ImportanceDisparities exist in access to timely prenatal care between immigrant women and US-born women. Exclusions from Medicaid eligibility based on immigration status may exacerbate disparities.ObjectiveTo examine changes in timely prenatal care by nativity after Medicaid expansion.Design, Setting, and ParticipantsA cross-sectional difference-in-differences (DID) and triple-difference analysis of 22 042 624 singleton births from January 1, 2011, to December 31, 2019, in 31 states was conducted using US natality data. Data analysis was performed from February 1, 2021, to August 24, 2022.ExposuresWithin 16 states that expanded Medicaid in 2014, the rate of timely prenatal care by nativity in years after expansion was compared with the rate in the years before expansion. Similar comparisons were conducted in 15 states that did not expand Medicaid and tested across expansion vs nonexpansion states.Main Outcomes and MeasuresTimely prenatal care was categorized as prenatal care initiated in the first trimester. Individual-level covariates included age, parity, race and ethnicity, and educational level. State-level time-varying covariates included unemployment, poverty, and Immigrant Climate Index.ResultsA total of 5 390 814 women preexpansion and 6 544 992 women postexpansion were included. At baseline in expansion states, among immigrant women, 413 479 (27.3%) were Asian, 110 829 (7.3%) were Black, 752 176 (49.6%) were Hispanic, and 238 746 (15.8%) were White. Among US-born women, 96 807 (2.5%) were Asian, 470 128 (12.1%) were Black, 699 776 (18.1%) were Hispanic, and 2 608 873 (67.3%) were White. Prenatal care was timely in 75.9% of immigrant women vs 79.9% of those who were US born in expansion states at baseline. After Medicaid expansion, the immigrant vs US-born disparity in timely prenatal care was similar to the preexpansion level (DID, –0.91; 95% CI, –1.91 to 0.09). Stratifying by race and ethnicity showed an increase in the Asian vs White disparity after expansion, with 1.53 per 100 fewer immigrant women than those who were US born accessing timely prenatal care (95% CI, –2.31 to –0.75), and in the Hispanic vs White disparity (DID, –1.18 per 100; 95% CI, –2.07 to –0.30). These differences were more pronounced among women with a high school education or less (DID for Asian women, –2.98; 95% CI, –4.45 to –1.51; DID for Hispanic women, –1.47; 95% CI, –2.48 to –0.46). Compared with nonexpansion states, differences in DID estimates were found among Hispanic women with a high school education or less (triple-difference, –1.86 per 100 additional women in expansion states who would not receive timely prenatal care; 95% CI, –3.31 to –0.42).Conclusions and RelevanceThe findings of this study suggest that exclusions from Medicaid eligibility based on immigration status may be associated with increased health care disparities among some immigrant groups. This finding has relevance to current policy debates regarding Medicaid coverage during and outside of pregnancy.
A core issue in reproductive justice concerns how racism impacts reproductive health outcomes for Black women. However, the intersectional experiences of middle-class Black women navigating racism in reproductive health systems have not been fully captured in psychological literature. By utilizing a Black feminist approach to qualitative inquiry, this study situates the psychological dynamics behind middle-class Black women's interpretations of and reactions to gendered racism in reproductive settings within the historical context of slavery and its aftermath. The data analysis of 12 interviews captures how middle-class Black women reflect on their interactions with gynecologists, narrate their anticipation of gendered racism, and interpret and respond to experiencing gendered racism. Findings from this study suggest that gendered racism is a haunting of embodied gynecological trauma that maps onto the historical legacy of slavery. This study offers psychology an empirical and analytical framework for moving forward with its conceptualizations of how race, gender, and class intersect in service of reproductive justice. Results from this study can be used by clinicians to guide their clients towards healing gendered-racist-related stress, as well as medical schools to educate obstetricians and gynecologists on how to provide anti-racist care to their Black patients.
Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis.
In the United States, pregnant people considering a vaginal birth after cesarean delivery (VBAC) face this decision in a highly contested environment where VBAC is simultaneously encouraged—situated within discourses promoting vaginal birth—and discouraged through discourses emphasizing reproductive risk. Woven through these competing discourses is a shared emphasis on maternal responsibility, reflective of a socially constructed belief that birth method is bound implicitly to one's “goodness” as a mother. This paper employs a discursive analytic lens to examine the experiences of 16 pregnant people in New York City seeking VBACs for their upcoming births. We examine how sociocultural discourses of “responsible” mothering shape participants’ experiences of considering VBAC and examine participants’ anxieties over VBAC and its attainability in light of their past birth experiences. Our analysis demonstrates that participants reproduce discourses privileging vaginal birth, and simultaneously challenge these discourses by invoking an “embodied knowledge” that enables them to assert themselves as responsible mothers in the context of past cesarean deliveries and uncertainty surrounding their upcoming births. Implications are discussed in the context of existing literature on birth and discourses of maternal responsibility.
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