The Impact of Racism and Midwifery's Lack of Racial Diversity: A Literature Review

Institutional forces that influence the precepting of midwifery students

BACKGROUND

The lack of clinical preceptors, who play a key role in educating future healthcare providers, is often cited as a limitation to growing the midwifery and nursing workforce.

PURPOSE

To explore midwives' perspectives on barriers to precepting midwifery students in order to support growing the preceptor workforce.

METHODS

In-depth qualitative interviews were conducted with 18 midwives from across New Jersey. Analysis was guided by the tenets of thematic analysis and the Socioecological Model.

DISCUSSION

Three overarching institutions were responsible for many of the barriers midwives experienced to precepting students and practicing to the full extent of their training: the state, the hospital, and the university. Recommendations from participants about improvements to support precepting included actionable items for each institution.

CONCLUSION

State governments, hospital systems, and academic institutions are vital to efforts to expand the pool of midwifery clinical preceptors needed to grow and diversify the perinatal healthcare workforce, including midwives, in the United States.

Historical Study of the Graduates of the Tuskegee School of Nurse-Midwifery, a Program for Black Nurses

OBJECTIVE

To increase awareness of the contributions of Black nurses to midwifery and to provide an understanding of how initiatives in the past address racial disparities in maternal health that are still relevant today.

DESIGN

Historical research.

SETTING

The Tuskegee School of Nurse-Midwifery.

DATA SOURCES

Thirty-one Black nurse-midwives who graduated from the Tuskegee School of Nurse-Midwifery and oral histories of two of these graduates.

METHODS

Historical research that involved locating and analyzing primary and secondary sources about the graduates of the Tuskegee School of Nurse-Midwifery from 1941 to 1946; the oral histories conducted with two graduates are examples of primary sources.

RESULTS

The Tuskegee School of Nurse-Midwifery opened September 15, 1941, in Tuskegee, Alabama. The purpose of the school was to educate Black nurses in midwifery to address maternal health in the Black communities where the maternal and infant mortality rates were greatest. By the end of the second year of the program, the maternal mortality rate declined from 8.5 per 1,000 live births to 0, and the infant mortality rate decreased from 45.9 per 1,000 to 14 among the women served in Macon County. However, the school closed in 1946 after graduating 31 Black nurse-midwives.

CONCLUSION

The history of early Black nurse-midwives is relevant to the disciplines of nursing, midwifery, and public health. The Tuskegee graduates obtained an education in a relatively new and evolving profession during a time when racism and discrimination in education, financial opportunity, and housing profoundly affected the health and well-being of Black communities. These factors continue to contribute to racial disparities in maternal health and create barriers for those in the Black community who want to become nurses or midwives. The challenges and successes Black nurse-midwives experienced are significant to the present day, but their stories are often not told.

Growth and diversification of the perinatal nursing workforce: An American Academy of Nursing consensus paper

Perinatal care in the United States is in crisis. U.S. childbearing women are dying at higher rates than in comparable economically developed countries, despite the fact that four of every five perinatal deaths are preventable. The crisis disproportionately affects Black and American Indian and Alaska Native women, who are dying at two to three times the rate of their White counterparts. These disparities have been linked to systemic and structural racism and lack of access to care. A perinatal care workforce that reflects and meets the needs of a racially and ethnically diverse U.S. population is warranted to increase the likelihood of equitable care and decrease perinatal disparities. Using a health equity lens, this paper provides policy recommendations for a system-wide approach to growing and diversifying the perinatal nursing workforce as part of the solution to decrease disparities in perinatal outcomes.

"With an unwanted pregnancy, we are looking for midwives in the neighbourhood to show us what to do." Stakeholder perceptions of midwife-led woman-centred comprehensive abortion care in the province of Kinshasa, Democratic Republic of Congo: a qualitative descriptive study

PROBLEM

Midwives are an essential yet underutilised health human resource for improving unsafe abortion outcomes and increasing abortion access and contraceptive care.

BACKGROUND

In Democratic Republic of Congo (DRC), morbidity and mortality resulting from unsafe abortions are alarmingly high. The recent ratification of the Maputo Protocol in 2018 has made safe abortion accessible. National implementation strategies recognise midwives as providers of comprehensive abortion care (CAC), yet there is little understanding of their current role in its provision.

AIM

To understand the obstacles and facilitators in integrating the midwifery model of CAC in DRC's health system.

METHODS

A qualitative descriptive design was used to explore health system stakeholders' perceptions regarding the midwifery model of CAC in Kinshasa, DRC. Data sources included n = 43 key informant interviews and n = 2 FGDs. Results were member-checked with DRC Midwives' Association (SCOSAF) members.

FINDINGS

Findings highlight midwives provided all aspects of CAC, with attention to the psycho-social well-being of their clients and acted as health service navigators in the community. Appropriate midwifery legislation, scope of practice that includes CAC, administrative support and remuneration, and better access to continuing education are facilitating health system factors for the midwifery model of CAC. Finally, SCOSAF, the Midwives' Association, played an influential role in the implementation, positively supporting CAC integration by midwives.

DISCUSSION

Understanding health system levers and the involvement of Midwives' Associations are important considerations when integrating and sustaining the midwifery model of CAC. Gender transformative approaches are appropriate given systemic gender inequities inherent in midwifery.

CONCLUSION

Further research is needed to understand the impact of the midwifery model of CAC in DRC.

Midwifery Students' Experiences of Bias in the Clinical Setting: Prevalence, Types, and Impact

INTRODUCTION

Exposure to bias in clinical learning environments may undermine students' confidence, cause emotional harm, impede learning, and potentially delay graduation. However, little is known about the prevalence of bias experienced by midwifery students in the United States. This cross-sectional, descriptive study aimed to quantify clinical midwifery students' experiences of bias based on 7 self-identified characteristics (gender identity, race or ethnicity, body size, age, sexual orientation, religion, and occupational background). Additionally, this research explored the impact of bias on student well-being, learning, and professional commitment.

METHODS

The survey consisted of 39 items addressing (1) prevalence and types of bias, (2) emotional impact and influence on clinical learning, (3) ways students coped, (4) whether anyone spoke up at the time bias occurred, (5) whether students reported bias to faculty, and (6) impact of bias on commitment to midwifery. The survey was distributed to midwifery students and recent graduates in 2022 via American College of Nurse-Midwives email discussion lists and social media. Participants were eligible if they were in a clinical rotation in an Accreditation Commission for Midwifery Education-accredited midwifery program between 2019 and 2022.

RESULTS

Surveys were returned by 383 participants, with 301 meeting inclusion criteria. Most participants (66.5%) reported personally experiencing or witnessing bias against at least 1 of 7 personal characteristics. The most commonly reported biases were related to gender, occupational background, age, and race or ethnicity. Only half of the participants reported these occurrences to someone with academic authority, and nearly a third considered withdrawing from their educational programs.

DISCUSSION

In this study bias was common and significantly impacted students. These results underscore the need for creative and bold interventions at personal, educational, and institutional levels to prevent and mitigate bias. Safeguarding clinical learning environments will enable students to thrive, graduate with confidence and competence, and thereby contribute to the diversification and strengthening of the midwifery profession.

Transformative justice to support truth and reconciliation within nurse-midwifery education

Nursing education holds a history framed in white supremacy and whiteness. Efforts to employ antiracist strategies have been hindered, largely due to an inability for faculty to acknowledge and hold accountability for racialized harms that occur within nursing educational structures. A nurse-midwifery program in the Pacific Northwest United States uncovered harm that impacted students and identified a need to respond and hold accountability. Guided by the framework of Transformative Justice, a truth and reconciliation process was implemented as a first step to better address racism within nursing and nurse-midwifery education. This paper describes the process to support other institutions in their work to address harms within nursing education.

Protocol for Evaluating Remote Patient Blood Pressure Monitoring Adapted to Black Women and Birthing Persons

Cardiovascular disease is the leading cause of maternal death among Black women in the United States. A large, urban hospital adopted remote patient blood pressure monitoring (RBPM) to increase blood pressure monitoring and improve the management of hypertensive disorders of pregnancy (HDP) by reducing the time to diagnosis of HDP. The digital platform integrates with the electronic health record (EHR), automatically inputting RBPM readings to the patients' chart; communicating elevated blood pressure values to the healthcare team; and offers a partial offset of the cost through insurance plans. It also allows for customization of the blood pressure values that prompt follow-up to the patient's risk category. This paper describes a protocol for evaluating its impact. Objective 1 is to measure the effect of the digitally supported RBPM on the time to diagnosis of HDP. Objective 2 is to test the effect of cultural tailoring to Black participants. The ability to tailor digital content provides the opportunity to test the added value of promoting social identification with the intervention, which may help achieve equity in severe maternal morbidity events related to HDP. Evaluation of this intervention will contribute to the growing literature on digital health interventions to improve maternity care in the United States.

Disrupting Racism in Ontario Midwifery

INTRODUCTION

There are a limited number of Canadian studies that explore the experiences of racism among health care providers who are Black, Indigenous, or people of color (BIPOC), and specifically within the context of midwifery in Ontario. More information is needed to better understand how to achieve racial equity and justice at all levels of the midwifery profession.

METHODS

Semistructured key informant interviews were conducted with racialized midwives in Ontario to understand how racism manifests in the midwifery profession and to conduct a needs assessment of interventions required. The researchers used thematic analysis to identify patterns and themes within the data and to develop a better understanding of participants' experiences and perspectives.

RESULTS

Ten racialized midwives participated in key informant interviews. The vast majority of participants reported experiences of racism in their work as a midwife, including being subject to or witnessing racism from clients and colleagues, tokenism, and exclusionary hiring practices. More than half of participants also emphasized their commitment to providing culturally concordant care for BIPOC clients. Participants relayed that access to BIPOC-centered gatherings, workshops, peer reviews, conferences, support groups, and mentorship opportunities constitute important supports for improving diversity and equity in midwifery. They also expressed a need for midwives and midwifery organizations to actively work to disrupt racism and the power structures in midwifery that enable racial inequity to proliferate.

DISCUSSION

The manifestations of racism in midwifery have negative impacts on the career trajectory, career satisfaction, interpersonal relationships, and well-being of BIPOC midwives. It is crucial to understand the role of racism in midwifery and make meaningful changes toward dismantling interpersonal and systemic racism in the profession. These progressive changes will serve to create a more diverse and equitable profession, where all midwives can belong and thrive.

Current practices and perspectives on clerkship grading in obstetrics and gynecology

BACKGROUND

Clerkship grades in obstetrics and gynecology play an increasingly important role in the competitive application process to residency programs. An analysis of clerkship grading practices has not been queried in the past 2 decades in our specialty.

OBJECTIVE

This study aimed to investigate obstetrics and gynecology clerkship directors' practices and perspectives in grading.

STUDY DESIGN

A 12-item electronic survey was developed and distributed to clerkship directors with active memberships in the Association of Professors of Gynecology and Obstetrics.

RESULTS

A total of 174 of 236 clerkship directors responded to the survey (a response rate of 73.7%). Respondents reported various grading systems with the fewest (20/173 [11.6%]) using a 2-tiered or pass or fail system and the most (72/173 [41.6%]) using a 4-tiered system. Nearly one-third of clerkship directors (57/163 [35.0%]) used a National Board of Medical Examiners subject examination score threshold to achieve the highest grade. Approximately 45 of 151 clerkship directors (30.0%) had grading committees. Exactly half of the clerkship directors (87/174 [50.0%]) reported requiring unconscious bias training for faculty who assess students. In addition, some responded that students from groups underrepresented in medicine (50/173 [28.9%]) and introverted students (105/173 [60.7%]) received lower evaluations. Finally, 65 of 173 clerkship directors (37.6%) agreed that grades should be pass or fail.

CONCLUSION

Considerable heterogeneity exists in obstetrics and gynecology clerkship directors' practices and perspectives in grading. Strategies to mitigate inequities and improve the reliability of grading include the elimination of a subject examination score threshold to achieve the highest grade and the implementation of both unconscious bias training and grading committees.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes

OBJECTIVES

Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes.

METHODS

This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission.

RESULTS

The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations.

CONCLUSIONS FOR PRACTICE

Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

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).

'Only for the white'. A qualitative exploration of the lived experiences of Black, Asian and Minority Ethnic midwifery students

BACKGROUND

An ethnically diverse workforce has been identified as a key component of safe, compassionate maternity care, and yet midwifery remains a predominantly White profession across the Global North. Understanding the experiences of Black, Asian and Minority Ethnic midwifery students is key to addressing this disparity.

OBJECTIVE

To capture the university and placement experiences of Black, Asian and Minority Ethnic midwifery students in a culturally White environment.

METHODS

A qualitative approach underpinned by a feminist, inductive, interpretivist paradigm informed a study undertaken with student midwives studying at three separate universities in South East England. Five virtual focus groups and two semi-structured interviews were conducted with thirteen current student midwives and one preceptee (recently graduated) midwife self-identifying as Black, Asian or Minority Ethnic. Analysis was inductive, data-driven and thematic. Standards for Reporting Qualitative Research recommendations have been used to formulate this report.

FINDINGS

Although some participants reported positive experiences and felt well-supported, an overarching narrative emerged of midwifery as an exclusive and White profession. Institutionalised Whiteness was experienced in university, in placement and within individual student cohorts. Four themes were identified: 'being an outsider', 'prejudice, discrimination and racism', 'nowhere to turn' and 'positive forces'.

CONCLUSIONS

Racist and discriminatory beliefs and practices in some midwifery education and placement settings negatively impact student experience and are likely to result in poorer care being provided to Global Ethnic Majority women and families. An unwillingness among some White educators and students to recognise the presence and impact of inequitable and racist environments, and a lack of clear, acceptable, and effective pathways for students to use to raise and discuss concerns, makes it difficult to challenge and change this injustice.

Intergenerational Continuity of Child Maltreatment, Parenting, and Racism: Commentary on Valentino et al., (2012)

Recent editorials published in Child Maltreatment bring much needed attention to racism in child maltreatment reporting and investigation. In this commentary, we extend these efforts by responding to Valentino et al., (2012) and addressing prior omissions in our race-related work by explicitly discussing the role of racism in our explanation of key study findings. Together with scholars with expertise in the impact of racism on children and families, this commentary (a) discusses theoretical models of child maltreatment and of the influence of racism on parenting and child development; (b) discusses parental responses to racism in relation to the Valentino et al., (2012) findings; and (c) highlights future research directions.

American Midwifery Certification Board Certification Demographic and Employment Data, 2016 to 2020: The Certified Nurse-Midwife and Certified Midwife Workforce

INTRODUCTION

Expansion and diversification of the midwifery workforce is a federal strategy to address the maternal health crisis in the United States. Understanding characteristics of the current midwifery workforce is essential to creating approaches to its development. Certified nurse-midwives and certified midwives (CNMs/CMs) certified by the American Midwifery Certification Board (AMCB) constitute the largest portion of the US midwifery workforce. This article aims to describe the current midwifery workforce based on data collected from all AMCB-certified midwives at the time of certification.

METHODS

Midwife initial certificants and recertificants were administered an electronic survey about personal and practice characteristics at the time of certification by AMCB between 2016 and 2020 for administrative purposes. Given the standard 5-year certification cycle, every midwife certified during this period completed the survey once. The AMCB Research Committee conducted a secondary data analysis of deidentified data to describe the CNM/CM workforce.

RESULTS

In 2020 there were 12,997 CNMs/CMs in the United States. The workforce was largely White and female with an average age of 49. There has been a slow increase (15% to 21%) of initial certificants identifying as midwives of color. The proportion of CMs to all AMCB-certified midwives remained less than 2%. Physician-owned practices were the most common employer. Approximately 60% of midwives attend births, and hospitals were the most common birth setting. Over 10% of those certified to practice reported not working within the discipline of midwifery.

DISCUSSION

Targeted recruitment and retention of midwives must take into consideration not just expansion but dispersion, scope of practice, and diversification. The proportion of midwives attending births was lower than reported in previous years. Expansion of the CM credential and accessible educational pathways are 2 potential solutions to workforce growth. Developing strategies to retain those who are trained but not practicing presents an opportunity for workforce maintenance.

Choosing Midwifery - The perceptions and experiences of Black, Asian and Minority Ethnic applicants to midwifery programmes: A mixed methods study

AIM

to explore recruitment to UK midwifery programmes from the perspective of applicants from Black, Asian and Minority Ethnic (BAME) groups and describe the perceptions and experiences of the application process for these applicants and those from white backgrounds.

BACKGROUND

Midwifery in the Global North is an overwhelmingly white profession. This lack of diversity has been cited as a factor in the poorer outcomes experienced by women from non-white backgrounds. There is a need for midwifery programmes to recruit and support more ethnically and racially diverse cohorts if this situation is to be addressed. Very little is currently known about the recruitment experiences of midwifery applicants.

DESIGN

A mixed methods study comprising a survey and individual interview or focus group. The study was conducted between September 2020 and March 2021 in three universities in South East England. Participants comprised 440 applicants to midwifery programmes and 13 current or recently qualified BAME midwifery students.

FINDINGS

Although many survey findings in respect to choosing a midwifery programme were broadly similar between candidates from BAME and non-BAME backgrounds, some trends were noted. More BAME applicants cited school/college rather than family as encouraging. More BAME applicants also indicated that they would consider issues of diversity when selecting a place of study, and BAME respondents appeared less likely to consider location and university life. Survey and focus group findings combined may indicate deficits in social capital available to BAME midwifery applicants. Focus group findings in particular suggest multiple experiences of challenge and inequity at all stages of the application process, together with a perception that midwifery is a niche and white profession. Applicants value proactive support from universities and would appreciate increased diversity, opportunities for mentorship and an individualised approach to recruitment.

CONCLUSIONS

BAME applicants to midwifery can face additional challenges which have an impact on their ability to secure a place. There is a need to reposition midwifery as an inclusive and welcoming option for people from all backgrounds and to develop equitable recruitment processes that value a range of skills and life experiences.

Midwifery care during labor and birth in the United States

The intrapartum period is a crucial time in the continuum of pregnancy and parenting. Events during this time are shaped by individuals' unique sociocultural and health characteristics and by their healthcare providers, practice protocols, and the physical environment in which care is delivered. Childbearing people in the United States have less opportunity for midwifery care than in other high-income countries. In the United States, there are 4 midwives for every 1000 live births, whereas, in most other high-income countries, there are between 30 and 70 midwives. Furthermore, these countries have lower maternal and neonatal mortality rates and have consistently lower costs of care. National and international evidences consistently report that births attended by midwives have fewer interventions, cesarean deliveries, preterm births, inductions of labor, and more vaginal births after cesarean delivery. In addition, midwifery care is consistently associated with respectful care and high patient satisfaction. Midwife-physician collaboration exists along a continuum, including births attended independently by midwives, births managed in consultation with a physician, and births attended primarily by a physician with a midwife acting as consultant on the normal aspects of care. This expert review defined midwifery care and provided an overview of midwifery in the United States with an emphasis on the intrapartum setting. Health outcomes associated with midwifery care, specific models of intrapartum care, and workforce issues have been presented within national and international contexts. Recommendations that align with the integration of midwifery have been suggested to improve national outcomes and reduce pregnancy-related disparities.

Racism is a motivator and a barrier for people of color aspiring to become midwives in the United States

OBJECTIVE

To understand motivators and barriers of aspiring midwives of color.

DATA SOURCES AND STUDY SETTING

Primary data were collected via a national online survey among people of color in the United States interested in pursuing midwifery education and careers between February 22 and May 2, 2021.

STUDY DESIGN

Cross-sectional survey consisted of 76 questions (75 closed-ended and 1 open-ended questions) including personal, familial, community, and societal motivators and barriers to pursuing midwifery.

DATA COLLECTION/EXTRACTION METHODS

We recruited respondents 18 years and older who identified as persons of color by posting the survey link on midwifery, childbirth, and reproductive justice listservs, social media platforms, and through emails to relevant midwifery and doula networks. We conducted descriptive and bivariate analyses by demographic characteristics and used exemplar quotes from the open-ended question to illustrate findings from the descriptive data.

PRINCIPAL FINDINGS

The strongest motivating factors for the 799 respondents were providing racially concordant care for community members (87.7 percent), reducing racial disparities in health (67.2 percent), and personal experiences related to midwifery care (55.4 percent) and health care more broadly (54.6 percent). Main barriers to entering midwifery were direct (58.2 percent) and related (27.5 to 52.8 percent) costs of midwifery education, and lack of racial concordance in midwifery education and the midwifery profession (31.5 percent) that may contribute to racially motivated exclusion of people of color. Financial and educational barriers were strongest among those with lower levels of income or education.

CONCLUSIONS

Structural and interpersonal racisms are both motivators and barriers for aspiring midwives of color. Expanding and diversifying the perinatal workforce by addressing the financial and educational barriers of aspiring midwives of color, such as providing funding and culturally-competent midwifery education, creating a robust pipeline, and opening more midwifery schools, is a matter of urgency to address the maternal health crisis.

Evidence-informed framework for gender transformative continuing education interventions for midwives and midwifery associations

INTRODUCTION

Continuing education for midwives is an important investment area to improve the quality of sexual and reproductive health services. Interventions must take into account and provide solutions for the systemic barriers and gender inequities faced by midwives. Our objective was to generate concepts and a theoretical framework of the range of factors and gender transformative considerations for the development of continuing education interventions for midwives.

METHODS

A critical interpretive synthesis complemented by key informant interviews, focus groups, observations and document review was applied. Three electronic bibliographic databases (CINAHL, EMBASE and MEDLINE) were searched from July 2019 to September 2020 and were again updated in June 2021. A coding structure was created to guide the synthesis across the five sources of evidence.

RESULTS

A total of 4519 records were retrieved through electronic searches and 103 documents were included in the critical interpretive synthesis. Additional evidence totalled 31 key informant interviews, 5 focus groups (Democratic Republic of Congo and Tanzania), 24 programme documents and field observations in the form of notes. The resulting theoretical framework outlines the key considerations including gender, the role of the midwifery association, political and health systems and external forces along with key enabling elements for the design, implementation and evaluation of gender transformative continuing education interventions.

CONCLUSION

Investments in gender transformative continuing education for midwives, led by midwifery associations, can lead to the improvement of midwifery across all United Nations' target areas including governance, health workforce, health system arrangements and education.

Toward a contextualized understanding of well-being in the midwifery profession: An integrative review

Our integrative review synthesizes and evaluates two decades of empirical research on well-being in the midwifery profession to reveal (1) how researchers have studied midwives’ well-being; (2) key findings of research on midwives’ well-being; (3) underlying assumptions of this research; and (4) limitations of this research. We find that research on midwives’ well-being is disproportionately focused on individual midwives, who are assumed to be largely responsible for their own well-being, and that well-being in the midwifery profession is generally equated with the absence of mental health problems such as burnout, anxiety, and stress. Researchers have largely taken a narrow and instrumental approach to study midwives’ well-being, focusing on work-related antecedents and consequences, and overlooking the influence of nonwork factors embedded in the broader socioeconomic and cultural environment. Drawing on more comprehensive and contextualized well-being frameworks, we propose a research model that (1) expands the well-being construct as it applies to midwives and (2) situates midwives’ well-being in broader social, economic, political, and cultural contexts. Although developed in the midwifery context, our proposed research model can be applied to a host of professions.

LGBTQ+ Healthcare Teaching in UK Medical Schools: An Investigation into Medical Students' Understanding and Preparedness for Practice

OBJECTIVES

Lesbian, gay, bisexual, trans* and queer/questioning + (LGBTQ+) healthcare teaching within UK medical schools is currently lacking, potentially impacting on patients' confidence in health services and ability to access care. The current study conducted a multi-site analysis aiming to investigate medical students' perceptions towards the teaching of LGBTQ+ healthcare in UK medical schools, as well as to gain a greater understanding of medical students' level of knowledge of LGBTQ+ healthcare, and preparedness for working with LGBTQ+ patients.

METHODS

Medical students (N = 296) from 28 UK institutions responded to a 15-question online survey distributed via course leads and social media. Thematic analysis of qualitative data was conducted, as well as statistical analysis of quantitative data using SPSS.

RESULTS

Only 40.9% of students reported having any teaching on LGBTQ+ healthcare, 96.6% of whom said this was one-off or very irregular sessions. Only 1 in 8 felt their knowledge and skills on LGBTQ+ healthcare was sufficient. 97.2% of students questioned wanted more knowledge on LGBTQ+ healthcare.

CONCLUSION

The current study highlighted that UK medical students felt underprepared for working with LGBTQ+ patients due to insufficient education. Given that teaching on LGBTQ+ healthcare is often optional and extra-curricular, it may not be reaching those who need it most. The authors are calling for the mandatory inclusion of LGBTQ+ healthcare in the teaching of all UK medical schools, within their individual curriculum frameworks, and with regulatory support from the General Medical Council. This will ensure a wider understanding among medical students, and subsequently qualified doctors, of the health inequities and unique health issues LGBTQ+ people face, which will better equip them to provide high-quality care to LGBTQ+ patients, and start to tackle the inequities they face.

Factors influencing intrapartum health outcomes among Black birthing persons: A discursive paper

AIM

To examine factors that influence intrapartum health outcomes among Black childbearing persons, including cisgender women, transmasculine and gender-diverse birthing persons.

BACKGROUND

Black childbearing persons are three to four times (243%) more likely to die while giving birth than any other racial/ethnic group. Black birthing persons are not just dying from complications but also from inequitable care from healthcare providers compared to their white counterparts.

DESIGN

Discursive paper.

METHOD

Searching national literature published between 2010 and 2021 in PubMed, CINAHL, Embase and SCOPUS, we explored factors associated with poor intrapartum health outcomes among Black childbearing persons.

DISCUSSION

Several studies have ruled out social determinants of health as sufficient causative factors for poor intrapartum health outcomes among Black birthing persons. Recent research has shown that discrimination by race heavily influences whether a birthing person dies while childbearing.

CONCLUSIONS

There is a historical context for obstetric medicine that includes harmful stereotypes, implicit bias and racism, all having a negative impact on intrapartum health outcomes. The existing health disparity among this population is endemic and requires close attention.

IMPACT ON NURSING PRACTICE

Nurses and other healthcare professionals must understand their role in establishing unbiased care that promotes respect for diversity, equity and inclusion.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement in the design or drafting of this discursive paper.

The Early Care Model for Initiation of Perinatal Care: "I Actually Felt Listened To"

Early access to prenatal care is a crucial component in reducing poor perinatal outcomes. Institutional barriers such as insurance enrollment, clinic wait times, and systemic racism dramatically influence perinatal care engagement. The Early Care model seeks to address these barriers through a collaborative care model with licensed midwives and certified nurse-midwives. In contrast to traditional models of prenatal care in which the first visit is deferred until gestational age allows for a dating ultrasound, the Early Care model allows for care to be initiated at any gestation. Patients are offered accessible telehealth early pregnancy appointments for thorough assessment of clinical and social needs to better meet each person's unique and diverse experiences. Patients can receive timely referrals for emergent clinical and social needs, as well as education about all care options. This model promotes improved outcomes and decreased disparities, as well as broader awareness of midwifery care. This article provides an overview of the Early Care model experience.

Midwifery in the Time of COVID-19: An Exploratory Study from the Perspectives of Community Midwives

INTRODUCTION

An increasing number of people in the United States are choosing to give birth in a community setting. There is anecdotal evidence that interest in community birth further increased during the COVID-19 pandemic. The purpose of this study was to explore the needs, barriers, and successes of community midwifery during COVID-19 and how these experiences can inform future efforts to support and sustain community-based midwifery.

METHODS

This qualitative study used semi-structured interviews conducted online with 11 community midwives from the greater Seattle area who were practicing during the COVID-19 pandemic. Interviews were transcribed verbatim from audio recordings. Transcripts were analyzed using deductive and inductive coding.

RESULTS

Participants all reported challenges navigating COVID-19-related changes, such as implementing personal protective equipment, using telehealth, and limiting support people at births. Although participants saw an increased interest in their services, the increase in uncompensated labor contributed to burnout. Many participants described regularly encountering stigma and misperceptions about community midwifery when their patients transferred to hospitals, which occurred more often among clients who chose midwifery primarily because of COVID-19 concerns. Community midwives expressed a desire to increase interprofessional collaboration with hospitals to sustain the future of community midwifery.

CONCLUSIONS

The experiences of community midwives practicing during the COVID-19 pandemic indicate strategies to reduce burnout and support community midwifery during the pandemic, natural disasters, and beyond. These strategies include improved interprofessional collaboration and higher reimbursement rates.

Cultivating the ideal obstetrical patient: How physicians-in-training describe pain associated with childbirth

We explore the work labor pain does in cultivating obstetrics and gynecology (OB/GYN) resident physicians' conceptualization of the "ideal" obstetrical patient - replete with moral, pharmacological, classed, and racialized dimensions. Our data is derived from a single-site, qualitative study conducted at an urban academic OB/GYN residency program in the midwestern U.S. between 2018 and 2019. 36 residents, 9 from each post-graduate year, were randomly selected to complete a semi-structured interview on their perceptions of patient pain surrounding OB/GYN procedures. Grounded theory analysis of the OB/GYN residents' interviews revealed the idealized obstetrical patient is quiet and easily controlled. Residents praised women whom they believed were suppressing their labor pain, a racialized and classed concept that furthers misconceptions about the "obstetric hardiness" of Black women and the hypersensitivity of wealthy White women. Participants' conceptions of "bad" patients included those with less cultural health capital due to low health literacy and socioeconomic status, which impeded the patients' ability to participate in shared decision-making. Despite acknowledging the importance of patient autonomy regarding pain control during labor, the interviewed residents positioned themselves as the ultimate authority. Their subjective assessment of patients' pain inherently invoked their personal biases, such as conflating low socioeconomic status and race. Some participants posited an inverse relationship between hardship and pain, while others questioned whether those with low health literacy exaggerate their pain due to fear of the clinical encounter or to secure medical attention. Both framings have concerning implications for inadequate pain control and the unintentional perpetuation of obstetric violence and obstetric racism within the profession.

Validation of an Instrument Assessing Certified Nurse Midwives' Attitudes toward Breastsleeping

To date, attitudes towards breastsleeping among certified nurse-midwives caring for post-partum women are not well known. This study describes the validation procedures of two instruments assessing the attitudes of certified nurse-midwives (CNMs) towards breastsleeping. These tools were validated using an 18-item survey administered to a convenience sample of certified nurse-midwives. Participating CNMs were recruited for anonymous participation in an online survey in September-November of 2019. Factor analysis and parallel analysis each revealed a two-factor solution, suggesting that there were two main concepts representing the attitudes of certified nurse-midwives towards breastsleeping; breastsleeping safety and breastfeeding experience. Statistically significant differences for mean breastsleeping safety scores were noted by age group, place of practice, and US geographical region. This article is protected by copyright. All rights reserved.

The Pharmacology and Clinical Applications of Psychedelic Medicines Within Midwifery Practice

The research and use of psychedelic medicines to treat common mental health disorders has increased substantially in the past 2 decades. At the same time, knowledge is relatively uncommon among midwives regarding (1) the relative benefits of psychedelic-assisted therapy, (2) best practices associated with the delivery of psychedelic-assisted therapy, and (3) responsible integration of this potentially useful intervention into mental health treatment plans. The purpose of this review is to describe current applications of psychedelic medicines to treat common mental health disorders, to describe the current legal status of these medicines used in this context, and to explore the potential for midwifery practice in this area with further training. This article also addresses the disparities regarding LGBTQIA+ and BIPOC populations in relation to this topic and their historical exclusion from research and treatment access in this field.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020

PURPOSE

The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes.

METHODS

Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor.

RESULTS

While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication.

CONCLUSION

This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

Refocusing the Conduct of Maternal Mortality Research in Black Pregnant Populations: Ethical Considerations

INTRODUCTION

Maternal morbidity and mortality rates are on the rise in the United States, particularly among Black populations. Recently, there has been an uptick in research funding to identify and address root causes, particularly among at-risk groups. However, given the historical trauma experienced by Black populations in research settings, novel approaches built firmly on ethical principles and grounded in a framework of reproductive justice are necessary to minimize harm and center the research process on maintaining the dignity and respect of research participants.

METHODS

Ethical principles as outlined by the American Nurses Association, Black Mamas Matter Alliance, and federal research guidelines are reviewed within the context of conducting maternal mortality-focused research. In addition, community developed research frameworks and methodologies are presented and discussed within the research context.

CONCLUSIONS

Black pregnant people have reported mistreatment during clinical encounters; therefore, intentional protections to promote safety must be considered in the research setting. Ethical principles must be considered when designing and implementing research initiatives focused on addressing maternal mortality risk in Black communities.

The Journey towards resilience following a traumatic birth: A grounded theory

Statistics have shown that up to 30% of women experience birth as traumatising. However, most women do not go on to develop post-traumatic stress disorder (PTSD), and instead appear to be resilient. Research is still sparse in the field of traumatic birth and resilience, and it is not known how women develop resilience after a traumatic birth.

OBJECTIVES

The aim of this study was to understand the process of fostering resilience after a traumatic birth.

METHOD

Semi-structured interviews were conducted with eight female participants aged 30 to 50 years who experienced a traumatic birth. A constructivist grounded theory was used to analyse interviews.

RESULTS

Two main themes were identified which were developed into an emergent model: 1) the feeling of powerlessness during a traumatic birth; and 2) the journey towards resilience. The powerlessness of a traumatic birth was related to a perceived lack of voice and abandonment by healthcare professionals. The model revealed that women's journey towards resilience was aided by both internal and external resources that included healing self-care and ownership of the role of mother; and drawing upon faith, spirituality and supportive relationships.

DISCUSSION

The findings suggest resilience is a process whereby women draw upon internal and external resources or both at different points in their journey. The implications of the findings include training healthcare professionals in communication to avoid trauma during labour; and prompting women to identify and utilise both internal and external resources to help them to overcome any trauma.

Addressing Positionality Within Case-Based Learning to Mitigate Systemic Racism in Health Care

BACKGROUND

Case-based learning has historically focused on the individual patient; however, there is often little consideration within this teaching method of how social determinants of health, such as structural racism and its adverse health effects, bear upon patients' health status and consequent patient outcomes.

PROBLEM

Implementing case studies necessitates taking into account the positionality of patients, as well as health care providers, to counter the racial oppression and discrimination embedded in existing health care and educational systems.

APPROACH

We describe a process for creating an inclusive, antiracist environment for case-based learning within nursing education, outlining steps for preparing students to more effectively examine case studies through social determinants of health framing and lens to mitigate harmful impacts from systemic racism and racial discrimination in clinical care.

CONCLUSIONS

Addressing positionality in case-based learning is one antiracist strategy to begin rectifying health disparities and moving health care toward equity.

Feasibility of using a peer coach to deliver a behavioral intervention for promoting postpartum weight loss in Black and Latina mothers

Peer coaching may provide a culturally relevant and potentially scalable approach for delivering postpartum obesity treatment. We aimed to evaluate the feasibility of peer coaching to promote postpartum weight loss among ethnic minority women with obesity. This pilot study was a prospective, parallel-arm, randomized controlled trial. Twenty-two obese, Black or Latina mothers ≤6 months postpartum were recruited from the Philadelphia Special Supplemental Nutrition Education Program for Women, Infants and Children (WIC) and randomly assigned to either: (a) a peer-led weight loss intervention (n = 11) or (b) usual WIC care (n = 11). The intervention provided skills training and problem solving via six calls and two in-person visits with a Black mother trained in behavioral weight control strategies. Text messaging and Facebook served as platforms for self-monitoring, additional content, and interpersonal support. Both arms completed baseline and 14 week follow-up assessments. All participants were retained in the trial. Intervention engagement was high; the majority (55%) responded to at least 50% of the self-monitoring text prompts, and an average of 3.4 peer calls and 1.7 visits were completed. Mean weight loss among intervention participants was -1.4 ± 4.2 kg compared to a mean weight gain of 3.5 ± 6.0 kg in usual WIC care. Most intervention participants strongly agreed that the skills they learned were extremely useful (90%) and that the coach calls were extremely helpful for weight control (80%). Results suggest the feasibility of incorporating peer coaching into a postpartum weight loss intervention for ethnic minority women with obesity. Future research should examine the sustained impact in a larger trial.

Social-ecological considerations for the sleep health of rural mothers

Using a social-ecological framework, we identify social determinants that interact to influence sleep health, identify gaps in the literature, and make recommendations for targeting sleep health in rural mothers. Rural mothers experience unique challenges and protective factors in maintaining adequate sleep health during the postpartum and early maternal years. Geographic isolation, barriers to comprehensive behavioral medicine services, and intra-rural ethno-racial disparities are discussed at the societal (e.g., public policy), social (e.g., community) and individual levels (e.g., stress) of the social-ecological model. Research on sleep health would benefit from attention to methodological considerations of factors affecting rural mothers such as including parity in population-level analyses or applying community-based participatory research principles. Future sleep health programs would benefit from using existing social support networks to disseminate sleep health information, integrating behavioral health services into clinical care frameworks, and tailoring culturally-appropriate Telehealth/mHealth programs to enhance the sleep health of rural mothers.

Midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies: A qualitative study

PROBLEM

Childbearing women from ethnic minority groups in the United Kingdom (UK) have significantly poorer perinatal outcomes overall.

BACKGROUND

Childbearing women from ethnic minority groups report having poorer experiences and outcomes in perinatal care, and health professionals report having difficulty in providing effective care to them. Yet barriers in relation to providing such care remain underreported.

AIM

The aim of this study was to elicit midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies and how to overcome these barriers.

METHODS

A qualitative study was undertaken in a single obstetric led unit in London, UK. A thematic analysis was undertaken to identify themes from the data.

FINDINGS

A total of 20 midwives participated. They self-identified as White British (n=7), Black African (n=7), Black Caribbean (n=3) and Asian (n=3). Most (n=12) had more than 10 years' experience practising as a registered midwife (range 2 - 35 years). Four themes were identified: 1) Communication, 2) Continuity of carer, 3) Policy and 4) Social determinants. Racism and unconscious bias underpin many of the findings presented.

DISCUSSION

Co-created community hubs may improve access to more effective care for childbearing women from ethnic minority groups. A focus on robust anti-racism interventions, continuity of carer, staff wellbeing and education along with the provision of orientation and bespoke translation services are also suggested for the reduction of poorer outcomes and experiences.

CONCLUSION

Along with policies designed to promote equality and irradicate racism, there is a need for co-created community hubs and continuity of carer in perinatal services. Further research is also required to develop and evaluate culturally safe, and evidence-based interventions designed to address the current disparities apparent.

A paradigm shift to address racial inequities in perinatal healthcare

Health inequities are not caused by personal failings or shortcomings within disadvantaged groups, which can be erased with behavioral interventions. The scope of the problem is much greater and will only fully be addressed with the examination of the systems, structures, and policies that perpetuate racism, classism, and an economic, class, race, or gender divide between patients and the people who care for them. Solution-oriented strategies to achieve health equity will remain elusive if researchers continue to focus on behavior modification in patients while failing to do harder work that includes focusing on the institutions, community, and societal contexts in which pregnant women are living; addressing social determinants of health; considering racism in study design, analysis, and reporting; valuing the voices of patients, practitioners, and researchers from historically disadvantaged groups; disseminating research findings back to the community; and developing policy and reimbursement structures to support care delivery change that advances equitable outcomes. A case study shows us how group prenatal care may be one viable vehicle through which to affect this change. Group prenatal care is one of the few interventions shown to improve pregnancy outcomes for black women. Studies of group prenatal care have predominantly focused on the patient, but here we propose that the intervention may exert its greatest impact on clinicians and the systems in which they work. The underlying mechanism through which group prenatal care works may be through increased quantity and quality of patient and practitioner time together and communication. We hypothesize that this, in turn, fosters greater opportunity for cross-cultural exposure and decreases clinician implicit bias, explicit bias, and racism, thus increasing the likelihood that practitioners advocate for systems-level changes that directly benefit patients and improve perinatal outcomes.

Client-care provider interaction during labour and birth as experienced by women: Respect, communication, confidentiality and autonomy

INTRODUCTION

Respectful Maternity Care is important for achieving a positive labour and birth experience. Client-care provider interaction-specifically respect, communication, confidentiality and autonomy-is an important aspect of Respectful Maternity Care. The aim of this study was twofold: (1) to assess Dutch women's experience of respect, communication, confidentiality and autonomy during labour and birth and (2) to identify which client characteristics are associated with experiencing optimal respect, communication, confidentiality and autonomy.

METHODS

Pregnant women and women who recently gave birth in the Netherlands were recruited to fill out a validated web-based questionnaire (ReproQ). Mean scores per domain (scale 1-4) were calculated. Domains were dichotomised in non-optimal (score 1, 2,3) and optimal client-care provider interaction (score 4), and a multivariable logistic regression analysis was performed.

RESULTS

Of the 1367 recruited women, 804 respondents completed the questionnaire and 767 respondents completed enough questions to be included for analysis. Each domain had a mean score above 3.5. The domain confidentiality had the highest proportion of optimal scores (64.0%), followed by respect (53.3%), communication (45.1%) and autonomy (36.2%). In all four domains, women who gave birth at home with a community midwife had a higher proportion of optimal scores than women who gave birth in the hospital with a (resident) obstetrician or hospital-based midwife. Lower education level, being multiparous and giving birth spontaneously were also significantly associated with a higher proportion of optimal scores in (one of) the domains.

DISCUSSION

This study shows that on average women scored high on experienced client-care provider interaction in the domains respect, communication, confidentiality and autonomy. At the same time, client-care provider interaction in the Netherlands still fell short of being optimal for a large number of women, in particular regarding women's autonomy. These results show there is still room for improvement in client-care provider interaction during labour and birth.

Validação de conteúdo do instrumento Percepção sobre Discriminação Racial Interpessoal nos Serviços de Saúde (Driss)

Resumo Com o objetivo de elaborar e validar o conteúdo do instrumento de medida das Percepções sobre Discriminação Racial Interpessoal nos Serviços de Saúde Brasileiros (Driss), foi conduzido um estudo do tipo metodológico com base na Teoria Clássica dos Testes. O pool de itens inicial, com 49 itens, foi elaborado a partir dos resultados de uma revisão abrangente de literatura, um estudo qualitativo prévio e recomendações de um grupo de pesquisa sobre desigualdades étnico-raciais. Para a validação de conteúdo, um comitê de especialistas foi formado. Critérios qualitativos e quantitativos foram empregados para garantir rigor metodológico. Após a avaliação da versão 1 do Driss pelo comitê de especialistas, houve exclusão de 28 itens, além do desmembramento e/ou modificação de outros dez. A partir disso, elaborou-se a versão 2, submetida a pré-teste, que mostrou a necessidade de se incluírem questões introdutórias para melhor entendimento por parte da população-alvo quanto aos objetivos do estudo. Posteriormente, elaborou-se a versão 3, com conteúdo que busca valorizar as percepções e sentimentos experimentados pelos indivíduos que sofreram discriminação racial nos serviços de saúde. A validade de conteúdo da versão 3 foi verificada, por meio da Razão de Validade de Conteúdo, sendo considerada satisfatória e pronta para a verificação da validade de constructo.

Listening to Women: Recommendations from Women of Color to Improve Experiences in Pregnancy and Birth Care

INTRODUCTION

Women of color are at increased risk for poor birth outcomes, often driven by upstream social determinants and socially structured systems. Given the increasing rate of maternal mortality in the United States, particularly for women of color, there is a pressing need to find solutions to improving care quality and access for racially marginalized communities. This study aims to describe and thematically analyze the recommendations to improve pregnancy and birth care made by women of color with lived experience of perinatal health care.

METHODS

Twenty-two women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit organization participated in semistructured interviews about their experiences receiving health care during pregnancy and birth. Interviews were audio-recorded and transcribed, and transcripts were analyzed using thematic analysis to highlight recommendations for improving perinatal care experiences.

RESULTS

Participants shared experiences and provided recommendations for improving care at the individual health care provider level, including spending quality time, relationship building and making meaningful connections, individualized person-centered care, and partnership in decision making. At the health systems level, recommendations included continuity of care, racial concordance with providers, supportive health care system structures to meet the needs of women of color, and implicit bias trainings and education to reduce judgment, stereotyping, and discrimination.

DISCUSSION

Participants in this study shared practical ways that health care providers and systems can improve pregnancy and birth care experiences for women of color. In addition to the actions needed to address the recommendations, health care providers and systems need to listen more closely to women of color as experts on their experiences in order to create effective change. Community-centered research, driven by and for women of color, is essential to improve health disparities during pregnancy and birth.

Barriers to malaria prevention among immigrant travelers in the United States who visit friends and relatives in sub-Saharan Africa: A cross-sectional, multi-setting survey of knowledge, attitudes, and practices

BACKGROUND

Despite achievements in the reduction of malaria globally, imported malaria cases to the United States by returning international travelers continue to increase. Immigrants to the United States from sub-Saharan Africa (SSA) who then travel back to their homelands to visit friends and relatives (VFRs) experience a disproportionate burden of malaria illness. Various studies have explored barriers to malaria prevention among VFRs and non-VFRs-travelers to the same destinations with other purpose for travel-but few employed robust epidemiologic study designs or performed comparative analyses of these two groups. To better quantify the key barriers that VFRs face to implement effective malaria prevention measures, we conducted a comprehensive community-based, cross-sectional, survey to identify differences in malaria prevention knowledge, attitudes, and practices (KAP) among VFRs and others traveling to Africa and describe the differences between VFRs and other types of international travelers.

METHODS AND FINDINGS

Three distinct populations of travelers with past or planned travel to malaria-endemic countries of SSA were surveyed: VFRs diagnosed with malaria as reported through a state health department; members of the general VFR population (community); and VFR and non-VFR travelers presenting to a travel health clinic, both before their pretravel consultation and again, after return from travel. A Community Advisory Board of African immigrants and prior qualitative research informed survey development and dissemination. Across the three groups, 489 travelers completed surveys: 351 VFRs and 138 non-VFRs. VFRs who reported taking antimalarials on their last trip rated their concern about malaria higher than those who did not. Having taken five or more trips to SSA was reported more commonly among VFRs diagnosed with malaria than community VFRs (44.0% versus 20.4%; p = 0.008). Among travel health clinic patients surveyed before and after travel, VFR travelers were less successful than non-VFRs in adhering to their planned use of antimalarials (82.2% versus 98.7%; p = 0.001) and employing mosquito bite avoidance techniques (e.g., using bed nets: 56.8% versus 81.8%; p = 0.009). VFRs who visited the travel health clinic were more likely than VFR respondents from the community to report taking an antimalarial (83.0% versus 61.9%; p = 0.009), or to report bite avoidance behaviors (e.g., staying indoors when mosquitoes were out: 80.9% versus 59.5%; p = 0.009).

CONCLUSIONS

We observed heterogeneity in malaria prevention behaviors among VFRs and between VFR and non-VFR traveler populations. Although VFRs attending the travel health clinic appear to demonstrate better adherence to malaria prevention measures than VFR counterparts surveyed in the community, specialized pretravel care is not sufficient to ensure chemoprophylaxis use and bite avoidance behaviors among VFRs. Even when seeking specialized pretravel care, VFRs experience greater barriers to the use of malaria prevention than non-VFRs. Addressing access to health care and upstream barrier reduction strategies that make intended prevention more achievable, affordable, easier, and resonant among VFRs may improve malaria prevention intervention effectiveness.

Incorporating an Equity Agenda into Health Professions Education and Training to Build a More Representative Workforce

Efforts to achieve health equity goals in the United States require the recruitment, retention, and graduation of an increasingly diverse student body of aspiring health professionals. Improving access to health care providers who are culturally congruent with the populations served is a related ethical priority that has the potential to improve the health inequities faced by communities of color and others in the United States. Midwifery education program administrators and faculty have responded to this need by acknowledging that creation of a more representative midwifery workforce starts with midwifery education. The Equity Agenda Guideline, related conceptual model, and website resources were developed for the purpose of supporting health professions educators and institutions who recognize a need for change and are seeking answers about how to train and graduate more health care providers from communities that are currently underrepresented. Using a systems approach to outline the transformative multilevel changes required, these resources offer a roadmap for how to address the underlying problems of racism and other differentisms that have limited the growth and diversification of the health and helping professions. This article addresses how health education programs interested in making an impact on this complex and persistent problem can adopt or adapt the Equity Agenda Guideline, originally developed for midwifery education programs in the United States.

Evaluating awareness of Cultural Safety in the Australian midwifery workforce: A snapshot

PROBLEM

There are no validated tools to measure midwives' awareness of Cultural Safety.

BACKGROUND

Cultural Safety is an important component of midwifery practice. Measurement can inform practice and evaluate professional development strategies.

AIM

To adapt and evaluate the Awareness of Cultural Safety Scale with the midwifery workforce.

METHODS

An online survey was distributed to members of Australian College of Midwives and Congress of Aboriginal and Torres Strait Islander Nurses and Midwives. Measures included the Awareness of Cultural Safety Scale - Revised, Self-assessment of Cultural Knowledge and Perceptions of Racism scales.

FINDINGS

The revised Awareness scale had a Cronbach's alpha of 0.87. Principal Component Analysis with varimax rotation produced a three-factor structure accounting for 67% of variance. Awareness scores correlated with Self-assessment of Cultural Knowledge (r=0.22 p<0.03) and Perceptions of Racism (r=0.62 p<0.001) scales. Educators scored significantly higher on awareness compared to clinicians (t (1,80)=-3.09, p=0.003). Perceptions of Racism predicted Awareness of Cultural Safety scores (F (2,87) 29.25, adjusted r square=0.39 p<0.001 95% Confidence Interval=1.09, 1.93).

DISCUSSION

The revised scale was a reliable and valid measure of Cultural Safety across a diverse sample of midwives. Midwives working in education settings have a higher awareness of Cultural Safety than clinical peers.

CONCLUSION

The Awareness of Cultural Safety Scale can be used with midwives across practice settings. Professional organisations and education providers need to promote the professional responsibilities of midwives towards Cultural Safety in clinical practice and education.

The Experience and Motivations of Midwives of Color in Minnesota: Nothing for Us Without Us

INTRODUCTION

Racial disparities in birth outcomes originate with a confluence of factors including social determinants of health, toxic stress, structural racism, and barriers to engaging, high-quality perinatal care. Historically and currently, midwives are disproportionately white, and attention to the racial and ethnic diversity of midwives is an increasing focus in birth equity efforts. This qualitative study helps fill the gap in literature by assessing the perspectives and motivations of midwives of color.

METHODS

Building on concepts from critical race theory, semistructured interviews (30-90 minutes long) were used to elicit an authentic voice from midwives of color, who primarily identified as African American. Participants (N = 7) were midwives who were affiliated with an African American-owned birth center in north Minneapolis, Minnesota. Participants represented an estimated 58% of all midwives of color in the state of Minnesota. Emergent themes were identified using a grounded theory, inductive approach. Three rounds of coding were conducted, and key themes were identified and analyzed.

RESULTS

Three primary themes emerged as motivations for midwives of color: 1) offering racially concordant care to the community, 2) racial justice as a primary motivation in their work, and 3) providing physically and emotionally safe care. Racially concordant care was identified both as a motivating factor and as a way of providing physically and emotionally safe care.

DISCUSSION

Findings suggest that midwives of color maintain a critical analysis of and commitment to eliminating racial perinatal inequities. Their motivation to provide racially concordant care elicits an urgency in current efforts to recruit and train more midwives of color, recognizing the current lack of racial and ethnic diversity in the field. Understanding how to support the work of equity-minded midwives of color may help to improve access to racially concordant health care providers and care that better meets the unique needs of African American individuals.

Transforming institutional racism at an Australian hospital

Objectives The aims of this study were to: (1) examine institutional racism's role in creating health outcome discrepancies for Aboriginal and Torres Strait Islander peoples; and (2) assess the management of institutional racism in an Australian hospital and health service (HHS). Methods A literature review informed consideration of institutional racism and the health outcome disparities it produces. Publicly available information, provided by an Australian HHS, was used to assess change in an Australian HHS in five key areas of institutional racism: inclusion in governance, policy implementation, service delivery, employment and financial accountability. These findings were compared with a 2014 case study. Results The literature concurs that outcome disparity is a defining characteristic of institutional racism, but there is contention about processes. Transformative change was detected in the areas of governance, service delivery and employment at an Australian HHS, but there was no change in financial accountability or policy implementation. Conclusions The health outcomes of some racial groups can be damaged by institutional racism. An external assessment tool can help hospitals and health services to change. What is known about the topic? Institutional racism theory is still developing. An external assessment tool to measure, monitor and report on institutional racism has been developed in Australia. What does this paper add? This study on institutional racism has useful propositions for healthcare organisations experiencing disparities in outcomes between racial groups. What are the implications for practitioners? The deleterious effects of institutional racism occur regardless of practitioner capability. The role for practitioners in ameliorating institutional racism is to recognise the key indicator of poorer health outcomes, and to then seek change within their hospital or healthcare organisation.