Health Inequities in the Postpartum Period/Pregnancy Interval Care

Health Inequities in the Postpartum Period/Pregnancy Interval Care

Ashish Premkumar

Divya Mallampati

Melissa A. Simon


Health disparities in the United States, both in terms of access to health care and the prevalence of adverse outcomes, continue to influence the landscape of interpregnancy and postpartum care. For the purposes of this chapter, we adhere to the definition of health disparity put forth by the National Institutes of Health, namely that certain groups face disproportionate morbidity and mortality when compared to the general population.1 Markers of sociohistorical inequality—race/ethnicity, socioeconomic status, gender identity, sexual preference, non-English primary language usage, (dis) ability, and geographic residence—work in synergistic ways to contribute to poor health outcomes and resource utilization among women considered to be marginalized or vulnerable.2,3 While multiple authors have advocated for programs aimed at reducing health disparities during the peripartum period, the postpartum and interpregnancy periods are increasingly becoming targets of novel care interventions.2,4,5,6

This chapter will broadly outline key issues in the interpregnancy and postpartum periods relating to disparities in both healthcare utilization and outcomes. We limit our discussion to the United States, primarily given the authors’ own experience as well as the complexity of the legal, bureaucratic, economic, social, and historical context that contributes to health disparities in the country. Changes in health insurance policy, particularly surrounding the passage of and opposition to the Affordable Care Act (ACA) and Medicaid coverage including expansion or extension, as well as the complexities in accessibility to comprehensive reproductive health specialists—based on insurance status, geographic location, and other factors—all contribute to the unique disparities in the United States during the postpartum and interpregnancy periods. Our limited analytic framework is not meant to be exclusive but is meant to act as a starting point for understanding wider issues surrounding women’s health after delivery and to stimulate conversations on a global scale regarding why certain groups face adverse outcomes when compared with others.

Important to note regarding any discussion of health inequities is that the United States has one of the highest pregnancy-related mortality rates among high-income countries, reflecting the deeply troubling disparities that demonstrate long-standing inequity rooted in racism and structural racism within our healthcare system. The US pregnancy-related mortality rate has increased from 14.5 pregnancy-related deaths per 100,000 live births in 2007 to 16.9 per 100,000 in 2016.7 Between 2007 and 2016, there were 40.8 pregnancy-related deaths per 100,000 live births among non-Hispanic black mothers and 29.7 pregnancy-related deaths per 100,000 live births among non-Hispanic American Indian/Alaska Native mothers compared with 12.7 pregnancy-related deaths per 100,000 live births among non-Hispanic white mothers.8 Nearly a quarter of pregnancy-related deaths occur between 43 days and 1 year postpartum, with cardiomyopathy being the leading cause of death.9,10 State-level data show that substance use disorder and perinatal mental health are some of the leading causes of mortality postpartum11. Two out of three pregnancy-related deaths may be preventable.10


Recent events have drawn public attention to structural racism, or “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems… [that] in turn reinforce discriminatory beliefs, values, and distribution of resources.”12 From biases embedded into algorithms, screening tools, and predictive models utilized by clinicians to the shortage of underrepresented minorities in the clinician workforce, structural racism is embedded in every aspect of our healthcare system leading to unacceptable health outcomes13. The ongoing COVID-19 pandemic has highlighted and exacerbated these issues, where African Americans have more than twice the odds of hospital admission and where Native Americans are being infected at up to four times the rate of their white counterparts.14,15 Bias and systemic racism in healthcare must be addressed, given the differences in maternal mortality experienced by black women, after accounting for other sociodemographic risk factors.16

Common Barriers to Care

Barriers that affect minority women are grounded in social, economic, psychosocial, cultural, and historical factors (Table 54.1). Barriers faced by low-income minority women include lack of social support, employment, cultural acceptance, and racism. Recognizing these disparities are essential as the benefits of reducing these barriers to care are greatest for minority women and infants who are disproportionately affected by poor health outcomes.30

Healthcare Insurance Coverage

Although not a panacea to address all facets of structural racism, extending Medicaid coverage from 6 weeks to 12 months postpartum may reduce inequities in care. Currently, the federal mandate for pregnancy-related Medicaid provides coverage to women living within 138% of the federal poverty line (FPL) up to 60 days postpartum. Women of color are disproportionately enrolled in Medicaid during the perinatal period. Half of women who have births that are funded by Medicaid are uninsured prior to pregnancy, and 55% of Medicaid-insured women will experience a gap in insurance coverage by 6 months postpartum.27 The improvement in coverage provided by postpartum Medicaid extension may provide similar benefits as Medicaid expansion through the ACA, which reduced income eligibility for nonpregnant adults to 138% FPL. Medicaid expansion decreased the uninsured rate among women who gave birth in the past year, increased preconception Medicaid enrollment among low-income women, reduced racial disparities in preterm birth and low birth weight, and decreased infant mortality.21,25,26,31 Support from professional societies such as the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association has led to passage of legislation extending Medicaid to cover postpartum care in several states, including Missouri, which was a nonexpansion state at that time. Legislation extending Medicaid coverage postpartum has also been introduced in several nonexpansion states, namely Texas, Georgia, Wisconsin, and South Carolina. While the passage of legislation is promising, other changes will be necessary to facilitate implementation and to collect data supporting adoption of this policy elsewhere.

Reimbursement is a critical aspect of implementation of postpartum Medicaid extension. Most states pay for maternity care through Medicaid by using a bundled payment for the perinatal period, which includes prenatal care, labor and delivery, and postpartum care.32 Episode payments, particularly with the incorporation of carefully selected quality metrics, could lead to efficient value-based care and waste reduction via gain sharing, where clinicians and institutions can convert savings from efficient care provision into increased service provision in areas that are not covered by insurers. However, the global payment structure will need to be adjusted to account for an increased number of visits for postpartum or well-woman care in the first year postpartum. Options could include increasing the value of the global fee, unbundling the payment structure, or careful identification of high-risk issues that merit increased reimbursement, eg, postpartum depression or peripartum cardiomyopathy. Without appropriate reimbursement, passage of policies extending postpartum Medicaid coverage may not result in increased access to care postpartum.

Socioeconomic Status and Postpartum Care

Socioeconomic status (SES) is one of the key drivers affecting follow-up and retention in care in the postpartum period.33,34,35 However, the effects of low SES
on adverse health outcomes and retention in care in the postpartum period have yet to be fully evaluated, due, in part, to limitations in data collection as patients may switch healthcare clinicians, move out of a given medical center’s catchment area, or lose health insurance altogether. In a retrospective analysis of Medicaid claims in Maryland from 2003 to 2009, Bennett and colleagues note that 51.7% of people with uncomplicated and 56.6% of people with complicated pregnancies (eg, those affected by hypertensive disorders of pregnancy) had a follow-up primary care visit within 12 months after delivery.29 While this could be due to a myriad of factors, one crucial issue facing people of low SES is that of applying for Medicaid during pregnancy; pregnancy-related Medicaid allows for coverage of all medically necessary and preventative services during pregnancy and up to 60 days after delivery. If an individual cannot transition to full-scope Medicaid due to income restrictions (ie, their household income exceeds the cutoff for full-scope Medicaid), then insurance coverage will not continue.36 With the passage of the ACA in 2010 and its subsequent rollout in 2014, researchers have noted a rise in preconception insurance coverage among low-income women living in states that underwent ACA expansion versus those residing in states that did not.21 How the ACA expansion affects retention in care among pregnant people with low SES will be the subject of future studies. Despite the ACA, there remain significant coverage gaps for US women. Medicaid extension or expansion has been proposed in some states to help increase the care of postpartum women up through 1 year.

HIV Status

An important line of inquiry within disparities in postpartum follow-up has to do with women
living with HIV (WLHIV). A single-site retrospective study of 213 postpartum WLHIV receiving care between 2006 and 2011 noted that almost 40% of the cohort failed to follow up for HIV care postpartum.37 On multivariable regression modeling, women who identified as non-Hispanic black had higher odds of loss-to-follow-up when compared with non-black women (adjusted odds ratio [aOR] 2.15, 95% confidence interval [CI] 1.15-4.04). These data are in line with previous data demonstrating a low frequency of engagement in care among WLHIV. In an analysis of WLHIV participating in the Women and Infants Transmission Study (WITS), Mellins and colleagues note that at 6 months postpartum, 44% of participants reported complete antiretroviral adherence, compared with 61% during the third trimester.38 A retrospective cohort study of 980 WLHIV who gave birth between 2008 and 2010 noted that 24% of WLHIV were lost to HIV-related care in the year following delivery, with preconception participation in HIV-related care being a strong predictor of postpartum engagement (adjusted risk ratio [aRR]: 2.70; 95% CI: 2.09-3.49).23 A prospective, qualitative study of focusing on postpartum HIV care adherence among 18 WLHIV in Alabama during the same time period notes that transportation, work schedule, and appointment duration were significant barriers to attending care visits.39

Immigrant Status

Women who immigrate to the United States have unique health needs and considerations that may contribute to disparities in health outcomes in the postpartum and interpregnancy intervals. Important considerations, such as proficiency in English, legal status, and ability to access health insurance, may impart a lower likelihood of accessing health services and thus poorer health outcomes.40 Some data suggest that immigrant women may have better health outcomes, particularly in regard to lower incidences of preterm birth.17,19,20,28,41 Some have hypothesized that this is due to immigration being undertaken by only the healthiest subpopulations from a given area (ie, “healthy immigrant” theory) or because immigrants are not exposed to the chronic racial, structural, and economic segregation that disadvantages minority women in the United States. Disparities in care immigrant women do experience are commonly understood through the guise of acculturation or the change in cultural norms due to a change in cultural setting.42,43,44,45,46,47

Data also suggest, however, that if this population is linked into care during pregnancy, they are more likely to continue in care after delivery. A single-site retrospective study of a primary care clinic in Massachusetts noted that, among all pregnant women who immigrated or migrated to the United States between 2001 and 2013, refugee women (aOR 2.0, 95% CI 1.04-3.83) and Spanish-speaking immigrants (aOR 2.79, 95% CI 1.72-4.53) were more likely to attend postpartum care visits than matched controls.24 An important consideration is the degree of acculturation of the given population; Bermudez-Parsai et al note that women who were only involved in their home culture (unassimilated) were 1.81 times less likely to attend a postpartum visit than women participating in both the home and host culture (bicultural). Interestingly, women who fully assimilated into the host culture were 3.13-times less likely than bicultural women to attend a postpartum visit.48 These findings raise the possibility of an enclave effect—wherein members of a certain social community interact with each other and share important information about key resources, such as health care. People classified as unassimilated or bicultural may have improved knowledge, based on the community they interact with, of healthcare services; however, only bicultural individuals have the requisite resources (eg, ability to speak English proficiently) in order to access the resources. Finally, the effect of full acculturation on lower likelihood of engaging with postpartum care is in line with theories of acculturation, namely that health behaviors become less like those of unassimilated individuals and more like the general population of the host country.43,44,45,46

It is also important to consider potential unique postpartum needs for women from different heritages. A secondary analysis of the Postpartum Contraceptive Project, a prospective cohort study of postpartum women in three Texas hospitals, focused on outcomes of 593 women of Mexican origin. This analysis noted that 39% of women who were born and underwent education in Mexico exclusively breastfed at 10 months postpartum versus 22% of women born and educated in the United States (aOR 2.01, 95% CI 1.24-3.26). However, among women of Mexican origin, a return to work
reduced breastfeeding at 7 (aOR 0.46, 95% CI 0.30-0.70) and 10 months postpartum (aOR 0.59, 95% CI 0.37-0.93) by 50% to 60%.49 These data would suggest that not only heritage, but modes of acculturation—such as education—and incorporation into the workforce have a relationship with breastfeeding patterns, which can have longstanding effects on maternal and neonatal health.

Intimate Partner Violence

Intimate partner violence (IPV), or “a pattern of assaultive behavior and coercive behavior that may include physical injury, psychologic abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion,” is a significant problem in the United States, affecting almost one out of three women during their lifetime.18,50 In a seminal retrospective analysis of North Carolina’s Pregnancy Risk Assessment Monitoring System (PRAMS) data between 1997 and 1998, Martin and colleagues noted that, among 2648 women, 6.9% (95% CI 5.6%-8.2%) affirmed active IPV 12 months prior to conception and 6.1% (95% CI 4.8%-7.4%) affirmed active IPV during pregnancy. The authors also noted that there was a significant association between abuse during pregnancy and postpartum abuse (OR 38, 95% CI 5.8-247.3).51 Women who experienced abuse were more likely to be unmarried, with low SES, younger, and with less than a high school education when compared with women who did not experience abuse.

Women who experience IPV also appear to have increased morbidity and mortality, particularly in the postpartum period. A retrospective analysis of North Carolina’s Violent Death Reporting System between 2004 and 2006 noted a homicide rate of 2.93/100,000 person-years for pregnant/postpartum women and that former partners of the deceased were the most common suspects for homicide.52 Evaluation of data between 2005 and 2010 from 37 states suggests that postpartum homicide accounts for 6.8% of all deaths that occur during pregnancy or within 1 year after delivery.53 Risk of homicide among pregnant and postpartum women is 1.84 times higher than for women who are not pregnant and not postpartum (95% CI 1.71-1.98). The risks of pregnancy-related homicide are exacerbated by racial disparities—the majority of pregnancy-related homicides are three times more likely to occur among non-Hispanic black women when compared to non-Hispanic white women.53

IPV has also been associated with a variety of complications in the postpartum period, including contraceptive use, that disproportionately affect certain racial/ethnic groups. An analysis of PRAMS data from 2004 to 2008 noted that, among women who had prenatal birth control counseling, the odds of postpartum contraceptive use was lower for women reporting preconception IPV (2.8% vs 3.7%, OR 0.74, 95% CI 0.67-0.83), particularly among non-Hispanic white women and non-Hispanic black women. Similarly, among non-Hispanic white, non-Hispanic black, and Hispanic women who received prenatal birth control counseling, prenatal IPV was associated with lower odds of reporting postpartum birth control usage.22 Furthermore, IPV has been associated with postpartum depressive symptoms, although one cross-sectional study of 301 postpartum women in Michigan suggested that degree of poverty may act as a confounding factor in the relationship between IPV and postpartum depression.54,55

A related concept to IPV is reproductive and sexual coercion, or the “explicit attempts to impregnate a partner against her will, control outcomes of a pregnancy, coerce a partner to have unprotected sex, and interfere with contraceptive methods.”50 This type of abuse occurs more often in women with a prior history of IPV. A cross-sectional survey among pregnant women aged 16 to 29 years in northern California reported that reproductive and sexual coercion occurred in up to 33% of individuals who had a history of ongoing IPV.56

Health Behaviors

Understanding the role of health behaviors during the postpartum period in relation to adverse health outcomes is paramount (Table 54.2). Postpartum care has been identified as a crucial moment in which to address pregnancy complications (eg, preeclampsia, fetal anomalies, gestational diabetes mellitus), as well as chronic medical comorbidities that may impact a woman’s overall health, both mentally and physically, over her life course.5,6 Therefore, the concept of a continuum of care—reaching from the preconception period, through pregnancy, postpartum, and onwards—has gained traction within medical organizations dedicated to women’s health such as the ACOG6 (Figure 54.1). Importantly, the ACOG considers postpartum care as an “ongoing process, rather than a single encounter” that is both
individualized and woman centered. Issues such as engagement in care, breastfeeding, and tobacco use will be discussed in this section.

Postpartum Care

Follow-up care after delivery is highly variable, with some studies noting disparities based on maternal race/ethnicity and insurance status. In one study focused on postpartum women in Maryland between 2003 and 2009, 51.7% to 56.6% women using government payor insurance (eg, Medicaid/Medicare) attended a primary care physician visit after delivery versus 49.5% to 60% of women using commercial payor insurance.29 Similar incidences of low postpartum care attendance have been noted in more recent datasets, particularly in a cross-sectional analysis of Medicaid managed care organizations between 2012 and 2015.64 Importantly, authors noted a significantly higher incidence of attending a postpartum visit if the woman identified as Asian (73%, 95% CI 69%-78%), when compared with either non-Hispanic white (63%, 95% CI 62%-64%) or non-Hispanic black (56%, 95% CI 54%-58%) women.

Conversely, other studies have demonstrated that the incidence of attending a postpartum visit is upwards of 90%, based primarily on timing of data analysis and state of interest.57,58,61 For example, a single-site retrospective cohort analysis between 2006 and 2010 in Massachusetts demonstrated that 80.7% of women attended a primary care visit between 2 months and 2 years after delivery and over 90% of women attended a postpartum visit.58 Despite the increased frequency of attending both primary care and postpartum visits, the same study demonstrated that Asian women were less likely to return to care when compared with white women (aOR 0.56, 95% CI 0.43-0.74). The authors also noted that women living closer to the institution of care were more likely to follow up when compared with those living farthest from institution (aOR 0.74, 95% CI 0.61-0.90).58 A secondary analysis of a survey of women who had a live birth in Los Angeles, California, noted that Hispanic mothers were less likely to go to postpartum visit than white mothers (aOR 0.57, 95% CI 0.38-0.87). Furthermore, mothers from families with incomes less than 20,000 USD/year (aOR 2.89, 95% CI 1.43-5.82) were less likely to attend a postpartum visit when compared with women from households with incomes > 100,000 USD per year. Finally, women using government payor insurance were twice as likely to not attend a postpartum visit when compared with those using commercial insurance (aOR 2.19, 95% CI – 1.54-3.11).61

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Jun 19, 2022 | Posted by in OBSTETRICS | Comments Off on Health Inequities in the Postpartum Period/Pregnancy Interval Care
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