Maternal health does not suffer from a shortage of recommendations. We have clinical guidelines, maternal warning-sign campaigns, mental health screening recommendations, referral programs, community resources, educational materials, toolkits, hotlines, and public health initiatives designed to improve outcomes during pregnancy and postpartum.
Many of them are valuable, some are even lifesaving, but creating a resource, recommending an intervention, or adopting a policy does not mean it has become part of a mother’s care. That distinction deserves more attention in maternal health and in public health more broadly.
I learned that distinction from the other side of the healthcare system. I experienced a traumatic birth, developed postpartum preeclampsia that was initially missed, and was readmitted to the hospital seven days after giving birth. In the months that followed, I also struggled with postpartum depression and anxiety that went undiagnosed at my six-week postpartum visit. It took approximately six months for me to finally get the help I needed.
I eventually began researching not only what had happened to me, but what mothers are supposed to receive during pregnancy, childbirth, and postpartum. That work led me to ask a larger question: If so many recommendations, resources, and interventions already exist, why are mothers still falling through the gaps?
The answer is complicated. Some resources and services do not exist where they are needed. In other cases, the existence of a service is not the same as its implementation. A resource can exist without reaching the mother who needs it. A screening can occur without leading to follow-up. A referral can be placed without resulting in an appointment. Education can be provided without anyone knowing whether the mother understands what she has been told or knows how to act on it. In each case, the system has done something and nothing all at once.
Through my work in maternal health education and advocacy, I have come to see many of these failures as falling into three interconnected gaps: how we prepare mothers—or don’t prepare them—how we educate professionals, and how we implement the resources and interventions we already have.
When an Action Becomes the Outcome
Public health and healthcare systems understandably measure activities that can be counted: screenings completed, referrals placed, educational materials distributed, programs launched, people reached. Those measures often tell us what a system did rather than what happened next.
Consider maternal mental health screening. Screening can identify mothers who may need further evaluation or care, but identification is only useful if something happens afterward. The American College of Obstetricians and Gynecologists’ guidance on interpregnancy care emphasizes the importance of postpartum follow-up, ensuring mothers have a postpartum medical home, and connecting pregnancy and birth complications to appropriate ongoing care.
The screening itself is not the endpoint, and the same principle applies to education and referrals. Giving a mother information about postpartum warning signs is important, but the public health question should not end with whether the information was distributed. Did she understand which symptoms required urgent attention? Did she know whom to call? Could she access care if she needed it?
A referral may appear in a medical record, but that does not tell us whether the mother reached the clinician, whether an appointment was available, whether she could afford or travel to it, or whether she ultimately received care. Delivery is not the same as implementation.
Maternal Care Makes This Problem Especially Visible
The postpartum period exposes how easily responsibility can become fragmented. A mother may receive prenatal care from an obstetric practice, give birth in a hospital, return to an obstetrician or midwife for postpartum care, receive primary care somewhere else, encounter her child’s pediatrician more frequently than her own clinicians, and depend on mental health providers, public health departments, community organizations, lactation professionals, or other services for additional support.
ACOG has acknowledged this fragmentation, noting that postpartum care is often divided among maternal and pediatric healthcare providers and that communication during the transition from inpatient to outpatient care is often inconsistent. Its guidance calls for postpartum care to become an ongoing process rather than a single encounter and recommends identifying who will assume responsibility for a mother’s ongoing care.
Fragmentation is not merely an inconvenience. A national study of postpartum readmissions examined more than 141,000 readmissions within 60 days of delivery and found that approximately 15% occurred at a hospital other than the one where the woman had delivered. Those fragmented readmissions were associated with an 81% higher adjusted risk of severe maternal morbidity compared with readmissions to the delivery hospital.
The study does not establish that fragmentation caused those outcomes, but it demonstrates why continuity and coordination deserve serious attention in postpartum care. This is not always a matter of having too few resources. Some communities need additional services, clinicians, funding, transportation, mental health care, or other supports, but adding resources and implementing resources are different public health tasks. Sometimes what is missing is the infrastructure connecting what already exists.
We May Be Measuring the Wrong Finish Line
If public health wants to know whether maternal health initiatives are working, we need measures that extend beyond whether an intervention was offered. Instead of stopping at “Was a referral made?” we should also ask, “Did the mother reach care?” Instead of “Was education provided?” ask, “Did she understand the information she needed to act on it?” Instead of “Was she screened?” ask, “What happened after the result?” And instead of asking whether a maternal health resource exists, ask whether the clinicians, hospitals, families, and organizations that need it know it exists, and whether mothers can realistically access it.
This is the kind of gap that implementation science is designed to examine. The CDC’s description of implementation science emphasizes not only the adoption of evidence-based interventions, but their implementation and maintenance in real-world settings. Maternal health should make greater use of that lens.
Academic public health has an important role here. Researchers can study whether programs are adopted and whether mothers encounter and benefit from them. Schools and programs of public health can prepare the workforce to think beyond program creation toward implementation, evaluation, coordination, and sustainability. Health departments can map existing maternal health resources and identify where connections between clinical care and community services routinely break down. Health systems and public health partners can also build accountability into those connections. If everyone is responsible for connecting mothers to care, it can become easy for no one to be responsible for determining whether the connection occurred.
Implementation is Also an Equity Issue
The burden of a fragmented system does not fall equally. When care depends on a mother locating resources, understanding complicated instructions, calling multiple providers, determining insurance coverage, arranging transportation, finding childcare, taking time away from work, and repeatedly explaining her medical history, the system is requiring resources of its own from her. Some mothers will have them, others will not.
A 2026 systematic review of barriers to maternal healthcare in the United States identified financial, systemic, educational, geographic, and health-related barriers to maternal healthcare access. Among the systemic barriers were fragmented care, communication gaps, lack of provider continuity, and other structural obstacles that can impede equitable access to care.
That makes implementation not only an efficiency issue, but an equity issue. A resource technically available to everyone may still be functionally available only to those with the time, knowledge, money, transportation, language access, insurance coverage, or social support necessary to reach it.
From Availability to Implementation
Improving maternal health will continue to require new policies, programs, research, services, and investment. We should not interpret implementation problems as evidence that every community already has what it needs because many do not. Alongside the question “What is missing?”, public health should routinely ask, “What already exists, and is it actually reaching the mothers it was designed to serve?”
That means mapping resources before duplicating them, studying where referrals fail, evaluating whether education is understood rather than merely distributed, and connecting health systems with public health agencies and community organizations instead of expecting mothers to build those bridges themselves. It also means including mothers in that evaluation.
A maternal health system can appear well connected on an organizational chart while feeling almost impossible to navigate from the other side. Public health has helped generate an extraordinary amount of knowledge about how to improve maternal health. Clinical organizations have issued recommendations, governments and communities have built programs, and researchers continue to identify interventions capable of improving outcomes.
The next challenge is making sure those interventions survive the journey from recommendation to reality. In maternal health, availability is not implementation, and an intervention cannot improve an outcome if the mother it was designed to help never truly reaches.
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Casey Keen is the Founder of Perinatal Education & Advocacy and holds a B.S. in Psychology from Drexel University and an M.S. in Forensic Medicine from the Philadelphia College of Osteopathic Medicine. She is the author of The Alchemy of Motherhood: Unspoken Truths of Birth Trauma and the Postpartum Journey (Cynren Press, 2026), and her writing on maternal health has appeared in Undark and The Philadelphia Inquirer.