1. The Association between Antenatal Depression and Adverse Birth Outcomes among Women Receiving Medicaid in Washington State Amelia R. Gavin, PhD School of Social Work University of Washington

2. Rationale The field is poised to examine of the contribution of antenatal depression to increased risk of LBW, PTD, and SGA Not all women who experience antenatal depression experience adverse birth outcomes Identify the moderators of the association between antenatal depression and LBW, PTD, and SGA 2

3. Washington State Maternity Care Services Maternity Care Access Act (1989) TANF eligible pregnant women Medicaid eligible pregnant women First Steps Program 3

4. From 1991-2004, 46% of all births in WA State were funded by Medicaid and nearly 350,000 women had received services through the First Steps Program Despite the implementation of First Steps, disparities still exist – Medicaid-eligible women and African Americans have higher prevalence of LBW 4

5. Objectives 1.Examine the prevalence of ICD-9 depression diagnoses among women who received Medicaid-funded maternity services in Washington State and compare demographics, pregnancy complications, and birth outcomes (e.g., LBW, PTD, SGA) for women with and without an ICD-9 depression diagnosis, while controlling for known confounders for LBW, PTD, and SGA 2.Determine whether mothers with and without ICD-9 depression diagnoses differ on antenatal risk factors 3.Examine potential moderators (e.g., race, citizenship, TANF- eligibility) of the association between ICD-9 depression diagnoses and LBW, PTD, and SGA 5

6. Methods Design – Birth data from the WA State First Steps Database for women receiving Medicaid at the time of delivery from 2006-08 – Birth certificate data for all live births to Washington State residents from 2006-08 will be linked with the Medicaid claims database from the same time interval – Birth certificate-Medicaid claims database will be linked with the Comprehensive Hospitalization Abstract Reporting System (CHARS) 6

7. Methods Selection criteria 15 years or older who were Medicaid-eligible during the period 2006-08 Women who received Medicaid-paid maternity services or at least 3 months of capitated payments in the 6 months prior to delivery Low-income pregnant women enrolled in Washington State Basic Health Plan who meet Medicaid eligibility guidelines and were transferred into Medicaid for prenatal and postpartum care Those with birth hospitalization data available from the CHARS in WA State Women who are WA State residents who gave birth in WA State with infants with valid birth data recorded in the WA State Birth Certificate System 7

8. Data SourceVariable Name and Coding WA Birth Certificate System Birth outcomes LBW (< 2500 g or 5.5 lbs) PTD (< 37 completed gestation) SGA (<10 th percentile in birth weight for infants of same gestational age and sex) Sociodemographic characteristics Maternal race Maternal age Maternal education Comprehensive Hospitalization Abstract Reporting System (CHARS) First Steps Medicaid Database Antenatal depression and anxiety disorders ICD-9-CM (296.2, 296.3, 298.0, 200.4, 309.0, 309.1, 311.0) ICD-9-CM (300.0-300.9) First Steps Medicaid Database Antenatal medical risk factors Body Mass Index and gestational weight gain 1.BMI ≥30 (obese) and weight gain within IOM guidelines 2.BMI ≥30 (obese) and weight gain outside IOM guidelines 3.BMI <18.5 (underweight) and weight gain outside IOM guidelines 4.BMI 18.5-24.9 (normal) and weight gain within IOM guidelines

9. Data SourceVariable Name and Coding First Steps Medicaid Database Antenatal medical risk factors Pre-gestational and gestational hypertension (642.0-642.3; 642.3-642.7) 1.Pre-gestational hypertension (current pregnancy) 2.Gestational hypertension (current pregnancy) 3.No hypertension (current pregnancy) Pre-gestational and gestational diabetes (648.0; 648.83) 1.Pre-gestational diabetes (current pregnancy) 2.Gestational diabetes (current pregnancy) 3.No diabetes (current pregnancy) Prenatal care 1.Inadequate – care started after 4 th month or <50% of recommended visits 2.Intermediate – care started by 4 th month & 50-79% recommended visits 3.Adequate – care started by 4 th month & 80%-109% of recommended visits 4.Adequate plus – care started by 4 th month & 110% or more recommended visits Health behaviors 1.Current smoking (yes v. no) 2.Alcohol use (yes v. no) 3.Illicit drug use (yes v. no)

10. Analysis The analysis will follow a 2-step approach: 1.Logistic regression modeling will be used to assess the association between antenatal depression and adverse birth outcomes while controlling for known risk factors 2.Next, a series of interaction terms will be created to examine whether the antenatal depression-adverse birth outcome association varied according to moderator status. Interaction terms will include: 1.Antenatal depression*race 2.Antenatal depression*citizenship (U.S. citizen) 3.Antenatal depression*TANF-eligible 10