Pregnancy complications are increasing in the United States, and this is worse for Black patients, who are three to four times more likely to die from pregnancy than White patients. Pregnancy complications and deaths cause large physical, social, and financial burdens for patients and their families. Black patients who experience higher levels of institutional racism and discrimination from healthcare providers and institutions are more likely to have pregnancy complications, such as delivering a baby with low birthweight. Low birthweight (less than 5 pounds 9 ounces) is related to many short-term and long-term health problems for both baby and mother.

This study -- Accountability for Care through Undoing Racism and Equity for Moms (ACURE4Moms) -- aims to decrease pregnancy complications for all patients, but especially for Black patients, by decreasing institutional racism and bias in health care and improving community-based social support during pregnancy. The primary outcome will be to decrease low birthweight deliveries among Black women. The team will get information about low birthweight and other pregnancy outcomes from prenatal practice electronic healthcare records. A secondary outcome will be to decrease experiences with discrimination during prenatal care among Black patients; this information will be collected from an internet survey that will be completed at four time points between a patient’s first prenatal visit and three months after delivery.

To meet the study aims, the team will test two types of interventions. The first type (the “Data Accountability interventions”) will be focused on healthcare providers and their clinics. The team will improve accountability by setting up electronic Maternal Warning Systems to notify the clinics whenever a patient has a risk factor for low birthweight that needs to be treated or misses a scheduled appointment. Nurse navigators and provider champions from each clinic will make sure the clinic acts on the warning. Secondly, the team will improve transparency by showing the clinics their pregnancy-related complication data for different racial groups every three months through a Disparities Dashboard. This dashboard will show the providers any differences in pregnancy complications for people of different races in their clinic and encourage them to come up with ways to improve the quality of their care to decrease those differences. The team will hire practice facilitators to help the clinics improve their workflows and communication with patients. Finally, all the staff at the clinics will undergo interactive racial equity training to help them recognize any implicit biases they have and understand how racism affects pregnancy care for patients of color.

The second type of interventions will be focused on improving community-level support for high-risk pregnant patients. The team will do this by matching community-based doulas who are trained to provide culturally relevant care with high-risk patients after their first prenatal appointment. The doulas will then provide support to these patients during pregnancy and up to one year after birth by setting up peer support groups for clients with similar due dates, attending two prenatal visits with them, supporting them for up to 24 hours during labor, and performing a postpartum home visit (the “doula interventions”).

To test how each of these interventions improves low birthweight alone and when combined together, the team will randomize 40 prenatal practices across North Carolina, into one of four groups: (a) no interventions; (b) data accountability interventions; (c) doula interventions; or (d) both the data accountability and doula interventions. The team predicts that about 30,000 patients will start prenatal care at one of the 40 practices during the study. For the patient survey, the team plans to enroll 100 Black patients from each of the 40 practices, for a total of 4,000 patients. The team will also interview up to 463 practice staff, doulas, patients, and practice facilitators to understand how well the study interventions fit their needs.

This study is led by a stakeholder advisory board, which includes patients of color who have had a pregnancy complication, community doulas, practice representatives, health insurance payers, a patient advocacy group, healthcare organizations, and the North Carolina Department of Public Health. The majority of members will be people of color. The board will meet every three months throughout the study to advise us about patient-centered outcomes, assist with dissemination of results, and advocate for related policy change.