The postpartum period is a vulnerable time for both birthing parent and newborn and is critically important to their health and well-being. The American College of Obstetricians and Gynecologists (ACOG) recommends ongoing, comprehensive care, including physical, social, and psychological services, during the postpartum period. In large part because of an increasing maternal mortality rate in the US – one that is 3 to 4 times higher for African-American and Native American pregnant people – public and private decision makers have increased their focus on care in the postpartum period.

We use HCCI's unique dataset to characterize spending on care used by birthing parents with employer-sponsored insurance during the postpartum period. Because the postpartum period is defined differently depending on the entity and purpose, our analysis of postpartum utilization and spending covers a full year after birth. 

We also include estimates for shorter periods, specifically 60 and 90 days, since those may be of particular interest to public and private decision makers. For example, while newborns born with Medicaid coverage are eligible for up to a full year, Medicaid programs are only required to cover most pregnant people with incomes below 133 percent of the federal poverty level through 60 days postpartum (though 36 states and the District of Columbia extend eligibility beyond that). 

Some members of Congress have proposed extending Medicaid eligibility for pregnant people to one year postpartum to align with the coverage that children receive. To assess the potential need for health care services among birthing parents in the year after delivering a baby we analyzed the spending of health care services among the commercially insured population across a full year, focusing on birthing parents, not newborns.

More than 70 percent of postpartum spending occurs after 90 days 

Spending on behalf of birthing parents spans the full year following childbirth among our sample. Although nearly 20 percent of overall postpartum spending was in the first 60 days, and almost 30 percent of spending was in the first 90 days, approximately 70 percent of spending occurred over the rest of the year (Figure 1). Per person spending for the 60 days after delivery was $580, and $870 for the first 90 days postpartum. Over the course of the full postpartum year, per person spending was just above $3,100. 

Figure 1: Spending Across the Postpartum Year

Our data in (Table 1 below) show differences in postpartum spending per person by age. For example, birthing parents ages 25-34, about 60 percent of our sample, had the lowest average per person spending ($2,904). Average spending per birthing parent age 45-54 was 50 percent higher ($4,634), though those parents accounted for less than 0.5 percent of our sample.

Table 1: Full-Year Postpartum Spending by Age Group (2016)

Low-Frequency, High-Cost Services Account for More than 40 percent of Postpartum Spending

Among our sample, surgery accounted for the largest percentage of postpartum health care spending. Over the year following birth, 26 percent of total spending was on surgery, with emergency room and ambulance services, and evaluation and management services rounding out the top 3. As shown in Table 2, we observe a similar pattern in the 60-day and 90-day postpartum periods.

Table 2: Percent of Spending by Detailed Service Category

Figure 2 illustrates how spending was distributed across detailed service categories in each week following delivery. While the first week following delivery had the highest average weekly spending per person (about $120), we also find that our sample averaged fairly consistent spending across weeks for the remainder of the year following delivery. Per person spending ranged from $71 to $79 in weeks 6 through 11 and from $51 to $66 in weeks 12 through 52. Over the course of the year, we find that spending on low-frequency, but high-cost events, like surgery and emergency room and ambulance service, account for the plurality of spending in every week.

Conclusion

Recent reporting about the US's troubling maternal mortality rate has illustrated the importance of health care in the postpartum period. Indeed, more than half of pregnancy-related deaths occur in the postpartum period with nearly 12 percent of those (for which timing was known) occurring between six weeks and the year after delivery. Data from the Pregnancy Mortality Surveillance System suggest that infection, cardiomyopathy, other cardiovascular conditions, hypertensive disorders of pregnancy, and cerebrovascular accidents account for the majority of postpartum deaths.  Cardiomyopathy, other non-cardiovascular conditions, and other cardiovascular conditions are reported as the three most frequent causes of pregnancy-related deaths between six weeks postpartum and the rest of the postpartum year.

This study illustrates that spending on behalf of birthing parents with employer-sponsored insurance spans the full year following childbirth; that it did not meaningfully decrease after the first several weeks postpartum. Among this population, most spending occurs after 60 days postpartum, and we observe fairly consistent spending across weeks throughout the year. Unusual and costly services appear to account for most of that spending, highlighting the critical role that insurance coverage plays in people's ability to access and afford care in the year after childbirth. Yet, in many states, birthing parents' access to Medicaid coverage ends after 60 days. Private and public policymakers looking to improve maternal health may find this analysis informative as they consider the role of postpartum care in that improvement.