Equity in prenatal healthcare services globally: an umbrella review.

BACKGROUND: Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics. METHODS: For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews. RESULTS: The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors. CONCLUSIONS: This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

Fruit and Vegetable Purchasing Patterns and Supplemental Nutrition Assistance Program Participation: Findings From a Nationally Representative Survey.

BACKGROUND: Previous studies suggest that Supplemental Nutrition Assistance Program (SNAP) participants purchase less produce than nonparticipants. Whether this is due to buying smaller amounts or to being less likely to buy any produce is unclear. Purchase patterns may also differ over the monthly distribution cycle. OBJECTIVE: To examine differences in the likelihood and amounts of fruits and vegetables purchased between SNAP household compared with nonparticipant households and to determine differences in produce purchases among SNAP households at different time points in the monthly distribution cycle. DESIGN: Cross-sectional. PARTICIPANTS/SETTING: Data from 4708 households in the National Household Food Acquisition and Purchase Survey (April 2012 to January 2013). Participants recorded all foods acquired over 7 days. MAIN OUTCOME MEASURES: Fruits and vegetables acquired over a 7-day period. STATISTICAL ANALYSES PERFORMED: Weighted logistic and linear regression models adjusting for household and primary respondent characteristics were used to compare odds of purchasing fruits and vegetables and amounts purchased across 3 categories: SNAP participants, SNAP-eligible nonparticipants, and ineligible nonparticipants. SNAP participants were further subdivided according to weeks since last receiving benefits. RESULTS: In adjusted analyses, SNAP participants and nonparticipants were similarly likely to purchase fruits and vegetables. However, SNAP households within a week of receiving benefits were more likely than SNAP households later in the benefit cycle to buy fruit overall, especially frozen or canned fruit, and vegetables overall, including fresh, frozen or canned, starchy, and nonstarchy vegetables (fruit odds ratio [OR] 1.68, 95% confidence interval [CI] 1.12, 2.53; vegetable OR 1.63, 95% CI 1.04, 2.55 vs households in middle of cycle). In contrast, those in the last week of the benefit cycle were less likely to purchase fruit, especially fresh fruit, and vegetables, especially fresh and nonstarchy vegetables (fruit OR 0.58, 95% CI 0.35, 0.94; vegetable OR 0.58, 95% CI 0.42, 0.79 vs. households in middle of cycle), and when they bought vegetables, they bought significantly less. CONCLUSION: Considering all SNAP households together at different points in their distribution cycle masks substantial declines in purchasing fruits and vegetables over the monthly cycle.

The Healthfulness of Food-at-Home Expenditures, the Local Food Environment, and Childhood Obesity.

PURPOSE: Despite the growth of food-away-from-home expenditures, food-at-home (FAH) expenditures still constitute the majority of American families' food dollars. The FAH expenditures may have important impacts on children's diets and, consequently, their weight statuses. This study examined the association between the composition of FAH expenditures and childhood overweight or obesity. DESIGN: We compiled a longitudinal data set from the 2010 to 2012 IRI Consumer Panel and its associated MedProfiler surveys. SETTING: This study took place in the United States. PARTICIPANTS: One thousand seven hundred thirty-one households across the United States, with 2645 children aged 2 to 17, were surveyed over 3 years (2010-2012). MEASURES: The binary outcome variable indicated whether a child was overweight or obese. The key predictor variable-composition of FAH expenditures-was an index reflecting households' adherence to expenditure shares for 24 food categories recommended by the United States Department of Agriculture (USDA) Thrifty Food Plans. The key control variables were FAH expenditure shares from different food stores. ANALYSIS: Data were analyzed by multilevel logistic regressions that controlled for a number of individual-level and household-level characteristics. RESULTS: Higher compliance with the USDA Thrifty Food Plans was associated with lower risk of childhood overweight or obesity. Channel expenditure shares were not significantly associated with the weight outcomes. CONCLUSION: To prevent childhood obesity, the USDA Thrifty Food Plans can provide potential guidelines for households to decide the composition of their FAH expenditures.

Food Environments and Obesity: Household Diet Expenditure Versus Food Deserts.

OBJECTIVES: To examine the associations between obesity and multiple aspects of the food environments, at home and in the neighborhood. METHODS: Our study included 38,650 individuals nested in 18,381 households located in 2104 US counties. Our novel home food environment measure, USDAScore, evaluated the adherence of a household's monthly expenditure shares of 24 aggregated food categories to the recommended values based on US Department of Agriculture food plans. The US Census Bureau's County Business Patterns (2008), the detailed food purchase information in the IRi Consumer Panel scanner data (2008-2012), and its associated MedProfiler data set (2012) constituted the main sources for neighborhood-, household-, and individual-level data, respectively. RESULTS: After we controlled for a number of confounders at the individual, household, and neighborhood levels, USDAScore was negatively linked with obesity status, and a census tract-level indicator of food desert status was positively associated with obesity status. CONCLUSIONS: Neighborhood food environment factors, such as food desert status, were associated with obesity status even after we controlled for home food environment factors.