State Experiences Linking Medicaid Data With Birth Certificates and Other Data Sources : Medical Care

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State Experiences Linking Medicaid Data With Birth Certificates and Other Data Sources

Predmore, Zachary PhD*; Heins, Sara PhD; Hoch, Emily MSc*; Baxi, Sangita MAS; Grigorescu, Violanda MD, MSPH§; Smith, Scott PhD§

Author Information
Medical Care 61(6):p 353-359, June 2023. | DOI: 10.1097/MLR.0000000000001853


Maternal mortality rates in the United States have increased steadily from 2000 to 20201,2 and are over twice that of other high-income countries.3 Significant racial and ethnic disparities in maternal and infant health exist with Black, Native American, and Hispanic populations bearing a disproportionate burden of maternal and infant mortality.4,5 Medicaid is the payer for almost half of all births in the United States, including more than half of all births by Black and Hispanic women,6 and as such is a critical factor in policies needed to improve maternal and infant health. Maternal and infant Medicaid claims and enrollment data are tracked by state Medicaid agencies and contain detailed longitudinal data on diagnoses and health care utilization that are not captured on birth certificates. Births are registered by state vital records offices and reported to the National Center for Health Statistics at the Centers for Disease Control and Prevention.7 Information on birth certificates varies by state but they typically contain information on key maternal and infant health characteristics, many of which are not captured in claims (eg, parent’s educational attainment) or are captured inconsistently (eg, low birth weight).

Medicaid data linked with birth certificates or other sources of data are a potentially rich data resource for research on the outcomes and effectiveness of public health programs, different models of clinical care, and policy interventions. Efforts to link Medicaid claims to birth certificates for the purposes of maternal and child health (MCH) research have been ongoing for more than 20 years.8,9 In addition, once Medicaid data are linked to birth certificates, Medicaid data can then be linked to other sources of data that are already regularly linked to birth certificate data. For example, birth certificates are used to create the sample for the Pregnancy Risk Assessment Monitoring System—a large Centers for Disease Control and Prevention and health department survey on maternal and infant health administered in 46 states, the District of Columbia, and 2 U.S. territories,10 allowing for the Pregnancy Risk Assessment Monitoring System to be linked to Medicaid data. Other data that some states may regularly link with live birth certificate data include death certificates and hospital discharges.

Despite the benefits of linking Medicaid data with birth certificates and other data, efforts to link these data at the state level have been fragmented. Across these linkage efforts, there is substantial variation in the data sources linked to Medicaid data, linking methods, fields used to create linkages, match rates, and research and policy applications of the linked data.

The specific aim of this study is to comprehensively describe efforts to link Medicaid claims to birth certificates and other data and provide examples of how these linked data can be used and expanded upon to advance public health for researchers and policymakers. This aim is achieved through a structured literature review and semistructured discussions with representatives of states that link these data.


We took a 3-pronged approach to study current data linkage practices of Medicaid claims to birth certificates and other data sources across U.S. states and territories. First, we conducted a structured literature review, followed by an inventory of state and territory linkage efforts, and lastly, we held semistructured discussions with representatives from 9 states identified as having ongoing data linkage processes. Organization‘s Institutional Review Board reviewed and approved the study protocol (2022-N0054). All participants received a consent document with study information in advance of the discussion and provided oral consent. A technical expert panel of federal government employees with expertise in MCH data linkages provided guidance on the design of the literature review, inventory of state efforts, and discussion guide.

Literature Review

We conducted a structured literature review of recent (February 28, 2017–March 1, 2022) peer-reviewed articles to identify published research that linked Medicaid or all-payer claims database (APCD) claims (including Medicaid claims) at the individual level with data from birth certificates or other sources of data. Using a predetermined set of databases and search terms (Supplemental Appendix 1, Supplemental Digital Content 1,, we conducted a title and abstract search. All articles from the search were then screened by 2 researchers based on predetermined inclusion criteria (Supplemental Appendix 2, Supplemental Digital Content 1, The researchers then abstracted articles using predetermined codes relating to state, years of data linked, types of data linked, and details of linkages (Supplemental Appendix 3, Supplemental Digital Content 1, When we identified studies using secondary analyses of previously linked data, we included information from the original study if cited in the article.

State and Territory Inventory

We developed an Inventory of state and territory linkage efforts by conducting targeted searches for each state and territory of each state’s Medicaid agency website, vital records and statistics website, health department website, MCH Title V Block Grant Fiscal Year 2022 Application/2020 Annual Report,11 and APCD website, where applicable.

Semistructured Discussions

We organized and facilitated semistructured discussions with representatives from 9 states that had more than 50,000 live births in 202012 and perform ongoing data linkages of Medicaid claims with other data for the purposes of improving maternal health. The states were purposefully sampled to include states of varying population sizes (split into the larger and smaller half of eligible states sorted by the number of births) and from different census regions; sampling was informed by the literature review and inventory of state efforts (details on state selection in Supplemental Appendix 4, Supplemental Digital Content 1, Representatives included state agency leads, data analysts, academics, and public health practitioners who analyze the data and/or conduct linkages. We developed a semistructured discussion guide that included questions about the origins of the linkage, the technical specifications, uses of the linked data for research, policy, or practice, and any barriers or facilitators to creating or maintaining the linkage (Supplemental Appendix 5, Supplemental Digital Content 1, Semistructured discussions were attended by at least 2 members of the study team, conducted virtually, typically lasted 1 hour, and were audio-recorded and transcribed. Transcripts were coded by a single coder and reviewed and edited by a second coder in Dedoose version 9.0.5413 to identify common themes using a conventional content analysis approach.14 There were no major areas of disagreement between the 2 coders.


Literature Review

The initial search identified 687 articles. Articles were excluded for no U.S. data (N = 145), no in-scope study type (N = 70), not a maternal/child health topic (N = 60), no in-scope data linkage used (N = 349), and not a state-level linkage (N = 18) (Supplemental Appendix 6, Supplemental Digital Content 1, A total of 45 studies were included that used data from 22 different states, including 4 studies that used data from multiple states, one of which used data from 3 unspecified states.15 The findings are presented in Table 1. States linked Medicaid data to a variety of types of other data, with some studies involving linkages to multiple other types of data. Birth certificates were the most commonly linked type of data in 75.6% of studies followed by social services data (15.6% of studies) and death certificates (13.3% of studies). Of the studies, 37.8% linked claims with more than one category of data. Just over half of the studies provided details on whether the linkages were deterministic, probabilistic, or both, and specified the types of variables used to link. Less than half of the studies provided match rates or validation analyses. References for all articles included in the literature review are provided in Supplemental Appendix 7 (Supplemental Digital Content 1,

TABLE 1 - Summary of Linkage Processes in Literature Review (N = 45)
Linkage characteristic No. studies; n (%)
Claims dataset linked
 Medicaid 42 (93.3)
 All-payer claims (including Medicaid) 3 (6.7)
Other datasets linked to claims*
Birth certificates 34 (75.6)
 Social services data 7 (15.6)
 Death certificates 6 (13.3)
 State MCH program enrollment 4 (8.9)
 EHR/Health Information Exchange data 4 (8.9)
 Registries 3 (6.7)
 Hospital Discharge Data 3 (6.7)
 Other 7 (15.6)
 Multiple categories 17 (37.8)
Types of linkages used
 Deterministic only 15 (33.3)
 Probabilistic only 3 (6.7)
 Both 7 (15.6)
 Not specified 20 (44.4)
Variables used in linkages*
 Child's date of birth 13 (28.9)
 Mother's date of birth 11 (24.4)
 Delivery date 3 (6.7)
 Child's Social Security number 4 (8.9)
 Mother's Social Security number 6 (13.3)
 Mother's and/or child's name 14 (31.1)
 Health record or enrollment number 4 (8.9)
 Geographic identifier 6 (13.3)
 Other 4 (8.9)
 Not specified 20 (44.4)
Match rate
 At least one match rate provided 21 (46.7)
 No match rate specified 24 (53.3)
Validation analyses
 Analyses described 4 (8.9)
 No analyses described 41 (91.1)
*Sum of frequencies exceeds 100% as some studies linked claims to multiple types of datasets.
Bold indicates the number of studies in which data from multiple of the “other datasets” listed above are linked.
EHR indicates electronic health record; MCH, maternal and child health.

State and Territory Inventory

Of the 59 jurisdictions with Medicaid programs reviewed, 33 jurisdictions had in-scope data linkage efforts (excluding those identified in the peer-reviewed literature), of which 28 (47.4%) mentioned a Medicaid-to-birth record linkage in the Title V MCH report and 5 jurisdictions mentioned an APCD (inclusive of Medicaid claims) to vital record linkage (Table 2). Among those that mentioned an APCD, 2 jurisdictions had no in-scope linkages described in the Title V MCH report. We noted that 14 articles from the peer-reviewed literature were from 6 states that did not have publicly available information on current, in-scope state-level data linkage efforts. Some of these articles used older data, whereas others may have linked data solely for a specific research project. In total, 39 jurisdictions had in-scope data linkage efforts when considering both the peer-reviewed literature and the targeted reviews of state agency websites. Some of the Title V MCH reports discussed challenges related to data linkages and infrastructure including staff turnover, lack of expertise needed to develop and maintain data infrastructure, interagency access to data (even within the same state), and resource diversion to the COVID-19 pandemic response. A list of information found for each jurisdiction is provided in Supplemental Appendix 8 (Supplemental Digital Content 1,

TABLE 2 - Characteristics of Linked Data and Details on Linkage Process
Data characteristic Number (%)
Claims linkage types* N = 59 total jurisdictions
 Medicaid in-scope linkages (reported in Title V MCH report) 28 (45.8)
 APCD in-scope linkages 5 (8.5)
 Other in-scope linkages not reported in Title V MCH report 4 (5.1)
 Data used in a peer-reviewed article 22 (37.3)
 No in-scope linkages identified 21 (35.6)
Details of in-scope linkage available* N = 33 jurisdictions with in-scope linkage (excluding peer-reviewed articles)
Years of linked data 11 (35.4)
Linkage type (probabilistic, deterministic, and both) 4 (12.9)
Fields used to create linkages 4 (12.9)
Match rate 4 (12.9)
*Sum of percentages may exceed 100 as states categories are not mutually exclusive.
Bold indicates there were 33 jurisdictions in which we are able to abstract some details of the linkage.
APCD indicates all-payer claims database; MCH, maternal and child health.

Group Discussions

We conducted discussions with representatives from 9 states with ongoing linkages to Medicaid claims; included states along with data features and example use cases are presented in Table 3. The number of discussion participants from each state varied from 2 to 5. Most states conducted data linkages within a specific agency in their state department of health, but a few outsourced linkages to academic or private partners. Most of the linkages were done using probabilistic approaches. Also, most linkages were done annually, though there were a few that did more frequent linkages. Variables used for the linkage commonly included mother or child name, mother or child date of birth, and mother or child Social Security numbers. Address or other geographic variables like the county of residence were used less frequently. Some states included the payer on the birth certificate, which was helpful when present; one state included the Medicaid ID number on the birth certificate, which facilitated matches. We also included several states that linked Medicaid and birth certificate data through larger efforts to build data warehouses or health information exchanges.

TABLE 3 - Data Features and Use Cases
State Data features Example use cases
California Department of Public Health holds vital records data and sends it to the Department of Health Care Services (which has Medicaid data), where the linkage happens annually using a combination of probabilistic and deterministic approaches. Additional ongoing efforts at the Children’s Data Network to build a state-level integrated database across many agencies in the state Comparing performance measures in the Medicaid population to the general population
Colorado Linkages are done within the Vital Statistics program in the Department of Public Health and Environment. Department of Health Care Policy (which has Medicaid data) sends a list of claims for prenatal care and childbirth, which are then linked to birth certificates using a quarterly, mostly deterministic approach Maternity dashboard, outcomes of specific programs (eg, the Prenatal Plus program), analysis of outcomes by region of the state (smoking during pregnancy and low birth weight), developing reports for policymakers.
Quantitative data supplemented by qualitative data from Medicaid clients
Kentucky The Cabinet for Health and Family Services contains departments responsible for Medicaid, vital statistics, and MCH, so all can directly access data. They use a deterministic approach to link data Comparing outcomes for babies with neonatal abstinence syndrome to those without, additional health outcomes for mothers and babies including maternal depression screening, outcomes for Medicaid versus non-Medicaid births
Louisiana Probabilistic linkages are done annually by staff at the University of Louisiana Monroe Outcomes for mothers and babies, including the rate of breastfeeding, burden of chronic disease among Medicaid-eligible women. Medicaid managed care plans can access linked data to conduct individual outreach to women with a previous preterm delivery
Maryland Medicaid and Vital Records working together directly to link Medicaid and birth certificate data. Additional ongoing efforts to link claims in their health information exchange with various data sources through a Master Patient Index Assessing outcomes of their maternal opioid misuse model. Within the larger health information exchange linkage, individual-level outreach to follow up on COVID test results and vaccinations
Michigan Birth certificates and claims data are linked as part of the state’s data warehouse, which uses a probabilistic approach through a Master Patient Index Outcomes for mothers and babies, including the impact of the delivery of prenatal services on rates of fetal death. Also, since the data warehouse is statewide, additional outcomes across housing, schools, and corrections can be assessed
New York Vital Statistics Program conducts an annual linkage of Medicaid and birth certificate data.
Additional ongoing efforts to build an APCD and link with various data sources through a Master Patient Index
Evaluation of interventions, quality improvement, maternal and infant morbidity and mortality, environmental health conditions (impact of county levels of air pollution on birth outcomes), and patient-level screening data
North Carolina The State Center for Health Statistics runs an annual probabilistic linkage using data from the Vital Records office and Medicaid Program evaluation (Maternal Support Services, also known as the “Baby Love Program,”) WIC program outcome assessment, mothers and infant health outcomes, including low birth weight, infant mortality, and impact of the delivery of prenatal care on outcomes
Ohio Linkage was historically done by a consulting firm, the Government Resource Center, but transferred to Medicaid in early 2022. The probabilistic linkage is run quarterly Evaluation and technical assistance for Medicaid programs (including “Baby and Me Tobacco Free”) and quality improvement for health systems (eg, assessing the relationship between hypertension and maternal morbidity and mortality). Also, have linked Medicaid claims with COVID case records for reporting outcomes
APCD indicates all-payer claims database; COVID, coronavirus disease; MCH, maternal and child health; WIC, women, infants, and children.

The linked data are used for a variety of purposes, but most states used data primarily to assess MCH outcomes, often around specific programs or interventions they implemented. Several states used the linked data to target programs or quality improvement initiatives regionally, and 2 states reported using this linked data for individual patient-level outreach (Louisiana provides data to Medicaid managed care plans so they can reach out to mothers with a previous preterm delivery,16 Maryland has done outreach to remind people to complete coronavirus disease vaccination series17).

Generally, the closer that the Medicaid agency and the agency responsible for vital records were in the state government, the easier the data of each agency was to access for linkage. For example, in some states where these agencies were very close organizationally (within the same department or cabinet), staff at each agency were able to access data from the other agency without any additional data use agreements (DUAs). However, in other states where the agencies may not be housed within the same department, DUAs were needed to share data between agencies.

Almost every state allowed external researchers to access linked data, usually by submitting a proposal that needed to be approved by each agency providing data. Some states also required review and approval by the state’s Institutional Review Board before data could be shared. The frequency of these requests varied; some states reported rarely or almost never receiving them, whereas others reported getting monthly requests for linked data.

Discussion participants reported challenges with linking data, including several related to the nature of the datasets being linked as presented in Table 4. There were some issues, around which services were billed to a mother versus a child’s Medicaid plan, as sometimes the baby’s claims ended up on the mother’s plan. Sometimes the baby’s name on the birth certificate was “Baby Boy” or “Baby Girl,” impairing the ability to match claims data. Twins were reported to be hard to match, as were babies born out of state. Missing data were also cited as a common concern. Despite these concerns, match rates were almost always over 90% and every discussion participant believed these linked datasets were of high enough quality to conduct research.

TABLE 4 - Discussion Themes and Illustrative Quotes
Theme Illustrative quotes
Linkage origins
 Linkages often began as a way to answer a specific question, then expanded as their value became clear “A common problem such as severe maternal morbidity or mortality can force those agencies to work more cooperatively.”
“It originated with us, meaning within (the Division of MCH). We were attempting to look at several different birth outcomes among Medicaid versus non-Medicaid infants, and so that is how the whole linkage process started several years ago, and then we have just built upon that over time.”
“We started doing these Medicaid birth certificate linkages back in the year for a state report that was required. And when the state contractor went into business, they asked us to continue to do those linkages.”
 Relationships between state agencies vary, even within a state “Well, I think with Medicaid and the Health Department, I think all issues have been settled a long time ago. And we settled into a relationship where everybody knows their roles and we follow the rules. We do have issues with other state agencies and linkage data with some datasets is really prohibited or has to be done in a certain way.”
“State and large city within the state jurisdictions are separate, and we have good working relationships, so we at the Vital Statistics program, we receive data from both jurisdictions and we combine it, reconcile, and otherwise clean it, and we provide—we focus on agents for both jurisdictions that combine the data and provide it for data requesters. So yes, it is a unique situation, but we make it work.”
“From the VS perspective, the Department of Health programs, use it to evaluate their intervention programs, their quality improvement programs, and specifically the Division of Family Health. They use these data linkages that we provide to them every quarter, so they work on infant and maternal mortality projects. That is important to them. Some other programs such as Office for Child Services use it for their purposes, linkages birth data are very much protected and programs have to have DUAs with a very specific purpose for data usage.”
 Characteristics of the data introduce linking challenges “Mom has a clear record and a Medicaid number, baby gets born, baby does not necessarily get a Medicaid identifier right away, so some of the baby’s services get billed under mom’s number. So doing that linkage for the baby can be more problematic.”
“Twins with similar first names can be really challenging because they have the same address, the same birthday, and very similar names, and so we have a team that is running data quality checks and trying to merge or split individuals as appropriate to make sure that the data integrity stays high.”
 Recruiting and retaining staff with specialized knowledge is challenging “Having dedicated staffing is often the hardest part of all of this; having staff with the knowledge and the time, particularly of the Medicaid data. That is probably the biggest challenge that we have in terms of the timeliness and just pulling off matches like this.”
“Staff turnover really has tanked a lot of these efforts, staff turnover and also leadership change and loss of momentum and funding there.”
“It is hard to keep good researchers in Medicaid.”
 Champions of linking data demonstrate its value through different use cases “It is a priority. A lot of what we do hinges upon those data linkages and helping to determine whether we are succeeding in meeting our goals and objectives or whether we need to redesign a program, so it is also utilized for evaluation purposes.”
“I think that issue of having a strong champion or champions for the importance of really looking at the data sources you have and that you can leverage to better answer the questions you have or forecast what some of the needs are of the population you are serving, is sort of the moral of the story, or one of the great facilitators.”
“it is so important to have the folks that will really go out and sell the linkage so that people really understand what you can do with it”
 Maintaining positive relationships is a key to success “We work hard to maintain and keep that relationship on a positive note. We are very respectful of their data. We do not rerelease it without their permission.”
“If there is not a good relationship between your Department of Public Health and your Medicaid agency, that is a huge problem for the state, certainly for a researcher. There tend to be ownership problems.”
DUA indicates data use agreement; MCH, maternal and child health; VS, vital statistics.

Staff turnover was another challenge, as establishing and maintaining linkages often required staff with specialized technical knowledge. Facilitators of linkage efforts included having strong leaders who were able to drive multiyear projects across multiple departments, and strong relationships between staff working in these departments; in many states, the key people at Medicaid and Vital Records agencies had worked together for years and connected regularly for these linkages and other projects.


In this study, we detailed state and territory efforts to link Medicaid claims with birth certificate data and other data sources and to use these data to improve population health. Our review of the academic and grey literature identified linkage efforts between Medicaid claims and birth certificates or other data sources in more than half of jurisdictions. Birth certificates were the type of data most commonly linked to Medicaid claims followed by social services data and death certificate data. These findings were supported by our discussions with state officials, though multiple states also noted recent efforts to link immunization data. This was a new dataset not noted in the peer-reviewed literature but may represent a new key source of data that could be valuable in the state’s responses to the COVID-19 pandemic and other public health issues. Through both reviews of state agency websites and discussions with state representatives, we noted several recent efforts to develop more centralized data repositories linking APCD data with birth certificates and other sources of data or creating health information exchanges across state agencies. Some of these states use central data hubs using Master Patient Indexes to facilitate quick-turnaround analysis projects using linked data (including California, Maryland, Michigan, and New York). Some states performed linkages within the state health department or Medicaid agency whereas others subcontracted the linkage to a local university or government contractor.

Common challenges noted included obtaining access to data across agencies or departments within a state and finding time, resources, and experienced staff to develop and maintain data infrastructure. Facilitators to data linkage efforts including strong relationships between staff working in different agencies and institutional buy-in to the importance of building and maintaining data linkage capacity.


We note some limitations that should be considered when interpreting our findings. First, although we restricted our search to studies used in the past 5 years, due to lags in analyzing and publishing data some of the data used in the studies were much older and may not be generalizable to data linkages today, which are rapidly evolving in scope and sophistication. Second, states may not consistently report on linkage efforts or may report conflicting information. Although we examined diverse sources including published literature, state websites, and state reports, we may not have captured every major state linkage effort. Supplemental Appendix 8 (Supplemental Digital Content 1, provides additional information on the few instances of conflicting information that we noted. We also did not systematically explore the quality of the data linkages in this study, so researchers interested in using these linked data may need to be mindful of potential problems with missingness or other data quality issues. Finally, we note that our group discussions were limited to larger states with ongoing data linkage efforts and with representatives who had availability to speak with us. This allowed us to get information on methods related to large-scale linkages, but limited generalizability to other states and territories. We also did not systematically explore the fine-grained technical details of the linkages. Future studies could include technical document reviews to rigorously study the methods used and technical details of these linkages.

Policy Implications

The results of this study demonstrate that the large-scale linkage of Medicaid data with birth certificates and other data sources is feasible and has many potential applications to research, policy, and practice. Our literature review found that linked data have been used extensively by researchers to evaluate the impact of policies such as Medicaid expansion18–23 and social services24,25 on mothers and infants. Group discussions with states who link these data also identified key use cases involving policy analysis such as evaluating the maternal and infant health outcomes after postpartum Medicaid expansion or receipt of supplemental nutrition programs. States, either alone or in partnership with academic institutions, can analyze linked data to inform important policy decisions. Another use case for these data highlighted by states was identifying populations or individuals that need to be targeted with additional resources. For example, states might use linked data to direct additional resources to counties with high maternal morbidity and mortality rates. States even gave examples of using linked data to target appropriate programs for individuals with specific risk factors.

These use cases could justify the additional effort to support the development, expansion, and maintenance of data linkages. Many states have demonstrated the value of performing these linkages to decision-makers and secured dedicated funding and staff to perform linkages. Data linkages do not necessarily have to be performed in-house, however, and some states have found success by partnering with academic institutions or contracting data linkages. States can also support data linkages in ways that do not necessarily require significantly increased funding. For example, states may be able to integrate linkages of Medicaid and birth certificate data into existing APCD or health information exchange efforts. States can also facilitate data sharing by simplifying the DUA process within the state by creating a universal form that can be used by all agencies. However, these are state-based efforts and the differences among states make it harder to aggregate linked data for national-level research and programmatic and policy-making decisions. As suggested by respondents, state data linkages could benefit from federal support to achieve a consensus on the best processes for linkage methods.


In this 3-pronged study consisting of a literature review, inventory of state efforts, and group discussions, we found many applications for using Medicaid data linked with birth certificates and other data sources and highlight several barriers and potential facilitators to build and maintain these linkages. Researchers may consider using linked data from more than one state when conducting policy evaluations, particularly in the areas of maternal and infant health. In addition, discussion participants suggested that the state collaboratives or networks could facilitate the use of linked data to inform policymaking and that technical expertise could identify best practices for data linkage strategies.


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medicaid claims; data infrastructure; birth certificates; maternal and child health

Supplemental Digital Content

Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.