Provider characteristics desired by African American women in prenatal care

Patient-Provider Satisfaction and Communication in U.S. Prenatal Care: A Systematic Review

INTRODUCTION

This is a systematic review on patient-provider satisfaction in U.S. prenatal care by addressing the following research question: What factors influence patient-provider satisfaction during prenatal care?

METHODS

Thirty six online databases were searched for peer-reviewed research from February to September of 2018 using 10 key terms published in English on U.S. populations between the years 1993-2018 on the topic of provider communication skills and patient satisfaction in the prenatal context. Searches yielded 2563 articles. After duplicates were reviewed and eligibility determined, 32 articles met criteria and were included in the final content analysis. All reported study variables were entered into EXCEL, data reported in each study were analyzed by two people for inter-rater reliability and included in the qualitative content analysis. Two researchers also utilized assessment tools to assess the quality of the articles.

RESULTS

Results indicate the importance of good patient-provider communication, that patients have a need for more information on a plethora of topics, and that Hispanic and African American women reported less satisfaction.

DISCUSSION

We recommend that future studies measure potentially significant themes not adequately present in the reviewed studies such as practitioner demographics (e.g. gender, years of experience, or race/ethnicity), mothers under 18 years of age, inclusion of religious minorities, patients with differing immigration statuses, and patients with disabilities.

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.

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.

Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period

Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.

Innovations and Opportunities in Care for Black Mothers and Birthing People

In recent years, there has been increased attention given to how racism fuels health inequities, including the inadequacy of prenatal care (PNC) that Black women and Black birthing people receive. This increase of attention has brought notable advancements in research, practice, and policy that intend to better understand and address these systemic inequities within the health care system. This review aims to provide an overview of promising developments in the study of Black mothers' and birthing people's experiences in PNC and delivery, to detail current research surrounding interventions to improve quality and mitigate bias in obstetric care, and to offer ways in which legislation can support such strategies targeting the root causes of inequities in care.

Provider Characteristics That Hinder Relationships with Black Women in the Perinatal Period

Black women have often reported challenges in their relationships with health care providers during the perinatal period. This study synthesized the findings of qualitative studies to describe health care providers' characteristics that hinder therapeutic relationships with Black women in the perinatal period. A systematic search was conducted and findings from 12 qualitative studies were synthesized using a thematic synthesis approach. Two overarching themes that included seven descriptive themes were discovered. The seven descriptive themes include the following: (1) provides differential treatment; (2) expresses biased attitudes; (3) lacks empathy; (4) limits choices; (5) communicates inadequate health information; (6) provides deficient care; and (7) dismisses concerns. Participants experienced challenged relationships with health care providers who held implicit biases and discouraged them from participating in their care. The findings suggest the importance of confronting implicit biases, promoting a bias-free health care system, and providing quality care that is respectful to Black women in the perinatal period.

Black women's experiences with professional accompaniment at prenatal appointments

U.S. public health statistics report dismal Black infant and maternal mortality rates. Prenatal care alone, while essential, does not reduce such disparities.

OBJECTIVES

The purpose of the study was to explore Black women's experiences when a perinatal support professional (PSP) accompanies them to prenatal medical appointments.

DESIGN

This research used a phenomenological approach, using data from in-depth individual interviews to explore the essence of 25 Black women's experiences.

RESULTS

We identified three major themes from the data that together, show that PSPs served as communication bridges for their clients. Clients said their PSPs helped them to understand and feel seen and heard by their medical providers during their prenatal appointments. The third theme was the deep level of trust the clients developed for their PSPs which made the first two themes possible. PSPs' intervention resulted in reduced stress and uncertainty in medical interactions and increased women's trust in their providers' recommendations.

CONCLUSIONS

Including a trusted, knowledgeable advocate like a PSP may be an important intervention in improving Black women's prenatal care experiences, reducing stress associated with medical interactions, and ultimately reducing pregnancy-related health disparities.

"Why Would I Talk To Them About Sex?": Exploring Patient-Provider Communication Among Black Women Experiencing Sexual Pain

Ineffective patient-provider communication poses a potential health risk to Black women if medical providers are not addressing their needs or concerns. Additionally, less than half of OBGYNs report asking their patients about sexual difficulties, which limits women's opportunities to disclose their experiences of sexual pain. The purpose of this qualitative study is to explore Black women's experiences of patient-provider communication about sexual pain (reoccurring unwanted genital pain). Specifically, we aimed to describe the pathway from sexual pain disclosure to treatment among N = 25 premenopausal Black women living in the southern United States who were experiencing sexual pain. Using constructivist grounded theory, open-ended responses to six interview questions related to healthcare experiences, treatment, and patient-provider communication were qualitatively analyzed and categorized to form a conceptual framework of patient-provider communication about sexual pain. Five key categories emerged related to Black women's experiences with their medical providers regarding sexual pain: (1) provider preferences, (2) healthcare experiences, (3) reasons for non-disclosure, (4) provider responses to sexual pain, and (5) treatment for sexual pain. Useful strategies to improve patient-provider communication are presented for both patients and providers.

Meanings Assigned by Primary Care Professionals to Male Prenatal Care: A Qualitative Study

Background:

Considering recent strategies used in prenatal care, the involvement of fathers has been considered an important factor in ensuring that pregnancy and delivery are successful.

Objective:

The aim of this study is to identify the meanings assigned by primary health care professionals to male prenatal care.

Methods:

This is a descriptive study with a qualitative approach. A total of 19 interviews were conducted with primary health care professionals registered in the City Health Department of Teresina, Piauí, Brazil. Data were collected through semi-structured interviews and analyzed according to the Collective Subject Discourse methodology.

Results:

Three themes emerged from the reports’ analysis: The importance of the role of fathers in the gestational process, attitudes of men toward male prenatal care and formal education and training in primary health care. Health practitioners understand the importance of male prenatal care but reported they lack proper training to provide effective care.

Conclusion:

The expansion of continuing education strategies focusing on male prenatal care and directed to primary health care professionals is recommended to promote greater adherence on the part of fathers in prenatal care, with the purpose of strengthening bonds and improving the care provided to the entire family. The humanized care can facilitate the approach of the paternal figure during male prenatal care.

The lived experience of severe maternal morbidity among Black women

Black women are 3-4 times more likely to die from a pregnancy-related complication and twice as likely to experience severe maternal morbidity when compared to white women in the United States. The risks for pregnancy-related maternal mortality are well documented, yet Black women's experiences of life-threatening morbidity are essentially absent in the nursing literature. The purpose of this interpretive phenomenological study was to understand the experiences of Black women who developed severe maternal morbidity. Face-to-face, one-to-one, in-depth conversational interviews were conducted with nine Black women who experienced life-threatening complications during childbirth or postpartum. Five essential themes emerged (1) I Only Know What I Know; (2) How You Cared for Me; (3) Race Matters; (4) Faced with Uncertainty; and (5) Still Healing. These themes illuminate the complexity of Black women's subjective interpretations of severe maternal morbidity, and reveal ways in which racism, not race, places Black women at risk for poor maternal health outcomes. The author envisions greater equity for Black mothers entrusted to nursing care, guided by nursing theories informed by these study findings.

Development of the person-centered prenatal care scale for people of color

BACKGROUND

Given the stark disparities in maternal mortality and adverse birth outcomes among Black, indigenous, and other people of color, there is a need to better understand and measure how individuals from these communities experience their care during pregnancy.

OBJECTIVE

This study aimed to develop and validate a tool that can be used to measure person-centered prenatal care that reflects the experiences of people of color.

STUDY DESIGN

We followed standard procedures for scale development-integrated with community-based participatory approaches-to adapt a person-centered maternity care scale that was initially developed and validated for intrapartum care in low-resource countries to reflect the needs and prenatal care experiences of people of color in the United States. The adaptation process included expert reviews with a Community Advisory Board, consisting of community members, community-based health workers, and social service providers from San Francisco, Oakland, and Fresno, to assess content validity. We conducted cognitive interviews with potential respondents to assess the clarity, appropriateness, and relevance of the questions, which were then refined and administered in an online survey to people in California who had given birth in the past year. Data from 293 respondents (84% of whom identified as Black) who received prenatal care were used in psychometric analysis to assess construct and criterion validity and reliability.

RESULTS

Exploratory factor analysis yielded 3 factors with eigenvalues of >1, but with 1 dominant factor. A 34-item version of the person-centered prenatal care scale was developed based on factor analyses and recommendations from the Community Advisory Board. We also developed a 26-item version using stricter criteria for relevance, factor loadings, and uniqueness. Items were grouped into 3 conceptual domains representing subscales for "dignity and respect," "communication and autonomy," and "responsive and supportive care." The Cronbach alphas for the 34-item and the 26-item versions and for the subscales were >0.8. Scores based on the sum of responses for the 2 person-centered prenatal care scale versions and all subscales were standardized to range from 0 to 100, where higher scores indicate more person-centered prenatal care. These scores were correlated with global measures of prenatal care satisfaction suggesting good criterion validity.

CONCLUSION

We present 2 versions of the person-centered prenatal care scale: a 34-item and a 26-item version. Both versions have high validity and reliability in a sample made up predominantly of Black women. This scale will facilitate measurement to improve person-centered prenatal care for people of color and could contribute to reducing disparities in birth outcomes. The similarity with the original scale also suggests that the person-centered prenatal care may be applicable across different contexts. However, validation with more diverse samples in additional settings is needed.

"I fought my entire way": Experiences of declining maternity care services in British Columbia

BACKGROUND

The 2016 WHO Standards for improving quality of maternal and newborn care in health facilities established patient experience of care as a core indicator of quality. Global health experts have described loss of autonomy and disrespect as mistreatment. Risk of disrespect and abuse is higher when patient and care provider opinions differ, but little is known about service users experiences when declining aspects of their maternity care.

METHODS

To address this gap, we present a qualitative content analysis of 1540 written accounts from 892 service users declining or refusing care options throughout childbearing with a large, geographically representative sample (2900) of childbearing women in British Columbia who participated in an online survey with open-ended questions eliciting care experiences.

FINDINGS

Four themes are presented: 1) Contentious interactions: "I fought my entire way", describing interactions as fraught with tension and recounting stories of "fighting" for the right to refuse a procedure/intervention; 2) Knowledge as control or as power: "like I was a dim girl", both for providers as keepers of medical knowledge and for clients when they felt knowledgeable about procedures/interventions; 3) Morbid threats: "do you want your baby to die?", coercion or extreme pressure from providers when clients declined interventions; 4) Compliance as valued: "to be a 'good client'", recounting compliance or obedience to medical staff recommendations as valuable social capital but suppressing desire to ask questions or decline care.

CONCLUSION

We conclude that in situations where a pregnant person declines recommended treatment, or requests treatment that a care provider does not support, tension and strife may ensue. These situations deprioritize and decenter a woman's autonomy and preferences, leading care providers and the culture of care away from the principles of respect and person-centred care.

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

INTRODUCTION

Women of color are at increased risk for poor birth outcomes, often driven by upstream social determinants and socially structured systems. Given the increasing rate of maternal mortality in the United States, particularly for women of color, there is a pressing need to find solutions to improving care quality and access for racially marginalized communities. This study aims to describe and thematically analyze the recommendations to improve pregnancy and birth care made by women of color with lived experience of perinatal health care.

METHODS

Twenty-two women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit organization participated in semistructured interviews about their experiences receiving health care during pregnancy and birth. Interviews were audio-recorded and transcribed, and transcripts were analyzed using thematic analysis to highlight recommendations for improving perinatal care experiences.

RESULTS

Participants shared experiences and provided recommendations for improving care at the individual health care provider level, including spending quality time, relationship building and making meaningful connections, individualized person-centered care, and partnership in decision making. At the health systems level, recommendations included continuity of care, racial concordance with providers, supportive health care system structures to meet the needs of women of color, and implicit bias trainings and education to reduce judgment, stereotyping, and discrimination.

DISCUSSION

Participants in this study shared practical ways that health care providers and systems can improve pregnancy and birth care experiences for women of color. In addition to the actions needed to address the recommendations, health care providers and systems need to listen more closely to women of color as experts on their experiences in order to create effective change. Community-centered research, driven by and for women of color, is essential to improve health disparities during pregnancy and birth.

South Asian patients' perceptions and experiences of compassion in healthcare

Background: South Asians are one of the fastest growing ethnic populations in Western countries. Accordingly, providing culturally sensitive healthcare to South Asians is becoming increasingly important. Compassion is a key component of quality healthcare and is central to bridging ethnic and cultural differences between patients and their healthcare providers (HCP).Objective: We aimed to identify and describe the perspectives, experiences, importance, and impact of compassion among South Asian patients.Methods: Straussian grounded theory was used to examine the perspectives of South Asians patients who had recent experience(s) with the Canadian healthcare system. A convenience sample of 19 South Asian participants underwent semi-structured audio-recorded interviews in either English, Hindi, or Punjabi. Transcribed interview data were analyzed using constant comparison.Results: Three categories were generated from the data: (1) South Asians' understandings of compassion, (2) HCPs' cultural sensitivity as an indicator of compassion, and (3) enhancing compassion: importance and patient recommendations for overcoming barriers to compassion. The first category included themes exploring South Asian patients' perspectives of compassion. The second category was divided into themes which examined how delivery and receipt of compassion can be influenced by ethnic and cultural differences between patients and HCPs. The third category consisted of themes highlighting participants' views on the importance of compassion, recommendations for overcoming language and cultural barriers to providing compassion, and the role of compassion in bridging language, culture and ethnic differences between patients and HCPs.Conclusion: Compassion was described as a universal concept that is interpreted through the cultural and ethnic background of the recipient and provider in the way it is perceived, enacted, and received. This information can aid HCP to modulate compassion to South Asian patients and may provide a foundation for future studies on compassion within other cultural groups.

A Novel Model for a Free Clinic for Prenatal and Infant Care in Detroit

PURPOSE

Detroit experiences the highest preterm birth rate and some of the worst birth outcomes in the country. Women and children have extremely high levels of poverty and face numerous barriers to care including lack of trust and racial disparities in care and concrete barriers such as limited transportation and childcare, work hour conflicts, and lack of insurance.

DESCRIPTION

We report on a unique model of patient care focused on providing patient-centered care and building trusting relationships. This model is encompassed in a new free, volunteer-run, faith-based clinic which offers prenatal, postpartum, and infant care.

ASSESSMENT

In the first 2 years of operation, demand for services rose rapidly and there were stellar clinical outcomes, despite the fact that Luke patients are among the medically and socially highest risk populations in the nation.

CONCLUSION

While marginalized populations have worse birth outcomes and far more infant deaths, making care accessible and responsive to patient needs while focusing on building patient relationships is an important strategy to improve outcomes.

Development and Testing of the Preparation for Labor and Birth Instrument

OBJECTIVE

To develop and assess the reliability and validity of a new instrument used during the third trimester of pregnancy to measure women's confidence in their ability to achieve physiologic birth, the Preparation for Labor and Birth (P-LAB) instrument.

DESIGN

Two-phase instrument development study that consisted of item generation and a prospective field test.

SETTING

Field testing occurred in five midwestern U.S. prenatal clinics.

PARTICIPANTS

Participants in the field test were 203 nulliparous and parous pregnant women who intended to give birth vaginally.

METHODS

Psychometric testing consisted of test-retest reliability testing and assessments of content validity, face validity, and construct validity. We measured construct validity using exploratory factor analysis and correlation with the Sense of Coherence Scale.

RESULTS

The 22-item P-LAB showed good content validity, good internal consistency, and stability over time. All items had content validity index scores greater than or equal to 0.8, and the total instrument content validity index was 0.95. We identified four factors related to women's confidence in their ability to achieve physiologic birth: Planned Use of Pain Medication, Relationship With Care Provider and Supportive Birth Environment, Beliefs About Labor, and Labor Support (social and professional). Cronbach's alpha coefficient for the four extracted factors were .93, .76, .73 and .74, respectively. Intraclass correlation [95% confidence interval] for the total questionnaire was .92 [.88, .94]. We found no linear association between total P-LAB scores and sense of coherence.

CONCLUSION

Our findings demonstrate acceptable initial psychometric properties for the P-LAB instrument. Additional testing is required to evaluate the instrument's construct, convergent, and divergent validity.

Identifying the Key Elements of Racially Concordant Care in a Freestanding Birth Center

INTRODUCTION

There is empirical evidence that the quality of interpersonal care patients receive varies dramatically along racial and ethnic lines, with African American people often reporting much lower quality of care than their white counterparts. Improving the interpersonal relationship between clinicians and patients has been identified as one way to improve quality of care. Specifically, research has identified that patients feel more satisfied with the care that they receive from clinicians with whom they share a racial identity. However, little is known about how clinicians provide racially concordant care. The goal of this analysis was to identify the key components of high-quality care that were most salient for African American birthworkers providing perinatal care to African American patients.

METHODS

We conducted semistructured interviews (30 to 90 minutes) with clinicians (N = 10; midwives, student midwives, and doulas) who either worked at or worked closely with an African American-owned birth center in North Minneapolis, Minnesota. We used inductive coding methods to analyze data and to identify key themes.

RESULTS

Providing racially concordant perinatal care to African American birthing individuals required clinicians to acknowledge and center the sociocultural realities and experiences of their patients. Four key themes emerged in our analysis. The first overarching theme identified was the need to acknowledge how cultural identity of patients is fundamental to the clinical encounter. The second theme that emerged was a commitment to racial justice. The third and fourth themes were agency and cultural humility, which highlight the reciprocal nature of the clinician-patient relationship.

DISCUSSION

The most salient aspect of the care that birthworkers of color provide is their culturally centered approach. This approach and all subsequent themes suggest that achieving birth equity for pregnant African American people starts by acknowledging and honoring their sociocultural experiences.

Black Maternal Mortality-The Elephant in the Room

Maternal mortality is on the rise in the United States and it disproportionately affects black women. The reasons for this staggering discrepancy hinge on three central issues: First, black women are more likely to have pre-existing cardiovascular morbidity that increase the risk of maternal mortality. Second, black women are more likely to experience adverse pregnancy outcomes which puts them at risk for developing long-term cardiovascular disease. Third, racial bias of providers and perceived racial discrimination from patients (the elephant in the room) impacts black patients' trust in their providers and the medical community at large. Reducing black maternal mortality involves a multi-tiered approach involving the patient, provider and public health policy.

The colours and contours of compassion: A systematic review of the perspectives of compassion among ethnically diverse patients and healthcare providers

OBJECTIVE

To identify and describe the perspectives, experiences, importance, and impact of compassionate care among ethnically diverse population groups.

METHODS

A systematic search of peer-reviewed research focused on compassionate care in ethnically diverse populations published between 1946 and 2017 was conducted.

RESULTS

A total of 2296 abstracts were retrieved, out of which 23 articles met the inclusion criteria. Synthesis of the literature identified the perspectives, facilitators and barriers of compassion in healthcare within ethnic groups. Compassion was described as being comprised of healthcare provider (HCP) virtues (honesty, kindness, helpful, non-judgment) and actions (smile, touch, care, support, flexibility) aimed at relieving the suffering of patients. The importance and impact of providing compassion to ethnically diverse patients was also identified which included overcoming cultural differences, alleviating distress at end-of-life, promoting patient dignity and improving patient care. This review also identified the need for more contextual studies directly exploring the topic of compassion from the perspectives of individuals within diverse ethnic groups, rather than superimposing a pre-defined, enculturated and researcher-based definition of compassion.

CONCLUSIONS

This review synthesizes the current evidence related to perceptions of compassion in healthcare among diverse ethnic groups and the role that compassion can play in bridging ethno-cultural differences and associated challenges, along with identifying gaps in literature related to compassionate care within diverse ethnic groups. Establishing an evidence base grounded in the direct accounts of members of diverse ethnic communities can enhance culturally sensitive compassionate care and improve compassion related health outcomes among diverse ethnic groups.

More Than a "Number": Perspectives of Prenatal Care Quality from Mothers of Color and Providers

INTRODUCTION

African American mothers and other mothers of historically underserved populations consistently have higher rates of adverse birth outcomes than White mothers. Increasing prenatal care use among these mothers may reduce these disparities. Most prenatal care research focuses on prenatal care adequacy rather than concepts of quality. Even less research examines the dual perspectives of African American mothers and prenatal care providers. In this qualitative study, we compared perceptions of prenatal care quality between African American and mixed race mothers and prenatal care providers.

METHODS

Prenatal care providers (n = 20) and mothers who recently gave birth (n = 19) completed semistructured interviews. Using a thematic analysis approach and Donabedian's conceptual model of health care quality, interviews were analyzed to identify key themes and summarize differences in perspectives between providers and mothers.

FINDINGS

Mothers and providers valued the tailoring of care based on individual needs and functional patient-provider relationships as key elements of prenatal care quality. Providers acknowledged the need for knowing the social context of patients, but mothers and providers differed in perspectives of "culturally sensitive" prenatal care. Although most mothers had positive prenatal care experiences, mothers also recalled multiple complications with providers' negative assumptions and disregard for mothers' options in care.

CONCLUSIONS

Exploring strategies to strengthen patient-provider interactions and communication during prenatal care visits remains critical to address for facilitating continuity of care for mothers of color. These findings warrant further investigation of dual patient and provider perspectives of culturally sensitive prenatal care to address the service needs of African American and mixed race mothers.

Research Ethics in Behavioral Interventions Among Special Populations: Lessons From the Peer Approaches to Lupus Self-Management Study

BACKGROUND

Research involving a homogenous cohort of participants belonging to a special population must make considerations to recruit and protect the subjects. This study analyses the ethical considerations made in the peer approaches to lupus self-management project which pilot tested a peer mentoring intervention for African American women with systemic lupus erythematosus.

METHODS

Considerations made at the outset of the project are described and their justifications and reasoning are given. Through analysis of feedback from a postintervention focus group and mentors' logs, implications on program outcomes and participant satisfaction are discussed.

RESULTS

Feedback indicated the importance of recruiting and training capable mentors, consistent contact from study staff to avert adverse events and avert fear or mistrust and careful consideration that must go into the pairing of mentors and mentees. Participant feedback also indicated that sensitive topics must be addressed carefully to prevent distress and dissatisfaction.

CONCLUSIONS

Applying the lessons learned from this work as well as the considerations that proved successful may improve the contextualization and ethical conduct of behavioral interventions in special populations resulting in improved tailoring and acceptability toward historically underserved individuals.

Employing Community Voices: Informing Practice and Programming through Camden Healthy Start Focus Groups

Objectives Women living in communities with low-socioeconomic status, substandard healthcare, and ongoing exposure to social disparities encounter barriers to healthcare, often making it difficult to access health services. Barriers may stem from provider interactions with clients, conditions of the healthcare facility, or even language barriers. This prompts a call for providers to be keenly aware of the obstacles women encounter when attempting to access services. Methods In an effort to facilitate better access to services, Camden Healthy Start conducted six focus groups. Thirty-nine women between the ages of 22–56 participated. A total of 39 questions were posed to participants about health behavior, health services, pregnancy, reproductive health, and barriers to accessing services. Each 2 h session was audio recorded, translated and transcribed. Following the format of the Women’s Health: Attitudes and Practices in North Carolina Focus Group Research, responses were analyzed and themes emerged. Results This article discusses characteristics of healthcare services and cultural insensitivity that impact women’s access and act as barriers to care. The results signal the need for Healthy Start to apply a more relational engagement when providing services. Consideration for Practice Relational engagement includes getting to know the client as a person first, respecting their rights to autonomy in the decision making process, and demonstrating an understanding of the client’s culture and inclusion of their voices in the conversation.

Providers' perspectives of barriers experienced in maternal health care among Marshallese women

PROBLEM

Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care.

PURPOSE

The purpose of this study was twofold: (1) to explore maternal health care providers' perceptions and experiences of barriers in providing care to Marshallese women, and (2) providers perceived barriers of access to care among Marshallese women. This is the first paper to explore perceived barriers to maternal health care among a Marshallese community from maternal health care providers' perspectives in the United States.

METHODS

A phenomenological, qualitative design, using a focus group and in-depth interviews with 20 maternal health care providers residing in northwest Arkansas was chosen.

FINDINGS

Several perceived barriers were noted, including transportation, lack of health insurance, communication and language, and socio-cultural barriers that described an incongruence between traditional and Western medical models of care. There was an overall discord between the collectivist cultural identity of Marshallese families and the individualistic maternal health care system that merits further research.

DISCUSSION

Solutions to these barriers, such as increased cultural competency training for maternal health care providers and the incorporation of community health workers are discussed.

Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey

BACKGROUND

Previous qualitative studies suggest that women with physical disabilities face disability-specific barriers and challenges related to prenatal care accessibility and quality. This study aims to examine the pregnancy and prenatal care experiences and needs of U.S. mothers with physical disabilities and their perceptions of their interactions with their maternity care clinicians.

MATERIALS AND METHODS

We conducted the first survey of maternity care access and experiences of women with physical disabilities from 37 states. The survey was disseminated in partnership with disability community agencies and via social media and targeted U.S. women with a range of physical disabilities who had given birth in the past 10 years. The survey included questions regarding prenatal care quality and childbirth and labor experiences.

RESULTS

A total of 126 women with various physical disability types from 37 states completed the survey. Almost half of the respondents (53.2%) reported that their physical disability was a big factor in their selection of a maternity care provider and 40.3% of women reported that their prenatal care provider knew little or nothing about the impact of their physical disability on their pregnancy. Controlling for maternal demographic characteristics and use of mobility equipment, women who reported that their prenatal care provider lacked knowledge of disability and those who felt they were not given adequate information were more likely to report unmet needs for prenatal care.

CONCLUSIONS

The findings from this study suggest the need for training and education for clinicians regarding the prenatal care needs of women with physical disabilities.

Patient-provider communication, maternal anxiety, and self-care in pregnancy

RATIONALE

Favorable relationships with health care providers predict greater patient satisfaction and adherence to provider recommendations. However, the specific components of patient-provider relationships that account for these benefits have not been identified. The potential benefits of strong patient-provider relationships in pregnancy may be especially important, as care providers have frequent, intimate interactions with pregnant women that can affect their emotions and behaviors. In turn, prenatal emotions and health behaviors have potent effects on birth outcomes.

OBJECTIVE

This study investigated whether pregnant women's relationships with their midwives predicted better self-care. Specific components of the patient-provider relationship (communication, integration, collaboration, and empowerment) were examined. We also investigated a mechanism through which these relationship components may be associated with salutary health behaviors: by alleviating women's anxiety.

METHODS

In total, 139 low-risk patients of a university-affiliated midwifery practice in the northeastern United States completed well-validated measures assessing their relationship with midwives, state anxiety, and prenatal health behaviors in late pregnancy; state anxiety was also assessed in mid-pregnancy.

RESULTS

Women's perceptions of better communication, collaboration, and empowerment from their midwives were associated with more frequent salutary health behavior practices in late pregnancy. Controlling for mid-pregnancy anxiety, lower anxiety in late pregnancy mediated associations of communication and collaboration with health behavior practices, indicating that these associations were attributable to reductions in anxiety from mid- to late pregnancy.

CONCLUSION

Results substantiate that benefits of patient-provider relationships in pregnancy may extend beyond providing medical expertise. Some aspects of patient-provider relationships may offer direct benefits to pregnant women in promoting better health practices; other aspects of these relationships may indirectly contribute to better health practices by alleviating negative emotions. The benefits of strong midwife relationships may derive from the reassurance, comfort, and warmth these relationships offer, as well as the information and education that midwives provide to their patients.

Using acupressure to minimize discomforts during pregnancy

OBJECTIVE

To describe responses issued by pregnant women, and the improvement of the gravidic discomforts after the use of the acupressure technique.

METHOD

Qualitative and descriptive study conducted with 15 pregnant women between November 2013 and February 2014 in a Basic Health Unit in Natal, RN, Brazil. The data were collected through unstructured interviews and depositions that were then transcribed and treated according to Minayo's operative proposal, carefully read, compared and organized into two groups.

RESULTS

The categories that resulted were: Positive effects of acupressure, and the recommended use of acupressure. According to pregnant women, the discomforts of pregnancy cramps, fatigue in the legs, lower back pain and headaches decreased with the use of acupressure.

CONCLUSIONS

Based on the results, acupressure should be introduced by the nurse in pre-natal care as a therapeutic resource for the pregnant woman's well-being.

Anatomy of Good Prenatal Care: Perspectives of Low Income African-American Women on Barriers and Facilitators to Prenatal Care

BACKGROUND

Although early, consistent prenatal care (PNC) can be helpful in improving poor birth outcomes, rates of PNC use tend to be lower among African-American women compared to Whites. This study examines low-income African-American women's perspectives on barriers and facilitators to receiving PNC in an urban setting.

METHODS

We conducted six focus groups with 29 women and individual structured interviews with two women. Transcripts were coded to identify barriers and facilitators to obtaining PNC; codes were reviewed to identify emergent themes.

RESULTS

Barriers to obtaining PNC included structural barriers such as transportation and insurance, negative attitudes towards PNC, perceived poor quality of care, unintended pregnancy, and psychosocial stressors such as overall life stress and chaos. Facilitators of PNC included positive experiences such as trusting relationships with providers, respectful staff and providers, and social support.

CONCLUSIONS

Findings suggest important components in an ideal PNC model to engage low-income African-American women.

What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women

BACKGROUND

Global uptake of antenatal care (ANC) varies widely and is influenced by the value women place on the service they receive. Identifying outcomes that matter to pregnant women could inform service design and improve uptake and effectiveness.

OBJECTIVES

To undertake a systematic scoping review of what women want, need and value in pregnancy.

SEARCH STRATEGY

Eight databases were searched (1994-2015) with no language restriction. Relevant journal contents were tracked via Zetoc.

DATA COLLECTION AND ANALYSIS

An initial analytic framework was constructed with findings from 21 papers, using data-mining techniques, and then developed using meta-ethnographic approaches. The final framework was tested with 17 more papers.

MAIN RESULTS

All continents except Australia were represented. A total of 1264 women were included. The final meta-theme was: Women want and need a positive pregnancy experience, including four subthemes: maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death); effective transition to positive labour and birth; and achieving positive motherhood (including maternal self-esteem, competence, autonomy). Findings informed a framework for future ANC provision, comprising three equally important domains: clinical practices (interventions and tests); relevant and timely information; and pyschosocial and emotional support; each provided by practitioners with good clinical and interpersonal skills within a high quality health system.

CONCLUSIONS

A positive pregnancy experience matters across all cultural and sociodemographic contexts. ANC guidelines and services should be designed to deliver it, and those providing ANC services should be aware of it at each encounter with pregnant women.

TWEETABLE ABSTRACT

Women around the world want ANC staff and services to help them achieve a positive pregnancy experience.

A qualitative study of older adults seeking appropriate treatment to self-manage their chronic pain in rural North-East Thailand

BACKGROUND

Many older adults suffer from chronic pain which decreases their functional capacity and reduces quality of life. Health behaviours and self-care during chronic illness and chronic pain can exert an important influence on health outcomes. The aims of this study were to (a) understand how older adult Thai individuals seek appropriate treatment to self-manage their chronic pain, and (b) to identify factors that contribute to effective pain self-management.

METHODS

Qualitative interviews were conducted with 32 older adults living in villages in north-east Thailand. Observations were also conducted with consenting individuals. Most interviews were audio-recorded and transcripts were coded and analysed using a grounded theory approach.

RESULTS

Six contextual determinants affected the way participants choose to self-manage their chronic pain, including: priority accorded to pain management; information and resource seeking skills; critical appraisal skills; access to pain-related information; access to treatment; and satisfaction and preferences for practitioners. Participants used several strategies to inform and develop their self-management plans: accessing and responding to information, sourcing resources, trial and error, evaluating treatment and evaluating practitioners.

CONCLUSIONS

Attempts to increase accessibility, affordability and acceptability of pain treatment can promote pain self-management in older Thais. These findings have important implications for health professionals and government organisations seeking to enhance the self-management of pain and quality of life in this population.

Understanding low-income African American women's expectations, preferences, and priorities in prenatal care

We aimed to explore factors affecting prenatal care attendance and preferences for prenatal care experiences among low-income black women by conducting a focus group study using a community-based participatory research framework and nominal group technique. Discussions were audiorecorded, transcribed, and coded by trained reviewers. Friends/family and baby's health were the top attendance motivators. Greatest barriers were insurance, transportation, and ambivalence. Facilitators included transportation services, social support, and resource education. In a "perfect system," women wanted continuity of care, personal connection, and caring/respect from providers. Relationship-centered maternity care models may mitigate disparities. Group prenatal care may provide the continuity and support system desired.

Iranian women and care providers' perceptions of equitable prenatal care: A qualitative study

BACKGROUND

Equity as a basic human right builds the foundation of all areas of primary healthcare, especially prenatal care. However, it is unclear how pregnant women and their care providers perceive the equitable prenatal care.

OBJECTIVE

This study aimed to explore Iranian women's and care providers' perceptions of equitable prenatal care.

RESEARCH DESIGN

In this study, a qualitative approach was used. Individual in-depth unstructured interviews were conducted with a purposeful sample of pregnant women and their care providers. Data were analyzed using inductive content analysis method.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 10 pregnant women and 10 prenatal care providers recruited from six urban health centers across Ahvaz, a south western city in Iran, were participated in the study.

ETHICAL CONSIDERATIONS

The study was approved by the Ethics Committee affiliated to Ahvaz Jundishapur University of Medical Sciences. The ethical principles of voluntary participation, confidentiality, and anonymity were considered.

FINDINGS

Analysis of participants' interviews resulted in seven themes: guideline-based care, time-saving care, nondiscriminatory care, privacy-respecting care, affordable comprehensive care, effective client-provider relationships, and caregivers' competency.

CONCLUSION

The findings explain the broader and less discussed dimensions of equitable care that are valuable information for the realization of equity in care. Understanding and focusing on these dimensions will help health policy-makers in designing more equitable healthcare services for pregnant women.

African American women and prenatal care: perceptions of patient-provider interaction

Poor patient-provider interaction among racial/ethnic minorities is associated with disparities in health care. In this descriptive, cross-sectional study, we examine African American women's perspectives and experiences of patient-provider interaction (communication and perceived discrimination) during their initial prenatal visit and their influences on perceptions of care received and prenatal health behaviors. Pregnant African American women (n = 204) and their providers (n = 21) completed a pre- and postvisit questionnaire at the initial prenatal visit. Women were also interviewed face to face at the subsequent return visit. Women perceived high quality patient-provider communication (PPC) and perceived low discrimination in their interaction with providers. Multiple regression analyses showed that PPC had a positive effect on trust in provider (p < .001) and on prenatal care satisfaction (p < .001) but not on adherence to selected prenatal health behaviors. Findings suggest that quality PPC improves the prenatal care experience for African American women.

A randomised controlled trial on the Four Pillars Approach in managing pregnant women with anaemia in Yogyakarta-Indonesia: a study protocol

Background

Anaemia is a common health problem among pregnant women and a contributing factor with a major influence on maternal mortality in Indonesia. The Four Pillars Approach is a new approach to anaemia in pregnancy, combining four strategies to improve antenatal and delivery care. The primary objective of this study is to measure the effectiveness of the Four Pillars Approach. The barriers, the facilitators, and the patients’ as well as the midwives’ satisfaction with the Four Pillars Approach will also be measured.

Methods/Design

This study will use a cluster randomised controlled trial. This intervention study will be conducted in the Public Health Centres with basic emergency obstetric care in Yogyakarta Special Province and in Central Java Province. We will involve all the Public Health Centres (24) with emergency obstetric care in Yogyakarta Special Province. Another 24 Public Health Centres with emergency obstetric care in Central Java Province which have similarities in their demographic, population characteristics, and facilities will also be involved. Each Public Health Centre will be asked to choose two or three nurse-midwives to participate in this study. For the intervention group, the Public Health Centres in Yogyakarta Special Province, training on the Four Pillars Approach will be held prior to the model’s implementation. Consecutively, we will recruit 360 pregnant women with anaemia to take part in part in the study to measure the effectiveness of the intervention. The outcome measurements are the differences in haemoglobin levels between the intervention and control groups in the third trimester of pregnancy, the frequency of antenatal care attendance, and the presence of a nurse-midwife during labour. Qualitative data will be used to investigate the barriers and facilitating factors, as to nurse-midwives’ satisfaction with the implementation of the Four Pillars Approach.

Discussion

If the Four Pillars Approach is effective in improving the outcome for pregnant women with anaemia, this approach could be implemented nationwide and be taken into consideration to improve the outcome for other conditions in pregnancy, after further research.

Trial registration

Current Controlled Trials ISRCTN35822126.

Prenatal psychosocial risk assessment using event history calendars with Black women

OBJECTIVE

To explore the clinical acceptability and perceptions of use of a prenatal event history calendar (EHC) for prenatal psychosocial risk assessment in Black pregnant women.

DESIGN

A qualitative descriptive study focused on interviews and prenatal EHCs completed by Black pregnant women.

SETTING

Inner city hospital prenatal care clinic in Southeastern Michigan.

PARTICIPANTS

Thirty 18-35 year old pregnant Black women receiving prenatal care at the participating clinic.

METHODS

Women completed the prenatal EHCs and their perceptions of its use were obtained through face to face interviews. The constant comparative method of analysis (Glaser, 1978, 1992) revealed themes from participants' descriptions about use of a prenatal EHC for prenatal psychosocial risk assessment.

RESULTS

Three main themes emerged describing how the prenatal EHC enhanced communication. The prenatal EHC provided "an opening" for disclosure, "an understanding with you," and a way for providers to "know you, your life, and future plans." The participants' completed prenatal EHCs included information regarding their pre-pregnancies, trimester histories, and future plans. These completed prenatal EHCs showed patterns of change in life events and behaviors that included worries, stressors, and risk behaviors. The participants perceived the prenatal EHC as an easy to use tool that should be used to improve communication with health care providers.

CONCLUSIONS

The prenatal EHC allows the patient and provider to "start on the same page" and provides an additional avenue for discussion of sensitive psychosocial issues with Black pregnant women. As a clinical tool, the prenatal EHC facilitated patient-provider communication for pregnant women often marked by health disparities. The prenatal EHC is a clinically acceptable tool to assess for psychosocial risk factors of Black women in a prenatal clinical setting.

Women's and care providers' perspectives of quality prenatal care: a qualitative descriptive study

BACKGROUND

Much attention has been given to the adequacy of prenatal care use in promoting healthy outcomes for women and their infants. Adequacy of use takes into account the timing of initiation of prenatal care and the number of visits. However, there is emerging evidence that the quality of prenatal care may be more important than adequacy of use. The purpose of our study was to explore women's and care providers' perspectives of quality prenatal care to inform the development of items for a new instrument, the Quality of Prenatal Care Questionnaire. We report on the derivation of themes resulting from this first step of questionnaire development.

METHODS

A qualitative descriptive approach was used. Semi-structured interviews were conducted with 40 pregnant women and 40 prenatal care providers recruited from five urban centres across Canada. Data were analyzed using inductive open and then pattern coding. The final step of analysis used a deductive approach to assign the emergent themes to broader categories reflective of the study's conceptual framework.

RESULTS

The three main categories informed by Donabedian's model of quality health care were structure of care, clinical care processes, and interpersonal care processes. Structure of care themes included access, physical setting, and staff and care provider characteristics. Themes under clinical care processes were health promotion and illness prevention, screening and assessment, information sharing, continuity of care, non-medicalization of pregnancy, and women-centredness. Interpersonal care processes themes were respectful attitude, emotional support, approachable interaction style, and taking time. A recurrent theme woven throughout the data reflected the importance of a meaningful relationship between a woman and her prenatal care provider that was characterized by trust.

CONCLUSIONS

While certain aspects of structure of care were identified as being key dimensions of quality prenatal care, clinical and interpersonal care processes emerged as being most essential to quality care. These processes are important as they have a role in mitigating adverse outcomes, promoting involvement of women in their own care, and keeping women engaged in care. The findings suggest key considerations for the planning, delivery, and evaluation of prenatal care. Most notably, care should be woman-centred and embrace shared decision making as an essential element.

Flavor learning in utero and its implications for future obesity and diabetes

The concept of prenatal flavor learning can be used to motivate women to eat healthy foods. The flavors of the foods in the maternal diet are found in the amniotic fluid swallowed by the fetus, with the fetus developing a preference for those flavors that is shown to persist in infancy. Furthermore, flavor preferences in infancy can persist into childhood and even into adulthood. Thus, the intrauterine environment may have a life-long influence on flavor preferences and healthy eating. This is an empowering concept for a pregnant woman: her baby will develop a preference for what she eats. However, education alone about this concept may not be sufficient to motivate behavior change. The evidence for health promotion strategies demonstrated to be effective in pregnancy is presented here, along with associated implications for prenatal flavor learning and the prevention of obesity and diabetes.