Insurers can help improve care after adverse pregnancy outcomes

September 9, 2024

About one in five pregnancies has an adverse pregnancy outcome (APO), which can include gestational hypertension or diabetes, a child who is small for gestational age, or preterm delivery. The rate of APO is increasing, likely due to increased average maternal age. Those who had an APO in one pregnancy are at higher risk during subsequent pregnancies.

APOs are associated with high lifetime risks. For instance, those who had hypertension in pregnancy were 63% more likely to have subsequent cardiovascular disease, and those who had gestational diabetes are ten times more likely to have subsequent diabetes. This increased risk persists for as much as 50 years after pregnancy and cannot be explained by other risk factors before pregnancy.

Obstetricians may be aware of their patients’ increased future risk, but women generally transfer care to primary care clinicians after childbirth, and these clinicians are often not fully aware of these women’s increased risk and might not be aware of recommended evidence-based care. Many patients may themselves be unaware of their increased risk.

Policy experts in JAMA Health Forum detail the role that payers can play to address the increased cardiovascular risk of those who had APOs. Their recommendations include member education, incentives to primary care clinicians to provide guideline-based care, provision of information to primary care practices on health plan member risk, reimbursement of primary care for services delivered to this population, and benefit design that reduces out of pocket cost burden for those who had APOs to receive guideline-recommended care. Guideline-based care for those who had APOs include routine monitoring of postpartum blood pressure and Hemoglobin A1C, an indication of potential diabetes, nutritional counseling and appropriate mental health support. Those who have had APOs might be advised to have subsequent deliveries at hospitals which have high level nurseries and are better equipped to address high-risk pregnancies.

Implications for employers:

• Employers can ask their health plans about what efforts they make to identify, educate, and follow those who have had an adverse pregnancy outcome.

• Employers can ask about health plan direction of those with high-risk pregnancies to facilities capable of dealing with potential birth complications.

• Employers can also ask for reporting on this special population at risk.

• Access to a plan without especially high deductibles can encourage women at risk to follow up with recommended care.

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  Illustration by Dall-E

Tomorrow: Higher rate of hypertension in areas with greater social needs