Changes in prenatal care and birth outcomes after federally qualified health center expansion

Abstract

Objective: To evaluate whether the expansion of Federally Qualified Health Centers (FQHCs) improved late prenatal care initiation, low birth weight, and preterm birth among Medicaid-covered or uninsured individuals.

Data sources and study setting: We identified all FQHCs in California using the Health Resources and Services Administration's Uniform Data System from 2000 to 2019. We used data from the U.S. Census American Community Survey to describe area characteristics. We measured outcomes in California birth certificate data from 2007 to 2019.

Study design: We compared areas that received their first FQHC between 2011 and 2016 to areas that received it later or that had never had an FQHC. Specifically, we used a synthetic control with a staggered adoption approach to calculate non-parametric estimates of the average treatment effects on the treated areas. The key outcome variables were the rate of Medicaid or uninsured births with late prenatal care initiation (>3 months' gestation), with low birth weight (<2500 grams), or with preterm birth (<37 weeks' gestation).

Data collection/extraction methods: The analysis was limited to births covered by Medicaid or that were uninsured, as indicated on the birth certificate.

Principal findings: The 55 areas in California that received their first FQHC in 2011-2016 were more populous; their residents were more likely to be covered by Medicaid, to be low-income, or to be Hispanic than residents of the 48 areas that did not have an FQHC by the end of the study period. We found no statistically significant impact of the first FQHC on rates of late prenatal care initiation (ATT: -10.4 [95% CI -38.1, 15.0]), low birth weight (ATT: 0.2 [95% CI -7.1, 5.4]), or preterm birth (ATT: -7.0 [95% CI -15.5, 2.3]).

Conclusions: Our results from California suggest that access to primary and prenatal care may not be enough to improve these outcomes. Future work should evaluate the impact of ongoing initiatives to increase access to maternal health care at FQHCs through targeted workforce investments.

Keywords: Medicaid; maternal and perinatal care and outcomes; observational data/quasi-experiments; obstetrics/gynecology; uninsured/safety net providers.

FIGURE 1

Mechanisms of FQHC impact on prenatal care and birth outcomes [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

California primary care service areas that received their first FQHC (treatment) in 2011–2016, by year. The boundaries in the map represent the Primary Care Service Areas (PCSAs) that are at least partially within California (N = 348). The PCSAs shown in white are excluded from the analysis because they received their first FQHC prior to 2011 (N = 199), or after 2016 (N = 10), or because they had fewer than 10 uninsured or Medicaid‐covered births in any year between 2007 and 2019 (N = 36).

FIGURE 3

Primary Care Service Area (PCSA) population characteristics by treatment group and year. Each solid line represents the average across treated PCSAs. Each dotted line represents the average synthetic control based on the low birth weight outcome. Data on all measures were obtained from the American Community Survey. *ZIP‐Code level insurance coverage information was only collected by the United States Census American Community Survey beginning in 2013. Other public insurance does not include Medicare or TRICARE.

FIGURE 4

The Impact of the first FQHC in a primary care service area on late prenatal care initiation and birth outcomes. The black dots show the ${\widehat{\mathit{ATT}}}_k$, or difference between the treatment group and synthetic control, for each k years relative to the year of treatment (k = 0). The gray bands are 95% confidence intervals from the wild bootstrap procedure.