Supporting Birthing People and Supporting Doulas: The Impact of the COVID-19 Pandemic on a Community-Based Doula Organization in San Francisco.

Background: Beginning in March 2020, health care systems in the United States restricted the number of support people who could be present during pregnancy-related care to reduce the spread of COVID-19. We aimed to describe how SisterWeb, a community-based doula organization that employs Black, Pacific Islander, and Latinx doulas in San Francisco, California, adapted to the COVID-19 pandemic. Methods: As part of process and outcome evaluations conducted through an academic-community partnership, we interviewed SisterWeb doulas, mentors, and leaders in 2020, 2021, and 2022 (n=26 interviews). We identified preliminary themes using the Rapid Assessment Process and then conducted thematic analysis of data related to COVID-19. Results: SisterWeb leadership remained committed to safeguarding doulas by shifting to virtual support until doulas were onboarded as benefitted employees. Doulas reported hospital policies impacted clients' pregnancy-related care. Initially, doulas adapted to virtual support by connecting with clients more frequently through phone and text. When permitted to meet in person, doulas adjusted to client preference. Finally, as the pandemic impacted doulas' well-being, they turned to mentors for emotional support. Discussion and Health Equity Implications: This analysis contributes to a growing body of literature describing doulas' experiences during the pandemic. By shifting to virtual support, SisterWeb leaders prioritized the health, safety, and financial stability of doulas, who were members of communities disproportionately impacted by COVID-19. Our findings suggest that public health guidance, organizational COVID-19 precautions, and hospital policies hindered SisterWeb's goal of ensuring clients receive equitable medical care. In addition, we found that emotional support for doulas is vital to their work.

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.

Clinicians' Perspectives on Racism and Black Women's Maternal Health.

Objective: The objective of this study was to explore clinician perceptions of how racism affects Black women's pregnancy experiences, perinatal care, and birth outcomes. Materials and Methods: We conducted 25 semi-structured interviews with perinatal care clinicians practicing in the San Francisco Bay Area (January to March 2019) who serve racially diverse women. Participants were primarily recruited through "Dear Perinatal Care Provider" email correspondences sent through department listservs. Culturally concordant, qualitatively trained research assistants conducted all interviews in person. The interviews ranged from 30 to 60 minutes and were audio-recorded and professionally transcribed verbatim. We used the constant comparative method consistent with grounded theory to analyze data. Results: Most participants were obstetrician/gynecologists (n = 11, 44%) or certified nurse midwives (n = 8, 32%), had worked in their current role for 1 to 5 years (n = 10, 40%), and identified as white (n = 16, 64%). Three themes emerged from the interviews: provision of inequitable care (e.g., I had a woman who had a massive complication during her labor course and felt like she wasn't being treated seriously); surveillance of Black women and families (e.g., A urine tox screen on the Black baby even though it was not indicated, and they didn't do it on the white baby when, in fact, it was indicated); and structural care issues (e.g., the history of medical racial experimentation). Conclusion: Clinicians' views about how racism is currently operating and negatively impacting Black women's care experiences, health outcomes, and well-being in medical institutions will be used to develop a racial equity training for perinatal care clinicians in collaboration with Black women and clinicians.

"My 9 to 5 Job Is Birth Work": A Case Study of Two Compensation Approaches for Community Doula Care.

With the increased policy emphasis on promoting doula care to advance birth equity in the United States, there is a vital need to identify sustainable and equitable approaches for compensation of community doulas, who serve clients experiencing the greatest barriers to optimal pregnancy-related outcomes. This case study explores two different approaches for compensating doulas (contractor versus hourly employment with benefits) utilized by SisterWeb San Francisco Community Doula Network in San Francisco, California. We conducted qualitative interviews with SisterWeb doulas in 2020 and 2021 and organizational leaders in 2020. Overall, leaders and doulas reported that the contractor approach, in which doulas were paid a flat fee per client, did not adequately compensate doulas, who regularly attend trainings and provide additional support for their clients (e.g., referrals to promote housing and food security). Additionally, this approach did not provide doulas with healthcare benefits, which was especially concerning during the COVID-19 pandemic. As hourly, benefited employees, doulas experienced a greater sense of financial security and wellbeing from receiving consistent pay, compensation for all time worked, and benefits such as health insurance and sick leave, allowing some to dedicate themselves to birth work. Our study suggests that efforts to promote community doula care must integrate structural solutions to provide appropriate compensation and benefits to doulas, simultaneously advancing birth equity and equitable labor conditions for community doulas.

Occurrence of fatal police violence during pregnancy and hazard of preterm birth in California.

BACKGROUND: Exposure to fatal police violence may play a role in population-level inequities in risk for preterm delivery. OBJECTIVE: To evaluate whether exposure to fatal police violence during pregnancy affects the hazard of preterm delivery and whether associations differ by race/ethnicity and fetal sex. METHODS: We leveraged temporal variation in incidents of fatal police violence within census tracts to assess whether occurrence of fatal police violence in a person's tract during pregnancy was associated with increased hazard of extremely (20-27 weeks), early (28-31 weeks), moderate (32-33 weeks), and late (32-36 weeks) preterm delivery in California from 2007 to 2015. We used both death records and the Fatal Encounters database to identify incidents of fatal police violence. We estimated hazard ratios (HR) using time-varying Cox proportional hazard models stratified by census tract, controlling for age, race/ethnicity, educational attainment, health insurance type, parity, and the year and season of conception. We further stratified by race/ethnicity and infant sex to evaluate whether there were differential effects by these characteristics. RESULTS: Exposure to an incident of fatal police violence was associated with a small increase in the hazard of late preterm birth using both the death records (N = 376,029; hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.00, 1.10) and the Fatal Encounters data (N = 938,814; HR 1.03, 95% CI 1.00, 1.06). We also observed an association for moderate preterm birth in the Fatal Encounters data (HR 1.06, 95% CI 0.98, 1.15). We did not observe associations for early or extremely preterm birth in either data source. Larger relative hazards of moderate (HR 1.25, 95% CI 0.93, 1.68) and late preterm delivery (HR 1.18, 95% CI 1.05, 1.33) were observed among Black birth parents with female births in the Fatal Encounters data. CONCLUSIONS: Preventing police use of lethal force may reduce preterm delivery in communities where such violence occurs.

Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among Black birthing communities.

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

Racial diversity in abortion education and intention to provide abortion in postresidency practice: data from the Ryan Program.

BACKGROUND: In 2011, 38% of US reproductive-aged women lived in the 89% of counties with no abortion provider. Physicians from racial and ethnic minority backgrounds (black, Latino, Native American, and Asian American) are more likely than white physicians to practice in underserved areas and serve patients who are poor or minorities. Abortion patients are racially diverse. However, we know little about racial and ethnic makeup of abortion providers and the differences in physicians' interest in providing abortions. OBJECTIVE: The objective of the study was to examine racial differences in participation in abortion training and intention to provide abortion in postresidency practice. STUDY DESIGN: This is a cross-sectional study of Ryan Program residents after completing a family-planning rotation. The Ryan Program supports obstetrics-gynecology residency programs to incorporate routine abortion care into training. Since 2003 the Ryan Residency Program has administered postrotation resident surveys, and race/ethnicity was added in 2015. We assessed correlates of intention to provide abortion, specifically comparing minorities with whites and whether training participation varied by race. We conducted a modified mediation analysis to assess the role of potential mediators in the relationship between race and intention to provide abortion. RESULTS: A total of 777 residents (79.0%) responded from September 2015 through August 2018. The proportions were as follows: 64.9% white, 8.5% black, 4.1% Hispanic/Latino, 18.8% Asian, and 3.8% as other. Overall, 56.9% intended to provide abortion for all indications and 82.4% for pregnancy complications. In a univariate analysis, Asian residents were significantly more likely to intend to provide abortions for all indications compared with white residents (68.4% vs 56.0%, odds ratio, 1.69, confidence interval, 1.13-2.53). This difference was not significant when controlling for religiosity and abortion attitudes. Religiosity (odds ratio, 0.60, confidence interval, 0.47-0.77) and abortion attitude (odds ratio, 3.32, confidence interval, 2.48-4.44) were significantly correlated with intention to provide abortion for nonmedical indications after residency. In a modified mediation analysis, the relationship between race and intention to provide was mediated by religiosity for black residents and abortion attitude for Asian residents. There was no difference in participation in abortion training by race/ethnicity. CONCLUSION: Racial differences in intention to provide abortion in postresidency practice are mediated by religiosity and abortion attitude. Better understanding the intricate relationships between race, religiosity, participation in training, and future practice will allow us to improve abortion training while paving the way to support a more diverse abortion provider workforce.

A framework to promote equity in clinical clerkships.

BACKGROUND: Diversifying the medical student body without striving for equity in the clerkship (first full-time clinical training year) learning environment disadvantages under-represented in medicine (UIM) students and undermines the educational process. CONTEXT: To characterise and address inequities within an internal medicine clerkship, we conducted a multi-phased process to promote equity in the clerkship learning environment at an urban medical school with multiple sites. … we conducted a multi-phased process to promote equity in the clerkship learning environment … INNOVATION: The process to improve the learning environment and equity in the clerkship included: (i) a literature review and needs assessment (focus group) with UIM students; (ii) a medicine clerkship retreat with school leaders and diversity experts to reflect on the needs assessment data and generate interventions to improve equity; (iii) a member checking session with UIM students to ensure that the proposed solutions addressed the inequities that were noted in the needs assessment. IMPLICATIONS: The needs assessment revealed eight themes in the clerkship learning environment that were mapped to a published framework describing barriers encountered by UIM students. These themes informed the development of five clerkship pilot interventions. Implementing interventions inspired by UIM student perspectives may improve the learning environment in clinical clerkships by encouraging a culture of equity. The three-phased approach described here provides leaders who direct educational programmes with a framework to initiate change by characterising inequities as a springboard for developing solutions.

Beyond Silence and Inaction: Changing the Response to Experiences of Racism in the Health Care Workforce.

The issue of race and ethnicity within obstetrics and gynecology has come to the forefront in the current social and political climate. Understanding the ill effects of racism within the clinical space requires an acknowledgment of both the ongoing problem and current limitations in the state of knowledge and praxis among clinicians, trainees, and educators alike. In this commentary, the issue of race and racism within obstetrics and gynecology is discussed through a case of discrimination experienced by an intern working in an urban, academic hospital. By attending to the different layers of hierarchy within medical education and care as well as the multitude of silences from potential allies, we demonstrate a critical need to understand racism and inequality in the clinical and educational space. We deconstruct the issue of race and racism by contextualizing it with ongoing discussions in the social sciences and public health as well as wider discussions of the relationship of race with professional training and employment in biomedical fields. Finally, we offer both action items and calls for future educational and practice-based solutions to affect change in the way obstetrics and gynecology is taught and practiced.

Abortion and contemporary hip-hop: a thematic analysis of lyrics from 1990-2015.

OBJECTIVE: To evaluate the representation of abortion in contemporary hip-hop music, gaining insight into the myriad of attitudes of abortion in the black community. STUDY DESIGN: We used Genius, an online storehouse for lyrical content, to identify songs by querying the database for search terms related to family planning, including slang terms. We then cross-referenced identified songs using an online list of songs about abortion. We analyzed eligible songs using grounded theory in order to identify key themes. RESULTS: Of 6577 songs available, a total of 101 songs performed by 122 individual artists met inclusion criteria. The majority of artists were Black men; five artists were Black women. Key themes were: use of abortion as braggadocio; equating abortion with sin, genocide, or murder; male pressure for women to seek abortion; and the specific association of Planned Parenthood services with abortion. CONCLUSIONS: The moral and ethical themes surrounding abortion in hip-hop lyrics reveal a unique perspective within a marginalized community. The overall negative context of abortion in hip-hop lyrics needs to be reconciled with the gendered, economic, historical, political, racial and ethnic background of hip-hop and rap music in America. IMPLICATIONS: This study is the first to evaluate lyrical content from contemporary popular music in relation to abortion and family planning. Examining the intersection of reproductive rights and popular culture can provide a unique insight into the limited knowledge of the perspectives of abortion in the black community.

Racial and ethnic differences in contraception use and obstetric outcomes: A review.

In the United States, racial and ethnic minority women experience higher rates of contraceptive non-use, failure, unintended pregnancy, and lower use of long-acting reversible contraception (LARC), compared to whites. Simultaneously researchers have found that unintended pregnancy is associated with poor pregnancy outcomes and pregnancy behaviors, including pre-term birth and late initiation of prenatal care, respectively. Due to the association of pregnancy intention and obstetrical outcomes, public health efforts have focused on the increase in contraception use among these populations as a way to decrease poor pregnancy outcomes. In this review, we present the current literature on unintended pregnancy and contraception use by racial and ethnic minorities in the United States and the association of pregnancy intention and obstetrical outcomes and place these associations within the social and historical context in which these patients live and make their reproductive choices.

Connecting Police Violence With Reproductive Health.

Since the police-involved deaths of Michael Brown and Freddie Gray, activists have argued for connecting police violence with reproductive justice. We argue that systematic violence, including police violence, should be evaluated in relation to reproductive health outcomes of individual patients and communities. Beyond emphasizing the relationship between violence and health outcomes, both qualitative and epidemiologic data can be used by activists and caregivers to effectively care for individuals from socially marginalized communities.

Racial and ethnic differences in women's preferences for features of contraceptive methods.

OBJECTIVES: To understand women's preferences for specific features of contraceptive methods, the extent to which features of existing methods match women's preferences and whether this match differs by racial and ethnic subgroups. STUDY DESIGN: Using data from 1783 women in family planning and abortion clinics across the United States, we performed analyses of racial and ethnic differences in contraceptive features reported to be "extremely important" by participants. We explored how preferences vary for more and less effective contraceptive methods. RESULTS: In multivariate analysis, non-Hispanic Black, Latinas and Asian Pacific Islander women were more likely to report the following features as extremely important compared to non-Hispanic Whites (p<0.05): being able to stop using the method at any time, using a method only with intercourse and the method not changing her menstrual periods. Non-Hispanic Black and Latina women were statistically more likely to report that protection against sexually transmitted diseases, having control over when and whether to use the method and being able to become pregnant after stopping use were extremely important. The contraceptive feature preferences of racial and ethnic minority women in our study had a relatively lower match with high efficacy methods and higher match for low efficacy methods compared to White women (p<0.05). CONCLUSIONS: High rates of unintended pregnancy among minority women may be due in part to differences in contraceptive features preferences and discrepancy between their preferences and the features of currently available highly effective methods. IMPLICATIONS: In the context of disparities in rates of unintended pregnancy by racial and ethnic group, this variation in preferences for contraceptive features by race/ethnicity may explain differences in contraceptive use and can inform the development of more acceptable methods of contraception.

Interest in and experience with IUD self-removal.

OBJECTIVES: In the United States, the popularity of intrauterine devices (IUDs) is low despite many positive attributes such as high effectiveness and ease of use. The requirement that a clinician remove the IUD may limit US women's interest in the method. Our objective was to describe women's experience with self-removal and its effect on attitudes toward the method. STUDY DESIGN: We assessed interest in attempting and success in IUD self-removal among women seeking IUD discontinuation from five US health centers. Women were given the option of attempting self-removal of the IUD. Participants were asked to complete two surveys about their reasons for desiring IUD removal, attitudes toward IUD use and experience with self-removal and/or clinician removal. RESULTS: Three hundred twenty-six racially diverse women participated (mean age, 28 years; body mass index, 27; duration of IUD use, 3 years); more than half were willing to try self-removal [95% confidence interval (CI): 45-65%], and among those who tried, one in five was successful (95% CI: 14-25%). More than half of participants (54%) reported they were more likely to recommend IUD use to a friend now that they know that it might be possible to remove one's own IUD; 6% reported they were less likely to recommend the IUD to a friend. African American women were particularly interested in the option of IUD self-removal. CONCLUSIONS: Many women are interested in the concept of IUD self-removal, although relatively few women currently succeed in removing their own IUD. IMPLICATIONS: Health educators, providers and advocates who inform women of this option potentially increase IUD use, reducing rates of undesired pregnancy.

Can women accurately assess the outcome of medical abortion based on symptoms alone?

BACKGROUND: The primary purpose of this study was to evaluate whether women undergoing medical abortion can accurately assess abortion outcome based on symptoms alone. Our secondary aim was to identify predictors of medical abortion failure. STUDY DESIGN: We conducted a case-control study of women undergoing medical abortion from January 1, 2004, to December 31, 2005, who were 63 days' gestation or less and received 200 mg mifepristone followed by 800 mcg of vaginal misoprostol 6-72 h later. Cases were defined as women who required uterine evacuation for a retained gestational sac or ongoing pregnancy. Separate analyses were conducted for the subset of cases with ongoing pregnancies. Controls were defined as women who successfully expelled the pregnancy without uterine evacuation. RESULTS: During the study period, 53 women had a retained gestational sac (N = 26) or ongoing pregnancy (N = 27), and a total of 53 controls were selected, matched by site and date of procedure. Case subjects were more likely than controls to report minimal vaginal bleeding and ongoing pregnancy symptoms and to express doubt that they expelled the pregnancy. When predictive modeling was performed, ongoing pregnancy symptoms, minimal bleeding and gestational age as determined by ultrasound measurement of gestational sac or crown-rump length accurately identified only 68% of medical abortion failures. We also found that the odds of medical abortion failure decreased progressively from approximately 4 to 7 weeks' gestational age, was lowest at approximately 7 weeks and increased from 7 to 9 weeks' gestation. CONCLUSION: Patient symptomatology and self-assessment of complete abortion alone are moderately useful in identifying medical abortion failure. An objective measure of complete abortion, such as a pregnancy test, is still required.