Listening to Women: Recommendations from Women of Color to Improve Experiences in Pregnancy and Birth Care

Racism and Postpartum Blood Pressure in a Multiethnic Prospective Cohort

BACKGROUND

Postpartum hypertension is a key factor in racial-ethnic inequities in maternal mortality. Emerging evidence suggests that experiences of racism, both structural and interpersonal, may contribute to disparities. We examined associations between gendered racial microaggressions (GRMs) during obstetric care with postpartum blood pressure (BP).

METHODS

We conducted a prospective postpartum cohort of 373 Asian, Black, and Hispanic people in New York City and Philadelphia. At delivery, we administered the GRM in obstetrics scale. We measured BP for 3 months using text-based monitoring. We estimated place-based structural racism with the Structural Racism Effect Index. We used mixed models to estimate associations between GRM and mean postpartum systolic BP and diastolic BP. We adjusted for race-ethnicity, education, body mass index, chronic hypertension (diagnosed at <20 weeks of gestation), age, and the Structural Racism Effect Index. We examined effect modification by hypertensive disorder of pregnancy and place-based structural racism.

RESULTS

A total of 4.6% of participants had chronic hypertension, 20.9% had pregnancy hypertension, and 13.4% had preeclampsia, comprising a hypertensive disorder of pregnancy subgroup (n=117). A total of 37.5% of participants experienced ≥1 GRM. Participants who experienced ≥1 GRM versus none had 1.88 mm Hg higher systolic BP from days 1 to 10 (95% CI, -0.19 to 3.95) and 2.19 mm Hg higher systolic BP from days 11 to 85 (95% CI, 0.17-4.22). Associations followed a similar pattern for diastolic BP and were stronger among the hypertensive disorder of pregnancy subgroup. Participants experiencing GRM and a high Structural Racism Effect Index had systolic BP 7.55 mm Hg (95% CI, 3.41-11.69) and diastolic BP 6.03 mm Hg (95% CI, 2.66-9.41) higher than those with neither.

CONCLUSIONS

Structural racism and interpersonal racism are associated with increased postpartum BP, potentially contributing to inequities in postpartum morbidity and mortality and lifecourse cardiovascular disease.

Women's Lives and Birth Experiences Are Important! Evaluation of Women's Perceptions of Respectful Maternal Care: The Mother-Friendly Hospital Difference

AIM

The aim of this study is to determine women's perceptions of respectful maternity care, the effect of giving birth in a mother-friendly hospital on this perception and other factors affecting this perception.

BACKGROUND

The philosophy of a mother-friendly hospital includes respectful maternity care. Few quantitative studies have been conducted in Turkey to assess the prevalence of respectful maternity care during childbirth and none have examined the difference between respectful maternity care in mother-friendly and nonmother-friendly hospitals.

METHODS

This descriptive and comparative study was conducted between December 2023 and September 2024 with 319 primiparous women who applied to the Obstetrics and Gynecology Outpatient Clinic of a mother-friendly and a nonmother-friendly hospital in Turkey for postpartum follow-up. The data were collected face-to-face using the Descriptive Characteristics Form and Women's Perception of Respectful Maternity Care Scale. For data analysis, χ2 and independent samples t test methods were used in SPSS 26 program.

RESULTS

In the study, a significant difference was obtained between the Perception of Respectful Maternity Care Scale scores of women according to the type of hospital where the birth was performed and the level of education (p < 0.05). The mean scale scores of women who gave birth in a mother-friendly hospital and whose educational level was secondary education and above were higher than other women (p < 0.05). There was no significant difference between the scale scores of women according to the variables of age, employment status, place of residence, number of pregnancies and the last pregnancy being planned (p > 0.05).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It was determined that women's perception of respectful maternity care was highly positive, and the factors affecting this perception were delivery in a mother-friendly hospital and educational level. The current study may contribute to the development of policies for the dissemination of mother-friendly practices and the provision of respectful birth services, and may also support efforts to improve the quality of care.

Patient-Provider Prenatal Nutrition Conversations Using a Human Factors Approach

OBJECTIVE

To examine patient-provider nutrition conversations at initial prenatal visits.

DESIGN

Convergent mixed methods observational study.

SETTING

Two large metropolitan clinics in the midwestern United States.

PARTICIPANTS

Sixteen providers and 20 racially diverse pregnant women.

METHODS

Guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, we observed and audio-recorded initial prenatal visits with obstetric providers. Patients completed post-visit surveys and interviews, and providers completed post-visit interviews. Finally, we sent a practice-wide electronic survey to all providers. We completed quantitative data analysis for descriptive statistics of observation and survey results. We completed qualitative thematic analysis of visit and interview transcripts and combined and categorized results into components of the SEIPS 2.0 model.

RESULTS

We identified multiple dynamic and interacting factors relevant to the work system and processes in the SEIPS 2.0 model in patient-provider conversations about nutrition. Although nutrition was covered in all visits, most conversations were provider-centered and covered basic, general recommendations related to a limited number of topics. Few individualized collaborative discussions that addressed contextual factors occurred.

CONCLUSION

Finding ways to incorporate and address contextual factors into patient-centered conversations about nutrition is vital to optimize the dietary habits of women, especially those from vulnerable populations. To do this, multidisciplinary teams that include nurse practitioners, nurses, obstetricians, and registered dietitians who can address the multiple social determinants of health that affect dietary choices are needed.

Respectful Maternity Care in the United States: A Scoping Review of the Research and Birthing People's Experiences

INTRODUCTION

Birthing people around the world experience mistreatment during labor and birth, contributing to adverse maternal health outcomes. The adoption of respectful maternity care (RMC) has been recommended to address this mistreatment and improve care quality. Most RMC and mistreatment research has been conducted internationally. The purpose of this scoping review was to (1) explore the extent of RMC research and (2) describe labor and birth experiences in the United States.

METHODS

Embase, Scopus, and CINAHL databases were searched for concepts relating to RMC and mistreatment. A total of 66 studies met review inclusion criteria. Two reviewers screened titles, abstracts, and full-text articles. Data were extracted and categorized using the Bohren et al typology of mistreatment. Summary statistics and narrative summaries were used to describe study characteristics and birthing people's experiences.

RESULTS

Most studies represented national or urban samples and Western or Northeastern US regions. Few were from the South, and only one represented rural participants specifically. Few studies represented the unique experiences of justice-involved birthing people, and none represented sexual and gender minorities or Indigenous people. Qualitative methods were predominant. The most common forms of mistreatment included (1) poor rapport between women and health care providers (88% of studies), (2) stigma and discrimination (79%), and (3) a failure to meet professional standards of care (73%).

DISCUSSION

The extent of mistreatment in the United States highlights the need for robust programs and policies targeting provision of RMC. Additional research is needed to better understand the experiences of additional minority communities and those living rural areas and in the Southern United States.

Beyond Tuskegee: A contemporary qualitative assessment of barriers to research participation among Black women

BACKGROUND

Health care inequities have partially contributed to the existing racial gaps in health. Despite having lower incidence rates of breast cancer, Black women have a 41% higher mortality rate than White women. Black individuals remain underrepresented in research. Diversity in research is paramount to the improvement of clinical care practices and subgroup-specific guidelines.

METHODS

Black women from various community venues across geographic regions of the United States were invited via email, online fliers, social media platforms, and word of mouth to participate in focus groups. Six online focus groups of six to 10 Black women aged 25-65 years (N = 38) with and without a history of cancer were conducted with an in-depth semistructured discussion guide.

RESULTS

Most participants were college educated (32 of 38; 84.2%), aged 50 years or older (31 of 38; 81.6%), and had an annual income of $50,000 or more (26 of 38; 68.4%). Several barriers to research participation were identified. They included a lack of empathy and respect in health care settings, apprehension regarding the sharing of personal information, mistrust of medical research, and logistical/technical barriers. Alternatively, building individual and community trust and communicating the value of conducting research beneficial to the Black community were viewed as facilitators to research participation.

CONCLUSIONS

Successful engagement of Black women in research requires the acknowledgment and consideration of the numerous barriers that affect their ability to participate. Black women are more inclined to participate in research when the research team is knowledgeable, has experience within their communities, and engages trusted community partners. Additionally, the research must be meaningful and impactful to future generations of Black women.

Institutional Delivery in the Philippines: Does a Minimum of 8 Antenatal Care Visits Matter?

OBJECTIVES

This cross-sectional study investigated the association between the utilization of 8 antenatal care (ANC) visits and delivery in a healthcare institution in the Philippines, using data from the 2022 National Demographic and Health Survey.

METHODS

A sample of women who had given birth within the past 3 years was selected for analysis (n=4452). The association between ANC utilization and institutional delivery was assessed using logistic regression models, covariates by relevant socio-demographic factors, and childbirth history.

RESULTS

We found that 97.2% of respondents who completed ANC opted for institutional delivery. A higher proportion of rural residents did not undergo institutional delivery than urban residents (12.9 vs. 6.9%). The group aged 20-24 years had the highest coverage (92.8%), and the group aged 40-44 years had the lowest. Higher education levels, employment, and greater wealth were associated with higher institutional delivery rates. Divorced or widowed mothers (85.1%) and grand multiparous mothers had lower rates than other groups. Multivariable logistic regression analysis showed a significant positive association between ANC utilization and institutional deliveries after adjusting for covariates (adjusted odds ratio, 2.486; 95% confidence interval, 2.485 to 2.487; p<0.001).

CONCLUSIONS

ANC visits were associated with deliveries in institutions in the Philippines. Policymakers should promote ANC by ensuring 8 World Health Organization-recommended visits, strengthening programs, conducting community outreach, addressing access barriers, and integrating maternal health services to increase institutional births and improve maternal and infant health.

REVIVE Is an Evidence-Based Approach for Nurses to Universally Apply Trauma-Informed Care in Maternity Settings

The principles of trauma-informed care-safety, compassion, collaboration, communication, autonomy, and empowerment-are also the domains most vulnerable to implicit bias and most cited in adverse outcomes in maternal health. Perinatal nurses can practice trauma-informed care universally and thereby foster and advance person-centered care for all individuals with respect to race, ethnicity, religion, or lived experiences. In this article, we present evidence-based nursing interventions, collectively called REVIVE, that are known to promote principles of trauma-informed care. Taken together, the REVIVE interventions may improve health outcomes and reduce disparities in maternal health outcomes because they are proactive nursing interventions independent of implicit bias. REVIVE is described here and intended for use by individual nurses or health care teams to implement and evaluate in different maternity settings.

Let this be a safe place: a qualitative study into midwifery care for forcibly displaced women in the Netherlands

BACKGROUND

Forcibly displaced women in the Netherlands face increased chances of perinatal mortality and other adverse pregnancy and childbirth outcomes compared to the resident country population, which has been linked to suboptimal care. This study was conducted to gain insights from the experiences of Dutch midwives to inform and enhance the provision of tailored and equitable care for forcibly displaced women.

METHODS

We conducted a qualitative study using semistructured interviews with community midwives who provide care for forcibly displaced women (asylum seekers and recognized refugees) in the Netherlands. Through thematic analysis, we identified the barriers midwives encounter in providing care and explored their strategies for navigating these barriers, aiming to inform recommendations that advance equitable care provision.

RESULTS

Interviews with eleven midwives revealed barriers across three thematic levels: (1) the interactional level, where barriers related to language and interpreters, cultural differences, and building trust impeded positive interactions between midwives and forcibly displaced women; (2) the organizational level, where barriers concerning relocations of asylum seekers, delays in accessing care, and interdisciplinary collaboration impeded optimal care; and (3) the contextual level, where barriers related to women's housing conditions, the resettlement process and the mental health of forcibly displaced women impeded midwives' to respond to clients' needs. These levels of barriers culminated in a core theme of imbalance between midwives' expanded responsibilities and the limited resources and strategies available to them in care for forcibly displaced women. This imbalance forced midwives into multiple roles, increased both the practical and emotional burden on them, and undermined their ability to provide optimal, equitable care.

CONCLUSIONS

To enhance the provision of equitable pregnancy and childbirth care for forcibly displaced women in the Netherlands, it is crucial to target the imbalance between the responsibilities that midwives bear and the resources available to them. This requires dismantling barriers at the interactional, organizational and contextual level of care through targeted policy interventions. Structural determinants that perpetuate the imbalance in midwives' work and restrict their scope of influence, such as restrictive migration policies that contribute to socioeconomic marginalization and poor housing conditions, need to be addressed. Ultimately, midwives themselves require more support and education to recognize and combat injustices in pregnancy and childbirth care for forcibly displaced women.

Social Support Is Protective Against the Effects of Discrimination on Parental Mental Health Outcomes

BACKGROUND

Discrimination, or unfair treatment based on individual characteristics such as gender, race, skin color, and or sexual orientation, is a pervasive social stressor that perpetuates health disparities by limiting social and economic opportunity and is associated with poor mental and physical health outcomes.

AIMS

The purpose of the present study is to (1) examine the association between maternal experiences of discrimination and paternal experiences of discrimination; (2) explore how discrimination relates to parental (maternal and paternal) stress and depressive symptoms; and (3) examine whether social support exerts protective effects.

METHODS

The sample was 2,510 mothers and 1,249 fathers from the Child Community Health Network study. Linear regression models were conducted to explore associations between maternal and paternal discrimination. In addition, mediation analyses were conducted to explore if social support functioned as a mediator between discrimination on parental stress and depressive symptoms.

RESULTS

Most mothers (40.3%) and fathers (50.7%) identified race as the predominant reason for discrimination. Experiencing discrimination was significantly related to stress and depressive symptoms for both parents, and all forms of social support mediated these relationships. Our findings suggest that social support can act as a protective factor against the negative association between discrimination and both stress and depressive symptoms.

CONCLUSIONS

These findings highlight the need to integrate social support into existing interventions and include fathers in mental health screenings in primary-care settings. Finally, we briefly describe the role of nurses and other allied health professionals in addressing discrimination in health care and health policy implications.

A Call for the Implementation of Physical Activity as a Vital Sign (PAVS) During Pregnancy

Despite decades of research and clinical insights on the importance of physical activity during pregnancy for maternal and infant health, over 75% of pregnant individuals do not meet general physical activity guidelines of 150 minutes of moderate-intensity physical each week. This may be due to several barriers that restrict engagement in physical activity during pregnancy. Without providing individualized facilitators to overcome these respective barriers, physical activity engagement during pregnancy may be severely limited and/or reduced. This literary review presents the challenges specific populations face and strategies to facilitate the inclusion of physical activity as a vital sign (PAVS) during pregnancy to assist individuals to engage in and maintain physical activity throughout pregnancy. Additionally, the Exercise is Medicine's global initiative's ability to assist in implementing PAVS during pregnancy is discussed. We conclude by defining recommendations for routine prenatal care to consider PAVS to aid pregnant individuals in meeting physical activity guidelines.

Societal Discrimination, Vigilance, and Patient-Provider Relationships Among Perinatal Women: A Mixed Methods Study

INTRODUCTION

In the United States, maternal mortality is high and patterned by race and socioeconomic status (SES). Patient-provider relationships and societal discrimination have been separately associated with poor maternal outcomes, but it is not clear how such mechanisms may be interrelated. Thus, the present study investigates how societal experiences of discrimination are associated with and manifest in patient-provider relationship quality among perinatal women.

METHODS

The study uses a mixed methods design with an explanatory-sequential approach. First, a path analysis using structural equation modeling of a cross-sectional representative survey of 244 perinatal women in Kalamazoo County, Michigan, was conducted. Second, a thematic qualitative analysis was conducted of focus groups composed of survey participants (n = 34).

RESULTS

In the quantitative analyses, race and SES were associated with experiences of societal discrimination in the expected directions (race: b, 1.87; SE, 0.58; P = .001; SES: b, 2.18; SE, 0.60; P < .001), discrimination positively predicted vigilant behaviors (b, 0.81; SE, 0.15; P < .001), and more vigilant behaviors predicted worse patient-provider relationship quality (b, 0.18; SE, 0.07; P < .001). In the qualitative findings, we found detailed accounts linking provider discrimination, vigilance, and patient-provider relationships among focus groups composed of only women of color (n = 9).

DISCUSSION

Overall, the quantitative analyses find support for the conceptual model showing race and SES are associated with societal discrimination, which is associated with vigilant behaviors and, in turn, quality of patient-provider relationships. The qualitative analyses provide preliminary evidence for how these pathways manifest in care settings and demonstrate the importance of establishing trust in patient-provider relationships, especially among women of color.

Listening to Black Women's Perspectives of Birth Centers and Midwifery Care: Advocacy, Protection, and Empowerment

INTRODUCTION

Black women in Texas experience high rates of adverse maternal outcomes that have been linked to health inequities and structural racism in the maternal care system. Birth centers and midwifery care are highlighted in the literature as contributing to improved perinatal care experiences and decreased adverse outcomes for Black women. However, compared with White women, Black women underuse birth centers and midwifery care. Black women's perceptions in Texas of birth center and midwifery care are underrepresented in research. Thus, this study aimed to highlight the views of Black women residing in Texas on birth centers and midwifery care to identify their needs and explore ways to increasing access to perinatal care.

METHODS

Semistructured interviews were conducted with 10 pregnant and postpartum Black women residing in Texas. Questions focused on the women's access, knowledge, and use of birth centers and midwifery care in the context of their lived maternal care experiences. Interview transcripts were reviewed and analyzed using inductive, qualitative content analysis.

RESULTS

The Black women interviewed all shared experiences of discrimination and bias while receiving obstetric care that affected their interest in and overall perceptions of birth center and midwifery care. Participants also discussed financial and institutional barriers that impacted their ease of access to birth center and midwifery care services. Additionally, participants highlighted the need for culturally sensitive and respectful perinatal health care.

DISCUSSION

The Black women interviewed in this study emphasized the prevalence of racism and discrimination in perinatal health care encounters, a reflection consistent with current literature. Black women also expressed a desire to use birth centers and midwifery care but identified the barriers in Texas that impede access. Study findings highlight the need to address barriers to promote equitable perinatal health care access for Black women.

Birth Experience Among Black Women in the United States: A Qualitative Meta-Synthesis

INTRODUCTION

There are striking disparities in perinatal health outcomes for Black women in the United States. Although the causes are multifactorial, research findings have increasingly identified social and structural determinants of health as contributors to perinatal disparities. Maltreatment during perinatal care, which is disproportionately experienced by Black women, may be one such contributor. Qualitative researchers have explored Black women's perinatal care experiences, but childbirth experience data has yet to be analyzed in-depth across studies. The aim of this meta-synthesis was to explore the birthing experience of Black women in the United States.

METHODS

PubMed, Embase, PsycINFO, and CINAHL databases were searched. Inclusion criteria were qualitative research studies that included birth experience data shared by self-identified Black or African American women who had given birth in the United States. Exclusion criteria were reports that did not include rich qualitative data or only included experience data that did not specify the race of the participant (eg, data pooled for women of color). The search began February 2022 and ended June 2022. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to appraise the research. Results were synthesized using content analysis.

RESULTS

Fifteen studies met inclusion criteria. Main themes included (1) trust: being known and seen; (2) how race influences care; (3) preserving autonomy; and (4) birth as trauma.

DISCUSSION

Fragmented care resulted in reports of poor birth experiences in several studies. Open communication and feeling known by perinatal care providers was influential in improving childbirth experiences among Black women; these themes are consistent with existing research. Further prospective research exploring relationships among these themes and perinatal outcomes is needed. Limitations of this report include the use of content analysis and meta-synthesis which may lose the granularity of the original reports; however, the aggregation of voices may provide valuable, transferable, actionable insight that can inform future supportive care interventions.

Health Equity and Perinatal Mental Health

PURPOSE OF REVIEW

Pregnancy and the postpartum period are vulnerable times to experience psychiatric symptoms. Our goal was to describe existing inequities in perinatal mental health, especially across populations, geography, and in the role of childbirth.

RECENT FINDINGS

People of color are at an increased risk for perinatal mental health difficulties and more likely to experience neglect, poor communication, and racial discrimination. LGBTQ + individuals encounter unique challenges, implicating the role of heteronormativity, cisnormativity, and gender dysphoria through pregnancy-related processes. Rural-dwelling women are significantly less likely to seek care, be screened for, or receive treatment for perinatal mental health conditions. Trauma-informed, comprehensive mental health support must be provided to all patients during pregnancy, childbirth, and the postpartum period, especially for racially and ethnically minoritized individuals that have often been omitted from care. Future research needs to prioritize inclusion of perinatal populations not well represented in the literature, including rural-dwelling individuals.

A Model for Engaging Citizen Scientists: A Community-Partnered Research Collaboration to Address Inequities for Black Birthing People

PURPOSE

Co-creation of a citizen-science research initiative with a collaborative team of community members and university-based scientists to address regional disparities in maternal and fetal health outcomes for Black birthing people.

DESCRIPTION

Citizen scientist-led projects, where community members actively contribute to each discovery step, from setting a research agenda to collecting data and disseminating results, can extend community participatory research initiatives and help reconceptualize traditional research processes. The Pregnancy Collaborative is a citizen-science research initiative and one of nine scientific committees of The Pittsburgh Study-a longitudinal, community-partnered study designed to bring together collaborators to improve child thriving.

ASSESSMENT

Ten community members and five university-based scientists participated during all phases of developing a citizen-scientist collaboration over an initial two-and-a-half-year period. Phases include forming the Pregnancy Collaborative and group research ethics training; co-creating a research agenda grounded in shared principles; and community-partnered data collection, analysis, and dissemination. These phases produced three key co-designed products: (1) a mission and vision statement of the Pregnancy Collaborative, (2) a Collaborative-endorsed research agenda, and (3) a citizen-scientist-executed research survey.

CONCLUSION

Lessons learned from the formation of the Pregnancy Collaborative highlight the importance of equitable power distribution through bidirectional knowledge sharing and by centering intellectual effort, lived experience, and tools and resources of those affected by health inequities. Using a citizen science approach to co-designing and executing research helps us move maternal health inequity work from "research on" to "research with."

A Scoping Review of Patient-Centered Perinatal Contraceptive Counseling

INTRODUCTION

Contraceptive counseling during the perinatal period is an important component of comprehensive perinatal care. We synthesized research about contraceptive counseling during the perinatal period, which has not previously been systematically compiled.

METHODS

We developed search criteria to identify articles listed in PubMed, Embase, and Popline databases published between 1992 and July 2022 that address patients' preferences for, and experiences of, perinatal contraceptive counseling, as well as health outcomes associated with this counseling. Search results were independently reviewed by multiple reviewers to assess relevance for the present review. Methods were conducted in accordance with PRISMA guidelines.

RESULTS

Thirty-four articles were included in the final full text review. Of the included articles, 10 included implementation and evaluation of a contraceptive counseling method or protocol, and 24 evaluated preferences for or experiences of existing contraceptive counseling in the perinatal period. Common themes included the acceptability of contraceptive counseling in the peripartum and postpartum periods, and a preference for contraceptive counseling at some point during the antenatal period and before the inpatient hospital experience, and direct provider-patient discussion instead of video or written material. Multiple studies suggest that timing, content, and modality should be individualized. In general, avoiding actual or perceived directiveness and providing multi-modal counseling that includes both written educational materials and patient-provider conversations was desired.

DISCUSSION

The perinatal period constitutes a critical opportunity to provide contraceptive counseling that can support pregnant and postpartum people's management of their reproductive futures. The reviewed studies highlight the importance of patient-centered approach to providing this care, including flexibility of timing, content, and modality to accommodate individual preferences.

Postpartum care for parent-infant dyads: A community midwifery model

INTRODUCTION

Postpartum health is in crisis in the United States, with rising pregnancy-related mortality and worsening racial inequities. The World Health Organization recommends four postpartum visits during the 6 weeks after childbirth, yet standard postpartum care in the United States is generally one visit 6 weeks after birth. We present community midwifery postpartum care in the United States as a model concordant with World Health Organization guidelines, describing this model of care and its potential to improve postpartum health for birthing people and babies.

METHODS

We conducted semi-structured interviews with 34 community midwives providing care in birth centers and home settings in Oregon and California. A multidisciplinary team analyzed data using reflexive thematic analysis.

RESULTS

A total of 24 participants were Certified Professional Midwives; 10 were certified nurse-midwives. A total of 14 midwives identified as people of color. Most spoke multiple languages. We describe six key elements of the community midwifery model of postpartum care: (1) multiple visits, including home visits; typically five to eight over six weeks postpartum; (2) care for the parent-infant dyad; (3) continuity of personalized care; (4) relationship-centered care; (5) planning and preparation for postpartum; and (6) focus on postpartum rest.

CONCLUSION

The community midwifery model of postpartum care is a guideline-concordant approach to caring for the parent-infant dyad and may address rising pregnancy-related morbidity and mortality in the United States.

Evaluating Prenatal Care Compliance and Barriers to Prenatal Care Among Pregnant Individuals in Forsyth County, North Carolina

Background

Individuals who gave birth from May 2021 through July 2021 at Atrium Health Wake Forest Baptist (AHWFB) Hospital were surveyed to identify barriers to prenatal care (PNC), assess adequacy of PNC, and examine how these measures relate to race, ethnicity, and income.

Methods

A survey was administered to 200 individuals giving birth at AHWFB. Eligibility included English- or Spanish-speaking, aged 18 years or older, and a gestational age of 35 weeks or greater at delivery. Primary outcomes included PNC receipt and PNC barriers. Stratification by race, ethnicity, and income were also evaluated.

Results

PNC receipt rates were 81%, 87%, and 88% in the first 28 weeks, between 28 and 36 weeks, and after 36 weeks, respectively, with 76% of individuals receiving adequate PNC throughout pregnancy. Non-White or Hispanic participants experienced lower PNC rates in the first 28 weeks, and participants reporting an annual household income of less than $20,000 experienced lower PNC rates throughout pregnancy. While 19% of participants reported at least one barrier to PNC, the number of barriers reported did not differ based on race, ethnicity, or income. However, it was found that participants who reported at least one barrier were less likely to receive PNC throughout pregnancy.

Limitations

This study was limited by convenience sampling and the potential for recall bias. Conclusions: Although race, ethnicity, and income were not associated with the number of reported barriers, they did impact the likelihood of receiving adequate PNC. As self-reported race/ethnicity in our study likely served as a proxy for racism and race-based discrimination, future research should more formally investigate the role of structural racism in the receipt of PNC.

Black Women's Maternal Health: Insights From Community Based Participatory Research in Newark, New Jersey

This study on Black women's maternal health engaged a group of six community members in a community based participatory research project in a state with one of the largest racial disparities in maternal mortality and severe maternal morbidity in the United States. The community members conducted 31 semi-structured interviews with other Black women who had given birth within the past 3 years to examine their experiences throughout the perinatal and post-partum period. Four main themes emerged: (1) challenges related to the structure of healthcare, including insurance gaps, long wait times, lack of co-location of services, and financial challenges for both insured and uninsured people; (2) negative experiences with healthcare providers, including dismissal of concerns, lack of listening, and missed opportunities for relationship building; (3) preference for racial concordance with providers and experiences with discrimination across multiple dimensions; and (4) mental health concerns and lack of social support. CBPR is a research methodology that could be more widely deployed to illuminate the experiences of community members in order to develop solutions to complex problems. The results indicate that Black women's maternal health will benefit from multi-level interventions with changes driven by insights from Black women.

Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections

BACKGROUND

Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections.

METHODS

We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits.

RESULTS

Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health.

CONCLUSION

Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.

Reframing the experience of childbirth: Black doula communication strategies and client responses during delivery hospitalization

Doulas, or birth coaches, are said to be "changing the world, one birth at a time." Black doulas have been suggested to mitigate against lack of representation in obstetric care, limited identity acknowledgement and accommodation, and obstetric racism. However, scientific inquiry into the specific communication strategies and messages used by Black doulas to advocate for clients was non-existent in extant literature. Guided by the Agency-Identity Model, we analyzed 20 diary-interviews of nine Black doulas who recently served Black clients. Specifically, we explored Black doulas' communication strategies and whether these strategies had an impact on client agency. We found that Black doulas prepare their clients for patient-provider interactions, including conversations about certain medical treatments and procedures and the risks for Black women and birthing people, the importance of informed consent, how to be heard, and how to resist neglect or abuse. We found that, in turn, most Black clients were able to enact agentic responses. We describe the specific doula messages, and contextualize our findings, considering how these collective interpersonal communication strategies of Black doulas, and their clients' agentic transformations, may index a sociopolitical movement to reframe the experience of childbirth in America.

Nursing student perceptions of racism and health disparities in the United States: A critical race theory perspective

BACKGROUND

Limited research has been done on nursing students' awareness of racial disparities and their readiness to address bias and racism in clinical practice.

PURPOSE

This study investigated nursing students' perceptions of how racial disparities affect health outcomes, including maternal outcomes, in the United States.

METHODS

Interpretive description was used and supported by the critical race theory as a framework to guide the data collection, analysis, and interpretation to understand participants' perceptions surrounding racism and health disparities.

DISCUSSION

Nurse educators should guide students to look beyond individual behavioral and risk factors and consider systemic issues as a leading contributors to health disparities.

CONCLUSION

The most critical finding was the lack of participants' understanding of systemic racism and its impact on health disparities. While they often attributed racial disparities to low socioeconomic status and lack of education, they did not understand the relationships between social determinants of health and systemic racism.

Birth Care Gaps in the Childbirth Options, Information, and Person-Centered Explanation (CHOICEs) Measure

PURPOSE

The objective of this study was to revise and improve the intrapartum items of the shared decision-making (SDM) measure, CH ildbirth O ptions, I nformation and person- C entered E xplanation (CHOICEs).

STUDY DESIGN AND METHODS

Methodological sequential triangulation was used to select a purposive sample of 29 people who gave birth in the United States between August 2019 and June 2021. A qualitative descriptive approach was used to analyze and interpret the data. We used an interview guide with questions related to the nine intrapartum items in CHOICEs to address the question: How did decision-making occur during your most recent birth?

RESULTS

Four major themes were identified: provider told me what to do ; communication about interventions during labor and birth ; preferences overlooked ; multiple team members . Under the theme of provider told me what to do , there was one sub-theme of induction of labor .

CLINICAL IMPLICATIONS

Participants noted lack of shared decision-making, poor communication, and obstetric violence. We found the need for perinatal providers to improve communication with birthing people on topics such as fetal monitoring, induction of labor, and multiple team members who may participate in their care. Revisions of CHOICEs will include seven new items to further address birth preferences, feeling heard, and multiple team members.

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

Healthcare Experiences of Black Patients During and After Pregnancy: a Needs Assessment for Provider Training to Improve Quality of Care

BACKGROUND

Black patients are at a higher risk of experiencing less safe and lower quality care during pregnancy and childbirth, compared to their White counterparts. Behaviors that healthcare professionals engage in that can facilitate or hinder high-quality care for this population are underexplored. We sought to explore Black patients' experiences with healthcare professionals during and after pregnancy, as a needs assessment to inform the development of training for healthcare professionals.

METHODS

We conducted semi-structured interviews of Black patients who were in their third trimester of pregnancy or within 18 months of giving birth. Questions focused on experiences with healthcare professionals during pregnancy-related healthcare, including quality of care and discrimination. Thematic analysis was conducted using a combined deductive-inductive approach. Findings were considered in the context of the Institute of Medicine's Six Domains of Quality (equitable, patient-centered, timely, safe, effective, efficient).

RESULTS

We interviewed 8 participants who received care from various clinics and institutions. Over half (62%) described experiencing discrimination or microaggressions during their pregnancy-related healthcare. Participants most commonly reflected upon experiences within the patient-centered care domain, regarding whether care was in alignment with their preferences, positive and negative interpersonal interactions, and varied experiences with patient education/shared decision-making.

CONCLUSIONS

Black patients commonly report experiencing discrimination from healthcare professionals during pregnancy-related healthcare. Reducing microaggressions and improving patient-centered care is a key focus for healthcare professionals who serve this group. Training needs include addressing implicit bias, educating on common microaggressions, improving communication, and promoting an inclusive workplace.

Midwives' experience of telehealth and remote care: a systematic mixed methods review

INTRODUCTION

Increasing the midwifery workforce has been identified as an evidence-based approach to decrease maternal mortality and reproductive health disparities worldwide. Concurrently, the profession of midwifery, as with all healthcare professions, has undergone a significant shift in practice with acceleration of telehealth use to expand access. We conducted a systematic literature review to identify and synthesize the existing evidence regarding how midwives experience, perceive and accept providing sexual and reproductive healthcare services at a distance with telehealth.

METHODS

Five databases were searched, PubMed, CINHAL, PsychInfo, Embase and the Web of Science, using search terms related to 'midwives', 'telehealth' and 'experience'. Peer-reviewed studies with quantitative, qualitative or mixed methods designs published in English were retrieved and screened. Studies meeting the inclusion criteria were subjected to full-text data extraction and appraisal of quality. Using a convergent approach, the findings were synthesized into major themes and subthemes.

RESULTS

After applying the inclusion/exclusion criteria, 10 articles on midwives' experience of telehealth were reviewed. The major themes that emerged were summarized as integrating telehealth into clinical practice; balancing increased connectivity; challenges with building relationships via telehealth; centring some patients while distancing others; and experiences of telehealth by age and professional experience.

CONCLUSIONS

Most current studies suggest that midwives' experience of telehealth is deeply intertwined with midwives' experience of the response to COVID-19 pandemic in general. More research is needed to understand how sustained use of telehealth or newer hybrid models of telehealth and in-person care are perceived by midwives.

The Birth Bundle Project: A Rainier Valley Midwifery-led Collaborative Care Initiative Offering Patients and Providers a Paradigm Shift to Impact Health Equity

Innovative midwifery-led collaborative care models have the potential to build on grassroots approaches to make transformative change within systems that work with families. Rainier Valley Midwives operates the Bundle Birth Project, a successful program that serves communities who are at higher risk for poor birth outcomes and face barriers to adequate medical, prenatal, and postpartum care, including Black, Indigenous, and persons of color. This project offers wraparound perinatal care services to provide a missing community of support to traditionally marginalized families before, during, and after birth while also bridging the gaps between midwives and physicians who attend births in different settings. By strengthening and formalizing the relationships between different types of perinatal providers including community-based doulas and lactation support professionals, this midwifery-led initiative improves the continuity and quality of care available to families including immigrant, refugee, and families of color in south Seattle, Washington.

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review

INTRODUCTION

Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication.

METHODS

We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations.

RESULTS

Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations.

DISCUSSION

Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

Obstetric Racism, Education, and Racial Concordance

ABSTRACT

The United States holds the distinction of being the developed country with the worst perinatal outcomes despite spending the most per capita on health care. Black women are three to four times more likely than White women to experience adverse birth outcomes. These outcomes persist despite access to prenatal care, insurance, and college education. A long overdue racial reckoning has arrived, beginning with acknowledging the fallacy of race-based medicine and the role of enduring systemic racism as foundational to obstetric racism in the reproductive lives of Black women. Centering voices of Black women and honoring their lived experiences are essential to providing respectful maternity care. Naming micro- and macroaggressions experienced by Black women allows for dismantling of systemic barriers which perpetuate inequitable outcomes and enable substandard care. Racial concordance (shared racial identity) is one tool to consider in creating safe health care spaces for Black women. Improving diversity of the nursing workforce specifically, and the health care workforce in general, is necessary to affect racial concordance. Application of skills in cultural humility can mitigate challenges associated with adverse patient encounters for Black women as diversity pipeline strategies are explored. Histories of foundational fallacy, their impact on care and outcomes, and patient-driven indicators for improving pregnancy care experiences for women of color are explored through the lens of a Black physician and the collective reproductive health workforce.

Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis: A Diverse Multicenter Cohort

BACKGROUND AND OBJECTIVES

Racial disparities exist in both neurologic and obstetric populations, underscoring the importance of evaluating pregnancy outcomes in diverse women with multiple sclerosis (MS). The objective of this multicenter retrospective study was to compare pregnancy care and outcomes between Black and Hispanic (underrepresented) and White women with MS.

METHODS

Demographic and clinical data were extracted from medical records of 9 US MS centers for women with MS/clinically isolated syndrome who delivered live births between 2010 and 2021. Sites identified at last 15 consecutive Black/Hispanic women and a matching number of White women. Socioeconomic factors, pregnancy, and MS care/outcomes were compared between groups (underrepresented and White and then Black and Hispanic) using Wilcoxon rank sum (U statistic and effect size r reported), χ2, t tests and logistic regressions as appropriate to data type. Multiple imputation by chained equation was used to account for missing data.

RESULTS

Overall, 294 pregnancies resulting in live births were analyzed ( 81 Black, 67 Hispanic, and 146 White mothers). Relative to underrepresented women, White women lived in areas of higher median (interquartile range [IQR]) Child Opportunity Index (79 [45.8] vs 22 [45.8], U = 3,824, r = 0.56, p < 0.0001) and were more often employed (84.9% vs 75%, odds ratio [OR] 2.57, CI 1.46-4.50, p = 0.0008) and privately insured (93.8% vs 56.8%, OR 11.6, CI 5.5-24.5, p < 0.0001) and more received a 14-week ultrasound (98.6% vs 93.9%, OR 4.66, CI 0.99-21.96, p = 0.027). Mode of delivery was significantly different between the three groups (X2(10,294) = 20.38, p = 0.03); notably, Black women had the highest rates of emergency cesarean deliveries, and Hispanic women highest rates of uncomplicated vaginal deliveries. Babies born to underrepresented women had lower median (IQR) birthweights than babies born to White women (3,198 g [435.3 g] vs 3,275 g [412.5 g], U = 9,255, r = 0.12, p = 0.04) and shorter median (IQR) breastfeeding duration (4.5 [3.3] vs 6.0 [4.2] months, U = 8,184, r = 0.21, p = 0.003). While underrepresented women were younger than White women (mean [SD] 30.9 [4.8] vs 33.8 [4.0], t = 1.97, CI 1.96-3.98, p < 0.0001), their median (Q1-Q3, IQR) Expanded Disability Status Scale was higher (1.5 [1-2.5, 1.5] vs 1 [0-1.5, 1.5], U = 7,260, r = 0.29, p < 0.0001) before pregnancy. Finally, medical records were missing more key data for Black women (19.7% missing vs 8.9% missing, OR 2.54, CI 1.25-5.06, p = 0.008).

DISCUSSION

In this geographically diverse multicenter cohort, underrepresented women entered pregnancy with higher disability and fewer health care resources. Pregnancy represents a pivotal window where structural factors affect maternal and fetal health and neurologic trajectories; it is a critical period to optimize care and health outcomes.

Experiences of breastfeeding peer counseling among women with low incomes in the US: a qualitative evaluation

BACKGROUND

Person-centered breastfeeding counseling is a key but often overlooked aspect of high-quality services. We explored women's experiences of the Breastfeeding Heritage and Pride™ program, an evidence-based breastfeeding peer counseling program serving women with low incomes in the United States.

METHODS

This study was conducted through an equitable community-clinical-academic partnership and guided by the World Health Organization (WHO) quality of care framework for maternal and newborn health, which highlights three domains of positive experiences of care: effective communication; respect and dignity; and emotional support. In-depth interviews were conducted with a purposive sample of women participating in the Breastfeeding Heritage and Pride™ program. Women were asked to describe their experiences with the program including examples of when good quality counseling was or was not provided. Each interview was conducted in English or Spanish, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Once themes were generated, they were organized according to the three care experience domains in the WHO quality of care framework.

RESULTS

Twenty-eight in-depth interviews were conducted with a racially/ethnically and socio-economically diverse sample of women. Three themes described effective communication practices of peer counselors: tailoring communication to meet women's individual needs; offering comprehensive and honest information about infant feeding; and being timely, proactive, and responsive in all communications across the maternity care continuum. Two themes captured why women felt respected. First, peer counselors were respectful in their interactions with women; they were courteous, patient, and non-judgmental and respected women's infant feeding decisions. Second, peer counselors showed genuine interest in the well-being of women and their families, beyond breastfeeding. The key theme related to emotional support explored ways in which peer counselors offered encouragement to women, namely by affirming women's efforts to breastfeed and by providing reassurance that alleviated their worries about breastfeeding. These positive experiences of counseling were appreciated by women.

CONCLUSIONS

Women described having and valuing positive experiences in their interactions with peer counselors. Efforts to expand access to high-quality, person-centered breastfeeding counseling should, as part of quality assurance, include women's feedback on their experiences of these services.

Rosie, a Health Education Question-and-Answer Chatbot for New Mothers: Randomized Pilot Study

BACKGROUND

Stark disparities exist in maternal and child outcomes and there is a need to provide timely and accurate health information.

OBJECTIVE

In this pilot study, we assessed the feasibility and acceptability of a health chatbot for new mothers of color.

METHODS

Rosie, a question-and-answer chatbot, was developed as a mobile app and is available to answer questions about pregnancy, parenting, and child development. From January 9, 2023, to February 9, 2023, participants were recruited using social media posts and through engagement with community organizations. Inclusion criteria included being aged ≥14 years, being a woman of color, and either being currently pregnant or having given birth within the past 6 months. Participants were randomly assigned to the Rosie treatment group (15/29, 52% received the Rosie app) or control group (14/29, 48% received a children's book each month) for 3 months. Those assigned to the treatment group could ask Rosie questions and receive an immediate response generated from Rosie's knowledgebase. Upon detection of a possible health emergency, Rosie sends emergency resources and relevant hotline information. In addition, a study staff member, who is a clinical social worker, reaches out to the participant within 24 hours to follow up. Preintervention and postintervention tests were completed to qualitatively and quantitatively evaluate Rosie and describe changes across key health outcomes, including postpartum depression and the frequency of emergency room visits. These measurements were used to inform the clinical trial's sample size calculations.

RESULTS

Of 41 individuals who were screened and eligible, 31 (76%) enrolled and 29 (71%) were retained in the study. More than 87% (13/15) of Rosie treatment group members reported using Rosie daily (5/15, 33%) or weekly (8/15, 53%) across the 3-month study period. Most users reported that Rosie was easy to use (14/15, 93%) and provided responses quickly (13/15, 87%). The remaining issues identified included crashing of the app (8/15, 53%), and users were not satisfied with some of Rosie's answers (12/15, 80%). Mothers in both the Rosie treatment group and control group experienced a decline in depression scores from pretest to posttest periods, but the decline was statistically significant only among treatment group mothers (P=.008). In addition, a low proportion of treatment group infants had emergency room visits (1/11, 9%) compared with control group members (3/13, 23%). Nonetheless, no between-group differences reached statistical significance at P<.05.

CONCLUSIONS

Rosie was found to be an acceptable, feasible, and appropriate intervention for ethnic and racial minority pregnant women and mothers of infants owing to the chatbot's ability to provide a personalized, flexible tool to increase the timeliness and accessibility of high-quality health information to individuals during a period of elevated health risks for the mother and child.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06053515; https://clinicaltrials.gov/study/NCT06053515.

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

"I was able to take it back": Seeking VBAC after experiencing dehumanizing maternity care in a primary cesarean

In this article, we present findings from a qualitative narrative analysis that examined the pregnancy, primary cesarean, and subsequent birth experiences of women in the United States. Using a maximal variation sampling strategy, we recruited participants via social media and networking to participate in semistructured interviews. Twenty-five women from diverse backgrounds and geographic locations across the U.S. participated, eight self-identified as racialized and seventeen as non-Hispanic, White. Data were analyzed iteratively using Clandinin and Connelly's approach to Narrative Inquiry. Across their narratives, participants described their experiences of maternity care that were either generally negative (dehumanizing care) or positive (humanized care). They further described how their experiences of dehumanizing or humanized care impacted their decision-making for subsequent births, mental health, relationships with the healthcare system, early parenting birth satisfaction, and family planning. Findings suggest that regardless of ultimate mode of birth, what was most important to women was how they are treated by their maternity care team. We suggest practice changes that may improve the experience of maternity care for primary cesarean and subsequent births, especially among those made marginal by systems of oppression.

Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates

BACKGROUND

Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate.

OBJECTIVE

This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity.

STUDY DESIGN

A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients.

RESULTS

Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity.

CONCLUSION

The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.

Psychometric assessment of the US person-centered prenatal and maternity care scales in a low-income predominantly Latinx population in California

OBJECTIVES

To assess psychometric properties of two scales developed to measure the quality of person-centered care during pregnancy and childbirth in the United States-the Person-Centered Prenatal Care (PCPC-US) and Person-Centered Maternity Care (PCMC-US) scales-in a low-income predominantly Latinx population in California.

METHODS

Data were collected from July 2020 to June 2023 from surveys of low-income pregnant and birthing people in Fresno, California, participating in the "Engaging Mothers and Babies; Reimagining Antenatal Care for Everyone" (EMBRACE) trial. Research staff administered the 26-item PCPC-US scale at 30-34 weeks' gestation (n = 315) and the 35-item PCMC-US scale at 10-14 weeks after birth (n = 286), using the language preferred by the participant (English or Spanish). We assessed construct, criterion, and known group validity and internal consistency of the scales.

RESULTS

78% of respondents identified as Latinx. Factor analysis identified one dominant factor for each scale that accounted for over 60% of the cumulative variance, with most items loading at > 0.3. The items also loaded adequately on sub-scales for "dignity and respect," "communication and autonomy," and "responsive and supportive care." Cronbach's alpha for the full scales were > 0.9 and between 0.70 and 0.87 for the sub-scales. Summative scores range from 0 to 100, with higher scores indicating higher person-centered care. Correlations with scores on scales measuring prenatal care quality and birth experience provided evidence for criterion validity, while associations with known predictors provided evidence for known-group validity.

CONCLUSIONS

The PCPC-US and PCMC-US scales, which were developed using a community-engaged process and found to have good psychometric properties in a largely high-income sample of Black women, were shown to also have good psychometric properties in a sample of low-income primarily Latinx women. Both scales provide valid and reliable tools to measure person-centered care experiences among minoritized communities to support efforts to reduce existing birth inequities.

Beyond Being Insured: Insurance Coverage Denial as a Major Barrier to Accessing Care During Pregnancy and Postpartum

This study investigates the association between insurance coverage denial and delays in care during pregnancy and postpartum. An online survey was administered in March and April 2022 to women who were either pregnant or within 1 year postpartum (n = 1,113). The outcome was delayed care, measured at four time points: during pregnancy and 1 week, 2 to 6 weeks, and after 7 weeks postpartum. The key covariate was insurance coverage denial by providers during pregnancy. Delayed care due to having an unaccepted insurance and being "out-of-network" was more pronounced at 1 week postpartum with 3.37 times and 3.47 times greater odds and in 2 to 6 weeks postpartum with 5.74 times and 2.97 times greater odds, respectively. The association between insurance denial and delays in care encapsulated transportation, rural residency, time issues, and financial constraints. The findings suggest that coverage denial is associated with significant delays in care, providing practical implications for effective perinatal care.

Recommendations to improve maternal health equity among Black women in "The South": A position paper from the SNRS minority health research interest & implementation group

Black women in the United States experience a higher maternal mortality rate compared to other racial groups. The maternal mortality rate among non-Hispanic Black women is 3.5 times that of non-Hispanic White women and is higher in the South compared to other regions. The majority of pregnancy-related deaths in Black women are deemed to be preventable. Healthy People 2030 directs healthcare providers to advance health equity through societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities. The Southern Nursing Research Society has put forward this position paper to provide recommendations to improve maternal health equity among Black women. Recommendations for nurses, multidisciplinary healthcare providers, policymakers, and researchers are discussed.

Vital Signs: Maternity Care Experiences - United States, April 2023

Introduction

Maternal deaths increased in the United States during 2018-2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths.

Methods

CDC analyzed data from the PN View Moms survey administered during April 24-30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care.

Results

Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider.

Conclusions and implications for public health practice

Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.

Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care

INTRODUCTION

A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams.

MATERIALS AND METHODS

Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes.

RESULTS

Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians.

CONCLUSIONS

The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.

Patient-provider communication quality as a predictor of medical mistrust among young Black women

The present study explores the association between patient-provider communication quality and medical mistrust in a sample of 174 young Black women, aged 18-24. Data were collected as part of a larger mixed-methods study examining sexual health communication and behaviors. Participants were recruited via non-probabilistic sampling methods between June 2018 and December 2018. Eligible respondents completed a self-administered online study that examined, among other components, healthcare experiences and medical mistrust. Hierarchical linear regression was used to explore the relationship between patient-provider communication quality and medical mistrust. Patient-provider communication quality was a significant predictor of medical mistrust; as communication quality increased, medical mistrust decreased (p < .001). Educational attainment also emerged as a significant predictor. Relative to not completing any college, completing some college was associated with lower medical mistrust (p= .031). Our findings suggest that for providers seeking to address medical mistrust in patients identifying as young Black women, focusing on patient-centered communication may be particularly impactful.

Lactation Experiences of Black Mothers Who Breastfed a Child Beyond Age One

Background: Although it is recommended that breastfeeding continues for at least 2 years, less than 30% of Black/African American children are still breastfed by their first birthday. This indicates the need to better understand the factors that affect continued and long-term (after 12 months of life) breastfeeding. The goal of this research was to hear from Black mothers who had long-term breastfeeding experiences to understand the barriers and facilitators of setting and reaching long-term breastfeeding goals. Materials and Methods: Participants were recruited through a variety of organizations serving breastfeeding mothers. Qualitative interviews were conducted through a secure, online meeting platform. Interviews were transcribed and analyzed using Qualitative Content Analysis. Participant demographics were collected and analyzed using descriptive statistics. Results: A total of 18 interviews were completed and six themes were identified: initiating breastfeeding, deciding to continue beyond 12 months, pressure to stop breastfeeding, support to continue breastfeeding, need for effective education and information about breastfeeding, and overall struggles. Discussion: This research provides insight for developing interventions to support optimal breastfeeding duration for Black families. Population-specific interventions must always be guided by the voices and experiences of members of that population. This research adds to existing knowledge by providing recommendations for health care providers and breastfeeding advocates based on experiences shared directly from Black breastfeeding mothers.

Acceptability of reproductive goals assessment in public mental health care

OBJECTIVE

To assess patient and provider perspectives on the acceptability of reproductive goals assessment in public mental health clinics and inform potential tailoring for these settings.

DATA SOURCES AND STUDY SETTING

Primary qualitative data from patients and providers at four clinics in an urban public mental health system serving individuals with chronic mental illness (collected November 2020-October 2021).

STUDY DESIGN

This was an exploratory qualitative study with patients (English-speaking women of reproductive age, primarily Black or Latina) and mental health providers (psychiatrists, psychotherapists, case managers, nurses). We examined the acceptability of reproductive goals assessment within mental health care and obtained feedback on two reproductive goals assessment conversation guides: PATH (Pregnancy Attitudes, Timing, and How Important is Pregnancy Prevention) and OKQ (One Key Question).

DATA COLLECTION

We conducted semi-structured telephone interviews with 22 patients and 36 providers. We used rapid qualitative analysis to summarize interview transcripts and identified themes using matrix analysis.

PRINCIPAL FINDINGS

Perceptions of reproductive goals assessment were generally positive. Providers said the conversation guides would "open the door" to important discussions, support a better understanding of patients' goals, and facilitate medication counseling and planning. A minority of patients expressed discomfort or ambivalence; several suggested providers ask permission or allow patients to raise the topic. Additional themes included the need for framing to provide context for these personal questions, the need to build rapport before asking them, and the challenge of balancing competing priorities. Many participants found both PATH and OKQ prompts acceptable; some preferred the "conversational" and "open-ended" PATH phrasing.

CONCLUSIONS

Participants perceived reproductive goals assessment as a promising practice in mental health care with unique functions in this setting. Areas of discomfort highlight the sensitivity of these topics for some women with chronic mental illness and suggest opportunities to tailor language, framing, and provider training to support effective and appropriate implementation.

Mitigating Misogynoir: Inclusive Professionalism as a Health Equity Strategy

As Obstetrics and Gynecology begins to recognize how structural racism drives inequitable health outcomes, it must also acknowledge the effects of structural racism on its workforce and culture. Black physicians comprise ~5% of the United States physician population. Unique adversities affect Black women physicians, particularly during residency training, and contribute to the lack of equitable workforce representation. Eliminating racialized inequities in clinical care requires addressing these concerns. By applying historical context to present-day realities and harms experienced by Black women (ie, misogynoir), Obstetrics and Gynecology can identify interventions, such as equity-focused recruitment and retention strategies, that transform the profession.

Antibias Efforts in United States Maternity Care: A Scoping Review of the Publicly Funded Health Equity Intervention Pipeline

Antibias training is increasingly identified as a strategy to reduce maternal health disparities. Evidence to guide this work is limited. We conducted a community-guided scoping review to characterize new antibias research. Four of 508 projects met our criteria: US-based, publicly funded, initiated from January 1, 2018 to June 30, 2022, and featuring an intervention to reduce bias or racism in maternal health care providers. Training was embedded in multicomponent interventions in 3 projects, limiting its evaluation as a stand-alone intervention. Major public funders have sponsored few projects to advance antibias training research in maternal health. More support is needed to develop a rigorous and scalable evidence base.

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.

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

Losing Connection: Experiences of Virtual Pregnancy and Postpartum Care During the COVID-19 Pandemic

INTRODUCTION

The rapid uptake of telehealth for perinatal care during the coronavirus disease-2019 (COVID-19) pandemic has led to mixed evidence as to its effectiveness, with limited research demonstrating satisfaction and appropriateness for communities at risk for poor birth outcomes. The purpose of this article is to describe the experiences of virtual care during pregnancy and postpartum among a diverse group of pregnant/birthing people in Washington State during the COVID-19 pandemic.

METHODS

We conducted a thematic analysis study exploring experiences of care during the COVID-19 pandemic for 15 pregnant and birthing people in Washington State. This secondary analysis utilized data specific to experiences receiving care via telehealth.

RESULTS

Three dominant themes were identified: loss of connection and relationships with providers; need for hands-on interactions for reassurance; and virtual care is good for some things but not all-desire for immediate, accessible care when appropriate. The majority of participants felt that it was subpar to in-person care due to a lack of connection and the inability to receive necessary tests and hands-on reassurance.

DISCUSSION/CONCLUSIONS

Our study findings encourage very judicious use of virtual care for communities that are at high risk for birth disparities to avoid impacting relationship building between patient and provider.