Acute health care utilization in the first 24 months postpartum by rurality and pregnancy complications: A prospective cohort study

Document Type


Publication Date


Publication Title

Health Services Research Volume59, Issue1 February 2024


Muskie, Public Health, Staff Scholarship, postpartum, rurality and pregnancy complications



To estimate the rate of acute health care use (hospitalizations and emergency department [ED] visits) among postpartum persons by rurality of residence and pregnancy complications.

Data Sources and Study Setting

2006–2021 data from the Maine Health Data Organization's All Payer Claims Data.

Study Design

We estimated the rates of hospitalizations and ED visits during the first 24 months postpartum, separately, overall and by four-level rurality of residence (urban, large rural, small rural, and isolated rural) and by pregnancy complications (prenatal depression, hypertensive disorders of pregnancy [HDP], and gestational diabetes mellitus [GDM]). We used Poisson regression models, adjusting for potential confounders. Data were weighted to account for censoring before 24 months postpartum.

Data Extraction Methods

Deliveries during 2007–2019 (n = 122,412).

Principal Findings

Approximately 4% of persons had at least one hospitalization within 24 months postpartum (mean monthly rate per 100 deliveries = 0.35). Adjusted rates were not different by rurality. Persons with prenatal depression (adjusted rate ratio [aRR] = 1.9; 95% confidence interval [CI] 1.5–2.5), HDP (aRR = 1.4; 1.0–2.0), and GDM (aRR = 1.4; 0.9–2.0) had higher hospitalization rates than those without these conditions. Approximately 44% of persons had at least one ED visit within 24 months postpartum (mean monthly rate per 100 deliveries = 5.4). Adjusted ED rates were higher for persons living in small rural areas as compared with urban areas (aRR = 1.3; 1.2–1.4). Persons with prenatal depression (aRR = 1.8; 1.7–1.9), HDP (aRR = 1.1; 1.0–1.2), and GDM (aRR = 1.3; 1.2–1.4) had higher ED rates than those without these conditions; ED rates were highest among those living in small rural areas.


New policies and care practices may be needed to prevent acute health care encounters in the first 24 months after delivery for persons with common pregnancy conditions. Efforts to identify why postpartum people living in small rural areas have higher rates of ED visits are warranted.