Health care experiences and birth outcomes: Results of an Aboriginal birth cohort

Trauma and Posttraumatic Stress Disorder as Important Risk Factors for Gestational Metabolic Dysfunction

Gestational metabolic diseases adversely impact the health of pregnant persons and their offspring. Pregnant persons of color are impacted disproportionately by gestational metabolic disease, highlighting the need to identify additional risk factors contributing to racial-ethnic pregnancy-related health disparities. Trauma exposure and posttraumatic stress disorder (PTSD) are associated with increased risk for cardiometabolic disorders in nonpregnant persons, making them important factors to consider when identifying contributors to gestational metabolic morbidity and mortality health disparities. Here, we review current literature investigating trauma exposure and posttraumatic stress disorder as psychosocial risk factors for gestational metabolic disorders, inclusive of gestational diabetes, low birth weight and fetal growth restriction, gestational hypertension, and preeclampsia. We also discuss the physiological mechanisms by which trauma and PTSD may contribute to gestational metabolic disorders. Ultimately, understanding the biological underpinnings of how trauma and PTSD, which disproportionately impact people of color, influence risk for gestational metabolic dysfunction is critical to developing therapeutic interventions that reduce complications arising from gestational metabolic disease. KEY POINTS: · Gestational metabolic diseases disproportionately impact the health of pregnant persons of color.. · Trauma and PTSD are associated with increased risk for cardiometabolic disorders in nonpregnant per.. · Trauma and PTSD impact physiological cardiometabolic mechanisms implicated in gestational metabolic..

Cohort profile: The Aboriginal Families Study - a prospective cohort of Aboriginal children and their mothers and caregivers in South Australia

PURPOSE

The Aboriginal Families Study is a prospective, intergenerational cohort study with well-established Aboriginal governance arrangements and community partnerships to support all research processes including data collection, interpretation and knowledge translation.

PARTICIPANTS

344 Aboriginal and Torres Strait Islander children born in South Australia between July 2011 and June 2013 and their mothers and other primary caregivers. Two waves of survey data collection have been undertaken: early in the first year postpartum and when the study children were aged 5-8 years. Children participated in direct developmental assessments of their cognitive, speech and language development at 5-8 years of age. Social and cultural determinants of health and well-being have been assessed at each wave of data collection.

FINDINGS TO DATE

Publications and policy briefs to date focus on social determinants of women's and children's physical and mental health; identifying gaps in access to pregnancy, postnatal, primary, specialist and allied healthcare; and evidence that Aboriginal-led services in South Australia have improved women's experiences and access to antenatal care.

FUTURE PLANS

Wave 3 follow-up is planned as the study children reach 14-16 years of age. Longitudinal follow-up of women and children in the cohort will generate new knowledge about factors promoting children and young people's social and emotional well-being. Our goal is to build a stronger understanding of the potential for key domains of social and emotional well-being (eg, connection to community, family and kin, country and spirituality) to buffer the impacts of social determinants of health, including intergenerational trauma and social inequity.

Self-determination in programmes of perinatal health for Aboriginal Communities: A systematic review

OBJECTIVE

The importance of self-determination in restoring the wellbeing of Australian First Nations peoples is becoming understood. For thousands of years, Aboriginal women gave birth on Country and Grandmothers' Lore and Women's Business facilitated the survival of the oldest living civilisations on earth. Following colonisation, however, Aboriginal and Torres Strait Islander practices of maternal and perinatal care were actively dismantled, and self-determination by Aboriginal people was destroyed. This had significant implications for the wellbeing of Aboriginal and Torres Strait Islander people and their Cultures and practices.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-based systematic review of research about programmes of birthing and perinatal health care for Australian Aboriginal and Torres Strait Islander women and their children was undertaken. The review's primary aim was to assess the Cultural context of programme development and delivery, its secondary aim was to assess the Cultural appropriateness of programme components. Electronic databases SCOPUS, PsycINFO, Medline, and CINAHL were searched for peer-reviewed studies published in English in Australia between 2000 and 2023.

RESULTS

Twenty-eight publications met inclusion criteria. Included studies were assessed for their methodological characteristics, birthing-support characteristics, perinatal care and continuity of care characteristics. Overall, programmes were limited in meeting the Cultural needs of women, children, and individual Communities. The role of Aboriginal Communities in identifying, delivering, and reviewing programmes was also limited.

CONCLUSIONS

Findings articulate the importance of self-determination in maintaining strong Indigenous Cultures and informing the Culturally appropriate development and delivery of Culturally safe programmes of perinatal care for Aboriginal women, children, and Communities.

IMPLICATIONS FOR PUBLIC HEALTH

Programmes and services for use by Aboriginal and Torres Strait Islander people must involve Aboriginal and Torres Strait Islander people and their Communities in processes of programme planning, delivery, and review. The evaluation of a programme or service as "Culturally safe" represents a determination that is most appropriately made by service users based on their experience of that programme or service.

A beautiful bush space on Country: Indigenous women's perspectives on the cultural significance of a placenta garden

BACKGROUND

Australian Aboriginal and Torres Strait Islanders, hereafter respectfully referred to as First Nations women, often experience maternity care incongruent with their cultural needs. To date, there is limited research on First Nations women's perceptions of the role that placental burial and a placenta garden may play in promoting connection to culture for women and their babies.

AIM

This study aimed to understand First Nations women's perceptions of placenta burial and a dedicated placenta garden in supporting connection to their culture.

METHODS

In this qualitative descriptive study, decolonising methods were used to recruit eight First Nations women using message stick sampling via First Nations mentors. Stories were told through yarns using a semi-structured yarning guide. Reflexive thematic analysis led to theme generation. Member-checking of preliminary themes by participants and endorsement by First Nations mentors occurred before finalisation of themes.

FINDINGS

Four themes captured the women's perspectives on the significance of placental burial and gardens. Recognising the Barriers explores factors impacting on culture and maternity care experiences. Enabling Continuity of Care describes a desire to work with a midwife towards a continuum throughout the perinatal period. Promoting Connection for Mum and Baby explores how the placenta garden can act as a conduit for connection. Finally, Creating Opportunity for Healing describes the essential healing that can be initiated through engaging in cultural placental burial.

CONCLUSION

First Nations women described placental burial as essential to strengthening their connection to culture and perceived that continuity of care with a culturally knowledgeable midwife facilitated connection.

Factors associated with negative birth experience in Peruvian Quechua-speaking indigenous women in a context of contagion due to COVID-19

OBJECTIVE

The aim of this study was to determine the factors associated with negative birth experience in Peruvian Quechua-speaking indigenous women in the context of contagion due to COVID-19.

METHODS

This was a cross-sectional study, with 142 women from the Olleros community (Huaraz-Peru, 3336 m a.s.l.), whose birth occurred between November 2020 and December 2021. Two questionnaires were applied between January and June 2022, prior voluntary informed consent and approval by an ethics committee. The SPSS program version 24 and the odds ratio (OR) were used with 95% confidence interval (CI).

RESULTS

A total of 62.7% of women (89/142) had a negative birth experience. The main factors associated were hospital and biosafety factors, highlighting the restriction to choose the position during birth (OR = 15.64, CI: 1.89-128.99, P = 0.001), care of women in a language other than Quechua (OR = 5.86, CI: 1.51-22.76, P = 0.005) and fear of health personnel when approaching women due to COVID-19 (OR = 10.61, CI: 3.94-28.56, P < 0.001).

CONCLUSION

Hospital and biosafety factors are associated with negative birth experience in Peruvian Quechua-speaking indigenous women, with less emphasis on sociodemographic and obstetric factors. The results found show that, in the case of this research, the negative birth experience is not only due to the restrictions imposed by COVID-19 pandemic, but also to the limited application of the intercultural approach in Peru, where the opinion of women is not taken into account. In this sense, intervention actions are required through health policies with an intercultural approach that involve the active participation of women.

Exploring satisfaction among women having a First Nations baby at one of three maternity hospitals offering culturally specific continuity of midwife care in Victoria, Australia: A cross-sectional survey

BACKGROUND

Continuity of midwife care is recommended to redress the inequitable perinatal outcomes experienced by Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however more evidence is needed about First Nations women's views and experiences of their care.

AIMS

This study aimed to explore levels of satisfaction among women having a First Nations baby, who received maternity care at one of three maternity services, where new culturally specific midwife continuity models had been recently implemented.

METHODS

Women having a First Nations baby who were booked for care at one of three study sites in Naarm (Melbourne), Victoria, were invited to complete one questionnaire during pregnancy and then a follow up questionnaire, 3 months after the birth.

RESULTS

Follow up questionnaires were completed by 213 women, of whom 186 had received continuity of midwife care. Most women rated their pregnancy (80 %) and labour and birth care (81 %) highly ('6 or '7' on a scale of 1-7). Women felt informed, that they had an active say in decisions, that their concerns were taken seriously, and that the midwives were kind, understanding and there when needed. Ratings of inpatient postnatal care were lower (62 %), than care at home (87 %).

CONCLUSIONS

Women having a First Nations baby at one of three maternity services, where culturally specific, continuity of midwife care models were implemented reported high levels of satisfaction with care. It is recommended that these programs are upscaled, implemented and sustained.

Trends and associations between maternal characteristics and infant birthweight among Indigenous and non-Indigenous people in Tasmania, Australia: a population-based study

OBJECTIVE

This study aimed to investigate the trends and associations of maternal characteristics and birthweight among Indigenous and non-Indigenous infants.

STUDY DESIGN

This was a retrospective population-based study.

METHODS

Fourteen years (2005-2018) of birthweight and perinatal health data of live-born singletons and their mothers obtained from the Tasmanian Data Linkage Unit were used to assess the trends and associations between maternal characteristics and infant birthweight using regression modelling.

RESULTS

Compared with non-Indigenous mothers (n = 76,750), Indigenous mothers (n = 3805) had a significantly higher prevalence of risk factors during the 14-year period. Although the prevalence of prepregnancy obesity and gestational diabetes mellitus (GDM) markedly increased in both groups, the rate of increase was higher (P < 0.001) for Indigenous than non-Indigenous mothers. Smoking, alcohol consumption and illegal drug use during pregnancy reduced over the years, and there was no significant difference in the rate of reduction between the groups. Large-for-gestational-age (LGA) births increased while small-for-gestational-age (SGA) births decreased in both groups over time. In addition, high birthweight (HBW) births decreased while low birthweight (LBW) births increased. The rates of increase in LGA and LBW births and the rates of decrease in SGA and HBW births were significantly higher in Indigenous mothers compared with non-Indigenous mothers (P < 0.001 for all). The association between Indigenous ethnicity and LBW and SGA births weakened after adjusting for other confounding maternal and perinatal variables. LBW and SGA were positively associated with Indigenous ethnicity, age <18 years, smoking, alcohol consumption and illegal drug use, pre-eclampsia, underweight prepregnancy body mass index and low socio-economic status. Women with higher parity, pre-existing diabetes and prepregnancy overweight or obesity were more likely to give birth to an infant with HBW or LGA.

CONCLUSIONS

The prevalence of risk factors for abnormal birthweight is higher among Tasmanian Indigenous mothers, contributing to a gap in birthweight outcomes between Indigenous and non-Indigenous infants. The dramatic increase in prepregnancy obesity and GDM in both groups highlight the importance of screening and management of GDM during pregnancy. Comprehensive programmes co-designed and co-managed in consultation with Indigenous people are needed to support healthy lifestyle choices among Indigenous women to address the barriers to individuals adopting behaviour change and to help close the health outcomes-related gap between Indigenous and non-Indigenous mothers and infants.

Racism, xenophobia, and discrimination: mapping pathways to health outcomes

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Perceived racism or racial discrimination and the risk of adverse obstetric outcomes: a systematic review

BACKGROUND

Racial disparities are differences among distinct subgroups of the human species; biologically, there are no scientifically proven reasons for them to exist.

OBJECTIVE

To assess the impact of racism or racial discrimination on obstetric outcomes.

DESIGN AND SETTING

Systematic review conducted at a tertiary/academic hospital.

METHODS

The Cochrane Library, SCOPUS/EMBASE, PubMed, Web of Science and ClinicalTrials.gov databases were searched from inception to June 2020. Studies presenting any type of racial discrimination, or any manifestation of racism that was perceived by women of any age in an obstetric scenario were included. Studies that only assessed racial disparities without including direct racism were excluded. The secondary outcomes evaluated included quality of antenatal care, intra and postpartum care, preterm birth and birthweight. The Risk of Bias In Non-randomized Studies - of Interventions (ROBINS-I) scale was used to assess the quality of evidence from non-randomized studies.

RESULTS

A total of 508 records were retrieved and 29 were selected for qualitative synthesis. No meta-analysis could be performed due to the high heterogeneity across studies. Perceived racism was associated as a risk factor in 7/10 studies focusing on pregnancy and postpartum maternal outcomes, five studies on preterm birth, one study on small for gestational age and two studies on low birthweight. Overall, among the 29 studies, the risk of bias was classified as moderate.

CONCLUSIONS

Perceived racism presented an association with poor obstetric outcomes. Anti-racist measures are needed in order to address the problems that are causing patients to perceive or experience racism.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO database, CRD42020194382.

Racial discrimination and adverse pregnancy outcomes: a systematic review and meta-analysis

Introduction

Racial discrimination has been consistently linked to various health outcomes and health disparities, including studies associating racial discrimination with patterns of racial disparities in adverse pregnancy outcomes. To expand our knowledge, this systematic review and meta-analysis assesses all available evidence on the association between self-reported racial discrimination and adverse pregnancy outcomes.

Methods

Eight electronic databases were searched without language or time restrictions, through January 2022. Data were extracted using a pre-piloted extraction tool. Quality assessment was conducted using the Newcastle–Ottawa Scale (NOS), and across all included studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects meta-analyses were performed on preterm birth and small for gestational age. Heterogenicity was assessed using Cochran’s χ² test and I² statistic.

Results

Of 13 597 retrieved records, 24 articles were included. Studies included cohort, case–control and cross-sectional designs and were predominantly conducted in the USA (n=20). Across all outcomes, significant positive associations (between experiencing racial discrimination and an adverse pregnancy event) and non-significant associations (trending towards positive) were reported, with no studies reporting significant negative associations. The overall pooled odds ratio (OR) for preterm birth was 1.40 (95% CI 1.17 to 1.68; 13 studies) and for small for gestational age it was 1.23 (95% CI 0.76 to 1.99; 3 studies). When excluding low-quality studies, the preterm birth OR attenuated to 1.31 (95% CI 1.08 to 1.59; 10 studies). Similar results were obtained across sensitivity and subgroup analyses, indicating a significant positive association.

Conclusion

These results suggest that racial discrimination has adverse impacts on pregnancy outcomes. This is supported by the broader literature on racial discrimination as a risk factor for adverse health outcomes. To further explore this association and underlying mechanisms, including mediating and moderating factors, higher quality evidence from large ethnographically diverse cohorts is needed.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

Longitudinal Follow Up of Early Career Midwives: Insights Related to Racism Show the Need for Increased Commitment to Cultural Safety in Aboriginal Maternity Care

Racism in health care undermines equitable service delivery, contributes to poorer health outcomes and has a detrimental effect on the Aboriginal workforce. In maternity care settings, Aboriginal women’s perceptions of discrimination are widespread, with the importance of cultural practices surrounding childbirth often not recognised. Efforts to build midwives’ cultural capabilities and address health disparities have seen Aboriginal content included in training programs but little is known about its application to clinical practice. This study reinterviewed midwives who had previously completed university midwifery training that aimed to increase understanding of Aboriginal people and cultural safety in health care. Participants were 14 non-Indigenous midwives and two Aboriginal midwives. Interviews explored the legacy of program initiatives on cultural capabilities and observations and experiences of racism in maternity care settings. Methods followed qualitative approaches for research rigour, with thematic analysis of transcribed interviews. Findings revealed the positive impact of well-designed content and placements, with non-Indigenous participants cognisant and responsive to casual racism but largely not recognising institutional racism. The Aboriginal midwives had experienced and were attuned to racism in all its guises and suggested initiatives to heighten awareness and dispel stereotypes. It is evident that greater attention must be paid to institutional racism in educational programs to increase its recognition and appropriate actions within health care settings.

Racial discrimination and allostatic load among First Nations Australians: a nationally representative cross-sectional study

BACKGROUND

Increased allostatic load is linked with racial discrimination exposure, providing a mechanism for the biological embedding of racism as a psychosocial stressor. We undertook an examination of how racial discrimination interacts with socioecological, environmental, and health conditions to affect multisystem dysregulation in a First Nations population.

METHODS

We conducted latent class analysis (LCA) using indicators of life stress, socioeconomic background, and physical and mental health from a nationally representative sample of Australian Aboriginal adults (N = 2056). We used LCA with distal outcomes to estimate the effect of the latent class variable on our derived allostatic load index and conducted a stratified analysis to test whether allostatic load varied based on exposure to racial discrimination across latent classes.

RESULTS

Our psychosocial, environmental, and health measures informed a four-class structure; 'Low risk', 'Challenged but healthy', 'Mental health risk' and 'Multiple challenges'. Mean allostatic load was highest in 'Multiple challenges' compared to all other classes, both in those exposed (4.5; 95% CI: 3.9, 5.0) and not exposed (3.9; 95% CI: 3.7, 4.2) to racial discrimination. Allostatic load was significantly higher for those with exposure to racial discrimination in the 'Multiple challenges' class (t = 1.74, p = .04) and significantly lower in the 'Mental health risk' class (t = - 1.67, p = .05).

CONCLUSIONS

Racial discrimination may not always modify physiological vulnerability to disease. Social and economic contexts must be considered when addressing the impact of racism, with a focus on individuals and sub-populations experiencing co-occurring life challenges.

Relational Decision-Making in the Context of Life-Limiting Fetal Anomalies: Two Cases of Anencephaly Diagnosis

Life-limiting fetal diagnoses such as anencephaly require families to make decisions in which no options offered will lead to the desired outcome of a healthy newborn. Although informed choice and shared decision-making are important aspects of ethics regarding care choices, they have limitations. In this article, 2 cases of anencephaly diagnosis are presented, and a relational decision-making model of care is proposed as an alternative for aiding pregnant people and their families in making challenging choices in the context of perinatal care.