This study aimed to identify actual and perceived barriers to postpartum care among a probability sample of women who gave birth in Los Angeles County, California in 2007. Survey data from the 2007 Los Angeles Mommy and Baby (LAMB) study (
The postpartum care (PPC) visit is an important opportunity to assess the physical and psychosocial health of the mother [
Data on the utilization, content, and quality of the PPC visit are limited and often lack a comprehensive preventive care component [
Many factors influence the decision to seek PPC. A study by Kogan et al. reported that the strongest indicator of whether a woman would obtain PPC was her use of prenatal care [
Maternal physical and mental health status may also predict PPC utilization. New mothers are often sleep deprived, overwhelmed, and have limited time to tend to their personal health care needs. The intent of the pregnancy may also influence maternal regard for postpartum health [
Sociodemographic factors play an important role in PPC utilization as well. A number of subpopulations are less likely to seek PPC. Some studies report that women with less than a high school education, less than 26 years of age, a household income of less than $20,000, and high parity are associated with a low acceptance rate of the PPC visit [
Several studies have analyzed barriers to PPC utilization. Access barriers further decrease the likelihood that a new mother will schedule a PPC visit. Medicaid programs serve a higher proportion of pregnant women of low socioeconomic status with special needs than do private insurers [
In light of the expanding Hispanic population in the US, our study is focused on a predominantly Hispanic multiethnic sample of low-income women. To address gaps in the literature, our study used data from a recent probability sample of mothers from Los Angeles County to study the determinants of and barriers to PPC utilization. To our knowledge, this is the first study to date to highlight actual and perceived barriers to PPC in this subpopulation.
Data from the 2007 Los Angeles Mommy and Baby (LAMB) study (
This study was a collaborative effort between the University of California, Los Angeles (UCLA) and the Los Angeles County Department of Maternal, Child, and Adolescent Health. The sample was derived from a stratified random sample of census tract defined neighborhoods. A total of 10,000 surveys were mailed to eligible women within 6 months after delivery. The response rate was 56%, after adjusting for faulty addresses, language issues, maternal deaths, and loss of follow-up due to inability to locate the respondent. The recruitment process consisted of a (1) notification letter 4 months after child birth, (2) mailed questionnaires, (3) mailed reminder letters, (4) and telephone follow-up to nonresponders. The questionnaires were translated into Spanish and Chinese and a telephone translation service provided access in 88 languages. Information about the recruitment strategy and methodology has been published in detail elsewhere [
This study was approved by both the Los Angeles County Department of Public Health and the UCLA Institutional Review Boards (IRBs) in 2007.
The current analysis focused on the determinants of, and barriers to, postpartum care. Respondents were asked whether or not they obtained a postpartum care visit (yes/no). A range of maternal sociodemographic factors including race (Non-Hispanic White, Hispanic, Non-Hispanic Black, Asian/Pacific Islander (API), and Native American), age in years (0–16, 17-18, 19–29, 30–39, 40–49), marital status (married, separated/divorced, widowed, never married but living together, never married but living apart), income (<$20,000, $20,000–39,000, $40,000–59,000, $60,000–99,000, >$100,000), and education (less than high school, high school graduate, some college or more, and not stated) were included in the analyses (Table
Sociodemographic and maternal characteristics of study sample, 2007 LAMB (
|
% | SE | |
---|---|---|---|
Maternal race/ethnicity | |||
Non-Hispanic White | 794 | 12.3 | 0.85 |
Hispanic | 2495 | 74.1 | 1.30 |
Non-Hispanic Black | 244 | 4.6 | 0.46 |
Asian/pacific islander | 501 | 8.3 | 0.75 |
Native American | 41 | 0.7 | 0.12 |
Maternal age, years | |||
0 to 16 | 44 | 1.5 | 0.23 |
17 to 18 | 176 | 6.0 | 0.45 |
19 to 29 | 1970 | 51.5 | 0.96 |
30 to 39 | 1716 | 37.8 | 0.95 |
40 to 49 | 169 | 3.3 | 0.29 |
Family income | |||
<$20,000 | 1509 | 44.7 | 1.22 |
$20,000–39,000 | 858 | 21.8 | 0.74 |
$40,000–59,000 | 402 | 8.2 | 0.48 |
$60,000–99,000 | 530 | 9.5 | 0.56 |
>$100,000 | 536 | 8.5 | 0.67 |
Not stated | 240 | 7.3 | 0.51 |
Marital status | |||
Married | 2373 | 52.7 | 1.08 |
Separated/divorced | 103 | 2.9 | 0.31 |
Widowed | 6 | 0.2 | 0.07 |
Never married but living together | 1098 | 31.5 | 0.99 |
Never married but living apart | 431 | 11.0 | 0.57 |
Not stated | 64 | 1.7 | 0.22 |
Maternal education | |||
Less than HS | 1019 | 37.4 | 1.32 |
HS Grad | 1045 | 25.4 | 0.79 |
Some college or more | 873 | 18.9 | 0.71 |
Not stated | 1138 | 18.3 | 0.99 |
Pregnancy intendedness | |||
Yes | 1181 | 27.7 | 0.79 |
Yes, but not trying hard | 481 | 11.2 | 0.52 |
No, trying hard to keep from getting pregnant | 611 | 14.7 | 0.62 |
Neither trying nor preventing pregnancy | 1735 | 44.2 | 0.86 |
Not stated | 67 | 2.1 | 0.29 |
Prenatal care | |||
Yes | 4019 | 98.5 | 0.21 |
No | 56 | 1.5 | 0.21 |
Care received prior to pregnancy | |||
Yes | 1212 | 26.7 | 0.79 |
No | 2184 | 56.0 | 0.89 |
Not stated | 679 | 17.4 | 0.63 |
Preterm birth/low birth weight | |||
Yes | 739 | 15.7 | 0.51 |
No | 3336 | 84.3 | 0.51 |
Newborn visit | |||
Yes | 3980 | 97.4 | 0.26 |
No | 62 | 1.7 | 0.22 |
Not stated | 33 | 0.9 | 0.16 |
Insurance status | |||
No insurance | 1339 | 40.2 | 1.05 |
Medi-Cal | 788 | 22.0 | 0.89 |
Private | 1692 | 32.3 | 1.16 |
Other | 119 | 2.3 | 0.22 |
Not stated | 137 | 3.2 | 0.29 |
Postpartum care | |||
Yes | 3748 | 91.7 | 0.47 |
No | 327 | 8.3 | 0.47 |
Additional variables of interest included insurance type (no insurance, medi-Cal/medicaid, private insurance, other), prenatal care utilization (yes/no), care received prior to pregnancy (reasons for seeking care: to have a healthy pregnancy, chronic medical problem, problem with previous pregnancy, expected to get pregnant, encouraged by doctor or nurse), intendedness of pregnancy (yes, yes but not trying very hard, trying hard to keep from getting pregnant, or neither trying nor preventing pregnancy), preterm birth, low birth weight (yes/no), and whether or not the infant attended a newborn visit (yes/no).
We analyzed the data using SAS 9.3 (SAS Institute Inc., Cary, NC). Weights were added to account for the sampling design and survey nonresponse. To test differences between women who did and did not obtain postpartum care on select socio-demographic factors and other possible determinants,
Maternal demographic and socioeconomic characteristics by postpartum visit status. 2007 LAMBS.
|
Has postpartum visit | Lacks postpartum visit |
Chi square |
|||
---|---|---|---|---|---|---|
3748 (92%) | 327 (8%) | |||||
% | SE | % | SE | |||
Maternal race/ethnicity |
|
|||||
Non-Hispanic White | 794 | 92.7 | 1.11 | 7.3 | 1.11 | |
Hispanic | 2495 | 91.7 | 0.54 | 8.3 | 0.54 | |
Non-Hispanic Black | 244 | 85.4 | 2.27 | 14.6 | 2.27 | |
Asian/pacific islander | 501 | 93.8 | 1.16 | 6.2 | 1.16 | |
Native American | 41 | 90.2 | 4.65 | 9.8 | 4.65 | |
Maternal age, years |
|
|||||
0 to 16 | 44 | 75.4 | 6.72 | 24.6 | 6.72 | |
17 to 18 | 176 | 87.7 | 2.75 | 12.3 | 2.75 | |
19 to 29 | 1970 | 90.2 | 0.68 | 9.8 | 0.68 | |
30 to 39 | 1716 | 94.7 | 0.56 | 5.3 | 0.56 | |
40 to 49 | 169 | 95.3 | 1.86 | 4.7 | 1.86 | |
Family income |
|
|||||
<$20,000 | 1509 | 89.0 | 0.82 | 11.0 | 0.82 | |
$20,000–39,000 | 858 | 93.3 | 0.90 | 6.7 | 0.90 | |
$40,000–59,000 | 402 | 93.3 | 1.37 | 6.7 | 1.37 | |
$60,000–99,000 | 530 | 95.9 | 0.96 | 4.1 | 0.96 | |
>$100,000 | 536 | 97.3 | 0.80 | 2.7 | 0.80 | |
Not stated | 240 | 90.1 | 1.97 | 9.9 | 1.97 | |
Marital status |
|
|||||
Married | 2373 | 94.9 | 0.49 | 5.1 | 0.49 | |
Separated/divorced | 103 | 85.1 | 3.64 | 14.9 | 3.64 | |
Widowed | 6 | 84.9 | 14.20 | 15.1 | 14.20 | |
Never married but living together | 1098 | 89.2 | 0.90 | 10.8 | 0.90 | |
Never married but living apart | 431 | 85.0 | 1.80 | 15.0 | 1.80 | |
Not stated | 64 | 93.1 | 3.10 | 6.9 | 3.10 | |
Maternal education |
|
|||||
Less than HS | 1019 | 90.5 | 0.97 | 9.5 | 0.97 | |
HS grad | 1045 | 90.8 | 0.91 | 9.2 | 0.91 | |
Some college or more | 873 | 91.4 | 0.91 | 8.6 | 0.91 | |
Not stated | 1138 | 95.7 | 0.65 | 4.3 | 0.65 | |
Pregnancy intendedness |
|
|||||
Yes | 1181 | 95.3 | 0.67 | 4.7 | 0.67 | |
Yes, but not trying hard | 481 | 91.4 | 1.41 | 8.7 | 1.41 | |
No, trying hard to keep from getting pregnant | 611 | 89.5 | 1.36 | 10.5 | 1.36 | |
Neither trying nor preventing pregnancy | 1735 | 90.2 | 0.76 | 9.8 | 0.76 | |
Not stated | 67 | 92.6 | 3.17 | 7.4 | 3.17 | |
Prenatal care |
|
|||||
Yes | 4019 | 92.0 | 0.46 | 8.0 | 0.46 | |
No | 56 | 73.6 | 6.12 | 26.4 | 6.12 | |
Care received prior to pregnancy |
|
|||||
Yes | 1212 | 93.8 | 0.73 | 6.2 | 0.73 | |
No | 2184 | 91.0 | 0.68 | 9.0 | 0.68 | |
Not stated | 679 | 90.7 | 1.14 | 9.3 | 1.14 | |
Preterm birth/low birth weight |
|
|||||
Yes | 739 | 89.5 | 1.13 | 10.5 | 1.13 | |
No | 3336 | 92.1 | 0.50 | 7.9 | 0.50 | |
Newborn visit | 0.09 | |||||
Yes | 3980 | 91.9 | 0.46 | 8.1 | 0.46 | |
No | 62 | 85.1 | 4.62 | 14.9 | 4.62 | |
Not stated | 33 | 85.4 | 6.90 | 14.6 | 6.90 | |
Insurance status |
|
|||||
No insurance | 1339 | 92.2 | 0.74 | 7.8 | 0.74 | |
Medi-Cal | 788 | 85.6 | 1.27 | 14.4 | 1.27 | |
Private | 1692 | 94.7 | 0.59 | 5.3 | 0.59 | |
Other | 119 | 97.3 | 1.60 | 2.7 | 1.60 | |
Not stated | 137 | 93.8 | 2.25 | 6.2 | 2.25 |
Bolded text indicates the association was statistically significant.
Adjusted odds of lacking a postpartum visit among women who gave birth in Los Angeles County. 2007 LAMBS.
Model 1 | Model 2 | |||||
---|---|---|---|---|---|---|
OR | 95% CI | OR | 95% CI | |||
Maternal race/ethnicity | ||||||
Non-Hispanic White | Reference | Reference | ||||
Hispanic |
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|
|
|
|
|
Non-Hispanic Black | 0.99 | 0.59 | 1.65 | 0.99 | 0.59 | 1.66 |
Asian/pacific islander | 0.76 | 0.46 | 1.25 | 0.77 | 0.46 | 1.27 |
Native American | 0.75 | 0.24 | 2.32 | 0.89 | 0.28 | 2.84 |
Maternal age, yrs | ||||||
0 to 16 | 2.11 | 0.97 | 4.60 | 1.95 | 0.85 | 4.44 |
17 to 18 | 0.95 | 0.56 | 1.63 | 0.92 | 0.54 | 1.55 |
19 to 29 | Reference | Reference | ||||
30 to 39 |
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40 to 49 | 0.60 | 0.25 | 1.46 | 0.56 | 0.23 | 1.35 |
Family income | ||||||
<$20,000 |
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$20,000–39,000 | 2.06 | 0.98 | 4.30 | |||
$40,000–59,000 | 2.05 | 0.94 | 4.45 | |||
$60,000–99,000 | 1.49 | 0.66 | 3.35 | |||
>$100,000 | Reference | |||||
Not stated |
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Marital status | ||||||
Married | Reference | Reference | ||||
Separated/divorced |
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Widowed | 1.55 | 0.16 | 15.14 | 1.68 | 0.20 | 14.17 |
Never married but living together |
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Never married but living apart |
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Pregnancy intendedness | ||||||
Yes | Reference | Reference | ||||
Yes, but not trying hard |
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No, trying hard to keep from getting pregnant |
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Neither trying nor preventing pregnancy |
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Prenatal care | ||||||
Yes | Reference | Reference | ||||
No |
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Care received prior to pregnancy | ||||||
Yes | Reference | Reference | ||||
No | 1.09 | 0.78 | 1.52 | 1.20 | 0.86 | 1.68 |
Preterm birth/low birth weight | ||||||
Yes | 1.28 | 0.97 | 1.69 | 1.30 | 0.98 | 1.72 |
No | Reference | Reference | ||||
Newborn visit | ||||||
Yes | Reference | Reference | ||||
No | 1.52 | 0.73 | 3.17 | 1.55 | 0.73 | 3.26 |
Insurance status | ||||||
No insurance | 1.24 | 0.87 | 1.77 | |||
Medi-Cal |
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|
|
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Private | Reference | |||||
Other | 0.47 | 0.14 | 1.62 |
OR: odds ratio; SE: standard error; CI: confidence interval.
Bolded text indicates the association was statistically significant.
The final analytic sample consisted of 4,075 women in LA County. The sample was predominantly Hispanic, between 19 and 39 years old, married, had an annual income <$20,000, and obtained a high school-level education or less. Table
Table
Figure
Top reasons reported for not receiving a postpartum checkup (
Our paper highlights the many factors influencing a woman’s decision to seek postpartum care. Our study population was multiethnic, predominantly Hispanic and low-income, based on the demographics of Los Angeles County. In the multivariable analyses, postpartum care utilization was lowest among women who were low income, separated/divorced, and had an unplanned pregnancy. In our study, Hispanic women were more likely to obtain PPC compared to non-Hispanic White women. Consistent with other studies, prenatal care was the strongest predictor of postpartum care utilization [
Results from this study indicate that targeted educational efforts are needed. The top 5 reasons for not seeking PPC indicate that women who lacked PPC did not consider the PPC visit a high priority (Figure
In addition to educational barriers, access barriers are evident as well. PPC must be made available to women who do not have private insurance. Medi-Cal is the Medicaid program available to residents in the State of California. This public health insurance program provides health care services to low-income individuals and families. In California, certain eligibility requirements apply to receive 60 days of PPC through Medi-Cal services. If the eligibility requirements are met, covered services include hospital and scheduled office visits during puerperium, assessment of uterine involution, and contraceptive counseling [
Our findings indicate that women enrolled in Medi-Cal are twice as likely to lack a PPC visit compared to those with private insurance. These findings further support the need for national and state level policies addressing barriers to postpartum care. The Affordable Care Act addresses this need through the inclusion of provisions to support pregnant and postpartum women [
Several limitations must be considered when interpreting our findings. The LAMB study was a cross-sectional study based on a sampling of live birth certificates. It relied on maternal recall and may be subject to bias. In addition, the mother’s current relationship with the baby’s father may differ from their relationship status during pregnancy and as a result has a bearing on the survey responses. As this study took place in LA County, findings may not be generalizable. However, this study contributes to the growing body of the literature emphasizing the importance of the postpartum visit and identifying barriers to PPC.
In our study population, despite the many barriers to obtaining postpartum care, Hispanic women were more likely to receive postpartum services compared with non-Hispanic White mothers. Both financial resources and familial support appear to influence PPC utilization rates. An interesting finding of our study was that perceptions about the barriers to postpartum care were the result of a perceived low value of the postpartum visit. This indicates a need for health care facilities and providers to make concerted efforts to increase knowledge about the importance of the postpartum visit, enhance the use or design of medical encounters, identify community resources, and develop targeted interventions [
The views expressed are the authors’ and not necessarily those of the Health Resources and Services Administration or the Department of Health and Human Services.
The authors have no financial relationships or conflicts of interests to disclose.
This study was supported by Grant np. R40MC06635 from the Maternal and Child Health Research Program, Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.