Pre-Conception & Pregnancy in Ohio

Pre-Conception & Pregnancy in Ohio Elizabeth Conrey, PhD 1 January 217 1 State Maternal and Child Health Epidemiologist, Ohio Department of Health

EXECUTIVE SUMMARY The primary objective of the analyses in this chartbook is to describe the preconception health and health care of Ohio women aged 19-44 years, considered of reproductive age. Preconception health is the health of a woman during her reproductive years. Preconception health care is the medical care a woman receives that may increase the chance of having a healthy baby. Differences by demographics and changes over time are explored. Data from the 212 and 215 Ohio Medicaid Assessment Surveys (OMAS) were analyzed and figures are presented throughout the chartbook. Estimates in this chartbook profile 1) healthcare coverage, (insurance status), 2) healthcare access, utilization and quality, 3) health status, 4) health behaviors, and 5) select pregnancy and postpartum characteristics. Key findings from this analysis included: Women of childbearing age are generally doing better in 215, compared to 212, with greater educational attainment and less poverty and unemployment. Women report better healthcare coverage. The uninsured rate decreased among women of all races and ethnicities. The proportion covered by Medicaid insurance increased while employer-sponsored insurance remained unchanged. Experiencing a gap in insurance coverage in the past year increased within nearly all groups assessed. Fewer women reported any unmet healthcare need in 215 and racial disparities in unmet needs lessened. Across poverty levels, race/ethnicity, and educational attainment, more women had routine checkups. Fewer women were cigarette smokers in 215, but the smoking rate remained high, especially among women with less than a high school education. Fewer women are reporting poor health status, with the largest improvement seen in women aged 25-34 or who identified as Hispanic. However, more women were obese. These findings suggest that the preconception health and health care of Ohio women has recently improved. However, some groups continue to have challenges achieving optimal health and healthcare post Medicaid expansion and many women experience gaps in insurance coverage. Visit www.grc.osu.edu/projects/omas for additional information about OMAS, including the data and electronic version of this chartbook. 2

CONTENTS BACKGROUND Slide 4 OBJECTIVES Slide 5 METHODS Slide 6 REFERENCES Slide 53 ACKNOWLEDGEMENTS Slide 54 APPENDIX: DEFINITIONS Slide 55 RESULTS SECTION 1: DEMOGRAPHICS Slides 7-9 SECTION 2: HEALTH CARE COVERAGE Slides 1-15 SECTION 3: HEALTH CARE ACCESS Slides 16-32 SECTION 4: HEALTH BEHAVIORS Slides 33-36 SECTION 5: HEALTH STATUS Slides 37-46 SECTION 6: PREGNANCY AND Slides 47-5 POST-PARTUM KEY FINDINGS Slide 51 CONCLUSIONS Slide 52 3

BACKGROUND Women s Preconception Health Many babies in Ohio are born preterm, of low birth weight, or with birth defects, and Ohio s infant mortality rate is among the worst in the nation. The disparities in birth outcomes for certain racial and ethnic groups and geographic areas in Ohio are of particular concern. African-American babies are more than twice as likely to die in the first year of life as white babies and areas of urban and Appalachian Ohio represent locations of higher risk 1. Improving the health of women of childbearing age, before they conceive, is essential to changing these outcomes 2,3. Yet, many women do not receive evidence based prevention services, primary care, and treatment due to a lack of health coverage or limited access to care. Many women do not currently benefit from services that could improve their health for a lifetime and help them have healthy babies when, and if, they choose to do so. Unfortunately, many women also continue to face other barriers such as poverty or lack of education, and might live in neighborhoods that impede their ability to reach their potential for health and well being 4,5. Pregnancy A woman s health around the time of pregnancy may be different than when she is not pregnant. For example, certain conditions such as gestational diabetes are unique to pregnancy. Her healthcare access and utilization may also be unique around the time of pregnancy as her insurance eligibility may change and her inclination to seek care may also be different 6. The Ohio Medicaid Assessment Survey The Ohio Medicaid Assessment Survey (OMAS) is a telephone survey that samples both landline and cell phones in Ohio. The survey examines access to the health system, health status, and health determinant characteristics of Ohio s Medicaid, Medicaid eligible, and non-medicaid populations. OMAS is an important tool to help the Ohio Department of Medicaid and State of Ohio health-associated agencies identify gaps in needed health services, develop strategies to increase service capacity, and monitor Ohioans health status and health risk. Administered by the Ohio Department of Medicaid with the assistance of the Ohio Colleges of Medicine Government Resource Center (GRC), the OMAS is a critical research data set for assessing Ohioans access to and use of clinical health care, insurance status, chronic and acute conditions, mental health, and health status stressors such as poverty, joblessness, and low socioeconomic status. The OMAS provides data at the geographic levels of the State and for Ohio s Appalachian, rural, suburban, metropolitan county clusters, and Medicaid Managed Care Planning Regions. These data do not support estimates for all of Ohio s 88 counties. Work began on the 215 OMAS in August 214. The selected survey vendor, RTI International, began administering the survey in January 215 and completed data collection in the spring of 215. 4

OBJECTIVES The objectives of this report are to 1) Describe the following among Ohio women with 19-44 years of age, considered to be women of reproductive age: a. Demographics, b. Healthcare coverage, c. Healthcare access, utilization and quality, d. Health status, e. Health behaviors, and f. Select pregnancy and postpartum characteristics, and 2) Explore demographic differences in the above as well as changes between 212 and 215. 5

METHODS The Ohio Medicaid Assessment Survey (OMAS) is a populationbased survey that examines access to the health system, health status, and health determinant characteristics of Ohio s Medicaid, Medicaid eligible, and non-medicaid child and adult populations. The 215 OMAS used a random stratified dual-frame telephone survey design to collect data from samples representative of all non-institutionalized Ohio residents. This survey included both landline and cell phone frames. The landline sampling was based upon a list-assisted stratified random digit dial (RDD) procedure. African-Americans, Asians, and Hispanics were oversampled in landline sampling. The cell phone sampling was a stratified random sample of cell phone numbers by the county in which their cellphone was activated, with oversampling of African-Americans. From January through June 215, trained telephone interviewers administered the OMAS to 42,876 adult Ohio residents, with 16,453 completed in the landline sample and 26,423 completed in the cell phone sample. For landline telephone numbers, households were randomly selected through a list assisted 1+block RDD method. Upon reaching the household, the interviewer selected an eligible adult aged 19 years and older who had the most recent birthday to complete the adult component of the survey. For cellphone telephone numbers, persons were randomly selected through a random sample of cellphone numbers in eligible 1,-blocks. Upon reaching a person, the interviewer asked the predominant user of the cellphone, if he/she was 19 years or older, to complete the adult component of the survey. If the predominant user of the cellphone was under 19 years old, the telephone number was classified as ineligible for the survey. The overall response rate for the survey was 24.1%, including a 25.8% response rate for the landline sample and 22.9% for cell phone sample. A detailed description of the survey methodology can be found at www.grc.osu.edu/projects/omas. The analyses in this report are limited to women of reproductive age in the adult OMAS survey, aged 19-44 years. Point estimates and 95% confidence intervals were calculated accounting for survey design and weighting. 6

RESULTS SECTION 1: DEMOGRAPHICS Women of childbearing age are generally doing better in 215, compared to 212. The proportion of women with higher education increased while the proportion of Ohio women unemployed, impoverished and being uninsured decreased. The age distribution of Ohio women between 19-44 years shifted, with more of these women being older in 215, compared to 212. In 215, non-hispanic Whites made up 77.3% of Ohio women of reproductive age and Non-Hispanic Black women comprised 13.9% of this population. The majority of Ohio women of reproductive age lived in metropolitan counties. 7

DEMOGRAPHICS Figure: Demographics of Ohio Women (19-44 Years), by Education and Poverty Status, 212-215 6 5 51.4 46.6 212 215 4 3 2 1 9.9 9.2 34.7 29.7 9. 9.6 33.1 25.9 13.4 9.7 1.8 1.9 17. 14. 32.332.9 Less than high school High school graduate Education College degree Advanced degree 1% 11-138% 139-2% 21-3% > 3% Poverty Status (% FPL) More women of childbearing age in 215 have more education than in 212, and 34.7% of women had a college degree in 215 compared to 29.7% in 212. Nearly 1% of women obtained an advanced degree in 215. Poverty status is divided into categories based on percentage of the Federal Poverty Level (FPL). The figure above shows the percent of women living in poverty in 215 compared to 212. Overall women of childbearing age tend to have a lower rate of poverty in 215. 8

DEMOGRAPHICS Figure: Demographics of Ohio Women (19-44 Years), by Employment and Insurance Status, 212-215 8 7 6 5 4 3 2 1 62.2 69.8 37.7 3. 47.4 49.4 24.4 31.9 212 215 17. 7.7 Employed Unemployed Insured, employersponsored Insured, any Medicaid Uninsured Employment Status Insurance Status The chart above shows rates of employment increased nearly 8.% in 215 as rates of unemployment decreased. In 212, 17.% of women were uninsured compared to 7.7% in 215. There was a shift from uninsured to Medicaid from 212 to 215. 9

RESULTS SECTION 2: HEALTHCARE COVERAGE Women of childbearing age report better healthcare coverage in 215, compared to 212. The uninsured rate decreased by 11 percentage points to 7.7%, Medicaid coverage increased by 5.7 percentage points to 31.9%, and employer-sponsored insurance remained the same at approximately 49.%. Uninsured rates dropped the most for younger women and women with less than a high school education. Uninsured rates dropped for all race/ethnicity categories. Hispanics experienced the largest drop (18.6%), but still had the highest rate of uninsured in 215 (24%). As expected with Ohio s Affordable Care Act Medicaid expansion, women reporting incomes within the Medicaid expansion income threshold ( 138% FPL), had the largest decrease in uninsured rate at 16 percentage points. However, experiencing a gap in insurance coverage in the past year increased within nearly all groups assessed. 1

Insurance HEALTHCARE COVERAGE: Status INSURANCE Distribution STATUS DISTRIBUTION 6 Figure: Insurance Status of Ohio Women (19-44 Years), 212 and 215 212 215 5 49.5 49.4 4 3 26.2 31.9 2 18.7 1 8.8 6.6 7.7 Insured, any Medicaid Insured, employer-sponsored Insured, other Uninsured From 212 to 215, the rate of uninsured decreased 9.%, while the rate of women insured by Medicaid increased 5.7%. The rate of women insured by employer-sponsored plans remained relatively constant between 212 and 215. 11

HEALTHCARE COVERAGE: DEMOGRAPHICS OF UNINSURED Figure: Uninsured Ohio Women (19-44 Years), by Age and Education, 212 and 215 4 35 3 33.6 212 215 25 2 15 1 5 15.4 2. 8.8 1.4 5.3 3.9 3.4 18.9 18.6 9.3 7.9 14.5 6.3 Less than high school High school graduate Education College degree Advanced degree 19-24 25-34 35-44 Age The uninsured rate for Ohio women aged 19-44 decreased across all levels of education and age group from 212 to 215. The percentage of uninsured women with less than a high school education more than halved, decreasing from 33.6% to 15.4% in 215. However, women with less than a high school education are three times more likely to be uninsured compared to women with a college degree in 215. 12

HEALTHCARE COVERAGE: DEMOGRAPHICS OF UNINSURED 45 4 Figure: Uninsured Ohio Women (19-44 Years), by Race/Ethnicity and Poverty Status, 212 and 215 42.6 212 215 35 31.2 3 25 2 15 1 5 15.5 6.2 21.1 1.5 24. 12.4 8.8 25.2 1. 12.4 18. 1.4 14.9 7.2 5. 3.3 Non-Hispanic Non-Hispanic White Black Hispanic Non-Hispanic Other 1% 11-138% 139-2% 21-3% > 3% Race/Ethnicity Poverty Status (% FPL) The rate of uninsured non-hispanic White and non-hispanic Black women more than halved from 212 to 215. The largest decrease in rate of uninsured women was for Hispanic women, yet their rate of uninsured remains high at 24% in 215. Women within 11-138% of the FPL also saw a large decrease in rate of uninsured, decreasing from 31.2% to 12.4% in 215. 13

HEALTHCARE COVERAGE: GAP IN COVERAGE IN LAST YEAR Figure: Gaps in Insurance Coverage in the Past Year among Ohio Women (19-44 Years), by Insurance Type, 212 and 215 5 45 4 35 35. 45.2 212 215 3 25 2 15 22. 25.9 19.1 12.1 16.6 19.6 1 5 Overall Insured, any Medicaid Insured, employer-sponsored Insured, other Ohio women aged 19-44 were more likely to experience a gap in coverage in 215 (25.9%) than 212 (22.%). 14

HEALTHCARE COVERAGE: GAP IN COVERAGE IN LAST YEAR 45 4 35 3 25 2 15 1 Figure: Gaps in Insurance Coverage in the Past Year among Ohio Women (19-44 Years), by Education and Poverty Status, 212 and 215 15.4 38. 31.3 29. 21.7 17. 17.8 13.4 33.6 42.4 32.5 39.3 28.8 3.6 26.3 212 215 21.1 1. 8.1 5 Less than high school High school graduate College degree Advanced degree 1% 11-138% 139-2% 21-3% >3% In 215, more than double the rate of Ohio women with less than a high school education experienced a gap in insurance coverage over the past year than 215. Nearly all income levels experienced increases in gaps in coverage, with the largest increase (8.8%) for women 1% FPL. 15

RESULTS SECTION 3: HEALTHCARE ACCESS, UTILIZATION, AND QUALITY Women of childbearing age reported better health services utilization and less unmet needs in 212 than 215. Women reporting any unmet healthcare need decreased by 6.5 percentage points to 36%. Racial disparities in unmet needs lessened significantly. Unmet healthcare needs lessoned in the areas of dental health, prescription drugs, vision care, and mental health care and for all age groups, educational attainment groups, and insurance plan (i.e., Medicaid or employer-sponsored insurance) groupings. Healthcare utilization increased for routine checkups across poverty levels, race/ethnicity, and educational attainment. Having a routine dental visit did not change. Rate of care consistent with a patient-centered medical home was 3.6% in 215. Experience of this care decreased with decreasing income or education and was lower among minorities and women living in Appalachia. 16

UNMET HEALTHCARE NEEDS The percentage of women who reported any unmet need decreased from 42.5% in 212 to 36.% in 215. In 215, racial disparities in unmet needs were almost eliminated. In comparison to 212, the difference in unmet need between Non- Hispanic White women and Non- Hispanic Black women was reduced from 11.4% to 3.7%. In 212, 29.8% of Blacks reported unmet dental need in comparison to 18.6% of Whites. By 215, this racial disparity fell to 16.5% of Whites and 2.3% of Blacks reporting unmet dental need. 6 5 4 3 2 1 Figure: Any Unmet Need among Ohio Women (19-44 Years), by Race/Ethnicity, 212 and 215 42.5 41.6 Overall 36. 35.4 Non-Hispanic White 53. 41.4 39.1 38.9 Non-Hispanic Black Race/Ethnicity Hispanic 212 215 23.7 32. Non-Hispanic Other 17

UNMET HEALTHCARE NEEDS OVERALL 45 4 35 Figure: Unmet Healthcare Needs among Ohio Women (19-44 Years), 212 and 215 42.5 212 215 36. 3 25 2 15 1 2. 17.2 25.5 19.9 15.3 13. 9.2 7.2 15. 1.4 5 Any Dental Prescription Vision Mental Health Need Other Unmet healthcare needs decreased among Ohio women of childbearing age from 42.5% in 212 to 36.% in 215. Unmet prescription needs were the highest in both years, but decreased the most, from 1 in 4 women in 212 to 1 in 5 women in 215. One third of women still experience some type of unmet healthcare need in 215. 18

UNMET HEALTHCARE NEEDS Figure: Any Unmet Need among Ohio Women (19-44 Years), by Education and Insurance Status, 212 and 215 8 7 6 5 4 3 212 215 54.5 41.2 45.3 38.6 37.8 34.1 28.8 24.6 42.5 38.5 33.8 29.7 44.7 36.7 67.5 62.9 2 1 Education Insurance Status In 215, the percentage of women who reported any unmet need decreased for women of all education levels and of each insurance status. In both years, as education level advanced, the percentage of women who reported unmet need decreased. 19

UNMET DENTAL HEALTH NEED Figure: Unmet Dental Health Need among Ohio Women (19-44 Years), by Race/Ethnicity and Poverty Status, 212 and 215 35 3 25 2 15 2. 18.6 17.2 16.5 29.8 2.3 26.9 23.8 12.5 29.6 27.6 25.5 24.8 26.9 21.7 18.5 14.2 212 215 1 5 6.1 7.5 7.9 Overall Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other 1% 11-138% 139-2% 21-3% > 3% Race/Ethnicty Poverty Status (% FPL) Unmet dental health needs decreased for non-hispanic Black and White women and Hispanic women. The absolute black/white disparity in unmet dental health care needs decreased from 11.2 percentage points to 3.8 percentage points. Unmet dental health needs decreased for women within all FPL categories. Unmet need decreased the most among women living at 11 to 138% of the FPL, from nearly 3% in 212 to almost 25% in 215. While unmet needs decreased, they remained high for many women, with about 1 in 5 women living at or below 2% of FPL having an unmet dental health need in 215. 2

UNMET DENTAL HEALTH NEED Figure: Unmet Dental Health Need among Ohio Women (19-44 Years), by County Type and Insurance Status, 212 and 215 5 45 4 35 3 25 2 15 1 5 212 215 25.1 2.1 18.2 18.7 17. 17.1 17. 15. 2.5 21.8 11. 1. 23.9 16.6 42.7 43.9 County Type Insurance Status The percentage of women who reported unmet dental health need declined from 2.% in 212 to 17.2% in 215. However, women who were insured by Medicaid were still twice as likely to report an unmet dental health need than women with private insurance. One in four women living in Appalachia had an unmet dental health need in 212 but dropped to less than 1 in 5 by 215, similar to the unmet need in other regions. 21

UNMET PRESCRIPTION NEED Figure: Unmet Prescription Need among Ohio Women (19-44 Years), by Race/Ethnicity, 212 and 215 35 3 32.9 212 215 25 2 15 24.8 19.8 2.3 23. 24.4 16.6 13.8 1 5 Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Race/Ethnicity The percentage of all women aged 19 to 44 who reported unmet prescription need decreased from 25.5% in 212 to 19.9% in 215. The percentage of women who reported unmet prescription need decreased for non-hispanic White and Black women, and the racial disparity dramatically decreased. However, the percentage of Hispanic women who had unmet prescription needs remained relatively unchanged, and was the group with the greatest unmet prescription need in 215. 22

UNMET PRESCRIPTION NEED Figure: Unmet Prescription Need among Ohio Women (19-44 Years), by Education and Insurance Status, 212 and 215 5 45 4 35 3 25 2 15 1 5 212 215 34.1 26.6 21.1 21.2 23.4 19.2 17.4 14.4 21.1 22. 22.7 18.9 19. 16. 45.5 43.5 Education Insurance Status The greatest drop in unmet prescription need was among with less than high school education. Disparities in unmet prescription need between levels of education decreased from 212 to 215. Within every insurance status, unmet prescription need decreases, and in 215 was the lowest among Medicaid-insured women, at 16.%. In 215, 23

UNMET VISION CARE NEED Figure: Unmet Vision Care Need among Ohio Women (19-44 Years), by Education and Poverty Status, 212 and 215 3 25 2 15 1 5 24.7 18. 16.5 14.5 11.711.1 8.3 7.6 18.6 17.8 19.9 15.5 22.4 17.2 18.7 12.4 212 215 6.1 7. Less than high school High school graduate College degree Advanced degree 1% 11-138% 139-2% 21-3% > 3% Education Poverty Status (% FPL) The percentage of women who reported unmet vision care need remained relatively unchanged, from 15.1% in 212 to 13.% in 215. The percentage of women who reported unmet vision care need decreased the most drastically for women who did not complete high school. However, the percentage of women under 1% FPL who reported unmet vision care needs remained relatively unchanged from 212 to 215. 24

UNMET MENTAL HEALTH NEED Figure: Unmet Mental Health Need among Ohio Women (19-44 Years), by Education and Poverty Status, 212 and 215 25 212 215 2 19.3 16.1 15 1 5 11. 1.4 8.5 6.4 5.6 4.5 3.3 11.3 1.3 1.6 8.7 8.4 7.4 6.8 4.5 4.1 Less than high school High school graduate College degree Advanced degree 1% 11-138% 139-2% 21-3% > 3% Education Poverty Status (% FPL) The percentage of all women aged 19 to 44 who reported an unmet mental health need decreased from 9.2% in 212 to 7.2% in 215. Women who were within 11 to 138% of the FPL experienced the worst unmet mental health need in 212, at 19.8%. However, only 8.7% of women at this poverty level reported unmet mental health need in 215. 25

HEALTHCARE UTILIZATION Healthcare utilization increased overall from 212 to 215, as 74.2% of all women ages 19 to 44 had a routine check-up in the past year in 215, compared to 69.4% in 212. In 215, 78.2% of women insured by any Medicaid had a routine check-up in the past year. Among uninsured women, 51.1% had no routine check-up within the last year. However, the percentage of women with a dental visit within the last year remained relatively unchanged, from 74.7% in 212 to 75.5% in 215. 9 8 7 6 5 4 3 2 1 Figure: Routine Check-Up Within Last Year for Ohio Women (19-44 Years), Overall and by Insurance Status, 212 and 215 74.2 69.4 77.1 78.2 73.9 76.3 69.8 Insurance Status 71.5 212 215 48.9 43.8 26

HEALTHCARE UTILIZATION: ROUTINE CHECKUP Figure: Routine Check-Up Within Last Year for Ohio Women (19-44 Years), by County Type, 212 and 215 78 76 74 72 7 68 66 64 62 6 65. 73.3 69.9 76.2 67.1 69.4 212 215 74.2 71.7 58 Appalachian Metropolitan Rural, non-appalachian Suburban Women in Appalachian counties reported the largest increase in routine check-ups 65.% in 212 to 73.3% in 215. In 215, over ¾ of women living in metropolitan counties reported a routine check-up. 27

HEALTHCARE UTILIZATION: ROUTINE CHECK-UP Figure: Routine Check-Up Within Last Year for Ohio Women (19-44 Years), by Race/Ethnicity, 212 and 215 9 8 7 6 5 4 3 2 1 72.5 68.7 84.6 Non-Hispanic Non-Hispanic White Black 75.8 73.673.7 72.8 74.3 68.6 Race/Ethnicty Hispanic 56.8 Non-Hispanic other 212 215 75.677.8 71. 72. 71.1 67.1 61.6 63.1 1% 11-138% 139-2% 21-3% > 3% Poverty Status The percentage of Hispanic women who had a routine check-up remained relatively unchanged between 212 and 215. The percentage of women with a routine check-up within the last year increased within all levels of the FPL from 212 to 215, with the largest increase for women within 11 2% of the FPL. 28

HEALTHCARE UTILIZATION: DENTAL VISIT Figure: Dental Visit Within Last Year for Ohio Women (19-44 Years), by Education, 212 and 215 1 9 8 7 6 5 4 3 2 1 212 215 9.7 83.2 86.2 79.3 7.1 72.8 63.4 55.5 Less than high school High school graduate College degree Advanced degree Education The percentage of women with a recent dental visit within the last year remained relatively unchanged from 74.7% in 212 to 75.5% in 215. In 215, 71.6% of women with any Medicaid insurance reported a recent dental visit. Over half (53.6%) of uninsured women did not have a recent dental visit within the last year. 78.9% of women in a Suburban county reported a recent dental visit versus only 7% of women in an Appalachian county. As shown in the chart above, the percentage of women who reported a recent dental visit increased as education level increased. 29

HEALTHCARE QUALITY In 215, only 3.6% of all women aged 19 to 44 received care consistent with Patient Centered Medical Home (PCMH). Receiving care consistent with a PCMH is a marker of quality of care. Among women with any Medicaid insurance, 2.6% received consistent care, and only.2% of uninsured women received consistent care. Data regarding whether care was consistent with Patient-Centered Medical Homes (PCMH) is not available for 212, as standards for Consistent Care were measured differently (see Appendix I). 3

HEALTHCARE QUALITY: CARE CONSISTENT WITH PCMH Figure: Care Consistent with PCMH for Ohio Women Aged 19-44 Years, by Race and Ethnicity and County Type, 215 6 5 4 4.3 4.1 4.3 3 2 1.5 2.3 2.1 2.5 1.3 Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Appalachian Metropolitan Rural, non- Appalachian Suburban Race/Ethnicty County Type Non-Hispanic White women were nearly 3 times more likely than non-hispanic Black women to have care consistent with PCMH. Women living in an Appalachian county had the lowest rates for care consistent with PCMH. 31

HEALTHCARE QUALITY: CARE CONSISTENT WITH PCMH Figure: Care Consistent with PCMH for Ohio Women Aged 19-44 Years, by Education and Poverty Status, 215 7 6 6.1 5 4.6 4 3 2 1.3 3.9 3.7 2. 2.3 2.9 3.9 1 High school or less High school graduate College degree Advanced degree 1% 11-138% 139-2% 21-3% > 3% Education Poverty Status (% FPL) Receiving care consistent with PCMH increased as income increased. Women with an income > 3% of the FPL were three times more likely then women with an income 1% of the FPL to experience care consistent with PCMH. A similar pattern existed with education level where women with an advanced degree were more than 3 times as likely to experiences PCMH compared to women with a high school degree or less. 32

RESULTS SECTION 4: HEALTH BEHAVIORS The overall smoking rate for women aged 19-44 decreased from 212 to 215. Prescription drug misuse decreased overall from 212 to 215, but remained high among women with a high school education or less. The disparity between non-hispanic white and non- Hispanic black women for prescription drug misuse decreased from 212 to 215. Binge drinking is more common among women aged 19-24 years old and women with less than high school education status. In 215, binge drinking varied little by race and ethnicity. 33

HEALTH BEHAVIORS: SMOKING 6 5 Figure: Smoking among Ohio Women (19-44 Years), by Age, Race/Ethnicity, Education, 212 and 215 54.5 5.3 212 215 4 3 2 25. 2.2 34.3 31.2 26.3 27.6 27.2 26.8 27.4 21.6 21. 21.6 35.3 3.9 18.16.5 1 9.9 5.3 6.5 4.7 Age Race/Ethnicity Education The percentage of Ohio women aged 19 to 44 who reported being a current smoker decreased from 29.5% in 212 to 25.1% in 215. Non-Hispanic White women were most likely to report being a smoker in both 212 and 215. Education was strongly associated with smoking in both years, but smoking decreased within each education category from 212 to 215. In 215, women with less than a high school education were over three times more likely to smoke than women with a college degree. 34

HEALTH BEHAVIORS: PRESCRIPTION DRUG MISUSE Figure: Prescription Drug Misuse in Ohio Women (19-44 Years), by Age, Education, and Race/Ethnicity, 212 and 215 6 5 5.3 5.1 5.5 5.5 4.6 5.6 5.5 5.4 212 215 4 3 2 3.6 3.3 3.2 2.8 3.4 3.9 3. 1.6 2.6 3.9 3.2 3.6 3.7 3.7 1 19-24 25-34 35-44 Less than high school High school graduate College degree Advanced degree Non-Hispanic Non-Hispanic White Black Age Education Race/Ethnicity Hispanic Non-Hispanic Other The percentage of all women ages 19 to 44 who reported any prescription drug misuse within the past 12 months decreased from 4.2% in 212 to 3.4% in 215. In 215, prescription drug misuse varied little by age group. In both years, the percentage of women misusing prescription drugs decreased as education increased. The non-hispanic Black and non-hispanic White disparity in prescription drug misuse decreased from 1.7% to.4% from 212 to 215. 35

HEALTH BEHAVIORS: BINGE DRINKING Figure: Binge Drinking among Ohio Women (19-44 Years), by Age, Education, and Race/Ethnicity 212 and 215 7 6 5 4 3 2 48.1 44.6 4.6 39.7 31.1 28.9 49. 43.8 41.7 42.6 34.5 35. 28.8 26.8 36.9 38.3 38.3 35.5 62. 212 215 37.5 39. 35.7 1 Age Education Race/Ethnicity The percentage of all women ages 19 to 44 who reported binge drinking for one day or more in the past year remained relatively unchanged, at 37.7% in 212 and 37.9% in 215. The percentage of Hispanic women who reported binge drinking dropped drastically from 62% in 212 to 27.5% in 215. Women who were between the ages of 19 and 24 were more likely to report binge drinking than women ages 24 to 44, and women who did not graduate high school were almost twice as likely to report binge drinking as women with advanced degrees. 36

RESULTS SECTION 5: HEALTH STATUS From 212 to 215, general health status has improved for Ohio women aged 19-44 years, with the largest improvement seen in women aged 25-34 or who identified as Hispanic. The percentage of women experiencing mental distress changed little from 212 to 215 but varied greatly with educational attainment. In 215 non-hispanic black women were slightly less than twice as likely to report hypertension than non- Hispanic white women. Women under 1% of the federal poverty line are 6 times more likely to report cardiovascular disease than women over 3% of the poverty line. The percentage of women reporting diabetes decreases as education and poverty level increase. The overall percentage of women with obesity increased, with the largest increase among women aged 19-24 years. 37

HEALTH STATUS Figure: Poor Health Status among Ohio Women (19-44 Years), by Age and Race/Ethnicity, 212 and 215 45 4 39.7 212 215 35 3 25 2 15 1 12.1 1.3 19. 12.3 22. 19.8 17.4 13.6 23.6 19. 24.9 7.6 8.6 5 19-24 25-34 35-44 Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Age Race/Ethnicity General health status improved from 212 to 215, particularly for women aged 25 to 34. In 212, 18.6% of all women aged 19 to 44 reported poor health status, compared to 14.6% in 215. Hispanic women reported the largest improvement in health status between 212 and 215. 38

HEALTH STATUS Figure: Poor Health Status among Ohio Women (19-44 Years), by Education and Poverty Status, 212 and 215 5 45 4 35 3 25 2 15 1 5 45.8 33.3 Less than high school 2.1 17.4 High school graduate 11.4 9. College degree 3.9 2.8 Advanced degree 212 215 32.3 26.8 2.5 18.5 15.8 14.3 14.1 1.6 7.5 5.1 1% 11-138% 139-2% 21-3% > 3% Education Poverty Status (%FPL) Poor health status decreased among all education levels between 212 and 215, but women with education less than high school had the largest decrease at 12.5%. Still, women with less than a high school education were more than 1 times as likely to have poor health status versus women with an advanced degree. All poverty levels had improved health status between 212 and 215, except 11-138%. The gradient of health status by poverty status still persisted. 39

HEALTH STATUS: MENTAL DISTRESS 18 16 14 12 1 8 6 4 2 Figure: Frequent Mental Distress among Ohio Women (19-44 Years), by Education and Poverty Status, 212 and 215 17. 16. Less than high school 9. 8.7 High school graduate Education 3.4 3.6 College degree 1.4.9 Advanced degree 13.4 13.4 11.4 8.8 6.8 4.6 4.3 1% 11-138% 139-2% 21-3% > 3% Poverty Status (% FPL) 212 215 4.2 2.5 2.4 The overall percentage of Ohio women of reproductive age reporting mental distress decreased slightly from 7.4% in 212 to 6.8% in 215. The percentage of mental distress decreased as education increased, but percentages remained relatively consistent at each level of education between 212 and 215. Women at 11-138% of the poverty level experienced the largest decrease in mental distress from 212 to 215. 4

HEALTH STATUS: HYPERTENSION 3 Figure: Hypertension among Ohio Women (19-44 Years), by Age, Race/Ethnicity, and Education, 212 and 215 27.4 212 215 25 2 15 1 5 8.7 6.9 14.9 11. 21.8 2.8 15.6 13.1 22. 2. 17. 11.6 4.9 7. 21.7 17.2 14.3 13.1 1.8 12.1 8.6 19-24 25-34 35-44 Non-Hispanic Non-Hispanic White Black Hispanic Non-HispanicLess than high Other school High school graduate Age Race/Ethnicity Education College degree Advanced degree From 212 to 215, the percentage of Ohio women aged 19-44 decreased from 15.9% to 14%. In 215, women aged 35-44 were nearly twice as likely to report having hypertension than women aged 25-34 and three times as likely than women aged 19-24. Non-Hispanic Black women are more likely than other racial categories to have hypertension, with a 2% increase from 212 to 215. Hypertension has decreased from 212 to 215 at all education levels except for women with a college degree. Women with less than a high school education experienced the greatest improvement in hypertension. 41

HEALTH STATUS: CARDIOVASCULAR DISEASE 5. 4.5 4. 3.5 3. 2.5 2. 1.5 1..5. Figure: Cardiovascular Disease among Ohio Women (19-44 Years), by Age and Poverty Status, 212 and 215.8.5 1.8 1.3 3.6 4.3 3.1 3.2 19-24 25-34 35-44 1% 11-138% 139-2% 21-3% > 3% Age The overall percentage of women who reported any cardiovascular disease decreased from 2.3% in 212 to 1.7% in 215. Cardiovascular disease varied drastically for women of different poverty statuses, as women who were under 1% of the poverty line were over six times as likely to report any cardiovascular disease. 2.7% of women insured by Medicaid reported any cardiovascular disease, in contrast to.7% of women with employer-sponsored insurance and 3.2% of uninsured women who reported any cardiovascular disease. 2.9 2.8 2.2 2. Poverty Status (% FPL) 1. 1.1 212 215.8.5 42

HEALTH STATUS: DIABETES 14 12 1 8 6 4 Figure: Diabetes among Ohio Women (19-44 Years), by Age, Education, and Poverty Status, 212 and 215 3.63.7 6.3 5.4 9. 11.2 12.2 9.7 8. 7. 6.1 5.3 4.44.6 1.7 9.5 6.3 8.7 4.2 7.3 6.3 5.4 212 215 5.1 4.4 2 19-24 25-36 35-44 Less than high school High School College degree Advanced degree 1% 11-138% 139-2% 21-3% > 3% Age Education Poverty Status (% FPL) The percentage of all women ages 19 to 44 who reported diabetes increased from 6.8% in 212 to 7.1% in 215. In 215, as age increased, women were more likely to report diabetes; 11.2% of women ages 35 to 44 reported diabetes, which is over three times the percentage of women ages 19 to 24 who reported diabetes. 43

HEALTH STATUS: OBESITY Figure: Obesity among Ohio Women (19-44 Years), by Age and Race/Ethnicity, 212 and 215 45 4 35 3 33.2 3.6 39.6 36.7 32.3 29.9 41.5 39.6 31.2 38.4 212 215 25 2 15 1 19.7 23.6 1.4 17.7 5 19-24 25-34 35-44 Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Age Race/Ethnicity The percentage of all women aged 19 to 44 who were obese increased from 3.5% to 33.2% in 215. The obesity rate increased the most drastically among women aged 19 to 24, with a 3.9% increase from 212 to 215, and among Hispanic women, with a 7.2% increase from 212 to 215. 44

HEALTH STATUS: OBESITY Figure: Obesity among Ohio Women (19-44 Years), by Education and Poverty Status, 212 and 215 5 45 4 35 3 25 2 15 1 5 4.64.4 Less than high school 35. 33.2 High School 26.4 32.2 College degree 21.8 17.9 Advanced degree 44.1 212 215 42. 37.2 36.1 33.8 3.3 28.7 27.6 25.324.2 1% 11-138% 139-2% 21-3% > 3% Education Poverty Status (% FPL) Obesity rates remained relatively unchanged for women who did not graduate high school. However, the obesity rate for women with a college degree increased 5.6% from 212 to 215. The obesity rate increased drastically (15.4%) for women within 11 to 138% of the FPL from 212 to 215. Obesity also increased in women who living under 1% of the FPL, and remained relatively unchanged for women above 139% of the FPL. 45

HEALTH STATUS: OBESITY 45 4 35 3 25 2 15 1 5 Figure: Obesity among Ohio Women (19-44 Years), by County Type and Insurance Status, 212 and 215 31.8 38.3 31.9 29.4 33.8 3.9 Appalachian Metropolitan Rural, non- Appalachian 32.7 32.2 Suburban 41.9 4.3 Insured, any Medicaid 29. 27. Insuredemployer sponsored 24.9 22.1 Insured, other 212 215 31.6 37. Uninsured County Type Insurance Status Women living in suburban counties saw relatively no change in the obesity rate while women in metropolitan and rural non- Appalachian counties saw an increase of 2.5% and 2.9%, respectively. The obesity rate for women with employer sponsored insurance increased by 2% from 212 to 215. Women insured with Medicaid and uninsured women had an increase in obesity rates. 46

RESULTS SECTION 6: PREGNANCY AND POSTPARTUM Pregnant women with employer-sponsored insurance were nearly 25% more likely to intend to solely breastfeed than women with Medicaid insurance. There was an overall increase in pregnant women who intended to breastfeed for 6 or more months from 212 to 215. The percentage of women with a history of Gestational Diabetes (and no other diabetes) remained relatively constant from 212 to 215. 47

BREASTFEEDING INTENTION 1 9 8 7 6 5 4 3 2 1 Figure: Intention of Breastfeeding Only among Pregnant Ohio Women (19-44 Years), by County Type and Insurance Status, 212 and 215 52.2 55.4 49.7 62.3 55.1 69.7 Appalachian Metropolitan Rural, non- Appalachian 88.2 8.9 Suburban 4. 55. Insured, any Medicaid 78.8 212 215 79.5 Insured, employersponsored County Type Insurance Status In 215, 64.7% of all pregnant women aged 19 to 44 reported their intention to exclusive breastfeeding. Nearly 25% more women with employer-sponsored insurance reported intention to exclusively breastfeed than women insured by Medicaid. However, the intention to solely breastfeed for women insured by Medicaid increased 15 percentage points from 212 to 215. 48

BREASTFEEDING DURATION Figure: Intended Duration of Breastfeeding 6 Months or More among Pregnant Ohio Women (19-44 Years), by County Type and Insurance Status, 212 and 215 9 8 7 6 5 4 3 2 1 7.4 85.3 81.3 81.8 78.3 76.2 Appalachian Metropolitan Rural, non- Appalachian County Type The overall percentage for Ohio women aged 19-44 who intend to breastfeed for 6 months or more increased from 76.7% to 79.7% in 212 to 215. Women living in suburban counties reported the largest increase in intended breastfeeding duration of 6 or more months. Women with employer-sponsored insurance are more likely to report having the intention to breastfeed for at least 6 months. 58.2 71.8 73.6 212 215 74.9 76.6 81.7 Suburban Insured, any Medicaid Insured, employersponsored Insurance Status 49

GESTATIONAL DIABETES Figure: History of Gestational Diabetes Only among Ohio Women (19-44 Years), by Education and Race/Ethnicity, 212 and 215 8 7 212 215 6.9 6 5 4 3 2 3.7 2.5 2.6 2.1 1.8 1.8 2.5 2.4 2.4 2.1 1.5 1.5 3. 1.9 2. 1 Less than high school High school graduate College degree Advanced degree Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Education Race/Ethnicity The overall percentage of Ohio women aged 19-44 with a history of Gestational Diabetes (GDM) remained relatively constant from 2.2% in 212 to 2.3% in 215. These women are at high risk for developing Type 2 Diabetes or recurring and more severe GDM in a future pregnancy. Women who had GDM in the past, but have since developed Type 2 Diabetes are not included in this estimate. 5

KEY FINDINGS The uninsured rate for all women decreased 11%, while Hispanic women reported the greatest decrease in uninsured status at 24%. Overall, health care coverage has improved in 215 from 212. Nearly 1 in 5 women with less than high school education and 43.5% of uninsured women still report unmet prescription needs. Between 212 and 215, health care utilization has increased nearly 5% for all women in Ohio. However, over half of uninsured women did not receive a routine check-up in the past year. The smoking status of Ohio women aged 19 to 44 decreased 5% from 212 to 215. Rates of binge drinking among all Ohio women remained relatively constant between 212 and 215. Women aged 19 to 24 reported the highest rates of binge drinking for both years. Women aged 35 to 44 are nearly 3 times more likely to experience hypertension than women aged 19-24. Non-Hispanic black women report higher levels of hypertension than non-hispanic white women by nearly 9%. Women under the poverty line are 6 times more likely to report cardiovascular disease than women over 3% of the poverty line. The obesity rate for all Ohio women aged 19 to 44 increased nearly 3%. Hispanic women reported the largest increase from 31.2% to 38.4%, while non- Hispanic black women have the highest rate of obesity at 41.5%. The percentage of women reporting diabetes increased slightly from 212 to 215. As age increases, the percentage of women reporting diabetes also increases. On the other hand, as income increases, the percentage of women experiencing diabetes decreases. Women with employer-sponsored insurance were nearly 25% more likely to report having the intention to breastfeed only. The intention to breastfeed for 6 months or more postpartum increased from 212 to 215. Women with employer-sponsored insurance are only 5.1% more likely than women Medicaid insurance to report the intention to breastfeed for 6 months or more. 51

CONCLUSION From 212 to 215, the rate of uninsured women decreased while the rate of women with Medicaid insurance increased. Women between 11-138% of the poverty line reported the largest decrease in uninsured rate. These improvements are likely due to Ohio s Affordable Care Act Medicaid expansion. However, the increasing proportion of women experiencing a gap in coverage is troubling. Healthcare utilization overall increased from 212 to 215; however, over 5% of uninsured women reporting having no routine check-up within the past year. Women with an income of 11-138% of the poverty line saw the largest increase in receiving a routine check-up visit within the past year. Despite improved insurance coverage for Ohio women, 36% of women aged 19 to 44 report an overall unmet healthcare need, with unmet prescription and dental needs being the most common. Unmet healthcare needs are more likely to be experienced by low income and uninsured women. Women aged 35-44 report higher levels of poor health status, hypertension, cardiovascular disease, obesity, and diabetes. A women who becomes pregnant with these preexisting health conditions has increased risk for adverse maternal and infant health outcomes including gestational diabetes, severe maternal morbidity, and maternal or infant death. The opportunity for improvement exists in the percentage of women who intend to breastfeed only as well as the intended duration for breastfeeding. Breastfeeding has been associated with decreased risk of diabetes, osteoporosis, and some cancers. Providers should education women on the short term and long term health benefits of breastfeeding for the mother and infant. These findings suggest that the preconception health and health care of Ohio women has recently improved and some racial disparities have decreased or been eliminated. However, some groups continue to have challenges achieving optimal health and healthcare post Medicaid expansion and many women experience gaps in insurance coverage. 52

REFERENCES 1 Ohio Department of Health (ODH). 215 Infant Mortality Data: General Findings. https://www.odh.ohio.gov/- /media/odh/assets/files/cfhs/oei/215-ohio-infant-mortality-report- FINAL.pdf?la=enssed Nov 1, 216. 2 Moos MK. Preconception health: Where to from here?. Women's Health Issues. 26;16(4):156-8. 3 Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care United States. MMWR Recommendations and Reports. 26;55(RR-6):1 23 4 Fine A, Kotelchuck M. Rethinking MCH: The life course model as an organizing framework. US Department of Health and Human Services Health Resources and Services Administration Maternal and Child Health Bureau.[Internet] Available from: http://www.hrsa.gov/ourstories/mchb75th/images/rethinkingmch.pdf. 5 Nobles Botkin J, Lincoln A, Cline J. Preconception care resources: Where to start. Journal of Midwifery & Women s Health. 216;61(3):365-9. 6 Johnson K, Applegate M, Gee RE. Improving Medicaid: three decades of change to better serve women of childbearing age. Clinical obstetrics and gynecology. 215;58(2):336-54. 53

ACKNOWLEDGMENTS Carolyn Lullo McCarty Nari Johnson Leah Sadinski Timothy R. Sahr Marcus Berzofsky 54

APPENDIX: DEFINITIONS Preconception Health The health of a woman during her reproductive years. Preconception Health Care The medical care a woman or man receives from the doctor or other health professionals that focuses on the parts of health that have been shown to increase the chance of having a healthy baby. Mental Distress Mental distress was characterized by experiencing stress, depression, and problems with emotions or substance abuse that kept women from doing work or other usual activities in the past 3 days. (6) Received after hours care (if needed) without a problem (7) Received specialist care (if needed) without a problem A respondent was still considered to have a PCMH if she did not require care for the last three criteria. Gap in Coverage A respondent was considered to have a gap in coverage if she did not have health insurance at any point in time during the past 12 months. Patient Centered Medical Home (PCMH) A respondent was considered to have a PCMH if she met the following criteria: (1) Has an appropriate, usual source of care (2) Has a personal care provider ( a health provider that knows you well and is familiar with your health history ) (3) Has seen the above provider in the past 12 months (4) Reported good personal communication with the provider (5) Received urgent care (if needed) without a problem 55