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Saldanha IJ, Adam GP, Kanaan G, Zahradnik ML, Steele DW, Chen KK, Peahl AF, Danilack-Fekete VA, Stuebe AM, Balk EM. Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review. JAMA Netw Open 2023; 6:e2316536. [PMID: 37266938 PMCID: PMC10238947 DOI: 10.1001/jamanetworkopen.2023.16536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/02/2023] [Indexed: 06/03/2023] Open
Abstract
Importance Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. Objective To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. Evidence Review Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. Findings A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. Conclusions and Relevance The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.
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Affiliation(s)
- Ian J. Saldanha
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ghid Kanaan
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Michael L. Zahradnik
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Dale W. Steele
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Departments of Emergency Medicine and Pediatrics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Kenneth K. Chen
- Department of Medicine, Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Alex F. Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Valery A. Danilack-Fekete
- Center for Outcomes Research and Evaluation, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Alison M. Stuebe
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill
| | - Ethan M. Balk
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
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