HJAR May/Jun 2025

HEALTHCARE JOURNAL OF ARKANSAS I  MAY / JUN 2025 11 (MacDorman and Mathews, 2011). While there are many racial disparities related to maternal and infant mortality, it is impor- tant to acknowledge race as a social con- struct (Bryant et al., 2022). Births covered by Medicaid, of which there is a higher percent- age in Southern states, have higher rates of severe maternal morbidity and mortality (Chen et al., 2021; Agency for Healthcare Research and Quality, 2024). However, lit- tle is known about the health care utiliza- tion patterns of mothers whose births are covered by Medicaid. Arkansas, the location for this study, is a state with poor health rankings. Arkansas’ infant mortality rate is considerably higher than the rest of the U.S (US Department of Health and Human Services HRSA, 2024), andArkansas has one of the highest mater- nal mortality ratios of any state in the U.S (Centers for Disease Control and Preven- tion, 2024). Social determinants of health contribute toArkansas’ poor maternal out- comes—the state is largely rural (41 % of Arkansans vs 14 %U.S.), has higher poverty rates (16.8 % in Arkansas vs 12.6 % U.S.) (United States Census Bureau, 2024), and has a large percentage of births covered by Medicaid (41 %) (Kaiser Family Foundation, 2023). In recognition of these health mater- nal and infant health challenges inMarch of 2024, the governor of Arkansas signed an executive order to support mothers, protect babies, and improve maternal health (E.O. 24–03), with a specific call to better under- stand and improve utilization of prenatal care inArkansas (Office of Governor Sarah Huckabee Sanders, 2024). Initiating prenatal care early and main- taining regular appointments throughout pregnancy enhances a pregnant woman’s health and the likelihood of delivering a healthy baby (American Academy of Pedi- atrics and American College of Obstetri- cians and Gynecologists, 2017). Early and adequate prenatal care has been associ- ated with a substantial (43.8 %) decrease in postpartum maternal mortality (Liu et al., 2015), while receiving fewer than the rec- ommended number of prenatal care visits is associated with higher rates of adverse maternal and infant outcomes (Partridge et al., 2012). Differential rates of prenatal care utilizationmay also contribute to racial/eth- nic disparities in maternal outcomes. Pre- vious studies have documented that Black women are more likely to receive inade- quate prenatal care, which was associated with increased risk for maternal mortality and poor infant outcomes (Moaddab et al., 2016; Green, 2018). The American College of Obstetricians and Gynecologists recom- mend initiation of prenatal care as early as possible in pregnancy and ideally before the fourth month of gestation (AmericanAcad- emy of Pediatrics and American College of Obstetricians and Gynecologists, 2017). For most women, the number and recom- mended frequency of prenatal care visits is determined by the stage of pregnancy in which prenatal care was initiated. Follow- ing the recommended schedule, a woman with a low-risk pregnancy would receive 12 to 14 in-person prenatal care visits (Kotel- chuck, 1997; Peahl and Howell, 2021). Ade- quate prenatal care is generally defined as initiating care within the first four months of gestation and receiving 80 % of the recom- mended number of prenatal visits (Ameri- can Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2017) This study aims to examine associa- tions between sociodemographic factors and prenatal care utilization among moth- ers in Arkansas, including total number of reported prenatal care visits, reporting fewer than the recommended number of prenatal care visits, reporting late initiation of prenatal care (at or after 4 months gesta- tion), or reporting no prenatal care. 2. METHODS 2.1. Data and population Vital records data from the National Center for Health Statistics (NCHS) birth records were used. The study population consisted of singleton live births in Arkan- sas between January 1, 2014 and December 31, 2022. Given our goal to examine prena- tal care utilization based on sociodemo- graphic characteristics including insurance coverage, mothers were excluded from the current study if the delivery was self-pay, if the payer was listed as “other,” or if the payer was unknown. This study uses sec- ondary data analysis and was deemed non- human subjects research by the University of Arkansas for Medical Sciences Institu- tional Review Board on September 12, 2023. 2.2. Variable definitions The primary outcomes of interest included: 1) total number of reported pre- natal care visits, 2) fewer than the recom- mended number of prenatal care visits, 3) late initiation of prenatal care, or 4) no pre- natal care. Fewer than the recommended number of prenatal care visits was defined as receiving less than 80 % of the recom- mended number of prenatal care visits based on gestational age at birth (Ameri- can Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2017). Late initiation of prenatal care was defined as not receiving a prenatal care visit until after the third month of pregnancy (i.e., month 4 or later or not receiving any pre- natal care). No prenatal care was defined as reporting zero prenatal care visits. To assess differences in prenatal care utilization, we considered three key demo- graphic variables of interest: payer, race/ ethnicity, and rural/urban residence. Payer was defined as the payer for the birth and included Medicaid or private/other (i.e., private, TRICARE, or Indian Health Ser- vice [IHS]). We included IHS with private because there is less separate coverage compared to Medicaid. Maternal race/eth- nicity was self-reported on the birth cer- tificate and included non-Hispanic Ameri- can Indian or Alaska Native (AIAN), Asian, Black, Hispanic (regardless of race), Native Hawaiian or Pacific Islander (NHPI), multi- racial, and white. Rural-Urban Continuum codes from 2023 were used to designate the maternal county of residence as a metropol- itan area (urban) or nonmetropolitan area (rural) using the classification provided by the U.S. Department of Agriculture (United States Department of Agriculture Economic Research Service, 2024). Additional covariates included maternal information obtained from birth records.