Abstract
Background Maternal mortality in the United States has risen over the past three decades, with over half of deaths occurring between one week and one year postpartum. Despite this, most clinical guidelines and care-delivery models focus on the initial 12 weeks after birth.
Narrative This narrative review examines barriers to care beyond the fourth trimester and highlights policy, health-system, and clinical strategies for optimizing maternal health across the first postpartum year, recognizing that structural challenges—including insurance loss, workforce shortages, and adverse social determinants of health—pose additional challenges for marginalized populations. Interventions ranging from the expansion of Medicaid to patient-centered medical homes, integration of maternal and pediatric care, standardized visit protocols, home blood pressure monitoring, patient navigation, and digital tools offer promise in improving maternal health and reducing preventable maternal morbidity.
Conclusions The provision of postpartum care beyond the fourth trimester is essential to reducing maternal morbidity and mortality and advancing health equity. Family physicians and primary care teams are uniquely positioned to provide longitudinal, multidisciplinary postpartum care through the postpartum year. Achieving this vision requires system-level reforms, expanded workforce capacity, clinical tools and support, along with improved transitions between obstetric, pediatric, and primary care providers and services.
- Maternal Mortality
- Patient-Centered Care
- Postpartum Period
- Preventive Medicine
- Primary Health Care
- Quality Improvement
- Women’s Health
Introduction
Maternal mortality remains a pressing public health concern in the United States due to its profound impact on women, families, and communities. Over the past three decades, the United States maternal mortality rate has increased, in contrast to steady declines observed in other high-income nations.1 This upward trajectory has intensified in recent years, with the rate nearly doubling from 17.4 to 32.9 deaths per 100,000 live births between 2018 and 2021.2 Racial and ethnic disparities persist: Black and American Indian/Alaska Native individuals are two to three times more likely to die from pregnancy-related causes than white individuals.2 According to the Centers for Disease Control and Prevention (CDC), over 80% of pregnancy-related deaths in the United States between 2017 and 2019 were preventable.3 State maternal mortality review committees have similarly concluded that most deaths could be avoided through timely and risk-appropriate prenatal and postpartum care.4
The maternal mortality rate is a sentinel indicator of health-system performance and broader socioeconomic development. High, inequitable, and largely preventable mortality reflects critical deficiencies in access to care and persistent structural disparities in health and healthcare delivery.5
Focus on Care During the “Fourth Trimester”
Current public health and clinical efforts increasingly emphasize the “fourth trimester”—the first 12 weeks following childbirth—as a critical period for maternal health intervention.6 Multiple professional organizations have issued guidance for postpartum care during this period, though recommendations vary in scope and timing. The American College of Obstetricians and Gynecologists (ACOG) recommends a comprehensive postpartum evaluation within 12 weeks of delivery, addressing physical recovery, mental health, chronic disease management, sleep, and contraceptive planning.7 The World Health Organization (WHO) suggests performing follow-up at three days, one to two weeks, and six weeks after childbirth, and the National Institute of Health and Care Excellence (NICE) recommends performing postpartum depression (PPD) screening once at 10 to 14 days after childbirth. However, a significant gap in the clinical guidance for postpartum care exists after the 12-week point. This disparity is particularly worrying because 53% of pregnancy-related deaths happen one week to one year after giving birth.3 Cardiovascular disorders, such as cardiomyopathy, hypertensive disorders, and coronary disease, are the most prevalent, contributing to about 49% of deaths within the postpartum period. Suicide and overdose are mental health conditions that are contributing factors to 23% of deaths.3
The Need for Extended Postpartum Care Models
Given the significant proportion of maternal deaths that occur after the initial 12 weeks, there is an urgent need to establish evidence-based guidance for the provision of comprehensive, longitudinal postpartum care. Primary care clinicians are uniquely positioned to support ongoing maternal health needs but often lack structured recommendations for this phase of care. Addressing this gap is critical for improving long-term maternal health outcomes.
This review aims to extend the current framework of postpartum care by focusing on the entire first postpartum year. We first examine barriers to accessing primary care during this period and then propose policy, health-system, and clinical strategies to enhance the delivery of effective, equitable postpartum care that extends beyond the fourth trimester.
Barriers to Care During the First 12 Months Postpartum
Despite the importance of postpartum care, up to 40% of individuals do not attend a postpartum visit.7 Among those screening positive for postpartum depression, only 22% receive mental health services.8 Improvement in postpartum health is contingent upon establishing care with a primary care provider (PCP) following delivery. With consistent follow-up, PCPs can help improve health outcomes through the early identification and management of varying pathologies.
Access to care during the first year is hindered by structural barriers such as inadequate insurance, high costs, and limited provider availability.9 Medicaid finances almost half of US births, but in states that have not expanded Medicaid under the Affordable Care Act (ACA), beneficiaries lose coverage after 60 days postpartum.1 In a cohort study of high-risk postpartum individuals, only 25% completed a subsequent primary care visit after their initial postpartum appointment; those who lost insurance had 66% lower odds of being evaluated by a PCP.10
Fragmentation between obstetric and primary care often results in unmet postpartum health needs.11 Additional barriers including transportation challenges, lack of childcare, mental health stigma, limited social support, and caregiving demands further impede access. These barriers disproportionately affect low-income, minority, and medically underserved populations, compounding existing disparities in maternal outcomes.12
Health Policy and Health System Interventions
Expanding and Extending Medicaid
Extending Medicaid coverage to 12 months postpartum has been linked to improved care continuity, a key determinant of maternal health.13 In Colorado, extended eligibility led to 1.5 additional months of insurance and a 12% increase in continuous coverage during the first year.14
During the COVID-19 pandemic, the Families First Coronavirus Response Act mandated continuous Medicaid enrollment. Women with extended coverage used twice as many postpartum services, accessed preventive, contraceptive, and behavioral health care 2–10 times more often, and had 37% fewer short-interval pregnancy-related services.15
Professional societies, including the Society for Maternal-Fetal Medicine, support policies that extend Medicaid coverage through 12 months postpartum, emphasizing that such coverage is essential to optimize maternal health following childbirth and to decrease preventable causes of maternal morbidity and mortality.16 While extending coverage improves access to care, evidence of direct improvements in maternal health outcomes is still being evaluated. Some studies suggest potential benefits, such as reductions in postpartum hospitalizations. For example, analyses have indicated reduced hospitalizations within 6 months of delivery following the Affordable Care Act Medicaid expansion.17 However, more comprehensive research is needed to fully understand the impact of extended postpartum Medicaid coverage on long-term maternal health outcomes.
Expanding covered services such as doula and lactation support may further enhance care utilization.18 A study of Medicaid claims data from 2014 to 2023 found that those who received doula support were 46% more likely to attend postpartum checkups compared to the control group.19
Linking Uninsured Women to Care
Women who are uninsured are much less likely to have a postpartum visit or management of chronic conditions.20 In 2024, over one-in-ten US women 19–54 years of age were uninsured.21 Practical strategies for linking individuals who are uninsured because they do not qualify for Medicaid and/or are unable to afford private or Health Exchange plans, include the following:
Use the Health Resources and Services Administration (HRSA) “Find a Health Center Tool” to find federally qualified health centers, community clinics, and organizations that provide primary health care on a sliding scale and/or that provide services for pregnant and postpartum women and their infants.22
Identify county-funded hospital systems that provide financial assistance and/or sliding scale care to residents in covered counties.
Contact state or local public health departments to identify women’s health services available to low-income, uninsured women.
Assist patients in identifying patient-assistance programs or generic substitutions for their needed medications.
Anticipatory Guidance and Patient Education on Postpartum Warning Signs
Public awareness of postpartum warning signs remains limited. A 2022 survey of 588 adults residing in Georgia assessed general knowledge of maternal health complications and found that only approximately 50% of respondents could identify any postpartum warning signs and symptoms, and just 31.7% could identify four or more signs and symptoms associated with postpartum cardiovascular complications.23 Awareness of postpartum warning signs and symptoms was particularly low among respondents who identified as male, Black or Hispanic, and/or were nulliparous.23 While this study did not investigate actual or preferred sources of knowledge among participants, its findings highlight that knowledge of maternal signs and symptoms that warrant immediate medical care is not uniform in the population and may contribute to delays in care seeking.
Improving knowledge of postpartum complications empowers patients to monitor their health and seek timely care when necessary. Digital health education tools offer an accessible approach to disseminating this information. Two web-based educational programs, Balance After Baby and Healthy Beyond Pregnancy, have effectively improved postpartum outcomes. In a cohort study, 86% of women who participated in Healthy Beyond Pregnancy attended a postpartum visit, compared to 53% who did not receive such education.24 Similarly, participants with gestational diabetes who engaged with Balance After Baby were closer to their postpartum weight goals at 12 months than those in the control group.25
Anticipatory guidance is essential for individuals who have limited prenatal care, as they may be at increased risk for undetected complications. ACOG recommends educating all postpartum patients on key warning signs of potentially life-threatening conditions. These “red flag” symptoms should be included in discharge instructions and verbally reviewed with patients before discharge.26
Transitions of Care, Patient Navigation, and Patient-Centered Medical Homes
Effective transitions of care (TOC) from inpatient to outpatient settings are essential for preventing complications and ensuring timely access to follow-up services. However, nearly 20% of patients experience suboptimal care at discharge due to fragmented communication between hospital systems and outpatient providers.27 Patient navigators and other care-coordination interventions have emerged as practical tools to address these gaps during the postpartum period.
At Brigham and Women’s Hospital, the Transition Care Team employed patient navigators to coordinate follow-up for patients with hypertensive disorders of pregnancy, achieving a 79.5% follow-up rate among those with in-network primary care providers.28 Northwestern Memorial Hospital’s Navigating New Motherhood program used navigators to support scheduling, insurance, and transportation. The program increased postpartum visit attendance to 88.1%, compared to 62.9% in controls.29
Behavioral science–informed strategies have also proven effective. One randomized trial used default scheduling and tailored messaging, leading to higher rates of postpartum primary care visits, increased mental health screening, and fewer hospital readmissions.30,31 Similarly, in another study, an enhanced referral pathway for patients with gestational diabetes or hypertensive disorders resulted in greater odds of primary care follow-up and timely HbA1c and lipid screening.32
Although randomized controlled trials evaluating patient-centered medical homes (PCMHs) in postpartum populations are limited, these models may offer a scalable framework for integrated care by co-locating generalists and specialists. Meta-analyses have linked PCMHs to reductions in depressive symptoms, hospitalizations, and improved blood pressure (BP) control.33 Additionally, a systematic review supports the effectiveness of PCMHs and structured TOC in enhancing continuity and improving maternal health outcomes.34
Improved Communication and Self Blood Pressure Monitoring
Digital tools are increasingly used to support postpartum self-monitoring and care continuity, particularly for managing chronic conditions. The SNAP-HT trial in the UK showed that self-monitoring blood pressure after hypertensive pregnancies resulted in sustained reductions lasting 3–4 years postpartum.35 Early use of home monitoring and antihypertensive therapy improved diastolic control at six months, with effects persisting for approximately 3.6 years after discontinuation of medication.36
Providing patients with home BP monitors, medications, and remote monitoring platforms may reduce maternal morbidity while accommodating caregiving and work responsibilities. Telehealth offers scalable access to health care with the option of escalating to in-person care when needed. Moreover, postpartum patients had a positive experience with remote blood pressure monitoring and follow-up. In a study of 128 postpartum patients, 91% recommended remote monitoring, and 84% reported high satisfaction.37
Health systems are also reducing missed appointments through telehealth. At Truman Medical Center, patients who arrived late were offered same-day virtual visits, with 79.4% accepting.38 Telemedicine is proving to be a successful modality by which we can diminish barriers to quality and satisfactory care.
Integration of Postpartum Care with Well-Child Visits
Integrating postpartum care with pediatric well-child visits represents a promising strategy to improve maternal health outcomes. While nearly 90% of infants attend scheduled well-child visits, only approximately 50% of birthing individuals complete a designated postpartum visit, highlighting a critical opportunity to engage mothers in ongoing care during pediatric encounters.39 This model has demonstrated effectiveness, particularly in the management of hypertensive disorders of pregnancy and other comorbidities. Amro et al reported that incorporating maternal blood pressure monitoring into well-child visits facilitated early identification and management of hypertension, offering a cost-effective and accessible approach to extend postpartum care to individuals who might otherwise lack follow-up.39
Evidence also supports the integration of postpartum depression screening into routine pediatric care. Studies have shown that embedding mental health assessments within well-child visits can lead to timely referrals, increased access to mental health services, and improved maternal mental health outcomes.40,41 The American Academy of Pediatrics (AAP) currently recommends postpartum depression screening at the 1-, 2-, 4-, and 6-month well-child visits.42
To ensure patients receive appropriate care following screening, primary care clinicians should maintain updated referral lists of community-based programs that accept Medicaid or offer sliding-scale services. Additionally, perinatal psychiatry access programs (PPAPs) can also provide consultation and support to clinicians managing perinatal mental health conditions, enhancing their capacity to deliver evidence-based care within the primary care setting.
Shared Medical Appointments
Shared medical appointments (SMAs) have emerged as an effective model for enhancing postpartum care delivery and engagement. Centering Parenting is a group-based care model that brings together cohorts of 6 to 7 mothers and their infants for longitudinal care throughout the first year of life.43 This approach integrates well-baby care with maternal health and provides developmental education and safety counseling, fostering peer support and community building.43,44 A similar model focused on prenatal care, Centering Pregnancy, yields particularly positive outcomes for mothers from vulnerable populations, including those who are unmarried, overweight or obese, or of lower socioeconomic status.45
Shared medical visits can be tailored to address specific maternal health concerns. For example, 90-minute group appointments informed by the American College of Cardiology’s Postpartum Hypertension Clinic Development Toolkit can focus on educating and managing cardiovascular complications.46
Whether delivered in group or individual formats, postpartum visits should include codified core components that assess physical recovery, mental health, contraceptive planning, and chronic disease management. Emphasis should especially be placed on the prevention and control of chronic conditions such as hypertension, diabetes, and obesity, which contribute to long-term maternal morbidity and mortality and may influence outcomes in subsequent pregnancies.
Primary Care Practice Interventions
Standardizing the Overall Approach to Patient Care Following Birth
A standardized approach to postpartum care in primary care settings is essential to improving patient outcomes following childbirth. All individuals assigned female at birth who are new to a primary care practice should be asked about their obstetric history, including any complications during pregnancy, labor, or the postpartum period. A comprehensive reproductive history allows clinicians to identify individuals at elevated risk for future health complications and tailor screening and preventive interventions accordingly.47
The use of structured note templates and standardized clinical checklists can support consistent care delivery. Incorporating prompts and safety alerts into electronic medical records (EMRs), such as flags for abnormal lab values, medication contraindications, and other clinical risks may help prevent medical errors and guide appropriate escalation of care.
The American College of Obstetricians and Gynecologists (ACOG) has outlined recommended goals for postpartum visits, many of which can be operationalized within EMR systems to guide comprehensive care.7 These goals include:
Mental health and substance-use screenings such as depression, anxiety, tobacco, and other substance use
Counseling on return to work/school and childcare planning
Verification of the infant’s pediatric medical home and caregiver immunizations
Breastfeeding support and assessment
Screening for material needs such as housing, food, transportation
Counseling on contraception, birth spacing, and sexual health
Evaluation of sleep, fatigue, and overall maternal well-being
Monitoring physical recovery and chronic disease management
Medication review
Preventive care, including cervical cancer screening and pelvic exams, as indicated
Standardizing these components within primary care workflows can ensure more comprehensive, equitable, and proactive postpartum care.
Standardizing the Approach to Management of Specific Risk Conditions
Diabetes
Primary care providers should prioritize identifying and managing cardiometabolic risk factors in postpartum patients. Postpartum weight retention and diabetes are associated with increased risk for atherosclerotic cardiovascular disease (ASCVD), including coronary artery calcification, heart failure, and stroke, conditions that also elevate risks in future pregnancies. Routine assessment of HbA1c and Body Mass Index (BMI) or waist circumference is recommended throughout the first year postpartum.35
ACOG recommends a 75-gram oral glucose tolerance test (OGTT) at 4–12 weeks postpartum for women who had gestational diabetes mellitus, using nonpregnancy diagnostic criteria.48 This recommendation is supported by the American Diabetes Association, which notes the OGTT is the preferred test, as it is more sensitive than HbA1c for detecting persistent diabetes and prediabetes in the early postpartum period, which is when anemia and peripartum blood loss may render HbA1c falsely low.49 Abnormal results warrant ongoing care for specialized management, while normal results should prompt ongoing screening every 1–3 years.50 The Women’s Preventive Services Initiative (WPSI) also recommends postpartum screening for type 2 diabetes in patients with prior gestational diabetes beginning as early as 4–6 weeks with fasting plasma glucose, HbA1c, or OGTT. WPSI advises repeat testing within 6 months for those initially screened with HbA1c (regardless of whether the test results are positive or negative) due to its lower accuracy during this period.51 For low-risk patients, delaying screening until after 6 months may improve accuracy and efficiency, whereas high-risk individuals should be screened within 4-6 weeks, with repeat testing after 6 months. By 6 months postpartum, physiologic changes of pregnancy and delivery have usually resolved, making all standard screening tests appropriate.51 Quality improvement initiatives demonstrate that team-based approaches and provider education can substantially increase postpartum screening rates, which remain suboptimal in routine practice.52
Obesity
Obesity is a significant challenge during the postpartum period. Many individuals enter pregnancy overweight or obese, and nearly half experience excessive gestational weight gain.53 Approximately 20% retain 1–5.5 kg of this weight one year postpartum, increasing the long-term risk of cardiometabolic disease and reducing breastfeeding initiation and duration.53,54 The US Preventive Services Task Force (USPSTF) recommends intensive behavioral interventions for adults with a BMI ≥ 30 kg/m2 but lacks postpartum-specific guidance or defined measurement intervals.55
Currently, there are no established guidelines for the frequency of BMI assessment in the postpartum period. However, if postpartum care is aligned with well-child visits, BMI calculation at the 2-, 4-, 6-, 9-, and 12-month appointments may be appropriate to support healthy weight trajectories. A weight loss goal of 1–2 pounds per week, consistent with general population recommendations, may be reasonable until a BMI of 18.5–24.9 kg/m2 is achieved.56–58 Individualized targets should be established for patients with pre-existing obesity.
Patients should also be counseled on lifestyle changes and self-weighing to help avoid postpartum weight retention. Self-monitoring strategies, such as regular self-weighing, can aid in weight management. In a cohort of 10,000 adults, weight gain was more likely when self-weighing was not performed for over 30 days, particularly among those with pre-existing overweight or obesity.59 A smaller study suggested consistency, rather than frequency, was the key factor in successful weight maintenance.60 Based on this evidence, we recommend that postpartum patients weigh themselves consistently at intervals no longer than 30 days.
Lifestyle counseling should include dietary modifications and physical activity. Patients should be encouraged to adopt a plant-based diet and at least 150 minutes of moderate-intensity aerobic exercise weekly.35 However, dietary intake plays a more significant role than energy expenditure in postpartum weight retention and should be a focus of intervention.54
Hypertension
There is limited standardized guidance on the long-term management of postpartum hypertension. ACOG recommends monitoring blood pressure within the first 72 hours postpartum and again between 7–10 days; however, they offer little guidance on screening intervals beyond this period.7 To fill procedural gaps, the 2024 Hypertension in Pregnancy Change Package provides an evidence-informed listing of process-oriented tools to support early identification and optimal management of hypertensive disorders during pregnancy and postpartum, including guidance on preferred medications in lactation (inclusive of starting dose, maximum dose, precautions, and considerations).61 In the general population, low-risk adults over 40 years old typically undergo BP assessment during their annual wellness visit.62 Thus, for postpartum patients without hypertensive disorders, annual BP measurement following the immediate postpartum period may be sufficient. In contrast, those with persistent hypertension should have blood pressure monitored at each clinical encounter throughout the first year.
A toolkit from the American College of Cardiology (ACC) supports clinicians, healthcare teams, and health systems in providing optimal care to individuals with a recent hypertensive disorder of pregnancy.46 This comprehensive postpartum toolkit covers clinical models of care (including coding and billing), postpartum hypertension medication selection and titration, strategies for remote blood pressure monitoring, and clinical supports such as note templates, dot phrases, and comprehensive patient education materials.
Although current evidence does not confirm a mortality benefit, cohort studies suggest that home blood pressure monitoring is effective for BP control.63 Home BP readings are typically 20% lower than in-office measurements, so the ACC and American Heart Association (AHA) recommend home monitoring to mitigate white coat hypertension.64 We recommend individualized home blood pressure monitoring schedules developed with patients to optimize antihypertensive management and improve diagnostic accuracy, even without demonstrated mortality impact.
Cardiac strain during pregnancy and delivery may result in myocardial injury and adverse remodeling.36 Angiotensin-converting enzyme (ACE) inhibitors may benefit blood pressure control and cardiac recovery in affected patients. Given the teratogenic risks associated with ACE inhibitors, patients should concurrently receive contraceptive counseling.65 In patients at elevated cardiovascular risk, noninvasive cardiac imaging such as electrocardiogram and echocardiography may be warranted to assess myocardial function and guide long-term management.36
Depression
The prevalence of postpartum depression rose by 105% between 2010 and 2021, with the highest relative increases among Asian (280%), Black (140%), and Hispanic (110%) women.66 Although the increase among White women was smaller (60%), it remains significant.66 Elevated rates were noted across all BMI categories, with the highest prevalence among obese individuals.66 While increased screening may partially account for these trends, the data highlight a substantial burden of undiagnosed and untreated PPD in prior years. Given these findings, routine screening for PPD at every clinical encounter is strongly warranted.
Clinical Practice Challenges and Supports
Although current recommendations emphasize broad and comprehensive postpartum care, addressing multiple priorities—including preventive care and screenings, mental health assessments, chronic disease management, and family planning—within the confines of a single or even multiple visits is challenging. Limited time, competing demands, and fragmented care systems often leave key issues unaddressed. These challenges underscore the importance of continuity of care and the reframing of postpartum care as a longitudinal process best supported by team-based, primary care models. At the systems level, policy changes that expand reimbursement for ongoing care and foster interprofessional collaboration are critical to making comprehensive postpartum care feasible. At the practice level, EMR supports such as structured checklists, automated prompts, pre-configured order panels and documentation templates can operationalize coordinated, longitudinal postpartum care. By reducing cognitive and time burdens, these tools ensure that essential concerns are consistently addressed across encounters, even in resource-constrained settings. A postpartum care timeline and checklist, along with the recommended elements of postpartum care throughout the first postpartum year, are outlined in Tables 1 and 2. In addition, practice tools for the provision of postpartum care for those with hypertensive disorders can be found in the American College of Cardiology toolkit.46
Summary and Recommendations
Family physicians are uniquely positioned to provide comprehensive postpartum care through one year after delivery and beyond, as they are trained to manage both mother and infant’s preventive and primary care needs. Ideally, family physicians would engage in postpartum care for patients they delivered and/or for those transitioning to primary care following delivery. However, the proportion of family physicians providing maternity care has declined from 23.3% in 2000 to 9.7% in 2010 and 7% in 2016.67,68 Moreover, the capacity of the primary care workforce at large is insufficient. Only 24.4% of US physicians practice primary care, far below the 50% considered ideal.69
To improve postpartum care throughout the first year, primary care physicians should:
Provide anticipatory guidance on postpartum warning signs at discharge and follow-up
Use default scheduling and embed standardized checklists in the EMR
Integrate maternal care into well-child visits or co-schedule appointments (2, 4, 6, 9, and 12 months)
Follow ACOG-recommended visit content and consider the implementation of the following:
Diabetes screening (4–6 weeks with OGTT, fasting glucose, or HbA1c and repeated after 6 months for high-risk and for low-risk patients initially screened with HbA1c regardless of result)
BMI/waist circumference assessments (2, 4, 6, 9, and 12 months)
Blood pressure monitoring (4–6 weeks, then annually; at every visit and/or remote monitoring if hypertensive)
Depression screening and lifestyle counseling
Extensive pregnancy history documentation
ACE inhibitor therapy when appropriate, and cardiac imaging for high-risk patients
Maintain referral lists for local, affordable mental health service
Implement TOC programs using patient navigators or TOC clinics
Encourage consistent self-weighing (at least every 30 days)
Advocate for policies that support maternal health, including:
Extending Medicaid coverage through 12 months postpartum
Expanding insurance coverage to include supportive services such as doulas, lactation consultants
Investing in patient-centered medical homes
Finally, targeted efforts to recruit and inspire medical students, nurse practitioners, and physician assistants to enter primary care are essential to building the workforce to deliver high-quality postpartum care.
Conflicts of Interest
None.
Authors’ Contributions
AD conceived the narrative review, supervised/managed the project, performed the literature review, drafted parts of the manuscript, revised the manuscript, and acted as the corresponding author. KC performed the literature review, drafted parts of the manuscript, and revised it. ON performed the literature review, drafted parts of the manuscript, and revised the manuscript. All authors critically reviewed the manuscript and approved the final version.
Corresponding Author
Anne L. Dunlop, MD, MPH, Emory University School of Medicine.
This article was externally peer reviewed.
- Received for publication July 29, 2025.
- Accepted for publication November 3, 2025.
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