Integrated Supportive Care Policies to Improve Maternal Health Equity: Evaluating the Multi-level Effects and Implementation of Doula Programs for Medicaid-Eligible Birthing People in New York City

改善孕产妇健康公平的综合支持性护理政策：评估纽约市符合医疗补助资格的新生儿导乐计划的多层次影响和实施情况

• 批准号: 10833919
• 负责人: Jamie Roberta Daw
• 金额: $ 78.67万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-09-21 至 2028-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10833919
• 关键词: Address; Age; Birth; Black Populations; Black race; Cardiovascular system; Caring; Cities; Client; Clinical; Communities; Data; Ecosystem; Effectiveness; Equity; Ethnic Origin; Evaluation; Face; Focus Groups; Friends; Geography; Health; Health Services; Health Services Accessibility; Health system; Hispanic; Hospitals; Income; Individual; Inequality; Intervention; Interview; Lead; Leadership; Link; Low income; Maternal Health; Maternal Mortality; Maternal health equity; Maternity Hospitals; Medicaid; Medicaid eligibility; Mental Health; Methods; Modeling; Neighborhoods; New York; New York City; Outcome; Personal Satisfaction; Persons; Play; Policies; Process; Psyche structure; Quasi-experiment; Race; Research; Risk; Role; Services; Site; Social Work; Social status; Socioeconomic Status; Strategic Planning; Structure; Supportive care; Surveys; Testing; Training; Trauma; United States; United States National Institutes of Health; Universities; access disparities; community organizations; community partnership; comorbidity; cost; design; disability; ethnic minority population; evidence base; experience; health care service utilization; health equity; health inequalities; high risk; implicit bias; improved; innovation; member; novel; obstetric services; patient oriented; postpartum health; pregnancy related death; prenatal; programs; racial minority population; severe maternal morbidity; social; social determinants; social disparities; social health determinants; stakeholder perspectives; structural health determinants; support network; Address; Age; Birth; Black Populations; Black race; Cardiovascular system; Caring; Cities; Client; Clinical; Communities; Data; Ecosystem; Effectiveness; Equity; Ethnic Origin; Evaluation; Face; Focus Groups; Friends; Geography; Health; Health Services; Health Services Accessibility; Health system; Hispanic; Hospitals; Income; Individual; Inequality; Intervention; Interview; Lead; Leadership; Link; Low income; Maternal Health; Maternal Mortality; Maternal health equity; Maternity Hospitals; Medicaid; Medicaid eligibility; Mental Health; Methods; Modeling; Neighborhoods; New York; New York City; Outcome; Personal Satisfaction; Persons; Play; Policies; Process; Psyche structure; Quasi-experiment; Race; Research; Risk; Role; Services; Site; Social Work; Social status; Socioeconomic Status; Strategic Planning; Structure; Supportive care; Surveys; Testing; Training; Trauma; United States; United States National Institutes of Health; Universities; access disparities; community organizations; community partnership; comorbidity; cost; design; disability; ethnic minority population; evidence base; experience; health care service utilization; health equity; health inequalities; high risk; implicit bias; improved; innovation; member; novel; obstetric services; patient oriented; postpartum health; pregnancy related death; prenatal; programs; racial minority population; severe maternal morbidity; social; social determinants; social disparities; social health determinants; stakeholder perspectives; structural health determinants; support network

In New York City (NYC) and State (NYS), pervasive inequalities in access to respectful, culturally congruent, patient-centered maternity services drive maternal mortality (MM) rates that are 8× higher for Black versus White individuals and severe maternal mortality (SMM) rates that are 2.3× higher. Policy interventions that emphasize Medicaid, which serves low-income and racially and ethnically minoritized populations at greatest risk of SMM/MM, and that increase access to quality obstetric services and improve the social and structural determinants of health (SDOH) - i.e., integrated supportive care (ISC) - hold significant promise. NYC and NYS are at the forefront of Medicaid-relevant doula programs, with recent policy advances to expand the Maternity Hospital Quality Improvement Network (MHQIN), which supports hospitals in integrating doulas, Standards for Respectful Care, implicit bias trainings, SDOH clinical reviews, and community linkages into care structures, and the Citywide Doula Initiative (CDI), which trains and provides doulas at no cost for NYC residents in select neighborhoods who are income-eligible for Medicaid. However, there is little empirical evidence on the effectiveness of doula care models or the facilitators and barriers doulas face in practicing within their full scope, integrating into the care team, and strategies for effective, sustainable ISC policy implementation, in part because state Medicaid programs have not included doula services and the community and governmental organizations delivering them have limited research capacity. Guided by our multi-sector partnership and novel integrated conceptual framework, we propose a rigorous mixed-methods evaluation of the multi-level impacts and implementation of NYC’s doula programs. In Aim 1, we will use a quasi-experimental design and unique Medicaid claims linked to social services data to evaluate the overall and differential effects by race, ethnicity, age, socioeconomic status, and geography of the CDI on 1a) birth, mental health, cardiovascular, and SMM outcomes; 1b) prenatal and postpartum healthcare utilization; and 1c) receipt of social services, among Medicaid-eligible birthing people from 2022 to 2027. In Aim 2, we will analyze diverse perspectives on and experiences with the MHQIN program components and its implementation among birthing clients and hospital, Medicaid, and doulas/community stakeholders via in-depth individual interviews, focus group discussions, and surveys. In Aim 3, our Community Coalition Research Leadership Advisory Board will lead a co-design process to develop an evidence-based strategic plan for policy implementation to scale and sustain Medicaid-supported ISC, including doula reimbursement. We will generate new evidence on the role that doulas play in improving maternal health equity, strengthen local partnerships for policy action, and serve as a model for national replicability. Our proposal is highly aligned with NIH’s strategic plan for innovative research to advance community-derived, multi-level policy solutions to redress the crisis of MM for birthing people across the U.S.

在纽约市（纽约市）和州（纽约州）中，普遍存在的不平等现象是获得尊重，文化的一致性， 以患者为中心的产妇服务驱动孕产妇死亡率（MM）率，黑色与黑人的率更高 白人个体和严重的产妇死亡率（SMM）率高2.3倍。政策干预措施 强调医疗补助，该医疗补助最大的人群为低收入，大致和种族少的人群提供服务 SMM/mm的风险，增加获得优质产科服务并改善社会和结构的风险 确定健康（SDOH） - 即综合支持护理（ISC） - 保持着巨大的希望。纽约和纽约州 是与医疗补助相关的Doula计划的最前沿，最近的政策进步扩大了产妇 医院质量改善网络（MHQIN）支持医院整合杜拉斯，标准 尊重的护理，隐性偏见培训，SDOH临床评论以及社区与护理结构的联系， 以及全市的杜拉倡议（CDI），该计划在纽约市居民无需提供训练和提供杜拉斯 有资格获得医疗补助的社区。但是，关于 Doula护理模型或促进者和障碍Doulas在实践中面对的有效性 范围，融入护理团队以及有效，可持续的ISC政策实施的策略， 部分是因为州医疗补助计划不包括杜拉服务以及社区和政府 提供它们的组织的研究能力有限。在我们的多部门伙伴关系和新颖的指导下 综合概念框架，我们提出了对多层次影响的严格混合方法评估 以及纽约市Doula计划的实施。在AIM 1中，我们将使用准实验设计和独特 与社会服务数据相关的医疗补助索赔，以评估种族，种族，种族，种族的整体和差异影响 CDI的年龄，社会经济状况和1A的地理位置）出生，心理健康，心血管和SMM 结果； 1B）产前和产后医疗保健利用；和1C）社会服务的收到 从2022年到2027年，符合医疗补助资格的生日。在AIM 2中，我们将分析潜水员的观点， MHQIN计划组件及其在生日客户和医院中实施的经验， Medicaid和Doulas/社区利益相关者通过深入的个人访谈，焦点小组讨论和 调查。在AIM 3中，我们的社区联盟研究领导咨询委员会将领导共同设计的过程 制定基于证据的战略计划，以实施政策，以扩展和维持医疗补助的支持 ISC，包括杜拉斯报销。我们将为杜拉斯在改善的角色中生成新的证据 孕产妇健康平等，加强政策行动的当地合作伙伴关系，并作为国家的典范 可复制性。我们的建议与NIH的创新研究战略计划高度一致 社区衍生的多层次政策解决方案，以纠正美国生日人们的MM危机