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Mattocks K, Marteeny V, Walker L, Wallace K, Goldstein KM, Deans E, Brewer E, Bean-Mayberry B, Kroll-Desrosiers A. Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections. Womens Health Issues 2024:S1049-3867(24)00028-8. [PMID: 38760279 DOI: 10.1016/j.whi.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections. METHODS We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits. RESULTS Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health. CONCLUSION Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.
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Affiliation(s)
- Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts.
| | - Valerie Marteeny
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
| | - Lorrie Walker
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
| | - Kate Wallace
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
| | - Karen M Goldstein
- VA HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Elizabeth Deans
- Duke University, Durham, North Carolina; Women's Health Clinic, Durham VA Health Care System, Durham, North Carolina
| | - Erin Brewer
- VA Southeast Louisiana Veterans Healthcare System, New Orleans, Louisiana
| | - Bevanne Bean-Mayberry
- VA Greater Los Angeles Healthcare System, Los Angeles, California; David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts
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Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean. PLoS One 2022; 17:e0274790. [PMID: 36137150 PMCID: PMC9499210 DOI: 10.1371/journal.pone.0274790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 09/05/2022] [Indexed: 11/19/2022] Open
Abstract
Objective
High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S.
Methods
Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother’s Autonomy in Decision Making Scale; MADM).
Results
Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician.
Conclusion
Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.
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Highland KB, Robertson I, Lutgendorf M, Herrera GF, Velosky AG, Costantino RC, Patzkowski MS. Variation by default: cesarean section discharge opioid prescription patterns and outcomes in Military Health System hospitals: a retrospective longitudinal cohort study. BMC Anesthesiol 2022; 22:218. [PMID: 35820819 PMCID: PMC9277874 DOI: 10.1186/s12871-022-01765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background To examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid naïve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30 days) across a large healthcare system. Methods The Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was “female,” age was 18 years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home < 4 days after the Cesarean section. Results Across 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225 mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts. Conclusion Significant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01765-8.
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Affiliation(s)
- Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Ian Robertson
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | - Monica Lutgendorf
- Department of Gynecological and Obstetrics Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Germaine F Herrera
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Ryan C Costantino
- Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, TX, USA.,Department of Military and Emergency Medicine, School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Michael S Patzkowski
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA
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Abstract
PURPOSE OF REVIEW Healthcare disparities are health differences that adversely affect disadvantaged populations. In the United States, research shows that women of color, in particular Black and Hispanic women and their offspring, experience disproportionately higher mortality, severe maternal morbidity, and neonatal morbidity and mortality. This review highlights recent population health sciences and comparative effectiveness research that discuss racial and ethnic disparities in maternal and perinatal outcomes. RECENT FINDINGS Epidemiological research confirms the presence of maternal and neonatal disparities in national and multistate database analysis. These disparities are associated with geographical variations, hospital characteristics and practice patterns, and patient demographics and comorbidities. Proposed solutions include expanded perinatal insurance coverage, increased maternal healthcare public funding, and quality improvement initiatives/efforts that promote healthcare protocols and practice standardization. SUMMARY Obstetrical healthcare disparities are persistent, prevalent, and complex and are associated with systemic racism and social determinants of health. Some of the excess disparity gap can be explained through community-, hospital-, provider-, and patient-level factors. Providers and healthcare organizations should be mindful of these disparities and strive to promote healthcare justice and patient equity. Several solutions provide promise in closing this gap, but much effort remains.
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Abstract
PURPOSE OF REVIEW Health equity is an important priority for obstetric anesthesia, but describing disparities in perinatal care process and health outcome is insufficient to achieve this goal. Conceptualizing and framing disparity is a prerequisite to pose meaningful research questions. We emphasize the need to hypothesize and test which mechanisms and drivers are instrumental for disparities in perinatal processes and outcomes, in order to target, test and refine effective countermeasures. RECENT FINDINGS With an emphasis on methodology and measurement, we sketch how health systems and disparity research may advance maternal health equity by narrating, conceptualizing, and investigating social determinants of health as key drivers of perinatal disparity, by identifying the granular mechanism of this disparity, by making the economic case to address them, and by testing specific interventions to advance obstetric health equity. SUMMARY Measuring social determinants of health and meaningful perinatal processes and outcomes precisely and accurately at the individual, family, community/neighborhood level is a prerequisite for healthcare disparity research. A focus on elucidating the precise mechanism driving disparity in processes of obstetric care would inform a more rational effort to promote health equity. Implementation scientists should rigorously investigate in prospective trials, which countermeasures are most efficient and effective in mitigating perinatal outcome disparities.
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Farrell ME, Lutgendorf MA. Term Singleton Vertex Cesarean Birth Rates in the Military Health System. J Perinat Neonatal Nurs 2021; 35:313-319. [PMID: 34726647 DOI: 10.1097/jpn.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cesarean births have increased in the United States, accounting for approximately one-third of all births. There is concern that cesarean birth is overused, due to the wide variation in rates geographically and at different institutions within the same region. Despite the rising rate, there has not been an improvement in maternal or neonatal outcomes. Consequently, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published recommendations aimed at the safe prevention of primary cesarean births in 2014. The purpose of this project was to identify the term singleton vertex cesarean birth rates in the Military Health System's hospitals; to compare the Military Health System's rate of term singleton vertex cesarean birth to published benchmarks; and to compare term singleton vertex cesarean birth rates over time and among facilities within the Military Health System to determine whether variation existed. This was a retrospective review of aggregate data reported by the National Perinatal Information Center. Data were analyzed over 9 years at 2-year intervals from 2011 through 2019 inclusively. The Military Health System exceeded national benchmarks for term singleton vertex cesarean birth rates and had less variation over time and among facilities.
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Affiliation(s)
- Maureen E Farrell
- Medical Directory Gynecologic Surgical Services, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Dr Farrell); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts (Dr Farrell); and Division of Maternal Fetal Medicine, Naval Medical Center San Diego, San Diego, California (Dr Lutgendorf)
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Coronavirus Trauma and African Americans' Mental Health: Seizing Opportunities for Transformational Change. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073568. [PMID: 33808216 PMCID: PMC8037715 DOI: 10.3390/ijerph18073568] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/20/2021] [Accepted: 03/27/2021] [Indexed: 01/24/2023]
Abstract
The COVID-19 pandemic is a natural disaster of historic proportions with widespread and profound psychological sequelae. African Americans fall ill and die more than whites from COVID and more survivors and loved ones face psychological risk. African Americans also experience greater personal, social, and financial stress even when not personally touched by COVID illness, and they are again vulnerable as COVID diminishes African American community’s capacity for mutual support. Enactment of the American Rescue Act of 2021 can moderate if not eliminate African Americans’ greater adversity and greater psychological challenge; other provisions can move the mental health treatment system beyond its previous failure to reach African Americans as it constructively responds to the crisis that COVID presents. From outreach through trusted community actors and institutions for meeting African Americans’ needs of varying intensity and duration, and by providing a spectrum of evidence supported interventions—culturally adapted as needed—newfound success can mark a turning point toward new approaches and lasting success.
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Tilden EL, Phillippi JC, Snowden JM. COVID-19 and Perinatal Care: Facing Challenges, Seizing Opportunities. J Midwifery Womens Health 2020; 66:10-13. [PMID: 33314675 DOI: 10.1111/jmwh.13193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ellen L Tilden
- Department of Nurse-Midwifery School of Nursing, Oregon Health & Science University, Portland, Oregon.,Department of Obstetrics and Gynecology School of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Jonathan M Snowden
- Department of Obstetrics and Gynecology School of Medicine, Oregon Health & Science University, Portland, Oregon.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, Oregon
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Snowden JM, Osmundson SS, Kaufman M, Blauer Peterson C, Kozhimannil KB. Cesarean birth and maternal morbidity among Black women and White women after implementation of a blended payment policy. Health Serv Res 2020; 55:729-740. [PMID: 32677043 PMCID: PMC7518810 DOI: 10.1111/1475-6773.13319] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To test whether Minnesota's blended payment policy had differential effects on cesarean use and maternal morbidity among black women and white women in Minnesota, as compared to six control states. DATA SOURCES/STUDY SETTING Claims data from births to Medicaid fee-for-service beneficiaries, 2006-2012, in Minnesota (policy state) and six control states (Wisconsin, Iowa, Illinois, Oregon, Idaho, and Montana). STUDY DESIGN The key study intervention was Minnesota's blended payment policy, which established one single payment rate for uncomplicated vaginal and cesarean births in 2009. The primary outcome was cesarean birth, and secondary outcomes were maternal morbidity (composite), postpartum hemorrhage, and chorioamnionitis. Policy effects were assessed using race-stratified comparative interrupted time series analysis. PRINCIPAL FINDINGS Following policy implementation, cesarean use decreased among both black and white women in Minnesota compared to control states; this decline was larger among black women (-2.88 percent 3-year cumulative decline, from a prepolicy cesarean rate of 22.2 percent) than among white women (-1.32 percent, P = .0013). Postpartum hemorrhage increased, with larger increases among black women (1.20 percent 3-year cumulative increase), compared with white women (0.48 percent, P < .001) in Minnesota compared with control states. CONCLUSIONS Policy-related declines in cesarean use after Minnesota's blended payment policy were larger in black women. Increases in postpartum hemorrhage signal potential unintended consequences of policy-related cesarean reduction.
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Affiliation(s)
- Jonathan M. Snowden
- School of Public HealthOregon Health and Science University / Portland State UniversityPortlandOR
| | - Sarah S. Osmundson
- Department of Obstetrics and GynecologyVanderbilt University Medical CenterNashvilleTN
| | - Menolly Kaufman
- School of Public HealthOregon Health and Science University / Portland State UniversityPortlandOR
| | - Cori Blauer Peterson
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMN
| | - Katy Backes Kozhimannil
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMN
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