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

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 (NYC) 和纽约州 (NYS)，在获得尊重、文化一致、 以患者为中心的产妇服务导致黑人的孕产妇死亡率 (MM) 高出 8 倍 白人和严重孕产妇死亡率 (SMM) 高出 2.3 倍。 强调医疗补助，最多为低收入和少数种族人口提供服务 SMM/MM 的风险，并增加获得优质产科服务的机会并改善社会和结构 健康决定因素 (SDOH) - 即综合支持性护理 (ISC) - 具有重大前景。 处于与医疗补助相关的导乐计划的最前沿，最近的政策进展扩大了产科 医院质量改进网络 (MHQIN)，支持医院整合导乐、标准 尊重护理、隐性偏见培训、SDOH 临床审查以及护理结构中的社区联系， 以及全市导乐计划 (CDI)，该计划为纽约市部分地区的居民免费提供培训和提供导乐服务 然而，关于这一点的经验证据很少。 导乐护理模式的有效性或导乐在充分实践中面临的促进因素和障碍 范围、融入护理团队以及有效、可持续的 ISC 政策实施策略， 部分原因是州医疗补助计划不包括导乐服务以及社区和政府 在我们的多部门合作伙伴关系和新颖的指导下，提供这些服务的组织的研究能力有限。 综合概念框架，我们提出了对多层次影响进行严格的混合方法评估 在目标 1 中，我们将使用准实验性设计和独特的方法。 医疗补助索赔与社会服务数据相关联，以评估按种族、族裔、 CDI 在 1a) 出生、心理健康、心血管和 SMM 方面的年龄、社会经济地位和地理位置 结果；1b) 产前和产后保健利用；以及 1c) 接受社会服务，其中 2022 年至 2027 年符合医疗补助资格的生育人群。在目标 2 中，我们将分析不同的观点 MHQIN 计划组成部分及其在分娩客户和医院中实施的经验， 医疗补助和导乐/社区利益相关者通过深入的个人访谈、焦点小组讨论和 在目标 3 中，我们的社区联盟研究领导咨询委员会将领导一个共同设计过程。 制定基于证据的政策实施战略计划，以扩大和维持医疗补助支持 ISC，包括导乐报销 我们将生成新的证据来证明导乐在改进方面所发挥的作用。 孕产妇健康公平，加强地方政策行动伙伴关系，并成为国家政策的典范 我们的建议与 NIH 推进创新研究的战略计划高度一致。 源自社区的多层次政策解决方案，以解决美国各地分娩者的多发性骨髓瘤危机