Provision of On-Site Prenatal Care Services at US Federally Qualified Health Centers

BACKGROUND

Low-income pregnant patients face significant inequities in access to care, (1) with maternity care access barriers worsening over the last decade. (2) Meanwhile, Federally Qualified Health Centers (FQHCs) are required to directly provide prenatal care or waive this requirement and refer patients to an external maternity care provider. Because FQHCs are located in medically underserved areas and provide comprehensive primary care services to over 32 million low-income patients across the US,(3) directly providing prenatal services at FQHCs has the potential to address inequities in prenatal care access, where one study found that FQHCs fill gaps in "maternity deserts" through use of family and nurse practitioners who provide maternity care services.(4) However, little is known about the national prevalence of prenatal service provision at FQHCs.

OBJECTIVE

The objective of this study was to describe national rates of on-site versus referral-only prenatal care at FQHCs, describe FQHC- and area-level characteristics associated with offering on-site prenatal care, and depict geographic variation in FQHC provision of prenatal care based on regional maternity desert status.

METHODS

The primary data source was the 2024 Uniform Data System (UDS), a national, facility-level dataset that includes the universe of Health Resources and Services Administration (HRSA)-funded FQHCs. Secondary county-level data from March of Dimes were used to classify maternity deserts. Our study sample included all FQHCs in operation in 2024, excluding FQHCs serving <100 adult female patients or located in US territories. The primary outcome was provision of on-site prenatal services (yes/no).

The unit of analysis was the FQHC. First, we descriptively compared characteristics of FQHCs with on-site versus referral-only prenatal care. Next, we mapped county-level variation in provision of on-site prenatal care at any FQHC in the county, stratified by whether the county was classified as a maternity desert.

Data were analyzed in December 2025 using Stata 18 (Stata Corp). The Boston University Institutional Review Board approved this study. We followed the STROBE reporting guidelines.

The funder had no role in the design, conduct, analysis, or submission of this study.

FINDINGS

In 2024, among 1,326 FQHCs serving approximately 8.0 million females of reproductive age, 884 (66.7%) provided on-site prenatal care while 442 (33.3%) exclusively referred pregnant patients to external providers (Table 1). On average, FQHCs with on-site prenatal care (versus referral-only) had greater percentages of patients who were enrolled in Medicaid (45.4% vs. 38.4%), were Black (20.6% vs. 17.1%) or Hispanic (37.9% vs. 22.3%), had income under the federal poverty level (66.3% vs. 62.7%), or had limited English proficiency (25.9% vs. 15.2%). FQHCs with on-site prenatal care were also more often in urban locations (66.2% vs. 46.4%), served more total females of reproductive age (7,499/FQHC vs. 3,057/FQHC), and were less likely to be located in maternity deserts (6.5% vs. 12.5%), with standardized differences >0.10.

Table 1.

Characteristics of US FQHCs by On-Site Provision of Prenatal Care (2024)

	Total (N=1326 FQHCs, serving 7.98 million females age 15-44)	Yes, on-site prenatal care (N=884 FQHCs, serving 6.63 million females age 15-44)	No, referral- only prenatal care (N=442 FQHCs, serving 1.35 million females age 15-44)	Standardized difference
Percent of total	100%	66.7%	33.3%	N/A
Patient characteristics (all patients)
Insurance type, %
Medicaid	43.1%	45.4%	38.4%	−0.38
Private insurance	23.5%	22.4%	25.8%	0.27
Medicare	12.7%	11.3%	15.6%	0.53
Uninsured	20.1%	20.3%	19.8%	−0.03
Sex, %
Female	56.4%	57.3%	54.5%	−0.50
Male	43.6%	42.7%	45.5%	−0.50
Age group, %
<18	24.3%	26.6%	19.7%	−0.56
18-64	61.6%	60.6%	63.8%	0.18
≥65	14.0%	12.8%	16.5%	0.43
Income, %
<100% FPL	65.1%	66.3%	62.7%	−0.18
101-200% FPL	24.7%	24.1%	25.8%	0.16
>200% FPL	10.2%	9.6%	11.5%	0.15
Race/ethnicity, %
White, non-Hispanic	42.6%	35.6%	56.5%	0.69
Black, non-Hispanic	19.4%	20.6%	17.1%	−0.15
Hispanic	32.7%	37.9%	22.3%	−0.57
Asian, non-Hispanic	3.4%	3.9%	2.3%	−0.17
Other race, non-Hispanic	1.9%	2.0%	1.8%	−0.06
Limited English proficiency, %	22.5%	25.9%	15.2%	−0.53
FQHC characteristics
Total female patients of reproductive age, mean	6,019	7,499	3,057	−0.65
FQHC located in urban area, %	59.6%	66.2%	46.4%	−0.41
FQHC located in Medicaid expansion state, %	69.5%	69.8%	68.8%	−0.02
OB/GYNs per 100k in FQHC county, mean	36.9	39.8	30.9	−0.33
Maternity access classification of FQHC county, %
“Maternity desert”	8.5%	6.5%	12.5%	0.21
Low access	3.3%	2.4%	5.0%	0.14
Moderate access	1.7%	1.6%	2.0%	0.03
Full access	86.5%	89.6%	80.5%	−0.26

FQHC is federally qualified health center; FPL is federal poverty level. Provision of on-site prenatal services was measured in the Uniform Data System (UDS) by the question: “Check the ‘Prenatal Care by Referral Only’ box if you provide prenatal care to patients only through direct formal written referral to another provider. DO NOT check this box if your health center providers provide some or all prenatal care to patients directly” Maternity access classifications based on the March of Dimes classification system, where “maternity desert” is defined as a county without a single birthing facility, birthing hospital, or obstetric clinician. Standardized differences compare on-site versus referral-only FQHCs, where standardized differences of >10% are considered meaningfully different. Total female patients of reproductive age (15-44 years) serves as a proxy for FQHC size. Patient characteristics reflect the entire FQHC patient population and are not specific to females of reproductive age.

On-site prenatal care provision at FQHCs varied across US counties (Figure 1). Northeast and Pacific West counties were least likely to be maternity deserts, with many counties having FQHCs with on-site prenatal care. South and Western Midwest counties were most likely to be maternity deserts, with many counties having no FQHCs or FQHCs without on-site prenatal care.

Figure 1. County-level Availability of On-Site Prenatal Care at FQHCs by Maternity Desert Status (2024).

FQHC is federally qualified health center. Provision of on-site prenatal services was measured in the Uniform Data System (UDS). If one or more FQHC in the county offered on-site prenatal care, the county was classified as such. Maternity access classifications based on the March of Dimes classification system, where “maternity desert” is defined as a county without a single birthing facility, birthing hospital, or obstetric clinician.

DISCUSSION

This observational study provides national estimates of on-site prenatal service provision at FQHCs, finding that 2 in 3 FQHCs offered prenatal care directly in 2024, while 1 in 3 did not. FQHCs with high percentages of Black, Hispanic, Medicaid-enrolled, and limited English proficiency patients were most likely to offer prenatal care, suggesting that FQHCs may provide access to prenatal care for populations that otherwise experience barriers to accessing quality maternal health care. This aligns with findings from an earlier study on a subset of FQHCs.(5) Further, on average, FQHCs not offering prenatal care were located in counties with lower maternal health workforce capacity and greater rurality, suggesting opportunity to expand FQHC provision of maternity services in maternity deserts and rural regions to mitigate access-related barriers to care; expanding HRSA resources for building new FQHCs in these regions may also improve access. Study limitations include lack of patient-level data, lack of data on where FQHC patients receive prenatal care in absence of on-site care, and inability to measure maternity care capacity or specific prenatal care services within FQHCs. Nonetheless, findings motivate the need for future research that assesses if and how on-site provision of prenatal services at FQHCs impacts access to and quality of care for perinatal populations, alongside factors that shape FQHC decisions to offer prenatal care. In turn, this evidence may inform workforce, payment, and delivery system policies that enhance the ability of FQHCs to serve vulnerable pregnant populations.