<p>Public health infrastructure (PHI) serves as the core foundation for essential public health and its services. However, the U.S. PHI has been weakened by understaffing, underfunding, limited resources and partnerships, and outdated data and information systems over the past few decades. The recent COVID-19 pandemic exacerbated its vulnerability and weakened nature, resulting in increased health disparities and worse health outcomes in general for the nation. The goal of this study was to identify elements of local PHI that are associated with the completion of 20 key public health activities while adjusting for state differences. Cross-sectional secondary data were acquired and linked from two national surveys of local health departments, the National Profile of Local Health Departments survey and the National Longitudinal Survey of Public Health Systems. In total, 20 multivariable logistic regression models were created to analyze the relationships between variables. State fixed effects were used in multivariable models to control for state differences. It was found that state differences affected the correlations of infrastructure variables. Several staffing elements, abilities to provide certain services, and participation in certain types of actions were strongly correlated with the completion of best practice activities. These findings will add to the discussion of what the minimum necessary elements of PHI may be.</p>

In 2010 Medicaid financed approximately 48% of all births in the United States and nearly 30% of all births in Virginia. Due to strict state-specific eligibility criteria, many low-income women qualify for Medicaid coverage exclusively as a result of pregnancy status. As the nation moves forward with the Patient Protection and Affordable Care Act (PPACA), state-elected Medicaid expansion has the potential to expand services to women of reproductive age that would precede pregnancy events and offer continuous access to care postpartum. Despite this potential influx of newly insured women, little is known about how this population may make decisions regarding reproductive healthcare services and if these selections influence process and outcome measures. This study examines two research aims that provide insight into these knowledge gaps. First, utility theory and discrete choice modeling is used to examine clinic and patient level factors associated with clinic type choice. Specifically, this study examines the role of high risk pregnancy status and travel distance to clinic as associated with clinic selection. Second, Donabedian’s Structure, Process, Outcome framework provides a conceptual lens to examine if clinic selection is associated with maternal and infant measures. The linear probability model and logistic regression models are employed to examine two process measures, including prenatal care inadequacy and postpartum visit nonattendance, and three outcome measures including maternal long acting reversible contraceptive method (LARC) use and infant birthweight and gestational age. Results examining clinic type selection reveal significant associations between independent and dependent variables. Women experiencing a high risk pregnancy are significantly more likely to select a hospital based clinic for care, compared to women experiencing a normal risk pregnancy. However, when specifically examining women experiencing their first pregnancy, this association is no longer significant. Additionally, as distance to clinic type increase, women are significantly less likely to select that clinic type for prenatal care. Clinic selection was found to be significantly associated with maternal measures, but not significantly associated with infant outcomes. Selecting a public health department or Federally Qualified Health Center for prenatal care services was associated with a significant decrease in inadequate prenatal care, postpartum visit nonattendance, and non-LARC use compared to a private physician office. Clinic type selection, however, was not found to be significantly associated with infant outcomes including preterm birth and low birthweight babies. Results from Research Aim 1 have a variety of implications for clinic and public policy and offer guidance for future research. Clinics that seek to provide care to pregnant Medicaid beneficiaries should examine local residential patterns of current and potential future pregnant Medicaid recipients and consider how these might affect decisions about future clinic locations. Results suggest that women are more likely to attend clinic types closer to their area of residence, and this close proximity may have additional implications beyond shorter travel time to clinic including the minimization of transportation and childcare issues. Results from Research Aim 2 analyses offer a variety of public policy implications and guidance for future research. This research provides evidence that public health facilities including public health departments and FQHCs have improved prenatal care adequacy and postpartum visit attendance compared to private physician offices, providing evidence that public funding should continue for these facility types. As the United States moves forward with PPACA, healthcare organization administration should turn to the public facilities in their communities to learn how to manage and improve the health of these patient populations and ultimately aim to improve access and quality care among the nation’s most vulnerable populations.