Contribution of Health Care Practitioner and Maternity Services Factors to Racial Disparities in Alabama: A Qualitative Study.

OBJECTIVE: Black patients are three times more likely to die of pregnancy-related causes than White patients in the United States, and Alabama has the third worst maternal mortality rate in the nation. We sought to identify health care practitioner and maternity service factors contributing to disparities in Alabama, as well as potential strategies to address these contributors. METHODS: We conducted key informant interviews with obstetricians, nurses, doulas, lactation counselors, health system administrators, and representatives of professional organizations who deliver maternity care to racially and ethnically diverse patients in Alabama. The interview guide was developed using Howell's conceptual framework on racial and ethnic disparities in severe maternal morbidity and mortality. Adopting a thematic analysis approach, we coded and analyzed transcripts using NVivo 12 software. Open coding and selective coding were conducted to identify themes related to health care practitioner- and maternity services-level determinants. RESULTS: Overall, 20 health care practitioners or administrators were interviewed. Primary themes related to health care practitioners included implicit bias and explicit racism, lack of communication and lack of positive patient-health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes related to maternity services included lack of accessibility, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Strategies suggested by participants to address these factors included bias trainings for health care practitioners, improvements in racial and interdisciplinary diversity in the maternity workforce, and evidence-based interventions such as group prenatal care, disparities dashboards, simulation trainings, early warning signs criteria, and coordinated care. CONCLUSION: We gained diverse perspectives from health care practitioners and administrators on how maternity health care practitioner and maternity health services factors contribute to inequities in maternal health in Alabama. Strategies to address these contributing factors were multifaceted.

Community and Systems Contributors and Strategies to Reduce Racial Inequities in Maternal Health in the Deep South: Provider Perspectives.

Purpose: Black pregnant individuals in Alabama are disproportionately affected by severe maternal morbidity and mortality (SMM). To understand why racial disparities in maternal health outcomes persist and identify potential strategies to reduce these inequities, we sought perspectives from obstetric health care providers, health administrators, and members of local organizations who provide pregnancy, delivery, and postpartum care services in Alabama. Methods: We conducted qualitative in-depth interviews with stakeholders (n=20), purposively recruited from community-based organizations, clinical settings, government organizations, and academic institutions. Interview guides were based on Howell's conceptual model of pathways to racial disparities in maternal mortality. Data were coded using a modified framework theory approach and analyzed thematically. Results: Racism, unjust laws and policies, and poverty/lack of infrastructure in communities emerged as major themes contributing to racial disparities in maternal health at the community and systems levels. Inadequate health insurance coverage was described as a strong driver of the disparities. Service providers suggested strategies for Alabama should be community focused, evidence based, and culturally sensitive. These should include Medicaid expansion, expanded parental leave, and removal of laws restricting choice. Community- and systems-level interventions should include community infrastructure improvements, choice in maternity services, and provision of digital communication options. Conclusions: Providers shared perspectives on community and structural areas of intervention to reduce racial inequities in SMM. These results can inform discussions with health system and community partners about Alabama and other Deep South initiatives to improve maternal health outcomes in black communities.

Birth includes us: Development of a community-led survey to capture experiences of pregnancy care among LGBTQ2S+ families.

BACKGROUND: Limited research captures the intersectional and nuanced experiences of lesbian, gay, bisexual, transgender, queer, two-spirit, and other sexual and gender-minoritized (LGBTQ2S+) people when accessing perinatal care services, including care for pregnancy, birth, abortion, and/or pregnancy loss. METHODS: We describe the participatory research methods used to develop the Birth Includes Us survey, an online survey study to capture experiences of respectful perinatal care for LGBTQ2S+ individuals. From 2019 to 2021, our research team in collaboration with a multi-stakeholder Community Steering Council identified, adapted, and/or designed survey items which were reviewed and then content validated by community members with lived experience. RESULTS: The final survey instrument spans the perinatal care experience, from preconception to early parenthood, and includes items to capture experiences of care across different pregnancy roles (eg, pregnant person, partner/co-parent, intended parent using surrogacy) and pregnancy outcomes (eg, live birth, stillbirth, miscarriage, and abortion). Three validated measures of respectful perinatal care are included, as well as measures to assess experiences of racism, discrimination, and bias across intersections of identity. DISCUSSION AND CONCLUSIONS: By centering diverse perspectives in the review process, the Birth Includes Us instrument is the first survey to assess the range of experiences within LGBTQ2S+ communities. This instrument is ready for implementation in studies that seek to examine geographic and identity-based perinatal health outcomes and care experiences among LGBTQ2S+ people.

Relationship Between Neighborhood Socioeconomic Disadvantage and Severe Maternal Morbidity and Maternal Mortality.

Background: Rates of severe maternal morbidity and maternal mortality (SMM/MM) in the United States are rising. Disparities in SMM/MM persist by race, ethnicity and geography, and could partially be attributed to social determinants of health. Purpose: Utilizing data from the largest, statewide referral hospital in Alabama, we investigated the relationship between residence in disadvantaged neighborhoods and SMM/MM. Methods: Data on all pregnancies between 2010 and 2020 were included; SMM/MM cases were identified using CDC definitions. Area deprivation index (ADI) available at the census-block group was geographically linked to individual records and categorized using quintile cutoffs; higher ADI score indicated higher socioeconomic disadvantage. Generalized estimating equation models were used to adjust for spatial autocorrelation and ORs were computed to evaluate the relationship between ADI and SMM/MM, adjusted for covariates including age, race, insurance, residence in medically underserved areas/population (MUAP), and urban/rural residence. Results: Overall, 32,909 live-birth deliveries were identified, with a prevalence of 9.8% deliveries with SMM/MM with blood transfusion and 5.3% without blood transfusion, respectively. Increased levels of ADI were associated with increased odds of SMM/MM. Compared to women in the lowest quintile, the adjusted OR for SMM/MM among women in highest quintile was 1.78 (95%CI, 1.22-2.59, P=.0027); increasing age, non-Hispanic Black, government insurance and residence in MUAP were also significantly associated with increased odds of SMM/MM. Conclusion: Our results suggest that residence within disadvantaged neighborhoods may contribute to SMM/MM even after adjusting for patient-level factors. Measures such as ADI can help identify the most vulnerable populations and provide points to intervene.

Coercion and non-consent during birth and newborn care in the United States.

In the United States, Black, Indigenous, and People of Color (BIPOC) experience more adverse health outcomes and report mistreatment during pregnancy and birth care. The rights to bodily autonomy and consent are core components of high-quality health care. To assess experiences of coercion and nonconsent for procedures during perinatal care among racialized service users in the United States, we analyzed data from the Giving Voice to Mothers (GVtM-US) study. METHODS: In a subset analysis of the full sample of 2700, we examined survey responses for participants who described the experience of pressure or nonconsented procedures or intervention during perinatal care. We conducted multivariable logistic regression analyses by racial and ethnic identity for the outcomes: pressure to have perinatal procedures (eg, induction, epidurals, episiotomy, fetal monitoring), nonconsented procedures performed during perinatal care, pressure to have a cesarean birth, and nonconsented procedures during vaginal births. RESULTS: Among participants (n = 2490), 34% self-identified as BIPOC, and 37% had a planned hospital birth. Overall, we found significant differences in pressure and nonconsented perinatal procedures by racial and ethnic identity. These inequities persisted even after controlling for contextual factors, such as birthplace, practitioner type, and prenatal care context. For example, more participants with Black racial identity experienced nonconsented procedures during perinatal care (AOR 1.89, 95% CI 1.35-2.64) and vaginal births (AOR 1.87, 95% CI 1.23-2.83) than those identifying as white. In addition, people who identified as other minoritized racial and ethnic identities reported experiencing more pressure to accept perinatal procedures (AOR 1.55, 95% CI 1.08-2.20) than those who were white. DISCUSSION: There is a need to address human rights violations in perinatal care for all birthing people with particular attention to the needs of those identifying as BIPOC. By eliminating mistreatment in perinatal care, such as pressure to accept services and nonconsented procedures, we can help mitigate long-standing inequities.

Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States.

BACKGROUND: To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States. METHODS: Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects. RESULTS: Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive. CONCLUSION: Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Community-Engaged Curriculum Development in Sexual and Reproductive Health Equity: Structures and Self.

BACKGROUND: Inequitable outcomes in sexual and reproductive health disproportionately burden communities minoritized by systems of oppression. Although there is evidence linking structural determinants to these inequities, clinical learners have limited exposure to these topics in their training. We developed a curriculum aimed to teach clinical learners the structural determinants of sexual and reproductive health. METHOD: We implemented Kern's six-step method for curriculum development. Through literature review, we identified structural competency as the foundational framework and explored community priorities for clinical training. We assessed learner needs regarding structural equity training, articulated goals and objectives, and chose video modules as the primary educational strategy. We collaboratively developed content with community scholars and reproductive justice advocates. For phase 1 of our curriculum, we created pillar videos with reflection questions, resources, and a visual glossary of key terms. All materials are available through an online educational platform offering open-access, evidence-based curricula. EXPERIENCE: We launched our curriculum with a social media campaign and presented our videos at several national convenings. We implemented videos with clinical learners with positive preliminary evaluation results. CONCLUSION: With rigorous development rooted in community engagement, our curriculum contributes to the tools promoting structural equity training in obstetrics and gynecology.

COVID-19's Impact on Women: A Stakeholder-Engagement Approach to Increase Public Awareness Through Virtual Town Halls.

Women face unprecedented challenges imposed by the COVID-19 pandemic. Emerging evidence suggests that women are unduly burdened by inequitable access to economic, health, and social resources during the pandemic. For many women, COVID-19 has presented new urgency to challenges and illuminates unique issues long encountered. Gendered roles such as family caregiving and frontline occupations increase women's exposure to COVID-19 infections and critical outcomes. To increase dialogue around COVID-19's impact on women, the University of Alabama at Birmingham School of Public Health convened a moderated virtual town hall on April 25, 2020, with 2 sexual and reproductive health experts. The town hall was the second in a series to increase public awareness of COVID-19's impact on vulnerable populations. This report highlights policy and practice implications that are particularly relevant for engaging key populations and delivering information to increase public awareness of COVID-19.

Reflecting on Equity in Perinatal Care During a Pandemic.

Growing discourse around maternity care during the pandemic offers an opportunity to reflect on how this crisis has amplified inequities in health care. We argue that policies upholding the rights of birthing people, and policies decreasing the risk of COVID-19 transmission are not mutually exclusive. The explicit lack of standardization of evidence-based maternity care, whether expressed in clinical protocols or institutional policy, has disproportionately impacted marginalized communities. If these factors remain unexamined, then it would seem that equity is not the priority, but retaining power and control is. We advocate for a comprehensive understanding of how this pandemic has revealed our deepest failures.

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.

Working Towards Safe Motherhood: Delays and Barriers to Prenatal Care for Women in Rural and Peri-Urban Areas of Georgia.

Objectives Georgia has the highest rate of maternal mortality in the United States, and ranks 40th for infant mortality. The Georgia Maternal and Infant Health Research Group was formed to investigate and address the shortage of obstetric care providers outside the Atlanta area. Because access to prenatal care (PNC) can improve maternal and infant health outcomes, we used qualitative methods to identify the access barriers experienced by women who live in rural and peri-urban areas of the state. Methods We conducted semi-structured, in-depth interviews with 24 mothers who gave birth between July and August 2013, and who live in either shortage or non-shortage obstetric care service areas. We also conducted key informant interviews with four perinatal case managers, and analyzed all data using applied thematic analysis. We then utilized Thaddeus and Maine's "Three Delays to Care" theoretical framework structure to describe the recognized barriers to care. Results We identified delays in a woman's decision to seek PNC (such as awareness of pregnancy and stigma); delays in accessing an appropriate healthcare facility (such as choosing a doctor and receiving insurance coverage); and delays in receiving adequate and appropriate care (such as continuity of care and communication). Moreover, many participants perceived low self-worth and believed this influenced their PNC exchanges. Conclusion As a means of supporting Georgia's pregnant women who face barriers and delays to PNC, these data provide a rationale for developing contextually relevant solutions to both mothers and their providers.

Obstetric Provider Trainees in Georgia: Characteristics and Attitudes About Practice in Obstetric Provider Shortage Areas.

Objectives In Georgia, 52 % of the primary care service areas outside metropolitan Atlanta have a deficit of obstetric providers. This study was designed to identify factors associated with the likelihood of Georgia's obstetric trainees (obstetrics and gynecology (OB/GYN) residents and certified nurse midwifery (CNM) students) to practice in areas of Georgia that lack obstetric providers and services, i.e. rural Georgia. Methods Pilot-tested electronic and paper surveys were distributed to all of Georgia's OB/GYN residents (N = 95) and CNM students (N = 28). Mixed-methods survey questions assessed characteristics, attitudes, and incentives that might be associated with trainee desire to practice in areas of Georgia that lack obstetric providers and services. Surveys also gathered information about concerns that may prevent trainees from practicing in shortage areas. Univariate and bivariate analyses were performed, and qualitative themes were abstracted from open-ended questions. Results The survey response rate was 87.8 % (108/123). Overall, 24.4 % (19/78) of residents and 53.6 % (15/28) of CNM students expressed interest in practicing in rural Georgia, and both residents and CNM students were more likely to desire to practice in rural Georgia with the offer of any of six financial incentives (P < 0.001). Qualitative themes highlighted trainees' strong concerns about Georgia's political environment as it relates to reproductive healthcare. Conclusions Increasing state-level, rurally-focused financial incentive programs and emphasizing the role of CNMs may alleviate obstetric provider shortages in Georgia.

Georgia Maternal and Infant Health Research Group (GMIHRG): Mobilizing Allied Health Students and Community Partners to Put Data into Action.

Purpose Despite having an obstetrician/gynecologist (ob/gyn) workforce comparable to the national average, Georgia is ranked 50th in maternal mortality and 40th in infant mortality. The Georgia Maternal and Infant Health Research Group (GMIHRG) was founded in 2010 to evaluate and address this paradox. Description In the several years since GMIHRG's inception, its graduate allied health student researchers and advisors have collaborated with community partners to complete several requisite research initiatives. Their initial work demonstrated that over half the Georgia areas outside metropolitan Atlanta lack adequate access to obstetric services, and their subsequent research evaluated the reasons for and the consequences of this maldistribution of obstetric providers. Assessment In order to translate their workforce and outcomes data for use in policymaking and programming, GMIHRG created reader-friendly reports for distribution to a wide variety of stakeholders and prepared concise, compelling presentations with targeted recommendations for change. This commitment to advocacy ultimately enabled them to: (a) inspire the Georgia Study Committees on Medicaid Reform and Medical Education, (b) influence Georgia General Assembly abortion bills, medical scholarship/loan legislation, and appropriations, and (c) motivate programming initiatives to improve midwifery education and perinatal regionalization in Georgia. Conclusion GMIHRG members have employed inventive research methods and maximized collaborative partnerships to enable their data on Georgia's maternal and infant outcomes and obstetric workforce to effectively inform state organizations and policymakers. With this unique approach, GMIHRG serves as a cost-efficient and valuable model for student engagement in the translation of research into advocacy efforts, policy change, and innovative programming.

The Amazing Power of Cancer Cells to Recapitulate Extraembryonic Functions: The Cuckoo's Tricks.

Inflammation is implicated in tumor development, invasion, and metastasis. Hence, it has been suggested that common cellular and molecular mechanisms are activated in wound repair and in cancer development. In addition, it has been previously proposed that the inflammatory response, which is associated with the wound healing process, could recapitulate ontogeny through the reexpression of the extraembryonic, that is, amniotic and vitelline, functions in the interstitial space of the injured tissue. If so, the use of inflammation by the cancer-initiating cell can also be supported in the ability to reacquire extraembryonic functional axes for tumor development, invasion, and metastasis. Thus, the diverse components of the tumor microenvironment could represent the overlapping reexpression of amniotic and vitelline functions. These functions would favor a gastrulation-like process, that is, the creation of a reactive stroma in which fibrogenesis and angiogenesis stand out.