Dr. Bryant Mantha’s clinical, research, and health policy interests concern racial, ethnic, and socioeconomic disparities in obstetrical care and pregnancy outcomes. She is particularly interested in expanding health care coverage of women’s health and family planning before and between pregnancies as a means to improving birth outcomes for underserved women. She pursued additional research methodology training at University of California, San Francisco (UCSF), and completed a KL2 award at UCSF and an Amos Medical Faculty Development Award through the Robert Wood Johnson Foundation. Her research uses mixed methods to determine barriers to and impact of interconception care on pregnancy outcomes in low-income populations. Dr. Bryant Mantha served on the advisory board of California’s Black Infant Health Program and the Women’s Health Advisory Board of the San Francisco Department of Public Health. She currently serves as a member of the Boston Public Health Commission’s Clinical Task Force for Perinatal Care. Dr. Bryant Mantha attended Harvard College, graduating cum laude with a degree in Biology in 1994. She graduated from Harvard Medical School in 1998, and completed her residency in Obstetrics and Gynecology at the Brigham and Women’s and Massachusetts General Hospitals in 2002. She also completed training in Maternal Fetal Medicine at the Brigham and Women’s Hospital in 2005. She was a CFHU Fellow, and received her M.P.H. from the Harvard School of Public Health in 2004.
Allison Bryant Mantha, MD, MPH
Associate Professor of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA
Potential Impact of the Medicaid Family Planning Waiver Upon Racial Disparities in Pregnancy Outcomes
To determine the potential role of changes in financial access to interconception care and family planning to reduce racial disparities in pregnancy outcomes, including short interpregnancy intervals and very low birth weight births and deaths, using the Florida Medicaid Family Planning Waiver as a model.
There are marked disparities in urban communities between rates of infant mortality, preterm birth and very low birth weight for Black and White infants. Risk factors for these adverse outcomes include poor maternal health status, short interpregnancy intervals and unintended pregnancy, all of which are more common amongst Black women. Current Medicaid policy allows for expanded coverage of prenatal care in all states, but these policies have not been shown to significantly improve pregnancy outcomes, especially those outcomes which are influenced by maternal health status prior to pregnancy. In the majority of states, the expanded eligibility to provide pregnancy health care coverage terminates 60 days after delivery. Eighteen states, including Florida, have implemented Medicaid Family Planning Waivers, providing family planning and primary care services to women who would otherwise lose their Medicaid coverage postpartum. While these programs have been evaluated for budget-neutrality and effects upon subsequent birth rates, there has been little discussion of the potential impact of the programs upon racial disparities in health outcomes.
Two analyses were undertaken: in the first, data was used from the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) database to examine rates of poor pregnancy outcomes amongst Black and White women in the time period before the implementation of the waiver and the period after. In the second, Medicaid claims data, linked with birth files from vital records, were used to assess the proportion of teens with Medicaid deliveries in 1999 that went on to have a subsequent birth within 24 months. Results were stratified by race, a proxy for income, and use of family planning services, as defined by the presence of a Medicaid family planning claim.
Subsequently, modeling was undertaken to estimate the number of averted births and very low birth weight births. Lastly, several interviews were conducted with key members of the public health infrastructure in Florida in an attempt to gain further understanding of the findings qualitatively.
In the first analysis, there was a significant decline in proportions of Black and White women with Medicaid-funded deliveries in the time period after implementation of the Family Planning Waiver (2000-2001) as compared with the period before (1996-1997). Between the two time periods, there were no significant differences in rates of very low or low birth weight births to either Black or White women, and there was no apparent change in the Black-White disparity. In the second analysis, Black teens had similar rates of Medicaid family planning claims as did Whites, but as compared to non-users of family planning services, Black teen family planning users had a greater reduction in rates of subsequent births within two years of an index pregnancy than did Whites (34% vs. 16% reduction, p<0.001). A greater number of averted and potentially averted total and VLBW births amongst Black teens (RR 2.66 – 9.76, p<0.001) is also noted. Interviews with key members of the public health community in Florida revealed several common themes which might explain these findings.
Providing interconception care and family planning services through programs like the Medicaid Family Planning Waiver may have differential effects upon health outcomes amongst Black women as compared to White women. Improving access to care and baseline health status of women prior to pregnancy is likely to reduce some of the racial disparities in pregnancy outcomes.
Magda Peck, ScD, Executive Director, CityMatCH
Paul Wise, MD, MPH, Co-Chief, Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital