Racial and ethnic disparities in access to community-based perinatal mental health programs: results from a cross-sectional survey.

BACKGROUND: Perinatal mental health is a major public health problem that disproportionately affects people from racial and ethnic minority groups. Community-based perinatal mental health programs, such as peer support groups, are essential tools for the prevention and treatment of perinatal depression. Yet, little is known about racial and ethnic disparities in accessibility and utilization of community-based perinatal mental health programs. METHODS: We conducted a cross-sectional study using an online survey with program administrators representing perinatal mental health community-based services and support programs throughout New Jersey. Descriptive analysis and mapping software was used to analyze the data. RESULTS: Thirty-three program administrators completed the survey. Results showed substantial racial and ethnic disparities in availability and utilization of community-based programs. In the majority of programs, Black, Hispanic, and Asian individuals made up less than 10% of total annual participants and less than 10% of facilitators. There were also geographic disparities in program accessibility and language availability across counties. Program administrators identified mental health stigma, lack of support from family, fear of disclosure of mental health challenges, social determinants, lack of language-concordant options in programs, and limited awareness of programs in the community as significant barriers to participation of racial and ethnic minorities. Strategies to address barriers included adding language options, improving program outreach, and increasing diversity of facilitators. CONCLUSIONS: This study provides new evidence on racial and ethnic disparities in access to community-based perinatal mental health programs. Efforts to build the resources and capacities of community-based programs to identify equity gaps, increase diversity of staff, and address barriers to participation is critical to reducing racial and ethnic inequities in perinatal mental health.

A Qualitative Investigation of the Experiences of Women with Perinatal Depression and Anxiety during the COVID-19 Pandemic.

OBJECTIVES: The COVID-19 pandemic has had significant impacts on maternal mental health. We explored the lived experiences of women with perinatal depression and anxiety to elucidate their perceptions of how the pandemic influenced their mental health and access to care. METHODS: We conducted a qualitative descriptive study using semi-structured interviews. From March to October 2021, purposive sampling was used to recruit a socio-demographically diverse sample of women with self-reported perinatal depression or anxiety who were pregnant or within one year postpartum between March 2020 and October 2021. Interviews were conducted remotely and thematically analyzed. RESULTS: Fourteen women were interviewed. Three major themes arose. Theme 1, Negative impacts of COVID-19 on symptoms of depression and anxiety, described how the pandemic magnified underlying symptoms of depression and anxiety, increased social isolation, generated anxiety due to fears of COVID-19 infection, and caused economic stress. In theme 2, Negative impacts of COVID-19 on access to and quality of health care, women described stressful and isolating delivery experiences, negative psychological impact of partners not being able to participate in their perinatal health care, interruptions and barriers to mental health treatment, and challenges in using telehealth services for mental health care. Theme 3, Positive impacts of COVID-19 on mental health, identified advantages of increased telehealth access and ability to work and study from home. CONCLUSIONS FOR PRACTICE: The COVID-19 pandemic negatively affected women with perinatal depression and anxiety by magnifying underlying symptoms, increasing stress and social isolation, and disrupting access to mental health care. Findings provide support for policies and interventions to prevent and address social isolation, as well as optimization of telehealth services to prevent and address gaps in perinatal mental health treatment.

An Initiative to Improve Postpartum Discharge Education.

OBJECTIVE: To evaluate an online POST-BIRTH Warning Signs (PBWS) project focused on improving nurses' knowledge and how they teach individuals in the postpartum period about potential complications. DESIGN: Quality improvement project with exploratory pretest/posttest. SETTING: Seventy hospitals with maternity services throughout the United States. PARTICIPANTS: A sample of 2,363 registered nurses. INTERVENTION/MEASUREMENTS: An online educational program with four surveys and a chart audit tool were used as evaluation measures. RESULTS: There was an 11% increase in nurses' knowledge after the online course intervention. A majority of nurses reported that they would improve how they educate patients and families about PBWS, that they would change their clinical practice based on what they learned, and that their facility implemented a protocol to educate patients about PBWS after the implementation of the course. The nurses' reported confidence in their teaching increased 59% after implementation of the course. CONCLUSION: The majority of maternal deaths in the United States occur during the postpartum period. Therefore, it is vital that nurses provide standardized and structured educational messaging when teaching individuals in the postpartum period about signs and symptoms of potential complications. This quality improvement project demonstrated that the PBWS online education course was associated with an increase in nurses' knowledge and confidence when teaching about potential complications that can arise during the postpartum period.

The Lived Experiences of New Nurses During the COVID-19 Pandemic and Their Contributions to Nursing Education and Professional Development.

Background The COVID-19 pandemic had a major impact on new nurses' transition to the staff nurse role in hospital settings. New staff nurses were not prepared to care for COVID-19 patients based on their previous nursing education. Method A qualitative descriptive design with purposive sampling was used for this study. Twenty-nine new nurses were recruited. They were interviewed using a semi-structured guide to elicit data that were coded and analyzed using content analysis. Results Five themes were identified: "You might have to risk your own life to save others," "I wish I had developed a thicker skin," "There is real world and there is nursing school," "Learning how to handle your own mental health," and "What I would tell them." Conclusion New nurses described their preparedness from baccalaureate education to clinical practice as insufficient in certain areas that were needed in the care of COVID-19 patients. Nurse educators who teach in pre-licensure and hospital orientation programs can revise or expand on the themes voiced by new nurses in order to improve their transition to the staff nurse role. [J Contin Educ Nurs. 2022;53(10):451-459.].

Challenges faced by new nurses during the COVID-19 pandemic.

INTRODUCTION: COVID-19 can be considered a unique and complex form of trauma with potentially devastating consequences for nurses in general and new nurses specifically. Few studies have been published that explain how relatively new nurses were prepared for COVID-19 in terms of knowledge and skill and how these nurses fared physically and emotionally. DESIGN: A qualitative descriptive design utilizing purposive sampling to recruit a diverse group of nurses who were within 2 years post-graduation from nursing school. METHODS: In-depth interviews of 29 nurses were conducted using a semi-structured interview guide to elicit data, which was coded and analyzed using thematic analysis. RESULTS: Six main themes and multiple subthemes were identified in the data. The main themes were: "We were not prepared," "I was just thrown in," "Avoiding infection," "It was so sad," "We did the best we could," and "I learned so much." CONCLUSION: The nurses who participated in this study expressed fear, weariness, exhaustion, isolation, and distress, observations echoed by studies from other countries. Retention of new nurses in acute care settings has always been a concern. In the recent Current Population Survey, a 4% reduction in nurses under 35 years of age has been reported, imperiling the retention of an effective workforce for decades to come. CLINICAL RELEVANCE: A recent report suggests that a larger than expected number of young nurses have left the profession in the wake of the pandemic. Staff shortages threaten the ability of the remaining nurses to do their jobs. This is the time to listen to the needs of new nurses to retain them in the profession and to avoid an even greater shortage in the near future.

Consensus Bundle on Postpartum Care Basics: From Birth to the Comprehensive Postpartum Visit.

In the weeks after childbirth, a woman navigates multiple challenges. She must recover from birth, learn to care for herself and her newborn, and cope with fatigue and postpartum mood changes as well as chronic health conditions. Alongside these common morbidities, the number of maternal deaths in the United States continues to increase, and unacceptable racial inequities persist. One third of pregnancy-related deaths occur between 1 week and 1 year after delivery, with a growing proportion of these deaths due to cardiovascular disease; one fifth occur between 7 and 42 days postpartum. In addition, pregnancy-associated deaths due to self-harm or substance misuse are increasing at an alarming rate. Rising maternal mortality and morbidity rates, coupled with significant disparities in outcomes, highlight the need for tailored interventions to improve safety and well-being of families during the fourth trimester of pregnancy, which includes the period from birth to the comprehensive postpartum visit. Targeted support for growing families during this transition can improve health and well-being across generations.

The Impact of Delays in Low-Income Women's Breast Cancer Experiences.

BACKGROUND: Low-income, underinsured and uninsured women are less likely to be diagnosed via mammogram and more often diagnosed at later stages, with a resultant negative impact on survival. The New Jersey Cancer Education and Early Detection Program provides access to cancer screening services for low-income, underinsured and uninsured individuals. This program was recently evaluated, and it was found that enrollees were more likely to be diagnosed at later stages than nonenrollees, which may be related to delays in diagnosis and treatment OBJECTIVE: The aim of this study was to determine if there were delays in diagnosis and treatment for program enrollees and, if so, what were the causes of these delays. METHODS: A qualitative methodology was used incorporating in-depth interviews with 20 women diagnosed with breast cancer through the New Jersey Cancer Education and Early Detection Program. Qualitative content analysis was used for data analysis. RESULTS: Three themes emerged: poor access to healthcare, lack of knowledge, and sense of spirituality. Nineteen of 20 women experienced delays in care; 9 were diagnosed with late stage (III or IV) disease. CONCLUSIONS: While the lack of insurance was a factor, fear, family needs, and a tendency to not prioritize their own health were additional reasons for delays in diagnosis and treatment. IMPLICATIONS FOR PRACTICE: Programs such as this are integral to the care of low-income, uninsured individuals. However, such programs are not sufficient to meet the needs of low-income women. The lack of a usual source of care is likely to be a factor in the delays these women experienced.

A 10-Year Evaluation of New Jersey's National Breast and Cervical Cancer Early Detection Program: Comparison of Stage at Diagnosis in Enrollees and Nonenrollees.

Purpose: The New Jersey Cancer Education and Early Detection (NJCEED) program provides breast cancer screening to low income, uninsured, and underinsured women. The purpose of this study was to evaluate the effectiveness of the NJCEED program by considering stage at diagnosis for women enrolled in NJCEED compared to women diagnosed in the state of New Jersey who were not enrollees. Materials and Methods: The sample included 47,162 women diagnosed with breast cancer; of those, 1,364 women were NJCEED enrollees. Enrollees were significantly different from nonenrollees in age, race, ethnicity, education, and poverty level. Results: In the logistic regression, NJCEED enrollees had 88.3% higher odds of being diagnosed at a late stage compared with nonenrollees (odds ratio [OR]: 1.883, confidential interval [CI]: 1.678-2.109). African American women had 54.9% higher odds of being diagnosed at a later stage (OR: 1.549, CI: 1.457-1.646). The likelihood of a late stage diagnosis increased as poverty level increased. Conclusion: These results were consistent with other National Breast and Cervical Cancer Early Detection Program state evaluations, and with evaluations of the national program. Providing a free screening service is not in itself adequate to encourage screening in low-income uninsured women.

Rising Rates of Contralateral Prophylactic Mastectomy as a Treatment for Early-Stage Breast Cancer.

BACKGROUND: The rate of contralateral prophylactic mastectomy (CPM) in women with unilateral mastectomy is increasing with no plateau. OBJECTIVES: The aim of this study was to improve the understanding of patient- and tumor-related factors that influenced the choice of mastectomy with CPM as treatment for early-stage breast cancer at an academic medical center in New Jersey. METHODS: This was a retrospective analysis of 10 years of breast cancer data including 1556 women aged 40 to 80 years treated for breast cancer at an academic medical center. Logistic regression models identified possible associations between type of surgery and various patient- and tumor-related characteristics. RESULTS: Women most likely to be treated with CPM were younger (P < .0001), white (P = .003), and privately insured (P < .0001). Factors that increased the odds of receiving CPM included year of surgery (odds ratio, 1.441; confidence interval, 1.328-1.564) and residing in a relatively wealthy community (odds ratio, 11.159; confidence interval, 3.467-35.917). CONCLUSIONS: The rate of CPM as a treatment for unilateral breast cancer continues to rise, and this treatment decision seems to be relatively independent of tumor-related factors and clinical evidence of efficacy. More research is needed to ascertain why women are choosing this surgical option. IMPLICATIONS FOR PRACTICE: The large majority who are choosing CPM are doing so regardless of the lack of clinical efficacy, yet there are few articles in the nursing literature preparing nurses to understand and counsel these women who may be asking for advice. Nurses are well situated to provide unbiased and fact-based information to help women making potentially life-altering decisions in response to a cancer diagnosis.

A Systematic Review of Barriers and Facilitators to Mammography in American Indian/Alaska Native Women.

INTRODUCTION: The purpose of this systematic review was to synthesize the current knowledge of factors that enable or impede American Indian and Alaska Native (AI/AN) women from accessing breast cancer screening. METHODOLOGY: A systematic search of MEDLINE and CINAHL databases identified relevant research studies published from 2007 to 2017. RESULTS: Consistent with other low-income populations, socioeconomic factors were related to lower rates of screening in AI/AN women. However, some factors, such as reliance on the Indian Health Service, cultural issues, and traditionality were unique to this population. DISCUSSION: AI/AN women appear to face many of the difficulties that other low-income minority women face in accessing preventive care; however, they may face unique challenges and circumstances in accessing care. Efforts to work with tribes in the development of interventions framed by community-based participatory research are needed to tackle the disparities in the AI/AN community.

Healthcare Strategies for Reducing Pregnancy-Related Morbidity and Mortality in the Postpartum Period.

The majority of pregnancy-related deaths in the United States occur in the postpartum period, after a woman gives birth. Many of these deaths are preventable. Researchers and health care providers have been focusing on designing and implementing strategies to eliminate preventable deaths and ethnic and racial disparities. Six healthcare strategies for reducing postpartum maternal morbidity and mortality will be described. These strategies, if provided in an equitable manner by all providers to all women, will assist in closing the disparity in outcomes between black women and women of all other races and ethnicities who give birth throughout the United States.

Using Geographic Information Systems to Visualize Relationships Between Perinatal Outcomes and Neighborhood Characteristics When Planning Community Interventions.

OBJECTIVE: To describe maternal morbidity, birth outcomes, and neighborhood characteristics of urban women from a racially segregated city with the use of a geographic information system (GIS). DESIGN: Exploratory neighborhood-level study. Existing birth certificate data were linked and aggregated to neighborhood-level data for spatial analyses. SETTING: Southern city in New Jersey. SAMPLE: Women and their 7,858 live births that occurred between 2009 and 2013. METHODS: Secondary analyses of extant sources were conducted. Maternal health and newborn birth outcomes were geocoded and then aggregated to the neighborhood level for further exploratory spatial analyses through our GIS database. An iterative process was used to generate meaningful visual representations of the data through maps of maternal and infant health in 19 neighborhoods. RESULTS: The racial and ethnic residential segregation and neighborhood patterns of associations of adverse birth outcomes with poverty and crime were illustrated in GIS maps. In 43% of the births, women had a documented medical risk. Significantly more preterm births occurred for Black women (p < .01) and women older than 35 years of age (p = .01). The rate of diabetes was greater in Hispanic women, and the rate of pregnancy-related hypertensive disorders was greater in Black women. CONCLUSION: Data-driven maps can provide clear evidence of maternal and infant health and health needs based on the neighborhoods where mothers live. This research is important so that maternity care providers can understand contextual factors that affect mothers in their communities and guide the design of interventions.

Breast Cancer Stage at Diagnosis in a New Jersey Cancer Education and Early Detection Site.

OBJECTIVES: The National Breast and Cervical Cancer Early Detection Program provides free or low-cost screening to uninsured or underinsured women and has had positive results; however, only a few state programs have been evaluated. This study will provide a first snapshot of the effectiveness of the New Jersey program, by comparing stage at diagnosis for enrollees as compared with nonenrollees who received definitive treatment for breast cancer at the same academic medical center. MATERIALS AND METHODS: A retrospective analysis of 5 years of breast cancer data abstracted from the Cancer Registry of a large urban hospital in the Northeast United States. Bivariate analysis and logistic regression were utilized. RESULTS: One thousand forty women were screened for and diagnosed with breast cancer at this site; they were more likely to be racially (P<0.001) and ethnically (P<0.002) diverse as compared with nonenrollees. Enrollees were more likely to be symptomatic at diagnosis (P<0.001), and diagnosed at a late stage when compared with nonenrollees (odds ratio, 1.88; 95% confidence interval, 1.07-3.29). CONCLUSIONS: This national program was developed to serve low income, under and uninsured women who may otherwise have limited access to cancer screening services. It appears that many women enroll in this program needing diagnostic rather than screening services, after breast symptoms were noted. This finding helps to emphasize the fact that just providing free screening services is not enough to make up for the lack of a usual source of preventive care for low income and uninsured women.

Nurses' Knowledge and Teaching of Possible Postpartum Complications.

PURPOSE: The purpose of this study was to assess postpartum nurses' knowledge of maternal morbidity and mortality, and information they shared with women before discharge about identifying potential warning signs of postpartum complications. STUDY DESIGN & METHODS: Registered nurses (RNs) who care for women during postpartum (N = 372) completed an electronic survey. Descriptive statistics and bivariate analyses were used for data analysis. RESULTS: Fifty-four percent of nurse participants were aware of the rising rates of maternal mortality in the United States and 12% accurately reported the correct percentage of deaths that occurred during the postpartum period. Ninety-three percent of nurses were more likely to identify hemorrhage as a leading cause of maternal mortality. On the day of discharge, 67% of RNs spent less than 10 minutes focusing on potential warning signs. Ninety-five percent of RNs reported a correlation between postpartum education and mortality; however, only 72% strongly agreed it was their responsibility to provide this education. Nurse respondents who were over the age of 40 were significantly more likely to report feeling very competent when providing education on all of the postpartum complication variables measured (p values <0.001-0.003). CLINICAL IMPLICATIONS: The majority of nurses in this study were not up-to-date on the rates and timing of maternal mortality during the postpartum period in the United States. They did not always provide comprehensive education to all women prior to discharge from the hospital after childbirth. There is a need for nurses to provide consistent messages about potential warning signs that may ultimately reduce maternal death and severity of maternal complications.

Improving Postpartum Education About Warning Signs Of Maternal Morbidity and Mortality.

Maternal morbidity and mortality rates remain high in the United States compared with other developed countries. Of particular concern is the rise in postpartum deaths, because many of the risk factors for complications associated with maternal morbidity and mortality may not be clearly identified before a woman's discharge after birth. Although nurses provide some form of postpartum discharge education to all women who give birth, the information women receive on common potential complications is not always consistent or evidence based. By improving postpartum education, nurses may be better poised to teach women how to recognize and respond to warning signs. This article describes a project intended to increase women's access to predischarge education about the risks for postbirth complications.

Discharge Education on Maternal Morbidity and Mortality Provided by Nurses to Women in the Postpartum Period.

OBJECTIVE: To explore what types of educational materials and discharge information are currently used by postpartum nurses to educate women about the warning signs of postpartum complications to determine what key messages should be presented to women after birth and before discharge. DESIGN: Exploratory qualitative. SETTING: Six hospitals located in New Jersey and Georgia. PARTICIPANTS: Fifty-two nurses. METHODS: Six focus group discussions were conducted using a semistructured interview guide to elicit data on how and what nurses taught women about maternal post-birth warning signs. The focus group discussions were audiotaped, transcribed, coded, and clustered into categories. RESULTS: Most nurses described some of the warning signs related to maternal morbidity and mortality to the women; however, these elements were not the primary focus of the education throughout the hospital stay and were most often discussed on the day of discharge. Nurses also did not consistently describe the same signs and symptoms of the warning signs with each and every woman. The primary mechanism for education consisted of individualized instruction with booklets or folders of information. CONCLUSION: These data indicate that improvements may be needed in how nurses educate women who just gave birth about the most common post-birth warning signs before they are discharged from the hospital. These findings also suggest that nurses need more information and guidance on how to teach all women about the post-birth warning signs.

National Initiatives to Improve Systems for Postpartum Care.

Purpose To showcase several current national initiatives that focus on reducing maternal mortality and severe maternal morbidity and promote postpartum health and wellness for all women. Description Maternal injuries and deaths are a serious public health concern with tremendous impact on families, communities, and healthcare providers. Over the past two decades, it has become apparent that the timing of serious maternal complications has shifted, with more than half of deaths occurring in the immediate postpartum period up to 1 year following birth. Many of these reported deaths could have been prevented, and the number of "near misses" of maternal morbidity cases continues to grow exponentially. In addition, postpartum women experience substantial unmet health needs, compromising their wellbeing. Assessment The American College of Obstetricians and Gynecologists and the Association of Women's Health, Obstetric, and Neonatal Nurses have thoroughly assessed the significance of the rising trends in maternal morbidity/mortality and are leading efforts to reduce these rates and improve overall health and wellbeing for all women during the postpartum period. Conclusion Developing national initiatives to improve postpartum health are vital to increasing the effectiveness of postpartum discharge education, and improving the participation in and the quality of postpartum care. Hopefully, evidence-based practice and widespread dissemination of these efforts will lead to a reduction in preventable post-birth maternal morbidity and mortality.

Women's Educational Needs and Perceptions About Survivorship Following Bilateral Mastectomy.

BACKGROUND: More women are choosing to have a bilateral mastectomy to treat unilateral breast cancer despite it not being considered the standard of care. Women are making this choice for various reasons, including anxiety of follow-up screening of the other breast, risk of cancer recurrence for the rest of their lives, and desire to maintain control over the localized cancer. Currently, evidence-based information is lacking regarding this treatment choice. In addition, the concept of survivorship has yet to be examined in this population of women. OBJECTIVES: This study aimed to explore women's educational needs and perceptions about survivorship following bilateral mastectomy as a treatment for unilateral breast cancer. METHODS: In-depth interviews were conducted with 23 women using a semistructured interview guide. Data were elicited, coded, and analyzed using thematic analysis. FINDINGS: Two themes were identified that addressed education and survivorship.

Exploratory Study of Childbearing Experiences of Women With Asperger Syndrome.

Increasing numbers of girls have been diagnosed with Asperger syndrome and other autism spectrum disorders (ASDs) over the past two decades; therefore, more women with ASDs are entering the childbearing phase of their lives. Little is known about the childbearing experiences of women with ASDs. This qualitative study describes the childbearing experiences of eight women with Asperger syndrome. Four major themes emerged: Processing Sensations, Needing to Have Control, Walking in the Dark, and Motherhood on My Own Terms. Clinicians can provide sensitive, individualized care by asking women with Asperger syndrome about their specific sensory experiences, counseling them about coping strategies for sensory intrusions, providing targeted support, and modifying the clinical environment to decrease distressing stimuli.

Survey of Nursing Faculty Preparation for Teaching About Autism Spectrum Disorders.

The prevalence of autism spectrum disorders (ASDs) has increased significantly in children and adults. Nursing faculty's ability to teach students about best practices in their care across the lifespan is important. This study explored nurse educators' perceived knowledge of, and levels of comfort in, their abilities to teach nursing students about nursing care of people with ASD. Strategies are proposed to incorporate competencies for care of people with ASD into nursing curricula.