Integrated Supportive Care Policies to Improve Maternal Health Equity: Evaluating the Multi-level Effects and Implementation of Doula Programs for Medicaid-Eligible Birthing People in New York City

In New York City (NYC) and State (NYS), pervasive inequalities in access to respectful, culturally congruent, patient-centered maternity services drive maternal mortality (MM) rates that are 8× higher for Black versus White individuals and severe maternal mortality (SMM) rates that are 2.3× higher. Policy interventions that emphasize Medicaid, which serves low-income and racially and ethnically minoritized populations at greatest risk of SMM/MM, and that increase access to quality obstetric services and improve the social and structural determinants of health (SDOH) - i.e., integrated supportive care (ISC) - hold significant promise. NYC and NYS are at the forefront of Medicaid-relevant doula programs, with recent policy advances to expand the Maternity Hospital Quality Improvement Network (MHQIN), which supports hospitals in integrating doulas, Standards for Respectful Care, implicit bias trainings, SDOH clinical reviews, and community linkages into care structures, and the Citywide Doula Initiative (CDI), which trains and provides doulas at no cost for NYC residents in select neighborhoods who are income-eligible for Medicaid. However, there is little empirical evidence on the effectiveness of doula care models or the facilitators and barriers doulas face in practicing within their full scope, integrating into the care team, and strategies for effective, sustainable ISC policy implementation, in part because state Medicaid programs have not included doula services and the community and governmental organizations delivering them have limited research capacity. Guided by our multi-sector partnership and novel integrated conceptual framework, we propose a rigorous mixed-methods evaluation of the multi-level impacts and implementation of NYC’s doula programs. In Aim 1, we will use a quasi-experimental design and unique Medicaid claims linked to social services data to evaluate the overall and differential effects by race, ethnicity, age, socioeconomic status, and geography of the CDI on 1a) birth, mental health, cardiovascular, and SMM outcomes; 1b) prenatal and postpartum healthcare utilization; and 1c) receipt of social services, among Medicaid-eligible birthing people from 2022 to 2027. In Aim 2, we will analyze diverse perspectives on and experiences with the MHQIN program components and its implementation among birthing clients and hospital, Medicaid, and doulas/community stakeholders via in-depth individual interviews, focus group discussions, and surveys. In Aim 3, our Community Coalition Research Leadership Advisory Board will lead a co-design process to develop an evidence-based strategic plan for policy implementation to scale and sustain Medicaid-supported ISC, including doula reimbursement. We will generate new evidence on the role that doulas play in improving maternal health equity, strengthen local partnerships for policy action, and serve as a model for national replicability. Our proposal is highly aligned with NIH’s strategic plan for innovative research to advance community-derived, multi-level policy solutions to redress the crisis of MM for birthing people across the U.S.