• Healthcare Delivery Strategies – Where Care Is Provided
  • For general postpartum care (5 randomized controlled trials [RCTs] and 1nonrandomized comparative study [NRCS]), whether the visit is conducted at home/by telephone or at the clinic may not impact depression or anxiety symptoms (low strength of evidence [SoE]).
  • For breastfeeding care (7 RCTs and 1 NRCS), whether the initial visit is conducted at home or at the pediatric clinic may not impact depression symptoms (up to 6 months postpartum), anxiety symptoms (up to 2 months), hospital readmission (up to 3 months),or other unplanned care utilization (up to 2 months) (all low SoE).
• Healthcare Delivery Strategies – How Care Is Provided
  • For general postpartum care (4 RCTs), integration of care (e.g., combined versus separate postpartum/well-child visits, multidisciplinary postpartum clinic versus standard care) may not impact depression symptoms or substance use up to 1 year (all low SoE).
• Healthcare Delivery Strategies – When Care Is Provided
  • For contraceptive care (9 RCTs), earlier, compared with later, contraception is probably associated with comparable continued intrauterine device (IUD) use at 3 and 6 months but greater implant use at 6 months (all moderate SoE).
• Healthcare Delivery Strategies – Who Provides Care
  • For breastfeeding care, peer support (10 RCTs) is probably associated with higher rates of any breastfeeding at 1 month and 3 to 6 months and of exclusive breastfeeding at 1month but with comparable rates of exclusive breastfeeding at 3 months and nonexclusive breastfeeding at 1 and 3 months (all low SoE). Care by a lactation consultant (6 RCTs and 1 NRCS) is probably associated with higher rates of any breastfeeding at 6 months but not at 1 month or 3 months. Lactation consultant care is probably associated with comparable rates of exclusive breastfeeding at 1 or 3 months(all moderate SoE).
• Healthcare Delivery Strategies – Coordination and Management of Care
  • For screening/testing care (1 RCT and 2 NRCSs), provision of reminders for testing is probably associated with greater adherence to oral glucose tolerance testing up to 1 year postpartum but not random glucose testing or hemoglobin (Hb) A1c testing (moderate SoE).
  • For general postpartum care (2 NRCSs) and screening (1 RCT and 2 NRCSs), no conclusions are feasible because of insufficient evidence.
• Healthcare Delivery Strategies – Use of Information or Communication Technology (IT)
  • For breastfeeding care (7 RCTs), IT use and nonuse are probably associated with comparable rates of any breastfeeding at 3 months and 6 months and of exclusive breastfeeding at 3 months (all moderate SoE).
• Healthcare Delivery Strategies – Interventions Targeting Healthcare Providers
  • For breastfeeding care (2 RCTs), no conclusions are feasible because none of the prioritized outcomes were reported.
  • For screening care (1 RCT and 1 NRCS), no conclusions are feasible because of insufficient evidence.
• Health Insurance – More comprehensive insurance (28 NRCSs) is probably associated with greater attendance at postpartum visits (moderate SoE based on 11 NRCSs) and may be associated with fewer preventable readmissions and emergency room (ER) visits (low SoE based on 1 NRCS). There was insufficient evidence regarding symptoms or diagnoses of mental health conditions.

Objectives. This systematic review assesses postpartum care for individuals up to 1 year after pregnancy. We addressed two Key Questions (KQs) related to the comparative effectiveness and harms of: (1) alternative strategies for postpartum healthcare delivery and (2) extension of postpartum health insurance coverage.

Data sources and review methods. We searched Medline®, Embase®, Cochrane CENTRAL, CINAHL®, and ClinicalTrials.gov from inception to November 16, 2022, to identify comparative studies in the United States and Canada (for KQ 1) and in the United States (for KQ 2). We extracted study data into the Systematic Review Data Repository Plus (SRDR+; https://srdrplus.ahrq.gov). We assessed the risk of bias and evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42022309756).

Results. We included 50 randomized controlled trials (RCTs) and 14 nonrandomized comparative studies (NRCSs) for KQ 1 and 28 NRCSs for KQ 2. Risk of bias was moderate to high for most RCTs and all NRCSs. KQ 1: Regarding where healthcare is provided, for general postpartum care (6 studies), whether the visit is at home/by telephone or at the clinic may not impact depression or anxiety symptoms (low SoE). For breastfeeding care (8 studies), whether the initial visit is at home or at the pediatric clinic may not impact depression symptoms up to 6 months postpartum, anxiety symptoms up to 2 months, hospital readmission up to 3 months (summary relative risk [RR] 1.38, 95% confidence interval [CI] 0.90 to 2.13; 4 studies), or other unplanned care utilization up to 2 months (low SoE, all outcomes). Regarding how care is provided, for general postpartum care (4 studies), integration of care (i.e., care provided by multiple types of providers) may not impact depression symptoms or substance use up to 1 year (low SoE). Regarding when care is provided, for contraceptive care (9 studies), compared with later contraception, earlier contraception start is probably associated with comparable continued IUD use at 3 and 6 months but greater implant use at 6 months (summary RR 1.36, 95% CI 1.13 to 1.64; 2 RCTs) (moderate SoE). Regarding who provides care, for breastfeeding care (19 studies), compared with no peer support, peer support is probably associated with higher rates of any breastfeeding at 1 month (summary effect size [ES] 1.13, 95% CI 1.03 to 1.24; 4 studies) and 3 to 6 months (summary ES 1.22, 95% CI 1.06 to 1.41; 4 studies) and of exclusive breastfeeding at 1 month (summary ES 1.10, 95% CI 1.02 to 1.19; 6 studies) but probably yields comparable rates of exclusive breastfeeding at 3 months and nonexclusive breastfeeding at 1 and 3 months (all moderate SoE). Compared with no lactation consultant, breastfeeding care by a lactation consultant is probably associated with higher rates of any breastfeeding at 6 months (summary ES 1.43, 95% CI 1.07 to 1.91; 3 studies) but not at 1 month or 3 months (all moderate SoE). Lactation consultant care may not be associated with rates of exclusive breastfeeding at 1 or 3 months (moderate SoE). Regarding coordination/management of care, provision of reminders for testing is probably associated with greater adherence to oral glucose tolerance testing up to 1 year postpartum but not random glucose testing or hemoglobin A1c testing (moderate SoE). Regarding use of information or communication technology (IT; 8 studies), IT use for breastfeeding care is probably associated with comparable rates of any breastfeeding at 3 months and 6 months and of exclusive breastfeeding at 3 months (all moderate SoE). Because of sparse evidence, inconsistent results, and/or the lack of reporting of prioritized outcomes, no conclusions related to interventions targeting healthcare providers are feasible (4 studies). KQ 2: Regarding health insurance (28 studies), more comprehensive health insurance is probably associated with greater attendance at postpartum visits (moderate SoE) and may be associated with fewer preventable readmissions and emergency room visits (low SoE).

Conclusion. Most studies included in this systematic review enrolled predominantly healthy postpartum individuals. Researchers should therefore design studies that, either entirely or in part, enroll individuals at high risk of postpartum complications due to chronic conditions, pregnancy-related conditions, or incident or newly diagnosed conditions. New high-quality research is needed, especially for interventions targeting healthcare providers and the impact of more comprehensive or extended health insurance on postpartum health. Patient-reported outcomes, such as quality of life, should also be reported. Researchers should report separate data for various population subgroups, which could help close gaps in health outcomes among the races of postpartum individuals in the United States.

Saldanha IJ, Adam GP, Kanaan G, Zahradnik ML, Steele DW, Danilack VA, Peahl AF, Chen KK, Stuebe AM, Balk EM. Postpartum Care up to 1 Year After Pregnancy: A Systematic Review and Meta-Analysis. Comparative Effectiveness Review No. 261. (Prepared by the Brown Evidence-based Practice Center under Contract No. 75Q80120D00001.) AHRQ Publication No. 23-EHC010. PCORI Publication No. 2023-SR-01. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. DOI: https://doi.org/10.23970/AHRQEPCCER261. Posted final reports are located on the Effective Health Care Program search page.

Saldanha IJ, Adam GP, Kanaan G, et al. Delivery strategies for postpartum care: a systematic review and meta-analysis. Obstet Gynecol. 2023 Aug 3. [Epub ahead of print.] PMID: 37535967. doi: 10.1097/AOG.0000000000005293.

Saldanha IJ, Adam GP, Kanaan G, et al. Health insurance coverage and postpartum outcomes in the U.S.: a systematic review. JAMA Network Open. 2023;6(6):e2316536. DOI: www.doi.org/10.1001/jamanetworkopen.2023.16536.