Housing instability: Exploring socioecological influences on the health of birthing people

STUDY AIM

To describe how socioecological influences of housing instability affect pregnancy health among birthing and postpartum people.

DESIGN

We used the socioecological framework to guide this exploratory descriptive study using semi-structured, in-depth interviews.

METHODS

We purposively recruited birthing people in the southern mid-Atlantic region. Seventeen one-time, semi-structured interviews were conducted between February 2020 and December 2021 with English-speaking unstably housed participants ≥18 years old, currently pregnant, or recently postpartum. Qualitative and quantitative content approaches were used to analyse transcribed interviews. Dedoose software was used to identify code patterns and refine the codebook until group consensus. The team examined code patterns, explored meaning in text and codified code-generated categories to describe experiences.

RESULTS

Majority (82.4%) of participants were African Americans between 22 and 41 years, and most were postpartum (76.5%). Participants described multiple forms of housing instability, reasons for losing housing, challenges with finding housing and strategies for finding housing. Participants did not describe housing instability as a barrier to receiving prenatal care. Building and sustaining individual relationships and social support were prominent factors affecting their housing challenges. Participants also reported a lack of obstetric provider inquiry about housing status during pregnancy. Many reported that challenges with housing triggered mental health issues, especially depression.

CONCLUSION

Nurses and other obstetric providers are key points of contact in the prenatal care setting for assessing housing stability. Additionally, refining social structures and funding support services within communities and prenatal health systems should be a strategy for future programme and policy planning improvement.

IMPACT

This study highlights critical areas for consideration when addressing social determinants for birthing people and reinforces the need for more comprehensive assessment in the prenatal setting.

PATIENT OR PUBLIC CONTRIBUTION

Members of the public participated in this study as key informants for study interviews.

Role of Maternal Age in Increasing Severe Maternal Morbidity Rates in the United States

OBJECTIVE

To evaluate a commonly proposed explanation for increasing rates of severe maternal morbidity (SMM) in the United States: shifts in the birthing population to older maternal ages, a known risk factor for SMM.

METHODS

We conducted a cross-sectional analysis comparing delivery hospitalizations from two time points (2008-2009 to 2017-2018) using hospital discharge data from the National Inpatient Sample. We used demographic decomposition techniques to evaluate whether increasing rates of SMM and nontransfusion SMM were explained by population-level increases in maternal age or changes in age-specific rates. Analyses were stratified by race and ethnicity.

RESULTS

Rates of SMM and nontransfusion SMM significantly increased in the United States between 2008 and 2018 from 135.6 to 170.5 and 58.8 to 67.9 per 10,000 delivery hospitalizations, respectively, with increases observed for nearly all racial and ethnic groups. Over this same period, the proportion of births to people younger than age 25 years decreased and births to people of advanced maternal age (35 years and older) increased, with the largest increases occurring among people identified as non-Hispanic American Indian/Alaskan Native (9.8-13.0%), non-Hispanic Black (10.7-14.4%), and Hispanic (12.1-17.1%). Decomposition analyses indicated that the changing maternal age distribution had little effect on SMM trends. Rather, increases in SMM and nontransfusion SMM were primarily driven by increases in age-specific SMM rates, including rising rates among younger people. Contributions of maternal age shifts were minimal for all racial and ethnic groups except among non-Hispanic Black people, for which 17-34% of the rise in SMM was due to increasing maternal age.

CONCLUSION

Except among certain racial groups, increases in U.S. population-level SMM rates over the past decade were due to increases in age-specific rates rather than shifts to older maternal age among the birthing population. Increasing SMM rates across the maternal age spectrum could indicate worsening prepregnancy health status of the birthing population.

Linking Adverse Experiences to Pregnancy and Birth Outcomes: A Life Course Analysis of Racial and Ethnic Disparities Among Low-Income Women

Racial and ethnic disparities in birth outcomes have persisted in the United States for decades, though the causes remain poorly understood. The life course perspective posits that poorer outcomes of Black birthing people stem from heightened exposure to stressors early in life and cumulative exposure to stressors over time. Despite its prominence, this perspective has seldom been investigated empirically. We analyzed longitudinal data gathered from 1319 women in low-income households in Wisconsin who received perinatal home visiting services. Variable- and person-centered analyses were performed to assess whether 15 adverse childhood experiences (ACEs) and 10 adverse adult experiences (AAEs) were associated, alone and in combination, with pregnancy loss, preterm birth, and low birth weight among Hispanic (i.e., Latinx) and non-Hispanic Black and White participants. As expected, there were disparities in preterm birth and low birth weight, and both ACEs and AAEs were linked to poorer pregnancy and birth outcomes. Unexpectedly, bivariate and multivariate analyses showed that the associated effects of ACEs and AAEs were most robust for non-Hispanic White women. A latent class analysis produced four patterns of life course adversity, and multigroup latent class analyses confirmed that, compared to White women, higher-adversity class assignments were associated with less robust effects for Hispanic women, and even less robust effects for Black women. We discuss interpretations of the paradoxical findings, including the possibility that alternative sources of stress such as interpersonal and structural racism may better account for the reproductive disparities that disproportionately affect Black birthing people.

Beyond "patient-provider race matching." Black midwives clarify a vision for race-concordant care to achieve equity in Black perinatal health: A commentary on "Do Black birthing persons prefer a Black health care provider during birth? Race concordance in birth"

Racial concordance has been identified as a potential strategy to improve the perinatal health of Black women and birthing people by mitigating implicit bias and improving mutual trust, healthy communication, and satisfaction. In a recent article published in BIRTH: Issues in Perinatal Care, Bogdan-Lovis et al. surveyed 200 Black women to determine whether they possessed a race and gender practitioner preference for their birth practitioner and examined whether race and gender concordance was associated with greater birth satisfaction and perceived respect, trust, practitioner competence, empathy, and use of inclusive communication. In this commentary, written by a group of Black midwives, we respond to the study and offer a vision for race-concordant care that encompasses cultural safety provided in a community-based setting.

Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity

Black birthing people are twice as likely to experience severe maternal morbidity (SMM) as their white counterparts. Structural racism provides a framework for understanding root causes of perinatal health disparities. Our objective was to investigate associations between measures of structural racism and severe maternal morbidity (SMM) among Black birthing people in the US. We linked delivery hospitalizations for Black birthing people in the National Inpatient Sample (2008-2011) with data from the American Community Survey 5-year estimates and the Vera Institute of Justice Incarceration Trends datasets (2008-2011). Structural racism measures included the Index of Concentration at the Extremes for race and income (i.e., racialized economic segregation) and Black-white incarceration inequality, assessed as quintiles by hospital county. Multilevel logistic regression assessed the relationship between these county-level indicators of structural racism and SMM. Black birthing people delivering in quintiles 5 (concentrated deprivation; OR = 1.45, 95% CI = 1.16-1.81) and 3 (OR = 1.27, 95% CI = 1.04-1.56) experienced increased odds of SMM compared to those in quintile 1 (concentrated privilege). After adjusting for individual characteristics, obstetric comorbidities, and hospital characteristics the odds of SMM remained elevated for Black birthing people delivering in quintiles 5 (aOR = 1.32, 95% CI = 1.02-1.71) and 3 (aOR = 1.24, 95% CI = 1.02-1.51). Delivering in the quintile with the highest incarceration inequality (Q5) was not significantly associated with SMM (aOR = 0.95, 95% CI = 0.72-1.25) compared to those delivering in counties with the lowest incarceration inequality (Q1). In this national-level study, racialized economic segregation was associated with SMM among Black birthing people. Our findings highlight the need to promote maternal and perinatal health equity through actionable policies that prioritize investment in communities experiencing deprivation.

Experiences of pregnant women exposed to Hurricanes Irma and Maria in the US Virgin Islands: a qualitative study

INTRODUCTION

Hurricanes Irma and Maria made landfall in the US Virgin Islands (USVI) in 2017. To date, there is no published literature available on the experiences of pregnant women in the USVI exposed to these hurricanes. Understanding how hurricanes affect pregnant women is key to developing and executing targeted hurricane preparedness and response policies. The purpose of this study was to explore the experiences of pregnancy and birth among women in the USVI exposed to Hurricanes Irma and Maria.

METHODS

We employed a qualitative descriptive methodology to guide sampling, data collection, and analysis. Semi-structured interviews of 30-60 min in length were conducted with a purposive sample of women (N = 18) in the USVI who were pregnant during or became pregnant within two months after the hurricanes. Interviews were transcribed verbatim and data managed in MAXQDA. Team members developed a codebook, applied codes for content, and reconciled discrepancies. We thematically categorized text according to a socioecological conceptual framework of risk and resilience for maternal-neonatal health following hurricane exposure.

RESULTS

Women's experiences were organized into two main categories (risk and resilience). We identified the following themes related to risk at 3 socioecological levels including: (1) individual: changes in food access (We had to go without) and stress (I was supposed to be relaxing); (2) household/community: diminished psychosocial support (Everyone was dealing with their own things) and the presence of physical/environmental hazards (I was really scared); and (3) maternity system: compromised care capacity (The hospital was condemned). The themes related to resilience included: (1) individual: personal coping strategies (Being calm); (2) household/community: mutual psychosocial and tangible support (We shared our resources); and (3) the maternity system: continuity of high-quality care (On top of their game).

CONCLUSIONS

A socioecological approach provides a useful framework to understand how risk and resilience influence the experience of maternal hurricane exposure. As the frequency of the most intense hurricanes is expected to increase, clinicians, governments, and health systems should work collaboratively to implement hurricane preparedness and response plans that address pregnant women's unique needs and promote optimal maternal-infant health.

'If the Partner Finds Out, then there's Trouble': Provider Perspectives on Safety Planning and Partner Interference When Offering HIV Pre-exposure Prophylaxis (PrEP) to Women Experiencing Intimate Partner Violence (IPV)

Pre-exposure prophylaxis is an effective women-controlled HIV prevention strategy but women experiencing intimate partner violencefear partners' interference and subsequent violence could limit its utility. This study explores provider perceptions of safety planning strategies to prevent escalating violence, mitigate partner interference, and promote daily oral PrEP adherence. We conducted interviews (N = 36) with healthcare providers (n = 18) and IPV service providers (n = 18) in Baltimore and New Haven. Using the Contextualized Assessment for Strategic Safety Planning model we organized data into two categories: the appraisal process and strategic safety planning. Themes revealed during the appraisal process, providers conduct routine IPV screening, facilitate HIV risk perception, and offer PrEP. Strategic safety planning utilizes concealment tactics, informal sources of support, role playing and cover stories. Future interventions to enhance PrEP services among women exposed to IPV should implement safety planning strategies, integrate PrEP care with IPV services, and employ novel PrEP modalities to maximize effectiveness.

Systematic Review of Contraceptive Use Among Sex Workers in North America

OBJECTIVE

To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making.

DATA SOURCES

We searched PubMed, CINAHL, and Embase databases using the search terms "sex work(ers)," "transactional sex," "exchange sex," "prostitution," "contraception," "contraceptive agents," "birth control," "female," and "women."

STUDY SELECTION

Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria.

DATA EXTRACTION

Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell's theory of gender and power as an analytic framework to further identify factors that limited reproductive agency.

DATA SYNTHESIS

Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion.

CONCLUSION

The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.

"I can't breathe": A call for antiracist nursing practice

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Nurses are positioned to respond to the epidemic of racism in our healthcare system and communities.

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This call to action highlights ways that nurses can adopt antiracist practices.

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Actions include recognition of personal biases, confronting systemic inequities, policy and political action, new approaches to research, and using antiracist pedagogy.

Communicating with African-American Women Who Have Had a Preterm Birth About Risks for Future Preterm Births

PURPOSE

African-American women are at higher risk of preterm birth (PTB) compared with other racial/ethnic groups in the USA. The primary objective was to evaluate the level of understanding among a group of African-American women concerning risks of PTB in future pregnancies. Secondary objectives were to evaluate how some women obtain information about PTB and to identify ways to raise their awareness.

METHODS

Six focus groups were conducted in three locations in the USA during 2016 with women (N = 60) who had experienced ≥ 1 PTB (< 37 weeks of gestation) during the last 5 years. The population was geographically, economically, and educationally diverse.

RESULTS

We observed a tendency to normalize PTB. Knowledge about potential complications for the infant was lacking and birth weight was prioritized over gestational age as an indicator of PTB. Participants were largely unaware of factors associated with increased PTB risk, such as a previous PTB and race/ethnicity. The most trusted information source was the obstetrical care provider, although participants reported relying on mobile apps, websites, and chat rooms. The optimal time to receive information about PTB risk in subsequent pregnancies was identified as the postpartum visit in the provider's office.

CONCLUSIONS

Awareness of the risks of recurrent PTB was limited in this diverse population. Educational programs on the late-stage development of neonates may strengthen knowledge on the relationship between gestational age and PTB and associated health/developmental implications. For educational efforts to be successful, a strong nonjudgmental, positive, solutions-oriented message focused on PTB risk factors is crucial.

Integrative Review of Pregnancy and Birth Outcomes After Exposure to a Hurricane

OBJECTIVE

To appraise and analyze published research on the relationships among hurricane exposure and adverse pregnancy and birth outcomes.

DATA SOURCES

A literature search was conducted in four electronic databases: CINAHL Plus, Embase, PubMed, and Web of Science. The following search terms were used: "cyclonic storms," "cesarean section," "premature birth," "fetal mortality," "low birth weight," "infant mortality," "pregnancy complications," and "pregnancy outcome."

STUDY SELECTION

Documents were included if they were peer-reviewed, full-text articles or government documents published in English through February 2020 that focused on the associations among exposure to hurricanes and adverse pregnancy and birth outcomes. The initial search yielded 211 articles, and one article was identified through a hand search. After 48 duplicates were removed, we screened the titles and abstracts of 164 articles. We conducted a full-text review of 57 articles, and 19 articles were included in the integrative review.

DATA EXTRACTION

We extracted data from the full text of each article into a standardized table with the following headings: author, year of publication, location, hurricane and year, population studied, study design, outcomes, data source, and results.

DATA SYNTHESIS

We analyzed study findings based on the outcomes of pregnancy complications, preterm birth, cesarean birth, labor and birth complications, low birth weight, abnormal newborn conditions, and fetal mortality. We synthesized data in a narrative format, and the synthesis indicated that hurricane exposure was frequently associated with pregnancy complications, preterm birth, low birth weight, cesarean birth, and abnormal newborn conditions. However, these associations were not always consistent. Extant research is limited by inconsistency among study designs and the type of hurricane exposure.

CONCLUSION

Interdisciplinary teams that include nurses, midwives, obstetricians and gynecologists, and other health care professionals should ensure that hurricane preparedness and response efforts specifically address the needs of pregnant women to mitigate adverse outcomes.

Experiences of Reproductive Coercion Among Latina Women and Strategies for Minimizing Harm: "The Path Makes Us Strong"

INTRODUCTION

Latina women disproportionately report experiencing reproductive coercion (RC), a set of behaviors that interfere with autonomous reproductive decision making. Given RC's associations with intimate partner violence (IPV) and unintended pregnancy, it is critical to identify and address RC to assist women to achieve safety, autonomy, and reproductive life plans. The purpose of this study was to describe and understand the context of RC and the use of RC safety strategies among Latina women receiving services at an urban clinic, through listening to the experiences of the women in their own words.

METHODS

Qualitative descriptive methodology was used. Semistructured interviews were conducted with a purposive sample of 13 Latina women recruited from a Federally Qualified Health Center in the Washington, DC, area.

RESULTS

Data were organized into 3 a priori categories: (1) RC behaviors, (2) co-occurrence of RC and IPV, and (3) RC harm reduction strategies. New RC behaviors emerged, and immigration status was used as a method of coercive control. From these a priori categories emerged 4 themes: impact of immigrant and citizenship status, machismo, strength and bravery, and importance of family. Harm reduction strategies included less detectable contraception; some sought community services, but others resorted to deception and stalling as the only tools available to them.

DISCUSSION

Less detectable methods of contraception remained useful harm reduction strategies for women experiencing RC. Midwives should inquire about method fit and be mindful of honoring the request when patients ask to change methods. Women's strength and resilience emerged as a vital source of power and endurance. This diverse sample and the powerful voices of the women who participated make a significant contribution to the understanding of RC experienced by Latina women in the United States.

Communicating with African-American Women Who Have Had a Preterm Birth About Risks for Future Preterm Births

Purpose

African-American women are at higher risk of preterm birth (PTB) compared with other racial/ethnic groups in the USA. The primary objective was to evaluate the level of understanding among a group of African-American women concerning risks of PTB in future pregnancies. Secondary objectives were to evaluate how some women obtain information about PTB and to identify ways to raise their awareness.

Methods

Six focus groups were conducted in three locations in the USA during 2016 with women (N = 60) who had experienced ≥ 1 PTB (< 37 weeks of gestation) during the last 5 years. The population was geographically, economically, and educationally diverse.

Results

We observed a tendency to normalize PTB. Knowledge about potential complications for the infant was lacking and birth weight was prioritized over gestational age as an indicator of PTB. Participants were largely unaware of factors associated with increased PTB risk, such as a previous PTB and race/ethnicity. The most trusted information source was the obstetrical care provider, although participants reported relying on mobile apps, websites, and chat rooms. The optimal time to receive information about PTB risk in subsequent pregnancies was identified as the postpartum visit in the provider’s office.

Conclusions

Awareness of the risks of recurrent PTB was limited in this diverse population. Educational programs on the late-stage development of neonates may strengthen knowledge on the relationship between gestational age and PTB and associated health/developmental implications. For educational efforts to be successful, a strong nonjudgmental, positive, solutions-oriented message focused on PTB risk factors is crucial.