1.1. Background

In recent decades, the United States has witnessed a considerable rise in maternal morbidity and mortality.¹ In 2020, the maternal mortality ratio was 23.8 per 100,000 live births (the highest among industrialized countries), with wide racial and ethnic gaps (e.g., non-Hispanic Black: 55.3 deaths per 100,000 live births, non-Hispanic White: 19.1, and Hispanic: 18.2).² Almost two-thirds (65%) of the deaths occurred between 1 and 365 days postpartum (22% occurred during pregnancy and 13% on the day of delivery).^2,3 Additionally, in the United States, there is a large burden of severe postpartum morbidities, including cardiac events, cerebrovascular events, postpartum hemorrhage, kidney failure, and postpartum depression, anxiety, and posttraumatic stress disorder.⁴ Those who experience severe maternal morbidity, such as cardiac and cerebrovascular events, are at approximately twice the risk of dying postpartum compared with those who do not experience complications.⁴ The postpartum period, therefore, is not only a critical time for new mothers and families to recover from delivery, transition to parenthood, and consider future family planning, but also to mitigate immediate and lifelong health risks by addressing pregnancy-related, mental health, and chronic conditions, and promoting healthy behaviors. Postpartum care is intended to serve multiple purposes, such as supporting the transition to parenthood, enabling maternal-infant care and feeding, providing family planning care consistent with the patient’s goals, optimizing interpregnancy intervals, reducing mental and physical maternal morbidity, and preventing maternal mortality. Ideally, the goal of postpartum care is to ensure that birthing people not only survive pregnancy and its ramifications, but that they thrive.

More than 60 percent of pregnancy-related deaths are considered preventable.^3,5 Interdependent factors that have been implicated in causing deaths include systems of care factors (e.g., lack of coordination among providers), provider factors (e.g., misdiagnoses, ineffective treatment), and patient and family factors (e.g., lack of knowledge about warning signs). These factors play a particularly important role in the postpartum period, during which access to care and insurance coverage may be suboptimal. Receipt of optimal care may be limited by existing payment models, which are marked by variable coverage for key services. Global reimbursement models, in which providers receive bundled payments for postpartum care during the perinatal period (regardless of how many, or how few, postpartum visits occur),⁶ may disincentivize healthcare centers from providing adequate postpartum care.^7,8 Additionally, new parents may struggle to balance the demands of caring for a newborn with managing their own health. Given this confluence of factors, up to half of postpartum individuals in the United States do not receive routine healthcare after delivery.^9–12 Moreover, federal Medicaid coverage for pregnant individuals currently lapses after the last day of the month in which the 60^th postpartum day occurs, limiting longer-term postpartum care. With the goal of improving health outcomes and reducing disparities, the American Rescue Plan Act of 2021 allows states to request a waiver for postpartum Medicaid coverage to extend postpartum care for up to 1 year after delivery.¹³ As of February 23, 2023, 28 states and the District of Columbia have implemented approved extensions, seven states are planning to implement extensions, three states have pending legislations to seek federal approvals through waivers, and two states have proposed limited coverage extensions.¹⁴ Extended coverage for approved states began on April 1, 2022 and runs for a 5-year period.¹³

In addition to barriers to receiving postpartum care, coordination of care is often suboptimal. Care can be fragmented across multiple providers, each of whom focuses on specific aspects of maternal health (e.g., breastfeeding management, contraception, pelvic floor recovery, chronic health conditions, mental health), with no single care or support provider addressing needs holistically.¹⁵ In addition, there are various disparities by race, ethnicity, education level, socioeconomic position, geographic location, and immigrant status.¹⁶ The design of current postpartum care delivery also may not meet current needs. Many postpartum concerns, such as difficulty with breastfeeding and postpartum mood changes, occur within 1 to 2 weeks postpartum, but postpartum visits are commonly scheduled at 4 to 6 weeks after delivery. Most postpartum visits occur in-person, though many new mothers have difficulty traveling to clinics and their concerns may easily be addressed through virtual modalities. Postpartum visits in the United States often suffer from low attendance, with a mean of 72% (range 25% to 92%).¹⁷ Among Medicaid enrollees, rates are below 60%.¹¹ Low attendance may reflect a mismatch between how services are provided and the preferences of postpartum individuals. In addition, inadequate paid parental leave and/or paid time off for postpartum visits may contribute to low attendance, particularly among the most marginalized postpartum individuals.

According to the most recent estimates (2017 to 2019) in the United States, among the 65 percent of pregnancy-related deaths that occur in the postpartum period, 12 percent occur between 1 and 6 days after delivery, 23 percent between 7 and 42 days, and 30 percent between 43 days and 1 year.¹⁸ A 2018 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion recommends an initial interaction with the clinical care provider within 3 weeks postpartum, followed by ongoing care as needed and a comprehensive postpartum visit no later than 12 weeks (i.e., 84 days) postpartum.¹⁹ However, most postpartum deaths occur before 12 weeks postpartum; thus, having the comprehensive visit at 12 weeks may be too late. ACOG also recommends that postpartum individuals with chronic medical conditions (e.g., hypertensive disorders, diabetes) be further counseled regarding the importance of timely followup for ongoing care.¹⁹ However, ACOG does not provide details regarding what constitutes “timely followup” for postpartum individuals with chronic medical complications.

ACOG Committee Opinions are assessments of emerging issues in obstetrics and gynecology practice. The 2018 ACOG Committee Opinion included recommendations based on expert consensus. Updated clinical practice guidelines that are explicitly evidence-based (i.e., based on a systematic review) are needed to ensure that postpartum care is effective and meets the needs of postpartum individuals, their families, and the healthcare system. There are several important aspects of postpartum care to examine, such as where care is provided (e.g., home, clinic), managing postpartum care volume (e.g., optimal visit timing and frequency), types of providers (e.g., obstetricians and gynecologists [OB/GYNs], family physicians, pediatricians, midwives, advanced practice providers), peer support (community health workers, doulas, lactation peer counselors), and communication technology (e.g., telemedicine).

1.2. Purpose of the Review

This systematic review addresses healthcare for postpartum individuals within 1 year postpartum. Specifically, the review addresses the comparative benefits and harms of the following on postpartum individuals:

• Alternative strategies for postpartum healthcare delivery (Key Question 1)
• Extension of postpartum health insurance coverage or improvements in access to care (Key Question 2)

Outcomes reflecting offspring health were outside the scope of this review. The intended audience for this systematic review includes clinical practice guideline developers, policymakers, and OB/GYNs, midwives, maternal-fetal medicine specialists, family medicine clinicians, primary care physicians, pediatricians, nurse practitioners, and other providers of care or support for postpartum individuals. It is expected that the findings will inform clinical guidance for strategies to manage postpartum care.