Alternative Perinatal Care Practices to Reduce Black Infant Mortality and Improve Maternal Wellness

Home , Infant mortality

CALIFORNIA ST ATE UNIVERSITY SAN MARCOS

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THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF PUBLIC HEALTH

THESIS TITLE: Alternative Perinatal Care Practices to Reduce Black Infant Mortality and Improve Maternal Wellness

AUTHOR: Marissa Cardwell

DA TE OF SUCCESSFUL DEFENSE: November 2l 5t, 2019

THE THESIS HAS BEEN ACCEPTED BY THE THESIS C PARTIAL FULFILLMENT OF THE REQUIREMEN · OR, I • PUBLIC HEALTH.

Asherlev Santos \.jJ,-1 1, i THESIS COMMITTEE CHAIR �

Lisa Bandong THESIS COMMITTEE MEMBER �dt/� Alternative Perinatal Care to Reduce Black Infant Mortality

and

Improve Wellness of Black Mothers

Marissa Cardwell

California State University San Marcos ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Abstract

Infant mortality rate, or IMR, is a significant indicator of the health of a nation. The U.S.

has a high IMR in comparison to other developed nations in the world. The burden of the

high U.S. IMR falls on Black families. Black infants are dying at significantly higher

rates than White infants. The main contributor of this disparity is preterm birth and low

birth weight due to elevated stress levels experienced by Black mothers because of the

historic context of racism and discrimination in the U.S. This conceptual literature review

identifies global, alternative perinatal care practices that reduce rates of preterm birth,

low birthweight and improve maternal wellness. The three domains of these methods

were found to be: herbal remedies, mind and body practices and traditional birthing

practices. Perinatal care practices that are rooted in maternal wellness and stress relief

could be implemented to reduce the Black infant mortality disparity in the U.S.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Acknowledgements

I would like to thank my Mom for being there for me throughout every phase of my journey.

Mom, you have molded me into the woman I am today and I truly would not have made it to this point without your unconditional love and support. I love you Mooks! Thank you to my village.

You all have been there for me in every way imaginable. I could not have been blessed with a better team and loving family. I love you dad, my second parents, my grandparents, my uncles, my aunts, my 10 siblings, my cousins, my best friends, and my Popo. I love you sissy!

Thank you to my thesis committee for your time and expertise, your knowledge has inspired me and shaped the way I see Public Health and the world.

Thank you to all the beautiful, powerful Black women who have taken a part in this fight- you all have inspired me.

Last but not least, a very special thank you to my mentor, Dr. Rivera, who believed in me when I didn’t believe in myself.

I’m forever grateful to you all.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

List of Tables

Table 1. Characterization of Articles Included in Review to Reduce Black Infant Mortality and

Improve Overall Wellness of Black Mothers

Table 2. Practices Categorized by Domain and OECD Countries vs. Non-OECD Countries

Table 3. Benefits of Birthing Outcomes: Domain 1

Table 4. Benefits of Birthing Outcomes: Domain 2

Table 5. Benefits of Birthing Outcomes: Domain 3

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

List of Figures

Figure 1. Flow Chart of Articles Included in Literature Review

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Table of Contents

Abstract ...... 2

List of Tables ...... 4

List of Figures ...... 5

Introduction ...... 8 Infant Mortality Rate- Global Perspective ...... 8 Preterm Birth and Low Birthweight ...... 10 Perinatal Health Disparities in the U.S...... 11 Historic Context of Perinatal Health Disparities ...... 12 Perinatal Health Equity as Social Justice ...... 15 Statement of the Problem ...... 16

Methods...... 18 Search Strategy ...... 18 Search Terms...... 19 Analyzed Article Selection ...... 19 Inclusion Criteria...... 19 Country Criteria...... 20 Exclusion Criteria...... 20

Results ...... 21 Domain 1: Herbal Remedies ...... 21 Herbal Remedies and Their Uses ...... 21 Accessible and Cost Efficient ...... 22 Limits to Herbal Remedies ...... 22 Domain 2: Mind and Body Practices ...... 24 Yoga ...... 24 Meditation ...... 25 Manipulative Therapies ...... 26 Social Ties ...... 27

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Domain 3: Traditional Birthing Practices ...... 29 Midwifery care ...... 30 Doula Services ...... 31 Birthing Centers ...... 32

Discussion ...... 34 Implications...... 38 Strengths and Limitations ...... 39 Summary ...... 40 Conclusion ...... 40

References ...... 41

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Introduction

The current infant mortality rate, or IMR, of Black infants indicates that there is a need for improvement in U.S. health systems when it comes to perinatal care of Black women. It was reported by the CDC that Black infants are dying at 2.3 times the rate of White infants (CDC,

2016).

The Social Justice Framework, created to reduce the health inequities in Australia, explains that in order for all communities to be considered equitable and fair, all communities should have equity in availability of resources, access to resources regardless of age, gender, ethnicity or sexual orientation, ability to participate in decisions made that affects livelihood and health of individuals, and rights to be informed about decisions that affect the community and appeal decisions that are unfair (Health and Community Workforce Council, n.d.). This thesis will utilize the Social Justice conceptual framework to identify equitable methods to reduce Black infant mortality rates in the

U.S. by exploring fair, accessible and representative care methods that have been proven to advance birthing outcomes and wellness of mothers. Specifically identifying effective practices that decrease the rates of preterm birth and low birth weight, infant mortality, and the overall mental wellness of Black mothers in order to contribute to research of solutions that address the disparity of Black infant mortality in the U.S.

Infant Mortality Rate- Global Perspective

The infant mortality rate is a substantial indicator when assessing the health of a country. Infant mortality rate is defined by deaths per 1,000 live births (Willis, MCmanus, Magallanes, Johnson

& Majnik, 2014). IM rates are symptomatic of a nation’s access to quality care, public health practices and socioeconomic status (or SES) (McDorman, Mathews, Mohangoo & Zeitlin 2014).

Despite the seemingly advanced medical care and technology in the U.S., the infant mortality rate

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY in the U.S. is alarmingly high, signifying that these rates are not indicative of the status of overall health in the U.S.

Higher healthcare expenditures are commonly associated with reduced infant mortality rates.

For example, data shows that countries with the lowest infant mortality rates are countries that are industrialized (US Department of State, 2019).

For global context of the U.S. IMR, it’s important to look at countries with comparable resources and wealth. In order to do this, the U.S. IMR was compared to the IMR of countries that are members of the Organization for Economic Cooperation and Development, or OECD (Willis et al., 2014). According to the U.S. Department of State, the OECD is a forum that includes approximately 36 member-state economies to promote economic growth and sustainability. These countries account for 63% of the world’s gross domestic product, or GDP, and three quarters of the world trade (US Department of State, 2019).

When compared to other wealthy or developed nations, the U.S. is falling short of achieving an acceptable infant mortality rate, relative to the resources and public health practices available.

Compared to 25 wealthy nations, the U.S. IMR is among the highest of the OECD countries. The

U.S. has an IMR of 5.8 deaths per 1,000 live births (McDorman et al., 2014), but has the largest healthcare budget (Sawyer and Cox, 2018). The Committee for a Responsible Federal Budget reports that the U.S. spends more money on health than any other country in the world, about $3.5 trillion annually, which is more than double the cost in other wealthy nations (Committee for a

Responsible Federal Budget, 2018). Research reports that the average amount of money spent on healthcare per person, per year in the U.S. is about $10,224, in comparison to approximately

$5,000 per person in other industrialized nations (Sawyer and Cox, 2018). This shows that the

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY factors contributing to infant mortality rate in the U.S., have little to do with access to resources or a lack thereof.

Considering that the U.S. falls on the higher end of IM ratings, in comparison to other developed nations, it’s important to identify perinatal practices that have been successful in countries who have obtained a lower IMR and who practice innovative methods to improve maternal wellness that may be out of the normal realm of healthcare expenditures in the U.S.

Preterm Birth and Low Birthweight

The CDC reports that following birth defects, preterm birth, maternal pregnancy complications, sudden infant death syndrome, or SIDS, and unintentional injuries are among the leading causes of infant mortality around the world (CDC, 2019).

Literature reports that preterm births are defined as births occurring before 37 weeks (Smith et al., 2018). Preterm births, or births occurring with a low gestational age are positively associated with low birth weight. A baby who is born before 37 weeks, misses the crucial development needed to not only increase birth weight, but to fully develop major organs, such as the brain, lungs and liver (CDC, 2019). This means that preterm birth and low birthweight increases the risk for death and long term mental and physical disabilities (Willis et al., 2014). Black infant deaths, due to preterm birth, were more than two times the rate of those for White infants (Willis et al., 2014).

Although preterm birth is the second leading cause of infant mortality, preterm birth and low birth weight account for the infant mortality disparity in the U.S., which contribute to the high

IMR. It was reported in the 2015 National Vital Statistics Report that the IMR of white infants was

5.06, while the IMR for black infants was 11.11 (Matthews, MacDorman, Thoma, 2015). This means that black infants are dying at double the rates of their white counterparts. White infants in the U.S. have an overall IMR that is comparable to countries with similar wealth and resources.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

However, in the U.S., IMR rates for Black infants alone, mirror the rates of low income nations, such as Thailand or Grenada (Smith, Bentley-Edwards, El-Amin, & Darity, 2018).

Perinatal Health Disparities in the U.S.

The burden of the high IMR in the U.S. falls on Black families. For the past 35 years, Black infants have had the highest IMR among all other ethnicities in the U.S. (Smith et al., 2018). Due to preterm birth and low birth weight, Black infants are dying at 2.3 times the rate of their White counterparts (CDC, 2016). Black women are 50% more likely to experience preterm birth than

White women and 73% of Black infant deaths are related to preterm birth (Smith et al., 2018).

Preterm birth is detrimental to the health of infants because the longer the gestational age of an infant, the better health outcomes for the infant.

In a research study assessing the Black White infant mortality gap, researchers report that preterm birth is caused by risk factors such as alcohol and drug use, age, education, and stress.

However, even when preterm risk factors are accounted for, the disparity still exists between Black and White infants. Black women are not receiving the same benefit from what would be considered

“protective factors” for other pregnant women.

For instance, when accounting for SES, a higher SES is generally a protective factor from preterm birth, decreasing the likelihood of delivering preterm by 50%. However, having a high

SES only decreases the likelihood for a preterm birth by 0.4% for Black mothers (Smith et al.,

2018).

When examining the association between age and preterm birth among White women, generally the risk for preterm birth is higher in the teen years, then significantly reduced for women once their ages 20-24. Because preterm birth is related to IMR, this means that the teen IMR for white women is 8.5 and is reduced to 6 by the time they are no longer a teen. The IMR continues

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY to decline by half until their 40’s, with the lowest IMR at 3.9 in the early 30’s (Smith et al., 2018).

For Black women, the IMR is reduced from 11.7 to 10.9 infant deaths per 1,000 live births by the time a black woman is no longer a teen and stays around that margin until it increases at 40 (Smith et al., 2018). This means that birth is dangerous for a Black woman at essentially any age (Smith et al.,2018).

Likewise, for educational attainment. Whereas higher educational status decreases the risk for infant mortality significantly among White mothers, a higher educational status does little to decrease the risk in infant mortality among Black infants (Smith et al., 2018). For example, a Black mother with a doctorate degree still faces a higher IMR than a White mother who did not receive a GED (Smith et al., 2018).

Similarly, when looking at risky behaviors such as drinking during pregnancy, the rates of drinking prenatally are not significantly different among Black and White mothers (Smith et al.,

2018). It was also found that three times as many White mothers smoked during pregnancy than

Black mothers (Smith et al., 2018). However, black women still experience higher IM rates. This shows that even when considering protective factors and high risk health behaviors, the disparity still exists.

Historic Context of Perinatal Health Disparities

It is not enough to look at preterm birth as a significant factor that contributes to Black infant mortality, but to look at the causes of preterm birth.

In addition to Black infants suffering from higher mortality rates, the historic maltreatment of Black people in the U.S. has a significant influence on health outcomes of Black people. If not resulting in death, preterm birth also negatively effects the health of Black babies in the long term.

For example, babies born before 37 weeks are shown to experience a decrease in cognitive,

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY sensory, and motor development, as well as reduced behavioral and physical health, putting Black infants at a greater risk for poorer health outcomes in the future (Smith et al., 2018).

Black mothers also have the lowest rates of breastfeeding, when compared to other ethnicities in the U.S. (Asiodu, Waters, Lee, Lyndon, 2016). Literature states that not only is public breastfeeding support and breastfeeding messages not representative of Black women, there is also sociocultural contexts that hinder breastfeeding (Asiodu et al., 2016). For example, Black mothers not being able to breastfeed their children during slavery because they were often used as “wet nurses” and midwives for white babies (Hoban, 2016). This means that Black mothers weren’t allowed to foster the maternal attachment and black babies didn’t receive the health benefits that come from breastfeeding (Asiodu et. al, 2016). Not only did that affect the immediate generation of black people, but future generations to follow. Literature shows this history negatively impacted messages about breastfeeding, such as breastfeeding being considered “a white thing” and rarely shared as a positive, healthy act throughout generations (Hoban, 2016). Having low rates of breastfeeding is significant to the health of the Black population because breastmilk provides nutrients that strengthen a baby’s immune system and prevents the likelihood of developing respiratory and chronic diseases as an adult (Asiodu et al., 2016). If Black people are breastfeeding at lower rates, Black people are becoming more vulnerable to these health issues.

Another adverse health outcome of the Black experience in the U.S. is increased levels of stress hormones found in Black people (Asiodu et al., 2016). Black people are more likely to endure stressful situations such as financial hardship, discrimination, exposure to ambient stressors in work or home environment, including adverse treatment from healthcare providers (Geronimus et al., 2011). Additionally, by the age of 30, Black women experience higher cortisol levels than

Black men and White women (Geronimus et al., 2011). In a research study comparing the stress

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY levels of Black and White women, the results show that Black women between the age of 49 and

55 are 7.5 years “biologically older than” White women, primarily due to weathering, which is defined as the negative health impacts from chronic exposure to stress (Geronimus et al, 2011).

Research shows that the stress caused from perceived racism and discrimination negatively impacts gestational age (Smith et al., 2018). Furthermore, the social conditions that stem from structural racism contribute to lower birth weight and preterm birth (Geronimus et al.,

2011). On a daily basis, Black people are subjected to discrimination, inferior treatment from everyday encounters and stereotyping. An example of this maltreatment of Black people was reported especially negative in healthcare settings by Black mothers. Unfair treatment and lower quality of care in healthcare settings has also been a contributor of disparities in Black infant mortality (National Partnership for Women and Families, 2018). In a 2018 report identifying the birthing experience of Black mothers, a common theme was feeling unheard or listened to by healthcare providers when expressing concerns (National Partnership for Women and Families,

2018). In addition, Black mothers reported feeling increased anxiety and depression perinatally, as well as discrimination during childbirth (National Partnership for Women and Families,

2018). Women also reported being treated unfairly by being handled with less care and attentiveness by medical staff (National Partnership for Women and Families, 2018). There were also reports of feeling a lack of support and communication between healthcare staff and

Black patients (National Partnership for Women and Families, 2018).

The basis of adverse experiences could be due to the fact that traditional healthcare providers are not culturally sensitive and representative of the minority populations they serve, commonly resulting in implicit bias, a concept that may take generations to change. As a consequence, Black mothers may experience elevated levels of stress or may not be given the

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY needed treatments and care relative to their chief complaints about birthing (National Partnership for Women and Family, 2018). To mitigate this, women should have access to diverse perinatal healthcare providers and the option to choose birthing processes that work better for them. For example, birthing at a birthing center, closer to home with the space for more familial support.

Anti-discriminatory laws and implicit bias trainings can only offer so much to a history of racism in America. It’s important to focus on things that can be changed in this generation.

Because preterm birth, associated with biological weathering of Black women, is the leading cause of the Black IM disparity, it is important to identify perinatal care methods to decrease stress levels and improve the wellness of Black mothers in order to reduce the risk of preterm birth, infant mortality, and to advance the overall birthing experience of the Black mother. All women should have access to methods of care that reduce stress levels and provide equitable support during the perinatal period.

Perinatal Health Equity as Social Justice

In Australia, the social justice framework is effective in reducing the health inequalities among aboriginal people, who are a marginalized community, by focusing on the principles of the framework; advocacy, empowerment, equity, access, and diverse participation (Health and

Community Workforce Council, n.d.). In order to address the need for social justice in equity of healthcare delivery to aboriginal women, there was research conducted to assess the unique healthcare needs of the aboriginal community, relative to perinatal health care. The women participated in focus groups to share information about experiences of birthing and maternity care in their lands. A major finding of the study was that women felt healthcare was most effective when healthcare providers were culturally competent and representative of their culture (Marriott et al, 2019). Because women were given access to participate in healthcare decisions that directly

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY affected them, these methods was more equitable and diverse. As a result, researchers were able to address the need for healthcare providers to be diverse, culturally competent, and representative of the audience, and policies were created to provide equal access to healthcare services, clean water, and other resources (Health and Community Workforce Council, n.d.).

Based on the successful outcomes of these findings, Black mothers, infants, and families should have the right to fair and equitable healthcare guided by the social justice framework.

Considering this model, if there is advocacy for Black mothers to be listened to by healthcare providers, empowerment to be able to make informed birthing choices, equity in treatment, access to quality healthcare, and participation by providers and health educators that are culturally competent and diverse to provide innovative and complementary perinatal care practices for Black mothers, then the Black IMR disparity can be significantly reduced.

If alternative and complementary perinatal care is effective in reducing stressors and increasing gestational age, then when utilized by Black mothers, the Black infant mortality rate should be reduced. In order for these alternative and innovative practices to reflect the principles of the social justice framework, practices should be accessible for all black mothers.

Statement of the Problem

Black infants and mothers are disproportionately affected by the high infant mortality rate in the U.S. Not merely because of race, but because of factors that stem from racism and the Black experience in the U.S. (Smith et al., 2018). Research shows that Black people, or people of African descent, have better birthing outcomes around the world (Taylor & Sarathchandra, 2014).

Additionally it is reported that these favorable health outcomes are due to healthier behavioral practices and cultures that function to increase social support and reduce stress (Taylor &

Sarathchandra, 2014). Because the history of structural and institutional racism in the U.S., social

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY support is weakened, and racism and discrimination exist, decreasing positive birth outcomes of

Black women in the U.S. Efforts to strengthen social ties and reduce stressors must be prioritized in order to improve health outcomes for mothers and babies.

The goal of this study is to identify traditional and alternative methods to perinatal care that will be effective in reducing Black infant mortality, preterm birth and improving overall maternal wellness for Black mothers.

For the sake of this paper, traditional perinatal health care methods are defined as culturally competent and representative, historically used perinatal practices that would be appropriate in supporting the perinatal health of Black mothers. For example, the use of Black doulas and midwives, offering Black-lead support groups for mothers, educational perinatal classes and workshops specific to unique Black experiences, advocacy for Black mothers in hospital settings, and culturally competent lactation support (Thomas et al. 2017). With proper implementation, Black mothers should feel heard and respected, empowered and informed, and they should feel they are being supported and treated equally (Karlstrom et al. 2015). For the sake of this paper, improved maternal wellness is defined by practices that improve mental and physical health. This also includes engaging in practices that take a holistic approach to improving the health of the mind and body (Jelly, Yadav & Dey, 2018). Lastly, this review assesses perinatal health because research shows that many adverse experiences and outcomes are faced before and after pregnancy, as opposed to merely prenatally. Identifying alternative healthcare methods to reduce Black infant mortality can significantly lessen the Black IMR gap.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Methods

A systematic literature review was conducted in order to identify innovative and global perinatal care practices to reduce preterm birth and low birthweight, infant mortality, and to improve the maternal wellness among Black mothers in the U.S. The conceptual literature review consists of literature published since 2014.

In order to choose methods that could mitigate racial inequalities in the U.S., methods included followed the principles of the social justice framework. For example, perinatal care practices that were identified by the literature as being equitable and fair, methods that were easily accessible and cost-effective, culturally competent and diverse, and methods led by those competent of the communities needs in which the service is being provided.

In order to identify an alternative perinatal care method as effective, studies were included where research showed an improved perinatal experience, longer gestational age, lower rate of infant or maternal mortality, or less adverse hospital experiences.

The literature analyzed global standards of care and innovative perinatal practices. This data was then reviewed to identify the association of these alternative care methods and mental wellness, gestational age, and infant survival rate.

Search Strategy

In order to examine the full scope of available information, the initial search did not include specific countries or methods. The academic databases that were used to conduct the literature search for this study were PubMed, National Institute of Health and Google Scholar.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Search Terms.

In the initial search, the following key words were used: “perinatal health and Black mothers,” “alternative perinatal health,” “Black infant mortality,” “Black mother experience in hospitals,” “global perinatal care practices,” “perinatal support for Black mothers,” and

“perinatal health.” The initial search identified themes, (or domains), definitions, and general information about the current literature.

After the initial search, a more informed search was conducted in order to increase the amount of literature to examine for each domain. A more informed search included the terms

“birth outcomes and doulas,” “birth outcomes and midwifery care,” “mind and body perinatal practices,” “alternative and complementary medicine,” and “herbal remedies during the perinatal period.” These terms were chosen because they were described by the literature as following at least one of the social justice principles.

Analyzed Article Selection

A search of key words yielded a total of 313 articles. Of the 313 articles, 138 were excluded by title, 20 were excluded by abstract, 103 were excluded by relevance, 18 were excluded as duplicates and 12 articles were excluded by study characteristics, reducing the remaining articles to 22. Of the 22 articles remaining, the articles were categorized into three domains. Of the 22 articles, seven were included for Domain 1, eight were included for Domain

2, and six were included for Domain 3. Theses domains were created based on global common themes found in complementary and alternative perinatal care practices around the world.

Inclusion Criteria.

Inclusion of literature was determined by the studies that specified an alternative care practice and presented the associated health outcomes as a result of the practice. Specific

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY outcomes that were included were practices that improved mental well-being, birthing experience, and decreased the rate of preterm birth, low birth weight, and infant mortality.

Articles included also focused on care practices that were innovative, by being different from the western-traditional hospital/doctor method and could be categorized as a mind and body care method, herbal remedy, or utilized alternative and supplementary medical systems and followed the principles of the social justice conceptual framework.

Country Criteria.

Opening the inclusion criteria to include practices utilized in a global context aided in capturing a diverse range of effective perinatal practices. However, the article selection was limited to include literature that described alternative perinatal care practices in countries that were relative to the U.S. For example, countries that were comparable in nation’s wealth and/or disparities experienced by marginalized communities.

Exclusion Criteria.

Literature that was excluded from the analyzed articles was literature that was specific to alternative care for a specific disease. For example, alternative care methods for mothers with a chronic disease or acute mental disorders. Articles that were not data driven were also excluded.

Research that did not yield results relevant to search domains and determinants of health, as defined in this review, were also excluded. Lastly, studies without results, e.g., pilot programs, were excluded.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Results

This systematic review explored alternative, innovative perinatal practices that have shown to improve birthing experience, overall mental wellness, and decreased low birth weight and infant mortality. The literature revealed that Herbal Remedies, Mind and Body Practices, and

Traditional Birthing Practices were effective in reducing infant mortality and improving overall birthing experience, by reducing stress, and reducing the prevalence of preterm birth, and low birth weight.

Domain 1: Herbal Remedies

The use of herbal remedies, as a means to support prenatal health and childbirth, is a practice that has been widely used among pregnant women around the world for centuries (Jaafari,

Fothoohi, Razavi & Asl, 2016). Herbal remedies have been defined by the literature as medicines that have been extracted from plants for preventative and medicinal purposes (Jaafari et al., 2016).

Herbal remedies include plant parts and account for about 65-80% of the use of herbal medicines around the world (Laelago, Yohannes, Lemango, 2016). Furthermore, in some contexts, herbal remedies are also encompassing of minerals, shells, animal parts, fungal and bee products (Jaafari et al., 2016). Herbalism is considered a non-traditional form of medicine because its use and creation do not follow the scientific method and most commonly are not as streamlined as evidence-tested pharmaceutical drugs.

Herbal Remedies and Their Uses

There are various herbal remedies that have health benefits specific to the woman during the perinatal period. For example, arnica which is a plant native to Europe, that can be rubbed on the skin and is reported to relieve labor-related pain and improve muscle functions, and pulsatila, when dried, is used as a homeopathic medicine which is reported to encourage healing from child

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY birth and manage perinatal mood disorders (Jelly et al., 2018). Herbal remedies are most commonly used for back pain, neck pain and anxiety during pregnancy among women in the

United States (Johnson, Kozhimannil, Jou, Ghildayal, & Rockwood, 2016). Some of the most common herbal remedies used by women perinatally are garlic, red raspberry leaf, ginger, and eucalyptus (Laelago et al., 2016). The literature explains that many users of herbal medicine find it effective and safe (Jelly et al., 2018).

Accessible and Cost Efficient

The literature shows that rates of herbal medicine use are quite common around the world, with approximately 70-80% of the world depending on herbal remedies (Zaitoun Marwah, Al-

Nowis, Alhumaidhan, Khalil, 2019). More specifically, in the U.S., 67% of women of reproductive-age reported using complementary and alternative herbal medicines (Johnson et al.,

2016). In Nigeria, 82.1% of women reported using alternative medicine (Onyiapat et al., 2017), while 63% of participants in a Saudi Arabia study preferred herbal remedies over drugs during pregnancy (Zaitoun et al., 2019). Complementary and alternative herbal remedy users reported that herbal remedies were successful in treating multiple symptoms and increased energy levels during pregnancy (Zaitoun et al., 2019). Furthermore, the literature reports that aside from being effective and deemed natural, herbal remedies are far more cost-efficient and accessible (Zaitoun et al., 2019). Additionally, women who cannot afford prescription drugs rely on herbal remedies to address pregnancy related discomforts.

Limits to Herbal Remedies

Because herbal remedies are not formally regulated, there is a lack of evidence regarding safe dosages and related side effects (Onyiapat et al, 2017). A common theme in the literature explains the need for regulation, as well as the need for healthcare providers to be properly

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY informed about the usage of herbal remedies in order to be able to effectively educate healthcare patients on the risks and benefits associated with using herbal products. On the other hand, while the actual safety of the product use may not be documented, many pregnant women reported using the product anyway, without reporting the use to their doctor (Onyiapat et al., 2017).

Table 3. Benefits of Birthing Outcomes: Domain 1

Herbal Reduces Pregnancy Supports Healthier Mental Healing from Pregnancy Remedies Related Discomforts Health and Wellness Related Complications

Arnica x

Aloe Vera x

Coffee x

Chamomile x x

Eucalyptus x

Fenugreek x x

Garlic x

Ginger x

Green Tea x x

Red x x Raspberry Leaf Pulsatilla x x

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Domain 2: Mind and Body Practices

Mind and body practices are among the most common and widely accepted forms of traditional medicine (Jelly et al., 2018). Mind and body medicine can include wellness practices such as yoga, meditation, and manipulative therapies, e.g., massage and acupuncture (Jelly et al.,

2018). The literature explains that these practices have multiple, diverse health benefits directly related to pregnancy. The literature reports that the most common perinatal healthcare providers of these services are midwives (Jelly et al., 2018). Furthermore, the most commonly reported benefits of mind and body practices are increased benefits of mental health, for example, lower anxiety, depression, and stress levels (Akarsu & Gulay, 2018). This is important because the literature reports that poor mental health negatively impacts perinatal health for mother and infant

(Chan, 2015). Additionally, poor mental health is also a driver of preterm birth and low birthweight

(Chan, 2015). The literature proves that mind and body practices that reduce mental stress are shown to improve birth outcomes (Chan, 2015).

Yoga

Yoga has been defined by the literature as a mixture of mindful breathing techniques and focus on the relationship of mind and body (Bershadsky, Trumpfheller, Kimble, Pipaloff, & Yim,

2014). Yoga is explained by the literature as being a common practice of women during pregnancy since the 20th century, proven to have numerous health benefits during pregnancy (Akarsu &

Rathfisch, 2018). Yoga has been associated with increased prenatal attachment, longer gestational periods, reduced risk of stress and preterm birth (Akarsu & Rathfisch, 2018). In a study on pregnant women who participated in 90-minute yoga sessions, the women who practiced yoga had lower levels of the stress hormone, cortisol, than pregnant women who did not (Bershadsky et al., 2015).

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Research also revealed that women who participated in yoga had a more positive outlook and effect after practicing (Bershadsky et al., 2015). The literature also reports that women who practiced yoga prenatally experienced less depressive symptoms (Akarsu & Rathfisch 2018).

Overall, the literature reveals that yoga is not only effective in improving physical health during pregnancy, but also mental health.

Meditation

Meditation is a mind and body practice that involves self-awareness, a shift in mental practice, and training and transforming of the mind (Chan, 2015). Some examples of meditation practices are through prayer or spiritual practices, music therapy, hypnosis or using creative, artistic outlets (Jelly et al., 2018). Mental health is a crucial factor in determining birth outcomes and is significantly affected by daily thoughts (Chan, 2015). Meditative practices that mitigate emotional and mental health related challenges have been successful in improving birth experience and gestational age (Chan, 2015).

Research reports that a cohort of pregnant women in China participated in a prenatal meditation program (Chan, 2015). By participating in the program, pregnant women practiced mindful skills to improve their ability to cope with stress, problem solving, and to promote self- esteem and positive thinking (Chan, 2015). Overall, the study found that the participants experienced improvement in pregnancy related physical discomforts, such as experiencing better sleep (Chan, 2015). Participants were also more relaxed and reported an improvement in maternal- fetal relationship (Chan, 2015). Findings also show that focus on spiritual and mental well-being is effective in enhancing health outcomes (Wainapel, Rand, Fishman, & Halstead-Kenny, 2015).

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

In an Australian study assessing the outcomes of women who participated in a mindful parenting program, participants who practiced mindful caring of the mind and body experienced reduced stress related to parenting and less depressive symptoms (Townshend, Caltabiano, Powrie

& O’Grady, 2018). There was also significant improvement in self-compassion, which was linked to prenatal attachment and mental well-being and increased gestational age. (Townshend et al.,

2018). Results also show that even women who have experienced trauma have less prevalence of depression and anxiety when practicing mindful thinking and meditation (Townshend et al., 2018).

Manipulative Therapies

Manipulative therapies have been defined by the literature widely as body-based practices such as chiropractic care, massages and acupuncture (Jelly et al., 2018).

Acupuncture is reported as an ancient Chinese practice that has been utilized for the past

2,000 years, in which specific parts of the body are stimulated by needles, heat, pressure, or magnetic energy, for healing purposes (Jelly et al., 2018). In birth, acupuncture is beneficial in ripening the cervix, reducing the prevalence of medical intervention and a shortened length of labor (Jelly et al., 2018). The literature also reveals that women who utilize acupuncture during pregnancy experienced an improved birthing experience (Williams, Sweet & Graham, 2019). In

Australia, acupuncture has been a common practice administered by midwives, to pregnant women

(Williams et al., 2019). Findings from literature also report that acupuncture promoted natural birth (Williams et al., 2019).

Massage has been linked to lessening the length of labor, the need for medical interventions, and managing pain during child birthing. Massage, or reflexology, is the manipulation of muscles, tendons, joints, and soft tissues (Wainapel et al., 2015). The literature reports that in a study of 100 pregnant women in England, those who received massages had a

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY shortened duration of labor as well as less need for medical intervention (Wainapel et al., 2015).

It was found that women who received massages were less likely to have to take strong pain medication during labor (Wainapel et al., 2015). Massages have also been associated with decreasing back pain related to pregnancy (Wainapel et al., 2015). Overall, massages are associated with improved birthing experience and fewer medical interventions (Williams et al.,

2019). Fewer medical interventions have been described by the literature as facilitating a healthier mental well-being among women during the perinatal period (Williams et al., 2019).

Social Ties

Strengthened social ties of pregnant women is shown by the literature to improve birthing outcomes (Kane, 2016). Social ties have been defined by the literature as relationships, marriage, and family and peer support (Kane, 2016). The literature reveals that when social ties of pregnant women are stronger, pregnant women are more likely to practice healthier behaviors (Kane, 2016).

For example, women who have stronger social ties experience lower rates of prenatal smoking, receive encouragement to begin prenatal care early in pregnancy, experience increased positive feelings about pregnancy, and achieve greater financial status (Kane, 2016). In fact, a research study reports that strengthening ties, through marriage, decrease the rates of low birth weight and preterm birth (Kane, 2016).

Another method of social support found to result in more positive birthing outcomes are group prenatal care classes. In group prenatal care classes, participants are educated about the birthing experience, while engaging in peer support with other group participants. The literature explains that group prenatal care is more effective than the most common, individual care model

(Earnshaw et al., 2016). For example, in a 2015 study of over 300 sites implementing a group prenatal care model, it was found that participants in the group care gave birth to infants with

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY longer gestational age and heavier birth weight (Earnshaw et al., 2016). Furthermore, the same study also found that group attendance and engagement were greatly influenced by the diversity in age among other participants that shared a similar cultural background (Earnshaw et al., 2016).

The study revealed that Black women who participated in group prenatal care with a wide age range of other Black pregnant women experienced a greater sense of belonging and were more receptive to healthy birthing advice (Earnshaw et al., 2016).

Recent literature also revealed that mobile health was effective in improving birth outcomes. The World Health Organization, or WHO, defines mobile health as public health and medical practices supported and accessed through mobile devices (Asiodu et al., 2015).

Specifically for Black mothers, information and social support, via social media and mobile apps provided Black pregnant women with beneficial health information surrounding birth and breastfeeding (Asiodu et al., 2015). The literature reports that in a study with women who utilized social media platforms to access health information, participants had an increased rate of breastfeeding rates and reported feeling greater support through the perinatal period, as well as an improved birthing experience (Asiodu et al., 2015). However, it was also reported that a key gap in this method was that messaging was not representative of Black mothers or culturally sensitive to Black people (Asiodu et al., 2015). As a response to this need, mothers from this study reported that social media health information should be targeted and representative of those most affected by poorer birth and breastfeeding outcomes (Asiodu et al., 2015).

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Table 4. Birthing Outcome Benefits: Domain 2

Mind and Body Birthing Benefits Practices

Yoga  Increases prenatal attachment  Longer gestational period  Reduces rate of preterm birth  Reduces stress levels Meditation  Helps manage pregnancy related discomforts  Improves mental health  Improves coping skills Acupuncture  Shorter length of labor  Increases ripening of the cervix  Can improve birth experience Massage  Releases pregnancy related discomforts  Provides support during pregnancy  Can improve wellness  Fewer medical interventions  Shortens the length of labor Social Ties  Longer gestational age  Heavier babies  Increased mental wellness

Domain 3: Traditional Birthing Practices

In a report that highlighted Black mothers experience and perspective in healthcare settings, many women described feeling rushed and ignored by healthcare providers (National

Partnership for Women and Families 2018). It was common for women to also report feeling like their needs were not met and listened to, resulting in unequal and inadequate healthcare treatment during the perinatal period. The literature goes on to explain that this unequal treatment and access to obtaining quality care contributes to the disparity in health outcomes among Black mothers and babies (Thomas, Amman, Brazier, Noyes & Maybank, 2017). The literature also reports that

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY women reported feeling more supported and receiving better care when utilizing alternative birthing processes, such as birthing with a midwife at a birthing center or utilizing a doula perinatally (Thomas, Ammann, Brazier, Noyes & Maybank, 2017).

Midwifery care

The search of keywords yielded the most data on the health benefits of midwifery care.

Most commonly, midwifery care was considered the most preferred and healthiest option for mothers during the perinatal period. Midwifery services have been related to greater satisfaction among patients, fewer medical interventions and increased support during the perinatal period

(Long et al., 2016). For example, in South Africa, midwifery care was linked to a decrease in maternal mortality rate (Long, et al., 2019). Because of this, the literature concluded that midwifery care was a safe and cost-effective alternative to perinatal care (Long et al., 2019).

In Austria, the majority of maternity care is hospital-based, without the use of midwives

(Bodner-Alder et al., 2017). However, in a study that incorporated midwife-led care into maternity care settings, the result was improved satisfaction and fewer birthing complications (Bodner-Alder et al., 2017).

Lastly, participants in an Irish focus group, in which the study explored preferences and experiences in supplemental and alternative perinatal care, the literature explains that women who utilized midwifery care felt more support and reassurance from healthcare providers (Fawsitt et al., 2017). Overall, midwifery led care was reported to improve maternal mental health, satisfaction, and health of the infant.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Doula Services

Doulas provide supplemental support to assist women during the birthing process (Thomas et al., 2017). Doulas have been associated with positive birth outcomes, such as lower rates of cesarean section, preterm birth, and higher rates of breastfeeding initiation (Thomas et al., 2017).

Doulas have also been reported by the literature as representative liaisons, which can effectively advocate for their patient during the birthing process and provide support throughout the perinatal period (Thomas et al., 2017). In a research study that examined the needs of Aborigine mothers in Australia, the literature reports that women felt that their care would be more effective if there were healthcare providers that were culturally competent and representative of their culture

(Marriott, 2019). For example, mothers felt that having perinatal care providers that shared the same culture would result in feeling more supported and that their cultural needs were being met.

Furthermore, the text explained that addressing this disconnect between women from marginalized communities and the implicit bias in healthcare settings would mitigate disparities and result in better birth outcomes (Thomas et al., 2017). Participants also reported that representative care was an important need in perinatal care. Women reported that representative care resulted in women feeling that they were listened to, and cultural awareness was a major part in the effectiveness of care delivery. Doula services have been associated with a more positive experience and positive health outcomes for mothers.

Literature also reports that doula support reduces maternal stress, ultimately improving the birthing experience of Black mothers (Thomas et al., 2017). Doulas can also provide massages and support yoga and mindful practices, which has been linked to less maternal stress (Thomas et al.,

2017).

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Birthing Centers

In one article, the data reported that births in free standing midwifery units increased the prevalence of spontaneous, vaginal birth, lowering the rate of caesarean section, epidurals and other serious birth interventions (Christensen & Overgaard, 2017). Birthing in a freestanding midwifery unit also gave the mother and family a more “close to home,” familiar birthing experience (Christensen & Overgaard, 2017). This strengthens social ties by allowing the family the freedom and space to be involved in the birthing process, as well as in the perinatal healthcare process. Strengthened social ties were associated with longer gestational periods and other healthier birth outcomes, such as improved maternal mental health and fewer medical interventions

(Cane, 2015).

In a research study that examined the birthing outcomes associated with mothers who utilized freestanding midwifery units and compared the outcomes to those who birthed in a hospital, it was found that mothers who birthed at midwifery units had better outcomes

(Christensen & Overgaard, 2017). Women who birthed in birthing centers also felt that they had more options in the birthing and labor process and felt that their birth plan and needs were respected (Bodner-Alder et al., 2017). Overall the literature revealed that women reported having the best birthing experience when they had freedom to make informed decisions about their birth

(Fawsitt et al., 2017).

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Table 5. Beneficial Birthing Outcomes: Domain 3

Traditional Birthing Outcomes Birthing Systems Midwifery Care  Patient centered care  Less medical interventions  Reduced rate of cesarean section  Longer gestational periods Doula  Services associated with greater advocacy for patients birthing process  Increased support fosters longer gestational age and heavier babies  Provides comfort throughout labor, lessening the need for more medical interventions

Birth Centers  Facilitates stronger social ties  Gives mother the freedom to labor more naturally  Patient Center Care

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Discussion

The findings indicate that there is not an apparent single solution to addressing the infant mortality disparity in the U.S. Not only are there many factors that contribute to the disparity, research has shown that likewise, there are various alternative care methods to address the disparity. This is significant because all moms are different and having a wide range of options to care that is preferential to the individual mom is beneficial to mental health, stress and anxiety, it’s also equitable in giving mothers a choice in health decisions that affect them.

Considering the historic context of race in the U.S., practices that follow the social justice principles are needed to mitigate the root causes of the disparity. The three major domains identified provide a diverse range of practices that can implemented in improve maternal wellness and decrease preterm birth and low birthweight.

The first domain examined the birthing outcomes associated with using herbal remedies as opposed to prescription pills. Overall, herbal remedies were found to be very common, especially among populations that have little access to prescription medications. Herbal remedies were also reported as effective in reducing pregnancy-related complications and to be useful for pain relief related to pregnancy (Jaafari et al., 2016).

While many women reported that herbal remedies were effective in improving maternal and infant health when used perinatally, research also suggests that there is little regulation of herbal remedies, which can be potentially dangerous due to unknown dosage effects. In order for herbal remedies to become a more widely used and safe method of alternative perinatal care to

Black mothers, there is a need for further information and research to ensure that the types and dosage of herbal remedies are safe for consumption.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Herbal remedies were often reported as being a more cost-effective, natural, and effective alternative to prescription medications (Jaafari et al., 2016). Herbal remedies are equitable, because they can be accessible to pregnant women who can’t afford prescriptions or in places where there is no access to a pharmacy.

Research indicates that herbal remedy use was more prevalent in countries with lower financial status (Onyiapat et al., 2017). The literature reports that herbal remedy use was most common in Nigeria, Ethiopia, Iran and Saudi Arabia and the U.S. Only one of these countries is a part of the OECD, which is the U.S. This means that there is a lot that can be learned from countries that may not be as industrialized as the U.S. when it comes to providing medicines that are natural and much cheaper to consumers. Likewise, the U.S. has a strong FDA model and policy, this can help other countries by providing support and framework to develop safe regulation and usage of herbal remedies. Overall, many herbal remedies were proven to be effective, cost efficient, and more accessible than prescription pills to treat common pregnancy-related symptoms.

The second domain explored the mental and physical benefits of practicing mind and body wellness during the perinatal period. The research shows that mind and body health include a broad scope of practices. For example, yoga, meditation, acupuncture, chiropractic care, and strengthening social ties have been proven to reduce stress, improve mental health, and reduce the occurrence of preterm birth (Jelly et al., 2018). Yoga was found to improve birth weight and reduce perinatal stress and depression (Jelly et al., 2018). Yoga was also effective in relieving pregnancy related pain and discomfort, which improves mothers’ birthing experience (Jelly et al., 2018). With the high rates of stress and anxiety faced by Black mothers, utilizing mindful techniques, such as meditation or yoga, can significantly decrease stress levels, resulting in a healthier pregnancy.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Yoga, as a perinatal care practice, aligns with the social justice framework because yoga can be free and few, if any, resources are needed to practice yoga. This makes yoga a holistic practice that is accessible. However, a limit to yoga is that its effectiveness could be hindered if a person has a disability that affects their movement and agility.

Meditation can be a useful practice that nearly anyone can participate in. Because meditation is very intrinsic and reflective, the individual is in control of its effectiveness, meaning that it can be equitable to all people who practice.

Manipulative practices such as massage and acupuncture can be an effective alternatives to hospital settings and conventional healthcare because they can be performed by various professionals such as massage therapists, doulas, or midwives. Being an effective perinatal care method that can be practiced by various people, manipulative therapy can be an effective and accessible alternative. This can also potentially be helpful for Black mothers who have experienced trauma from racism or other life experiences, as the literature reports that mindful programs can mitigate anxiety and depression prevalence among women who have experienced trauma.

Social ties are another equitable practice that can be managed at the interpersonal level.

Social ties are also diverse because women can choose to create ties with other people they relate to, based on what is individually perceived as beneficial to health. Access to social ties can be strengthened by increasing spaces where diverse perinatal care providers and support groups are available. Social ties increased through social media is equitable because nearly every American has a smart phone. With breastfeeding apps, as described in the literature, positive messages about breastfeeding can be reintegrated into Black culture and Black breastfeeding rates can improve.

Prenatal attachment can also be restored through increased rates of breastfeeding.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Additionally, most mind and body research was conducted in countries that are a part of the OECD. With a collaborative already in place, sharing best practices and ideas of interventions that have a positive effect on birthing outcomes can be done with little effort and provide support for implementation of policy and practices that are equitable ad effective.

The third domain identifies the health and satisfaction associated with using alternative and supplemental health systems, including utilizing a midwife and/or doula and birthing outside of the hospital, such as at a birthing center or a home birth. By doing so, women have reported having a better birthing experience with fewer medical interventions (Christensen & Overgaard, 2017).

By utilizing midwifery care or birthing centers/home births, women have the opportunity to birth in a space with more freedom and family support. Women have the opportunity to feel more listened to and to take their time in a non-hospital setting. Birthing outside of the hospital can also mitigate implicit bias from healthcare staff. Midwifery care, doula services and homebirths are equitable because services are primarily cheaper than birthing in hospital, or having a surgery related to birth. Doulas are also chosen by the patient, which means women could have the opportunity to choose a healthcare provider who looks like them or shares the same culture or religion.

The literature reports that although Black women are often the most in need of these services, they are the least likely to receive them (Thomas et al., 2017). Making doula service more accessible would be an equitable practice. This goal could be achieved by recognizing doula care as a medical practice to be included in insurance coverage, or greater education and utilization of doulas in healthcare spaces. The literature also reports that supplemental support during labor is a significant mean of mitigating these disparities (Thomas et al., 2017). If there is a more diverse perinatal workforce trained and employed to provide services, this can be beneficial in mitigating

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY disparities. This can be implemented by policy or funding that encourages perinatal training among

Black women or education about the health benefits of increasing black medical professionals on black infant health disparities.

Implications

Potential implications for this research are alternative perinatal care solutions that can address barriers that contribute to the health disparity found in Black infant mortality rates and preterm birth rates experienced in the U.S. Because alternative perinatal care methods, as defined in this paper, are linked to reducing Black infant mortality and improving birthing experience for

Black mothers, government funding and public health efforts should prioritize implementation of supplemental perinatal support for Black mothers to address this gap in healthcare.

By implementing policy that creates accessible perinatal health services, communities could be empowered to seek alternative methods of birthing for better outcomes. This could be achieved by updating policy to include midwifery care and doula support into both private health insurance and Medicaid coverage.

Additionally, identifying the need for culturally competent and representative perinatal healthcare could foster more diversity. This could be led by implementing cultural competency training among perinatal healthcare providers. Ultimately, by pooling alternative perinatal methods that have proven to create more positive birthing outcomes globally and nationally, public health could better address the disparity in infant mortality and preterm birth experienced by Black mothers and improve birthing outcomes in the U.S. and around the world.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Strengths and Limitations

This study identified a diverse range of alternative and traditional methods of perinatal care practiced in various countries around the world. The study also explores innovative methods of care that are both effective and accessible. The literature reviewed was recent, having been published in the last 5 years, ensuring that the data and trends are still relatively up to date with a big enough time range to update or correct findings as needed. The data also includes results that have been proven to reduce preterm births and low birth weight, which are the top contributors to infant mortality rates in the U.S.

The limitations of this study are the availability of research and literature specific to Black mothers during the perinatal period. Although the research reports methods that increase favorable birthing outcomes and maternal health, there is a gap in research that specifies these outcomes for

Black mothers. Furthermore, it is important to examine the efficacy of these methods specifically in relation to Black culture in the U.S and to ensure that practices are culturally competent. For example, there should be black yoga instructors that can empower black women to practice yoga in neighborhoods or locations where black people are.

When using data from the birthing outcomes of mothers in other comparable countries, it was difficult to find populations that experienced similar racism and discrimination compared to what Black people in the U.S. are exposed to. For example, most countries with data available for complementary and alternative perinatal medical practices were other developed or wealthy nations. Because of this, data may not be representative of effective methods that are being practiced in places where there is no research being conducted or available.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Summary

A literature review was conducted in order to identify alternative and complementary medical practices to reduce infant mortality and improve maternal wellness among Black mothers.

The key word search resulted in 22 articles that were categorized into 3 domains: Herbal Remedies,

Mind and Body Practices, and Traditional Birthing Practices. The findings identify traditional birthing processes and methods that have been proven to improve the mental wellness of mothers, decreased rates of preterm birth and low birth weight, and ultimately, reduced rates of infant mortality. Some of these practices include perinatal yoga, the use of midwifery and doula services, group prenatal care that is representative of the patients served, acupuncture, meditation, and herbal remedies. With this information, further research needs to be conducted in order to measure the efficacy of these practices in reducing the infant mortality rate when utilized by Black mothers in the U.S. These findings can be integral in reducing the Black infant mortality disparity in the

U.S., as well as improving birth outcomes for mothers around the world.

Conclusion

The disparity in infant mortality rates in the U.S. is a major public health concern. When looking at the main contributors of preterm birth; educational attainment, SES, age, and drinking and alcohol usage, among Black mothers, do little to explain this disparity. However, elevated stress levels due to the Black experience in the U.S., is positively associated with preterm birth and low birthweight. This explains that the disparity exists not because of race, but because of racism (Smith et al., 2018).

The historic context of racism and implicit bias can take generations to change. However,

Black mothers being provided with equitable care and freedom in birthing options can impact change now. With holistic solutions, to address stress levels and improve maternal wellness being

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY proven to improve adverse birth outcomes, there is urgency for public health efforts to advocate for social justice and to implement this advocacy in perinatal care practices. Black mothers deserve the right and opportunity to have healthy babies. Achieving social justice means health disparities can be non-existent.

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Smith, I. Z., Bentley-Edwards, K. L., El-Amin, S., & Darity, W. (2018). Fighting at Birth:

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ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Table 1. Characterization of Articles Included in Review to Reduce Black Infant Mortality and

Improve Overall Wellness of Black Mothers

Article Objective Key Findings Conclusion 1. Complementary To identify CAM usage Natural based and Alternative complementary and among pregnant products have therapies in alternative medicine women was most shown to be a Perinatal Period: (CAM) practices and commonly to healthier option Current Scenario describe the health relieve pregnancy when relieving (Jelly, Yadav & effects these practices related pregnancy related Dey ,2018) have on the perinatal conditions. health conditions, period. Five common however CAM practices individuals must be identified were properly informed Whole Medical about the health Systems, Mind- advantages and Body Medicine, disadvantages Biologically before using. Based Practices, Midwives are Manipulative and successful in Body-Based providing holistic Practices, and care and Energy Medicine. understanding the specific needs of pregnant women.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 2. Perceived To understand the use About 76.2% of The study Indications, Safety of herbal and spiritual mothers in the confirmed that and efficacy of remedies and their study used herbal many women were Perinatal Use of perceived indications and/or spiritual using traditional Traditional and and safety when used remedies during medicine during Spiritual Remedies by mothers during the the perinatal the perinatal period Among Mothers of perinatal period. period. and there is a need Under-Five 3% of mothers to regulate and Children in Kano, reported using streamline the use North Western complementary of both traditional Nigeria. and orthodox medicine and (Muhammad, medicines. herbal remedies Lawan, Takai, Less than half of through training Abdullahi, Ramla, the participants and awareness Kamal & Umar, received advice campaigns. 2017) on using herbal remedies.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 3. Complementary To obtain information 82% of pregnant There is a high rate and Alternative about the use of CAM women in Udi of usage of CAM Medicine Use: among pregnant LGA reported products by Results from a women. using CAM pregnant women in descriptive study of during Nigeria. There is a pregnant women in pregnancy. need for midwives Udi local Of the 82% of and other government area of women who used healthcare Enugu State, CAM during providers to inform Nigeria pregnancy, also pregnant users of (Onyiapat, Okafor, did so in previous the safe use of Okoronkwo, pregnancies. these products. Anarado, Biological Chukwukelu, products Nwaneri &Okpala, commonly used 2017) are herbal tea, and herbal mixtures.

4. The Effect of To evaluate the Cortisol levels Overall, yoga Prenatal Hatha association of yoga and were lower for during pregnancy Yoga on Affect, the cortisol levels in participants on has health benefits Cortisol and pregnant women. the days that they both mentally and Depressive engaged in yoga. physical. Study Symptoms Positive effects found that yoga (Bersahdsky, were also improved pregnant Trumpfheller, observed on yoga women’s feeling of Kimble, Pipaloff, days. contentment. Yim, 2014) Regular practices of yoga were associated with fewer depressive symptoms.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 5. Doula Services To assess the birthing Participants who Doula services are Within a Healthy outcomes associated participated in an important Start Program: with utilizing doula the By My Side component in Increasing Access services. Program and addressing birth for an Underserved utilized doula inequities. Population services had (Thomas, lower rates of Ammann, Brazier, preterm birth and Noyes, Maybank, low birthweight. 2017)

6. “Our culture To understand the birth Most important Aboriginal women how it is to be us”- experience of ongoing cultural report having better Listening to Aboriginal Women practices during care and Aboriginal Women who birth on country. pregnancy is understanding about on Country family present at through pregnancy Urban Birthing the time or when healthcare (Marriot, Reibel, shortly after providers are Coffin, Gliddon, birth. representative of Griffin, Robinson, Participants their culture and Eades & Maddox, reported cultural family is present. 2019) security with Aboriginal medical staff.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 7. A Ten-Year To analyze maternal Midwifery care Midwife care Study of Midwife- and neonatal outcomes was associated produced positive led Care at an associated with with significant physiological Austrian Tertiary utilizing midwives. decrease in outcomes for Care Center: a medical women perinatally Retrospective interventions, and should be Analysis with such as the use of offered to all low Special oxytocin, risk pregnant Consideration of artificial rupture mothers. Perineal Trauma of membranes (Bodner-Adler, and fewer Kimberger, episiotomies. Griebaum, Upright birthing Husslein & position most Bodner, 2017) often utilized with midwife led- care.

8. Onsite Midwife- To assess the health OMBUs On-site midwife led Birth Units for outcomes of onsite associated with led care has been Care Around the midwife-led birth units better satisfaction proven to be safe Tie of Childbirth: (OMBUs) for mother from pregnant and cost effective A Systematic and baby in mothers, lower alternative to Review comparison to standard rates of maternal traditional perinatal (Long, Allanson, obstetric units. death, lower risk care. Pontre, Tuncalp, of postpartum Hofmeyr & hemorrhage and Gulmezoglu, 2016) lower risk of infants being admitted to the special care baby unit.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 9. Are Freestanding To determine if Women who Overall use of Midwifery Units a birthplace affects utilized a midwife Safe Alternative to perinatal and maternal freestanding freestanding units Obstetric Units for morbidity and the use midwifery unit is associated with Low-Risk, of obstetric were significantly better health Primiparous interventions. less likely to outcomes for mom Childbirth? An experience and baby. Analysis of Effect complications Difference by that would Parity in a Matched require a Cohort Study. caesarean (Christensen, section. Overgaard, 2017)

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 10. Marriage To understand how The average birth Marriage, as a Advantages in marriage plays a role in weight in this social tie, has been Perinatal Health: prenatal factors and study was 7.5 positively Evidence of intergenerational pounds, over associated with Marriage Selection transmission of 59% of the average birth or Marriage inequality via birth participants were weight and Protections? weight. married, 24% healthier (Kane 2016) cohabitating and pregnancies. 17% single. Strategies in Married mothers improving family had higher levels ties could create of prenatal better health education, higher outcomes for levels of capital infants. and religious beliefs and more likely to abstain from prenatal smoking Cohabitating parents were second to married, having better health outcomes to single parent homes.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 11. Breastfeeding To understand social Study found that Social Media can and Social Media media use among first- participants used be a powerful tool Among First-Time time African American social media in informing African American mothers and their often for mothers and Mothers support partners during educational and support persons (Asiodu, Waters, the perinatal period. social support. about solutions to Dailey, Lee & Participants often health disparities Lyndon, 2015) sought out and improve breast information feeding rates of regarding Black mothers. parenting and perinatal care. Women sought out information regarding breast feeding.

12. Exploring To determine the Groups with the Young mothers, Group association between greatest diversity who were apart of Composition group prenatal care and in age among diverse age range Among Young, participant satisfaction, women resulted group of Black Urban Women of engagement and in the most prenatal care, had Color in Prenatal attendance. attendance and greater attendance, Care: Implications engagement. which leads to for Satisfaction better health Engagement, and outcomes. Group Attendance (Earnshaw, Rosenthal, Cunningham, Kershaw, Lewis, Rising, Stasko, Tobin & Lckovis, 2016)

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 13. A Preliminary To investigate how CBMP Psychological well- Study Investigating effective the CBMP is significantly being, during the Effectiveness on reducing pregnant reduces pregnancy of the Caring for women’s anxiety, participants stress significantly affects Body and Mind in stress and depression. levels, anxiety gestational age. Pregnancy (CBMP) and depression, CBMP showed to in Reducing for all scores be effective in Perinatal except improving pregnant Depression, mindfulness. mother’s mental Anxiety and Stress Mindfulness and health. (Townnshend, Self-Compassion Caltabiano, Powrie Scores increased & O’Grady, 2018) after CBMP intervention.

14. What Women To identify the Women preferred Women overall felt Want: Exploring preferred method of a hybrid of positively about Pregnant Women’s perinatal care among midwife and perinatal care, Preferences for pregnant women in the consultant-lead whether it was Alternative Models UK. care. consultant-led, of Maternity Care Preferences were midwifery-lead or (Fawsitt, Bourke, driven by safety private, as long as Lutomski, Meaney, concerns. it’s safe and there’s McElroy, Murphy, freedom of choice. Greene, 2017)

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 15. To examine the use of Over 67% of Because the use of Complementary complementary and women reported CAM in the U.S. is and Alternative alternative medicine using CAM in the so prevalent, there Medicine (CAM) among women of past year. is a need for policy Use Among reproductive age in the Uses of CAM: about regular Women of U.S. Back pain evaluation and Reproductive Age (17.1%), anxiety education about in the United States (3.7%) and neck proper use. (Johnson, pain (7.7%). Kozhimannil, Jou, Ghildayal & Rockwood, 2016)

16. Use of Herbs To identify the needs Most commonly Because CAM is Among Pregnant and usage of CAM used CAM are widely used and Women in Saudi among pregnant peppermint, potentially harmful, Arabia: A Cross women in Saudi ginger, anise, there is a strong Sectional Study Arabia. green tea, thyme, need for regulation (Zaitoun, Al- coffee, nigella, and an increase Nowis, myrrh and knowledge about Alhumaidhan & cinnamon. safety of use of Khalil, 2019) More than 98% CAM. of women used herbs during pregnancy 31.5% of participants preferred herbs over synthetic drugs.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 17. Prevalence of To assess the Many women Healthcare Herbal Medicine prevalence of herbal used herbal providers should be Use and Associated medicine and to medicines during aware and give Factors Among identify the factors pregnancy. health education to Pregnant Women associated with Most commonly patients about the attending Antenatal pregnant women used herbal effects of using Care at Public attending perinatal remedies are herbal medicines Health Facilities in clinics. ginger, garlic, perinatally. Hossana Town, tenaadam, Southern Ethiopia damakasse and Facility Based eucalyptus. Cross Sectional Study (Laelago, Yohannes & Lemango, 2016)

18. Acupuncture To understand the 68% of Overall, women During Pregnancy perceptions, attitudes, participants who utilized and the Perinatal beliefs and experience reported using acupuncture during Period: Women’s of pregnant women acupuncture., and pregnancy reported Attitudes, Beliefs using acupuncture. The 68% of those having a positive and Practices. study also aimed to participants used experience and (Williams, Sweet, identify the acceptance acupuncture good birthing Graham, 2019) of midwives providing during pregnancy results. acupuncture for pregnancy treatments. related concerns. The majority of participants reported that they would use acupuncture and midwives during pregnancy.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 19. Herbal To identify the efficacy Use of herbal While medicinal Medicine in and prevalence of medicine during herbs can be useful Pregnancy herbal medicine use pregnancy is during pregnancy, (Jaafari, Fotoohi, during pregnancy. common around it is highly Razavi & Asl, the world. recommended that 2016) Herbal medicine pregnant women is more consult their doctor accessible and before use. cost effective. Effects of herbal medicine are not highly researched.

20. The Effect of To identify how Significant Prenatal yoga is Pregnancy Yoga on prenatal yoga affects a difference in effective in the Pregnant pregnant women’s mean anxiety and improving pregnant Psychosocial psychosocial health stress subscale, mother’s Health and Prenatal and prenatal which indicated psychosocial health Attachment attachment. decrease in stress and prenatal (Akarsu & and anxiety attachment. Rathfisch, 2018) levels after practicing yoga.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Article Objective Key Findings Conclusion 21. Perceptions and To understand the Of the women Overall, study Experiences of experiences of Chinese who participated found that prenatal Pregnant Chinese women who meditate in the EBMI practice of Women in Hong during pregnancy. program, the meditation supports Kong on Prenatal majority of the coping with mental Meditation: A participants and physical stress, Qualitative Study reported having social relationships, (Chan, 2015) more optimistic improves spiritual feelings about empowerment and life and easier problem solving. pregnancies. Women also reported having less stress and feeling of discomfort during pregnancy.

22. Integrating To examine the Yoga has many Research has Complementary/ association between health benefits shown that Alternative osteopathic for pregnant complementary and Medicine into manipulation, yoga and women. alternative Primary Care: acupuncture on CAM therapies medicine have been Evaluating the physiological effects utilized by more valuable to the Evidence and and use for treatment than a third of the health of pregnant Appropriate of medical conditions population. patients. Implementation among pregnant (Wainapel, Rand, women. Fishman & Halstead-Kenny, 2015)

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Table 2. Interventions and Practices by Country

Table 2. Practices Categorized by Domain and OECD Countries vs. Non-OECD Countries

Global Practices OECD Countries Non-OECD Countries

Domain 1-  U.S.  Enugu State, Nigeria Herbal  Ethiopia Remedies  Iran  Saudi Arabia  North West Nigeria

Domain 2-  Australia  India Mind and Body  China Practices  Turkey  U.S.

Domain 3-  Australia  South Africa Traditional  Denmark Birthing Process  U.S.

The use and practice were culturally related to the country. For example, yoga was a common perinatal practice and India, while herbal remedies were often used in African and Middle-

Eastern countries. On the other hand, midwifery are units is a common healthcare system used in

Australia.

ALTERNATIVE PERINATAL CARE METHODS TO REDUCE DISPARITY

Figure 2. Flow Chart of Articles Included in Literature Review

After the initial conceptual search, 313 potential articles were returned. 138 of the articles were excluded because the title was irrelevant. 20 more articles were excluded by abstract. Of the remaining 155 articles, a secondary search was conducted to find more information about the identified domains. A total of 22 articles were included in the review.