A Pragmatic Trial of Integrating Community-based Patient Navigation into the Continuum of Maternal Care for Black Women in a Safety-Net Health System: Effects on Maternal Health, Health Care, Morbidit

摘要 美国的孕产妇死亡率远高于其他发达国家，其中格鲁吉亚排名第二 在各州中最高。格鲁吉亚的产妇死亡率和严重产妇发病率不断上升， 在黑人、公共保险或未保险的人中， 医院的产妇发病率和死亡率是连续发生的， 可以通过获得和利用高质量的保健来预防事件的严重性。格鲁吉亚的母亲 死亡率审查委员会得出结论，三分之二的孕产妇死亡是可以预防的， 慢性病、精神疾病、 药物使用和妊娠并发症，往往难以获得护理， 而且质量不够。专家强调，以公平为中心的医疗保健方法-其中嵌入 通过利益攸关方的投入和黑人领导的护理模式，将变革方面纳入其设计，包括 社会支持，以消除与种族主义和风化有关的压力-最有希望减少 不平等新出现的数据支持，将种族一致的，以社区为基础的病人 导航员可以提高护理的文化能力，同时解决歧视，系统性种族主义， 高质量护理的体制障碍。然而，到目前为止，有限的研究已经评估了这一有前途的战略， 使用具有足够样本量和确定发病率的严格方法的现实生活环境， 死亡率终点对于确定有效性和推动大规模政策和实践变革至关重要。 我们认为，将基于社区的患者导航员纳入孕产妇护理将改善孕产妇的健康状况。 通过满足社会需求，降低压力和抑郁症状， 获得和利用护理，从而促进更好和更及时地管理疾病， 减少并发症的发生和发展。为了验证这一假设，我们建议执行一个 将基于社区的患者导航器整合到 从怀孕中期开始，一直持续到分娩一年， 500名黑人妇女在安全网医院系统中确定了健康和社会需求， 成果评价，以查明降低孕产妇发病率和死亡率的有效性， 评估，以提高对RCT结果的理解。我们将采用尊重产妇护理和 NIMHD研究框架严格评估医院系统中的孕产妇健康结果， 主要服务于黑人妇女与高未满足的需求谁经历了不良孕产妇死亡率过高 通过在卫生服务和社区研究方面经验丰富的多学科团队， 以公平为中心的护理，并有能力实施高度忠诚的护理模式干预， 获取和利用卫生系统和患者报告的数据，进行全面、高质量的评估。

ABSTRACT US maternal mortality is substantially higher than that of other developed nations, with Georgia ranking second highest among the states. Maternal mortality and severe maternal morbidity (SMM) are increasing in Georgia, with the highest rates among those who are Black, publicly insured or uninsured, and deliver in safety-net hospitals. Maternal morbidity and mortality occur on a continuum in which the accumulation and progression in severity of events can be prevented through access to and utilization of quality health care. Georgia’s Maternal Mortality Review Committee concludes that two-thirds of maternal deaths are preventable and attributes recent increases to rising rates of inadequately managed chronic health conditions, mental health disorders, substance use, and pregnancy complications in the setting of care that is often difficult to access, fragmented and of insufficient quality. Experts emphasize that equity-centered health care approaches – which embed transformational aspects into their design through stakeholder input and Black-led models of care that include social support to counter stress related to racism and weathering – offer the most promise for reducing inequities. Emerging data support that the incorporation of racially-concordant, community-based patient navigators can enhance the cultural-competence of care while addressing discrimination, systemic racism, and institutional barriers to quality care. To date, however, limited research has evaluated this promising strategy in real-life settings using rigorous methods with sufficient sample size and ascertainment of morbidity and mortality endpoints critical for determining effectiveness and motivating large-scale policy and practice change. We posit that the integration of community-based patient navigators into maternal care will improve maternal health outcomes through meeting social needs, lowering stress and depressive symptoms, and improving access to and utilization of care thereby promoting better and more timely management of conditions and reducing the occurrence and progression of complications. To test this hypothesis, we propose to perform a pragmatic randomized controlled trial (RCT) of the integration of community-based patient navigators into the continuum of maternal care, starting prior to mid-pregnancy and continuing through one-year of birth, among 500 Black women with identified health and social needs in a safety-net hospital system to include both outcome evaluation, to discern effectiveness in reducing maternal morbidity and mortality, and process evaluation, to enhance understanding of RCT findings. We will employ the Respectful Maternity Care and the NIMHD Research Frameworks to rigorously evaluate maternal health outcomes in a hospital system that primarily serves Black women with high unmet needs who experience excessive rates of adverse maternal health outcomes via a multi-disciplinary team experienced in health services and community-based research, equity-centered care, and with the capacity to implement a care model intervention with high fidelity and acquire and utilize health system and patient-reported data to conduct comprehensive, high-quality evaluation.