Correlates of Postpartum Visits Among Medicaid Recipients: An Analysis Using Claims Data from a Managed Care Organization

Abstract

Background:

The postpartum care visit (PPCV) plays an important role in ensuring the well-being of mother and infant. This study sought to assess correlates of PPCV attendance among women who are at high risk of nonattendance.

Materials and Methods:

This study used deidentified medical claims data from Virginia Premier—a nonprofit Managed Care Organization that provides health insurance for Medicaid beneficiaries. The association between various correlates and PPCV attendance was examined using multiple logistic regression analyses.

Results:

Of the 25,692 women in the study, more than half (50.5%) did not attend a postpartum visit. Racial/ethnic minorities and women receiving the majority of their care at hospitals, Health Departments, or Federally Qualified Health Centers were more likely to attend their postpartum visit. Women who smoked and those who did not attend prenatal care had reduced odds of postpartum visit attendance. Age, education, and delivery method were not found to be significantly associated with PPCV attendance.

Conclusions:

Our results highlight factors associated with attendance of PPCVs in low income populations. The continued disparity in postpartum care utilization compels additional efforts to improve access to health services across socioeconomic and demographic boundaries.

Introduction

The postpartum care visit (PPCV) is an important time for healthcare providers to assess the physical and psychosocial well-being of mothers.¹ Providers also address adverse pregnancy-related conditions (e.g., gestational diabetes, persistent postpartum bleeding, endometritis, urinary incontinence, and thyroid disorders).² The visit also allows for counseling on infant care and screening for postpartum depression and other chronic conditions.³ One study that followed women's physical health problems 2 months after childbirth reported that 96% of participants experienced at least one physical health symptom—for example, excessive fatigue, backaches, and perineal pain.⁴ These common health issues can affect a woman's overall well-being and ability to care for her baby.⁵

The PPCV helps women transition from pregnancy to well women care and, thus, plays a vital role in the continuity of health services.⁵ For instance, family planning discussions are an important aspect of postpartum care to educate women on optimal birth spacing and encourage them to engage in health-promotion measures that reduce medical and psychosocial risks.⁶ On a similar note, postpartum contraceptive counseling has been shown to be effective in preventing rapid repeat pregnancies^7,8 and increasing contraceptive use after delivery.⁹ In addition, the PPCV facilitates behavioral counseling and breastfeeding education, which may help increase breastfeeding continuation.² Women with a history of substance abuse can also receive support during the PPCV in an effort to prevent relapse into prepregnancy behaviors.⁶ For these reasons, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have recommended that women have a PPCV 4–6 weeks after delivery.¹⁰ In addition, Healthy People 2020 calls for the increase in proportion of women giving birth to attend a PPCV.¹¹

Despite all the benefits of PPCV, need analyses demonstrate that barriers to access and utilization of postdelivery maternal care continue to be a problem.^12,13 Chart and utilization review studies have demonstrated that rates of attendance are much lower in some population subgroups (e.g., women with less education, those who did not receive prenatal care, and Medicaid recipients).^1,14

–17 The PPCV is particularly vital for many recipients of Medicaid, whose access to healthcare are limited after the end of their 60-day postpartum coverage.¹⁸ Realizing that the time period around pregnancy may be the only time some women have access to broad health coverage, providers should help their patients connect to needed follow-up care and take advantage of available services.⁵ Postpartum women are at risk for unintended pregnancy if contraception methods are not used. One cross-sectional study that assessed women's sexual health after childbirth reported that 62% of the respondents had resumed sexual activity by 8 weeks.¹⁹ It is therefore vital for the health of women to receive the appropriate counseling and services for family planning to prevent rapid repeat pregnancies and poor birth outcomes. Identifying risk factors for postpartum care usage is important, especially among populations that are at elevated risk during pregnancy, such as low income and racial minorities.²⁰

Previous studies have identified numerous factors affecting PPCV attendance. Low attendance has been attributed to demographic factors such as maternal age (≤20 or ≥35),^1,21
–23 lower education level,^1,18,21,23 rural residence,²³ low income,^1,18,23 transportation barriers,^1,20 lack of comprehensive health insurance coverage^1,5; poor maternal health^1,5,21,22,24; maternal depression¹ or substance abuse^1,17; pregnancy-related factors such as high parity,^1,17,21,22 unplanned pregnancy,¹ vaginal delivery,^22,24 poor birth outcomes¹; and health utilization factors such as lack of prenatal care^1,18 or no scheduled appointment before hospital discharge.^21,24 Nonetheless, there have been some gaps and limitations in literature, including potential recall or social desirability bias,^{1,20,21,23,24} the inability to verify information,²² and lack of generalizability to populations at highest risk of nonattendance.¹⁷ Much of the previous research has focused on the broader population; thus, there are limited data on certain groups such as those of low income, living in rural areas, or women relying on Medicaid who are not as likely to attend their PPCV.^1,5,18,23,25 The continued disparity in postpartum care utilization compels additional efforts to improve access to health services across socioeconomic and demographic boundaries.

Grounded in Anderson's behavioral model that identifies predisposing (demographics, social structure, and health beliefs), enabling (personal/family and community resources), and need for care (perceived and evaluated health needs) factors associated with health service utilization,²⁶ this study aims to identify correlates of PPCVs among low-income women across rural and urban areas in Virginia. Focusing on individual characteristics, personal health choices, healthcare needs, and use of health services, we hope to identify risk or protective factors of PPCV attendance to identify areas for interventions and subsequently increase postpartum care utilization in women who are at greatest need.

Materials and Methods

Virginia Premier Health Plan is a nonprofit Managed Care Organization (MCO) that provides public insurance for ∼200,000 Medicaid patients across Virginia. Claims, demographic, and administrative information were obtained from Virginia Premier on women with singleton live births between 2008 and 2012. If a mother gave birth more than once in the time period, the most recent birth was analyzed.

The outcome of interest, postpartum visit attendance, was determined by medical claims data containing codes from the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) code for routine postpartum follow-up (i.e., V24.2) 3–8 weeks postdelivery. Postpartum visit attendance status was categorized as “yes” or “no.”

Potential correlates were identified from previous literature^{17,18,22,26

–29} and grouped according to the three domains of Anderson's Behavioral Model of Health Services Use (predisposing, enabling, and need for care factors).²⁶ Predisposing factors included maternal age (<19, 20–29, 30–34, >35 years), race/ethnicity (White; Black; Hispanic; Other), and education (less than high school; high school graduate; at least some college). Enabling factors included region of residence in Virginia, which was categorized into seven regions: Danville/Lynchburg, Southwest, Fredericksburg, Richmond, Roanoke, Tidewater, and Western. While Danville/Lynchburg, Southwest, and Western regions are predominantly rural, Fredericksburg, Roanoke, and Richmond are urban areas; the type of healthcare system most utilized by women for prenatal care services (private office; hospital; health department or Federally Qualified Health Centers (FQHCs); and antenatal or prenatal care attendance (yes; no). Need for care factors included pregnancy complications (yes, no), depression (yes, no), tobacco use (yes, no), drug abuse/dependence (yes, no), alcohol abuse/dependence (yes, no), delivery type, and birth outcome variables. Pregnancy complications included gestational diabetes mellitus, preeclampsia, eclampsia, hypertension, anemia, cervical incompetence, uterine inertia, premature separation of placenta, and placenta previa. Delivery method was categorized as vaginal or cesarean; and birth outcome was categorized into: term normal weight; preterm normal weight; term low birth weight; and preterm low birth weight. Normal weight was defined as ≥2,500 g, and term was defined as a gestational age of ≥37 weeks.

Frequency distribution of correlates was examined using percentages. Chi-square tests and p-values were used to test for differences in proportions between attendance groups. All variables were tested for interaction. In addition, we tested for interaction between race and prenatal care, pregnancy complications and age, and pregnancy complications and race based on prior literature.^{17,18,22,26

–30} However, there was no statistically significant interaction. Logistic regression analyses provided crude (COR) and adjusted odds ratios (AOR) and confidence intervals (95% CI). All calculations and analyses were conducted using SAS v9.4 (Cary, NC).

Results

The final sample consisted of 25,692 women. More than half of all women did not attend a postpartum visit (51%) (Table 1). Most participants were 20–29 years old (68%), White (56%), and had a high school education (51%). The majority of women had vaginal delivery (67%) and gave birth to a normal weight and full-term baby (87%). In the unadjusted analysis, no racial/ethnic differences were observed between women who did and did not attend a postpartum visit; however, there were differences by prenatal care attendance, location of services, and region of residence (Table 2). In addition, there were statistically significant associations between postpartum attendance and factors such as tobacco use, drug abuse/dependence, history of depression, pregnancy complications, and birth outcomes. Women who received the majority of their prenatal care at a hospital or health department/FQHC had higher odds of attending their postpartum checkup compared to women who went to a private clinic (COR = 1.34, 95% CI = 1.22–1.47; COR = 1.99, 95% CI = 1.72–2.30, respectively). With the exception of women residing in the Tidewater region, women from the remaining regions (Danville/Lynchburg, Southwest, Richmond, Roanoke, and Western) had significantly increased odds of attending their postpartum visit compared to women living in Fredericksburg. The magnitude of association was greatest in women from the Danville/Lynchburg area who had more than thrice greater odds of attendance (COR = 3.32, 95% CI = 2.93–3.78). In contrast, substance users were significantly less likely to attend a postpartum visit compared to nonusers (tobacco use, COR = 0.83, 95% CI = 0.78–0.87; drug abuse/dependence, COR = 0.67, 95% CI = 0.60–0.74). Likewise, women with low birth weight and preterm infants had reduced odds of postpartum visit attendance (COR = 0.85, 95% CI = 0.77–0.95). However, depression, drug use during pregnancy, pregnancy complication, and low birth weight and preterm birth lost their statistical significance in the adjusted analysis.

Table 1.

Distribution of Population Characteristics by Postpartum Visit Attendance

	Postpartum visit
	Yes, N = 12,711 (49.5%)	No, N = 12,981 (50.5%)	Total population N = 25,692
Characteristics	Column %
Predisposing factors
Age, years
≤19	13.7	13.6	13.6
20–29	67.8	67.1	67.5
30–34	12.5	13.0	12.8
≥35	6.1	6.2	6.1
Race
White	55.6	56.0	55.8
Black	26.0	25.0	25.5
Hispanic	3.4	3.4	3.4
Other	15.0	15.7	15.3
Education
<High school	18.8	20.3	19.5
High school	51.8	50.8	51.3
>High school	29.4	29.0	29.2
Enabling factors
Location for majority of services
Private	6.4	8.6	7.5
Hospital	87.6	87.4	87.5
Health department/FQHC	6.0	4.0	5.0
Region of residence in Virginia
Danville/Lynchburg	14.3	5.9	10.1
Southwest	3.3	3.4	3.4
Fredericksburg	5.6	7.7	6.7
Richmond	14.5	14.6	14.6
Roanoke	27.2	31.9	29.6
Tidewater	15.7	20.7	18.2
Western	19.3	15.8	17.5
Antenatal or prenatal care
Yes	92.8	83.1	87.9
No	7.3	17.0	12.2
Need factors
Pregnancy complications	30.9	26.6	28.7
Depression	7.3	6.5	6.9
Tobacco use	25.5	29.3	27.4
Drug abuse/dependence	4.9	7.1	6.0
Alcohol abuse/dependence	0.9	1.1	1.0
Delivery
Normal vaginal	67.2	67.4	67.3
C-section	32.8	32.6	32.7
Birth outcomes
Normal weight and term	87.2	86.1	86.7
Normal weight and preterm	3.9	3.9	3.9
Low birth weight and term	3.4	3.7	3.6
Low birth weight and preterm	5.4	6.3	5.9

Antenatal or prenatal care for normal or high-risk pregnancies; pregnancy complications = diabetes, preeclampsia, eclampsia, hypertension, anemia, cervical incompetence, ectopic pregnancy, uterine inertia, premature separation of placenta, and placenta previa.

FQHC, federally qualified health center.

Table 2.

Correlates of Postpartum Visit Attendance

	Postpartum visit row %	Crude OR (95% CI)	Adjusted OR (95% CI)
Predisposing factors
Age, years
≤19	49.6	1.00 (0.93–1.07)	0.93 (0.75–1.15)
20–29	49.7	1.00	1.00
30–34	48.5	0.95 (0.88–1.02)	0.89 (0.73–1.08)
≥35	48.9	0.97 (0.87–1.07)	1.25 (0.95–1.63)
Race
White	49.8	1.00	1.00
Black	50.9	1.04 (0.97–1.12)	1.22 (1.03–1.44)
Hispanic	50.1	1.01 (0.85–1.20)	1.12 (0.81–1.55)
Other	49.0	0.97 (0.89–1.05)	1.26 (1.04–1.54)
Education
<High school	52.2	0.91 (0.79–1.05)	0.90 (0.73–1.12)
High school	54.7	1.01 (0.90–1.12)	0.98 (0.85–1.14)
>High school	54.5	1.00	1.00
Enabling factors
Location for majority of services
Private	42.5	1.00	1.00
Hospital	49.7	1.34 (1.22–1.47)	1.41 (1.09–1.82)
Health Department/FQHC	59.5	1.99 (1.72–2.30)	1.76 (1.17–2.63)
Region of residence in Virginia
Danville/Lynchburg	70.3	3.32 (2.93–3.78)	2.48 (1.77–3.46)
Southwest	48.8	1.34 (1.13–1.58)	1.79 (0.78–4.11)
Fredericksburg	41.6	1.00	1.00
Richmond	49.3	1.36 (1.22–1.53)	0.64 (0.47–0.88)
Roanoke	45.6	1.18 (1.06–1.31)	0.84 (0.63–1.11)
Tidewater	42.7	1.04 (0.93–1.17)	0.63 (0.46–0.86)
Western	54.4	1.68 (1.50–1.88)	1.18 (0.87–1.59)
Antenatal or prenatal care
Yes	52.1	1.00	1.00
No	29.5	0.38 (0.35–0.42)	0.43 (0.34–0.55)
Need factors
History of depression	52.5	1.14 (1.03–1.25)	1.19 (0.91–1.54)
Pregnancy complications	53.2	1.23 (1.17–1.29)	1.22 (1.05–1.42)
Tobacco use	46.0	0.83 (0.78–0.87)	0.84 (0.72–0.98)
Drug abuse/dependence	40.0	0.67 (0.60–0.74)	0.77 (0.55–1.06)
Alcohol abuse/dependence	45.1	0.84 (0.66–1.07)	0.84 (0.43–1.65)
Delivery
Normal vaginal	49.5	1.00	1.00
C-section	49.6	1.01 (0.96–1.06)	1.05 (0.91–1.21)
Birth outcomes
Normal weight and term	49.8	1.00	1.00
Normal weight and preterm	49.9	1.00 (0.88–1.14)	1.02 (0.73–1.43)
Low birth weight and term	47.3	0.90 (0.79–1.03)	0.95 (0.67–1.35)
Low birth weight and preterm	45.8	0.85 (0.77–0.95)	0.82 (0.60–1.12)

Antenatal or prenatal care for normal or high-risk pregnancies; bold indicates statistical significance.

CI, confidence interval; OR, odds ratio.

The fully adjusted model showed predisposing factors, including race; enabling factors, including location of services, region of residence, and prenatal care attendance; and need factors, including pregnancy complications and tobacco use, were associated with postpartum visit attendance in the adjusted model (Table 2). Black women (AOR = 1.22, 95% CI = 1.03–1.44) and women of other race/ethnicity (AOR = 1.26, 95% CI = 1.04–1.54) had significantly higher odds of attending their PPCV, while Hispanic women (AOR = 1.12, 95% CI = 0.81–1.55) had a nonsignificant increased odds of attending their visit. Women who did not attend prenatal care were less likely to attend their postpartum visit compared to women who did attend (AOR = 0.43, 95% CI = 0.34–0.55). Women who received the majority of their prenatal care at a hospital or Health Department/FQHC were also more likely to attend their postpartum appointment (Hospital, AOR = 1.41, 95% CI = 1.09–1.82; Health Department/FQHC, AOR = 1.76, 95% CI = 1.17–2.63) compared to those who received care from private locations. Differences were observed by region of residence with increased odds of attendance for women from Danville/Lynchburg (AOR = 2.48, 95% CI = 1.77–3.46) and a nonstatistically increased odds of attendance at Far Southwest (AOR = 1.79, 95% CI = 0.78–4.11) and Western (AOR = 1.18, 95% CI = 0.87–1.59) regions compared to the Fredericksburg region. In contrast, women from Richmond (AOR = 0.64, 95% CI = 0.47–0.88), Roanoke (AOR = 0.84, 95% CI = 0.63–1.11), and Tidewater (AOR = 0.63, 95% CI = 0.46–0.86) had a lower odds of attending their postpartum visit compared to those residing in the Fredericksburg region. Women who had pregnancy complications had a 22% higher odds of attending their postpartum visit compared to those without complications (AOR = 1.22 95% CI = 1.05–1.42). Tobacco users had reduced odds of attending a postpartum checkup (AOR = 0.84, 95% CI = 0.72–0.98).

Although not statistically significant, advanced age (≥35 years), depression, cesarean delivery, and having a normal weight preterm baby had higher odds of postpartum attendance. In contrast, being 34 years or under; having high school or less education; term and preterm low birth weight; and drug and alcohol dependence had lower odds of attendance.

Discussion

This study assessed correlates of PPCV among women of low income. Approximately half of the study population did not attend their postpartum visit which indicates low levels of postpartum care utilization among women who are considered to be at high risk for nonattendance and compels further action to increase PPCV attendance in women. Racial minorities, those who received their care from hospitals, health department clinics/FQHC, residents in the Danville/Lynchburg area, and who had pregnancy complications had higher odds of attending their postpartum visit. In contrast, women who did not receive prenatal care and resided in the Richmond and Tidewater regions had lower odds of attending their PPCV.

Factors associated with PPCV attendance have important implications in terms of prevention and quick diagnosis of health conditions, which can serve to reduce maternal and infant morbidity and mortality. Identifying these factors can help guide public health policies in an effort to increase utilization of postpartum care services.²⁶ The postpartum period provides a crucial opportunity for women to be educated on a variety of issues, including breastfeeding, family planning, and reliable forms of contraception.¹⁴ Moreover, women are often more motivated to engage in health behavioral changes during the time period around pregnancy; as a result, increasing PPCV attendance can provide a smooth transition into primary care and help women to engage in lifelong preventive health behaviors.¹⁴

The current study found that Black women were more likely to attend PPCV compared to White women. This differs from previous studies that indicated Black women are at increased risk of missing their PPCV.^1,18,25,31 The difference in results may have been due to the elevated proportion of Black women receiving additional services to ameliorate the risk of poor pregnancy outcomes. Existing programs target efforts at high-risk groups, including Black women, due to the high rates of infant mortality and morbidity.^32

–35 For example, the Healthy Start program focuses on reducing disparities in maternal and infant health and has reached over 500,000 women, children, and families in underserved urban, rural, and other communities across the United States, including several programs in Virginia^36,37 These types of programs have shown promising results in increasing positive birth outcomes and maternal health in diverse settings.^{37

–44}

Furthermore, regional differences observed in the current study (e.g., increased attendance by women from Danville/Lynchburg; decreased attendance by women from Richmond, Roanoke, and Tidewater) may be attributed to levels of population density or urbanization of locations and the availability and access to hospitals or FQHCs in the respective areas. A stratified analysis to investigate the reasons for the regional or location differences was not possible due to small samples for FQHCs. However, previous studies have found that residing in more urbanized areas was associated with increased PPCV attendance.^23,24 Proximity and access to resources may be important to consider in efforts to improve the delivery and management of healthcare services. Future research studies are needed to examine the reasons for these differences to guide interventions.

Our study also showed that women who attended prenatal care had increased odds of attending their PPCV. Patients are often educated about the importance of the PPCV during prenatal care visits,¹ which is disadvantageous to women having inconsistent or infrequent contact with the healthcare system during pregnancy. Prenatal care is an important time to provide healthcare services, counseling, and referrals to Medicaid recipients, many of whom are no longer covered within 60 days after delivery.¹⁸ Thus, improving access to health or social services in the prenatal period may aid in increasing the number of women who also attend the PPCV.

Moreover, this study showed that women who received the majority of their prenatal care at a hospital or Health Department/FQHC were more likely to attend their postpartum appointment compared to women who mostly went to private clinics. It is possible that Health Departments and FQHC provide more preventive programs and referrals. It is also possible that “private clinics” may not put a lot of effort in getting Medicaid recipients for their routine postpartum visit because the visit is not included within the global fee for delivery care and does not generate additional revenue; therefore, it is more cost effective to fill clinics with other revenue-generating visits. This finding acknowledges the specialized efforts provided by Health Departments and FQHCs to reach out to underserved populations. In addition, the odds of PPCV attendance were almost twice greater for participants who attended FQHCs for the majority of their prenatal care, which suggests that FQHCs are well positioned to assist low-income populations with managing their care. These FQHCs provide comprehensive services to marginalized populations and serve over 22 million Americans. Furthermore, FQHCs are specifically important in rural locations, where around a third of the population receives care from these health centers.³⁰

Women who smoked were less likely to attend the PPCV, which is consistent with existing literature.²⁷ Although the current study did not show differences by drug use, previous studies have found that women who used substances were more likely to receive inadequate prenatal care and avoid treatment due to numerous concerns such as fear of being reported to the police or social services, disbelief in the effectiveness of care, along with other sociodemographic and psychosocial risk factors that occur with substance use.^44

–47 Policies that reduce barriers to care and encourage health-seeking behavior are greatly needed in populations at high risk for nonattendance. For instance, access to ancillary programs such as healthy start that target low income and minority women are necessary to overcome the challenges of nonattendance.

The increased odds of PPCV in women with complications (e.g., preeclampsia, gestational diabetes) suggest that healthcare providers are following NIH and CDC recommendations^48
–50 to closely monitor this group at risk for postnatal complications, which can be addressed during the postpartum visit.^24,47 Inconsistent with previous studies, history of depression was not a statistically significant correlate of PPCV. However, in the unadjusted analyses, history of depression was shown to increase the odds of women attending their PPCV. Although depression can negatively affect a woman's willingness to follow through with medical appointments,^1,46 physicians caring for the women in our population may have focused more attention to women with history of depression or at elevated risk for depression in accordance with ACOG guidelines.⁴⁸

Contrary to other studies that found maternal age (≤20 or ≥35),^1,22,23 lower educational levels,^1,18,21,23 and vaginal delivery^22,24 to be associated with low attendance of PPCV, our study did not find age, education, or delivery method to be significantly associated with PPCV. The difference in results may have been attributed to our study having a similar population of low-income women compared to others that focused more broadly on the general population.^15,18 Nonetheless, studies were often hindered by limitations such as the potential for recall bias,^1,18,23 reporting bias,^18,21,22 inability to verify information,^21,22 lack of generalizability to United States or high-risk populations,^1,23 and reliance on cross-sectional data, which does not allow for causal inferences.²³

The strengths of our study include the focus on a population that is considered to be at high risk for nonattendance of PPCVs. By focusing on this particular group, we were able to more specifically identify factors associated with attendance. The data analyzed in this study came from medical claims data, which are more objective than other types of cross-sectional data subject to recall error or social desirability bias. In addition, we were able to assess a variety of medical factors and patients' interactions with the healthcare system. Nonetheless, some limitations to note include a lack of generalizability of the results to a more general population. In addition, by relying on claims data, some factors such as smoking, alcohol abuse, and drug abuse may have been underreported and medical record reviews and focus groups would be useful to include in future studies. In addition, prenatal care visit attendance was documented as yes/no, without considering the adequacy or quality of care. It would have been more informative to provide information on the adequacy of prenatal care using an index such as the Kotelchuck Index. In addition, assessing the quality of care received at each visit may have helped to examine differences in the content of care provided. However, data on entry to prenatal care or the quality of care were not available. Medicaid eligible pregnant women receive care at safety net providers until their Medicaid is approved. Therefore, the first prenatal care visit in our dataset may not be the first prenatal care received by the women and does not indicate entry to prenatal care. Moreover, there were factors that previous studies identified to be associated with PPCV attendance that were not assessed in our study—for example, high parity,^1,17,21,22 transportation barriers,^1,20 low income,^1,18,23 lack of comprehensive health insurance coverage,^1,5 unplanned pregnancy,¹ and not having a scheduled appointment before hospital discharge.^21,24

Conclusion

Understanding correlates related to the use of PPCV can have a large implication for policy makers, helping them decide where additional efforts are most needed.¹⁶ Our results highlight factors that are correlated with lower attendance of PPCV in low-income populations and indicate that additional focus should be placed on the influence of regional differences, substance use, and type of healthcare location. By identifying risk or protective factors for attendance, we hope that our study will help guide more effective interventions to improve PPCV attendance and decrease the long-standing disparities in women's healthcare. Targeted efforts should be taken to address utilization barriers both during and after pregnancy. The PPCV is a good opportunity for providers to counsel women on self-care, provide education on contraception and breastfeeding, and assess the health status of both mother and child.⁵¹ In addition, it is important to continue investing in federal programs (e.g., FQHCs), which are playing a vital role in underserved populations. Overall, our findings support the need for continued federal funding and public policies to address barriers to postpartum care. More research should be conducted to understand the reason for regional differences in PPCV attendance, and specific action should be taken to increase awareness and access to services to all women. Informed by our findings on the correlates of PPCVs, future studies can create focused interventions to improve PPCV attendance. Our study contributes to the growing body of the literature highlighting the importance of PPCVs and identifying barriers to the healthcare of women.

Footnotes

Acknowledgment

This study was funded by Virginia Premier Health Plan, Inc.

Author Disclosure Statement

No competing financial interests exist.

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