Reducing Maternal Health Disparities: Effects of Recent Health Workforce Policies

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PROJECT SUMMARY/ABSTRACT The U.S. is facing a serious crisis of rising rates of maternal mortality and severe morbidity, which are attributable to multiple factors, such as the persistent, deep shortages of maternal care workforce in disadvantaged urban communities and rural areas. Since half of U.S. counties do not have a single obstetrician-gynecologist (OB-GYN), access to maternal care is a daunting challenge facing the nearly seven million reproductive-age women living in those counties. To address the problem of unequal distribution of clinicians, policymakers have taken considerable efforts in recent decades. Among the efforts, the National Health Service Corps (NHSC) remains the single largest policy intervention that has been launched to recruit clinicians to health professional shortage areas (HPSAs). The NHSC has experienced a dramatic expansion during the past decade, first through the American Recovery and Reinvestment Act in 2009 and then by the Affordable Care Act in 2010. Prior studies have found that these two Acts have raised the NHSC’s annual budget by over 100% and led to a significant expansion of the NHSC’s clinician workforce, such as OB-GYNs and certified nurse-midwives. However, no study to date has evaluated the impact of the NHSC expansion on disparities in maternal care and outcomes between the HPSAs and other areas. This proposed project aims to examine these issues and fill the gap in the literature. To our knowledge, it will be the first study to examine the effect of the recent NHSC expansion on disparities in maternal care and outcomes. Specifically, the project aims to assess how the recent NHSC expansion affects disparities in (1) maternal mortality overall and in-hospital mortality in particular, (2) severe maternal morbidity during childbirth hospitalizations and the associated hospital delivery costs and length of stay, (3) labor and delivery care, and (4) timing and adequacy of prenatal care and birth outcomes. To examine these aims, we will use multiple large, national data files over an extended period of 15 years between 2005 and 2019. To analyze the data, we will take two complementary approaches, including a difference-in-differences method, and an instrumental variable approach. Our analyses are expected to provide rigorous quasi-experimental evidence about the effects of workforce policy changes on disparities in maternal mortality and severe morbidity, which are key objectives of the Healthy People 2030. Our study findings will have important implications for the upcoming implementation of the 2018 Improving Access to Maternity Care Act, the latest NHSC policy change intended to better serve reproductive-age women in HPSAs by further increasing the NHSC supported maternal care providers.