Perinatal Uninsurance Disproportionately Impacted Rural Americans Before Pandemic

Perinatal uninsurance disproportionately affected Americans living in rural areas before the pandemic, with Hispanic and indigenous individuals experiencing the greatest inequities, according to findings published in Obstetrics & Gynecology.

Uninsurance during prepregnancy has been linked to delayed and lower-quality prenatal care, said Lindsay K Admon, MD, MSc, affiliated with the University of Michigan Ann Arbor, and coauthors. Additionally, many people without insurance during the postpartum period experience hypertension and depression, “and nearly a quarter report at least 1 unmet need for medical care.”

“Health insurance is an important prerequisite for accessing quality health care before, during, and after pregnancy,” Dr Admon and coinvestigators said. “The Centers for Disease Control and Prevention has identified lack of timely access to health care as a key contributor to pregnancy-related mortality.”

To better understand coverage disparities, researchers conducted a cross-sectional analysis data from the Pregnancy Risk Assessment Monitoring System. The data were collected from rural and urban Americans in 43 states as well as the District of Columbia and New York City.

Included in the analysis were 154,992 individuals who gave birth from 2016 to 2019. Of these, 15.6% lived in rural areas (n=32,178). 

Compared to urban Americans, a higher proportion of rural residents were non-Hispanic White (75.9% vs 55.4%), reported incomes up to 138% of the federal poverty level (42.7% vs 31.2%), and lived in states where Medicaid was not expanded (47.5% vs 33.6%). Rural residents were also more likely to be of younger ages, have unintended pregnancies, and report chronic conditions like diabetes, obesity, hypertension, and depression.

Rurality was associated with lower rates of commercial insurance during prepregnancy (57.4% vs 66.5%; adjusted odds ratio [aOR] 0.87, 95% CI 0.82-0.92), at birth (45.9% vs 57.7%; aOR 0.76, 95% CI 0.72-0.81), and during the postpartum period (52.1% vs 62.5%; aOR 0.84, 95% CI 0.79-0.89). 

Rural residents also experienced higher rates of uninsurance during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38).

Perinatal uninsurance disproportionately impacted ethnic minority individuals, according to the findings. Indigenous and Hispanic residents comprised approximately 10% of all rural residents but an estimated 40% of those who were uninsured, researchers said.

Additionally, at birth, Medicaid coverage was more common among rural vs urban individuals (49.5% vs 39.5%; aOR 1.19, 95% CI 1.12-1.26). Rural residents were therefore at greater risk of uninsurance during the postpartum period, since Medicaid coverage for pregnancy typically expires 60 days after birth, researchers said.

“Our findings are concerning and reveal that rural residents with postpartum uninsurance were more likely to be older than age 35 years and to have obesity or chronic hypertension compared with urban residents who are uninsured postpartum. These conditions place postpartum individuals at greater risk of medical complications in the postpartum year—including maternal morbidity and mortality,” Dr Admon and coauthors said.

Researchers encouraged greater policy efforts to reduce inequities for rural residents, saying insurance coverage is the first step toward improving access to high-quality perinatal care.

Reference:
Admon LK, Raw JR, Interrante JD, Ibrahim BB, Millette MJ, Kozhimannil KB. Rural and urban differences in insurance coverage at prepregnancy, birth, and postpartum. Obstet Gynecol. Published online February 2, 2023. doi:10.1097/AOG.0000000000005081