Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

Health insurance, race, and receipt of a postpartum visit among patients giving birth in a referral hospital in the US South

BACKGROUND

The United States faces a maternal mortality crisis with stark and unacceptable disparities. Postpartum care (PPC) is crucial for identifying and managing complications after childbirth. However, access to PPC is inconsistent, especially for marginalized individuals such as Black birthing people and Medicaid beneficiaries. We examined the effect of the intersection of race and insurance type on the patients' receipt of postpartum care (PPC) in a large referral hospital in the Southeast US.

METHODS

In this cross-sectional retrospective cohort study, we analyzed data from electronic health records for 14,531 people who gave birth from January 2014 to March 2020 in a labor and delivery unit caring for more than 4000 births per year in the Southern US. Variables included race/ethnicity, insurance status, maternal age, number of living children, mode of delivery, and presence of chronic conditions. We produced descriptive statistics and used multivariable log-binomial models to estimate adjusted risk ratios (RR) for receiving PPC, including interaction terms between race and insurance.

RESULTS

In a retrospective analysis of electronic health records of 14,531 patients who gave birth in a large health system in the US South, 53.0% of patients received a clinic-based PPC visit. Having private insurance, compared to Medicaid insurance, was associated with a higher likelihood of receiving clinic-based PPC but a lower likelihood of visiting the Maternity Evaluation Unit, a special unit for urgent or emergency care.

CONCLUSION

Type of insurance is associated with receipt of postpartum care. Disparities in PPC are modestly influenced by the interaction between race and insurance type. Private insurance, as compared to Medicaid insurance, increases the likelihood of postpartum care across all racial groups with some differences in this relationship by race/ethnicity. Next steps should include qualitative research that helps us better understand the differences in receipt of PPC by insurance coverage and the interactions between insurance status and race. Implementation research should also test practical strategies to increase access to postpartum care, particularly for Medicaid-insured and other marginalized individuals.

Sepsis in obstetric care for the emergency clinician: A review

Sepsis remains a leading cause of mortality among pregnant and recently pregnant patients, rendering it a subject of vital importance to emergency clinicians in the US. However, death by sepsis has been found to be largely preventable with prompt and appropriate intervention. This narrative review provides a summary of the physiologic, epidemiologic, and systemic factors specific to obstetric sepsis that contribute to delays in diagnosis and treatment. Additionally, it provides a framework for emergency department providers to approach infection identification, antimicrobial selection, and appropriate resuscitation prior to disposition.

"Health challenges and midwifery support for new mothers after childbirth: A cross-sectional study in Sweden"

OBJECTIVE

This study aimed to investigate new mothers' self-rated and perceived health problems and complications; their reasons for, and the frequency of, emergency department visits; how emergency department visits were associated with sociodemographic and obstetric factors; and new mothers' experiences of received support from the midwifery clinic.

DESIGN

A cross-sectional survey.

SETTING AND PARTICIPANTS

The study was conducted at 35 of 64 midwifery clinics in Stockholm, Sweden. The study population consisted of 580 new mothers.

MEASUREMENT AND FINDINGS

Descriptive statistics and logistic regression were used. New mothers experience a range of different health problems and complications during the first four weeks after giving birth. Sixteen percent sought emergency care. The odds of seeking emergency care increased for women with higher age and poorer self-rated health. Sixty-three percent of the new mothers received support from a midwife in primary care within the first four weeks after childbirth. Mothers who did not receive the support they wanted, expressed a wish for earlier contact and better accessibility.

CONCLUSION AND IMPLICATION FOR PRACTICE

It is notable that 16 % of new mothers seek emergency care in the first weeks after childbirth. This study has practical implications for midwifery practice and policy. There is a need for tailored postnatal support strategies so that midwives potentially are able to mitigate emergency department visits. Further studies should look at whether the high number of emergency visits among new mothers varies throughout Sweden, and whether this may be a result of reduced time of hospital stay after childbirth or other factors.

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017

BACKGROUND

Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks.

OBJECTIVE

To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status.

METHODS

Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores.

RESULTS

Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88).

CONCLUSIONS

Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.