Dissertation Title:  "Prenatal Care in the United States: Improving Quality Measurement, Access to Care, and Outcomes"

Prenatal care anchors policy and public health approaches to improving maternal and child health in the United States. However, little is understood about the quality of this care and how to promote equitable access. In this dissertation, I developed new measures of prenatal care quality and evaluated two programs that could improve access to care and outcomes for low-income pregnant people.

In Chapter 1, we developed new measures of guideline-based prenatal care and documented their variation in a commercially insured population. Prenatal care quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. We used a large dataset of commercial health insurance claims to measure whether patients received 8 prenatal services recommended by clinical guidelines. We found that, on average, patients only received 6 of the 8 services, and receiving more prenatal visits was not associated with more guideline-based care. Guideline-based care also varied across the population. For example, rates of Tdap vaccination were 27% lower in counties with low median income and 13% lower in counties with a high proportion of non-Hispanic Black residents. This work demonstrated that measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.

Chapter 2 is an evaluation of a prenatal nurse home visiting program, the Nurse Family Partnership (NFP), which aims to improve prenatal care utilization and pregnancy health. We conducted a randomized controlled trial among 5,670 Medicaid-eligible pregnant individuals in South Carolina. We used an intent-to-treat approach to compare outcomes between the two groups during pregnancy using birth certificates, hospital discharge, and Medicaid claims data. We found no statistically significant change in the intensity of prenatal care utilization, no improvement in receipt of guideline-based prenatal care services, and no change in use of specialist care, smoking cessation, or gestational weight gain. These results were consistent in a subgroup of participants considered particularly vulnerable to challenges during pregnancy and parenthood (46.9% of the sample) and among Black non-Hispanic participants (55.5%). Our findings may reflect the limitations of individual-focused programming and suggest that more systemic or structural solutions are needed to address barriers to high quality prenatal care and to improve pregnancy health.

In Chapter 3, we studied a structural approach to increasing access to high-quality primary and prenatal care for people of reproductive age. Federally Qualified Health Centers (FQHCs) provide affordable health care to low-income individuals, including nearly 1 in 10 pregnant people. We studied whether the expansion of FQHCs between 2011-2016 improved early prenatal care initiation, low birth weight, and preterm birth among Medicaid-covered individuals in California. We used a synthetic control approach to compare areas that received their first FQHC early in the study period to areas that received it later, or that never had an FQHC. We used the Health Resources and Services Administration’s Uniform Data System to identify treated areas and measured the outcomes in California vital records data. We found no statistically significant impact on the three primary outcomes, and no evidence that this result was driven by demographic changes in the birthing population. This result suggests that access to primary and prenatal care may not be sufficient for improving these outcomes at the population level. More targeted strategies may be needed to improve access to high-quality outpatient care for pregnant individuals.