PROJECT SUMMARY Low-income pregnant and postpartum patients (PPP), especially persons of color, experience significant inequities in quality of care and health outcomes across the perinatal period; this is driven, in part, by lack of access to care, inadequate coordination and integration of primary care and maternity care, and failure to address unmet social needs. Federally qualified health centers (FQHCs) could play a central role in addressing these maternal health challenges, as the unique FQHC model includes providing access to culturally competent care for underserved patients; integrating and coordinating primary and maternity care; and linking patients to social services. While use of FQHCs versus other outpatient settings for primary care has been associated with improved care quality, the impact of FQHC use for pregnancy care is unknown. Moreover, one key factor affecting the ability of FQHCs to improve perinatal outcomes may include whether the FQHC directly provides maternity services, with our preliminary data finding that 1 in 3 US FQHCs do not directly provide prenatal care. Yet, there is no known literature on how offering maternity services at FQHCs may impact pregnancy outcomes, despite important policy opportunities to expand services at FQHCs. Our long-term goal is to identify effective health system reform strategies that improve outcomes and equity for low-income PPP. As an immediate objective, this R01 will use a quasi-experimental, mixed methods approach to study if and how FQHCs may improve access, quality, and equity of care for PPP, using national data on the universe of Medicaid-covered births. The specific aims are to (1) Characterize Medicaid-enrolled PPP who receive care at FQHCs vs non-FQHC practices (1-A) and compare quality of care-sensitive measures for these groups across the prenatal (e.g., timely prenatal care), delivery (e.g., SMM, preterm birth), and postpartum (e.g., postpartum linkage to primary care) periods, using entropy balancing to balance on observables (1-B); (2) Among PPP who receive care at FQHCs, evaluate how expanding FQHC services to include maternity care impacts quality of care-sensitive measures using a difference-in-differences study to compare measures for Medicaid-enrolled PPP at FQHCs that implement maternity care vs FQHCs with continuous maternity care vs FQHCs with continuous referral-only maternity care; and (3) Assess the role of FQHCs in integrating, coordinating, and providing access to care for PPP through semi-structured interviews with health systems and FQHC leadership, including successes and challenges of FQHCs in integrating and coordinating primary care, maternity care, and social services for PPP, implications for quality and equity, and key policy opportunities and challenges in expanding maternity care at FQHCs. All Aims will examine differential impacts by racial/ethnic identity. Collectively, these aims will fill critical evidence gaps to help policymakers, Medicaid providers, and managed care plans understand how FQHCs may shape maternal health outcomes and equity at scale, which in turn can inform policy, delivery system design, workforce initiatives, and plan contracting.

PROJECT NARRATIVE Low-income pregnant and postpartum people (PPP) enrolled in Medicaid experience suboptimal and inequitable quality of care and pregnancy-related outcomes, especially PPP from racial/ethnic minorized groups. Federally qualified health centers (FQHCs) could play a key role in improving maternal health outcomes and equity at scale by addressing drivers of maternal health care inequities, as FQHCs may improve access, care integration and coordination, and address unmet social needs, yet very limited evidence is available to guide policymakers, health systems, managed care plans, or FQHCs. This research will therefore fill this critical evidence gap by evaluating if and how FQHCs, and direct provision of maternity care at FQHCs, can improve quality and equity of care for PPP by leveraging a novel natural experiment using national claims data and qualitative interview data.