Racial and Ethnic Disparities in Postpartum Care in the Greater Boston Area During the COVID-19 Pandemic

Key Points Question How did postpartum care access change during the COVID-19 pandemic, and were these changes different by maternal race and ethnicity? Findings In this cohort study of 45 588 women, the overall postpartum care attendance rate decreased from 75.2% in January to December 2019 (prepandemic) to 41.7% in January to March 2020 (early pandemic) and subsequently rebounded to 60.9% in April 2020 to November 2021 (late pandemic). Black and Hispanic women showed slower reductions in nonscheduling rates during April 2020 to November 2021 compared with their White counterparts. Meaning The study highlights racial and ethnic disparities in postpartum care access both before and after the onset of the pandemic, raising concerns about disparities in postpartum care–associated maternal and infant outcomes.


Introduction
The postpartum period is a critical time for women to recover from childbirth and adapt to multiple biological, psychological, and social transitions. 1This "fourth trimester" is critical for their long-term well-being. 1 Most importantly, high-quality postpartum care can enhance maternal and infant health 2 through prevention, early detection, and treatment of physical and mental complications that lead to maternal morbidity and mortality. 3,4The American College of Obstetricians and Gynecologists (ACOG) has recommended that women should seek comprehensive postpartum care no later than 90 days after delivery. 5However, postpartum care visits may have been interrupted during the COVID-19 pandemic with large-scale social distancing measures. 6,7Compared with women who delivered before the pandemic, women who delivered in the early pandemic (April 2020) were 7.8% less likely to attend postpartum care. 8Postpartum care interruption might put new mothers at risk of life-threatening health complications, as approximately 61% of maternal deaths occur in the postpartum period. 9Women who delay or skip postpartum care miss valuable opportunities to address challenging health concerns, 10 resulting in frequent emergency department visits, disproportionate hospitalizations, 11 and undiagnosed postpartum depression. 12The COVID-19 pandemic has been evolving and changing dramatically, which can deteriorate pregnancy outcomes post partum.
Prior to the COVID-19 pandemic, racial disparities in postpartum care and maternal health outcomes persisted. 13Black mothers had the highest risks and the fastest increasing rate in pregnancy-related mortality and morbidity across all race and ethnicity groups. 14,15Compared with White individuals, Black individuals were 3 to 4 times more likely to die from pregnancy-related complications, 16 had 3-fold higher severe maternal morbidity rates, 17 and were more than 2 times as likely to be diagnosed with postpartum depression, [18][19][20] the long-term effects of which would impact their offspring. 21,22Lack of adequate postpartum care access likely contributed to these maternal health disparities facing Black patients, 23 who were 3.5% less likely than White patients to attend postpartum visits. 24Nearly half of racial and ethnic minority individuals, compared with only 9% of White individuals, reported unmet postpartum care needs. 25ring the COVID-19 pandemic, Black and Hispanic pregnant people have been more than twice as likely as non-Hispanic White pregnant people to be infected and/or die from COVID-19, 26 putting these racial and ethnic minority women at increased risk of adverse postpartum behaviors and outcomes.As stated in the United Nations Secretary-General's policy, the COVID-19 pandemic has exposed vulnerabilities in social, political, and economic systems, widening preexisting inequalities. 27e impacts of the pandemic were amplified among populations that earn less, save less, hold less secure jobs, and have less access to social protection. 27The fear of infection risk, 28 the stress of constrained health care supply, 29 the limited access to transportation, 7 and the reduced outside support due to social isolation, 30 -all of which disproportionately affected Black pregnant individuals 31,32 -have complicated postpartum care during the pandemic.
Postpartum care access and its racial disparities during the COVID-19 pandemic have not been well explored, 33 making it difficult to remedy the disparities in postpartum care access and its associated maternal health burden.Using electronic health records (EHR) data from a large health system, this study aimed to examine the changes in postpartum care access before and during the COVID-19 pandemic, overall and by maternal race.

Data Sources and Study Participants
This study analyzed EHR data of women visiting and giving birth in 8 hospitals with obstetric units in the Mass General Brigham (MGB) system (previously named Partners Health System) in Massachusetts.The EHR provided information on women's delivery year and month, demographic

Measures Postpartum Care Access
Postpartum care access was identified by the record of postpartum encounter status at 90 days post partum.Encounters were categorized into 3 groups: (1) attended, (2) scheduled but canceled, and (3) never scheduled.

Maternal Race and Ethnicity
Race and ethnicity information was recorded in the EHR data.It was categorized into Asian (n = 4735), Hispanic (n = 6950), non-Hispanic Black (hereafter, Black; n = 3399), non-Hispanic White (hereafter, White; n = 28 526), and other races, including American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races (n = 1269).

Delivery Month
To assess racial and ethnic differences of postpartum care access from January 2019 to November 2021, delivery month was considered continuous with 2 cutoffs: January 2020, when the first US reproductive-age woman was confirmed with COVID-19 26 and when COVID-19 was declared a public health emergency globally by the World Health Organization (WHO), 36 and April 2020, when MGB launched units for COVID-19 tests and treatments for patients. 37Delivery month was therefore categorized into 3 periods: prepandemic (January to December 2019), early pandemic (January to March 2020), and late pandemic (April 2020 to November 2021).

Covariates
Covariates were selected based on Andersen behavioral model of health services use. 38mographic information included age (<18, 18-24, 25-

Results
The White, and 1269 [2.8%] other races).Overall, women were predominantly aged 25 to 34 years and married and had full-term pregnancies, vaginal deliveries, and no clinical conditions, while the distributions varied across racial and ethnic groups (Table 1).As shown in Figure 1, 41 the proportion of women attending, canceling, and not scheduling postpartum care within each race and ethnicity group was relatively stable during prepandemic period, from January to December 2019.In the early pandemic (January to March 2020), among all race and ethnicity groups, the attending rate rapidly dropped (from 75.2% to 41.7%), while the canceling and nonscheduling rates correspondingly increased.In the late pandemic (April 2020 to November 2021), the crude attending rate rebounded gradually (to 60.9%), and the crude canceling and nonscheduling rates started to diminish.However, as of November 2021, the crude attending rates were still lower than prepandemic rate within each racial group.Crude cancelation rates as of November 2021 were still higher than those in November 2019.

Associations Between Maternal Characteristics and Postpartum Care Access Over Time
Black and Hispanic women consistently had lower attending rates over the 3 time periods compared with their White counterparts.From prepandemic to early pandemic periods, the canceling rate among Black and Hispanic women increased from 9.1% to 21.5% and from 7.4% to 19.5%, respectively, while that among White women increased from 3.2% to 16.6%.Yet, from the early pandemic to late pandemic periods, White women had stronger improvements in postpartum care access, with a relatively larger drop in canceling rates (from 16.6% to 3.7%), than Black women (from 21.5% to 10.0%) and Hispanic women (from 19.5% to 7.6%).Most maternal demographic characteristics and clinical conditions were associated with postpartum care access regardless of time periods.For example, women who were married or had a life partner had a higher rate of attending postpartum care than single women.A few maternal characteristics showed varied associations with postpartum care access across time.For example, women who had severe maternal morbidity were significantly less likely to not schedule postpartum care compared with women who had no severe maternal morbidity (28.7% vs 34.5%; P < .001)during the late pandemic period, but not during the prepandemic or early pandemic periods (Table 2).percentage points (95% CI, −4.1 to −0.9 percentage points; P = .002)among women of other racial groups.Overall, during the late pandemic period, the probability of not scheduling postpartum care among Black women and Hispanic women increased more than among their White counterparts (Black women: AME, 1.1; 95% CI, 0.6-1.6;Hispanic women: AME, 1.3; 95% CI, 0.9-1.6).

Racial and Ethnic Disparity in Monthly Trends of Postpartum Care Access
During the prepandemic period (January to December 2019), White women experienced a slightly increasing trend in not scheduling postpartum care; with every 1 month, the probability of not scheduling postpartum care among White women increased by 0.7 percentage points (95% CI, 0.5-0.8percentage points; P < .001)(Figure 2).No differential trend of postpartum care access during the prepandemic and early pandemic periods was found across racial and ethnic groups.During the late pandemic period, compared with the monthly trends for White women, rates of not scheduling postpartum care among Black women increased more rapidly, with 1.1 percentage (95% CI, 0.6-1.6;P < .001)per month.Among Hispanic women, the rate increased 1.3 percentage more rapidly (95% CI, 0.9-1.6;P < .001)than White women.

Discussion
This exploratory study quantified the change in postpartum care access during 3 phases of the COVID-19 pandemic.In the prepandemic period (January to December 2019), the overall postpartum care attendance rate was 75.2%, while it dropped to 41.7% during the early pandemic period (January to March 2020) and rebounded back to 60.9% in the late pandemic period (April 2020 to

Figure 1 .
Figure 1.Trends in Postpartum Care Attendance, Cancellation, and Nonscheduling by Delivery Month Between January 2019 and November 2021 Attendance A

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34d Ethnic Disparities in Postpartum Care During the COVID-19 Pandemic to 2017-2019 American Community Surveys34for county-level social vulnerability index.35Toobtain access to the data set and ensure confidentiality of patient information, researchers at MGB deidentified patient information and provisionally approved data access by the team at the University of South Carolina (UofSC).The research protocol has been exempted by the institutional review board of both UofSC and MGB.This study followed Strengthening the Reporting of characteristics, pregnancy-related characteristics, clinical conditions, and maternal residential JAMA Network Open.2022;5(6):e2216355.doi:10.1001/jamanetworkopen.2022.16355(Reprinted) June 23, 2022 2/16 Downloaded From: https://jamanetwork.com/ by a University of Massachusetts User on 10/20/2022 county, linking

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between maternal characteristics and postpartum care access in different time periods were conducted using χ 2 tests.Multinomial logistic regression in an interrupted time series approach was used to assess monthly changes in postpartum care access across racial groups, controlling for the aforementioned covariates.To compare monthly trends between race and ethnicity subgroups in each of the periods, contrast statements were used for each interaction of race and ethnicity and delivery month.

Table 1 .
Maternal Characteristics by Race and Ethnicity Among 45 588 Women Who Delivered Between January 2019 and November 2021 in the Mass General Brigham System (continued) a Other racial groups include American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races.b Differences in maternal characteristics across race groups were calculated with χ 2 tests, with non-Hispanic White as the reference group.c Severe maternal morbidity was identified with the US Centers for Disease Control and Prevention list of 21 indicators, including acute myocardial infarction, aneurysm, acute d Social vulnerability was indicated by the social vulnerability index and was categorized into quartiles.Higher quartile indicates greater vulnerability.

Table 2 .
Bivariate Associations Between Maternal Characteristics and Postpartum Care Access Among 45 588 Women Who Delivered Between January 2019 and November 2021 in the Mass General

com/ by a University of Massachusetts User on 10/20/2022Table 2 .
Racial and Ethnic Disparities in Postpartum Care During the COVID-19 Pandemic Bivariate Associations Between Maternal Characteristics and Postpartum Care Access Among 45 588 Women Who Delivered Between January 2019 and November 2021 in the Mass General include American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races.

Table 3 .
Average Marginal Effects of Cancelling or Nonscheduling Relative to Attending Postpartum Care Visits in Multinomial Logistic Regression a