The US maternal mortality ratio (26.4 maternal deaths per 100,000 livebirths) is the highest among developed nations, with wide variation across states and racial/ethnic groups. The state of Georgia has the second highest maternal mortality (66.3 per 100,000), with a 60% higher rate for black vs white women (95.6 vs 59.7 per 100,000). Nearly 100 times more common than maternal mortality, however, is severe maternal morbidity (SMM). Maternal mortality and SMM are highest among women who are black, publicly insured or uninsured, and deliver in safety-net hospitals. In Georgia, nearly two-thirds of maternal deaths and SMM are deemed preventable, with chronic health conditions, obesity, delays in accessing and fragmentation of care as key contributors. Current data indicate that postpartum SMM is increasing at a faster rate than SMM during the delivery hospitalization. Proposed solutions to the maternal health crisis in Georgia include improved prenatal and postpartum follow-up and case management, control of chronic health conditions, and extension of Medicaid coverage. However, there is a dearth of evidence regarding whether such strategies can improve maternal health or reduce racial disparities in SMM or mortality. The proposed study will begin to fill this void with a multidisciplinary, mixed-methods approach. We will first analyze Georgia linked vital records, hospital discharge, and claims data to provide an overview of the extent, location and determinants of differences in SMM among non-Hispanic black and non-Hispanic white women at delivery and 3 to 12 months postpartum. Using regression-based decomposition methods we will highlight the portions of the racial/ethnic differences explained by observable and unobservable factors. We will use these findings and in-depth interviews with postpartum women and their health care providers and case managers to contextualize the analysis of two postpartum interventions targeting women at risk for adverse outcomes ? an existing Medicaid policy and a newly designed health system intervention. The Georgia Medicaid Planning for Healthy Babies (P4HB) Medicaid program provides postpartum women with a very low birth weight delivery primary care inclusive of nurse case management and Resource Mother outreach to link women to social supports. This study will be the first to evaluate the effects of this Medicaid policy on SMM disparities. These analyses will then be used to inform the design of the new postpartum care system for women who deliver at a safety-net hospital in Atlanta, Georgia, and are at increased risk for SMM. Women (N = 320) will be randomly assigned to either this enhanced postpartum care system vs. standard care, with assessment of outcomes within 12 weeks and 12 months postpartum, including attendance of postpartum care visits, receipt of recommended care, and adverse outcomes such as hospital readmissions. The insights gained from the proposed work will fill critical knowledge gaps regarding policy and practice approaches for reducing maternal health disparities and can serve as a foundation for future prevention and intervention strategies within the state and nationally.

Public Health Relevance

Racial disparities in maternal health in Georgia are stark and in need of systematic review, analysis, and intervention. This study will combine a statewide assessment of racial disparities in adverse maternal health outcomes with an evaluation of Georgia?s Medicaid Inter-pregnancy Care Program and a randomized trial of a comprehensive postpartum care system in an urban safety-net hospital. By studying the complex array of individual, health care system, community, and societal level factors that culminate in women?s lack of access we will fill critical gaps in knowledge regarding policy and health system approaches for reducing disparities in maternal 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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Emory University
Obstetrics & Gynecology
Schools of Medicine
United States
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