Severe maternal morbidity and mortality in the U.S. disproportionately affect African-American (AA)
women. Inequities occur at many levels, including community, provider/practice, and health system levels. This
proposal will test the effectiveness and cost-effectiveness of a multilevel intervention to address AA maternal
morbidity and mortality in two Michigan counties: Genesee County (which includes Flint) and Kent County (which
includes Grand Rapids). Interventions were developed or co-developed by our partners in these counties, who
include AA women residents, enhanced prenatal and postnatal care (EPC) staff (including race-matched
community health workers), and physician/health system staff and providers.
Community level intervention. We will expand access to EPC services (i.e., home visiting programs,
Healthy Start programs) using telehealth and flexible scheduling. Despite being designed for minority women,
about 60% of eligible AA women in Michigan do not enroll in EPC services. Pilot work indicates that 50% of
minority women who declined EPC services would participate if a telehealth option was available. We will provide
this option. Provider/practice level intervention. We will address provider and health system implicit and
explicit bias and corresponding structures and practices and make this learning actionable using daylong
experiential trainings. Training will include didactics, reflection, discussion, windshield tours, and brainstorming
ways to tailor participants’ practices and settings to better meet the needs of perinatal AA women. Training will
include everyone from physicians to front desk staff. System level intervention. We will implement community
care patient safety bundles targeting maternal health disparities throughout the intervention counties.
We will test the effects of the multilevel intervention using a quasi-experimental difference-in-difference
with propensity scores approach to compare pre (2016-2019) to post (2021-2024) changes in outcomes among
Medicaid women in the two intervention counties with similar women in other Michigan counties. The sample
will include all Medicaid insured women observed during pregnancy, at birth, and/or up to 1 year postpartum,
who delivered in Michigan from 2016 – 2024 (approximately 540,000 births, including ~162,000 births to AA
women). Measures will be taken from a pre-existing linked dataset that includes Medicaid claims, death records,
birth records, and EPC program data. The specific aims are to: (1) Assess the effectiveness of the multilevel
intervention on AA severe maternal morbidity and mortality; (2) Test improved service utilization and non-severe
maternal morbidity as mechanisms of the effect of the multilevel intervention on severe maternal morbidity, and
(3) Evaluate the cost-effectiveness of the multilevel intervention. This project will be among the first to evaluate
a multilevel intervention to reduce AA maternal morbidity and mortality at the population level. The trial tests
whether the intervention engages the mechanisms presumed to underlie intervention effects and provides
cost-effectiveness data that systems need to make informed decisions about adoption, speeding implementation.
