For high risk postpartum women receiving public payment for care does provision of intensive postpartum services improve appointment uptakeAll women who experienced poor maternal outcome or who have chronic medical conditions that put them at risk for increasing severity of these conditions postpartum or during subsequent pregnancies. Subgroups should includeMethod of payment public vs private. Use of Medicaid or other public payment for birth is associated with poor return for postpartum care. Race black vs. other. AfricanAmerican women have significantly higher incidence of poor maternal and infant outcome.Maternal length of stay 2 days for vaginal 5 days for cesarean birth vs other. Prolonged length of stay postpartum is an indicator of a maternal health challenge. Provider type obstetriciangynecologist family medicine midwife. Protocols for arranging postpartum visits may vary between provider groups. The important healthrelated benefits and harms you are interested in. For example improvements in symptoms or problems with diagnosis.Important healthrelated benefits and harms of interestBenefits Improvement in attendance and content of the postpartum visit should increase identification and follow up of current and potential poor maternal health while the woman is engaged in the health care system. Early timing of the visit should allow for additional screening and referral under timelimited insurance plans such as prenatal Medicaid or CHIP as well as counseling for accessing insurance through the Affordable Care Act. In addition for women who received counseling or treatment for substance use and mental health problems during pregnancy the additional stresses of infant care require the development of structured plans for continued assistance. The birth spacing offered by family planning counseling and provision during the early postpartum visit reduces the incidence of low birth weight and prematurity in subsequent pregnancies and improves overall maternal health. Harms Women who experience maternal morbidity such as severe hypertension hemorrhage venous thrombosis sepsis cardiac changes and diabetes are a great risk for escalation of poor health postpartum and require intensive followup care to avoid stroke pulmonary embolus ruptured abscesses cardiac failure Type II diabetes. Unrecognized or undertreated depression severe anxiety and substance dependence which should be identified in a postpartum visit are responsible for over 50 of maternal deaths in the late postpartum period.

IMPORTANCEAlthough the U.S. health system closely tracks prenatal care visits statistics on the content and utilization of the postpartum visit and postpartum health problems are greatly lacking and postpartum care is frequently decried as a missed opportunity and too limited to meet the health needs of women Albers 2000. Pregnancy is said to be a window into womens future health Saade 2009. Gestational diabetes hypertension cardiac changes and mental illness that occur within a pregnancy will frequently occur within the subsequent 5 to 10 years as a chronic condition for that woman. Severity can be altered by close followup and preventive measures. Every postpartum appointment should be considered a time of preconception care. For women with chronic conditions provision of family planning counseling and methods is critical to provide time for treatment. IMPACTIt is important to recognize that women who have had a poor birth outcome in a prior pregnancy are at increased risk for having a poor birth outcome in a subsequent pregnancy. Hospital stays with pregnancyrelated complications tend to be longer 2.72.9 days compared with those without complicating conditions 1.9 days. In 2008 maternal stays with complicating conditions were 50 more expensive 8000 compared with those without complications 2600. Maternal stays with pregnancy and delivery complications accounted for 17.4 billion or 5 of total hospital costs in the United States. In addition intensive postpartum care with behavioral and mental health components providing treatment or acceptable referral for postpartum mood disorders and substance use reduce the increasingly heavy burden on the family and society for these conditions. Family planning services offered for publicly funded women during the early postpartum visit save 4 for every 1 spent Frost 2008.

This research will assist our broad coalition currently involved in improving postpartum and intrapartum care content and attendance to identify and design implementation strategies for our alliance. Our goal is to provide primary and secondary prevention methods to avoid poor birth outcomes including infant mortality and severe maternal morbidity and mortality.

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American College of Obstetricians and Gynecologists

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Jennifer Moore PhD RNHealth Scientist and Team Lead Office of Womens Health Gender ResearchPatient Centered Outcomes Research Program Officer Division of Research EducationAHRQ