After giving birth, a woman leaves the hospital with discharge instructions and a referral. But the specialist has not received her records, the first appointment is weeks away, and the organization that supported her during pregnancy is unsure whether its services continue. While recovering and caring for a newborn, she must work out who can help her.
The example is hypothetical, but the problem is familiar. We fund maternal health services without always funding the work that connects them. We expect patients to move between providers as though the transfer happens on its own.
Care does not end at discharge
The American College of Obstetricians and Gynecologists recommends postpartum contact within three weeks of birth and a comprehensive visit no later than 12 weeks. Recovery does not follow a discharge schedule.
The Centers for Disease Control and Prevention reports that maternal mortality review committees classified about 86% of pregnancy-related deaths reviewed in 2022 as preventable, where preventability could be determined. Not all involved coordination failures, but the findings underscore the importance of care after discharge.
Public health agencies and Medicaid programs have expanded postpartum coverage, home visiting, and behavioral health services. These investments matter. But a service can exist and still be hard to reach when no one owns the next step.
The work between organizations is still work
Consider a patient recovering from pregnancy-related hypertension who needs primary care. Someone must transfer her clinical history, arrange follow-up, and help address barriers to attending. If no one owns that handoff, a clinically appropriate plan can fall apart before the first appointment. Similar challenges arise when a mother needs behavioral health treatment, transportation, or housing assistance. The work crosses institutional boundaries, even when funding does not.
A hospital may measure discharges. A health plan may track postpartum visits. A community organization may count referrals. Each measure is useful, but none necessarily shows whether a patient reached the next service.
A 2026 Commonwealth Fund analysis found variation in postpartum services addressed in Medicaid managed care contracts. Without clear expectations, coordination can depend on personal relationships and already stretched staff.
What would a continuity budget support?
Budgets account for staffing, services, technology, and evaluation. They should also account for the time it takes to help patients move between programs. A continuity budget would recognize that work without necessarily creating another department.
Care managers, community health workers, nurses, and referral coordinators already do much of this work. Yet the hours spent tracking down records, calling another office, or helping a family navigate a delay may be overlooked when long-term funding decisions are made.
Dedicated funding could give staff time to resolve stalled referrals, maintain shared procedures, and clarify who takes the next step. It could support secure information sharing and confirmation of follow-up. Technology can help track referrals, but a dashboard cannot call a patient or secure an appointment. People need time and authority to act. The goal is to support existing teams, not replace them.
Dedicated funding is not a guarantee of better outcomes. Programs should assess completed follow-up, patient experience, equitable access, and clinical outcomes where possible.
Accountability should not become another burden on patients
When a follow-up appointment is missed, it is easy to label the problem “patient engagement.” That can obscure what happened. Did someone call the patient? Was an appointment actually available? Did the receiving office have the information it needed? Those questions matter because patients may choose not to use a service, and that choice should be respected. But an unanswered referral, an unavailable appointment, or missing records should not be treated as a failure by the patient.
Transportation difficulties, unstable housing, language barriers, and provider shortages can make follow-up harder. Programs should recognize those barriers rather than treating every delay as a patient failure.
Programs should track whether referrals are accepted, how long patients wait, and where follow-up breaks down. The goal is improvement, not blame. Measures must respect patient preferences and acknowledge unavailable services. Coordination cannot make up for too few clinicians or community resources. It can, however, show more clearly where those shortages leave patients without care.
Sustainability begins before the grant ends
A Commonwealth Fund report on maternal and infant health partnerships emphasizes sustained collaboration among healthcare organizations, public health agencies, and community partners. That collaboration needs staffing, clear responsibilities, and financing that can survive a change in leadership or the end of a grant.
Sustainability often becomes a priority near the end of a grant. By then, staff may be leaving, and their coordination work may never have appeared in the budget. Sometimes one person has kept things moving because she knows whom to call. Families notice when that person leaves.
Before launch, funders and partners should ask: Who follows up when a referral stalls? How will they know whether care happened? Who pays for that work? Who takes responsibility when the grant ends? These questions belong in program design, not in the final report.
Fund what happens after the referral
Improving maternal health requires good clinical care, community services, and action on the conditions that shape health. It also requires attention to what happens between organizations. Giving someone a referral is a beginning, not proof that she received care. A launch budget pays for what a program offers. A continuity budget helps families reach those services without navigating every boundary alone. Maternal health needs both.
References
American College of Obstetricians and Gynecologists. Optimizing Postpartum Care. Committee Opinion No. 736 (2018). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
Centers for Disease Control and Prevention. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees. https://www.cdc.gov/maternal-mortality/php/data-research/mmrc/
Commonwealth Fund. Fortifying Medicaid Managed Care for Postpartum Enrollees (2026). https://www.commonwealthfund.org/publications/issue-briefs/2026/jan/fortifying-medicaid-managed-care-postpartum-enrollees
Commonwealth Fund. Improving Maternal and Infant Health Through Community Partnerships (2024). https://www.commonwealthfund.org/publications/fund-reports/2024/dec/improving-maternal-infant-health-community-partnerships