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Obstetric violence has been documented throughout the world, yet this human rights issue has mostly been investigated in middle- and low-income countries where the intensity and brutality of abuse and mistreatment is more easily recognised as problematic. This integrative review aimed to analyse sources about obstetric violence in high-income countries with the objective of identifying gaps in the research, challenges to the study of obstetric violence, and solutions to framing research that meets those challenges. A systematic search was conducted using the PubMed and CINAHL databases from February to June 2022. Empirical and non-empirical sources, published in English, with no date restrictions, were retrieved. Citation searching was also done. Forty-six sources were included. Identified gaps in the research were: (a) scarce attention to obstetric violence in most high-income countries; (b) most US sources are non-scientific and from outside the healthcare disciplines; (c) inconsistencies in terminology; (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the association between obstetric violence and traumatic birth was under-recognised. Identified challenges to the study of obstetric violence were: (1) factors that enable and perpetuate obstetric violence are multilevel and nonlinear; (2) the phenomenon is contextually complex; and (3) blind spots from routinised harmful practices and normalised mistreatment can prevent healthcare providers and birthing people from recognising obstetric violence. A systems approach and complexity theory are guiding frameworks recommended as solutions to the challenges of studying and correcting obstetric violence.

The growing identification of \"obstetric violence,\" first in Latin America and subsequently far more widely around the world and in supra-national human rights forums' jurisprudence, has been a pivotal site for contesting the power asymmetries encoded into the biomedical paradigm and examining reproductive governance. A key aspect of deploying \"obstetric violence,\" as opposed to the discourses of \"disrespect and abuse\" or, in the United States, the more common \"obstetric mistreatment\" has been to challenge the treatment of pregnancy and childbirth as a medical condition or event, as opposed to a natural process. Until now, little attention has been paid to post-partum obstetric violence beyond egregious acts such as detentions in health facilities for non-payment of fees. We argue here for expanding consideration of the post-partum period gure to include pharmaceuticalization, with a focus on the US context. Rapidly increasing diagnoses of PPD, especially among women of color, and newly available pharmaceutical solutions, may appear as a solution to lack of access. However, the biomedical framing shifts attention from the socio-political causes of emotional distress-with significant consequences for individual women and public health. Taking the recent approval of the 'first-ever' pill for post-partum depression, zuranolone (brand name Zurzuvae) as a case example, we argue here that the reduction of reproductive subjects' experiences to biochemical disorders, and the lowering of regulatory standards for the pharmaceutical industry, threaten to perpetuate a subtle but damaging form of obstetric violence, which warrants concern.The growing identification of \"obstetric violence,\" first in Latin America and subsequently far more widely around the world and in supra-national human rights forums' jurisprudence, has been a pivotal site for contesting the power asymmetries encoded into the biomedical paradigm and examining reproductive governance. A key aspect of deploying \"obstetric violence,\" as opposed to the discourses of \"disrespect and abuse\" or, in the United States, the more common \"obstetric mistreatment\" has been to challenge the treatment of pregnancy and childbirth as a medical condition or event, as opposed to a natural process. Until now, little attention has been paid to post-partum obstetric violence beyond egregious acts such as detentions in health facilities for non-payment of fees. We argue here for expanding consideration of the post-partum period gure to include pharmaceuticalization, with a focus on the US context. Rapidly increasing diagnoses of PPD, especially among women of color, and newly available pharmaceutical solutions, may appear as a solution to lack of access. However, the biomedical framing shifts attention from the socio-political causes of emotional distress-with significant consequences for individual women and public health. Taking the recent approval of the 'first-ever' pill for post-partum depression, zuranolone (brand name Zurzuvae) as a case example, we argue here that the reduction of reproductive subjects' experiences to biochemical disorders, and the lowering of regulatory standards for the pharmaceutical industry, threaten to perpetuate a subtle but damaging form of obstetric violence, which warrants concern.

Abstract Maternal and child health constitutes a subsector of public management that is responsible for social and human development indicators such as fertility rates, infant mortality, and maternal mortality. In this article, we discuss the first results of a qualitative research conducted with healthcare providers from the Brazilian Unified Health System (SUS), in primary and tertiary care in the state of Alagoas. We invited these subjects to contribute in identifying challenges and potentialities that mark their professional daily lives to build continuous health education strategies, bridging the gap between scientific dissemination and the exercise of an interprofessional and humanized practice in maternal and child health. We reflect here on two worrying aspects that emerged in the stories: permanent education focused on continuous education and the challenges in facing day to day racism. Data analyses are guided to construct an experimental strategy that contributes to developing successful practices in the care of those who experience the pregnancy-puerperal cycle in our territory. Resumo A saúde materno-infantil configura um subsetor da gestão pública que é responsável por indicadores de desenvolvimento social e humano, tais como as taxas de fecundidade, de mortalidade infantil e de mortalidade materna. Neste artigo, dialogamos sobre informações oriundas do primeiro desfecho de uma pesquisa qualitativa com trabalhadoras de saúde que atuam no Sistema Único de Saúde (SUS), nos cenários da atenção primária e terciária no estado de Alagoas. Convidamos essas sujeitas para estarem como parceiras na identificação de desafios e potencialidades que marcam seus cotidianos profissionais a fim de construirmos estratégias de educação permanente em saúde que possibilitem a aproximação entre a divulgação científica e o exercício de uma prática interprofissional e humanizada em saúde materno-infantil. Refletimos aqui sobre dois aspectos que nos inquietaram nas histórias que escutamos: a educação permanente focada na educação continuada e os desafios frente a práticas de racismo cotidiano. Essas primeiras análises nos guiaram a refletir os resultados da pesquisa, fazendo-nos imaginar a construção de uma estratégia experimental que contribua com o desenvolvimento de práticas exitosas no cuidado em saúde de pessoas que vivenciam o ciclo gravídico-puerperal no nosso território.

Systemic racism is embedded in healthcare settings and is linked to high maternal mortality rates for Black women in US Society. Doulas, or birth support workers, are uniquely positioned to advocate for women of color going through the birthing process, but little is understood on how doulas come to terms with race, racism, and whiteness in maternal healthcare settings. Using qualitative in-depth interviews with 11 doulas in northeast Florida, this research study found that doulas’ advocacy for maternal justice leads to an intersection with racial justice through their support of minority women clients. Doulas shared stories of racial injustice when they compared their white and Black client experiences, leading to shifting strategies to address racism in maternal healthcare settings. Doulas also grappled with their connection to whiteness through their own identities and interaction with white and minority clients. Many doulas shared a need for anti-racism training and recruitment of Black doulas to meet the needs of women of color going through the birthing process.

ObjectivesStructural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth.MethodsData for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017–2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics.ResultsA total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio.Conclusions for PracticeState-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.SignificanceWhat is already known on this subject? Structural racism is viewed as a root cause of racial and ethnic disparities in maternal health outcomes, independent of socioeconomic determinants of health. However, supporting evidence is scant.What this study adds? In this population-based study in 2017–2018, state-level Black-to-white inequities in unemployment and incarceration are associated with significantly increased odds of severe adverse maternal outcomes (i.e., blood transfusion, hysterectomy, and ICU admission) during childbirth for non-Hispanic Black women, and to a lesser extent, for non-Hispanic white women. Addressing structural racism in maternal care may contribute to improving maternal health equity.

The legacies of slavery today are seen in structural racism that has resulted in disproportionate maternal and infant death among African Americans. The deep roots of these patterns of disparity in maternal and infant health lie with the commodification of enslaved Black women’s childbearing and physicians’ investment in serving the interests of slaveowners. Even certain medical specializations, such as obstetrics and gynecology, owe a debt to enslaved women who became experimental subjects in the development of the field. Public health initiatives must acknowledge these historical legacies by addressing institutionalized racism and implicit bias in medicine while promoting programs that remedy socially embedded health disparities.

In the United States, maternal health inequities disproportionately affect Global Majority (e.g., Asian, Black, and Hispanic) populations. Despite a substantial body of research underscoring the influence of racism on these inequities, little research has examined how experiences of gendered racial microaggressions during pregnancy and birth impact racially and ethnically diverse Global Majority pregnant and birthing people in obstetric hospital settings. We evaluated the psychometric properties of an adapted version of Lewis & Neville’s Gendered Racial Microaggressions Scale, using data collected from 417 Global Majority birthing people. Findings from our study indicate that our adapted GRMS is a valid tool for assessing the experiences of gendered racial microaggressions in hospital-based obstetric care settings among Global Majority pregnant and birthing people whose preferred languages are English or Spanish. Item Response Theory (IRT) analysis demonstrated high construct validity of the adapted GRMS scale (Root Mean Square Error of Approximation = 0.1089 (95% CI 0.0921, 0.1263), Comparative Fit Index = 0.977, Standardized Root Mean Square Residual = 0.075, log-likelihood c2 = -85.6, df = 8). IRT analyses demonstrated that the unidimensional model was preferred to the bi-dimensional model as it was more interpretable, had lower AIC and BIC, and all items had large discrimination parameters onto a single factor (all discrimination parameters > 3.0). Given that we found similar response profiles among Black and Hispanic respondents, our Differential Item Functioning analyses support validity among Black, Hispanic, and Spanish-speaking birthing people. Inter-item correlations demonstrated adequate scale reliability, α = 0.97, and empirical reliability = 0.67. Pearsons correlations was used to assess the criterion validity of our adapted scale. Our scale’s total score was significantly and positively related to postpartum depression and anxiety. Researchers and practitioners should seek to address instances of gendered racial microaggressions in obstetric settings, as they are manifestations of systemic and interpersonal racism, and impact postpartum health.

Background Circumstances that lead to maternal death are complex and multifactorial, including inequity and racism issues. Quality improvement (QI) strategies have demonstrated success in improving maternal outcomes. The Collaborative Abraço de Mãe (CAM) reduced the institutional maternal mortality rate (iMMR) by 34.2% from the baseline rate in 19 Brazilian maternity hospitals. Objective To present the integration of anti-racism and equity strategies implemented during the CAM. Methods A QI report assessing the CAM focused on strengthening the awareness of obstetric teams about ethnic-racial inequalities and institutional racism as social determinants of maternal outcomes. A mixed methods approach was used to understand the overall impact of the intervention. Measures included the Anti-Racist Leadership Survey and interviews (individual and grouped). Qualitative and quantitative data were applied simultaneously but independently, followed by a triangulated comparison to define convergences. Results The domain with the highest average score was emotional resources and communication; the lowest was fundamental knowledge and translation of the knowledge in action. Interviews evidenced three categories: (A) equity and anti-racism training contributed to a more profound recognition of race and racism awareness, leading to a change in culture; (B) Priority change ideas and actions focusing on anti-racism and equity were demonstrated in several ways among the leaders; and (C) Challenges when equity is centralised in the care model. Triangulations revealed two convergences: (i) Evidence of a better understanding of ethnic-racial inequalities, institutional racism, and racism recognition by the leaders and participating institutions, and (ii) Resistance when trying to bring new content to the clinical staff, as well as a lack of tools when dealing with the emotional resources needed to confront interpersonal racism. Conclusion With a significant reduction in iMMR, the CAM reveals that a QI intervention addressing inequities and racism issues is a feasible and promising approach to improve maternal outcomes within an equity-oriented model of care. Significance What is already known on this topic? • Maternal deaths have decreased worldwide, yet pregnancy-related mortality continues to be a major public health concern, particularly in low- and lower-middle-income countries. The disparities in maternal deaths are shaped by factors beyond biological differences, including systemic issues such as inequity and racism. What does this study add? • The quality improvement Collaborative Abraço de Mãe (CAM) achieved a 34.2% reduction in the institutional maternal mortality rate across 19 participating maternity hospitals. • This study demonstrates how CAM addressed ethnic-racial inequalities and institutional racism as key social determinants of maternal outcomes, incorporating equity and anti-racism training for obstetric staff as a vital component of its strategy. How might this study affect research and practice? • This study advocates for integrating equity and anti-racism training within healthcare systems to enhance the quality of care for all women. • Our methodologies and findings may impact future research, clinical practice, and policymaking in maternal healthcare, especially in contexts affected by racial and socio-economic disparities.

Of Aspirin, Preeclampsia, and RacismThe stress imposed by structural and individual racism on Black people may contribute to the development of preeclampsia. But use of race to guide prevention-related decisions could be problematic.