Addressing inequities in maternal health among women living in communities of social disadvantage and ethnic diversity

Association of Psychiatric Emergency Visits and Warm Ambient Temperature during Pregnancy: A Time-Stratified Case-Crossover Study

BACKGROUND

Acute exposure to high ambient temperature and heat waves during the warm season has been linked with psychiatric disorders. Emerging research has shown that pregnant people, due to physiological and psychological changes, may be more sensitive to extreme heat, and acute exposure has been linked to increased risk of pregnancy complications; however, few studies have examined psychiatric complications.

OBJECTIVE

Our objective was to examine the association between acute exposure to warm ambient temperatures and emergency department (ED) visits for mental disorders during pregnancy.

METHODS

A time-stratified case-crossover design with conditional logistic regression was performed on ∼ 206,000 psychiatric ED visits for pregnant patients in North Carolina, from May to September 2016 to 2019. Daily average ambient temperature was the main exposure and was linked to daily visits by maternal zip code of residence for prenatal mood and anxiety disorders (PMAD), severe mental illness (SMI), mental disorder of pregnancy (MDP), suicidal thoughts (SUIC), and any psychiatric disorder (Any). Effect modification by trimester, residential segregation, economic segregation, urbanicity, and availability of greenspace was also investigated.

RESULTS

Each 5 ° C increase in same-day exposure to warm ambient temperature on case days was associated with an increase in incidence rate ratio (IRR) for any psychiatric disorder [IRR = 1.07; 95% confidence interval (CI): 1.01, 1.14] including anxiety (IRR = 1.14; 95% CI: 1.00, 1.30), bipolar disorder (IRR = 1.28; 95% CI: 0.98, 1.67), and suicidal thoughts (IRR = 1.28; 95% CI: 1.00, 1.65) compared to control days. In general, the associations were strongest for warm season temperatures on the same day of exposure or for temperatures averaged over the 3 or 6 d preceding the ED visit. The greatest risk of an incident ED admission for PMAD (RR = 1.20; 95% CI: 1.04, 1.39), particularly for anxiety (RR = 1.30; 95% CI: 1.07, 1.59), and any psychiatric disorder (RR = 1.17; 95% CI: 1.07, 1.28) occurred following cumulative exposure to hot temperatures the week before admission. Higher psychiatric burden from temperature was observed in urban areas and on extreme heat days.

CONCLUSIONS

For this pregnant population in the southeastern United States, short-term exposure to high ambient temperatures during the warm season was associated with a greater risk of ED visits for an array of psychiatric disorders. Findings show that climate-related increases in ambient temperature may contribute to psychiatric morbidity in pregnant people. https://doi.org/10.1289/EHP13293.

Equity in prenatal healthcare services globally: an umbrella review

BACKGROUND

Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics.

METHODS

For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews.

RESULTS

The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors.

CONCLUSIONS

This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

Experiences of postpartum anxiety during the COVID-19 pandemic: A mixed methods study and demographic analysis

INTRODUCTION

The first wave of the COVID-19 pandemic saw the reconfiguration of perinatal and maternity services, national lockdowns, and social distancing measures which affected the perinatal experiences of new and expectant parents. This study aimed to explore the occurrence of postpartum anxieties in people who gave birth during the pandemic.

METHODS

An exploratory concurrent mixed-methods design was chosen to collect and analyse the quantitative and qualitative data of an online survey during the first UK lockdown. The survey included the Postpartum Specific Anxiety Scale-Research Short Form-for use in global Crises [PSAS-RSF-C] psychometric tool, and open-ended questions in relation to changes in birth plans and feelings about those changes and giving birth in a pandemic. Differences in measured scores were analysed for the participant's ethnicity, sexual orientation and disability using independent Student's t-tests, and for age, the analysis was completed using Pearson's correlation. Qualitative data from open-ended questions were analysed using a template analysis.

RESULTS

A total of 1,754 new and expectant parents completed the survey between 10th and 24th April 2020, and 381 eligible postnatal women completed the psychometric test. We found 52.5% of participants reported symptoms consistent with a diagnosis of postnatal anxiety-significantly higher than the rates usually reported. Younger women and sexual minority women were more likely to score highly on the PSAS-RSF-C than their older or heterosexual counterparts (p<0.001). Younger participants reported anxieties in the 'infant safety and welfare' category, whilst lesbian, gay, bisexual, and pansexual participants scored highly in the 'psychosocial adjustment to motherhood' category.

DISCUSSION

Postpartum anxiety is under-reported, and demographic differences in the rates of postpartum anxiety are under-researched. This research demonstrates for the first time a difference in postpartum anxiety rates amongst sexual minority women.

A consensus statement on perinatal mental health during the COVID-19 pandemic and recommendations for post-pandemic recovery and re-build

Introduction

The COVID-19 pandemic posed a significant lifecourse rupture, not least to those who had specific physical vulnerabilities to the virus, but also to those who were suffering with mental ill health. Women and birthing people who were pregnant, experienced a perinatal bereavement, or were in the first post-partum year (i.e., perinatal) were exposed to a number of risk factors for mental ill health, including alterations to the way in which their perinatal care was delivered.

Methods

A consensus statement was derived from a cross-disciplinary collaboration of experts, whereby evidence from collaborative work on perinatal mental health during the COVID-19 pandemic was synthesised, and priorities were established as recommendations for research, healthcare practice, and policy.

Results

The synthesis of research focused on the effect of the COVID-19 pandemic on perinatal health outcomes and care practices led to three immediate recommendations: what to retain, what to reinstate, and what to remove from perinatal mental healthcare provision. Longer-term recommendations for action were also made, categorised as follows: Equity and Relational Healthcare; Parity of Esteem in Mental and Physical Healthcare with an Emphasis on Specialist Perinatal Services; and Horizon Scanning for Perinatal Mental Health Research, Policy, & Practice.

Discussion

The evidence base on the effect of the pandemic on perinatal mental health is growing. This consensus statement synthesises said evidence and makes recommendations for a post-pandemic recovery and re-build of perinatal mental health services and care provision.

Safe Babies, Safe Moms: A Multifaceted, Trauma Informed Care Initiative

PURPOSE

This report describes a multifaceted, trauma-informed initiative developed to address racial/ethnic maternal and infant health inequities in Washington, D.C.

DESCRIPTION

Structural racism and systemic oppression of marginalized communities have played a critical role in maternal and infant health inequities in the United States. Black birthing individuals are exponentially more likely to experience adverse birth outcomes, including preterm birth, low birth weight and maternal mortality. In response to these statistics, the Safe Babies Safe Moms (SBSM) initiative was developed to support patients of marginalized identities and improve health outcomes. SBSM Women's and Infants' Services Specialty Care (WIS-SC) is one component of this initiative focused on perinatal services.

ASSESSMENT

SBSM WIS-SC includes trauma-informed clinical services, nurse navigation, lactation, diabetes and nutrition education, social work services, medical-legal services, and behavioral health support. Services are delivered by a multidisciplinary team trained on the following domains: (1) building connection within diverse care teams; (2) recognizing systemic barriers to trauma-informed approaches; (3) learning the brain science of implicit bias, trauma, and resilience; (4) Integrating self-care practices; and (5) acknowledging progress. Since the inception of the program, SBSM WIS-SC has served over 1500 patients.

CONCLUSION

The SBSM WIS-SC intervention reflects a patient-centered approach to care, offering the multidisciplinary services required for perinatal patients with complex medical, psychosocial, and legal needs. Trauma informed training and team building is foundational to successful service delivery to address these multifaceted health needs of historically marginalized perinatal populations nationwide.

Reflective, pragmatic, and reactive decision-making by maternity service providers during the SARS-CoV-2 pandemic health system shock: a qualitative, grounded theory analysis

BACKGROUND

Pregnant and postpartum women were identified as having particular vulnerability to severe symptomatology of SARS-CoV-2 infection, so maternity services significantly reconfigured their care provision. We examined the experiences and perceptions of maternity care staff who provided care during the pandemic in South London, United Kingdom - a region of high ethnic diversity with varied levels of social complexity.

METHODS

We conducted a qualitative interview study, as part of a service evaluation between August and November 2020, using in-depth, semi-structured interviews with a range of staff (N = 29) working in maternity services. Data were analysed using Grounded Theory analysis appropriate to cross-disciplinary health research.

ANALYSIS & FINDINGS

Maternity healthcare professionals provided their views, experiences, and perceptions of delivering care during the pandemic. Analysis rendered three emergent themes regarding decision-making during reconfigured maternity service provision, organised into pathways: 1) 'Reflective decision-making'; 2) 'Pragmatic decision-making'; and 3) 'Reactive decision-making'. Whilst pragmatic decision-making was found to disrupt care, reactive-decision-making was perceived to devalue the care offered and provided. Alternatively, reflective decision-making, despite the difficult working conditions of the pandemic, was seen to benefit services, with regards to care of high-quality, sustainability of staff, and innovation within the service.

CONCLUSIONS

Decision-making within maternity care was found to take three forms - where at best changes to services could be innovative, at worst they could cause devaluation in care being delivered, and more often than not, these changes were disruptive. With regard to positive changes, healthcare providers identified staff empowerment, flexible working patterns (both for themselves and collectively as teams), personalised care delivery, and change-making in general, as key areas to capitalise on current and ongoing innovations borne out of the pandemic. Key learnings included a focus on care-related, meaningful listening and engagement of staff at all levels, in order to drive forward high-quality care and avoid care disruption and devaluation.

Pregnant in a Pandemic: Mental Wellbeing and Associated Healthy Behaviors Among Pregnant People in California During COVID-19

INTRODUCTION

Pregnancy is a time of increased vulnerability to mental health disorders. Additionally, the COVID-19 pandemic has increased the incidence of depression and anxiety. Thus, we aimed to assess mental health and associated healthy behaviors of pregnant people in California during the pandemic in order to contextualize prenatal well-being during the first pandemic of the twenty-first century.

METHODS

We conducted an online cross-sectional study of 433 pregnant people from June 6 through July 29, 2020. We explored 3 hypotheses: (1) mental health would be worse during the pandemic than in general pregnant samples to date; (2) first-time pregnant people would have worse mental health; and (3) healthy behaviors would be positively related to mental health.

RESULTS

Many of our participants (22%) reported clinically significant depressive symptoms and 31% reported clinically significant anxiety symptoms. Multiparous pregnant people were more likely to express worries about their own health and wellbeing and the process of childbirth than were primiparous pregnant people. Additionally, as pregnancy advanced, sleep and nutrition worsened, while physical activity increased. Lastly, anxious-depressive symptomology was significantly predictive of participant sleep behaviors, nutrition, and physical activity during the past week.

DISCUSSION

Pregnant people had worse mental health during the pandemic, and this was associated with worse health-promoting behaviors. Given that the COVID-19 pandemic and associated risks are likely to persist due to low vaccination rates and the emergence of variants with high infection rates, care that promotes mental and physical well-being for the pregnant population should be a public health priority.

"We Should Be Working Together, and It Felt like They Disrupted That": Pregnant Women and Partners' Experiences of Maternity Care in the First UK COVID-19 Pandemic Lockdown

Pregnant women were identified as being at elevated risk from COVID-19 early in the pandemic. Certain restrictions were placed upon birth partners accompanying their pregnant partner to in-person maternity consultations and for in-patient maternity care. In the absence of a central directive in England, the nature of restrictions varied across maternity services. Eleven participants (seven pregnant women and four partners), who were expectant parents during the first UK COVID-19 pandemic lockdown, took part in serial interviews in pregnancy and the postnatal period. Data were subject to a reflexive thematic analysis. Four main themes were identified, with sub-themes: uncertainty and anxiety (uncertainty and anxiety about COVID-19, uncertainty and anxiety about maternity services); disruption of partnering and parenting role; complexity around entering hospital spaces (hospitals offering protection while posing threat, individual health professionals in inflexible systems); and attempting to feel in control. Separating couples may result in disruption to their anticipated roles and significant distress to both partners, with potential impacts for mental health and future family relationships. Trauma-informed perspectives are relevant for understanding parents' experiences of maternity care in the pandemic and identifying ways to improve care to promote and protect the mental health of all parents.

Project20: maternity care mechanisms that improve access and engagement for women with social risk factors in the UK - a mixed-methods, realist evaluation

OBJECTIVES

To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how?

DESIGN

Realist evaluation.

SETTING

Two UK maternity service providers.

PARTICIPANTS

Women accessing maternity services in 2019 (n=1020).

METHODS

Prospective observational cohort with multinomial regression analysis to compare measures of access and engagement between models and place of antenatal care. Realist informed, longitudinal interviews with women accessing specialist models of care were analysed to identify mechanisms.

MAIN OUTCOME MEASURES

Measures of access and engagement, healthcare-seeking experiences.

RESULTS

The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings.

CONCLUSION

Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.

Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

OBJECTIVES

To consolidate the available evidence around ethnic minority women's experiences and needs when accessing maternity care.

METHODS

A qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.

RESULTS

Twenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme 'the struggles and fears of ethnic minority women' was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women's needs, and isolation-related impact due to the COVID pandemic.

CONCLUSIONS

Overall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.

The impact of digital healthcare on vulnerable pregnant women: A review of the use of the MyCare app in the maternity department at a central London tertiary unit

Introduction

Digitalisation offers innovative solutions within maternity services; however, vulnerable groups risk being overlooked. University College London Hospital's (UCLH) successful implementation of a digital maternity app, MyCare, gives women access to test results, information about appointments, and enables communication with healthcare professionals (HCPs). Yet, little is known about access and engagement among vulnerable pregnant women.

Methodology

Research was conducted over a 3-month period (April-June 2022) in the Maternity Department at UCLH, UK. MyCare datasets were analysed, and anonymised surveys completed by vulnerable pregnant women and HCPs.

Results

Lower rates of utilisation and engagement with MyCare were seen in vulnerable pregnant women especially among refugee/asylum seekers, those with mental health issues, and those facing domestic violence. Non-users were also more likely to be individuals from ethnic minority backgrounds, with a lower average social-deprivation-index decile, whose first language was not English, and with a significant history of non-attendance to appointments. Patient and HCP surveys highlighted various barriers to MyCare engagement, including a lack of motivation, limited language options, low e-literacy levels, and complex app interfaces.

Conclusion

The use of a single digital tool, without a formulated pathway to identify and assist those not accessing or engaging with it, risks unequal care provision which may exacerbate health inequalities. This research advances the idea that digital exclusion is not necessarily a matter of access to technology, but an issue of a lack of engagement with these tools. Therefore, vulnerable women and HCPs must be integral to the implementation of digital strategies, to ensure no one is left behind.

Addressing inequalities in the identification and management of perinatal mental health difficulties: The perspectives of minoritised women, healthcare practitioners and the voluntary sector

Background

Perinatal mental health (PMH) difficulties affect approximately one in five birthing women. If not identified and managed appropriately, these PMH difficulties can carry impacts across generations, affecting mental health and relationship outcomes. There are known inequalities in identification and management across the healthcare pathway. Whilst barriers and facilitators have been identified there is a lack of clarity about how these relate to the avoidable and unfair inequalities experienced by various groups of women. Further research is required to understand how to address inequalities in PMH.

Aim

To understand the key factors that enable and hinder access to PMH care for women from minoritised groups across the PMH care pathway, and how these have been affected by the COVID-19 pandemic.

Methods

A sequential mixed-methods approach gathered views and experiences from stakeholders in one region in northern England. This included an online survey with 145 NHS healthcare practitioners and semi-structured interviews with 19 women from ethnic minority and/or socio-economically deprived backgrounds who had experienced PMH difficulties, and 12 key informants from the voluntary and community sector workforce. Quantitative data were analysed using descriptive statistics and framework analysis was applied to qualitative data.

Findings

Barriers and facilitators were mapped using a socio-technical framework to understand the role of (i) processes, (ii) people (organised as women, practitioners and others), (iii) technology, and (iv) the system as a whole in deepening or alleviating inequalities. Influences that were identified as pertinent to inequalities in identification and management included provision of interpreters, digital exclusion, stigma, disempowerment, distrust of services, practitioner attitudes, data capture, representation in the workforce, narrow rules of engagement and partnership working. Stakeholder groups expressed that several barriers were further compounded by the COVID-19 pandemic.

Discussion

The findings highlight the need for change at the system level to tackle inequalities across the PMH care pathway. Four inter-connected recommendations were developed to enable this systems change: building emotional safety between professionals and women; making PMH a part of core healthcare business; increasing cultural competency specific to PMH; and enhanced partnership working.

Developing shared understanding of pre-eclampsia in Haiti and Zimbabwe using Theory of Change

Pre-eclampsia, a complex and multi-system disorder specific to pregnancy, is a leading cause of preventable maternal and perinatal deaths in low-resource settings. Early detection and appropriate intervention with management of hypertension, prevention of eclampsia and timely delivery are effective at reducing mortality and morbidity. Outcomes can be greatly improved with the provision and uptake of good quality care. Cultural contexts of maternal care, social practices and expectations around pregnancy and childbirth profoundly shape understanding and prioritisation when it comes to seeking out care. Few studies have addressed health education specifically targeting pre-eclampsia in low resource settings. The existing literature has limited descriptions of contextual barriers to care or of the intervention development processes employed. More engaging, holistic approaches to pre-eclampsia education for women and families that recognise the challenges they face and that support a shared understanding of the disorder, are needed. We describe our experience of developing a Theory of Change (ToC) as part of the co-production of educational resources for pre-eclampsia in Haiti and Zimbabwe.

social determinants of health in multiple sclerosis

Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants — that is, the ‘risks of risks’ — on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed.

Here, the authors discuss the potential effects of social determinants of health on multiple sclerosis risk and outcomes. They suggest that addressing these determinants of health could substantially improve the lives of individuals with multiple sclerosis and call for more research.

Addressing an individual’s social determinants of health — that is, the conditions under which they are born, grow, live, work and age — could provide opportunities to reduce the burden of living with multiple sclerosis (MS).

Individual factors that may influence MS-related outcomes include sex, gender and sexuality, race and ethnicity, education and employment, socioeconomic status, and domestic abuse.

Societal infrastructures, including access to food, health care and social support, can also affect MS-related outcomes.

Awareness of the specific circumstances of a patient with MS might help neurologists deliver better care.

Social determinants of health are not static and can change according to wider sociopolitical contexts, as highlighted by the COVID-19 pandemic.

Rigorous studies of interventions to ameliorate the effects of poor social determinants on people with MS are urgently needed.

Role of ethnicity in high-level obstetric clinical incidents: a review of cases from a large UK NHS maternity unit

Introduction

Women from ethnic minority groups are at more risk of adverse outcomes in pregnancy compared with those from white British groups; suboptimal care may contribute to this increased risk. This study aimed to examine serious clinical incidents at two maternity units to explore causative factors for women from ethnic minorities and determine whether these differed from white women.

Methods

A retrospective review was conducted of all serious incidents (n=36) occurring in a large National Health Service maternity provider (~14 000 births per annum) between 2018 and 2020. Data were collected from case records for variables which could mediate the association between ethnicity and adverse outcome. The incident reviews were blinded and reviewed by two independent investigators and data regarding root causes and contributory factors were extracted.

Results

Fourteen of the 36 incidents (39%) occurred in women from minority ethnic groups, which is comparable to the maternity population. Women involved in serious clinical incidents frequently had pre-existing medical or obstetric complications. Booking after 12 weeks’ gestation occurred more frequently in women from minority ethnic groups than in the background population. There were differences in root causes of serious incidents between groups, a lack of situational awareness was the most frequent cause in white women and staff workload was most frequent in women from minority ethnic groups. Communication issues and detection of deterioration were similar between the two groups.

Discussion

Although there was no difference in the proportion of serious incidents between the groups, there were differences in medical and pregnancy-related risk factors between groups and in the root causes identified. Efforts are needed to ensure equity of early access to antenatal care and to ensure that there is adequate staffing to ensure that women’s needs are met; this is particularly cogent when there are complex medical or social needs.

Realist inquiry into Maternity care @ a Distance (ARM@DA): realist review protocol

INTRODUCTION

One of the most commonly reported COVID-19-related changes to all maternity services has been an increase in the use of digital clinical consultations such as telephone or video calling; however, the ways in which they can be optimally used along maternity care pathways remain unclear. It is imperative that digital service innovations do not further exacerbate (and, ideally, should tackle) existing inequalities in service access and clinical outcomes. Using a realist approach, this project aims to synthesise the evidence around implementation of digital clinical consultations, seeking to illuminate how they can work to support safe, personalised and appropriate maternity care and to clarify when they might be most appropriately used, for whom, when, and in what contexts?

METHODS AND ANALYSIS

The review will be conducted in four iterative phases, with embedded stakeholder involvement: (1) refining the review focus and generating initial programme theories, (2) exploring and developing the programme theories in light of evidence, (3) testing/refining the programme theories and (4) constructing actionable recommendations. The review will draw on four sources of evidence: (1) published literature (searching nine bibliographic databases), (2) unpublished (grey) literature, including research, audit, evaluation and policy documents (derived from Google Scholar, website searches and e-thesis databases), (3) expertise contributed by service user and health professional stakeholder groups (n=20-35) and (4) key informant interviews (n=12). Included papers will consist of any study design, in English and from 2010 onwards. The review will follow the Realist and Meta-narrative Evidence Synthesis Evolving Standards quality procedures and reporting guidance.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of Nottingham, Faculty of Medicine and Health Sciences Ethics Committee (FMHS 426-1221). Informed consent will be obtained for all key informant interviews. Findings will be disseminated in a range of formats relevant to different audiences.

PROSPERO REGISTRATION NUMBER

CRD42021288702.

A case study on the use of Public Narrative as a leadership development approach for Patient Leaders in the English National Health Service

Background

In 2016 the National Health Service (NHS) England embraced the commitment to work for maternity services to become safer, more personalized, kinder, professional and more family-friendly. Achieving this involves including a service users' organizations to co-lead and deliver the services. This article explores how Public Narrative, a framework for leadership development used across geographical and cultural settings worldwide, can enhance the confidence, capability and skills of service-user representatives (or Patient Leaders) in the National Health Service (NHS) in England. Specifically, we analyse a pilot initiative conducted with one cohort of Patient Leaders, the Chairs of local Maternity Voices Partnerships (MVPs), and how they have used Public Narrative to enhance their effectiveness in leading transformation in maternity services as part of the NHS Maternity Transformation Programme.

Methods

Qualitative two-phase case study of a pilot training and coaching initiative using Public Narrative with a cohort of MVP Chairs. Phase 1 consisted of a 6-month period, during which the standard framework was adapted in co-design with the MVP Chairs. A core MVP Chair Co-Design Group underwent initial training and follow-up coaching in Public Narrative. Phase 2 consisted of qualitative data collection and data analysis.

Results

The study of this pilot initiative suggests two main ways in which Public Narrative can enhance the effectiveness of Patient Leaders in service improvement in general and maternity services in specific. First, training and coaching in the Public Narrative framework enables Patient Leaders to gain insight into, articulate and then craft their lived experience of healthcare services in a way that connects with and activates the underlying values of others ("shared purpose"), such that those experiences become an emotional resource on which Patient Leaders can draw to influence future service design and decision-making processes. Second, Public Narrative provides a simple and compelling structure through which Patient Leaders can enhance their skills, confidence and capability as "healthcare leaders," both individually and collectively.

Conclusions

The Public Narrative framework can significantly enhance the confidence, capability and skills of Patient Leaders, both to identify and coalesce around shared purpose and to advance genuine co-production in the design and improvement of healthcare services in general and maternity services in specific.

Precarity and preparedness during the SARS-CoV-2 pandemic: A qualitative service evaluation of maternity healthcare professionals

Introduction

The SARS‐CoV‐2 pandemic has devastated populations, posing unprecedented challenges for healthcare services, staff and service‐users. In the UK, rapid reconfiguration of maternity healthcare service provision changed the landscape of antenatal, intrapartum and postnatal care. This study aimed to explore the experiences of maternity services staff who provided maternity care during the SARS‐CoV‐2 pandemic to inform future improvements in care.

Material and methods

A qualitative interview service evaluation was undertaken at a single maternity service in an NHS Trust, South London. Respondents (n = 29) were recruited using a critical case purposeful sample of maternity services staff. Interviews were conducted using video‐conferencing software, and were transcribed and analyzed using Grounded Theory Analysis appropriate for cross‐disciplinary health research. The focus of analysis was on staff experiences of delivering maternity services and care during the SARS‐CoV‐2 pandemic.

Results

A theory of “Precarity and Preparedness” was developed, comprising three main emergent themes: “Endemic precarity: A health system under pressure”; “A top‐down approach to managing the health system shock”; and “From un(der)‐prepared to future flourishing”.

Conclusions

Maternity services in the UK were under significant strain and were inherently precarious. This was exacerbated by the SARS‐CoV‐2 pandemic, which saw further disruption to service provision, fragmentation of care and pre‐existing staff shortages. Positive changes are required to improve staff retention and team cohesion, and ensure patient‐centered care remains at the heart of maternity care.

A qualitative study of minority ethnic women's experiences of access to and engagement with perinatal mental health care

Background

Approximately one in five women will experience mental health difficulties in the perinatal period. However, for a large group of women, symptoms of adverse perinatal mental health remain undetected and untreated. This is even more so for women of ethnic minority background, who face a variety of barriers which prevents them from accessing appropriate perinatal mental health care.

Aims

To explore minority ethnic women’s experiences of access to and engagement with perinatal mental health care.

Methods

Semi-structured interviews were conducted with 18 women who had been diagnosed with perinatal mental health difficulties and who were supported in the community by a specialist perinatal mental health service in South London, United Kingdom. Women who self-identified as being from a minority ethnic group were purposefully selected. Data were transcribed verbatim, uploaded into NVivo for management and analysis, which was conducted using reflective thematic analysis.

Results

Three distinct overarching themes were identified, each with two or three subthemes: ‘Expectations and Experiences of Womanhood as an Ethnic Minority’ (Shame and Guilt in Motherhood; Women as Caregivers; Perceived to Be Strong and Often Dismissed), ‘Family and Community Influences’ (Blind Faith in the Medical Profession; Family and Community Beliefs about Mental Health and Care; Intergenerational Trauma and Family Dynamics) and ‘Cultural Understanding, Empowerment, and Validation’ (The Importance of Understanding Cultural Differences; The Power of Validation, Reassurance, and Support).

Conclusion

Women of ethnic minority background identified barriers to accessing and engaging with perinatal mental health support on an individual, familial, community and societal level. Perinatal mental health services should be aware ethnic minority women might present with mental health difficulties in different ways and embrace principles of cultural humility and co-production to fully meet these women’s perinatal mental health needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04698-9.

The lived experiences of women exploring a healthy lifestyle, gestational weight gain and physical activity throughout pregnancy

BACKGROUND

Weight gain is inevitable during pregnancy. However, high prepregnancy body mass index and excessive gestational weight gain are associated with poor pregnancy outcomes. Understanding the experiences, social influences and decisions women make to maintain a healthy lifestyle during pregnancy are essential to consider how to improve services and interventions to help women engage in a healthy diet and physical activity (PA) behaviours.

OBJECTIVE

The study investigated women's opinions and lived experiences of engaging in a healthy diet, promoting optimal gestational weight gain and PA during and after pregnancy.

DESIGN AND METHODS

Twenty-two pregnant women contributed to qualitative data collection for this Grounded Theory (GT) study. Nineteen women completed semi-structured interviews and three patient and public involvement (PPI) representatives sought to validate the analysis and GT framework.

RESULTS

Two substantive categories were constructed: (1) Evolving from 'I' to 'we', as informed by two subcategories and (2) the power of information and guidance, as informed by three subcategories. These categories informed the core category, 'A navigational journey and evolution of the pregnant self'. The navigational journey involves constantly searching for knowledge and information to support and balance the interests of personal beliefs, the health of their unborn baby, their social circle and the wider world. A woman's psychological capability (e.g., their knowledge of a healthy lifestyle and confidence to implement such knowledge) is continuously tested.

CONCLUSIONS

Pregnancy may create a 'teachable moment' but there is a need for appropriate guidance from professionals to assist with lifestyle choices during pregnancy. The findings showed a significant influence of online resources, and lack of guidance on behaviour during pregnancy and may highlight areas of focus for future research and intervention.

PUBLIC CONTRIBUTION

Three pregnant women were recruited to act as PPI representatives to assist with the validation of the analytical findings and aid the final theoretical saturation of the GT framework. Commentary from these PPI representatives was used to validate the analysis and support the interpretation of the data. In addition, these PPI representatives were also invited to provide commentary on the draft manuscript and those involved in this later process have been included as coauthors.

“Never let a good crisis go to waste”: Positives from disrupted maternity care in Australia during COVID-19

Objective

Due to the COVID-19 pandemic, a number of changes to maternity care were rapidly introduced in all countries, including Australia, to reduce the risk of infection for pregnant women and their care providers. While many studies have reported on the negative effects of these changes, there is a paucity of evidence on factors which women and their providers perceived as positive and useful for future maternity care.

Design

Data was analysed from the Birth in the time of COVID-19 (BITTOC 2020) study survey. Conventional content analysis and descriptive statistics were used to analyse the data and examine which aspects of COVID-amended care women experienced as positive. Data from women were compared to data from midwives.

Setting

This project took place in Australia in 2020-2021.

Participants

The survey was distributed to women who gave birth and midwives who worked in Australia during the COVID-19 pandemic (March 2020 onwards).

Measurements and findings

Women reported a variety of positives from their maternity care during COVID-19. These included both care-related factors as well as contextual factors. The most commonly mentioned positives for pregnant and postnatal women were care-related, namely fewer visitors in hospital, having increased access to telehealth services. These were also the most commonly reported positives by midwives. Having midwifery continuity of care models, giving birth at home and having their partner work from home were also highlighted by women as positives.

Key conclusions

Despite the negative effect of COVID-19-related restrictions on maternity care, a variety of changes were viewed as positive by both women and midwives, with strong agreement between the two groups.

Implications for practice

These findings provide evidence to support the inclusion of these positive elements of care and ensure that the lessons learned from the pandemic are utilised to improve maternity care in Australia going forward.

Racial and ethnic disparities in pregnancy complications and the protective role of greenspace: A retrospective birth cohort study

Greenspace may positively impact pregnancy health for racially and economically minoritized populations; few studies have examined local availability and accessibility of green/park space in reducing maternal morbidity. The objective of this retrospective birth cohort study was to examine the association between residential exposure to greenspace and adverse pregnancy health outcomes in a Southern US state characterized by high poverty and racial disparities in maternal health (2013-2017). National data from the Protected Area database - United States (PAD-US) and ParkServe estimated three publicly available and accessible residential greenspace measures-a more direct proxy than using remotely-sensed greenness indicators (e.g., normalized difference vegetation index (NDVI))-(a) percent area of greenspace (M1), (b) area of available greenspace per person (M2), (c) total population within a 10-minute walk (M3). Generalized Estimating Equations with logistic regression were used to examine the association between individual greenspace metrics and South Carolina hospital deliveries (n = 238,922 deliveries) for women with correlated maternal health outcomes for gestational hypertension (GHTN), gestational diabetes (GD), severe maternal morbidity (SMM), preeclampsia (PRE), mental disorders (MD), depressive disorders (DD), and preterm birth (PTB). Lowest compared to highest tertiles of all three metrics were associated with increased risk for MD, DD, and a monotonic increase in GD, particularly for black women. Women with the lowest access to M2 and M3 were more at risk for PRE, PTB, and MD. We observed that women in low-income, majority-black communities in the lowest versus highest tertile of M2 were more likely to experience a DD, MD, SMM, or PTB compared to primarily high-income majority-white communities. Available and accessible green/park space may present as an effective nature-based intervention to reduce maternal complications, particularly for gestational diabetes and other pregnancy health risks for which there are currently few known evidence-based primary prevention strategies.

Experiences of Perinatal Mental Health Care among Minority Ethnic Women during the COVID-19 Pandemic in London: A Qualitative Study

(1) Background: Approximately one in five women will experience mental health difficulties in the perinatal period. Women from ethnic minority backgrounds face a variety of barriers that can prevent or delay access to appropriate perinatal mental health care. COVID-19 pandemic restrictions created additional obstacles for this group of women. This study aims to explore minority ethnic women's experiences of perinatal mental health services during COVID-19 in London. (2) Methods: Eighteen women from ethnic minority backgrounds were interviewed, and data were subject to a thematic analysis. (3) Results: Three main themes were identified, each with two subthemes: 'Difficulties and Disruptions to Access' (Access to Appointments; Pandemic Restrictions and Disruption), 'Experiences of Remote Delivery' (Preference for Face-to-Face Contact; Advantages of Remote Support); and 'Psychosocial Experiences' linked to COVID-19 (Heightened Anxiety; Social Isolation). (4) Conclusions: Women from ethnic minority backgrounds experienced disrupted perinatal mental health care and COVID-19 restrictions compounding their mental health difficulties. Services should take women's circumstances into account and provide flexibility regarding remote delivery of care.

Supporting Perinatal Mental Health and Wellbeing during COVID-19

Mental health is especially important as women transition into parenthood. The COVID-19 pandemic has necessitated the rapid reconfiguration of maternity services, including perinatal mental healthcare, as offered by Specialist Perinatal Mental Health Midwives, in NHS Trusts in the United Kingdom. This article represents work undertaken in rapid response to the COVID-19 pandemic and aims to document the findings from March 2020 up until May 2021 in literature published on perinatal mental health through the pandemic, as well as to engage in a knowledge mapping exercise across five NHS Trusts in London. In this research, we utilised a critical review methodology which purposefully selects and synthesises materials after extensive literature searching to provide a broad and informed narrative around an issue. For our knowledge mapping exercise, we utilised an inclusive stance to gather, pool, and synthesise data from five NHS Trusts regarding the provisions and reconfigurations of their perinatal mental health services, creating a comparable and translatable snapshot in time. Our rapid, critical review highlighted two themes: ‘Increased Perinatal Distress’ and ‘Inaccessible Services and Support’. Our knowledge mapping exercise produced four themes: ‘Retention of Existing Service Provision’; ‘Additional Services Provided’; ‘Reconfiguration of Service Provision’; ‘Additional Provision to Support Staff Wellbeing’. We conclude by offering best practice guidance in order to provide shared learning to aid the transition through para-pandemic circumstances to service delivery in a post-pandemic ‘new normal’.

Poverty, Racism, and the Public Health Crisis in America

The purpose of this article is to discuss poverty as a multidimensional factor influencing health. We will also explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. Poverty is one of the most significant challenges for our society in this millennium. Over 40% of the world lives in poverty. The U.S. has one of the highest rates of poverty in the developed world, despite its collective wealth, and the burden falls disproportionately on communities of color. A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe. Importantly, poverty is much more than just a low-income household. It reflects economic well-being, the ability to negotiate society relative to education of an individual, socioeconomic or health status, as well as social exclusion based on institutional policies, practices, and behaviors. Until structural racism and economic injustice can be resolved, the use of evidence-based prevention and early intervention initiatives to mitigate untoward effects of socioeconomic deprivation in communities of color such as the use of social media/culturally concordant health education, social support, such as social networks, primary intervention strategies, and more will be critical to address the persistent racial/ethnic disparities in chronic diseases.

Experiences of Quality Perinatal Care During the US COVID-19 Pandemic

INTRODUCTION

Quality perinatal care is recognized as an important birth process and outcome. During the coronavirus disease 2019 (COVID-19) pandemic, quality of perinatal care was compromised as the health care system grappled with adapting to an ever-changing, uncertain, and unprecedented public health crisis.

METHODS

The aim of this study was to explore the quality of perinatal care received during the COVID-19 pandemic in the United States. Data were collected via an online questionnaire completed by people who gave birth in the United States after March 15, 2020. The questionnaire included the Mothers on Respect Index and the Mothers Autonomy in Decision Making validated measures. Low-quality perinatal care was defined as decreased respect and/or autonomy in the perinatal care received. Responses were geocoded by zip code to determine COVID-19 case-load in the county on the date of birth. Multivariate regression analyses described associations between respect and autonomy in decision-making for perinatal care and levels of COVID-19 outbreak across the United States.

RESULTS

Participants (N = 707) from 46 states and the District of Columbia completed the questionnaire. As COVID-19 cases increased, participants' experiences of autonomy in decision-making for perinatal care decreased significantly (P = .04). Participants who identified as Black, Indigenous, and people of color, those who had an obstetrician provider, and those who gave birth in a hospital were more likely to experience low-quality perinatal care. Those with a midwife provider or who had a home birth were more likely to experience high-quality perinatal care in adjusted models.

DISCUSSION

Variability in experiences of high-quality perinatal care by sociodemographic characteristics, birth setting, and provider type may relate to implicit bias, structural racism, and inequities in maternal health and COVID-19 outcomes for birthing people from marginalized communities.