County-Level Pregnancy Criminalization Rates and Prenatal Care Initiation and Utilization in Alabama, 2014–2022

Abstract Objective We investigated whether higher rates of county-level pregnancy-related arrests were associated with delayed and inadequate prenatal care among births in Alabama (2014–2022). Methods We used restricted-use natality data from the National Center for Health Statistics and data on annual pregnancy-related arrests by county from Pregnancy Justice. We fit log Poisson generalized estimating equation models with cluster robust standard errors to estimate the relative risk and 95% confidence intervals (CIs), stratified by race and ethnicity, and adjusted for individual- and county-level confounders. Results Fully adjusted models suggest individuals living in counties with higher pregnancy criminalization rates were moderately more likely to delay prenatal care initiation (1.11, 95% CI [1.08, 1.14]) and receive inadequate prenatal care (1.05, 95% CI [1.03, 1.06]) compared with those living in a county with no arrests. We found positive associations among non-Hispanic white and Latina/Hispanic women, and null or slightly protective associations among non-Hispanic Black women. Conclusions These findings suggest pregnancy criminalization has an indirect chilling impact on prenatal health care access. The rise in the criminalization and surveillance of pregnancy, particularly in a post-Dobbs context, requires evidence-based policy responses that support maternal health and reproductive autonomy.