Tag: black maternal health

Maternal Health Awareness Day 2024

Today is, National Maternal Health Awareness Day 2024. This year the focus is on Access to Care. Access in Crisis.

Elizabeth Rochin, PhD, RN, NE-BC | January 23, 2024

Posted under: Maternal Health, Quality of Care

The definition of “maternal health awareness” might depend on who you ask. And where.

This year the focus is on Access to Care. Access in Crisis.

And that is true. For many rural communities, closures of obstetric units and hospitals have created tremendous burdens in obstetric availability. Medicaid reimbursement has created significant voids in hospital budgets that are no longer sustainable. Insurance costs have created chasms in care, leading to a lack of obstetric specialists and delivery options in states least likely to afford lapses in care.

But there is more to accessing high-quality maternal care than we realize. Or recognize. Or care to admit. I will give you a few examples that create challenges to accessing even the most well-supported maternal care sites.

1. Racial disparities and racism: In April 2023, the Centers for Disease Control published Maternity Care Experiences that revealed troubling facts (survey methodology available within the CDC document):
  • 30% of Black, Hispanic, and multiracial mothers reported mistreatment (e.g., violations of physical privacy or verbal abuse) during maternity care.

  • 40% of Black, Hispanic, and multiracial mothers reported discrimination during maternity care.

  • 45% of all mothers reported holding back from asking questions or discussing concerns with their provider.
It is very easy to state, “That’s someone else,” or “That doesn’t happen here.” Are you listening to your patients? Are you able to hold space for the possibility that their experience is different from your own? Do ALL patients feel safe in accessing care in your facilities?

Researchers from the University of California at San Francisco found that “racialized pregnancy stigma may result in reduced access to quality health care; barriers to services, resources, and social support; and poorer psychological health”.
The experiences of Black women at the intersection of race, gender, and pregnancy | Bixby Center for Global Reproductive Health (ucsf.edu)

2. Obesity stigma: The stigma associated with obesity continues to impact a woman’s or birthing person’s choice of providers, or their willingness to seek out care. Obesity stigma is fueled by misconceptions and assumptions about people with obesity and continues to exist today. Have you ever seen a colleague or co-worker roll their eyes upon receiving the report of a pregnant patient with severe obesity? Have your own eyes rolled? What assumptions do you make about weight? And how are these assumptions keeping women and birthing people from accessing care due to obesity stigma from healthcare providers?

3. Mental health stigma: The stigma that continues to permeate healthcare is that of mental health disorders. “The bipolar patient in room 3…” Have you heard that recently? Ever? In 2019, researchers in California reviewed 300 records of women who died within one year of giving birth. The second leading cause of death was substance use disorder. Two-thirds of these women had at least one (1) interaction with the healthcare system. Are we seeing despair? Are we making assumptions about maternal mental health? Check out the Maternal Mental Health Leadership Alliance for more information.

4. Homelessness: Back in 2022, I wrote a blog entitled Homelessness is Not Neglect. There is incredible stigma that is associated with homelessness, and more particularly pregnant women who are homeless. Between assumptions, misconceptions, and other issues that can taint perception, homelessness can be a significant deterrent to seeking maternal health care. Here is a quote from the blog I wrote, and it is just as important now as it was then:

 “Members of our team immediately called CPS on a Black mother for being homeless. She left AMA during labor, and we do not know where she delivered. I was so distraught. Our policy directs us to contact CPS for homeless parents. Like they have not been traumatized enough already. We must change our policies to protect these mothers and families and make every effort to keep these newborns with their mothers.”

5. Incarceration: According to Knittel et al (2022), “We Don’t Wanna Birth It Here”: A Qualitative Study of Southern Jail Personnel Approaches to Pregnancy: Women & Criminal Justice: Vol 33, No 5, approximately 55,000 pregnant people are incarcerated in jails each year. As many of these people are of childbearing age, it would stand that some of these people would deliver while incarcerated. In 2018, Black women were incarcerated at twice the rate of white women (Equitable Care for Pregnant Incarcerated Women: Infant Contact After Birth - A Human Right (umich.edu)). This commentary by Franco et al provides a bleak picture of maternal health in our carceral systems. I would strongly encourage the review of this paper and learn more about how to advocate for maternal health patients who experience incarceration. Not only is there stigma of patients during their period of incarceration, but also upon release and their re-entry into their community.

Access to care can mean many things. But one thing is certain. Access to high-quality, affordable, and available care in the community can be life-sustaining and life-changing. Let’s improve maternal health everywhere. Every patient, every time, everywhere.

National Maternal Health Awareness Day 2024
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Maternal Mental Health Awareness Month

May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need.

Elizabeth Rochin, PhD, RN, NE-BC | May 4, 2023

Posted under: Maternal Health, Mental Health

“I couldn’t bring myself to tell my doctors or nurses, or the doctors and nurses in the NICU about the way I was feeling. I was already that “bipolar patient.” I had used opiates for a few years to cope with the pain that depression brought with the disease. I could feel myself becoming more and more depressed and desperate for help, but thought that if I asked for help, my baby would be taken away from me. My bipolar disorder had haunted me for most of my adult life, had labeled me, and now with a new baby, had no one to reach out to. Each time I left the NICU, I thought it would be the last time I would see my baby. That feeling was so traumatic, and even though my baby is now 1 year old, I still relive that fear every day.” –A.R., during a postpartum interview

Overview
May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need. Compound this maternal mental health need with the public health crisis of racism and a stark picture emerges of women and birthing people in need of tremendous support. There are many facets that must be addressed within maternal mental health—access to care, transportation, stigma, insurance coverage, stable housing, to name a few. An area of concern that has been identified is that of opioid use disorder during pregnancy. A greater prevalence of comorbid psychiatric disorders, physical and sexual abuse, intimate partner violence, and chronic pain disorders likely contribute to disproportionate rates of opioid use and misuse in women and particularly women during pregnancy. Beyond opioid use are other substances that are used frequently to mask mental health symptoms that can be treated by other means. But that treatment costs money and access can be sparce depending on location and availability of providers.

The National Perinatal Information Center continues to track maternal mental health outcomes, including substance use disorder. In 2019, substance use disorder (ICD O99.3XX) was coded in 1.9% of patients (n = 334,402) and by September 2023, 2.3% were coded with substance use disorder (n = 325,195). While that number might not seem high, it continues to reinforce the need to remain vigilant in assessing patients in the prenatal, intrapartum, and postpartum period.

In the time period October 1, 2021 through September 30, 2022, 30-40 patient records were coded with postpartum psychosis (ICD -10 F53.1). In seeing this information, I thought about the patient behind the data. I wondered what their support systems were like. I wondered if they had support, or if they were alone in their suffering. I hope these women had what they needed to not only bring life into this world, but also had those to support them while they nurtured that new life.

Maternal mental health directly impacts the outcomes of a newborn. Perinatal mood disorders are some of the most identified maternal mental health concerns and are associated with increased risks of maternal and infant mortality and morbidity and are recognized as a significant patient safety issue. In addition to perinatal mood disorders, there are other mental health diagnoses that must be appreciated, including pre-existing psychiatric illness (major depression, bipolar disorder, schizophrenia, etc.) that often is underreported and undertreated due to stigma and fear of reporting. During the month of May, it is critical to recognize certain elements of maternal mental health that must be addressed:
  1. Destigmatize mental illness: Stigma is a complex phenomenon, that has three different types: public, self and institutional. Self-stigma develops from shame, blame and internalization of mental illness, which is most often fueled by public and institutional stigma. Supporting women and birthing people experiencing maternal mental health illness, and reducing shame and self-blame, is critical in achievement of treatment regimens and continued engagement with healthcare providers.

  2. Screening women for mental health during the postpartum period: NICU’s across the United States have begun to engage in various forms of screening and intervention to assist in reducing stress and depressive symptoms in mothers during newborn admission. In many cases, maternal mental health concerns remain under identified and undertreated during a NICU stay, which can have deleterious effects on the offspring, both in short-term outcomes while in the NICU as well as long-term neurodevelopmental and behavioral outcomes. Mendelson et al performed a systematic review and metanalysis of NICU programs designed to evaluate for postpartum depression and anxiety and found it increasingly important to evaluate maternal mental health during NICU admissions to assure engagement and understanding of treatment and discharge plans.

  3. Disparities in maternal mental health treatment: Overall, Black women are 3-4 times more likely to die during childbirth or within the first year after delivery. Increasingly, studies describe inequity in mental health screening, identification, and treatment for women of color and other vulnerable populations. Sidebottom and colleagues described the findings of their study in which African American, Asian, and non-white women were less likely to be screened for postpartum depression than their white counterparts. In addition, this study also revealed that women insured by Medicaid and other state programs were less likely to be screened than those women with private insurance.

  4. Access to care: Psychiatrists, psychologists, social workers, and others can be difficult to access, particularly in rural environments. Paying for these services can be difficult, if not impossible, as many providers may not accept Medicaid or patients may not have the means to cover services not covered by insurance. Credentialed/certified community health workers (CHW) can be an invaluable resource for supporting patients in seeking resources for maternal mental health care. Psychiatric Mental Health Nurse Practitioners (PMH-NPs) can also be a vital community resource for patients. Supporting legislation to provide avenues for advanced practice is key in further developing this critical community resource. Advocating for coverage for postpartum maternal mental health is critical to supporting mothers in our communities. Finding new and innovative ways of using and supporting telehealth and digital access to maternal mental health access is imperative. But this access to mental health is dependent upon providers, access to broadband, technology, treatment (medication/therapy) and the cycle begins anew.



Telehealth Access Wheel: Foundational Needs for Telehealth (NPIC, 2023).

This month, it is essential that we create space to discuss maternal mental health, and to develop sustainable strategies for treatment and maternal well-being. Whether that be in a prenatal visit, admission to Labor and Delivery, during a NICU visit, or in the community, as a nation we must be prepared to destigmatize maternal mental health, assure equitable care and access, and create a compassionate course of treatment for women and birthing people who continue to suffer in silence.


References
Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public health crisis we can no longer ignore. The Lancet. 2020;395(10242):e112-e113. doi:10.1016/S0140-6736(20)31371-4

Ouyang JX, Mayer JLW, Battle CL, Chambers JE, Salih ZNI. Historical Perspectives: Unsilencing Suffering: Promoting Maternal Mental Health in Neonatal Intensive Care Units. NeoReviews. 2020;21(11):e708-e715. doi:10.1542/neo.21-11-e708

Patrick SW, Schiff DM, Prevention C on SUA. A Public Health Response to Opioid Use in Pregnancy. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-4070

Patrick SW, Barfield WD, Poindexter BB, Committee on Fetus and Newborn C on SU and P. Neonatal Opioid Withdrawal Syndrome. Pediatrics. 2020;146(5). doi:10.1542/peds.2020-029074

Kendig S, Keats JP, Hoffman MC, et al. Consensus Bundle on Maternal Mental Health. Obstet Gynecol. 2017;129(3):422-430. doi:10.1097/AOG.0000000000001902

Pescosolido BA. The Public Stigma of Mental Illness: What Do We Think; What Do We Know; What Can We Prove? J Health Soc Behav. 2013;54(1):1-21. doi:10.1177/0022146512471197

Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based Interventions to Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-1870
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Restoration of Black Autonomy and Joy in Perinatal Nursing Leadership

There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Elizabeth Rochin, PhD, RN, NE-BC | April 13, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Six years ago, the Black Mamas Matter Alliance launched Black Maternal Health Week, a week each April that would highlight and amplify the unacceptable and sustained increase in Black maternal deaths . Within the global COVID-19 pandemic, the outcome disparities within Black and Brown maternal health communities continued to grow and were impacted at greater rates. On April 13, 2022, Vice President Kamala Harris convened Cabinet secretaries to address the ongoing maternal morbidity and mortality crisis in the United States. The President’s FY23 budget included $470 million to address additional maternal disparities projects, including supporting the perinatal health workforce.

The perinatal health workforce has become an important discussion point, as the need for community health workers, doulas, and other Black maternal health advocates center conversations about the needs of Black mothers and parents. While there is a significant need for a community health focus, inpatient obstetric care requires intentional focus and strong leadership. As reported by the CDC and MMRIA report, 13% of maternal deaths occur on the day of delivery. Inpatient obstetric teams require experienced nursing leadership to support the infrastructure and care delivery required to provide high quality, respectful, and culturally competent care. Open nursing leadership positions within Women’s and Children’s service lines that were once rarely available or open now sit vacant for weeks, and in some cases, months. An area of healthcare leadership that is not often studied is that of frontline perinatal nursing leaders.

So how does this connect to Black Maternal Health Week? There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Weeks ago, Synova Associates and the National Perinatal Information Center launched a white paper that reported on the effects of chronic stress on perinatal nursing leaders (Supporting Perinatal and Neonatal Nurse Leaders: Identification and Moderation of Chronic Stress, IRB #1321780). These nursing leaders represented inpatient settings throughout the United States such as neonatal intensive care (NICU), labor and delivery, postpartum, well-baby nurseries, lactation services, antepartum, and those nursing leaders who are responsible for multiple units. The findings of this study revealed significant racial disparities in many areas, including turnover intent (p < .001), job control (p < .001) and organizational constraints (p < .001).

Based on the results of this study, the following recommendations are suggested for hospital leadership to address:
  1. Healthcare leaders and communities must be made aware of the extrinsic stressors that exist for Black/African American and diverse perinatal nursing leaders. Within this study population, stressors were described as physical symptoms (chest pain, shortness of breath, p < .001) that cannot be ignored, and require additional research and development for strategies by and for those most impacted by these findings. We cannot discuss the physical impacts upon Black nursing leaders without recognizing racism and structural barriers that create environments that impact physical health.

  2. Turnover intention, particularly as described in this study (“I won’t be working here one year from now” p < .001) for Black and Brown perinatal nursing leaders must be more thoroughly explored, and the urgency of this finding addressed. It will be important to replicate this study within other service lines to establish if these findings are unique to perinatal services, or if these findings are more global to diverse nursing leaders regardless of setting.

  3. Job Control, or the perceived ability to make decisions or the freedom to decide how to work, was also significantly decreased for Black and Brown nursing leaders (p < .001). In addition, organizational constraints (hospital rules/procedures; adequate help from others) was also significant (p < .001), which continues to generate further need for examining systems and structures in place that create these real and/or perceived barriers to effective leadership. Exploring these differences is critical and may aid in better understanding turnover intent as well as the symptoms of chronic stress described within Black perinatal nurse leaders. #structuralbarriers
During Black Maternal Health Week, it is important to center the conversation around Black women and birthing people and the continued unacceptable outcome disparities that exist despite data saturation. While assuring the health, well-being, and bodily autonomy of our diverse patients and communities continues to be a priority in our healthcare systems, it is just as important to ensure that we are providing that same level of effort and intensity at assuring the health and well-being of Black nursing leaders within our systems. During Black Maternal Health Week this year, celebrate the richness and diversity of Black communities and Black perinatal leaders. Support the Black Mamas Matter Alliance and the Restoration of Black Autonomy and Joy. Commit ourselves to amplifying Black voices and experiences and follow their lead for innovative and sustainable solutions to eradicating Black maternal morbidity and mortality.


References
National Minority Health Month. NIMHD. Accessed April 9, 2022. https://www.nimhd.nih.gov/programs/edu-training/nmhm/

Black Maternal Health Week. Black Mamas Matter Alliance. Accessed April 9, 2022. https://blackmamasmatter.org/bmhw/

Trocado V, Silvestre-Machado J, Azevedo L, Miranda A, Nogueira-Silva C. Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2020;0(0):1-13. doi:10.1080/14767058.2020.1781809

Di Mascio D, Khalil A, Saccone G, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM. 2020;2(2, Supplement):100107. doi:10.1016/j.ajogmf.2020.100107
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