A professor describes severe maternal morbidity in low-income women as a public health crisis – now, Medicaid expansion seems to be improving pregnancy outcomes
According to the Center for Disease Control, severe maternal morbidity (SMM) is when “unexpected outcomes” of labour and delivery create health problems. These problems can be long or short-term, but they come from the pregnancy itself. This has been increasing in the US in recent years, impacting over 50,000 known women since 2014.
Jean Guglielminotti, MD, PhD, in the Department of Anesthesiology, Columbia Medical Center, explained: “Our findings indicate that the 2014 Medicaid expansion under the ACA in New York has contributed to reducing severe maternal morbidity in low- income women.
“These findings are of public health importance given the ongoing increase in maternal morbidity and mortality on the national level.”
How did pregnancy outcomes in New York change?
The Columbia University Mailman School of Public Health and Columbia University Irving Medical Center has found that Medicaid expansion in 2014 in New York State was associated with a reduction in severe maternal morbidity – especially when looking at low-income women during delivery, in comparison to high-income women.
The experience of severe maternal morbidity was even more striking for racial and ethnic minority women – who faced increased odds of good health when insured, but remained below white women in terms of pregnancy outcomes.
Of 2,286,975 delivery-related discharges in 173 hospitals, 611,020 were among low-income women (27%). Compared with high-income women, low-income women had a higher incidence of SMM (2.6% vs 1.9%, respectively).
This is one of the first studies to examine the link between Medicaid access and maternal health outcomes, which have been worsening in the US until this policy intervention.
‘Earlier prenatal care during pregnancy’
“We hypothesized that the introduction of Medicaid expansion in January 2014 would not be associated with an abrupt change in the incidence of SMM immediately after its introduction but rather with a gradual decrease over time,” said Guglielminotti.
“We based this on the fact that a pregnancy lasts 3 quarter-years and that the beneficial effect of health insurance coverage on maternal health outcomes during delivery hospitalizations is thought to be mediated by earlier prenatal care during pregnancy and a better quality of prenatal care.”
The outcome of a 5% increase in insured women
Medicaid beneficiaries increased from 43% in the pre-expansion study period to 48% in the post-expansion study period. The proportion of the uninsured decreased 5% and by a decline of 9% among privately insured women. The 2014 New York State Medicaid expansion increased the income eligibility threshold for pregnant women from 200% to 223% of the Federal Poverty Level.
According to earlier Columbia research, even though half of pregnant women are covered by Medicaid nationwide, up to 13% are uninsured in the month of delivery.
Firstly, while insured women may receive earlier and better care throughout pregnancy and postpartum – an earlier and higher utilisation of prenatal care is also associated with better maternal and neonatal outcomes. Secondly, insured women might seek earlier care if symptomatic of a complication without worrying about financial implications.
Finally, care during hospitalisation can be influenced by insurance type by removing financial barriers to care delivery such as the utilisation of expensive procedures.