How do experiences of childbearing women on Medicaid and private insurance compare?: A Listening to Mothers III data brief
Medicaid and CHIP (the Child Health Insurance Program) are important safety net programs that pay for a large proportion of the nearly four million U.S. births each year. States and the federal government have an interest in ensuring adequate access, quality care, and optimal health outcomes for childbearing women and newborns insured by these programs; taxpayers expect good value for these investments; and these programs provide policy makers with opportunities to improve maternity care. The Listening to MothersSM III surveys provides the fullest and most current data on the childbearing experiences of U.S. women, including variation by source of payment. These nationally representative data are from an initial survey of 2400 women, 18-45, who had given birth to a single baby in U.S. hospitals from July 2011 through June 2012 and could participate in English, as well as a follow-up survey of 1072 of the initial participants carried out several months later. It compares women whose primary payment source for their maternity services was Medicaid or CHIP (“Medicaid,” below) with those whose primary payment source was private insurance. Not included are those whose primary source of payment was other government programs (e.g., Tricare, Federal Employees Health Benefits) or self pay. Childbirth Connection’s Listening to MothersSM III surveys were conducted by Harris Interactive and funded by the W.K. Kellogg Foundation.
SUMMARY OF KEY FINDINGS
Medicaid-insured women are more likely to have unplanned pregnancies than women with private insurance. More than 4 in 10 (43%) said they had hoped to get pregnant at a later time or not at all, versus 27% of privately insured women.
Women covered by Medicaid enter pregnancy underweight, overweight or obese more often than women with private insurance, and gaps in obesity widen over time. Just 40% of Medicaid-insured women began pregnancy with a body mass index (BMI) considered to be in the normal range, compared with 54% of women with private insurance. Among women with Medicaid coverage, 11% were underweight, 25% were overweight, and 24% were obese just before pregnancy. During pregnancy, privately insured women were more likely to have their maternity care provider recommend a certain amount of weight gain (62%), compared with just under half (49%) of women covered by Medicaid. After birth, Medicaid-insured mothers lost an average of 13 pounds compared with 21 for mothers with private insurance. As a results in 34% of Medicaid-insured mothers met criteria for obesity compared with 21% of mothers with private insurance three or more months after birth. At the time of the follow-up survey, 49% of women with private insurance were in a normal weight range compared with just 30% of women covered by Medicaid.
Medicaid-insured women have greater need for basic services in pregnancy and the postpartum. Medicaid beneficiaries were more likely than women with private insurance to say that during pregnancy they had needed help with food, nutritional counseling, treatment for depression, and help with smoking cessation. Differences in identified need were greatest for help with food (77% versus 22%). Among those who needed the services, Medicaid beneficiaries were more likely than privately insured moms to get help with food and nutritional counseling, but less likely to receive needed treatment for depression or help with smoking cessation.
- Almost all Medicaid beneficiaries who needed help with food received such help (93%), largely through enrollment in the Women, Infants, and Children (WIC) Supplemental Nutrition Program. However, one in four Medicaid beneficiaries (27%) who received WIC were not enrolled until after their first trimester. After birth, 55% of women with Medicaid coverage were using WIC services for themselves and their babies, compared with 12% of women with private insurance
- One-third (32%) of Medicaid-insured women who said they needed counseling or treatment for depression in pregnancy reported that they did not receive these services
- Only 41% of Medicaid-insured women who reported they needed help to quit smoking received such help.
Medicaid-insured women are less likely to take childbirth education classes and more likely to have unmet need for doula support in labor.
- Only 28% of Medicaid-insured women took childbirth education classes, compared with 39% of privately insured women.
- Despite the significant potential benefits of doula support in labor, women covered by Medicaid were much less likely than women with private insurance to be aware of this option: 36% insured by Medicaid versus 19% with private insurance had never heard about this type of care.
- Among those who did have an understanding of doula care but did not have this type of support in labor, 35% of Medicaid beneficiaries stated they would have liked to have had doula care, compared with 21% of privately insured women.
Induction and cesarean section were common, often for reasons that did not reflect best evidence or women’s preferences. Use of induction was more common and access to vaginal birth after cesarean (VBAC) was less common for women covered by Medicaid.
- Nearly half of women covered by Medicaid (46%) experienced labor induction versus 37% with private insurance.
- Almost one-third (31% Medicaid, 32% private insurance) gave birth by cesarean section.
- Forty percent of Medicaid-insured women and 45% of privately insured women reported having the option to plan a vaginal birth after cesarean (VBAC). Many mothers cited a medical reason (other than a history of cesarean) for the repeat cesarean (39% Medicaid, 48% private), and many said that their care provider was unwilling to assist a VBAC (27% Medicaid, 20% private).
- Among women with one or two prior cesareans whose care provider mentioned a possible repeat cesarean, only 62% of moms with Medicaid versus 81% of with private insurance had this situation framed as a choice. More mothers with Medicaid felt this had been the provider’s decision (30% versus 9%), and fewer would definitely make the same decision again (57% versus 73%).
Moms covered by Medicaid experienced breastfeeding-related gaps. Medicaid beneficiaries were less likely to intend to exclusively breastfeed (47% versus 61% of privately insured women), and less likely to be exclusively breastfeeding a week after birth (42% versus 57%). Among those intending to breastfeed, Medicaid-insured women may have experienced deficits in several hospital practices (though only pacifier use was significantly different):
- Getting help to get started with breastfeeding (78% versus 81%), receiving encouragement to nurse the baby on demand (64% versus 69%), and being informed of community breastfeeding resources (47% versus 53%)
- Saying the staff gave their babies pacifiers (46% versus 38%) or formula/water supplementation (39% versus 35%) while in the hospital.
Of mothers covered by private insurance, 47% correctly identified the American Academy of Pediatrics recommended duration of exclusive breastfeeding (6 months) compared with 33% of mothers covered by Medicaid.
Medicaid-insured women felt better informed in their postpartum visits. More mothers with Medicaid coverage reported having “definitely” received enough information on a variety of topics from their postpartum care providers than did privately insured women. These topics included healthy eating (50% versus 29%), exercise (45% versus 28%), and changes in sexual response (41% versus 22%).
Among those who had been employed during pregnancy, an equal proportion of mothers with Medicaid and private insurance were again working at paid jobs at the time of the follow-up survey. For both groups, 77% of those who had been employed during pregnancy had returned to work at the time of the follow-up survey. Whereas 28% of women with Medicaid coverage reported experiencing an unwanted reduction in hours, 8% with private insurance reported such a change. Women with Medicaid coverage were twice as likely (20%) to report caring for their babies while doing paid work as women with private insurance (9%).
Women with Medicaid coverage for maternity services were more likely to be uninsured at the time of the follow-up survey than women who had been covered by private insurance. At the time of the follow-up survey, over one-quarter (26%) of women who had named Medicaid as the primary payer of their maternity services had no health insurance compared with 10% of women who had named private insurance as the primary payer of maternity services.
Medicaid-insured mothers appear to have been more concerned about experiencing a medical error. About a quarter of moms with Medicaid were “very concerned” that a medical error would lead to serious injury or harm at a prenatal office visit (23%) or in the hospital after birth (25%). By contrast, 11% and 13%, respectively, of privately insured women reported having this level of concern. Similarly, 38% of women with Medicaid were “somewhat” or “very” concerned about a serious medical error occurring during a postpartum office visit versus 22% of women with private insurance), and 42% of women with Medicaid had such concerns about a visit to the baby’s health care provider versus 28% of women with private insurance.