Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs.

BACKGROUND: Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. METHODS: We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. DISCUSSION: Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Co-occurring conditions during pregnancy and hospitalizations in the first year postpartum among persons with opioid use disorder.

INTRODUCTION: Pregnant persons with opioid use disorder (OUD) face a multitude of comorbid conditions that may increase the risk of adverse drug and health outcomes. This study characterizes typologies of comorbidities among pregnant persons with OUD and assesses the associations of these typologies with hospitalizations in the first year postpartum. METHODS: A cohort of pregnant persons with OUD at delivery in 2018 were identified in a Pennsylvania statewide hospital dataset (n = 2055). Latent class analysis assessed 12 comorbid conditions including substance use disorders (SUDs), mental health conditions, and infections. Multivariable logistic regressions examined the association between comorbidity classes and hospitalizations (all-cause, OUD-specific, SUD-related, mental health-related) during early (0-42 days) and late (43-365 days) postpartum. RESULTS: A three-class model best fit the data. Classes included low comorbidities (56.9% of sample; low prevalence of co-occurring conditions), moderate polysubstance/depression (18.4%; some SUDs, all with depression), and high polysubstance/bipolar disorder (24.7%; highest probabilities of SUDs and bipolar disorder). Overall, 14% had at least one postpartum hospitalization. From 0 to 42 days postpartum, the moderate polysubstance/depression and high polysubstance/bipolar disorder classes had higher odds of all-cause and mental health-related hospitalization, compared to the low comorbidities class. From 43 to 365 days postpartum, the high polysubstance/bipolar disorder class had higher odds of all-cause hospitalizations, while both the high polysubstance/depression and moderate polysubstance/bipolar disorder classes had higher odds of SUD-related and mental health-related hospitalizations compared to the low comorbidities class. CONCLUSIONS: Findings highlight the need for long-term, multidisciplinary healthcare delivery interventions to address comorbidities and prevent adverse postpartum outcomes.

Implementation and early effects of medicaid policy interventions to promote racial equity in pregnancy and early childhood outcomes in Pennsylvania: protocol for a mixed methods study.

BACKGROUND: There are large racial inequities in pregnancy and early childhood health within state Medicaid programs in the United States. To date, few Medicaid policy interventions have explicitly focused on improving health in Black populations. Pennsylvania Medicaid has adopted two policy interventions to incentivize racial health equity in managed care (equity payment program) and obstetric service delivery (equity focused obstetric bundle). Our research team will conduct a mixed-methods study to investigate the implementation and early effects of these two policy interventions on pregnancy and infant health equity. METHODS: Qualitative interviews will be conducted with Medicaid managed care administrators and obstetric and pediatric providers, and focus groups will be conducted among Medicaid beneficiaries. Quantitative data on healthcare utilization, healthcare quality, and health outcomes among pregnant and parenting people will be extracted from administrative Medicaid healthcare data. Primary outcomes are stakeholder perspectives on policy intervention implementation (qualitative) and timely prenatal care, pregnancy and birth outcomes, and well-child visits (quantitative). Template analysis methods will be applied to qualitative data. Quantitative analyses will use an interrupted time series design to examine changes over time in outcomes among Black people, relative to people of other races, before and after adoption of the Pennsylvania Medicaid equity-focused policy interventions. DISCUSSION: Findings from this study are expected to advance knowledge about how Medicaid programs can best implement policy interventions to promote racial equity in pregnancy and early childhood health.

Pre-exposure and post-exposure prophylaxis access in rural versus urban pharmacies in Georgia and Pennsylvania.

BACKGROUND: Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) prevent HIV among individuals at high risk for acquisition. Pre-existing structural barriers to PrEP/PEP access among rural patients may be exacerbated further if pharmacies do not keep PrEP/PEP in stock, constituting a significant barrier to mitigating the HIV epidemic. OBJECTIVES: To compare PrEP/PEP availability for same-day pickup in rural vs urban Georgia and Pennsylvania pharmacies. METHODS: We conducted a cross-sectional simulated patient caller study, calling pharmacists in Georgia and Pennsylvania to see whether PrEP/PEP was available for same-day pickup. We identified retail pharmacies through state pharmacy boards and categorized rurality using state-based definitions. We used multivariable logistic regression to assess PrEP availability by rurality and Ending the HIV Epidemic (EHE) designation, accounting for chain pharmacy status and county-level racial composition. RESULTS: Among 481 pharmacies contacted (304 in Pennsylvania and 177 in Georgia), only 30.77% had PrEP for same-day pickup and only 10.55% had PEP for same-day pickup. PrEP availability did not differ significantly by state. Urban pharmacies had 2.02 (95% CI: 1.32-3.09) greater odds of PrEP same-day availability compared to rural pharmacies. Pharmacies in EHE counties had 3.45 (95% CI: 1.9-6.23) times higher odds of carrying PrEP compared to non-EHE counties. CONCLUSIONS: Pharmacies were unlikely to carry PrEP or PEP. Pharmacies in rural compared to urban, and non-EHE compared to EHE locations were less likely to carry PrEP. Addressing pharmacy barriers to PrEP/PEP may enhance access to HIV prevention for those living at high risk of HIV.

Punitive legal responses to prenatal drug use in the United States: A survey of state policies and systematic review of their public health impacts.

BACKGROUND: Punitive legal responses to prenatal drug use may be associated with unintended adverse health consequences. However, in a rapidly shifting policy climate, current information has not been summarized. We conducted a survey of U.S. state policies that utilize criminal or civil legal system penalties to address prenatal drug use. We then systematically identified empirical studies evaluating these policies and summarized their potential public health impacts. METHODS: Using existing databases and original statutory research, we surveyed current U.S. state-level prenatal drug use policies authorizing explicit criminalization, involuntary commitment, civil child abuse substantiation, and parental rights termination. Next, we systematically identified quantitative associations between these policies and health outcomes, restricting to U.S.-based peer-reviewed research, published January 2000-December 2022. Results described study characteristics and synthesized the evidence on health-related harms and benefits associated with punitive policies. Validity threats were described narratively. RESULTS: By 2022, two states had adopted policies explicitly authorizing criminal prosecution, and five states allowed pregnancy-specific and drug use-related involuntary civil commitment. Prenatal drug use was grounds for substantiating civil child abuse and terminating parental rights in 22 and five states, respectively. Of the 16 review-identified articles, most evaluated associations between punitive policies generally (k = 12), or civil child abuse policies specifically (k = 2), and multiple outcomes, including drug treatment utilization (k = 6), maltreatment reporting and foster care entry (k = 5), neonatal drug withdrawal syndrome (NDWS, k = 4) and other pregnancy and birth-related outcomes (k = 3). Most included studies reported null associations or suggested increases in adverse outcome following punitive policy adoption. CONCLUSIONS: Nearly half of U.S. states have adopted policies that respond to prenatal drug use with legal system penalties. While additional research is needed to clarify whether such approaches engender overt health harms, current evidence indicates that punitive policies are not associated with public health benefits, and therefore constitute ineffective policy.

Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees.

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.