriers to healthy pregnancy spacing among Medicaid beneficiaries: findings from the national Strong Start Initiative. Women’s Health Issues 2018;28(2):152-157.
[11] Wilcox A, Levi EE, Garrett JM. Predictors of non-attendance to the postpartum follow-up visit. Matern Child Health J 2016;20(1):22-27.
[12] Brousseau EC, Danilack V, Cai F, Matteson KA. Emergency department visits for postpartum complications. J Womens Health 2018;27(3):253-257.
[13] Strong Start awardees implementing Group Prenatal Care predominantly used the CenteringPregnancy approach, an evidence-based model of Group Prenatal Care formalized in 1998 through the Centering Healthcare Institute (CHI), a 501(c) 3 nonprofit organization that assists health care providers in making the changes needed to implement Group Prenatal Care. For more information about CHI or CenteringPregnancy, see https://www.centeringhealthcare.org.
[14] The Midwives Model of Care. Midwives Alliance North America, n.d.
[15] Hill I, Benatar S, Courtot B, et al. Strong Start for Mothers and Newborns evaluation: Year 4 annual report, 2 vols. Centers for Medicare & Medicaid Services 2018;1-110.
