Florida Doulas' Perspectives on Their Role in Reducing Maternal Morbidity and Health Disparities.

BACKGROUND: Maternal mortality rates continue to rise in the United States. Considerable racial disparities exist, as Black women face two to three times the risks of dying from pregnancy-related complications compared with white women. Doulas have been associated with improved maternal outcomes. This study aimed to 1) investigate Florida doulas' perspectives and influence on severe maternal morbidity/mortality and related inequities, as well as 2) identify opportunities for actionable change. The social ecological model, which acknowledges how individual, interpersonal, institutional, community, and public policy factors intersect, informed our analysis. METHODS: This qualitative study included seven online in-depth interviews and seven focus groups with doulas (N = 31) in Florida. Interview guides investigated how doulas perceive their role in the context of a) maternal morbidity and b) health disparities. RESULTS: Doulas associated maternal morbidity and health disparities with Black pregnant people, identifying racism as a major contributor. Doulas identified their role as one that most often intersects with the individual and interpersonal levels of the social ecological model. Doulas report providing positive social surveillance and emotional support, contributing education and resources, and championing for advocacy in health care settings. Actionable steps recommended by doulas to further mitigate health disparities include the integration of implicit bias training into doula certification programs, increasing public health funding to bolster a doula workforce that can serve racial and ethnic communities, establishing doula-hospital partnerships to improve relational communication, providing tailored resources for clients featuring representative messaging, and doulas' continued engagement in positive social surveillance of their clients. CONCLUSIONS: Doulas perceived their role as integral to mitigating maternal morbidity and health disparities, particularly in the context of supporting and advocating for birthing persons on all levels of the social ecological model. Equitable access to doulas for low-income and/or minoritized populations may be one key strategy to improve maternal health equity.

Ethnic disparity in diagnosing asymptomatic bacterial vaginosis using machine learning.

While machine learning (ML) has shown great promise in medical diagnostics, a major challenge is that ML models do not always perform equally well among ethnic groups. This is alarming for women's health, as there are already existing health disparities that vary by ethnicity. Bacterial Vaginosis (BV) is a common vaginal syndrome among women of reproductive age and has clear diagnostic differences among ethnic groups. Here, we investigate the ability of four ML algorithms to diagnose BV. We determine the fairness in the prediction of asymptomatic BV using 16S rRNA sequencing data from Asian, Black, Hispanic, and white women. General purpose ML model performances vary based on ethnicity. When evaluating the metric of false positive or false negative rate, we find that models perform least effectively for Hispanic and Asian women. Models generally have the highest performance for white women and the lowest for Asian women. These findings demonstrate a need for improved methodologies to increase model fairness for predicting BV.

Prenatal Counseling and Preparation for Breastfeeding.

Breastfeeding is the gold standard of infant nutrition and current guidelines suggest exclusive breastfeeding for 6 months, with continued breastfeeding through 24 months or beyond. Obstetric care professionals can encourage and educate their patients about breastfeeding through the prenatal period when many expectant parents make decisions about their infant feeding choices. Education and support should extend through the postpartum period and include parents who may have concerns surrounding medical comorbidities, breast augmentation, or substance use disorders.

Improving Racial and Ethnic Equity in Clinical Trials Enrolling Pregnant and Lactating Individuals.

Racial and ethnic marginalized populations have historically been poorly represented, underrecruited, and underprioritized across clinical trials enrolling pregnant and lactating individuals. The objectives of this review are to describe the current state of racial and ethnic representation in clinical trials enrolling pregnant and lactating individuals and to propose evidence-based tangible solutions to achieving equity in these clinical trials. Despite efforts from federal and local organizations, only marginal progress has been made toward achieving equity in clinical research. This continued limited inclusion and transparency in pregnancy trials exacerbates health disparities, limits the generalizability of research findings, and may heighten the maternal child health crisis in the United States. Racial and ethnic underrepresented communities are willing to participate in research; however, they face unique barriers to access and participation. Multifaceted approaches are required to facilitate the participation of marginalized individuals in clinical trials including partnering with the local community to understand their priorities, needs, and assets; establishing accessible recruitment strategies; creating flexible protocols; supporting participants for their time; and increasing culturally congruent and/or culturally sensitive research staff. This article also highlights exemplars in pregnancy research.

Maternal gut microbiota in the postpartum Period: A Systematic review.

Studies have demonstrated the importance of the gut microbiota during pregnancy, and there is emerging literature on the postpartum maternal gut microbiota. The primary objective of this paper was to synthesize the literature on the postpartum gut microbiome composition and diversity measured in stool samples from healthy mothers of predominantly term infants. The secondary objectives were (1) to identify biological and environmental factors that influence postpartum maternal gut microbiota and (2) to assess health conditions and clinical intermediate measures associated with postpartum gut microbiota changes in all mothers. Electronic searches were conducted November 9, 2020 and updated July 25, 2021 without publication time limits on PubMed, Embase, CINHAL, Scopus, Cochrane Library, BioArchives, and OpenGrey.eu. Primary research on maternal gut microbiota in the postpartum (up to one year after childbirth) were eligible. Postpartum gut microbiota comparisons to pregnancy or non-pregnancy gut microbiota were of interest, therefore, studies examining these in addition to the postpartum were included. Studies were excluded if they were only conducted in animals, infants, pregnancy, or microbiome of other body locations (e.g., vaginal). Data extraction of microbial composition and diversity were completed and synthesized narratively. Studies were assessed for risk of bias. A total of 2512 articles were screened after deduplication and 27 were included in this review. Of the 27 included studies, 22 addressed the primary objective. Firmicutes was the predominant phylum in the early (<6 weeks) and late postpartum (6 weeks to 1 year). In early postpartum, Bacteroides was the predominant genus. Findings from longitudinal assessments of alpha and beta diversity from the early to the late postpartum varied. Nineteen of the 27 studies assessed biological and environmental factors influencing the postpartum gut microbial profile changes. Timing of delivery, probiotic supplementation, triclosan exposure, and certain diets influenced the postpartum gut microbiota. Regarding health conditions and intermediate clinical measures assessed in 8 studies; inflammatory bowel disease, postpartum depression, early-onset preeclampsia, gestational diabetes, excessive gestational weight gain, and anthropometric measures such as body mass index and waist-to-hip ratio were related to gut microbiota changes. There is limited data on the maternal postpartum gut microbiota and how it influences maternal health. We need to understand the postpartum maternal gut microbiome, establish how it differs from non-pregnancy and pregnancy states, and determine biological and environmental influencers. Future research of the gut microbiome's significance for the birthing parent in the postpartum could lead to a new understanding of how to improve maternal short and long-term health.

Peripartum women's perspectives on research study participation in the OneFlorida Clinical Research Consortium during COVID-19 pandemic.

Introduction: The COVID-19 pandemic created an unprecedented need for population-level clinical trials focused on the discovery of life-saving therapies and treatments. However, there is limited information on perception of research participation among perinatal populations, a population of particular interest during the pandemic. Methods: Eligible respondents were 18 years or older, were currently pregnant or had an infant (≤12 months old), and lived in Florida within 50 miles of sites participating in the OneFlorida Clinical Research Consortium. Respondents were recruited via Qualtrics panels between April and September 2020. Respondents completed survey items about barriers and facilitators to participation and answered sociodemographic questions. Results: Of 533 respondents, most were between 25 and 34 years of age (n = 259, 49%) and identified as White (n = 303, 47%) and non-Hispanic (n = 344, 65%). Facebook was the most popular social media platform among our respondents. The most common barriers to research participation included poor explanation of study goals, discomforts to the infant, and time commitment. Recruitment through healthcare providers was perceived as the best way to learn about clinical research studies. When considering research participation, "myself" had the greatest influence, followed by familial ties. Noninvasive biological samples were highly acceptable. Hispanics had higher positive perspectives on willingness to participate in a randomized study (p = 0.009). Education (p = 0.007) had significant effects on willingness to release personal health information. Conclusion: When recruiting women during the pregnancy and postpartum periods for perinatal studies, investigators should consider protocols that account for common barriers and preferred study information sources. Social media-based recruitment is worthy of adoption.

Risk Factors, Symptoms, and Treatment of Lactational Mastitis.

This JAMA Insights Clinical Update reviews the risk factors for and symptoms of lactational mastitis and provides a potential treatment algorithm.

Doula Perspectives on Lactation Education and Breastfeeding Support for Diverse, Low-income Women: A Field Report.

Women living below the federal poverty level have low breastfeeding rates and historically have lacked access to doula care. This disparity is particularly evident among African American women. The objective of this pilot study was to assess doulas' experiences delivering lactation education to racially/ethnically diverse, primarily Medicaid-eligible pregnant women and describe doulas' perceptions of client barriers to breastfeeding. We also wanted to understand doulas' views of infant feeding and lactation education during their participation in a quality improvement intervention that trained doulas to provide lactation education and breastfeeding support at 4 clinics serving low-income clients. Two focus groups were conducted with 7 doulas. Focus group data were transcribed, coded, and analyzed using qualitative thematic analysis. Doulas reported close relationships with their clients and provided consistent breastfeeding support and education to women in prenatal, birth, and postpartum phases of care. Doulas emphasized the need for more lactation education, especially to overcome clients' perceived milk insufficiency and early termination due to breastfeeding barriers. Doula-led breastfeeding education and support may improve breastfeeding outcomes for diverse women from underserved areas.

Innovations in Breastfeeding Support.

Despite the numerous benefits that breastfeeding confers to those who breastfeed and their infants, the United States' exclusive breastfeeding rates and any breastfeeding rates at 12 months remain low and inequitable. This public health crisis has been prioritized in the US Healthy People 2030 goals. Current evidence-based practices to support lactation have afforded limited progress, thus, achieving national breastfeeding goals requires innovative ideas in thinking, technology, and care. This article highlights potential innovative strategies in the field of lactation to improve outcomes and work toward achieving health equity, while underscoring the critical role that perinatal caregivers play in lactation support.

Impact of Doula-Led Lactation Education on Breastfeeding Outcomes in Low-Income, Minoritized Mothers.

Prenatal education may improve breastfeeding outcomes among low-income women. Our objective was to assess breastfeeding intentions and knowledge among women participating in doula-facilitated prenatal education classes from August 2016 to October 2017. Breastfeeding knowledge and infant feeding intentions were assessed before and after the classes. Breastfeeding rates were assessed at birth, 2-4 weeks postpartum, and 6-8 weeks postpartum. Paired t-tests tests were conducted. A total of 121 racially diverse, low-income women were enrolled. Intentions to breastfeed increased pre- to post-intervention (p = 0.007). Breastfeeding knowledge scores increased pre- to post-intervention (p <.001); specifically, among women who were exclusively breastfeeding or breastfeeding while supplementing with formula at birth (p < .001 and p = 0.046, respectively). Doula-facilitated breastfeeding education may help improve breastfeeding outcomes for low-income women.

A Statewide Evaluation of the Breastfeeding Resource Nurse Model.

OBJECTIVE: To evaluate a statewide initiative to increase the provisioning of human milk in NICUs. DESIGN: A survey of nurses before participation in an educational session, immediately after education, and again 9 months later. SETTING: Nurses from 22 hospitals throughout Florida. PARTICIPANTS: We surveyed 121 participants, including some nurses who had prior breastfeeding education or certification as well as those without specialized breastfeeding training. INTERVENTION: An educational project called the Breastfeeding Resource Nurse Master program was intended to educate NICU nurses to implement the "Ten Steps to Promote and Protect Human Milk and Breastfeeding in Vulnerable Infants." MEASUREMENT: A quantitative needs assessment survey was administered to participants to determine current hospital practices, policies, and perceived areas for improvement. Pre- and immediate posttraining surveys assessed NICU nurses' knowledge, attitudes, and beliefs about human milk feeding of critical care infants and their self-efficacy for implementing the program in their respective NICUs. A follow-up, open-ended survey was administered at 9 months to yield information on program implementation. RESULTS: NICU breastfeeding practices varied widely at baseline. Nurses' scores for knowledge, beliefs, and behavioral intentions improved postsession, but the implementation of practice changes related to the Ten Steps for Vulnerable Infants proved difficult. Nurses identified insufficient time and resources as barriers to educating others and changing practice. CONCLUSIONS: Policies and regulations that make hospitals accountable for increasing human milk provision to vulnerable infants may be necessary to ensure that hospitals devote adequate resources to implementing practice changes in this area.

Modesty and Security: Attributes Associated with Comfort and Willingness to Engage in Telelactation.

The objectives were to identify conditions under which mothers may be willing to use telelactation and explore associations between participant characteristics, willingness, and beliefs regarding telelactation use. Mothers 2-8 weeks postpartum were recruited from two Florida maternal care sites and surveyed to assess demographics, breastfeeding initiation, and potential telelactation use. Analyses included descriptive statistics and logistic regression models. Of the 88 participants, most were white, married, earned less than USD 50,000 per year, had access to technology, and were willing to use telelactation if it was free (80.7%) or over a secure server (63.6%). Fifty-six percent were willing to use telelactation if it involved feeding the baby without a cover, but only 45.5% were willing if their nipples may be seen. Those with higher odds of willingness to use telelactation under these modesty conditions were experienced using videochat, white, married, and of higher income. Mothers with security concerns had six times the odds of being uncomfortable with telelactation compared to mothers without concerns. While telelactation can improve access to critical services, willingness to use telelactation may depend on conditions of use and sociodemographics. During the COVID-19 pandemic and beyond, these findings offer important insights for lactation professionals implementing virtual consultations.

"Breast Is Best, But " According to Childcare Administrators, Not Best for the Childcare Environment.

Background: Nearly 74% of U.S. mothers work full-time and employment is a cited reason for stopping breastfeeding. In the effort to increase breastfeeding duration, childcare providers could facilitate continuation of human milk feeding when mothers return to work. Yet, mothers report receiving little support when transitioning infants into childcare. Objective: Explore the themes of comfort with human milk and formula feeding among childcare administrators near Tampa, Florida. Material and Methods: Twenty-eight childcare administrators participated in semistructured interviews regarding policies and perceptions about infant feeding practices at their center. Using Applied Thematic Analysis, interview themes were identified. Results: Most administrators agreed "breastfeeding is best." However, they expressed discomfort with mothers breastfeeding at the center and perceived risk with handling and feeding human milk. These perceptions are illustrated through the theme "Formula feeding is normative" and four emergent subthemes: "Human milk is potentially harmful," "People are uncomfortable with breastfeeding in public," "I'm not the expert," and "'Breastfeeding is best', in theory." Conclusion: While breastfeeding may be best for health, from the childcare administrators' perspectives, it may not be best for the childcare environment. A cultural shift may be needed to change norms and perceptions in the childcare environment to support mothers in their effort to provide human milk. Perhaps it is time for a new message, such as "We can help you."

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.

Uterine artery pseudoaneurysm and embolisation during pregnancy.

Uterine artery pseudoaneurysm in pregnancy is a dangerous condition as rupture can be catastrophic due to the large volume of uterine blood flow. We present a case of a healthy, young woman with a desired pregnancy at 15 weeks of gestation incidentally discovered to have a pseudoaneurysm of the uterine artery during a routine prenatal ultrasound. She underwent initial thrombin injection followed by endovascular coil embolisation of the left uterine artery and carried the pregnancy to term without further complications.

Impact of a Formal Lactation Curriculum for Residents on Breastfeeding Rates Among Low-Income Women.

Obstetrics-gynecology residents have inadequate training in lactation management and are typically unable to address basic breastfeeding needs. A retrospective study was performed to evaluate the impact of a formal lactation curriculum for obstetrics-gynecology residents on breastfeeding. Demographic information, medical history, and breastfeeding rates were derived from medical records and hospital lactation logs. Breastfeeding outcomes of women with term, singleton infants were analyzed before and after curriculum implementation. The study included 717 women, 337 prior to intervention and 380 after intervention. Women who delivered after curriculum implementation were more likely to breastfeed exclusively at 6 weeks postpartum (odds ratio [OR]: 2.01; 95% confidence interval [CI]: 1.28-3.15). A targeted breastfeeding curriculum was associated with increased exclusive breastfeeding rates at 6 weeks postpartum in a diverse, low-income population.

Historical Antecedents of Breastfeeding for African American Women: from the Pre-Colonial Period to the Mid-Twentieth Century.

INTRODUCTION: African American women have much lower breastfeeding rates than other racial and ethnic groups in the USA. While researchers are beginning to explore contemporary factors contributing to this inequality, much less research has been devoted to the historical conditions that have contributed to these disparities. AIM: The aim of this paper was to describe the social, economic, and political factors that have influenced African American breastfeeding behavior in the USA from the colonial era through the mid-twentieth century. METHODS: A thematic analysis was conducted across multiple databases and sources. A social history framework, which focuses on the experiences of ordinary people and events, was used to identify and integrate themes found within the reviewed literature. RESULTS: Three themes emerged: (1) Labor forces and other socio-cultural factors affected feeding practices and communal caregiving; (2) history of supplementation; and (3) influence of medicalization of birth and mobility on infant feeding in the twentieth century. These themes illustrate how African American women's ability to breastfeed has been significantly constrained throughout the U.S. HISTORY: Supplementation with non-human milk substitutes and communal caregiving helped African American women navigate infant rearing under adverse socioeconomic circumstances. CONCLUSIONS: Social, political, and economic factors have contributed significantly to African American women's ability to breastfeed throughout the U.S. HISTORY: Understanding the influences of historical antecedents on breastfeeding decisions over time may be key to finding effective interventions that might increase breastfeeding rates within this population.

Improving Drug Exposure Knowledge During Lactation: Quality Improvement Initiative in Low-Income Women.

Objectives: To improve maternal knowledge on medication and substance usage during lactation through prenatal breastfeeding education and assess breastfeeding rates at 2-4 and 6-8 weeks postpartum. Study Design: This quality improvement initiative occurred between August 2016 and October 2017. Pregnant women without contraindications to breastfeeding receiving prenatal care at one of four prenatal sites in Florida were eligible. Enrolled women participated in a 1-hour interactive session consisting of basic breastfeeding education and medication or substance use during lactation. Demographic information, medical history, and pre/post breastfeeding knowledge scores were obtained. Regression analysis was utilized to evaluate the influence of medication usage on breastfeeding rates at 2-4 and 6-8 weeks postpartum. Results: The majority of participants (N = 121; median age = 26) were Hispanic (64%), unmarried (70%), and unemployed (60%). Approximately 25% were on medications other than supplements. Of those, one-third reported concerns regarding medication usage and infant safety during lactation. Knowledge regarding postpartum medications or substances and their breastfeeding compatibility increased significantly postintervention; however, women who were using medications at 2-4 and 6-8 weeks postpartum were 4 times as likely to mix feed or formula feed as compared with mothers not taking medications (adjusted odds ratio [OR] at 2-4 weeks = 3.693 confidence interval [95% CI]: 1.398-9.757) and adjusted OR at 6-8 weeks = 4.208 (95% CI: 1.009-17.548). Conclusions: This prenatal breastfeeding education targeting low-income women improved knowledge on medication usage and lactation. However, despite increasing breastfeeding knowledge, medication use appears to influence infant feeding behaviors at 2-4 and 6-8 weeks postpartum.

The development of intestinal dysbiosis in anemic preterm infants.

OBJECTIVE: Anemia and Proteobacteria-dominant intestinal dysbiosis in very low birth weight (VLBW) infants have been linked to necrotizing enterocolitis, a severe gut inflammatory disease. We hypothesize that anemia of prematurity is related to the development of intestinal dysbiosis. STUDY DESIGN: Three hundred and forty-two weekly stool samples collected prospectively from 80 VLBW infants were analyzed for bacterial microbiomes (with 16S rRNA). Linear mixed-effects model was used to determine the relationships between the onsets of anemia and intestinal dysbiosis. RESULTS: Hematocrit was associated with intestinal microbiomes, with lower Hct occurring with increased Proteobacteria and decreased Firmicutes. Infants with a hematocrit <30% had intestinal microbiomes that diverged toward Proteobacteria dominance and low diversity after the first postnatal month. The microbiome changes were also related to the severity of anemia. CONCLUSIONS: This finding supports a potential microbiological explanation for anemia as a risk factor for intestinal dysbiosis in preterm infants.

Neonatal Abstinence Syndrome among Infants Born to Mothers with Sickle Cell Hemoglobinopathies.

OBJECTIVE: The objective of this study is to examine risk factors for neonatal abstinence syndrome (NAS) among infants born to mothers with sickle cell hemoglobinopathies (SCH). STUDY DESIGN: Retrospective cohort study of nonanomalous, singleton infants born to mothers with laboratory confirmed SCH. Infants were included if they were diagnosed with NAS prior to hospital discharge. The outcome of interest was the association of maternal variables with NAS. RESULTS: Of 131 infants born to mothers with SCH, 4% (n = 5) were diagnosed with NAS. Mothers of infants with NAS were more likely to have SC disease (80%) compared with other SCH (20%), p = 0.001. Fifteen women had antepartum (AP) admissions for pain and/or sickle crisis. Of these patients, four infants (29%) were diagnosed with NAS. The median (5th and 95th percentile) maternal AP length of stay for women with infants diagnosed with NAS to mothers with sickle cell disease was 132 (5, 180) days (p = 0.02). CONCLUSION: Incidence of NAS among mothers with SCH is low; severe disease characterized by AP sickle cell crisis requiring prolonged AP admission for pain control significantly increases the risk of NAS. Further studies are needed to investigate the association of maternal opioid dose and NAS.