Who receives adequate prenatal care in Ohio, and who doesn’t?

Five years of Ohio birth records reveals a stark reality about prenatal care inadequacies in Ohio, especially for uninsured, BIPOC, or undereducated patients. Access to prenatal care is important for birthing healthy babies and it’s a priority area that The Center for Community Solutions is regularly writing, and writing, and researching, and writing, (and still writing!) about.

After combing through roughly 641,000 birth records (2018-2022), communicating with the Ohio Department of Health (ODH), and creating a massive Pivot table, there are some noteworthy findings. During that five-year period, 15.8 percent of births were deemed to have inadequate prenatal care. This represents a little over 94,800 births, slightly higher than the national rate of 14.5 percent. Our healthcare systems do not appear to prioritize—or are less successful with—delivering prenatal care to birthing people:

  • Who are uninsured
  • Who are Black, Hispanic and/or American Indian
  • Who have less than a high school diploma education

These indicators are certainly not mutually exclusive, nor are they exhaustive. They are, however, helpful in providing some insight into who is, and who isn’t getting adequate prenatal care.

How prenatal care adequacy is measured

One of the most common tools for rating the adequacy of a birthing person’s prenatal care is the Adequacy of Prenatal Care Utilization (APNCU) Index, also referred to as the Kotelchuck Index. This Index, as described by Dr. Kotelchuck himself, uses two data points to make a determination:

1) When prenatal care was initiated

2) The ratio of prenatal visits attended over the number of prenatal visits recommended by the    American College of Obstetricians and Gynecologists.

These two data points are used to rate a person’s prenatal care as either: Inadequate, Intermediate, Adequate, or Adequate Plus. The APNCU Index has critics, which point out limitations; for example, the scale may tend to miscategorize premature births, but that goes beyond the scope of this analysis. Of note: the APNCU Index is not a measure of the quality of the actual prenatal care received.

Prenatal care in Ohio; who isn’t getting the help?

The disparity between white birthing people compared to American Indian, Black, and Hispanic birthing people in the percentage of births categorized as adequate/adequate plus was 11 to 13 percentage points.

Less than half of uninsured birthing people had adequate prenatal care.

Less than half (46 percent) of uninsured birthing people had adequate prenatal care. Nearly nine in ten birthing people with private insurance received adequate/adequate plus prenatal care, compared to roughly seven in ten people on Medicaid. Over half of uninsured individuals didn’t receive adequate care.

The percentage of birthing people who received inadequate care shrunk with each category of more formal education. An alarming 49 percent of people with an 8th grade education or less received inadequate care, compared to only eight and seven percent of people with a Bachelor’s or a Graduate degree, respectively.

Exploring the disparities

It is well established that not only does the United States have high rates of maternal and infant mortality compared to other countries, but that this burden is disproportionately experienced by Black birthing people. In the state of Ohio, Black infants are 2.8 times more likely to die than white infants, and infant mortality continues to rise according to a report released just this week by the Ohio Department of Children and Youth.

In the state of Ohio, Black infants are 2.8 times more likely to die than white infants.

These disparities exist regardless of the birthing person’s education/income. Adequacy of prenatal care and birthing outcomes/mortality are not the same thing, so I wanted to explore if these established racial disparities could be identified in the APNCU Index data as well, regardless of education or insurance status.

Regarding race/ethnicity and education, the previously discussed relationship between educational attainment and adequacy of care was observed amongst white, Black, and Hispanic birthing people; as educational attainment rose, rates of prenatal care inadequacy dropped. However, at all levels of educational attainment, white birthing people had the lowest rates of inadequate prenatal care compared to Black individuals and Hispanic individuals of any race.

White individuals with high school diplomas had essentially the same rates of inadequate care as Black individuals with graduate degrees. Of some note, this disparity in prenatal care was minimal amongst individuals without a high school diploma.
The results for insurance status and race/ethnicity were much of the same story; regardless of insurance type, white birthing people almost always had lower rates of inadequate prenatal care. The one exception to this was for uninsured individuals; 42 percent of white and 42 percent of Hispanic individuals received inadequate care. However, this rate of 42 percent was still eight percentage points lower than for Black individuals without insurance, half of whom didn’t receive adequate prenatal care.

Interpreting the information; avoiding racist traps and tropes

A natural next step is to wonder why these disparities exist. But it’s important to not to interpret the data without context, nor should we fall into the common trap of assigning individualistic shortcomings to systemic failings (the myth of individualism is revered in the United States).

To blame birthing individuals who didn’t receive adequate prenatal care—with little understanding of context—would lead to dangerous and racist hypotheses.

To blame birthing individuals who didn’t receive adequate prenatal care—with little understanding of context—would lead to dangerous and racist hypotheses like ‘white people care more about their births, which is why they prioritize seeking out more prenatal care.’ A theory like this ignores centuries of systemic racism and oppression, and instead subscribes to false racialized narratives about lazy single mothers on welfare.

Instead, there is well established research on the systemic causes for health disparities by race that must be considered when interpreting these findings. According to the Centers for Disease Control, “Health disparities are inequitable and are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources.” Black birthing people also may experience medical racism, such as medical professionals not believing their pregnancy related pain. Or implicit bias and microaggressions amongst medical professionals, which can ruin rapport, limit treatment options provided to Black patients (because medical professionals assume they won’t be adhered to), and increase reports of mistreatment.

Finally, the link between the stresses of experiencing racism and a litany of negative health outcomes (including adverse birth outcomes). All of this information provides critical context for why Black and Hispanic birthing people are receiving less adequate prenatal care than their white neighbors. It’s not as simplistic as individual failings. If it sounds like I’m belaboring a point here, it’s because I am. Analyses like this have a history of being weaponized against BIPOC communities to pass predictably cruel and ineffective legislation.

Humanizing the data

The newly released Infant Mortality Report by the Ohio Department of Children and Youth indicates that since 2012, more people of all races are accessing prenatal care. While this is encouraging, there are still populations of birthing people in Ohio that are more likely to not receive adequate prenatal care.

The Ohio Department of Health aims to address these disparities with programs like the Ohio Equity Initiative, which seeks to provide funding to local programs working to address the inequities in birthing experiences. Part of this funding aims to employ the use of Local Neighborhood Navigators (read about one team in Hamilton County) to reach Black populations in Ohio and connect them with adequate birthing care. The navigators emphasize “non-traditional avenues of outreach designed and tailored to identify people where existing systems and programs do not currently reach.” There are also programs like First Year Cleveland, which seek to help Black families before, during, and after their pregnancies.

It may be easy to get lost in the data of hundreds of thousands of birthing Ohioans.

It may be easy to get lost in the data of hundreds of thousands of birthing Ohioans. Grounding ourselves in human scale stories help frame the data and offer a bit of hope. A piece by Zulma Zabala, Becoming a Mom: The Risks We Face, recounts the trauma of childbirth and solutions to helping other BIPOC birthing people stay safe during that vulnerable experience. Second, a piece by Taneisha Fair, Village of Healing: A Beacon of Hope, reflects on the historic and ongoing racism Black women have faced in childbearing and birthing, and an affirmation of the amazing work being done in the community to provide meaningful care to birthing Ohioans.


Note: This study includes data provided by the Ohio Department of Health which should not be considered an endorsement of this study or its conclusions