Facilitators of prenatal care access in rural Appalachia

Prenatal care in US birth centers: Midwives' perceptions of contributors to birthing People's confidence in physiologic birth

OBJECTIVE

The purpose of this study was to describe US freestanding birth center models of prenatal care and to examine how the components of this care contribute to birthing people's confidence in their ability to have a physiologic birth.

DESIGN

This was a qualitative descriptive study utilizing semi-structured interviews with birth center midwives. Data were analyzed using thematic analysis, constant comparative method and consensus coding to ensure rigor.

SETTING AND PARTICIPANTS

Midwives from six urban and rural freestanding birth centers in a Midwestern US state were interviewed. Twelve birth center midwives participated.

FINDINGS

Six themes emerged: the birth center physical space and organization of care, dimensions of midwifery care within the birth center, continuity of care and seamless service, the empowered birthing person, physiologic birth as normative, and the hospital paradigm and US cultures of birth.

KEY CONCLUSIONS

We identified significant components of birth center models of prenatal care that midwives believe enhance birthing people's confidence for physiologic childbirth. These components may be considered for application to other settings and may improve perinatal care and outcomes.

Associations Between Surface Mining Airsheds and Birth Outcomes in Central Appalachia at Multiple Spatial Scales

A considerable body of research exists outlining ecological impacts of surface coal mining, but less work has explicitly focused on human health, and few studies have examined potential links between health and surface coal mining at fine spatial scales. In particular, relationships between individual birth outcomes and exposure to air contaminants from coal mining activities has received little attention. Central Appalachia (portions of Virginia, West Virginia, Kentucky, and Tennessee, USA), our study area, has a history of resource extraction, and epidemiologic research notes that the region experiences a greater level of adverse health outcomes compared to the rest of the country that are not fully explained by socioeconomic and behavioral factors. The purpose of this study is to examine associations between surface mining and birth outcomes at four spatial scales: individual, Census tract, county, and across county-sized grid cells. Notably, this study is among the first to examine these associations at the individual scale, providing a more direct measure of exposure and outcome. Airsheds were constructed for surface mines using an atmospheric trajectory model. We then implemented linear (birthweight) and logistic (preterm birth [PTB]) regression models to examine associations between airsheds and birth outcomes, which were geocoded to home address for individual analyses and then aggregated for areal unit analyses, while controlling for a number of demographic variables. This study found that surface mining airsheds are significantly associated with PTB and decreased birthweight at all four spatial scales, suggesting that surface coal mining activities impact birth outcomes via airborne contaminants.

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample's (n = 93) median SVI score [IQR] was 0.55 [0.25-0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88-0.98] compared with 0.38 [0.19-0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13-0.97), midwifery care (aOR 0.35, 95% CI 0.12-0.99), doula support (aOR 0.30, 95% CI 0.11-0.84), postpartum support groups (aOR 0.25, 95% CI 0.09-0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01-0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.

A Qualitative Study of US Women's Perspectives on Confidence for Physiologic Birth in the Birth Center Model of Prenatal Care

INTRODUCTION

The purpose of this study was to increase understanding of the components of the US birth center model of prenatal care and how the birth center prenatal care model contributes to birthing people's confidence for physiologic childbirth.

METHODS

This was a qualitative descriptive study using semistructured interviews with individuals who gave birth in freestanding birth centers. Birthing people were recruited from freestanding birth centers in a Midwestern US state and were between the ages of 18 and 42, were English-speaking, and had experienced a birth center birth within the previous 6 months. Interviews were transcribed and analyzed using Glaser's constant comparative method.

RESULTS

Twelve women who gave birth in birth centers, representing urban and rural settings, participated. Four core categories were identified encompassing the components of birth center prenatal care and how the birth center model contributes to women's confidence for physiologic birth: birth center culture and processes, midwifery model of care within the birth center, internal influences, and outside influences.

DISCUSSION

Women who gave birth in birth centers believed that the birth center culture and environment, the midwifery model of care in the birth center, internal influences including the belief that birth is a normal physiologic process, and outside influences including family support and positive birth stories contributed to their confidence for physiologic birth.

Reproductive-Age Women's Experience of Accessing Treatment for Opioid Use Disorder: "We Don't Do That Here"

PURPOSE

For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD.

METHODS

Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question "Please give an objective play-by-play of the description of what happened in this conversation."

FINDINGS

Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers.

CONCLUSIONS

Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia

OBJECTIVE

Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings.

DATA SOURCE

We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings.

DATA EXTRACTION

Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest.

DATA SYNTHESIS

Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework.

RESULTS

A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels.

CONCLUSIONS

Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

Perspectives on Barriers and Facilitators in Caring for Women with Gestational Diabetes in Rural Appalachia

PURPOSE

The purpose of this study was to explore perspectives of healthcare providers in rural Appalachia who care for pregnant women with gestational diabetes, including management facilitators and barriers.

STUDY DESIGN AND METHODS

Qualitative study with interviews and thematic analysis. Thematic analysis was conducted using the sort and sift method after inductive content analysis with open coding, identifying categories, and abstraction.

RESULTS

Twenty-one advanced practice nurses and 10 physicians participated in the study. Three themes were identified: rural healthcare challenges including limited resources and lack of adherence to recommendations, cultural influences including normalization of diabetes and food culture, and collaborative care including accessible resources and patient motivation.

CLINICAL IMPLICATIONS

The themes provide insight into the perceived barriers and facilitators of healthcare providers caring for women with gestational diabetes in rural Appalachia. Consistent, evidence-based communication with cultural consideration supports effective education and care of women with gestational diabetes. Healthcare providers' knowledge of local resources, accessible electronic medical records, and communication among the various team members enhance collaboration in diabetic management in the rural setting.

A Planning Checklist for Interprofessional Consultations for Women in Midwifery Care

Team-based, interprofessional models of maternity care can allow women to receive personalized care based on their health needs and personal preferences. However, involvement of multiple health care providers can fragment care and increase communication errors, which are a major cause of preventable maternal morbidity and mortality. In order to improve communication within one health system, a community-engaged approach was used to develop a planning checklist for the care of women who began care with midwives but developed risks for poor perinatal outcomes. The planning checklist was constructed using feedback from women, nurses, midwives, and physicians in one interprofessional, collaborative network. In feasibility testing during 50 collaborative visits, the planning checklist provided a prompt to generate a comprehensive plan for maternity care and elucidate the rationale for interventions to women and future health care providers. In interviews after implementation of the checklist within a new collaborative format of prenatal physician consultations, women were pleased with the information received, and nurses, midwives, and physicians were positive about improved communication. This tool, developed with stakeholder input, was easy to implement and qualitatively beneficial to satisfaction and health system function. This article details the creation, implementation, and qualitative evaluation of the planning checklist. The checklist is provided and can be modified to meet the needs of other health systems.

A Guide to Field Notes for Qualitative Research: Context and Conversation

Field notes are widely recommended in qualitative research as a means of documenting needed contextual information. With growing use of data sharing, secondary analysis, and metasynthesis, field notes ensure rich context persists beyond the original research team. However, while widely regarded as essential, there is not a guide to field note collection within the literature to guide researchers. Using the qualitative literature and previous research experience, we provide a concise guide to collection, incorporation, and dissemination of field notes. We provide a description of field note content for contextualization of an entire study as well as individual interviews and focus groups. In addition, we provide two "sketch note" guides, one for study context and one for individual interviews or focus groups for use in the field. Our guides are congruent with many qualitative and mixed methodologies and ensure contextual information is collected, stored, and disseminated as an essential component of ethical, rigorous qualitative research.