Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

Abstract

Objective Approximately one-third of maternal deaths occur postpartum. Little is known about the intersection between the postpartum period, emergency department (ED) use, and opportunities to reduce maternal mortality. The primary objectives of this systematic review are to explore the incidence of postpartum ED use, identify postpartum disease states that are evaluated in the ED, and summarize postpartum ED use by race/ethnicity and payor source. Study Design We searched PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, Cochrane CENTRAL, Social Services Abstracts, and Scopus from inception to September 19, 2019. Each identified abstract was screened by two authors; the full-text manuscripts of all studies deemed to be potential candidates were then reviewed by the same two authors and included if they were full-text, peer-reviewed articles in the English language with primary patient data reporting care of a female in the ED in the postpartum period, defined as up to 1 year after the end of pregnancy. Results A total of 620 were screened, 354 records were excluded and 266 full-text articles were reviewed. Of the 266 full-text articles, 178 were included in the systematic review; of these, 108 were case reports. Incidence of ED use by postpartum females varied from 4.8 to 12.2% in the general population. Infection was the most common reason for postpartum ED evaluation. Young females of minority race and those with public insurance were more likely than whites and those with private insurance to use the ED. Conclusion As many as 12% of postpartum women seek care in the ED. Young minority women of lower socioeconomic status are more likely to use the ED. Since approximately one-third of maternal deaths occur in the postpartum period, successful efforts to reduce maternal mortality must include ED stakeholders. Systematic Review Registration CRD42020151126. Key Points

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012–2017

“…Overall, our findings for birthing people with Medicaid align with the limited prior research on postpartum care-seeking 4,40–43 . Our analysis highlighted that Medicaid beneficiaries are much more likely (4-fold) to repeatedly seek care in the ED compared with births funded by other commercial plans, including HDHPs, with 14.4% having multiple ED visits.…”

“…Overall, our findings for birthing people with Medicaid align with the limited prior research on postpartum careseeking. 4,[40][41][42][43] Our analysis highlighted that Medicaid beneficiaries are much more likely (4-fold) to repeatedly seek care in the ED compared with births funded by other commercial plans, including HDHPs, with 14.4% having multiple ED visits. While the ED is excellent for the effective and efficient treatment of emergent conditions, it is a costly and suboptimal setting to provide preventative or therapeutic care for postpartum individuals.…”