BACKGROUND Evidence-based reproductive care reduces morbidity and mortality for women and their children, decreases health disparities and saves money. Community health centres (CHCs) are a key point of access to reproductive and primary care services for women who are publicly insured, uninsured or unable to pay for care. Women of reproductive age (15-44 years) comprise just of a quarter (26%) of the total CHC patient population, with higher than average proportions of women of colour, women with lower income and educational status and social challenges (e.g. housing). Such factors are associated with poorer reproductive health outcomes across contraceptive, preventive and pregnancy-related services. The Affordable Care Act (ACA) prioritised reproductive health as an essential component of women's preventive services to counter these barriers and increase women's access to care. In 2012, the United States Supreme Court ruled ACA implementation through Medicaid expansion as optional, creating a natural experiment to measure the ACA's impact on women's reproductive care delivery and health outcomes. METHODS This paper describes a 5-year, mixed-methods study comparing women's contraceptive, preventive, prenatal and postpartum care before and after ACA implementation and between Medicaid expansion and non-expansion states. Quantitative assessment will leverage electronic health record data from the ADVANCE Clinical Research Network, a network of over 130 CHCs in 24 states, to describe care and identify patient, practice and state-level factors associated with provision of recommended evidence-based care. Qualitative assessment will include patient, provider and practice level interviews to understand perceptions and utilisation of reproductive healthcare in CHC settings. DISCUSSION To our knowledge, this will be the first study using patient level electronic health record data from multiple states to assess the impact of ACA implementation in conjunction with other practice and policy level factors such as Title X funding or 1115 Medicaid waivers. Findings will be relevant to policy and practice, informing efforts to enhance the provision of timely, evidence-based reproductive care, improve health outcomes and reduce disparities among women. Patient, provider and practice-level interviews will serve to contextualise our findings and develop subsequent studies and interventions to support women's healthcare provision in CHC settings.

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研究方案：《负担得起的医疗保健法》实施后，在安全网中对女性医疗保健进行混合方法研究-EVERYWOMAN。

背景技术基于证据的生殖保健降低了妇女及其子女的发病率和死亡率，减少了健康差距并节省了资金。社区卫生中心是公共保险，无保险或无力支付护理费用的妇女获得生殖和初级保健服务的关键点。育龄妇女（15-44岁）仅占CHC患者总数的四分之一（26％），有色妇女，收入较低，受教育程度较低和社会挑战（例如住房）的妇女比例高于平均水平。这些因素与避孕，预防和妊娠相关服务的生殖健康结果较差有关。《平价医疗法案》（ACA）将生殖健康列为妇女健康的重要组成部分。提供预防服务，以克服这些障碍并增加妇女获得护理的机会。2012年，美国最高法院裁定通过扩大医疗补助金来实施ACA是一项可选措施，从而创建了一项自然实验来衡量ACA对妇女生殖保健服务和健康结果的影响。方法本文描述了一项为期5年的混合方法研究，比较了ACA实施前后妇女的避孕，预防，产前和产后护理以及医疗补助扩张和非扩张状态之间的关系。定量评估将利用来自ADVANCE临床研究网络的电子健康记录数据，该网络由24个州的130多家CHC组成，用于描述护理并确定与提供推荐的循证护理有关的患者，执业和州级因素。定性评估将包括患者，提供者和实践水平的访谈，以了解对CHC环境中生殖健康保健的看法和利用。讨论据我们所知，这将是第一项使用来自多个州的患者水平电子健康记录数据，结合其他实践和政策水平因素（例如，Title X资金或1115医疗补助豁免）评估ACA实施的影响的研究。调查结果将与政策和实践有关，为加强及时提供循证生殖保健，改善健康结果和减少妇女之间的差异提供信息。患者，提供者和实践层面的访谈将有助于根据我们的发现进行背景调查，并开展后续研究和干预措施，以支持在CHC环境中提供女性医疗保健服务。