Perinatal outcomes among multiracial women compared to both Monoracial Majority and Minority groups in a Medicaid sample: 2017-2019

Perinatal outcomes among multiracial women compared to both Monoracial Majority and Minority groups in a Medicaid sample: 2017-2019 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perinatal outcomes among multiracial women compared to both Monoracial Majority and Minority groups in a Medicaid sample: 2017-2019 Karen M. Tabb, Andrea Pangori, Anca Tilea, Gloria Sugg, Stephanie V. Hall, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6835988/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: This study aims to explore prevalence of perinatal mental health conditions among Multiracial women in the United States compared to Monoracial Minority and Monoracial Majority women. Methods: We analyzed Medicaid claims data from 2016-2020 for 1,863,150 delivering women across 30 states, focusing on those with continuous enrollment from nine months prior to delivery to three months postpartum. We categorized women as Multiracial (two or more races), Monoracial Majority, Monoracial Minority, and Hispanic. Results: Multiracial women compared to Monoracial Minority women demonstrated higher rates of mental health conditions. Multiracial women were 16% less likely than Monoracial Majority (OR: 0.84, 95% CI: 0.79-0.89) and 45% more likely than Monoracial Minority (OR: 1.45, 95% CI: 1.34-1.56) to have a perinatal depression diagnosis. Multiracial women had higher suicidal ideation diagnoses compared to both Monoracial Minority and Monoracial Majority women. Conclusions: The findings highlight disparities in perinatal mental health conditions among Multiracial female Medicaid beneficiaries. Policy Implications: Researchers and policymakers should work further to address the unique mental health needs of perinatal Multiracial women, with an emphasis on addressing suicidal ideation. Figures Figure 1 Introduction Perinatal mental health conditions increased dramatically in the United States (U.S.) in recent years. 1 Significant disparities exist in perinatal mental health conditions complications such as adverse birth outcomes. 2 Additionally, racial/ethnic groups have differential access to mental health care. 3 , 4 Multiracial women represent the fastest growing demographic group in the U.S, yet despite documented perinatal mental health disparities by race/ethnicity, few studies examine Multiracial populations using either surveys or claims data. Recent investigations found increased perinatal mental health conditions for Multiracial women compared to White women. 5 – 7 The present study analyzes Medicaid claims data to document prevalence of perinatal mental health conditions among Multiracial women compared to single race non-White minority (Monoracial Minority) and single race White majority (Monoracial Majority) women. Methods This cross-sectional study uses national Medicaid administrative claims from April 2016 through March 2020 to assess outcomes related to deliveries that occurred between January 2017 and December 2019. We conducted the study in accordance with the Declaration of Helsinki. The University of Michigan Institutional Review Board approved the study under HUM00204182. We restricted our analysis to women with 9 months of continuous enrollment prior and 3 months after delivery. Medicaid’s Data Quality Atlas assesses race/ethnicity data quality collected in each state. 8 We included states with “low” and “medium” concern race/ethnicity quality, leaving 32 states in 2017 and 30 states in 2018 and 2019. Our primary covariate of interest is race/ethnicity, found in the demographic beneficiary table and categorized as American Indian and Alaskan Native (AIAN) non-Hispanic, Asian non-Hispanic, Black non-Hispanic, Hawaiian/Pacific Islander non-Hispanic, Hispanic (all races), Multiracial non-Hispanic, Other non-Hispanic, or White non-Hispanic. The Research Data Assistance Center (ResDAC) assigns these categories using an established algorithm. 9 We found more than one record for race/ethnicity for less than 1% of eligible beneficiaries, within and across years and states. To consolidate race/ethnicity information within a beneficiary’s record, we implemented a revised algorithm to categorize race/ethnicity. If an individual had more than one race/ethnicity record within a year and one of the records was Hispanic, we classified the individual as Hispanic, following ResDAC’s algorithm. If we found at least two different not Hispanic records within the year, we classified the individual as Multiracial. Once we applied the algorithm to all years individually, we applied the same algorithm across years. The algorithm assigned one race/ethnicity record to each beneficiary. We categorized these races/ethnicities into 4 groups: 1) Monoracial Majority (White non-Hispanic), 2) Monoracial Minority (Black, Asian, AIAN, Hawaiian/Pacific Islander, and Other, non-Hispanic), 3) Multiracial, and 4) Hispanic. 10 Our outcomes of interest include perinatal mood and anxiety disorder (PMAD), anxiety, depression, suicidal ideation, post-traumatic stress disorder (PTSD), and bipolar disorder. We identified these outcomes using one inpatient or two outpatient claims in the 9 months prior or 3 months after the delivery using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Our demographic variables include age and Bateman Obstetric Comorbidity Index (OBCMI). OBCMI is a validated risk score for severe maternal morbidity (SMM) with higher score indicating increased SMM risk. 11 Statistical analysis We first summarized demographic characteristics overall and by race/ethnicity groups for all individuals. We applied unadjusted logistic regression models to quantify race/ethnicity differences for each outcome. We first used the Monoracial Majority group as the reference group, then repeated these models with Monoracial Minority as the reference group applying a Bonferroni correction to adjust for multiple comparisons. We used two-sided statistical tests with an alpha level of 0.05 for all statistical analyses. We conducted data management in SAS version 9.4 (SAS Institute) and statistical analyses in R version 4.3.2. Results From 2017 to 2019, we identified 1,863,150 delivering women, including 714,534 (38.4%) Monoracial Majority, 628,357 (33.7%) Monoracial Minority, 478,254 (25.7%) Hispanic, 12,193 (0.6%) Multiracial, and 29,812 (1.6%) with missing race/ethnicity value. Since we did not include unknown race in the models, our analytical sample consisted of 1,833,338 women. Supplemental Table 1 describes age and OBCMI. Multiracial and Hispanic groups were younger than Monoracial Majority and Minority, but OBCMI score remainedsimilar across race/ethnicity groups. As shown in Fig. 1 , we found that Multiracial women were 25% less likely than Monoracial Majority (OR: 0.75, 95% CI: 0.71–0.79) and 58% more likely than Monoracial Minority (OR: 1.58, 95% CI: 1.48–1.68) to have a PMAD diagnosis. Multiracial women were 33% less likely than Monoracial Majority (OR: 0.67, 95% CI: 0.63–0.72) and 83% more likely than Monoracial Minority (OR: 1.83, 95% CI: 1.69–1.98) to have a perinatal anxiety diagnosis. Multiracial women were 16% less likely than Monoracial Majority (OR: 0.84, 95% CI: 0.79–0.89) and 45% more likely than Monoracial Minority (OR: 1.45, 95% CI: 1.34–1.56) to have a perinatal depression diagnosis. We also found that Multiracial women were 39% more likely than Monoracial Majority (OR: 1.39, 95% CI: 1.16–1.65) and 46% more likely than Monoracial Minority (OR: 1.46, 95% CI: 1.17–1.79) to have suicidal ideation. We found no significant difference in likelihood of perinatal PTSD diagnosis between Multiracial and Monoracial Majority women (OR: 1.04, 95% CI: 0.93–1.15) and found that Multiracial individuals were 88% more likely to have a perinatal PTSD diagnosis than Monoracial Minority (OR: 1.88, 95% CI: 1.64–2.14). Similarly, we found no significant difference in likelihood of a perinatal bipolar diagnosis between Multiracial and Monoracial Majority women (OR: 1.07, 95% CI: 0.97–1.16) and found that Multiracial women were 77% more likely to have a perinatal bipolar disorder diagnosis than Monoracial Minority (OR: 1.77, 95% CI: 1.58–1.97). Discussion This study examined perinatal mental health conditions among Multiracial women compared to single race/ethnicity peers. Our findings align with recent studies reporting increased burden of these conditions among Multiracial women. 5 – 7 As a major literature contribution, we compared Multiracial and Monoracial Medicaid beneficiaries and found that diagnoses for suicidal ideation were significantly greater for Multiracial women compared to White and non-White counterparts. This suicidal ideation finding is alarming and needs urgent replication. Among Multiracial women enrolled in Medicaid with PTSD and bipolar disorder diagnoses, we found no differences from Monoracial populations, contrasting with a recent study highlighting an increased burden of bipolar disorder diagnosis among Multiracial women in California. 12 In our Medicaid sample, Multiracial women experienced greater diagnoses for PMAD, anxiety, and depression than the overall sample but less than Monoracial Majority women. A limitation of this study is that our analytical sample may represent those with greater health care access, as we restricted Medicaid claims data to beneficiaries who gave birth with continuous enrollment nine months prior to delivery and three months post-delivery. These data indicate clinical diagnosis, not prevalence of disease, and therefore may not account for disparities in detection due to differential access to care or other biases within the health care system. Privately insured or uninsured women may have different results. Given past documented associations between Multiracial individuals and poor perinatal mental health outcomes, 5 future work should aim to determine clinical practices and public health education campaigns. Conclusions Since little information existed about the rate of depression and suicidal ideation diagnoses and its determinants among Multiracial women compared to Monoracial Minority and Monoracial Majority peers prior to this study, we began to fill the knowledge gap of Multiracial health disparities. Results from this study represent the start of a scientific journey to explore potential risks and unique needs among perinatal Multiracial women. Declarations Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Michigan Institutional Review Board (IRB HUM00204182). Waiver of informed consent was granted for secondary use of data. Therefore the need to consent to participate was waived by the University of Michigan Institutional Review Board for this secondary analysis. Consent for publication: Not applicable. Availability of data and materials: The data that support the findings of this study are available from the Centers for Medicare & Medicaid Services. Restrictions apply to the availability of these data, which were used under DUA RSCH-2022-57879 for this study, and thus are not publicly available. Competing interests: None Funding: The National Institutes of Health provided funding for this study (R01MD014958). Authors’ contributions: KT and KZ made substantial contributions to the conception and design of the work; KZ, AP, AT, the acquired the data, AP and AT performed analysis, KT, SH, VD, KZ interpretated the data; KT, GS, HH, SH have drafted the work or substantively revised it, KT, AP, AT, GS, SH, HH, VD, KZ approved the submitted version (and any substantially modified version that involves the author's contribution to the study); KT, AP, AT, GS, SH, HH, VD, KZ have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. References Zivin K, Pangori A, Zhang X, et al. Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008–20: Study examines trends in perinatal mood and anxiety disorders among privately insured people, 2008–20. Health Affairs . 2024;43(4):496-503. Tabb KM, Beck DC, Tilea A, et al. The relationship between diagnosed antenatal depression and anxiety and adverse birth outcomes between 2009 and 2020. General hospital psychiatry . 2023;85:239. Nakamura L, Jo D, Masuda A. Mental health help-seeking experience and attitudes in Asian American, multiracial American, and White American emerging adults. International Journal for the Advancement of Counselling . 2022;44(3):432-452. Udry JR, Li RM, Hendrickson-Smith J. Health and Behavior Risks of Adolescents with Mixed-Race Identity. American Journal of Public Health . 2003;93(11):1865-1870. doi:10.2105/ajph.93.11.1865 Daw JR, MacCallum-Bridges CL, Admon LK. Trends and Disparities in Maternal Self-Reported Mental and Physical Health. JAMA Internal Medicine . 2025;doi:10.1001/jamainternmed.2025.1260 Sidebottom A, Vacquier M, LaRusso E, Erickson D, Hardeman R. Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care. Archives of women's mental health . 2021;24:133-144. Haight SC, Daw JR, Martin CL, et al. Racial And Ethnic Inequities In Postpartum Depressive Symptoms, Diagnosis, And Care In 7 US Jurisdictions: Study examines racial and ethnic inequities in postpartum depressive symptoms, diagnosis, and care. Health Affairs . 2024;43(4):486-495. Centers for Medicare & Medicaid Services (CMS). DQ Atlas: Race and Ethnicity. https://www.medicaid.gov/dq-atlas/landing/topics/single/map?topic=g3m16&tafVersionId=17 Research Data Assistance Center (ResDAC). Race and Ethnicity Constructed Code - Latest in Year. https://resdac.org/cms-data/variables/race-and-ethnicity-constructed-code-latest-year Rockquemore KA, Brunsma DL, Delgado DJ. Racing to theory or retheorizing race? Understanding the struggle to build a multiracial identity theory. Journal of Social Issues . 2009;65(1):13-34. Bateman B, Gagne J. The Obstetric Comorbidity Index predicts severe maternal morbidity. BJOG: An International Journal of Obstetrics & Gynaecology . 2015;122(13):1756-1756. Eigbike M, Baer RJ, Nidey N, et al. What racial disparities exist in the prevalence of perinatal bipolar disorder in California? Frontiers in Psychiatry . 2025;16:1550634. Additional Declarations No competing interests reported. Supplementary Files SupplementalTable1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6835988","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492787550,"identity":"5e87767b-5871-49f9-967f-6de657c1b061","order_by":0,"name":"Karen M. Tabb","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBACCQYGNmaGCgkZPmYgLwEkdICQFjaQljMSPGykaWFsY+BhgwsR0iI5v/nZ48J5Fjxs7LwHHzz4wyDHdyMBvxZpNjZz45nbQA7jSzZIbGMwliSkRY6NwUyaF6yFx0wisYEhcQNhLezfpHnnQLUk/GGoJ6hFmo0HaEsDTAsbQ4IBIS2SbTnlxjOOgbUYA/0iYTjzzAP8WiQOH9/2uKCmTo6f/4zhwx9/bOT5jhOwBcMI0pSPglEwCkbBKMAOADkBNIFjZcTWAAAAAElFTkSuQmCC","orcid":"","institution":"University of Illinois at Urbana-Champaign","correspondingAuthor":true,"prefix":"","firstName":"Karen","middleName":"M.","lastName":"Tabb","suffix":""},{"id":492787551,"identity":"bfd2845c-3a33-4112-bcb0-68695cefc982","order_by":1,"name":"Andrea Pangori","email":"","orcid":"","institution":"University of Michigan","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Pangori","suffix":""},{"id":492787553,"identity":"79dce07d-c445-40b0-b249-f1419b9fd5f2","order_by":2,"name":"Anca Tilea","email":"","orcid":"","institution":"University of Michigan","correspondingAuthor":false,"prefix":"","firstName":"Anca","middleName":"","lastName":"Tilea","suffix":""},{"id":492787555,"identity":"94c62966-2918-4cf3-ada0-c61c9a7fe0dd","order_by":3,"name":"Gloria Sugg","email":"","orcid":"","institution":"University of Illinois at Urbana-Champaign","correspondingAuthor":false,"prefix":"","firstName":"Gloria","middleName":"","lastName":"Sugg","suffix":""},{"id":492787556,"identity":"081527b6-2afa-4c52-993d-f15f1f32db5b","order_by":4,"name":"Stephanie V. Hall","email":"","orcid":"","institution":"University of Michigan","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"V.","lastName":"Hall","suffix":""},{"id":492787558,"identity":"c643fe39-9e10-4ffc-af5b-e64eda99c028","order_by":5,"name":"Hsiang Huang","email":"","orcid":"","institution":"Harvard Medical School, Cambridge Health Alliance","correspondingAuthor":false,"prefix":"","firstName":"Hsiang","middleName":"","lastName":"Huang","suffix":""},{"id":492787561,"identity":"529531c5-9e3a-434b-854d-5fdf7a7d3c5c","order_by":6,"name":"Vanessa Dalton","email":"","orcid":"","institution":"University of Michigan","correspondingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"","lastName":"Dalton","suffix":""},{"id":492787563,"identity":"c44c5302-7d54-4199-8ad6-d4aa68d84910","order_by":7,"name":"Kara Zivin","email":"","orcid":"","institution":"University of Michigan","correspondingAuthor":false,"prefix":"","firstName":"Kara","middleName":"","lastName":"Zivin","suffix":""}],"badges":[],"createdAt":"2025-06-06 10:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6835988/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6835988/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88196687,"identity":"131df4f5-ce00-40ee-930a-263c7f99d01a","added_by":"auto","created_at":"2025-08-03 17:12:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":141982,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest Plot of perinatal mental health conditions among Multiracial Medicaid beneficiaries\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Footnote: Confidence intervals that cross the dotted line at 1 did not reach statistical significance at the 0.05 alpha level.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6835988/v1/1bbfd747ec9a76a32faaa9d0.png"},{"id":103907239,"identity":"ef850684-3fb8-4333-adc7-314a860eda63","added_by":"auto","created_at":"2026-03-04 11:12:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":524127,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6835988/v1/a521aa76-2756-4da8-b594-07de499d0b76.pdf"},{"id":88196685,"identity":"7fbc1c9b-d5db-4869-ba81-0be7aaaddf11","added_by":"auto","created_at":"2025-08-03 17:12:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16970,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6835988/v1/4cee4c43535c03e80cb9ee4d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perinatal outcomes among multiracial women compared to both Monoracial Majority and Minority groups in a Medicaid sample: 2017-2019","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePerinatal mental health conditions increased dramatically in the United States (U.S.) in recent years.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Significant disparities exist in perinatal mental health conditions complications such as adverse birth outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Additionally, racial/ethnic groups have differential access to mental health care.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Multiracial women represent the fastest growing demographic group in the U.S, yet despite documented perinatal mental health disparities by race/ethnicity, few studies examine Multiracial populations using either surveys or claims data. Recent investigations found increased perinatal mental health conditions for Multiracial women compared to White women.\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The present study analyzes Medicaid claims data to document prevalence of perinatal mental health conditions among Multiracial women compared to single race non-White minority (Monoracial Minority) and single race White majority (Monoracial Majority) women.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional study uses national Medicaid administrative claims from April 2016 through March 2020 to assess outcomes related to deliveries that occurred between January 2017 and December 2019. We conducted the study in accordance with the Declaration of Helsinki. The University of Michigan Institutional Review Board approved the study under HUM00204182. We restricted our analysis to women with 9 months of continuous enrollment prior and 3 months after delivery. Medicaid’s Data Quality Atlas assesses race/ethnicity data quality collected in each state.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e We included states with “low” and “medium” concern race/ethnicity quality, leaving 32 states in 2017 and 30 states in 2018 and 2019.\u003c/p\u003e\u003cp\u003eOur primary covariate of interest is race/ethnicity, found in the demographic beneficiary table and categorized as American Indian and Alaskan Native (AIAN) non-Hispanic, Asian non-Hispanic, Black non-Hispanic, Hawaiian/Pacific Islander non-Hispanic, Hispanic (all races), Multiracial non-Hispanic, Other non-Hispanic, or White non-Hispanic. The Research Data Assistance Center (ResDAC) assigns these categories using an established algorithm.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWe found more than one record for race/ethnicity for less than 1% of eligible beneficiaries, within and across years and states. To consolidate race/ethnicity information within a beneficiary’s record, we implemented a revised algorithm to categorize race/ethnicity. If an individual had more than one race/ethnicity record within a year and one of the records was Hispanic, we classified the individual as Hispanic, following ResDAC’s algorithm. If we found at least two different not Hispanic records within the year, we classified the individual as Multiracial.\u003c/p\u003e\u003cp\u003eOnce we applied the algorithm to all years individually, we applied the same algorithm across years. The algorithm assigned one race/ethnicity record to each beneficiary. We categorized these races/ethnicities into 4 groups: 1) Monoracial Majority (White non-Hispanic), 2) Monoracial Minority (Black, Asian, AIAN, Hawaiian/Pacific Islander, and Other, non-Hispanic), 3) Multiracial, and 4) Hispanic.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOur outcomes of interest include perinatal mood and anxiety disorder (PMAD), anxiety, depression, suicidal ideation, post-traumatic stress disorder (PTSD), and bipolar disorder. We identified these outcomes using one inpatient or two outpatient claims in the 9 months prior or 3 months after the delivery using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Our demographic variables include age and Bateman Obstetric Comorbidity Index (OBCMI). OBCMI is a validated risk score for severe maternal morbidity (SMM) with higher score indicating increased SMM risk.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eWe first summarized demographic characteristics overall and by race/ethnicity groups for all individuals. We applied unadjusted logistic regression models to quantify race/ethnicity differences for each outcome. We first used the Monoracial Majority group as the reference group, then repeated these models with Monoracial Minority as the reference group applying a Bonferroni correction to adjust for multiple comparisons. We used two-sided statistical tests with an alpha level of 0.05 for all statistical analyses. We conducted data management in SAS version 9.4 (SAS Institute) and statistical analyses in R version 4.3.2.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2017 to 2019, we identified 1,863,150 delivering women, including 714,534 (38.4%) Monoracial Majority, 628,357 (33.7%) Monoracial Minority, 478,254 (25.7%) Hispanic, 12,193 (0.6%) Multiracial, and 29,812 (1.6%) with missing race/ethnicity value. Since we did not include unknown race in the models, our analytical sample consisted of 1,833,338 women. Supplemental Table\u0026nbsp;1 describes age and OBCMI. Multiracial and Hispanic groups were younger than Monoracial Majority and Minority, but OBCMI score remainedsimilar across race/ethnicity groups.\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, we found that Multiracial women were 25% less likely than Monoracial Majority (OR: 0.75, 95% CI: 0.71\u0026ndash;0.79) and 58% more likely than Monoracial Minority (OR: 1.58, 95% CI: 1.48\u0026ndash;1.68) to have a PMAD diagnosis. Multiracial women were 33% less likely than Monoracial Majority (OR: 0.67, 95% CI: 0.63\u0026ndash;0.72) and 83% more likely than Monoracial Minority (OR: 1.83, 95% CI: 1.69\u0026ndash;1.98) to have a perinatal anxiety diagnosis. Multiracial women were 16% less likely than Monoracial Majority (OR: 0.84, 95% CI: 0.79\u0026ndash;0.89) and 45% more likely than Monoracial Minority (OR: 1.45, 95% CI: 1.34\u0026ndash;1.56) to have a perinatal depression diagnosis.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWe also found that Multiracial women were 39% more likely than Monoracial Majority (OR: 1.39, 95% CI: 1.16\u0026ndash;1.65) and 46% more likely than Monoracial Minority (OR: 1.46, 95% CI: 1.17\u0026ndash;1.79) to have suicidal ideation. We found no significant difference in likelihood of perinatal PTSD diagnosis between Multiracial and Monoracial Majority women (OR: 1.04, 95% CI: 0.93\u0026ndash;1.15) and found that Multiracial individuals were 88% more likely to have a perinatal PTSD diagnosis than Monoracial Minority (OR: 1.88, 95% CI: 1.64\u0026ndash;2.14). Similarly, we found no significant difference in likelihood of a perinatal bipolar diagnosis between Multiracial and Monoracial Majority women (OR: 1.07, 95% CI: 0.97\u0026ndash;1.16) and found that Multiracial women were 77% more likely to have a perinatal bipolar disorder diagnosis than Monoracial Minority (OR: 1.77, 95% CI: 1.58\u0026ndash;1.97).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined perinatal mental health conditions among Multiracial women compared to single race/ethnicity peers. Our findings align with recent studies reporting increased burden of these conditions among Multiracial women.\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e As a major literature contribution, we compared Multiracial and Monoracial Medicaid beneficiaries and found that diagnoses for suicidal ideation were significantly greater for Multiracial women compared to White and non-White counterparts. This suicidal ideation finding is alarming and needs urgent replication.\u003c/p\u003e\u003cp\u003eAmong Multiracial women enrolled in Medicaid with PTSD and bipolar disorder diagnoses, we found no differences from Monoracial populations, contrasting with a recent study highlighting an increased burden of bipolar disorder diagnosis among Multiracial women in California.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In our Medicaid sample, Multiracial women experienced greater diagnoses for PMAD, anxiety, and depression than the overall sample but less than Monoracial Majority women.\u003c/p\u003e\u003cp\u003eA limitation of this study is that our analytical sample may represent those with greater health care access, as we restricted Medicaid claims data to beneficiaries who gave birth with continuous enrollment nine months prior to delivery and three months post-delivery. These data indicate clinical diagnosis, not prevalence of disease, and therefore may not account for disparities in detection due to differential access to care or other biases within the health care system. Privately insured or uninsured women may have different results.\u003c/p\u003e\u003cp\u003eGiven past documented associations between Multiracial individuals and poor perinatal mental health outcomes,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e future work should aim to determine clinical practices and public health education campaigns.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSince little information existed about the rate of depression and suicidal ideation diagnoses and its determinants among Multiracial women compared to Monoracial Minority and Monoracial Majority peers prior to this study, we began to fill the knowledge gap of Multiracial health disparities. Results from this study represent the start of a scientific journey to explore potential risks and unique needs among perinatal Multiracial women.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Michigan Institutional Review Board (IRB HUM00204182). Waiver of informed consent was granted for secondary use of data. Therefore the need to consent to participate was waived by the University of Michigan Institutional Review Board for this secondary analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the Centers for Medicare \u0026amp; Medicaid Services. Restrictions apply to the availability of these data, which were used under DUA RSCH-2022-57879 for this study, and thus are not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The National Institutes of Health provided funding for this study (R01MD014958).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e KT and KZ made substantial contributions to the conception and design of the work; KZ, AP, AT, the acquired the data, AP and AT performed analysis, KT, SH, VD, KZ interpretated the data; KT, GS, HH, SH have drafted the work or substantively revised it, KT, AP, AT, GS, SH, HH, VD, KZ approved the submitted version (and any substantially modified version that involves the author's contribution to the study);\u003c/p\u003e\n\u003cp\u003eKT, AP, AT, GS, SH, HH, VD, KZ have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZivin K, Pangori A, Zhang X, et al. Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008\u0026ndash;20: Study examines trends in perinatal mood and anxiety disorders among privately insured people, 2008\u0026ndash;20. \u003cem\u003eHealth Affairs\u003c/em\u003e. 2024;43(4):496-503. \u003c/li\u003e\n\u003cli\u003eTabb KM, Beck DC, Tilea A, et al. The relationship between diagnosed antenatal depression and anxiety and adverse birth outcomes between 2009 and 2020. \u003cem\u003eGeneral hospital psychiatry\u003c/em\u003e. 2023;85:239. \u003c/li\u003e\n\u003cli\u003eNakamura L, Jo D, Masuda A. Mental health help-seeking experience and attitudes in Asian American, multiracial American, and White American emerging adults. \u003cem\u003eInternational Journal for the Advancement of Counselling\u003c/em\u003e. 2022;44(3):432-452. \u003c/li\u003e\n\u003cli\u003eUdry JR, Li RM, Hendrickson-Smith J. Health and Behavior Risks of Adolescents with Mixed-Race Identity. \u003cem\u003eAmerican Journal of Public Health\u003c/em\u003e. 2003;93(11):1865-1870. doi:10.2105/ajph.93.11.1865\u003c/li\u003e\n\u003cli\u003eDaw JR, MacCallum-Bridges CL, Admon LK. Trends and Disparities in Maternal Self-Reported Mental and Physical Health. \u003cem\u003eJAMA Internal Medicine\u003c/em\u003e. 2025;doi:10.1001/jamainternmed.2025.1260\u003c/li\u003e\n\u003cli\u003eSidebottom A, Vacquier M, LaRusso E, Erickson D, Hardeman R. Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care. \u003cem\u003eArchives of women\u0026apos;s mental health\u003c/em\u003e. 2021;24:133-144. \u003c/li\u003e\n\u003cli\u003eHaight SC, Daw JR, Martin CL, et al. Racial And Ethnic Inequities In Postpartum Depressive Symptoms, Diagnosis, And Care In 7 US Jurisdictions: Study examines racial and ethnic inequities in postpartum depressive symptoms, diagnosis, and care. \u003cem\u003eHealth Affairs\u003c/em\u003e. 2024;43(4):486-495. \u003c/li\u003e\n\u003cli\u003eCenters for Medicare \u0026amp; Medicaid Services (CMS). DQ Atlas: Race and Ethnicity. https://www.medicaid.gov/dq-atlas/landing/topics/single/map?topic=g3m16\u0026amp;tafVersionId=17\u003c/li\u003e\n\u003cli\u003eResearch Data Assistance Center (ResDAC). Race and Ethnicity Constructed Code - Latest in Year. https://resdac.org/cms-data/variables/race-and-ethnicity-constructed-code-latest-year\u003c/li\u003e\n\u003cli\u003eRockquemore KA, Brunsma DL, Delgado DJ. Racing to theory or retheorizing race? Understanding the struggle to build a multiracial identity theory. \u003cem\u003eJournal of Social Issues\u003c/em\u003e. 2009;65(1):13-34. \u003c/li\u003e\n\u003cli\u003eBateman B, Gagne J. The Obstetric Comorbidity Index predicts severe maternal morbidity. \u003cem\u003eBJOG: An International Journal of Obstetrics \u0026amp; Gynaecology\u003c/em\u003e. 2015;122(13):1756-1756. \u003c/li\u003e\n\u003cli\u003eEigbike M, Baer RJ, Nidey N, et al. What racial disparities exist in the prevalence of perinatal bipolar disorder in California? \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e. 2025;16:1550634.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6835988/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6835988/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjectives: This study aims to explore prevalence of perinatal mental health conditions among Multiracial women in the United States compared to Monoracial Minority and Monoracial Majority women.\u003c/p\u003e\n\u003cp\u003eMethods: We analyzed Medicaid claims data from 2016-2020 for 1,863,150 delivering women across 30 states, focusing on those with continuous enrollment from nine months prior to delivery to three months postpartum. We categorized women as Multiracial (two or more races), Monoracial Majority, Monoracial Minority, and Hispanic.\u003c/p\u003e\n\u003cp\u003eResults: Multiracial women compared to Monoracial Minority women demonstrated higher rates of mental health conditions. Multiracial women were 16% less likely than Monoracial Majority (OR: 0.84, 95% CI: 0.79-0.89) and 45% more likely than Monoracial Minority (OR: 1.45, 95% CI: 1.34-1.56) to have a perinatal depression diagnosis. Multiracial women had higher suicidal ideation diagnoses compared to both Monoracial Minority and Monoracial Majority women.\u003c/p\u003e\n\u003cp\u003eConclusions: The findings highlight disparities in perinatal mental health conditions among Multiracial female Medicaid beneficiaries.\u003c/p\u003e\n\u003cp\u003ePolicy Implications: Researchers and policymakers should work further to address the unique mental health needs of perinatal Multiracial women, with an emphasis on addressing suicidal ideation.\u003c/p\u003e","manuscriptTitle":"Perinatal outcomes among multiracial women compared to both Monoracial Majority and Minority groups in a Medicaid sample: 2017-2019","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-03 17:12:26","doi":"10.21203/rs.3.rs-6835988/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d39f3559-47f5-461f-b645-0e82ce3d82e8","owner":[],"postedDate":"August 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T11:11:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-03 17:12:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6835988","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6835988","identity":"rs-6835988","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}