Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records

  • Catherine J. Vladutiu
  • Elizabeth M. Stringer
  • Veni Kandasamy
  • Jill Ruppenkamp
  • M. Kathryn Menard


Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.


Emergency department Medicaid North Carolina Pregnancy 



The authors would like to acknowledge Dana Smith from Kaiser Permanente for her assistance with conceptualizing the study and her contributions to earlier iterations of this manuscript; Kate Berrien from the Community Care of North Carolina for her assistance with conceptualizing the study; and Carlos Jackson from the Community Care of North Carolina for his help with data acquisition. None of these individuals received funding for this research.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflicts of interest.


  1. American College of Obstetricians and Gynecologists. (2014). Health disparities in rural women. Committee Opinion No. 586. Obstetrics & Gynecology, 123, 384–388.CrossRefGoogle Scholar
  2. Cunningham, S. D., Magriples, U., Thomas, J. L., Kozhimannil, K. B., Herrera, C., Barrette, E., Shebl, F. M., & Ickovics, J. R. (2017). Association between maternal comorbidities and emergency department use among a national sample of commerically insured pregnant women. Academic Emergency Medicine, 24(8), 940–947.CrossRefGoogle Scholar
  3. Feijen-de Jong, E. I., Jansen, D. E., Baarveld, F., van der Schans, C. P., Schellevis, F. G., & Reijneveld, S. A. (2012). Determinants of late and/or inadequate use of prenatal healthcare in high-income countries: A systematic review. The European Journal of Public Health, 22(6), 904–913.CrossRefGoogle Scholar
  4. Healthcare Cost and Utilization Project (HCUP). (2018). Clinical Classifications Software (CCS) for ICD-9-CM. Agency for Healthcare Research and Quality. Rockville, MD. Retrived from
  5. Kilfoyle, K. A., Vrees, R., Raker, C. A., & Matteson, K. A. (2017). Nonurgent and urgent emergency department use during pregnancy: An observational study. American Journal of Obstetrics and Gynecology, 216(2), 181-e1.CrossRefGoogle Scholar
  6. LaCalle, E., & Rabin, E. (2010). Frequent users of emergency departments: The myths, the data, and the policy implications. Annals of Emergency Medicine, 56(1), 42–48.CrossRefGoogle Scholar
  7. Magriples, U., Kershaw, T. S., Rising, S. S., Massey, Z., & Ickovics, J. R. (2008). Prenatal health care beyond the obstetrics service: Utilization and predictors of unscheduled care. American Journal of Obstetrics and Gynecology, 198(1), 75.e71–75.e77.CrossRefGoogle Scholar
  8. Malik, S., Kothari, C., MacCallum, C., Liepman, M., Tareen, S., & Rhode, K. V. (2017). Emergency department use in the perinatal period: An opportunity for early intervention. Annals of Emergency Medicine, 70(6), 835–839.CrossRefGoogle Scholar
  9. Martin, J. A. (2007). United States vital statistics and the measurement of gestational age. Paediatric and Perinatal Epidemiology, 21(Suppl 2), 13–21.CrossRefGoogle Scholar
  10. Moore, B. J., Stocks, C., & Owens, P. L. (2017). Trends in Emergency Department Visits, 2006–2014. HCUP Statistical Brief #227. Retrieved from
  11. Nannini, A., Lazar, J., Berg, C., Barger, M., Tomashek, K., Cabral, H., Barfield, W., & Kotelchuck, M. (2011). Rates of hospital visits for assault during pregnancy and the year postpartum: Timing matters. Public Health Report, 126(5), 664–668.CrossRefGoogle Scholar
  12. North Carolina State Center for Health Statistics. (2017). Risk factors and characteristics for 2016 North Carolina resident live births: overall, all mothers. Retrieved from
  13. Rui, P., & Kang, K. (2014). National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables. Retrieved from
  14. Sharp, B. R., Sharp, K. M., Patterson, B., & Dooley-Hash, S. (2016). Treatment of nausea and vomiting in pregnancy: Factors associated with ED revisits. Western Journal of Emergency Medicine, 17(5), 585–590.CrossRefGoogle Scholar
  15. U.S. Census Bureau. (2018). State-based metropolitan and micropolitan statistical area maps. Retrieved from
  16. Weiss, H. B., Sauber-Schatz, E. K., & Cook, L. J. (2008). The epidemiology of pregnancy-associated emergency department injury visits and their impact on birth outcomes. Accident Analysis & Prevention, 40(3), 1088–1095.CrossRefGoogle Scholar
  17. Wittels, K. A., Pelletier, A. J., Brown, D. F., & Camargo, C. A. Jr. (2008). United States emergency department visits for vaginal bleeding during early pregnancy, 1993–2003. American Journal of Obstetrics and Gynecology, 198(5), 523-e1.CrossRefGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply  2019

Authors and Affiliations

  • Catherine J. Vladutiu
    • 1
    • 2
  • Elizabeth M. Stringer
    • 2
  • Veni Kandasamy
    • 3
  • Jill Ruppenkamp
    • 4
  • M. Kathryn Menard
    • 2
  1. 1.Office of Epidemiology and Research, Maternal and Child Health BureauHealth Resources and Services AdministrationRockvilleUSA
  2. 2.Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, School of MedicineUniversity of North CarolinaChapel HillUSA
  3. 3.Oak Ridge Affiliated Universities, Oak Ridge Institute for Science and EducationOak RidgeUSA
  4. 4.Johnson & JohnsonNew BrunswickUSA

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