Infant Health Care Disruptions by Race and Ethnicity, Income, and Insurance During the COVID-19 Pandemic

Abstract

Objective:

Research has found disruptions in pediatric care during the COVID-19 pandemic, likely exacerbating existing disparities, which has not been explored among infants. This study evaluated how infant health care was disrupted during the COVID-19 pandemic overall and by race and ethnicity, income, and insurance type.

Methods:

This cross-sectional study used the Pregnancy Risk Assessment Monitoring System COVID-19 supplement with data from 29 jurisdictions to examine infant health care disruptions due to the pandemic: 1) well visits/checkups canceled or delayed, 2) well visits/checkups changed to virtual appointments, and 3) postponed immunizations. Unadjusted, weighted proportions of outcomes were calculated overall and by race and ethnicity, income, and insurance. We estimated multivariable odds ratios for the association between infant care disruptions and race and ethnicity, income, and insurance.

Results:

Overall, among 12,053 parental respondents with infants born from April to December 2020, 7.25% reported cancelations or delays in infant well visits/checkups, 5.49% reported changes to virtual infant care appointments, and 5.33% reported postponing immunizations, with significant differences by race and ethnicity, income, and insurance type. In adjusted analyses, we found higher odds of canceling/delaying visits and postponing immunizations among nonHispanic Black infants and infants whose parents were uninsured or had Medicaid-paid deliveries. The odds of switching to virtual appointments were significantly higher among Hispanic infants and infants whose parents had Medicaid-paid deliveries.

Conclusions:

Study findings suggest that the COVID-19 pandemic particularly affected infant health care for nonHispanic Black infants and infants whose parents were uninsured or had Medicaid, with important implications for addressing infant health inequities and improving health outcomes in the United States.

Background

The United States has one of the highest infant mortality rates among peer nations, with large socioeconomic and racial and ethnic disparities that have persisted despite overall infant health improvements.^1,2 The infant mortality rate among Black infants is over twice the rate among White infants² and is over 1.5 times higher among infants whose birthing parents had Medicaid-paid or self-paid deliveries compared to privately insured birthing parents.³ Structural factors such as access to care, health care quality, and income impact systematic inequities in infant health.²

Research has found disruptions in pediatric care during COVID-19, including delayed and missed pediatric preventive visits.⁴ Data from the Centers for Disease Control and Prevention found that fewer orders for recommended childhood vaccines were placed, and fewer childhood vaccine doses were administered during the pandemic.⁵ The American Academy of Pediatrics recommends screenings, surveillance, physical examinations, and immunizations for infants in their first months of life.⁶ Timely infant health care visits can catch early warning signs that require treatment and prevent diseases amenable to infant vaccination.⁷ Delays in vaccination increase the risk of never receiving the vaccinations altogether and they are most vulnerable.⁷

However, health care disruptions among infants during the COVID-19 pandemic have not been explored. In addition, there may have been important differences in infant health care disruptions among groups hardest hit by the pandemic, likely exacerbating existing disparities.⁸ Thus, the objective of this study was to evaluate how infant health care was disrupted during the COVID-19 pandemic overall and by race and ethnicity, income, and insurance type.

Methods

Data and sample

This cross-sectional study used data from the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) COVID-19 supplement to examine pandemic experiences. PRAMS periodically includes supplemental questions to examine subjects of significant interest or emerging concern.⁹ The COVID-19 survey questions were a 1-time supplement to identify the effects of the COVID-19 pandemic on the health, health care, and wellbeing of birthing parents and their infants. The supplement surveyed individuals with a live birth between April and December 2020 sampled 2–6 months after delivery from birth certificates in participating PRAMS jurisdictions. Data were available from 29 jurisdictions including 26 states, the District of Columbia, New York City, and Puerto Rico that reached a survey response rate threshold of 50% or higher, with a median weighted response rate of 58.6% among the study population.¹⁰ This study was considered not human participants research by Brown University’s Institutional Review Board.

Measures

Outcomes of interest were the ways in which the COVID19 pandemic affected routine health care for infants by 2–6 months old, measured as 1) well visits or checkups canceled or delayed, 2) well visits or checkups changed from in-person visits to virtual appointments (video or telephone), and 3) postponed immunizations. These outcomes were assessed through the survey question “In what ways did the COVID-19 pandemic affect your baby’s routine health care?” which included these options as the three response categories. Birthing parent respondents could answer yes to more than 1 way that health care for their baby was affected.

Demographic variables included age of the birthing parent at delivery (19 years or younger, 20–24, 25–29, 30–34, 35–39, 40 years, or older), marital status (married or unmarried), educational attainment (high school or less, or more than high school), infant race and ethnicity (nonHispanic Asian or Pacific Island, non-Hispanic Black, Hispanic, non-Hispanic White, or non-Hispanic other), income as a percent of the federal poverty level (FPL) (138% or less, 139%–199%, 200%, or more), and insurance type at delivery (uninsured, Medicaid, or private). Infant race and ethnicity were measured from self-reported maternal and paternal race and ethnicity, recorded on the birth certificate files. As PRAMS includes categorical income options for survey respondents, we calculated FPL based on the mid-point of the income category and the respondent’s household size. Missing category indicators were created for all covariates with missing data.

Statistical analysis

We examined weighted self-reported demographic characteristics of the birthing parents and infants from PRAMS and the birth certificate files. Next, we calculated the unadjusted, weighted proportion of survey respondents reporting these infant health care disruptions overall and by infant race and ethnicity, income, and insurance coverage. Finally, we estimated odds ratios for the association between infant health care disruption outcomes and demographic characteristics using weighted multivariable logistic regression models adjusting for race and ethnicity, income, insurance, age, marital status, education, and jurisdiction. Data were weighted using PRAMS survey weights provided by the Centers for Disease Control and Prevention, which accounts for the complex sampling design, nonresponse, and omission from the sampling frame.

Results

The sample included 12,053 parental respondents with infants born from April to December 2020, representing a weighted total of 634,567 individuals with an infant 2–6 months old. Table 1 describes the demographic characteristics of the sample. Birthing parents were primarily 25–29 (27.63%) or 30–34 years old at delivery (30.52%). The majority of parental respondents were married (61.15%) and had educational attainment of more than high school (63.41%). The highest share of respondents had non-Hispanic White infants (48.93%) and incomes of 138% of the FPL or less (29.03%). The majority, 53.77%, of birthing parents had private coverage at delivery.

Table 1.

Demographic Characteristics of the Study Sample

Variables	% (95% CI)
Age at Delivery
< 20 years old	3.69 (3.18, 4.27)
20–24 years old	17.51 (16.44, 18.63)
25–29 years old	27.63 (26.41, 28.90)
30–34 years old	30.52 (29.28, 31.79)
35–39 years old	16.79 (15.82, 17.81)
40+ years old	3.86 (3.37, 4.41)
Marital Status
Married	61.15 (59.80, 62.48)
Unmarried	38.79 (37.46, 40.14)
Educational Attainment
High school or less	63.41 (62.06, 64.73)
More than high school	35.86 (34.54, 37.20)
Race and Ethnicity
Asian or Pacific Islander, NH	4.04 (3.64, 4.49)
Black, NH	13.34 (12.55, 14.18)
Hispanic	24.96 (23.84, 26.12)
White, NH	48.93 (47.64, 50.21)
Income (% of the FPL)
≤ 138	29.03 (27.80, 30.30)
139–199	9.43 (8.62, 10.30)
≥ 200	22.39 (21.28, 23.55)
Coverage at Delivery
Uninsured	3.35 (2.88, 3.89)
Medicaid	40.64 (39.34, 41.95)
Private	53.77 (52.44, 55.10)

NH indicates non-Hispanic; FPL, federal poverty level, calculated based on the mid-point of the PRAMS income category and household size; and PRAMS, Pregnancy Risk Assessment Monitoring System. CI, confidence interval.

Note: N = 12,053. Weighted proportions are presented. Infant race and ethnicity were based on maternal and paternal race and ethnicity, reported on the birth certificate files. Coverage was measured as the primary payer for childbirth from the birth certificate.

Overall, 7.25% reported cancelations or delays in well visits/checkups among their infants, 5.49% reported shifts to virtual appointments, and 5.33% reported postponing immunizations (Table 2). Reports of visit cancelations/delays and postponing immunizations were highest for non-Hispanic Black infants (10.21% and 8.67%, respectively), while shifts to virtual appointments were highest for Hispanic infants (7.64%) by race and ethnicity. The prevalence of all disruptions was highest among the lowest income group and lowest among the highest income group. Birthing parents who were uninsured at delivery reported the highest visit cancelation/delays (15.25%) and postponed immunizations (11.13%) among their infants, while birthing parents with Medicaid-paid deliveries reported the highest prevalence of shifts to virtual care (7.78%).

Table 2.

Prevalence of Infant Health Care Disruptions During the COVID-19 Pandemic by Respondent Characteristics in 29 US Jurisdictions, 2020

Variable	Well Visits/Checkups Canceled or Delayed	Changed to Virtual	Immunizations Postponed
Overall	7.25 (6.60, 7.96)	5.49 (4.92, 6.12)	5.33 (4.76, 5.96)
Race and Ethnicity
Asian or Pacific Islander, NH	4.23 (2.33, 7.56)	7.21 (4.74, 10.80)	1.76 (0.93, 3.32)
Black, NH	10.21 (8.27, 12.56)	7.13 (5.49, 9.21)	8.67 (6.80, 10.97)
Hispanic	8.42 (7.11, 9.95)	7.64 (6.31, 9.22)	6.98 (5.72, 8.49)
White, NH	5.75 (4.91, 6.71)	3.84 (3.17, 4.64)	3.81 (3.14, 4.63)
Income (% of the FPL)
≤ 138	9.73 (8.37, 11.28)	7.46 (6.23, 8.91)	8.36 (7.08, 9.84)
139–199	8.55 (6.39, 11.35)	5.74 (4.09, 7.99)	6.34 (4.46, 8.94)
≥ 200	6.71 (5.44, 8.25)	4.04 (3.20, 5.10)	3.84 (2.94, 5.02)
Coverage at Delivery
Uninsured	15.25 (10.32, 21.95)	7.34 (3.99, 13.13)	11.13 (6.82, 17.65)
Medicaid	9.31 (8.20, 10.55)	7.78 (6.72, 8.98)	7.73 (6.69, 8.93)
Private	5.20 (4.47, 6.05)	3.67 (3.08, 4.35)	3.02 (2.48, 3.67)

NH indicates non-Hispanic; FPL, federal poverty level, calculated based on the mid-point of the PRAMS income category and household size; and PRAMS, Pregnancy Risk Assessment Monitoring System. CI, confidence interval.

Note: N = 12,053. Weighted proportions are presented. Infant race and ethnicity were based on maternal and paternal race and ethnicity, reported on the birth certificate files. Coverage was measured as the primary payer for childbirth from the birth certificate.

In adjusted analyses, the odds of visit cancelations/delays were significantly higher among non-Hispanic Black infants (1.50, 95% confidence interval (CI): 1.07–2.10) compared to non-Hispanic White infants and among infants whose parents had Medicaid (1.61, 95% CI: 1.19–2.16) or were uninsured at delivery (3.16, 95% CI: 1.94–5.15) compared to respondents with private coverage (Figure). The adjusted odds of having appointments changed to virtual care were significantly higher among Hispanic infants (1.43, 95% CI: 1.04–1.96) compared to non-Hispanic White infants and among infants whose parents had Medicaid-paid deliveries (1.53, 95% CI: 1.10–2.14) compared to privately insured deliveries. NonHispanic Asian or Pacific Islander infants had significantly lower odds of postponing immunizations (0.35, 95% CI: 0.17, 0.69), while non-Hispanic Black infants had significantly higher odds (1.64, 95% CI: 1.12–2.39) relative to non-Hispanic White infants. The adjusted odds of postponing immunizations were significantly higher among infants whose parents had Medicaid (1.76, 95% CI: 1.26–2.45) or were uninsured at delivery (3.25, 95% CI: 1.78–5.95) compared to private insurance. There were no significant differences in the odds of infant health care disruptions by income for any outcomes.

Figure 1. Adjusted odds of infant health care disruptions during the COVID-19 pandemic by respondent characteristics in 29 US jurisdictions, 2020.

Note: N = 12,053. Weighted odds ratios are presented from multivariable logistic regression models adjusting for age, marital status, education, and jurisdiction. Error bars represent 95% CIs. Infant race and ethnicity were based on maternal and paternal race and ethnicity, recorded on the birth certificate files. Coverage was measured as the primary payer for childbirth from the birth certificate. NH indicates non-Hispanic; FPL, federal poverty level, calculated based on the mid-point of the PRAMS income category and household size; and PRAMS, Pregnancy Risk Assessment Monitoring System. *P < .05, **P < .01, and ***P < .001.

Discussion

In this cross-sectional analysis of health care disruptions by 2–6 months of age among infants born from April to December 2020, we found a higher prevalence of canceling/delaying visits and postponing immunizations during the pandemic among non-Hispanic Black infants and infants whose parents were uninsured or had Medicaid-paid deliveries. The odds of these care disruptions were over 3 times higher among infants whose parents were uninsured at delivery. Transitions to virtual care potentially alleviated some disruptions when inperson care was not available, with a higher likelihood of virtual care transitions among Hispanic infants and infants whose parents had Medicaid. Additional data from the early pandemic also suggested higher virtual care use among Latinos,¹¹ but these telehealth patterns were not consistent across studies.¹² Telehealth appointments were seen as a major strategy to preserve access to health services during the pandemic,¹³ but virtual appointments could not replace all visits entirely for services such as immunizations that require in-person visits.

Early health care use in the first months of life is important for monitoring infant development, providing appropriate medical guidance, referrals for intervention services, and providing immunizations in line with the vaccination schedule.¹⁴ Infant health care disruptions identified in this study could potentially worsen health outcomes and widen preexisting socioeconomic and racial and ethnic infant health disparities.¹⁵ Our results find that Black infants and infants whose parents were Medicaid-insured or uninsured at delivery were the most at risk of having well visits or checkups canceled or delayed and having immunizations postponed. As uninsured families may already face the greatest obstacles to accessing care for their children, these disruptions could present barriers that impede health care access among a group that is already vulnerable to foregoing care.¹⁶ Furthermore, larger disruptions in care for Black infants could be particularly detrimental given long-standing racial disparities in infant health outcomes by race and ethnicity, including infant mortality.1,2 Targeted efforts should be made for patient engagement among families whose infants’ care was disrupted to reduce the effects of delays and foregone care. Specific consideration should be given by health care systems to build trust and address the systems that failed communities during the pandemic, especially among Black communities and uninsured or Medicaid-insured populations.¹⁷ Ensuring timely catch-up appointments will be necessary to address infant care disruptions, particularly for immunizations with specific interval periods.¹⁸ Our findings suggest that pandemic mitigation responses should incorporate strategies that account for existing disparities to prevent the exacerbation of inequities in health outcomes.

Although the clinical significance of canceling and delaying care for infants can vary based on the type of care and duration of delay, care for newborns is essential for ensuring healthy development.7,18 This survey was conducted among parents of infants approximately 2–6 months after childbirth, which reflects care disruptions among infants in their early months of life that requires specific catch-up schedules for missed care.^18,19 Future research should explore if infant care disruptions continued among infants born in later pandemic periods, as strain on the health system may have lessened, and if there were lasting effects of infant care disruptions, such as worsened health outcomes.

Limitations

Study limitations include that only 29 jurisdictions were included, which limits generalizability and the ability to examine further subgroup differences. Second, it is possible that some visit cancelations and delays would have occurred regardless of the pandemic context. Because these questions were asked in a 1-time 2020 supplement, we could not examine changes in the prevalence of these disruptions before and after the pandemic. However, because the survey question wording specifically asks respondents about ways that the COVID-19 pandemic affected infant health care, we can conclude that these estimates reflect disruptions that parents felt were attributable to the COVID-19 pandemic. Third, survey questions did not investigate the length of disruption that occurred from postponing care or if canceled appointments were ever rescheduled. Previous studies have found that longer delays in care are associated with worse infant health outcomes.⁷ Therefore, it is important to consider the length of care disruptions and postponements when considering the consequences of care disruptions for infant health. Fourth, insurance type only reflects coverage at delivery, which may not indicate subsequent parental or infant insurance. Fifth, PRAMS does not include information regarding where care was received. As the COVID-19 pandemic affected health care sectors differently, structural differences in access to care could have been a contributor to inequities in infant health care disruptions.²⁰ Finally, all data in this study were self-reported, which could lead to measurement errors or biases, such as recall or reporting bias.

Conclusions

Study findings indicate that the COVID-19 pandemic particularly disrupted health care for non-Hispanic Black infants and infants whose parents were uninsured or had Medicaid-paid deliveries, with important implications for addressing preexisting infant health inequities. These results underscore the urgency to identify mitigation strategies to reach vulnerable populations during crises to reduce barriers to care. Furthermore, these findings suggest a need for targeted efforts to ameliorate the effects of these infant health care disruptions from the COVID-19 pandemic and for additional research on the long-term effects of care disruptions on health outcomes and disparities among infants born in 2020. Identifying the types of care disruptions and disparate consequences of the pandemic for infants is essential for promoting health equity and improving infant health outcomes in the United States.