Examining the Impact of States’ Title X Investments on Maternal Mortality

• In Event: State and Local Evidence for Policy Change and Vulnerable Populations

Abstract

A significant public health problem facing the US is that it has the highest rate of maternal mortality in the developed world. Moreover, severe maternal morbidity (e.g., eclampsia, acute heart failure, severe hemorrhage) is also on the rise and nearly 100 times more common than maternal mortality. These adverse maternal health outcomes highlight key gaps in the US health care system that put at risk the lives of women – especially black women – and defy at least some traditional explanations for why US women are dying giving birth (e.g., insurance status doesn’t appear to be predictive). This project aims to systematically evaluate the public health impact of family planning policies on maternal health, and offer guidance for additional scholars seeking to better grasp this public health problem and successful policy interventions.

We evaluate the public health impact of investments in Title X across the 50 states for over 10 years. Despite the US’s comparatively high maternal mortality rate, there is little systematic analysis of its prevalence and mitigating factors across several states and over time, and we address this deficit in the literature. We expect that given the wide-ranging services offered at Title X clinics – wellness exams, contraceptive care, STD testing and treatment, HIV testing, cancer screenings – greater access to these clinics will facilitate healthier and more planned rather than unplanned pregnancies, and in turn be associated with better maternal health outcomes within lower-income populations. While Title X reauthorizations had long been bipartisan, amid rising polarization at both federal and state levels it has since been entangled in the politics of abortion restrictions. The question then arises to what extent Title X cuts due to increased restrictions on abortion access can have spillover effects of increasing other adverse non-abortion-related women’s health outcomes such as maternal mortality and morbidity.

To test our hypotheses, we FOIAed from HHS the list of Title X clinics across the US from 1996-2018, amount of money allotted to each of them per year, and number of medical services rendered per clinic per year so as to gauge at the state- and county-year level the number of clinics in the communities, the extent to which they are resourced, and the extent of community reliance on them. Our main dependent variable is the state-year maternal mortality rate, identified through the CDC Wonder database at the state level and supplemented with data from the county-level Global Health Data Exchange. Because we also seek to evaluate the broader impact of access to these safety-net programs (e.g., entry of prenatal care and likelihood of having a postpartum visit), we utilize the CDC’s Natality and PRAMS (Pregnancy Risk Assessment and Monitoring System) datasets, the latter of which also asks detailed questions on such topics as whether women experienced domestic violence before or during pregnancy, indicators for economic insecurity, and depression during pregnancy and postpartum, all risk factors for adverse maternal health outcomes.

We conduct multivariate statistical analysis of states’ Title X enrollment, funding levels, and number of safety-net clinics, and the impact that we observe on maternal health, with state and year fixed effects. We find that greater state-year investments in Title X clinics are not only associated with lower maternal mortality rates overall, but are associated with a narrowed racial gap between the maternal mortality rates of white and black women. We do not find a difference in the racial gap in maternal mortality rates between white and Hispanic women, though Hispanic women’s maternal mortality rate is actually slightly lower than that of white women, while black women’s maternal mortality rate is staggeringly higher.

That states’ Title X investments have a statistically and substantively significant effect in reducing both the overall maternal mortality rate and reducing the racial gap in maternal mortality (the bluntest measure under our examination) highlights both the significance of this policy investment and the adverse public health consequence of tying this health program to policies specific to the more politically controversial procedure of abortion. We examine also the more sweeping public health impact of states’ investment in Title X as evidenced by such factors as health status and behaviors before and during pregnancy, timing of women’s entry into prenatal care, and efforts to improve health prior to pregnancy. These cumulatively shed light on the important public health impact of Title X – a highly salient safety-net family planning program newly targeted by the Trump Administration – on the apolitical issues of maternal mortality and other key maternal health outcomes now endangered by sweeping attacks on the program based on its now prior association with some organizations that included abortions among its services provided.

Authors

• Miranda Elyse Yaver, University of California, Los Angeles

• Atheendar Venkataramani, University of Pennsylvania