title: Improvements in prenatal insurance coverage and utilization of care in California: an unsung public health victory.
abstract: OBJECTIVE
  To examine trends in prenatal insurance coverage and utilization of care in California over two decades in the context of expansions in Medi-Cal (California's Medicaid) and other public efforts to increase prenatal care utilization.
  
  
  METHODS
  Retrospective univariate and bivariate analysis of prenatal care coverage and utilization data from 10,192,165 California birth certificates, 1980-99; descriptive analysis of California poverty and unemployment data from the U.S. Census Bureau Current Population Survey; review of public health and social policy literature.
  
  
  RESULTS
  The proportion of mothers with Medi-Cal coverage for prenatal care increased from 28.2 to 47.5% between 1989 and 1994, and the proportion uninsured throughout pregnancy decreased from 13.2 to 3.2%. Since the mid-1990s, fewer than 3% of women have had no insurance coverage for prenatal care. Between 1989 and 1999, the proportion of women with first trimester initiation of prenatal care increased from 72.6 to 83.6%, reversing the previous decade's trend, and the proportion of women with adequate numbers of visits rose from 70.7 to 83.1%. Improvements in utilization measures were greater among disadvantaged social groups. Improvements in California during the 1990s coincided with a multifaceted public health effort to increase both prenatal care coverage and utilization, and do not appear to be explained by changes in the economy, maternal characteristics, the overall organization/delivery of health care, or other social policies.
  
  
  CONCLUSIONS
  While this ecologic study cannot produce definitive conclusions regarding causality, these results suggest an important victory for public health in California.
authors.affiliation: Department of Family and Community Medicine, University of California-San Francisco, San Francisco, California 94143-0900, USA. dianer@itsa.ucsf.edu
authors.forename: Diane R
authors.initials: DR
authors.lastname: Rittenhouse
authors.forename: Paula
authors.initials: P
authors.lastname: Braveman
authors.forename: Kristen
authors.initials: K
authors.lastname: Marchi
mesh_terms: D000293:Adolescent; D000328:Adult; D001719:Birth Certificates; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008484:Medicaid / Q000706:statistics & numerical data*; D017057:Medically Uninsured; D008913:Minority Groups; D011203:Poverty; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D011295:Prenatal Care / Q000191:economics* / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013221:State Health Plans / Q000706:statistics & numerical data*; D014481:United States