Graduation Date

Summer 8-14-2026

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Programs

Health Services and Policy Research

First Advisor

Dr David Palm

Second Advisor

Dr Hyo Jung Tak

Third Advisor

Dr Chad Abresch

Fourth Advisor

Dr Ann Anderson Berry

Abstract

Maternal health inequities persist across the United States, with Black, Native American, and immigrant-origin women facing disproportionate barriers to timely prenatal care. This dissertation examined access to prenatal care in Nebraska, a mixed rural and urban state with extensive maternity care deserts, through three interrelated aims. Aim 1 analyzed PRAMS data using survey-weighted regression with race-by-socioeconomic-status interactions to characterize disparities in the timing and barriers to care. Aim 2 evaluated the state’s October 2020 Medicaid expansion across pre-pandemic, acute pandemic, and post-expansion periods. Aim 3 applied qualitative description and the Consolidated Framework for Implementation Research to interviews withtwenty-three maternity care stakeholders about integrating doula services.

Aim 1 revealed an income paradox. Rather than narrowing at higher socioeconomic positions, the Black-White gap in first-trimester care widened, and the educational gradient for financial barriers reversed among Black mothers, extending weathering and diminishing-returns frameworks into healthcare access, with financial barriers concentrated among Hispanic mothers and personal barriers among Native American mothers. Aim 2 found that the enrollment increase the expansion was designed to produce had not materialized in the study window, and that a modest improvement in early initiation was broadly shared across subgroups rather than concentrated among the newly eligible, indicating that the expansion was necessary but not sufficient and was entangled with pandemic-era care delivery and federal economic relief. Aim 3 identified the absence of a Medicaid reimbursement pathway as the central obstacle to doula integration and surfaced an integration paradox: the independence that makes doula care effective is threatened by formal incorporation, thereby requiring an emergent, equity-centered domain beyond the standard framework.

Read together, the aims show that equity cannot be achieved through any single lever. Stable coverage, delivery-system investment, economic security, and community-based doula care must work in concert, an imperative made urgent as current policy contracts the supports on which the most vulnerable mothers depend.

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