Leveraging a Longitudinally Linked Dataset to Assess Recurrence of Severe Maternal Morbidity.

OBJECTIVES: Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization. METHODS: We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period. Our outcome measure was recurrence of SMM in the second birth. We calculated the prevalence of SMM at second birth, compared SMM conditions between births, and estimated the adjusted risk ratios and 95% confidence intervals for having an SMM event at second birth among those who had an SMM at the first birth. We also examined overall hospital utilization including inpatient admissions, emergency room visits, and observational stays, and hospital utilization by interpregnancy intervals (IPIs) between the first and second birth. RESULTS: There were 2,814 birthing people with at least one birth after the first SMM singleton birth. Among those, 198 (7.0%) had a subsequent SMM. The percentage of people with a second SMM event varied by age, race/ethnicity, insurance, IPI, and history of hypertension at first case of SMM (all p < .05). Between births, people with a second SMM event had significantly higher proportions of inpatient admissions (60.1% vs. 33.2.0%; p < .001), emergency room visits (71.7% vs. 57.7%; p < .001), and observational stays (35.4% vs. 19.5%; p < .001) compared with those who did not experience a second SMM event. CONCLUSION: Hospital utilization after a birth with SMM might indicate an elevated risk of a second SMM event. Providers should counsel their patients about prevention and warning signs.

Systemic racism and Non-Hispanic Black to Non-Hispanic White disparities in infant mortality at the county level.

OBJECTIVE: To use a novel measure of systemic racism to examine its relationship with Non-Hispanic Black (NHB) to Non-Hispanic White (NHW) racial disparities in infant mortality across U.S. counties. STUDY DESIGN: In this cross-sectional study, a composite, multi-dimensional measure of systemic racism at the county level was developed using confirmatory factor analysis based on indicators across five dimensions of systemic racism. Using linear regression analysis, we examined the relationship between the systemic racism factor scores and the NHB to NHW racial disparities in county-level infant mortality rates. Additionally, we performed a multi-level analysis of infant mortality, with births nested within counties by running a random intercept model that controlled for factors at both the individual and county levels to take into account the clustered nature of the data. RESULTS: There were 325 counties that met inclusion criteria for the county level analysis and 1181 counties for the individual level analysis. Each one standard deviation increase in the Systemic Racism Index was associated with an increase of 10.4% in the Non-Hispanic Black to Non-Hispanic White infant mortality rate ratio at the county level (aOR 1.104, 95% CI [1.061-1.148]). After controlling for individual level clinical factors and county level factors, each one standard deviation increase in the systemic racism index score was associated with a decrease of 3.5% in the NHW infant mortality rate (aOR 0.965, 95% CI [0.943-0.988]). CONCLUSION: Systemic racism is significantly associated with differences between counties in the magnitude of their Non-Hispanic Black to Non-Hispanic White racial disparities in infant mortality rates.

Birth outcomes in relation to neighborhood food access and individual food insecurity during pregnancy in the Environmental Influences on Child Health Outcomes (ECHO)-wide cohort study.

BACKGROUND: Limited access to healthy foods, resulting from residence in neighborhoods with low-food access or from household food insecurity, is a public health concern. Contributions of these measures during pregnancy to birth outcomes remain understudied. OBJECTIVES: We examined associations between neighborhood food access and individual food insecurity during pregnancy with birth outcomes. METHODS: We used data from 53 cohorts participating in the nationwide Environmental Influences on Child Health Outcomes-Wide Cohort Study. Participant inclusion required a geocoded residential address or response to a food insecurity question during pregnancy and information on birth outcomes. Exposures include low-income-low-food-access (LILA, where the nearest supermarket is >0.5 miles for urban or >10 miles for rural areas) or low-income-low-vehicle-access (LILV, where few households have a vehicle and >0.5 miles from the nearest supermarket) neighborhoods and individual food insecurity. Mixed-effects models estimated associations with birth outcomes, adjusting for socioeconomic and pregnancy characteristics. RESULTS: Among 22,206 pregnant participants (mean age 30.4 y) with neighborhood food access data, 24.1% resided in LILA neighborhoods and 13.6% in LILV neighborhoods. Of 1630 pregnant participants with individual-level food insecurity data (mean age 29.7 y), 8.0% experienced food insecurity. Residence in LILA (compared with non-LILA) neighborhoods was associated with lower birth weight [ß -44.3 g; 95% confidence interval (CI): -62.9, -25.6], lower birth weight-for-gestational-age z-score (-0.09 SD units; -0.12, -0.05), higher odds of small-for-gestational-age [odds ratio (OR) 1.15; 95% CI: 1.00, 1.33], and lower odds of large-for-gestational-age (0.85; 95% CI: 0.77, 0.94). Similar findings were observed for residence in LILV neighborhoods. No associations of individual food insecurity with birth outcomes were observed. CONCLUSIONS: Residence in LILA or LILV neighborhoods during pregnancy is associated with adverse birth outcomes. These findings highlight the need for future studies examining whether investing in neighborhood resources to improve food access during pregnancy would promote equitable birth outcomes.

Corrigendum: The impact of hostile abortion legislation on the United States maternal mortality crisis: a call for increased abortion education.

[This corrects the article DOI: 10.3389/fpubh.2023.1291668.].

A Qualitative Study of Hospitals and Payers Implementing Community Doula Support.

INTRODUCTION: The impact of doula care on birth outcomes is well-established; however, doula support remains underutilized. Identifying barriers and facilitators to implementation is integral as the demand for doula care increases. The primary objective of this study was to examine doula program implementation across hospitals and payers at varying stages of implementation. METHODS: Representatives from 4 hospitals and 2 payers participated in focus group discussions. The doula programs were categorized as anticipated, initial, and advanced implementation statuses. Coding and thematic analysis were conducted using a deductive application of the Consolidated Framework for Implementation Research. RESULTS: There were 20 participants across 5 focus group discussions. Participants were mostly female, and nearly all had worked at their organization for at least 2 years. Salient themes shared across participants included valuing internal outcome data or peer-reviewed literature to support doula care as well as anecdotal stories; the reality of the resource-intensive nature of doula care implementation that goes beyond funding for doulas; and both the need for individual champions for change, such as midwives, and a supportive organizational culture that values health equity. DISCUSSION: The findings of this study highlight 3 contextual aspects that should be considered when implementing doula programs. These recommendations include: (1) use of a combination of research evidence and anecdotes when eliciting stakeholder support; (2) consideration of resources beyond funding such as program implementation support; (3) critical evaluation of organizational culture as a primary driver influencing the implementation of doula care. The future of the doula workforce in United States hospitals rests on the crux of intentional buy-in from hospital administration and clinical providers as well as the availability of requisite resources.

The impact of hostile abortion legislation on the United States maternal mortality crisis: a call for increased abortion education.

The growing restrictive abortion policies nationwide and the Supreme Court decision on Dobbs v. Jackson Women's Health Organization place increasing barriers to abortion access in the United States. These restrictions disproportionately affect low-income people of color, immigrants, and non-English speakers, and have the potential to exacerbate already existing racial inequities in maternal and neonatal outcomes. The United States is facing a Black maternal health crisis where Black birthing people are more than twice as likely to experience maternal mortality and severe maternal morbidity compared to White birthing people. Restrictions creating geographic, transportation, and financial barriers to obtaining an abortion can result in increased rates of maternal death and adverse outcomes across all groups but especially among Black birthing people. Restrictive abortion laws in certain states will decrease already limited training opportunities in abortion care for medical professionals, despite the existing abortion provider shortage. There is an immediate need for federal legislation codifying broad abortion care access into law and expanding access to abortion training across medical education. This commentary explores the impact of restrictive abortion laws on the Black maternal health crisis through multiple pathways in a logic model. By identifying current barriers to abortion education in medical school and residency, we created a list of action items to expand abortion education and access.

Prior Hospitalization, Severe Maternal Morbidity, and Pregnancy-Associated Deaths in Massachusetts From 2002 to 2019.

OBJECTIVE: To examine demographic and clinical precursors to pregnancy-associated deaths overall and when pregnancy-related deaths are excluded. METHODS: We conducted a retrospective cohort study based on a Massachusetts population-based data system linking data from live birth and fetal death certificates to corresponding delivery hospital discharge records and a birthing individual's nonbirth hospital contacts and associated death records. Exposures included maternal demographics, severe maternal morbidity (without transfusion), hospitalizations in the 3 years before pregnancy, comorbidities during pregnancy, and opioid use. In cases of postpartum deaths, hospitalization between delivery and death was examined. The primary outcome measure was pregnancy-associated death , defined as death during pregnancy or up to 1 year postpartum. RESULTS: There were 1,291,626 deliveries between 2002 and 2019, of which 384 were linked to pregnancy-associated deaths. Pregnancy-associated but not pregnancy-related deaths (per 100,000 deliveries) were highest for birthing people with opioid use before pregnancy (498.3), severe maternal morbidity (387.3), a comorbidity (106.3), or a prior hospitalization (88.9). In multivariable analysis, the adjusted risk ratios associated with severe maternal morbidity (9.37, 95% CI, 6.14-14.31) and opioid use (6.49, 95%, CI, 3.71-11.35) were highest. Individuals with pregnancy-associated deaths were also more likely to have been hospitalized before or during pregnancy (2.30, 95% CI, 1.62-3.26). Among postpartum deaths, more than two-thirds (69.9%) of birthing people had a hospital contact after delivery and before their death. CONCLUSION: Severe maternal morbidity and opioid use disorder were precursors to pregnancy-associated deaths. Individuals with pregnancy-associated but not pregnancy-related deaths experienced a history of hospital contacts during and after pregnancy before death.

Investigating the Role of Race and Stressful Life Events on the Smoking Patterns of Pregnant and Postpartum Women in the United States: A Multistate Pregnancy Risk Assessment Monitoring System Phase 8 (2016-2018) Analysis.

OBJECTIVE: To examine the smoking patterns of women who experienced stressful life events and the impact of racial disparities on the relationship between stressful life events, and prenatal/ postpartum smoking. METHODS: The study analyzed data from the Pregnancy Risk Assessment Monitoring System Phase 8 (2016-2018) survey across five states (CT, LA, MA, MO, WI). Four stressful life event categories were created using thirteen affiliated questions: financial, trauma, partner, and emotional. We assessed: 1) the association between smoking and stressful life events, 2) the impact of race on the relation between smoking and stressful life events, and 3) the long-term effects of smoking on health by assessing the association between smoking and maternal morbidity. Bivariate statistics and multivariate Poisson regression models were conducted. RESULTS: A total of 24,209 women from five states were included. 8.9% of respondents reported smoking during pregnancy, and 12.7% reported smoking postpartum. There was a significant association between all stressful life events and smoking. Trauma stressful life event had the strongest association with smoking during pregnancy (adjusted PR=2.01; CI: 1.79-2.27) and postpartum (adjusted PR= 1.80; CI: 1.64-1.98). Race and stressful life event interaction effects on smoking had varied significant findings, but at least one racial/ ethnic minority group (Black, Hispanic, Asian) had a higher smoking prevalence than non-Hispanic White per stressful life event category. Lastly, the prevalence of maternal morbidity was higher for smoking during pregnancy (adjusted PR= 1.28; CI: 1.19-1.38) and postpartum (adjusted PR= 1.30; CI: 1.22-1.38) compared to no smoking. CONCLUSIONS FOR PRACTICE: Culturally congruent, multi-disciplinary care teams are needed to address both clinical and social needs to reduce stressful life events and smoking. Screenings for stress should be standardized with a referral system in place to provide ongoing support.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts.

OBJECTIVE: The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative. METHODS: Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle. RESULTS: Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle. CONCLUSION: Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Approaches and geographical locations of respectful maternity care research: A scoping review.

BACKGROUND: Peripartum mistreatment of women contributes to maternal mortality across the globe and disproportionately affects vulnerable populations. While traditionally recognized in low/low-middle-income countries, the extent of research on respectful maternity care and the types of mistreatment occurring in high-income countries is not well understood. We conducted a scoping review to 1) map existing respectful maternity care research by location, country income level, and approach, 2) determine if high-income countries have been studied equally when compared to low/low-middle-income countries, and 3) analyze the types of disrespectful care found in high-income countries. METHODS: A systematic search for published literature up to April 2021 using PubMed/MEDLINE, EMBASE, CINAHL Complete, and the Maternity & Infant Care Database was performed. Studies were included if they were full-length journal articles, published in any language, reporting original data on disrespectful maternal care received from healthcare providers during childbirth. Study location, country income level, types of mistreatment reported, and treatment interventions were extracted. This study was registered on PROSPERO, number CRD42021255337. RESULTS: A total of 346 included studies were categorized by research approach, including direct labor observation, surveys, interviews, and focus groups. Interviews and surveys were the most common research approaches utilized (47% and 29% of all articles, respectively). Only 61 (17.6%) of these studies were conducted in high-income countries. The most common forms of mistreatment reported in high-income countries were lack of informed consent, emotional mistreatment, and stigma/discrimination. CONCLUSIONS: Mapping existing research on respectful maternity care by location and country income level reveals limited research in high-income countries and identifies a need for a more global approach. Furthermore, studies of respectful maternity care in high-income countries identify the occurrence of all forms of mistreatment, clashing with biases that suggest respectful maternity care is only an issue in low-income countries and calling for additional research to identify interventions that embrace an equitable, patient-centric empowerment model of maternity care.

Investigating Maternal Stress, Depression, and Breastfeeding: A Pregnancy Risk Assessment Monitoring System (2016-2019) Analysis.

Breastfeeding is invaluable for postpartum physical healing and mental wellbeing, but psychosocial stress and depression impede such recovery processes. To inform future interventions and policies, associations between breastfeeding, maternal stress, and depression were examined. Data from the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed (2016-2019). Logistic regression models were used to calculate adjusted odds ratios with 95% confidence intervals. Of the total sample (n = 95,820), approximately 88% of participants attempted breastfeeding. Our findings indicate that participants who experienced any form of stress had a slightly higher likelihood of breastfeeding compared to those without stress. Specifically, partner-related and financial-related stressors were significantly associated with increased odds of breastfeeding. However, no significant associations were observed trauma-related or emotional-related stressors and breastfeeding. Additionally, no significant association was found between depression at different stages (preconception, prenatal, and postpartum) and breastfeeding. A significant interaction effect was noted between having experienced any of the 13 stressors and Black race/ethnicity on breastfeeding odds. Similarly, significant interaction effects were observed between partner-related, trauma, financial, or emotional stressors and Black race/ethnicity. These findings emphasize the importance of considering various factors when promoting breastfeeding in diverse populations, and screening for psychosocial stress during postpartum visits. Our study recommends tailoring breastfeeding interventions to address the needs of Black mothers which could significantly improve maternal health and breastfeeding outcomes.

Preconception and perinatal hospitalizations as indicators of risk for severe maternal morbidity in primiparas.

BACKGROUND: Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. A statewide longitudinally linked database was used to examine hospitalization during and before pregnancy for birthing people with severe maternal morbidity at delivery. OBJECTIVE: This study aimed to examine the association between hospital visits during pregnancy and 1 to 5 years before pregnancy and severe maternal morbidity at delivery. STUDY DESIGN: This study was a retrospective, population-based cohort analysis of the Massachusetts Pregnancy to Early Life Longitudinal database between January 1, 2004, and December 31, 2018. Nonbirth hospital visits, including emergency department visits, observational stays, and hospital admissions during pregnancy and 5 years before pregnancy, were identified. The diagnoses for hospitalizations were categorized. We compared medical conditions leading to antecedent, nonbirth hospital visits among primiparous birthing individuals with singleton births with and without severe maternal morbidity, excluding transfusions. RESULTS: Of 235,398 birthing individuals, 2120 had severe maternal morbidity, a rate of 90.1 cases per 10,000 deliveries, and 233,278 did not have severe maternal morbidity. Compared with 4.3% of patients without severe maternal morbidity, 10.4% of patients with severe maternal morbidity were hospitalized during pregnancy. In multivariable analysis, there was a 31% increased risk of hospital admission during the prenatal period, a 60% increased risk of hospital admission in the year before pregnancy, and a 41% increased risk of hospital admission in 2 to 5 years before pregnancy. Compared with 9.8% of non-Hispanic White birthing people, 14.9% of non-Hispanic Black birthing people with severe maternal morbidity experienced a hospital admission during pregnancy. For those with severe maternal morbidity, prenatal hospitalization was most common for those with endocrine (3.6%) or hematologic (3.3%) conditions, with the largest differences between those with and without severe maternal morbidity for musculoskeletal (relative risk, 9.82; 95% confidence interval, 7.06-13.64) and cardiovascular (relative risk, 9.73; 95% confidence interval, 7.26-13.03) conditions. CONCLUSION: This study found a strong association between previous nonbirth hospitalizations and the likelihood of severe maternal morbidity at delivery.

The Efficacy of Provider-Based Prenatal Interventions to Reduce Maternal Stress: A Systematic Review.

PURPOSE: Exposure to stress during the prenatal period is often associated with adverse maternal and neonatal health outcomes and is increasing in prevalence in the United States. Health care providers play a crucial role in addressing and mitigating this stress, but there is a lack of consensus regarding effective interventions. This review evaluates the effectiveness of prenatal provider-based interventions that reduce stress for pregnant people, especially those who are disproportionately affected by stress. METHODS: A search of relevant English-language literature was conducted using PubMed, CINAHL, Web of Science, Embase, and PyscInfo. Inclusion criteria were 1) the target population was pregnant people, 2) the intervention was delivered within the U.S. health care system, and 3) the study intervention had the goal of reducing stress (stress-reducing intervention). RESULTS: A total of 3,562 records were identified in the search and 23 were included in analysis. The four identified categories for provider-led stress-reducing prenatal interventions included in the review are 1) skills-building, 2) mindfulness, 3) behavioral therapy, and 4) group support. Findings suggest an increased overall likelihood of mood and maternal stress improvement among pregnant people who complete provider-based stress-reducing interventions, especially group-based therapies that integrate resource allocation, skills-building, mindfulness, and/or behavioral therapy into an intersectional program. However, the efficacy of each type of intervention varies by category and type of maternal stress targeted. CONCLUSIONS: Although few studies demonstrated a significant reduction in stress for pregnant people, this review highlights the critical need for increased research and attention to stress-reducing interventions in the prenatal period, especially as it pertains to minoritized populations.

Can US Medical Schools Teach About Structural Racism?

Policy Points There need to be sweeping changes to medical school curricula that addresses structural racism in medicine and how to attend to this in medical practice. The Liaison Committee on Medical Education should develop and promulgate specific learning objectives and curricular offerings that require medical schools to teach about structural racism and antiracist medical practice in ways that are robust and standardized. The federal government, through the Health Resources and Services Administration, should prioritize support for antiracism education in medical schools, residency, and continuing medical education in similar ways and with similar effort in scale and scope to its support for primary care, providing technical assistance and grants for programs across the educational spectrum that provide antiracist training. State governments should mandate, as part of continuing education requirements for physicians, 2 or more hours per recertification cycle of antiracist training. CONTEXT: Since the beginning of COVID-19 and the rise of social justice movements sparked by the murders of George Floyd and Breonna Taylor in the summer of 2020, many medical schools have made public statements committing themselves to become antiracist institutions. The notions that US society generally, and medicine, are rife with structural racism no longer seems as controversial in the academic community. Challenges remain, however, in how this basic understanding gets translated into medical education practice. Understanding where the profession must go should start with understanding where we currently are. METHODS: Prior to the events of 2020, in the spring of 2018, we conducted nine key informant interviews to learn about the challenges and best practices from schools deemed to be positive deviants in teaching about structural racism. FINDINGS: Our interviews showed that even those schools deemed positive deviants in the amount of teaching done about structural racism faced significant barriers in providing a robust education. CONCLUSIONS: Significant structural change, perhaps far beyond what most schools consider themselves willing and able to engage in, will be necessary if future US physicians are to fully understand and address structural racism as it affects their profession, their practice, and their patients.

An Evaluation of the Successes of the NASTAD Minority Leadership Program and Its Implications for Leadership in State Health Departments.

OBJECTIVE: The Minority Leadership Program (MLP) was developed by the National Alliance of State and Territorial AIDS Directors (NASTAD) to enhance leadership skills among public health professionals of color that work within HIV, viral hepatitis, or drug user health programs in health departments. The goal of the study was to analyze experiences of MLP alumni in their respective health departments, explore opportunities to address cultural issues, and explore leadership opportunities for alumni. DESIGN: The research team conducted a mixed-methods approach to this study. It included qualitative data analysis of 2018-2019 MLP applicants (n = 32), online surveys to MLP alumni (n = 51), and key informant interviews with former MLP cohort members (n = 7). Thematic coding was conducted for all qualitative data collection tools using Dedoose. SETTING AND PARTICIPANTS: Study was conducted virtually between September 2020 and March 2021. A total of 90 individuals participated in this evaluation research study. These individuals were former cohort members of MLP by NASTAD. INTERVENTION: No health intervention was conducted. MAIN OUTCOME MEASURE: Achievement of participant-level experiences after completion of MLP. RESULTS: Microaggressions in the workplace, lack of diversity in the workplace, positive experiences participating in the MLP, and networking opportunities were common themes throughout the study. Other themes included challenges and successes experienced after MLP completion, and MLP's contribution to advancing professionally within the health department. CONCLUSIONS: Overall, participants had positive experiences participating in MLP and spoke highly of the networking opportunities available in the program. Individuals who participated recognized a lack of open dialogue and conversations surrounding racial equity, racial justice, and health equity within their respective departments. The research evaluation team recommends that NASTAD continue collaborating with health departments to address issues on racial equity and social justice with health department staff. Programs such as MLP are critical to diversifying the public health workforce to adequately address issues on health equity.

Perspectives on cultural competency and race concordance from perinatal patients and community-based doulas.

BACKGROUND: As awareness of perinatal health disparities grows, many birthing people of color are seeking racially and/or culturally concordant providers. We described preferences for, and perceptions of, racial and/or cultural concordance and cultural competence in the context of the doula-client relationship. METHODS: Seven focus group discussions (FGDs) with a total of 27 participants were conducted to investigate the perspectives of patients and doulas across Massachusetts, United States. An interdisciplinary stakeholder group informed the data collection instrument content and design. Two coders achieved 0.89 Kappa for inter-rater reliability prior to coding the remaining transcripts. We used a modified grounded theory approach and Dedoose software for coding. RESULTS: Two major themes emerged. First, cultural competency in doula care is a learning process, with definitions consistent with terms such as "cultural humility" and "structural competency." Doulas discussed listening to clients' needs rather than making assumptions, the importance of understanding privilege and power dynamics, and self-initiating relevant education beyond formal doula training. Second, trust was most frequently cited as an indicator of successful doula-patient relationships. CONCLUSIONS: Most study participants specified the importance of cultural humility in doula-client relationships. Doulas approaching the relationship humbly with a willingness to learn and challenge their own assumptions-regardless of the level of concordance-can make a meaningful impact on the perinatal experience.

Trends and inequities in severe maternal morbidity in Massachusetts: A closer look at the last two decades.

It is estimated that 50,000-60,000 pregnant people in the United States (US) experience severe maternal morbidity (SMM). SMM includes life-threatening conditions, such as acute myocardial infarction, acute renal failure, amniotic fluid embolism, disseminated intravascular coagulation, or sepsis. Prior research has identified both rising rates through 2014 and wide racial disparities in SMM. While reducing maternal death and SMM has been a global goal for the past several decades, limited progress has been made in the US in achieving this goal. Our objectives were to examine SMM trends from 1998-2018 to identify factors contributing to the persistent and rising rates of SMM by race/ethnicity and describe the Black non-Hispanic/White non-Hispanic rate ratio for each SMM condition. We used a population-based data system that links delivery records to their corresponding hospital discharge records to identify SMM rates (excluding transfusion) per 10, 000 deliveries and examined the trends by race/ethnicity. We then conducted stratified analyses separately for Black and White birthing people. While the rates of SMM during the same periods steadily increased for all racial/ethnic groups, Black birthing people experienced the greatest absolute increase compared to any other race/ethnic group going from 69.4 in 1998-2000 to 173.7 per 10,000 deliveries in 2016-2018. In addition, we found that Black birthing people had higher rates for every individual condition compared to White birthing people, with rate ratios ranging from a low of 1.11 for heart failure during surgery to a high of 102.4 for sickle cell anemia. Obesity was not significantly associated with SMM among Black birthing people but was associated with SMM among White birthing people [aRR 1.18 (95% CI: 1.02, 1.36)]. An unbiased understanding of how SMM has affected different race/ethnicity groups is key to improving maternal health and preventing SMM and mortality among Black birthing people. SMM needs to be addressed as both a medical and public health challenge.