RESEARCH AND PRACTICE
The Importance of Geographic Data Aggregation in
Assessing Disparities in American Indian Prenatal Care
Pamela Jo Johnson, MPH, PhD, Kathleen Thiede Call, PhD, and Lynn A. Blewett, PhD
The 2007 National Healthcare Disparities Re-
port suggests that many indicators of disparity
in quality of care between American Indians/
Alaska Natives (AIANs) and Whites and most
indicators of disparity in access to care between
the 2 groups are improving.1 However, these
conclusions are drawn from nationally aggre-
gated data. Questions remain about whether,
and to what extent, national data on AIAN
disparities mask geographic variation in access to
care and disparities in access at subnational levels
(e.g., states and localities).
Access to care is a critical element to im-
proving health status and is 1 of the 10 Leading
Health Indicators that is monitored at the
national level.2 Each Leading Health Indicator
has Healthy People 2010 objectives associated
with it. For example, the objectives used to
monitor access to care in the United States are (1)
insurance coverage, (2) having a usual source of
care, and (3) prenatal care utilization.2 For this
article, we focus on prenatal care as a key
indicator to measure both access to care and
disparities in access for the AIAN population.
It is generally assumed that women who
receive adequate prenatal care have better
birth outcomes, although the relevant content
and effectiveness of prenatal care remain de-
batable.3,4 Initiating prenatal care early in preg-
nancy and continuing with prescribed visits
provides opportunity for medical management
of health complications, lifestyle and health
behavior advice, and referral to additional health
and social welfare resources when necessary.
Between 1990 and 1998, the proportion
of all infants whose mothers began prenatal
care in the first trimester increased, but the rate
for AIANs still lagged behind other population
groups. The rate for AIANs increased from
58% to 69%, compared with an increase from
83% to 88% for non-Hispanic Whites.5 In-
creases in early prenatal care have been greatest
among those whose risk profiles and adverse
birth outcome rates are highest. However, AIANs
are still more than 3.6 times more likely than are
122 | Research and Practice | Peer Reviewed | Johnson et al.
Objectives. We sought to determine whether aggregate national data for
American Indians/Alaska Natives (AIANs) mask geographic variation and sub-
stantial subnational disparities in prenatal care utilization.
Methods. We used data for US births from 1995 to 1997 and from 2000 to 2002
to examine prenatal care utilization among AIAN and non-Hispanic White
mothers. The indicators we studied were late entry into prenatal care and
inadequate utilization of prenatal care. We calculated rates and disparities for
each indicator at the national, regional, and state levels, and we examined
whether estimates for regions and states differed significantly from national
estimates. We then estimated state-specific changes in prevalence rates and
disparity rates over time.
Results. Prenatal care utilization varied by region and state for AIANs and non-
Hispanic Whites. In the 12 states with the largest AIAN birth populations,
disparities varied dramatically. In addition, some states demonstrated sub-
stantial reductions in disparities over time, and other states showed significant
increases in disparities.
Conclusions. Substantive conclusions about AIAN health care disparities
should be geographically specific, and conclusions drawn at the national level
may be unsuitable for policymaking and intervention at state and local levels.
Efforts to accommodate the geographically specific data needs of AIAN health
researchers and others interested in state-level comparisons are warranted. (Am
J Public Health. 2010;100:122–128. doi:10.2105/AJPH.2008.148908)
non-Hispanic Whites to enter prenatal care in the inadequate prenatal care use compared with all
third trimester or to have no prenatal care at all.5 other races.7,8 Few studies have closely exam-
The Healthy People 2010 goals for the nation ined AIAN disparities in prenatal care utilization;
include goals to increase the proportion of those that have tend to use nationally aggregated
pregnant women who receive early and ade- data. However, beginning with 2005 data, the
quate prenatal care. The 2 specific goals are: (1) National Center for Health Statistics revised its
to increase the proportion of all infants whose data-release policy to comply with state require-
mothers begin prenatal care in the first trimester ments. The revised policy is ‘‘consistent with
from a baseline of 83% to the target of 90%, CDC and NCHS goals to make data available as
and (2) to increase the proportion of all infants widely as possible while protecting respondent
whose mothers have early and adequate pre- confidentiality, assuring data quality, and con-
natal care from a baseline of 74% to the target forming to state laws and regulations on re-
of 90%.2 Although the goals are the same for all release of vital statistics data.’’9 In practice,
groups, the baseline rates for AIANs and non- national vital records public-use data files no
Hispanic Whites are quite different. The baseline longer contain geographic identifiers, making
proportion of all infants whose mothers had local-area analyses more difficult.
adequate prenatal care was 57% for AIANs and We disaggregated national-level data to re-
79% for non-Hispanic Whites. gional and state levels to examine whether
Disparities in prenatal care utilization have national data on AIAN disparities mask geo-
narrowed for some groups,6 but AIANs have graphic variation and substantial subnational
consistently recorded the highest rates of disparities in access to health care for 2
American Journal of Public Health | January 2010, Vol 100, No. 1
 RESEARCH AND PRACTICE

indicators of access: late entry into prenatal analyzed our findings in terms of adverse
care and inadequate utilization of prenatal events: late prenatal care and inadequate pre- TABLE 1—Percentage of Records With
care. Our intent is not to dispute the conclu- natal care. Late entry into prenatal care was Missing Data for Prenatal Care
sions of the National Healthcare Disparities defined as not receiving prenatal care in the Indicators by Geography, Maternal
Report but rather to examine whether the story first trimester of pregnancy. We could not Race, and Time Period: National
is more complicated than what the report calculate late prenatal care for 1.8% of our Perinatal Mortality Data Files, 1995–
indicates. records because data about the month prenatal 1997 and 2000–2002
care began were missing. Inadequate prenatal 1995–1997 2000–2002
METHODS care utilization was calculated using the Ade-
AIAN, White, AIAN, White,
quacy of Prenatal Care Utilization Index, which % % % %
We used publicly available data from the is calculated on the basis of a comparison of
National Vital Statistics System at the National actual number of visits to the recommended Late prenatal care
Center for Health Statistics. The data are from number of visits based on month of entry into United States 2.8 1.7 2.8 1.7
the National Perinatal Mortality Data files, care and length of the pregnancy.12,13 The Northeast 4.9 3.0 3.9 3.0
which are compiled annually at the national Adequacy of Prenatal Care Utilization Index is Midwest 2.3 1.2 2.3 1.3
level and contain birth-certificate data for all used to classify women’s prenatal care utilization Minnesota 5.5 3.4 6.0 3.2
live births collected by each of the 50 states. into 4 categories: adequate-plus, adequate, in- North Dakota 1.1 0.3 3.2 0.5
Our analytic sample comprises all records for termediate, and inadequate. We could not cal- South Dakota 1.9 0.3 0.6 0.2
singleton infants born from 1995 through culate adequacy of prenatal care for 3.5% of our Wisconsin 0.5 0.2 0.4 0.3
1997 and from 2000 through 2002 to AIAN records because data were missing for at least 1 South 3.5 1.5 2.3 1.2
mothers (n =111520 and n =123 231, respec- of the necessary variables. North Carolina 1.0 0.4 0.5 0.4
tively) and non-Hispanic White mothers For analysis, dichotomous indicator vari- Oklahoma 5.6 8.1 3.3 3.1
(n = 6 870 891 and n = 6 741055, respec- ables were created for each prenatal care West 2.4 1.4 3.3 2.0
tively). measure. Late prenatal care was defined as not Alaska 1.3 1.2 4.4 3.5
entering care in the first trimester compared Arizona 1.4 1.1 1.7 1.1
Measures with all others. Inadequate prenatal care was California 1.1 0.6 1.9 1.1
Prenatal care utilization is assessed most defined as not receiving adequate or adequate- Montana 1.1 0.3 0.6 0.4
simply by the trimester in which prenatal care plus care compared with all others. For each New Mexico 3.6 3.5 3.8 4.5
began, with entry into prenatal care in the first indicator variable, missing data were coded Washington 8.9 5.4 10.9 6.5
trimester considered the goal. However, the as late prenatal care or inadequate prenatal Inadequate prenatal care
trimester in which prenatal care began, in care, respectively. Table 1 shows the percent United States 5.2 3.4 4.9 3.3
isolation, provides little information about the missing for each indicator by race, geography, Northeast 6.5 4.4 5.4 4.5
pattern of prenatal care utilization throughout and time. Midwest 3.7 2.3 3.4 2.3
pregnancy. Thus, indices representing ade- Geographic levels for analysis included re- Minnesota 7.1 4.7 7.6 4.6
quacy of prenatal care utilization have been gions and states. Although policy is not made at North Dakota 1.4 0.5 3.9 0.9
developed that take into account the timing of the regional level, we used region juxtaposed South Dakota 2.1 0.7 1.0 0.3
entry into prenatal care as well as the number with state to demonstrate geographic variabil- Wisconsin 1.1 0.4 0.6 0.4
of prenatal care visits, adjusted for the gesta- ity at changing levels of data aggregation. South 5.4 2.9 3.6 2.6
tional age of the infant at delivery. Each index Geography was defined according to mother’s North Carolina 1.1 0.6 0.7 0.7
uses an algorithm to define categories of pre- residence at time of delivery. State of residence Oklahoma 8.1 11.8 4.5 4.8
natal care utilization ranging from intensive was identified on each birth record by Federal West 5.5 5.0 6.1 5.2
usage to inadequate or no care.10 It is important Information Processing Standards codes, and Alaska 2.1 1.6 6.5 7.6
to note that estimates and overall trends in we used these codes to classify records accord- Arizona 3.1 3.2 3.2 2.8
prenatal care utilization will differ depending on ing to US Census Bureau–defined regions.14 California 9.3 5.6 11.2 6.3
which measure is used.11 Montana 1.6 0.6 1.0 0.7
The indicators of interest for this study were Analysis New Mexico 4.9 5.4 5.1 6.2
2 standard measures of prenatal care utiliza- First, we calculated race-specific rates and Washington 17.2 11.2 16.1 11.1
tion, 1 representing late entry into prenatal measures of disparity for each indicator at the Note. AIAN = American Indian/Alaska Native. An AIAN
care and the other representing inadequate national, regional, and state levels. Rates are infant is defined as an infant born to an AIAN mother.
prenatal care utilization. Although Healthy presented as percent of infants with mothers A White infant is defined as an infant born to a
non-Hispanic White mother. The only states listed
People 2010 goals for prenatal care are defined who did not enter prenatal care in the first individually are those with more than 2100 AIAN births
in terms of favorable events (increases in early trimester (late prenatal care) and percent of for each period.
utilization and adequate utilization), we infants whose mothers did not receive

January 2010, Vol 100, No. 1 | American Journal of Public Health Johnson et al. | Peer Reviewed | Research and Practice | 123
 RESEARCH AND PRACTICE

adequate prenatal care (inadequate prenatal

care). Second, we examined whether estimates TABLE 2—Regional and State Differences From National Rates of Late and Inadequate
for regions and for states differed significantly Prenatal Care, by Maternal Race and Time Period: National Perinatal Mortality Data Files,
from national estimates for each race group. 1995–1997 and 2000–2002
We calculated z scores to test for the difference 1995–1997 2000–2002
between 2 proportions (i.e., subnational rate
AIAN, % White, % AIAN, % White, %
compared with national rate for each subna-
tional stratum). Finally, using a difference- Late prenatal care
in-differences approach, we estimated state- US rate 34.5 14.1 32.6 13.1
specific changes in prevalence rates and rate Northeast –4.5*** –0.1*** –8.8*** 0.3***
disparities for late prenatal care and inade- Midwest –1.0** –0.5*** 0.5 –0.5***
quate prenatal care between the 2 time pe- Minnesota 8.4*** 1.9*** 9.0*** 0.6***
riods. State analyses focused on the 12 states North Dakota –4.0*** –0.1 4.4*** –1.5***
with the largest AIAN birth populations, which South Dakota 3.2*** 0.6** 8.2*** 4.5***
we defined as those with more than 2100 Wisconsin –1.4 –1.8*** –3.9*** –0.7***
births to AIAN mothers during each period South –3.4*** –0.5*** –3.5*** –0.6***
(Table 1). All analyses were conducted using North Carolina –6.0*** –3.4*** –9.9*** –3.5***
Stata statistical software, version 9.2.15 Oklahoma 1.0* 10.7*** 0.7 7.8***
West 2.2*** 1.7*** 2.4*** 1.7***
RESULTS Alaska –9.0*** 2.8*** 0.0 5.8***
Arizona 6.9*** 3.6*** 2.9*** 0.8***
Regional rates of late prenatal care were California –3.5*** –0.2*** –6.0*** –2.1***
significantly different from the national rate of Montana –1.0 1.7*** 2.7*** 1.3***
late prenatal care for both races and in both New Mexico 12.6*** 9.7*** 10.6*** 13.7***
time periods, with the exception of the Midwest Washington 0.1 4.5*** 2.8*** 6.6***
AIAN rate for the 2000–2002 period (Table Inadequate prenatal care
1). Regional rates of inadequate prenatal care US rate 46.2 24.8 44.6 23.9
were also significantly different from the na- Northeast –7.5*** 3.7*** –10.0*** 4.6***
tional rate of inadequate prenatal care for both Midwest 1.5*** –1.8*** 0.6 –2.6***
races and in both time periods, with the Minnesota 12.5*** 0.9*** 11.7*** 2.4***
exception of the Midwest AIAN rate for the North Dakota 7.0*** 5.7*** 12.0*** 5.0***
2000–2002 period. South Dakota 10.2*** –4.5*** 7.8*** –3.9***
The upper panel of Table 2 displays the Wisconsin –2.9** –7.3*** –5.9*** –3.6***
difference between state rates and the US South –6.4*** –2.3*** –6.4*** –2.6***
rates for late prenatal care by maternal race North Carolina –12.5*** –10.9*** –18.3*** –10.0***
and time period. For AIANs in the 1995– Oklahoma 1.2** 10.1*** –0.9* 7.7***
1997 period, state rates of late prenatal care West 3.0*** 3.1*** 4.0*** 4.0***
range from 9.0% lower than the US AIAN Alaska –2.0*** –0.5 9.0*** 9.3***
rate in Alaska to 12.6% higher than the US Arizona 9.0*** 0.2 4.2*** 0.4**
AIAN rate in New Mexico. For AIANs in the California –4.2*** –2.5*** –4.8*** –0.2***
2000–2002 period, state rates of late pre- Montana 5.8*** –1.7*** 7.3*** 1.5***
natal care range from 9.9% points below the New Mexico 12.0*** 13.7*** 10.2*** 15.3***
US AIAN rate in North Carolina to 10.6% Washington 6.4*** 5.8*** 5.3*** 11.6***
points above the US AIAN rate in New
Note. AIAN = American Indian/Alaska Native. An AIAN infant is defined as an infant born to an AIAN mother. A White infant is
Mexico. For Whites, state rates of late prenatal defined as an infant born to a non-Hispanic White mother. The only states listed individually are those with more than 2100
care for the 1995–1997 period range from AIAN births for each period. Asterisks indicate significant differences from national rates by z test.
*P < .05;**P < .01;***P < .001.
3.4% below the US White rate in North
Carolina to 10.7% above the US White rate in
Oklahoma; for the 2000–2002 period, state
rates of late prenatal care range from 3.5% The lower panel of Table 2 shows differ- inadequate prenatal care range from 16.1%
below the US White rate in North Carolina to ences between state rates and US rates for below the US AIAN rate in North Carolina to
13.7% above the US White rate in New inadequate prenatal care by maternal race and 12.5% above the US AIAN rate in Minnesota
Mexico. time period. For AIANs, state rates of for the 1995–1997 period, and from 18.3%

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 RESEARCH AND PRACTICE

below in North Carolina to 12.9% above in
North Dakota for the 2000–2002 period. For
Whites, state rates of inadequate prenatal care
range from 10.5% below the US White rate
in North Carolina to 15.4% above the US
White rate in New Mexico for the 1995–1997
period, and from 10.0% below in North
Carolina to 15.3% above in New Mexico for the
2000–2002 period.
Table 3 displays late prenatal care rates and
late prenatal care disparities by maternal race
and geography over time. For the nation, the
AIAN–White disparity for late entry into pre-
natal care shrank by nearly 1 percentage point
from the 1995–1997 period to the 2000–
2002 period (from 20.4% to 19.5%; P < .001).
This same pattern held true for the South and
West regions. For the Northeast, the reduction
in disparity was more dramatic, at nearly 6
percentage points (from 16.0% to 10.4%;
P < .001); the Midwest had no significant
change. Patterns for state-level disparities var-
ied more widely. New Mexico showed a re-
duction in AIAN-White disparity of nearly 7
percentage points (from 23.2% to 16.3%;
P < .001), but North Dakota demonstrated an
increase in disparity of 9 percentage points
(from 16.4% to 25.4%; P < .001). Minnesota
had the largest absolute AIAN–White disparity
for late prenatal care in both periods (26.9%
and 27.9%), although no statistically significant
changes occurred over time.
Table 4 shows inadequate prenatal care
rates and inadequate prenatal care disparities
by maternal race and geography over time.
Overall, the AIAN-White disparity in rates of
inadequate prenatal care declined by 0.6 per-
centage points from the 1995–1997 period to
the 2000–2002 period (from 21.3% to
20.7%; P = .002). For the Northeast, the de-
cline in disparity was again more dramatic, at
more than 4 percentage points (10.2% and
6.1%; P < .001); the Midwest, South, and West
regions showed no significant changes. Patterns
for state-level disparities also varied. Washing-
ton had the largest decline in AIAN–White
disparity, at 4.6 percentage points (from 19.0%
to 14.4%; P < .001), and North Dakota again
had a disparity increase, this time of more than
6 percentage points (from 21.4% to 27.7%;
P < .001).
DISCUSSION
Rates of late prenatal care and inadequate
prenatal care utilization varied by region and
state both for AIANs and for non-Hispanic
Whites. Disparities also differed by geographic
level, revealing stark differences from the
national average. The Midwest generally had
the widest AIAN–White disparities for both
indicators, even though it was the only region
with no significant change in disparities over
time. When focused on the 12 states with the
largest AIAN birth populations, our analysis
suggests that changes in disparities in prenatal
care utilization varied dramatically, with some
states showing substantial reductions in dis-
parities and other states showing marked in-
creases in disparities.
Our findings are consistent with previous
studies that have shown geographic variation in

TABLE 3—Late Prenatal Care Rates by Maternal Race and Geographic Region, and Changes in Disparities Over Time:
National Perinatal Mortality Data Files, 1995–1997 and 2000–2002

AIAN–White Disparities
1995–1997 2000–2002 Change in Disparity
AIAN, % White, % AIAN, % White, % 1995–1997, % (SE) 2000–2002, % (SE) % Change (SE) t P

US rate 34.5 14.1 32.6 13.1 20.4 (0.14) 19.5 (0.13) –0.9 (0.20) –4.42 <.001
Northeast 30.0 14.0 23.8 13.4 16.0 (0.66) 10.4 (0.57) –5.7 (0.87) –6.47 <.001
Midwest 33.5 13.7 33.1 12.6 19.8 (0.33) 20.5 (0.31) 0.7 (0.46) 1.62 .105
Minnesota 42.9 16.0 41.6 13.7 26.9 (0.88) 27.9 (0.80) 1.0 (1.19) 0.84 .400
North Dakota 30.4 14.1 37.0 11.6 16.4 (1.02) 25.4 (1.02) 9.1 (1.45) 6.27 <.001
South Dakota 37.7 14.8 40.8 17.6 22.9 (0.74) 23.1 (0.73) 0.2 (1.04) 0.19 .851
Wisconsin 33.1 12.4 28.7 12.4 20.7 (0.94) 16.3 (0.84) –4.4 (1.26) –3.47 .001
South 31.1 13.6 29.1 12.5 17.5 (0.28) 16.6 (0.25) –0.8 (0.38) –2.24 .025
North Carolina 28.5 10.7 22.7 9.6 17.8 (0.67) 13.1 (0.60) –4.7 (0.90) –5.22 <.001
Oklahoma 35.4 24.9 33.3 20.9 10.6 (0.44) 12.4 (0.40) 1.8 (0.60) 3.01 .003
West 36.7 15.8 35.0 14.8 20.9 (0.20) 20.3 (0.19) –0.7 (0.28) –2.40 .016
Alaska 25.5 17.0 32.6 18.9 8.5 (0.59) 13.7 (0.63) 5.2 (0.87) 5.95 <.001
Arizona 41.4 17.7 35.5 13.9 23.6 (0.41) 21.6 (0.38) –2.1 (0.56) –3.65 <.001
California 31.0 13.9 26.6 11.0 17.1 (0.47) 15.6 (0.47) –1.6 (0.66) –2.35 .019
Montana 33.5 15.8 35.3 14.4 17.6 (0.82) 20.9 (0.79) 3.3 (1.14) 2.86 .004
New Mexico 47.1 23.9 43.2 26.8 23.2 (0.57) 16.3 (0.56) –6.9 (0.80) –8.63 <.001
Washington 34.6 18.7 35.4 19.7 15.9 (0.67) 15.8 (0.64) –0.2 (0.93) –0.20 .838

Note. AIAN = American Indian/Alaska Native. An AIAN infant is defined as an infant born to an AIAN mother. A White infant is defined as an infant born to a non-Hispanic White mother. The only
states listed individually are those with more than 2100 AIAN births for each period.

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 RESEARCH AND PRACTICE

TABLE 4—Inadequate Prenatal Care Rates by Maternal Race and Geographic Region, and Changes in Disparities Over Time:
National Perinatal Mortality Data Files, 1995–1997 and 2000–2002

AIAN–White Disparities
1995–1997, % 2000–2002, % 1995–1997, % 2000–2002, % Change in Disparity
AIAN White AIAN White Disparity SE Disparity SE Change, % SE, % t P

US rate 46.2 24.8 44.6 23.9 21.3 0.15 20.7 0.14 –0.6 0.21 –3.13 .002
Northeast 38.7 28.5 34.6 28.6 10.2 0.70 6.1 0.64 –4.1 0.95 –4.35 <.001
Midwest 47.6 23.1 45.2 21.4 24.6 0.35 23.9 0.33 –0.7 0.49 –1.37 .171
Minnesota 58.7 29.5 56.3 26.3 29.2 0.88 30.0 0.81 0.8 1.19 0.64 .519
North Dakota 57.4 36.0 56.6 28.9 21.4 1.12 27.7 1.08 6.4 1.55 4.09 <.001
South Dakota 56.3 21.3 52.5 20.0 35.0 0.77 32.4 0.74 –2.6 1.07 –2.43 .015
Wisconsin 42.3 20.3 38.7 20.3 22.0 0.98 18.4 0.91 –3.6 1.34 –2.68 .007
South 39.7 22.5 38.2 21.4 17.2 0.30 16.8 0.27 –0.4 0.40 –1.03 .305
North Carolina 30.0 14.4 26.4 13.9 15.7 0.69 12.5 0.63 –3.2 0.93 –3.46 .001
Oklahoma 46.7 37.8 43.7 31.6 8.9 0.46 12.1 0.43 3.2 0.63 5.06 <.001
West 49.2 28.0 48.7 28.0 21.2 0.21 20.7 0.20 –0.5 0.29 –1.84 .065
Alaska 45.2 26.1 53.6 33.3 19.1 0.68 20.3 0.70 1.2 0.97 1.23 .217
Arizona 52.4 28.8 48.9 24.3 23.5 0.42 24.5 0.41 1.0 0.59 1.76 .079
California 41.6 25.5 39.8 23.7 16.1 0.50 16.1 0.53 0.0 0.72 –0.01 .990
Montana 52.6 25.3 51.9 25.5 27.3 0.88 26.4 0.84 –0.9 1.21 –0.72 .474
New Mexico 55.1 40.3 54.8 39.3 14.8 0.58 15.5 0.58 0.7 0.82 0.82 .414
Washington 53.6 34.6 49.9 35.5 19.0 0.70 14.4 0.68 –4.6 0.98 –4.71 <.001

Note. AIAN = American Indian/Alaska Native and is defined as an infant born to an AIAN mother. White is defined as an infant born to a non-Hispanic White mother. The only states listed individually
are those with more than 2100 AIAN births for each period.

adequacy of prenatal care for AIAN women.
One study of nationwide urban AIAN maternal
and infant health found that Minneapolis–St.
Paul, Minnesota, was the urban area with the
highest rate of inadequate prenatal care for
AIANs from 1989 through 1991 (29.8%), and
Fayetteville, North Carolina, had the lowest
rate (4.4%).16 In another study, the authors
compared urban and rural AIANs and found
that overall, rural AIANs had slightly higher rates
of inadequate prenatal care usage than their urban
counterparts.17 However, when the data were
stratified by Indian Health Service (IHS) service
area, there were substantial differences in the
relationship between rural or urban status and
prenatal care usage. In the 12 IHS service areas
studied, rural AIANs had higher rates of in-
adequate prenatal care than urban AIANs in 6 of
the areas, and the opposite was true for 4 other
IHS service areas. (Rural–urban comparisons
were not made for the other 2 IHS service areas
because 1 of the areas was classified as entirely
rural, and the other was predominantly urban.)17
AIAN women in rural or reservation areas
may have low rates of prenatal care use
because of the poor proximity of most pro-
viders to women in remote areas or to women
who have limited transportation options.
However, limited data on urban AIANs suggest
that AIAN women in some large cities may
have had higher rates of inadequate prenatal
care than their rural counterparts.18,19 Another
study found that AIANs in urban areas served by
federally funded urban Indian health organiza-
tions were more likely to have late or no prenatal
care than the general population in those areas,
but as a group urban AIANs were no different
from the national population of AIANs.20 We
were unable to find any studies that compared
urban–rural differences by state.
Limitations
The findings presented here should be con-
sidered in light of certain limitations. First, the
rates reported are unadjusted rates, similar to the
rates monitored and reported in national sur-
veillance reports. However, AIANs and non-
Hispanic Whites have been shown to differ
significantly on many sociodemographic mea-
sures. Age, education, and marital status are
strongly associated with prenatal care utilization,
so it is possible that differences in the demo-
graphic composition of individual states account
for some of the variability from national rates.
Future research using multilevel models might
help explain this state-level heterogeneity.
Second, vital records data are collected for
civil registration and surveillance purposes,
not for research; thus, a number of key vari-
ables may be of questionable quality.21,22
Several studies have suggested that maternal
demographics on the birth certificates were
generally good.23–25 This was likely due, in most
circumstances, to demographic data being sup-
plied by the mother. However, 1 study indicated
that although maternal race/ethnicity data on the
birth certificate was quite good for most race
groups, the sensitivity for maternal race data for
AIANs in California was only 54%.26 This may
have been because hospital staff reported race
rather than mothers providing self-reports. Cal-
ifornia is 1 of the states highlighted in this study,
so it is possible that some AIAN women were
misclassified as White in our analyses for that
state.

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Validation studies on the use of birth
certificate data for determining prenatal care
utilization have produced mixed results.
Some studies indicated acceptable prenatal
care data quality,23–25,27 whereas others in-
dicated extremely poor agreement between
birth certificates and medical records.28 To the
extent that the prenatal care data available in
our vital records data underestimated the timing
and adequacy of care for both groups, the
pattern of disparities is likely robust. However, if
there was differential misclassification of late or
inadequate prenatal care by maternal race, by
time period, or by state, our calculation of
AIAN–White disparities may be biased.
Finally, missing vital-records data elements
are also a concern. Specifically, we needed
data on the month when prenatal care be-
gan, the number of prenatal visits, and gesta-
tional age to calculate our measures of
prenatal care utilization. However, excluding
those who were missing data would have
caused the removal of those potentially at
highest risk for inadequate prenatal care; thus,
it is recommended that incomplete records
be included in analyses of vital records data.29
For our calculations, we assumed that missing
prenatal care data often results from late or
inadequate care. Therefore, we retained those
with missing data and classified them in the
adverse category. To assess the robustness of
our results in light of this assumption, we ran
the analyses with the missing data excluded,
and the results did not change appreciably,
with the exception of Oklahoma and Alaska
(results not shown). For Oklahoma, the
change in both prenatal care disparities over
time became nonsignificant. For Alaska, late
prenatal care disparity did not change, and
inadequate prenatal care disparity increased
significantly.
Conclusions
The 2007 National Healthcare Disparities
Report suggests that many indicators of dis-
parity in quality of care and most indicators
of disparity in access to care for AIANs
compared with Whites are improving.1 How-
ever, these conclusions are drawn from nation-
ally aggregated data. Results from our current
study suggest that substantive conclusions about
AIAN health care disparities should be geo-
graphically specific, and conclusions drawn at
January 2010, Vol 100, No. 1 | American Journal of Public Health
RESEARCH AND PRACTICE
the national level may be inaccurate—even
misleading—for policymaking and intervention
at state and local levels. It is therefore necessary
to monitor health care access disparities for
AIANs at relevant geographic levels.
Information to track national trends is
important, but decisions regarding policy and
funding priorities are often made at
the state and local levels. Under the new
National Center for Health Statistics data-
release policy, states are still able to perform
their own analyses on internal data. However,
AIAN communities, Tribal Epidemiology
Centers, and Urban Indian Health researchers
are finding it increasingly difficult to access
data for specific communities or geographic
areas. Without easily accessible data to show
improvements in prenatal care for AIAN
women and reductions in the disparity be-
tween AIANs and non-Hispanic Whites, it will
be all but impossible to target resources
effectively. We recommend that efforts be
made to accommodate the geographic data
needs of researchers studying AIAN health, to
better inform decision makers and care pro-
viders committed to improving the health
status of AIAN mothers and newborns.
Level of data aggregation does matter for
AIAN health care disparities research, espe-
cially when the direction or magnitude of
difference from national rates varies between
the race groups being compared. Moreover,
although most state-specific measures of dis-
parity remained the same or decreased over
time, the magnitude of AIAN-White dispar-
ities in prenatal care utilization remains un-
acceptably high. Additional research is war-
ranted to understand the causes and
consequences of state-specific or local-area
disparities in prenatal care utilization for
AIANs. j
About the Authors
Pamela Jo Johnson, Kathleen Thiede Call, and Lynn A.
Blewett are with the State Health Access Data Assistance
Center, Division of Health Policy and Management,
School of Public Health, University of Minnesota, Min-
neapolis.
Correspondence should be sent to Pamela Jo Johnson,
MPH, PhD, Center for Healthcare Innovation, Allina
Hospitals & Clinics, 2925 Chicago Ave, Mail Route
10105, Minneapolis, MN 55407. (e-mail: johns245@
umn.edu). Reprints can be ordered at http://www.ajph.org
by clicking the ‘‘Reprints/Eprints’’ link.
This article was accepted April 9, 2009.
Johnson et al. | Peer Reviewed | Research and Practice | 127
Contributors
P. J. Johnson conceptualized the study, carried out the
analyses, and wrote the initial draft of the article. K. T.
Call helped interpret findings and provided comments
on the article. L. A. Blewett helped interpret findings and
provided critical revision of the article. All authors
revised the article and approved the final draft.
Acknowledgments
Research for this article was conducted as part of a Health
Disparities Research Loan Repayment Award from the
National Institutes of Health (L60 MD002033-01 to P. J.
Johnson). Funding was provided in part by a grant from
the Robert Wood Johnson Foundation to the University
of Minnesota.
Human Participant Protection
No protocol approval was necessary because data were
obtained from secondary sources.
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