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In a survey of about 4, mental health providers, more than one-quarter of the respondents did not have a single Medicaid patient. In fact, the incentive for providers to remain out-of-network is great: Commercial plans reportedly reimburse out-of-network mental health care providers 53 percent more for psychotherapy services compared to in-network providers. As a result, countless patients have at best inadequate insurance coverage for mental health services, forcing many to seek out-of-network care and absorb higher out-of-pocket costs. Other cost barriers faced by pregnant and postpartum women of color are structural in nature. The shortage of mental health professionals throughout the United States poses a significant challenge related to the availability and accessibility of mental health care.
A report by HRSA revealed that, by , there will be significant shortages of psychiatrists, psychologists, social workers, and other mental health professionals. Regional differences are also stark. Almost 70 percent of counties in the New England region had access to a psychiatrist, while only 6 percent of counties in the West North Central region, including Oklahoma, Missouri, and North Dakota, had similar access. Policymakers need to take a multipronged approach to address barriers to accessing care, which in many cases are interconnected. In the short term, policymakers should focus on encouraging existing mental health providers to participate in greater numbers in Medicaid as well as in other public and private insurances sources so that patients can access a greater breadth and quality of care and associated benefits.
Higher Medicaid payment rates will encourage more behavioral health providers to participate in the program. Second, to help offset these costs for states, federal policymakers should increase the federal share of Medicaid payments for mental health care services. Higher payment rates are a critical first step in ensuring that all women enrolled in Medicaid can access vital benefits such as screenings for depression for pregnant and postpartum women. Telehealth is a new field that brings together advances in technology with the growing demand for greater access to healthcare.
The technology, accessible through mobile phones or computers, provides patients with access to health care services at the tip of their fingers and the ability to manage their health care, thereby cutting down on costs, unnecessary travel, and other barriers. As of , providers are reporting a telehealth adoption rate of 71 percent and are seeing great utility in using this technology to enhance their practice. Department of Veterans Affairs VA announced a rule last year that would allow VA doctors, nurses, and other providers to administer care to veterans using telehealth technology for, among other things, mental health services.
Likewise, telehealth can be used to improve maternal mental health outcomes, linking pregnant and postpartum women who may otherwise be unable to access vital mental health services with the care they need through digital avenues. States can also increase access to mental health services by covering transportation costs to and from appointments. Medicaid currently provides enrollees with access to nonemergency medical transportation NEMT , a benefit that is predominantly used for mental and behavioral health services.
These are the times when women are at increased risk of experiencing life stressors and mood disorders are more likely to arise. In addition, the federal government should provide states with funding to implement patient safety bundled care. A concept introduced by the Institute for Healthcare Improvement IHI , bundles offer a way to standardize care across hospital systems and practices while improving the quality of care and patient outcomes. Mental health screenings, another key improvement to service delivery, should be routine and integrated into other health care settings for pregnant and postpartum women, as recommended by the U. Unfortunately, one-third of state Medicaid programs still do not permit reimbursement for maternal depression screenings provided during pediatric visits.
Barriers to accessing behavioral health providers and treatment, including prescription drugs, therapy sessions, and alternative therapies, still exist for many and have a disproportionate impact on people of color with mental health challenges. Policymakers should fund research to examine the barriers to screenings, the uptake of follow-up mental health care, as well as whether disparities exist in the implementation of mental health services. These changes are certainly important short-term interventions, but federal policymakers must also make longer-term investments to build a more robust, well-trained behavioral health care workforce that can provide culturally appropriate care. Proposals to accomplish this include expanding federal and state loan repayment programs for mental health professionals to practice in underserved areas and expanding the numbers of midlevel and paraprofessional providers added to the workforce.
In addition, programs run by nonprofit, community-based organizations such as Mamatoto Village are also vital to addressing mental health conditions amongst pregnant and postpartum women, particularly women of color, because they are rooted in the community and are committed to crafting solutions that meet a woman where she is. The stigma associated with mental health is yet another barrier preventing many women from seeking mental health care. That being the case, policymakers should fund education campaigns and other efforts that work to change the culture and thinking around mental health that contribute to its stigmatization.
Policymakers should ensure that pregnant and postpartum women with disabilities, including mental health disabilities, are provided accommodations to access mental health care—a right that is protected under these important federal civil rights laws. Health care providers and communities must be educated about the importance of access to and utilization of mental health care among African American women. Good mental health should be acknowledged as an essential part of overall wellness.
The supported education campaigns should reach local and national audiences and must prioritize the lived experiences of pregnant and postpartum African American women, including the need to dismantle the perception that black women must be strong at all times and do not need the space to be vulnerable, also known as strong black woman syndrome These efforts must also help African American women to recognize the signs and symptoms associated with mood disorders and address the ways that racism, ableism, and gender discrimination impact mental health.
Policymakers should issue grants for such campaigns and work with an array of entities, including religious organizations, women of color-led groups at the national and state level, disability justice groups, and community-based organizations. However, research also shows that forming strong, supportive relationships with adults is key to helping children overcome this trauma. To this end, a few states and territories have recognized the key role of local governments in detecting ACEs and quickly connecting families to treatment.
In , Washington state became the first state to enact legislation aimed at this issue, passing a law that required a multistakeholder group to identify ways to reduce and prevent ACEs. Gavin Newsom D released a state budget that includes significant investments in early developmental screening, including screening for ACEs, and trauma-informed care. As a black woman and expert in ACEs and social determinants of health, Dr. Burke Harris can use her lived experiences to reach and inform families across the state. All parents with infants need support to thrive, especially during the critical time before and after birth. This period can be especially stressful for African American mothers, who may have experienced complications during pregnancy and delivery and who also carry the physical and emotional impact of structural racism.
Mothers without enough physical and emotional support may miss critical pre- and postpartum medical care and can develop physical complications for example, hypertension or gestational diabetes and mental health complications for instance, postpartum depression that endanger her long-term health as well as the health and development of her infant. As many new mothers are still physically recuperating from childbirth, they also face the demands of caring for an infant at a moment when two critical resources—money and time—are especially scarce. Because parents of infants are often early in their careers, they earn less and have less savings on which to draw.
As parents encounter the financial strain of a new infant, they find themselves waking throughout the night to feed and care for their infant, which leaves them sleep deprived or exhausted throughout the day. Postpartum sleep difficulties are common and insidious, and research points to a vicious cycle between sleep and postpartum depression. It should come as no surprise then that perinatal mood disorders affect approximately 20 percent to 25 percent of mothers from all backgrounds. However, there are few programs that treat it as such. A lack of investment in critical pre- and postpartum programs means that adjusting to parenthood can be especially difficult for the 1 in 5 families of infants and toddlers living in poverty. In addition, hourly earners and low-wage workers—with women of color and black women over represented in both categories—are less likely to have paid leave.
To be sure, maternal and infant mortality rates are elevated for black women and infants across the socio-economic spectrum and, as mentioned above, education and income do not guard against maternal and infant mortality. At the same time, poverty is correlated with maternal and infant deaths. Poverty can be understood as another mechanism through which racism results in disparities in maternal and infant mortality. Ultimately, to improve the well-being of African American families across the socio-economic spectrum, targeted interventions should be embedded in a larger system of robust, universal, and appropriately financed services.
This first means ensuring that all families can meet their basic needs and easily access the care and resources that support their health. Next, it means promoting a dense network of positive social supports and connections, especially for new families. These connections can help protect against the emotional and physical effects of traumatic events and improve mental well-being. Finally, it requires that services and supports be delivered via community-based solutions. Community leaders already working with those most affected by maternal and infant mortality should spearhead these programs.
This approach helps address the systematic bias that has undermined the efficacy of support programs, fostering trust and reciprocal help in its place. The federal government funds several benefit programs that provide income, housing, nutrition, and other supports to families. These programs improve maternal and infant health by providing basic living supports essential to the immediate safety and well-being of families. For example, studies show that participation in nutrition assistance programs such as WIC and the Supplemental Nutrition Assistance Program SNAP is associated with a decline in low birth weight births and higher rates of breastfeeding. In , Title V grants were dispersed to 59 states and jurisdictions and provided funding for health care services for 56 million Americans.
Many of these programs have experienced an erosion of funding and subsequent reduction in number of families served. Families looking for additional support face a fragmented system, beginning with where services are located. A family seeking housing or food assistance must begin by visiting a social service office during regular business hours. This can require taking time off work, arranging for child care or bringing children to appointments , and securing transportation—often with no guarantee that, in the end, they will receive the necessary supports.
In many cases, they must repeat this entire process for each benefit. In addition, when these programs are integrated in the community and staffed by caring, culturally sensitive workers, staff can be a valuable source of social support that help families weather stressful events in their lives. Although frontline workers can perpetuate stigma and racism, hiring, training, and promoting empathic, sensitive workers from within the community to staff these programs can help increase social support for women of color and their children.
Examples of these programs can be found throughout the country but are still not the norm for most families seeking financial support for their basic needs. In Washington, D. And across the country, Head Start and Early Head Start are designed to link families to services beyond early learning, including parenting and health education, crisis intervention, mental health services, and housing assistance. In rural communities, where fewer services are available, Head Start plays an outsize role in connecting families to resources.
Research shows that this community-based, one-stop approach can promote healthy behaviors and reduce negative outcomes associated with maternal and infant mortality. Indeed, one study showed that although African American women continued to experience higher rates of preterm birth compared to white women, community health centers nearly cut the disparity in half. Federal policymakers can promote these comprehensive programs by first building upon investments in existing programs such as community health centers, Title V, and Head Start. Appropriators should guarantee robust funding for these programs and invest in research on how these programs can continue to improve access to service and service delivery.
State and local policymakers, particularly mayors and county executives, can also prioritize building integrated student supports into local schools. Locating comprehensive social services in a single location is only one way to increase access to services. Many states require families to complete lengthy, duplicative application forms for each program, often requiring families to repeatedly verify their claims through documents such as pay stubs and proof of residence. As discussed earlier, increasing access to comprehensive services is a key to improving maternal and infant health. Recognizing that information collected by one benefit program can be used in others, some states and localities are already experimenting with ways to screen and enroll families more efficiently.
Various localities are part of the Advancing Strategies to Align Programs ASAP initiative, an advocacy initiate that aims to streamline enrollment through information sharing and program coordination. First, simplifying application and enrollment removes some of the burden from families in need. Second, it can reduce the time families must wait to receive benefits, a crucial priority. State and local policymakers should identify opportunities under federal law to use eligibility determinations in one program to simplify the application and enrollment process in others. State policymakers can facilitate cross-enrollment through measures such as improving data matching algorithms and notifying program participants of their potential eligibility for other programs.
Policymakers too can foster linkages between programs where none yet exist. For example, the Earned Income Tax Credit EITC is a large income support program with no existing linkages with other benefit programs such as nutrition or housing assistance. To increase enrollment across programs, policymakers can provide training to staff on eligibility rules and processes for the EITC in order to ensure families applying to traditional benefit programs also have an opportunity to enroll in others.
Home visiting is a voluntary, evidence-based program that delivers comprehensive family services in the home. In some models, a certified nurse partners with parents and focuses on child health and family stability. Due to limited resources, most federally funded programs prioritize serving specific families: families with low incomes; pregnant women under age 21; families with a history of child welfare system involvement or substance abuse; tobacco users; military families; and families of children with developmental delays or disabilities. Home visiting works to improve maternal and infant health by providing emotional support in addition to another opportunity to link families to the services and education they need.
Home visitors in intensive programs can become trusted advisers to families and a source of social support to help soften the stress that comes with navigating pregnancy and parenthood. By developing deep relationships with families, home visitors can also help introduce and cultivate norms and attitudes that promote health. For example, many programs provide lactation education and support in culturally appropriate contexts. Research shows home visiting is an effective intervention that addresses many of the causes and correlates of maternal and infant mortality. Additionally, mothers who participate in home visiting are more likely to breastfeed and adopt healthy eating habits and less likely to take up behaviors such as drinking alcohol or smoking during or after pregnancy.
Infants whose mothers were enrolled in home visiting were less likely to be born preterm or at a low birth weight and had fewer emergency room hospitalizations. For example, fewer delivery complications and preterm births reduce the length of hospital stays for mothers and infants. Given that Medicaid pays for nearly half of all U. Although a recent national evaluation—the Maternal and Infant Home Visiting Program Evaluation MIHOPE study—showed little effect on known correlates of infant mortality such as birth weight, the authors found that home visiting nevertheless contributed to other positive outcomes, including fewer emergency department visits, improved home environments, and improved maternal mental health.
Although most home visiting programs in the United States target families with high needs, a few evidence-based universal home visiting programs have developed in recent years. Family Connects is designed to bridge the gap between family needs and community resources for parents of newborns. All families, regardless of income, are eligible to receive between one to three free home visits from a registered nurse and are referred to further services as needed. Families characterize these nurse visits as a valuable source of support during a tumultuous time.
Welcome Baby is a free, voluntary home visiting program locally designed and implemented in Los Angeles. Originally launched in one downtown Los Angeles community and offering services to all families giving birth within a five-mile radius of the local hospital, the program now serves families throughout the county. In contrast to Family Connects, Welcome Baby offers prenatal services delivered by a parenting coach. Studies show participation in Welcome Baby is associated with positive outcomes, including stronger maternal responsiveness, lower parenting stress, and greater social and communication skills for children. These effects persisted up to three years after the intervention.
Over time, it moved from the private, voluntary sector into public health, eventually finding a home in the National Health Service NHS in For example, a family facing a complex, long-term challenge, such as postpartum depression, will receive more intensive supports than a family experiencing temporary short-term feeding difficulty. The United Kingdom has also taken bold steps to ensure that pregnant women and new mothers receive care that prioritizes their well-being.
British pregnant women and mothers also receive care that spans from the prenatal period to well after birth and is highly standardized and regulated. The federal government supports home visiting through the Maternal, Infant, and Early Childhood Home Visiting MIECHV program, which has strengthened state programs by supporting services, research, and local infrastructure since its inception in As part of the next reauthorization, Congress should significantly increase MIECHV funding to provide evidence-based services to all high priority families, including families in poverty and families of infants.
This funding should also be flexible enough to support innovative, promising community-based approaches that do not yet have enough evidence to qualify as evidence-based. In addition to directly increasing home visiting funding by increasing MIECHV dollars, federal policymakers can help states leverage other resources such as Medicaid to augment dedicated home visiting funds. Finally, Congress should consider establishing grants to support innovations in home visiting. First, it should increase research funding for rapid-cycle evaluations of home visiting models to better understand what aspects of these services work best for specific populations, including families of color and families that have individuals with a disability.
Second, Congress should establish pilot programs that implement universal home visiting in a geographic area, such as Family Connects. Research shows that the majority of families need additional support after the birth of a child, and experts contend that a universal approach is an effective way to find and serve families who are in greatest need. Across the country, communities launch educational campaigns and communication initiatives to address specific areas for improvement. To support these efforts, policymakers should ensure diverse representation in grant-making to community-based organizations to establish or support these initiatives.
Programs should identify a clear need in the community that is unmet and develop a concrete plan to address this need through leveraging community resources. These grants can provide initial funding for promising community-based solutions that can be sustained in the long term through increased local investment. In , Baltimore had the fourth-highest infant mortality rate among comparable U.
After an extensive period of community engagement and analysis of local needs, initiative leaders developed a locally driven initiative to reduce instances of premature birth, low birth weight, and unsafe sleep. Unfortunately, the city has recently seen a spike in sleep related infant deaths, although it remains too soon to determine the cause. Nevertheless, these deaths have prompted conversations about how to respond. Public health practitioners have long understood that data are critical to illustrate the prevalence and concentration of maternal and infant mortality. Collecting and disseminating reliable, consistent data on maternal and infant mortality is essential to developing solutions.
But progress on this front has not been uniform. Data have not always been collected in a consistent manner, and not all states have effective systems for collecting the type of data that can help inform action to avoid future deaths. The CDC releases revised death certificate standards to all states every 10 to 15 years. The last revisions, issued in , included a checkbox to identify whether a person was pregnant at the time of death or had been pregnant within specified time periods for example, within 42 days of death or within one year of death. The reason for this update is that previous ways of reporting maternal mortality failed to identify all cases, leading to systematic underestimation of maternal deaths. To complicate the labor- and time-intensive process of collecting and analyzing new data, states were also transitioning to or updating electronic birth registration systems as they were rolling out the revised death certificate forms.
This process required additional staff training and investments in data infrastructure. The CDC administers several national data sources for estimating maternal and infant mortality, which can lead to confusion when reporting or investigating longitudinal trends or international comparisons. Each of these sources uses slightly different measures to count deaths, especially maternal or pregnancy-related deaths, and not all are compatible with methods used by organizations such as the World Health Organization WHO or the Institute for Health Metrics and Evaluation.
The center collects these vital statistics from 57 records jurisdictions: 50 states, five territories, the District of Columbia, and New York City. To do so, the CDC requests the 52 reporting areas to voluntarily send copies of death certificates for all women who died within a year of being pregnant as well as copies of the matching birth or fetal death certificate. Pregnancy Risk Assessment Monitoring System PRAMS , a joint public health surveillance project of the CDC and state health departments, collects state-specific data on maternal attitudes and experiences before, during, and shortly after pregnancy.
Unlike the previous programs, rather than collect data on the entire population of women, PRAMS only collects information from a sample of women who have had a live birth in the last year. Within those states, however, it can be used to identify groups of women and infants at higher risk for health problems, monitor changes in health status, and measure progress toward reducing maternal and infant mortality.
In addition to these data sources, some states and localities have conducted extensive and systematic reviews of maternal and infant deaths. Unlike the CDC surveillance programs described above, these review programs are more localized and are designed to elicit information that can inform improvement plans. Moreover, they often integrate interviews with affected families in order to capture important context not readily available through vital statistics, medical records, or survey data. The maternal mortality review committee MMRC is a comprehensive review process operating at the state level that identifies and analyzes maternal deaths; disseminates findings; and develops recommendations.
For example, after establishing its MMRC in , California found that maternal hemorrhage was among the most common preventable causes of maternal deaths. The bill, which was signed into law after unanimously passing both chambers of Congress, represents an important first step toward addressing the maternal mortality crisis. The Preventing Maternal Death Act:. Importantly, this bill does not contain provisions to collect data on infant deaths. To date, Congress has not passed comparable legislation to support data collection for infant mortality.
Despite the importance of this legislation, more work is needed. Review committees rely on accurate vital statistics data in order to identify cases to review and recommend improvements, but states too often inconsistently report this information. Moreover, not all states have review committees, and even among states with established committees, underfunding compromises the efficacy of their work. Given the recent legislative advances on collecting data on maternal mortality, it will be especially important that policymakers at all levels ensure that data collection efforts around fetal and infant mortality keep pace.
Given the racial disparity in both maternal and infant mortality, states need to better incorporate equity in their review processes. The first step in developing robust, effective mortality committees is collecting accurate and comprehensive vital statistics. However, as a result of inconsistent public health surveillance practices across states, the United States has not published an official maternal mortality rate since To improve the quality of vital statistics and thereby support state mortality review committees, Congress should ensure adequate funding to NCHS, and states should significantly invest in their vital statistics systems in order to ensure rapid implementation of the next round of birth and death certificates from the CDC.
In a report from Marian MacDorman and colleagues analyzing the impact of the death certificate revisions on maternal mortality, the authors claim that chronic underfunding contributed to significant delays in the adoption of revised birth and death certificates. As part of the revision process, federal and state policymakers can work together to address several challenges that plague vital statistics systems by developing technical assistance plans and resources. First, policymakers should provide technical assistance on ways to improve completeness of data, amend records, and account for incomplete data in analyses.
During analyses, cases with incomplete data might be excluded, which could potentially leave out some of the mothers and infants who were at the highest risk of infant mortality. For example, one California study found an association between incomplete birth certificates—those that are missing important information such as gestational age, number of prenatal visits, or maternal education—and infant mortality. Second, policymakers should also provide funding for technical assistance on ways to reduce misclassification of race on medical and mortality records. Doing so will help states more accurately measure racial disparities and avoid underestimating maternal and infant mortality for certain communities.
As a result, racial misclassification is common, especially for AIAN communities, who may trace tribal membership through either parent. To address this issue, policymakers can provide technical assistance on certain practices such as linking data from tribal registries and hospital records, which can reduce racial misclassification in mortality data. Finally, in consultation with experts, advocates, and a diverse array of stakeholders, policymakers should consider ways of collecting data on birth and death certificates that are inclusive of a broad range of gender identities. The pregnancy and parenting experience of transgender, intersex, and nonbinary individuals deserves robust study, which is currently undermined by a dearth of adequate data.
It is important to note that legislation on collecting fetal and infant mortality data has not advanced in the wake of the passage of the Preventing Maternal Deaths Act. In locales without FIMRs, this additional funding can be used to train staff in existing child fatality review committees—which operate in all 50 states and investigate deaths throughout childhood and adolescence—on ways to use components of the FIMR process to more effectively review infant deaths.
Federal policymakers should also consider establishing a new grant program to create or improve FIMRs. Funding should be directed to states that do not currently have FIMRs or have too few programs to serve their states. California and the United Kingdom have been praised as examples of using data to prevent maternal deaths. However, these examples also shed light on the limitations of such an approach. Although California was able to dramatically reduce its overall maternal mortality—it is currently one-third the national average—African American mothers in the state are still nearly four times more likely to die from causes related to pregnancy or childbirth as non-Hispanic white mothers. These examples make clear that collecting data alone is not enough. State review boards can support these interventions if they are able to better integrate equity in their efforts.
In order to accomplish this, Congress should, first, ensure that state review boards have funding to support the collection of qualitative interviews that illuminate the role of racism, sexism, and other social determinants of health on outcomes. The Black Mamas Matter Alliance—a black women-led cross-sectoral policy, research, and advocacy alliance—argues that qualitative data provide insight into the impact of racial discrimination on the care women receive and perceptions of quality. Indeed, in a recent survey of FIMR programs nationwide, half reported that a lack of funding represents a significant barrier to conducting a maternal interview.
Second, as part of the implementation of the Preventing Maternal Deaths Act and any comparable legislation for infants, Congress should ensure that states have funds to cover technical assistance around incorporating equity and social determinants of health into their review process. Geocoding where a death occurs and triangulating that information with publicly available data from the American Community Survey ACS or Area Health Resource File AHRF can illuminate the connection between geographic location and the uneven distribution of resources such as hospitals.
These socio-spatial indicators can help review committees describe community factors that contribute to inequality and complement qualitative data. Whereas spatial analysis can help a community describe access to care, interviews can describe the quality of care. Technical assistance to program staff can help programs collect any type of data that can inform improvements. Finally, as states and localities establish or expand their MMRCs and FIMR committees, local policymakers must ensure that they include people affected by maternal and infant mortality at all levels. Community engagement has been an integral part of the FIMR process since its inception, and MMRCs are beginning to more thoughtfully integrate representation in the review process. For example, both Washington, D.
Ensuring workplace supports and humane treatment within the criminal justice system are also vital to eliminating racial disparities in maternal and infant mortality. Pregnant and postpartum African American women deserve accommodations, benefits, and protections that help lead to positive health outcomes for themselves and their infants, regardless of the settings within which they live or work. Workplace policies that support pregnant women and new mothers can improve maternal and infant health, leading to better birth outcomes and fewer instances of mortality and morbidity. Unfortunately, many women of color tend to work in low-wage jobs that lack the protections and benefits afforded to high-wage workers.
There are several ways to support pregnant workers and working mothers, including adopting a comprehensive national paid family and medical leave policy; ensuring access to high-quality affordable child care; and enforcing and expanding the Pregnancy Discrimination Act. Whereas most of the aforementioned programs may benefit women across the socio-economic spectrum, it is nevertheless important to recognize that poverty is a powerful predictor of health throughout the lifespan. Moreover, institutional racism has made African American women overrepresented in the lower end of the socio-economic spectrum.
Experiencing pregnancy discrimination in the workplace can also be detrimental to maternal and infant health. According to the National Partnership for Women and Families, about 3 in 10 pregnancy discrimination claims were filed by African American women from —, double the proportion of black women ages 16 to 54 in the labor force. Pregnancy discrimination can have severe health consequences. An investigation by The New York Times included a review of thousands of documented cases in the public record where pregnant women suffered miscarriages and premature labor after being denied accommodations in the workplace, especially in positions requiring manual labor.
The absence of paid family leave is particularly troubling, given nearly two decades of research outlining the benefits of paid leave on maternal and infant health. Studies indicate that having access to paid family leave contributes to fewer low birth weight infants, fewer infant deaths, higher rates of breastfeeding, improved mental health, longer parental lifespan, and long-term achievement for children. Unfortunately, most U. Only 17 percent of American workers have paid leave; nearly three-quarters of mothers who worked during pregnancy return to work within six months of giving birth; and nearly 1 in 4 mothers return to work less than two weeks after giving birth to their infants.
When it comes to women of color, those numbers are even more alarming. Women of color are less likely to have access to any form of paid leave, although the differences vary—44 percent of Latinas, 40 percent of Asian American women, 37 percent of African American women, and 36 percent of white women do not have access to paid leave. Pregnant women and new mothers also need access to paid sick days, which allow them time off work to care for themselves—such as attending prenatal doctor appointments—or their new child.
Yet, 34 million people do not have access to paid sick days, and this disparity is worse for workers of color, especially Latinos. Workplace support for breastfeeding is critical to supporting women in breastfeeding for the six months recommended by the AAP. For new mothers working in low-wage jobs, manual labor, or the service industry, which disproportionately represent women of color, workplace breastfeeding supports can be even harder to obtain. Because disparities still exist in breastfeeding trends, policymakers must do more to incentivize the implementation of policies already in place to support adequate space and time for new mothers to express breast milk while at work. The ACA mandated workplace supports for breastfeeding mothers, including a requirement that employers provide break time and private space for mothers to express breast milk.
Policymakers could go even further by requiring such support for all workers, regardless of employer size or industry. When parents return to work, they need access to affordable, quality child care options that keep children safe. However, the high cost of licensed child care is out of reach for many families. Sometimes these options are ideal for the parent, child, and caregiver. For families of color, the challenges of finding affordable child care are even more pronounced.
Among African American families, 3 in 4 children have all available parents in the workforce, as compared to 66 percent for children across all races. Both traditional Medicaid and Medicaid expansion should be implemented without so-called work requirements, which serve as harsh time limits that disproportionately harm women of color. Because of this, they could risk losing access to vital health care.
For example, in Arkansas—a state that recently imposed a work requirement of 80 hours per month—more than 18, people have already lost coverage due to work requirements, and fewer than 2, of those individuals reenrolled. Tax credits also represent a critical support for families at the birth of a child. Investing in these families requires improving the Child Tax Credit by making it fully refundable; making it available on a monthly basis to cover basics such as formula and diapers; and providing a boost for families with children under age 6. Women of color are disproportionately represented in the criminal justice system.
Specifically, parental incarceration is classified as an ACE. Importantly, African American children are more than twice as likely as non-Hispanic white children to have an incarcerated parent or guardian due to decades of racial discrimination and predatory sentencing practices in the criminal justice system. Incarcerated women endure many routines and procedures that impact them negatively, including the practice of shackling.
Outlawed in by the Federal Bureau of Prisons, shackling is still practiced in most state and local jails and prisons as well as in Immigration and Customs Enforcement ICE detention. Twenty-eight states and ICE use restraints on pregnant women while they are in labor, during transport, and during recovery in the postpartum period. Shackling is inhumane and can be a source of trauma for women in the criminal justice system as well as a host of other health-related issues. According to the ACOG, shackling can lead to dangerous health effects for incarcerated pregnant women, including a delay in the assessment of vaginal bleeding and hypertensive disease, which can in turn lead to maternal deaths.
Reproductive justice groups have worked tirelessly to end shackling. In , the work of SisterSong and Forward Justice resulted in North Carolina abandoning the practice of shackling incarcerated pregnant women during childbirth. As noted earlier, U. This can be seen in recently implemented draconian policy changes and attacks on immigrant communities as well as the persistent criminalization of black and brown women for minor offenses. As a consequence, there is an overrepresentation of these populations within both ICE detention centers and in prisons and jails across the country. Addressing the practice of shackling and the criminalization of women of color are key to broader criminal justice reform efforts.
Policymakers should issue a total ban on shackling of incarcerated pregnant women in both public and private prisons as well as those in ICE custody. Policymakers must also ensure access to comprehensive, quality health care for pregnant and postpartum women in the criminal justice system. In doing so, they must hold public and private prisons accountable in the provision of quality care. Poor quality of care and negligent procedures can contribute to already high levels of stress experienced by incarcerated pregnant black women in particular. Reproductive health care, voluntary family planning, screening for HIV and sexually transmitted infections STIs , substance abuse treatment, and mental health care are all vital aspects in the spectrum of health care services pregnant and postpartum incarcerated women need.
Health care staff serving the prison population must operate under the highest standards and offer incarcerated women quality care. Policymakers should mandate bonding time for incarcerated new mothers after the birthing process, which has been shown to have positive health effects for the infant. The needless, preventable deaths of African American mothers and infants is a national tragedy and disgrace.
Eliminating racial disparities in maternal and infant mortality must be a priority for the United States. As articulated in this report, there is no single policy solution that will solve this public health crisis—the approach must be comprehensive and multipronged. The Center for American Progress has recommended a set of policy strategies that includes improving access to critical services; improving the quality of care provided to pregnant women; addressing maternal and infant mental health; ensuring supports for families before and after birth; and improving data collection and oversight.
If implemented fully, these policy strategies will allow African American women to navigate a more compassionate and woman-centered health care system and do so freely with the bodily autonomy they deserve. The policy strategies also promote the overall health and well-being of families of color, helping to instigate better health outcomes for African American infants and ensure that they thrive throughout childhood. And despite the shameful historical foundations of racism upon which this country was built, concrete policy strategies, as laid out in this report, can address the manifestations of racism and how they instigate poor maternal and infant health outcomes. The lives and health of African American mothers and infants depend on it. Taylor has two decades of public policy and advocacy experience, beginning her career as a congressional staff member in the office of Rep.
Robert C. Scott D-VA in the late s. Taylor has published and presented extensively on topics related to reproductive health and rights and public policy. Taylor graduated with honors from Hampton University with a Bachelor of Arts in political science. Taylor serves on the board of directors for Provide, Inc. Cristina Novoa is a senior policy analyst for Early Childhood at the Center for American Progress, where she uses her training in developmental psychology and public policy to advance policies that benefit young children. Most recently, she worked as a researcher on a range of early childhood issues at SRI International.
Prior to joining American Progress, she completed fellowships at the National Academies of Sciences, Engineering, and Medicine and in the office of Sen. Kirsten E. Gillibrand D-NY. Novoa studied developmental psychology and public policy, specializing in the academic and behavioral development of children from immigrant families. Corresponding author. Correspondence to Dr Melissa DeJonckheere; ude. No commercial re-use. See rights and permissions. Published by BMJ. This article has been cited by other articles in PMC.
Associated Data Supplementary Materials Supplementary data. Abstract Semistructured in-depth interviews are commonly used in qualitative research and are the most frequent qualitative data source in health services research. Keywords: qualitative research. Introduction Semistructured interviews can be used by family medicine researchers in clinical settings or academic settings even with few resources. Perspectives about and approaches to weight gain in pregnancy: a qualitative study of physicians and nurse midwives. BMC Pregnancy and Childbirth ; Br J Gen Pract Designing for clinical change: creating an intervention to implement new statin guidelines in a primary care clinic.
To elicit provider perspectives of their uptake of new statin guidelines. To tailor a local quality improvement intervention to improve statin prescribing. Becoming pregnant: exploring the perspectives of women living with diabetes. Br J Gen Pract ;—90 4. To explore women's accounts of their journeys to becoming pregnant while living with type 1 diabetes Four UK specialist diabetes antenatal clinics 15 semistructured interviews with women with pregestational type 1 diabetes; thematic analysis Saigal P, Takemura Y, Nishiue T, et al.
Factors considered by medical students when formulating their specialty preferences in Japan: findings from a qualitative study BMC Med Educ , Open in a separate window. Table 2 Definitions of qualitative interviews. Figure 1. Purpose of semistructured interviews The overall purpose of using semistructured interviews for data collection is to gather information from key informants who have personal experiences, attitudes, perceptions and beliefs related to the topic of interest. Designing and conducting semistructured interviews In the following section, we provide recommendations for the steps required to carefully design and conduct semistructured interviews with emphasis on applications in family medicine and primary care research see table 3.
Table 3 Steps to designing and conducting semistructured interviews. Step Task 1 Determining the purpose and scope of the study 2 Identifying participants 3 Considering ethical issues 4 Planning logistical aspects 5 Developing the interview guide 6 Establishing trust and rapport 7 Conducting the interview 8 Memoing and reflection 9 Analysing the data 10 Demonstrating the trustworthiness of the research 11 Presenting findings in a paper or report.
Steps for designing and conducting semistructured interviews Step 1: determining the purpose and scope of the study The purpose of the study is the primary objective of your project and may be based on an anecdotal experience, a review of the literature or previous research finding. Step 2: identifying participants After deciding on the purpose of the study and research question s , the next step is to determine who will provide the best information to answer the research question. Step 3: considering ethical issues An ethical attitude should be present from the very beginning of the research project even before you decide who to interview.
Step 4: planning logistical aspects Careful planning particularly around the technical aspects of interviews can be the difference between a great interview and a not so great interview. Table 4 Suggestions for successful audio recording of interviews. Many interviewers use small battery-powered recorders but sometimes the microphones do not work well. Reliable Audio-recording equipment needs to be reliable and easy to use. Increasingly, researchers are using their smartphones to record interviews. Familiarity Whatever kind of recording equipment is used, the researcher needs to be familiar with it and should test it at the interview location before starting the actual interview—you do not want to be fumbling with technology during the interview.
Backup If you are the sole interviewer and do not have an additional person taking notes, we recommend having two recording devices for each interview in case one device fails or runs out of batteries. Make sure to bring extra batteries. Note-taking Some researchers recommend taking notes or having a partner take notes during the interviews in addition to the audio recording. Table 5 Questions and prompts in semistructured interviewing. Type of question Definition Purpose Example Grand tour General question related to the content of the overall research question, which participant knows a lot about Initiate the interview Help participant to start talking about their experience How has your pregnancy been so far?
Core questions Five to 10 questions that directly relate to the information the researcher wants to know Answer the research question s Help participant talk openly about the topic in an exploratory way Typically asked of all participants What do you think pregnant women should do for exercise during pregnancy? Planned follow-up questions Specific questions that ask for more details about particular aspects of the core questions Answer particular aspects of the core interview questions Obtain greater detail about responses Asked depending on participant responses It sounds like you exercise most days.
What activities do you do for exercise? Can you tell me more about that? Supplementary data fmchsupp Step 6: establishing trust and rapport Interviews are a special form of relationship, where the interviewer and interviewee converse about important and often personal topics. Step 7: conducting the interview Location and set-up The interview should have already been scheduled at a convenient time and location for the interviewee.
Beginning the interview Many interviewers start with chatting to break the ice and attempt to establish commonalities, rapport and trust. Interviewer stance During the interview, the interviewer should adopt a friendly and non-judgemental attitude. Active listening During a face-to-face interview, there is an opportunity to observe social and non-verbal cues of the interviewee. Continuing the interview As the interview progresses, the interviewer can repeat the words used by the interviewee, use planned and unplanned follow-up questions that invite further clarification, exploration or elaboration.
Table 6 Probing techniques for semistructured interviews modified from Bernard Probing technique Description Example Wait time Interviewer remains silent after asking a question. This allows the interviewee to think about their response and often encourages the interviewee to speak. What do you think pregnant women should do for exercise during pregnancy? Right, so it was hard to exercise after working all day. Verbal agreement Interviewer uses affirming words to encourage the interviewee to continue speaking. Yes… Okay… Expansion Interviewer asks participant to elaborate on a particular response. Tell me more. Give me an example of that. Can you describe that? Explanation Interviewer asks participant to clarify a specific comment. Leading Interviewer asks interviewee to explain their reasoning.
You said that you decided to only exercise after the baby is born. Tell me how you came to that decision. Step 8: memoing and reflection After an interview, it is essential for the interviewer to begin to reflect on both the process and the content of the interview. Step 9: analysing the data The data analysis strategy should also be developed during planning stages because analysis occurs concurrently with data collection. Step demonstrating the trustworthiness of the research Similar to validity and reliability, qualitative research can be assessed on trustworthiness.
Step presenting findings in a paper or report When presenting the results of interview analysis, researchers will often report themes or narratives that describe the broad range of experiences evidenced in the data. Conclusions Though semistructured interviews are often an effective way to collect open-ended data, there are some disadvantages as well. Qualitative research in health care. Footnotes Correction notice: This article has been corrected. References 1. BMC Pregnancy Childbirth ; 13 GPs' perceptions of workload in England: a qualitative interview study. Br J Gen Pract ; 67 :e— Br J Gen Pract ; 58 — Factors considered by medical students when Formulating their specialty preferences in Japan: findings from a qualitative study.
BMC Med Educ ; 7 Older adults' preferences for when and how to discuss life expectancy in primary care. J Am Board Fam Med ; 30 —5. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs ; 72 — Naturalistic inquiry. The qualitative research interview. Med Educ ; 40 — Whiting LS. Semi-structured interviews: guidance for novice researchers. Nurs Stand ; 22 — Hatch JA. Doing qualitative research in education settings. Suny Press, How many interviews are enough? An experiment with data saturation and variability. Field methods ; 18 — Sample size in qualitative interview studies: guided by information power. Qualitativehealth research ; 26 — Edwards R, Holland J.
Britten N. Qualitative interviews. Qualitative research in health care, 12— Spradley JP. The ethnographic interview. Waveland Press, Shank GD. Qualitative research: a personal skills approach. Pearson Merrill Prentice Hall, Opdenakker R. Advantages and disadvantages of four interview techniques in qualitative research. Anderson K, Jack DC. Learning to listen: interview techniques and analyses , 11— Qualitative data analysis: an expanded sourcebook. Qualitative data analysis. SAGE, Babchuk WA. Fundamentals of qualitative analysis in family medicine.
Fam Med Com Health ; 7 :e Creswell JW. Qualitative inquiry and research design: choosing among five approaches. Forman J, Damschroder L. Qualitative content analysis. In: Empirical methods for bioethics: A primer. Emerald Group Publishing Limited, 39— Shenton AK. Strategies for ensuring trustworthiness in qualitative research projects. Education for Information ; 22 — Watkins DC. Qualitative research: the importance of conducting research that doesn't "count".
Four clinical programmes affiliated with an urban academic medical centre. DiCicco-Bloom and Crabtree Hatch Kvale 7. Josselson Determining the purpose and scope of the study. Demonstrating the trustworthiness of the research. Audio-recording equipment needs to be reliable and easy to use. Whatever kind of recording equipment is used, the researcher needs to be familiar with it and should test it at the interview location before starting the actual interview—you do not want to be fumbling with technology during the interview.
If you are the sole interviewer and do not have an additional person taking notes, we recommend having two recording devices for each interview in case one device fails or runs out of batteries.Within Childbirth Attitudes Questionnaire Analysis states, Childbirth Attitudes Questionnaire Analysis, it can be used to identify groups of women and infants at higher risk for health problems, monitor changes in Childbirth Attitudes Questionnaire Analysis status, and measure progress toward reducing maternal and infant mortality. Parent Information. At times, this choice is due to a lack of proximity to a hospital. Childbirth Attitudes Questionnaire Analysis pregnancy, receipt of recommended prenatal Childbirth Attitudes Questionnaire Analysis can help Childbirth Attitudes Questionnaire Analysis reduce Childbirth Attitudes Questionnaire Analysis risk Childbirth Attitudes Questionnaire Analysis pregnancy complications Childbirth Attitudes Questionnaire Analysis poor Childbirth Attitudes Questionnaire Analysis outcomes by promoting healthy behaviors Childbirth Attitudes Questionnaire Analysis. Note-taking Some researchers recommend taking notes or having a partner Childbirth Attitudes Questionnaire Analysis notes Childbirth Attitudes Questionnaire Analysis the interviews in addition to the audio recording. Chaffin, M. Trainings to foster cultural Argumentative Essay On Conversion Therapy should be Childbirth Attitudes Questionnaire Analysis in both Childbirth Attitudes Questionnaire Analysis programs and licensing for staff and be embedded in regular ongoing trainings that occur in health care settings as a requirement of maintaining licensure.