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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Postpartum Visit.

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Strategy. Medicaid Expansion/Extension

Approach. Support policy that expands and extends Medicaid coverage to pregnant women beyond 60 days postpartum

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Overview. State policies that expand emergency Medicaid to include postpartum care or extend Medicaid to pregnant people beyond 60 days postpartum are likely to improve postpartum care usage.[1,2,3,4] Evidence suggests that Medicaid expansion and extension of postpartum coverage is an effective strategy to increase postpartum healthcare utilization among eligible women. The American College of Obstetricians and Gynecologists, together with other women’s health organizations, maintain that adequate access to health insurance during the full year postpartum contributes to preventable maternal morbidity and mortality.[1,5,6] States that adopt the federally-supported option to extend Medicaid coverage through 12 months postpartum are likely to see increases in postpartum visit attendance, which may in turn be associated with fewer preventable readmissions and emergency department visits.[7,8].

Evidence. Moderate Evidence. Strategies with this rating are likely to work. These strategies have been tested more than once and results trend positive overall; however, further research is needed to confirm effects, especially with multiple population groups. These strategies also trend positive in combination with other strategies. (Clarifying Note: The WWFH database calls this "some evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

Examples from the Field. There are currently no ESMs that use this strategy. As Title V agencies begin to incorporate this strategy into ESMs, examples will be available here. Until then, you can search for ESMs that have similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of pregnant and postpartum individuals enrolled in expanded or extended Medicaid coverage. (Indicates the reach and utilization of the strategy)
  • Number of healthcare providers, clinics, and health systems that accept and provide services to individuals with expanded or extended Medicaid coverage. (Shows the provider participation and network adequacy for the strategy)

OUTCOME MEASURES:

  • Number of preventable maternal morbidities, mortalities, and adverse outcomes averted through the increased access to postpartum care afforded by expanded or extended Medicaid coverage. (Indicates the health impact and cost-saving potential of the strategy)
  • Number of postpartum individuals who receive continuous, comprehensive, and coordinated care throughout the first year after birth through expanded or extended Medicaid coverage. (Shows the care continuity and quality outcomes of the strategy)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of eligible pregnant and postpartum individuals who are enrolled in and maintain expanded or extended Medicaid coverage. (Indicates the uptake and retention of the strategy)
  • Percent of Medicaid-enrolled postpartum individuals who receive education, outreach, and navigation support to access postpartum care services. (Shows the member engagement and support approach of the strategy)

OUTCOME MEASURES:

  • Percent of Medicaid-enrolled postpartum individuals who attend a postpartum visit within the recommended time frame. (Indicates the timeliness and adherence to postpartum care guidelines)
  • Percent reduction in disparities in postpartum care utilization and maternal health outcomes between Medicaid-enrolled and privately insured postpartum individuals. (Shows the health equity impact of the strategy)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of partners, including healthcare providers, payers, policymakers, and community supporters, engaged in educating about and implementing expanded or extended Medicaid coverage for postpartum individuals. (Indicates the coalition-building and collective action approach of the strategy)
  • Number of policies, guidelines, and reimbursement models developed to support the sustainable implementation and financing of expanded or extended Medicaid coverage for postpartum care. (Shows the enabling environment and systems change efforts for the strategy)

OUTCOME MEASURES:

  • Number of states that achieve significant and sustained improvements in postpartum care utilization, maternal health outcomes, and health equity through the implementation of expanded or extended Medicaid coverage. (Indicates the state-level impact and spread of the strategy)
  • Number of national organizations, funders, and policymakers that prioritize and invest in expanded or extended Medicaid coverage as a key lever for advancing postpartum health and health equity. (Shows the field-building and agenda-setting influence of the strategy)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • Percent of Medicaid funding and resources allocated to address social determinants of health and upstream drivers of postpartum health inequities, such as housing, food security, and transportation. (Indicates the social and structural determinants focus of the strategy)
  • Percent of Medicaid performance and accountability measures that prioritize postpartum care outcomes, health equity, and community-defined measures of success. (Shows the equity-centered and community-responsive measurement approach of the strategy)

OUTCOME MEASURES:

  • Percent reduction in structural and systemic barriers to postpartum care access and utilization, such as discrimination, stigma, and poverty, through the equity-focused design and implementation of expanded or extended Medicaid coverage. (Indicates the social justice and health equity outcomes of the strategy)
  • Percent of overall population health and health equity indicators, such as maternal mortality, preterm birth, and infant health, that improve as a result of the increased access, continuity, and quality of postpartum care enabled by expanded or extended Medicaid coverage. (Shows the societal and intergenerational impact of the strategy)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] Wang, X., Pengetnze, Y. M., Eckert, E., Keever, G., & Chowdhry, V. (2022). Extending Postpartum Medicaid Beyond 60 Days Improves Care Access and Uncovers Unmet Needs in a Texas Medicaid Health Maintenance Organization. Frontiers in public health, 10, 841832. https://doi.org/10.3389/fpubh.2022.841832.
[2] DeSisto, C. L., Rohan, A., Handler, A., Awadalla, S. S., Johnson, T., & Rankin, K. (2020). The Effect of Continuous Versus Pregnancy-Only Medicaid Eligibility on Routine Postpartum Care in Wisconsin, 2011-2015. Maternal and child health journal, 24(9), 1138–1150. https://doi.org/10.1007/s10995-020-02924-4.
[3] Rodriguez, M. I., Skye, M., Lindner, S., Caughey, A. B., Lopez-DeFede, A., Darney, B. G., & McConnell, K. J. (2021). Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care. JAMA network open, 4(12), e2138983. https://doi.org/10.1001/jamanetworkopen.2021.38983.
[4] Gordon, S. H., Sommers, B. D., Wilson, I. B., & Trivedi, A. N. (2020). Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization. Health affairs (Project Hope), 39(1), 77–84. https://doi.org/10.1377/hlthaff.2019.00547.
[5] American College of Obstetricians and Gynecologists (ACOG). (2018) Committee Opinion No. 736 https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2018/05/optimizing-postpartum-care.pdf.
[6] American College of Obstetricians and Gynecologists (ACOG). (2021) Protecting and expanding Medicaid to improve women’s health https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/06/protecting-and-expanding-medicaid-to-improve-womens-health.
[7] Georgetown University, CCS. (2022) Opportunities to support maternal and child health through Medicaid’s new postpartum coverage extension https://ccf.georgetown.edu/2022/07/15/opportunities-to-support-maternal-and-child-health-through-medicaids-new-postpartum-coverage-extension/.
[8] Saldanha, I. J., Adam, G. P., Kanaan, G., Zahradnik, M. L., Steele, D. W., Chen, K. K., Peahl, A. F., Danilack-Fekete, V. A., Stuebe, A. M., & Balk, E. M. (2023). Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review. JAMA network open, 6(6), e2316536. https://doi.org/10.1001/jamanetworkopen.2023.16536.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.