Hearing the Silenced Voices of Underserved Women: The Role of Qualitative Research in Gynecologic and Reproductive Care

Hysterectomy inequities between black and white patients in the US military health system: A retrospective cohort study

OBJECTIVE

To evaluate multicomponent aspects of hysterectomy-related care in the US Military Health System including the probability of open hysterectomy (versus vaginal or laparoscopic hysterectomy), probability of having a length of stay > 1 day, and discharge milligram morphine equivalent dose (MED). Analyses sought to identify the presence and strength of healthcare inequities between Black and white patients.

METHODS

In this retrospective cohort study, records of patients (N = 11,067) ages 18-65 years enrolled in TRICARE who underwent a hysterectomy between January 2017 to January 2021 in US military treatment facilities (direct care) or civilian facilities (purchased care) were included. Graphic representations illustrated provider and facility variation. Generalized additive mixed models (GAMMs) evaluated inequities across outcomes. Sensitivity analyses included only direct care receipt and added a random effect for the facility.

RESULTS

There was significant variation in provider use of open versus vaginal or laparoscopic hysterectomies, as well as provider and facility discharge MED. The GAMMs indicated Black patients were more likely to receive an open hysterectomy [log(OR) -0.54, (95 %CI -0.65, -0.43), p < 0.001] and have a length of stay > 1 day [log(OR) 0.18, (95 %CI 0.07, 0.30), p = 0.002], but had similar discharge MED [-2 mg (95% CI -7 mg, 3 mg), p = 0.51], relative to white patients. Patients receiving care in purchased care, relative to direct care, were more likely to receive a vaginal or laparoscopic hysterectomy [log(OR) 0.28, (95 %CI 0.17, 0.38), p = 0.002] and received approximately 21 mg lower discharge MED (95 %CI 16-26 mg less, p < 0.001), but were more likely to have a hospital stay > 1 day [log(OR) 0.95, (95 %CI 0.83, 0.1.10), p < 0.001]. Additional gynecological conditions (e.g., uterine fibroids) and prescription receipt were associated with some, but not all outcomes.

CONCLUSION

Improving timely care receipt, especially for uterine fibroids, increasing access to vaginal and laparoscopic hysterectomies, and reducing unwarranted variation in discharge MED could improve care quality and equity in the US Military Health System.

Informational Preferences of Women Seeking Treatment for Symptomatic Uterine Fibroids: A Qualitative Study

STUDY OBJECTIVE

To establish the informational needs and preferences of women navigating treatment options for symptomatic uterine fibroids.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Academic institution.

PATIENTS

Participants had a diagnosis of symptomatic uterine fibroids with an active treatment plan.

INTERVENTIONS

Semistructured video interviews were conducted with female patients undergoing treatment for symptomatic uterine fibroids (n = 20). Women were recruited from the outpatient Center for Complex Gynecology in Chicago, IL. Interviews were recorded and transcribed verbatim. A codebook was developed based on the interview transcripts, and the finalized coding was used to conduct a thematic analysis.

MEASUREMENTS AND MAIN RESULTS

Four distinct themes emerged from the interviews: (1) Social supports-including social media-play an important role in informing patients' treatment choices; (2) Patients spend significant energy seeking additional information beyond their obstetrician-gynecologist; (3) Patients prioritize receiving full and complete information from their provider; and (4) Patients experience information-related delays in receiving care.

CONCLUSION

Patients seeking care for symptomatic uterine fibroids have strong preferences about both the quality and extent of information they receive from their gynecologists. Physicians treating these conditions must adapt to changing informational desires and consider expanding physician engagement with patients' social media needs.

Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs

BACKGROUND

Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women's experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site.

METHODS

Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence.

RESULTS

Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women's specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose.

CONCLUSIONS

Findings demonstrate the ways in which gendered social and structural environments shape women's daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.

Maternity Care Deserts and Pregnancy-Associated Mortality in Louisiana

BACKGROUND

Maternal mortality is an issue of growing concern in the United States, where the incidence of death during pregnancy and postpartum seems to be increasing. The purpose of this analysis was to explore whether residing in a maternity care desert (defined as a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with risk of death during pregnancy and up to 1 year postpartum among women in Louisiana from 2016 to 2017.

METHODS

Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all pregnancy-associated deaths verified by the Louisiana Department of Health (n = 112 from 2016 to 2017) and geocoded live births occurring in Louisiana during the same time period (n = 101,484), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory spatial analysis to identify significant associations between place of residence and risk of death.

RESULTS

We found that the risk of death during pregnancy and up to 1 year postpartum owing to any cause (pregnancy-associated mortality) and in particular death owing to obstetric causes (pregnancy-related mortality) was significantly elevated among women residing in maternity care deserts compared with women in areas with greater access (adjusted risk ratio [aRR] for pregnancy-associated mortality, 1.91; 95% confidence interval [CI], 1.15-3.18; aRR for pregnancy-related mortality, 3.37; 95% CI, 1.71-6.65). A large racial inequity in risk persisted above and beyond differences in geographic access to maternity care (non-Hispanic Black vs. non-Hispanic White aRR for pregnancy-associated mortality, 2.22; 95% CI, 1.39-3.56; aRR for pregnancy-related mortality, 2.66; 95% CI, 1.16-6.12).

CONCLUSIONS

Ensuring access to maternity care may be an important step toward maternal mortality prevention, but may alone be insufficient for achieving maternal health equity.

Planned, unplanned and in-between: the meaning and context of pregnancy planning for young people

OBJECTIVE

To understand how young people conceptualize planned, unplanned and "in-between" pregnancies.

METHODS

We conducted individual qualitative interviews with 50 young (ages 18-24) women and their male partners (n=100) in the San Francisco Bay Area to investigate prospective pregnancy intentions. In this analysis, we focused on participants' conceptualization of planned and unplanned pregnancies, as well as a status in between planned and unplanned.

RESULTS

Conceptualizations of pregnancy planning were influenced by personal experiences and life circumstances, including previous unplanned pregnancies. While many participants held up planned pregnancies as an ideal, the majority of participants (n=71) also felt that a status in between planned and unplanned pregnancy existed. Many described this in-between stage occurring when someone is "not not trying" or would find an unplanned pregnancy acceptable. Notably, a few participants mentioned that pregnancy planning was not possible because either it was uncommon among their peers or they felt a general lack of control over pregnancy.

CONCLUSION

Our analysis suggests that binary operationalization of pregnancies as "planned" and "unplanned" neglects the complexity of young people's lived experiences and perspectives. Contraceptive counseling approaches that allow patients the flexibility to express their considerations and feelings toward a potential future pregnancy could improve the quality of family planning visits and patient-provider interactions.

IMPLICATIONS

The traditional binary conceptualization of pregnancies as planned and unplanned may not holistically capture the diverse perspectives of young people. Increased understanding of the complexities in young people's conceptualizion of pregnancy planning can inform family planning care that is inclusive, relevant and supportive of a variety of perspectives.

One Step for a Hospital, Ten Steps for Women: African American Women's Experiences in a Newly Accredited Baby-Friendly Hospital

BACKGROUND

Despite strides made by the Baby-Friendly Hospital Initiative to improve and normalize breastfeeding, considerable racial inequality persists in breastfeeding rates. Few studies have explored African American women's experience in a Baby-Friendly Hospital Initiative system to understand sources of this inequality. Research aim: This study aimed to explore African American women's experiences of the Ten Steps to Successful Breastfeeding at a women's center associated with a university-affiliated hospital that recently achieved Baby-Friendly status.

METHODS

Twenty African American women who had received perinatal care at the women's center and the hospital participated in qualitative interviews about their experiences. Data were organized using the framework method, a type of qualitative thematic analysis, and interpreted to find how African American women related to policies laid out by the Ten Steps to Successful Breastfeeding.

RESULTS

Three key themes emerged from the women's interviews: (a) An appreciation of long-term relationships with medical professionals is evident at the women's center; (b) considerable lactation problems exist postpartum, including lack of help from Baby-Friendly Hospital Initiative sources; and (c) mothers' beliefs about infant autonomy may be at odds with the Ten Steps to Successful Breastfeeding.

CONCLUSION

Hospitals with Baby-Friendly status should consider models of breastfeeding support that favor long-term healthcare relationships across the perinatal period and develop culturally sensitive approaches that support breastfeeding beliefs and behaviors found in the African American community.