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.
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).
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).
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.
