The role of home visiting in addressing postpartum care gaps: Evidence from a large community sample

BackgroundMaternal mortality in the United States has doubled over the last two decades, primarily due to cardiovascular disease, with more than half of deaths occurring postpartum. Despite national calls to action, attendance at postpartum clinic visits remains low. The role of alternative care delivery strategies, such as home visiting, remains insufficiently studied.ObjectiveTo describe postpartum clinic visit attendance among participants in a large national home visiting program, identify sociodemographic and clinical factors associated with attendance, and examine how timing and duration of enrollment relate to postpartum follow-up.DesignWe conducted a retrospective cohort study of pregnancy episodes among mothers enrolled in the Parents as Teachers (PAT) national home visiting program between July 2016 and September 2024.MethodsThe primary outcome was documented attendance at a postpartum clinic visit within 12 weeks of delivery. Descriptive analyses estimated overall attendance rates and characterized variation by pregnancy risk status, geography, calendar year, and sequential pregnancies. Multilevel logistic regression with random intercepts for participant and site was used to account for repeated pregnancies and clustering. Sensitivity analyses included all pregnancies, including those exiting home visiting prior to 12 weeks postpartum.ResultsAmong 46,899 pregnancy episodes from 39,498 participants, median maternal age was 27 years (IQR 18-36). Overall, 30.1% (95% CI 29.6-30.5) attended a postpartum clinic visit within 12 weeks, including 33.2% (95% CI 32.3-34.1) among high-risk pregnancies. Attendance was lower among Black (adjusted OR 0.80 [95% CI 0.75-0.86]), American Indian/Alaska Native (0.61 [0.55-0.68]), rural participants (0.77 [0.73-0.82]), and participants who primarily used the emergency room or urgent care for medical care before pregnancy (0.78 [0.72-0.85]). Attendance washigher among recent immigrants (1.17 [1.05-1.30]), women with high-risk pregnancies (1.13 [1.06, 1.20]),and those enrolled prenatally (1.93 [1.84-2.04]).ConclusionsPostpartum clinic attendance was low in this national home visiting cohort. Prenatal and sustained engagement in home visiting were associated with higher odds of attendance. Home visiting is a potential complementary care model to extend early care beyond clinical settings and promote sustained engagement in clinical follow-up.