Racial disparities in birth care: Exploring the perceived role of African-American women providing midwifery care and birth support in the United States

Characterizing the utilization of doula support services among birthing people of color in the United States: a scoping review

BACKGROUND

Birthing people of color experience disproportionately higher rates of infant and maternal mortality during pregnancy and birth compared to their white counterparts. The utilization of doula support services may lead to improvements in the birthing experiences of birthing people of color. Yet, the research in this area is sparse. Thus, the purpose of this review is to characterize the research on doula utilization among birthing people of color, identify gaps in the field, and provide recommendations for future research.

METHODS

Utilizing PRISMA guidelines, we conducted a scoping review, searching PubMed, PsycINFO, CINAHL, and Google Scholar for peer-reviewed articles published between January 1, 2016, to July 3, 2022.

RESULTS

Twenty-five articles met inclusion criteria. We identified the three themes characterizing included studies: (1) how doulas support (HDS) their clients, (2) doula support outcomes (DSO), and (3) considerations for implementing doula support services (CIDS). Despite doulas being described as agents of empowerment, and providing social support, education, and advocacy, birthing people of color reported low utilization of doula support services and findings regarding their effectiveness in improving birthing outcomes were mixed.

CONCLUSIONS

While some studies suggest that doulas may offer important services to birthing people of color, doulas are largely under-utilized, with many birthing people reporting low knowledge of their potential roles during the pre- and post-partum periods. Moreover, few studies were designed to assess intervention effects, limiting our ability to draw firm conclusions. Birthing people of color are at elevated risk for maternal mortality. As such, interventions are needed to support this population and improve outcomes. Our review suggests that, while doulas have the potential to make important contributions to the birthing support team, they are underutilized, and intervention studies are needed to enable estimates of their true effectiveness.

Influence of the Physical Environment on Maternal Care for Culturally Diverse Women: A Narrative Review

OBJECTIVES

This narrative literature review aims to develop a framework that can be used to understand, study, and design maternal care environments that support the needs of women from diverse racial and ethnic groups.

BACKGROUND

Childbirth and the beginning of life hold particular significance across many cultures. People's cultural orientation and experiences influence their preferences within healthcare settings. Research suggests that culturally sensitive care can help improve the experiences and outcomes and reduce maternal health disparities for women from diverse cultures. At the same time, the physical environment of the birth setting influences the birthing experience and maternal outcomes such as the progression of labor, the use of interventions, and the type of birth.

METHODS

The review synthesizes articles from three categories: (a) physical environment of birthing facilities, (b) physical environment and culturally sensitive care, and (c) physical environment and culturally sensitive birthing facilities.

RESULTS

Fifty-five articles were identified as relevant to this review. The critical environmental design features identified in these articles were categorized into different spatial scales: community, facility, and room levels.

CONCLUSIONS

Most studies focus on maternal or culturally sensitive care settings outside the United States. Since the maternal care environment is an important aspect of their culturally sensitive care experience, further studies exploring the needs and perspectives of racially and ethnically diverse women within maternal care settings in the United States are necessary. Such research can help future healthcare designers contribute toward addressing the ongoing maternal health crisis within the country.

Measuring midwives' perceptions of their practice climate across racial-ethnic identities: An invariance analysis of the Midwifery Practice Climate Scale

Diversification of the midwifery workforce is key to addressing disparities in maternal health in the United States. Midwives who feel supported in their practice environments report less burnout and turnover; therefore, creating positive practice environments for midwives of color is an essential component of growing and retaining midwives of color in the workforce. The Midwifery Practice Climate Scale (MPCS) is a 10-item instrument developed through multiphase empirical analysis to measure midwives' practice environments, yet the MPCS had not been independently tested with midwives of color. We conducted invariance analyses to test whether latent means can be compared between midwives of color and non-Hispanic White samples. A step-up approach applied a series of increasingly stringent constraints to model estimations with multiple group confirmatory factor analyses with two pooled samples. A configural model was estimated as the basis of multiple group comparisons where all parameters were allowed to freely vary. Metric invariance was estimated by constraining item factor loadings to be equal. Scalar invariance was estimated by constraining intercepts of indicators to be equal. Each model was compared to the baseline model. The findings supported scalar invariance of MPCS across midwives of color and non-Hispanic White midwives, indicating that the MPCS is measuring the same intended construct across groups, and that differences in scores between these two groups reflect true group differences and are not related to measurement error. Additionally, in this sample, there was no statistically significant difference in perceptions of the practice environments across midwives of color and non-Hispanic White midwives (p > 0.05).

Racism is a motivator and a barrier for people of color aspiring to become midwives in the United States

OBJECTIVE

To understand motivators and barriers of aspiring midwives of color.

DATA SOURCES AND STUDY SETTING

Primary data were collected via a national online survey among people of color in the United States interested in pursuing midwifery education and careers between February 22 and May 2, 2021.

STUDY DESIGN

Cross-sectional survey consisted of 76 questions (75 closed-ended and 1 open-ended questions) including personal, familial, community, and societal motivators and barriers to pursuing midwifery.

DATA COLLECTION/EXTRACTION METHODS

We recruited respondents 18 years and older who identified as persons of color by posting the survey link on midwifery, childbirth, and reproductive justice listservs, social media platforms, and through emails to relevant midwifery and doula networks. We conducted descriptive and bivariate analyses by demographic characteristics and used exemplar quotes from the open-ended question to illustrate findings from the descriptive data.

PRINCIPAL FINDINGS

The strongest motivating factors for the 799 respondents were providing racially concordant care for community members (87.7 percent), reducing racial disparities in health (67.2 percent), and personal experiences related to midwifery care (55.4 percent) and health care more broadly (54.6 percent). Main barriers to entering midwifery were direct (58.2 percent) and related (27.5 to 52.8 percent) costs of midwifery education, and lack of racial concordance in midwifery education and the midwifery profession (31.5 percent) that may contribute to racially motivated exclusion of people of color. Financial and educational barriers were strongest among those with lower levels of income or education.

CONCLUSIONS

Structural and interpersonal racisms are both motivators and barriers for aspiring midwives of color. Expanding and diversifying the perinatal workforce by addressing the financial and educational barriers of aspiring midwives of color, such as providing funding and culturally-competent midwifery education, creating a robust pipeline, and opening more midwifery schools, is a matter of urgency to address the maternal health crisis.

"This work that we're doing is bigger than ourselves": A qualitative study with community-based birth doulas in the United States

CONTEXT

Community-based birth doulas support pregnant women, transgender men, and gender non-binary individuals during the perinatal period and provide essential services and expertise that address health inequities, often taking on additional roles to fill systemic gaps in perinatal care in the United States (US). Despite the benefits that community-based birth doulas provide, there is little research exploring the work-related conditions and stressors community-based doulas experience. To address this gap, we examined the work experiences, related stressors, and stress management strategies of individual community-based birth doulas.

METHODS

In this qualitative, descriptive study we conducted 18 interviews in March through June 2021 with individuals who self-identified as community-based doulas working in underserved communities in the US. We analyzed the interviews for themes, which we defined and finalized through team consensus.

RESULTS

The doulas reported engaging in specific strategies in their work to address perinatal inequities. They also described facing several work-related stressors, including witnessing discrimination against clients, experiencing discrimination in medical environments, and struggling with financial instability. To mitigate these stressors and job-related challenges, interviewees reported they relied on doula peer support and reconnected with their motivations for the work.

CONCLUSIONS

Community-based doulas provide essential services and expertise which address inequities and systemic gaps in perinatal care. However, as they work to improve perinatal health, doulas themselves are providing equity work amidst an inequitable system and with insufficient political or financial support. Increased compensation and systemic support which acknowledges the breadth of services provided is needed to strengthen and sustain this critical part of the perinatal workforce.

Preterm and low birthweight birth in the United States: Black midwives speak of causality, prevention, and healing

BACKGROUND

Low birthweight (LBW) and preterm birth (PTB) are more common among Black infants than white infants in the United States. Although multiple hypotheses have been proposed to explain elevated rates of PTB and LBW, the perspectives of Black midwives who serve Black communities are largely missing from the literature.

METHODS

Using semi-structured interviews and focus groups with a purposive sample of midwives (n = 29), we elicited midwives' perceptions of PTB and LBW causation, as well as insights on culturally congruent strategies for prevention. We used consensus coding and reciprocal ethnography to increase the rigor of our analyses.

RESULTS

Midwives identified three intersecting and predisposing root causes: (1) systemic racism; (2) the epigenetic legacy of enslavement; and (3) ongoing cultural loss. In response to these stressors, midwives recommended variants of two additional themes-(4) community building; and (5) culturally centered care-as essential to reversing mortality trends among Black babies.

DISCUSSION

Midwives' perspectives, which are supported by relevant literature, provide critical insights that should inform both research and policy aimed at promoting birth justice in the United States and beyond.

Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States

Purpose: Birth doulas support pregnant people during the perinatal period. Evidence of doulas' positive impacts on pregnancy and birth outcomes, particularly among underserved populations, supports expanding access. However, health workforce-related barriers challenge the development of robust doula services in the United States. This study examined the various approaches organizations have taken to train, recruit, and employ doulas as well as their perspectives on what system-level changes are needed to redress health inequities in underserved communities and expand access to birth doula services.

Methods: In addition to literature and policy reviews, we conducted 16 semistructured interviews from March to August 2020 with key informants from organizations involved in training, certifying, advocating for, and employing doulas, and informants involved in state policy making. We analyzed data using qualitative analysis software to identify cross-cutting themes.

Results: The landscape of organizations involved in doula training and certification is diverse. In discussing their training and curriculum, interviewees from large organizations and community-based organizations (CBOs) stressed the importance of incorporating a focus on structural racism in maternal health into training curricula. CBOs specifically offered three areas of systems-level change that can help equitably grow doula services: the importance of addressing structural racism, changing the balance of power in decision making and policy making, and a cautious approach to Medicaid reimbursement.

Conclusion: This study provides evidence of how doula organizations move the field toward better serving the specific needs of underserved populations. It recognizes the expertise of CBOs in developing policy to expand doula services to communities in need. The information from this study highlights the complexities of facilitating consistency across doula training and certification requirements and implementing a sustainable funding mechanism while also meeting communities' unique needs.

Midwives Mentoring Midwives: A Review of the Evidence and Best Practice Recommendations

Mentoring involves a reciprocal relationship between a more experienced person (mentor) who offers guidance and counsel to a less experienced person (mentee). Reported benefits of mentoring among students of varying health professions include skill acquisition, understanding of the professional role, acclimation to the culture of the health profession, and personal and professional development. Globally, the midwifery profession has a long-standing history of mentoring students and new graduate midwives. However, only one study has described a formal mentoring program within the US midwifery profession. Therefore, to inform best practice for both formal and informal mentoring programs, current mentoring programs are summarized and a state of the science review on mentoring within midwifery in the United States and internationally was conducted. Three types of mentoring relationships are discussed: (1) student to student (peer), (2) midwife to student, and (3) midwife to new graduate midwife. Effective models and recommended approaches for the development and expansion of mentoring are discussed, to sustain, diversify, and scale up the midwifery workforce. Personal attributes and action steps of effective mentors and mentees are provided.

A social history of racial disparities in breastfeeding in the United States

Over the past five decades in the United States, White women have breastfed at higher rates than Black women. While a small but growing body of social historical research has examined racial disparities in breastfeeding over time, empirical research, particularly quantitative research, has focused on single historical snapshots, unintentionally treating the persistent racial disparities in breastfeeding as a static phenomenon, rather than one with distinct social mechanisms at different points in time. Further, few studies on racial disparities in health deconstruct difference both within and across racial groups. But what if we thought about persistent racial disparities instead as discrete trends with distinct social mechanisms at different points in time? In a binary logistic regression of breastfeeding initiation rates from 1973 to 2015 using the National Survey of Family Growth (NSFG), I found that the persistent racial disparities were actually comprised of three distinct types of changing racial disparities: (1) increases in racial disparities that derive from improvements for Whites not captured by Blacks (1973-1982); (2) decreases in racial disparities that stem from improvements for Whites captured even more strongly by Blacks (1995-2006); and, (3) leveling off of racial disparities (2006-2015). Placing results of this quantitative analysis within the context of public policy and social movement history, I identify three distinct mechanisms that drive the different trends in racial disparities in breastfeeding. This paper contributes to the literature on motherhood, race, and health a more nuanced understanding of the social historical mechanisms that pattern breastfeeding, and more broadly, racial disparities in health.

Street-Race in Reproductive Health: A Qualitative Study of the Pregnancy and Birthing Experiences among Black and Afro-Latina Women in South Florida

OBJECTIVE

The lived-experience of race and racism among historically vulnerable populations needs critical examination in the United States' (US) maternal and reproductive healthcare system. This study aims to measure how street-race influences the experiences of pregnancy and birthing among Black and Afro-Latina women in the South Florida region. Street-race, in this study, focuses on the lived experiences of phenotype and colorism (as real consequences due to structural racism) imposed on women during clinical encounters.

METHODS

Twenty-five women who self-reported their racial and street-identity as Black and / or Afro-Latina were interviewed, utilizing the qualitative approaches of narrative medicine and phenomenology. Study participants also had to have at least one recent pregnancy or birth of a living child (< 24 months).

RESULTS

Adverse maternal mortality outcomes also do not tell the full story of what it means to be Black while giving birth in North America. The dominance of White-presenting Latinx individuals in South Florida (a seemingly "diverse" urban region) is also historical and persistent. These oppositional consequences at the clinical encounter, regarding street-race, further illustrate how White-dominance (via phenotype and skin color) are ever-present across US healthcare institutions serving pregnant women.

RELEVANCE

The lived experience of hegemonic racial hierarchies (e.g., Black and White), ongoingly contributes to the racialization of maternal and reproductive healthcare in the US, as more attention is needed to achieve health equity.

Creativity, Resilience and Resistance: Black Birthworkers' Responses to the COVID-19 Pandemic

This article documents the experiences of Black birthworkers supporting pregnant and birthing people and new mamas during the first six months of the COVID-19 pandemic. Building on the methodology and outcomes of Battling Over Birth-a Research Justice project by and for Black women about their experiences of pregnancy and childbirth-the authors utilized a "community-based sheltered-in-place research methodology" to collect the narratives of Black birthworkers, including doulas, certified nurse-midwives (CNMs), homebirth midwives, lactation consultants, community health workers and ob/gyns. The article examines the impact of restrictions put in place by hospitals and clinics, including inadequate or inconsistent care, mandatory testing, separation from newborns, and restrictions on attendance by birth support people, including doulas. Birthworkers shared the innovative approaches that they have devised to continue to offer care and the ways that they have expanded the care they offer to make sure the needs of Black birthing people and new parents are being met during this uncertain time. The article also explores the threats to health, safety, and financial security faced by Black birthworkers as a result of the pandemic, and the overt and subtle forms of racism they had to navigate. Finally, it documents the sources of strength that Black birthworkers have found to sustain them at the frontlines of a maternal health care system in crisis.

Building Strong Futures: The Feasibility of Using a Targeted Digital Media Campaign to Improve Knowledge About Pregnancy and Low Birthweight Among Black Women

Objective

Low birthweight is one of the main causes of poor health outcomes among newborns, with Black women having a disproportionately high prevalence. A digital intervention targeted Black women in Orange County, Florida with information on positive pregnancy-related knowledge and attitudes related to low birthweight. This paper reports on campaign methods for the first 2.5 years of implementation.

Methods

Campaign content was tailored toward Black women, around a reproductive empowerment lens. Content focused on emphasizing healthy pregnancy-related behaviors and creating positive representations of Black women throughout the various stages of pregnancy through both static images and a web series. Digital metrics gauged campaign engagement. Three cross-sectional online surveys conducted in the intervention county examined Black women’s pregnancy-related knowledge, attitudes, and behaviors.

Results

After two years of campaign implementation, social media accounts showed 1784 followers. While Facebook showed more average monthly impressions, Instagram showed more average monthly engagements. Survey results showed some increases in knowledge about prenatal care, weight gain, exercise, and the health impacts of low birthweight.

Conclusions for Practice

This study highlights the potential for a culturally-appropriate digital intervention to promote positive pregnancy outcomes among at-risk women. Digital interventions offer a potential way to achieve positive pregnancy-related behavior changes on a larger scale. This may be particularly important given that the COVID-19 pandemic may be changing the ways that pregnant women access information. Studies should examine the impact and feasibility of using culturally-appropriate digital interventions that directly address Black women and their specific experiences during pregnancy.

Nature and scope of certified nurse-midwifery practice: A workforce study

AIMS AND OBJECTIVES

To describe the nature and scope of nurse-midwifery practice in Texas and to determine legislative priorities and practice barriers.

BACKGROUND

Across the globe, midwives are the largest group of maternity care providers despite little known about midwifery practice. With a looming shortage of midwives, there is a pressing need to understand midwives' work environment and scope of practice.

DESIGN

Mixed methods research utilising prospective descriptive survey and interview.

METHODS

An online survey was administered to nurse-midwives practicing in the state of Texas (N = 449) with a subset (n = 10) telephone interviewed. Descriptive and inferential statistics and content analysis was performed.

RESULTS

The survey was completed by 141 midwives with eight interviewed. Most were older, Caucasian and held a master's degree. A majority worked full-time, were in clinical practice in larger urban areas and were employed by a hospital or physician group. Care was most commonly provided for Hispanic and White women; approximately a quarter could care for greater numbers of patients. Most did not clinically teach midwifery students. Physician practice agreements were believed unnecessary and prescriptive authority requirements restrictive. Legislative issues were typically followed through the professional organisation or social media sites; most felt a lack of competence to influence health policy decisions. While most were satisfied with current clinical practice, a majority planned a change in the next 3 to 5 years.

CONCLUSIONS

An ageing midwifery workforce, not representative of the race/ethnicity of the populations served, is underutilised with practice requirements that limit provision of services. Health policy changes are needed to ensure unrestricted practice.

RELEVANCE TO CLINICAL PRACTICE

Robust midwifery workforce data are needed as well as a midwifery board which tracks availability and accessibility of midwives. Educators should consider training models promoting long-term service in underserved areas, and development of skills crucial for impacting health policy change.