The U.S. is facing a serious crisis of rising rates of maternal mortality and severe morbidity, which are
attributable to multiple factors, such as the persistent, deep shortages of maternal care workforce in
disadvantaged urban communities and rural areas. Since half of U.S. counties do not have a single
obstetrician-gynecologist (OB-GYN), access to maternal care is a daunting challenge facing the nearly seven
million reproductive-age women living in those counties.
To address the problem of unequal distribution of clinicians, policymakers have taken considerable efforts
in recent decades. Among the efforts, the National Health Service Corps (NHSC) remains the single largest
policy intervention that has been launched to recruit clinicians to health professional shortage areas (HPSAs).
The NHSC has experienced a dramatic expansion during the past decade, first through the American
Recovery and Reinvestment Act in 2009 and then by the Affordable Care Act in 2010. Prior studies have found
that these two Acts have raised the NHSC’s annual budget by over 100% and led to a significant expansion of
the NHSC’s clinician workforce, such as OB-GYNs and certified nurse-midwives. However, no study to date
has evaluated the impact of the NHSC expansion on disparities in maternal care and outcomes between the
HPSAs and other areas.
This proposed project aims to examine these issues and fill the gap in the literature. To our knowledge, it
will be the first study to examine the effect of the recent NHSC expansion on disparities in maternal care and
outcomes. Specifically, the project aims to assess how the recent NHSC expansion affects disparities in (1)
maternal mortality overall and in-hospital mortality in particular, (2) severe maternal morbidity during childbirth
hospitalizations and the associated hospital delivery costs and length of stay, (3) labor and delivery care, and
(4) timing and adequacy of prenatal care and birth outcomes.
To examine these aims, we will use multiple large, national data files over an extended period of 15 years
between 2005 and 2019. To analyze the data, we will take two complementary approaches, including a
difference-in-differences method, and an instrumental variable approach. Our analyses are expected to provide
rigorous quasi-experimental evidence about the effects of workforce policy changes on disparities in maternal
mortality and severe morbidity, which are key objectives of the Healthy People 2030. Our study findings will
have important implications for the upcoming implementation of the 2018 Improving Access to Maternity Care
Act, the latest NHSC policy change intended to better serve reproductive-age women in HPSAs by further
increasing the NHSC supported maternal care providers.