The importance of geographic data aggregation in assessing disparities in American Indian prenatal care

Objectives. We sought to determine whether aggregate national data for American Indians/Alaska Natives (AIANs) mask geographic variation and substantial 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 nonHispanic Whites. In the 12 states with the largest AIAN birth populations, disparities varied dramatically. In addition, some states demonstrated substantial reductions in disparities overtime, 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.