Trenton Makes but Cannot Deliver: The Impact of Changes in Trenton’s Maternal Health Care Delivery System on Access to Maternity Care and Maternal Health Outcomes

Abstract

In 2011, the Trenton maternity care landscape drastically changed when Capital Health shuttered their Mercer Hospital campus on Bellevue Avenue as part of a larger plan to open a new hospital outside the city in neighboring Hopewell. Since then, Trenton has sustained several hospital-based obstetric unit closures, discontinued prenatal care services, and a shortage of maternal care providers who accept Medicaid insurance. Given the immense transformation of Trenton’s maternal health care infrastructure in the past decade, this thesis seeks to determine the impact that such changes have had on the health of one of the city’s most vulnerable populations: pregnant and postpartum women. Specifically, this thesis examines how the gradual erosion of maternity care services in Trenton has affected maternal health care access and outcomes between the years 2009 and 2015. The first analysis on prenatal care utilization hypothesizes that these closures impaired women’s ability to access maternity care by not only reducing the availability of these services but also exacerbating the barriers that women already face in the maternal health care delivery system. The second analysis on preterm births hypothesizes that the significant reductions in Trenton’s obstetric services have adversely impacted maternal health outcomes by disrupting women’s continuum of maternity care. An additional analysis examines the variations among outcomes across different races and ethnicities, determining the role that these changes have played in increasing racial and ethnic disparities in maternal health care access and outcomes. Using a mixed-methods approach, this thesis first examines each hypothesis for all mothers in Trenton. It then evaluates each hypothesis across mothers of three racial and ethnic identities: non- Hispanic white, non-Hispanic Black, and Hispanic. In the quantitative analysis, multivariate logistic regressions are used to identify whether women experienced decreased odds of prenatal care utilization and increased odds of preterm birth after each obstetric unit closure. In the qualitative analysis, interviews with stakeholders in advocacy, health care, academia, and government provide first-person perspectives on how changes in the health care delivery system have resulted in severe maternal morbidity and amplified existing racial and ethnic disparities. The quantitative analysis results demonstrate trends of decreasing odds of women initiating prenatal care and increasing odds of preterm birth following two Trenton maternity care facility closures. When the results are examined across women of different racial and ethnic identities, the data does not align with the qualitative analysis findings. Stakeholder interviews concluded that the stress of navigating Trenton’s maternity care landscape, compounded by experiences with interpersonal and structural racism within the healthcare system, has impaired many Black and Hispanic women’s maternal health care access and outcomes. Despite the Murphy Administration’s focus on maternal health as a priority issue for the state, the capital city remains a maternity care desert––a region where access to maternity care services is limited or absent, through either reductions in sites of care or barriers to accessing care. Thus, Trenton requires a reinvestment in the city through state- and community-level initiatives that meet the profound needs of mothers and support them during their prenatal, delivery, and postpartum periods. Without targeted, cross-cutting interventions, Trenton’s current maternal health care delivery system will continue to compromise the city’s maternal and newborn health outcomes.