Medicaid status, race and ethnicity are independently associated with increased odds of severe maternal morbidity

1. Medicaid status was independently associated with higher odds of having severe maternal morbidity and mortality across racial and ethnic patient populations.

2. Maternal morbidity rates increased over 40% from 2015 to 2022.

Evidence Rating Level: 3 (Average)

Study Rundown: Maternal morbidity and mortality rates continue to rise in the United States, and disproportionately affect racial and ethnic minorities and Medicaid recipients. However, the intersectional relationship of insurance coverage and race and ethnicity is undefined in the literature and not reflective of recent changes in legislation regarding Medicaid and reproductive health policies. Srajer et al. evaluated nationwide severe maternal morbidity (SMM) trends and the intersectional influence of insurance status and race and ethnicity. Using the National Inpatient Sample, this cross-sectional study included over 27 million weighted delivery hospitalizations from 2015-2022 in the United States. Patients were assessed for insurance status (Medicaid, private), and race and ethnicity before cross-classification into intersectional groups. Within the study period, composite SMM rates increased over 40% and individual complications increased by over 76%. The odds of SMM were elevated in all intersectional groups compared to White privately insured patients and in Medicaid recipients compared to the privately insured. Notably, Medicaid status was independently associated with higher SMM odds and mortality rates across race and ethnicity groups. This study demonstrates that American maternal outcomes are worsening and impacted by structural inequities tied to Medicaid status and race and ethnicity. These challenges suggest a need for further policy reform regarding maternal health. The study benefits from its use of a national dataset and validated health measures but is confined by its limited, predetermined race and ethnicity categories and exclusion of ante- and post-partum hospitalizations.

Click here to read the study in JAMA.

Relevant Reading: “Race, Medicaid Coverage, and Equity in Maternal Morbidity”

In-Depth [cross-sectional study]: Srajer et al. conducted a serial cross-sectional study with delivery hospitalization data (2015-2022) from the National Inpatient Sample which contains a stratified sampling of American hospital discharges. A validated health database algorithm was used to identify pregnancy-related hospitalizations; deliveries involving miscarriage, therapeutic abortion, molar/ectopic pregnancies were excluded. Exposure variables included insurance coverage (Medicaid vs. private) and race and ethnicity (Asian or Pacific Islander, Hispanic, Native American, Black, White). Outcomes were determined by ICD-10 codes with primary outcomes being composite SMM (hospitalizations with at least one SMM complication), nontransfusion-only SMM (ntSMM), and SMM-related mortality.

Of the 27,341,986 weighted delivery hospitalizations included, composite SMM was more prevalent in Medicaid recipients, caesarean deliveries, and racial and ethnic minorities. Across the 7-year period, composite SMM and ntSMM rates grew to 40.5% and 36.2%, respectively. Additionally, most individual complications and SMM-related mortality increased significantly (p<0.001, p<0.0001), with the only decreasing complication being eclampsia. The most prevalent complications included blood transfusion, sepsis, and disseminated intravascular coagulation. Black, Hispanic, and Native American patients made up more of the Medicaid population than in the privately insured.

Odds of composite SMM and nt-SMM increased with Medicaid status and across racial and ethnic minorities compared to private insurance and White patients, respectively. Adjusted odds of composite SMM were additionally elevated across intersectional groups in comparison with White patients with private insurance. In Black, Hispanic, and White populations, Medicaid status was associated with increased odds of SMM-related mortality. Higher odds of mortality were present in both privately and Medicaid insured Asian or Pacific Islander patients. Odds of kidney failure, transfusion, sepsis, and sickle cell crisis were elevated across all racial and ethnic minorities.

Citation: Srajer A, Ronksley P, Quinn A, Brennand E, Metcalfe A. National Trends in Severe Maternal Morbidity by Insurance and Race and Ethnicity. JAMA Netw Open. 2026 Nov 2;9(11):e2642154. doi: 10.1001/jamanetworkopen.2026.42154. PMID: 42975897; PMCID: PMC13732502.

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