Effect of Medicaid expansion status on risk of late or no prenatal care in black and white US mothers: analysis of US natality data, 2010–17

Abstract

Background: Prenatal care is essential for a good pregnancy outcome for mothers and infants. Many women in the USA receive late (starting in third trimester) or no prenatal care (PNC), resulting in avoidable adverse health outcomes. Black women have been more likely to receive late or no PNC for decades. The Affordable Care Act provided for the option of Medicaid expansion that would improve access to health care, including prenatal health services, for many US women. However, not all states accepted Medicaid expansion, thus allowing us to make a comparison of rates of late or no PNC by Medicaid expansion status, before and after expansion was implemented. Methods: We extracted data from the Births Files, CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) to calculate the proportion of women who received late or no PNC for the periods 2010–13 (baseline) and 2014–17 (after implementation of Medicaid expansion). We compared the numbers and proportions of births in women who received late or no PNC by whether states had accepted or decided against Medicaid expansion at baseline and also after implementation, by maternal race (black women and white women). Risk ratios [RR] and 95% CIs were calculated for each race at baseline and after Medicaid expansion implementation. Findings: By 2014, 26 of 50 US states had accepted Medicaid expansion, and 24 had decided against. At baseline, the risk of late or no PNC in black women was 7·24% in states that went on to implement Medicaid expansion and 7·69% in states that decided against Medicaid expansion (RR=0·94, 95% CI=0·93–0·95). In 2014–17, the risk of late or no PNC in black women rose in all states, but the protective effect associated with being in a state that implemented Medicaid expansion increased: in non-Medicaid-expansion states, risk of late or no PNC rose to 9·39%, whereas in Medicaid expansion states, it rose to only 8·53% (RR=0·90, 0·90–0·92), with a 9·17% difference in the protective effect of being in a Medicaid expansion state between baseline and 2014–17. In white women, however, overall risk of late or no PNC rose modestly from 4·26% at baseline to 5·02% in 2014–17 (from 3·30% to 4·20% in Medicaid expansion states and from 5·26% to 5·71% in non-Medicaid-expansion states; the protective effect of being in an ME state declined from 37·0% to 26·4%). Interpretation: It is unclear why the risk of receiving late or no PNC rose in women of both races, or why the protective effect of living in an Medicaid expansion state declined for white women after implementation and what aspects of Medicaid expansion were associated with its protective effect in black women. However, Medicaid expansion introduction was associated with a modest but significant mitigation of the rise in the risk of late or no PNC in black women, in whom late or no PNC is a much greater problem. Funding: None