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Postpartum Care Up To One Year After Pregnancy: A Systematic Review

Draft Comments Nov 16, 2022
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Table of Contents

Postpartum Care Up To One Year After Pregnancy: A Systematic Review

  • Healthcare Delivery Strategies—Where Care is Provided
    • For breastfeeding care (6 randomized controlled trials [RCTs] and 1 nonrandomized comparative study [NRCS]), whether the initial visit is conducted at home or at the pediatric clinic may not impact maternal depression symptoms (up to 6 months postpartum), anxiety symptoms (up to 2 months), hospital readmission (up to 3 months), or other unplanned care utilization (up to 2 months) (all Low strength of evidence [SoE]).
  • Healthcare Delivery Strategies—How Care is Provided
    • For general postpartum care (4 RCTs), integration of care (e.g., combined versus separate postpartum/well-child visits, multidisciplinary postpartum clinic versus standard care) may not impact depression symptoms (up to 1 year) or substance use (up to 2 years) (all Low SoE).
  • Healthcare Delivery Strategies—When Care is Provided
    • For contraceptive care (9 RCTs), earlier, compared with later, contraception is probably associated with comparable continued IUD use at 3 and 6 months but greater implant use at 6 months (all Moderate SoE).
  • Healthcare Delivery Strategies—Who Provides Care
    • For breastfeeding care, peer support (9 RCTs) is probably associated with higher rates of any breastfeeding at 1 month and 3 to 6 months and of exclusive breastfeeding at 1 month but is probably associated with comparable rates of exclusive breastfeeding at 3 months and nonexclusive breastfeeding at 1 and 3 months (all Low SoE). Care by a lactation consultant (6 RCTs and 1 NRCS) is probably associated with higher rates of any breastfeeding at 6 months but not at 1 month or 3 months. Lactation consultant care is probably associated with comparable rates of exclusive breastfeeding at 1 or 3 months (all Moderate SoE).
  • Healthcare Delivery Strategies—Coordination and Management of Care
    • For general postpartum care (1 NRCS) and screening (1 NRCS), no conclusions are feasible because of insufficient evidence. 
  • Healthcare Delivery Strategies—Use of Information or Communication Technology (IT)
    • For breastfeeding care (6 RCTs), IT use and nonuse are probably associated with comparable rates of any breastfeeding at 3 months and 6 months and of exclusive breastfeeding at 3 months (all Moderate SoE).
  • Healthcare Delivery Strategies—Interventions Targeting Healthcare Providers
    • For breastfeeding care (2 RCTs), no conclusions are feasible because none of our prioritized outcomes were reported.
  • Health Insurance—More comprehensive insurance (16 NRCSs) is probably associated with greater attendance at postpartum visits (Moderate SoE based on 5 NRCSs). There was insufficient evidence regarding other outcomes

Objectives. This systematic review assesses postpartum care for individuals up to 1 year after pregnancy. We addressed two Key Questions (KQs) related to the comparative effectiveness and harms of: (1) alternative strategies for postpartum healthcare delivery and (2) extension of postpartum health insurance coverage.

Data sources and review methods. We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov from inception to December 9, 2021, to identify comparative studies in the United States and Canada (for KQ 1) and in the United States (for KQ 2). We extracted study data into the Systematic Review Data Repository Plus (SRDR+). We assessed the risk of bias and evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number <#>).

Results. We included 45 randomized controlled trials (RCTs) and 9 nonrandomized comparative studies (NRCSs) for KQ 1 and 16 NRCSs for KQ 2. Risk of bias was moderate to high for most RCTs and all NRCSs. KQ 1: Regarding where healthcare is provided, for breastfeeding care (7 studies), whether the initial visit is at home or at the pediatric clinic may not impact maternal depression symptoms up to 6 months postpartum, anxiety symptoms up to 2 months, hospital readmission by 3 months (summary relative risk [RR] 1.38, 95% confidence interval [CI] 0.90 to 2.13; 4 studies), or other unplanned care utilization up to 2 months (Low SoE, all outcomes). Regarding how care is provided, for general postpartum care (4 studies), integration of care (i.e., care provided by multiple types of providers) may not impact depression symptoms (up to 1 year) or substance use (up to 2 years) (Low SoE). Regarding when care is provided, for contraceptive care (9 studies), compared with later contraception, earlier contraception is probably associated with comparable continued IUD use at 3 and 6 months but greater implant use at 6 months (summary RR 1.36, 95% CI 1.13 to 1.64; 2 RCTs) (Moderate SoE). Regarding who provides care, for breastfeeding care (17 studies), peer support is probably associated with higher rates of any breastfeeding at 1 month (summary effect size [ES] 1.13, 95% CI 1.03 to 1.24; 4 studies) and 3 to 6 months (summary ES 1.22, 95% CI 1.06 to 1.41; 4 studies) and of exclusive breastfeeding at 1 month (summary ES 1.10, 95% CI 1.02 to 1.18; 5 studies) but probably yields comparable rates of exclusive breastfeeding at 3 months and nonexclusive breastfeeding at 1 and 3 months (all Low SoE). Breastfeeding care by a lactation consultant is probably associated with higher rates of any breastfeeding at 6 months (summary ES 1.43, 95% CI 1.07 to 1.91; 3 studies) but not at 1 month or 3 months (all Moderate SoE). Lactation consultant care may not be associated with rates of exclusive breastfeeding at 1 or 3 months (Moderate SoE). Regarding use of information or communication technology (IT; 7 studies), IT use is probably associated with comparable rates of any breastfeeding at 3 months and 6 months and of exclusive breastfeeding at 3 months (all Moderate SoE). Because of sparse evidence, inconsistent results, and/or the lack of reporting of our prioritized outcomes, no conclusions are feasible related to care coordination or management (2 studies) and information targeting healthcare providers (2 studies). KQ 2: Regarding health insurance (16 studies), more comprehensive health insurance is probably associated with greater attendance at postpartum visits (Moderate SoE).

Conclusion. Most studies included in this SR enrolled predominantly healthy postpartum individuals. Researchers should therefore design studies that, either entirely or in part, enroll individuals at high risk of postpartum complications due to chronic conditions, pregnancy-related conditions, or incident or newly diagnosed conditions. New high-quality research is needed, especially for healthcare coordination or management, interventions targeting healthcare providers, and the impact of more comprehensive or extended health insurance on postpartum health. Patient-reported outcomes, such as quality of life, should also be reported.

Project Timeline

Postpartum Care for Women up to One Year After Birth

Aug 9, 2021
Topic Initiated
Feb 24, 2022
Nov 16, 2022
Draft Comments
Nov 15, 2022 - Dec 31, 2022
Page last reviewed November 2022
Page originally created November 2022

Internet Citation: Draft Comments: Postpartum Care Up To One Year After Pregnancy: A Systematic Review. Content last reviewed November 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/postpartum-care-one-year/draft-comment

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