Association for Public Policy Analysis & Management

Objective: Postpartum care is important for promoting maternal and infant health and well-being, yet nationally, less than 60% of Medicaid-enrolled women attend their postpartum visit. In addition to promoting overall health, postpartum care can aid detection of cardiac or hypertensive complications or suicidal ideation that can lead to maternal mortality, which is particularly high in the United States. Postpartum care is especially important when women have complications such as depression, obesity, hypertension, diabetes, and substance use disorders during pregnancy. This research examines a variety of approaches to increasing engagement in postpartum care among participants in Strong Start for Mothers and Newborns, a federal initiative to prevent preterm birth among Medicaid participants.

Design: We report qualitative analysis of case studies that include coded notes from 739 interviews with program staff and providers; 133 focus groups with 951 pregnant or postpartum Strong Start participants; four years of annual memos capturing activities by each of 27 awardees; and data from interviews with Medicaid officials in 20 states.

Population: Strong Start participants (n=45,999) and the awardees (n=27) that served them from 2013 to 2017 in 32 states, the District of Columbia, and Puerto Rico.

Findings: Strategies that appeared to increase access to and completion of postpartum care among Strong Start participants included educating women about the importance of postpartum care during prenatal care visits; establishing provider and/or care manager continuity across prenatal, birth, and postpartum care; connecting women to ongoing postpartum insurance coverage; offering postpartum support groups; phone follow-up; home visit options; linking women to needed services such as treatment for postpartum depression; addressing barriers related to transportation and childcare; and aligning incentives to encourage prioritization of postpartum care among patients and providers. Even when programs employed one or more of these enhancements, many barriers to postpartum visit attendance persisted, including transportation, childcare, and information gaps related to postpartum care availability and coverage. Key informants indicated that Medicaid payment policies such as provider incentives for postpartum visits or specific screenings, can support providers and health plans in ensuring women attend postpartum visits.

Conclusions: Postpartum care is a focus of national efforts to improve maternal and infant health and reduce mortality rates. Almost half of pregnant women get their maternity care through Medicaid, and many are at high medical or social risk, increasing their need for timely and comprehensive postpartum care. Lack of provider continuity and ongoing access to care once Medicaid/CHIP maternity coverage ends both remain major challenges to beneficiaries’ postpartum engagement in health care. Innovative approaches to fill gaps mitigate some barriers and promote postpartum visit attendance. Further research is needed to quantify the impact of specific practices on postpartum engagement and maternal and infant health outcomes.

Implications: Providers who offer maternity care in Medicaid can advance innovative strategies from Strong Start to improve postpartum visit access and attendance, and states can disseminate best practices. Increasing care continuity through postpartum care, targeted education and outreach, additional postpartum support tailored to women’s needs, and focusing on linkages to ongoing care are particularly promising approaches.