Fresh Evidence on Disparities in Maternal Health Care

Despite advancements in medical care, the U.S. has the highest maternal mortality rate among high-income countries. Pregnant people from minority groups have particularly high rates of poor outcomes, including mortality and severe complications with long-term effects on health and well-being. But more than 80 percent of pregnancy-related deaths are preventable.

In this Q&A, AIR Principal Researcher Daniela Zapata and Senior Researcher Sarah Pedersen, a practicing doula, share key findings from research on Medicaid’s role in maternal health outcomes and care—the first studies that used Medicaid claims data to ensure the accuracy of data on maternal health procedures. This research could inform policies and practices to advance health equity. The AIR Opportunity Fund (formerly the AIR Equity Initiative) funded this work.
 

Q. Why is it important to study disparities in access to and outcomes of maternal health care?

Pedersen: It’s important to understand why disparities in maternal health outcomes exist. There are systems, practices, and policies that are discriminatory based on race, class, sex, and location. Minority birthing people, and those with Medicaid insurance or no insurance, are less likely to receive early and adequate prenatal care and more likely to experience acts of discrimination during childbirth, such as being ignored and dismissed by their health care team. Maternity care deserts—places in the U.S. with no access to maternal health care—affect over two million pregnant people and more than 150,000 births a year. These factors show how the maternal health care system is, by and large, failing families.

The COVID-19 pandemic exacerbated poor outcomes for birthing people, especially minority individuals. Since then, there have been heightened federal and state efforts to address disparities through better access to care, particularly community-based care like freestanding birth centers and midwifery models of care.
 

Q. Your research examined the effects of Medicaid expansion to states under the Affordable Care Act. What did you learn about the role of Medicaid policy in reducing inequities in maternal health care?

Zapata: Because Medicaid now covers about 41 percent of all U.S. births, and most births of minority women, we wanted to explore whether Medicaid policies could be used to improve maternal health outcomes. We conducted systematic literature reviews on the role of Medicaid policy in reducing racial disparities in prenatal and postpartum home visiting services, freestanding birth centers, and postpartum, long-acting reversible contraception.

Pedersen: There’s much evidence generally about the effectiveness of these policies, but there is limited evidence examining them with an equity lens, in terms of racial and ethnic disparities. Our literature review across the three policies underscored the importance of Medicaid coverage for the provision of screenings and referrals, and the need to better integrate community-based providers and perinatal health workers, who can offer comprehensive care and support that goes beyond medical needs. Researchers also are learning more about the role of external factors in maternal health, such access to food, stable housing, safe neighborhoods, and transportation, and how these factors influence disparities in access to care and outcomes.

Zapata: I’d add that I learned the importance of diversity in your research team. Research Associate Drew Wood-Palmer, an African American researcher on our team, was invaluable for the literature review that covered long-acting, reversible contraception. This type of contraception has sometimes been associated with forced medical sterilization in the Black community. Other researchers on our team were hesitant to investigate this topic because they were afraid to offend people of color or make it seem that we were advocating for forced medical sterilization. Drew framed the topic in a way that was not offensive and highlighted the positive and negative aspects of this policy on long-acting, reversible contraception. She became the lead author of our article because her contributions were invaluable to our research.
 

Q. You also focused on Medicaid expansions in two states, Louisiana and Virginia. What did that research reveal?

Zapata: We found that both expansions increased first trimester enrollment rates in Medicaid for women who are racial minorities and reduced the probability of cesarean deliveries across different races. This is a notable result, because both states’ baseline cesarean delivery rates were high—more than 25 percent—and unnecessary cesareans can result in significant complications and adverse outcomes. On the other hand, both Medicaid expansions reduced the probability of having at least one prenatal care visit among certain groups, which suggests that increasing the number of people with Medicaid coverage creates challenges in provider availability.

Pedersen: Even 10 years after the Affordable Care Act went into effect, there continues to be a shortage of maternity care providers, ranging from obstetricians to community-based perinatal health workers, such as midwives, peer counselors, and doulas. There has been a significant push by the federal government in the last couple of years, through the White House Blueprint on the Maternal Health Crisis, to increase and diversify the maternal care workforce.
 

Q. You also studied freestanding birth centers. What are some insights from that work?

Pedersen: There’s a lot of evidence showing that maternal health outcomes and experiences are better, and care is less costly, at freestanding birth centers than in hospitals. We also know that a key indicator of positive outcomes and experiences is having a shared identity between provider and patient. Minorities, however, represent fewer than one-quarter of births in birth centers. Also, fewer than five percent of the just over 400 birth centers in the U.S. are led or owned by people of color.

To our knowledge, this study is the first to use a mixed-method approach to understand the barriers people of color face in accessing and using birth centers. Our hope is that our study shines a light on why so few minorities own and use birth centers and underscores the important role of birth centers in advancing equity.

Using heat maps to plot county-level data on race and ethnicity, socioeconomic status, urbanization level, and density of obstetricians and gynecologists, we found wide disparities in the distribution of birth centers and access to maternal care across the U.S.

Zapata: We also conducted two sets of focus groups—one with owners of white- and minority-owned birth centers to gather data on the motivators and barriers to opening and operating a birth center and one with individuals who had received care at a birth center to learn about their experiences.
 

Q. You deviated from your original research plan. How did support from the AIR Opportunity Fund make that possible?

Zapata: We had wanted to do a rigorous, quasi-experimental study on the effect of Medicaid coverage of birth center and home visiting services on minority birthing people. But birth centers serve a small percentage of the population, most of whom are white. From a quantitative point of view, the sample size was not large enough to answer our questions. We decided to take a completely different approach and look at the facts of the Medicaid expansions under the Affordable Care Act and investigate birth centers from a qualitative point of view.

Given the focus of the AIR Opportunity Fund to provide insightful, evidence-based answers to advance the conversation on equity, we had the freedom to redesign the study.