African American women; Hispanic American women; Maternal health services; Minority women; Prenatal care; Women; White


Despite gains in prenatal care (PNC) usage and birth outcomes for minority women during the past few decades, observed disparities between non-Hispanic Whites, Blacks, and Hispanics persist. Using the National Center for Health Statistics’ (NCHS) natality files from 1981 through 1998, Alexander, Kogan, & Nabukera (2002) examined live births of U.S. residents by trimester in which PNC was initiated and the appropriateness of that care based on the Adequacy of Prenatal Care Utilization Index (APNCU) (Kotelchuck, 1994). They found racial disparities between White and Black women in both the trimester of PNC initiation and the number of PNC visits made.

Alexander et al.(2002) noted reductions in racial disparities in PNC; specifically, Blacks were steadily increasing in the number of prenatal visits and in first trimester initiation of PNC. However, a weakness of their study was the exclusivity of racial categories; only White and Black racial groups were analyzed based on the mother’s self reported race. Other racial groups were not included because Hispanic data were not identifiable for some states during part of the study period, and other racial groups lacked sufficient numbers to establish trending in the categories of interest (Alexander et al., 2002). Thus Hispanics identified their race as White and their ethnicity as Hispanic. Alexander et al. counted both non-Hispanic Whites and Hispanics as ‘Whites’ regardless of ethnicity or the availability of ethnicity in their analysis. This created a potential source of bias, as one could speculate that the reported narrowing of racial disparities in the number of PNC visits and earlier initiation of care between Whites and Blacks could be the result of increasing births to Hispanic women included in the ‘White’ birth group. The reported narrowing of disparities could simply be the result of failing to separate Hispanic women in the analysis, a potentially significant portion of the ‘White’ group given their high fertility rates and increased percentage of the total U.S. population. While the expansion of Medicaid-sponsored funding for pregnant women likely contributed to some of the reported increases in earlier PNC initiation and the number of prenatal visits in the late 1980s and early 1990s (Hessol, Vittingoff, & Fuentes-Afflick, 2004; Hueston, Geesey, & Diaz, 2008), it is not clear if this expansion benefited one racial group over another, particularly when Hispanic ethnicity is taken into account.

Therefore, the purpose of this study was to evaluate differentials in birth outcomes for singletons by race for Whites, Blacks, and Hispanics beginning in 1979 (the year when Hispanic identifiers became available in the natality files) through 2006. Specifically, we examined trends the trimester that PNC was initiated, the number of PNC visits, and birth weight by race and ethnicity. While previous studies have evaluated pregnancy outcomes based on race, the exclusion of Hispanic identifiers in the analysis (Alexander, Kogan, Himes, Mor, & Goldenberg, 1999; Alexander et al., 2002; Alexander, Wingate, Bader, & Kogan, 2008; Cox, Zhang, & Zotti, 2009; Hunsley, Levkoff, Alexander, & Tompkins, 1991) potentially introduced a bias in results reported. We estimated racial disparities between Blacks and Whites with and without Hispanic identification. Hence, we quantified the bias created due to Hispanics being identified as Whites. Although Gavin et al. (Gavin, Adams, Hartmann, Benedict, & Chireau, 2004) attempted to address this gap by including Hispanics in their analysis, only pregnancy-related care among Medicaid recipients in four states (Florida, Georgia, New Jersey, and Texas) was examined, therefore omitting a significant portion of the childbearing population. In this current study, the addition of Hispanics as a separate racial group and the extension of analysis back to 1979 through 2006 provide an additional decade of observations over previous reports. Hence this analysis is unique and more comprehensive than previous reports.