African American women are more likely to experience preterm birth compared with White women (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018). Social factors such as neighborhood disorder (e.g., vacant housing) and experiences of racial discrimination, which disproportionately affect African American women, may partially explain these disparities (Dominguez, Dunkel-Schetter, Glynn, Hobel, & Sandman, 2008). Discrimination has been defined as the “social practice that organizes prejudicial attitudes into the formal or informal segregation of social groups or classes stigmatized by the collective prejudice” (Turner, 2006, p. 146). African American women who live in neighborhoods with higher disorder and reported more situations of racial discrimination are more likely to experience preterm births (Giurgescu et al., 2012; Sealy-Jefferson, Giurgescu, Helmkamp, Misra, & Osypuk, 2015). African American women are more likely to experience psychological distress compared with White women and women who experience psychological distress during pregnancy are at increased risk for preterm birth (Grote et al., 2010; Seng, Kohn-Wood, McPherson, & Sperlich, 2011). African American women who reported more disorder in their neighborhoods were more likely to have preterm birth, and psychological distress mediated these associations (Giurgescu et al., 2012, 2017). However, the majority of studies that examined the role of neighborhood disorder, experiences of racial discrimination, and psychological distress on preterm birth used solely quantitative measures to assess these factors. Women's salient experiences of racial discrimination may not be fully captured using quantitative measures only.
Studies using mixed-methods approaches to examine pregnant women's experiences of living in neighborhoods with higher disorder and experiencing racial discrimination are limited. In one of the few studies that used a mixed-methods complementary approach, Giurgescu et al. (2013) found that 7 of the 11 pregnant African American participants reported high levels of stress due to either their neighborhoods, experiences of racial discrimination, financial situation, or social network (Giurgescu et al., 2013). However, all 11 of the women had full-term births. Recommendations from that study included further testing of congruence between measures for these concepts. Therefore, the purpose of this study was to explore pregnant African American women's perceptions of neighborhood disorder, experiences of racial discrimination, psychological distress, and the potential influences of these concepts on preterm birth.
We obtained a comprehensive understanding of each concept by using a mixed-methods approach with multiple sources of data including demographics, a survey, validated tools, and interviews (Creswell & Plano Clark, 2018).
Thirty-eight women were enrolled in the study if they self-identified as African American, were at least 18 years of age, had a singleton pregnancy, were of any parity, and were 8 to 18 weeks gestation at the time of enrollment. Women were excluded if they had a multiple gestation. Seven women participated in qualitative interviews in addition to the questionnaires and comprised the subsample reported here. Names presented here are not the participants' names.
Guidelines for Research Recruitment of Underserved Populations
Matsuda, Brooks, and Beeber (2016, p. 164) published guidelines summarized as: “1) Evaluate the composition of the research team; 2) Engage fully with the community by working with key informants and cultural insiders; 3) Reflect the unique cultural characteristics of the community in the research conduct; and 4) Carefully use a matching technique.” Although our study was conducted prior to publication of the guidelines, our study met all of the guidelines. We used race-matching for research assistants who recruited study participants. Details on how the other guidelines were addressed are available from the authors.
Maternal Characteristics. Sociodemographic characteristics, and medical and obstetrical history including income, marital status, and parity were obtained from self-report and medical records. Preterm birth was defined as birth <37 completed weeks gestation.
Neighborhood Disorder. The Ross Neighborhood Disorder Scale is a 15-item instrument that measures neighborhood disorder (e.g., vandalism, housing conditions, crime) on a 4-point scale (strongly disagree = 0; strongly agree = 3) (Ross & Mirowsky, 1999). The scale has established construct validity in a statewide sample of Illinois households that was 16% African American (Ross & Mirowsky). Total score ranges from 0 to 45 with higher scores representing higher levels of neighborhood disorder. Exploratory factor analysis revealed two factors: physical disorder (e.g., vacant housing, vandalism) and social disorder (e.g., robbery, assault). The tool was reliable in this study with 38 pregnant African American women (Cronbach's α = 0.82).
Experiences of Racial Discrimination. The Experiences of Discrimination (EOD) tool measures experiences of discrimination due to race, ethnicity, or color in nine situations (e.g., at school; at work) (Krieger & Sidney, 1996). Participants respond yes = 1 or no = 0 for each of the situations. Total score can range from 0 to 9 with higher scores representing more situations of discrimination. The EOD has established construct validity in a sample of African American adults (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005). The instrument has been reliable in pregnant African American women (Cronbach's α = 0.79) (Giurgescu et al., 2017).
Psychological Distress. The Center for Epidemiological Studies Depression Scale (CES-D) is a 20-item instrument that assesses how participants felt in the past week (Radloff, 1977). The CES-D has demonstrated validity among African American adult women (Torres, 2012). Total score can range from 0 to 60 with higher scores representing more depressive symptoms. Scores ≥16 represent clinically depressive symptoms (Misra, Strobino, & Trabert, 2010). The CES-D was reliable among African American women (Cronbach's α = 0.85-0.89) (Giurgescu et al., 2013; Misra et al.).
The Psychological General Well-Being Index (PGWB) is a 22-item tool that measures how participants have been feeling over the past month on a 5-point scale (Dupuy, 1984). Concurrent validity of the PGWB was confirmed with correlations ranging from 0.52 to 0.80 but no assessments of validity have been conducted with African Americans (Dupuy). The total score can range from 0 to 110 with higher scores representing greater general well-being. Scores ≤72 represent psychological distress. The tool had good internal consistency reliability in samples of postpartum African American women (Cronbach's α = 0.91) (Giurgescu et al., 2012).
Interview Guide. The interview guide consisted of open-ended questions with probes designed to address a wide range of responses. Participants were asked if they had personal experience with preterm birth or if someone close to them who had experienced preterm birth. They were also asked about their neighborhood, experiences of racial discrimination, psychological distress, and their views about the influence of these topics on pregnancy and preterm birth. Some examples of questions included: “Can you describe the area where you live?”; “What is this neighborhood like?”; and “Can you tell me about any experience your family has had with racial discrimination?”
The study was approved by the Institutional Review Boards at the University and the clinical site. African American women were recruited from a prenatal clinic affiliated with an urban medical center from the Midwest. Research staff approached women who fit inclusion criteria before or after their prenatal visit, explained the study, and invited them to participate. Women completed the consent process prior to data collection. Participants completed questionnaires between 8 and 20 weeks gestation on a tablet personal computer. They were reimbursed with a $30 store gift card for their time completing questionnaires, which took between 20 and 40 minutes. As part of the consent process, women were asked if they would like to be contacted for an optional in-depth interview. Participants who expressed an interest were called to schedule the interview. The qualitative interview was offered up to 32 weeks gestation. Fifteen women agreed to be contacted for a qualitative interview at the time they gave consent to participate in the study. Of the 15, 7 women completed the interview. Reasons for not completing the qualitative interview included not being able to reach the women for interviews and close of the gestational age window for conducting interviews. Each of the seven women participated in an individual, digitally recorded, semistructured interview after completing the questionnaire (median = 35 days between completion of the questionnaire and completion of the qualitative interview). All interviews were conducted by phone by a research staff member and were matched on race. Prior successful strategies to prevent and alleviate psychological distress, such as allowing for breaks during the interview, were planned for but not needed. Interviews lasted about 45 to 60 minutes. Women who participated in the interviews were reimbursed with a $25 gift card. Pregnancy and birth data were collected from medical records by research staff.
Data Management and Analysis
Quantitative Data Management. Questionnaire data were collected using the Qualtrics Research Suite, a web-based platform for creating online surveys. Password-protected, customer-controlled survey data were captured in real time and stored on Qualtrics' secure and Transport Layer Security encrypted servers. Data were analyzed using SPSS version 23.
Qualitative Data Management. Qualitative interviews were digitally recorded into audio files, transcribed verbatim by a third-party transcription company, and checked for accuracy. Corrected interviews were then coded using a code book developed by three research team members (AD, AM, KK) using interview data. The first four interviews were double coded. To double code, a trained research staff member independently applied codes to interview data and compared their application of the codes to ascertain adequacy of the coding schema. This process was done to ensure consistent application of codes and enhance data quality as described by Guest, MacQueen, and Namey (2011). Once coding was complete for an individual interview, a descriptive case summary was created for each interview. In a manner similar to double coding, each summary was the product of agreement between two independently prepared summaries to achieve data quality. The main constructs of the study served as the framework for the case summary.
Mixed Methods. A series of matrices were prepared with each matrix focused on a major construct (e.g., racial discrimination) that included both quantitative and qualitative data for that construct. Several team members were again involved in the construction of matrices to ensure data quality (CG, KK, EDM). Within- and across-case analyses were conducted to compare agreement and discordance between the data sources for each construct and to note patterns in the data (Ayres, Kavanaugh, & Knafl, 2003). Conventional content analysis was conducted to describe and summarize patterns within each of the major categories of data (Hsieh & Shannon, 2005).
Sample characteristics are shown in detail in Table 1 and Table 2 (Supplemental Digital Content, Table 2, http://links.lww.com/MCN/A58).
Scores on the Ross Neighborhood Disorder Scale ranged from 9 to 32 with only two participants scoring ≥23 (top 75th percentile) (see Supplemental Digital Content, Table 2, http://links.lww.com/MCN/A58). Nicole had a score of 32 representing high levels of perceived neighborhood disorder; however, she did not report any concern about her neighborhood during the qualitative interview. She noted police patrol the neighborhood frequently and describes her neighborhood as quiet: Everyone looks out for each other...I mean there might be few kids in the neighborhood, but they're not really like out and loitering and lingering around. It's a pretty decent neighborhood and police patrol all the time. The other participants did not identify any concerns about their neighborhood, and described them as good or quiet. Tamara reported feeling that she enjoyed the convenience and proximity of shops in her neighborhood, which was an improvement over her old neighborhood, I like this place more because it has a lot of stores. You know, they're close by. In contrast, Victoria had a score of 21 indicating lower levels of perceived neighborhood disorder, but reported that she did not feel safe in her neighborhood: [...] you have weirdos everywhere. So, you know, people looking for prey...and then people are getting robbed and raped together by three different dudes. Even if I was walking with my boyfriend, no matter his size or you just don't want to put in a predicament like that.
Experiences of Racial Discrimination
The EOD scores ranged from 0 to 4. However, two of the three women who had an EOD score of 0 reported an experience of racial discrimination during the interview. Thus, six of the seven women reported racial discrimination on the survey or during the qualitative interview. Women described a variety of experiences of discrimination from receiving services including medical care to discrimination in the work place. Four of the women described experiences of discrimination in establishments in which they were customers. These experiences left the women feeling judged or unwanted in an establishment. Tamara said: You know...racism is alive...I feel like everybody, you know, has some type of, you know, racist encounter...There are racist people everywhere.
The three women who experienced preterm birth had disturbing experiences of discrimination. Jessica, one of the three women who had preterm birth, described a specific incident where the police questioned her activities while she was buying a used car from two White men. She also received a ticket for illegal license plates even after she explained that she was only test driving the car and did not own it. Two officers they saw us. And they kind of just pulled up and asked us what were we doing out there...So, he ticketed me...even after explaining to him that it wasn't my car...I feel really discriminated against. Kim, who also had preterm birth, had an EOD score of 1, and described an experience where she felt that a shop owner did not want her to buy anything. So we went into the liquor store...and he was just looking at us and he didn't want us to purchase nothing. We walked in the store, he sent us out. He didn't want us to purchase nothing.
Scores on CES-D ranged from 5 to 27 and PGWB scores ranged from 72 to 82. Three women had CES-D scores ≥16, which represent clinically relevant depressive symptoms, and one woman had a PGWB score of 72, which represents psychological distress. Jessica, who had a CES-D score of 19, described her feelings: I have days where I'm like, sometimes I ask myself afterwards like what's wrong with you...But it was understanding that being pregnant itself is like when you not experiencing it, you know, understand how stressful it can be or just how you feel at times. Olivia felt she was more often irritable since getting pregnant: I don't really know...just my attitude changed with this. I'm mean or something. Sometimes, like arguments that wouldn't happen before because that wasn't my attitude...I'm really mean right now.
During the interviews, four of the seven women described their stress that was due to their work situation or relationships with family members, including the father of the baby or their own parents. Kim had a PGWB score of 82, which does not represent psychological distress; however, she indicated during the qualitative interview that she was experiencing high levels of stress: Well, I moved this pregnancy. Working, my job and a lot of, [sic] just been bills and kids and husband. It's been real stressful. Kim also said that she felt that work was particularly stressful: And there is a lot of stuff going on. And I tried to tell my general manager about it, but it's like she's not doing nothing about it really. And I'm like so ready to walk away from this job because it's bad because you know what's going on, you see what's going on...you see everything.
Perceptions of the Impact of Neighborhood Disorder, Racial Discrimination, and Stress on Preterm Birth
Neighborhood Disorder. Although five of the seven women did not report concerns about their neighborhoods, six of the seven women felt that where a woman lives could affect her pregnancy. Kim did not have concerns about her own neighborhood, but said during the interview that where a woman lives can negatively affect her pregnancy: It could affect the pregnancy because if you had to wake up every day and you got to stress about, if you can't take your trash out or if you can't even go check your mailbox without somebody grabbing you or having a gun, getting shot at or something like that, yea that could really affect the pregnancy and cause you to have a preterm labor. Victoria was one of the women who felt that her own neighborhood was somewhat of a concern and that when women worry about the physical environment where they live, this can cause problems during the pregnancy: Constantly thinking about small house, burn down houses surrounding her. May not know how to go about picking up pieces and do better. This may lead to sorrow and the environment may be an outlook of how you feel inside. Tamara reported low concern about her neighborhood but shared that she felt that women's pregnancies can be affected by where they live and explained why, Cause you can't go out and do the things that you usually do. You know, walk around.
Racial Discrimination. Only three of the women felt that racial discrimination had the potential to negatively impact pregnancy. Two of the three women felt that the discrimination would have to be a significant event to cause problems with the pregnancy. Jessica said: I really can't say, cause it's not something that I've experienced...But I don't see where that would too much cause you to...like have a premature baby or really have any lasting effect unless it was something really serious. Kim, one of the four women who rejected the idea that experiences with racial discrimination could have an impact on pregnancy described her beliefs as the following: I don't think it would affect her pregnancy at all. Because if you allow one person to get you angry about yourself, then there is something within yourself that you dislike. Period. That's how I feel. You should love yourself no matter what nobody thinks about you because at the end of the day they're not you, you are you.
Psychological Distress. Six of the seven women stated that the stress felt during pregnancy had the potential to impact a woman's pregnancy and baby. Two of the women who experienced preterm birth perceived stress to have an overall impact on preterm birth. Brittany believed that stress could lead to preterm birth because of a woman's negativity and worrying. She shared the same point of view as Kim, that the baby may feel what the mother is feeling. Kim said, Because if stuff is stressing you out, it can stress your baby out. Stuff at work, period, could stress you out. It could be so stressful that it could stress your pregnancy out.
Three of the seven women felt that stress specific to job or finances may cause preterm birth. Tamara stated the stress of being a single parent and certain jobs might lead to preterm birth. Kim indicated that stress at home or about relationships with others had the potential to cause preterm birth. I think, honestly, because they have stuff going on at home. A lot of them don't really say, because it's something personal. I feel that some of them are fighting at home with their significant others.
Our results suggest pregnant women's perceptions of neighborhood disorder, experiences of racial discrimination, and psychological distress, including the way they perceive stress to have an influence on pregnancy are not easily captured by questionnaires alone. Data derived from interviews, or conversations with pregnant women may help clinicians understand what is important to them in their own words. The mixed-methods approach contributed to a more robust understanding of the concepts. In many instances, participants were more willing to disclose perceptions of these constructs during an interview setting where there is more flexibility and choice in the way they can respond.
Maternal–child nurses should pay special attention to pregnant women's perceptions of their neighborhood environment, experiences of racial discrimination, and psychological distress as these factors may influence a woman's pregnancy (see Supplemental Digital Content, Table 2, http://links.lww.com/MCN/A58). Nurses should understand how their interactions with women may be perceived as discriminatory and thus may contribute to overall experiences of racial discrimination. Nurses can be attuned to how lived experiences with racism and discrimination may have an impact on psychological and physical well-being of pregnant women. Referrals to social service agencies that have counseling or other stress-reduction services should be considered for women who report high levels of psychological distress during their pregnancies. Pregnant women may be reluctant to disclose feelings of depression during healthcare encounters due to fear of stigma or concern about infants being taken away (Sambrook Smith, Lawrence, Sadler, & Easter, 2019). Maternal–child nurses can help create safe spaces where pregnant women feel comfortable having open discussions about their feelings. Through better assessment of the multiple social and psychological factors that women experience during pregnancy, nurses will be better equipped to provide a high level of care to pregnant women. Maternal–child nurses are uniquely positioned to take a leadership role in further research in this area. They can advocate for access to safe neighborhoods for pregnant women by providing referrals to housing agencies and other local social services in order to improve health outcomes for women and their infants. Pregnant women who live with parents have more housing stability compared with those who live alone, and nurses can recommend this type of housing during pregnancy if it is acceptable to those involved (Carrion et al., 2015). Streamlining service coordination within prenatal care delivery models to offer multidisciplinary integration including social services and well-baby care is another way that nurses can help link pregnant women to services (Lu et al., 2010).
This study has several limitations. The sample size was small and the opportunity to participate in interviews was limited to those who had reliable access to a telephone and had time to participate. Participants were recruited from one clinic in the Midwest, which may limit the assessment of neighborhood factors and generalizability of the results to women from other settings. Our study had important strengths, however, particularly the inclusion of the individual perspectives of the women. The mixed-methods approach revealed the varied perceptions the African American women had about neighborhood environment, racial discrimination, and psychological distress.
National Institutes of Health, National Institute of Minority Health and Health Disparities, NIH Grant # R01 MD 01157502 (Dr. Giurgescu)
Center for Urban Responses to Environmental Stressors, NIH Grant # P30 ES 020957 (Dr. Giurgescu)
- Maternal–child nurses should assess pregnant women's perceptions of neighborhood environment, racial discrimination, and psychological distress.
- Nurses should understand how women's perceptions about neighborhood environment, racial discrimination, and psychological distress may contribute to their fears and perceived risk for preterm birth.
- Nurses should be aware of how their interactions with pregnant women may be perceived as discriminatory and thus may contribute to overall experiences of racial discrimination.
- Referrals to social service agencies that have counseling or other stress-reduction services should be considered for women who report high levels of psychological distress during their pregnancies.
- Nurses must advocate for safe neighborhoods by providing referrals to housing agencies and other local social services.
Congratulations to MCN 2019 Award Winners!
2019 Research Article of the Year Award
Clinicians' Perspectives on Admission of Pregnant Women: A Triad
Rachel Blankstein Breman, PhD, MPH, RN, Stacey Iobst, PhD, RNC-OB, C-EFM, Julie Paul, DNP, CNM, PMHNP-BC, PMH-C, FACNM, Lisa Kane Low, PhD, CNM, FACNM, FAAN
Published in the September / October 2019 issue of MCN (Volume 44, Issue 5)
2019 Quality Improvement Article of the Year Award
A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth
Adriane Burgess, PhD, RNC-OB, CCE, CNE, Amy Harris, BSN, RNC-MNN,Julia Wheeling, MBA, BSN, RN, Roni Dermo, MD
Published in the September / October 2019 issue of MCN (Volume 44, Issue 5)
2019 Practice Article of the Year Award
Safety of Over-the Counter Medications in Pregnancy
Angela Y. Stanley, DNP, APRN-BC, PHCNS-BC, NEA-BC, RNC-OB, C-EFM, Catherine O. Durham, DNP, FNP-BC, James J. Sterrett, PharmD, BCPS, CDE, Jerrol B. Wallace, DNP, MSN, CRNA
Published in the July / August 2019 issue of MCN (Volume 44, Issue 4)
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