Most pregnant people are in regular touch with their maternity care providers over the course of nine months, with ever-more-frequent visits, tests, and scans as their due date nears. For many patients, this is the first time in their lives they’ve been in such close, routine contact with the health system.
Then, after delivering the child, this attention all but vanishes. Mothers are told to schedule a follow-up postpartum visit with their maternity care provider about six weeks after birth, and that’s about it. This is despite the fact that 52% of maternal deaths happen in the year following birth, and that maternal conditions like preeclampsia, gestational diabetes, and postpartum depression (PPD) all warrant monitoring after a baby is born.
It’s what Jessica Cohen, a health economist at the Harvard Chan School of Public Health, calls the “postpartum cliff.” She experienced it herself: After being diagnosed with preeclampsia during pregnancy, she was told to follow up with a primary care physician — but there was no established structure for her to do so.
“There was no formal communication to the PCP [primary care physician]. I had to print out my records and bring them to the primary care doctor because there was no record sharing,” she told STAT.
A new study co-authored by Cohen, published Tuesday in JAMA Network Open, tested a different approach to helping postpartum women transition to regular health care. The model is focused on reducing the administrative burden for new parents via automated, op-out appointments with primary care physicians, as well as reminders and some educational messages.
Cohen said she began devising the intervention when Massachusetts expanded postpartum Medicaid to a year after childbirth, because that opened up opportunities to provide care to more postpartum individuals.
“Throughout the postpartum year, how do we move toward better health and well-being? That requires that postpartum people get attention,” said Cohen. “Insurance coverage is a necessary condition, but there’s really nothing else that supports this transition after delivery away from your pregnancy care provider toward primary care.”
Transitioning new mothers from pregnancy to primary care
Medicaid coverage — which pays for 41% of births in the U.S. — has been extended to a year postpartum in all but three states. But Cohen says that too many new mothers fall through the cracks because of the same lack of structural support she encountered. That motivated her to think of ways behavioral economic interventions could improve the likelihood of new mothers transitioning to primary care.
This is an issue the maternal health community has been actively trying to address through various approaches. Some smaller, more integrated clinics screen mothers for specific conditions (diabetes, hypertension, postpartum health issues) during their well-child visits, though that doesn’t necessarily address the need for birth parents to transition to the care of a primary care doctor.
To test Cohen’s model, the study randomized 360 English- and Spanish-speaking patients who had given birth between November 2022 and December 2023 and had conditions including anxiety and depression, hypertensive disorder, and diabetes, dividing them into two groups.
The intervention group received targeted text messages explaining the importance of follow-up postpartum care with a primary care physician, and offering help scheduling an appointment. The patients’ options were opting out or sharing their scheduling preferences. The study staff would then schedule a visit within four months postpartum, or within a year from their last primary care visit if they had one during the previous year. Reminders were then sent one month after the delivery date, and one week prior to the visit.
The study used automated SMS messages, with no direct interactions with people, in order to make the intervention as simple and low-resource as possible, said Mark Clapp, a maternal and fetal medicine specialist at Harvard and the paper’s lead author.
While automation and relief of administrative burden was the main focus of the intervention, the wording of messages also received dedicated attention in the study design.
“There is quite a lot of literature in behavioral economics that wording and framing matters,” Cohen said. “It can move the needle on patient behavior a little bit.” This is why the study adopted what is known as “salient labeling,” or wording that gives the most simple, direct indication of what the appointment is for. In the study’s case, the label was “pregnancy to primary care transition appointment,” to mark the end of maternity care while highlighting that there was another dedicated health care structure to move to.
The improvement was significant: 40% of patients in the intervention group completed their follow-up primary care physician visits, compared to 22% of the control group, which received no messages.
The path to expanding postpartum care
The paper shows automated interventions could be an effective tool to increase postpartum engagement with the health system, said Louise Wilkins-Haug, the head of maternal and fetal medicine at Mass General Brigham, who was not involved in the study.
Wilkins-Haug leads Brigham’s Center for Connected Postpartum Care, with the goal of providing continuum care for women who had complicated pregnancies or developed gestational conditions. In her program, the administrative burden is eased by direct human intervention. Health care workers follow up with patients to ensure they keep up with their screenings (for instance, taking their blood pressure) and their appointments.
The goal of the program is to help postpartum women receive care at least through the year after delivery, and potentially for a second year. With a relatively limited patient pool, it’s possible to employ these more labor-intensive interventions. But focusing on women who have had complications or conditions arise during pregnancy is only “the tip of the iceberg,” said Wilkins-Haug, noting the importance of finding ways — such as automated interventions — to increase engagement with steady primary health care for the whole postpartum population.
But in order to meaningfully expand postpartum care, the U.S. needs more primary care physicians. The shortage is such that without support finding a provider, many postpartum patients would receive limited benefit from reminder messages, said Clapp. In addition, many new mothers who are on Medicaid didn’t have access to coverage before pregnancy, said Clapp — meaning that many lower-income mothers don’t have a preexisting provider to go visit, no matter how many reminders they get.