Perinatal Mood and Anxiety Disorder and Reproductive Justice: Examining Unmet Needs for Mental Health and Social Services in a National Cohort.

Introduction: Perinatal Mood and Anxiety Disorders (PMADs) are the most common complications during the perinatal period. There is limited understanding of the gaps between need and provision of comprehensive health services for childbearing people, especially among racialized populations. Methods: The Giving Voice to Mothers Study (GVtM; n=2700), led by a multistakeholder, Steering Council, captured experiences of engaging with perinatal services, including access, respectful care, and health systems' responsiveness across the United States. A patient-designed survey included variables to assess relationships between race, care provider type (midwife or doctor), and needs for psychosocial health services. We calculated summary statistics and tested for significant differences across racialized groups, subsequently reporting odds ratios (ORs) for each group. Results: Among all respondents, 11% (n=274) reported unmet needs for social and mental health services. Indigenous women were three times as likely to have unmet needs for treatment for depression (OR [95% confidence interval, CI]: 3.1 [1.5-6.5]) or mental health counseling (OR [95% CI]: 2.8 [1.5-5.4]), followed by Black women (OR [95% CI]: 1.8 [1.2-2.8] and 2.4 [1.7-3.4]). Odds of postpartum screening for PMAD were significantly lower for Latina women (OR [95% CI]=0.6 [0.4-0.8]). Those with midwife providers were significantly more likely to report screening for anxiety or depression (OR [95% CI]=1.81 [1.45-2.23]) than those with physician providers. Discussion: We found significant unmet need for mental health screening and treatment in the United States. Our results confirm racial disparities in referrals to social services and highlight differences across provider types. We discuss barriers to the integration of assessments and interventions for PMAD into routine perinatal services. Implications: We propose incentivizing reimbursement schema for screening and treatment programs; for community-based organizations that provide mental health and social services; and for culture-centered midwife-led perinatal and birth centers. Addressing these gaps is essential to reproductive justice.

Measuring midwives' perceptions of their practice climate across racial-ethnic identities: An invariance analysis of the Midwifery Practice Climate Scale.

Diversification of the midwifery workforce is key to addressing disparities in maternal health in the United States. Midwives who feel supported in their practice environments report less burnout and turnover; therefore, creating positive practice environments for midwives of color is an essential component of growing and retaining midwives of color in the workforce. The Midwifery Practice Climate Scale (MPCS) is a 10-item instrument developed through multiphase empirical analysis to measure midwives' practice environments, yet the MPCS had not been independently tested with midwives of color. We conducted invariance analyses to test whether latent means can be compared between midwives of color and non-Hispanic White samples. A step-up approach applied a series of increasingly stringent constraints to model estimations with multiple group confirmatory factor analyses with two pooled samples. A configural model was estimated as the basis of multiple group comparisons where all parameters were allowed to freely vary. Metric invariance was estimated by constraining item factor loadings to be equal. Scalar invariance was estimated by constraining intercepts of indicators to be equal. Each model was compared to the baseline model. The findings supported scalar invariance of MPCS across midwives of color and non-Hispanic White midwives, indicating that the MPCS is measuring the same intended construct across groups, and that differences in scores between these two groups reflect true group differences and are not related to measurement error. Additionally, in this sample, there was no statistically significant difference in perceptions of the practice environments across midwives of color and non-Hispanic White midwives (p > 0.05).

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

BACKGROUND: Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality. METHODS: We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains. RESULTS: Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28). CONCLUSION: Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

Reimagining Perinatal Mental Health: An Expansive Vision For Structural Change.

Diagnoses of depression, anxiety, or other mental illness capture just one aspect of the psychosocial elements of the perinatal period. Perinatal loss; trauma; unstable, unsafe, or inhumane work environments; structural racism and gendered oppression in health care and society; and the lack of a social safety net threaten the overall well-being of birthing people, their families, and communities. Developing relevant policies for perinatal mental health thus requires attending to the intersecting effects of racism, poverty, lack of child care, inadequate postpartum support, and other structural violence on health. To fully understand and address this issue, we use a human rights framework to articulate how and why policy makers must take progressive action toward this goal. This commentary, written by an interdisciplinary and intergenerational team, employs personal and professional expertise to disrupt underlying assumptions about psychosocial aspects of the perinatal experience and reimagines a new way forward to facilitate well-being in the perinatal period.

"I fought my entire way": Experiences of declining maternity care services in British Columbia.

BACKGROUND: The 2016 WHO Standards for improving quality of maternal and newborn care in health facilities established patient experience of care as a core indicator of quality. Global health experts have described loss of autonomy and disrespect as mistreatment. Risk of disrespect and abuse is higher when patient and care provider opinions differ, but little is known about service users experiences when declining aspects of their maternity care. METHODS: To address this gap, we present a qualitative content analysis of 1540 written accounts from 892 service users declining or refusing care options throughout childbearing with a large, geographically representative sample (2900) of childbearing women in British Columbia who participated in an online survey with open-ended questions eliciting care experiences. FINDINGS: Four themes are presented: 1) Contentious interactions: "I fought my entire way", describing interactions as fraught with tension and recounting stories of "fighting" for the right to refuse a procedure/intervention; 2) Knowledge as control or as power: "like I was a dim girl", both for providers as keepers of medical knowledge and for clients when they felt knowledgeable about procedures/interventions; 3) Morbid threats: "do you want your baby to die?", coercion or extreme pressure from providers when clients declined interventions; 4) Compliance as valued: "to be a 'good client'", recounting compliance or obedience to medical staff recommendations as valuable social capital but suppressing desire to ask questions or decline care. CONCLUSION: We conclude that in situations where a pregnant person declines recommended treatment, or requests treatment that a care provider does not support, tension and strife may ensue. These situations deprioritize and decenter a woman's autonomy and preferences, leading care providers and the culture of care away from the principles of respect and person-centred care.

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.

Internet Search for Midwifery Fellowship Programs.

INTRODUCTION: The purpose of this study was to identify existing US midwifery fellowships and their key attributes. METHODS: The study team adapted an internet-search methodology that was recently used to identify nurse practitioner fellowships and residencies and identified 1) search terms likely to locate websites describing or promoting midwifery fellowship or residency programs and 2) program attributes likely to be outlined in the websites. Two investigators conducted full, independent Google searches and then reconciled minor differences in terminology and findings via teleconference and simultaneous reviews of websites. RESULTS: Eight programs were identified that had sufficient information on a website to clearly establish them as midwifery fellowship programs. No programs used the term residency. The fellowship programs tended to be located in the western United States and predominantly focused on newly graduated certified nurse-midwives. Four programs were operated by university units, with the clinical experience located in the hospital. Four programs were operated by birth centers, with the clinical experience obtained in a combination of birth center, home, and/or hospital setting. Typical program lengths varied but were reported to be about 12 months. DISCUSSION: This study offers baseline information on the current midwifery fellowship offerings available via public internet search. This study also identifies key attributes of fellowships that may be helpful to stakeholders as they consider the role of fellowships for midwifery graduates and any need for accountability, such as accreditation review, among the programs.