The United States (U.S.) rates of maternal morbidity and mortality surpass rates in other high-income countries (Tikkanen et al., 2020). Women from racially and ethnically minoritized groups experience higher rates of maternal morbidity and mortality compared to white women (Hoyert, 2024; Interrante et al., 2022). For example, Black women experience two to three times the rates of severe maternal morbidity and maternal mortality compared to white women (Hoyert, 2024). Racially and ethnically minoritized families also experience disproportionately higher rates of neonatal and infant mortality and preterm births (Kozhimannil et al., 2018; Laurore et al., 2020; B. Wu et al., 2023); Black infants experience 60% higher rates of preterm birth and nearly double the risk of infant mortality during their first year of life (MacDorman & Mathews, 2011). Although there is limited data on Native Hawaiian and Pacific Islander (NHPI) and American Indian and Alaska Native (AIAN) communities, the available data demonstrates both groups have increased risk of maternal morbidity and mortality and increased rates of preterm birth and low birth weight (Anderson et al., 2016; Burns et al., 2023; Heck et al., 2021; Nembhard et al., 2019; Raglan et al., 2016; Rhoades et al., 2008; Wong et al., 2008; Bohao Wu et al., 2023). Births covered by Medicaid, regardless of race or ethnicity, have higher rates of severe maternal morbidity and mortality (Agency for Healthcare Research and Quality, 2024; Chen et al., 2021). Adequate prenatal care use was trending upward prior to 2020 but steeply declined afterward with severe consequences for Hispanic individuals (Lee et al., 2024).

Initiating prenatal care early and attending all recommended prenatal care visits throughout pregnancy allows for early detection and management of maternal and infant health concerns and increases the likelihood of delivering a healthy infant (Michel & Fontenot, 2023; S. Partridge et al., 2012). Early and adequate prenatal care has also been associated with reduced risk of adverse maternal and infant outcomes by improving management of preexisting conditions as well as by detecting conditions that emerge during pregnancy, such as gestational diabetes (Michel & Fontenot, 2023; S Partridge et al., 2012; S. Partridge et al., 2012). Variations in prenatal care utilization may contribute to racial/ethnic disparities in perinatal outcomes. Previous studies have shown Black women are more likely to receive inadequate prenatal care, a factor associated with increased risks of maternal mortality and poor infant outcomes (Green, 2018). The American College of Obstetricians and Gynecologists recommends initiating prenatal care by the first trimester (ACOG, 2017). The recommended number and frequency of prenatal care visits depends on the stage of pregnancy in which prenatal care was initiated, the weeks of gestation when birth occurs, and risk factors. For example, a woman with a low-risk pregnancy who gives birth at 40 weeks would attend 12 to 14 in-person prenatal care visits following the recommended schedule (Peahl & Howell, 2021).

Given the importance of prenatal care utilization on the health of women and infants, this study examined differences in prenatal care utilization by race/ethnicity and payer using three separate measures of inadequate prenatal care, including having 1) fewer than the recommended number of prenatal care visits, 2) late initiation of prenatal care (at or after 4 months gestation), or 3) no prenatal care.

Early and adequate prenatal care utilization improves health outcomes for both women and infants (S Partridge et al., 2012). This national study of birth records found significant variation in prenatal care utilization by race/ethnicity, with all minoritized racial/ethnic groups having greater risk for multiple measures of inadequate prenatal care utilization relative to white populations and with Medicaid-covered births having increased risk of inadequate prenatal care for every minoritized racial/ethnic group. Given the improvements in maternal and infant outcomes associated with prenatal care and the large racial/ethnic disparities in perinatal outcomes (Hoyert, 2024; MacDorman & Mathews, 2011), understanding factors associated with prenatal care is important for reducing inequities in perinatal outcomes.

When assessing differences in prenatal care utilization by race/ethnicity, the largest disparities were found for NHPI and AIAN women. Specifically, NHPI women had more than twice the risk of late initiation of prenatal care or no prenatal care and approximately 40% higher risk of having fewer than the recommended number of visits. AIAN women similarly had more than twice the risk of no prenatal care and approximately 31% higher risk of having late initiation of prenatal care.

Although prior literature has documented disparities in prenatal care utilization in other minoritized populations (Green, 2018), our study provides new information documenting disparities in prenatal care utilization among NHPI and AIAN women, who have been underrepresented in the maternal health literature, either because of the relatively smaller size of this population compared to other groups or the frequent aggregation of their data with Asian populations. To our knowledge, this is the one of the first national studies to report prenatal care utilization among NHPI and AIAN. Prior qualitative research has identified several barriers to prenatal care including difficulty understanding and navigating Medicaid, a lack of transportation or financial resources to get to appointments, language barriers, and concerns about lack of culturally congruent care (Ayers et al., 2018; Hanson, 2012). Prior research with NPHI subpopulations has also identified a lack of awareness of the importance of early and consistent prenatal care among some groups and experiences with discrimination and fear when seeking prenatal care (Ayers et al., 2018; Hanson, 2012). Experiences of language barriers, discrimination, and fear are unsurprising given NHPI populations are underrepresented in many facets of medicine (e.g., the physician workforce, clinical research) and are the least represented racial/ethnic group in U.S. medical schools (Association of American Medical Colleges, 2023; Sakala et al., 2018). Many extant studies fail to disaggregate Asian and NHPI individuals (Heyrana et al., 2023; Taparra, 2021); however, survey research of California revealed Asian and NHPI birthing individuals in composite are less likely to seek certain types of care and more likely to experience biased care related to their languages (Sakala et al., 2018). The stark disparities in prenatal care utilization among NHPI and AIAN women compared to white women found in our study is concerning. Given the prior research documenting both NHPI and AIAN have poor maternal and infant health outcomes (Anderson et al., 2016; Burns et al., 2023; Heck et al., 2021; Nembhard et al., 2019; Raglan et al., 2016; Rhoades et al., 2008; Wong et al., 2008; Bohao Wu et al., 2023), a lack of prenatal care may contribute to or exacerbate these poor outcomes.

Women who are Medicaid recipients, regardless of race/ethnicity, were more likely to have fewer than the recommended number of prenatal care visits and were less likely to have early prenatal care than those with private/other insurance. This finding supports a national study of delivery hospitalizations that reported the highest rates of maternal morbidity and mortality among Black, AIAN, Asian, and NHPI women with Medicaid (Interrante et al., 2022). Further analysis demonstrated there was a significant interaction between race/ethnicity and payer across all three prenatal care utilization variables, with the greatest impact associated with Medicaid coverage among white women who had almost three times the relative risk of receiving no prenatal care compared to white women with private/other insurance.

This study does not investigate why Medicaid was associated with significantly less prenatal care utilization. However, it is important to note that Medicaid policy varies state by state and several policies and practices may have contributed to the association. Many states do not offer presumptive Medicaid, requiring women to wait until their Medicaid application is complete and approved before they can access prenatal care. Additionally, states vary regarding Medicaid and Children's Health Insurance Program (CHIP) coverage for qualified immigrants, with some states not offering coverage and some states requiring a five year wait period for qualified immigrants (Interrante et al., 2024). Many health care providers will not see patients until their Medicaid is approved and will often limit the number of Medicaid patients they take (Bellerose et al., 2022). Some states utilize a bundled payment approach for perinatal care, which reduces financial incentives for additional prenatal care visits or for seeing women early in their pregnancy (MACPAC, 2021). Women qualify for Medicaid when they are pregnant if their income is at ~200% of the federal poverty limit (Healthinsurance.org, 2024). Because Medicaid eligibility is income-based, individuals enrolled in Medicaid have lower household incomes and may face additional barriers to prenatal care utilization, such as lower health literacy and challenges related to transportation and childcare (Bellerose et al., 2022). ACOG emphasizes the importance of Medicaid reimbursement rates matching the cost of care to ensure sustainable and equitable access to high-quality care for eligible patients (ACOG, 2021).

We found a statistically significant difference in prenatal care utilization between women living in rural and urban areas. Women living in urban areas were more likely to have inadequate prenatal care visits and no prenatal care compared to those living in rural area. Urban women were also more likely to experience late initiation of prenatal care compared to those living in rural areas. This finding differs from some studies which have documented higher rates of inadequate prenatal care utilization among rural women when using individual state-level birth record data (McElfish et al., 2025). Few prior studies have used a nation-wide U.S. sample to examine rural/urban difference in prenatal care utilization. Analysis of U.S. Pregnancy Risk Assessment Monitoring System data found rural women had lower odds of receiving adequate prenatal care compared to urban residents (Polavarapu et al., 2024). Additional research with more nuanced use of the RUCC codes is needed to better understand disparities in prenatal care utilization. While most prior studies have used a dichotomous classification, with the three most populus codes representing metro/urban and the six less populus codes representing non-metro/rural (Economic Research Service, 2025), scholars have begun to criticize the utility of this classification and called for classifications that consider very urban, suburban, rural, and frontier.

Racial/ethnic and economic disparities in perinatal health in the U.S. are of national concern. Prenatal care is an important intervention to prevent adverse maternal and newborn outcomes. This study identifies racial/ethnic differences in prenatal care utilization, particularly for NHPI and AIAN women, that may contribute to disparate maternal health outcomes. Differences in prenatal care between women with Medicaid and private/other insurance also suggest modifications to Medicaid policies may improve prenatal care access among beneficiaries.