PROJECT SUMMARY/ABSTRACT: There is a maternal health crisis in the United States that
disproportionately affects Black birthing people. Black birthing people are two times more likely to experience
severe maternal morbidity (SMM) - “unexpected outcomes of labor and delivery that result in significant
short- or long-term consequences to a birthing person’s health” – than non-Hispanic White birthing people.
Preventing preeclampsia, increased or maintained engagement in healthy behaviors (e.g., physical activity),
and support addressing health-related social needs can enhance receipt of timely, appropriate care and
reduce risk for SMM. The Maternal OutcoMes (MOMs) Program implemented at Northwell Health is an
effective integrated care approach that identifies and supports high-risk birthing people immediately post-
delivery. In preliminary analysis based on data from 2500 participants, the MOMs Program significantly
reduced risk for SMM-related hospital admissions 30-days post-delivery by 77% among Black participants.
These preliminary findings are promising; however, the long-term effectiveness needs to be established as
well as the feasibility and effectiveness of extending the MOMs Program to the prenatal period.
The purpose of this study is to test the effectiveness of an integrated care model approach at two different
levels of intensity designed to facilitate timely, appropriate care for high-risk Black birthing people and reduce
risk for SMM. Black birthing people with an Obstetrics-Comorbidity Index Score ¿ 3 and/or a history of pre-
eclampsia will be identified via the electronic health record and 674 will be recruited and randomized during
the first trimester to one of two study arms: MOMs High-Touch (MOMs-HT) vs. MOMs Low-Touch (MOMs-
LT). MOMs-HT will consist of close clinical and behavioral health monitoring via chatbot technology and
navigation to timely care and services by the MOMs team throughout the prenatal and postpartum periods;
12 bi-weekly self-management support calls with the MOMs team during the prenatal period; and 4 weekly
postpartum clinical check-in calls with navigation by the MOMs team immediately post-delivery. MOMs-LT
will also include clinical and behavioral health monitoring via the chatbot along with navigation to services by
the MOMs team and 4 weekly postpartum clinical check-in calls with navigation. The two study arms will be
compared on incidence of SMM at labor and delivery (Aim 1), incidence rate of SMM-related hospitalizations
at 1-month and 1-year postpartum (Aim 1a), rate of preeclampsia diagnosis (Aim 2), change in perceived
social support domains (Aim 3), and physical activity trajectories (exploratory Aim 4). Findings from this
study will help to determine how to feasibly implement an effective and sustainable integrated care approach
to address SMM disparities.
