African immigrants' favorable preterm birth rates challenge genetic etiology of the Black-White disparity in preterm birth

Background

We examined over a million California birth records for 2010 through 2021 to investigate whether disparities in preterm birth (PTB) by nativity and race support the widely held but hitherto unsubstantiated belief that genetic differences explain the persistent Black-White disparity in PTB.

Methods

We examined PTB rates and risk ratios among African-, Caribbean-, and U.S.-born Black women compared to U.S.-born White women. Multivariate analyses adjusted for maternal age, education, number of live births, delivery payer, trimester of prenatal care initiation, pre-pregnancy BMI, smoking, and prevalence of poverty in a woman's residence census tract; and for paternal education.

Results

In adjusted analyses, African-born Black women's PTB rates were no different from those of U.S.-born White women.

Discussion

The results add to prior evidence making a genetic etiology for the racial disparity in PTB unlikely. If genetic differences tied to "race" explained the Black-White disparity in PTB among U.S.-born women, the African immigrants in this study would have had higher rates of PTB, not the lower rates observed. Multiple explanations for the observed patterns and their implications are discussed. Failure to distinguish causes of PTB from causes of the racial disparity in PTB have likely contributed to erroneous attribution of the racial disparity to genetic differences. Based on the literature, unmeasured experiences of racism, including racism-related stress and adverse environmental exposures, are plausible explanations for the PTB disparity between Black and White U.S.-born women. The favorable birth outcomes of African-born Black immigrants may reflect less exposure to racism during sensitive life periods, e.g., childhood, when they were in African countries, where Black people are in the racial majority.

Severe maternal hardships are associated with food insecurity among low-income/lower-income women during pregnancy: results from the 2012–2014 California maternal infant health assessment

Background

Assess the associations between ten severe maternal hardships and food insecurity experienced during pregnancy.

Methods

Data on 14,274 low-income/lower-income women (below 400% of the income to federal poverty guideline ratio) from the statewide-representative 2010–2012 California Maternal and Infant Health Assessment were used to estimate food security status prevalence. Prevalence of severe maternal hardships by food security status was estimated. Multinomial logistic regression was used to assess the associations between severe maternal hardship and food security status, adjusting for sociodemographic characteristics.

Results

Food insecurity was common among low- and lower-income pregnant women in California; 23.4% food insecure and an additional 11.5% marginally secure. In adjusted analysis, nine of ten hardships were associated with food security status. Only the respondent or someone close to the respondent having a problem with alcohol or drugs was not associated with food security status after adjusting for socioeconomic factors. Husband/partner losing a job, depressive symptoms, not having practical support and intimate partner violence were consistently associated with marginal, low and very low food security status. Each additional severe maternal hardship a woman experienced during pregnancy was associated with a 36% greater risk of reporting marginal food security (Relative Risk Ratio 1.36, 95% CI: 1.27, 1.47), 54% for low food security (Relative Risk Ratio 1.54, 95% CI: 1.44, 1.64), and 99% for very low food security (Relative Risk Ratio 1.99, 95% CI: 1.83, 2.15).

Conclusions

Food security status was strongly linked with several maternal hardships that could jeopardize maternal and/or infant health.

Services—including prenatal care and nutritional assistance—for a large proportion of pregnant women should address a wide range of serious unmet social needs including food insecurity.

Are the poverty histories of neighbourhoods associated with psychosocial well-being among a representative sample of California mothers? An observational study

BACKGROUND

We examine the association between the poverty histories of neighbourhoods and three indicators of psychosocial well-being-depressive symptoms, sense of control and number of stressors-in an observational study of mothers of young children in California. We also consider if length of residence in a neighbourhood moderates the association between neighbourhood poverty history and psychosocial well-being.

METHODS

Data come from the Geographic Research on Well-being (GROW) Study, a subsample of mothers who completed the population-based California Maternal and Infant Health Assessment in 2003-2007 and were reinterviewed in 2012-2013. Poverty histories of neighbourhoods were constructed using the Neighbourhood Change Database (1970-2000) and American Community Survey (2005-2009). The analytic sample included 2726 women from GROW residing in 1906 census tracts.

RESULTS

Adjusting for individual socioeconomic and demographic characteristics, women living in neighbourhoods where poverty decreased over the 40-year period had lower odds of depressive symptoms and a greater sense of control than women living in long-term, low-poverty neighbourhoods. Women living in long-term high-poverty neighbourhoods or in neighbourhoods where poverty increased over the 40-year period reported lower sense of control than women living in long-term, low-poverty neighbourhoods and these effects were modified by length of time living in the neighbourhood. No significant effects of neighbourhood poverty histories were found for number of stressors.

CONCLUSIONS

Policies aimed at reducing neighbourhood poverty may improve mothers' psychosocial well-being.

Post-partum Residential Mobility Among a Statewide Representative Sample of California Women, 2003-2007

OBJECTIVES

Researchers often examine neighborhood socioeconomic environment and health during the perinatal period using geocoded addresses recorded on birth certificates at the time of delivery. Our objective was to assess the potential for post-partum neighborhood misclassification by examining whether women move neighborhoods during the immediate post-partum period, whether they move to neighborhoods of different socioeconomic status (SES), and whether mobility differs by maternal characteristics.

METHODS

We used data from the 2003-2007 California Maternal and Infant Health Assessment (MIHA), an annual, statewide-representative survey of post-partum women, to examine women's neighborhood mobility patterns between giving birth and completing a survey 2-7 months post-partum. We examined whether women changed neighborhoods, whether moves were to neighborhoods of higher, lower, or similar socioeconomic status (SES), and whether these patterns differed by maternal race/ethnicity, maternal SES, or other demographic characteristics.

RESULTS

Overall, 93% of women either did not move neighborhoods or moved to a neighborhood of similar SES post-partum. Only 4% of women moved to a neighborhood of lower SES and 3% to an area of higher SES. Mothers who were non-Hispanic black or US-born Hispanic, young, unmarried, primiparous, or lower SES were slightly more likely to move overall and more likely to move to neighborhoods with different SES, compared to other women.

CONCLUSIONS

These findings suggest that geocoded addresses from birth certificates can be used to estimate women's neighborhood SES during the early post-partum period with little misclassification, an especially relevant finding for researchers using post-partum surveys.

Racial/Ethnic Disparities in Depressive Symptoms Among Pregnant Women Vary by Income and Neighborhood Poverty

We examined racial/ethnic disparities in depressive symptoms during pregnancy among a population-based sample of childbearing women in California (N = 24,587). We hypothesized that these racial/ethnic disparities would be eliminated when comparing women with similar incomes and neighborhood poverty environments. Neighborhood poverty trajectory descriptions were linked with survey data measuring age, parity, race/ethnicity, marital status, education, income, and depressive symptoms. We constructed logistic regression models among the overall sample to examine both crude and adjusted racial/ethnic disparities in feeling depressed. Next, stratified adjusted logistic regression models were constructed to examine racial/ethnic disparities in feeling depressed among women of similar income levels living in similar neighborhood poverty environments. We found that racial/ethnic disparities in feeling depressed remained only among women who were not poor themselves and who lived in long-term moderate or low poverty neighborhoods.

Beyond the cross-sectional: neighborhood poverty histories and preterm birth

OBJECTIVES

We examined associations between longitudinal neighborhood poverty trajectories and preterm birth (PTB).

METHODS

Using data from the Neighborhood Change Database (1970-2000) and the American Community Survey (2005-2009), we categorized longitudinal trajectories of poverty for California neighborhoods (i.e., census tracts). Birth data included 23 291 singleton California births from the Maternal and Infant Health Assessment (2003-2009). We estimated associations (adjusted for individual-level covariates) between PTB and longitudinal poverty trajectories and compared these to associations using traditional, cross-sectional measures of poverty.

RESULTS

Compared to neighborhoods with long-term low poverty, those with long-term high poverty and those that experienced increasing poverty early in the study period had 41% and 37% increased odds of PTB (95% confidence interval [CI] = 1.18, 1.69 and 1.09, 1.72, respectively). High (compared with low) cross-sectional neighborhood poverty was not associated with PTB (odds ratio = 1.08; 95% CI = 0.91, 1.28).

CONCLUSIONS

Neighborhood poverty histories may contribute to an understanding of perinatal health and should be considered in future research.

Limited socioeconomic opportunities and Latina teen childbearing: a qualitative study of family and structural factors affecting future expectations

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents' childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.

Sociocultural determinants of teenage childbearing among Latinas in California

Objectives U.S. Latinas have a persistently high rate of teenage childbearing, which is associated with adverse outcomes for both mother and child. This study was designed to investigate the roles of socioeconomic factors and acculturation in teenage childbearing in this population. Methods Logistic regression was used to analyze the association of measures of acculturation (language spoken at home, nativity, and age at immigration) and respondents’ parents’ education with age at first birth in a stratified sample of post-partum women in California. Results The unadjusted odds ratio for teenage birth for Latinas versus non-Latina Whites was 5.2 (95% CI 4.1–6.6). Nativity was not significantly associated with teen birth, but speaking Spanish at home was positively associated and immigrating at a later age was negatively associated with teen birth. Overall, these measures of acculturation accounted for 17% (95% CI 8–28%) of the difference in odds of teen birth between Latinas and non-Latina Whites. Higher levels of education among respondents’ parents had differentially protective effects across the racial/ethnic groups. Controlling for disparities in respondents’ parents’ education without changing its differential effects across racial/ethnic groups reduced the odds ratio for Latinas compared to non-Latina Whites by 30% (95% CI 14–60%). Conclusion These findings call into question common assumptions about the protective effect of acculturation on teen fertility and suggest that improving childhood socioeconomic factors among Latinas may decrease teen childbearing.

Poverty, near-poverty, and hardship around the time of pregnancy

To describe income levels and the prevalence of major hardships among women during or just before pregnancy. We separately analyzed 2002-2006 population-based postpartum survey data from California's Maternal and Infant Health Assessment (n = 18,332) and 19 states participating in CDC's Pregnancy Risk Assessment Monitoring System (n = 143,452) to examine income and several hardships (divorce/separation, domestic violence, homelessness, financial difficulties, spouse/partner's or respondent's involuntary job loss or incarceration, and, in California only, food insecurity and no social support) during/just before pregnancy. In both samples, over 30% of women were poor (income </=100% of federal poverty level [FPL]) and 20% near-poor (101-200% FPL); and around 60% of low-income (poor or near-poor) women experienced at least one hardship. While hardship prevalence decreased significantly as income increased, many non-low-income women also experienced hardships; e.g., in California, 43% of all women and 13% with incomes >400% FPL experienced one or more hardships. These findings paint a disturbing picture of experiences around the time of pregnancy in the United States for many women giving birth and their children, particularly because 60% had previous births. The high prevalence of low income and of serious hardships during pregnancy is of concern, given previous research documenting the adverse health consequences of these experiences and recognition of pregnancy as a critical period for health throughout the life course. Low income and major hardships around the time of pregnancy should be addressed as mainstream U.S. maternal-infant health and social policy issues.

Is neighborhood deprivation independently associated with maternal and infant health? Evidence from Florida and Washington

OBJECTIVES

To determine whether a widely used measure of neighborhood-level socioeconomic deprivation was associated with unintended pregnancy, delayed/no prenatal care, low birth weight (LBW), and not breastfeeding, after adjusting for a more comprehensive set of individual-level socioeconomic factors than previously reported.

METHODS

Data from CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) in Washington and Florida (1997-1998) were linked with census tract-level data (2000) based on birth certificate addresses. For each state, logistic regression models were estimated for associations between neighborhood deprivation measured by the Townsend Index and each dependent variable, unadjusted and then adjusting for maternal age, parity, racial/ethnic group, and education; paternal education; and family income. Similar models were estimated for each racial/ethnic group separately.

RESULTS

Despite significant unadjusted associations between neighborhood deprivation and all dependent variables except LBW in Washington, few statistically significant associations were found in the adjusted models overall. In stratified models, African American women in low-deprivation Florida neighborhoods had higher odds of delayed/no prenatal care compared with their moderate-deprivation counterparts, and only among European American women were high-deprivation neighborhoods associated with increased odds of delayed/no prenatal care.

CONCLUSIONS

These results, which may not be generalizable beyond Florida and Washington or to other health indicators, suggest that some previously reported associations between neighborhood characteristics and the selected health indicators may reflect residual confounding by individual-level socioeconomic status/position. Until methodological and conceptual challenges regarding mediation ("over-controlling") and measurement of neighborhood exposure are overcome, conclusions regarding independent neighborhood associations should be made with caution.

Infant sleep position: associated maternal and infant factors

OBJECTIVE

To determine the maternal and infant characteristics associated with the back sleep position for infants to guide efforts to increase its use and reduce the risk of Sudden Infant Death Syndrome.

METHODS

Cross-sectional survey of 3349 mothers delivering in California, February-May 1999.

RESULTS

Fifty-two percent of infants were placed in the back sleep position. Factors associated with a lower likelihood of using the back position included all levels of maternal education less than college (eg, for education eighth grade or less--adjusted odds ratio [OR] 0.59; 95% confidence interval [CI], 0.40-0.86); income at or below federal poverty level (OR, 0.65; 95% CI, 0.47-0.90); multiparity (OR, 0.80; 95% CI, 0.67-0.95); race/ethnicity African American (OR, 0.49; 95% CI, 0.37-0.65) and Asian/Pacific Islander (OR, 0.65; 95% CI, 0.48-0.89); speaking a non-English language (OR, 0.69; 95% CI, 0.55, 0.86); and infant age over 7 months (OR, 0.70, 95% CI, 0.52-0.96). Women in Los Angeles (OR, 0.57; 95% CI, 0.42-0.77) and urban areas other than San Diego (OR, 0.70; 95% CI, 0.53-0.92) were less likely to use the back position than those in San Francisco.

CONCLUSIONS

Greater efforts are needed to promote the back sleep position among families with mothers who lack education beyond some college; live in poverty; and who are African American, Asian/Pacific Islander, multiparous, or non-English speaking.

Improvements in prenatal insurance coverage and utilization of care in California: an unsung public health victory

OBJECTIVE

To examine trends in prenatal insurance coverage and utilization of care in California over two decades in the context of expansions in Medi-Cal (California's Medicaid) and other public efforts to increase prenatal care utilization.

METHODS

Retrospective univariate and bivariate analysis of prenatal care coverage and utilization data from 10,192,165 California birth certificates, 1980-99; descriptive analysis of California poverty and unemployment data from the U.S. Census Bureau Current Population Survey; review of public health and social policy literature.

RESULTS

The proportion of mothers with Medi-Cal coverage for prenatal care increased from 28.2 to 47.5% between 1989 and 1994, and the proportion uninsured throughout pregnancy decreased from 13.2 to 3.2%. Since the mid-1990s, fewer than 3% of women have had no insurance coverage for prenatal care. Between 1989 and 1999, the proportion of women with first trimester initiation of prenatal care increased from 72.6 to 83.6%, reversing the previous decade's trend, and the proportion of women with adequate numbers of visits rose from 70.7 to 83.1%. Improvements in utilization measures were greater among disadvantaged social groups. Improvements in California during the 1990s coincided with a multifaceted public health effort to increase both prenatal care coverage and utilization, and do not appear to be explained by changes in the economy, maternal characteristics, the overall organization/delivery of health care, or other social policies.

CONCLUSIONS

While this ecologic study cannot produce definitive conclusions regarding causality, these results suggest an important victory for public health in California.

Timing of insurance coverage and use of prenatal care among low-income women

OBJECTIVES

This study examined the relationship between timing of insurance coverage and prenatal care among low-income women.

METHODS

Timeliness of prenatal care initiation and adequacy of number of visits were studied among 5455 low-income participants in a larger cross-sectional statewide survey of postpartum women in California during 1994-1995.

RESULTS

Although only 2% of women remained uninsured throughout pregnancy, one fifth lacked coverage during the first trimester. Rates of untimely care were highest (> or =64%) among women who were uninsured throughout their pregnancy or whose coverage began after the first trimester; rates were lowest (about 10%) among women who obtained coverage during the first trimester. Women who first obtained Medi-Cal coverage during pregnancy were at low risk of having too few visits.

CONCLUSIONS

Timing of prenatal coverage should be considered in research on the relationship between coverage and care use among low-income women. Earlier studies that relied solely on principal payer information, without data on when coverage began, may have led to inaccurate inferences about lack of coverage as a barrier to prenatal care.

Measuring socioeconomic status/position in studies of racial/ethnic disparities: maternal and infant health

OBJECTIVE

Theoretical and empiric considerations raise concerns about how socioeconomic status/position (abbreviated here as SES) is often measured in health research. The authors aimed to guide the use of two common socioeconomic indicators, education and income, in studies of racial/ethnic disparities in low birthweight, delayed prenatal care, unintended pregnancy, and breastfeeding intention.

METHODS

Data from a statewide postpartum survey in California (N = 10,055) were linked to birth certificates. Overall and by race/ethnicity, the authors examined: (a) correlations among several measures of education and income; (b) associations between each SES measure and health indicator; and (c) racial/ethnic disparities in the health indicators "adjusting" for different SES measures.

RESULTS

Education-income correlations were moderate and varied by race/ethnicity. Racial/ethnic associations with the health indicators varied by SES measure, how SES was specified, and by health indicator.

CONCLUSIONS

Conclusions about the role of race/ethnicity could vary with how SES is measured. Education is not an acceptable proxy for income in studies of ethnically diverse populations of childbearing women. SES measures generally should be outcome- and population-specific, and chosen on explicit conceptual grounds; researchers should test multiple theoretically appropriate measures and consider how conclusions might vary with how SES is measured. Researchers should recognize the difficulty of measuring SES and interpret findings accordingly.

Risk factors for late or no prenatal care following Medicaid expansions in California

OBJECTIVES

To describe the characteristics and risk factors of women with only third-trimester (late) or no prenatal care.

METHODS

A statewide postpartum survey was conducted that included 6364 low-income women delivering in California hospitals in 1994 and 1995.

RESULTS

The following factors appeared most important, considering both prevalence and association with late or no care: poverty, being uninsured, multiparity, being unmarried, and unplanned pregnancy. Forty-two percent of women with no care were uninsured, and uninsured women were at dramatically increased risk of no care. Over 40% of uninsured women with no care had applied for Medi-Cal prenatally but did not receive it. Risks did not vary by ethnicity except that African American women were at lower risk of late care than women of European background. Child care problems were not significantly associated with either late or no care, and transportation problems (not asked of women with no care) were not significantly related to late care.

CONCLUSIONS

Lack of insurance appeared to be a significant barrier for the 40% of women with no care who unsuccessfully applied for Medi-Cal prenatally, indicating a need to address barriers to Medi-Cal enrollment. However, lack of financial access is unlikely to completely explain the dramatic risks associated with being uninsured. In addition to eliminating barriers to prenatal coverage, policies to reduce late/no care should focus on pre-pregnancy factors (e.g., planned pregnancy and poverty reduction) rather than on logistical barriers during pregnancy.

The validity of information on "race" and "Hispanic ethnicity" in California birth certificate data

OBJECTIVE

To evaluate the validity of racial/ethnic information in California birth certificate data.

DATA SOURCES

Computerized birth certificate data and postpartum interviews with California mothers.

STUDY DESIGN AND DATA COLLECTION

Birth certificates were matched with face-to-face structured postpartum interviews with 7,428 mothers to compare racial/ethnic information between the two data sources. Interviews were conducted in Spanish or English during delivery stays at 16 California hospitals, 1994-1995.

PRINCIPAL FINDINGS

The sensitivity of racial/ethnic classification in birth certificate data was very high (94 percent to 99 percent) for African Americans, Asians/Pacific Islanders, Europeans/Middle Easterners, and Latinas (Hispanics). For Native Americans, however, the sensitivity was only 54 percent. The positive predictive value of birth certificate classification of race/ethnicity was high for all racial/ethnic groups (96 percent to 97 percent).

CONCLUSIONS

Despite limited training of birth clerks, the maternal racial/ethnic information in California birth certificate data appears to be a valid measure of self-identified race and Hispanic ethnicity for groups other than Native Americans.

Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors

OBJECTIVE

This study, designed to avoid methodologic limitations of previous research, aimed to identify the important noninsurance barriers to timely prenatal care.

METHODS

We identified a subsample of a cross-sectional statewide representative postpartum survey conducted in California during 1994-1995, focusing on 3071 low-income women with Medi-Cal or private coverage throughout pregnancy.

RESULTS

Twenty-eight percent of those women had untimely care, although only 6% were unaware of their pregnancies during the first trimester. Controlling for numerous sociodemographic factors; knowledge, attitudes, beliefs, and behaviors; stressful life circumstances; and logistic obstacles that might deter seeking or receiving care, the following risk factors for untimely care were significant and experienced by more than one fifth of women: unwanted or unplanned pregnancy (affecting 43% and 66% of women, respectively), no regular provider before pregnancy (affecting 22% of women), and no schooling beyond high school (affecting 76% of women). Transportation problems, affecting 8% of women, appeared to be the only significant logistic barrier to timely care.

CONCLUSION

Improving timeliness of prenatal care among low-income women with third-party coverage is likely to require broad social and health policies that focus on factors affecting women before pregnancy. Assistance with transportation could contribute to more timely care for some low-income women, but programs focusing primarily on other noninsurance barriers during pregnancy might not substantially improve the timeliness of care, at least among low-income women with third-party coverage.

Adolescent health insurance coverage: recent changes and access to care

OBJECTIVE

To assess the health insurance status of adolescents, the trends in adolescent health care coverage, the demographic and socioeconomic correlates of insurance coverage, and the role that insurance coverage plays in influencing access to and use of health care. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage.

METHODS

We analyzed data on 14 252 adolescents, ages 10 to 18 years, included in the 1995 National Health Interview Survey. The survey obtained information on insurance coverage and several measures of access and utilization, including usual source of care, site of the usual source of care, indications of missed or delayed care, and use of ambulatory physician services by adolescents. We conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and health status on the likelihood of insurance coverage. We conducted bivariate and multivariate analyses to ascertain how insurance coverage was related to each of the access and utilization measures obtained in the survey. We also examined trends in health insurance coverage using the 1984, 1989, and 1995 editions of the National Health Interview Survey.

RESULTS

An estimated 14.1% of adolescents were uninsured in 1995. Risk of being uninsured was higher for older adolescents, minorities, adolescents in low-income families, and adolescents in single parent households. Compared with their insured counterparts, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during the course of a year. Between 1984 and 1995 the percentage of adolescents with some form of health insurance coverage remained essentially unchanged. During this period, the prevalence of private health insurance decreased, while the prevalence of public health insurance increased.

CONCLUSIONS

This study demonstrates the critical importance of health insurance as a determinant of access to and use of health services among adolescents. It also shows that little progress has been made during the past 15 years in reducing the size of the uninsured adolescent population. The new State Children's Health Insurance Program could lead to substantial improvements in access to care for adolescents, but only if states implement effective outreach and enrollment strategies for uninsured adolescents.adolescents, health insurance, access, Medicaid, SCHIP.

The prevalence of low income among childbearing women in California: implications for the private and public sectors

OBJECTIVES

This study examined the income distribution of childbearing women in California and sought to identify income groups at increased risk of untimely prenatal care.

METHODS

A 1994/95 cross-sectional statewide survey of 10,132 postpartum women was used.

RESULTS

Sixty-five percent of all childbearing women had low income (0%-200% of the federal poverty level), and 46% were poor (0%-100% of the federal poverty level). Thirty-five percent of women with private prenatal coverage had low income. Most low-income women with Medi-Cal (California's Medicaid) or private coverage received their prenatal care at private-sector sites. Compared with women with incomes over 400% of the poverty level, both poor and near-poor women were at significantly elevated risk of untimely care after adjustment for insurance, education, age, parity, marital status, and ethnicity (adjusted odds ratios = 5.32 and 3.09, respectively).

CONCLUSIONS

This study's results indicate that low-income women are the mainstream maternity population, not a "special needs" subgroup; even among privately insured childbearing women, a substantial proportion have low income. Efforts to increase timely prenatal care initiation cannot focus solely on women with Medicaid, the uninsured, women in absolute poverty, or those who receive care at public-sector sites.

Validity of insurance information on California birth certificates

OBJECTIVES

This study assessed the validity of health insurance information on California birth certificates.

METHODS

Insurance information from birth certificates and linked face-to-face interviews was compared for 7428 postpartum women in California.

RESULTS

There was excellent agreement between insurance information in birth certificate and interview data, especially when capitated plans were grouped with all other private coverage. Analyses using both data sources produced similar estimates of the likelihood of untimely prenatal care according to type of insurance coverage.

CONCLUSIONS

Birth certificate data including insurance information appear to be an appropriate resource for examining both the extent of coverage for maternity care and associations between prenatal care use and insurance status.

Problems associated with early discharge of newborn infants. Early discharge of newborns and mothers: a critical review of the literature

OBJECTIVE

To determine whether research supports the advisability of early discharge of healthy newborns and mothers.

METHODS

Critical review of English-language literature cited in the Index Medicus or the International Nursing Index.

FINDINGS

No adequately designed studies have examined discharge before 48 hours after delivery without additional postdischarge services. Few studies have examined the consequences of recommending a clinic visit within the first days after discharge; studies of this practice among low-income populations found high no-show rates. Some small studies suggest that early discharge is likely to be safe for selected populations at low psychosocial, socioeconomic, and medical risk, with careful antenatal screening and preparation and multiple postpartum home visits. Some studies suggested adverse outcomes associated with early discharge even with early follow-up.

CONCLUSIONS

Published research provides little knowledge of the consequences of short maternal/newborn hospital stays or varying postdischarge practices for the general population. The studies that have concluded that early discharge was safe were applied under restricted circumstances or were too small to detect clinically significant effects on important outcomes. Further research is needed to inform clinical and reimbursement policy on health services in the first days of life and parenting. Rigorous studies of sufficient size are needed to examine the impact of different hospital stays and different postdischarge practices on a range of outcomes for mothers and newborns in diverse populations and settings. Given a priori concerns, decisions on neonatal/obstetric discharge planning should be made cautiously.