A pooled cross-sectional analysis of the relationship between payer at delivery and timely prenatal care initiation in the United States, 2021–2024

Timely entry into prenatal care is widely recognized as an important indicator of access to maternal health services. Differences in prenatal care initiation have been documented across insurance and payer groups, but continued national assessment is important for understanding how these differences have changed during the post-COVID period. This study examined the relationship between payer recorded at delivery and late or no prenatal care in the United States and assessed whether payer-related differences changed between 2021 and 2024. A pooled cross-sectional analysis was conducted using National Vital Statistics System (NVSS) natality public use files from 2021 to 2024. The analytic sample included live births with complete data on prenatal care timing, payer at delivery, race and ethnicity, maternal age, education, and parity. Payer at delivery was categorized as Medicaid, private insurance, self-pay, or other public insurance. Late or no prenatal care was defined as initiation during the second or third trimester or no recorded prenatal care. Descriptive analyses and grouped binomial logistic regression models were used to examine differences by payer category. Payer-by-year interactions were estimated, and population-averaged adjusted probabilities and absolute differences relative to private insurance were used to characterize changes over time. A linear probability model was included as a sensitivity analysis of absolute differences. Late or no prenatal care was most common among births with self-pay recorded at delivery, increasing from 45.5% in 2021 to 46.7% in 2024, followed by Medicaid births (30.3% to 34.0%) and privately insured births (12.9% to 15.0%). After adjustment, Medicaid (AOR = 1.79), self-pay (AOR = 3.50), and other public insurance (AOR = 1.32) were associated with higher odds of late or no prenatal care than private insurance. Population-averaged absolute differences versus private insurance increased from 9.03 to 10.00 percentage points for Medicaid and changed from 24.06 to 23.34 percentage points for self-pay. The linear probability model produced a similar pattern. Payer recorded at delivery was associated with prenatal care timing. Absolute differences were largest for self-pay births, while the Medicaid–private gap increased modestly. These results should be interpreted as associations, not effects.