Policy solutions for addressing structural racism in maternal health disparities

The broad, long-term objective of NY-CHAMP's Project 3 is to inform efforts to improve population maternal health equity by understanding and addressing the underlying determinants of racial and ethnic disparities in severe maternal morbidity (SMM) and mortality (MM) and ensuring equitable access to quality, culturally appropriate maternal health care. U.S. racial and ethnic minoritized birthing people are about three times as likely as non-Hispanic White birthing people to experience life-threatening complications and die during pregnancy and postpartum. Persistent racial and ethnic disparities in maternal health are not fully explained by known risk factors. Although structural racism (SR) is viewed as the fundamental cause of health disparities generally, few, if any, studies have empirically evaluated it role in excess SMM and mortality among racial and ethnic minority birthing people. Evidence regarding effective policy interventions—at state, local and hospital levels—to address SR in SMM/MM is even more scant. We propose a rigorous mixed methods project with specific aims to: 1) assess the associations of multidimensional indexes of SR with racial and ethnic disparities in SMM, suicidality, and mortality; and estimate the hospital costs of SMM attributable to SR; 2) assess the associations of two policy-relevant interventions (i.e., Medicaid eligibility generosity and healthcare workforce diversity) with racial and ethnic disparities in SMM, suicidality, and mortality; and quantify the moderating effects of these two interventions on associations between SR and maternal health outcomes; and 3) analyze the lived experiences of patients and community and hospital stakeholders to identify the mechanisms of, and effective solutions for, SR in maternal health care. We will analyze a robust triangulated set of quantitative and qualitative data from multiple sources, capturing both national and local samples, and apply a complementary suite of multilevel modeling, causal inference, and grounded theory research techniques. Data from the Healthcare Cost and Utilization Project, which provides information on 10 million childbirths from over 1200 hospitals in 21 states during 2016-2022 (Aims 1-2), will be complemented by prospective in-depth interview and focus group data from multisector stakeholders (patients, community, hospital) in three New York City hospital sites (Brooklyn, Washington Heights, Queens) of focus for NY-CHAMP's Intervention Project 2. Aims 1 and 2 will test the hypotheses that: 1) multidimensional indexes of SR are associated with significantly increased disparities in SMM, suicidality, and mortality; 2) higher state Medicaid eligibility generosity and healthcare workforce diversity are independently associated with lower disparities in SMM, suicidality, and mortality; and 3) Medicaid eligibility generosity and healthcare workforce diversity independently mitigate the impact of SR on disparities in maternal outcomes. Aim 3 will be hypothesis generating. Findings will help close important gaps in our understanding of the role that SR plays in SMM/MM disparities and generate urgently needed evidence for informing multilevel policy interventions to improve maternal health equity in our city, state, and across the country.