Development and testing of a decision aid to achieve shared decision-making for routine labor induction.

BACKGROUND: This quality improvement project aimed to create a decision aid for labor induction in healthy pregnancies at or beyond 39 weeks that met the needs of pregnant people least likely to experience shared decision-making and to identify and test implementation strategies to support its use in prenatal care. METHODS: We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery practices at a tertiary care hospital and two community health centers. Outcomes included patients' understanding of their choices, pros and cons of choices, and the decision being theirs or a shared one with their provider. RESULTS: Patient interview data indicated that shared decision-making on labor induction was achieved. Across three Plan-Do-Study-Act cycles, we interviewed a diverse group of 24 pregnant people: 20 were people of color, 16 were publicly insured, and 15 were born outside the United States. All but one (23/24) reported feeling the decision was theirs or a shared one with their provider. The majority could name induction choices they had along with pros and cons. Interviewees described the decision-making experience as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers stated the tool helped improve the quality of their counseling and reduce bias. CONCLUSION: This project suggests that using an evidence-based and well-tested decision aid can help achieve shared decision-making on labor induction for a diverse group of pregnant people.

Racial inequities in the course of treating perinatal mental health challenges: Results from listening to mothers in California.

BACKGROUND: Concern with depression during the perinatal period has resulted in multiple states enacting legislation to require universal screening of mothers for postpartum depression. Despite this concern, rates of women receiving mental health counseling during pregnancy and postpartum remain low. This study examines factors, especially inequities in race/ethnicity, associated with receiving perinatal mental health counseling. METHODS: This study draws on data from the Listening to Mothers in California survey of 2539 women, based on a representative sample of birth certificate files of women who gave birth in 2016. The survey included a series of mental health questions, based on the 4-item Patient Health Questionnaire (PHQ-4), and questions on the receipt of counseling, whether a practitioner asked respondents about their mental health, and whether the respondent was taking medications for anxiety or depression. RESULTS: We found non-Latina Black women to experience both higher rates of prenatal depressive symptoms and significantly lower use of postpartum counseling services and medications than non-Latina White women. Among women with depressive symptoms, those asked by a practitioner about their mental health status reported a 46% rate of counseling compared with 20% who were not asked, and in a multivariable analysis, those asked were almost six times more likely (aOR 5.96; 95% CI 1.6-21.7) to report counseling. DISCUSSION: These findings lend evidence to those advocating for state laws requiring universal screening for depressive symptoms to reduce inequities and help address the underuse of counseling services among all women with depressive symptoms, particularly women of color.

Preterm Birth Among US and Foreign-Born Non-Hispanic Black Birthing Parents in Massachusetts: Variation by Nativity, Region, and Country of Origin.

INTRODUCTION: Foreign-born non-Hispanic Black (NHB) birthing parents are less likely to have a preterm birth (PTB) than US-born NHBs. There is further variation by region and country of origin. We update previous studies by examining PTB rates by nativity, region and country of origin among NHBs in Massachusetts, a state with a heterogeneous population of foreign-born NHBs, including communities excluded from previous studies. METHODS: Using 2011-2015 natality data from the three largest metropolitan areas in Massachusetts, we documented associations between nativity, region, and 18 individual countries of origin and PTB, using multivariable logistic regression to adjust for individual-level risk factors. RESULTS: PTB was highest among US-born NHBs (9.4%) and lowest among those from Sub-Saharan Africa (SSA) (6.6%). Country-specific rates ranged from 4.0% among Angolans to 12.6% among those from Barbados and Trinidad and Tobago. While NHBs from SSA had significantly lower odds of PTB, risk among those from the Caribbean and Brazil was not different from US-born NHBs. The significantly lower risk among foreign-born NHBs and SSAs, in particular, remained robust in adjusted models. DISCUSSION: Individual-level factors do not explain observed variation among NHB birthing parents. Future research should investigate explanations for lower PTB risk among SSAs, and congruent risk among foreign-born Caribbeans, Brazilians and US-born NHBs. Exposure to racism, a known risk factor for PTB, likely contributes to these inequities in PTB and merits further exploration. Prenatal care providers should assess place of birth among foreign-born NHBs, as well as exposure to racial discrimination among all NLB birthing parents.

The Time has Come for All States to Measure Racial Discrimination: A Call to Action for the Pregnancy Risk Assessment Monitoring System (PRAMS).

INTRODUCTION: Racial/ethnic inequities in preterm birth (PTB) are well documented. Most of this research has focused on maternal behavioral and socio-demographic characteristics. However, the full magnitude of the racial/ethnic gap remains inadequately understood. Studies now point to the role of racial discrimination in producing PTB inequities, but limitations exist, namely the use of a single, dichotomous item to measures discrimination and the limited generalizability of most studies which have been conducted in single cities or states. METHODS: In this commentary we briefly review extant research on explanations for racial/ethnic inequities in PTB, and the role of racial discrimination in producing the racial/ethnic gap in adverse birth outcomes such as PTB. RESULTS: The Pregnancy Risk Assessment Monitoring System (PRAMS), a state-level, population-based survey, annually collects data from 51 states and cities ("states") on maternal behaviors and experiences in the perinatal period. The questionnaire consists of mandatory "Core" questions, and optional "Standard" questions. Currently 22 states include a "Standard" question on discrimination; 29 do not. PRAMS offers a unique opportunity to systematically assess discrimination among a diverse, population-based sample across the US. DISCUSSION: We urge PRAMS to at least include the current measure of discrimination as a mandatory "Core" question. Ideally, PRAMS should include a validated discrimination scale as a "Core" question. The time has come to name and assess the impact of discrimination on adverse birth outcomes. PRAMS can play a vital role in helping to close the racial/ethnic gap in PTB.

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey.

BACKGROUND: In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction. METHODS: To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth. RESULTS: Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth. CONCLUSIONS: While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.

Maternal perceptions of the experience of attempted labor induction and medically elective inductions: analysis of survey results from listening to mothers in California.

BACKGROUND: The rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women's experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section. METHODS: Study data are drawn from the 2119 respondents to the Listening to Mothers in California survey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective. RESULTS: Almost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21-4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11-2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93-6.90). CONCLUSION: Clinicians counselling mothers concerning the need for labor induction should be aware of mothers' perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction.

Early-life exposure to PM2.5 and risk of acute asthma clinical encounters among children in Massachusetts: a case-crossover analysis.

BACKGROUND: Associations between ambient particulate matter < 2.5 µm (PM2.5) and asthma morbidity have been suggested in previous epidemiologic studies but results are inconsistent for areas with lower PM2.5 levels. We estimated the associations between early-life short-term PM2.5 exposure and the risk of asthma or wheeze clinical encounters among Massachusetts children in the innovative Pregnancy to Early Life Longitudinal (PELL) cohort data linkage system. METHODS: We used a semi-bidirectional case-crossover study design with short-term exposure lags for asthma exacerbation using data from the PELL system. Cases included children up to 9 years of age who had a hospitalization, observational stay, or emergency department visit for asthma or wheeze between January 2001 and September 2009 (n = 33,387). Daily PM2.5 concentrations were estimated at a 4-km resolution using satellite remote sensing, land use, and meteorological data. We applied conditional logistic regression models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CI). We also stratified by potential effect modifiers. RESULTS: The median PM2.5 concentration among participants was 7.8 µg/m3 with an interquartile range of 5.9 µg/m3. Overall, associations between PM2.5 exposure and asthma clinical encounters among children at lags 0, 1 and 2 were close to the null value of OR = 1.0. Evidence of effect modification was observed by birthweight for lags 0, 1 and 2 (p < 0.05), and season of clinical encounter for lags 0 and 1 (p < 0.05). Children with low birthweight (LBW) (< 2500 g) had increased odds of having an asthma clinical encounter due to higher PM2.5 exposure for lag 1 (OR: 1.08 per interquartile range (IQR) increase in PM2.5; 95% CI: 1.01, 1.15). CONCLUSION: Asthma or wheeze exacerbations among LBW children were associated with short-term increases in PM2.5 concentrations at low levels in Massachusetts.

Correction to: Early-life exposure to PM2.5 and risk of acute asthma clinical encounters among children in Massachusetts: a case-crossover analysis.

After publication of the article [1], it was brought to our attention that a number in Table 1 is incorrect.

The Prevalence and Impact of Substance Use Disorder and Treatment on Maternal Obstetric Experiences and Birth Outcomes Among Singleton Deliveries in Massachusetts.

Objectives Despite widely-known negative effects of substance use disorders (SUD) on women, children, and society, knowledge about population-based prevalence and impact of SUD and SUD treatment during the perinatal period is limited. Methods Population-based data from 375,851 singleton deliveries in Massachusetts 2003-2007 were drawn from a maternal-infant longitudinally-linked statewide dataset of vital statistics, hospital discharges (including emergency department (ED) visits), and SUD treatment records. Maternal SUD and SUD treatment were identified from 1-year pre-conception through delivery. We determined (1) the prevalence of SUD and SUD treatment; (2) the association of SUD with women's perinatal health service utilization, obstetric experiences, and birth outcomes; and (3) the association of SUD treatment with birth outcomes, using both bivariate and adjusted analyses. Results 5.5% of Massachusetts's deliveries between 2003 and 2007 occurred in mothers with SUD, but only 66% of them received SUD treatment pre-delivery. Women with SUD were poorer, less educated and had more health problems; utilized less prenatal care but more antenatal ED visits and hospitalizations, and had worse obstetric and birth outcomes. In adjusted analyses, SUD was associated with higher risk of prematurity (AOR 1.35, 95% CI 1.28-1.41) and low birth weight (LBW) (AOR 1.73, 95% CI 1.64-1.82). Women receiving SUD treatment had lower odds of prematurity (AOR 0.61, 95% CI 0.55-0.68) and LBW (AOR 0.54, 95% CI 0.49-0.61). Conclusions for Practice SUD treatment may improve perinatal outcomes among pregnant women with SUD, but many who need treatment don't receive it. Longitudinally-linked existing public health and programmatic records provide opportunities for states to monitor SUD identification and treatment.

Differences by gender at twelve months in a brief intervention trial among Mexican-origin young adults in the emergency department.

In this study, we investigate the role of gender in prevalence and consequences of binge drinking and brief intervention outcomes among Mexican-origin young adults aged 18-30 years at the U.S.-Mexico border. We conducted a secondary analysis, stratified by gender, from a randomized controlled trial of a brief motivational intervention in a hospital emergency department. Intervention effects for males included reductions in drinking frequency, binge drinking, and alcohol-related consequences. For females the intervention was associated with reduction in drinking frequency and binge drinking but did not have a significant effect on alcohol-related consequences. Results suggest a new direction for tailoring interventions to gender.

Prepregnancy Obesity and Primary Cesareans among Otherwise Low-Risk Mothers in 38 U.S. States in 2012.

BACKGROUND: The United States has recently experienced increases in both its rate of obesity and its cesarean rate. Our objective was to use a new item measuring prepregnancy body mass index (BMI) on the U.S. Standard Certificate of Live Birth to examine at a population level the relationship between maternal obesity and primary cesarean delivery for women at otherwise low risk for cesarean delivery. METHODS: By 2012, 38 states with 86 percent of United States births had adopted the U.S. Standard Certificate. The sample was limited to the 2,233,144 women who had a singleton, vertex, term (37-41 weeks) birth in 2012 and no prior cesarean. We modeled the likelihood of a primary cesarean by BMI category, controlling for maternal socio-demographic and medical characteristics. RESULTS: Overall, 46.4 percent of otherwise low-risk mothers had a prepregnancy BMI in the overweight (25.1%) or obese (21.3%) categories, with the obese category distributed as follows: obese I (BMI 30.0-34.9, 12.4%); obese II (BMI 35.0-39.9, 5.5%); and obese III (BMI 40+, 3.5%). Obesity rates were highest among American Indian and Alaska Native (32.5%) and non-Hispanic black mothers (30.5%). After adjustment for demographic and medical risks, the adjusted risk ratios (95% confidence intervals) of cesarean for low-risk primiparas were: 1.61 (1.60-1.63) for obese I, 1.86 (1.83-1.88) for obese II, and 2.21 (2.18-2.25) for obese III mothers compared with mothers in the normal weight category. DISCUSSION: A relationship between prepregnancy obesity and primary cesarean delivery among relatively low-risk mothers remained even after controlling for social and medical risk factors.

Racial and Ethnic Differences in the Likelihood of Vaginal Birth After Cesarean Delivery.

BACKGROUND: A major contributor to the increase in cesarean deliveries over recent decades is the decline in vaginal births after cesarean (VBAC). Racial and ethnic disparities in other perinatal outcomes are widely recognized, but few studies have been directed toward racial/ethnic differences in VBAC rates. METHODS: We used the population-based Massachusetts Pregnancy to Early Life (PELL) database to investigate racial/ethnic differences in rates of VBAC for Massachusetts residents with one prior cesarean from 1998 to 2008. RESULTS: The overall VBAC rate was 17.3 percent. After adjusting for demographic, behavioral, and medical risk factors, non-Hispanic Asian mothers had a greater likelihood of VBAC than non-Hispanic white mothers (adjusted risk ratio 1.31 [95% CI 1.23-1.39]). No other racial/ethnic group was significantly different from non-Hispanic whites in adjusted analyses. The likelihood of VBAC also decreased with increasing maternal age. DISCUSSION: Non-Hispanic Asian women are significantly more likely to have VBAC than non-Hispanic white women. Efforts to reduce cesarean delivery rates in the United States should address these disparities. Future research should investigate factors underlying these differences to ensure that all women have access to appropriate maternity care services.

Labor and Delivery Experiences of Mothers with Suspected Large Babies.

OBJECTIVE: To characterize the prevalence of and factors associated with clinicians' prenatal suspicion of a large baby; and to determine whether communicating fetal size concerns to patients was associated with labor and delivery interventions and outcomes. METHODS: We examined data from women without a prior cesarean who responded to Listening to Mothers III, a nationally representative survey of women who had given birth between July 2011 and June 2012 (n = 1960). We estimated the effect of having a suspected large baby (SLB) on the odds of six labor and delivery outcomes. RESULTS: Nearly one-third (31.2%) of women were told by their maternity care providers that their babies might be getting "quite large"; however, only 9.9% delivered a baby weighing ≥4000 g (19.7% among mothers with SLBs, 5.5% without). Women with SLBs had increased adjusted odds of medically-induced labor (AOR 1.9; 95% CI 1.4-2.6), attempted self-induced labor (AOR 1.9; 95% CI 1.4-2.7), and use of epidural analgesics (AOR 2.0; 95% CI 1.4-2.9). No differences were noted for overall cesarean rates, although women with SLBs were more likely to ask for (AOR 4.6; 95% CI 2.8-7.6) and have planned (AOR 1.8; 95% CI 1.0-4.5) cesarean deliveries. These associations were not affected by adjustment for gestational age and birthweight. CONCLUSIONS FOR PRACTICE: Only one in five US women who were told that their babies might be getting quite large actually delivered infants weighing ≥4000 g. However, the suspicion of a large baby was associated with an increase in perinatal interventions, regardless of actual fetal size.

Refining Measurement of Substance Use Disorders Among Women of Child-Bearing Age Using Hospital Records: The Development of the Explicit-Mention Substance Abuse Need for Treatment in Women (EMSANT-W) Algorithm.

Substance use disorder (SUD) in women of reproductive age is associated with adverse health consequences for both women and their offspring. US states need a feasible population-based, case-identification tool to generate better approximations of SUD prevalence, treatment use, and treatment outcomes among women. This article presents the development of the Explicit Mention Substance Abuse Need for Treatment in Women (EMSANT-W), a gender-tailored tool based upon existing International Classification of Diseases, 9th Edition, Clinical Modification diagnostic code-based groupers that can be applied to hospital administrative data. Gender-tailoring entailed the addition of codes related to infants, pregnancy, and prescription drug abuse, as well as the creation of inclusion/exclusion rules based on other conditions present in the diagnostic record. Among 1,728,027 women and associated infants who accessed hospital care from January 1, 2002 to December 31, 2008 in Massachusetts, EMSANT-W identified 103,059 women with probable SUD. EMSANT-W identified 4,116 women who were not identified by the widely used Clinical Classifications Software for Mental Health and Substance Abuse (CCS-MHSA) and did not capture 853 women identified by CCS-MHSA. Content and approach innovations in EMSANT-W address potential limitations of the Clinical Classifications Software, and create a methodologically sound, gender-tailored and feasible population-based tool for identifying women of reproductive age in need of further evaluation for SUD treatment. Rapid changes in health care service infrastructure, delivery systems and policies require tools such as the EMSANT-W that provide more precise identification methods for sub-populations and can serve as the foundation for analyses of treatment use and outcomes.

The MOSART database: linking the SART CORS clinical database to the population-based Massachusetts PELL reproductive public health data system.

Although Assisted Reproductive Technology (ART) births make up 1.6 % of births in the US, the impact of ART on subsequent infant and maternal health is not well understood. Clinical ART treatment records linked to population data would be a powerful tool to study long term outcomes among those treated or not by ART. This paper describes the development of a database intended to accomplish this task. We constructed the Massachusetts Outcomes Study of Assisted Reproductive Technology (MOSART) database by linking the Society of Assisted Reproductive Technologies Clinical Outcomes Reporting System (SART CORS) and the Massachusetts (MA) Pregnancy to Early Life Longitudinal (PELL) data systems for children born to MA resident women at MA hospitals between July 2004 and December 2008. PELL data representing 282,971 individual women and their 334,152 deliveries and 342,035 total births were linked with 48,578 cycles of ART treatment in SART CORS delivered to MA residents or women receiving treatment in MA clinics, representing 18,439 eligible women of whom 9,326 had 10,138 deliveries in this time period. A deterministic five phase linkage algorithm methodology was employed. Linkage results, accuracy, and concordance analyses were examined. We linked 9,092 (89.7 %) SART CORS outcome records to PELL delivery records overall, including 95.0 % among known MA residents treated in MA clinics; 70.8 % with full exact matches. There were minimal differences between matched and unmatched delivery records, except for unknown residency and out-of-state ART site. There was very low concordance of reported use of ART treatment between SART CORS and PELL (birth certificate) data. A total of 3.4 % of MA children (11,729) were identified from ART assisted pregnancies (6,556 singletons; 5,173 multiples). The MOSART linked database provides a strong basis for further longitudinal ART outcomes studies and supports the continued development of potentially powerful linked clinical-public health databases.

Ethnic, Nativity and Country of Origin Inequities in Preterm Birth Among Hispanic and Non-Hispanic Whites in New York City: What's Stress Got to Do With It?

Hispanic populations experience good birth outcomes despite their socioeconomic disadvantage, a phenomenon referred to as the Hispanic paradox. This health advantage, however, deteriorates over time and understanding of this pattern is limited. Using data from the 2009-2013 New York City (NYC) PRAMS survey linked with birth certificate data, we tested whether stressful life events (SLEs) partially accounted for differences in preterm birth (PTB) between birthing parents across ethnicity, nativity and country of foreign birth (CFB). Experiencing 3+ SLEs in the prenatal period was associated with increased odds of PTB (OR = 1.49, 95% CI 1.13, 1.97). However, stressors were not associated with greater risk of PTB among US-born Hispanic participants, or differences across CFB. SLEs are associated with increased odds of PTB after a threshold of 3+, but do not explain greater PTB among US-born, or some Hispanic subgroups, despite differences in SLEs across ethnicity and CFB among Hispanic birthing parents.

Racial/ethnic variation in breastfeeding across the US: a multilevel analysis from the National Survey of Children's Health, 2007.

We examined whether differences across states in race/ethnicity-specific breastfeeding rates are due solely to state differences in individual factors associated with breastfeeding or additionally, certain state "contextual" factors. Using data from the 2007 National Survey of Children's Health, multilevel models examined whether state variability in race/ethnicity specific breastfeeding initiation and duration to 6 months were explained by (1) individual sociodemographic characteristics of women in states, and (2) an aggregate state measure of the availability of evidence-based maternity care services related to breastfeeding. Observed variability of race/ethnicity-specific breastfeeding rates was only minimally reduced after adjusting for sociodemographic characteristics (Median Odds Ratios (MOR), breastfeeding initiation: non-Hispanic White = 1.46, non-Hispanic Black = 2.26; Hispanic = 1.89. MOR, breastfeeding for 6 months: non-Hispanic White = 1.36, non-Hispanic Black = 1.84; Hispanic = 1.56). Overall variability in the degree of state gaps changed little in adjusted models (breastfeeding initiation: non-Hispanic Black σ(2) = 0.74, se 0.28, Hispanic σ(2) = 0.45, se 0.11; breastfeeding to 6-months: non-Hispanic Black σ(2) = 0.41, se 0.10, Hispanic σ(2) = 0.22, se 0.05). The measure of maternity care services was positively associated with breastfeeding overall but generally did not explain a substantial portion of between-state variability nor the overall variability in racial/ethnic gaps. Contextual sources of variation in state breastfeeding practices and disparities remain poorly understood. Differences in the socioeconomic makeup of states do not fully explain variability. The association of state breastfeeding rates and disparities with relevant policy and practice factors should be further investigated.

The Relationship between Social Support and Postnatal Anxiety and Depression: Results from the Listening to Mothers in California Survey.

BACKGROUND: Perinatal mood and anxiety disorders (PMADs) impact multiple domains of maternal and child well-being. Estimates of postpartum depressive symptoms range from 6.5% to 12.9% and from 8.6% to 9.9% for postpartum anxiety. We sought to identify the role social support could play in mitigating PMADs. METHODS: The data are drawn from the Listening to Mothers in California survey; results are representative of women who gave birth in 2016 in a California hospital. The Patient Health Questionnaire-4 was used to assess total symptoms of PMADs and anxiety and depressive symptoms individually. Two questions adapted from the Medical Outcomes Study Social Support Survey were used to assess emotional, practical, and functional (combined) social support. After exclusions for missing data related to PMADs or social support, we analyzed data from 2,372 women. RESULTS: At the time of survey administration (mean 5.7 months after birth), 7.0% of respondents reported elevated PMAD symptoms and 45.9% reported that they always received functional social support. In multivariable analysis, controlling for demographic and pregnancy-related factors and prenatal anxiety and depressive symptoms, women who reported consistent support had a prevalence of elevated PMAD symptoms one-half that of those who did not (adjusted odds ratio, 0.50; 95% confidence interval, 0.34-0.74). CONCLUSIONS: This study suggests that consistent social support serves as a robust protective factor against postpartum symptoms of PMADs. Because many predictors of PMADs are not modifiable, social support stands out as an important target for programmatic intervention, particularly in light of increased isolation related to the COVID-19 pandemic.

Being Known: A Grounded Theory Study of the Meaning of Quality Maternity Care to People of Color in Boston.

INTRODUCTION: Experiences of people of color with maternity care are understudied but understanding them is important to improving quality and reducing racial disparities in birth outcomes in the United States. This qualitative study explored experiences with maternity care among people of color to describe the meaning of quality maternity care to the cohort and, ultimately, to inform the design of a freestanding birth center in Boston. METHODS: Using a grounded theory design and elements of community-based participatory research, community activists developing Boston's first freestanding birth center and academics collaborated on this study. Semistructured interviews and focus groups with purposefully sampled people of color were conducted and analyzed using a constant comparative method. Interviewees described their maternity care experiences, ideas about perfect maternity care, and how a freestanding birth center might meet their needs. Open coding, axial coding, and selective coding were used to develop a local theory of what quality care means. RESULTS: A total of 23 people of color participated in semistructured interviews and focus groups. A core phenomenon arose from the narratives: being known (ie, being seen or heard, or being treated as individuals) during maternity care was an important element of quality care. Contextual factors, including interpersonal and structural racism, power differentials between perinatal care providers and patients, and the bureaucratic nature of hospital-based maternity care, facilitated negative experiences. People of color did extra work to prevent and mitigate negative experiences, which left them feeling traumatized, regretful, or sad about maternity care. This extra work came in many forms, including cognitive work such as worrying about racism and behavioral changes such as dressing differently to get health care needs met. DISCUSSION: Being known characterizes quality maternity care among people of color in our sample. Maternity care settings can provide personalized care that helps clients feel known without requiring them to do extra work to achieve this experience.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action.

BACKGROUND: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.