Viewpoint

Expanding Postpartum Medicaid Benefits to Combat Maternal Mortality and Morbidity

Originally published in Health Affairs Blog. Viewpoint articles are written by members of the SPH community from a wide diversity of perspectives. The views expressed are solely those of the author and are not intended to represent the views of Boston University or the School of Public Health. We aspire to a culture where all can express views in a context of civility and respect. Our guidance on the values that guide our commitment can be found at Revisiting the Principles of Free and Inclusive Academic Speech.

The weeks and months following delivery set the stage for the long-term health and well-being of pregnant and parenting people. Yet, for many new parents in the US, the official postpartum visit with maternity care providers, which traditionally occurs between two and six weeks after delivery, marks the end of formal maternity care support within the health care system. In fact, postpartum care is often absent or incomplete, with particularly low rates among Black and Brown mothers. These realities are particularly disturbing in light of the fact that one-third of pregnancy-related deaths occur between one week and one year after delivery, and almost 12 percent occur past the six-week postpartum visit. In 2018, the American College of Obstetricians and Gynecologists issued guidelines recommending extending postpartum care into the “fourth trimester” and key postpartum services, including management of chronic conditions, breastfeeding support, screening for mental health disorders, and contraception planning.     

While more than 20 states have introduced proposals to extend postpartum Medicaid eligibility beyond 60 days, significantly less attention has been paid to Medicaid’s postpartum maternity benefits. To highlight variation in maternity benefit coverage as a focus for future policy intervention, we examined the postpartum benefits each state covers using data from the Henry J. Kaiser Family Foundation report, “Medicaid Coverage of Pregnancy and Perinatal Benefits,” the Medicaid and Children’s Health Insurance Program Payment and Access Commission’s “Inventory of State-Level Medicaid Policies, Programs, and Initiatives to Improve Maternity Care and Outcomes,” state Medicaid websites, and personal correspondence. We focused on benefits that would apply to the majority of postpartum women and found substantial variation in benefits among state Medicaid programs. Our review points to a need for a dual focus on expanding coverage and comprehensive benefits for the extended postpartum period. We recommend that postpartum benefits are standardized to include postpartum mental health screening and care, home visiting, lactation consultation, and family planning services.

The Role Of Medicaid In Postpartum Care

Medicaid is a critical focal point for improving maternal health outcomes, as Medicaid financed 43 percent of all births in the US in 2018. Federal law requires that Medicaid covers pregnant women up to 138 percent of the federal poverty level, and 46 states extend coverage beyond the federal minimum. Notably, maternal morbidity and mortality occur disproportionately among low-income Black, Native American, Alaskan Native, and Latinx women, populations that are overrepresented in Medicaid enrollment.    

Every state covers a six-week postpartum appointment, yet only 61 percent of Medicaid beneficiaries nationally attend a postpartum visit. A California study shows Black women enrolled in Medicaid are less likely to attend a postpartum visit than White women enrolled in Medicaid. Likelihood to attend a postpartum visit also varies substantially by state. In 2019 in Oklahoma, 23 percent of Medicaid beneficiaries attended a postpartum visit compared to 72 percent in Rhode Island.

Many people whose pregnancies and births are covered through Medicaid cannot remain on Medicaid in the extended postpartum period unless they qualify through a different Medicaid eligibility pathway. With few exceptions, such as substance use treatment, Medicaid coverage for pregnancy begins at a positive pregnancy test and ends at 60 days postpartum for women who qualify for Medicaid on the basis of their pregnancy. Medicaid qualification for mothers after birth depends on state policies for income and eligibility thresholds for parents and low-income adults. For instance, Texas Medicaid covers pregnant women up to 203 percent of poverty but only covers parents in a family of three below 17 percent of poverty ($3,692 annual income) and does not cover other low-income adults. In comparison, Connecticut Medicaid covers pregnant women up to 263 percent of poverty, parents in a family of three up to 160 percent of poverty, and other low-income adults up to 138 percent of poverty.

The 60-day cutoff for postpartum Medicaid coverage does not reflect the medical and socioemotional needs of the postpartum period. The “fourth trimester” often presents challenges including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, and urinary incontinence. Furthermore, with only 60 days of coverage, Medicaid beneficiaries have a short window to schedule their postpartum appointment. In 2019–20, 21 states and Washington, DC, took legislative action to extend Medicaid coverage past 60 days postpartum. However, even if coverage is extended to cover the full postpartum year, new mothers may not receive the care they need if Medicaid does not cover all evidence-based benefits. Extending Medicaid coverage in the postpartum period is a necessary but insufficient policy solution if programs do not cover the services postpartum women need to maintain their health. In this blog post, we discuss four benefits Medicaid programs should cover to preserve and promote health in the postpartum period.

Mental Health Screening

Postpartum depression affects about one in nine postpartum women. It is particularly common in low-income mothers: 40–60 percent of low-income new mothers report depressive symptoms. Mothers on Medicaid are 25 percent more likely than mothers with private insurance to report postpartum depressive symptoms, and Black and Latinx women are about half as likely to receive postpartum depression care as White women.

Postpartum depression is associated with a host of issues for the mother-infant dyad. For mothers, depression is associated with decreased quality of life during the postpartum period and recurrent depressive episodes throughout the life course. Postpartum depression is also associated with decreased likelihood to engage in safe parenting practices. Mothers with postpartum depression are at two times greater risk of not attending adequate numbers of well-child visits and three times greater risk of not completing immunizations compared to similar mothers without depression. Children of mothers with depressive symptoms at two to four months have increased use of acute care, including emergency department visits, at one and a half times the rate of children whose mothers did not show depressive symptoms.

Thirty-four states and the District of Columbia cover postpartum mental health screening as a Medicaid benefit to identify postpartum depression. Although postpartum mental health screenings are effective at detecting postpartum depression, screening is not the same as treating maternal depression. Treatment beyond 60 days postpartum is rarely covered by Medicaid. In many states, women can be screened for maternal depression in pediatric well-child visits during their child’s first year of life, but there are few requirements or incentives for providers to connect mothers to treatment.

The absence of treatment coverage is concerning as approximately 30–50 percent of postpartum depression–affected mothers remain depressed throughout the first postpartum year. Therefore, many mothers who qualify for Medicaid on the basis of pregnancy may lose Medicaid eligibility while receiving mental health treatment or perhaps before treatment has begun. One notable exception is California, which has extended postpartum Medicaid eligibility specifically for women with maternal mental health conditions through the state’s Provisional Postpartum Care Extension. Colorado Medicaid also offers a Special Connections program that provides limited services for pregnant women with alcohol or substance use disorders during the year after birth.

However, targeted postpartum eligibility extensions for women with mental health and substance use conditions may fall short because they exclude many women due to strict diagnosis-based eligibility criteria. The adoption of Medicaid expansion in the 12 states that have yet to do so and a universal extension of postpartum Medicaid eligibility to all women eligible for pregnancy-related Medicaid as proposed in the 2020 Momnibus Act offer more durable and comprehensive options.     

Postpartum Home Visits

Forty-one states and the District of Columbia cover postpartum home visits through their Medicaid programs. Of the remaining states, some, such as Wyoming, pay for home visits using non-Medicaid state and local funds. Home visiting can include case management, providing service referrals and monitoring developmental progress. Guidelines from the Department of Health and Human Services specify that to qualify for Medicaid funding, home visiting models must demonstrate statistically significant positive impacts. Currently, 19 distinct home visiting models fit these criteria.

Some home visiting models are associated with improved outcomes for infants and mothers. In a randomized control trial in Durham, North Carolina, infants whose families had home visits had 59 percent fewer emergency medical care episodes than infants without home visits and one and a half fewer overnights in the hospital during the first six months of life. Home visiting can also lead to increased rates of breastfeeding.

Home visiting programs provide a number of benefits to the health of low-income women and their families, and thus Medicaid can play an important role in increasing the accessibility and effectiveness of home visiting. While home visiting services as a whole are not specifically covered under Medicaid, providers can seek reimbursement from Medicaid for eligible components of home visiting programs such as visits, screenings, and case management. States have considerable flexibility in leveraging Medicaid dollars to support home visiting infrastructure through state plan amendments, Early and Periodic Screening, Diagnostic, and Treatment guidelines, or through contracting with managed care organizations.

However, federal guidance for increasing capacity for home visiting programs via Medicaid is limited. While there are examples of states that increased capacity for home visiting through aligning Medicaid funds with other state and federal initiatives, more states would be able to expand these services if the Centers for Medicare and Medicaid Services (CMS) issued home visiting-specific waiver guidelines. Offering clear, Medicaid-based options is a feasible and promising strategy given that the positive benefits of home visiting programs are well-documented, most states have an existing home visiting program that could be built on, and Medicaid is a funding source that can be better leveraged to support home visiting programs.

Lactation Consultation

The World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding, if possible, for the first year of life. Although provider support improves the likelihood and duration of breastfeeding, many physicians don’t feel they have sufficient time to discuss breastfeeding. Having a lactation consultation increases the odds a woman will initiate breastfeeding and exclusively breastfeed.

Thirty states cover lactation consultation in the hospital, and 20 states cover lactation consultants in clinic postpartum visits and at home. Lactation consultation in the hospital is particularly important, given that the earlier that women breastfeed, the more likely they are to exclusively breastfeed or breastfeed for an extended period of time.

Of the states that do not cover lactation consultants through Medicaid, some cover lactation consulting through another program, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). For instance, Georgia provides a robust breastfeeding program including lactation consultations through its WIC program. WIC in Georgia covers pregnant women up to 185 percent of poverty, while Medicaid in Georgia covers pregnant women up to 220 percent of poverty. Consequently, postpartum Medicaid beneficiaries in Georgia between 185 percent and 220 percent of poverty do not receive this evidence-based benefit.

Kansas Medicaid provides an example of an extensive lactation consultation benefit. The program requires that a lactation counseling session must be one on one and at least 30 minutes, and Kansas Medicaid covers up to five sessions for up to 90 minutes. Since Kansas has not expanded Medicaid, few mothers who qualify for Medicaid during pregnancy can take full advantage of this benefit.

Given the benefits for mothers and children, lactation counseling should be a universally covered benefit, just like the postpartum visit or labor and delivery services.

Family Planning Waivers/State Plan Amendments

Family planning is a critical part of postpartum care. Contraceptive use prevents unintended pregnancies and reduces induced abortions. Short birth spacing between pregnancies increases risks of preterm birth, low birthweight, and infants being small for gestational age, and birth spacing related to family planning reduces pregnancy morbidity and mortality.

All Medicaid programs must offer some family planning benefits, but CMS allows considerable discretion to states to decide these benefits. Particularly, Medicaid programs are more likely to cover prescription contraceptives and long-acting reversible contraceptives, such as intrauterine devices and implants, than emergency contraceptives. More than 20 years ago, CMS began to allow Medicaid programs to extend benefits to specific populations or for specific services as demonstration projects, experimental pilot programs studying the likely impacts of the new policies. Many states used these waivers to extend Medicaid family planning benefits to people who would otherwise be ineligible for Medicaid. Over time, these programs became part of the family planning safety net, rather than just demonstration projects. The Affordable Care Act allowed states to formally add family planning waivers to their Medicaid program through state plan amendments. Medicaid now plays a major role in providing contraceptive care to low-income women in the US.

Thirty states have waivers or state plan amendments that extend family planning benefits to people who are not Medicaid beneficiaries. The specific parameters of the waivers or state plan amendments vary substantially. Rhode Island covers family planning services for women with family incomes up to 250 percent of poverty who lose coverage at 60 days postpartum. Alabama covers family planning services for all women with family incomes up to 141 percent of poverty but specifies that they must be 19 years of age or older. Washington’s waiver offers the most comprehensive coverage and covers women losing Medicaid pregnancy-related coverage after 60 days postpartum and anyone with family incomes up to 260 percent of poverty. A 2015 study in Illinois, New York, and Oregon found family planning waivers decreased unplanned births by 5 percent among all adults and up to 8 percent among all people younger than age 21.

By expanding their family planning benefits to non-Medicaid populations, states with state plan amendments promote maternal and infant health. As a first step, states can take the lead from states such as Rhode Island and target postpartum individuals losing Medicaid coverage specifically. States with family planning waivers can apply for state plan amendments and make extended family planning services part of their permanent coverage.

Future Of Postpartum Care

A single health care appointment and 60 days of coverage is an insufficient approach to postpartum health. The US’s lack of investment in postpartum health is reflected in our high maternal morbidity and mortality and substantial racial inequities in maternal health outcomes. Given that low-income and racial minority populations carry much of the burden of poor maternal health outcomes in the US, addressing Medicaid gaps in the postpartum period is a clear path to improving maternal health for the most vulnerable.

Our analysis finds that Medicaid programs offer vastly different postpartum benefits across states. The lack of parity in Medicaid has the potential to exacerbate existing inequities. The attention of advocates and policy makers has been focused on the expansion of Medicaid coverage to the entire postpartum year. Our review suggests this approach may be incomplete. Our analysis points to a dual focus on coverage and comprehensive benefits for the extended postpartum period. We recommend that postpartum benefits are expanded and standardized to include postpartum mental health screening and care, home visiting, lactation consultation, and family planning services. This could be achieved in one of three ways: through state action to enhance benefits in states that have gaps, through federal guidance regarding postpartum care benefits in Medicaid and clear state options to add services, and through CMS rejecting waivers that do not include a comprehensive set of postpartum services.

Currently, Medicaid programs do not consistently cover care that prevents morbidity and mortality during the postpartum period. Our analysis and policy recommendations point a way forward to comprehensive care by focusing on the care that distinguishes the postpartum period from other points in the life course. Appropriate postpartum care sets the stage for the long-term health and well-being of pregnant and parenting people, their families, and their communities. Covering evidence-based benefits in the postpartum period is a commonsense step to improve maternal and child health for families at the greatest risk for poor health outcomes.

This work was supported by the Centers of Excellence in MCH Education, Science and Practice through a research fellowship awarded to Gray Babbs: HRSA/Maternal and Child Health Bureau grant T76MC00017-25-00.

Gray Babbs, Lois McCloskey, and Sarah H. Gordon, “Expanding Postpartum Medicaid Benefits to Combat Maternal Mortality and Morbidity,” Health Affairs Blog, January 14, 2021, https://www.healthaffairs.org/do/10.1377/hblog20210111.655056/

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