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Objective: The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment. Data Sources and Study Setting: Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions. Study Design: Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline‐recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five‐year waiting period for pregnant immigrants to access Medicaid. Data Collection/Extraction Methods: Survey responses from 35,779 postpartum individuals with self‐reported Hispanic ethnicity who gave birth during 2016–2020. Principal Findings: Compared to English‐speaking Hispanic people, Spanish‐speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage‐point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage‐point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish‐speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage‐point lower prenatal care adequacy, but 1.3 (95% CI:−1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage‐point higher postpartum care quality than English‐speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage‐points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage‐points higher. Conclusions: Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish‐speaking and English‐speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether the expansion of Federally Qualified Health Centers (FQHCs) improved late prenatal care initiation, low birth weight, and preterm birth among Medicaid‐covered or uninsured individuals. Data Sources and Study Setting: We identified all FQHCs in California using the Health Resources and Services Administration's Uniform Data System from 2000 to 2019. We used data from the U.S. Census American Community Survey to describe area characteristics. We measured outcomes in California birth certificate data from 2007 to 2019. Study Design: We compared areas that received their first FQHC between 2011 and 2016 to areas that received it later or that had never had an FQHC. Specifically, we used a synthetic control with a staggered adoption approach to calculate non‐parametric estimates of the average treatment effects on the treated areas. The key outcome variables were the rate of Medicaid or uninsured births with late prenatal care initiation (>3 months' gestation), with low birth weight (<2500 grams), or with preterm birth (<37 weeks' gestation). Data Collection/Extraction Methods: The analysis was limited to births covered by Medicaid or that were uninsured, as indicated on the birth certificate. Principal Findings: The 55 areas in California that received their first FQHC in 2011–2016 were more populous; their residents were more likely to be covered by Medicaid, to be low‐income, or to be Hispanic than residents of the 48 areas that did not have an FQHC by the end of the study period. We found no statistically significant impact of the first FQHC on rates of late prenatal care initiation (ATT: −10.4 [95% CI −38.1, 15.0]), low birth weight (ATT: 0.2 [95% CI −7.1, 5.4]), or preterm birth (ATT: −7.0 [95% CI −15.5, 2.3]). Conclusions: Our results from California suggest that access to primary and prenatal care may not be enough to improve these outcomes. Future work should evaluate the impact of ongoing initiatives to increase access to maternal health care at FQHCs through targeted workforce investments. [ABSTRACT FROM AUTHOR]

Objectives: To examine the effect of high-risk obstetrics (HROB) care management on infant health and Medicaid expenditures.Data Sources/study Setting: Medicaid administrative data and vital statistics from 2011 to 2013. In New York State, all Medicaid managed care plans provide HROB care management to their members.Study Design: We conducted a retrospective cohort study with a nonequivalent control group. Selection bias was addressed by using probit and OLS models with the Heckman correction and inverse probability weight with regression adjustment.Principal Findings: While program enrollment was associated with poor infant health outcomes (low birthweight, very low birthweight, preterm delivery, and gestational age), correcting for sample selection substantially improved most of these outcomes. All infant health outcomes significantly improved as the number of weeks in the program increased. We found that a 1-week increase in program duration is associated with a 0.01 percentage point decrease in low birthweight and a 0.03 percentage point decrease in very low birthweight. Further, a 1-week increase in program duration decreases the probability of preterm delivery by 0.01 percentage points and increases gestational age by 0.14 days. Medicaid expenditures for maternity care and newborn delivery were not significantly or materially affected by program enrollment or program duration.Conclusions: High-risk obstetrics care management appears to successfully identify individuals with high-risk pregnancies and improve health without substantially increasing medical expenses. [ABSTRACT FROM AUTHOR]

Objective: To determine individual- and country-level determinants of utilization of key maternal health services in sub-Saharan Africa (SSA).Study Setting: We used the most recent standard demographic and health survey data from the period of 2005 to 2015 for 34 SSA countries. Predictors of key maternal health service indicators were determined using a sample of 245 178 women who had at least one live birth 5 years preceding the survey.Study Design: We used a two-level hierarchical model, considering individual predictors at level one and country factors at level two of the hierarchy.Principal Findings: While the skilled birth attendance (SBA) utilization rate reached 53 percent during the study period, the recommended four or more antenatal care (ANC) coverage was commonly low with less significant differences among different groups of women and countries. Being in a middle-income country increased the individual-level association between ANC and SBA (OR = 2.34, 95% CI: 1.24, 4.44). Less privileged women with lower education level were less likely to receive maternal health services.Conclusions: This study reveals the existence of wide gaps between ANC and SBA coverage in SSA. Urgent policy attention is required to improve access, utilization, and quality of maternal health services. [ABSTRACT FROM AUTHOR]

Objective: To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant.Data Sources/study Setting: Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System.Data Collection/extraction Methods: The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents.Study Design: I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion.Principal Findings: I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization.Conclusions: Expanded Medicaid coverage for low-income adults has the potential to increase a woman's health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To examine effects of maternity care coordination (MCC) on perinatal health care utilization among low-income women.Data Sources: North Carolina Center for Health Statistics Baby Love files that include birth certificates, maternity care coordination records, WIC records, and Medicaid claims.Study Design: Causal effects of MCC participation on health care outcomes were estimated in a sample of 7,124 singleton Medicaid-covered births using multiple linear regressions with inverse probability of treatment weighting (IPTW).Principal Findings: Maternity care coordination recipients were more likely to receive first-trimester prenatal care (p < .01) and averaged three more prenatal visits and two additional primary care visits during pregnancy; they were also more likely to participate in WIC and to receive postpartum family planning services (p < .01). Medicaid expenditures were greater among mothers receiving MCC.Conclusions: Maternity care coordination facilitates access to health care and supportive services among Medicaid-covered women. Increased maternal service utilization may increase expenditures in the short run; however, improved newborn health may reduce the need for costly neonatal care, and by implication the need for early intervention and other supports for at-risk children. [ABSTRACT FROM AUTHOR]

Objectives: To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods.Data Sources: Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care.Study Design: Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014.Principal Findings: Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care.Conclusions: Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care. [ABSTRACT FROM AUTHOR]

Objective To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care. Data Sources/Study Setting Birth certificate data for women who gave birth in Washington D.C. and D.C. residents who gave birth in other jurisdictions. Study Design Using propensity score modeling and instrumental variable analysis, we compare maternal and infant outcomes among women who receive prenatal care from birth center midwives and women who receive usual care. We match on observable characteristics available on the birth certificate, and we use distance to the birth center as an instrument. Data Collection/Extraction Methods Birth certificate data from 2005 to 2008. Principal Findings Women who receive birth center care are less likely to have a C-section, more likely to carry to term, and are more likely to deliver on a weekend, suggesting less intervention overall. While less consistent, findings also suggest improved infant outcomes. Conclusions For women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes. [ABSTRACT FROM AUTHOR]

Objective. This study investigates the impact of welfare reform on insurance coverage before pregnancy and on first-trimester initiation of prenatal care (PNC) among pregnant women eligible for Medicaid under welfare-related eligibility criteria. Data Sources. We used pooled data from the Pregnancy Risk Assessment Monitoring System for eight states (AL, FL, ME, NY, OK, SC, WA, and WV) from 1996 through 1999. Study Design. We estimated a two-part logistic model of insurance coverage before pregnancy and first-trimester PNC initiation. The impact of welfare reform on insurance coverage before pregnancy was measured by marginal effects computed from coefficients of an interaction term for the postreform period and welfare-related eligibility and on PNC initiation by the same interaction term and the coefficients of insurance coverage adjusted for potential simultaneous equation bias. We compared the estimates from this model with results from simple logistic, ordinary least squares, and two-stage least squares models. Principal Findings. Welfare reform had a significant negative impact on Medicaid coverage before pregnancy among welfare-related Medicaid eligibles. This drop resulted in a small decline in their first-trimester PNC initiation. Enrollment in Medicaid before pregnancy was independent of the decision to initiate PNC, and estimates of the effect of a reduction in Medicaid coverage before pregnancy on PNC initiation were consistent over the single- and two-stage models. Effects of private coverage were mixed. Welfare reform had no impact on first-trimester PNC beyond that from reduced Medicaid coverage in the pooled regression but separate state-specific regressions suggest additional effects from time and income constraints induced by welfare reform may have occurred in some states. Conclusions. Welfare reform had significant adverse effects on insurance coverage and first-trimester PNC initiation among our nation's poorest women of childbearing age. Improved outreach and insurance options for these women are needed to meet national health goals. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California, Data Sources/Study Setting. Longitudinal administrative data on Medical enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties-two long-standing MMC counties and one traditional fee-for-service Medicaid county in California between 1987 and 1992. Study Design. We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medical enrollment prior to delivery, data censoring, arid individual characteristics such as race and age. Principal Findings. Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. Conclusions. MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes. [ABSTRACT FROM AUTHOR]