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Severe maternal morbidity differences by state Medicaid expansion and abortion coverage: a retrospective cohort study
Ishana Shetty1, Mark C Valentine2, Jennifer A Reeves3
1Division of Complex Family Planning, Department of Obstetrics and Gynecology, Contraception and Gynecology, WashU Medicine, St. Louis, MO (Shetty, Eisenberg, Reeves); Division of Complex Family Planning, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN (Shetty).
Background:
Medicaid is the largest single payor of perinatal care, and the extent of Medicaid coverage for pregnancy services, including abortion care, varies state by state. Examining how these variations in Medicaid coverage are correlated with perinatal outcomes is critical to understanding the impact of public health policies on maternal health.
Objective:
To compare the rates of severe maternal morbidity state-by-state stratified by whether (1) Medicaid was expanded under the Affordable Care Act and (2) state Medicaid coverage of abortion care beyond Hyde requirements was provided. We hypothesized that states with more expansive coverage in either category would have lower rates of severe maternal morbidity.
Study Design:
This was a retrospective cohort study using state-level severe maternal morbidity rates (reported per 10,000 in-hospital deliveries) from 2014 through 2021. Severe maternal morbidity data were obtained from the publicly available Healthcare Cost and Utilization Project Fast Stats dataset. Kaiser Family Foundation data were used to classify states according to whether or not they expanded Medicaid coverage or provided state Medicaid coverage of abortion care. We used a negative binomial generalized linear mode to analyze severe maternal morbidity as a function of Medicaid expansion or abortion care coverage beyond Hyde requirements, including state and year as covariates.
Results:
The rate of severe maternal morbidity was significantly lower in states that expanded Medicaid than in those that did not (HR 0.91, 95% CI 0.85-0.97). Among the states that expanded Medicaid, the rate of severe maternal morbidity was lower in states that also provided state Medicaid abortion coverage than in those that did not (HR 0.92, 95% CI 0.86-0.99).
Conclusion:
The rate of severe maternal morbidity was significantly lower in states that expanded Medicaid under the Affordable Care Act than in states that did not. Among states that expanded Medicaid, those that also provided state Medicaid abortion coverage had significantly lower rates of severe maternal morbidity than those that did not. These findings add to growing evidence that Medicaid and abortion care coverage affect maternal health outcomes.
