Disparities in access to prenatal care based on citizenship status and education level

Immigrant pregnant people faced persistent inequities in obtaining timely prenatal care as compared with native-born pregnant people in the United States over an eight-year period, a factor that could be contributing to longstanding health disadvantages, according to an analysis published in JAMA Network Open on October 28.

The study, led by researchers from the Icahn School of Medicine at Mount Sinai and the University at Albany, SUNY, covered the period between 2011 and 2019, a time when access to prenatal care (defined by the study as health care provided to pregnant people within the first trimester) was increased in states that expanded Medicaid as part of the Affordable Care Act.

While access to timely prenatal care increased overall after Medicaid expansion, disparities between immigrant and U.S.-born pregnant people grew larger among those of Hispanic descent. In states that expanded Medicaid, 76.3% of immigrant Hispanic pregnant people received timely prenatal care after expansion versus about 81.1% of U.S.-born Hispanic pregnant people.

About one in every four births in the United States is to a person who is an immigrant or a non-U.S. citizen, according to the Centers for Disease Control and Prevention. Some immigrants are excluded from safety-net programs including Medicaid, which provides health care to low-income U.S. citizens.

"Our study shows that immigrant exclusions to Medicaid eligibility may exacerbate disparities," said co-corresponding author Teresa Janevic, Ph.D., MPH, Associate Professor of Obstetrics, Gynecology and Reproductive Science, Population Health Science and Policy, and Global Health and Health Systems Design at Icahn Mount Sinai. "Prompt and appropriate access to prenatal care is important because it benefits mothers and infants beyond pregnancy and birth. We know insurance coverage prior to pregnancy results in an earlier start to prenatal care; therefore, Medicaid coverage before pregnancy is an important lever to improve timely prenatal care."

The cross-sectional analysis used data from the National Center for Health Statistics and reviewed prenatal care among more than 6 million pregnant people pre- and post-Medicaid expansion in 16 states, including 400,000 immigrant pregnant people. The researchers also factored in characteristics including age, number of children, education level, race, and ethnicity.

Dr. Janevic said the findings could inform current policy discussions around maternal health equity, demonstrating that certain restrictions on Medicaid coverage based on immigration status contribute to disparities between native-born and immigrant people seeking prenatal care in the United States. The study also encourages health care workers and policymakers to address how citizen-based exclusions to health care and social benefits contribute to structural racism faced by immigrant communities, she said.

"Non-citizens face many obstacles to obtaining health coverage both during and outside of pregnancy," said co-corresponding author Ashley M. Fox, Ph.D., MA, Associate Professor of Public Administration and Policy at University at Albany, SUNY. "The pathways available for immigrants to access care are often complex and vary based on qualifying status, time in the country, and state or locality of residence. Recent policy changes that have extended Medicaid eligibility, both prior to and during the COVID-19 pandemic, have often excluded immigrants either inadvertently or advertently."