"Just Because You Have Ears Doesn't Mean You Can Hear"-Perception of Racial-Ethnic Discrimination During Childbirth

Characteristics of interventions that address racism in the United States and opportunities to integrate equity principles: a scoping review

BACKGROUND

As a driver of racial and health inequities, racism is deeply ingrained in the interconnected systems that affect health and well-being. Currently, no common frame is employed across researchers, interventionists, and funders to design, implement, and evaluate comprehensive interventions to address racism. Consequently, there is a need to examine the characteristics of interventions implemented in the United States that address racism across social and structural determinants of health and socio-ecological levels. Additionally, we utilized a Health Equity Action Research (HEART) framework to assess how interventions integrate equity principles.

METHODS

This scoping review examined the characteristics of multi-level interventions that addressed racism and appraised the interventions using a Health Equity Action Research frame. A comprehensive search strategy was conducted across nine electronic databases between 24 October 2022 through 15 November 2022. Records were included if they were available in English, discussed or evaluated a multi-level intervention or program conducted in the United States, and discussed or evaluated the intervention or program regarding the health and well-being of racialized and ethnically minoritized groups.

RESULTS

A total of 13,391 records were identified, of which 91 met the eligibility criteria and were included in the analysis. Most records reported the racialized group impacted by an intervention, of which the majority were racialized as African American or Black (n = 42) and Hispanic or Latino/a/x (n = 18). Eighty-one (89%) of interventions reported health outcomes and concentrated on the individual level. Most funders reported across the records, and 86 (51%) were a federal agency or department. A further 43 (25%) were private foundations, 12 (7%) were nonprofit organizations, 10 (6%) were private universities, and 4 (2%) were public universities. Regarding alignment with the HEART framework, 14% of interventions reported a mixed-methods approach, 45% reported community engagement, and less than 1% reported researcher self-reflection.

CONCLUSIONS

Most interventions prioritized people who are racialized as Black and report health outcomes. Since intervention designs, objectives, and methodological approaches vary, no standard frame defines racism and health equity. Applying the HEART framework offers a standard approach for interventionists and researchers to examine power, integrate community voice, and self-reflect to advance health equity.

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.

Perinatal care among Hispanic birthing people: Differences by primary language and state policy environment

OBJECTIVE

The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment.

DATA SOURCES AND STUDY SETTING

Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions.

STUDY DESIGN

Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline-recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five-year waiting period for pregnant immigrants to access Medicaid.

DATA COLLECTION/EXTRACTION METHODS

Survey responses from 35,779 postpartum individuals with self-reported Hispanic ethnicity who gave birth during 2016-2020.

PRINCIPAL FINDINGS

Compared to English-speaking Hispanic people, Spanish-speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage-point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage-point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish-speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage-point lower prenatal care adequacy, but 1.3 (95% CI:-1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage-point higher postpartum care quality than English-speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage-points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage-points higher.

CONCLUSIONS

Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish-speaking and English-speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth.

Latina Women's Perinatal Experiences and Perspectives Around Discrimination, Anti-immigrant Policies, and Community Violence

OBJECTIVE

To describe experiences of Latina women who were currently pregnant or recently gave birth around discrimination, anti-immigrant policies, and community violence during the early COVID-19 pandemic.

DESIGN

Qualitative secondary analysis.

SETTING

Online or phone interviews.

PARTICIPANTS

Latina women who were currently pregnant or recently gave birth (N = 26).

METHODS

We used reflexive thematic analysis to examine transcribed data from semistructured interviews conducted during the early COVID-19 pandemic with a subgroup of participants enrolled in a larger study related to prenatal care. Participants were English- or Spanish-speaking, Medicaid-eligible, Latina-identifying women who resided in Fresno County, California. We analyzed responses to questions about personal discrimination, the Black Lives Matter movement, and immigration policies using the theoretical frameworks of critical race theory and the political economy of health.

RESULTS

We identified four major themes: Avoidance of Community Engagement, Chronic Fear and Vigilance, The Role of Media, and Everyday Discrimination and Injustice.

CONCLUSION

Participant experiences reflect the pervasiveness of fear and socioeconomic inequity and call attention to the racialized structures that affect health and health care access for Latina women. These exposures during the perinatal period may have intergenerational effects. These findings underscore the need for responsive and race-conscious perinatal nursing care for Latina women, assessment of the effect of the current sociopolitical environment on well-being, and policies that support equitable access to health and social care.

Awe and Trepidation: The Role of Perinatal Care Providers in Black Fathers' Experiences of Childbirth in the U.S

Care provider communication with Black birthing families is impactful. This cross-sectional study asked 216 Black fathers to recall treatment by birthing care providers and tested variables contributing to birth satisfaction and fathering identity salience. Most fathers reported that care providers were respectful resulting in a positive birthing experience; however, 15% reported negative experiences with care providers. Perceived social support was shown to be a mediator between disrespect, mistreatment, inclusive communication, trust, and positive emotion with birth satisfaction and fathering identity salience. Care provider disrespect served as a "spoiler" of the birthing experience and subsequently diminished positive fathering identity salience. Analysis of open-ended comments showed that contrary to stereotypes about absent, disengaged Black fathers, fathers in this study were caring toward their newborns, present for them, and engaged in fathering. More work needs to be done with care provider communication to make every birth a positive and inclusive experience for Black fathers and their partners.

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.

Educating Families on Urgent Maternal Warning Signs: Learning From a Pilot to Improve Training and Tools for Maternal and Child Home Visiting Programs

Early recognition of the warning signs of pregnancy-related complications and provision of timely, quality care could prevent many maternal deaths. We piloted a maternal warning signs education intervention with five Maryland-based maternal, infant, and early childhood home visiting programs serving populations disproportionately affected by adverse maternal outcomes. The intervention included a 1.5-hr online training for home visitors, monthly collaborative calls with program managers, and a client education toolkit with a 3-min video, illustrated handout of 15 urgent maternal warning signs, magnet with the same, and discussion guide for home visitor-client interactions. A mixed-methods formative evaluation assessed the acceptability, feasibility, and utilization of different components of the intervention. Home visiting program staff reported that the materials were highly acceptable and easily understood by diverse client populations. They valued the illustrations, simple language, and translation of materials in multiple languages. Program managers found implementation a relatively simple process, feasible for in-person and remote visits. Despite positive reception, not all components of the toolkit were used consistently. Program managers and staff also identified the need for more guidance and tools to help clients communicate with health care providers and advocate for their health care needs. Feedback from pilot sites was used to adapt the training and tools, including adding content on patient self-advocacy. Home visiting programs have a unique ability to engage families during pregnancy and the postpartum period. This pilot offers lessons learned on strategies and tools that home visiting programs can use to improve early recognition and care-seeking for urgent maternal warning signs.

Using incident reports to diagnose communication challenges for precision intervention in learning health systems: A methods paper

Introduction

Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself.

Methods

We abstracted incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes.

Results

The use of incident reports to conduct research on communication was new for the health system. Conversations with health system-level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis-requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work.

Conclusions

Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation.

Racism against healthcare users in inpatient care: a scoping review

BACKGROUND

Racism in the healthcare system has become a burgeoning focus in health policy-making and research. Existing research has shown both interpersonal and structural forms of racism limiting access to quality healthcare for racialised healthcare users. Nevertheless, little is known about the specifics of racism in the inpatient sector, specifically hospitals and rehabilitation facilities. The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, focusing specifically on whether intersectional axes of discrimination have been taken into account when describing these experiences.

METHODS

Based on the conceptual framework developed by Arksey and O'Malley, this scoping review surveyed existing research on racism and racial discrimination in inpatient care in high-income countries published between 2013 and 2023. The software Rayyan was used to support the screening process while MAXQDA was used for thematic coding.

RESULTS

Forty-seven articles were included in this review. Specifics of the inpatient sector included different hospitalisation, admission and referral rates within and across hospitals; the threat of racial discrimination from other healthcare users; and the spatial segregation of healthcare users according to ethnic, religious or racialised criteria. While most articles described some interactions between race and other social categories in the sample composition, the framework of intersectionality was rarely considered explicitly during analysis.

DISCUSSION

While the USA continue to predominate in discussions, other high-income countries including Canada, Australia and the UK also examine racism in their own healthcare systems. Absent from the literature are studies from a wider range of European countries as well as of racialised and disadvantaged groups other than refugees or recent immigrants. Research in this area would also benefit from an engagement with approaches to intersectionality in public health to produce a more nuanced understanding of the interactions of racism with other axes of discrimination. As inpatient care exhibits a range of specific structures, future research and policy-making ought to consider these specifics to develop targeted interventions, including training for non-clinical staff and robust, transparent and accessible complaint procedures.

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.

Continuity of Clinician Type and Intrapartum Experiences During the Perinatal Period in California

INTRODUCTION

Continuity of care with an individual clinician is associated with increased satisfaction and better outcomes. Continuity of clinician type (ie, obstetrician-gynecologist or midwife) may also impact care experiences; however, it is unknown how common it is to experience discontinuity of clinician type and what its implications are for the birth experience. We aimed to identify characteristics associated with having a different clinician type for prenatal care than for birth and to compare intrapartum experiences by continuity of clinician type.

METHODS

For this cross-sectional study, data were from the 2017 Listening to Mothers in California survey. The analytic sample was limited to individuals with vaginal births who had midwifery or obstetrician-gynecologist prenatal care (N = 1384). Bivariate and multivariate analysis examined characteristics of individuals by continuity of clinician type. We then examined associations of clinician type continuity with intrapartum care experiences.

RESULTS

Overall, 74.4% of individuals had the same type of clinician for prenatal care and birth. Of individuals with midwifery prenatal care, 45.1% had a different birth clinician type, whereas 23.5% of individuals who had obstetrician-gynecologist prenatal care had a different birth clinician type. Continuity of clinician type was positively associated with having had a choice of perinatal care clinician. There were no statistically significant associations between clinician type continuity and intrapartum care experiences.

DISCUSSION

Findings suggest individuals with midwifery prenatal care frequently have a different type of clinician attend their birth, even among those with vaginal births. Further research should examine the impact of multiple dimensions of continuity of care on perinatal care quality.

Approaches for enhancing patient-reported experience measurement with ethnically diverse communities: a rapid evidence synthesis

BACKGROUND

Patient-reported experience measures (PREMs) are used to drive and evaluate unit and organisational-level healthcare improvement, but also at a population level, these measures can be key indicators of healthcare quality. Current evidence indicates that ethnically diverse communities frequently experience poorer care quality and outcomes, with PREMs data required from this population to direct service improvement efforts. This review synthesises evidence of the methods and approaches used to promote participation in PREMs among ethnically diverse populations.

METHODS

A rapid evidence appraisal (REA) methodology was utilised to identify the disparate literature on this topic. A search strategy was developed and applied to three major electronic databases in July 2022 (Medline; PsycINFO and CINAHL), in addition to websites of health agencies in Organisation for Economic Co-operation and Development countries via grey literature searches. A narrative evidence synthesis was undertaken to address the review question.

RESULTS

The review resulted in 97 included studies, comprised 86 articles from electronic database searches and 11 articles from the grey literature. Data extraction and synthesis identified five strategies used in PREM instruments and processes to enhance participation among ethnically diverse communities. Strategies applied sought to better inform communities about PREMs, to create accessible PREMs instruments, to support PREMs completion and to include culturally relevant topics. Several methods were used, predominantly drawing upon bicultural workers, translation, and community outreach to access and support communities at one or more stages of design or administration of PREMs. Limited evidence was available of the effectiveness of the identified methods and strategies. PREMs topics of trust, cultural responsiveness, care navigation and coordination were identified as pertinent to and frequently explored with this population.

CONCLUSIONS

The findings provide a basis for a maturity model that may guide change to increase participation of ethnically diverse communities in PREMs. In the short-medium term, health systems and services must be able to recognise and respond to cultural and linguistic diversity in the population when applying existing PREMs. In the longer-term, by working in collaboration with ethnically diverse communities, systems and services may co-create adapted or novel PREMs that tackle the factors that currently inhibit uptake and completion among ethnically diverse communities.

Broadening the Environmental Lens to Include Social and Structural Determinants of Women's Health Disparities

BACKGROUND

Due to the physical, metabolic, and hormonal changes before, during, and after pregnancy, women-defined here as people assigned female at birth-are particularly susceptible to environmental insults. Racism, a driving force of social determinants of health, exacerbates this susceptibility by affecting exposure to both chemical and nonchemical stressors to create women's health disparities.

OBJECTIVES

To better understand and address social and structural determinants of women's health disparities, the National Institute of Environmental Health Sciences (NIEHS) hosted a workshop focused on the environmental impacts on women's health disparities and reproductive health in April 2022. This commentary summarizes foundational research and unique insights shared by workshop participants, who emphasized the need to broaden the definition of the environment to include upstream social and structural determinants of health. We also summarize current challenges and recommendations, as discussed by workshop participants, to address women's environmental and reproductive health disparities.

DISCUSSION

The challenges related to women's health equity, as identified by workshop attendees, included developing research approaches to better capture the social and structural environment in both human and animal studies, integrating environmental health principles into clinical care, and implementing more inclusive publishing and funding approaches. Workshop participants discussed recommendations in each of these areas that encourage interdisciplinary collaboration among researchers, clinicians, funders, publishers, and community members. https://doi.org/10.1289/EHP12996.

Skin-To-Skin Contact During Cesarean Birth in the United States over the Last Decade

PURPOSE

To assess skin-to-skin contact during cesarean birth, including incidence and maternal characteristics.

STUDY DESIGN AND METHODS

A cross-sectional, retrospective study using survey methods was conducted. Women who had a cesarean birth within the last 10 years prior to January 2022 were recruited via social media. Descriptive statistics, chi square, and binary logistic regression analyses were calculated.

RESULTS

There were 2,327 participants, of which 29.7% experienced skin-to-skin contact during their cesarean birth. This was reported to be less often than desired. Significant associations were found among skin-to-skin contact during cesarean birth and planned cesarean birth, previous cesarean birth, maternal age, level of education, and birth region. Previous vaginal birth and race were not significantly associated with skin-to-skin contact during cesarean birth. Most (93.65%) respondents identified as White. Barriers to skin-to-skin contact during cesarean birth may be birth region, unplanned or emergency cesarean births, younger age, lacking a college degree, and lack of previous cesarean births.

CLINICAL IMPLICATIONS

There are differences in incidence and access to skin-to-skin contact during cesarean birth. Our findings emphasize the continued need to address disparities in care, increase maternal health care equity, and make skin-to-skin contact during cesarean birth available for all women who desire it.

Racism and access to maternal health care among garo indigenous women in Bangladesh: A qualitative descriptive study

Racism as social determinant of health significantly affects Indigenous women's maternal healthcare access. This study uses Jones' 'Three Levels of Racism' theory and an intersectional lens to explore how racism shapes the experience of maternal health care access among Garo Indigenous women in Bangladesh. Semi-structured interviews were conducted with 24 women of diverse backgrounds and pregnancy statuses using snowball sampling. Thematic analysis, incorporating inductive and deductive approaches, was employed for data analysis. The findings reveal a significant deviation from Jones' theory regarding the level of internalized racism within the specific context of Garo Indigenous women's experiences. Jones' theory usually focuses on how racism is internalized due to institutional and personally-mediated factors. On the contrary, this study uncovers a unique theme: 'women agency.' This theme emerges as a robust response among the Garo Indigenous women to their encounters with institutional and personally-mediated racism, highlighting their cultural resistance and resilience. The findings suggest that the complex relationship between these two forms of racism contributes to the strengthening of agency among Garo Indigenous women. Their agency stems from avoiding hospitals that disrespect their culture, manifesting their cultural resistance practice against the encountered racism at the institutional and relational levels. To increase biomedical healthcare access among Garo Indigenous women, it is recommended to address racism through intercultural competency training with the 'cultural safety' 'cultural humility' approach. This approach would foster inclusivity and empowerment, recognizing the agency of Garo women in healthcare decisions. Additionally, it would facilitate constructive dialogues between clinicians and Garo Indigenous women, acknowledging the shared experiences of racism within the latter group.

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.

"It's Important to Work with People that Look Like Me": Black Patients' Preferences for Patient-Provider Race Concordance

A compelling body of research supports the race concordance hypothesis, which asserts that racially minoritized patients who share the same race and ethnicity with their provider have improved communication, better perceptions of care, and better health outcomes. Using a mixed methods approach, this study examined (1) the association between racial identity and patients' preference for race-concordant patient-provider dyads and (2) Black patients' subjective experiences of race concordance. Data were gathered from 47 Black caregivers who completed both a survey and participated in a focus group. Quantitative analyses revealed that the majority (83%) of caregivers reported that it is important to have a mental health provider of the same race and ethnicity. Greater racial centrality, but not private or public regard, was associated with a stronger race concordance preference. Thematic analysis of qualitative data revealed six themes related to race-concordant preferences: aspects related to the patient care experience, cultural humility, relatability, diversity in cultural experiences, role models for children, and intersecting identities. Patients with a race concordance preference felt more comfortable with their provider, perceived that it was easier to build a rapport with their provider, and emphasized the value of representation for themselves and their children. Patients who were neutral in their race concordance preference emphasized professionalism over race, valued diverse perspectives, and appreciated their providers' cultural awareness and willingness to self-educate. The integration of these findings will help to elucidate a more nuanced understanding of the factors that build the therapeutic relationship and cultivate a framework of comfort and understanding in the clinical setting.

Maternal and Delivery Characteristics and Self-Reported Perceived Control During Labor

OBJECTIVE

To evaluate the association between maternal and delivery characteristics and self-reported perceived control during childbirth.

METHODS

A secondary analysis of a multicenter randomized trial was conducted to compare labor induction at 39 weeks of gestation with expectant management in low-risk nulliparous people. Six to 96 hours after delivery, participants who experienced labor completed the Labor Agentry Scale, a validated self-administered questionnaire to ascertain perceived control during childbirth. Scores range from 29 to 203, with higher scores indicating a sense of greater control. Multivariable linear regression was used to determine which maternal and delivery characteristics were associated with the Labor Agentry Scale score. Eligible characteristics included age, self-reported race and ethnicity, marital status, employment status, type of insurance, previous pregnancy loss before 20 weeks of gestation, body mass index (BMI), smoking, alcohol use, mode of delivery, labor pain (0-10 points), and a composite of perinatal death or severe neonatal complications. Significant variables ( P <.05) were retained in the final multivariable model, and adjusted mean differences (95% CIs) between groups were estimated.

RESULTS

Of 6,106 people enrolled in the trial, 6,038 experienced labor, of whom 5,750 (95.2%) completed the Labor Agentry Scale and were included in this analysis. Mean [95% CI] adjusted Labor Agentry Scale scores were significantly lower among those who identified as Asian (-6.4 [-10.5 to -2.3]) or Hispanic (-3.7 [-5.7 to -1.7]) compared with White, smoked compared with did not smoke (-2.8 [-5.5 to -0.1]), had BMIs of 35 or higher compared with less than 30 (-2.0 [-3.8 to -0.2]), were unemployed (-3.15 [-4.76 to -1.55]), did not have private health insurance (-2.61 [-4.47 to -0.76]), underwent operative vaginal (-5.1 [-7.7 to -2.6]) or cesarean (-14.4 [-16.1 to -12.6]) delivery compared with spontaneous vaginal delivery, and reported greater labor pain score of 8 or higher compared with less than 8 (-11.9 [-13.4 to -10.4]). Mean [95% CI] adjusted Labor Agentry Scale scores were significantly higher among people who were employed compared with unemployed (3.2 [1.6-4.8]) and had private compared with nonprivate insurance (2.6 [0.76-4.5]).

CONCLUSION

In nulliparous people at low risk, unemployment, lack of private health insurance, Asian race, Hispanic ethnicity, smoking, operative delivery, and more labor pain were associated with lower perceived control during labor.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT01990612.

Maternal and neonatal risk-appropriate care: gaps, strategies, and areas for further research

Risk-appropriate care is a strategy to improve perinatal health outcomes by providing care to pregnant persons and infants in facilities with the personnel and services capable of meeting their health needs. The Association of State and Territorial Health Officials hosted discussions among state health officials, health agency staff, and clinicians to advance risk-appropriate care. The discussions focused on neonatal levels of care, levels of maternal care, ancillary services utilized for care of both populations including transport and telemedicine, and issues affecting provision of care such as standardization of state policies or approaches, reimbursement for services, gaps in risk-appropriate care, and equity. State-identified implementation strategies for improvement were presented. In this Perspective, we summarize current studies describing provision of risk-appropriate care in the United States, identify gaps in research, and highlight ongoing and proposed activities to address research gaps and support state health officials and clinicians.

Differences in Determinants: Racialized Obstetric Care and Increases in U.S. State Labor Induction Rates

Induction of labor (IOL) rates in the United States have nearly tripled since 1990. We examine official U.S. birth records to document increases in states' IOL rates among pregnancies to Black, Latina, and White women. We test if the increases are associated with changes in demographic characteristics and risk factors among states' racial-ethnic childbearing populations. Among pregnancies to White women, increases in state IOL rates are strongly associated with changes in risk factors among White childbearing populations. However, the rising IOL rates among pregnancies to Black and Latina women are not due to changing factors in their own populations but are instead driven by changing factors among states' White childbearing populations. The results suggest systemic racism may be shaping U.S. obstetric care whereby care is not "centered at the margins" but is instead responsive to characteristics in states' White populations.

Association between primary Spanish language and quality of intrapartum care among Latina women: a secondary analysis of the Listening to Mothers in California survey

BACKGROUND

Language barriers play significant roles in quality of healthcare. Limited studies have examined the relationships between Spanish language and quality of intrapartum care. The objective was to determine the association between primary Spanish language and quality of intrapartum care so as to further inform best practices for non-English speaking patients in the labor and delivery setting.

METHODS

We used the 2016 Listening to Mothers in California survey data, which included a statewide representative sample of women who gave birth in hospitals. Our analytical sample included 1202 Latina women. Multivariable logistic regression was used to examine the association between primary language (monolingual English vs. monolingual Spanish vs. bilingual Spanish/English) and perceived discrimination due to language, perceived pressure for medical interventions, and mistreatment during labor, adjusting for maternal sociodemographics and other maternal and neonatal factors.

RESULTS

Over one-third of the study population spoke English (35.6%), less than one-third spoke Spanish (29.1%), and greater than one-third spoke bilingual Spanish/English (35.3%). Overall, 5.4% of Latina women perceived discrimination due to language spoken, 23.1% perceived pressure for any medical intervention, and 10.1% experienced either form of mistreatment. Compared to English-speakers, Spanish-speakers were significantly more likely to report discrimination due to language (aOR 4.36; 95% CI 1.15-16.59), but were significantly less likely to experience pressure for certain medical interventions (labor induction or cesarean delivery) during labor (aOR 0.34; 95% CI 0.15-0.79 for induction; aOR 0.44; 95% CI 0.18-0.97 for cesarean delivery). Bilingual Spanish/English-speakers also significantly reported discrimination due to language to a lesser extent than monolingual Spanish-speakers (aOR 3.37; 95% CI 1.12-10.13). Any form of Spanish language (monolingual or bilingual) was not significantly associated with mistreatment.

CONCLUSIONS

Spanish language may contribute to experiences of discrimination during intrapartum care among Latina women. Future research is needed to explore perceptions of pressure, discrimination and mistreatment, among patients with limited English proficiency.

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].

Obstetric experiences of young black mothers: An intersectional perspective

BACKGROUND

In Chicago, maternal morbidity and mortality is six times more likely among Black birthing people than white, despite policy initiatives to promote maternal health equity. Disparities in maternal morbidity and mortality reflect experiences of structural inequities - including limited quality obstetric care, implicit bias, and racism resulting patient mistrust in the health care system, inadequate social support, and financial insecurity. Although there is published literature on Black women's experiences with obstetric care, including experiences with individual and structural racism, little is known about the intersection of age and race and experiences with health care. The purpose of this study was to explore the maternal health and pregnancy experiences of young Black women utilizing an intersectional theoretical lens.

METHODS

In this study, we conducted two focus groups in a sample of 11 young Black pregnant people. We conducted a thematic analysis to identify codes, themes, and subthemes of the data.

RESULTS

We developed two overarching themes: obstetric racism and obstetric resistance. To elucidate how obstetric racism framed our participants' healthcare experiences, we identified sub-themes: intersectional identities as young Black women, medical mistrust, and pregnancy trauma. The second major theme describes ways in which participants protected themselves against obstetric racism to engender positive health experiences. These methods of resistance included identifying advocates and relying on trusted providers.

CONCLUSIONS

The current standard of obstetric care in the US is suboptimal due to individual and structural racism. This study provides unique data on the experiences with health care for young, Black pregnant individuals and delivers valuable insight into how individual and structural racism impacts obstetric care for young Black women.

An Integrative Review of the Perinatal Experiences of Black Women

OBJECTIVE

To synthesize the current body of evidence regarding the perinatal experiences of Black women.

DATA SOURCES

The databases PubMed, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus were searched with the search terms "African American" (in PubMed), "Black" (in Scopus), or "Black" OR "African American" (in CINAHL) AND "pregnancy" AND "experiences."

STUDY SELECTION

Searches yielded 266 articles published between January 2015 and May 2021. After initial screening, 68 articles were assessed for eligibility, yielding 23 studies that met the inclusion criteria of this review.

DATA EXTRACTION

Studies were reviewed for the perinatal experiences of Black women. Nonresearch articles, systematic reviews, and instrument development articles were removed. Also excluded were articles with a focus on adolescent pregnancy, breastfeeding experiences, and those outside of the perinatal time frame.

DATA SYNTHESIS

Analysis showed that Black women continue to report negative experiences in perinatal care and that these negative experiences spanned various sociodemographic characteristics. Although some Black women described positive interactions, many more expressed dissatisfaction with the lack of education, resources, and continuity in care, as well as poor communication. Additionally, experiences of racism and biases in care, mistrust in the health care system, and doubts of the efficacy or necessity of medical treatments exist.

CONCLUSION

Negative perinatal care experiences and dissatisfaction among Black women remain common. Although Black women desire more holistic, naturalistic, and empowering care, Black women first want safe, respectful care and a health care team that removes biases and racism from its system. More research is needed that includes the voices of Black women to understand these experiences and to develop interventions to improve the perinatal care experience. Nurses and other health care providers providing care in the perinatal period must also listen to, trust, and respect Black women.

A Qualitative Exploration of Stressors: Voices of African American Women who have Experienced Each Type of Fetal/Infant Loss: Miscarriage, Stillbirth, and Infant Mortality

Historically, African American women have experienced racial disparities in miscarriage, stillbirth, and infant mortality rates. Yet, little attention has been given to stressors that African American women may experience prior to, during, and after experiencing fetal/infant loss. This study provided an opportunity for African American women to describe their lived experiences of stressors prior to, during, and after experiencing each type of fetal/infant loss. Semi-structured interviews were conducted with seven African American women. Each participant experienced miscarriage, stillbirth, and infant mortality and were 18 years of age or older. Recruitment occurred in 2019 in a county in Northeast Ohio and data were analyzed using descriptive coding and thematic analysis. Four themes identified how these African American women navigated stressors prior to, during, and after experiencing each type of fetal/infant loss: (a) social support, (b) grief, (c) internal conflict, and (d) pregnancy, delivery, and death of child. Our findings expand the literature by being an innovative study may bring awareness and influence programs that assist African American women during their experience with fetal/infant loss.

Racial variations of adverse perinatal outcomes: A population-based retrospective cohort study in Ontario, Canada

Introduction

Racial differences in adverse maternal and birth outcomes have been studied in other countries, however, there are few studies specific to the Canadian population. In this study, we sought to examine the inequities in adverse perinatal outcomes between Black and White pregnant people in Ontario, Canada.

Methods

We conducted a population-based retrospective cohort study that included all Black and White pregnant people who attended prenatal screening and had a singleton birth in any Ontario hospital (April 1^st, 2012-March 31^st, 2019). Poisson regression with robust error variance models were used to estimate the adjusted relative risks of adverse perinatal outcomes for Black people compared with White people while adjusting for covariates.

Results

Among 412,120 eligible pregnant people, 10.1% were Black people and 89.9% were White people. Black people were at an increased risk of gestational diabetes mellitus, preeclampsia, placental abruption, preterm birth (<37, <34, <32 weeks), spontaneous preterm birth, all caesarean sections, emergency caesarean section, low birth weight (<2500g, <1500g), small-for-gestational-age (<10th percentile, <3^rd percentile) neonates, 5-minute Apgar score <4 and <7, neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment but had lower risks of elective caesarean section, assisted vaginal delivery, episiotomy, 3rd and 4th degree perineal tears, macrosomia, large-for-gestational-age neonates, and arterial cord pH≤7.1, as compared with White people. No difference in risks of gestational hypertension and placenta previa were observed between Black and White people.

Conclusion

There are differences in several adverse perinatal outcomes between Black and White people within the Ontario health care system. Findings might have potential clinical and health policy implications, although more studies are needed to further understand the mechanisms.

Dimensional Analysis of Shared Decision Making in Contraceptive Counseling

OBJECTIVE

To conduct a dimensional analysis to identify conceptual gaps around shared decision making (SDM) in reproductive health care and to refine the conceptual definition of SDM as related to contraceptive counseling.

DATA SOURCES

We identified source data through systematic searches of the CINAHL and PubMed databases.

STUDY SELECTION

We included peer-reviewed research and nonresearch articles that addressed contraceptive counseling for pregnancy prevention in the United States. We did not consider date of publication as an inclusion criterion. We included 35 articles in the final review.

DATA EXTRACTION

Using dimensional analysis, we extracted data to clarify the definition of SDM as a socially constructed concept that varies by perspective and context.

DATA SYNTHESIS

Data synthesis enabled us to compare SDM from patient and provider perspectives and to identify four primary dimensions of SDM that varied by context: Patient Preferences, Relationship, Provider Bias, and Clinical Suitability.

CONCLUSION

The four dimensions we identified illustrate the complexity and depth of SDM in contraceptive counseling encounters and broaden the definition of SDM to more than an encounter in which decision making incorporates clinician expertise and patient participation. We identified several assumptions that indicate the need for improved understanding that SDM is not a universal concept across perspectives and contexts. Most researchers in the included articles addressed the Patient Preferences dimension. Fewer considered the patient-provider relationship, the effect of provider bias, and the effect of specific clinical circumstances on SDM. We propose a conceptual map and model that can be used to refine the concepts that inform SDM and guide providers and researchers. Future research is needed to address the remaining gaps.

Racism in healthcare: a scoping review

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The relationship between obstetrical interventions and the increase in U.S. preterm births, 2014-2019

We examined the relationship between obstetrical intervention and preterm birth in the United States between 2014 and 2019. This observational study analyzed 2014-2019 US birth data to assess changes in preterm birth, cesarean delivery, induction of labor, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention (no labor cesarean or induction) after risk adjustment. The percentage of singleton preterm births in the United States increased by 9.4% from 2014-2019. The percent of singleton, preterm births delivered by cesarean increased by 6.0%, while the percent with induction of labor increased by 39.1%. The percentage of singleton preterm births where obstetrical intervention (no labor cesarean or induction) potentially impacted the gestational age at delivery increased from 47.6% in 2014 to 54.9% in 2019. Preterm interventions were 13% more likely overall in 2019 compared to 2014 and 17% more likely among late preterm births, after controlling for demographic and medical risk factors. Compared to non-Hispanic White women, Non-Hispanic Black women had a higher risk of preterm obstetric interventions. Preterm infants have higher morbidity and mortality rates than term infants, thus any increase in the preterm birth rate is concerning. A renewed effort to understand the trends in preterm interventions is needed to ensure that obstetrical interventions are evidence-based and are limited to those cases where they optimize outcomes for both mothers and babies.

From describing disparities to understanding why disparities exist: Anti-racist methods to support dental public health research

Racism is understudied in the oral health literature at the same time that race is overutilized as an explanatory factor in study design. Social and behavioral methodologies offer conceptual models that can be used to include racism in dental public health questions. In addition, interdisciplinary and mixed methods approaches allow for understanding racism as an underlying cause of social and health disparities and exploring solutions that address historical, institutional, social, political, and economic drivers of oral health inequity, while recognizing the limits of measuring racism quantitatively. In a collective acknowledgement of the limitations of conventional methods, there are new opportunities to explore how qualitative and mixed methods research can serve as drivers for both social justice and health equity, while building and sustaining a diverse research workforce that can better close these disparities and offer antiracist solutions to oral health inequities.

Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings from the MMRIA Racism & Discrimination Working Group

PURPOSE

The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form.

DESCRIPTION

In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality.

ASSESSMENT

Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs.

CONCLUSION

The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

"I just want us to be heard": A qualitative study of perinatal experiences among women of color

OBJECTIVES

Long-standing racial disparities, particularly between White and Black women, in maternal and birth outcomes necessitate an examination of the factors influencing these disparities. This study aimed to understand the experiences of women of color as they relate to pregnancy and/or birth complications to inform policy and strategy to decrease racial and ethnic health disparities.

METHODS

Six focus groups were conducted with women (n = 31) who were identified as a woman of color, were 18 years or older, self-identified as having experienced pregnancy or birth complications after 2016, and who spoke English. A focus group guide co-created with the research team, community partners, and peer researchers from the local community was utilized to elicit discussions related to barriers, successes, and existing opportunities to provide equitable care and services to families throughout the perinatal period. An inductive and iterative approach to qualitative analyses of the focus group transcripts was used to identify key themes.

RESULTS

The seven themes identified include: lack of knowledge, mental health, communication with providers, support systems, representation, social determinants of health, and discrimination and stigma. Women shared a variety of experiences related to their health care from before pregnancy into their post-partum period, revealing many areas for improvement to extant systems.

CONCLUSION

The inclusion of voices of the populations most deeply affected by health disparities is crucial to understanding how care and services provided can be improved. This analysis suggests the need for change at multiple levels of the health care and social services systems. These experiences provide valuable insight into some of the many struggles and barriers that women of color face during pregnancy and beyond.

Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression

Childbirth trauma is common and increases risk for postpartum depression (PPD). However, we lack brief measures to reliably identify individuals who experience childbirth trauma and who may be at greater prospective risk for PPD. To address this gap, we used data from a racially diverse prospective cohort (n=1082). We collected survey data during pregnancy and at 12 weeks postpartum, as well as clinician-reported data from medical records. A new three-item measure of patient-reported childbirth trauma was a robust and independent risk factor for PPD, above and beyond other known risk factors for PPD, including prenatal anxiety and depression. Cesarean birth, greater blood loss, and preterm birth were each associated with greater patient-reported childbirth trauma. Finally, there were prospective indirect pathways whereby cesarean birth and higher blood loss were related to higher patient-reported childbirth trauma, in turn predicting greater risk for PPD. Early universal postpartum screening for childbirth trauma, targeted attention to individuals with childbirth complications, and continued screening for depression and anxiety can identify individuals at risk for PPD. Such efforts can inform targeted interventions to improve maternal mental health, which plays a vital role in infant development.

Mechanisms for racial separation and inequitable maternal care in hospital maternity wards

Few studies have examined mechanisms of racial maternal separation (RMS) of birthing mothers in hospital maternity wards (MWs), and how separation might reinforce institutional healthcare racism and discrimination, leading to inequitable maternal care (MC). In Israel, while birth mothers report mostly pleasant experiences, RMS has become a matter of public debate. Although the Ministry of Health (MoH) condemns the practice, birthing Palestinian-Arab women have sued hospitals for discrimination after being assigned to separate MW rooms from other women. We drew on critical race theory (CRT) and intersectionality to uncover mechanisms for RMS and inequitable MC in hospital MWs at three levels-policy, practice, and women's experiences. In 2019-2020 we conducted 10 in-depth interviews with hospital directors (HDs) and 8 focus groups (FGs) with 40 midwives and nurses; then, in 2020-2021, we held 26 in-depth Zoom interviews with birthing women. Our findings reveal intersecting mechanisms for RMS through which structural racism and institutional discrimination outside hospitals in the form of ethno-racial residential segregation penetrate hospitals via women's requests to maintain separation in MWs. While all HDs opposed RMS and prized quality care, they instituted insufficient mechanisms to prohibit racial separation, which helped to institutionalize the practice. Commodification of Healthcare services (HCS) accelerates RMS as hospitals compete for funds derived from birthing mothers' care. Under the guise of cultural sensitivity and indirect pressure of hospital management, nursing staff comply with requests for RMS. Nurses assigned rooms based on stereotypical categorizations of women's group membership (ethno-national, religiosity level, class). RMS targeted mostly visibly religious Muslim Palestinian-Arab women. These mothers felt MC discrimination; others normalized RMS as preference. While the MoH cannot eliminate outside-hospital structural discrimination, more efforts should be made to eradicate inside-hospital RMS, as the practice violates the principle of universality enshrined in the National Health Insurance Law.

Demographic and Clinical Predictors of Postpartum Blood Pressure Screening Attendance

Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly dangerous, as it can go undiagnosed and cause complications. The American College of Obstetricians and Gynecologists recommends women with HDP undergo blood pressure (BP) screening 7-10 days after delivery to detect postpartum hypertension. This study aimed to describe predictors of postpartum BP screening attendance among a high-risk safety-net population in Atlanta, Georgia. Materials and Methods: We conducted a population-based cohort study of pregnant women who delivered at a large public hospital in Atlanta between July 1, 2016, and June 30, 2018. We manually abstracted demographic and clinical data from electronic medical records and used multivariable log binomial regression to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) for associations with BP screening attendance. Results: Of 1260 women diagnosed with HDP, 13.7% attended a BP screening visit within 10 days of delivery. Women with preeclampsia with severe features were more likely to attend a BP visit than women with gestational hypertension (aRR 2.10, 95% CI 1.35-3.27). Rates of BP screening attendance were lower for women with inadequate (aRR 0.42, 95% CI 0.26-0.67) and intermediate (aRR 0.40, 95% CI 0.21-0.74) prenatal care utilization relative to women with adequate utilization. Conclusions: Among a high-risk safety-net population with HDP, most women did not attend a BP screening visit within 10 days of delivery. Addressing this gap requires further research and creative solutions to address barriers at the individual, provider, and system levels.

A new perspective on the maternal mortality disparity

The disparity in maternal mortality rates between ethnicities in the United States is alarming, with Black women at far higher risk of dying than women of other ethnicities. Factors typically thought of as protective in health disparity research are not necessarily protective with maternal mortality. Building upon a social justice framework by utilizing a strength-based focus is needed when addressing this issue to build upon strengths and empower Black women as a part of the solution.

Birthing #blackboyjoy: Black Midwives Caring for Black Mothers of Black Boys During Pregnancy and Childbirth

Background

Structural racism mediates all aspects of Black life. The medicalization of pregnancy and childbirth, and its detrimental impacts on Black birth, is well documented. The Black Lives Matter movement has elevated the national consciousness on all aspects of Black life, but significant attention has been directed toward the murder and dehumanization of Black men and boys. Black midwives, caring for Black people, using the Midwives Model of Care© which consistently demonstrates its efficacy and better outcomes for Black people, are uniquely positioned to witness the physical and psychosocial experiences of birthing Black boys in America.

Methods

Between 2011 and 2013, the first author conducted interviews with 22 Black midwives to understand their perceptions of, and experiences in, predominantly white midwifery education programs and professional organizations. Convenience and snowball sampling were used. This paper investigates previously unreported and unexamined data from the original study by focusing on the witness and insight of nine midwives who provided care for Black mothers of boys during pregnancy and childbirth.

Findings

The data presented three themes: It’s a Boy: On Restlessness and Complicated Uneasiness; Desensitization of Black Death; and, Physiological Impacts of Toxic Stress.

Conclusions

The findings demonstrate that caring for Black people must be simultaneously theorized and executed within an anti-racist, relationship-centered, reproductive justice framework. Black midwives are uniquely positioned to do this work. Greater attention, in practice and in research, is needed to investigate the birth experiences of Black mothers of boys.

Patient and Provider Perspectives on Acceptability, Access, and Adherence to 17-Alpha-Hydroxyprogesterone Caproate for Preterm Birth Prevention

Background: Preterm birth (PTB) is a pressing maternal and child health issue with long-standing racial inequities in outcomes and care provision. 17-Alpha-hydroxyprogesterone caproate (17OHPC) has been one of few clinical interventions for recurrent PTB prevention. Little is known about the factors influencing successful administration and receipt of 17OHPC among mothers in the Medicaid program. Materials and Methods: We conducted individual semistructured interviews with 17OHPC-eligible pregnant women and obstetric providers from two academic medical centers in Philadelphia, PA. Patient participants were publicly insured, eligible for 17OHPC treatment, and purposively sampled as either (1) actively receiving treatment or (2) declining/discontinuing treatment. Providers had experience providing care to Medicaid-enrolled patients. Interview transcripts were coded and analyzed to identify themes related to treatment acceptability, access, and adherence. Results: Of the 17 patient participants, the mean age was 30 years. Ten providers (MDs, nurse practitioners, and registered nurses) were also interviewed. Factors facilitating 17OHPC uptake and adherence among patients included severity of prior PTB, provider counseling, and coordination among the clinic, pharmacy, and insurance. Pain was cited as the most significant barrier to 17OHPC for patients, while providers perceived social adversity and beliefs about patients' commitment to treatment to be primary patient barriers. For providers, clinical experience and practice guidelines contributed to their use of 17OHPC. Administrative complexity and coordination of services were the primary provider barrier to 17OHPC administration. Conclusions: Patient-provider communication is a primary driver of 17OHPC acceptability and adherence. Comprehensive patient-centered consultation may improve uptake of clinical therapies among pregnant women at high risk for PTB.

Reducing Perinatal Health Disparities by Placing Equity at the Heart of Performance Improvement

Multiple studies have demonstrated that low income and Black women in the United States are more likely to suffer from severe maternal morbidity and mortality during childbirth, even when accounting for the site of service. Structural racism, social determinants of health, and personally mediated racism are factors that may play a role. Assessing them is, therefore, critical in the attempt to deliver safe and equitable health care, which is a fundamental charge of performance-improvement committees. We argue that, for performance-improvement committees to fulfill their mandate, they must include equity as an organizing principle. A low rate of adverse outcomes in the overall population served by a hospital is not sufficient if, when stratified by race, a particular group is found to have rates above acceptable limits. In this piece we outline the process by which those charged with assuring optimal quality in departments of obstetrics and gynecology can include equity in their portfolio. This is a key step in moving beyond the recognition that disparities exist and toward a consideration of the specific ways in which inequity contributes to morbidity, and then to implementing steps to mitigate its effects.

Early Stage Investigators: Emerging Research Supporting Health Equity

Ethn Dis. 2020;30(4):517-518; doi:10.18865/ed.30.4.517