The impacts of state-level Medicaid bundled payment models will depend on many factors, such as maternity care facility structure, scope of services (e.g., presence of obstetric wards), and local patient bypassing behaviors during prenatal, intrapartum, and postpartum periods. For rural providers who often offer prenatal and postpartum care but not labor and delivery services, these bundled payments may impose additional financial and logistical challenges. Despite the longstanding barriers to perinatal care facing rural and minority communities, it is unclear how these bundled perinatal payments are distributed across all states and whether these have impacts on rural-urban and racial/ethnic disparities in perinatal care access and quality.

Using a mixed methods approach, this project has three aims:

1. To examine state-level scope of bundled reimbursement payment model (also known as “episode-based" payment model) for perinatal care – prenatal, labor and delivery, and postpartum services – in traditional, fee-for-service Medicaid programs across all 48 states with rural counties in the United States.
2. To assess state variations in perinatal care access, birthplace, workforce, and non-medically indicated labor induction or cesarean delivery from 2006-2023 by Medicaid FFS bundled payments for perinatal care.
3. To examine differential associations between the implementation of Medicaid perinatal bundled payments and outcomes in perinatal care access, birthplace, workforce model, and elective induction or cesarean deliveries. This analysis will be conducted overall and stratified by maternal rurality of residence and maternal race/ethnicity. Sensitivity analyses will further explore non-indicated inductions and cesarean deliveries by hospital rurality.