Association of Health Insurance, Geography, and Race and Ethnicity With Disparities in Receipt of Recommended Postpartum Care in the US

Abstract

ImportanceLittle is known about the quality of postpartum care or disparities in the content of postpartum care associated with health insurance, rural or urban residency, and race and ethnicity.ObjectivesTo examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity.Design, Settings, and ParticipantsThis cross-sectional survey of patients with births from 2016 to 2019 used data from the Pregnancy Risk Assessment Monitoring System (43 states and 2 jurisdictions). A population-based sample of patients conducted by state and local health departments in partnership with the Centers for Disease Control and Prevention were surveyed about maternal experiences 2 to 6 months after childbirth (mean weighted response rate, 59.9%). Patients who attended a postpartum visit were assessed for content at that visit. Analyses were performed November 2021 to July 2022.ExposuresMedicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups).Main Outcomes and MeasuresReceipt of 2 postpartum care components recommended by national quality standards (depression screening and contraceptive counseling), and/or other recommended components (smoking screening, abuse screening, birth spacing counseling, eating and exercise discussions) with estimated risk-adjusted predicted probabilities and percentage-point (pp) differences.ResultsAmong the 138 073 patient-respondents, most (59.5%) were in the age group from 25 to 34 years old; 59 726 (weighted percentage, 40%) were insured by Medicaid; 27 721 (15%) were rural residents; 9718 (6%) were Asian, 24 735 (15%) were Black, 22 210 (15%) were Hispanic, 66 323 (60%) were White, and fewer than 1% were Indigenous (Native American/Alaska Native) individuals. Receipt of both depression screening and contraceptive counseling both significantly lower for Medicaid-insured patients (1.2 pp lower than private; 95% CI, –2.1 to –0.3), rural residents (1.3 pp lower than urban; 95% CI, –2.2 to –0.4), and people of racially minoritized groups (0.8 pp lower than White individuals; 95% CI, –1.6 to –0.1). The highest receipt of these components was among privately insured White urban residents (80%; 95% CI, 79% to 81%); the lowest was among privately insured racially minoritized rural residents (75%; 95% CI, 72% to 78%). Receipt of all other components was significantly higher for Medicaid-insured patients (6.1 pp; 95% CI, 5.2 to 7.0), rural residents (1.1 pp; 95% CI, 0.1 to 2.0), and people of racially minoritized groups (8.5 pp; 95% CI, 7.7 to 9.4). The highest receipt of these components was among Medicaid-insured racially minoritized urban residents (34%; 95% CI, 33% to 35%), the lowest was among privately insured White urban residents (19%; 95% CI, 18% to 19%).Conclusions and RelevanceThe findings of this cross-sectional survey of postpartum individuals in the US suggest that inequities in postpartum care content were extensive and compounded for patients with multiple disadvantaged identities. Examining only 1 dimension of identity may understate the extent of disparities. Future studies should consider the content of postpartum care visits.

Trends in Cardiovascular Health Counseling Among Postpartum Individuals

“…All analyses were repeated in each 5-year age group, by self-identified race or ethnicity (Hispanic, non-Hispanic American Indian/Alaska Native, non-Hispanic Asian/Pacific Islander, non-Hispanic Black, or non-Hispanic White), educational status, and insurance status. To account for the PRAMS complex sampling design, a total analysis weight was assigned as recommended by the PRAMS analysis guide and consistent with prior publications . PRAMS supplies a sampling weight to account for selection probability, a nonresponse weight to account for survey completion failure, and a noncoverage weight to account for individuals who were not sampled.…”

“…PRAMS supplies a sampling weight to account for selection probability, a nonresponse weight to account for survey completion failure, and a noncoverage weight to account for individuals who were not sampled. The total analytic weight was calculated as the product of these analytic weights per PRAMS recommendations . Analyses were completed using Stata 14.0…”

Chronic Hypertension in Pregnancy: A Lens Into Cardiovascular Disease Risk and Prevention

“…3,76 Postpartum visit attendance is also the lowest among those with public insurance or who lose insurance 12 weeks after delivery in the United States where health care is not universal. 55,58…”

“…3,76 Postpartum visit attendance is also the lowest among those with public insurance or who lose insurance 12 weeks after delivery in the United States where health care is not universal. 55,58 Given these disparities, it is critical to identify barriers to equitable peripartum health care delivery. In a systematic review of qualitative literature in the United States, low-income individuals described several barriers to high-quality prenatal and postpartum care including difficulty navigating insurance policies, transitioning between providers, finding childcare and transportation, and experiencing discrimination during previous health care visits.…”

“…However, only 50% to 60% of those attending a postpartum visit in the United States receive diet and exercise counseling. 55 In addition, prevalence of subsequent follow-up with primary care for chronic disease management is low in the United States with estimates ranging from 17% to 60%, and <50% screen for a history of HDP as recommended by the ACC/AHA. [56][57][58][59][60] In the United Kingdom, where postpartum care is typically provided by general practitioners, only 25% to 30% of individuals felt confident they could contact their physician.…”