Racial And Ethnic Inequities In Postpartum Depressive Symptoms, Diagnosis, And Care In 7 US Jurisdictions.

Understanding whether racial and ethnic inequities exist along the postpartum mental health care continuum is vital because inequitable identification of depression can lead to inequitable referral to and receipt of care. We aimed to expand on existing cross-sectional and single-state data documenting potential racial and ethnic disparities in postpartum depression care. Using early (from two to six months) and late (from twelve to fourteen months) postpartum survey data from seven US jurisdictions, we documented patterns of early postpartum depressive symptoms, perinatal mood and anxiety disorder (PMAD) diagnosis, and receipt of postpartum mental health care overall and by racial and ethnic identity. Of 4,542 people who delivered live births in 2020, 11.8 percent reported early postpartum depressive symptoms. Among the sample with these symptoms, only 25.4 percent reported receiving a PMAD diagnosis, and 52.8 percent reported receiving some form of postpartum mental health care. There were no significant differences in diagnosis by race and ethnicity. Respondents identifying as Asian; Native Hawaiian or Pacific Islander; Southwest Asian, Middle Eastern, or North African; Hispanic; and non-Hispanic Black were significantly less likely than non-Hispanic White respondents to receive mental health care, demonstrating stark inequities in the management of postpartum depressive symptoms. Policies mandating and reimbursing universal postpartum depression screening, facilitating connection to care, reducing insurance coverage gaps, and enhancing clinician training in culturally responsive care may promote equitable postpartum mental health care.

The Challenge of Weight Stigma for Women in the Preconception Period: Workshop Recommendations for Action from the 5th European Conference on Preconception Health and Care.

Weight stigma is a well-recognised public health issue affecting many members of society including women during the preconception period. The impacts of preconception weight stigma on women are significant and may result in decreased access to and uptake of healthcare, and mental health concerns. The consequences of this weight stigma may translate to negative maternal outcomes and even intergenerational effects on the child. Eliminating weight stigma is therefore imperative. The aim of this paper is to report recommendations to reduce weight stigma for preconception women produced at a workshop with clinical and academic experts on preconception health and weight stigma at the 5th European Conference on Preconception Health and Care. The recommendations are related to two key areas: general societal recommendations prompting all people to acknowledge and adjust our attitudes towards larger-bodied people; and healthcare-specific recommendations imploring clinicians to upskill themselves to reduce weight stigma in practice. We therefore call for urgent approaches to address societal weight-stigmatising attitudes and norms related to both the general population and preconception women, while providing professional development opportunities for healthcare professionals relating to weight stigma. Eliminating weight stigma for preconception women may have positive impacts on the outcomes for mothers and children during pregnancy and beyond.

Looking Back, Visioning Forward: Preconception Health in the US 2005 to 2023.

Preconception health has always been about preventative health care, ensuring the overall wellbeing of people of reproductive age before they have children. However, just as public health and health care have shifted to prioritize equity and include ideas about how social determinants of health influence health outcomes, the field of preconception health has experienced a similar transition. The purpose of this paper is to provide an overview of the evolution of preconception health in the United States after 2005, highlighting the key tensions that have shaped the field. We provide an overview of the early history of the movement and describe how four phases of ideological tensions overtime have led to changes across seven categories of preconception health: definitions and frameworks, surveillance and measurement, messaging and education, strategic convenings and collaborations, clinical practice, and reproductive life planning. We also describe the historic and emerging challenges that affect preconception care, including limited sustained investment and ongoing threats to reproductive health. The vision of preconception health care we outline has been created by a diversity of voices calling for wellness, equity, and reproductive justice to be the foundation to all preconception health work. This requires a focus on preconception health education that prioritizes bodily autonomy, not just pregnancy intentions; national surveillance and data measures that center equity; attention to mental health and overall well-being; and the inclusion of transgender and non-binary people of reproductive age.

Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action.

OBJECTIVE (STUDY QUESTION): To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States. DATA SOURCES/STUDY SETTING: Data were collected from six groups of system actors via online focus groups. STUDY DESIGN: This is a qualitative multilevel study using the iceberg systems thinking framework. DATA COLLECTION/EXTRACTION METHODS: Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas. PRINCIPAL FINDINGS: Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders. CONCLUSIONS: By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Listening to patients: Opportunities to improve reproductive wellness for women with chronic conditions.

OBJECTIVE: To understand how Black and Native American women with chronic conditions experience reproductive health care and identify patient-centered strategies to improve care. STUDY SETTING AND PARTICIPANTS: We held a series of virtual focus groups between February 2021 and December 2021 with 34 women who self-identified as Black or Native American, were of childbearing age, had one or more chronic conditions, and lived in North Carolina. STUDY DESIGN AND ANALYSIS: This qualitative, community-engaged study reviewed notes, video recordings, and graphic illustrations from the focus group sessions. Content analysis was used to iteratively identify themes. Emerging themes were reviewed by community and patient partners. PRINCIPAL FINDINGS: There were six thematic areas that emerged on the current state of reproductive health care for people with chronic conditions: (1) lack of trust in health care providers and institutions, (2) lack of health care provider knowledge, (3) uncoordinated care, (4) need for self-advocacy, (5) provider bias, and (6) mental health strain from coping. Six approaches for care improvement emerged: (1) build on models of coordinated health care services from other conditions to design more comprehensive care clinics, (2) involve care coordinators or navigators, (3) improve educational materials for patients, (4) train clinicians to increase their capacity to be trustworthy and provide quality, equitable, person-focused care, (5) design scripts to improve clinicians' ability to talk with women about infertility, miscarriage, infant loss, and (6) all interventions and research should be co-designed to address patient priorities. CONCLUSIONS: Engaging Black and Native American patient partners with chronic conditions in research planning is feasible, necessary, and beneficial using methods that support connection, respect, and bi-directional learning. Patient partners defined actionable strategies to improve reproductive care and wellness including comprehensive care clinics with patient navigators, trust-enhancing interventions, and better provision of reproductive health related education.

Practical Approaches for Promoting Health Equity in Communities.

The Maternal and Child Health workforce, public health practitioners, researchers, and other groups need clear, practical guidance on how to promote health equity in the communities they serve. The National Maternal and Child Health Workforce Development Center's Health Equity Team synthesized eight approaches for promoting health equity that drew on their experience working with public health practitioners and communities. The approaches are to: Expand the understanding of the drivers of health and work across sectors; Take a systems approach; Reflect on your own organization; Follow the lead of communities who experience injustices; Work with community members, decision-makers, and other stakeholders to prioritize action; Foster agency within individuals and collective action within groups; Identify and collect data to show where health inequities currently exist to inform equitable investment of resources; and Be accountable to outcomes that reflect real improvements in people's lives. The fields of maternal and child health and public health more broadly is already engaged in the complex work of promoting equity and social justice, and in doing so, should refine, challenge, add to, and build upon these approaches.

Engaging Families in Life Course Intervention Research: An Essential Step in Advancing Equity.

Life course intervention research requires a thorough understanding of complex factors that interact to affect health over time. Partnerships with families and communities are critical to understanding these interconnections and identifying effective interventions. Here, family and community engagement are presented, aligned with the 5 phases of the life course intervention research framework: planning, design, implementation, evaluation, and translation. During planning, the researcher considers their own starting position and what they need to learn from families and the community. The design phase produces a plan for family engagement that is layered, iterative, and includes qualitative methods that will inform life course modeling and the research process. The implementation phase includes administrative actions such as creating opportunities for contributions and providing compensation to family and community partners. The evaluation phase requires measurement of the quality of partnerships with families and community and includes making adjustments as indicated to improve these partnerships. This phase also calls for reflection on the impact these partnerships had on the intervention, including if they made a difference for those being served. During translation, the researcher works with all partners, including families and communities, about follow up steps toward project continuation, replication, or completion. The researcher also works collaboratively in determining how the study results are shared. A holistic approach to health over the life course that is designed and executed in partnership with families and their community can generate research findings with broad practical applicability and strong translational potential.

What Makes an Intervention a Life Course Intervention?

OBJECTIVES: To develop an initial list of characteristics of life course interventions to inform the emerging discipline of life course intervention research. METHODS: The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives, and thought leaders, considered the principles, characteristics, and utility of life course interventions. After an in-person launch meeting in 2019, the steering committee collaboratively and iteratively developed a list of life course intervention characteristics, incorporating a modified Delphi review process. RESULTS: The Life Course Intervention Research Network identified 12 characteristics of life course interventions. These interventions (1) are aimed at optimizing health trajectories; (2) are developmentally focused, (3) longitudinally focused, and (4) strategically timed; and are (5) designed to address multiple levels of the ecosystem where children are born, live, learn, and grow and (6) vertically, horizontally, and longitudinally integrated to produce a seamless, forward-leaning, health optimizing system. Interventions are designed to (7) support emerging health development capabilities; are (8) collaboratively codesigned by transdisciplinary research teams, including stakeholders; and incorporate (9) family-centered, (10) strengths-based, and (11) antiracist approaches with (12) a focus on health equity. CONCLUSIONS: The intention for this list of characteristics of life course interventions is to provide a starting point for wider discussion and to guide research development. Incorporation of these characteristics into intervention designs may improve emerging health trajectories and move critical developmental processes and pathways back on track, even optimizing them to prevent or reduce adverse outcomes.

Family Health Development in Life Course Research: A Scoping Review of Family Functioning Measures.

BACKGROUND AND OBJECTIVES: Our objective is to identify common family functioning measurement tools and assess their compatibility with family-health development and life-course perspectives. METHODS: Data sources include PubMed, ERIC, CINAHL, Families and Societies Worldwide, PsychInfo, Web of Science, PsychNet, and Health and Psychosocial Instruments. Title and abstract screening and full-text review of articles were conducted by multiple reviewers based on prespecified inclusion criteria. Data extraction focused on features of identified measurements tools, including: (1) name (2) domains of family functioning measured, (3) established psychometric properties, and (4) original context of psychometric evaluation (eg, details about the study sample). RESULTS: Of the 50 measurement tools identified, 94% measured organizational patterns (eg, flexibility, connectedness, or resources), 46% measured belief systems (eg, making meaning of adversity, or positive outlook), and 54% measured communication processes (eg, open emotional sharing, or collaborative problem-solving). CONCLUSIONS: Existing measures of family functioning can aid life-course researchers in understanding family processes as contexts for health and well-being. There also remain opportunities to refine or develop measures of family functioning more compatible with a life-course perspective that assess family processes (1) at various life stages; (2) with various backgrounds, identities, structures, and experiences; and (3) embedded in or impacted by various contexts that may facilitate or hinder family functioning.

Building a Life Course Intervention Research Framework.

OBJECTIVES: To report on first steps toward building a Life Course Intervention Research Framework (LCIRF) to guide researchers studying interventions to improve lifelong health. METHODS: The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives and thought leaders, participated in an iterative review process. Building on the revised Medical Research Council Guidance for Developing and Evaluating Complex Interventions, they identified 12 additional key models with features for inclusion in the LCIRF, then incorporated the 12 characteristics identified by the Life Course Intervention Research Network as actionable features of Life Course Interventions to produce the new LCIRF. RESULTS: The LCIRF sets out a detailed step-wise approach to intervention development: (1) conceptualization and planning, (2) design, (3) implementation, (4) evaluation, and (5) spreading and scaling of interventions. Each step is infused with life course intervention characteristics including a focus on (1) collaborative codesign (2) health optimization, (3) supporting emerging health development capabilities (4) strategic timing, (5) multilevel approaches, and (6) health equity. Key features include a detailed transdisciplinary knowledge synthesis to inform intervention development; formation of strong partnerships with family, community, and youth representatives in intervention codesign; a means of testing the impact of each intervention on biobehavioral processes underlying emerging health trajectories; and close attention to intervention context. CONCLUSIONS: This first iteration of the LCIRF has been largely expert driven. Next steps will involve widespread partner engagement in framework refinement and further development. Implementation will require changes to the way intervention studies are organized and funded.

Postpartum Health Experiences of Women with Newborns in Intensive Care: The Desire to Be by the Infant Bedside as a Driver of Postpartum Health.

INTRODUCTION: Women with infants in a neonatal intensive care unit (NICU) encounter multiple challenges following childbirth, including greater burden of chronic disease and increased risk for depression, compared with women with well infants. At the same time, they are confronted with the trauma of a hospitalized infant while also managing their postpartum recovery. Limited research exists describing the health needs of these women, despite the many numbers living this experience daily. This study aimed to better understand postpartum health needs of women with infants in the NICU in the 90 days following birth and to propose actionable system improvements to address identified needs. METHODS: The authors conducted in-depth individual interviews with 50 postpartum women of infants admitted to the NICU at a quaternary care hospital. Eligible women were aged at least 18 years, spoke English or Spanish, and had infants in the NICU longer than 3 days. Interview topics included NICU experience, recommended and desired health care, and suggestions for improvement. Interviews were audiotaped and transcribed verbatim. The authors used qualitative description techniques including memo-writing, coding, matrices, diagramming, and team discussion to analyze the data. RESULTS: Women reported significant intrapartum health conditions and concerns (eg, preeclampsia, emergency cesarean birth, anxiety) and described unmet social, emotional, mental, and physical health needs. Unmet practical needs while in the NICU (eg, a place to rest, affordable parking, access to food, childcare) caused considerable burden. Despite disease burden and emergent health needs, few women reported regular monitoring of their postpartum health by maternal health care providers. Women frequently minimized and delayed care for their health needs so as to remain by the infant bedside. DISCUSSION: Women with infants in the NICU would benefit from patient-centered care that provides greater attention to their postpartum health and recovery while also supporting their drive to remain close to their hospitalized infant.

Assessing Preconception Wellness in the Clinical Setting Using Electronic Health Data.

Background: One key strategy to reduce maternal morbidity and mortality involves optimizing prepregnancy health. Although nine core indicators of preconception wellness (PCW) have been proposed by clinical experts, few studies have attempted to assess the preconception health status of a population using these indicators. Methods: We conducted a retrospective chart review study of patients who received prenatal or primary care, identified by pregnancy-related ICD-10 codes, at either of two health systems in geographically and socioeconomically different areas of North Carolina between October 1, 2015, and September 30, 2018. Our primary study aim was to determine the feasibility of measuring the proposed PCW indicators through retrospective review of prenatal electronic health records at these two institutions. Results: Data were collected from 15,384 patients at Site 1 and 6,983 patients at Site 2. The indicators most likely to be documented and to meet the preconception health goal at each site were avoidance of teratogenic medications (98.8% and 98.3% at Sites 1 and 2, respectively) and entry to care in the first trimester (64.5% and 73.5% at Sites 1 and 2, respectively), whereas our measures of folic acid use, depression screening, and discussion of family planning were documented less than 20% of the time at both sites. Conclusions: Differences in measuring and documenting PCW indicators across the two health systems in our study presented barriers to monitoring and optimizing PCW. Efforts to address health and wellness before pregnancy will likely require health systems and payors to standardize, incorporate, and promote preconception health indicators that can be consistently measured and analyzed across health systems.

Perinatal morbidity and health utilization among mothers of medically fragile infants.

OBJECTIVE: To determine the burden of perinatal morbidity among mothers of medically fragile infants. STUDY DESIGN: We conducted a retrospective cohort study of 6849 mothers who delivered liveborn infants at a quaternary care hospital during a two-year period. We compared mothers of well babies with mothers of infants admitted to the Neonatal Intensive Care Unit (NICU), and we used logistic regression to model predictors of postpartum acute care utilization among NICU mothers. RESULTS: Rates of obstetric morbidity were highest for mothers of infants staying ≥72 h in the NICU; 54.2% underwent cesarean birth, 7.5% experienced severe maternal morbidity, and 6.6% required a blood transfusion. Factors independently associated with postpartum acute care use included gestational age <28 weeks, ever smoking, non-Hispanic Black race, temperature >38 °C and receiving psychiatric medication during the birth hospitalization. CONCLUSION: Focused support for mothers of NICU infants has the potential to reduce maternal morbidity and improve health.

Evolving the Preconception Health Framework: A Call for Reproductive and Sexual Health Equity.

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course.

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.