Primary Care Shortages Matched Higher Maternal Obesity and Hypertension, but Not Narrower Racial Gaps
Geographic access to primary care did not erase racial disparities in maternal chronic disease among women who had a live birth, even though counties with fewer primary care resources carried a slightly heavier burden of obesity and hypertension. The analysis draws a hard line between proximity to services and the deeper forces shaping maternal health: location alone did not change the size of the gap between non-Hispanic Black and non-Hispanic White women.
The study linked 2020–2024 natality data with county-level health resource data across 1,374 counties in the contiguous United States. Investigators focused on three common prepregnancy conditions — obesity, hypertension, and diabetes — because each raises the risk of adverse perinatal outcomes and each is central to preconception care. The population was large: 18,026,492 births to women ages 15 to 44, excluding records with unknown county of residence. Connecticut’s historical county structure, Alaska, and Hawaii were left out for geographic reasons tied to linkage and access barriers.
The design asked a direct question: does a county’s primary care supply shape the prevalence of maternal chronic conditions, and does it change racial differences in those conditions? The answer was partial. Counties designated as a primary care shortage area, or counties with lower provider density, had modestly increased prevalence of obesity and hypertension. Diabetes did not follow the same pattern.
One sentence captures the central finding: more primary care nearby did not translate into smaller racial gaps.
County-Level Access Moved the Average, Not the Disparity
Geographic access was defined two ways. First, counties were classified by Health Resources and Services Administration primary care Health Professional Shortage Area designation. Second, provider density was measured in quartiles using the number of primary care providers per 100,000 residents. County data were merged with annual population estimates and health resource files, then analyzed with spatial Bayesian conditional autoregressive models, a method suited to county-to-county correlation and uneven geographic clustering.
The outcome data came from birth certificates, with obesity based on prepregnancy body mass index, and chronic hypertension and diabetes recorded by hospital staff using birth certificate checkboxes. Although these are not perfect clinical measurements, they are the standard population-level data available for surveillance across millions of births. Their scale gives the analysis reach, but the structure of the data also limits how finely the burden can be traced back to individual care access.
Across the chronic conditions, the racial disparity between non-Hispanic Black and non-Hispanic White women stayed largely constant regardless of whether a county had better or worse access to primary care. For obesity, the rate difference was 11.3 per 100 births in primary care shortage areas and 9.9 per 100 births in non-shortage areas. The adjusted β for the difference in rate differences was 0.005, with a 95% CI crossing zero from −0.005 to 0.014. In practical terms, the county’s primary care profile did not meaningfully alter the magnitude of the racial gap.
Why More Clinics Alone May Not Move Maternal Risk
The biology and the social context both argue against a simple access story. Obesity, hypertension, and diabetes rarely arise from a single missed appointment. They develop over years of nutrition patterns, stress exposure, neighborhood conditions, medication access, reproductive planning, and continuity of care before pregnancy. Primary care can identify these risks early, but identification is not the same as reversal, especially when treatment starts late or when structural barriers continue after the diagnosis is made.
The study’s discussion fits that reality. More than 90% of preventive care visits for reproductive-aged women occur in primary care settings, and routine prepregnancy screening and counseling are recommended during every clinical encounter. Even so, prior disparities in blood pressure screening and diabetes screening have been documented among Black women, uninsured women, and women with low incomes. A county may have more clinicians on paper and still leave many patients without reliable, repeated, and culturally responsive care.
The absence of a diabetes signal also deserves attention. Diabetes burden may depend more heavily on factors outside county-level primary care access, including chronic disease duration, pharmacologic treatment, food environments, and preexisting metabolic risk accumulated long before pregnancy. Hypertension and obesity, by contrast, may be somewhat more sensitive to the availability of preventive care and counseling, even if the effect size remains modest.
What the County Data Can and Cannot Prove
The study’s strength lies in its national scale and its attempt to connect geography with maternal risk. By aggregating five years of county-level births and applying spatial models, the analysis captured patterns that smaller studies might miss. It also controlled for county characteristics while comparing racial differences in rate differences, which makes the persistence of disparity harder to dismiss as a simple artifact of geography.
Still, the data are ecological. County access does not equal individual access, and living in a shortage area does not mean every resident lacks care, just as living in a better-resourced county does not guarantee timely screening or treatment. Birth certificate data also cannot fully capture medication adherence, primary care utilization, insurance instability, specialty referrals, or the quality of chronic disease management before conception. Those missing pieces matter because maternal chronic disease is shaped by cumulative exposure, not a single geographic marker.
The findings nevertheless send a clear signal to clinicians and public health planners. Expanding the number of primary care providers in a county may improve overall chronic disease prevalence slightly, but it is unlikely to close entrenched racial gaps by itself. The disparity between Black and White women remained stable across access strata, which points to barriers that operate beyond local provider supply.
Reproductive-Age Prevention Needs More Than Provider Counts
This work places preconception care back where it belongs: at the intersection of chronic disease prevention and maternal health equity. Women of reproductive age spend much of their preventive care time in primary care settings, yet the burden of obesity, hypertension, and diabetes remains unevenly distributed, and the racial gradient persists even where provider access improves. Geographic access is only one layer of exposure. Insurance coverage, racism in care delivery, continuity between pregnancies, medication affordability, and neighborhood conditions all shape whether a chronic condition is detected early and controlled before conception.
The study closes with a conclusion that is clinically uncomfortable but important. Geographic access to primary care did not attenuate racial disparities in the prevalence of chronic conditions among women who had a live birth. The next question is not whether more clinics are useful, but whether the health system can convert access into sustained chronic disease control before pregnancy begins.