Report by: Maggie Clark, Georgetown University CCF, & Debbie Smith, Alabama Arise

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Introduction

Alabama mothers face many barriers to good health. The state faces high maternal and infant mortality rates, high rates of uninsurance among women of childbearing age, and worsening access to maternity care providers. These problems are compounded by Alabama’s extremely low Medicaid eligibility limit for parents. A mother with two children would be over the income limit if she earns just $373 a month. This extremely low income limit restricts access to coverage to very few parents, and serves as a work disincentive for parents who earn too much money to qualify for Medicaid and do not have an offer of health insurance from their employer.

Alabama took an important step for women’s health in 2022 to extend the Medicaid postpartum coverage period from just 60 days to 12 months after the end of pregnancy. The state also has a proud history of covering children through the ALL Kids program and leads the South in reducing the number of uninsured children.

Alabama policymakers can affirm their commitment to maternal and child health by expanding Medicaid for low-income adults. Research shows that Medicaid expansion has significant benefits for maternal and infant health, as it allows moms to have access to health coverage, before, during and after pregnancy so that they can have healthy births and support their childrens’ development. Medicaid expansion also has a “welcome mat” effect for children too: when their parents are covered, children are more likely to be covered and receive more preventive care.

One in Six Women of Reproductive Age Is Uninsured in Alabama

Largely due to the state’s decision not to expand Medicaid, Alabama has one of the highest rates of uninsured women of reproductive age (18-44) in the country. About one in six (15.9 percent) Alabama women of childbearing age do not have health insurance. Alabama ranks 45th in the country for its rate of uninsured women between age 18-44.

Across all racial and ethnic groups, Alabama women have uninsured rates higher than the national average (11.7 percent). See Figure 2. White and Black women in Alabama are uninsured at similar rates; both groups are higher than the national average. Almost half (41.5 percent) of women of reproductive age who identify as Hispanic or Latina are uninsured in Alabama, and this is almost twice as high as the national average for Latinas (26.5 percent). American Indian/ Alaska Native (46.7 percent) and Multiracial/Other (29.7 percent) women also have very high uninsured rates. See Figure 2.

Poor Health Outcomes and Disparities for Alabama Mothers and Babies

The United States has a very high rate of maternal mortality  (20.4 deaths per 100,000 live births) compared to many of its peer nations, and Alabama’s rate (36.2) was the third-highest in the nation between 2018 and 2020, according to the Centers for Disease Control. Alabama’s 2020 Maternal Mortality Review found that cardiovascular-related events and substance overdose were among the leading causes of pregnancy-related deaths. The committee identified challenges in accessing health care as a contributing factor in many pregnancy-related deaths reviewed.

Infant mortality presents similarly, with Alabama babies dying at a rate of 7.2 infant deaths per 1,000 live births in 2020, much higher than the U.S. average (5.4 infant deaths per 1,000 live births). Black babies die at higher rates (11.1 infant deaths per 1,000 live births) in Alabama than White babies (5.5 infant deaths per 1,000 live births), and mortality rates for both Black and White babies in Alabama are higher than the respective national averages for both groups.

Research shows that adoption of Medicaid expansion is associated with lower rates of maternal mortality, and reduction in infant mortality as well. Medicaid expansion has also been found to increase preconception health counseling, folic acid intake, and postpartum contraception.

Alabama is Losing Rural Obstetric Care Providers

Alabama has experienced a steady rate of hospital maternity ward closures in recent years. Obstetric units in 29 out of Alabama's 54 rural counties closed between 1980 and 2019. This has had significant negative effects on maternal health. When rural hospitals close their obstetric units, pregnant women in those areas face increased challenges in accessing critical prenatal and delivery care, forcing them to travel long distances for maternity services. This lack of local obstetric care exacerbates existing disparities in maternal health outcomes, particularly for low-income women who may have limited resources for transportation and face barriers to accessing care.

Medicaid expansion can help improve maternal health in Alabama 

Research on the benefits of Medicaid expansion is clear: Alabama women of reproductive age will be greatly helped when the state expands Medicaid.

Research shows that having stable health coverage before, during and after pregnancy improves both maternal and infant health outcomes throughout their lives. Expansion has also been associated with improvements in preconception health and utilization of preventive care, earlier connection with prenatal care for moms, reducing racial disparities in babies born at low birth weight, and supporting healthy development of parents and children together.

Expanding Medicaid could also help strengthen access to maternity care providers by improving rural hospitals’ overall finances and reduce the amount of obstetric unit closures in the state.