Inequities in postpartum medical coverage vary by state across the U.S.

When immigrants gave birth in a U.S. state that limits postpartum public insurance eligibility based on their immigration status, they are less likely to receive medical care following childbirth, a study published July 18, 2023 in JAMA shows.

“Compared to states without insurance restrictions, immigrants in states with public insurance restrictions for postpartum immigrants are less likely to receive postpartum care,” write Maria W. Steenland of Brown University, Laura R. Wherry of New York University, Rachel Fabi at SUNY Upstate Medical University, and their colleagues. Hence, “Restricting public insurance coverage may be an important policy-driven barrier to receipt of recommended pregnancy care and improved maternal health among immigrants.”

The new study looks at data on 19 states and New York City and a total of 72,981 low-income women who gave birth between 2012 and 2019. Of the states examined by the researchers, 10 offer coverage for recently documented but not undocumented immigrants, and four offer no coverage to either immigrant group. The 10 states with coverage for recently documented but not undocumented immigrants that were included in the study were Colorado, Connecticut, Delaware, Hawaii, Maryland, Michigan, New Jersey, North Carolina, Pennsylvania, and Virginia. The four states with no coverage for either immigrant group were Alaska, Georgia, Oklahoma, and Utah.

In the opinion expressed by major professional associations for physicians and medical students, postpartum care is necessary to provide diagnosis and treatment of postpartum health concerns and ensure the health and wellbeing of postpartum individuals. An additional six states the researchers examined – Illinois, Massachusetts, Minnesota, New York, Oregon, and Rhode Island – offered coverage for postpartum care for both recently-documented and undocumented immigrants.

The pool of postpartum individuals covered by the research data for the study encompassed 20,971 immigrants (29%) and 52,010 non-immigrants (71%). The number of immigrants receiving postpartum care was found to be 11.3 percentage points lower in states with no coverage for recently documented and undocumented immigrants and 7 percentage points lower in states with coverage only for recently documented immigrants, when compared to immigrants in states that covered postpartum care for both of these groups.

As the study notes, deaths of women in connection with pregnancy or childbirth are higher in the U.S. than in any other high-income nation. Reflecting the importance that professional medical organizations place on postpartum services, 65% of pregnancy-related deaths occur at least one day after childbirth in the U.S., and 30% occur between six weeks and one year after childbirth. During a postpartum visit, women can be diagnosed and treated for common conditions that cause maternal mortality, such as postpartum depression and postpartum hypertension.

The study comes after 33 states and the District of Columbia have amended, at different times since 2021, their Medicaid policies to cover postpartum medical care through 12 months after delivery, up from the prior limit of 60 days for postpartum care. However, since these policy changes extending the availability of health services began to emerge, only a handful of states have opted to include undocumented immigrants under it.

Among all low-income women of reproductive age in the United States, 48% of noncitizens are medically uninsured, compared to 16% of U.S.-born women.

The study responds to a paucity of available data on postpartum care receipt among low-income immigrants and on the role of state coverage policies in the health of immigrant women and children. As representative data are scarce at both the state and national levels, the authors created an original dataset, using representative pre­­­­gnancy surveillance data at the state level and state birth certificates indicating maternal country of origin. This linked data enabled the researchers to document postpartum care receipt by low-income immigrants, which had not previously been studied beyond the local level.

In addition, a detailed state policy review conducted as part of the study determined the extent of public insurance for postpartum immigrants, offering the first available evidence on the relationship between state public insurance for postpartum immigrants and postpartum care receipt among low-income immigrants.

“While public health insurance plays a huge role in financing pregnancy related postpartum care of low-income pregnant people in the U.S., public insurance coverage options are limited for undocumented and recent immigrants,” according to the study. “In half of U.S. states, documented immigrants must wait five years after establishing legal residence (often referred to as a waiting period) to obtain pregnancy Medicaid. Meanwhile, undocumented immigrants are ineligible for coverage in the majority of states.”

Steenland is an assistant professor at Brown University’s Population Studies and Training Center, and Wherry is assistant professor of economics and public service at the Robert F. Wagner Graduate School of Public Service, New York University. Additional study authors include Rachel E. Fabi (Center for Bioethics and Humanities, SUNY Upstate Medical University), and Meghan Bellerose, Arielle Desire and Maggie S. White, current and former students at Brown School of Public Health.

This research was supported in part under a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) to the Brown Population Studies and Training Center.

Estimated Publication Date: July 25, 2022

First Estimated Application Due Date: November 30,  2022

Purpose

As part of the Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE) initiative, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, on behalf of the NIH Maternal Mortality Task Force, intends to promote a new initiative by publishing Funding Opportunity Announcements (FOAs) to solicit applications to establish a national network of Maternal Health Research Centers of Excellence. The collaborative FOAs will conduct research to mitigate preventable maternal mortality, decrease severe maternal morbidity, and promote health equity.

This Notice is being provided to allow potential applicants sufficient time to develop meaningful collaborations and responsive projects.

This FOA will utilize the U24 activity code for the research resource Hub and the U54 activity code for the Research Centers of Excellence. The FOAs are anticipated to be published in late Spring or early Summer 2022 with an expected application due date in Fall 2022. Details of the planned initiative are provided below.

Research Initiative Details

The collaborative Maternal Health Research Centers of Excellence FOAs represent one part of the multipronged Implementing a Maternal health and Pregnancy Outcomes Vision for Everyone (IMPROVE) initiative launched by the NIH in response to the rising rates of maternal mortality in the U.S. Over the past 25 years, the maternal mortality rate has more than doubled in the U.S. and is now higher than any high-income country in the world. Approximately 700 women die each year from conditions related to or associated with pregnancy or childbirth. In addition, severe maternal morbidities affect more than 65,000 women in the U.S. per year. Women experiencing severe maternal morbidity are at increased risk for future adverse health (e.g., hypertension, diabetes, dementias, mental health conditions, strokes, and heart disease). High rates of maternal deaths disproportionately affect Black/African American and American Indian/Alaska Native women. There are also disparities by age, education, socioeconomic status, and geographic region.

One-third of pregnancy-related deaths occur during pregnancy, one-third occur during or in the week after delivery, and one third occur between one week to one year postpartum. Causes of severe maternal morbidities and maternal mortality are multifaceted. In the U.S., the leading causes are cardiovascular disease, infection, hypertensive disorders, thromboembolism, and hemorrhage. Significant contributing factors include comorbid conditions (e.g., hypertension, diabetes, mental illness, and substance use disorders) and social determinants of health, which include structural racism and health care system factors. It is estimated that 60 to 70 percent of maternal deaths in the U.S. are preventable.

This Notice encourages multidisciplinary investigators with expertise in developing and testing strategies to address preventable contributors to severe maternal morbidity and maternal mortality in under-represented minority populations and proficiency in conducting novel systems research investigating health care and community-partnered approaches to maternal wellbeing to consider working with their relevant institutions to apply for this new FOA.

Projects must include a focus on one or more populations that experience maternal health disparities, such as underrepresented racial and ethnic communities (including but not limited to Blacks/African Americans, Hispanics/Latinos, American Indians/Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islanders), socioeconomically disadvantaged groups, underserved rural populations (e.g., living in obstetrical deserts), sexual and gender minority groups, or persons with disabilities. In addition to scientific diversity, applicants must incorporate diversity in their team development plan. Please refer to Notice of NIH’s Interest in Diversity, NOT-OD-20-031, for more details.

The planned U24 Hubs will serve as an indispensable research resource where data collected from the IMPROVE Centers of Excellence initiative, and possibly other IMPROVE initiatives, can be aggregated, accessed, analyzed, and shared within and across Maternal Health Research Centers of Excellence.

For more information: https://grants.nih.gov/grants/guide/notice-files/NOT-HD-22-022.html

In the United States, more than 20% of deaths during pregnancy and the first year after childbirth are due to drug use, suicide, or homicide, suggests a study funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).¹ The number of pregnancy-associated deaths from these causes increased between 2010 and 2019, with drug-related deaths nearly tripling (see figure). The research team also highlighted considerable racial and ethnic inequities in these deaths.

Maternal mortality statistics typically encompass deaths from causes directly related to or aggravated by pregnancy or pregnancy care. There have been few national estimates of the burden of deaths due to drug use, suicide, or homicide that occur during pregnancy or the first year postpartum. In the current study, researchers examined death certificate records from 33 states and Washington, DC, to estimate the prevalence of such pregnancy-associated deaths in the United States from 2010 to 2019.

Study Highlights Opioid Epidemic’s Toll on Recently Pregnant Women

Of the 11,782 pregnancy-associated deaths that the researchers identified, 11.4% were due to use of illicit or prescription drugs, 5.4% were due to suicide, and 5.4% were due to homicide. The prevalence of pregnancy-associated deaths because of drug use increased 190% between 2010 and 2019. Deaths from homicide rose 63%, and those due to suicide increased 30%.

“These data also demonstrate unacceptable racial and ethnic inequities in pregnancy-associated deaths,” the authors write. For example, they observed much higher rates of pregnancy-associated deaths due to suicide among American Indians and Alaska Natives, compared to other racial and ethnic groups. Non-Hispanic Black people had a disproportionately high risk of death from homicide.

Overall, homicide accounted for 8% of deaths during pregnancy, compared to only 3.4% of all deaths among females of reproductive age. Almost 60% of pregnancy-associated homicides occurred during pregnancy, while approximately half of drug-related deaths and suicides took place between six weeks and one year postpartum. The researchers speculate that the higher risk of drug-related and suicide deaths in the postpartum period may be attributable to lack of specialized mental health and substance use services, the stress of caring for a newborn, hormonal changes, and other factors.

Screening for Substance Abuse, Mental Health Problems, and Intimate Partner Violence Are Key

The findings indicate that deaths due to drug use, suicide, and homicide are substantial and growing contributors to pregnancy-associated mortality. The authors estimate that preventing such deaths would have saved more than 2,600 pregnant and postpartum people between 2010 and 2019. The data also underscore the need to address racial and ethnic disparities in these deaths.

The findings suggest the need for research to identify risk factors and prevention approaches for pregnancy-associated deaths due to drug use, suicide, and homicide. Such prevention approaches may include screening for substance use, mental health issues, and intimate partner violence and coordinating obstetric care with addiction medicine, behavioral health, and social services. The authors also call for attention to barriers to accessing care and support, including issues with housing, transportation, childcare, and domestic abuse.

This article was adapted from a Science Update by the Press Office at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The work of researchers from the NICHD-funded Population Dynamics Research Center at Johns Hopkins University is highlighted.

References

1. Claire Margerison et al., “Pregnancy-Associated Deaths Due to Drugs, Suicide, and Homicide in the United States, 2010-2019,” Obstetrics and Gynecology 139, no. 2 (2022): 172-80. doi: 10.1097/AOG.0000000000004649. PMID: 34991132