Study shines light on the health of pregnant people in the year after birth

Maternal mortality in the U.S. is on the rise and more than half of maternal deaths occur in the postpartum year.

A study by Columbia University Mailman School of Public Health and the School of Social Work provides insights into the challenges that birthing people face in the year after birth—both medical and social—which could be drivers of postpartum morbidity and mortality. The study is the first large-scale and representative survey of postpartum health ever conducted in the U.S. The findings are published online and in print in the journal Health Affairs.

"Most people think of labor and birth as the most dangerous part of pregnancy, but the highest risk time for maternal morbidity and mortality is actually after the baby is born," said Jamie Daw, Ph.D., Columbia assistant professor of health policy and management, and first author. "Yet, the postpartum period has long been overlooked and we understand very little about, and have taken very little action, to address the social and medical needs of mothers after birth."

In an effort to improve postpartum health, thirty-seven states and Washington, D.C., have adopted a new federal option to extend pregnancy Medicaid eligibility to one year postpartum. Medicaid covers almost half of all pregnancies in the U.S. and an even larger share of births among Black, rural, and low-income mothers who are at the highest risk of adverse outcomes.

"Pregnancy Medicaid typically ends 60 days after birth. By providing public health insurance through to one year postpartum, states hope to improve access to health care services that that will translate to better health," said Heidi Allen, Ph.D., associate professor, and senior author. In 2011–15, nearly two-thirds of maternal deaths were deemed to have been preventable with timely and high-quality medical care.

To shed light on the services and supports that postpartum people need, the researchers launched the Postpartum Assessment of Health Survey (PAHS), the first multi-state representative survey on postpartum health in the year after birth in the U.S. Data was collected from January 2021 to March 2022 in six states and New York City.

The researchers measured a comprehensive suite of self-reported variables related to postpartum well-being, including health insurance; health care access, quality, and use; health outcomes; substance use, and social needs. The findings are reported separately for people with Medicaid and those who had commercial insurance when they gave birth to better understand the unique needs of each population and how each program benchmarks against the other.

Approximately 1 in 5 mothers reported delaying or forgoing needed care in the postpartum year regardless of insurance type. Compared with respondents who had commercial insurance, Medicaid respondents were less likely to have a usual source of care and reported substantially less use of primary, specialty, and dental care in the postpartum year.

One in 4 Medicaid beneficiaries reported no health care use at all in the year after birth. With approximately 12% of Medicaid beneficiaries reporting depression symptoms and about 14% having anxiety symptoms at one year postpartum, the researchers point to the need for focusing on efforts to expand access to the availability of mental and behavioral health care.

The study also found that many social needs—which can affect health and well-being after birth—such as food insecurity, intimate partner violence, and financial strain were significantly higher in the Medicaid population. Among Medicaid beneficiaries, 20% reported not having enough food to feed their family, 57% reported financial strain and 7% reported experiencing intimate partner violence since giving birth.

"Our results clearly show there are significant gaps in postpartum health care access, particularly for mental health services and for mothers with Medicaid coverage. It is also clear that policymakers need to intervene beyond health care to address beneficiaries' social needs which are likely contributing to poor maternal health outcomes and disparities," observed Daw.

Daw and colleagues suggest that to achieve progress in improving overall postpartum health, states should leverage Medicaid's flexibilities and connections with other social services. And while postpartum people with commercial insurance generally had lower levels of social needs, higher care use, and better health outcomes than those with Medicaid, many outcomes still fell short of what may be considered ideal.

"Policymakers are actively working to improve maternal health in the U.S. Our findings emphasize that translating policies such as postpartum Medicaid extensions into improved postpartum health will require states to improve the uptake and availability of services to address social determinants of health, including food insecurity, housing instability, poverty, and intimate partner violence for families with young children," said Daw.

Co-authors include Kristen Underhill, Cornell University; and Chen Liu, Columbia University.