TABLE 1.

Medicaid member‐identified barriers to high‐quality, timely prenatal and postpartum care

Themes	Illustrative quotes
Individual barriers
Lack of awareness of pregnancy 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30	“I did not know that I was pregnant, so I kept going with my life as usual until I found out the belly was growing, and I was pregnant and then that's when I started searching for more information and doing everything. If I would've known before, I would have definitely [sought prenatal care at] an earlier stage in the pregnancy” 27
Considering abortion 27 , 29 , 31	“I did not want to have her, until it got to the point that I had no other choice. I was too late by then” 29
Shame and stigma surrounding with pregnancy 22 , 24 , 25 , 26 , 27 , 30 , 32	“…it was all surrounding my shame and embarrassment, and that's what was the driving force of me not seeking prenatal care from the beginning is mostly my insecurities, my guilt and shame that I still feel from my past bad decisions, bad choices. So I did not seek prenatal – and honestly I tried to ignore that this whole thing was even happening, which you can only do for so long. But I did not seek prenatal care for the first six months” 27
Limited support from friends or family 26 , 27 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40	“A lot of people do not know who to turn to or do not have their family's support at home” 33
Conflicting life priorities and challenges (e.g., exhaustion, poor mental health, drug use, homelessness) 22 , 23 , 27 , 28 , 29 , 30 , 32 , 34 , 36 , 38 , 41 , 42	“Yeah, when I was pregnant, like, I was like real [hungry] and we did not have any money. I always got food from home, but like at the end of the month our food always used to run out…. It used to run out a lot.” 42
Lack of knowledge or belief that prenatal or postpartum care visits are important, especially when feeling fine 22 , 25 , 26 , 28 , 31 , 43 , 44	“When you do not have a supportive mother, or a mother who was 14 when she had you, and did not get prenatal care and you were fine, why would you get prenatal care? They do not understand the value and importance of everything that could go wrong, but they just think, oh whatever, I'm pregnant” 26
Structural barriers
Medicaid enrollment challenges and delays and unreasonable cost of care without insurance 22 , 25 , 26 , 27 , 28 , 30 , 31 , 32 , 38 , 42 , 43 , 44 , 45 , 46 , 47	“If you call the doctor to make an appointment, they will ask you, “What type of Medicaid do you have?” They are going to ask for your ID number to clarify first that your Medicaid is active. And once it's active, then they will make your appointment. If they do not accept it, they will not even schedule your appointment” 43
	“If you say, well, I do not have Medicaid, you need to talk to DHS about getting signed up for it. So make an appointment with DHS. DHS wants you to prove you pregnant, so you have to still go to a clinic just to get the help. They're not going to take a home pregnancy test or a phone call either. The paperwork is what you need” 28
	“I was about 16–17 weeks when I found out being pregnant. They actually took them a month before they even gave me my Medicaid. I had to go to an emergency room and a free health center to do pregnancy testing and everything” 43
	“I had always intended on going and having prenatal care, but the first blocker was the welfare department and getting Medi‐Cal… They had denied me Medi‐Cal because I was homeless [and therefore did not have an address].” 32
Challenges finding a provider accepting new patients on Medicaid or an available appointment time 22 , 26 , 27 , 30 , 32 , 33 , 42 , 43 , 48	“They should have took them off instead of giving us numbers to doctors that did not accept Medicaid anymore. So we were going to these doctors and they were turning us around. So it took me about a month to find an actual doctor” 26
	“I found out I was pregnant at 5 weeks. It took time [to get into PNC] because I only had straight T‐19 [basic Medicaid] and a lot of doctors do not take that. So I was switching from doctor to doctor.” 30
Challenges with provider continuity and poor inter‐provider communication 23 , 26 , 27 , 31 , 33 , 35 , 39 , 42 , 47 , 49 , 50	“My problem was that I had three or four different doctors, and none of them talked to each other, as far as I could tell. So they would contradict each other to me in terms of when I could, leave in terms of when I'd get a particular test.” 39
	“They did not know I had a seizure when I was having my daughter. They did not know none of that… They just started over from the beginning, it was new, everything was new to them, each and every time… There were different [providers] in there questioning me, same questions over and over” 31
	“The day that [my Medicaid insurance] expired, [my postpartum care provider] did not accept me anymore… And they told me that I had to look for somewhere else… I did not have a choice” 42
Transportation challenges 22 , 23 , 27 , 28 , 30 , 31 , 32 , 34 , 36 , 41 , 42 , 43 , 44	“It has been very difficult for me because of transportation. There's no bus where I live, you cannot say, ‘I'm going to take a bus and go to the clinic or a store’, because there aren't any. There's no taxi. There's Uber, but I need to have a bank account to be able to access it, which I also do not have” 27
Childcare challenges 22 , 27 , 28 , 34 , 38 , 44	“Well, just like I said, it's harder because we have four other kids who are all pretty little… I keep going places that are really far away from where I live, so it takes like three or four hours by the time someone gets to my house or I take them somewhere and then go the appointment and then go all the way back. So, that's kind of hard… I did not have anybody else to watch them.” 27
Poor linkage to services, such as postpartum depression and substance use treatment 37 , 44 , 45	“They never once referred me to a drug program, not once gave me any kind of information, did not even attempt to… Then, once I. … had my baby, they wanted to take her from me. Right then and there…. If you guys are so concerned with my child, with keep[ing] me away. … and so worried about my child's well‐being, why did not you do anything while I was pregnant, why did not you refer me to some kind of program?” 37
Fear of legal consequences because of care or insurance seeking (e.g., immigration, drug use) 32 , 37 , 46	“When I was almost 5 months pregnant and they were already telling me, you know, you have been testing positive for meth and marijuana and so, if this happens in your next trimester, then you are gonna be CPS involved.” 37
Quality of care
Not feeling heard 28 , 32 , 33 , 39 , 49 , 51	“He wasn't answering my questions, he was very rushed. I'm trying to ask questions and he answered them on his way out the door. Then when I switched over to [new prenatal care site] I was voicing concerns about my pregnancy and they were just pushed off, not taken care of, pushed off. I wasn't happy about that” 32
Not enough time with providers, especially in comparison to wait times 25 , 28 , 30 , 31 , 40 , 42 , 51	“It was kind of a waste of time, to sit there all that time, and then, you know, be rushed out; pretty much I did not get anything accomplishedwith that” 28
	“You just get weighed. Other than that, paperwork and questions, and it's over” 28
Language barriers 46 , 52	“I'm worried about the day I go into labor. Will there be an interpreter there for me? Or should I look for someone who will translate for me so I do not have to fight for it, or how should I do it honestly that is something that really makes me anxious. I understand some things in English, right, but not everything, and when it comes to words they use in the hospital, you understand less because they are more difficult things. I worry when I think about that.” 52
Lack of respect for cultural differences and preferences 24 , 45 , 46 , 52	“I had a male interpreter‚ in my situation‚ well, I wasn't going to get undressed in front of him because I want a woman, but a man, no. I am very modest and besides the fact that I'm a woman‚ I'm not going to show everything in front of a man” 52
Racism or discrimination from providers 24 , 27 , 28 , 30 , 39 , 46 , 48 , 52 , 53	“I told [my midwife] I did not like going to my appointments, and one day she just asked me, “do you do crack?” …Just because I do not want to come to my appointments, I gotta be a drug addict?… Why would she ask me if I smoke crack? But because I'm Black, she said crack, that's probably what it is” 48
	“It's a way a person will talk to you, look at you, and it would just be their whole body language towards you and you'll be able to tell. This one lady…it was just her whole demeanor, she looked at me like I was dirty. Basically, it was just the way she acted towards me that I knew it was because of my skin color.” 30
Disrespectful, dehumanizing, and overmedicalized care 23 , 24 , 36 , 39 , 45 , 51	“They do not respect you; they talk down to you because you are a teen. Student doctors came in and out of the room all the time, disturbing me and waking me up. They practice on you like you are a guinea pig.” 24
	“That place is a puppy mill for babies. They do not want to answer questions, they were snotty and had no eye contact. The staff acted like they did not want to be bothered. The only reason I went was because Medicaid had not kicked in” 24
Feeling lesser than because of income, age, drug use, HIV‐status, or undocumented‐status 24 , 26 , 27 , 28 , 36 , 37 , 42 , 47 , 48	“It depends on the money you make. That's how I feel. It depends on whether you have Medicaid or insurance. When I was on insurance, they treated me like a queen. But when I was off insurance, they like put me in a back room.” 47
	“Providers act like I do not know anything just because I am poor. I want to learn. Didn't get nothing out of it; keep repeating; feel like I'm not smart enough to ask questions” 28