Postpartum Cliffs—Missed Opportunities to Promote Maternal Health in the United States

In April 2021, the Biden-Harris administration signed a proclamation committing to address the maternal health crisis in America, where the maternal mortality rate is far higher than comparable countries and Black and Indigenous people are 2 to 3 times more likely to die of pregnancy-related causes than White people.¹ Tangible improvements in maternal health will require coordinated clinical and policy changes to improve support during the postpartum year, when half of pregnancy-related mortality and a substantial share of maternal morbidity occur.¹

In 2018, the American College of Obstetricians and Gynecologists outlined a renewed model of postpartum care involving earlier and more frequent contacts and aiming to support patients’ longer-term well-being (eg, by managing chronic physical conditions and mental illness); however, many obstacles to achieving this model have been noted.² Soon after delivery, patients face a multidimensional postpartum “cliff,” including insurance interruptions, incomplete handoffs between obstetrician-gynecologists and other physicians, and limited quality monitoring and accountability. Patients navigate this transition largely unsupported, leaving many opportunities for the disparities present during pregnancy to be exacerbated postpartum. This Viewpoint highlights several interdependent postpartum cliffs compromising healthy transitions from pregnancy to parenthood, noting promising approaches to address them (Table).

Pregnant patients are commonly engaged in planning and decision-making regarding aspects of their maternity care such as genetic testing and labor pain management. American College of Obstetricians and Gynecologists guidelines emphasize the importance of anticipatory guidance and creation of a personalized postpartum care plan, including designation of a care team and needed social supports.^2,3 However, this level of planning and shared decision-making is rarely achieved in practice: in a 2013 survey, 1 in 4 postpartum women were unsure whom to call for their own care after birth.³ This cliff in planning and guidance puts the onus on patients to navigate the health and social resources they need, while also facing the challenge of caring for a newborn. In this context, as many as 40% of patients do not attend even the routine postpartum visit.² More evidence is needed on effective approaches to postpartum planning, including shared decision-making tools and longer prenatal care appointments that include robust patient-centered counseling.

Postpartum individuals typically have fragmented, uncoordinated care transitions from obstetric to primary and specialty care.^2,3 For example, many patients with mental illness or chronic conditions detected during pregnancy are simply instructed to follow up with other clinicians without support in scheduling appointments or a formal handoff of relevant clinical information or accountability. Innovative patient-facing programs to improve postpartum care engagement and continuity are being tested, including default appointment scheduling, patient navigators, and home-visiting programs. Scaled-up programs that also include physician-facing mechanisms to facilitate effective handoffs are needed.

Continuous insurance is critical for ensuring timely access to health care in the postpartum year. However, postpartum insurance disruptions occur following nearly 1 in 3 US births, with even higher rates among Medicaid-paid births and racial-ethnic minorities.⁴ Acknowledging that loss of pregnancy-related Medicaid eligibility 60 days after birth is a major driver of postpartum insurance disruption, the American Rescue Plan Act of 2021 included an option for states to extend Medicaid through 1 year postpartum with federal matching funds. Three states (Georgia, Illinois, and Missouri) have federal approval to implement a postpartum extension, and 26 states have pending or enacted legislation to seek approval.⁵ Previous Medicaid expansions have improved health and well-being,⁶ and postpartum Medicaid expansions may do so as well. Policies improving coverage continuity are also needed for those with incomes above Medicaid limits (eg, enhanced Marketplace subsidies, insurance navigators, establishing pregnancy as a qualifying event for special enrollment).

The Affordable Care Act designated routine prenatal and postpartum care visits exempt from cost sharing, but additional postpartum health care interactions may generate more out-of-pocket costs for patients. Many American families face financial strain after birth given the high out-of-pocket cost of maternity care.⁷ Even small out-of-pocket costs may have outsized effects on care seeking, exacerbating the behavioral and logistical barriers to seeking postpartum care. Establishing additional high-value postpartum visits as preventive services exempt from cost sharing could reduce financial barriers to achieving a more comprehensive postpartum care model.

Maternity care is typically reimbursed under a bundled payment covering prenatal care, birth, and the immediate postpartum period. This structure does not support care coordination, a more comprehensive postpartum care model with additional visits and new content, or accountability for longer-term outcomes. Commercial payers and state Medicaid programs are testing innovative value-based payment models that cover the mother-newborn dyad or pay more for high value (eg, long-acting reversible contraception) vs low-value maternity care (eg, early elective inductions and cesarean births).⁸ By connecting payment to outcomes, these alternative models provide incentives for health systems and payers to invest in care coordination and high-value postpartum services.

While well-established public health surveillance efforts exist to monitor pregnancy outcomes (eg, the Pregnancy Risk Assessment Monitoring System and birth certificates), postpartum data collection is extremely limited. Additional data could inform the prioritization, development, and evaluation of postpartum clinical and policy interventions. The few metrics available to monitor postpartum care limit incentives for payers, health systems, and clinical practices to invest in strategies to improve postpartum health or reduce disparities. Healthcare Effectiveness Data and Information Set measures include only the routine postpartum visit and, since 2020, postpartum depression screening and follow-up. Expanding routinely collected and reported metrics to include validated quality measures (eg, for postpartum contraception), as well as the development of new measures (eg, follow-up postpartum care for acute and chronic conditions, mood disorders, and substance use disorder), would be an important step toward increased accountability. Improved postpartum data collection may also facilitate needed research on the value of different postpartum services and delivery approaches, and rigorous evaluation of policies such as postpartum Medicaid extensions.

Achieving tangible improvements in postpartum health will require action and coordination on policies to address the interdependent cliffs that are barriers to change. Postpartum Medicaid expansions will have limited efficacy without effective transitions from obstetrics to primary care. Similarly, improved handoffs and quality measurements are unlikely to be successful without complementary value-based payment models. These approaches should be coupled with interventions to address other social challenges in the postpartum year, such as access to healthy food, adequate paid leave, and affordable, high-quality childcare. As with current efforts toward “right-sized” prenatal care, new postpartum care models should strive toward care individualization, offering flexibility to address patient preferences and need.⁹ By piecing together evidence-based solutions promoting access, engagement, accountability, and measurement, we can begin to follow through on the commitment to stem the rising tide of pregnancy-related morbidity and mortality in the US.

Published: December 17, 2021. doi:10.1001/jamahealthforum.2021.4164

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Cohen JL et al. JAMA Health Forum.

Corresponding Author: Jessica L. Cohen, PhD, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 (cohenj@hsph.harvard.edu).

Conflict of Interest Disclosures: None reported.