Role of Medicaid Policy on Reducing Racial Disparities in Maternal Mortality and Other Maternal Health Outcomes

Pregnant woman being visited at home by healthcare worker
Support for this work was provided by the AIR Equity Initiative.

Medicaid plays a key role in providing maternity-related services for birthing people, paying for slightly less than half of all births nationwide and nearly two-thirds of births to Black, Native, and Hispanic parents. Given the rising maternal mortality rate in the United States—especially among Black, Native, and Hispanic individuals—understanding Medicaid’s impact on reducing racial disparities in maternal health is critically important.

AIR is investing in the field of maternal health equity through two studies that aim to understand whether Medicaid policies are able to reduce racial disparities and advance health equity in maternal health outcomes among Medicaid recipients.

To promote rapid uptake of the findings, results and insights generated will be disseminated through a range of products, including abstracts submitted to conferences, issue briefs, and manuscripts.  

The Impacts of the Affordable Care Act Medicaid Expansions in Louisiana and Virginia

In the first study, the AIR team is investigating the impacts of the Affordable Care Act Medicaid expansions in Louisiana and Virginia had on Medicaid coverage: first trimester Medicaid enrollment, and cesarean delivery among 18- to 49-year-old white, Black, and Hispanic women who had a Medicaid-covered birth between 2016 and 2020. We use data from Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files Research Identifiable Files and a Difference in Differences approach.


Preliminary results show that the Medicaid expansion in Louisiana and Virginia affected many outcomes in a similar way.

Both expansions increased first trimester enrollment for women from racial minorities. Prior to these expansions, first trimester enrollment rates were high in both states, with enrollment rates over 75% across different races, because by federal law pregnant women were already eligible to be covered by Medicaid. In other words, the Medicaid expansion in these two states increased Medicaid enrollment of an already eligible group.

Both Medicaid expansions reduced the probability of having a cesarean delivery across women of different races. Louisiana’s Medicaid expansion reduced the probability of having a cesarean delivery among white and Black women. Virginia’s Medicaid expansion reduced the probability of having a cesarean delivery across all race subgroups (white, Black, Hispanic, and other races). This is an important result because Louisiana and Virginia’s baseline cesarean delivery rate for women in this sample was high (more than 25%).

Our results also show that both Medicaid expansions reduced the probability of having at least one prenatal care visit among certain groups. This finding suggests that it is possible that increases in the number of people with Medicaid coverage create challenges in provider availability. 

Racial and Ethnic Disparities in Freestanding Birth Center Access, Use, and Service Provision

The second study aims to understand barriers faced by birthing people of color in accessing and using freestanding birth centers and barriers to increasing the number of minority-led freestanding birth centers in the U.S.

To examine access barriers for birthing people of color, the AIR team used heat maps to plot the geographic locations of birth centers and overlay them with four measures: (1) county-level race/ethnicity composition (2020 American Community Survey data), (2) county-level socioeconomic status (SES) composition (2020 SES Centers for Disease Control and Prevention/ Agency for Toxic Substances and Disease Registry SES index), (3) county-level urbanization level (2013 National Center for Health Statistics data), (4) and county-level OB/GYN density (2020 Area Health Resources Files). This analysis identified whether birth centers are more frequently located in counties with characteristics that could account for disparities in utilization.


Results from the heat map analysis show that there are wide disparities in the distribution of birth centers across the U.S.

  • Some states have no freestanding birth centers, while other states have upwards of 90. 
  • Freestanding birth centers tend to be located in areas with a higher percentage of minority population and lower socio-economic status. Therefore, the location of freestanding birth centers alone cannot account for the disparities in use of freestanding birth centers by minority birthing people. 
  • However, there are geographic disparities in birth center location which impact access. The majority of birth centers are located in areas with a higher urbanization level, while birthing people living in rural areas have little to no access to freestanding birth centers. 
  • Additionally, birth centers are located in areas which already have a greater density of OB/GYN providers and are not currently providing expanded coverage in maternal health care deserts.

To further examine the research questions, the AIR team used a stratified sampling approach to recruit 16 freestanding birth centers across the U.S.—six minority-owned and ten white-owned—to participate in a qualitative study. The team collected data from participating birth centers on patient demographics, payment type, and staff demographics and composition and compared these with county-level demographics.

The team conducted interviews with birth center leadership and with minority midwives who practice at white-owned birth centers. The team also facilitated focus groups with birth center patients. The aim of the qualitative interviews and focus groups was to understand how state regulations, Medicaid and private insurance coverage, and other contextual factors influence the stand up and sustainability of birth centers, particularly those that are minority owned, and impact who birth centers serve, how care is delivered, how pregnant individuals of different races and ethnicities experience care, and how it affects (or does not affect) their access to and quality of care.

Results from the qualitative study will be available in Summer 2024.