Integrating maternal health and social-service data to improve care coordination and outcomes for high-risk mothers in the United States: A systematic review

Background: Maternal morbidity and mortality in the United States remain substantially higher than in peer high-income countries, with pronounced racial and socioeconomic disparities. Fragmentation across clinical, claims, and social-service data systems limit care coordination and impedes timely identification of high-risk mothers, particularly within Medicaid populations.
Objective: To systematically evaluate evidence (2020-2026) on the integration of Medicaid claims, electronic health records (EHRs), and/or social-service data systems within cross-sector maternal care frameworks, and to assess its impact on maternal care coordination and outcomes.
Methods: Following PRISMA 2020 guidelines, we searched PubMed, Scopus, Web of Science, and Embase for peer-reviewed studies published between January 2020 and March 2026. Eligible studies evaluated models linking Medicaid or public insurance claims with EHR and/or social-service datasets for pregnant or postpartum individuals. Where outcome homogeneity permitted, random-effects meta-analysis was conducted.
Findings: Thirteen studies met inclusion criteria, including ten conducted in the United States and three international comparators. Integration models included Health Information Exchanges, Medicaid accountable care organizations, cross-sector data platforms, and predictive analytics systems incorporating social determinants of health. Pooled analysis demonstrated higher postpartum visit completion (RR 1.18; 95% CI 1.10–1.27) and reduced preventable readmissions (RR 0.86; 95% CI 0.78–0.95) in integrated systems. Evidence for reductions in severe maternal morbidity was inconclusive, and data on maternal mortality remain limited.
Conclusion: Integration of Medicaid claims, EHR, and social-service data is associated with improved care coordination and selected maternal outcomes but alone is insufficient to address structural drivers of maternal morbidity and mortality. Scaling integration efforts alongside equity-focused policy and delivery reforms represent a critical opportunity for U.S. maternal health improvement.