Insurance Affects Low-Income Pregnant, Postpartum Women

Lack of insurance or shifts between having insurance and uninsurance from preconception to postpartum are associated with less chances a woman receives early prenatal care or recommended postpartum care compared with those who have continuous insurance.

Because many low-income women experience disruptions in health insurance during pregnancy and the first year postpartum, Lindsay K. Admon, M.D., M.Sc., and colleagues characterized the association between healthcare use and four patterns of insurance coverage across the perinatal period among that population. They used pooled 2015-2017 data from the Pregnancy Risk Surveillance and Monitoring System, which is a survey of postpartum women in 40 states and New York City that includes health insurance status at preconception, delivery, and postpartum. The team limited the sample to those who had complete insurance information and household incomes less than 138% of the federal poverty line, which was the minimum required by federal statute to qualify for pregnancy-related Medicaid.

Admon and the investigators characterized insurance at each time point into Medicaid, private, or uninsured categories. Then, they generated four insurance patterns across the time points: continuous insurance, shifts between private and Medicaid, shifts between insurance and uninsurance, and continuous uninsurance. The team examined three healthcare use outcomes: prenatal care in the first trimester, in-hospital birth, and postpartum visit attendance.

Overall, the sample comprised more than 39,000 women with a mean age of 27.4 years old. Of those included, 43.6% were continuously insured, 21.3% experienced shifts between private and Medicaid coverage, 32.8% had shifts between insurance and uninsurance, and 2.4% were continuously uninsured. Among the continuously uninsured, a majority (60.1%) were Spanish-speaking Hispanic women (95% CI, 52.9-66.8). For those who experienced a shift between insurance and uninsurance or continuous uninsurance, they were significantly less likely to receive prenatal care in the first trimester (marginal differences, −12.5% [95% CI, –14.8 to 10.2] and −24.2% [95% CI, –30.8 to –17.6], respectively) or a postpartum visit (marginal differences, −2.1% [95% CI, –3.7 to –.5] and −9.6% [95% CI, –15.9 to –3.4], respectively) compared to those who had continuous insurance (adjusted probabilities, 77.8% [95% CI, 76.8-78.8] and 84.3% [95% CI, 83.4-85.2], respectively; P <.001 for each comparison).

Most women (more than 98.4%) across the first three categories of insurance had in-hospital births, while 80% of those with continuous uninsurance had an in-hospital birth (marginal difference compared with continuous insurance, -19.4%; 95% CI, -24.5 to -14.2; P <.001).

The Patient Protection and Affordable Care Act’s Medicaid expansion has improved perinatal insurance continuity for low-income women, the investigators reported. Other ways to improve access to care for postpartum women include efforts to extend Medicaid through the first year postpartum.

The study, “Insurance Coverage and Perinatal Health Care Use Among Low-Income Women in the US, 2015-2017,” was published in JAMA Network Open.