Abstract
ObjectivesAmong childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type.MethodsWe estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007–2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics.ResultsDual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6–10.9) for privately insured to 15.9 (95% CI 9.1–27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7–3.5) for women with Medi-Cal to 5.4 (95% CI 3.5–8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0–8.3) to 19.4 (95% CI 10.3–36.3), respectively, among multiparas.ConclusionsRisk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health.
Highlights
Insurance coverage is an important contributor to U.S health disparities, with substantial differences in health status and outcomes observed among individuals without insurance coverage compared to individuals with coverage and across different categories of insurance (Dickman et al, 2017; Freeman et al, 2008; Griffith et al, 2017; Hadley, 2007; McWilliams 2009)
We categorized inpatient diagnosis and procedural codes associated with unexpected maternal outcomes of labor and birth as Severe maternal morbidity (SMM) using the published Centers for Disease Control and Prevention (CDC) algorithm(Centers for Disease Control & Prevention
Risk of dual burden of SMM and preterm birth was highest among women with no health insurance or other health insurance
Summary
Insurance coverage is an important contributor to U.S health disparities, with substantial differences in health status and outcomes observed among individuals without insurance coverage compared to individuals with coverage and across different categories of insurance (Dickman et al, 2017; Freeman et al, 2008; Griffith et al, 2017; Hadley, 2007; McWilliams 2009). Coverage influences health status, outcomes, and survival through determining access to health education, clinical and social preventive services, and clinical services for chronic and acute conditions (Chikani et al, 2015; Sommers et al, 2017; Woolhandler & Himmelstein, 2017). Uninsured non-elderly American adults are sicker, less likely to receive preventive services, and more likely to receive lower quality medical care than insured individuals when hospitalized for chronic and acute conditions (Institute of Medicine (US) Committee on the Consequences of Uninsurance, 2002; Woolhandler & Himmelstein, 2017). Even within the same facility, insurance type has been identified as an important factor determining quality of care (Spencer et al, 2013). Given the high costs and consequences of inadequate care access and low quality care during this vulnerable time, ensuring high quality coverage is of particular importance (Johnson et al, 2006; Sakala & Corry, 2008)
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