Association Between the Coronavirus Disease 2019 (COVID-19) Pandemic and National Disparities in Postpartum Visit Attendance

Abstract

This study used data from PRAMS (Pregnancy Risk Assessment Monitoring System) between 2016 and 2020 and found that postpartum visit attendance declined by 5.8 (95% CI −6.4 to −5.2) percentage points in the first 9 months of the coronavirus disease 2019 (COVID-19) pandemic. The greatest declines occurred among non-Hispanic Black individuals (−9.9, 95% CI −11.6 to −8.1 percentage points), individuals aged 19 years or younger (−9.9, 95% CI −13.5 to −6.2 percentage points), and individuals without postpartum insurance (−11.4, 95% CI −14.5 to −8.3 percentage points). Although the pandemic was associated with a decrease in reporting common barriers to attendance, including lack of transportation and not being able to leave work, it introduced new barriers that potentially contributed to widened disparities in postpartum care. A combination of health policy and health system approaches are needed to increase postpartum visit attendance and reduce disparities in use.

In Brief

The coronavirus disease 2019 (COVID-19) pandemic decreased national postpartum visit attendance and exacerbated disparities in attendance by race, ethnicity, age, and insurance coverage.

Racially and ethnically marginalized individuals and those with low incomes experience greater barriers to postpartum visit attendance and have lower rates of use relative to White individuals and those with higher incomes.^1–3 The coronavirus disease 2019 (COVID-19) pandemic further restricted access to postpartum care, potentially exacerbating existing disparities.^4–8 One multihospital study found a large decline in postpartum visits early in the pandemic and a slower rebound among non-Hispanic Black and Hispanic women compared with non-Hispanic White women.⁴ Our objective was to examine whether the COVID-19 pandemic was associated with changes in postpartum care visit attendance nationally and whether changes varied among subgroups.

METHODS

We used 2016–2020 PRAMS (Pregnancy Risk Assessment Monitoring System) data, annual state-representative surveys of people with live births in 45 states; Washington, DC; and New York City. The primary outcome was self-reported postpartum visit attendance. We also examined reasons for nonuse in a subset of seven states (Arizona, Illinois, Iowa, Maryland, Utah, Virginia, Wisconsin) that included a follow-up question about reasons for not attending a postpartum visit. The study exposure was an indicator of whether the respondent's recommended postpartum visit date occurred after the start of the pandemic (April 2020).

We used linear regression models to calculate the percentage-point change in postpartum visit attendance and reasons for nonuse after the start of the pandemic, overall and by subgroup. To compare differences in the change among subgroups, we used linear regression models with a group indicator, a pandemic indicator, and an interaction term between group and pandemic. All analyses used PRAMS survey weights, which account for nonresponse, noncoverage, and PRAMS’ complex design. Detailed methods and attendance rates by subgroup before and during the pandemic are provided in Appendix 1, available online at https://links.lww.com/AOG/C938. This study was considered not human subjects research by Brown University's IRB.

RESULTS

During the first 9 months of the pandemic, postpartum visit attendance declined by 5.8 (95% CI −6.4 to −5.2) percentage points (Fig. 1) (Appendix 2, available online at https://links.lww.com/AOG/C938). The greatest declines occurred among non-Hispanic Black individuals (−9.9, 95% CI −11.6 to −8.1 percentage points), individuals aged 19 years or younger (−9.9, 95% CI −13.5 to −6.2 percentage points), and individuals without postpartum insurance (−11.4, 95% CI −14.5 to −8.3 percentage points). The declines among Black non-Hispanic and Hispanic individuals were 5.9 (95% CI 4.0–7.8) and 3.1 (95% CI 1.2–5.0) percentage points greater, respectively, than the decline among White non-Hispanic individuals (Appendix 3, available online at https://links.lww.com/AOG/C938). The declines among people with no insurance and Medicaid insurance postpartum were 7.6 (95% CI 4.4–10.7) and 2.6 (95% CI 1.2–3.9) percentage points greater, respectively, compared with those with private insurance.

Fig. 1.: Change in postpartum visit attendance after the start of the coronavirus disease 2019 (COVID-19) pandemic in the overall sample of postpartum individuals and by subgroup, PRAMS (Pregnancy Risk Assessment Monitoring System), January 2016‒December 2020. Responses from 45 states; Washington, DC; and New York City. Error bars represent 95% CIs. All P<.001. *All non-Hispanic race groups aside from White, Asian, and Black.

The percentage of respondents reporting being “too busy” as a reason for not attending a postpartum visit decreased (−9.1, 95% CI−13.9 to −4.3 percentage points), as did not being able to leave work (−3.4, 95% CI −5.5 to −1.4 percentage points), not having insurance (−4.1, 95% CI −7.8 to −0.5 percentage points), and not having transportation (−2.8, 95% CI −4.8 to −0.8 percentage points) (Fig. 2) (Appendix 4, available online at https://links.lww.com/AOG/C938). The percentage of respondents selecting “other” and writing in an open-text response increased by 22.8 percentage points (95% 17.7–28.0). Common open-text responses indicated that COVID-19 made it more difficult to attend a visit due to lack of childcare and fear of leaving home (Appendix 5, available online at https://links.lww.com/AOG/C938).

Fig. 2.: Change in reasons for not attending a postpartum visit after the start of the coronavirus disease 2019 (COVID-19) pandemic, PRAMS (Pregnancy Risk Assessment Monitoring System), January 2016‒December 2020. Error bars represent 95% CIs. Responses are from the seven states (Arizona, Illinois, Iowa, Maryland, Utah, Virginia, and Wisconsin) that asked respondents who reported that they did not attend a postpartum visit, “Did any of these things keep you from having a postpartum check?” (n=2,290).

DISCUSSION

This study used data from 45 states; Washington, DC; and New York City, providing a near-national picture of postpartum care use before and after the start of pandemic. It relied on the use of self-reported outcome data, which could be subject to response bias, and was limited to the short duration of postpandemic data available.

Overall, these results indicate that the COVID-19 pandemic decreased postpartum visit attendance and exacerbated disparities in attendance by race, ethnicity, age, and insurance coverage. Although pandemic-related changes, such as a shift to telehealth services, alleviated some prepandemic barriers to attendance, the extent to which postpartum people experienced these decreased barriers likely differed among groups.^8–12 To raise postpartum visit attendance to prepandemic levels and reduce disparities in use, policymakers must identify and address the most common barriers through a combination of health policy and health system approaches.