THE EFFECT OF HEALTH COVERAGE FOR UNINSURED PREGNANT-WOMEN ON MATERNAL HEALTH AND THE USE OF CESAREAN-SECTION

Objectives.-Although there has been substantial policy interest in int erventions to improve the neonatal outcomes of disadvantaged women, li ttle attention has been paid to the health status of pregnant women th emselves. We therefore examined whether the provision of health covera ge to uninsured low-income pregnant women affects maternal health stat us or the use of cesarean section. Design.-Natural experiment in Massa chusetts. Patients.-All in-hospital, single-gestation births in 1984 ( N=57 257) and 1987 (N=64 346). Intervention.-Healthy Start is a statew ide health coverage program for uninsured pregnant women. In 1985, it covered women with incomes below 185% of the federal poverty level. Ma in Outcome Measures.-Rates of adverse maternal outcome (severe pregnan cy-related hypertension, placental abruption, and a length of stay at least 1 day longer than infants' stay) and cesarean section for uninsu red women, and for two concurrent control groups, women with Medicaid and women with private insurance. We calculated the difference in rate s between the uninsured and each concurrent control. We then examined the change in these interpayer differences in rates between 1984 and 1 987 to measure the effect of Healthy Start. Main Results.-In 1984, uni nsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% vs 5.1%, respectively; interpayer differ ence, 0.4%) and received fewer cesarean sections (1 7.2% vs 23.0%; int erpayer difference, -5.8%). Between 1984 and 1987 there was no statist ically significant change in the interpayer difference in adverse outc ome relative to women with private insurance. However, the interpayer difference in cesarean sections between the uninsured and the privatel y insured was reduced by 2.3% (95% confidence interval [CI], +0.4% to +4.2%), although the uninsured continued to undergo fewer cesarean sec tions (22.4% vs 25.9%). Similar results were observed when the uninsur ed women were compared with women with Medicaid. Conclusions.-The prov ision of health insurance alone to low-income pregnant women may not b e associated with an improvement in maternal health. Expanded coverage was associated, however, with an increase in the rate of cesarean sec tion.