Association of Medicaid Expansion With Neuraxial Labor Analgesia Use in the United States: A Retrospective Cross-Sectional Analysis.

BACKGROUND: The Affordable Care Act has been associated with increased Medicaid coverage for childbirth among low-income US women. We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia. METHODS: We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017. Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate. Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion. Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level. RESULTS: The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states. In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76.3%. Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1.7% in expansion states (95% CI, 1.6-1.8) and 0.9% (95% CI, 0.9-1.0) in nonexpansion states. The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0.47% points (95% CI, -0.63 to 1.57; P = .39). CONCLUSIONS: Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period. Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.

Trends in eclampsia in the United States, 2009-2017: a population-based study.

BACKGROUND: Reducing the prevalence of eclampsia, a major cause of maternal and perinatal morbidity, is a maternal health priority. However, sparse data exist examining trends in the USA prevalence of eclampsia. OBJECTIVE: The aim of this study was to assess temporal trends in the prevalence of eclampsia among live births in the United States from 2009 to 2017. STUDY DESIGN: This population-based cross-sectional study included live births in 41 USA states and the District of Columbia between 2009 and 2017. The prevalence of eclampsia among all women, women with chronic hypertension and hypertensive disorders of pregnancy were reported by 1000 live births. Risk ratios adjusted for maternal characteristics were used to assess temporal trends. RESULTS: Of 27 866 714 live births between 2009 and 2017, 83 000 (0.30%) were associated with eclampsia. The adjusted risk of eclampsia decreased 10% during the 7 most recent years of the cohort, with an adjusted risk ratio of 0.90 [95% confidence interval (95% CI): 0.87-0.93] in 2017 relative to 2009. Relative to 2009, the adjusted risk of eclampsia in 2017 was substantially lower among women with chronic hypertension (adjusted risk ratio: 0.51; 95% CI: 0.46-0.57) and women with hypertensive pregnancy disorders (adjusted risk ratio: 0.43; 95% CI: 0.40-0.47). Among nonhypertensive women, there was a slight increase in the adjusted risk of eclampsia in 2017 relative to 2009 (adjusted risk ratio: 1.14; 95% CI: 1.10-1.17). CONCLUSION: Despite reductions in the eclampsia prevalence among women with chronic hypertension and hypertensive disorders of pregnancy, public health initiatives are needed to reduce the overall eclampsia prevalence, especially in nonhypertensive women.