Abstract
Objectives Postpartum visits are increasingly recognized as a window of opportunity for health care providers to counsel new mothers and promote healthy behaviors, including increasing contraceptive use and screening for postpartum depression. In Maryland, there is a lack of research on postpartum visit (PPV) attendance and the specific risk factors associated with not receiving postpartum care. In this study, we estimated the proportion of mothers in Maryland who attended a PPV and assessed maternal sociodemographic characteristics and health behaviors associated with PPV non-attendance. Methods Data were analyzed from the 2012 and 2013 Maryland Pregnancy Risk Assessment Monitoring System (n = 2204). Bivariate and multivariable logistic regression were performed to examine the association between covariates and PPV non-attendance. Results Overall, 89.6% of women reported PPV attendance. Bivariate analyses between maternal sociodemographic and health behavior characteristics and PPV non-attendance indicated that being unmarried (OR 3.03, 95% CI 2.12–4.31), experiencing infant loss (OR 7.17, 95% CI 2.57–19.97), working during pregnancy (OR 0.44, 95% CI 0.31–0.63) and not receiving dental care (OR 2.03, 95% CI 1.43–2.88) as significant risk factors for PPV non-attendance. After controlling for known and theoretical confounders, experiencing an infant loss (aOR 5.18, 95% CI 1.54–17.4), not receiving dental care (aOR 1.54, 95% CI 1.06–2.26) and working during pregnancy (aOR 0.61, 95% CI 0.41–0.93) emerged as strong predictors of PPV non-attendance. Conclusions for Practice Mothers who recently experienced an infant death were at greatest risk for not attending a PPV, suggesting the need to establish comprehensive support networks, including grief counseling and additional service reminders for mothers who experienced an infant death.
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A sensitivity analysis was performed to compare mothers who responded to the PPV question to mothers who did not. Relative to mothers who responded to the PPV question, mothers who did not respond were three times as likely to not be married and have an unintended pregnancy (data not shown). Additionally, they were 5.24 times as likely to be <20 years old, as compared to mothers who completed item 65. Eighty-six percent of mothers who did not respond to the question about PPV also did not respond to the survey question about postpartum insurance. There were no observed differences in pre-pregnancy or postpartum depression, Kotelchuck prenatal care utilization or maternal education, when compared to respondents.
The Affordable Care Act supported Medicaid expansion to offer comprehensive insurance coverage to eligible pregnant women, including full Medicaid benefits until 60 days postpartum. Beginning in 2014, Maryland expanded its Medicaid coverage and in effect covered family planning services beyond the postpartum period for women who would have otherwise lost their coverage. While some states have permanent, State Plan Amendments for Medicaid coverage, Maryland has a temporary waiver.
Emphasizing the importance of the PPV as it pertains to reproductive health counseling and planning is increasingly recognized as priority content area to be discussed during the PPV. Speroff and Mishell recommend that providers encourage women to return for a PPV within three weeks post-childbirth to reduce the interval between childbirth and contraceptive uptake and subsequently, to prevent unintended pregnancies and short interpregnancy intervals. They note that often women engage in sexual intercourse by 6 weeks postpartum, placing them at risk for an unintended pregnancy (Speroff and Mishell 2008). Further, women who do not breastfeed begin ovulation as soon as four weeks post-childbirth, indicating the need for women to begin contraception as soon as possible (Connolly et al. 2005). In their evaluation of the “Quick Start” Contraceptive Initiation method in Federally Qualified Health Centers (FQHCs), Stechna et al. found that initiating a contraceptive at the 6-week PPV improved contraceptive uptake (Stechna et al. 2013). Additional research is needed to strengthen the evidence-base for postpartum care, specifically as it pertains to increases in family planning service utilization and mental health diagnoses and referral to care.
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Acknowledgements
We thank the Maryland Department of Health and Mental Hygiene for granting access to their PRAMS data. Further, we acknowledge the Centers for Disease Control and Prevention’s PRAMS Working Group (Cooperative Agreement #UR6/DP-000542).
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Morgan, I., Hughes, M.E., Belcher, H. et al. Maternal Sociodemographic Characteristics, Experiences and Health Behaviors Associated with Postpartum Care Utilization: Evidence from Maryland PRAMS Dataset, 2012–2013. Matern Child Health J 22, 589–598 (2018). https://doi.org/10.1007/s10995-018-2428-y
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DOI: https://doi.org/10.1007/s10995-018-2428-y