Qualitative methodologies and community participation in examining reproductive experiences: the Harlem Birth Right Project

Road to Equity in Maternal and Child Health: Honoring the Past and Blazing New Paths

PURPOSE

This paper is a historical account of an initiative, as recalled by the authors who were directly involved, that brought to the forefront the long-standing and unjust reproductive health inequities in the United States. It is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health.

DESCRIPTION

This paper is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health. Part I recounts the history and achievements of a Centers for Disease for Control and Prevention initiative in the 1980-90's, led by the Prematurity Research Group in the Division of Reproductive Health, Pregnancy and Infant Health Branch. This initiative stimulated a paradigm shift in how we understand and address black infant mortality and the inequities in this outcome. Part II illustrates examples of some exemplary programmatic and policy legacies that stemmed either directly or indirectly from the Centers for Disease for Control and Prevention paradigm shift. Part III provides a discussion of how effectively the current practice in Maternal and Child Health applies this paradigm to address inequities and proposes a path for accelerating Title V agencies' progress toward birth equity.

ASSESSMENT

This CDC initiative was transformative in that it raised the visibility of African American researchers, moved the field from a focus on traditional epidemiologic risks such as personal health promotion and medical interventions, to include racism as a risk factor for inequitable birth outcomes. The paradigm examined the specific roles of historical and structural racism, and the racialized, contextualized, and temporal exposures that are unique to Black women's experiences in the United States.

CONCLUSION

The initiative radically changed the narratives about the underlying factors contributing to inequities in birth outcomes of Black women, altered the way we currently approach addressing inequities, and holds the keys for transforming practice to a more holistic and systematic approach to building sustained organizational structures in maternal and child health that accelerate the achievement of birth equity.

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.

Association of preconception paternal health and adverse maternal outcomes among healthy mothers

BACKGROUND

Maternal morbidity continues to be an issue of national and global concern. Paternal preconception health may play a significant role in pregnancy outcomes and has received less attention than maternal health.

OBJECTIVE

This study aimed to examine the association between preconception paternal health and the risk for adverse maternal outcomes among healthy mothers.

STUDY DESIGN

This was a retrospective analysis of live births from 2009 through 2016 to healthy women aged 20 to 45 years recorded in the IBM Marketscan research database. Infants were linked to paired mothers and fathers using family ID. Preconception paternal health was assessed using the number of metabolic syndrome component diagnoses and the most common individual chronic disease diagnoses (hypertension, diabetes mellitus, obesity, hyperlipidemia, chronic obstructive pulmonary disease, cancer, and depression). Women with metabolic syndrome components were excluded to avoid potential confounding of maternal and paternal factors. Adverse maternal outcomes that were assessed included (1) abnormal placentation including placenta accreta spectrum, placenta previa, and placental abruption; (2) preeclampsia with and without severe features including eclampsia; and (3) severe maternal morbidity, identified as any indicator from the Centers for Disease Control and Prevention Index of life-threatening complications at the time of delivery to 6 weeks postpartum. The trend between preconception paternal health and each maternal outcome was determined using the Cochran-Armitage Trend test. The independent association of paternal health with maternal outcomes was also determined using generalized estimating equations models, accounting for some mothers who contributed multiple births during the study period, and by adjusting for maternal age, paternal age, region of birth, year of birth, maternal smoking, and average number of outpatient visits per year.

RESULTS

Among 669,256 births to healthy mothers, there was a significant trend between all adverse maternal outcomes and worsening preconception paternal health defined either as the number of metabolic syndrome diagnoses or number of chronic disease diagnoses (P<.001; Cochran-Armitage Trend test). In the generalized estimating equations model, the odds for preeclampsia without severe features increased in a dose-dependent fashion and were 21% higher (95% confidence interval, 1.17-1.26) among women whose partners had ≥2 metabolic syndrome diagnoses than among women whose partners had no metabolic syndrome diagnosis. The odds for preeclampsia with severe features and eclampsia increased in a dose-dependent fashion and were 19% higher (95% confidence interval, 1.09-1.30) among women whose partners had ≥2 metabolic syndrome diagnoses than among women whose partners had no metabolic syndrome diagnosis. The odds for severe maternal morbidity were 9% higher (95% confidence interval, 1.002-1.19) among women whose partners had ≥2 metabolic syndrome diagnoses than among women whose partners had no metabolic syndrome diagnosis. The odds for abnormal placentation were similar between the groups (adjusted odds ratio, 0.96; 95% confidence interval, 0.89-1.03).

CONCLUSION

Among healthy mothers, we report that preconception paternal health is significantly associated with increased odds of preeclampsia with and without severe features and weakly associated with increased odds of severe maternal morbidity. These findings suggest that paternally derived factors may play significant roles in the development of adverse maternal outcomes in healthy women with a low a priori risk of obstetrical complications.

Longitudinal Associations Between Immigrant Ethnic Density, Neighborhood Processes, and Latino Immigrant Youth Depression

Depression rates rise in adolescence and the prevalence of depression is higher among Latino adolescents than other race/ethnic groups. Ethnic density among immigrant populations is associated with better health and mental health outcomes among adults, but little is known about its effects among adolescents or its mechanisms. This study examines the pathways by which immigrant density may affect mental health outcomes among Latino youth. Using data from the National Longitudinal Study of Adolescent Health (Add Health), we drew a sample of 2,678 Hispanic youth. Multivariate multilevel logistic regression analyses found that Latino immigrant density predicted lower odds of depression among both male and female immigrant but not non-immigrant Latino adolescents. No mediating effects of neighborhood efficacy, perceived safety or perceived contentment were observed in this study. Results reaffirm the need to further explore the mechanisms through which ethnic density exerts its salubrious effect on immigrant youth mental health.

Contextualizing racial disparities in preterm delivery: a rhetorical analysis of U.S. epidemiological research at the turn of the 21st century

Preterm delivery (PTD), defined as delivery prior to 37 weeks gestation, is a key contributor to persistent racial disparities in infant mortality in the United States. Five major funding initiatives were devoted to advancing PTD epidemiology during the 1990s and 2000s. By examining content and rhetorical features of 94 studies conducted under these initiatives, and published between 1993 and 2011, this paper considers how calls for more "contextual" approaches (focusing on social and environmental contexts) interacted with more "conventional" approaches (focusing on individual-level risk factors) to PTD epidemiology during this period. Contextual advocates initially emphasized complex biosocial reasoning to better connect social adversity with embodied outcomes. Yet responses by researchers invested in conventional approaches, as well as in studies published under new initiatives that explicitly claimed to incorporate contextual insights, often reframed this complex reasoning in biologically reductionist terms. Subsequent contextual advocates then focused on developing statistical methods to support research about social and environmental causes of PTD, and this strategy appears to have gained some traction with conventional researchers. These findings call for closer attention to language and power in both social scientific studies of epidemiological knowledge production, as well as among epidemiologists themselves.

"ARVs" as sickness and medicine: examining children's knowledge and experience in the HIV era in urban Zambia

Since the roll out of no cost antiretroviral drugs (ARVs) in health centers in Zambia in 2004, the number of Zambians receiving treatment has substantially increased. While research has addressed adult responses to ARVs in Zambia and elsewhere, there is little known about how children experience and respond to the presence of treatment in their communities and households. The increasing acknowledgment that children provide care and treatment support to people with HIV in their households demands a better understanding of children's knowledge of HIV and ARVs. To examine children's ARV knowledge, this article focuses on three children's workshops carried out with 38 children ages 8-12, who participated in a yearlong ethnographic study in 2007 and 2008. All children lived in a low-income and heavily HIV-affected residential area in Lusaka, and many children lived with parents or guardians who had HIV. Findings suggest that, when the children discussed ARVs, they made two intersecting points: (1) local conditions make living with HIV, even while on antiretroviral therapy (ART), difficult; and (2) children face particular challenges, concerns, and insecurities when caring for and living with the ill. Children's discussions about ARVs offer a deeper understanding of experiences of HIV and childhood in a disproportionately HIV-affected and low-resource area. Such insights might productively inform future programming and research aimed at assisting children and adults.

"We are always asked; 'where are you from?'": Chilean women's reflections in midlife about their health and influence of migration to Sweden

AIM

This study explored how Chilean immigrant women living in Sweden perceived and related their life situations and health status during midlife to their migration experiences.

METHOD

Three focus group discussions (FGDs) were performed with 21 middle-aged Chilean women (40-60 years) who had lived in Stockholm for at least 15-20 years. In-depth interviews were held with three key informants. A combination of manifest and latent content analysis was performed to structure and categorize the tape-recorded and transcribed data.

FINDINGS

Three main themes emerged from the data: (i) Chilean women's reflections about migration and resettlement; (ii) Health during midlife; perceptions of Chilean women living in Sweden; and (iii) Strategies to manage their lives and to gain social acceptance and position. The Chilean women reflected about the discrimination they had met in the Swedish society and within the health care system along with health changes they had had during midlife. They connected some of their health related problems to their hardships of migration. They also expressed confusion about the health care they had received in Sweden including conflicting and mistrusting relationship with some health care providers. Important for their way of coping with their own health seemed to be a recognition of their own space, level of independence, self-acceptance and awareness of power relationships.

CONCLUSION

The results illuminate the importance of awareness of influence of gender and socio-cultural aspects, power relationships and communication skills among health care providers on women's health. Complementary interventions to the biomedical paradigm are needed and should be addressed in Swedish health staff educational programmes as well as in clinical training.

Improving research, policy and practice to promote paternal involvement in pregnancy outcomes: the roles of obstetricians-gynecologists

PURPOSE OF REVIEW

To review current research, policy, and practice on paternal involvement in pregnancy outcomes and suggest recommendations to improve paternal involvement in pregnancy and childbirth.

RECENT FINDINGS

Although much has been written about fathers' influence on child health and development, little is known about the expectant father's role in pregnancy and childbirth. Recent studies have demonstrated the importance of paternal involvement during pregnancy, but more research is needed to identify specific contributions expectant fathers make and their impact on reducing infant mortality and associated risk factors during pregnancy and childbirth.

SUMMARY

Obstetricians-gynecologists can play a greater role in promoting research, policy and practice to improve paternal involvement in pregnancy and childbirth.

Community health needs assessment with precede-proceed model: a mixed methods study

Background

Community health services in China have developed over the last few decades. In order to use limited health resources more effectively, we conducted a community health needs assessment. This aimed to provide an understanding of the community's health problems and the range of potential factors affecting risk behaviours for the priority health problems.

Methods

We used the precede-proceed model for the needs assessment. Triangulation of data, methods and researchers were employed in data collection.

Results

Main findings include: cardiovascular diseases (CVDs) were identified as the priority health problems in the study communities; risk factors associated with CVDs included smoking, physical inactivity and unhealthy eating behaviours, particularly amongst male residents with low education level; factors negatively affecting behaviours were classified into predisposing factors (limited knowledge, beliefs and lack of perceived needs), enabling factors (limited access to health promotion activities, unawareness of health promotion, lack of work-site and school health promotion, absence of health promotion related policy) and reinforcing factors (culture). Policies and organization were not perfect; there were limited staff skilled in providing health promotion in the community.

Conclusion

CVDs were identified by the communities as priority health problems. Future health programs should focus on smoking, physical inactivity and unhealthy eating behaviours. Behaviour change strategies should take predisposing factors, enabling factors and reinforcing factors into consideration. Policies, organization and human resource need strengthening.

Voices from the battlefield: reports of the daily experiences of urban Black mothers

There are persistent disparities in maternal child health in the United States. In this study I used an ethnographic design to portray the everyday lives of 130 Black, low-income, urban mothers. The women described daily battles related to a lack of material and human resources. To deal with these challenges, they assumed the role of soldiers, developed new tactical maneuvers, trusted in God for justice, shared their resources with their comrades, took short-lived breaks when they were wounded in action, and used escape mechanisms. Public health interventions are needed to deal with infrastructural deficits and support the women's defenses.

Timing of fetal exposure to stress hormones: effects on newborn physical and neuromuscular maturation

The purpose of the study was to determine the specific periods during pregnancy in which human fetal exposure to stress hormones affects newborn physical and neuromuscular maturation. Blood was collected from 158 women at 15, 19, 25, and 31 weeks' gestation. Levels of placental corticotropin-releasing hormone (CRH) and maternal cortisol were determined from plasma. Newborns were evaluated with the New Ballard Maturation Score. Results indicated that increases in maternal cortisol at 15, 19, and 25 weeks and increases in placental CRH at 31 weeks were significantly associated with decreases in infant maturation among males (even after controlling for length of gestation). Results also suggested that increases in maternal cortisol at 31 weeks were associated with increases in infant maturation among females, although these results were not significant after controlling for length of gestation. Findings suggest that stress hormones have effects on human fetal neurodevelopment that are independent of birth outcome.

Gestational weight and dietary intake during pregnancy: perspectives of African American women

OBJECTIVES

This investigation explored the participants' perspective on weight, nutrition, and dietary habits during pregnancy. The data of interest were culled from a larger ethnographic research study designed to gather information and ideas about the socio-cultural, psychological, and behavioral influences on maternal health during pregnancy (N=63).

METHODS

My study focused on the six participants (including three teenagers) who delivered low birth weight and/or preterm babies and 13 participants aged<or=18 years (teenagers) who delivered normal weight babies. Data were analyzed utilizing qualitative methodology.

RESULTS

Four of the participants who delivered low birth/weight preterm infants reported weight related concerns during pregnancy. These included: weight loss, lack of weight gain, and exceeding their expected weight gain. Frequently, the nutrition knowledge was based on miseducation, misconceptions, and/or 'a grain of truth' i.e. folk beliefs. Support group members had an influential role on participants' dietary habits during pregnancy.

CONCLUSION

The next step appears to be more qualitative work, with health care providers, the Women Infants and Children Program (WIC) nutrition counselors, clinical dietetic professionals, and women who already have children, to explore strategies for improving diet quality as well as address the issue of inadequate and excessive weight gain during pregnancy.

The culture of pregnancy and infant care in African American women: an ethnographic study

In Hamilton County, Ohio, the infant mortality rate for African American infants in 2002 was 18.1 per 1,000 live births compared with 14.4 for the United States. It is essential to engage community residents and leaders in identifying the underlying cultural factors contributing to this disparity. The purpose of the study was to explore the cultural contexts of prenatal and infant care practices among African American women of childbearing age living in an urban community located in Hamilton County, Ohio. This was an ethnographic community-based participatory research study. Seven participants were recruited for the study. Family support from mothers and sisters in obtaining needed resources related to pregnancy and child care emerged as the central theme. A strong family-based social network was core to the culture of pregnancy and infant care for these women. Nurses should consider developing family-centered interventions to reduce disparity in infant health.

The benefits of participatory methodologies to develop effective community dialogue in the context of a microbicide trial feasibility study in Mwanza, Tanzania

Background

During a microbicide trial feasibility study among women at high-risk of HIV and sexually transmitted infections in Mwanza, northern Tanzania we used participatory research tools to facilitate open dialogue and partnership between researchers and study participants.

Methods

A community-based sexual and reproductive health service was established in ten city wards. Wards were divided into seventy-eight geographical clusters, representatives at cluster and ward level elected and a city-level Community Advisory Committee (CAC) with representatives from each ward established. Workshops and community meetings at ward and city-level were conducted to explore project-related concerns using tools adapted from participatory learning and action techniques such as listing, scoring, ranking, chapatti diagrams and pair-wise matrices.

Results

Key issues identified included beliefs that blood specimens were being sold for witchcraft purposes; worries about specula not being clean; inadequacy of transport allowances; and delays in reporting laboratory test results to participants. To date, the project has responded by inviting members of the CAC to visit the laboratory to observe how blood and genital specimens are prepared; demonstrated the use of the autoclave to community representatives; raised reimbursement levels; introduced HIV rapid testing in the clinic; and streamlined laboratory reporting procedures.

Conclusion

Participatory techniques were instrumental in promoting meaningful dialogue between the research team, study participants and community representatives in Mwanza, allowing researchers and community representatives to gain a shared understanding of project-related priority areas for intervention.

Studies of Rural Elderly Individuals: Merging Critical Ethnography with Community-Based Action Research

A model to help reduce health disparities in vulnerable populations is used in this study with Hispanic migrant farm workers in Colorado and multicultural rural older adults in southwestern New Mexico.

Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy

Compared with European Americans, African American infants experience disproportionately high rates of low birth weight and preterm delivery and are more than twice as likely to die during their 1st year of life. The authors examine 5 explanations for these differences in rates of adverse birth outcomes: (a) ethnic differences in health behaviors and socioeconomic status; (b) higher levels of stress in African American women; (c) greater susceptibility to stress in African Americans; (d) the impact of racism acting either as a contributor to stress or as a factor that exacerbates stress effects; and (e) ethnic differences in stress-related neuroendocrine, vascular, and immunological processes. The review of literature indicates that each explanation has some merit, although none is sufficient to explain ethnic disparities in adverse birth outcomes. There is a lack of studies examining the impact of such factors jointly and interactively. Recommendations and cautions for future research are offered.

Participatory action research in practice: a case study in addressing domestic violence in nine cultural communities

Participatory action research (PAR) is increasingly recognized as a viable approach to developing relationships with communities and working closely with them to address complex public health problems. In the case of domestic violence research, where ensuring the safety of women participants who are battered is paramount, participatory approaches to research that include advocates and women who are battered in research design, implementation, analysis, and dissemination are critical to successful and mutually beneficial projects. This article presents a case study of a PAR project that conducted formative qualitative research on domestic violence in nine ethnic and sexual minority communities. The article describes the specific ways in which a PAR approach was operationalized and discusses in detail how community participation shaped various stages of the research. Furthermore, specific actions that resulted from the research project are reported.

"We don't really have cause to discuss these things, they don't affect us": a collaborative model for developing culturally appropriate sexual health services with the Bangladeshi community of Tower Hamlets

OBJECTIVE

To identify barriers to accessing sexual health care among the Bangladeshi community of east London and to develop a model of community participation in service development.

METHODS

Qualitative study using one to one interviews with sexual health service users plus focus groups in community settings.

RESULTS

58 people participated in the study, 12 in individual interviews and the remainder in six focus groups. All were of Bangladeshi origin. Four main themes were reported as impacting on access to services; confidentiality concerns, relevance of services to the community, problems with discussing sexual issues, and problems with previous experiences of health promotion. Community values regarding sex outside of marriage were an important underlying factor in participants' responses. Existing sexual health services were seen as culturally insensitive by patients and community groups.

CONCLUSIONS

Community based health initiatives among hard to reach ethnic minority groups should use existing networks of statutory and non-statutory groups to benefit from local expertise and relationships. Steering groups composed of members of the local communities served by the clinic can usefully inform service development.

Practical suggestions for community interventions using participatory action research

Advanced practice nurses and nurse researchers with experience in clinical settings may encounter challenges in the initial development and implementation of community-based projects. Participatory action research methodology, a user-friendly framework for community-based research activities, provides a way for researchers and community members to work together to define a problem, take action, and evaluate their work. This article attempts to bridge the theory-implementation gap by describing background steps that researchers can use when conceptualizing and initiating a research project with community partners. Suggestions for initial steps and the planning and review cycles are presented, along with examples from the literature.

Factors associated with variations in parental social support in primary care pediatric settings

OBJECTIVE

To examine social support (SS) among parents across sociodemographically distinct pediatric outpatient settings.

METHODS

We conducted a cross-sectional, self-administered, anonymous parent survey in 3 primary care sites in a Midwestern metropolitan area: inner-city health center, urban group practice, and suburban group practice. Participants were parents of children aged 6 weeks to 36 months. The main outcome measure was overall SS as measured by a previously validated 10-item instrument. Multivariate linear regression modeling was used to examine sociodemographic and health factors associated with overall SS scores.

RESULTS

The study sample included 463 parents. The strongest sources of SS were a significant other or spouse and parent's parent or grandparent. The range for overall SS was 0 to 20, with a mean score of 12.1 (SD, +/-4.2). Parents with overall SS in the lowest quartile (n = 123) comprised 43% of parents at the inner-city health center compared with 23% of parents at the urban practice and 16% of parents at the suburban practice. In a multivariate model, factors associated with lower overall SS were race other than white or black, single or cohabiting marital status, poorer parental health, and parental depressive symptoms.

CONCLUSIONS

Although parental SS was lowest in the most socioeconomically disadvantaged community in this sample, parents in all 3 communities had widely varying levels of support. Providers may gain insights about parents at increased risk for low SS by asking about parents' own physical and mental health.

Racial and ethnic disparities in birth outcomes: a life-course perspective

BACKGROUND

In the United States, Black infants have significantly worse birth outcomes than do White infants. The cause of these persisting racial disparities remains unexplained. Most extant studies focus on differential exposures to protective and risk factors during pregnancy, such as current socioeconomic status, maternal risky behaviors, prenatal care, psychosocial stress, or perinatal infections. These risk factors during pregnancy, however, do not adequately account for the disparities.

METHODS

We conducted a literature review for longitudinal models of health disparities, and presented a synthesis of two leading models, using a life-course perspective. Traditional risk factors during pregnancy are then reexamined within their life-course context. We conclude with a discussion of the limitations and implications of the life-course perspective for future research, practice, and policy development.

RESULTS

Two leading longitudinal models of health disparities were identified and discussed. The early programming model posits that exposures in early life could influence future reproductive potential. The cumulative pathways model conceptualizes decline in reproductive health resulting from cumulative wear and tear to the body's allostatic systems. We propose a synthesis of these two models, using the life-course perspective. Disparities in birth outcomes are the consequences of differential developmental trajectories set forth by early life experiences and cumulative allostatic load over the life course.

CONCLUSIONS

Future research on racial disparities in birth outcomes needs to examine differential exposures to risk and protective factors not only during pregnancy, but over the life course of women. Eliminating disparities requires interventions and policy development that are more longitudinally and contextually integrated than currently prevail.

Eliminating disparities in perinatal outcomes--lessons learned

The disparity between blacks and whites in perinatal health ranges from a 2.3-fold excess risk among black women for preterm delivery and infant mortality to a 4-fold excess risk among black women for maternal mortality. To stimulate concerted public health action to address such racial and ethnic disparities in health, the national Healthy People objectives call for elimination of all health disparities by the year 2010. Eliminating health disparities requires a greater understanding of the factors that contribute to their development. This commentary summarizes the state of the science of reducing such disparities and proposes a framework for using the results of qualitative studies on the social context of pregnancy to understand, study, and address disparities in infant mortality and preterm delivery. Understanding the social context of African American women's lives can lead to an improved understanding of the etiology of preterm birth, and can help identify promising new interventions to reduce racial and ethnic disparities in preterm delivery.