Structural Violence and Stress Experiences of Young Pregnant Black People.

INTRODUCTION: Approximately 10-20% of individuals suffer from mental health concerns during the prenatal period due to their vulnerability and emotional responses to stressful events. Mental health disorders are more likely to be disabling and persistent for people of color, and they are less likely to seek treatment due to stigma. Young pregnant Black people report experiencing stress due to isolation, feelings of conflict, lack of material and emotional resources, and support from significant others. Although many studies have reported the types of stressors experienced, personal resources, emotional stress responses on pregnancy, and mental health outcomes, there is limited data on young Black women's perceptions of these factors. METHODS: This study utilizes the Health Disparities Research Framework to conceptualize drivers of stress related to maternal health outcomes for young Black women. We conducted a thematic analysis to identify stressors for young Black women. RESULTS: Findings revealed the following overarching themes: Societal stress of being young, Black, and pregnant; Community level systems that perpetuate stress and structural violence; Interpersonal level stressors; Individual level effects of stress on mom and baby; and Coping with stress. DISCUSSION: Acknowledging and naming structural violence and addressing structures that create and fuel stress for young pregnant Black people are important first steps to interrogating systems that allow for nuanced power dynamics and for recognizing the full humanity of young pregnant Black people.

A Comparison of Obstetric Interventions and Outcomes Between Black and White Patients at an Urban Tertiary Medical Center.

The objective of the study is to evaluate whether rates of selected labor and delivery interventions and severe maternal morbidity (SMM) differ between Black and White pregnant patients. This retrospective observational cohort study included all Black or White pregnant patients who delivered at the University of Chicago Medical Center between January 2015 and December 2019. Data queried included demographic information, antepartum complications, preterm interventions, labor and delivery events, and neonatal outcomes. SMM was a composite outcome, including intensive care unit admission, blood transfusion, hysterectomy, eclampsia, cardiac arrest, or death. In total, 10,885 parturients (9001 Black and 1884 White) and 11,211 neonates (9254 born to Black and 1957 to White patients) were included in the study. Black patients were more likely to have preterm labor (3.51% vs. 1.86%, p = 0.0002) and no prenatal care (17.83% vs. 4.05%, p < 0.0001). There was no significant difference in the administration of magnesium sulfate for fetal neuroprotection (Black 44.78% vs. White 49.32%, p = 0.48) or antenatal corticosteroids (Black 67.83% vs. White 71.98%, p = 0.28) among those with preterm delivery. There was no significant difference in SMM (Black 2.24% vs. White 2.44%, p = 0.60), and SMM rates decreased over time (OR 0.79 per year, 95% CI: 0.72-0.87, p < 0.0001) for all patients. Black patients had more pregnancy complications, but their complications were addressed with similar rates of obstetrical interventions. In a high-resource setting, there was no difference in rates of SMM when compared to White patients.

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.

Melanated Group Midwifery Care: Centering the Voices of the Black Birthing Community.

Access to safe and dignified pregnancy, childbirth, and postpartum experiences is a fundamental right for all pregnant and postpartum people. In the United States, systemic racism fuels distrust and disengagement in a health care system that continues to dehumanize the Black community. The respectful maternity care literature explains how these systemic, structural, and institutional failings produce maternal health disparities and expose a pattern whereby Black women receive less adequate maternity care. The implementation of trustworthy policies and practices is urgently needed because no single intervention has or will substantially reduce maternal disparities. The purpose of this article is to describe a multicomponent maternity care innovation, Melanated Group Midwifery Care (MGMC). MGMC was codesigned with community partners and is responsive to the needs and desires of Black women, making MGMC a culturally adapted and patient-centered model. Racial concordance among care providers and patients, group prenatal care, perinatal nurse navigation, and 12 months of in-home postpartum doula support are 4 evidence-based interventions that are bundled in MGMC. We posit that a model that restructures maternity care to increase health system accountability and aligns with the needs and desires of Black pregnant and postpartum people will increase trust in the health care system and result in better clinical, physical, emotional, and social outcomes.

Racial Differences in Readmissions in Hypertensive Disorders of Pregnancy.

Hypertensive disorders of pregnancy (HDP) are associated with maternal and neonatal morbidity as well as postpartum hospital readmission. This study seeks to characterize differences among patients with postpartum readmissions related to HDP. This is a retrospective study of patients with HDP admitted at an urban tertiary care center from January 2019 to November 2019 following the implementation of a standardized readmission workflow for patients with HDP at a single institution. Medical information up to 6 weeks postpartum was collected by chart review. The primary outcome was readmission. Secondary outcomes included reason for readmission, location of initial evaluation, and blood pressure values at time of readmission. A total of 729 patients with HDP delivered over the study period, 79.7% (N = 581) of whom were Black and 11.0% (N = 80) of all patients were readmitted within 6 weeks of delivery. Patients who were older, privately insured, and with chronic hypertension/cardiac disease were more likely to be readmitted. There was no difference in readmission rate by race. However, Black patients were more likely to be readmitted for preeclampsia with severe features (43.3% vs 10.0% non-Black, p = 0.01). Black patients who were readmitted were more likely to be initially evaluated in the emergency room compared to non-Black patients (43.3% vs 15.0%, p = 0.03). Our results suggest although readmission rates did not differ by race, there are significant differences at the patient and system level between Black and non-Black patients readmitted to the hospital after a pregnancy affected by HDP.

Elimination of racial disparities in postpartum hypertension follow-up after incorporation of telehealth into a quality bundle.

BACKGROUND: Black people have a disproportionately higher risk of hypertensive disorders of pregnancy and postpartum complications than White people but historically lower rates of postpartum follow-up. Few studies have investigated telehealth in the postpartum population. OBJECTIVE: This study aimed to investigate whether rapid switch to telehealth with audio-based visits during the COVID-19 pandemic decreased racial disparities in postpartum hypertension follow-up adherence. STUDY DESIGN: This retrospective cohort study included all the patients with hypertensive disorders of pregnancy who delivered between December 2019 and June 2020 at an urban tertiary care center. A preexisting postpartum hypertension quality improvement initiative was in place at this institution. Follow-up adherence within 6 weeks postpartum and at the 6-week visit were compared before February 15, 2020 (pretelehealth period) and following March 14, 2020 (post-telehealth period), with a 1-month implementation or washout period. The blood pressures at these visits were compared between time periods as a secondary outcome. RESULTS: A total of 473 patients were included in this analysis, of whom 76.3% were non-Hispanic Black. There were 215 and 258 patients in the pre- and post-telehealth cohorts, respectively. Among those who attended follow-up, the proportion of visits done over telehealth went from 0% pretelehealth to 98.0% post-telehealth. The proportion of postpartum hypertension follow-up attendance changed from 48.5% to 76.3% among non-Hispanic Black people (P<.0001) and from 73.1% to 76.7% among non-Hispanic White people (P=.76), leaving only a 0.4% racial gap (P=.97). This resulted in an elimination of the racial disparities in the post-telehealth period. CONCLUSION: Transition to telehealth with audio-based visits at the onset of the COVID-19 pandemic improved attendance at postpartum hypertension visits among non-Hispanic Black people. This, therefore, led to significant decreases in the racial disparities in follow-up rates at our institution in the setting of an existing quality improvement initiative. Further research should focus on the intentional use of telehealth in improving maternal outcomes, especially among the non-Hispanic Black people.

Postpartum Outcomes With Systematic Treatment and Management of Postpartum Hypertension.

OBJECTIVE: To test the ability of a hospital-wide, bundled quality-improvement initiative to improve postpartum maternal blood pressure control and adherence to postpartum follow-up among patients with hypertensive disorders of pregnancy. METHODS: This quality-improvement initiative consisted of a bundle of clinical interventions including health care professional and patient education, a dedicated nurse educator, and protocols for postpartum hypertensive disorders of pregnancy care in the inpatient, outpatient and readmission setting. We implemented this initiative in patients with hypertensive disorders of pregnancy starting in January 2019 at the University of Chicago. The study period was divided into four periods, which correspond to preintervention, distinct bundle roll outs, and postintervention. Our primary outcome was postpartum hypertension visit adherence. Secondary outcomes included blood pressure values and antihypertensive medication use in the immediate postpartum and outpatient postpartum time periods. We then stratified our outcomes by race to assess whether the effect size differed. RESULTS: A total of 926 patients who delivered between September 2018 and November 2019 were included. Postpartum hypertension visit adherence improved from preintervention period compared with the full implementation period (33.5% vs 59.4%, P<.001). Blood pressure in the first 24 hours postpartum decreased from preintervention compared with full implementation (preintervention median [interquartile range] systolic blood pressure 149 mm Hg [138, 159] vs 137 [131, 146] in postimplementation; P<.001). After implementation, fewer patients experienced a blood pressure of 140/90 mm Hg or higher at the first postpartum blood pressure check, when compared with preintervention (39.1% vs 18.5%, P=.004). The effect size did not differ by race. CONCLUSION: A bundled quality-improvement initiative for patients with hypertensive disorders of pregnancy was associated with improved postpartum visit adherence and blood pressure control in the postpartum period.

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse.

'Medical iatrogenesis' was first defined by Illich as injuries 'done to patients by ineffective, unsafe, and erroneous treatments'. Following Lokumage's original usage of the term, this paper explores 'obstetric iatrogenesis' along a spectrum ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym 'UHDVA' for this spectrum. This paper draws attention to the systemic maltreatment rooted in the technocratic model of birth, which includes UH normalized forms of mistreatment that childbearers and providers may not recognize as abusive. Equally, this paper assesses how obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC childbearers. Much of the work on 'obstetric violence' that documents the most detrimental end of the UHDVA spectrum has focused on low-to-middle income countries in Latin America and the Caribbean. Based on a dataset of 62 interviews and on our personal observations, this paper shows that significant UHDVA also occurs in the high-income U.S., provide concrete examples, and suggest humanistic solutions.