The Affordable Care Act and Changes in Women's Health Insurance Coverage Before, During, and After Pregnancy in California.

OBJECTIVES: Having health insurance is associated with improvements in health care access and use, health behaviors, and outcomes. We examined changes in health insurance coverage for California women before, during, and after pregnancy after implementation of the Affordable Care Act (ACA). METHODS: We used data from the 2011-2017 California Maternal and Infant Health Assessment, an annual representative survey of women sampled from birth certificates (n = 47 487). We examined health insurance coverage at baseline before ACA implementation (2011-2013) and in each survey year from 2014 to 2017 for 3 periods (before, during, and after pregnancy). We calculated prevalence ratios to evaluate changes in health insurance coverage, adjusting for changes in demographic characteristics. Few women were uninsured during pregnancy before implementation of the ACA; therefore, analyses focused on health insurance before pregnancy and postpartum. RESULTS: Before ACA implementation, 24.4% of women reported being uninsured before pregnancy, which decreased to 10.1% in 2017. About 17% of women reported being uninsured postpartum before ACA implementation, and this percentage decreased to 7.5% in 2017. ACA implementation resulted in a >50% adjusted decline in the likelihood of being uninsured before pregnancy or postpartum, primarily because of substantial increases in Medicaid coverage. CONCLUSIONS: ACA implementation resulted in a dramatic reduction in mothers in California who were uninsured before and after pregnancy. Medicaid expansion played a major role in this improvement.

Medical Provider Promotion of Oral Health and Women's Receipt of Dental Care During Pregnancy.

Objectives Dental care during pregnancy is important. We examined whether promotion of oral health by medical providers during pregnancy and pregnant women's receipt of dental care improved between 2009 and 2012 in California. Methods We used population-based postpartum survey data collected during 2009 (n = 3105) and 2012 (n = 6810) to compare the prevalence of women's reports that, during pregnancy, (a) their medical providers discussed oral health and/or suggested they see a dentist, and (b) they received dental care. Results Between 2009 and 2012, the proportion of women reporting that their medical providers talked about oral health or referred them to a dentist increased significantly overall (from 36 to 42%, and 21-26%, respectively, p < 0.001). The proportion of women with a dental visit during pregnancy also increased, from 38% in 2009 to 42% in 2012 (p < 0.005). The improvements were largely among women of lower income and education levels, those covered by Medi-Cal, and Latinas. Women whose medical providers promoted oral health care were approximately two times more likely to report having had a dental visit during pregnancy, even after adjusting for several potential confounders. Conclusions for Practice Characteristics of women reporting that their medical providers promoted, and that they received, dental care during pregnancy in 2012 suggests that the increases in promotion and use of oral health care were largely concentrated among Medi-Cal recipients. Further improvement is needed for all populations of pregnant women. Both public and private providers need to incorporate promotion of and referral for dental care into routine prenatal care protocols.

Worry about racial discrimination: A missing piece of the puzzle of Black-White disparities in preterm birth?

OBJECTIVES: The causes of the large and persistent Black-White disparity in preterm birth (PTB) are unknown. It is biologically plausible that chronic stress across a woman's life course could be a contributor. Prior research suggests that chronic worry about experiencing racial discrimination could affect PTB through neuroendocrine, vascular, or immune mechanisms involved in both responses to stress and the initiation of labor. This study aimed to examine the role of chronic worry about racial discrimination in Black-White disparities in PTB. METHODS: The data source was cross-sectional California statewide-representative surveys of 2,201 Black and 8,122 White, non-Latino, U.S.-born postpartum women with singleton live births during 2011-2014. Chronic worry about racial discrimination (chronic worry) was defined as responses of "very often" or "somewhat often" (vs. "not very often" or "never") to the question: "Overall during your life until now, how often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?" Prevalence ratios (PRs) with 95% Confidence Intervals (CI) were calculated from sequential logistic regression models, before and after adjustment for multiple social/demographic, behavioral, and medical factors, to estimate the magnitude of: (a) PTB risks associated with chronic worry among Black women and among White women; and (b) Black-White disparities in PTB, before and after adjustment for chronic worry. RESULTS: Among Black and White women respectively, 36.9 (95% CI 32.9-40.9) % and 5.5 (95% CI 4.5-6.5) % reported chronic worry about racial discrimination; rates were highest among Black women of higher income and education levels. Chronic worry was significantly associated with PTB among Black women before (PR 1.73, 95% CI 1.12-2.67) and after (PR 2.00, 95% CI 1.33-3.01) adjustment for covariates. The unadjusted Black-White disparity in PTB (PR 1.59, 95%CI 1.21-2.09) appeared attenuated and became non-significant after adjustment for chronic worry (PR 1.30, 95% CI 0.93-1.81); it appeared further attenuated after adding the covariates (PR 1.17, 95% CI 0.85-1.63). CONCLUSIONS: Chronic worry about racial discrimination may play an important role in Black-White disparities in PTB and may help explain the puzzling and repeatedly observed greater PTB disparities among more socioeconomically-advantaged women. Although the single measure of experiences of racial discrimination used in this study precluded examination of the role of other experiences of racial discrimination, such as overt incidents, it is likely that our findings reflect an association between one or more experiences of racial discrimination and PTB. Further research should examine a range of experiences of racial discrimination, including not only chronic worry but other psychological and emotional states and both subtle and overt incidents as well. These dramatic results from a large statewide-representative study add to a growing-but not widely known-literature linking racism-related stress with physical health in general, and shed light on the links between racism-related stress and PTB specifically. Without being causally definitive, this study's findings should stimulate further research and heighten awareness of the potential role of unmeasured social variables, such as diverse experiences of racial discrimination, in racial disparities in health.

Latina Birth Outcomes in California: Not so Paradoxical.

Objectives To investigate Latina-White differences in birth outcomes in California from 2003 to 2010, looking for evidence of the often-cited "Latina paradox" and assessing the possible role of socioeconomic factors in observed differences. MethodsUsing statewide-representative data from the California Maternal and Infant Health Assessment, an annual population-based postpartum survey, we compared rates of preterm birth (PTB) and low birth weight (LBW) in five groups: U.S.-born non-Latina Whites ("Whites"), U.S.-born Mexican-Americans, U.S.-born non-Mexican Latinas, Mexican immigrants, and non-Mexican Latina immigrants. Logistic regression models examined the relative likelihood of PTB and LBW for women in each Latina subgroup compared with Whites, before and after adjustment for socioeconomic and other covariates. Results In unadjusted analyses, women in each Latina subgroup appeared more likely than White women to have PTB and LBW, although the increased likelihood of LBW among Mexican immigrants was statistically non-significant. After adjustment for less favorable socioeconomic characteristics among Latinas compared with Whites, observed differences in the estimated likelihoods of PTB or LBW for Latina subgroups relative to Whites were attenuated and (with the exception of PTB among U.S.-born Mexican Americans) no longer statistically significant. Conclusions We found no evidence of a "Latina paradox" in birth outcomes, which some have cited as evidence that social disadvantage is not always health-damaging. As observed in several previous studies, our findings were non-paradoxical: consistent with their socioeconomic disadvantage, Latinas had worse birth outcomes than non-Latina White women. Policy-makers should not rely on a "Latina paradox" to ensure good birth outcomes among socioeconomically disadvantaged Latina women.

The role of socioeconomic factors in Black-White disparities in preterm birth.

OBJECTIVES: We investigated the role of socioeconomic factors in Black-White disparities in preterm birth (PTB). METHODS: We used the population-based California Maternal and Infant Health Assessment survey and birth certificate data on 10 400 US-born Black and White California residents who gave birth during 2003 to 2010 to examine rates and relative likelihoods of PTB among Black versus White women, with adjustment for multiple socioeconomic factors and covariables. RESULTS: Greater socioeconomic advantage was generally associated with lower PTB rates among White but not Black women. There were no significant Black-White disparities within the most socioeconomically disadvantaged subgroups; Black-White disparities were seen only within more advantaged subgroups. CONCLUSIONS: Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black-White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature-including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate-as potential contributors to PTB among Black and White women with different levels of social advantage.

Most pregnant women in California do not receive dental care: findings from a population-based study.

OBJECTIVES: We examined the prevalence of dental care during pregnancy and reasons for lack of care. METHODS: Using a population-based survey of 21,732 postpartum women in California during 2002-2007, we calculated prevalence of dental problems, receipt of care, and reasons for non-receipt of care. We used logistic regression to estimate odds of non-receipt of care by maternal characteristics. RESULTS: Overall, 65% of women had no dental visit during pregnancy; 52% reported a dental problem prenatally, with 62% of those women not receiving care. After adjustment, factors associated with non-receipt of care included non-European American race/ethnicity, lack of a college degree, lack of private prenatal insurance, no first-trimester prenatal insurance coverage, lower income, language other than English spoken at home, and no usual source of pre-pregnancy medical care. The primary reason stated for non-receipt of dental care was lack of perceived need, followed by financial barriers. CONCLUSIONS: Most pregnant women in this study received insufficient dental care. Odds were elevated not only among the poorest, least educated mothers, but also among those with moderate incomes or some college education. The need for dental care during pregnancy must be promoted widely among both the public and providers, and financial barriers to dental care should be addressed.

Segmented assimilation theory and perinatal health disparities among women of Mexican descent.

A higher prevalence of infant low birth weight (<2500 g) has been observed among more acculturated mothers of Mexican descent living in the U.S. when compared to their less acculturated counterparts. Tests of the "acculturation hypothesis" have established that disparities in certain risks for low birth weight exist between subgroups of women of Mexican-origin. However, disparities observed by neighborhood of residence have yet to be explained. Most tests of the acculturation hypothesis assume a classical path of assimilation, whereby Mexican American health is expected to deteriorate with time spent residing in the U.S. and across the generations. The theory of segmented assimilation suggests that alternative paths are possible depending upon individual characteristics and the context of the neighborhood into which immigrant families and their children reside. This study tested the theory of segmented assimilation as a framework for examining the geographic, cultural, and socioeconomic underpinnings of population differences in infant low birth weight among women of Mexican descent in California using the 2000 U.S. Census and population-based data from the Maternal and Infant Health Assessment (1999-2005) (n=6442). Little support was found for the theory's hypotheses. Rather, increased odds for infant low birth weight were observed for English speakers residing in Latino immigrant neighborhoods when compared to English speakers in other neighborhoods, an effect attenuated for Spanish speakers. Elevated odds of low birth weight were also observed among English speakers residing in Latino immigrant neighborhoods when compared to Spanish speakers in the same neighborhoods. Findings suggest the transfer of health-specific social capital in ethnic neighborhoods may depend upon sociocultural consonance between individuals and neighborhood residents. The authors call for additional research that sheds light on the sociocultural dynamics of maternal and infant health at multiple levels.

Early postnatal care among healthy newborns in 19 States: pregnancy risk assessment monitoring system, 2000.

OBJECTIVE: To examine early postnatal care among healthy newborns during 2000 in 19 states. METHODS: Using data from the Pregnancy Risk Assessment Monitoring System, a multistate population-based postpartum survey of women, we calculated prevalences of early discharge (ED; stays of < or =2 days after vaginal delivery and < or =4 days after Cesarean delivery) and early follow-up (within 1 week) after ED. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) describing how ED and lack of early follow-up were associated with state legislation and maternal characteristics. RESULTS: While most healthy term newborns (83.5-93.4%) were discharged early, and most early-discharged newborns (51.5-88.5%) received recommended early follow-up, substantial proportions of early-discharged newborns did not. Compared with newborns in states where legislation covered both length of hospital stay (LOS) and follow-up, newborns in states without such legislation were more likely to have ED (aOR: 1.25; CI: 1.01-1.56). Lack of early follow-up was more likely among newborns in states with neither LOS nor follow-up legislation (aOR: 2.70, CI: 2.32-3.14), and only LOS legislation (aOR: 1.38, CI: 1.22-1.56) compared with those in states with legislation for both. ED was more likely among newborns born to multiparous women and those delivered by Cesarean section and less likely among those born to black and Hispanic mothers and mothers with less education. CONCLUSIONS: Lack of early follow-up among ED newborns remains a problem, particularly in states without relevant legislation. These findings indicate the need for continued monitoring and for programmatic and policy strategies to improve receipt of recommended care.

Socioeconomic status in health research: one size does not fit all.

Problems with measuring socioeconomic status (SES)-frequently included in clinical and public health studies as a control variable and less frequently as the variable(s) of main interest-could affect research findings and conclusions, with implications for practice and policy. We critically examine standard SES measurement approaches, illustrating problems with examples from new analyses and the literature. For example, marked racial/ethnic differences in income at a given educational level and in wealth at a given income level raise questions about the socioeconomic comparability of individuals who are similar on education or income alone. Evidence also shows that conclusions about nonsocioeconomic causes of racial/ethnic differences in health may depend on the measure-eg, income, wealth, education, occupation, neighborhood socioeconomic characteristics, or past socioeconomic experiences-used to "control for SES," suggesting that findings from studies that have measured limited aspects of SES should be reassessed. We recommend an outcome- and social group-specific approach to SES measurement that involves (1) considering plausible explanatory pathways and mechanisms, (2) measuring as much relevant socioeconomic information as possible, (3) specifying the particular socioeconomic factors measured (rather than SES overall), and (4) systematically considering how potentially important unmeasured socioeconomic factors may affect conclusions. Better SES measures are needed in data sources, but improvements could be made by using existing information more thoughtfully and acknowledging its limitations.

An approach to studying social disparities in health and health care.

OBJECTIVE: We explored methods and potential applications of a systematic approach to studying and monitoring social disparities in health and health care. METHODS: Using delayed or no prenatal care as an example indicator, we (1) categorized women into groups with different levels of underlying social advantage; (2) described and graphically displayed rates of the indicator and relative group size for each social group; (3) identified and measured disparities, calculating relative risks and rate differences to compare each group with its a priori most-advantaged counterpart; (4) examined changes in rates and disparities over time; and (5) conducted multivariate analyses for the overall sample and "at-risk" groups to identify particular factors warranting attention. RESULTS: We identified at-risk groups and relevant factors and suggest ways to direct efforts for reducing prenatal care disparities. CONCLUSIONS: This systematic approach should be useful for studying and monitoring disparities in other indicators of health and health care.

Surveillance for disparities in maternal health-related behaviors--selected states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2001.

PROBLEM/CONDITION: Disparities in maternal and infant health have been observed among members of different racial and ethnic populations and persons of differing socioeconomic status. For the Healthy People 2010 objectives for maternal and child health to be achieved (US Department of Health and Human Services. Healthy People 2010. 2nd ed. With understanding and improving health and objectives for improving health [2 vols.]. Washington DC: US Department of Health and Human Services, 2000), the nature and extent of disparities in maternal behaviors that affect maternal or infant health should be understood. Identifying these disparities can assist public health authorities in developing policies and programs targeting persons at greatest risk for adverse health outcomes. REPORTING PERIOD COVERED: 2000-2001. DESCRIPTION OF THE SYSTEM: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants. PRAMS employs a mixed mode data-collection methodology; up to three self-administered surveys are mailed to a sample of mothers, and nonresponders are followed up with telephone interviews. Self-reported survey data are linked to selected birth certificate data and weighted for sample design, nonresponse, and noncoverage to create annual PRAMS analysis data sets that can be used to produce statewide estimates of different perinatal health behaviors and experiences among women delivering live infants in 31 states and New York City. This report summarizes data for 2000-2001 from eight states (Alabama, Colorado, Florida, Hawaii, Illinois, Maine, Nebraska, and North Carolina) on four behaviors (smoking during pregnancy, alcohol use during pregnancy, breastfeeding initiation, and use of the infant back sleep position) for which substantial health disparities have been identified previously. RESULTS: Although the prevalence of each behavior varied by state, consistent patterns were observed among the eight states by age, race, ethnicity, education, and income level. Overall, the prevalence of smoking during pregnancy ranged from 9.0% to 17.4%. Younger (aged <25 years) women, white women, American Indian women, non-Hispanic women (except in Hawaii), women with a high school education or less, and women with low incomes consistently reported the highest rates of smoking. Overall, the prevalence of alcohol use during pregnancy ranged from 3.4% to 9.9%. In seven states, women aged >35 years, non-Hispanic women, women with more than a high school education, and women with higher incomes reported the highest prevalence of alcohol use during pregnancy. Overall, the prevalence of breastfeeding initiation ranged from 54.8% to 89.6%. Younger women, black women, women with a high school education or less, and women with low incomes reported the lowest rates of breastfeeding initiation. The size of the black-white disparity in breastfeeding varied among states. Overall, use of the back sleep position for infants ranged from 49.7% to 74.8%. Use of the back sleep position was lowest among younger women, black women, women with lower levels of education, and women with low incomes. Ethnic differences in sleep position varied substantially by state. INTERPRETATION: PRAMS data can be used to identify racial, ethnic, and socioeconomic disparities in critical maternal health-related behaviors. Although similar general patterns by age, education, and income were observed in at least seven states, certain racial and ethnic disparities varied by state. Prevalence of the four behaviors among each population often varied by state, indicating the potential impact of state-specific policies and programs. PUBLIC HEALTH ACTION: States can use PRAMS data to identify populations at greatest risk for maternal behaviors that have negative consequences for maternal and infant health and to develop policies and plan programs that target populations at high risk.sk. Although prevalence data cannot be used to identify causes or interventions to improve health outcomes, they do indicate the magnitude of disparities and identify populations that should be targeted for intervention. This report indicates a need for wider targeting than is often done. The results from this report can aid state and national agencies in creating more effective public health policies and programs. The data described in this report should serve as a baseline that states can use to measure the impact of policies and programs on eliminating these health disparities.

Newborn early discharge revisited: are California newborns receiving recommended postnatal services?

CONTEXT: Responding to safety concerns, federal and state legislation mandated coverage of minimum postnatal stays and state legislation in California mandated coverage of follow-up after early discharge. Little is known about the postnatal services newborns are receiving. OBJECTIVE: To describe rates of early discharge and of timely follow-up for early-discharged newborns. DESIGN AND SETTING: Retrospective, population-based cohort study using a 1999 postpartum survey in California. PARTICIPANTS: A total of 2828 infants of mothers with medically low-risk singleton births. MAIN OUTCOME MEASURES: Rates of early discharge (

Socioeconomic and racial/ethnic disparities in unintended pregnancy among postpartum women in California.

OBJECTIVE: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. METHODS: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. RESULTS: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. CONCLUSIONS: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women.