Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle

Decomposing the Black-White Racial Disparity in Severe Maternal Morbidity Risk: The Role of Hypertensive Disorders of Pregnancy

BACKGROUND

To our knowledge, no studies have explicitly studied the role of hypertensive disorders of pregnancy (HDP) in racial disparities in severe maternal morbidity (SMM).

METHODS

Using causal mediation models, we estimated the proportion of the non-Hispanic (NH) Black-White racial disparity in risk of SMM that is explained through the pathway of HDP. We linked 2006-2019 Georgia hospital discharge records with vital statistics birth and fetal death records for NH Black and NH White birthing persons. We used G-estimation of a structural nested mean model to decompose the absolute racial disparity in the incidence of SMM into pathways operating through HDP.

RESULTS

NH Black birthing people experienced an excess 56 SMM events (95% confidence interval [CI] = 52, 59) per 10,000 delivery hospitalizations compared with NH White birthing people. If counterfactual disparity measure estimation assumptions hold, the estimated absolute disparity remaining after blocking the causal pathways through HDP was 41 SMM events per 10,000 deliveries (95% CI = 38, 44), suggesting that 26% (95% CI = 12, 40) of the absolute racial disparity would be eliminated if there was no contribution of HDP to SMM risk.

CONCLUSION

Our results are consistent with the hypothesis that intervening to prevent HDP is an important (yet incomplete) pathway for reducing the excess risk among NH Black pregnancies compared with NH White pregnancies.

Recommendations to improve maternal health equity among Black women in "The South": A position paper from the SNRS minority health research interest & implementation group

Black women in the United States experience a higher maternal mortality rate compared to other racial groups. The maternal mortality rate among non-Hispanic Black women is 3.5 times that of non-Hispanic White women and is higher in the South compared to other regions. The majority of pregnancy-related deaths in Black women are deemed to be preventable. Healthy People 2030 directs healthcare providers to advance health equity through societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities. The Southern Nursing Research Society has put forward this position paper to provide recommendations to improve maternal health equity among Black women. Recommendations for nurses, multidisciplinary healthcare providers, policymakers, and researchers are discussed.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare

BACKGROUND

Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training.

OBJECTIVE

This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice.

STUDY DESIGN

We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses).

RESULTS

Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals.

CONCLUSION

We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

An Integrative Review of the Perinatal Experiences of Black Women

OBJECTIVE

To synthesize the current body of evidence regarding the perinatal experiences of Black women.

DATA SOURCES

The databases PubMed, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus were searched with the search terms "African American" (in PubMed), "Black" (in Scopus), or "Black" OR "African American" (in CINAHL) AND "pregnancy" AND "experiences."

STUDY SELECTION

Searches yielded 266 articles published between January 2015 and May 2021. After initial screening, 68 articles were assessed for eligibility, yielding 23 studies that met the inclusion criteria of this review.

DATA EXTRACTION

Studies were reviewed for the perinatal experiences of Black women. Nonresearch articles, systematic reviews, and instrument development articles were removed. Also excluded were articles with a focus on adolescent pregnancy, breastfeeding experiences, and those outside of the perinatal time frame.

DATA SYNTHESIS

Analysis showed that Black women continue to report negative experiences in perinatal care and that these negative experiences spanned various sociodemographic characteristics. Although some Black women described positive interactions, many more expressed dissatisfaction with the lack of education, resources, and continuity in care, as well as poor communication. Additionally, experiences of racism and biases in care, mistrust in the health care system, and doubts of the efficacy or necessity of medical treatments exist.

CONCLUSION

Negative perinatal care experiences and dissatisfaction among Black women remain common. Although Black women desire more holistic, naturalistic, and empowering care, Black women first want safe, respectful care and a health care team that removes biases and racism from its system. More research is needed that includes the voices of Black women to understand these experiences and to develop interventions to improve the perinatal care experience. Nurses and other health care providers providing care in the perinatal period must also listen to, trust, and respect Black women.

Barriers to labor after cesarean: A survey of United States midwives

INTRODUCTION

Despite calls for increased vaginal birth after cesarean (VBAC), <14% of candidates have VBAC. Requirements for documentation of scar type, and prohibitions on induction or augmentation of labor are not supported by evidence but may be widespread. The purpose of this study was to document midwives' perceptions of barriers to labor after cesarean (LAC) and their effects on midwives' ability to accommodate patient desires for LAC.

METHODS

Midwives certified by the American Midwifery Certification Board (AMCB) were surveyed in 2019. Multiple option and open-ended text responses were analyzed using quantitative statistics and thematic content analysis. Select barriers to LAC, ability to accommodate LAC, and supportiveness of collaborators among midwives offering LAC were explored.

RESULTS

Responses from 1398 midwives were analyzed. Eighty-four percent felt able to accommodate LAC "most of the time," and 39% reported one or more barriers to LAC. Barriers decreased ability to accommodate LAC by as much as 80%. Analysis of text responses revealed specific themes.

CONCLUSIONS

Thirty-nine percent of midwives reported their practice was limited by one or more barriers that were inconsistent with professional guidelines. Imposition of barriers was driven primarily by collaborating physicians, and superceded supportive practices of midwives, nurses, and system administrators. Affected midwives were significantly less able to accommodate patient requests for LAC than those not affected. Midwives also reported pride in providing VBAC care, restrictions specific to midwifery scope of practice, and variation in physician support for LAC within practices affecting their ability to provide care.

The 5D Cycle for Health Equity: Combining Black Feminism, Radical Imagination, and Appreciative Inquiry to Transform Perinatal Quality Improvement

Too often, quality improvement initiatives are rooted in the health care system's oppressive structures and hierarchies. Transformative quality improvement models that embody the wisdom and liberatory potential of oppressed groups areneeded to address the alarming inequities within perinatal health. Inspired by experiences with Appreciative Inquiry, a possibility-focused change model, and frustrated by the limits of traditional quality improvement, the author sought new approaches to perinatal quality improvement. Inquiry into Black feminist recommendations for perinatal quality improvement and the principles of radical imagination led to the creation of the 5D Cycle for Health Equity, which grounds Appreciative Inquiry's 5D cycle (define, discover, dream, design, deliver/destiny) in Black feminism and radical imagination. The 5D Cycle for Health Equity is an innovative approach to address health inequities by challenging oppressive quality improvement methods and health care structures. The cycle guides quality improvement collectives through a process that redefines harm and health equity; discovers new understandings of wellness across the past, present, and future; dreams of equitable care with the principles of antioppression and collectivity; designs solutions that embody the liberatory practices of oppressed groups; delivers solutions that strive to free everyone by freeing the most oppressed; and forges a new destiny. Midwives are well poised to use the 5D Cycle for Health Equity to disrupt structures of inequity and foster a health care system that supports the health and wellness of oppressed groups.

Addressing Racial Disparities in Pregnancy-Related Deaths: An Analysis of Maternal Mortality-Related Federal Legislation, 2017-2021

There has been increasing national attention to the issue of racial disparities in pregnancy-related deaths. Federal legislation can support approaches at multiple levels of intervention to improve maternal health. As part of the CDC Policy Academy, a team of CDC staff completed a policy analysis to determine the approaches addressed in federal legislation to reduce racial disparities in pregnancy-related deaths. We analyzed federal maternal mortality legislation introduced January 2017 through December 2021. Common approaches addressed by the legislation were categorized into themes and reviewed for their alignment with approaches identified in clinical and public health literature to reduce pregnancy-related deaths, with an emphasis on social determinants of health (SDOH) approaches and reducing racial disparities. Thirty-seven unduplicated bills addressed pregnancy-related deaths, including 27 House or Senate bills that were introduced but not passed, 6 resolutions highlighting the maternal health crisis, 2 bills that passed the House only, and 2 bills enacted into law (Preventing Maternal Deaths Act of 2018 and Protecting Moms Who Served Act). The most common themes mentioned in federal legislation were improving maternal health care, addressing health inequities and SDOH, enhancing data, and promoting women's health. Legislation focused on health inequities and SDOH emphasized implicit bias training and improving SDOH, including racism and other social factors. The reviewed federal legislation reflected common clinical and public health approaches to prevent pregnancy-related deaths, including a significant focus on reducing bias and improving SDOH to address racial disparities.

Postnatal Unit Care and Safe Transition Home

The United States has the highest maternal mortality rate among developed nations with 60% of deaths occurring during the postpartum period. This chapter presents the case study of Maya Howard. Maya represents of composite of qualitative research studies that reveals missteps, gaps, and oversights of Black mothers and birthing people during birth and the postpartum period. Using a Black feminist framework, the chapter offers solutions to improve postnatal unit care and the transition home, a critical step in improving care and saving lives for all mothers and birthing people.

Double, Triple, and Quadruple Jeopardy: Entering Pregnancy With Two or More Multimorbid Diagnoses and Increased Risk of Severe Maternal Morbidity and Postpartum Readmission

INTRODUCTION

Multimorbidity, the presence of two or more chronic disease diagnoses, is associated with an increased risk of mortality and high health care costs in the general population and older adults. However, little evidence is available about the prevalence and impact of multimorbidity in obstetric populations. The goal of this analysis was to estimate the association between multimorbidity and severe maternal morbidity (SMM) and 90-day postpartum readmission in an obstetric cohort in Atlanta, Georgia.

STUDY DESIGN

We conducted a retrospective cohort study of livebirths and stillbirths at Grady Memorial Hospital, from October 2015 to April 2021. To determine preexisting chronic conditions, we linked information on births to inpatient diagnoses within the prior year. Multimorbidity was defined as the presence of two or more chronic disease diagnoses at birth or within the prior year. We conducted multivariable log binomial regression to estimate risk ratios and 95% confidence intervals for the crude and adjusted (for age, race/ethnicity, parity, and insurance) association between multimorbidity (two or more chronic conditions vs. zero or one) and SMM (at or within 42 days after birth) or 90-day postpartum readmission for any reason.

RESULTS

Of 14,225 included births, 10.1% were to patients with multimorbidity. Overall, SMM complicated 7.5% of births, and the 90-day readmission rate was 2.4%. Both SMM and readmission were more common among women with multimorbidity (SMM, 18.6% among women with multimorbidity compared with 6.3% without; 90-day readmission, 5.4% compared with 2.1%). Adjusting for potential confounders, multimorbidity was associated with increased risk of SMM (adjusted risk ratio, 2.9; 95% confidence interval, 2.5-3.0) and readmission (adjusted risk ratio, 2.2; 95% confidence interval, 1.7-2.9).

CONCLUSIONS

Individuals entering pregnancy with two or more chronic diseases were at an increased risk of SMM and postpartum readmission compared with individuals with one or zero chronic disease diagnoses.

The relationship between the neighborhood built and social environment and hypertensive disorders of pregnancy: A scoping review

BACKGROUND

Theory and limited empirical research suggest that the neighborhood environment influences maternal health outcomes. The goal of this scoping review is to summarize extant research considering the impact of the built and social environment of resident neighborhood on hypertensive disorders of pregnancy (HDP) globally.

METHODS

We performed a systematic search of the literature using four databases, PubMed, Web of Science, CINAHL, and Embase on July 15, 2020. We excluded articles not in English, that did not consider one or more HDP as a primary or secondary outcome, and that did not include an element of the neighborhood built or social environment as an exposure. We applied a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to evaluate quality of included studies.

RESULTS

Our search identified 11,385 unique abstracts for screening. Following exclusions, we included 64 articles in the final review. The majority of articles measured an element of the built environment (70.3% (44)), most commonly traffic-related air pollution (42.2% (27)). A third of articles (31.3% (20)) considered an element of the neighborhood social environment, most commonly neighborhood deprivation (10.9% (7)). Global quality ratings were mostly moderate (29.7% (19)) or weak (68.8% (44)), primarily due to inattention to neighborhood-level confounding.

CONCLUSION

Critical gaps remain in understanding how the resident neighborhood may impact HDP. Future research should focus on designing high-quality studies incorporating elements of both the built and social environment to holistically understand how context may impact maternal health.

A new perspective on the maternal mortality disparity

The disparity in maternal mortality rates between ethnicities in the United States is alarming, with Black women at far higher risk of dying than women of other ethnicities. Factors typically thought of as protective in health disparity research are not necessarily protective with maternal mortality. Building upon a social justice framework by utilizing a strength-based focus is needed when addressing this issue to build upon strengths and empower Black women as a part of the solution.

Contribution of Prepregnancy Obesity to Racial and Ethnic Disparities in Severe Maternal Morbidity

OBJECTIVE

To evaluate the role of prepregnancy obesity as a mediator in the association between race-ethnicity and severe maternal morbidity.

METHODS

We conducted an analysis on a population-based retrospective cohort study using 2010-2014 birth records linked with hospital discharge data in New York City. A multivariable logistic regression mediation model on a subgroup of the sample consisting of normal-weight and obese women (n=409,021) calculated the mediation effect of obesity in the association between maternal race-ethnicity and severe maternal morbidity, and the residual effect not mediated by obesity. A sensitivity analysis was conducted excluding the severe maternal morbidity cases due to blood transfusion.

RESULTS

Among 591,455 live births, we identified 15,158 cases of severe maternal morbidity (256.3/10,000 deliveries). The severe maternal morbidity rate among obese women was higher than that of normal-weight women (342 vs 216/10,000 deliveries). Black women had a severe maternal morbidity rate nearly three times higher than White women (420 vs 146/10,000 deliveries) and the severe maternal morbidity rate among Latinas was nearly twice that of White women (285/10,000 deliveries). Among women with normal or obese body mass index (BMI) only (n=409,021), Black race was strongly associated with severe maternal morbidity (adjusted odds ratio [aOR] 3.02, 95% CI 2.88-3.17) but the obesity-mediated effect represented only 3.2% of the total association (aOR 1.03, 95% CI 1.02-1.05). Latina ethnicity was also associated with severe maternal morbidity (aOR 2.01, 95% CI 1.90-2.12) and the obesity-mediated effect was similarly small: 3.4% of the total association (aOR 1.02, 95% CI 1.01-1.03). In a sensitivity analysis excluding blood transfusion, severe maternal morbidity cases found a higher mediation effect of obesity in the association with Black race and Latina ethnicity (15.3% and 15.2% of the total association, respectively).

CONCLUSION

Our findings indicate that prepregnancy obesity, a modifiable factor, is a limited driver of racial-ethnic disparities in overall severe maternal morbidity.

Launching the Reduction of Peripartum Racial/Ethnic Disparities Bundle: A Quality Improvement Project

INTRODUCTION

Health care organizations have a responsibility to reduce racial and ethnic perinatal health disparities. In the United States, Black women experience the worst perinatal outcomes. The process for successfully addressing this problem in clinical practice remains unclear.

PROCESS

A community hospital implemented components of the Alliance for Innovation on Maternal Health Reduction of Peripartum Racial/Ethnic Disparities Patient Safety Bundle. The purpose was to collect and share perinatal disparities data, increase staff awareness of perinatal racial and ethnic disparities, and engage staff to address these disparities at the project site. Perinatal care data were reviewed by race and ethnicity and results were shared with staff. Staff were engaged through a series of activities including a Health Equity Party, implicit bias workshop, Snack and Learn sessions, online modules, 2 grand rounds, and the establishment of a Health Equity Committee.

OUTCOMES

Racial and/or ethnic disparities were identified for perinatal outcomes and experience of care indicators including rates of cesarean birth, newborn mortality, and 30-day readmission. Of the staff 137 (65.9%) participated in project activities. The majority of participants were registered nurses (n = 82). Certified nurse-midwives (n = 10) were the profession with the highest rate of attendance (83.3%). Staff developed 26 new recommendations to address racial and ethnic disparities in care. After project implementation, mean scores of High Provider Attribution, an indicator of readiness to address health disparities, increased from preimplementation scores (P = .01). There was also a significant increase in the number of staff who reported engaging in activities to address the health care needs of racial and ethnic minority patients (P < .001).

DISCUSSION

This quality improvement project demonstrated that interventions at the health care organization level can be effective in influencing health care providers and staff to address racial and ethnic perinatal disparities.

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta

BACKGROUND

Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta.

DESIGN

We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma.

RESULTS

Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)).

CONCLUSIONS

Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Variation in the Content of Postpartum Visits by Maternal Race/Ethnicity, Preconception, and Pregnancy-Related Cardiovascular Disease Risk, PRAMS, 2016-2017

OBJECTIVES

Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content.

METHODS

We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status.

RESULTS

Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0).

CONCLUSIONS

Health systems should consider novel strategies to improve and standardize the content of postpartum visits.

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.