Racial and Ethnic Disparities in Prenatal Care Utilization During the COVID Pandemic: Comparison Between Medicaid Expansion and Non-expansion States

This entry is part 13 of 17 in the series July 2023

Prenatal care utilization decreased during the pandemic among women in non-expansion states, particularly for American Indians/Alaska Natives and Asian/Pacific Islanders, compared with expansion states.

American Indians and Alaska Natives (AIANs) and non-Hispanic Blacks experience much higher risks of maternal and infant mortality than other racial and ethnic groups. While racial and ethnic disparities in mortality rates might partly stem from inadequate prenatal care utilization, racial and ethnic disparities have long existed in access to prenatal care in the United States. As detailed in our peer-reviewed paper in the JPHMP, we also found marked disparities in access to prenatal care during the COVID-19 pandemic.

Although the Medicaid expansion under the Affordable Care Act (ACS) in 2014 did not target pregnant women, uptake of Medicaid coverage might improve the coverage through private insurance among women. Previous findings on the impact of the ACA Medicaid expansion on prenatal care are varied. During the pandemic, prenatal visits decreased, and delayed care increased. Given the mixed findings on the impact of Medicaid Expansion on access to prenatal care and disparities in prenatal care utilization among racial and ethnic groups, we examined the impact of the COVID-19 pandemic on prenatal utilization by race and ethnicity and by Medicaid expansion status among US women who gave a birth during 2019 and 2020. For our analysis, we used 7.4 million birth records from the 2019-2020 National Natality file, which was based on 100% of the birth certificates registered in 50 US states and the District of Columbia (DC).


We found that prenatal care utilization decreased during the pandemic among women in non-expansion states, particularly for AIANs and Asian and Pacific Islanders (APIs), while women in expansion states had little change in prenatal care utilization.

  • During the COVID-19 pandemic, the adjusted odds of having no prenatal care decreased by 3% in expansion states but increased by 15% in non-expansion states.
  • In expansion states, most racial and ethnic groups experienced a significant decrease in odds of having no prenatal care, including a 6% decrease for non-Hispanic Blacks, a 14% decrease for AIANs, and a 7% decrease for Hispanic women.
  • In non-expansion states, the odds of having no prenatal care increased significantly by 17% for non-Hispanic Whites, 11% for non-Hispanic Blacks, 43% for AIANs, 27% for APIs, and 15% for Hispanics.
  • Women in expansion states experienced no change in delayed prenatal care during the pandemic, but women in non-expansion states experienced an increase in delayed care.


  • The ACA’s Medicaid expansion was associated with improvements in prenatal care utilization during the COVID-19 pandemic.
  • During the pandemic, Medicaid expansion states experienced a decrease in having no prenatal care or delayed prenatal care, while non-expansion states had an increase in having no prenatal care or delayed prenatal care.
  • The deterioration of prenatal care access among AIAN women in non-expansion states is of major concern. It is particularly important to improve prenatal care access among AIAN women to mitigate racial and ethnic disparities in infant mortality, maternal mortality, and birth outcomes.
  • APIs in non-expansion states had the second highest increase in having no prenatal care during the pandemic, suggesting a need for a comprehensive policy and practice approach that considers language barriers and cultural differences.

To learn more, read our research report, “The Differential Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among US Women by Medicaid Expansion and Race and Ethnicity,” in the July 2023 issue of the JPHMP.

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Hyunjung Lee, PhD, is a principal scientist in the Cancer Disparity Research team within the Surveillance and Health Equity Science (SHES) department at the American Cancer Society (ACS) and a visiting fellow at Department of Public Policy and Public Affairs, John McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston. Her research focuses on social and behavioral determinants of health disparities among vulnerable populations. She particularly focuses on social and environmental conditions that can be changed through policy action.

Gopal K. Singh, PhD, is a career federal scientist with over three decades of experience in public health research. He has published four books and more than 200 peer-reviewed articles in the field of health inequalities, population health, health equity, social determinants of health, maternal and child health, and cancer and cardiovascular epidemiology.

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