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Running Head: INTEGRATED REVIEW 1

African American preterm birth

Jasmine Wrenn

Bon Secours Memorial College of Nursing

Ms. Arlene Holowaychuk MSN

Nursing Research 4122

11/12/2017

I pledge
INTEGRATED REVIEW 2

Abstract

The purpose of this integrative review is to appraise literature related to African American

women and the increased risk of preterm birth. Preterm birth can lead to multiple conditions that

financially and emotionally have implications for the new family and society as a whole. The

search for articles was from Google Scholar and PubMed, well over 18,000 articles were found.

The results of the five articles chosen summarized a need for interventions that will reduce the

rate of preterm births in the African American population. Limitations for the articles were the

sample size, region, individual factors, and timeframe. There were limitations specific to the

researcher, which are lack of experience on this topic and difficulty finding articles to match the

PICO question within five years. All articles recommend studying of interventions. For future

research the focus should be dedicated to effectiveness of interventions in a longitudinal study.


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The purpose of this integrated review is to analyze risk factors and initiatives

implemented within community and governmental settings to show influence on the rate of

preterm births (PTB) in African American women. Preterm births in the United States have been

a well surveillance problem for a few decades. Preterm birth is considered an infant born before

37 weeks of gestational age (Giurgeseu, et al 2012). Infants born prematurely are at risks for

neonatal mortality, motor and mental developmental delays, failure in school, and chronic illness

(Giurgeseu et al, 2012, p. E52).

The CDC notes that rates of preterm births declined between 2007 and 2014, due to

initiatives started in 2006 (Preterm Birth, 2017). Declines were contributed to the decrease

number of teen/young mothers. The problem is that these rates continue to remain higher in

certain ethnic/racial groups. As current as 2016, the CDC claims that 14% of all births to African

American women are preterm, which is almost 50% higher than their white counterparts at 9%

(Preterm Birth, 2017). Systematically African American women have a higher incidence of

adverse birth outcomes, one being preterm birth.

While the amount of research that exists on this topic is extensive, there are large gaps

and repetition present. The repetition is a good thing because it confirms there is a systematic

problem but it does not move the problem forward and close to a resolution. New research within

the last five years is needed to see what interventions are possible/effective and for this specific

population. For pregnant African American women, does the use of community and/or

governmental initiatives reduce the future risk of preterm birth compared with no initiative at all.

The researcher has been interested in working with this population, so research is important to

gain knowledge.
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Design, search methods, search outcomes

In this Integrative Review there are five articles that have been compiled and analyzed for

usefulness within the healthcare field. Initial research on the topic was done through two

databases: Google Scholar and PubMed. An article search was refined through the criteria given

by the course instructor. Key words and phrases that were used throughout the search process

included: ‘preterm birth’, ‘African American women’, ‘adverse birth outcome’, ‘intervention’,

‘community initiative’, ‘doula’, and ‘Medicaid’. Using Google Scholar and PubMed the

researcher was able to find upwards of 18,000 articles related to the topic.

In order to find relevant articles, the criterion was implemented and all articles not

meeting the criteria were exempt. Articles must be peer-reviewed quantitative/qualitative

research studies, published within 5 years. The researcher was able to find articles that were

relevant and met criteria. An exception was made for an article published from 2011. This was

the only exemption made. To extend the year from 2012 to 2011 allowed for the inclusion of

meaningful interventions.

Five articles were selected with publications dates ranging from 2011 to 2013. Selection

was also made based on the close reliability to the researchers PICO question. All articles were

published in English with full text. Presented in this review are five quantitative research articles

related to the PICO question: For pregnant African American women does the use of community

and/or governmental initiative reduce the future risk of preterm birth compared with no initiative

at all.
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Finding/Results-include table

The findings and results of the five quantitative articles are similar in acknowledging a

need for interventions. The interventions are necessary to decrease the racial disparity present for

African American women in order to decrease preterm birth rates. One article looked at rural

areas versus urban areas, which showed that both extremes found higher rates of preterm births,

although the national average is declining (Kent, McClure, Zaitchik, & Gohlke, 2013). Two

articles found that racial discrimination was positively associated with psychological stress,

placing the mother at risk for preterm birth (Caty et al., 2011; Giuregeseu et al., 2012). The last

two articles looked at Medicaid expenses and how extended coverage could be a savings tool;

paying for prevention instead of intervention (Kozhimannil, Hardeman, Attanasio, Blauer, &

O’Brien, 2013; Zhang et al., 2013). In this integrative review two themes, environmental factors

and governmental initiatives will be examined and the potential influence it may have on

decreasing preterm births for African American women. A summary of all research articles is

located in Table 1.

Environmental Factors

Articles that exist presently include more information on risk factors than interventions.

The researchers gathered risk factors to connect with possible interventions. A common

agreement two quantitative articles is that factors within the mother's environment play a role in

maternal and fetal health (Giurgeseu et al., 2012; Kent et al., 2013). An important theme is to

address how environmental factors increase stress which places women at greater risk for

preterm birth (Giurgeseu et al., 2013). Incidence of preterm birth amongst African American

women is statistically significant in the southern states with a 95% Confidence Interval. It has

been found that Alabama’s rate of PTB is 15.6% which is higher than the national average at
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12% (Kent et al, 2013). Regional risk factors can affect the mother; also help identify what areas

of the United States need the most help.

Mothers that live in high poverty and high African American populations have shown

higher rates of PTB in Southwestern and Birmingham regions. Preterm births were higher in

mothers that were self-paid and did not complete college. Disparities widen between city and

rural isolated areas. This is peculiar despite down trends seen in the United States, since 2006.

Small towns that are isolated and urban areas have a statistical significance in having higher rates

of PTB when associated with high poverty and percent of African Americans living in the area.

During the last 20 years urban areas have consistently had higher rates of adverse birth

outcomes. (Kent et al, 2013)

In comparison, Giurgeseu et al. (2012) looked into rates of PTB from 7 communities in

Chicago. Similar to Kent et al. (2013), higher rates of PTB have been associated with

environmental factors. Contributions of abandoned buildings, litter, and violent crimes were all

related to elevated rates of PTB. These individuals are also more likely to experience racial

discrimination (Giurgeseu, 2012). Researchers noted from previous studies, “Thus theoretically,

neighborhood environment and racial discrimination can increase the stress of pregnant women

and ultimately place them at greater risk for preterm birth” (Giurgeseu, 2012, p. E52). This

differed from the current study, which found gestational age did not relate to any specific

variables. “Psychological distress was the only predictor of preterm birth whereas objective

social disorder and perceived crime were not significant as direct factors on preterm birth”

(Giurgeseu, 2012, p. E56). Healthy coping mechanisms or self-care outlets could potentially help

with the potential psychological stress.


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Government Initiative

The Center for Disease Control (CDC) implements programs in order to offset disparities

within disadvantaged communities. The CDC created Racial and Ethnic Approaches to

Community Health (REACH) program to combat racial/ethnic disparities in the United States.

Programs are built to include culturally appropriate interventions. “REACH gives funds to state

and local health departments, tribes, universities, and community-based organizations. Awardees

use these funds to build strong partnerships to guide and support the program’s work” (Racial

and Ethnic Approaches, 2017). This program implements and tracks the progress made over

time.

Carty et al. (2011) conducted a quantitative research study, using ANOVA, to find

connections between racism, health status, and birth outcomes. The finding concluded that

REACH participants on average had higher levels of agreement than non-REACH participants.

Also, REACH participants were more likely to report experiences of racial discrimination.

African Americans were more likely to report ‘some’ or ‘often’ encounters to racial

discrimination than European American women who reported ‘never’ or ‘rarely’ when going

about daily living. The difference in experiences and understanding of such experiences were 1.6

times larger gap in Reach participants and non-REACH participants than African Americans and

European Americans. REACH European American participants reported 1.8 less likely to see

racial group as regarded negatively (Carty et al., 2011). Finding one's racial group positive or

negative in social light can change psychosocial stress.

For African American women this social aspect of racial grouping causes more

psychosocial stress. REACH African Americans “reported more extreme emotional reactions to

race-related experiences than their respective non-REACH and European American


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counterparts” (Carty et al., 2011, p.89). REACH participants rated themselves in having better

overall health, despite increased perceived group racism. Factors predicting smoking included

discrimination and racism-related stress. Emotional response to perceived racism was the only

variable that related to birth outcome. Group racism associated with lower levels of perceived

health status (Carty et al., 2011).

REACH is not a Medicaid funded program, money from government grants are used for

funding. Medicaid is often used to offset medical coverage for disadvantaged individuals.

Individuals must qualify for benefits. Hospitals also must qualify to be reimbursed for expenses.

Expansion in coverage can be voted on by government officials. Results of two studies suggest

expanding benefits could potential save the government money in the long run (Zhang et al.,

2013; Kozhimannil et al. 2013).

Researchers investigated Medicaid recipients and potential savings in decreasing

disparities, results were reported from Zhang et al. (2013), African American women delivered at

a younger age compared with Hispanics and White counterparts. African American women had

an overall rate of 25.6% in adverse birth outcomes. It was also found that they stay longer in the

hospital (3.4 days) and have higher Medicaid cost on average each hospital encounter. White

counterparts had shorter stays, and lower costs per hospital stay. “The average preterm birth rate

was lower for women who received doula support than Medicaid beneficiaries generally (6.1%

vs. 7.3%) but this difference was not statistically significant in uncontrolled comparisons”

(Kozhimannil et al., 2013, p.e3). Factors associated with preterm births were related to race and

older maternal age. Savings were significantly found for the reduction of c-section on Medicaid

reimbursement.
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Discussion/Implications

Being aware of discrimination can make a person advocate for themselves and have a

better understanding of their racial status in connection with their health. National initiatives to

improve adverse birth outcomes started in 2006 (Preterm Birth, 2017). This has helped in overall

reduction of PTB but rates are not decreasing in rural isolated areas and urban regions. Isolated

rural areas typically have low flow of economic and social change. Often smoking prevalence is

higher and unintended pregnancies play a role. In these areas it is needed to maintain physicians

that are willing to work full-time. The implementation of more family providers can decrease the

time to care.

Although the facts of proving PTB rates are higher for African American women in any

setting, there is minimal assessment or mention of specific interventions in place (Kent et al,

2013). Researchers found that perceived crime increased the psychological distress, but no

association with PTB. More experiences of racial discrimination had higher levels of

psychological distress (Giurgeseu, 2012). Racial discrimination did not predict PTB as other

studies found (Giurgeseu, 2012).The only variable that predicted preterm birth was objective

physical disorder within neighborhood (housing vacancy).

Health care providers need to be aware of environmental stressors. Assist women in

stress relieving and relaxation techniques. Referrals should be considered, healthcare providers

should advocate for public policy that brings in resources to underserved areas. Local businesses,

churches, and public facilities are needed to collaborate. In addition to inclusive physicians, it

would be beneficial for at risk mothers that qualify for Medicaid, use doula’s for care. Although

this would be costly for each state’s Medicaid budget it would cut down on reimbursements to

hospitals (Kohimannil et al., 2013).


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Limitations

This integrative review is presented with limitations from the researcher. This review is

not exhaustive of all information available on this topic. In addition, there were only 5 articles

selected to be presented, within the timeframe from 2011-2017. Information, from 2006, could

have been more relevant to PICO question was not included due to the year published. The

researcher is a nursing student and the integrative review is a class assignment.

The limitations from the articles include: individual-level variables (smoking, alcohol,

psychosocial factors, and disease state of mother. Limitations were also present due to the use of

only summer months. Geographical regions make the information less applicable to the greater

public. Adverse birth outcomes remain higher in isolated rural and more population dense areas.

Interventions have been found to be effective in low socioeconomic status population, and can be

used to reduce disparities. (Kent et al, 2013). Some of the sample sizes were small, and all

information did not come from the same time period. None of the studies were longitudinal, so it

was not possible to rate change over time.

Conclusion

This integrative review combines the finding of 5 quantitative articles, in order to create

evidence based practice. Overall there has been minimal change and resolution to the disparities

of African American woman and their preterm birth rates. Each article addressed overarching

risk factors and their implications. More research is necessary to find an intervention that is

productive in reducing preterm births in African American women. This disparity is a

multivariable case and it is important to prevent future chronic illness within this population.
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References

Carty, D. C., Kruger, D. J., Turner, T. M., Campbell, B., DeLoney, E. H., & Lewis, E. Y. (2011).

Racism, health status, and birth outcomes: results of a participatory community-based

intervention and health survey. Journal of Urban Health, 88(1), 84-97.

Giurgescu, C., Zenk, S.N., Dancey, B.L., Park, C.G., Dieber, W., & Block, R. (2012).

Relationships among neighborhood environment, racial discrimination, psychological

distress, and preterm birth in African American women. JOGNN, 41. doi:10.111/j.1552-

6909.2012.01409.x

Kent, S. T., McClure, L.A., Zaitchik, B.F., & Gohlke, J.M. (2013). Area-level risk factors for

adverse birth outcomes: trends in urban and rural settings. BMC Pregnancy and

Childbirth, 11(129). Retrieved from http://www.biomedcentral.com/1471-2393/13/129

Kozhimannil, K. B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., & O’Brien, M.

(2013). Doula care, birth outcomes, and costs among Medicaid beneficiaries. American

journal of public health, 103(4), e1-e8.

Preterm Birth, Maternal and Infant Health, Reproductive Health (2017). Centers for Disease

Control and Prevention. Retrieved from

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm

Racial and Ethnic Approaches to Community Health (2017). Centers for Disease Control and

Prevention. Retrieved from https://www.cdc.gov/nccdphp/dnpao/state-local-

programs/reach/index.htm

Zhang, S., Cardarelli, K., Shim, R., Ye, J., Booker, K. L., & Rust, G. (2013). Racial disparities in

economic and clinical outcomes of pregnancy among Medicaid recipients. Maternal and

child health journal, 17(8), 1518-1525.


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Summary Table 1
Reference (APA) Giurgeseu, C., Zenk, S.N., Dancey, B.L., Park, C.G., Dieber, W., &
Block, R. (2012). Relationships among neighborhood environment,
racial discrimination, psychological distress, and preterm birth in
African American women. JOGNN, 41. doi:10.111/j.1552-
6909.2012.01409.x

Author Carmen Giurgeseu, PhD, RN, WHNP, assistant professor in the


(Year)/Qualifications College of Nursing, University of Illinois at Chicago, IL
Shannon N. Zenk, PhD, RN, is an assistant professor in the College
of Nursing, University of Illinois at Chicago, IL
Barbara L:. Dancy, PhD, RN, FAAN, is a professor in the College
of Nursing, University of Illinois at Chicago, IL
Chang G. Park, PhD is an assistant professor in the College of
Nursing, University of Illinois at Chicago, IL
William Dieber is the director of the Great Cities Urban Data
Visualization Program and Lab
Richard Block, PhD is Professor Emeritus, Department of
Sociology, Loyola University, Chicago, IL

Introduction/ Preterm birth can mean a lot for an infant. It has been found that
Background/Problem preterm birth can be associated with poor development, mortality,
Statement and even chronic illness. Socioeconomic status and reproductive
history and can put a woman at greater risk for preterm birth. This
risk can increase due to the maternal race, if she is African
American. Previous research has been included that acknowledges
psychological stress is associated with preterm birth.

Conceptual/ Theoretical framework was not stated but authors mentioned that
Theoretical Framework women are at greater risk if she lives in a poor neighborhood and or
experience racism.

Design/Research 72 self-identified African American women were surveyed during


Methods/Sample/ their stay after delivery. The survey was conducted 24 to 72 hours
Setting/Ethical after birth. The women were separated into two groups. One of the
Considerations/ groups consisted of 33 women that were considered preterm at <37
Major Variable Studied/ weeks gestational age and 39 women at full term >37 weeks
Measurement Tool/Data gestational age. Authors included criteria for inclusion, mothers
Collection Tool/Data could not participate if they delivered <24 weeks, if they were less
Analysis than 24 hours post-delivery, and had any chronic illness during the
course of their pregnancy.
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This research study was approved by an IRB board. Participants


were first contacted by their OB. Participants were given
questionnaires to complete on their own time. 25 dollars was given
for their time and inconvenience.

Findings/Results Mean age 23yrs, mean gestational age 36.7, 53% were employed,
82% of women were single at the time the study was conducted.
“Experiences of racial discrimination were positively related to
psychological distress” (p. E56). The Hosmer and Lemeshow
model was able to correctly predict preterm birth 61% of the time.
“Psychological distress was the only predictor of preterm birth”
(E56).

Discussion/ Finding were similar to a previous study that predicted African


Implications American women only are at a higher chance of preterm birth if the
neighborhood they reside in has a lot of home vacancy. This
research study did not find that violent crime was related to preterm
births like previous studies have. This could be contributed to the
fact that the neighborhood the participants lived in were low in
homicide rate and sexual assault. But the researchers did find that
psychological stress was increased by perceived crime and racial
discrimination. Racial discrimination did not predict preterm birth.

Health care providers need to be aware of the disadvantages their


patients have. Perception of choice versus reality needs to be
challenged. Clinicians should provide resources, teaching, and
relaxation techniques to their patients to combat psychosocial stress
that places a role of preterm birth. Health care providers need to
participate in policy and lobbying of resources being allocated to
disadvantaged neighborhoods (crime and disorder). Rallying of
volunteers to make sure services are provided using businesses,
churches, and police departments.

Limitations/ The sample size for the study was small. Only one medical center
Conclusions was used. The participants only came from 7 of the 77 communities
within Chicago. Information was gathered 24 to 72 hours after birth.

Appraisal/Worth to This research article was not helpful in the effectiveness of


practice interventions. It does however explain the relationship between
variables that ultimately affect the outcome of pregnant African
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American women (preterm birth).

Reference (APA) Kent, S. T., McClure, L.A., Zaitchik, B.F., & Gohlke, J.M. (2013).
Area-level risk factors for adverse birth outcomes: trends in urban
and rural settings. BMC Pregnancy and Childbirth, 11(129).
Retrieved from http://www.biomedcentral.com/1471-2393/13/129

Author Shia T Kent, Postdoctoral Researcher at University of Alabama at


(Year)/Qualifications Birmingham
Leslie A McClure, Postdoctoral Researcher at University of
Alabama at Birmingham
Ben F Zaitchik, Associate Professor at John Hopkins University
Julia M Gohlke, Adjunct Assistant Professor at University of
Alabama at Birmingham

Introduction/ Racial and income disparities have grown in the US. Low income
Background/Problem families have higher outcome of preterm birth (PT) and low birth
Statement weight (LBW) than their counterparts. African American women
have twice the number of PT and LBW. Individuals living in inner
city and rural areas have worse health outcomes. Factors affecting
birth outcomes in specific areas include smoking, inequality health
care, and environmental hazards.

Conceptual/ No mention of theoretical framework. Concepts are founded on


Theoretical Framework racial and social disparity/discrimination

Design/Research The methodology used in this study was mapping and B-splines
Methods/Sample/ were used to determine trends in low birth weight and preterm birth.
Setting/Ethical This was appropriate for the study because it highlighted areas that
were considered town or urban, and the population density within
Considerations/
those areas. Logistic regression model was used to examine
Major Variable Studied/ differences in zip code-level.
Measurement Tool/Data The sample was taken from Alabama residents and was
Collection Tool/Data randomized using the Rural-urban Commuting Area Codes
Analysis (RUCAs) and the Census 2000 population. There is no evidence of
a power analysis conducted to determine adequate sample size.The
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sampling is limited to the area’s demographic but authors concluded


that in 2010, Alabama residents had 15.6% rate of preterm birth
trumping the the national average at 12%. There is no mention of a
power analysis performed to determine adequate sampling. Of all
the births recorded between 1990-2010 authors were able to analyze
96% of them. Finding were further limited to births within summer
months (May-September). No attention was given to social context
during that time.
Within the article there is no evidence that subjects would be
notified of the use of their private information. Although the
authors did not include ethical considerations of the subjects and
how their information would remain private; it was stated that study
protocol was approved by Alabama Department of Public Health
(ADPH) and University of Alabama at Birmingham Institutional
Review Boards. It is also unclear whether participants were notified
of data analysis.

Findings/Results Small towns and urban areas were considered statistically


significant in having higher rates of preterm birth and low birth
weight. Researchers found that although low birth rates were
decreasing nationally it seemed not to affect isolated rural areas.
PTB and LBW rates are higher in mothers who are self-paid,
African American, and did not complete college. Previous studies
were connected and similar in results.

Discussion/ “Due to previously increasing national PTB rates, a concerted effort


Implications was initiated in 2006 to reduce PTB and overall rates have been
declining nationally and in Alabama since then, however our
analysis shows adverse birth outcome rates are not decreasing in the
most isolated rural regions.” (p.5) Over the last 20 years urban areas
have had higher adverse birth outcomes compared to other areas.
Moving demographical area and individual differences explained
the time trends but isolated rural areas maintained higher levels
overall. Previous literature has also made connections with lack of
social support and isolation tied to rural areas with maternal
smoking.
Rural women have more unintended pregnancies and poor
cardiovascular risk factors for women compared to urban areas.
“Finally, maintaining full-time physicians locally, particularly
family doctors and obstetricians is more difficult in rural regions,
and there is increased time-to-care in rural regions, so medical
advances that have allowed national decreses in adverse birth
outcome rates might not be reaching isolated rural regions (p.6).”
Inner city women deal with crime, stress, racial discrimination, and
environment factors (liquor store density and housing damage).
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Limitations/ “Structural confounding may arise from socioeconomic and racial


Conclusions segregation, which in turn may lead to a lack of adequate
distributions of individual-level factors within area-level strata
(p.7).” Other limitations include individual-level variables
(smoking, alcohol, psychosocial factors, disease state of mother.
Limitations were also present due to the use of only summer
months. Zip code-level less effective than census tract level
estimates.
Adverse birth outcomes remain higher in isolated rural and more
population dense areas. Interventions have been found to be
effective in low socioeconomic status population, and can be used
to reduce disparities.

Appraisal/Worth to Research article is important because geographical regions are used


practice as variables to adverse birth outcomes. Also, the nation has been on
a downward trend of PTB overall excluding isolated rural areas.

Reference (APA) Zhang, S., Cardarelli, K., Shim, R., Ye, J., Booker, K. L., & Rust, G.
(2013). Racial disparities in economic and clinical outcomes of
pregnancy among Medicaid recipients. Maternal and child health
journal, 17(8), 1518-1525.

Author Shun Zhang, Jiali Ye, and George Rust all work for National Center for
(Year)/Qualifications Primary care at Morehouse School of Medicine
Kathryn Caradarelli work for Department of Epidemiology at
University of North Texas Health Science Center
Ruth Shim works for the Department of Psychiatry at Morehouse
School of Medicine
K. L.

Introduction/ Preterm birth “adds risk of chronic bronchopulmonary disease and


Background/Problem severe chronic neurologic sequelae, such as cerebral palsy,
Statement intraventricular hemorrhage, and visual disturbances” (p.1519). The
Southern states within the United States have some of the highest rates
of adverse birth outcomes. Medicaid assist in one third of all births.
“Approximately $10.2 billion are spent for adverse pregnancy outcomes
in infant’s birth” (p.1519).
The purpose of this study is to connect racial groups with adverse birth
outcomes, and potential Medicaid savings if disparities were decreased.

Conceptual/ There was no mention of the theoretical framework


Theoretical
Framework
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Design/Research Medicaid Analytic eXtract (MAX) were used to gather financial


Methods/Sample/ records. Cross-sectional study of pregnancy women from years 2005 to
Setting/Ethical 2007. States that were included (Alabama, Arkansas, Florida, Georgia,
Kentucky, Louisiana, Maryland, Missouri, Mississippi, North Carolina,
Considerations/
South Carolina, Tennessee, Texas, and Virginia). 1,472,912 women
Major Variable were selected from excluded based on conflicting variables from
Studied/ 2,170,060.
Measurement Infant costs were not included in this study. Outpatient services and
Tool/Data Collection drug claims 9 months post delivery were included. African American
Tool/Data Analysis women were tested using ANOVA study. 95% confidence intervals
were set. Also statistical significant was set at 0.005.

Findings/Results African American delivered at a younger age compared with Hispanics


and White counterparts. African American women had an overall rate
of 25.6% in adverse birth outcomes. This study found that African
American women were younger at delivery. It was also found that they
stay longer in the hospital (3.4 days) and have higher Medicaid cost on
average each hospital encounter. White counterparts had shorter stays,
and lower costs per hospital stay.

Discussion/ All though attention has been brought to adverse birth outcomes, there
Implications continues to be disparities across the United States. African American
women overall experience higher rates of adverse birth effects, more
specifically preterm birth. All women had to meet the same
socioeconomic criteria in order to obtain Medicaid. Women who
received Medicare were more likely to receive prenatal care and
continue care throughout their pregnancy. The Affordable care made
expansion on coverage. Having a health care plan to provide primary
care to intervene tertiary intervention. Using Medicaid provide data
collection and monitoring for surveillance of adverse birth effects.
Providers are expected to meet expectations of service in order to
receive reimbursement. Having provider compliance is important to
make change in disparity gap between outcomes of African American
women and their non-Hispanic White counterparts. The hassle in
getting reimbursed fewer physicians is deciding to accept Medicaid
coverage. Medicare is restricting in the exact procedures that is covered
and the amount of times that procedure or diagnostic can be used.
Expanding the covered of progesterone injections could be useful in
preventing preterm births.
The studies mention previous research finding a decrease in preterm
birth in African American women from 2.8% to 1.1%. This can be
attributed to not just prenatal care but also transportation, social work,
behavioral support and communicate links. Medicaid paying for these
services to women who qualify would be a key factor in continuing to
limit maternal disparities amongst racial groups.
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Limitations/ Regional area including 14 southern states. Personal risk behaviors and
Conclusions experience to racism could not be collected through the database.
“...Clinical records, such as body-mass index, prenatal lab tests results
or ultrasound dating of pregnancy. Individual socioeconomic status was
not included in records.

Appraisal/Worth to Implications of the usefulness of Medicare in reducing incidence of


practice preterm birth in African American women. Expanding the coverage of
Medicare.

Reference (APA) Carty, D. C., Kruger, D. J., Turner, T. M., Campbell, B.,
DeLoney, E. H., & Lewis, E. Y. (2011). Racism, health status, and
birth outcomes: results of a participatory community-based
intervention and health survey. Journal of Urban Health, 88(1),
84-97.

Author Denise C. Carty, works for Prevention Research Center of


(Year)/Qualifications Michigan with University of Michigan
Daniel J. Kruger, works for Prevention Research Center of
Michigan with University of Michigan
Tonya M. Turner, Genesee County Health Department
Bettina Campbell, YOUR Center
E. Hill DeLoney, Flint Odyssey House Health Awareness Center
E. Yvonne Lewis, Faith access to community economic
development

Introduction/ REACH is Racial and Ethnic Approaches to Community Health


Background/Problem coalition. It is understood within this organization that racism is
Statement the cause of systemic racial health disparities and influence many
other social/institutional structures. “Interventions include (a)
community mobilization activities to improve awareness and
understanding of racism and promote individual and community
empowerment to ‘undo’ racism; and b (healthcare system
activities to combat institutional racism and improve patient care
for racially diverse populations (p.85).” Other studies have looked
into REACH but this paper goal is the highlight results.
Examine racism-related knowledge and held beliefs. Connect
education on racism to race consciousness, reduce prejudice, and
creating change within communities.

Conceptual/ Socioecological framework, integrating racism-related stress and


Theoretical Framework stress-adaptation theory
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Design/Research Survey developed by REACH in line with the principles of CBPR


Methods/Sample/ Partners were used to help with analysis, translation and
Setting/Ethical questionnaire. Reviewed by IRB at University of Michigan. ZIp
codes within Genesee county received computer assisted
Considerations/
telephone interviews.
Major Variable Studied/ 27% REACH participants and 73% non-REACH participants
Measurement Tool/Data Number of participants included 629 ages 18-45 (responded). 82
Collection Tool/Data participants filled out written version of the survey. Women
Analysis differed in race, education, and age (responded).
Survey contained 128 items, assessing for ses “beliefs and
experiences of racism; self-reported health; and pregnancy and
birth experiences (p.87).”
24 racism based questions
Time frame for experiences or feelings was past 12 months
ANOVA was used to analyze differences in experience.
Multivariable linear and logistic regression models were used

Findings/Results In regards historical understand and continued impact of racism,


slavery, segregation and prejudice this study found REACH
participants on average had higher levels of agreement than non-
REACH participants. The difference in experiences and
understanding of such experiences were 1.6 times larger gap in
Reach participants and non-REACH participants than African
Americans and European Americans. REACH participants were
more likely to report experiences of racial discrimination. African
American were more likely to report ‘some’ or ‘often’ encounters
to racial discrimination than European American who reported
‘never’ or ‘rarely’ when going about daily living. REACH
European American participants reported 1.8 less likely to see
racial group as regarded negatively. REACH African Americans
“reported more extreme emotional reactions to race-related
experiences than their respective non-REACH and European
American counterparts (p.89).”
REACH participants rated themselves in having better overall
health despite increased perceived group racism.
Factors predicting smoking included discrimination and racism-
related stress.
Emotional response to perceived racism was the only variable that
related to birth outcome.
Group racism associated with lower levels of perceived health
status.

Discussion/ After adjusting for race and highest education completed, REACH
Implications participants rated themselves as having better physical and mental
health status. REACH could impact health promotion,
psychosocial empowerment, health education, and strategies for
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improvement. Improved health assessments could be an optimal


outcome for African American patients. Implement within
community settings.
Women who reported higher levels of racism seemed to cope
better in reporting better health standard
Moving policy forward

Limitations/ Participants in REACH were not assessed prior to starting the


Conclusions program, so it is hard to tell how much change has occurred.
Effectiveness of training cannot be assessed. Need to assess how
training in translated into community and institutional settings.
Self reported cannot validate health status.
Individual barriers
Investigation into internalized, institutional, sociopolitical
manifestations of racism
Potential recall bias, but other research has shown that pregnancy-
related events are typically reported accurately even decades post
delivery.
Research could benefit from a study with a larger population
The purpose of this study is to bring about social change toward
racism (education, community engagement, and community
mobilization.

Appraisal/Worth to Good
practice

Reference (APA) Kozhimannil, K. B., Hardeman, R. R., Attanasio, L. B., Blauer-


Peterson, C., & O’Brien, M. (2013). Doula care, birth outcomes,
and costs among Medicaid beneficiaries. American journal of
public health, 103(4), e1-e8.

Author Katy Backes Kozhimannil, PhD MPA


(Year)/Qualifications Rachel R. Hardeman, MPH
Laura B. Attanasio, BA
Cori Blauer-Peterson, MPH
Michelle O’Brien, MD MPH

Introduction/ “Medicaid beneficiaries have higher risk of preterm birth and low
Background/Problem birth weight, than do privately insured women. The strong link
Statement between income, race/ethnicity, and adverse birth outcomes has
been well documented, but effective means of reducing this
disparity are lacking” (e1) . Home visits, birthing centers along
with midwife maternal care model have shown good promise.
The Affordable care act previously was working on expanding
INTEGRATED REVIEW 21

covered for pregnant women. Use of doulas also have not been
traditionally covered or reimbursed by health insurance.
Definition of doula listed within article. Doulas have been used to
provide support to mothers; it has been most effective when the
doula does not have any other connection with the mother.
Doulas on average are middle aged, married, and well educated.
Upper-middle class white women with experience or knowledge
of doulas use them more frequently than other race groups. 85%
of doulas are white (e1). Diversity of doulas may diversify or
influence other clients.

Conceptual/ No mention of theoretical framework


Theoretical Framework

Design/Research Sample was taken from Everyday Miracles which is a group of


Methods/Sample/ doulas operating as a nonprofit organization. Clients are referred
Setting/Ethical based on having Medicaid, which is the first group to accept
Medicaid for doula care. Data was used from Medicaid national
Considerations/
sample of single births in the year 2009. Nationwide Inpatient
Major Variable Studied/ Sample (NIS), Healthcare Cost and Utilization Project (HCUP)
Measurement Tool/Data were used to to collect samples.
Collection Tool/Data Data was de-identified, doulas filled out enrollment forms, and
Analysis trained interns filled out excel spreadsheet.
Total sample size was 1079.
95% confidence interval. T test used to look at rate difference,
logistic regression models to understand impact of doulas on
preterm birth.

Findings/Results “The average preterm birth rate was lower for women who
received doula support than Medicaid beneficiaries generally
(6.1% vs 7.3%) but this difference was not statistically significant
in uncontrolled comparisons (p.e3).” Factors associated with
preterm were related to Black race and older maternal age.
Savings were significantly found for the reduction of c-section on
Medicaid reimbursement.

Discussion/ Saving would be extended through the intrapartum period into the
Implications postpartum period. So having coverage for reimbursement for
Medicaid could extend saving amounts. Doula services can range
from $300 - $1800. DONA and the International Childbirth
Education Association have specific training requirements and
certification programs to streamline safe practices amongst all
doulas.

The women who stand to benefit from the services of doulas are
not receiving them. Doulas can diversify but only for women who
INTEGRATED REVIEW 22

have access to them. Recruitment in diversifying the field of


doulas providing care can increase trust and reliability for
potential clients. Recruiting is hard because the money for
funding is not there, which is a deterrent to potential providers.
Advertising to include women

Limitations/ Limited to Oregon because they are the first state to cover doula
Conclusions under Oregon’s Medicaid program. State to state difference in
cost of maternal care and services. Data collected were not all
from the same time period. Underreporting of complication to fit
with bias of support. Certain information was unattainable from
Medicaid records including: education level, marital status,
amount of prenatal care if any at all.

Appraisal/Worth to Important to consider including doulas under Medicaid coverage.


practice