Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review

Key Points

Question  Are health insurance coverage extension or improvements in access to health care associated with postpartum health care utilization and maternal outcomes within 1 year post partum?

Findings  This systematic review included 28 mostly moderate-risk-of-bias nonrandomized studies. An association between more comprehensive insurance and greater attendance at postpartum visits was observed in some studies based on a moderate strength of evidence; for other types of postpartum health care outcomes, the strength of evidence for association with insurance coverage improvement was low.

Meaning  These findings suggest that evidence identified is, at best, of moderate strength; future research should evaluate the impact of more comprehensive or extended health insurance on health outcomes in the postpartum period and beyond.

Importance  Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care.

Objective  To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum.

Evidence Review  Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide.

Findings  A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits.

Conclusions and Relevance  The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

Maternal morbidity and mortality have increased considerably in the US.¹ In 2020, the maternal mortality ratio was 23.8 per 100 000 live births (highest among industrialized countries), with wide racial and ethnic gaps (eg, non-Hispanic Black: 55.3 deaths per 100 000 live births, non-Hispanic White: 19.1, and Hispanic: 18.2).² More than 80% of pregnancy-related deaths are preventable,^3,4 with various related contributors, such as racism,⁵ system factors (eg, lack of coordination among practitioners), practitioner factors (eg, ineffective treatment), and patient/family factors (eg, poor knowledge about warning signs).

According to recent estimates, approximately 65% of pregnancy-related deaths in the US occur in the first year after giving birth.⁴ Among these, 12% occur within 6 days after delivery, 23% occur 7 to 42 days, and 30% occur 43 days to 1 year.⁴ The previously mentioned factors, including system-level factors, are associated with postpartum deaths. About half of postpartum individuals in the US do not receive routine postpartum health care.^6-9 Even for those with access, care may be limited by existing payment models that afford variable coverage for key services. The increasingly common global reimbursement models, in which practitioners receive bundled payments for postpartum care regardless of the number of postpartum visits,¹⁰ may also disincentivize adequate postpartum care.^11,12

Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs,¹³ which limits longer-term postpartum care. The American Rescue Plan Act of 2021 allowed states to request a waiver to extend postpartum Medicaid coverage up to 1 year after delivery.¹⁴ As of February 23, 2023, 28 states and the District of Columbia have implemented the approved extensions, 7 states are planning extensions, 3 states are seeking federal approvals through waivers, and 2 states have proposed limited coverage extensions.¹⁵ Extended coverage for approved states began on April 1, 2022, and is intended to run for 5 years.¹⁴

We conducted a systematic review for the Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute to support the American College of Obstetricians and Gynecologists (ACOG) in the development of new guidance on postpartum care of individuals within 1 year after giving birth. The full report addressed questions pertaining to alternative strategies for postpartum health care delivery and extension of postpartum health insurance coverage. Here, we address the second question: are extension of health insurance coverage or improvements in access to health care associated with postpartum health care utilization and maternal outcomes within 1 year post partum? Our outcomes of interest included health care utilization outcomes (eg, attendance at postpartum visits), clinical outcomes (eg, maternal mortality), and harms (eg, worsening health inequities) (Box). We evaluated whether outcomes vary by several patient-level factors (eg, age, race and ethnicity, socioeconomic status) and setting factors (eg, geographic location, different levels of neighborhood vulnerability).

Box Section Ref ID

We used standard systematic review methodology as outlined in AHRQ’s Methods Guide.¹⁶ We refined the research questions, eligibility criteria (including outcomes of interest), and planned methods after discussions with diverse groups of clinical and methodological experts and patient representatives. We prospectively registered the systematic review protocol through PROSPERO. This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline 2020 statement. Institutional review board and informed consent were not relevant for this systematic review because it relied on published information.

We searched for published studies in Medline (via PubMed), Embase, the Cochrane Central Register of Controlled Trials, and Cumulative Index to the Nursing and Allied Health Literature, and for unpublished studies with reported results in ClinicalTrials.gov. The searches included terms related to post partum, insurance coverage, and health care strategies (to address both research questions in the report) (eAppendix 1 in Supplement 1). All searches are current as of November 16, 2022. We also scanned the reference lists of relevant systematic reviews for potentially eligible studies.

Eight investigators (I.J.S., G.P.A., G.K., M.L.Z., D.W.S., A.F.P., V.A.D.-F., and E.M.B.) independently screened each title and abstract using Abstrackr.¹⁷ We rescreened (in duplicate) all accepted citations in full text. At both stages, we resolved discrepancies through full-team discussion or consultation with a third investigator (from among I.J.S., G.P.A., G.K., M.L.Z., D.W.S., A.F.P., V.A.D.-F., and E.M.B.).

We included studies of individuals (of any age) in the postpartum period (within 1 year after giving birth, which we defined as a live birth, intrauterine fetal death/stillbirth, or induced abortion that occurred at 20 or more weeks of gestation) in the US. Postpartum individuals could be healthy (general population) or at increased risk of postpartum complications due to preexisting conditions, pregnancy-related conditions, or newly diagnosed conditions post partum. Studies could address general postpartum care or specific aspects of postpartum care, such as breastfeeding. Herein, we focus on outcomes prioritized by stakeholder panels (Box). Additional (nonprioritized) outcomes (eg, breastfeeding, contraception) are reported in the full report. We considered as eligible randomized controlled trials with at least 10 participants per group and prospective or retrospective nonrandomized comparative studies with adequate statistical adjustment analyses and at least 30 participants per group.

One investigator (from among I.J.S., G.K., and M.L.Z.) assessed risk of bias and extracted data for each study into the Systematic Review Data Repository Plus.¹⁸ A second investigator (from among I.J.S., G.K., and M.L.Z.) verified all extractions. We used questions from the Cochrane Risk of Bias tool¹⁹ and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool.²⁰

For dichotomous outcomes, we preferentially evaluated risk ratios (RRs). For continuous outcomes, we evaluated net mean differences (NMDs) (ie, difference-in-differences) for outcomes measured at both baseline and postintervention, or mean differences (MDs) for outcomes measured only postintervention. For nonrandomized studies, we considered only reported adjusted analyses (aRR, aNMD, or aMD). We planned random-effects model meta-analyses where there were at least 3 studies reporting results from similar analyses, but the evidence did not allow for this.

We assessed strength of evidence (SoE) as per the AHRQ Methods Guide, considering risk of bias, consistency, precision, directness, and sparsity of the evidence.²¹ For each prioritized outcome, we assigned an SoE rating of high, moderate, low, or insufficient. High, moderate, and low grades indicate the degree of confidence we have that the estimate lies close to the true effect; an insufficient rating indicates the strength of the evidence does not warrant an estimation of the true effect.²¹ In accordance with AHRQ guidance,^22,23 we use qualifying language regarding SoE when communicating conclusions: “probably” for moderate SoE and “may” for low SoE.

For the full report, our electronic searches yielded 25 973 citations (Figure). We screened 589 full-text articles, of which 28 studies, reported in 29 articles,^24-52 were eligible for the current systematic review.

All 28 included studies were nonrandomized comparative studies (published between 2008 and 2022) with adequate statistical adjustment analyses, comprising a total of 3 423 781 postpartum individuals (range 1184 to 1 454 699) (eAppendix 2 in Supplement 1). The studies were conducted in single states (or in the District of Columbia) (16 studies^{24,25,27,29,31-33,35,38-44,51,52}), 2 states (4 studies^34,37,48,49), or 5 or more states (8 studies^{26,28,30,36,45-47,50}). Fifteen studies focused on general postpartum care and 13 studies focused specifically on contraceptive care.

Study participants were racially diverse, but studies were heterogeneous; between 4% and 83% were White and between 2% and 54% were Black across studies (eAppendix 3 in Supplement 1). Only 1 study reported on employment status; all 2509 participants were employed.²⁵ No study reported on participant gender or sexual identity status or on substance use disorders. Where reported, 59% to 74% of births were vaginal and 8% to 22% of births were preterm. Six studies explicitly reported that they excluded pregnancies resulting in stillbirths, spontaneous or induced abortions, or neonatal deaths.

The studies addressed various comparisons (Table 1). For each study, we classified individual comparator groups as more vs less comprehensive insurance coverage. Four studies compared outcomes associated with different types of health insurance. Of these, 2 studies compared private/commercial insurance with Medicaid insurance in Ohio³⁵ and North Carolina,³¹ 1 compared continuous Medicaid eligibility with pregnancy-only Medicaid eligibility in Wisconsin,⁵¹ and 1 compared an insurance plan that fully covered antepartum and postpartum care with a plan that included an annual deductible with out-of-pocket maximums in Massachusetts.²⁵ Thirteen studies evaluated the impact of policy changes that made insurance coverage more comprehensive. These included 9 studies of Medicaid expansion in various states^{24,33,36,37,39-42,44,52}; 1 study that evaluated the impact of a law requiring hospitals to provide the option of long-acting reversible contraception (LARC) placement after delivery in Ohio³²; 1 that evaluated the impact of unbundling (ie, separate reimbursement for immediate postpartum LARC) in Wisconsin²⁹; 1 that evaluated the transition from a pilot (Medicaid 1115) expansion of eligibility to individuals otherwise ineligible for Medicaid coverage to the State Plan Amendment, which provides contraceptive care for all, in various states²⁶; and 1 study in Texas that evaluated the impact of the Families First Coronavirus Response Act, a federal law that required states to provide continuous coverage to Medicaid enrollees during the COVID-19 pandemic.⁴³ In contrast, 2 studies evaluated the impact of policy changes that made insurance coverage less comprehensive: 1 study in North Carolina³⁸ that evaluated a policy reducing reimbursement rates for maternity care coordination by 19% and 1 study in Oregon that evaluated a policy requiring undocumented immigrants and legal immigrants within 5 years of immigration with Emergency Medicaid who wanted sterilization following vaginal delivery to pay for it.²⁷ Finally, 9 studies compared outcomes in various insurance expansion and nonexpansion (or contraction) states.^{28,30,34,45-50}

Nine of the 28 studies had overall high risk of bias due to moderate or serious risk of confounding and the lack of blinding of participants, study staff, and outcome assessors (eAppendix 4 and 5 in Supplement 1). We rated the remaining 19 studies at moderate risk of bias due to the lack of blinding of participants, study staff, and outcome assessors.

Eleven studies reported data on attendance at postpartum visits (Table 2 and eAppendix 6 and 7 in Supplement 1).^{25,31,33,34,38,39,41,43,48,50-52} Eight studies reported that more comprehensive health insurance was associated with greater attendance. For this and all outcomes, we could not conduct meta-analyses because of the heterogeneity in reported comparisons of insurance (eg, comparisons among insurance types, comparisons of Medicaid expansion vs no expansion) and inconsistent definitions of outcomes (eg, mean number of visits, categorical data on visit attendance).

Three studies reported data on mean number of postpartum visits (eAppendix 6 in Supplement 1). Cilenti et al³⁸ reported a higher number of visits per patient by 3 months comparing before vs after a North Carolina Medicaid policy that reduced reimbursement for maternity care coordination by 19% (aMD, 1.6 visits; P < .001; no 95% CI reported). Gordon et al³⁴ reported that, although the mean numbers of outpatient visits per patient by 1 month were comparable between Colorado and Utah, Colorado (a Medicaid expansion state) had more outpatient visits per patient than Utah (a nonexpansion state) by 3 months (aNMD, 0.10 visits; P < .001; no 95% CI reported) and 6 months (aNMD, 0.52; P < .01; no 95% CI reported). By 6 months, the mean number of visits was also greater among the subgroup of participants with severe maternal morbidity, such as hemorrhage, acute myocardial infarction, and sepsis (aNMD, 1.25; P < .01; no 95% CI reported).³⁴ Steenland et al^39,40 reported that Arkansas’ Medicaid expansion was associated with greater numbers of outpatient visits per patient by 2 months (aMD, 0.2 visits; 95% CI, 0.1 to 0.3) and by 6 months post partum (aMD, 0.9; 95% CI, 0.7 to 1.1).

Eight studies reported categorical data on attendance at postpartum visits (eAppendix 7 in Supplement 1). DeSisto et al⁵¹ reported that in Wisconsin, compared with participants with pregnancy-only Medicaid coverage, participants with continuous Medicaid eligibility had greater likelihood of the composite outcome of postpartum visit attendance, cervical cytology, intrauterine device (IUD) insertion, or a bundled service (aRD, 6.27%; 95% CI, 5.72 to 6.82) and the composite outcome of postpartum visit attendance, cervical cytology, or IUD insertion (aRD, 12.0%; 95% CI, 11.2 to 12.7). Similarly, Dunlop et al³³ reported that among income-eligible participants (but not among participants with pregnancy-only Medicaid coverage), Ohio’s Medicaid expansion was associated with greater attendance by 6 months (37.1% after Medicaid expansion vs 31.5% before Medicaid expansion; odds ratio [OR] adjusted marginal effect, 5.09; P < .01; no 95% CI reported). Rodriguez et al⁴⁸ reported that Medicaid expansion in Oregon was associated with greater attendance at postpartum visits when compared with South Carolina (a nonexpansion state) (adjusted net prevalence difference 47.9%; 95% CI, 41.3% to 54.6%). Taylor et al³¹ reported that in North Carolina, compared with patients with commercial insurance, attendance at the 6-week visit was lower among patients with Medicaid insurance (adjusted OR [aOR], 0.65; 95% CI, 0.58 to 0.74) and even lower for patients with no insurance (aOR, 0.42; 95% CI, 0.34 to 0.51).

On the other hand, Eliason et al⁵⁰ evaluated 15 states and reported that states with and without Medicaid expansion had comparable attendance at postpartum visits (adjusted net prevalence difference 0.3%; 95%, CI −3.1% to 3.9%). Similarly, Kozhimannil et al,²⁵ 2011 evaluated commercial insurance in Massachusetts and reported that participants with an annual deductible with out-of-pocket maximums had comparable attendance at visits between 21 and 56 days post partum as participants who had lower copayments after a policy change (aOR, 0.74; 95% CI, 0.42 to 1.32). Liberty et al⁵² evaluated South Carolina’s Medicaid policy covering immediate postpartum LARC, and Wang et al⁴³ evaluated Texas’s Families First Coronavirus Response Act, but neither study reported an adjusted effect size.

One study (Symum et al⁴²) reported on unplanned health care utilization (eAppendix 7 in Supplement 1). Florida’s Mandatory Medicaid Managed Care policy was associated with a lower rate of preventable readmissions (incidence rate ratio [IRR], 0.86; 95% CI, 0.80 to 0.93) and emergency department visits (IRR, 0.87; 95% CI, 0.82 to 0.93) by 1.5 months post partum.⁴²

Three studies reported inconsistent results regarding depression symptoms (“always” or “often” feeling down/depressed/hopeless or had little interest/pleasure in doing things since delivery) (eAppendix 8 in Supplement 1).^28,36,47 Austin et al,⁴⁷ which evaluated 20 states, and Margerison et al,²⁸ which evaluated 18 states, reported that there was no difference in the prevalence of reported depression symptoms in Medicaid expansion and nonexpansion states. However, Schuster et al³⁶ reported that Medicaid expansion was associated with a reduction in depression symptoms in 5 states (adjusted prevalence difference, −3.5%; P = .04; the prevalence estimates before and after Medicaid expansion were not reported). No study reported on condition-specific screening/testing/treatment or transition to primary care practitioner for long-term care, maternal mortality, quality of life, perceived stress, or harms (health inequities or reported discrimination).

The evidence identified in this systematic review of studies in the US (Table 2) suggests that more comprehensive health insurance coverage is probably associated with greater attendance at postpartum visits (moderate SoE) and may be associated with fewer preventable readmissions and emergency department visits (low SoE). We did not find evidence addressing the other prioritized health care utilization outcomes. There is insufficient evidence on whether more comprehensive insurance is associated with improved symptoms or diagnoses of mental health conditions. We did not find evidence addressing the other prioritized clinical outcomes or harms. Although more comprehensive insurance coverage is probably associated with greater attendance at postpartum visits, the impact of this association on maternal (or child) health outcomes is unclear.

We found that more comprehensive insurance coverage is probably associated with greater attendance at postpartum visits. In other words, uninsured and underinsured postpartum individuals are less likely to attend their scheduled postpartum visits. Although the evidence was not examined in this systematic review (our focus was on outcomes in the first postpartum year), uninsured and underinsured postpartum individuals are likely more susceptible to poorer outcomes in the long run.

Research is needed to evaluate the associations between comprehensiveness of health insurance and outcomes beyond postpartum visit attendance. The ongoing increase in the number of states that are extending postpartum care up to 1 year after delivery¹⁵ presents an excellent natural experiment and opportunity to examine how these policy changes may (or may not) impact postpartum health outcomes, both within and across states. For example, we are aware of another study by Steenland et al⁵³ published after our last search; its results are consistent with our conclusions regarding the associations between Medicaid expansion (ie, more comprehensive insurance coverage) and greater postpartum visit attendance and fewer hospitalizations.⁵³ The ongoing research also offers the opportunity to evaluate whether these policy changes may reduce the stark racial and other disparities in postpartum outcomes in the US.

Most studies included in this systematic review enrolled predominantly healthy individuals. Researchers should also design studies that, either entirely or in part, enroll individuals at high risk of postpartum complications due to chronic conditions (eg, preexisting diabetes), pregnancy-related conditions (eg, gestational hypertension) or incident or newly diagnosed conditions (eg, postpartum preeclampsia). There is a particular need to study how marginalized and most at-risk individuals may be impacted by changes to health insurance coverage related to barriers due to socioeconomic factors (eg, lack of paid maternity leave, paid time off for health care visits) or disabilities (eg, movement disorders, vision loss, hearing loss). When enrolled as part of a larger study, subgroup-specific data for these various subpopulations should be adequately analyzed and reported.

We urge researchers working on future studies to evaluate and report outcomes that were not adequately reported in the identified evidence, such as adherence to condition-specific screening or testing, transition to care by primary care practitioners, maternal mortality, patient-reported outcomes (eg, quality of life), reduction in health inequities, worsening health inequities, and reported discrimination.

We followed contemporary standards for systematic reviews, including (1) engagement with multiple types of stakeholders in defining and refining the research questions and (2) careful adherence to current systematic review standards for protocol publication and registration, literature searching, screening, data extraction, risk of bias assessment, qualitative synthesis, and SoE assessment. To maximize the applicability of the evidence to the US decision-making context, we restricted to US-based studies. The racial diversity of study participants generally mirrored the postpartum population in the US. On average, across the studies, patients ranged in age from their mid 20s to their mid 30s. As such, the conclusions in this systematic review apply generally to postpartum individuals in the US.

A few limitations of the evidence base are worth noting. Despite finding 28 studies, due to limited evidence for most outcomes of interest, we were able to make conclusions for only 2 prioritized outcomes, postpartum visit attendance and unplanned care utilization. Many of the prioritized outcomes were either not reported in any included study for specific comparisons or were reported in an insufficient number of studies to merit conclusions according to sufficient evidence. Some of these outcomes may be challenging for researchers to ascertain in retrospective studies because medical records may be incomplete if participants seek care at other clinical sites (eg, other hospitals or in other states) or if their insurance coverage changes following pregnancy or childbirth. In addition, harms were inadequately described; no study provided data for worsening health inequities or reported discrimination. The heterogeneity across studies in terms of the evaluated policy changes and comparisons also presented a challenge to our conducting a synthesis. We described the evidence narratively but recognize that differences in how “more comprehensive” insurance coverage was defined across studies varied.

The findings of this systematic review suggest that more comprehensive health insurance coverage is probably associated with greater attendance at postpartum visits and may be associated with fewer preventable readmissions and emergency department visits, but the association of insurance coverage with other health care utilization, clinical, and harm outcomes is unclear. Future research should evaluate the impact of more comprehensive or extended health insurance on health outcomes in the postpartum period and beyond. Researchers should report separate data for various population subgroups, so that decision-makers can understand the implications of health insurance extension for different populations.

Accepted for Publication: April 2, 2023.

Published: June 2, 2023. doi:10.1001/jamanetworkopen.2023.16536

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Saldanha IJ et al. JAMA Network Open.

Corresponding Author: Ian J. Saldanha, MBBS, MPH, PhD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, E7136, Baltimore, MD 21205 (isaldan1@jhu.edu).

Author Contributions: Dr Saldanha had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Saldanha, Adam, Steele, Chen, Peahl, Danilack-Fekete, Stuebe, Balk.

Acquisition, analysis, or interpretation of data: Saldanha, Adam, Kanaan, Zahradnik, Chen, Peahl, Danilack-Fekete, Stuebe.

Drafting of the manuscript: Saldanha, Kanaan.

Critical revision of the manuscript for important intellectual content: Saldanha, Adam, Zahradnik, Steele, Chen, Peahl, Danilack-Fekete, Stuebe, Balk.

Statistical analysis: Saldanha, Zahradnik.

Obtained funding: Saldanha, Balk.

Administrative, technical, or material support: Adam, Zahradnik, Chen, Peahl, Stuebe.

Supervision: Saldanha, Chen, Danilack-Fekete, Balk.

Conflict of Interest Disclosures: Dr Saldanha reported other from Agency for Healthcare Research and Quality Contract and other from Patient-Centered Outcomes Research Institute Contract during the conduct of the study. Mr Adam reported grants from AHRQ during the conduct of the study. Dr Peahl reported other from Maven Consultant during the conduct of the study. Dr Danilack-Fekete reported personal fees from AHRQ during the conduct of the study. Dr Stuebe reported grants from AHRQ, grants from NIH, grants from PCORI, and grants from American Heart Association during the conduct of the study. Dr Balk reported grants from Agency for Healthcare Research and Quality during the conduct of the study. No other disclosures were reported.

Funding/Support: This project was funded under Contract No. HHSA 75Q80120D00001/75Q80121F32007 from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (HHS), and the Patient-Centered Outcomes Research Institute (PCORI).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The authors of this systematic review are responsible for its content. Statements in the systematic review do not necessarily represent the official views of or imply endorsement by AHRQ, HHS, or PCORI.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The authors thank the following individuals who served as key informants and/or technical experts and helped us refine the research questions and develop the protocol: Tammy Chang, MD, MPH, MS (University of Michigan), Beth Choby, MD (Tennessee Baptist Memorial Hospital), Blair Darney, PhD, MPH (Oregon Health & Science University), Amy Gilliland, PhD (University of Wisconsin–Madison), Milton Kotelchuck, MPH, PhD (Harvard University), Eva Luo, MD (Harvard University), Monica Mallampalli, PhD (HealthyWomen®), Maria Piñeros-Leaño, PhD, MSW, MPH (Boston College), Pamela Stratton, MD (Eunice Kennedy Shriver National Institute of Child Health and Human Development), Amy Valent, DO (Oregon Health & Science University), Tiffany Wiggins, MD, MPH (Centers for Medicare & Medicaid Services), and Edwina Yeung, PhD (Eunice Kennedy Shriver National Institute of Child Health and Human Development). We are also grateful to the project’s Task Order Officer Jill Huppert, MD, MPH, and the EPC Program Director Craig Umscheid, MD, MPH (both at the Agency for Healthcare Research and Quality) and Program Officer Jennie Dalton, MPH and Program Associate Paula Eguino Medina, MPH (both at the Patient-Centered Outcomes Research Institute). Finally, we thank the full systematic review report’s Associate Editor Mary Butler, PhD, MBA (University of Minnesota) and the peer reviewers. None of these individuals were compensated beyond their normal salaries for their contributions.