Author ORCID Identifier
https://orcid.org/0000-0002-3137-2355
Defense Date
2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Healthcare Policy & Research
First Advisor
Dr. Askar Chukmaitov
Second Advisor
Dr. Bassam Dahman
Third Advisor
Dr. Dina Garcia
Fourth Advisor
Dr. Caitlin Martin
Fifth Advisor
Dr. Lauren Blum
Abstract
Maternal and neonatal outcomes offer a critical lens for assessing health system performance, quality, and access to care. Health care delivery and payment reforms have increasingly been used to improve care delivery, reduce financial barriers, and strengthen population health, yet despite continued policy attention, significant challenges persist. This dissertation evaluates two reforms in distinct policy contexts: hospital participation in Accountable Care Organizations (ACOs) in the United States and Kenya’s Free Maternal Services Policy (FMSP). The U.S. analysis used Healthcare Cost and Utilization Project State Inpatient Databases linked with hospital, environmental, and market data from 2011 to 2019 to assess whether ACO participation was associated with cesarean delivery, severe maternal morbidity, length of stay, and cost, and whether associations differed by contract expansion and hospital Black patient composition. Hospital-level robust staggered difference-in-differences models showed the most consistent evidence for severe maternal morbidity, with staggered models indicating an approximately 0.1 percentage-point decline, or 10 fewer cases per 10,000 deliveries. There were no meaningful differences in cesarean delivery, length of stay, or sustained post-adoption costs. The Kenya analysis used pooled 2008/2009, 2014, and 2022 Kenya Demographic and Health Surveys to examine whether FMSP was associated with cesarean delivery and neonatal mortality, with an exploratory qualitative review providing additional contextual insights. FMSP was associated with improved neonatal survival, especially in the later implementation period, but not with overall changes in cesarean delivery. Larger post-policy cesarean increases among urban births suggest persistent geographical disparities in obstetric care and newborn care.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
5-14-2026
Included in
Health Services Research Commons, International Public Health Commons, Maternal and Child Health Commons, Women's Health Commons