) Black women experience stark disparities in pregnancy care, complications, and outcomes, compared to White women. Recognizing, tracking and understanding patterns of severe maternal mortality (SMM) and associated inequities by race/ethnicity, along with developing and carrying out interventions to improve the quality of maternal care, are essential to reducing SMM and thereby maternal mortality. To date, there has been little research specifically aimed at understanding whether the maternal health inequities as experienced by Black women can be ameliorated through an integrated care model that includes engagement of mothers of color in the planning and implementation of maternal safety bundles in addition to prenatal, birth and postpartum support from community doulas. We intend to use the Health Impact Pyramid to develop, implement and assess the effectiveness of such a system in reducing disparities in SMM and mortality. The data sources for this study will include state-level and hospital-specific discharge data collected as part of the Alliance for Innovation on Maternal Health (AIM) project; the Maternal Mortality Review Committee (MMRC); and the Pregnancy to Early Life Longitudinal (PELL) data system, which focuses on population-level data needed to examine health inequities among racial and ethnic minorities in Massachusetts. In addition to these existing data sources, we intend to establish a data collection tool to assess doula services as well as analyze qualitative data from interviews with black women, and focus groups with providers and doulas to explore the effect of incorporating doula-provided services into prenatal, birth and postpartum care. This proposal has three main study areas that will lead to a systematic understanding of ways to address and prevent SMM among black women and thus, establish a foundation for the development, testing and scale-up of future interventions to improve maternal health outcomes: 1) Use longitudinally linked hospital discharge data from PELL (2008-2018) to characterize preconception, prenatal and postpartum hospital encounters among women with SMM in order to identify key points where opportunities to intervene were missed. 2): Among hospitals that serve black women, to assess the impact of implementing maternal safety bundles to ensure that black women are receiving quality obstetric care 3): Examine how systems integrating community-based doula support could decrease the inequities of SMM among black and white mothers. Our study will lead to a more systematic understanding of pregnancy outcomes for Black women at highest risk of SMM, thus establishing a foundation for development and testing of future interventions to improve maternal outcomes.

Public Health Relevance

(Public Health Significance) There is a paucity of research examining the intersection of race, ethnicity, maternal safety bundles, doulas, and maternal outcome in Black women at increased risk of severe maternal morbidity and mortality. The proposed mixed-methods study is the first systematic investigation of pregnancy complications and outcomes among Black women with whom maternal safety bundles including racial disparities, hemorrhage, and hypertension have been utilized and through the analysis of secondary state level data, this study will examine perinatal care, maternal outcomes, and healthcare utilization of Black women at increased risk of severe maternal morbidity and mortality compared with non-Latino white women. Additionally, through individual interviews with Black women and focus groups with obstetric health providers and doulas, the study will examine disparities and improve care by creating and disseminating a set of practice recommendations for maternity care for Black women at increased risk of morbidity and mortality.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZMD1)
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Dagher, Rada Kamil
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Tufts University
Public Health & Prev Medicine
Schools of Medicine
United States
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