Lois McCloskey

Background: Timely postpartum linkage to primary care is important for managing diabetes and hypertensive disorders of pregnancy (HDP), yet linkage remains suboptimal. Medicaid accountable care organizations (ACOs) aim to strengthen care coordination and improve postpartum linkage, although effects may vary by ACO design. Objective: Evaluate whether Massachusetts Medicaid ACO implementation was associated with changes in postpartum primary care linkage among enrollees with diabetes or HDP and whether effects differed by ACO model. Design: Retrospective cohort study using the 2016–2023 Massachusetts All-Payer Claims Database (APCD). Using a difference-in-differences approach, we compared outcomes before (2016–2017) versus after (2018–2023) implementation among health system/managed care partnership ACOs, primary care-led ACOs, and non-ACO enrollees. Subjects: In total, 38,340 Medicaid-covered deliveries among enrollees ages 18–44 with diabetes or HDP, continuously enrolled for at least 60 days before and after delivery. Main Measures: A primary care visit within 3, 6, and 12 months postpartum. Results: Overall, 53.6%, 76.8%, and 90.3% were linked to primary care by 3, 6, and 12 months, respectively. Although positive, ACO implementation was not associated with statistically significant changes at any interval for either model. At 3 months, model 1 was associated with a 2.44 percentage point [PP] increase (95% CI: −1.7 to 6.6) and model 2 with a 3.73 PP increase (95% CI: −0.5 to 8.0) versus non-ACO enrollees. Conclusions: Massachusetts Medicaid ACO implementation was not associated with significant changes in postpartum primary care linkage. Explicit postpartum performance measures and stronger coordination between maternity and primary care clinicians may be needed to improve transitions to ongoing care.

Policy Points: Medicaid Accountable Care Organization contracts that include maternal health metrics can act as an important lever to prioritize and improve maternal health care quality and equity within health care systems. Medicaid Accountable Care Organizations should implement specialized maternal health programs to support metric achievement and provide dedicated resources to meaningfully affect maternal health care quality and equity. Context: In the wake of a US maternal health crisis, Accountable Care Organizations (ACOs) may be a key opportunity to improve maternal health care. In 2018, Massachusetts Medicaid launched its ACO program through an 1115 waiver, which renewed and expanded in 2023. During the second waiver period, the ACOs expanded their emphasis on maternal health. However, there is limited understanding of how maternal health fits into Medicaid ACO strategic priorities, how ACOs implement maternal health initiatives, and the challenges they face. This study uses qualitative interviews with ACO leaders, clinicians, and care coordinators to explore how ACOs addressed maternal health care quality, while identifying key drivers of and challenges for change in maternal health care delivery across Massachusetts’ two waiver periods. Methods: We conducted 23 semistructed interviews with 26 ACO leaders, clinicians, and care coordinators representing six of 17 Massachusetts Medicaid ACOs between September 2023 and December 2024. We analyzed professionally transcribed interviews using thematic analysis. Findings: We identified three major themes: (1) Mandated ACO metrics drive maternal health priorities and practices, yet meeting metrics is challenging; (2) Shifts in Medicaid ACO priorities prompt the adaptation of existing programs or development of new initiatives to address maternal health; and (3) Health‐related social needs initiatives within the ACO are viewed as critical to maternal health care. The themes emphasized how Medicaid ACOs and health care systems adapted their programming in response to state‐level mandates to improve maternal health care quality. Conclusions: Findings highlight the importance of aligning the design of Medicaid ACO programs with robust infrastructure and resources to support sustainable improvements in maternal health. Massachusetts’ Medicaid program achieved success in improving maternal care quality when it intentionally and strategically incorporated maternal health‐specific provisions into Medicaid ACO contracts.

Despite recommendations for ongoing care after pregnancy, many individuals do not see a primary care clinician within the first postpartum year, missing a critical window to engage reproductive-age individuals in primary care. We administered an anonymous, cross-sectional, trilingual survey at a large urban safety-net hospital to assess postpartum individuals’ preferences, health concerns, and anticipated barriers to primary care during the year after pregnancy. While 90% of respondents preferred a visit within one year, most individuals – including those with complicated pregnancies – did not recall a primary care recommendation from their pregnancy care team. Respondents reported a variety of primary care-amenable health concerns, and many social and logistical barriers to care. Preference for virtual care increased if self-monitoring tools were hypothetically available, indicating virtual visits may improve primary care access.

Background COVID-19 exposes major gaps in the MCH safety net and illuminates the disproportionate consequences borne by people living in low resource communities where systemic racism, community disinvestment, and social marginalization creates a perfect storm of vulnerability. Methods We draw eight lessons from the first 8 months of the pandemic, describing how COVID-19 has intensified pre-existing gaps in the MCH support network and created new problems. For each lesson identified, we present supporting evidence and a call for specific actions that can be taken by MCH practitioners, researchers and advocates. Results LESSON #1: COVID-19 hits communities of color hardest, exposing and exacerbating health inequities caused by systemic racism. LESSON #2: Women experience the most devastating social, economic and mental health tolls during COVID-19. LESSON #3: Virulent pathogens find and exacerbate cracks in our public health and health care systems. LESSON #4: COVID-19 has become a pretext to limit access to sexual and reproductive health care. LESSON #5: COVID-19 has exposed and deepened fault lines in maternity care: over-medicalization, discrimination, lack of workforce diversity, underutilization of collaborative team approaches, and lack of post-delivery follow-up. LESSON #6: The pandemic adds impetus to much-needed Medicaid policy reforms that can have a lasting positive effect on maternal health. LESSON #7: Social and health policy changes, heretofore deemed infeasible, ARE possible under pandemic threat. LESSON #8: Finally, an overarching COVID-19 lesson: We are all inextricably connected. Conclusion COVID-19 is a loud wake up call for renewed action by MCH epidemiologists, policy-makers, and advocates.

Introduction: Women with gestational diabetes mellitus (GDM) have a marked increased risk of early onset type 2 diabetes, but less than half initiate postpartum glucose testing or connect with a primary care provider for continued follow‐up after giving birth. This study analyzed women's narratives about their GDM‐affected pregnancies to (1) identify different patterns (narrative archetypes) that capture the GDM experience; (2) explore how these patterns relate to awareness of ongoing risk after pregnancy and affect participation in self‐care, monitoring, and preventive health care going forward; and (3) explore the use of identified patterns to tailor conversations with patients during prenatal and postpartum care to their actual perceptions and concerns about future risk.Methods: Open‐ended interviews elicited women's experiences and perspectives about GDM and its management. A narrative analysis first identified segments of text related to risk and behaviors and then applied Frank's narrative archetypes (restitution, chaos, quest) as an interpretive lens.Results: Interviews were completed in English (n = 15), Spanish (n = 7), and Haitian Creole (n = 7). We found distinct patterns: stories of restitution (n = 13), quest (n = 4), chaos (n = 4), and mixed narratives (n = 7). Using these archetypes, we found differences in how women respond to challenges related to disease complexity, treatment, and future risks. These patterns led to marked differences in the steps women took to prevent early onset type 2 diabetes.Discussion: Frank's narrative types provided insight into women's responses to clinical protocols, health care advice, and subsequent prevention actions. A restitution pattern may result in premature closure and lack of awareness of risk. Similarly, a chaos pattern may contribute to a sense of helplessness to implement follow‐up recommendations, despite risk awareness. Understanding these patterns can help clinicians tailor individualized support as women transition from GDM with its focus on a healthy fetus and newborn to preventive self‐care to protect their health.

Objectives Complications of pregnancy such as gestational diabetes mellitus (GDM) forewarn future chronic illness and disability, and demonstrate the need for a life course approach to prevention. Our study had two aims: (1) to elucidate how experiences reported by patients and providers converge to facilitate or impede follow-up care after GDM, and (2) to elicit recommendations for system-level changes to enhance prevention across key care transitions. Methods We conducted in-depth interviews with 30 GDM patients and 29 providers of maternity, specialty and primary care in an urban safety hospital network, and used a three-tiered thematic analysis to interpret their narratives. Results Findings reveal that a ‘perfect storm’ gathers on the path to prevention across stages of care. At diagnosis, patients feel profound anxiety about the debilitating effects of type 2 diabetes mellitus in their communities, providers choose reassurance over risk communication, and both focus primarily on the birth of a healthy baby. Providers report that clinical teams often lack coordination, and confuse patients with a barrage of often-inconsistent advice. In the postpartum period, providers juggle competing clinical priorities and mothers juggle overwhelming demands; for both, the recommended 2-h oral glucose tolerance test is too arduous for women and providers to do as prescribed. Finally, the transition from maternity to primary care is complicated by communication barriers between clinicians and patients, and between maternity and primary care providers. Conclusions for Practice Respondents propose systems innovations to open communication between provider specialties in order to bridge the chasm between reproductive care and life course prevention.