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.

在纽约市和纽约州，在获得尊重、文化一致、 以患者为中心的孕产妇服务导致黑人的孕产妇死亡率（MM）是黑人的8倍， 白色个体和严重孕产妇死亡率（SMM）高出2.3倍。开展政策干预 强调医疗补助，它最大限度地服务于低收入和种族和民族少数群体 增加获得优质产科服务的机会，改善社会和结构 健康决定因素（SDOH）-即，综合支持性护理（ISC）-具有重大的前景。NYC和NYS 在与医疗补助相关的导乐计划中处于领先地位，最近的政策进展是扩大产妇护理计划， 医院质量改进网络（MHQIN），支持医院将导乐、导乐标准 尊重护理，隐性偏见培训，SDOH临床审查，以及社区与护理结构的联系， 和全市导乐倡议（CDI），培训和提供导乐在选择纽约市居民免费 有收入资格获得医疗补助的社区。然而，很少有经验证据表明， 导乐护理模式的有效性或导乐师在全方位实践中面临的障碍 范围，融入护理团队，以及有效，可持续的ISC政策实施战略， 部分原因是州医疗补助计划不包括导乐服务，社区和政府 提供这些服务的组织的研究能力有限。在我们的多部门合作伙伴关系和创新的指导下， 综合的概念框架，我们提出了一个严格的混合方法评估的多层次的影响 以及纽约市导乐计划的实施。在目标1中，我们将使用准实验设计和独特的 医疗补助索赔与社会服务数据相关联，以评估种族，民族， 年龄、社会经济地位和CDI的地理分布：1a）出生、心理健康、心血管和SMM 结果; 1b）产前和产后保健利用; 1c）接受社会服务， 从2022年到2027年，符合医疗补助条件的分娩人群。在目标2中，我们将分析不同的观点， MHQIN计划的组成部分及其在分娩客户和医院中的实施经验， 通过深入的个人访谈，焦点小组讨论， 调查。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 制定一项以证据为基础的政策实施战略计划，以扩大和维持医疗援助支持的 ISC，包括导乐报销。我们将产生新的证据，在改善的作用，导乐 孕产妇保健公平，加强地方政策行动伙伴关系，并作为国家 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，多层次的政策解决方案，以纠正危机的MM分娩的人在美国各地。