State differences in the effects of policy change on maternal health - Modified Project Summary/Abstract Section Severe maternal morbidity (SMM), or unexpected outcomes of labor or delivery resulting in significant consequences to heath, is a growing public health concern in the US. Approximately 60,000 women experience SMM annually and rates of SMM increased from 135.2/10,000 deliveries in 2008 to 206.1/10,000 in 2021. The incidence of SMM is 28% higher among women from racial/ethnic minority groups relative to white women and is 40% higher among lower socioeconomic status women. Rural women experience a 9% higher probability of SMM than urban residents. These trends are occurring against a background of growing differences in reproductive healthcare access across states. States differ in terms of income requirements for Medicaid coverage of family planning services and their decision to opt-in to Medicaid expansion programs. Since June 2022, 14 states have banned nearly all elective pregnancy terminations, and even prior to this time, many states had implemented laws that made reproductive healthcare more difficult to access. Previous research has documented that these policy changes reduce terminations and increase births; however, less is known about how these policy changes impact other reproductive health outcomes, such as choice of contraception, quality of prenatal care, and severe maternal morbidities (SMM). Understanding drivers of these disparities will help inform clinicians about where to target interventions. We propose using the Health Care Cost Institute (HCCI) patient claims data on diagnoses, prescriptions, and contact with the healthcare system to quantify the mechanisms driving disparities in birth outcomes, SMM, and prenatal patient care before and after federal and state reproductive health policy changes in 2022. This study has two specific aims. Aim 1 tests how state-wide reproductive health policies prior to June 2022 impact geographic disparities in these five outcomes: 1) contraceptive use, 2) fertility, 3) SMM, 4) distance between patient residence and provider and use of telehealth, and 5) patient contact with doctors during pregnancy. Aim 2 then extends these analyses to the Post-June 2022 period, exploring how state-wide policies change access to reproductive healthcare providers and the impacts on these five outcomes. We plan to test this by using state by year changes in legislation and geographic proximity to clinics to identify the causal impacts of these policies. We then test potential mechanisms that may explain observed changes in SMM to evaluate whether they are attributable to demographic changes in the women who give birth or whether they are attributable to changes in provider access and prenatal care. Because HCCI data includes a large sample of patients along with granular geographic information, we will be able to link patient outcomes to data on clinic locations or state-level legislation and explore within-state disparities in outcomes between rural and urban areas, high- and low-income areas, and areas with higher and lower racial/ethnic minority populations. Finally, we will be able to observe the geographic location of the patient and of the provider separately, along with whether care was provided via telemedicine, allowing us to document and evaluate changes in geographic access to reproductive health providers. Together, these analyses will demonstrate how changes in state-level reproductive health environments impact women’s post-birth health and inform how health care providers should adjust care in response to these changes. For example, if we see larger increases in SMM among rural patients attributable to increased travel time for prenatal care, these results would inform placement of Federally Qualified Health Centers in rural areas. The results of these analyses will inform healthcare across state settings, demonstrating how clinicians can respond as women’s reproductive health care decisions change across a variety of policy environm
