Maternal and Child Health Journal

, Volume 17, Issue 8, pp 1518–1525 | Cite as

Racial Disparities in Economic and Clinical Outcomes of Pregnancy Among Medicaid Recipients

  • Shun Zhang
  • Kathryn Cardarelli
  • Ruth Shim
  • Jiali Ye
  • Karla L. Booker
  • George Rust


To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of $114 to $214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.


Disparities Medicaid Economic burden Adverse maternal-child health outcomes and eliminating disparities 


  1. 1.
    Goldenberg, R. L., et al. (2008). Epidemiology and causes of preterm birth. The Lancet, 371(9606), 75–84.CrossRefGoogle Scholar
  2. 2.
    Mostello, D., et al. (2008). Recurrence of preeclampsia: Effects of gestational age at delivery of the first pregnancy, body mass index, paternity, and interval between births. American Journal of Obstetrics and Gynecology, 199(1), 55.e1–55.e7.Google Scholar
  3. 3.
    Hjartardottir, S., et al. (2006). Recurrence of hypertensive disorder in second pregnancy. American Journal of Obstetrics and Gynecology, 194(4), 916–920.PubMedCrossRefGoogle Scholar
  4. 4.
    Järvelä, I. Y., et al. (2006). Gestational diabetes identifies women at risk for permanent type 1 and type 2 diabetes in fertile age. Diabetes Care, 29(3), 607–612.PubMedCrossRefGoogle Scholar
  5. 5.
    Jovanovic, L., & Pettitt, D. J. (2001). Gestational diabetes mellitus. JAMA (Journal of the American Medical Association), 286(20), 2516–2518.CrossRefGoogle Scholar
  6. 6.
    Dyck, R., et al. (2002). A comparison of rates, risk factors, and outcomes of gestational diabetes between aboriginal and non-aboriginal women in the Saskatoon health district. Diabetes Care, 25(3), 487–493.PubMedCrossRefGoogle Scholar
  7. 7.
    Hosler, A. S., Nayak, S. G., & Radigan, A. M. (2010). Agreement between self-report and birth certificate for gestational diabetes mellitus: New York State PRAMS. Maternal and Child Health Journal, 14(5), 786–789.PubMedCrossRefGoogle Scholar
  8. 8.
    Bloom, B., & Dey, A. N. (2006). Summary health statistics for US children: National Health Interview Survey, 2004. Vital and Health Statistics (Series 10). Data from the National Health Survey (227), 1.Google Scholar
  9. 9.
    Bloom, B., & Cohen, R. A. (2007). Summary health statistics for US children: National Health Interview Survey, 2006. Vital and Health Statistics (Series 10). Data from the National Health Survey (234), 1.Google Scholar
  10. 10.
    Foust, R. F., & Carey, B. (2002). Achieving optimal maternal and infant health outcomes for medicaid patients, with application for commercial populations. Managed Care Interface, 15(6), 45–54.PubMedGoogle Scholar
  11. 11.
    Anum, E. A., et al. (2010). Medicaid and preterm births in Virginia: An analysis of recent outcomes. Journal of Women’s Health, 19(11), 1969–1975.PubMedCrossRefGoogle Scholar
  12. 12.
    Mason, M. V., et al. (2011). Effects of a pregnancy management program on birth outcomes in managed Medicaid. Managed Care (Langhorne, Pa), 20(4), 39.Google Scholar
  13. 13.
    Anum, E. A., Retchin, S. M., & Strauss, J. F., I. I. I. (2010). Medicaid and preterm birth and low birth weight: The last two decades. Journal of Women’s Health, 19(3), 443–451.PubMedCrossRefGoogle Scholar
  14. 14.
    Hawkins, M. R. (2005). The impact of a high-risk disease management program on perinatal outcomes in a managed care organization. The Case Manager, 16(4), 59–63.PubMedCrossRefGoogle Scholar
  15. 15.
    Howson, C. P. (2009). March of dimes: White paper on preterm birth: The global and regional toll. March of Dimes Foundation.Google Scholar
  16. 16.
    Xu, X., et al. (2009). Cost of racial disparity in preterm birth: Evidence from Michigan. Journal of Health Care for the Poor and Underserved, 20(3), 729.PubMedCrossRefGoogle Scholar
  17. 17.
    Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2006). Births: Preliminary data for 2005. National Vital Statistics Reports, 55(11), 1–18.Google Scholar
  18. 18.
    Healy, A. J., et al. (2006). Early access to prenatal care: Implications for racial disparity in perinatal mortality. Obstetrics & Gynecology, 107(3), 625.CrossRefGoogle Scholar
  19. 19.
    Xiang, A., et al. (2011). Racial and ethnic disparities in diabetes risk after gestational diabetes mellitus. Diabetologia, 54(12), 3016–3021.Google Scholar
  20. 20.
    Hunsberger, M., Rosenberg, K. D., & Donatelle, R. J. (2010). Racial/ethnic disparities in gestational diabetes mellitus: Findings from a population-based survey. Women’s Health Issues, 20(5), 323–328.PubMedCrossRefGoogle Scholar
  21. 21.
    Koh, H. K. (2010). A 2020 vision for healthy people. New England Journal of Medicine, 362(18), 1653–1656.PubMedCrossRefGoogle Scholar
  22. 22.
    Koh, H. K., Graham, G., & Glied, S. A. (2011). Reducing racial and ethnic disparities: The action plan from the Department of Health and Human Services. Health Affairs, 30(10), 1822–1829.PubMedCrossRefGoogle Scholar
  23. 23.
    Ananth, C. V., et al. (2005). Trends in preterm birth and perinatal mortality among singletons: United States, 1989 through 2000. Obstetrics & Gynecology, 105(5, Part 1), 1084.CrossRefGoogle Scholar
  24. 24.
    Chang, J., et al. (2003). Pregnancy-related mortality surveillance—United States, 1991–1999. MMWR Surveillance Summaries, 52(2), 1–8.Google Scholar
  25. 25.
    Wells, N., et al. (2008). The impact of nurse case management home visitation on birth outcomes in African-American women. Journal of the National Medical Association, 100(5), 547.PubMedGoogle Scholar
  26. 26.
    Satcher, D., et al. (2005). What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000. Health Affairs, 24(2), 459–464.PubMedCrossRefGoogle Scholar
  27. 27.
    Hoyert, D. L. (1995). Perinatal mortality in the United States, 19851991. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics.Google Scholar
  28. 28.
    Dominguez, T. P., et al. (2008). Racial differences in birth outcomes: The role of general, pregnancy, and racism stress. Health Psychology, 27(2), 194.PubMedCrossRefGoogle Scholar
  29. 29.
    Horsthemke, B., & Ludwig, M. (2005). Assisted reproduction: The epigenetic perspective. Human Reproduction Update, 11(5), 473–482.PubMedCrossRefGoogle Scholar
  30. 30.
    Dominguez, T. P. (2008). Race, racism, and racial disparities in adverse birth outcomes. Clinical Obstetrics and Gynecology, 51(2), 360.PubMedCrossRefGoogle Scholar
  31. 31.
    McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York Academy of Sciences, 840(1), 33–44.PubMedCrossRefGoogle Scholar
  32. 32.
    Harrell, S. P. (2000). A multidimensional conceptualization of racism-related stress: Implications for the well-being of people of color. American Journal of Orthopsychiatry, 70(1), 42–57.PubMedCrossRefGoogle Scholar
  33. 33.
    Krieger, N. (2003). Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: An ecosocial perspective. Journal Information, 93(2), 194–199.Google Scholar
  34. 34.
    Cardarelli, K., et al. (2005). Fundamental determinants of population health. In: Aday LA, (Ed.), Reinventing Public Health: Policies and Practices for a Healthy Nation. San Francisco, CA: Jossey-Bass Publishers.Google Scholar
  35. 35.
    Conley, D. (1999). Being black, living in the red: Race, wealth, and social policy in America. Berkeley, CA: University of California Press.Google Scholar
  36. 36.
    James, S. A. (2008). Confronting the moral economy of US racial/ethnic health disparities. American Journal of Public Health, 98(Suppl 1), S16.PubMedCrossRefGoogle Scholar
  37. 37.
    Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7(1), 13–30.PubMedCrossRefGoogle Scholar
  38. 38.
    Halfon, N., & Hochstein, M. (2002). Life course health development: An integrated framework for developing health, policy, and research. Milbank Quarterly, 80(3), 433–479.PubMedCrossRefGoogle Scholar
  39. 39.
    Kuh, D., et al. (2003). Life course epidemiology. Journal of Epidemiology and Community Health, 57(10), 778.PubMedCrossRefGoogle Scholar
  40. 40.
    Willinger, M., Ko, C. W., & Reddy, U. M. (2009). Racial disparities in stillbirth risk across gestation in the United States. American Journal of Obstetrics and Gynecology, 201(5), 469.e1–469.e8.Google Scholar
  41. 41.
    Martin, J. A., Osterman, M., & Sutton, P. D. (2010). Are preterm births on the decline in the United States? Recent data from the national vital statistics system. NCHS Data Brief, 39, 1.PubMedGoogle Scholar
  42. 42.
    Thorpe, L. E., et al. (2005). Trends and racial/ethnic disparities in gestational diabetes among pregnant women in New York City, 1990–2001. Journal Information, 95(9), 1536–1539.Google Scholar
  43. 43.
    Foundation, K. F. (2009). Births of low birthweight as a percent of all births by race/ethnicity. State health comparisons at, 2011.
  44. 44.
    Boggess, K. A., et al. (2003). Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstetrics & Gynecology, 101(2), 227.CrossRefGoogle Scholar
  45. 45.
    Michalowicz, B. S., et al. (2006). Treatment of periodontal disease and the risk of preterm birth. New England Journal of Medicine, 355(18), 1885–1894.PubMedCrossRefGoogle Scholar
  46. 46.
    Fry-Johnson, Y. W., et al. (2010). United States Black: White infant mortality disparities are not inevitable: Identification of community resilience independent of socioeconomic status. Ethnicity & Disease, 20(1 Suppl 1), S1.Google Scholar
  47. 47.
    Schlenker, T., & Ndiaye, M. (2009). Apparent disappearance of the Black-White infant mortality gap—Dane County, Wisconsin, 1990–2007. CDC Morbidity and Monthly Weekly Report, 58(20), 561–580.Google Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Shun Zhang
    • 1
  • Kathryn Cardarelli
    • 2
  • Ruth Shim
    • 3
  • Jiali Ye
    • 1
  • Karla L. Booker
    • 4
  • George Rust
    • 1
  1. 1.National Center for Primary Care at Morehouse School of MedicineAtlantaUSA
  2. 2.Department of EpidemiologyUniversity of North Texas Health Science CenterFort WorthUSA
  3. 3.Department of PsychiatryMorehouse School of MedicineAtlantaUSA
  4. 4.Division of Maternal-Child Health, Department of Family MedicineMorehouse School of MedicineAtlantaUSA

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