Meeting women where they are: Multilevel intervention addressing racial disparities in maternal morbidity and mortality

严重的孕产妇发病率和死亡率在美国不成比例地影响非洲裔美国人（AA） 妇女不平等现象发生在许多层面，包括社区、提供者/做法和卫生系统层面。这 一项提案将测试多层次干预措施的有效性和成本效益，以解决AA孕产妇 发病率和死亡率在两个密歇根州县：杰内塞县（其中包括弗林特）和肯特县（其中 包括大急流城）。干预措施是由我们在这些县的合作伙伴开发或共同开发的， 包括AA女性居民，加强产前和产后护理（EPC）工作人员（包括 社区卫生工作者）和医生/卫生系统工作人员和提供者。 社区一级的干预。我们将扩大对EPC服务的访问（即，家访计划， 健康的开始计划）使用远程保健和灵活的时间安排。尽管是为少数民族妇女设计的， 密歇根州约60%符合条件的AA妇女没有参加EPC服务。试点工作表明， 如果有远程保健选择，拒绝接受EPC服务的少数民族妇女将参加。我们将提供 这个选项。提供者/实践层面的干预。我们将解决供应商和卫生系统隐含的问题， 明确的偏见和相应的结构和做法，并使这种学习可操作使用整天 体验式培训。培训将包括教学法、反思、讨论、挡风玻璃图尔斯参观和头脑风暴 如何调整参与者的做法和设置，以更好地满足围产期AA妇女的需求。培训将 包括从医生到前台工作人员每一个人。系统级干预。我们将实施社区 针对干预县孕产妇保健差异的护理病人安全包。 我们将使用准实验的差异中的差异来检验多层次干预的效果 采用倾向评分法比较2016-2019年前后（2021-2024年）的结局变化， 两个干预县的医疗补助妇女与密歇根州其他县的妇女相似。样品 将包括所有在怀孕期间、分娩时和/或产后1年内观察到的医疗补助投保女性， 2016年至2024年在密歇根州分娩的婴儿（约540，000例分娩，包括约162，000例AA分娩） 妇女）。将从预先存在的链接数据集中采取措施，该数据集包括医疗补助索赔，死亡记录， 出生记录和EPC计划数据。具体目标是：（1）评估多层次的有效性 对AA重度孕产妇发病率和死亡率进行干预;（2）测试改善服务利用率和非重度 孕产妇发病率是多层面干预措施对孕产妇严重发病率产生影响的机制， (3)评价多层次干预的成本效益。该项目将是第一个评估 多层次干预，以减少AA产妇发病率和死亡率在人口一级。试验测试 干预是否涉及假定为干预效果基础的机制， 成本效益数据，系统需要这些数据来做出关于采用的明智决策，加速实施。

Severe maternal morbidity and mortality in the U.S. disproportionately affect African-American (AA) women. Inequities occur at many levels, including community, provider/practice, and health system levels. This proposal will test the effectiveness and cost-effectiveness of a multilevel intervention to address AA maternal morbidity and mortality in two Michigan counties: Genesee County (which includes Flint) and Kent County (which includes Grand Rapids). Interventions were developed or co-developed by our partners in these counties, who include AA women residents, enhanced prenatal and postnatal care (EPC) staff (including race-matched community health workers), and physician/health system staff and providers. Community level intervention. We will expand access to EPC services (i.e., home visiting programs, Healthy Start programs) using telehealth and flexible scheduling. Despite being designed for minority women, about 60% of eligible AA women in Michigan do not enroll in EPC services. Pilot work indicates that 50% of minority women who declined EPC services would participate if a telehealth option was available. We will provide this option. Provider/practice level intervention. We will address provider and health system implicit and explicit bias and corresponding structures and practices and make this learning actionable using daylong experiential trainings. Training will include didactics, reflection, discussion, windshield tours, and brainstorming ways to tailor participants’ practices and settings to better meet the needs of perinatal AA women. Training will include everyone from physicians to front desk staff. System level intervention. We will implement community care patient safety bundles targeting maternal health disparities throughout the intervention counties. We will test the effects of the multilevel intervention using a quasi-experimental difference-in-difference with propensity scores approach to compare pre (2016-2019) to post (2021-2024) changes in outcomes among Medicaid women in the two intervention counties with similar women in other Michigan counties. The sample will include all Medicaid insured women observed during pregnancy, at birth, and/or up to 1 year postpartum, who delivered in Michigan from 2016 – 2024 (approximately 540,000 births, including ~162,000 births to AA women). Measures will be taken from a pre-existing linked dataset that includes Medicaid claims, death records, birth records, and EPC program data. The specific aims are to: (1) Assess the effectiveness of the multilevel intervention on AA severe maternal morbidity and mortality; (2) Test improved service utilization and non-severe maternal morbidity as mechanisms of the effect of the multilevel intervention on severe maternal morbidity, and (3) Evaluate the cost-effectiveness of the multilevel intervention. This project will be among the first to evaluate a multilevel intervention to reduce AA maternal morbidity and mortality at the population level. The trial tests whether the intervention engages the mechanisms presumed to underlie intervention effects and provides cost-effectiveness data that systems need to make informed decisions about adoption, speeding implementation.