Postpartum Care Visits --- 11 States and New York City, 2004

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend that women who give birth have a postpartum care visit (PPCV) 4--6 weeks after delivery (1). PPCVs provide important opportunities to assess the physical and psychosocial well-being of the mother, counsel her on infant care and family planning, and detect and give appropriate referrals for preexisting or developing chronic conditions such as diabetes, hypertension, or obesity. To estimate the prevalence of PPCVs among U.S. women who deliver live infants, CDC analyzed population-based 2004 data (the most recent data available) from 12 areas (11 states and New York City) participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). This report summarizes the results of that analysis, which indicated that although the overall prevalence of PPCVs among U.S. women who deliver is high (89%), rates are significantly lower in certain population subgroups (e.g., 71% among women with <8 years of education and 66% among women who had not received prenatal care). To help reach all population subgroups, the importance of the PPCV should be communicated to all women at the time of discharge from the hospital after delivery.

PRAMS is an ongoing state- and population-based surveillance system designed to collect self-reported information on maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live infants. PRAMS is administered by CDC in collaboration with participating state and New York City health departments.* Each month, 100--300 randomly sampled mothers who have given birth during the previous 2--6 months are surveyed using stratified, systematic sampling of birth certificates of infants born to state residents. Mothers receive a questionnaire by mail, and nonrespondents receive follow-up mailings. Additional attempts to contact nonrespondents are made by telephone. Most states oversample certain smaller populations at higher risk, such as mothers of low-birthweight infants (<2500 g [<5 lbs, 8 oz]), to ensure adequate representation of these subgroups. Self-reported survey data are linked to birth certificate data and weighted to adjust for survey design, noncoverage, and nonresponse. The PRAMS questionnaire consists of core questions that appear on all state surveys, standard questions that states may select, and state-developed questions tailored to the individual needs of the states. In 2004, a question about PPCVs was a state-selected standard question for nine states and New York City; two states used slightly different wording for their PPCV question.

Data from 11 states (Arkansas, Georgia, Hawaii, Minnesota, New Jersey, New Mexico, Oklahoma, Rhode Island, South Carolina, Vermont and West Virginia) and New York City were included in this analysis because these localities used a question in 2004 pertaining to PPCVs. In most of the included states and New York City, mothers were asked a standard question, "Since your new baby was born, have you had a postpartum checkup for yourself? (A postpartum checkup is the regular checkup a woman has after she gives birth)." Two states modified the question slightly. In New Mexico, mothers were asked, "Since your new baby was born, have you seen a doctor, nurse, or midwife for yourself for any of these reasons?" Mothers could select from the following three options: "I received a routine checkup (6 weeks after delivery); I received care for a health problem; or I received a birth control method." If a mother selected the first answer, she was considered to have had a PPCV. In Oklahoma, mothers were asked, "After you delivered your new baby, did any of these things happen?" and then were asked to respond "yes" or "no" to "I had a postpartum checkup."

The annual weighted survey response rate during 2004 was 73.1% (range: 69.7%--82.8%). Women who did not answer the PPCV question were excluded from the analysis (n = 402; 2.1%), and data were analyzed for 18,558 respondents. Overall and state-specific PPCV rates and 95% confidence intervals were calculated. In addition, the prevalence of PPCV by selected maternal and infant characteristics was assessed; statistically significant differences (p<0.05) were tested using Pearson chi-square tests. Prevalence estimates, 95% confidence intervals, and chi-square tests were calculated using statistical software to account for the complex survey design.

The overall prevalence of PPCVs among women who delivered live infants was high (88.7%), but varied among the 11 states and New York City (range: 84.0%--93.9%) (Table 1). The PPCV prevalence varied significantly by several, but not all, maternal and infant characteristics (Table 2). A few subgroups had significantly lower PPCV rates, including mothers with <8 years of education (71.2%), mothers who had not received prenatal care (65.7%), mothers who had received late prenatal care (71.2%), and mothers whose infants did not have well-baby checkups (59.5%). The rate of PPCV did not vary significantly by any infant outcome (i.e., period of gestation, birthweight, and plurality).

Reported by: SY Chu, PhD, WM Callaghan, MD, CK Shapiro-Mendoza, PhD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; CL Bish, PhD, EIS Officer, CDC.

Editorial Note:

As with previous national and state-based reports (2--4), the overall prevalence of PPCVs in 2004 was high (89%); however, significantly lower prevalences (<75%) were observed among women with fewer years of education, who had received no or late prenatal care, and whose infants did not have a well-baby checkup. A study conducted using data from 1985--1987 also reported low prevalence of PPCV among women with fewer years of education (77% for those with a ninth-grade education or less) and inadequate prenatal care (63%) (4). The findings from that study suggested that women who deliver and have low PPCV rates might exhibit fewer health-seeking behaviors, have lower use of health care, or have less access to health care than women with high PPCV rates.

Historically, the primary reasons for recommending that a woman have a PPCV have been to assess her current health status and to begin preconception or family-planning counseling (1). Additionally, a PPCV is important as an opportunity to follow up women at increased risk for certain conditions such as hypertension, diabetes, and postpartum depression. As one example, both the American Diabetes Association and ACOG recommend postpartum glucose-tolerance testing in women in whom gestational diabetes mellitus (GDM) has been diagnosed (5); however, fewer than half (37%--45%) of women with GDM get tested for diabetes postpartum (6,7). The prevalence of GDM, an obesity-related condition, is increasing concurrent with the rising prevalence of obesity. Because approximately 50% of women with GDM will progress to type 2 diabetes within 5--10 years (8), postpartum glucose-tolerance testing during a routine PPCV is an important health intervention that can facilitate early diagnosis and treatment of type 2 diabetes. In addition, detecting impaired glucose tolerance in asymptomatic women who have GDM provides opportunities to offer dietary counseling, exercise recommendations, and other weight-management strategies for delaying or preventing diabetes (8,9).

The findings in this report are subject to at least three limitations. First, these data represent only 16% of all U.S. births in 2004, and the information obtained from these states might not be generalizable to the entire United States. Second, PRAMS data are self-reported by new mothers 2 to 9 months after delivery and thus are subject to recall error; birth certificate information is subject to reporting and recording errors. Finally, information on certain behaviors, such as heavy alcohol consumption and cigarette smoking, might be underreported.

Nearly 90% of women in this study population received their PPCV and thus potentially had an opportunity to address health concerns with their health-care providers, including concerns that first became apparent during their pregnancies and those related to ongoing health maintenance. Among women who typically have lower use of or access to health care (e.g., those with < 8 years of education and those who do not receive prenatal care), the prevalence of PPCVs was substantially lower. Under current AAP and ACOG recommendations, all women should be encouraged to receive a PPCV 4--6 weeks postpartum, and the importance of this visit should be communicated to women before their discharge from the hospital after delivery. Monitoring PPCV should be expanded and standardized, and data collected during these visits should be used to guide health-care--system planning. Understanding who is at risk for not receiving PPCVs is a first step in developing targeted messages for women, clinicians, and public health practitioners to encourage the receipt of PPCVs.

Acknowledgments

The findings in this report are due in part, to contributions by members of the PRAMS Working Group and the CDC PRAMS Team, Div of Reproductive Health, CDC.

References

1. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care, 6th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007.
2. National Committee for Quality Assurance. The state of health care quality 2007. Washington, DC: National Committee for Quality Assurance; 2007. Available at http://web.ncqa.org/tabid/543/default.aspx.
3. Bryant AS, Haas JS, McElrath TF, McCormick MC. Predictors of compliance with the postpartum visit among women living in Healthy Start Project areas. Matern Child Health J 2006;10:511--6.
4. Kogan MD, Leary M, Schaetzel TP. Factors associated with postpartum care among Massachusetts users of the Maternal and Infant Care Program. Fam Plann Perspect 1990;22:128--30.
5. American College of Obstetricians and Gynecologists. American College of Obstetricians and Gynecologists Committee on Practice bulletins--obstetrics. Clinical guidelines for obstetricians-gynecologists. Gestational diabetes. Obstet Gynecol 2001;98:525--38.
6. Russell MA, Phipps MG, Loson CL, Welch G, Carpenter MW. Rates of postpartum glucose testing after gestational diabetes mellitus. Obstet Gynecol 2006;108:456--62.
7. Smirnakis KV, Chasan-Taber L, Wolf M, Markenson G, Ecker JL, Thadhani R. Postpartum diabetes screening in women with a history of gestational diabetes. Obstet Gynecol 2005;106:1297--303.
8. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care 2002;25:1862--8.
9. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393--403.

Table 1


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Table 2




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Date last reviewed: 12/20/2007