Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston

Abstract

Community-based organizations are uniquely positioned to address critical gaps in social support that contribute to inequities in maternal health. Using a human-centered design process, we held 3 design workshops with members of 15 organizations in Greater Boston, including community-based organizations, allied hospital systems, and public health departments, to assess proposed solutions for gaps in social support services during pregnancy and the first year after childbirth. The workshops focused on solutions to problems that emerged from a mixed-methods research study with community-based organizations that provide social support services; workshop attendees explored facilitators and barriers to implementing solutions. Key considerations included colocation of solutions, shared ownership of program and client data, decision making about triage and referrals, and strengthening coordination of existing programs. Collaborative design workshops surfaced potential solutions to improve coordination of services, which require addressing structural and interpersonal racism in Greater Boston.

Racial and ethnic inequities in maternal health persist, with African American/Black and Native American individuals experiencing worse outcomes when compared with non-Hispanic White individuals, even after adjusting for socioeconomic factors.^1,2 These inequities are a national crisis even in states, such as Massachusetts, with relatively few maternal deaths and other adverse outcomes. There is growing attention to the postpartum period as a vulnerable moment in the life course for physical, mental, and family health. Gaps in social support during pregnancy and the first year after childbirth contribute to these inequities in maternal health.³ Community-based organizations (CBOs) and other allied organizations address critical gaps in social support but may not be adequately coordinated to optimize outcomes.⁴

This project launched in 2019 as a partnership with The Boston Foundation, The Women and Health Initiative at Harvard T. H. Chan School of Public Health, and Ariadne Labs. We set out to map the landscape of CBOs in Greater Boston, an area that includes Boston and about 100 neighboring cities and towns.⁵ The project aim was to create solution prototypes to address the gaps in social support services that we identified through prior surveys and interviews (findings to be published separately). This brief summarizes the design thinking process we used to develop solution prototypes.

Methods

We identified CBOs that provide social support services to pregnant and postpartum clients through professional networks, key informant interviews and snowball sampling, and publicly available information on Web sites. We analyzed surveys and interviews with 21 unique CBOs and other allied organizations in Greater Boston (findings to be published separately). We presented these findings at a networking reception of more than 140 CBOs, researchers, policy makers, and study participants in October 2020.⁶ We worked with design thinking experts to develop solution prototypes to close the gaps in social support during pregnancy and the first year after childbirth.

In fall 2020, we hosted 3 design workshops over Zoom to cocreate a set of solutions for the gaps identified in our first phase of work. Participants were invited to attend the design workshops if they (1) were on the original list of CBOs invited to participate in the research study, (2) were identified through snowball sampling from study respondents, or (3) attended the virtual networking reception. Potential participants received an e-mail describing the project and design workshops and replied on the basis of their availability and interest. Participants did not receive compensation for their participation. Organizations did decline to participate, especially given the concurrent COVID-19 pandemic. Attendance is reported as follows: design workshop 1: 55 invited and 14 (25%) attended; design workshop 2: 50 invited and 15 (30%) attended; and design workshop 3: 64 invited and 6 (9%) attended. Eight CBOs that participated in the earlier study joined the workshops, and 7 CBOs joined because they were engaged in our networking reception.

We organized design workshops to achieve 3 goals: (1) use interview and survey data to identify high-impact opportunities for solution prototypes; (2) obtain input from a variety of organizations; and (3) assess the usefulness of potential solutions. Ultimately, we aimed to enhance coproduction and ownership of the solution prototypes through the design workshops. The first 2 workshops lasted 1.5 hours, and the third and fourth workshops lasted 1 hour. We conducted a structured brainstorming process to generate new ideas and critically review potential solutions using Stanford University's Hasso Plattner Institute of Design (the “d.school”), IDEO's framework for design thinking,⁷ and Miro,⁸ an online collaborative whiteboard platform.

An expert in design thinking facilitated the workshops and used a virtual whiteboard space on Miro for discussion. Throughout the workshops, the facilitator encouraged participants to think about what could support a solution and what would impede its success. For example, there was an activity in which participants were asked to rank solutions for investment and discuss how to center community engagement in the solutions. Some workshops included breakout sessions where participants worked in smaller groups to brainstorm facilitators and barriers relevant to the solutions. Participants were also encouraged to share new ideas. The output of each workshop involved a Miro board of virtual “sticky notes” of ideas and discussion themes. During the workshops, we discussed solutions to address the top challenges to accessing social support for birthing people of color, as well as facilitators and barriers relevant to the solutions, and their potential impact in Greater Boston. Other key considerations included Boston's history with racism, high rates of health care coverage in Massachusetts, regional inequality, and variations in local governance across Greater Boston.

We conducted thematic analysis⁹ of the output from the design workshops and held a final, internal workshop to review the findings from the former 3 workshops. We reviewed the thematic analysis findings and integrated themes in the final workshop. We included experts in design thinking and maternal health in Boston to encourage our team to think strategically about the best focus for designing a solution to support CBOs and allied organizations. We focused our final workshop on the opportunity to improve coordination and collaboration among CBOs and allied organizations with a racial equity lens. An equity lens “asks what disparities exist among different groups; takes into account historical and current institutional and structural sources of inequality; and takes explicit steps to build the social, economic, and political power of the people most affected by inequities in order to narrow gaps while improving overall outcomes.”¹⁰ Finally, we conducted organizational analysis¹¹ of the participants, using publicly available data to assess common equity considerations, such as demographic diversity of organizational leadership, organizational history and mission, and annual financials for the nonprofit entities as a proxy for size.

Ethical approval for this research was obtained from the Harvard University Institutional Review Board (IRB) on February 27, 2020 (IRB20-0193). Informed consent was obtained for all participants in surveys and interviews.

Results

We included 28 organizations in the research and design phases of the work. The majority (71%; n = 20) of our participants were led or co-led by women or gender-expansive people,¹² based on publicly available data. Of the 28 organizations, 18% (n = 5) were led or co-led by women or gender-expansive Black or Indigenous People of Color (BIPOC) based on publicly available data. Most of the participants had current or historical ties to the health systems within Boston or Massachusetts. Organizations ranged in size and included centers in large health systems to small businesses providing emotional support for birthing people, among others. The design workshops included 15 participants from the following sectors: health care (n = 3), public interest or law (n = 3), public health (n = 2), mental health (n = 2), early childhood (n = 1), care coordination (n = 1), doula care (n = 1), education (n = 1) and housing (n = 1).

The Table details solutions, facilitators, and barriers explored in the workshops. Participants highlighted potential solutions to counter structural and interpersonal racism in Greater Boston, including supporting alternative birthing options (births at home or in a birth center). One participant emphasized that what may appear as an alternative birthing option to hospitals is historically the primary option for birth, particularly among communities of color. This sparked a discussion about the historical context of birth and what tangible steps could be taken to support all birthing options and ensure equitable outcomes regardless of a birthing person's preference for location of birth, such as expanded access to midwifery care or birthing centers. Participants also discussed enhanced coverage for doulas and lactation consultants, recruiting BIPOC doulas, and training doulas in the care of BIPOC individuals. Anti-racism and microaggression training in health care systems were key solutions in addressing structural and interpersonal racism within Greater Boston. For structural and interpersonal racism within organizations, participants explored paying community members for their time in program planning, creating deliberate strategic plans focused on equity, and implementing hiring practices and professional development focused on BIPOC staff. Participants discussed both positive and negative experiences within organizations in crafting anti-racist policies and cultures. For the lack of coordination of services, participants described potential solutions including centralized intake systems (referrals and screening for social services occur at one point of contact), coalitions that include birthing people, citywide shared data for referral eligibility, and municipal health navigators.

TABLE - Solutions Identified for the Top Challenges to Accessing Social Support

Structural and interpersonal racism in the Greater Boston area	Solutions: Support alternative birthing options for pregnant and birthing people when representation does not exist in the health care system Advocate for policies to enhance coverage for social support providers	Hold doula trainings and workshops specific to BIPOC Incorporate anti-racism and microaggression training into the health care system
	Facilitators: Acknowledge history and lived experiences of birthing people of color; strengthen informal support networks; invite culture change that is accountable Barriers: Historically restrictive policies in birth center/birth worker accreditation; lack of anti-racist curricula at all professional levels
Structural and interpersonal racism within CBOs	Solutions: Provide payments to community members for participating in programming Create a deliberate strategic plan to address equity	Offer professional development for BIPOC staff Implement recruitment and hiring practices to ensure a diverse workforce
	Facilitators: Make a plan within the organization that is intentional and measurable, available to the whole organization Barriers: Language is not always accessible for all
Lack of coordination of services	Solutions: Centralized, coordinated, or collaborative intake systems for social support needs Coalition that includes community members and birthing people to ensure social support services are prioritized	Citywide shared data (eg, Web site) about available social support services and eligibility criteria Health navigators at the city level to help individuals navigate support referrals
	Facilitators: Build up existing networks of services that already exist; obtain necessary human and financial resources to sustain intake systems Barriers: Staff for all necessary roles; identify backbone organization to lead
Crosscutting themes	Colocation of multiple solutions: Creating access points to referrals Shared ownership of data about social support services and eligibility criteria Who decides about screening and referrals for social support needs Strengthening and coordinating existing programs to avoid duplication of services and fill gaps

Abbreviations: BIPOC, Black, Indigenous, and People of Color; CBO, community-based organization.

Participants also identified opportunities for proposed solutions to complement each other, such as a centralized intake system that links into a health navigation program, ultimately improving coordination of services. Participants discussed ownership of data regarding social services and client eligibility, with careful attention to building trust with the community and capacity to report out on the data. The locus of decision making regarding triage and referrals was also explored, with providers or clients and families or an intermediate agent taking the responsibility for referrals. Finally, organizations identified existing resources and coordination mechanisms that could be further strengthened, minimizing inefficiency and potential duplicity. For example, participants explained that community support groups for breastfeeding and parenting exist but are not tied to specific organizations. This presents an opportunity to uplift existing programs within the community through better coordination with CBOs.

Implications for Policy & Practice

• While lack of coordination among CBOs and allied organizations is not new, there is a growing imperative for public health stakeholders to (1) apply an equity lens in dismantling racism as a key barrier and (2) support people navigating a vulnerable social transition in starting or growing young families.
• Workshops organized with human-centered design principles can increase engagement, generate diverse perspectives and experiences, and enhance solution prototyping. These principles center the voices of those directly impacted by the outcomes of the project, placing researchers in the role of facilitator and participants as the experts, and prioritize a transparent process that shares results directly back with the participants. This methodology supported the intention to uplift local knowledge and practice.
• Organizational analysis with attention to racial equity can contextualize recommendations from design workshops by identifying the perspectives that are represented and those that are missing. Such an analysis may reveal the dominance of certain voices or sectors, such as the health care sector in Greater Boston, and provide an opportunity to reduce marginalization as we further develop the solution.

Discussion and Conclusion

Despite a large number of CBOs and allied organizations providing a range of social support services in Greater Boston, gaps in social support persist for birthing people, particularly in communities of color. During design workshops, participants identified potential solutions to the top 3 challenges in the provision of social support services. We applied design thinking principles with a racial equity lens to develop a solution prototype to enhance coordination and collaboration among CBOs and allied organizations in Greater Boston. Our project highlights the value of design workshops as an important tool for public health practice by facilitating engagement with CBOs and allied organizations in the solution development process. In our next phase of work, we will refine the solution prototype for field testing with local partners and develop instruments to assess its impact.