Enriched Holistic Care to Eradicate Disparities in Maternal Morbidity

This randomized controlled trial addresses social and structural inequities to reduce severe maternal morbidity (SMM) and maternal mortality in the most at-risk patients - those that self-identify as Black, indigenous and people of color (BIPOC). Specifically, the intervention will implement and evaluate an integrated, multi-level maternity care home model (MCHM) that incorporates maternity care navigation, benefits navigation, social work, doula and mental health resources all within one care-delivery model. While previous studies have evaluated single social determinants (e.g. education and insurance) or single solutions (e.g. care navigator), these approaches lack a comprehensive, integrated approach that is responsive to all patient needs.

The study will test the central hypothesis that a patient-centered MCHM will address the gap in social, structural, and health system factors that contribute to disparities for the most vulnerable BIPOC patients, thereby reducing SMM. To test the effectiveness of this MCHM and ensure timely uptake of the results, the investigators propose a type 1 hybrid effectiveness-implementation trial to evaluate the effectiveness and implementation of an integrated MCHM that provides a comprehensive approach by partnering a unified model of social and structural service delivery with medical service delivery in all prenatal offices affiliated with the two largest birthing hospitals in Philadelphia.

Within this study, the investigators will determine the effectiveness of an integrated MCHM in reducing SMM among BIPOC patients (Aim 1). Patients will be randomized (n=2300) to a MCHM (office-based prenatal care that is integrated with social services within the MCHM) or standard of care (office-based prenatal care with individually outsourced social services referrals) and followed throughout pregnancy and for 1 year postpartum. To determine mechanisms by which this integrated MCHM impacts SMM (Sub-Aim 1a), the investigators will evaluate numerous factors that could plausibly mitigate the effects of health system failures, provider bias and adverse social conditions (e.g. improved health system access, care coordination). The investigators will also characterize patient, provider and organizational implementation determinants relevant to an integrated MCHM and identify barriers and facilitators to implementation and sustainability (Aim 2) as well as determine resource utilization and total cost/cost savings associated with the MCHM (Sub-Aim 2a) by partnering with commercial and Medicaid payers.

Importantly, the results of the proposed study will provide actionable evidence to support effective maternity care delivery that results in optimal and equitable outcomes, thereby revolutionizing the way in which prenatal, intrapartum and postpartum care is delivered and experienced. Additionally, even if the trial is negative in reducing SMM, there are still numerous other potential benefits to an integrated MCHM (including many of the secondary outcomes being evaluated) and the investigators will have therefore collected valuable information to inform the implementation of this model into clinical practice.

• Obstetric outcomes: Mode of delivery [Time frame: At delivery]
• Obstetric outcomes: Preterm birth less than 37 weeks [Time frame: At delivery]
• Obstetric outcomes: Preterm birth less than 34 weeks [Time frame: At delivery]
• Obstetric outcomes: Hypertensive disorders of pregnancy [Time frame: During pregnancy through 6 weeks postpartum]
• Composite adverse neonatal outcome [Time frame: From birth until 4 months after birth]
• Postpartum visit attendance [Time frame: From delivery discharge up to 12 weeks postpartum]
• Edinburgh Postnatal Depression Scale (EPDS) Screening [Time frame: At delivery and at 3-6 months postpartum]
• Unscheduled Emergency room/pregnancy triage visits [Time frame: Post-randomization to 1 year postpartum]
• Perceived stress scale [Time frame: Post-randomization to 1 year postpartum]
• Person centered prenatal care survey for people of color [Time frame: After delivery up to 6 weeks postpartum]
• Rate of Lactation initiation and continuation [Time frame: From delivery through 1 year postpartum]
• Perceived discrimination [Time frame: At randomization]