Postpartum care is vital for the well-being of both mothers and infants, as it enables the early detection and timely management of maternal morbidity. Guidelines from the American College of Obstetricians and Gynecologists recommend an initial postpartum follow-up within 21 days of childbirth, followed by a comprehensive visit by 84 days postpartum. Despite these recommendations, significant racial, ethnic, and geographic inequities persist.
For example, according to Medicaid data from Pennsylvania (November 2011-December 2015), only about half of Black people received postpartum care within 56 days of childbirth, compared to 63% of White people and 73% of Asian people. In 2019, similar disparities were reported, with 63.9% of Black individuals attending postpartum care within 56 days compared to 88.7% of non-Black individuals. Geographic disparities also exist: 88.1% of rural residents received any type of postpartum visit compared to 90.3% of the urban residents. These inequities contribute to adverse maternal outcomes and are associated with higher rates of pregnancy-related deaths among Black, American Indian, and rural populations, a trend further exacerbated by the COVID-19 pandemic.
Telehealth has emerged as a potential solution to reduce these disparities by improving appointment scheduling, care coordination, and access to care. Pre-pandemic research demonstrated its effectiveness in maternal, pediatric, and mental health care. Early pandemic data from the Northeast U.S. also showed encouraging results, including sustained postpartum visit rates and reduced racial disparities. Nevertheless, the role of telehealth in improving timely postpartum care in the Southern U.S., especially among racial, ethnic, and rural groups, remains underexplored. This study aimed to examine statewide disparities in postpartum care follow-up and timeliness using South Carolina Medicaid data, while also assessing the impact of pandemic exposure and telehealth use.
This population-based retrospective cohort study analyzed Medicaid claims linked to birth certificate data for all childbirths in South Carolina between January 2018 and September 2022 among individuals aged 15-49 years. Participants were categorized into three groups: never-exposed (January 2018–February 2019), partially-exposed (pre-pandemic births before March 1, 2020, with postpartum overlap during the pandemic), and fully-exposed (March 2020–September 2022). Telehealth use was assessed only in the fully exposed group. Key variables included race/ethnicity, residence (urban/rural), age, BMI, comorbidities, and hospital level. The primary outcome was timeliness of postpartum care initiation, defined as the number of days from hospital discharge to the first postpartum visit within 365 days, with a focus on the first 90 days.
Among 103,977 postpartum beneficiaries of Medicaid, 26,402 (25.4%) were never exposed, 22,441 (21.6%) were partially exposed, and 55,134 (53.0%) were fully exposed to the pandemic. Telehealth was used by only 3,103 (5.6%) individuals in the fully exposed group. The cohort included 42.6% non-Hispanic White, 41.8% non-Hispanic Black, 7.8% Hispanic, and 7.8% other or unknown individuals, with 16.7% residing in rural areas.
Overall, 68.9% of participants initiated postpartum care within 90 days, with a median time of 25 days (interquartile range: 14-41). Telehealth users had a 100% initiation rate and a shorter median time of 18 days (9-28) days respectively. Ninety-day initiation rates were similar for both Non-Hispanic White and Black individuals (~74%) but were lowest among Hispanic people (32.7%). Rural residents initiated postpartum care slightly later than urban residents (median: 26 vs. 25 days). Telehealth use was associated with reduced both urban–rural and racial disparities.
Among individuals who did not use telehealth, racial, ethnic, and urban–rural disparities in postpartum care initiation persisted. Telehealth users demonstrated higher follow-up rates and shorter initiation times, suggesting that telehealth may help overcome systemic barriers, particularly among Hispanic and urban populations. Although telehealth shows promise in improving timeliness and equity of care, challenges such as access to technology, digital literacy, and appropriate risk-based care delivery must be addressed.
Policymakers should focus on sustaining these benefits by equitable implementation of telehealth, especially for high-risk and underserved populations. Limitations of the study include its reliance on state-specific data, lack of information on digital literacy, and the absence of COVID-19 infection status. However, this study highlights the potential of telehealth to reduce longstanding disparities in the postpartum care initiation and inform future maternal health strategies.
References: Chatterjee A, Zhao X, Liu J, et al. Telehealth uptake and rural-urban and racial/ethnic disparities in postpartum care access among Medicaid beneficiaries in South Carolina, 2018–2022. Med Care. 2026. doi:10.1097/MLR.0000000000002298
