How to improve access to midwifery care and prevent perinatal morbidities

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PROJET SUMMARY/ABSTRACT Significance: Compared to countries at similar development levels, the United States suffers from far worse perinatal health outcomes at a much greater cost. Increasing the number of maternity care providers, especially midwives, is a proposed solution to improve perinatal health outcomes in the United States. Midwifery-led prenatal, labor and delivery, and postpartum care is characterized by increased education and support for pregnant and laboring mothers, an emphasis on continuation of care from the prenatal to postpartum periods, and limited use of technology and procedures. Compared with physician-led care, midwives utilize fewer medical interventions during labor and delivery and produce similar or improved perinatal health outcomes, particularly for low-income populations. However, many state-level policies prevent integration of midwives into the existing health system. Increasing access to midwifery care could improve perinatal health in the United States. Specific Aims: The proposed project will (1) evaluate the impact of reimbursement equity between midwives and physicians on the proportion of deliveries conducted by a midwife, (2) assess prevalence of perinatal morbidities in counterfactual scenarios where access to midwifery care is increased by 10%, 20%, and 50%, and (3) estimate prevalence of perinatal morbidities in a hypothetical intervention where all low-risk pregnancies among Medicaid enrollees engage in midwifery-led prenatal care. Approach: The proposed analysis will utilize data from three sources: (1) Legislative Updates from the journal the Nurse Practitioner that provide historical information on Medicaid reimbursement to midwives; (2) National Vital Statistics Data; and (3) data from the Pregnancy to Early Life Longitudinal Data System. Using a generalized difference-in-difference approach, Aim 1 will assess the association between state implementation of Medicaid policies that reimburse midwives at the same rate as physicians and access to midwifery-led delivery care. Aims 2 and 3 will utilize a causal inference framework for observational data analysis and application of the g-formula to determine the number of perinatal morbidities that could be averted if access to midwifery care were increased among the total population (Aim 2), and among Medicaid Enrollees (Aim 3). Fellowship information: The applicant is a PhD student in Maternal and Child Health and Epidemiology at UNC Chapel Hill, and a predoctoral trainee on the NICHD-funded T32 training program at the Carolina Population Center. Through coursework on perinatal health, epidemiology and health policy, support and guidance from a multidisciplinary team of mentors, and UNC Chapel Hill’s collaborative research environment, the proposed training plan will build on Ms. Simmons’ previous research experience. The training will assist Ms. Simmons in successfully completing her dissertation work, and achieving her long-term goal of becoming a successful independent researcher with expertise on health policy and perinatal health.