In a large urban community population-based study we explored postpartum medical care utilization and whether clinically relevant maternal and obstetric risk factors were associated with postpartum follow-up among women living in low-SES whom had recently given birth. Our results confirm that even though postpartum care utilization is well understood by clinicians to be an important preventative care component of maternal health, many women nevertheless fail to utilize these services, even when they are available. More importantly, women living in low-SES, who are also among the group reportedly at greatest risk for developing postpartum complications, represent the group with the lowest utilization rates (Chu et al. 2007; Morgan et al. 2018). Because a considerable amount of attention has recently been directed towards postpartum care (ACOG Committee Opinion No. 736, 2018) this study was designed to explore identifiable factors associated with reduced postpartum care utilization.
Not surprisingly, perceptions regarding the benefits of early maternal care among new mothers and clinicians often differ (Martin et al. 2014). Postpartum care in the United States is generally perceived by clinicians as preventative, providing the opportunity to assess physical, social and psychological adjustment to early motherhood (Blenning et al. 2005), whereas recent research has demonstrated that pregnant and postpartum women often lack knowledge about postpartum health concerns and its preventative benefits (Martin et al. 2014). This work demonstrates that factors beyond affordability (e.g. The Affordable Care Act of 2010) represent existing barriers to postpartum care utilization (Ko et al. 2013). Indeed, our findings reveal that despite the vast majority of women in this study having similar government subsidized healthcare, those women who had fewer prenatal visits, were of younger maternal age, or had delivered more children were significantly less likely to make use of available postpartum follow-up healthcare compared to those women who engaged in regular prenatal care, were of older maternal age, or had fewer children. While numerous reasons exist why a woman may elect not to return for available postpartum care,(Smith et al. 2000; Murphy et al. 2014; Syed et al. 2013; Bryant et al. 2006) evidence suggests that those who do may experience improved childhood outcomes (Sondik et al. 2010; WHO, 2014).
Awareness of health literacy disparities among low-SES and minority populations has been steadily increasing (Nesbitt and Palomarez, 2016). However, the relationship between low-SES and health service utilization is complex with factors that remain mostly undetermined or poorly understood (Muennig et al. 2005). What is known however is that the relative increase in morbidity with lower income accounts for a greater loss of health than any risk factor other than normal human aging (Cooper et al. 2012). The widely held hypothesis that poor health literacy across virtually all areas of medical care is a major determinant in the observed disparities among the lower-SES, minority populations and those with lower academic achievement (Mantwill et al. 2015). To this point, the American Congress of Obstetricians and Gynecologists (ACOG) released a Committee Opinion noting the need for increased attention to patients health literacy needs in the effort to promote better health outcomes as they relate to reproductive health (ACOG Committee Opinion No. 676, 2016). Supporting this recommendation, a recent meta-analysis exploring literacy and health disparity confirmed that health literacy is directly related to health utilization as it relates to reproductive health (Mantwill et al. 2015). Unfortunately, the majority of studies surveyed only focused on the relationship between health literacy and prenatal care, as opposed to postnatal care. The few studies surveyed that were focused on postnatal care were generally limited to birth outcomes, glucose follow-up or breast feeding behaviors (Lu and Prentice, 2002). More so, these studies generally sampled those who returned for postpartum care thereby assessing those who were either already literate about the benefits of postpartum care or simply compliant patients.
Given the current attention postpartum depression has been receiving, it is important to note that lower health literacy has also been shown to be associated with increased postpartum depression symptomatology (Weiss et al. 2009). Similarly, other studies have shown that improving health literacy around postpartum mood improves postpartum depressive symptomatology in those women who choose to return for screening (Howell et al. 2012). While this association seems to be promising, the association may in part represent a causality dilemma. That is, those women experiencing the more severe depressive symptomatology likely do not possess the necessary resources or do not perceive the need (Nadeem et al. 2009) to return for their follow-up care appointment. This is something that should be explored further. Nevertheless, our findings further underscore that given how pregnant and peripartum women represent a medically captured population, additional efforts towards increasing health literacy during these appointments may encourage more equitable care, further promote healthy reproductive behaviors as well as assist in increasing postpartum service utilization among those at greatest risk.
Although these findings are of potential importance, we do recognize some possible study limitations. First, the population explored is a clinical sample from a care-based clinic. As a convenience sample, it may not represent the entire population of women. Second, we only assessed each woman once during the sampling years. While it is probable that some woman gave birth more than once during the 2012-2015 time period assessed, their attendance or absence, whether repeated or not was not included. This methodology was chosen to avoid the problem of correlated observations between successive births and seemed to be the clearest approach. Third, the data we utilized was from electronic medical records and as such available data is subject to clinician detection, diagnostic certainty and recording accuracy. This is a well-understood limitation of medical registries and registry-based resolution. Finally, by design, the study’s outcome variable only represented treatment-seeking behavior. While, we did not assess the reasons why women elected to return, it is possible that some women returned without choice or without an understanding of choice. As such, the actual incidence of postpartum follow-up, as a function of voluntary behavior may have been overestimated.
Finally, in the effort to further reduce maternal morbidity and mortality, recent recommendations from the American College of Obstetricians and Gynecologists (ACOG) have noted the importance of a comprehensive ‘fourth trimester’ of care, transitioning from the traditionally recommended single postpartum visit within the first 6 weeks to multiple visits over the three months following child delivery. As noted in the ACOG Committee Report, “All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum” (ACOG Committee Opinion No. 736, 2018). Similarly, in recent years there has been both lay and legislative initiatives to provide and in some cases mandate universal depression screening in the postpartum period. However, these efforts will remain largely ineffective as long as a large percentage of high-risk women continue to choose not to return for postpartum healthcare services. Given that pregnant women represent a population that is receiving regular medical care, the results of this study point to the need and opportunity to address the importance of postpartum care follow-up during perinatal appointments and in the immediate window following delivery. Indeed, novel approaches towards enhancing this understanding and/or conveying the importance of postpartum healthcare to those least likely to make use of these services are needed. Further research should therefore focus on interventions to improve postpartum health literacy for those at greatest risk for poor postpartum healthcare utilization.