Effects of Preconception Care on Maternal Outcomes in Medicaid

摘要 在美国，孕产妇死亡率和严重孕产妇发病率(SMM)继续上升，妇女从 低收入社区、少数种族/民族群体以及那些有医疗补助或没有保险的人面临着 风险增加。分娩时的医院护理和怀孕期间的产前护理都发生在 对产妇结局有重要影响的病症进展。因此，扩大对 孕前护理是改善产妇健康和结局的一种很有前途的方法。循证的 先入为主的干预措施包括咨询患者的健康行为(如服用叶酸)、管理 慢性健康状况，并提供避孕护理，以计划怀孕的时机。对于许多低收入者来说 妇女接受先入为主的护理的一个主要障碍是缺乏医疗保险。这个 《平价医疗法案》(ACA)降低了育龄妇女的未参保率，为妇女提供了更多 获得先入为主的护理。一些州于#年开始实施ACA的医疗补助覆盖范围扩大 2014年，接受先兆健康咨询的女性报告在医疗补助中大幅增加 扩展状态与非扩展状态的比较。先前的研究已经确定了 先入为主的护理和降低SMM的风险，特别是在患有慢性病的妇女中。然而， 还需要进一步的研究来确定因果关系。这项研究将利用研究小组访问 全国范围内的医疗补助申请数据，并利用医疗补助的扩大作为一项自然的实验来估计 怀孕前护理对参加医疗补助的妇女SMM的因果影响。分析现有的医疗补助计划 索赔数据将使我们能够描述扩张和非扩张中的先孕护理和SMM比率的变化 扩展状态(目标1)。然后，我们将使用由国家政策变化(即 采用医疗补助扩展的时机)以评估先入为主的护理对SMM风险的因果影响， 在整个医疗补助人群和基于病史的风险最高的子组中(例如，慢性 疾病或既往SMM病史)或社会人口特征(目标2)。我们还将获得细微差别 使用定性焦点小组对SMM高危患者和护理他们的临床医生的看法 和关键线人面谈(目标3)。通过将定量的医疗补助申请和定性分析相结合，我们 将确定有很大可能减少SMM的先入为主的干预措施和方法，特别是 风险最高的女性。我们将把这些发现转化为一种新的怀孕前护理模式，它将 在今后的工作中有待检验。

ABSTRACT Maternal mortality and severe maternal morbidity (SMM) continue to rise in the United States, and women from low-income communities, minoritized racial/ethnic groups, and those with Medicaid or who are uninsured face increased risk. Hospital care at the time of delivery, and prenatal care during pregnancy, both occur late in the progression of conditions that are important to maternal outcomes. Therefore, expanding access to preconception care is a promising approach to improving maternal health and outcomes. Evidence-based preconception interventions include counseling patients on healthy behaviors (e.g. taking folic acid), managing chronic health conditions, and providing contraceptive care to plan timing of pregnancy. For many low-income women, a major barrier to receiving preconception care has been lack of health insurance coverage. The Affordable Care Act (ACA) reduced the uninsured rate among reproductive age women, giving women greater access to preconception care. Some states began implementing the ACA’s Medicaid coverage expansion in 2014, and women’s report of receiving counseling on preconception health increased significantly in Medicaid expansion states compared to non-expansion states. Prior research has identified an association between preconception care and decreased risk of SMM, particularly among women with a chronic disease. However, further research is needed to establish a causal effect. This study will harness the study team’s access to nationwide Medicaid claims data and leverage Medicaid expansion as a natural experiment to estimate the causal effect of preconception care on SMM for women insured by Medicaid. Analyzing existing Medicaid claims data will allow us to describe change in preconception care and SMM rates in expansion and non- expansion states (Aim 1). We will then use quasi-experimental design enabled by variation in state policy (i.e. timing of adopting Medicaid expansion) to estimate the causal effect of preconception care on risk of SMM, both in the Medicaid population overall and in sub-groups at highest risk based on medical history (e.g. chronic disease or history of prior SMM) or sociodemographic characteristics (Aim 2). We will also gain the nuanced perspectives of patients at high risk for SMM and clinicians who care for them, using qualitative focus groups and key informant interviews (Aim 3). By combining quantitative Medicaid claims and qualitative analyses, we will identify preconception interventions and approaches with high likelihood of reducing SMM, particularly for women at highest risk. We will translate these findings to develop a novel preconception care model that will be tested in future work.