State differences in the effects of policy change on maternal health - 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 policies reduce terminations and increase births; however, less is known about how policies which restrict pregnancy terminations impact other reproductive health outcomes such as choice of contraception, quality of prenatal care, and severe maternal morbidities (SMM), and potential mechanisms through which policy environments impact these outcomes. We propose using the Health Care Cost Institute (HCCI) patient claims data on diagnoses, prescriptions, and contact with the healthcare system to quantify the effects on 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 on 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 for the 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 provide a better understanding of the overall impacts of a reproductive health policy environment that is currently in flux across the United States. Our study will fill critical gaps in understanding how policies directly impact women’s reproductive health care decisions and the growing maternal morbidity public health crisis.
