Prenatal care to primary care: Understanding medical and psychosocial risk in Medicaid- insured pregnant women for transition to primary care

Background: The Affordable Care Act may provide opportunities for Medicaid insured pregnant women to move from prenatal care to primary care. A better understanding of psychosocial and medical risk factors may help to better identify and target populations of young women for primary care who are especially vulnerable for long term health problems. Objective: To evaluate whether pregnant women screened at high psychosocial risk during pregnancy also have higher rates of medical problems, underutilization of health services, and lack of basic health resources. Further, to compare whether there were differences among Black women with high psychosocial risk and others. Methods: A statewide analysis of 30,942 women with singleton live births in 2009 and 2010, who were enrolled in Medicaid care coordination through enhanced prenatal services (EPS). Linked vital record, Medicaid, and EPS data from the Michigan Department of Community Health were used. Women were identified as high risk based on an EPS algorithm (moderate to severe depression screen, violence, illicit drug use, alcohol use, no prenatal care established by second trimester, homeless). Bivariate and multivariate logistic regressions were used. Results: Overall, 38% of women reported any chronic illness; 25% smoked; 32% had a prior history of mental health diagnoses; 41% scored at high stress levels; about a quarter had food insecurity or housing instability; and 50% did not return for a postpartum visit. Using the EPS algorithm, 34% scored at high psychosocial risk. Women at high psychosocial risk had significantly higher rates of any chronic illness, asthma, hypertension, and heart/lung/kidney disease, when compared to other women. High psychosocial risk women were also more likely to smoke (34% vs.21%); had higher rates of a previous mental health problems (44% vs. 26%); reported higher stress (60% vs. 28%), have food insecurity (30% vs. 18%) or housing instability (34% vs. 22%), with a trend for incomplete postpartum visit. High psychosocial risk Black women had significantly higher rates than other high-risk women for these factors, except chronic conditions. Results were significant at p<0.01. Conclusion: Our study indicates that women identified at high psychosocial risk during pregnancy are more likely to have medical problems, risk behavior, high stress, and lack basic resources, associated with long term health problems, and would benefit from efforts to transition to primary care. Mechanisms are needed to improve collaboration between prenatal care and primary care, including EPS care coordinators, who continue to address psychosocial risks during the interconception period.