Lindsay K. Admon

Objective: Rural residents experience higher rates of postpartum uninsurance than their urban counterparts, contributing to rural–urban disparities in maternal health outcomes. We examined how Medicaid expansion under the Affordable Care Act affected rural–urban disparities in the rates of postpartum health insurance coverage among low-income women. Methods: We used nationally representative data from the 2010-2012 and 2015-2019 American Community Survey to compare rates of postpartum health insurance coverage among low-income women in states that expanded Medicaid and states that did not expand Medicaid (difference-in-differences analysis). We analyzed changes in disparities in postpartum health insurance coverage between women living in rural areas and women living in urban areas (difference-in-difference-in-differences analysis). Results: Women living in rural areas had the greatest increases in postpartum health insurance coverage, with a 17.0 percentage-point increase in states that expanded Medicaid (95% CI, 13.9-20.2) and an 11.5 percentage-point increase in states that did not expand Medicaid (95% CI, 9.2-13.8). Any postpartum health insurance coverage among rural residents relative to urban residents increased by 4.8 percentage points (95% CI, 2.0-7.7) in states that expanded Medicaid compared with states that did not. We observed similar trends for Medicaid postpartum health insurance coverage specifically. Conclusions: Rural women had greater increases in postpartum health insurance coverage relative to urban women following Medicaid expansion, thereby reducing geographic disparities in health insurance coverage during the postpartum period. Future research should focus on whether disproportionate gains in health insurance coverage for rural communities led to increased access to care during the postpartum period.

Exposure of mothers to neighborhood affluence or disadvantage during their childhood or adulthood may influence infant birth outcomes. Concurrently, these neighborhood exposures may be differently prevalent and impactful on health by race. Using a multigenerational dataset of maternally linked birth certificates from South Carolina (1989-2020), we investigated associations between maternal life course neighborhood exposure to affluence (neighborhood college completion) and disadvantage (neighborhood poverty) and infant low birth weight (LBW) and preterm birth (PTB), and differences by maternal Black/White race. Black women had a higher prevalence of LBW and PTB than White women, overall and within every exposure category. Black women were more often exposed to neighborhood disadvantage (high poverty) and less often exposed to neighborhood affluence (high college completion), in childhood and in adulthood than White women. Life course high (vs low) affluence and low (vs high) disadvantage neighborhood exposures were protectively associated with LBW, though only the latter was protective for PTB. Though we did not find evidence of differential vulnerability by maternal race to life course neighborhood exposures, the greater life course exposure of Black mothers to less affluent and more disadvantaged neighborhoods explained up to 9% of racial disparities even without effect modification present.

OBJECTIVE: To measure contemporary trends in the prevalence of short interpregnancy interval (IPI) births in the United States. METHODS: We conducted a repeated cross-sectional analysis using 2016–2022 natality data from the National Vital Statistics System. We included all singleton live births to individuals with at least one prior live birth. We examined trends over time in short IPIs less than 18 months, as well as for specific durations within this time frame (less than 6 months, 6–11 months, and 12–17 months), using linear probability models that estimated changes in the prevalence of each IPI duration over time. We then estimated the prevalence of each short IPI duration by maternal race and ethnicity, socioeconomic characteristics (age, education, insurance payer at delivery), and geography (U.S. census region, state of residence). RESULTS: The study sample included 14,770,411 singleton live births to individuals with at least one prior live birth in 2016–2022. Roughly a third (29.8%) of births had an overall IPI of less than 18 months (5.0% less than 6 months, 11.0% 6–11 months, and 13.8% 12–17 months). For IPIs less than 6 months, a slight statistical decline in prevalence was identified over the study period in unadjusted and adjusted models (adjusted annual percentage point change −0.02, 95% CI, −0.03 to −0.02). Slight statistical increases in the prevalence of IPIs of 6–11 and 12–17 months were identified in unadjusted models but were no longer significant and reversed direction in adjusted models, respectively. Long-standing inequities in the distribution of the shortest IPIs (less than 6 months) were stable compared with prior work across the indicators examined in this study. CONCLUSION: Overall, it appears the prevalence of short IPIs has remained stable between 2016 and 2022.

During the COVID-19 pandemic, nearly all US states enacted stay-at-home orders, upending usual childcare arrangements and providing a unique opportunity to study the association between childcare disruptions and maternal health. Using data from the 2021–2022 National Survey of Children's Health, we estimated the association between childcare disruptions due to the COVID-19 pandemic and self-reported mental and physical health among female parents of young children (ages 0–5 years). Further, we assessed racial, ethnic, and socioeconomic disparities in (1) the prevalence of childcare disruptions due to the COVID-19 pandemic and (2) the association between childcare disruptions and mental or physical health. Female parents who experienced childcare disruptions due to the COVID-19 pandemic were less likely to report excellent or very good mental (−7.4 percentage points) or physical (−2.5 percentage points) health. Further, childcare disruptions were more common among parents with greater socioeconomic privilege (ie, higher education, higher income), but may have been more detrimental to health among parents with less socioeconomic privilege (eg, lower education, lower income, and single parents). As state and federal policymakers take action to address the maternal health crisis in the United States, our findings suggest that measures to improve childcare stability may also promote maternal health and health equity.

OBJECTIVE: To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states. METHODS: We conducted a pooled, cross-sectional analysis of the 2016–2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC. We also examined SMM rates among non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance in a subgroup of 27 states (and Washington, DC). We generated unadjusted rates of composite SMM and the individual indicators of SMM that comprised the composite. Rate differences and rate ratios were calculated to compare SMM rates for non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance. RESULTS: The overall rate of SMM without blood transfusion was 146.2 (95% CI 145.1–147.3) per 10,000 deliveries (N=4,807,143). Rates of SMM ranged nearly threefold, from 80.3 (95% CI 71.4–89.2) per 10,000 deliveries in Utah to 210.4 (95% CI 184.6–236.1) per 10,000 deliveries in Washington, DC. Non-Hispanic Black individuals with Medicaid insurance (n=629,774) experienced a higher overall rate of SMM (212.3, 95% CI 208.7–215.9) compared with non-Hispanic White individuals with Medicaid insurance (n=1,051,459); (125.3, 95% CI 123.2–127.4) per 10,000 deliveries (rate difference 87.0 [95% CI 82.8–91.2]/10,000 deliveries; rate ratio 1.7 [95% CI 1.7–1.7]). The leading individual indicator of SMM among all individuals with Medicaid insurance was eclampsia, although the leading indicators varied across states and by race and ethnicity. Many states were concordant in leading indicators among the overall, non-Hispanic Black, and non-Hispanic White populations (ie, in Oklahoma sepsis was the leading indicator for all three). Most states, however, were discordant in leading indicators across the three groups (ie, in Texas eclampsia was the leading indicator overall, pulmonary edema or acute heart failure was the leading indicator among the non-Hispanic Black population, and sepsis was the leading indicator among the non-Hispanic White population). CONCLUSION: Interventions aimed at reducing SMM and, ultimately, mortality among individuals with Medicaid insurance may benefit from the data generated from this study, which highlights states that have the greatest burden of SMM, the differences in rates among non-Hispanic Black populations compared with non-Hispanic White populations, and the leading indicators of SMM overall, by state, and by race and ethnicity.

OBJECTIVE: To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents. METHODS: We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016–2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison. RESULTS: Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11–1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41–1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17–1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural–urban differences in uninsurance persisted across both Medicaid expansion and non–expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth. CONCLUSION: Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural–urban inequities in maternity care access and maternal health.

Objective: Half of maternal deaths occur during the postpartum year, with data suggesting greater risks among Black, Indigenous, and people of color (BIPOC) and rural residents. Being insured after childbirth improves postpartum health-related outcomes, and recent policy efforts focus on extending postpartum Medicaid coverage from 60 days to 1 year postpartum. The purpose of this study is to describe postpartum health insurance coverage for rural and urban U.S. residents who are BIPOC compared to those who are white. Materials and Methods: Using data from the 2016–2019 Pregnancy Risk Assessment Monitoring System ( n = 150,273), we describe health insurance coverage categorized as Medicaid, commercial, or uninsured at the time of childbirth and postpartum. We measured continuity of insurance coverage across these periods, focusing on postpartum Medicaid disruptions . Analyses were conducted among white and BIPOC residents from rural and urban U.S. counties. Results: Three-quarters (75.3%) of rural white people and 85.3% of urban white people were continuously insured from childbirth to postpartum, compared to 60.5% of rural BIPOC people and 65.6% of urban BIPOC people. Postpartum insurance disruptions were frequent among people with Medicaid coverage at childbirth, particularly among BIPOC individuals, compared to those with private insurance; 17.0% of rural BIPOC residents had Medicaid at birth and became uninsured postpartum compared with 3.4% of urban white people. Conclusions: Health insurance coverage at childbirth, postpartum, and across these timepoints varies by race/ethnicity and rural compared with urban residents. Policy efforts to extend postpartum Medicaid coverage may reduce inequities at the intersection of racial/ethnic identity and rural geography.