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， 低收入社区，少数民族/种族群体，以及那些有医疗补助或没有保险的人面临 增加风险。分娩时的医院护理和怀孕期间的产前护理都发生在怀孕后期， 对产妇结局有重要影响的疾病进展。因此，扩大获得 孕前保健是改善孕产妇健康和成果的一个有希望的办法。循证 孕前干预包括咨询患者健康行为（如服用叶酸）， 慢性健康状况，并提供避孕护理以计划怀孕时间。对许多低收入 妇女接受孕前保健的一个主要障碍是缺乏健康保险。的 《平价医疗法案》（ACA）降低了育龄妇女的无保险率， 获得孕前保健。一些州开始实施ACA的医疗补助覆盖范围扩大， 2014年，在医疗补助计划中，接受孕前健康咨询的妇女报告显着增加 膨胀状态与非膨胀状态相比。先前的研究已经确定了 孕前保健和SMM的风险降低，特别是在患有慢性疾病的妇女中。然而，在这方面， 需要进一步研究以确定因果关系。这项研究将利用研究小组的访问， 全国范围内的医疗补助索赔数据，并利用医疗补助扩张作为自然实验，以估计 孕前保健对医疗补助保险妇女SMM的因果影响。分析现有的医疗补助 索赔数据将使我们能够描述孕前保健和SMM率的变化， 扩展状态（目标1）。然后，我们将使用准实验设计，使国家政策的变化（即）。 采用医疗补助扩展的时间），以估计孕前护理对SMM风险的因果影响， 在总体医疗补助人群和基于病史的最高风险亚组中（例如慢性 疾病或既往SMM史）或社会人口统计学特征（目标2）。我们还将获得 SMM高风险患者和护理他们的临床医生的观点，使用定性焦点组 和关键线人访谈（目标3）。通过结合定量医疗补助索赔和定性分析，我们 将确定孕前干预措施和方法，减少SMM的可能性很高，特别是 女性风险最高。我们将把这些发现转化为一种新的孕前护理模式， 在今后的工作中加以检验。

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.