group synthesis

GROUP SYNTHESIS: DISPARITIES IN INFANT AND WOMEN’S HEALTH

Nursing Research

Group Synthesis: Healthcare Disparities in Women’s and Infant Health

Mackenzie McMinn, Gwendolyn Lewis, Crystal Campbell and Raquel Smith

Palm Beach Atlantic University

School of Nursing

Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane (PNHP, 2019). Over the years there have been various studies conducted on the disparities pertaining to minorities in women’s healthcare, which still exist today. The disparities to be discussed in this reading focus on both neonatal and postpartum care. As nursing student’s, it is our duty to ensure that we are aware of such disparities and work as a collective whole to help decrease the likelihood of these occurrences while utilizing evidence-based practice and deductive reasoning.

This reading includes the background, summary, nursing implications, synthesis and unanswered questions of four studies. The first study is entitled,” Early neonatal mortality and risk factors: a case-control study in Paraná State”. This study analyzes early neonatal mortality risk factors by analyzing secondary data from the Mortality and Live Birth Information System in 2014. The objective or purpose statement in this article is “To analyze the risk factors for Early Neonatal Mortality, according to the risk stratification criteria of the Guideline of the Rede Mãe Paranaense Program (Migoto, 2018).”

This study took place in Brazil, Prana state. The researchers stated, “this research was developed based on the following guiding question: What risk factors for Early Neonatal Mortality could innovate in the criteria adjustments included in the Guideline of the Rede Mãe Paranaense Program, and contribute to a more sensitive stratification of the pregnant woman’s and child’s risk (Migoto, 2018)?” The Rede Mãe Paranaense is a program in brazil that monitors the growth and development of children until they are one years old, researchers also focused on prenatal care and how it affects the mother and baby. The researchers found that there were 20,176 neonatal and infant deaths in Brazil, in 2016. Early Neonatal deaths were 53.2% of infant deaths and 6.7 deaths per thousand live births.

This is a quantitative, epidemiological, case control approach.” The researchers in this study gathered information of all the live births in the Prana state from secondary records, which consisted of 399 municipalities and 22 regional health units, these secondary records included: Live Birth Information System (SINASC) and the Brazil Mortality Information System (SIM). In the SINASC researchers found that between 01/01/2014 and 12/25/2014 there was 157,629 live births, this was the "control" group. In the SIM they found that there were 903 early neonatal deaths between 01/01/2014 and 12/31/2014, and this was their "case" group. The researchers performed a crude analysis “to verify the relationship between risk factors with early neonatal death, with a 95.0% confidence interval, and a 5.0 % significance level, and the support of SPSS 22.0.0.0 Program (Migoto, 2018)." The dependent variable is Early neonatal death. There are 4 Independent variables which included: 1. Maternal socioeconomic conditions (age, schooling, marital status and race); 2. Maternal obstetric (live children, miscarriages and type of pregnancy); 3. Regarding the newborn (gender, weight, gestational age, Apgar at the fifth minute and congenital anomaly); 4. Assistance (prenatal care onset, number of appointments and type of labor).

This study is important because it assist in identifying the risk factors for early neonatal deaths in brazil. Many of these risk factors are preventable while others are not. Because this study only took place in one country there needs to be a continuation of research to identify additional risk contributing to early neonatal death. As nurses we need to be aware of these risk factors in order to educate mothers and women of child nearing age, on ways to prevent infant death. Infant death is a worldwide issue.

Because this study took place in brazil, the main questions that remain are, do these risk factors contribute to infants all over the world or just in prana state brazil? What can we, as researchers and nurses do to prevent these risk factors? How much more research needs to be done to confirm that these factors are a threat to our children? Are the risk factors involving infants the same around the world, or does each country have different factors that are more prominent? As nurses we can research other articles that state risk factors contributing to infant death. Healthcare professionals need to review articles that take place different countries around the world and which risk factors seem to be prominent.

The next study in this group synthesis is entitled,” Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program”.” Thiel de Bocanegra, Braughton, Bradsberry, et al. (2017) conducted a study to determine the racial and ethnic disparities in access to postpartum care in California’s Medicaid program. The study was motivated by the fact that women, especially from African-American community do not utilize government-funded programs even if it is free.

As a result, the current study is designed to determine whether the visit rates have changed or are not following the adoption of Medi-Cal program. Medi-Cal program is designed to offer postpartum care services to women for free. The findings from the study would form the basis for future studies and policy adjustment. For example, if the study determines that African-American do not utilize postpartum services effectively, then policies directed to African-American can be instituted. Alternatively, the finding from the study will identify study gaps for further research.

The researchers utilized administrative data to analyze the utilization of the postpartum visits by low-income women aged 15-44 years from California. They selected those women who are part of Medi-Cal and Family PACT USING HEDIS technical specifications. Researchers then used ICD-9-CM diagnosis or procedure to determine the kind of care the women selected received. Researchers also used the Medi-Cal and Family PACT enrollment records to identify the independent variables such as race, primary language and age. Finally, researchers examined rates of HEDIS postpartum visits, the type of contraception women received and the demographic variable (Bradsberry et al., 2017).

The findings revealed that Latina, Caucasians and Asians women registered higher in visit rates of 71.8%, 14.1% and 6.1%, while African-American women registered lowest in visit rates at 5.5%. The findings also showed that Spanish speaking women registered higher visit rates of 53.7% compared to 42.7% registered by English speakers (Bradsberry et al., 2017).

In terms of age, those under the age of 20-19 and 30-39 received more visits at 58.9% and 27.7% respectively. The study also established that women who received any contraception within 99 days were 52.6%, while those who received highly effective contraception were 15.8%. Based on these findings, the researchers concluded that there are significant racial disparities in postpartum visits rates even after control for age, delivery type and residence (Bradsberry et al., 2017).

While the researchers confirmed that their findings match the findings from the initial study previously conducted by California Department of Public Health, researchers attempted to identify potential causes of disparities. Citing the work of Gemmill and Lindberg (2013), researchers alluded that short interpregnancy interval could be the reason why the visit rates of

African-American women are low. Similarly, ineffective programs such as the Black Infant Health program could be another reason.

The reason why Latinas seem to have more visit rates is that they want to utilize the funded program simply because they lack insurance. In terms of residence, the women from areas that are farther away are motivated to get contraceptives because they are not ready for frequent visits.

These findings reflect that transportation challenges are a crucial factor to consider. However, since the study only analyzed existing data, it just gives snapshot of the possible challenges. Therefore, more research should be conducted using qualitative research design in order to identify the reason for such differences.

The major implication of the research is that there is a need for urgent actions to sensitize African-American women on the significance of postpartum care and the contraception. Short interpregnancy could be a result of the lack of information about significance of proper planning. This lack of information could be contributed to by poor access to postpartum services. Another implication is that there is a need to determine whether there are beliefs that hinder African-American women from accessing postpartum services. This issue cannot be attributed to lack of finances because the services are free. In addition, there is need to evaluate the effectiveness of existing programs. For example, it is important to determine why Black Infant Health program does not help improve the utilization of postpartum care by African-American women. Lastly, since the study utilized the administrative data, it is important to carry out further studies that will adopt a qualitative approach in order to assess the obstacles that contribute to low rate of utilization of postpartum services.

Questions that remain unanswered, Will qualitative research design give more details about the variations in visit rates? What are the underlying factors for poor access by African- American women to the postpartum services? Does the issue of risk aversion influence the utilization of postpartum services among women?

The third contributing study of the group synthesis is entitled,” Black/White disparities in pregnant women in the United States: An examination of risk factors associated with Black/White racial identity”. The risk factors associated with Black/White racial identity”, is the outstanding difference between the adverse pregnancy outcomes such as low birth weights in Black pregnant women compared to White pregnant women.

Though there have been laws, to help bridge the gap between the disparities such as, legislative act H.R.45171, this law only improves the overall health of children by raising the awareness of infant mortality rates. However, the article calls out the need to pin point the issue in the disparity of care in the black women. Furthermore, the article will explore the factors associated with low birth weights in Black and White pregnant women. In turn, this article will also gather information on how institutionalized racism contributes to adverse pregnancy outcomes, looking at health behaviors and various factors to see if they’re different between the people groups.

The findings of the article: both black women and white women had similar trends in areas such as marital status (mostly unmarried), varying education levels and employment between the ages of 18-25. Most of the women did not smoke or use drugs however, most did drink alcohol. Nonetheless, both groups had insurance, most did not attend church, have a father in the household, and most were not depressed. In contrast, even though risks and behaviors seem about the same, black women were more likely to have Medicaid/Medicare rather than private insurance compared to white pregnant women.

Black women were less likely to be employed, and more likely to have less income levels. These findings conveyed that though both people groups have similar results in factors, black women have more of a challenge in their households. Higher stress levels are a burden and a contributing factor as to the reason why more black women than white women due to the economic and institutionalized stand point are disproportionally underserved. Institutionalized racism is defined as, the differences to the access to certain resources by their race and differences in politics, laws and practices that reinforce racial inequality” (p.655). Because they have less income, government issued insurance and lower paying jobs, these stressors combined with overwhelming effect of institutionalized racism has caused black pregnant women to have lower birth outcomes. In addition, the article shows that the low birth weights have nothing to do with the women’s health behaviors because white women are more likely to be involved in health eroding behaviors than black women. In fact, black women are less likely to smoke. Even with this trend white women will still deliver infants with a higher birth weights than black women.

The findings of this study propel a need for the advancement of healthcare awareness on pressing issues related to low birth weights. The overwhelming disparity and the poor outcomes of black infants and mothers has always been evident however, without substantial cause or reason as to why this is occurring. This article sheds light on the fact that there are additional underlying issues other than the perceived notion that black women’s health behaviors are a contributing factor in this healthcare issue.

This study reinforces the ideologies that institutionalized factors embedded in the laws, perceptions of care, insurance, bias in care and employment is the main cause of this gap. These implications are important because with an increase in awareness and acknowledgement of these key factors, changes can be made in handling of pregnant women black women. Being more aware as a health care provider of unconscious discrimination and be more attentive to black women’s needs, will assist in decreasing the mortality rate of black infants.

It is important to conduct additional research studies to explore the structural levels of discrimination and how it effects the people groups. If institutionalized racism is the key factor as to why black pregnant women have such high rates of low birth weight outcomes and infant mortality, further research is needed to determine how healthcare providers perpetuate this problem in their quality of care.

Finally, the last instillation of this group synthesis is entitled, “Increased risk of premature death following teenage abortion and childbirth- a longitudinal study”. In this study, independently of social background, premature death especially by suicide, violence, ischemic heart disease, cervical and lung cancer appears to be more common among women with a history of teenage childbirth than women without teenage pregnancy.” (Jalanko, Leppalahti, Heikinheimo & Gissler. p.845-846).

From 1986- 1987 to 2013 more women with a lower educational level, living in urban areas in Finland that had teenage pregnancies, died due to suicide, injury, poisoning and other external causes including alcohol related deaths. More so, than women that had higher education and did not have teenage pregnancies.

This study is important and significant because women that have teenage pregnancies are more susceptible to be of the minority group within education and level of income. These women should be monitored with proper medical techniques to determine their risk level for self-mutilating actions and potential risk for suicide.

Within this study, the questions remaining unanswered are, what type of medical services these women in urban areas receive? Because of their lack of education were they properly taught how to take care of themselves while going through a teenage pregnancy? This research should have also looked at medical files to see why these women died prematurely.

There are various similarities and differences amongst the four studies discussed in this reading. The first study entitled,” Early neonatal mortality and risk factors: a case-control study in Paraná State” will be referenced as study one. The second study entitled,” Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program” will be referenced as study two. The third study entitled,” Black/White disparities in pregnant women in the United States: An examination of risk factors associated with Black/White racial identity” will be referenced as study three. Lastly the fourth study entitled, “Increased risk of premature death following teenage abortion and childbirth- a longitudinal study” will be referenced as study four.

One of the similarities which exist in all the studies is contributing risk factors pertaining to women’s health or childbirth. For example, the contributing risk factor for studies one and two is the lack of prenatal care. The second study and third study focus on racial and ethnic disparities in postpartum care while the other two focus on predisposing risk factors pertaining to pregnancy, studies one and four. For example, the contributing risk factors in studies two and three pertain to disparities amongst African-American women. Two of the studies are based in countries outside of the United States, the first and fourth study while the others are centered within the United states; the second and third studies. The diversity in the locations of where these studies took place supports the nursing implications pertaining to these issues being worldwide. All the studies have an overall focus risk factors that can be detrimental to the health of the mother or infant. One significant difference is only one study focuses on the morality rate of teenage girls after giving birth. Two of the studies do not render the element of racial disparities but overall disparities in women's health pertaining to childbirth, studies one and four.

Then there are the limitations involved in each study. For example, in study one the limitations are SIM records only recorded 903 live births while SINASC recorded 983 live births. There was also a “lack of information in databases or codes not understandable by the data dictionary, and the questioning about the reliability of the secondary data worked here (Migoto, 2018)”. In the second study,” Deliveries that had claims with procedure or diagnosis codes for cesarean delivery within 7 days of their delivery date were considered cesarean. Deliveries with at least one vaginal delivery procedure or diagnosis code were considered vaginal. If no codes indicated mode of delivery, the delivery type was considered missing. Women were assigned to the publicly funded health care program (Medi-Cal Fee for Service, Medi-Cal Managed Care health plans, or Family PACT), where they were enrolled on the 99th day postpartum (Bocanegra, et al., 2017, p.2)”. "There were several limitations in this study in the third study. Researchers were restricted to data that already existed in the 2012 National Survey on Drug Use and Health (NSDUH). However, there were several variables that should have been explored such as the outcome of the pregnancy (e.g. normal birth weight, low birth weight or very low birth weight), other measures of institutionalized racism (e.g. occupation and family economic history), and direct measures of racism (e.g. perceived experience of racial behaviors/acts). Similarly, the restrictive database did not allow for inter-group analyses or multiracial analyses. Research has shown great health differences within different racial and ethnic groups such as Black women (e.g. African- born vs. US- born mothers) (David & Collins, 1997). Future research should continually explore racial differences (intra- and inter-group analyses) in risk factors of LBW but, should also compare the results to actual outcomes (if LBW variable is available in the data). Furthermore, researchers should continually look for measures of institutionalized racism and discrimination in existing data and incorporate measures into new data collection strategies"(Clay, Griffin, & Averhart, 2018, p.662). In the fourth study, maternal patients did not want to disclose pertinent information, move out of the country at the time of birth and women were dying before giving birth. These limitations affected the number of women from the pool that could be used for this research study (Jalanko, et al. p.846-847).

Unfortunately, although the four studies do involve women’s health and some form of childbirth it was extremely difficult to create a graph to depict this. Therefore, as a group we decided to explain the similarities, differences and limitations as best as we could within the reading.

In conclusion, one of the reigning themes of this course has been nursing research as it relates to healthcare through evidence-based practice. Through the synthesis of the studies referenced above, nursing students can draw an understanding of the significance of research studies and their nursing implications on the population. As nursing students, it is important to continue to review studies such as these in order to monitor dominating trends of contributing risk factors pertaining to all disease not just the issues addressed in these studies. The purpose of nursing research is to provide the foundation of evidence-based practice. Through evidence-based practice healthcare provider can provide pertinent information directly impacting patient outcomes.

References

Bocanegra, H. T., Braughton, M., Bradsberry, M., Howell, M., Logan, J., & Schwarz, E. B. (2017). Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program. American Journal of Obstetrics and Gynecology,217(1). Retrieved from doi:10.1016/j.ajog.2017.02.040

California Department of Public Health (2012). MIHA Snapshot, California by Race/Ethnicity, 2012 Maternal and Infant Health Assessment (MIHA) Survey. Available at:

https://www.cdph.ca.gov/Programs/CFH/DMCAH/MIHA/Pages/default.aspx

Clay, S. L., Griffin, M., & Averhart, W. (2018). Black/White disparities in pregnant women in the United States: An examination of risk factors associated with Black/White racial identity. Health & Social Care in the Community,26(5), 654-663. doi:10.1111/hsc.12565

Dr. Martin Luther King on health care injustice. (n.d.). Retrieved April 25, 2019, from http://pnhp.org/news/dr-martin-luther-king-on-health-care-injustice/

Gemmill A. and Lindberg L. D. (2013). Short interpregnancy intervals in the United States. Obstet Gynecol, 122:64-71.

Jalanko, E., Leppalahti, S., Heikinheimo, O., & Gissler, M. (2017). Increased risk of premature death following teenage abortion and childbirth-a longitudinal cohort study. European Journal of Public Health, 27(5), 845-849. Retrieved from https://doi-org.proxy.pba.edu/10.1093/eurpub/ckx065

Migoto MT, Oliveira RP, Silva AMR, Freire MHS. Early neonatal mortality and risk factors: a

case-control study in Paraná State. Rev Bras Enferm [Internet]. 2018;71(5):2527-34.

DOI: http://dx.doi.org/10.1590/0034-7167-2016-0586