“Regardless of how you give birth, it is an experience that should be cherished”: ensuring positive experiences during planned caesarean births for wāhine Māori in Aotearoa (New Zealand)

Can early prenatal care initiation reduce racial inequalities in birth outcomes? A causal decomposition approach.

BackgroundReal-world evaluations of complex interventions are scarce. We evaluated the effect of the Salut Programme, a universal child health promotion intervention in northern Sweden, on income-related inequalities in positive birth...

IntroductionHealth inequalities can be observed in early life as unfavourable birth outcomes. Evidence indicates that neighbourhood socioeconomic circumstances influence health. However, studies looking into temporal trends in inequalities in birth...

This study aimed to examine whether the relative importance of maternal age as a correlate of adverse birth outcomes has changed and to investigate if social inequalities in birth outcomes have widened during the past decade when the marriage and fertility related social environment has undergone tremendous change in Korea. Probabilities of adverse birth outcomes (prematurity and intrauterine growth retardation [IUGR]) were estimated with multinomial logistic regression models, utilizing the Korean birth registration data of 1995 and 2005. The main effects of maternal age and parental socioeconomic characteristics were compared between two study years, net of infant sex, birth order, and plurality. The association between maternal age and adverse birth outcomes, relative to the maternal and parental social characteristics, has clearly diminished between 1995 and 2005. During this period, differences in prematurity and IUGR by maternal age have also diminished, while those by parental social characteristics, particularly maternal education, have substantially widened. The intensified overall socioeconomic polarization since the economic crisis of the late 1990s is most likely responsible for the increased social inequality in adverse birth outcomes in Korea. A massive structural change in macro-economic conditions and culture during the study period may have modified the relationship between maternal age and birth outcomes.

ObjectiveTo examine socioeconomic inequalities in birth outcomes among infants born between 2008 and 2018 and assessed trends in inequalities during that period in Colombia, a middle-income country with high levels of inequality emerging from a long internal armed conflict.MethodsUsing birth certificate data in Colombia, we analysed the outcomes of low birth weight, an Apgar score <7 at 5 minutes after birth and the number of prenatal visits among full-term pregnancies. Maternal education and health insurance schemes were used as socioeconomic position (SEP) indicators. Inequalities were estimated using the prevalence/mean of the outcomes across categories of the SEP indicators and calculating the relative and slope indices of inequality (RII and SII, respectively).ResultsAmong the 5,433,265 full-term singleton births analysed, there was a slight improvement in the outcomes analysed over the study period (lower low-birth-weight and Apgar<7 prevalence rates and higher number of prenatal visits). We observed a general pattern of social gradients and significant relative (RII) and absolute (SII) inequalities for all outcomes across both SEP indicators. RII and SII estimates with their corresponding CIs revealed a general picture of no significant changes in inequalities over time, with some particular, time-dependent exceptions. When comparing the initial and final years of our study period, inequalities in low birth weight related to maternal education increased while those in Apgar score <7 decreased. Relative inequalities across health insurance schemes increased for the two birth outcomes but decreased for the number of prenatal visits.ConclusionThe lack of a consistent improvement in the magnitude of inequalities in birth outcomes over an 11-year period is a worrying issue because it could aggravate the cycle of inequality, given the influence of birth outcomes on health, social and economic outcomes throughout the life course. The findings of our analysis emphasize the importance of policies aimed at providing access to quality education and providing a health care system with universal coverage and high levels of integration.

Social inequality in adverse birth outcomes has been demonstrated in several countries. The present study examined the separate and joint effects of parental education and work in order to investigate the causal pathways of social class effects on adverse birth outcomes in Korea. The occurrence of low birth weight, preterm births, and intrauterine growth retardation was examined among 7,766,065 births in Korea from 1995 to 2008. The effect of social inequality, as represented by parental education and work, was examined against adverse birth outcomes using multivariate logistic regression after controlling for other covariates. Parental education had the most significant and greatest effect on all three adverse outcomes, followed by parental work and employment, which had lesser effects. For adverse birth outcomes, the gap between educational levels increased steadily in Korea from 1995 to 2008. Throughout the analysis, the effect of maternal manual work on adverse birth outcomes was apparent in the study results. Given this evidence of social inequality in education and employment, social interventions should aim at more in-depth and distal determinants of health.

With the current orientation towards patient-centered care, the health literacy level is an important predictor for the engagement in preventive health care services. Research has shown that adult immigrants have lower levels of health literacy compared to the host populations, however little is known about the health literacy of pregnant, immigrant women. The aim of this study was to analyze whether ethnic minority women found it more difficult to actively engage with their health professionals than ethnic Danish women did. Using cross-sectional data we studied the difference in the Health Literacy Questionnaire (HLQ) domain on actively engagement with health care providers between non-Western born and ethnic Danish women (n = 406). Pregnant women were recruited in 2016 from the largest maternity ward in Denmark. The mean health literacy level of actively engagement for ethnic Danish women was 4.15 and for non-Western born women, it was 3.97. In an adjusted model the non-Western born women had 1.15 (CI:-0.30; -0.01) lower levels of actively engagement compared to ethnic Danish women. These results indicate that this domain of the HLQ seems to be a useful link in understanding ethnic inequality in birth outcomes and thus relevant in the effect evaluation of the MAMAACT study. Currently, the health care system in Denmark has not focused on intercultural competence. The lower levels of self-reported ability to engage with health care providers and the known perspectives of lower patient safety in immigrant groups calls for more research in the interactional dynamics. A theoretical analysis using the concept of cultural health capital could be interesting for assessing how health care providers and non-Western women might value certain attitudes and behaviors exchanged during the encounter differently, which could lead to imbalance as the health care provider has more influence in this setting.

The Commission on Social Determinants of Health, sponsored by the World Health Organization, has identified measuring health inequities and evaluating interventions to reduce them as important priorities. We examined whether an unconditional prenatal income supplement for low-income women was associated with reduced population-level inequities in birth outcomes. We identified all mother-newborn pairs from the period 2003-10 in Manitoba, Canada, and divided them into the following three groups: low income exposed (received the supplement); low income unexposed (did not receive the supplement); and not low income unexposed (ineligible for the supplement). We measured inequities in low-birthweight births, preterm births, and breast-feeding initiation among these groups. The findings indicated that the socioeconomic gap in birth outcomes between low-income and other women was significantly smaller when the low-income women received the income supplement than when they did not. The prenatal income supplement may be an important driver in attaining population-level equity in birth outcomes; its success could inform strategies seeking to improve maternal and child health.

Low birth weight and preterm births vary by state, and Black mothers typically face twice the risk that their white counterparts do. This gap reflects an accumulation of psychosocial and material exposures that include interpersonal racism, differential experience with area-level deprivation such as residential segregation, and other harmful exposures that the authors refer to as "institutional" or "structural" racism. The authors use logistic regression models and a dataset that includes all births from 1994 to 2017 as well as five state policies from this period-Aid to Families with Dependent Children/Temporary Aid for Needy Families, housing assistance, Medicaid, minimum wage, and the earned income tax credit (EITC)-to examine whether these state social policies, designed to provide a financial safety net, are associated with risk reduction of low birth weight and preterm birth to Black and white mothers, and whether variations in state generosity attenuate the racial inequalities in birth outcomes. The authors also examine whether the relationship between state policies and racial inequalities in birth outcomes is moderated by the education level of the mother. We find that the EITC reduces the risk of low birth weight and preterm birth for Black mothers. The impact is much less consistent for white mothers. For both Black and white mothers, the benefits to birth outcomes are larger for mothers with less education.

Exploring Experiences of Structural Racism and its Influence on Maternal and Child Health

Inequities in birth outcomes are linked to experiential and environmental exposures. There have been expanding and intersecting wicked problems of inequity, racism, and quality gaps in childbearing care during the pandemic. We describe how an intentional transdisciplinary process led to development of a novel knowledge exchange vehicle that can improve health equity in perinatal services. We introduce the Quality Perinatal Services Hub, an open access digital platform to disseminate evidence based guidance, enhance health systems accountability, and provide a two-way flow of information between communities and health systems on rights-based perinatal services. The QPS-Hub responds to both community and decision-makers’ needs for information on respectful maternity care. The QPS-Hub is well poised to facilitate collaboration between policy makers, healthcare providers and patients, with particular focus on the needs of childbearing families in underserved and historically excluded communities.

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

BackgroundWeight-biased clinical practices and institutional characteristics can have a wide impact on the quality of care provided to women with obesity. This may substantially increase their risks for poor birth outcomes. The current study assessed experienced weight stigma by women during childbirth in maternity care settings in Switzerland. We aimed to identify frequencies, sources, and manifestations of weight-related stigmatization, hypothesizing that such stigma impacts birth outcomes, specifically cesarean birth (CB).MethodsData from a nationwide cross-sectional online survey was used to investigate the frequencies, sources, and manifestations of experienced weight stigma during childbirth. Binomial logistic regression was applied to predict CB from experienced weight stigma. Mediation analysis assessed the role of experienced weight stigma in the association between body mass index (BMI) and CB.ResultsIn a total of 1352 women who gave birth in the last five years, women with obesity (BMI ≥ 30 kg/m2) experienced weight stigma more often than their peers with healthy weight (BMI 18.5–24.9 kg/m2). Obstetricians were identified as a major source of weight stigma, accounting for 77.8% of stigmatization experienced by women, compared to stigmatization perceived from nurses (21.7%) and midwives (23.8%). Overall, weight stigma was mostly experienced in the form of dismissive or critical comments towards a woman’s figure or weight. Significantly more women with obesity indicated being blamed for weight-related risks during childbirth than their healthy-weighted peers (χ²(2) = 22.2, P < 0.001). An increase in the frequency of experienced weight stigma was related to higher odds of intrapartum CB ([aOR], 1.08; 95% CI, 1.02,1.15; P < 0.05), and it partially mediated the relationship between increased pre-pregnancy BMI and CB (b = 0.07, SE = 0.029; P < 0.05).ConclusionWomen with obesity reported the highest proportion of weight stigmatization during childbirth, experiencing stigma more frequently than women without obesity. This increased frequency of weight stigma was associated with higher odds of CB. Raising awareness among healthcare providers and reducing potential biases and stigmatization may improve care quality and health outcomes for women with obesity.

Inequality at birth: The scope for policy intervention

Biomarkers of pre-pregnancy allostatic load and subsequent adverse birth outcomes