Maternal health equity in Georgia: a Delphi consensus approach to definition and research priorities.

BACKGROUND: Pregnancy-related mortality in the United States is the greatest among all high-income countries, and Georgia has one of the highest maternal mortality rates-almost twice the national rate. Furthermore, inequities exist in rates of pregnancy-related deaths. In Georgia, non-Hispanic Black women are nearly 3 times more likely to die from pregnancy-related complications than non-Hispanic White women. Unlike health equity, a clear definition of maternal health equity is lacking, overall and in Georgia specifically, but is needed to reach consensus and align stakeholders for action. Therefore, we used a modified Delphi method to define maternal health equity in Georgia and to determine research priorities based on gaps in understanding of maternal health in Georgia. METHODS: Thirteen expert members of the Georgia Maternal Health Research for Action Steering Committee (GMHRA-SC) participated in an iterative, consensus-driven, modified Delphi study comprised of 3 rounds of anonymous surveys. In round 1 (web-based survey), experts generated open-ended concepts of maternal health equity and listed research priorities. In rounds 2 (web-based meeting) and 3 (web-based survey), the definition and research priorities suggested during round 1 were categorized into concepts for ranking based on relevance, importance, and feasibility. Final concepts were subjected to a conventional content analysis to identify general themes. RESULTS: The consensus definition of maternal health equity created after undergoing the Delphi method is: maternal health equity is the ultimate goal and ongoing process of ensuring optimal perinatal experiences and outcomes for everyone as the result of practices and policies free of interpersonal or structural bias that tackle current and historical injustices, including social, structural, and political determinants of health impacting the perinatal period and life course. This definition highlights addressing the current and historical injustices manifested in the social determinants of health, and the structural and political structures that impact the perinatal experience. CONCLUSION: The maternal health equity definition and identified research priorities will guide the GMHRA-SC and the broader maternal health community for research, practice, and advocacy in Georgia.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes.

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

A Prematurity Collaborative Birth Equity Consensus Statement for Mothers and Babies.

INTRODUCTION: In 2016, March of Dimes (MOD) launched its Prematurity Collaborative to engage a broad cross section of national experts to address persistent and widening racial disparities in preterm birth by achieving equity and demonstrated improvements in preterm birth. African-American and Native American women continue to have disproportionate rates of preterm birth and maternal death. As part of the Collaborative, MOD created the Health Equity Workgroup whose task was the creation of a scientific consensus statement articulating core values and a call to action to achieve equity in preterm birth utilizing health equity and social determinants of health frameworks. METHODS: Health Equity Workgroup members engaged in-person and virtually to discuss key determinant contributors and resolutions for disparate maternal and birth outcomes. Workgroup members then drafted the Birth Equity Consensus Statement that contained value statements and a call to action. The birth equity consensus statement was presented at professional conferences to seek broader support. This article highlights the background and context towards arriving at the core values and call to action, which are the two major components of the consensus statement and presents the core values and call to action themselves. RESULTS: The result was the creation of a birth equity consensus statement that highlights risks and protections of social determinants based on the prevailing science, and identifies promising solutions for reducing preterm birth and eliminating racial disparities. CONCLUSION: The birth equity consensus statement provides a mandate, guiding the work of March of Dimes and the broader MCH community, for equity-based research, practice, and policy advocacy at local, state, and federal levels. SIGNIFICANCE: This field report adds to the current knowledge base on racial and ethnic disparities in birth and maternal health outcomes. Research has documented the science behind eliminating health disparities. Scientists and practitioners should continue to explore in practice how the social determinants of birth and maternal health, which manifest historically and contemporarily, can be addressed.

Anticipated Negative Police-Youth Encounters and Depressive Symptoms among Pregnant African American Women: A Brief Report.

The widely publicized violent encounters between police and African American youth have unknown consequences for the emotional and mental health of pregnant African American women. Since studies document the hypervigilance black mothers exert to protect children from violence and racism and findings also reveal the association between racial and gendered stress (which includes parenting stressors) and depressive symptoms during pregnancy, an examination of the effects of stress from anticipated negative experiences between black youth and police on maternal mental health is warranted. Between July and August 2014, 100 mostly low income pregnant African American women who lived in metropolitan Atlanta and were in their first and second trimesters completed the Edinburgh postnatal depression scale, selected items from the Jackson, Hogue, Phillips contextualized stress measure, and a demographic form. Bivariate and logistic regression analyses were conducted in response to questions that asked: (1) is the anticipation of negative encounters between black youth and police associated with antenatal depressive symptoms and (2) how does the presence of prior children, male or female, contribute to the association? For question 1, the results showed that anticipated negative African American youth-police experiences were significantly associated with antenatal depressive symptoms χ 2 (2, N = 87) = 12.62, p = .002. For question 2, the presence of a preschool-aged male child in the home was significantly associated with antenatal depression (p = .009, odds ratio = 13.23). The observed associations between antenatal depressive symptoms and anticipated negative police-youth encounters have implications for clinical- and community-based interventions responding to the unique psychosocial risks for pregnant African American women.

Examining Life-Course Socioeconomic Position, Contextualized Stress, and Depression among Well-Educated African-American Pregnant Women.

PURPOSE: This article explores how childhood and adulthood socioeconomic position (SEP) and socioeconomic mobility, as indicators of life-course experiences, impact the relationship between contextualized stress and depression among well-educated, pregnant African-American women. METHODS: The Jackson, Hogue, Phillips Contextualized Stress Measure and the Beck Depression Inventory were administered to 101 well-educated, pregnant African-American women during their first and second trimesters. Bivariate associations and regression analysis were conducted to assess life-course SEP, mobility, and contextualized stress as predictors of depression. Based on the demographic data for childhood and adult SES, the SEP and mobility variables were created. RESULTS: Results from χ2 analysis revealed that high contextual stress was significantly associated with no change in mobility, that is, staying the same. Results from regression models found that contextualized stress was the only predictor for depression. Additionally, life-course SEP and mobility did not moderate the relationship between contextualized stress and depression. CONCLUSIONS: Our findings illuminated the persistence of racial and gendered stress as risk factors for depression among well-educated, pregnant African-American women, regardless of life-course SEP. We offer an explanation as to why African-American women who possess the material and social resources thought to mediate psychosocial and pregnancy risks remain in jeopardy.

Save 100 Babies©: engaging communities for just and equitable birth outcomes through Photovoice and Appreciative Inquiry.

This paper presents a community engagement model designed to advance social justice and equity for African American birth outcomes through the combined techniques of Photovoice and Appreciative Inquiry. In response to the persistent racial disparities in birth outcomes, Save 100 Babies© was constructed as a 2-day summit where the emphasis was placed on individual and community assets rather than deficits. The engagement was designed to create a level of readiness among individuals working within and outside the field of Maternal and Child Health to envision strategies to attain equitable birth outcomes. The goal of the conference was to facilitate higher level consciousness by guiding the participants though a process aimed at articulating assets, possibilities and the potential for co-creating the desired futures where racial disparities in birth outcome are eliminated [corrected]. As the result of the guided discourse that began with photographs of the lives of African American women, participants articulated the strengths they detected from the pictures, their recommendations for multifaceted changes in policies and practices, and their individual and organizational commitments for a changed future. Since the summit, participants have indicated ways they have fulfilled their vows that include informing families and communities about pregnancy risks, working with youth programs, supporting fatherhood involvement in pregnancy and birth, and advancing case management that is more attuned to women's strengths. Save 100 Babies© is evolving into a network and clearinghouse for sharing and disseminating information and resources for collaboration.

Contextualized stress, global stress, and depression in well-educated, pregnant, African-American women.

PURPOSE: Well-educated, pregnant, African-American women are disproportionately at risk for adverse birth outcomes and depression linked to stress has been established as a significant contributor to poor birth outcomes. Since racial and gendered stress have been identified as threats to birth outcomes, a cross-sectional study was conducted that utilized the Jackson, Hogue, Phillips Contextualized Stress Measure (JHP), a measurement of racial and gendered stress, and the Perceived Stress Scale (PSS), an assessment of global stress, to detect their associations and predictions for depression as measured by the Beck Depression Inventory II (BDI-II). METHOD: We recruited 101 pregnant, well-educated, African-American women from ob-gyn offices who were administered the JHP, the PSS, and the BDI-II. Correlational, chi-square, and stepwise regression analyses were conducted with the measures and the demographic variables of relationship status, the presence of other children, and annual household income. FINDINGS: The results revealed significant linear and covariate associations for the JHP, PSS, and BDI-II. Correspondingly, chi-square analysis found significant associations for the JHP and the BDI-II and the presence of other children, relationship status, and annual household income. Results from the regression models found that the contextualized and global stress measures were both predictive of depression. Demographic characteristics did not predict depression. CONCLUSION: The results argue for prenatal depression and stress screening. Furthermore, the link between contextualized stress and depression alerts health care providers and local communities to be responsive to the particular stressors that pose risks for pregnant African-American women and their babies.

The development of a race and gender-specific stress measure for African-American women: Jackson, Hogue, Phillips contextualized stress measure.

OBJECTIVE: Community-based research was conducted to develop an identity stress measure for African-American women. The aim of the investigation was to capture the voices of African-American women telling their experiences of stress and support and to have their voices inform the development of an identity stress measure representing the realities of being Black and female. In this paper, we describe the components of a race and gender-specific stress measure emerging from a multidisciplinary iterative process that employed qualitative and quantitative methods. METHOD: The research was initiated by focus groups and interviews where women were asked to share their experiences of stress and support. Four hundred seventy-four (474) African-American women from the metropolitan Atlanta area collaborated in the study by participating in one or more phases of the research. Content analysis of the qualitative data informed the development of a 71-item race and gender-specific stress measure for African-American women. The scale and a battery of validity measures (Spielburger Anger and Anxiety, John Henryism, and NHIS-depression) were administered twice over a 30-day period followed by group discussions and interviews. RESULTS: Content and factor analysis resulted in the development of six subscales: racism, burden, personal history, work, support/coping, and stress states. The measure has been validated with established measures of anger, anxiety, depression. Significant correlations were established for all of the stress subscales and measures of anger (trait anger, anger-in, anger-out, and anger expression). Findings indicate significant correlations for the burden subscale and anger-in (r=.33, <.01) and stress states and trait anxiety (r=.57, <.01).

Considerations for community-based research with African American women.

Although community-based research is intended to be culturally sensitive, more advanced consideration of the impact of race, gender, and class is needed for health disparity research involving women of color. Research processes must permit the simultaneous disclosures of the racial, gender, and class identities among women of color that are assumed and imposed. The authoritative knowledge that women of color have about their lives and their health should form the basis for collaboration between researchers and study participants. The dissemination of research findings to study participants, and dialogue on those findings, is imperative for the development of sustainable interventions.