Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Nutritional Knowledge and Practices of Low-Income Women During Pregnancy: A Qualitative Study in Two Oaxacan Cities

Background

Adequate dietary intake is critical for healthy pregnancies. Recent changes in social services in Mexico, coupled with high levels of food insecurity, call into question whether expecting women of the lowest socioeconomic status are able to meet their dietary and nutritional needs in this changing context. The aim of this study was to explore the nutritional practices, education and received and employed among women during their pregnancy.

Methods

Guided by Ecological Systems Theory and an Intersectionality Framework, this qualitative study was carried out in Oaxaca City and Puerto Escondido, in Oaxaca, a Mexican state with high levels of food insecurity. Women who had at least one child in the past five years and had lived in Oaxaca for the past five years were eligible to participate. Twenty-five women participated in semi-structured in-depth interviews conducted between June and December of 2023. A grounded theory approach was used for coding. NVivo was used for coding and analyses.

Results

Five key themes emerged linked to individual-level characteristics and the multiple social identities related to the social support for nutritional knowledge and practices among low-income Oaxacan women during pregnancy: 1) Life experiences, sociodemographic, and health characteristics that influence nutritional practices and knowledge during pregnancy; 2) Female family members as a primary source of nutritional knowledge and food support; 3) Support from other members of women's social networks; 4) Medical guidance for nutrition during pregnancy; and 5) Quality and gaps in the broader health care system and social services. These themes highlight how women's own experiences and social identities and the different interpersonal and community-level environments, particularly those of mothers and grandmothers and health care providers, interact and shape women's nutritional knowledge and practices, such as foods and nutritional supplements consumed, during pregnancy.

Conclusion

Nutritional knowledge and practices during pregnancy are impacted by multiple social identities women have and different factors at the individual, group, and structural level. Future research and programming that use multi-level approaches (considering the individual and the family and other social influences) are needed to address the gaps in nutrition that women in Oaxaca go through during the prenatal period.

Inequities between rural and urban realities: young Hispanic women's pregnancy intentions and birth outcomes

The present study sought to determine if inequities exist in Hispanic women's pregnancy intentions and birth outcomes by metropolitan status. In the U.S. pregnancy intentions and birth outcomes of young Hispanic women are a significant public health problem as they are often overlooked on health issues such as pregnancy and childbirth. Data were from the 2015 to 2019 National Survey of Family Growth and focused on the first pregnancies of Hispanic women aged 18 to 24 years old who were not pregnant at the time of the interview and answered the nativity question. Multivariable multinomial regression was used to evaluate how metropolitan status affects pregnancy intentions and birth outcomes. Additionally, multivariable multinomial regression was used to evaluate how metropolitan status affects each pregnancy intention-birth outcome combination. There was no significant association solely between metropolitan status and pregnancy intention (i.e. unintended pregnancy). Metropolitan Hispanic women reported more miscarriages than live births. Hispanic women in the suburbs were more likely to miscarry during an intended pregnancy than those in urban. These findings can improve family planning services for rural women by identifying the specific factors that affect pregnancy intentions and developing targeted interventions to reduce unintended pregnancies.

Postpartum recovery after severe maternal morbidity in Kilifi, Kenya: a grounded theory of recovery trajectories beyond 42 days

INTRODUCTION

The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored.

METHODS

This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity.

RESULTS

Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period.

CONCLUSION

Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.

A global analysis of the determinants of maternal health and transitions in maternal mortality

The reduction of maternal mortality and the promotion of maternal health and wellbeing are complex tasks. This Series paper analyses the distal and proximal determinants of maternal health, as well as the exposures, risk factors, and micro-correlates related to maternal mortality. This paper also examines the relationship between these determinants and the gradual shift over time from a pattern of high maternal mortality to a pattern of low maternal mortality (a phenomenon described as the maternal mortality transition). We conducted two systematic reviews of the literature and we analysed publicly available data on indicators related to the Sustainable Development Goals, specifically, estimates prepared by international organisations, including the UN and the World Bank. We considered 23 frameworks depicting maternal health and wellbeing as a multifactorial process, with superdeterminants that broadly affect women's health and wellbeing before, during, and after pregnancy. We explore the role of social determinants of maternal health, individual characteristics, and health-system features in the production of maternal health and wellbeing. This paper argues that the preventable deaths of millions of women each decade are not solely due to biomedical complications of pregnancy, childbirth, and the postnatal period, but are also tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development. This paper underscores the need for broader, multipronged actions to improve maternal health and wellbeing and accelerate sustainable reductions in maternal mortality. For women who have pregnancy, childbirth, or postpartum complications, the health system provides a crucial opportunity to interrupt the chain of events that can potentially end in maternal death. Ultimately, expanding the health sector ecosystem to mitigate maternal health determinants and tailoring the configuration of health systems to counter the detrimental effects of eco-social forces, including though increased access to quality-assured commodities and services, are essential to improve maternal health and wellbeing and reduce maternal mortality.