State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

Abstract

OBJECTIVE: To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states. METHODS: We conducted a pooled, cross-sectional analysis of the 2016–2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC. We also examined SMM rates among non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance in a subgroup of 27 states (and Washington, DC). We generated unadjusted rates of composite SMM and the individual indicators of SMM that comprised the composite. Rate differences and rate ratios were calculated to compare SMM rates for non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance. RESULTS: The overall rate of SMM without blood transfusion was 146.2 (95% CI 145.1–147.3) per 10,000 deliveries (N=4,807,143). Rates of SMM ranged nearly threefold, from 80.3 (95% CI 71.4–89.2) per 10,000 deliveries in Utah to 210.4 (95% CI 184.6–236.1) per 10,000 deliveries in Washington, DC. Non-Hispanic Black individuals with Medicaid insurance (n=629,774) experienced a higher overall rate of SMM (212.3, 95% CI 208.7–215.9) compared with non-Hispanic White individuals with Medicaid insurance (n=1,051,459); (125.3, 95% CI 123.2–127.4) per 10,000 deliveries (rate difference 87.0 [95% CI 82.8–91.2]/10,000 deliveries; rate ratio 1.7 [95% CI 1.7–1.7]). The leading individual indicator of SMM among all individuals with Medicaid insurance was eclampsia, although the leading indicators varied across states and by race and ethnicity. Many states were concordant in leading indicators among the overall, non-Hispanic Black, and non-Hispanic White populations (ie, in Oklahoma sepsis was the leading indicator for all three). Most states, however, were discordant in leading indicators across the three groups (ie, in Texas eclampsia was the leading indicator overall, pulmonary edema or acute heart failure was the leading indicator among the non-Hispanic Black population, and sepsis was the leading indicator among the non-Hispanic White population). CONCLUSION: Interventions aimed at reducing SMM and, ultimately, mortality among individuals with Medicaid insurance may benefit from the data generated from this study, which highlights states that have the greatest burden of SMM, the differences in rates among non-Hispanic Black populations compared with non-Hispanic White populations, and the leading indicators of SMM overall, by state, and by race and ethnicity.

State Variation in Severe Maternal Morbidity Among Individuals with Medicaid Insurance

“…We read with interest the article by Admon et al and the associated Editorial by Dr. Kern-Goldberger and Dr. Srivanas in the May 2023 issue. 1,2 The Guidelines for Letters. Letters posing a question or challenge to an article appearing in Obstetrics & Gynecology should be submitted within 8 weeks of the article's publication online.…”

Variation as Evidence of Preventability

“…Variation itself can serve as a marker of health care quality—or lack thereof—but also as an essential opportunity for intervention and, ultimately, prevention. This study by Admon et al 2 highlights how low a statewide SMM rate can be and provides a target for state programs looking to optimize maternal health and prioritize equity. At the same time, it demonstrates that variegated SMM drivers and disparities may require differential, localized solutions at the state level, and state perinatal quality collaboratives should harness these data to inform state-specific comprehensive clinical and policy strategies.…”

“…The study by Admon et al 2 in this month's edition of Obstetrics & Gynecology (see page 877) addresses this very issue by evaluating indicator-specific SMM rates by state and by race and ethnicity among individuals with Medicaid insurance. Unlike other data sets used to examine maternal outcomes, the TAF (Transformed Medicaid Statistical Information System Analytic Files), used for this study, enables a detailed evaluation of administrative data from the entire population (not a sampling) of obstetric patients with Medicaid insurance.…”

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

“…We read with interest the article by Admon et al and the associated Editorial by Dr. Kern-Goldberger and Dr. Srivanas in the May 2023 issue. 1,2 The work they describe in delineating severe maternal morbidity (SMM) is crucial to our ability to implement changes for improving outcomes, particularly for women who are poor and for those in underrepresented racial and ethnic minority groups. However, within this analysis, we were surprised at the lack of acknowledgment of social determinants of health and systemic racism.…”