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

美国严重的孕产妇发病率和死亡率对非裔美国人(AA)的影响不成比例 女人。不平等现象发生在许多层面，包括社区、提供者/诊所和卫生系统层面。这 该提案将测试多级干预措施的有效性和成本效益，以解决再生障碍性贫血产妇 密歇根州两个县的发病率和死亡率：杰内西县(包括弗林特)和肯特县(包括弗林特 包括大急流城)。干预措施是由我们在这些县的合作伙伴制定或共同制定的，他们 包括AA女性居民、加强产前和产后护理(EPC)工作人员(包括与种族匹配的工作人员 社区卫生工作者)、医生/卫生系统工作人员和提供者。 社区层面的干预。我们将扩大EPC服务的准入(即家访计划， 健康启动计划)使用远程医疗和灵活的日程安排。尽管是为少数族裔女性设计的， 在密歇根州，大约60%符合条件的再生障碍性贫血女性没有注册EPC服务。试点工作表明，50%的 如果有远程保健选择，拒绝EPC服务的少数族裔妇女将参与其中。我们将提供 此选项。提供者/实践层面的干预。我们将解决医疗服务提供者和医疗系统的隐含和 明确的偏见和相应的结构和实践，并使这种学习可操作使用一天 体验式培训。培训将包括教学、反思、讨论、挡风玻璃之旅和头脑风暴。 如何调整参与者的实践和环境，以更好地满足围产期再生障碍性贫血妇女的需求。培训将会 包括从医生到前台工作人员的每个人。系统层面的干预。我们将实施社区 护理患者安全包针对整个干预县的孕产妇健康差距。 我们将使用准实验差值来检验多水平干预的效果 使用倾向评分法比较结果变化前(2016-2019)和后(2021-2024) 这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。样本 将包括所有在怀孕期间、分娩时和/或产后一年内观察的医疗补助保险妇女， 世卫组织2016-2024年在密歇根州分娩(约54万名新生儿，包括约162,000名AA新生儿 女性)。措施将从预先存在的关联数据集中采取，该数据集包括医疗补助申请、死亡记录、 出生记录和EPC计划数据。具体目标是：(1)评估多层面的有效性 对再生障碍性贫血重度孕产妇发病率和死亡率的干预；(2)测试改善服务利用率和非重症 孕产妇发病率作为多水平干预对严重孕产妇发病率影响的机制，以及 (3)评价多层次干预的成本-效果。该项目将是第一批进行评估的项目之一 采取多层次干预措施，在人口层面减少再生障碍性贫血孕产妇发病率和死亡率。试验测试 干预是否使用了被推定为干预效果的基础的机制，并提供了 成本效益数据，系统需要这些数据来做出有关采用的明智决策，从而加快实施。

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.