Using mHealth to reduce disparities in Black maternal health: Perspectives from Black rural postpartum mothers.

BACKGROUND: Racial disparities are evident in maternal morbidity and mortality rates globally. Black women are more likely to die from pregnancy and childbirth than any other race or ethnicity. This leaves one of the largest gaps in women's health to date. OBJECTIVES: mHealth interventions that connect with women soon after discharge may assist in individualizing and formalizing support for mothers in the early postpartum period. To aid in developing an mHealth application, Black postpartum mothers' perspectives were examined. DESIGN: Utilizing the Sojourner Syndrome Framework and Maternal Mortality & Morbidity Measurement Framework, group interview discussion guides were developed to examine the facilitators and barriers of postpartum transitional care for rural Black women living in the United States to inform the development of a mobile health application. METHODS: In this study, seven group interviews were held with Black mothers, their support persons, and healthcare providers in rural Georgia to aid in the development of the Prevent Maternal Mortality Using Mobile Technology (PM3) mobile health (mHealth) application. Group interviews included questions about (1) post-birth experiences; (2) specific needs (e.g. clinical, social support, social services, etc.) in the postpartum period; (3) perspectives on current hospital discharge processes and information; (4) lived experiences with racism, classism, and/or gender discrimination; and (5) desired features and characteristics for the mobile app development. RESULTS: Fourteen out of the 78 screened participants were eligible and completed the group interview. Major discussion themes included: accessibility to healthcare and resources due to rurality, issues surrounding race and perceived racism, mental and emotional well-being in the postpartum period, and perspectives on the PM3 mobile application. CONCLUSION: Participants emphasized the challenges that postpartum Black women face in relation to accessibility, racism and discrimination, and mental health. The women favored a culturally relevant mHealth tool and highlighted the need to tailor the application to address disparities.

Recommendations to improve maternal health equity among Black women in "The South": A position paper from the SNRS minority health research interest & implementation group.

Black women in the United States experience a higher maternal mortality rate compared to other racial groups. The maternal mortality rate among non-Hispanic Black women is 3.5 times that of non-Hispanic White women and is higher in the South compared to other regions. The majority of pregnancy-related deaths in Black women are deemed to be preventable. Healthy People 2030 directs healthcare providers to advance health equity through societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities. The Southern Nursing Research Society has put forward this position paper to provide recommendations to improve maternal health equity among Black women. Recommendations for nurses, multidisciplinary healthcare providers, policymakers, and researchers are discussed.

Racial Disparities in Severe Maternal Morbidity in an Integrated Health Care System, Southern California, 2008-2017.

OBJECTIVE: The study's objectives were to examine rates of severe maternal morbidity (SMM) over a 10-year period and assess racial/ethnic disparities in SMM among insured women in a large, integrated health care system in Southern California. METHODS: We included Kaiser Permanente Southern California (KPSC) health plan members who gave birth at ≥20 weeks' gestation in a KPSC-owned hospital during 2008-2017. An SMM case was defined as presence of one or more indicators of an SMM event during a birth hospitalization, identified using maternal electronic health records. Crude SMM rates/10,000 births were calculated by year and maternal race/ethnicity. Modified Poisson regression models were used to assess the association between race/ethnicity and SMM adjusted for other maternal demographics, pregnancy characteristics, and preexisting conditions. RESULTS: We identified 5,915 SMM cases among 335,310 births. Crude SMM rates increased from 94.7 per 10,000 in 2008 to 192.6 in 2015 and 249.5 in 2017. Non-Hispanic Black (adjusted risk ratio [aRR] 1.52; 95% confidence interval [CI] 1.37-1.69), Asian/Pacific Islander (aRR 1.29, 95% CI 1.18-1.41), and Hispanic (aRR 1.18, 95% CI 1.10-1.27) women had greater likelihood of SMM than non-Hispanic White women. After further adjusting for preexisting health conditions, differences in SMM by race/ethnicity remained. CONCLUSIONS: SMM rates increased during 2008-2017 and women of racial and ethnic minority groups, particularly non-Hispanic Black women, were more likely to experience an SMM event than non-Hispanic White women. Multilevel approaches to understanding structural and social factors that may be associated with racial and ethnic disparities in SMM are needed to develop and test effective interventions to reduce SMM.

Understanding racial disparities in severe maternal morbidity using Bayesian network analysis.

Previous studies have evaluated the marginal effect of various factors on the risk of severe maternal morbidity (SMM) using regression approaches. We add to this literature by utilizing a Bayesian network (BN) approach to understand the joint effects of clinical, demographic, and area-level factors. We conducted a retrospective observational study using linked birth certificate and insurance claims data from the Arkansas All-Payer Claims Database (APCD), for the years 2013 through 2017. We used various learning algorithms and measures of arc strength to choose the most robust network structure. We then performed various conditional probabilistic queries using Monte Carlo simulation to understand disparities in SMM. We found that anemia and hypertensive disorder of pregnancy may be important clinical comorbidities to target in order to reduce SMM overall as well as racial disparities in SMM.

Factors influencing maternal healthcare seeking in a highland region of Madagascar: a mixed methods analysis.

BACKGROUND: In Madagascar, maternal mortality remains stable and high (426 deaths per 100,000 live births). This situation is mainly due to a delay or lack of use of maternal healthcare services. Problems related to maternal healthcare services are well documented in Madagascar, but little information related to maternal healthcare seeking is known. Thus, this paper aims to identify and analyze the factors that influence the utilization of maternal services, specifically, the use of antenatal care (ANC) during pregnancy and the use of skilled birth attendants (SBAs) at delivery. METHOD: We used quantitative and qualitative approaches in the study. Two communes of the Vakinankaratra region, which are located in the highlands, were the settings. Data collection occurred from October 2016 to July 2017. A total of 245 pregnant women were included and followed up in the quantitative survey, and among them, 35 participated in in-depth interviews(IDIs). Logistic regressions were applied to explore the influencing factors of antenatal and delivery healthcare seeking practices through thematic qualitative analysis. RESULTS: Among the 245 women surveyed, 13.9% did not attend any ANC visits. School level, occupation and gravidity positively influenced the likelihood of attending one or more ANC visits. The additional use of traditional caregivers remained predominant and was perceived as potentially complementary to medical care. Nine in ten (91%) women expressed a preference for delivery at healthcare facilities (HFs), but 61% of births were assisted by a skilled birth attendant (SBA).The school level; the frequency of ANCs; the origin region; and the preference between modern or traditional care influenced the use of SBAs at delivery. A lack of preparation (financial and logistics problems) and women's low involvement in decision making at delivery were the main barriers to giving birth at HFs. CONCLUSION: The use of maternal healthcare services is starting to gain ground, although many women and their relatives still use traditional caregivers at the same time. Relatives play a crucial role in maternal healthcare seeking. It would be necessary to target women's relatives for awareness-raising messages about ANC and childbirth in healthcare facilities and to support and formalize collaborations between traditional healers and biomedical caregivers.

Men perspectives on attending antenatal care visits with their pregnant partners in Misungwi district, rural Tanzania: a qualitative study.

BACKGROUND: Mens'attendance with their pregnant partners at facility-based antenatal care (ANC) visits is important for maternal and child health and gender equality yet remains uncommon in parts of rural Tanzania. This study examined men's perspectives on attending ANC with their pregnant partners in Misungwi District, Tanzania. METHODS: Twelve individual interviews and five focus group discussions were conducted using semi-structured questionnaires with fathers, expectant fathers, and in-depth interviews were done to health providers, volunteer community health workers, and village leaders. Interviews were recorded and transcribed in Swahili and later translated to English. The research team conducted thematic analysis to identify common themes among interviews. RESULTS: We identified two broad themes on the barriers to male attendance at facility-based ANC visits: (1) Perceived exclusion during ANC visits among men (2) Traditional gender norms resulting to low attendance among men. CONCLUSION: Attendance at health facility for ANC visits by men with their pregnant partners in the study areas were challenged by structural and local cultural norms. At the facility men were uncomfortable to sit with women due to lack of specific waiting area for men and that they perceived to be neglected. Local cultural norms demanded women to have secrecy in pregnancy while men perceived not to have a role of being with their partners during ANC visits.

Addressing inequities in maternal health among women living in communities of social disadvantage and ethnic diversity.

The response to the coronavirus outbreak and how the disease and its societal consequences pose risks to already vulnerable groups such those who are socioeconomically disadvantaged and ethnic minority groups. Researchers and community groups analysed how the COVID-19 crisis has exacerbated persisting vulnerabilities, socio-economic and structural disadvantage and discrimination faced by many communities of social disadvantage and ethnic diversity, and discussed future strategies on how best to engage and involve local groups in research to improve outcomes for childbearing women experiencing mental illness and those living in areas of social disadvantage and ethnic diversity. Discussions centred around: access, engagement and quality of care; racism, discrimination and trust; the need for engagement with community stakeholders; and the impact of wider social and economic inequalities. Addressing biomedical factors alone is not sufficient, and integrative and holistic long-term public health strategies that address societal and structural racism and overall disadvantage in society are urgently needed to improve health disparities and can only be implemented in partnership with local communities.

Using the Ecological Systems Theory to Understand Black/White Disparities in Maternal Morbidity and Mortality in the United States.

Maternal morbidity and mortality (MMM) is a significant problem in the USA, with about 700 maternal deaths every year and an estimated 50,000 "near misses." Disparities in MMM by race are marked; black women are disproportionately affected. We use Urie Bronfenbrenner's ecological systems theory to examine the root causes of racial disparities in MMM at the individual (microsystem), interpersonal (mesosystem), community (exosystem), and societal (macrosystem) levels of influence. This review discusses the interaction of these levels of influence on racial disparities related to MMM-covering preconception health, access to prenatal care, implicit bias among health care providers and its possible influence on obstetric care, "maternity care deserts," and the need for quality improvement among black-serving hospitals. Relevant policies-parental leave, Medicaid coverage during pregnancy, and Medicaid expansion-are considered. We also apply the ecological systems theory to identify interventions that would most likely reduce disparities in MMM by race, such as revising the educational curricula of health care professionals, enhancing utilization of alternate prenatal care providers, and reforming Medicaid policies.

Structural Racism and Maternal Health Among Black Women.

Historical foundations rooted in reproductive oppression have implications for how racism has been integrated into the structures of society, including public policies, institutional practices, and cultural representations that reinforce racial inequality in maternal health. This article examines these connections and sheds light on how they perpetuate both racial disparities in maternal health and high rates of maternal mortality and morbidity among Black women.

Health may be compromised by social interactions depending on culture among postpartum Arab and Jewish Israeli women.

BACKGROUND: Social support is generally perceived to facilitate health in postpartum women; however, previous research shows that this is not always true. Social interactions intended to provide support can be perceived as negative and in turn, may have negative impacts on maternal health. The purpose of the present study was to asses if social support and negative interactions at one month after childbirth can predict maternal health four months after childbirth, and if this relationship is influenced by culture. METHODS: This prospective longitudinal cohort study included randomly selected Arab (n = 203) and Jewish (n = 202) women who attended Mother and Child Health Clinics in Northern Israel one month after giving birth. The women were interviewed at one and four months after childbirth using a questionnaire including measures of health (self-reported health (SRH) and health problems), socioeconomic and demographic status, obstetric characteristics, social support, negative social interactions and perceptions of customs and traditions intended to help the mother cope after childbirth. Multivariable regressions were run to identify the variables predicting health four months after childbirth. RESULTS: The response rate for both interviews was 90%. Negative social interactions one month after childbirth significantly predicted health problems in Arab and Jewish women (Beta 0.20 and 0.37 respectively) and SRH among Arab women only (odds ratio (OR) 0.32, confidence interval (CI) 0.19-0.54) four months after childbirth. Social support at one month after childbirth significantly predicted better SRH in both Jewish and Arab women four months after childbirth (OR 2.33, CI 1.38-3.93 and 1.59, CI 1.01-2.46 respectively) and fewer health problems only among Jewish women (Beta - 0.37). CONCLUSIONS: Social support and negative social interactions appear to be predictive of health in postpartum women. Associations varied between Arabs and Jews, indicating that social support may be more important for predicting health among Jewish women and negative interactions may be more important among Arab women. Healthcare practitioners should be aware of the cultural context and social circumstances of postpartum women to ensure they receive the social support and care they need.

Enabling Breastfeeding to Support Lifelong Health for Mother and Child.

The health benefits of breastfeeding are well documented, and more than 80% of US women initiate breastfeeding; however, mothers in the United States face substantial challenges in meeting their personal breastfeeding goals, with approximately 60% weaning earlier than they had intended. In addition, there are significant racial/ethnic inequities in infant-feeding behaviors, and these inequities are a major public health concern. Enabling women to meet their breastfeeding goals is a public health priority. Infant feeding should be addressed as a modifiable health behavior, rather than a lifestyle choice.

Maternal health outcomes of socially marginalized groups in India.

PURPOSE: The present study delves into the health inequalities between the two most socially deprived groups namely Scheduled Tribes (STs) and Scheduled Castes (SCs) in rural India. DESIGN/METHODOLOGY/APPROACH: This study used health-specific three rounds of National Sample Survey Office (NSSO) unit-level data for analyses. Probit model has been used to predict the differences in access to maternal healthcare services. Blinder-Oaxaca decomposition method is used to explore the inequality in health of rural population in India and assess the estimated relative contribution of socioeconomic and demographic factors to inequalities in maternal health. FINDINGS: The study establishes that STs women often perform poorly compared to SCs in terms of maternal health such as antenatal care, postnatal care and institutional delivery. Blinder-Oaxaca decomposition method shows that there exist health inequalities between STs and SCs women. Difference in household income contributes 21-34 percent and women's education 19-24 percent in the gap of utilization of maternal healthcare services between SCs and STs women. A substantial part of this difference is contributed by availability of water at home and geographical region. Finally, the study offers some policy suggestions in order to mitigate the health inequalities among socially marginalized groups of SCs and STs women in rural areas. ORIGINALITY/VALUE: This study measures and explains inequalities in maternal health variables such as antenatal care, postnatal care and institutional delivery in rural India. Research on access to maternal healthcare facilities is needed to improve the health of deprived sections such as STs and SCs in India. The results of this study pinpoint the need for public health decision-makers in India to concentrate on the most deprived and vulnerable sections of the society. This study thus makes a detailed and tangible contribution to the current knowledge of health inequalities between the two most deprived social groups, i.e., SCs and STs.

How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous?

BACKGROUND: The current focus on monitoring health inequalities and the complexity around ethnicity requires careful consideration of how ethnic disparities are measured and presented. This paper aims to determine how inequalities in maternal healthcare by ethnicity change according to different criteria used to classify indigenous populations. METHODS: Nationally representative demographic surveys from Bolivia, Guatemala, Mexico, and Peru (2008-2016) were used to explore coverage gaps across maternal health care by ethnicity using different criteria. Women were classified as indigenous through self-identification (SI), spoken indigenous language (SIL), or indigenous household (IH). We compared the gaps through measuring coverage ratios (CR) with adjusted Poisson regression models. RESULTS: Proportions of indigenous women changed significantly according to the identification criterion (Bolivia:SI-63.1%/SIL-37.7%; Guatemala:SI-49.7%/SIL-28.2%; Peru:SI-34%/SIL-6.3% & Mexico:SI-29.7%/SIL-6.9%). Indigenous in all countries, regardless of their identification, had less coverage. Gaps in care between indigenous and non-indigenous populations changed, for all indicators and countries, depending on the criterion used (e.g., Bolivia CR for contraceptive-use SI = 0.70, SIL = 0.89; Guatemala CR for skilled-birth-attendant SI = 0.77, SIL = 0.59). The heterogeneity persists when the reference groups are modified and compare just to non-indigenous (e.g., Bolivia CR for contraceptive-use under SI = 0.64, SIL = 0.70; Guatemala CR for Skilled-birth-attendant under SI = 0.77, SIL = 0.57). CONCLUSIONS: The indigenous identification criteria could have an impact on the measurement of inequalities in the coverage of maternal health care. Given the complexity and diversity observed, it is not possible to provide a definitive direction on the best way to define indigenous populations to measure inequalities. In practice, the categorization will depend on the information available. Our results call for greater care in the analysis of ethnicity-based inequalities. A greater understanding on how the indigenous are classified when assessing inequalities by ethnicity can help stakeholders to deliver interventions responsive to the needs of these groups.

The oral health of Indigenous pregnant women: A mixed-methods systematic review.

BACKGROUND: Western models of care to improve the oral health of pregnant women have been successfully implemented in the healthcare setting across various developed countries. Even though Indigenous women experience poorer pregnancy and birth outcomes compared to other women, these models have not been developed with Indigenous communities to address the oral health needs of Indigenous pregnant women. This review aimed to understand the oral health knowledge, practices, attitudes and challenges of Indigenous pregnant women globally. METHODS: A comprehensive search including six electronic databases and grey literature up to September 2018 was undertaken (PROSPERO Registration Number: 111402). Quantitative and qualitative evidence exploring at least one of the four oral health domains relating to Indigenous pregnant women worldwide, including women pregnant with an Indigenous child, were retrieved. RESULTS: Eleven publications related to nine studies were included. Indigenous pregnant women's attitudes, practices and challenges relating to their oral health were influenced by socioeconomic and psychosocial factors, and their healthcare context. Availability of dental services varied depending on the healthcare model, whether services were public or private, and whether services met their needs. Although there was little evidence related to oral health knowledge, the literature suggests some misconceptions within this population. CONCLUSIONS: The availability of culturally appropriate dental services that fulfilled the needs of Indigenous pregnant women varied between developed countries. This review highlighted the need for community-tailored dental services and a care coordinator to provide both education and assistance to those navigating services.

Black Maternal and Infant Health: Historical Legacies of Slavery.

The legacies of slavery today are seen in structural racism that has resulted in disproportionate maternal and infant death among African Americans.The deep roots of these patterns of disparity in maternal and infant health lie with the commodification of enslaved Black women's childbearing and physicians' investment in serving the interests of slaveowners. Even certain medical specializations, such as obstetrics and gynecology, owe a debt to enslaved women who became experimental subjects in the development of the field.Public health initiatives must acknowledge these historical legacies by addressing institutionalized racism and implicit bias in medicine while promoting programs that remedy socially embedded health disparities.

Right to Health: A Buzzword in Health Policy in Indonesia.

The "right to health" operates as a buzzword in Indonesia to frame health policies as beneficial to citizens. Right to health is equated with access to Western biomedical services. Within the policy on partnership between biomedical and traditional midwives, only the biomedical midwife can fulfill the right to health. The "traditional" midwife is reframed as her assistant. Right to health language hides underlying tensions in relationships between these two categories of midwives by presenting the policy as mutually beneficial. Right to health language is effective in the post-Suharto era as it aligns with other incontestable values, including democracy and modernity.

Racial and ethnic disparities in severe maternal morbidity prevalence and trends.

PURPOSE: Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors. METHODS: We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997-2014 (n = 8,252,025). RESULTS: The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics. CONCLUSIONS: The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

"There Is a Big Question Mark": Managing Ambiguity in a Moroccan Maternity Ward.

In Morocco, where extramarital sex and abortion are illegal, single mothers' ambiguous status before the law inflects medical decision-making. Leaky boundaries between the court and the hospital required doctors and administrators to work with multiple forms of documentation while anticipating external surveillance. Gaps between everyday experience and legalized forms of identity created confusion across multiple institutions. When discussing single mothers, hospital staff often spoke of "question marks" that flagged tensions between legibility and liability, disappearance and documentation. Managing question marks ramified surveillance and categorization. Ultimately, however, attempts to administratively resolve single mothers' ambiguity created gaps and inconsistencies that allowed vulnerable patients to disappear from view.