Home Visits and the Use of Routine and Emergency Postpartum Care Among Low-Income People: A Secondary Analysis of a Randomized Clinical Trial

Abstract

Importance: Access to appropriate postpartum care is essential for improving maternal health outcomes and promoting maternal health equity.

Objective: To analyze the impact of the Nurse-Family Partnership (NFP) home visiting program on use of routine and emergency postpartum care.

Design, setting, and participants: This study was a secondary analysis of a randomized clinical trial that enrolled eligible participants between 2016 and 2020 to receive NFP or usual care from a South Carolina Medicaid program. Participants were nulliparous pregnant individuals at less than 28 weeks' gestation at enrollment who were enrolled in Medicaid during pregnancy or delivery. Analysis was performed February 2, 2023, to July 16, 2024.

Intervention: Participants were enrolled in a 2:1 ratio to receive NFP, an established model of nurse home visiting, or usual care. NFP visits are conducted prenatally and for up to 2 years post partum.

Main outcomes and measures: This study assessed one of the trial's preregistered secondary outcomes: attendance at a routine postpartum health care visit before 12 weeks post partum. Other exploratory outcomes included outpatient care use, hospitalization, and emergent, nonemergent, and any use of emergency department (ED) health services at 12 weeks and 1 year post partum. Subgroup analyses examined individuals who underwent cesarean delivery, had chronic disease, experienced pregnancy complications, reported non-Hispanic Black race and ethnicity, were socially vulnerable, or were unaffected by COVID-19.

Results: Among 5670 participants enrolled, 4877 were analyzed (median [IQR] age, 21 [19-25] years), including 3261 who received NFP and 1616 who received usual care. By race and ethnicity, the sample included 259 Hispanic individuals (5.7%); 56 non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander individuals (1.2%); 2535 non-Hispanic Black individuals (55.4%); 1587 non-Hispanic White individuals (34.7%); and 141 individuals (3.1%) with more than 1 race reported (and non-Hispanic ethnicity). There was no significant difference in attendance of routine postpartum visit at 12 weeks between NFP and usual care groups (63.8% vs 64.2%; adjusted difference [AD] -0.3 [95% CI, -3.2 to 2.5] percentage points). In exploratory analyses, the NFP group was less likely to have a visit to the ED without admission (AD, -2.5 [95% CI, -4.8 to -0.1] percentage points) in the first 12 weeks post partum. Other outcomes, including hospitalizations, outpatient visits, and emergent and nonemergent ED visits, were not different between intervention and control groups. There were also no statistically significant differences within subgroups.

Conclusions and relevance: In this secondary analysis of a randomized clinical trial of nulliparous pregnant individuals with low income, nurse home visiting did not increase use of routine postpartum care in the immediate or extended postpartum periods, even among those with greater health challenges. Nurse home visiting was associated with reduced ED use. More research is needed on how to improve continuity of perinatal care for low-income populations.

Trial registration: ClinicalTrials.gov Identifier: NCT03360539.

Figure.. Effects of Nurse Home Visiting Intervention for Full Sample and by Subgroup

ED indicates emergency department. Outpatient visits are exclusive of routine postpartum visits.