587587
research-article2015
TCNXXX10.1177/1043659615587587Journal of Transcultural NursingNypaver and Shambley-Ebron
Research Department
Using Community-Based Participatory Research to Investigate Meaningful Prenatal Care Among African American Women
Journal of Transcultural Nursing 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615587587 tcn.sagepub.com
Cynthia F. Nypaver, PhD, CNM, WHNP-BC, RN1, and Donna Shambley-Ebron, PhD, RN, CTN-A1
Abstract Purpose: In the United States, African American babies die more than twice as often as White babies. The cause for this difference remains elusive, yet is likely complex with one factor being inadequate cultural care of pregnant African American women. The purpose of this study was to explore African American women’s perspectives of meaningful prenatal care. Design: Community-based participatory research was employed for this study using photovoice. The sample included 11 African American mothers in an urban community in Midwestern United States. Findings: Five themes were abstracted from the data: (1) Access to Care; (2) Soul Nourishment; (3) Companionship; (4) Help Me, Teach Me; and (5) The Future. Discussion/Conclusion: Meaningful prenatal care is influenced by culture. African American women need physical, social, and soulful support to enhance meaningfulness of care during pregnancy. Practice Implications: The findings support that meaningfulness of prenatal care for African American women may be enhanced by accessible and uniquely designed, culturally congruent models of prenatal care. Keywords African American women, culture, health disparities, infant mortality, prenatal care, community-based participatory research, photovoice
Introduction The infant mortality rate (IMR), a marker for the health of a society, is an outcome of complex interactions between biological, social, psychological, and environmental factors that affect health status (Hauck, Tanabe, & Moon, 2011). This complexity could not be more evident than in the U.S. IMR. The overall U.S. IMR for 2010 was 6.15 deaths per 1,000 live births and when compared by race, was 5.1 for White infants and 11.99 for Black infants (Murphy, Xu, & Kochanek, 2013). Not only is the U.S. IMR higher than most industrialized nations, ranking 27th behind countries like Japan, Israel, Slovenia, Australia, Korea, and the United Kingdom (MacDorman, Hoyert, & Mathews, 2013; World Health Organization, 2015), but the disparity that exists between African Americans and Caucasians persists, despite efforts to understand and address it (Lu et al., 2010). Comprehension of this complex disparity continues to elude full understanding, yet it is likely multifactorial with one component being inadequate prenatal care among African American women. Prenatal care is one of the most funded health initiatives in the United States, and is highly structured based on the
biomedical model of care, whereby standardized education and interventions may be provided without consideration of cultural differences that may affect if and how pregnant women receive this type of care (Laudermilk, Perry, & Cashion, 2014; McIntosh, Jeffery, & Muhajarine, 2010). Furthermore, there is a dearth in the literature about meaningfulness of prenatal care for African American women. Sociopolitical, environmental, and psychological factors that affect health in women’s lives need to be explored to better address unique cultural needs during pregnancy. Therefore, the purpose of this study was to explore African American women’s perspectives of meaningful care during pregnancy by using community-based participatory research (CBPR) with a photovoice approach. Because this study was conducted with American women of African descent, the term African American will be used throughout. However, the 1
University of Cincinnati, Cincinnati, OH, USA
Corresponding Author: Cynthia F. Nypaver, University of Cincinnati, College of Nursing, 3110 Vine Street, PO Box 210038, Cincinnati, OH 45221-0038, USA. Email: [email protected]
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term Black may be used when it is referred to as such in the literature.
Background Two predominant risk factors for infant mortality are preterm birth (PTB) and low birth rate (LBW). Evidence suggests that women who receive early and continuous prenatal care have lower rates of PTB (defined as less than 37 completed gestation weeks) and LBW (defined as less than 2.500 grams) infants (Partridge, Balayla, Holcroft, & Abenhaim, 2012). Late entry into prenatal care (after 12 weeks gestation) and/ or inadequate or absence of prenatal care increases the risk of PTB and LBW (Debiec, Paul, Mitchell, & Hitti, 2010; U.S. Department of Health & Human Services, 2014). Osterman, Martin, Mathews, and Hamilton (2011) reported that 11.7% of Black women receive late or no prenatal care compared with only 5% of White women. Reasons for this disparity in obtaining prenatal care are complex, often revolving around issues that limit access to care (Agency for Healthcare Research and Quality, 2012); however, cultural, psychosocial, and maternal-behavioral factors must also be explored. Studies have identified some factors that may be associated with African American women’s decreased engagement in prenatal care, including perceived or prior experiences with racism within the health care system, higher parity, lack of or limited transportation, socioeconomic or educational disadvantage, substance abuse, unplanned pregnancies, inadequacy of the quality of care, inconsistent care from clinicians, and general distrust of the medical establishment (Armstrong et al., 2008; Green, Renfrew, & Curtis, 2000; Partridge et al., 2012; Slaughter-Acey, Caldwell, & Misra, 2013). Distrust of the medical establishment may interfere with health-seeking behaviors and adherence to health care recommendations (Armstrong et al., 2008). Dahlem, Villarruel, and Ronis (2014) reported that for African American women, a trustworthy relationship with a health care provider had a positive effect on trust and on prenatal care satisfaction. African American women valued relationships with their provider more than technical support (Armstrong et al., 2008). These studies have provided some insight into the culture-specific needs of African American women during pregnancy; however, more knowledge is needed that can be translated into sustainable models of care that may decrease racial differences in infant mortality.
Conceptual Framework The two theories that framed this study’s design and analysis were Africana Womanism (Hudson-Weems, 1993/2004) and Critical Race Theory (Delgado & Stefancic, 1991). Africana Womanism is a culture-specific theory that places culture, history, and lifeways of people of the African diaspora as central to analysis. This theory supports the methodology of this study with its tenet that Africana women (including
African American women) must create their own criteria for assessing their realities, both in thought and action. Critical Race Theory is a race-conscious approach to inquiry that is based on structural determinism and antiessentialism. Structural determinism posits that culture influences life context. Societal norms, beliefs, and practices define the context of one’s life, and once in place, are difficult to reestablish even if they are found to be crippling for some groups of people. Antiessentialism posits that individuals cannot be reduced into categories such as race, gender, or class but instead suggests that the combined experience of all categories are greater than the sum of the parts. Thus, the combined experience of being an African American woman in a society with a history of racism, sexism, and classism provides a unique lens through which one may view the perpetuation of health disparities. Sociopolitical structures that may contribute to meaningfulness of prenatal care must be explored. Historically, African American women are spiritual and share a strong sense of sisterhood and community (HudsonWeems, 1993/2004). Churches are common meeting grounds for sharing norms and beliefs. Knowledge is bequeathed to future generations orally through the use of storytelling. Elders are respected as the “knowers.” Hence, a community approach that included Elders was needed to critically examine cultural strengths that enhance health and sociopolitical barriers that may create and perpetuate differences in health outcomes such as infant mortality. Group discussion through the use of photovoice promotes critical pedagogy aimed at generating knowledge and transforming this new knowledge into power-sharing actions (Wang, 1997) that may reduce infant mortality disparities. Reducing disparities in health is ultimately a matter of social justice, the cornerstone of Critical Race Theory.
Methodology The method used for this study was CBPR using the photovoice approach. This collaborative approach to inquiry involves both the researcher and community members in the research process, with all parties taking ownership of the newly generated knowledge that can be translated into action to serve the community (Israel, Eng, Schulz, & Parker, 2005). Photovoice is a process by which people take pictures of a phenomenon of common interest or concern. Photovoice, an action research strategy based on health promotion principles, facilitates a diversity of perspectives to define and improve social, political, and ultimately health in groups of people (Wang, 2006). Photovoice has been used in multiple studies in varying contexts. It was used by Stedman-Smith, McGovern, Peden-McAlpine, Kingery, and Draeger (2011) to explore maternal knowledge of ways that children are exposed to pesticides. Mothers in the study were better able to identify the pesticide problem, became more aware of how
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Nypaver and Shambley-Ebron pesticide exposure affects health, and identified strategies to reduce pesticide exposure. Another study used photovoice to engage and empower immigrants in a Canadian town to identify and correct barriers to their health and well-being (Hague & Eng, 2011). According to Wang (2006), Photovoice enables people to connect the community to larger social audiences to advocate for community concerns and issues. The purpose of photovoice in this study was to: (1) enable the participants to take photographs to illuminate persons, places, and things that support pregnant women in their community; (2) promote critical dialogue about supportive care during pregnancy; (3) identify barriers to supportive prenatal care for African American women; and (4) reach change agents who have potential to remove identified barriers to support pregnancy in the community. The research questions were: Research Question 1: What are the ways that African American women care for themselves during pregnancy? Research Question 2: What are cultural meanings of prenatal care for African American women? Research Question 3: How does culture influence how African American women care for themselves during pregnancy? Research Question 4: What systems are currently in place to support African American women during their pregnancies? Research Question 5: What are the sociopolitical, economic, and personal barriers that hinder African American women from receiving meaningful care during pregnancy?
informed consent, (2) introductions, (3) study purpose and explanation, (4) outline of the photovoice project, (5) importance of attendance, (6) camera mechanics and photography tips, (7) photography ethics, and (8) ground rules for photovoice discussions. Before arriving at Sessions 2 through 5, participants took pictures that represented people, places, or things in their community that served as supports or barriers to meaningful care during pregnancy. At each session, the researcher downloaded the pictures onto a computer one at a time and projected onto the screen at the head of the meeting table. The researchers guided the discussion using the SHOWeD technique (Wang, 2006) which consists of the following questions: (1) What do you SEE? (2) What is HAPPENING? (3) How does this relate to OUR lives? (4) WHY do these issues exist? and (5) What can we DO about these issues? This resulted in dialogue as the women discussed, listened, and learned from multiple perspectives about the assets and barriers to meaningful prenatal care in their community. Topics were discussed until saturation was achieved. All discussions were audio recorded and the researcher took field notes to provide context for the discussion. Participants also kept reflective journals about the pictures they had taken. The various methods of collecting data (triangulation) were purposeful to strengthen credibility of the data.
Data Analysis
The study community was an urban housing project in the Midwest which is 90% African American and home to 4,500 families, the majority of whom earn below the federal poverty level. Meetings took place in a room in the community’s elementary school. African American women, less than 65 years of age, who were either currently pregnant or had been pregnant in the past were recruited for the study, through flyers posted in the community. Eleven women consented to be in the study, however, four were lost to attrition for various reasons including family emergency, lack of transportation, and scheduling conflicts. Table 1 provides the characteristics of the sample.
Data were analyzed using the constant comparative method, whereby data were coded, sorted, organized, and categorized to abstract conceptual themes (Glaser & Strauss, 1967). Trustworthiness of the study was assessed through Lincoln and Guba’s (1985) evaluation of credibility, transferability, dependability, and confirmability. The researcher listened to audiotape recordings by sessions, read and reread the transcriptions, journals, and field notes. The researcher then coded the transcribed data by session, segmenting data into portions of conversations about a particular idea. The HyperRESEARCH (Researchware, 2012) data management software was used to organize the data. To ensure intercoder reliability, a second researcher coded the data and both were compared for congruency. Codes were continually compared and categories formed. Data were finally abstracted to arrive at five themes. The researcher met with the participants in the community after data analysis was complete. Member checking was conducted to ensure credibility. The participants confirmed accuracy of the identified themes, conclusions, and recommendations. The researcher and participants disseminated findings at a community event.
Procedure
Researcher Reflexivity
The photovoice project consisted of six weekly sessions, culminating with a photo exhibit. The first session included (1)
To enhance trustworthiness of the study, the researcher acknowledges her own values, bias, and multiple influences
Institutional review board approval was obtained prior to recruitment of participants and initiation of the study. The researcher obtained informed consent of participants.
Sample and Setting
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Table 1. Characteristics of the Sample. Age (years) Range M ± SD Age at first pregnancy (range) Age at first pregnancy (M ± SD) Pregnancies (number) Range M ± SD Children (number) Range M ± SD Prenatal care Number of women who received prenatal care Number of women reporting missing one or more prenatal care visit Time of delivery Number of women who delivered a preterm infant Number of women who delivered term infant Infant birth weight Range M ± SD Education Education beyond high school Less than high school graduate General educational development Yearly earned income Range M ± SD Number of women reporting no earned income
28 to 55 42.7 ± 9.52 17 to 21 18.5 ± 1.49 2 to 5 2.71 ± 0.76 2 to 4 2.76 ± 0.57 7 7
1 6
5 lbs 3 oz to 9 lbs 6 lbs 6.9 oz ± 1.32 4 2 1 $0 to $25,000 $8,198 ± 10,024.85 3
Participant photographs and dialogues are displayed in Table 2 through Table 6.
Access to Care The first theme, Access to Care included subthemes of “Transportation” and “Wait” depicted in photographs by Participants #1 and #2, respectively. The participant who took “Transportation” from the interior of her home stated that there were buses and cars parked outside and within walking distance of her home, yet they were often unavailable to her for various reasons. The majority of the participants agreed that the primary form of transportation in their neighborhood is the bus, yet the cost to use it is often prohibitive. The second photograph titled “Wait” sparked reflective dialogue among the participants with all agreeing that prenatal care is important for good pregnancy outcomes, yet once at the facility that provides this care, most had encountered long waiting times to see a health care provider. The women stated that it was difficult and uncomfortable to sit in the waiting room, often with their other children, for long periods while pregnant to finally be seen for a short rushed visit.
Soul Nourishment Soul Nourishment, “the intangible psychosocial nourishment and support that is fundamentally needed by all women” (Nypaver, 2013, p. 95) was the next theme derived from the data. This theme resonated with the participants as spirituality in the form of God, Church, and Bible. Participant #3 photographed pages in the Bible and titled it “Life.” “I had a strong family and strong spiritual family that helped sustain me mentally and emotionally” (Participant #4).
Companionship she brings to the research process and data analysis. The researcher brings a health care provider perspective, having worked as a nurse–midwife for the past 15 years. She has the acute belief that there is an inherent inequality in the provider–client relationship whereby providers “instruct” “patients” based on standards of practice. Using a CBPR approach enabled her to explore perspectives of meaningful care during pregnancy from the women themselves. Because she could only bring her own perspective as a health care provider, she had to iteratively check with participants that her interpretations were in line with their experiences. By doing so, she was able to explore the answers to the research questions more authentically.
Companionship was another theme abstracted from the data. All the women were single mothers yet all desired companionship. The photograph titled “Empty” was taken by Participant #1 to depict this feeling.
Findings
The Future
Five themes were abstracted from the data. They were the following: (1) Access to Care; (2) Soul Nourishment; (3) Companionship; (4) Help Me, Teach Me; and (5) The Future.
The theme The Future expressed the need to build self-worth, self-esteem, and sense of life purpose for African American girls. Many of the participants voiced that young women
Help Me, Teach Me Help Me, Teach Me emerged as a theme as participants described their need for information and education about health in general, but specifically care and resources for pregnant women. “Many Questions, No Answers” was taken by Participant #1 to illustrate unawareness or resources during her pregnancy.
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Nypaver and Shambley-Ebron Table 2. Theme 1: Access to Care. Photographs
Dialogue The photograph titled “Transportation” was taken by Participant #1 from the interior of her home. She stated that there were buses and cars parked outside home yet not available. Most of the participants agreed that the primary form of transportation in their neighborhood is the bus, yet the cost to use it is often prohibitive. “There’s buses going up and down the street all day, but you can’t afford to get on one and sometimes you can get there but you can’t get home” (Participant #1).
Transportation Participant #2 took a photograph which she titled “Wait.” All participants agreed that prenatal care is important for good pregnancy outcomes, yet they often had to wait long periods of time to see their health care provider. They stated that it was difficult and uncomfortable to sit in a waiting room for long periods while pregnant to finally be seen for a short rushed visit. “I waited three hours to talk to the doctor for a five minute visit. That’s all he had because he was rushing through it because he was already behind” (Participant #2). Participant #5 admitted that if she was feeling well on the day of her prenatal care visit, rather than waiting a long time to be seen, she would choose not to attend this short visit. “Waiting” resulted in: “prenatal care visits getting missed, early childhood visits getting missed, and family planning visits getting missed” (Participant #6).
Wait
Table 3. Theme 2: Soul Nourishment. Photograph
Dialogue
Life
Soul Nourishment, defined as “the intangible psychosocial nourishment and support that is fundamentally needed by all women” (Nypaver, 2013, p. 95) was the next theme derived from the data. The women in this study discussed the relationship between physical and mental health. For them, physical health was perceived to be dependent on mental health. They made a clear distinction between the needs of the physical body and the needs of the spirit or soul. Examples they provided for bodily needs included water, food, and shelter. Examples of soulful needs were reported as family, spiritual, and emotional support. Soul Nourishment resonated most often with the participants as spirituality in the form of God, Church, and Bible. The participants reported that care during pregnancy should not be based solely on physical, medical care, but rather on intangible supportive care that nourishes the soul to achieve mental health. Participant #3 photographed pages in the Bible and titled it “Life.” “I had a strong family and strong spiritual family that helped sustain me mentally and emotionally”(Participant #4). Participant #3 explained that for her, this picture illustrated a parallel between new life within a pregnant woman and new life that the “Word of God” can provide resulting in a peaceful, calming effect. “Pregnant women need to ‘sit down’ and enjoy peaceful time. The baby can tell if you’re in a bad mood . . . kind of like tight cramps” (Participant #2). Several women reported that they found great strength in their belief in God while pregnant even when they felt alone and unsupported. All of the women believed that if spirituality was strengthened during pregnancy, this would lead to increased positive maternal and fetal emotions that would enhance physical well-being.
with higher self-esteem are confident with a purpose in life, can envision their future and set life goals that may include reproductive planning. Participant #3 took the photograph she titled “Train Up A Child.”
Discussion Data from this study support that African American women care for themselves and other pregnant women by attending to their physical, emotional, spiritual, and social needs (Soul Nourishment and Companionship). Prenatal care is valued as providing positive pregnancy outcomes but in order for it to be utilized, it must be meaningful. Meaningfulness is enhanced
by physical, psychosocial, and spiritual care rather than just an established number of prenatal care visits with a health care provider, a practice of the current biomedical model of care. In addition, adequate time must be allotted with unrushed health care providers ensuring vital exchange of knowledge between both parties and to provide the opportunity of building relationships where information exchange is trustworthy. Short, rushed prenatal care visits may not provide the opportunity to gather adequate information that is needed about pregnancy and motherhood nor may it allow time to build genuine, trusting relationships between patients and health care providers. Findings add to the body of knowledge that African American women are more likely to engage in early and continuous pre-
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Table 4. Theme 3: Companionship. Photograph
Dialogue Companionship was another theme abstracted from the data. All the women were single mothers yet all desired companionship. The photograph titled “Empty” was taken by Participant #1 to depict this feeling.
Empty
“There’s a pregnant belly. No health care, no support, no spiritual foundation, just alone and pregnant . . . ” (Participant #1). Even though many of the participants had support from spiritual families and friends, they knew of many African American women who were pregnant and alone.
Table 5. Theme 4: Help Me, Teach Me. Photograph
Dialogue Help Me Teach Me emerged as a theme as participants described their need for information and education about health in general, but specifically care and resources for pregnant women. The participants defined community resources as people, places, and things in their community that support women during pregnancy. They identified the community health center, local churches, a mobile van that provides prenatal education, the Women, Infants, and Children Program and Healthy Start Program as helpful resources in which they were aware of. However, they felt there were more resources that they were not aware of. “Many Questions, No Answers” was taken by Participant #1 to illustrate unawareness during her pregnancy.
Many Questions, No Answers
“Some people see the world like that. They see this big infrastructure, this big city and they don’t know, they feel lost.” “It’s out there but you just don’t know where to go. So I had to get out there and find other things that could help me” (Participant #1). The general consensus of the photovoice group was that most of the knowledge each obtained about their own pregnancies was learned from friends and family members and to a lesser extent health care providers.
natal care if it is meaningful for them, especially if it is relationship-centered care (Dahlem et al., 2014; Massey, Rising, & Ickovics, 2006) The themes Soul Nourishment and Companionship revealed that culture played a role in how African American women cared for themselves during pregnancy, how they received care, and how they cared for other pregnant women. Consistent with African Womanism Theory (HudsonWeems, 1993/2004), spirituality, sisterhood, Elder respect, and mothering/nurturing by others were important for the care of pregnant African American women. Soulful care is the term that this author uses to describe the intangible forms of care: spiritual care, social care (relationships), and psychological care (emotions), all of which are tightly interwoven according to the data from this study. Religion was identified as the most common form of spiritual care. The practice of religion brings people of faith together in common meeting spaces increasing the potential to build social support networks. Having historical roots from Africa, spirituality is a predictor of maternal, fetal, and infant health
(Jesse, Graham, & Swanson, 2006; Jesse & Reed, 2004; Mueller, Plevak, & Rummans, 2001). The participants identified intergenerational exchange of cultural beliefs and practices as the main source of advice about pregnancy and motherhood, particularly from their mothers, grandmothers, and elders. Cultural care involved companionship and formation of strong female support systems mainly with family members, friends, and spiritual families. According to the data from this study, African American women feel a deep-felt sense of obligation to serve as mentors, educators, and role models for youth and other pregnant women. Data from this study support the notion that African American women strive to care for themselves during pregnancy by creating time and spaces for peace and relaxation. There was common belief that this practice facilitates mental health, which in turn increases physical health that may lead to healthier pregnancy outcomes. The themes Access to Care, Help Me, Teach Me, and Companionship, identified both supportive systems and barriers for pregnant African American women seeking
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Nypaver and Shambley-Ebron Table 6. Theme 5: The Future. Photograph
Dialogue The theme The Future expressed the need to build self-worth, self-esteem, and sense of life-purpose for African American girls. Many of the participants voiced that young women with higher self-esteem are confident with a purpose in life, can envision their future and set life goals that may include reproductive planning. Participant #3 took the photograph she titled “Train Up A Child.”
Train Up A Child
All the participants agreed that it is everyone’s responsibility to teach young girls about their self-worth. If they have a sense of self-worth, they can begin to dream and set goals for their lives. They will begin to “believe that they can achieve their life goals” (Participant #4). Having experienced a teenage pregnancy, Participant #6 stated that she did not have self-esteem instilled in her when she was a child . . . “as far as my mom sitting me down telling me you’re a beautiful young lady, you somebody, you got a purpose in life, that did not happen.” Therefore, since she saw no life purpose she did not set goals and plan for her future. “Most people who set goals are people that are consistently focused not on just the present but the future and people who are focused on just the present find a lot of things happen in their lives unplanned such as unplanned pregnancies” (Participant #3). “I’ve see a lot in African American families, a lot of pregnancies that were not planned” (Participant #7).
meaningful prenatal care. Supportive systems ranged from local churches to a mobile prenatal care education van, and a community health care clinic. These venues have the potential to supply education about pregnancy, provide physical care, and enhance social support networks. Previous studies have demonstrated that social care has a positive effect on health outcomes (Ickovics et al., 2007; Ickovics et al., 2011; Jesse et al., 2006; Robertson, Aycock, & Darnell, 2009), whereas a lack of social support contributes to social stress which may be a major contributor to the excess risk for PTB among African Americans (Goldenberg, Culhane, Iams, & Romero, 2008; Rowley, 2001). Access to Care is hindered by lack of or poor transportation, lack of child care services, lack of adequate health care coverage, and long waiting times to see health care providers were barriers that hinder African American women from receiving meaningful care during pregnancy. Kitsantas, Gaffney, and Cheema (2012) reported that women who live in urban areas and have two or more barriers to care are twice as likely to initiate late prenatal care. Furthermore, inadequate health care coverage may prevent preconception and intraconception care, an opportune time for detecting and controlling chronic illnesses that are associated with poor pregnancy outcomes. Preconception and intraconception care provides an opportune time for disease prevention and health maintenance to achieve optimal health before a pregnancy exist. Last, the theme, The Future, identified the need to build self-worth and self-esteem in young women. Consistent with
the action portion of CBPR methodology, two of the participants were instrumental in forming and sustaining two separate girls-mentoring groups in their community, one at a local church and the other at the elementary school.
Limitations Limitations of this study were the focused sample, inclusion of participants from only one urban neighborhood in Ohio and a sample that did not include pregnant women. Samplings in several urban areas may have yielded more diverse findings. In addition, the sampling did not include women who were pregnant. Although pregnant women were targeted for recruitment, none enrolled. The perspective of meaningful care from a pregnant woman may be quite different from women recalling care they received during past pregnancies. Future studies using a CBPR approach with a larger sampling that included pregnant African American women along with those who have given birth in the past may yield richer data.
Conclusion This photovoice project empowered African American women to express their perceptions of meaningful care during pregnancy. Despite considerable body of literature devoted to prenatal care, there is very little written about what constitutes meaningful care for pregnant African American women. This study is unique because it captured
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perceptions of meaningful prenatal care from African American women who had experienced care in their past. The data support the belief that meaningful care is different from the standardized biomedical model of care because of unique psychosocial and spiritual needs of African American women in this study. Results revealed that prenatal care must be more encompassing of the psychological and social systems that support pregnant women, not merely the act of attending prenatal care visits with a health care provider. Perhaps, adequacy of prenatal care should not be measured by when and how many visits a woman attends but rather by the quality by which it is delivered, quality that satisfies cultural needs (Nypaver, 2013). Findings from this study, which came from the target population themselves, can be used to inform culturally appropriate prenatal care that aims to improve utilization of care and pregnancy outcomes.
Implications for Future Research and Practice The findings from this study have important implications for the care of pregnant African American women. First, different culturally congruent models of prenatal care need to be examined, implemented, and tested through intervention studies. These models of care must include broader views of preventative services such as preconception care, education, and psychosocial support. Although group prenatal care is not a new concept, limited studies on Centering Pregnancy have demonstrated increased patient satisfaction, social support, and infant birth weights, while decreasing the risk for PTB (Ickovics et al., 2007). Replication studies are needed in African American populations. Due to limited health care accessibility, future intervention research is needed to test delivery of prenatal care in alternative settings. One setting may include mobile units in neighborhoods identified as having high IMRs. Perhaps group prenatal care in a church or mobile van in at-risk neighborhoods may decrease barriers that limit access to care, while strengthening social networks. Redesigning models and settings for prenatal care may have the potential to decrease infant mortality among African Americans. Acknowledgments The authors wish to thank Ms. N, Ms. L, Ms. J, Ms. A, Ms. P, Ms. D, and Ms. T for their contribution in many stages of this work and for sharing their stories.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This
research was funded by the Dean’s New Investigator Research Award, College of Nursing, University of Cincinnati.
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Nypaver and Shambley-Ebron Jesse, D. E., & Reed, P. G. (2004). Effects of spirituality and psychosocial well-being on health risk behaviors in Appalachian pregnant women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 33, 739-747. Kitsantas, P., Gaffney, K. F., & Cheema, J. (2012). Life stressors and barriers to timely prenatal care for women with high-risk pregnancies residing in rural and nonrural areas. Women’s Health Issues, 22, e455-e460. doi:10.1016/j.whi.2012.06.003 Laudermilk, D. L., Perry, S. E., & Cashion, K. (2014). Maternity nursing (8th ed.). Maryland Heights, MO: Elsevier. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage. Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the Black-White gap in birth outcomes: A life-course approach. Ethnicity & Disease, 20(1 Suppl. 2), S2-62-76. MacDorman, M. F., Hoyert, D. L., & Mathews, T. J. (2013). Recent declines in infant mortality in the United States, 2005-2011 (NCHS Data Brief, no. 120). Hyattsville, MD: National Center for Health Statistics. Massey, Z., Rising, S. S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: Promoting relationship-centered care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 286-294. McIntosh, T., Jeffery, B., & Muhajarine, N. (Eds.). (2010). Redistributing health: New directions in population health research in Canada. Regina, Saskatchewan, Canada: Canadian Plains Research Center, University of Regina. Mueller, P. S., Plevak, D. J., & Rummans, T. A. (2001). Religious involvement, spirituality, and medicine: Implications for clinical practice. Mayo Clinic Proceedings, 76, 1225-1235. doi:S0025-6196(11)62799-7 Murphy, S. L., Xu, J., & Kochanek, K. D. (2013). Deaths: Final data for 2010. National Vital Statistics Reports, 61(4), 1-117. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr61/ nvsr61_04.pdf Nypaver, C. (2013). Picturing healthy moms, babies and communities (Doctoral dissertation). Retrieved from https:// etd.ohiolink.edu/ap/10?0::NO:10:P10_ACCESSION_ NUM:ucin1377869806
Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011). Expanded data from the new birth certificate, 2008. National Vital Statistics Reports, 59(7), 1-28. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf Partridge, S., Balayla, J., Holcroft, C. A., & Abenhaim, H. A. (2012). Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: A retrospective analysis of 28,729,765 U.S. deliveries over 8 years. American Journal of Perinatology, 29, 787-793. doi:10.1055/s-0032-1316439 Researchware. (2012). HyperRESEARCH (Version 3.5.2) [Qualitative Analysis Software]. Retrieved from http://www. researchware.com/products/hyperresearch.html Robertson, B., Aycock, D. M., & Darnell, L. A. (2009). Comparison of centering pregnancy to traditional care in Hispanic mothers. Maternal and Child Health Journal, 13, 407-414. doi:10.1007/ s10995-008-0353-1 Rowley, D. L. (2001). Closing the gap, opening the process: Why study social contributors to preterm delivery among black women. Maternal and Child Health Journal, 5, 71-74. Slaughter-Acey, J. C., Caldwell, C. H., & Misra, D. P. (2013). The influence of personal and group racism on entry into prenatal care among African American women. Women’s Health Issues, 23, e381-e387. doi:10.1016/j.whi.2013.08.001 Stedman-Smith, M., McGovern, P. M., Peden-McAlpine, C. J., Kingery, L. R., & Draeger, K. J. (2011). Photovoice in the red river basin of the north: A systematic evaluation of a community-academic partnership. Health Promotion Practice, 13, 599-607. doi:10.1177/1524839910370737 U.S. Department of Health & Human Services. (2014). Prenatal services. Washington, DC: Author. Wang, C. (2006). Youth participation and community change. Journal of Community Practice, 14(1-2), 147-161. doi:10.1300/ J125v14n01_09 Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24, 369-387. World Health Organization. (2015). Child Mortality Estimates, CME info. Retrieved from www.childmortality.org/index. php?r=site/compare
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research-article2015
TCNXXX10.1177/1043659615587587Journal of Transcultural NursingNypaver and Shambley-Ebron
Research Department
Using Community-Based Participatory Research to Investigate Meaningful Prenatal Care Among African American Women
Journal of Transcultural Nursing 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615587587 tcn.sagepub.com
Cynthia F. Nypaver, PhD, CNM, WHNP-BC, RN1, and Donna Shambley-Ebron, PhD, RN, CTN-A1
Abstract Purpose: In the United States, African American babies die more than twice as often as White babies. The cause for this difference remains elusive, yet is likely complex with one factor being inadequate cultural care of pregnant African American women. The purpose of this study was to explore African American women’s perspectives of meaningful prenatal care. Design: Community-based participatory research was employed for this study using photovoice. The sample included 11 African American mothers in an urban community in Midwestern United States. Findings: Five themes were abstracted from the data: (1) Access to Care; (2) Soul Nourishment; (3) Companionship; (4) Help Me, Teach Me; and (5) The Future. Discussion/Conclusion: Meaningful prenatal care is influenced by culture. African American women need physical, social, and soulful support to enhance meaningfulness of care during pregnancy. Practice Implications: The findings support that meaningfulness of prenatal care for African American women may be enhanced by accessible and uniquely designed, culturally congruent models of prenatal care. Keywords African American women, culture, health disparities, infant mortality, prenatal care, community-based participatory research, photovoice
Introduction The infant mortality rate (IMR), a marker for the health of a society, is an outcome of complex interactions between biological, social, psychological, and environmental factors that affect health status (Hauck, Tanabe, & Moon, 2011). This complexity could not be more evident than in the U.S. IMR. The overall U.S. IMR for 2010 was 6.15 deaths per 1,000 live births and when compared by race, was 5.1 for White infants and 11.99 for Black infants (Murphy, Xu, & Kochanek, 2013). Not only is the U.S. IMR higher than most industrialized nations, ranking 27th behind countries like Japan, Israel, Slovenia, Australia, Korea, and the United Kingdom (MacDorman, Hoyert, & Mathews, 2013; World Health Organization, 2015), but the disparity that exists between African Americans and Caucasians persists, despite efforts to understand and address it (Lu et al., 2010). Comprehension of this complex disparity continues to elude full understanding, yet it is likely multifactorial with one component being inadequate prenatal care among African American women. Prenatal care is one of the most funded health initiatives in the United States, and is highly structured based on the
biomedical model of care, whereby standardized education and interventions may be provided without consideration of cultural differences that may affect if and how pregnant women receive this type of care (Laudermilk, Perry, & Cashion, 2014; McIntosh, Jeffery, & Muhajarine, 2010). Furthermore, there is a dearth in the literature about meaningfulness of prenatal care for African American women. Sociopolitical, environmental, and psychological factors that affect health in women’s lives need to be explored to better address unique cultural needs during pregnancy. Therefore, the purpose of this study was to explore African American women’s perspectives of meaningful care during pregnancy by using community-based participatory research (CBPR) with a photovoice approach. Because this study was conducted with American women of African descent, the term African American will be used throughout. However, the 1
University of Cincinnati, Cincinnati, OH, USA
Corresponding Author: Cynthia F. Nypaver, University of Cincinnati, College of Nursing, 3110 Vine Street, PO Box 210038, Cincinnati, OH 45221-0038, USA. Email: [email protected]
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term Black may be used when it is referred to as such in the literature.
Background Two predominant risk factors for infant mortality are preterm birth (PTB) and low birth rate (LBW). Evidence suggests that women who receive early and continuous prenatal care have lower rates of PTB (defined as less than 37 completed gestation weeks) and LBW (defined as less than 2.500 grams) infants (Partridge, Balayla, Holcroft, & Abenhaim, 2012). Late entry into prenatal care (after 12 weeks gestation) and/ or inadequate or absence of prenatal care increases the risk of PTB and LBW (Debiec, Paul, Mitchell, & Hitti, 2010; U.S. Department of Health & Human Services, 2014). Osterman, Martin, Mathews, and Hamilton (2011) reported that 11.7% of Black women receive late or no prenatal care compared with only 5% of White women. Reasons for this disparity in obtaining prenatal care are complex, often revolving around issues that limit access to care (Agency for Healthcare Research and Quality, 2012); however, cultural, psychosocial, and maternal-behavioral factors must also be explored. Studies have identified some factors that may be associated with African American women’s decreased engagement in prenatal care, including perceived or prior experiences with racism within the health care system, higher parity, lack of or limited transportation, socioeconomic or educational disadvantage, substance abuse, unplanned pregnancies, inadequacy of the quality of care, inconsistent care from clinicians, and general distrust of the medical establishment (Armstrong et al., 2008; Green, Renfrew, & Curtis, 2000; Partridge et al., 2012; Slaughter-Acey, Caldwell, & Misra, 2013). Distrust of the medical establishment may interfere with health-seeking behaviors and adherence to health care recommendations (Armstrong et al., 2008). Dahlem, Villarruel, and Ronis (2014) reported that for African American women, a trustworthy relationship with a health care provider had a positive effect on trust and on prenatal care satisfaction. African American women valued relationships with their provider more than technical support (Armstrong et al., 2008). These studies have provided some insight into the culture-specific needs of African American women during pregnancy; however, more knowledge is needed that can be translated into sustainable models of care that may decrease racial differences in infant mortality.
Conceptual Framework The two theories that framed this study’s design and analysis were Africana Womanism (Hudson-Weems, 1993/2004) and Critical Race Theory (Delgado & Stefancic, 1991). Africana Womanism is a culture-specific theory that places culture, history, and lifeways of people of the African diaspora as central to analysis. This theory supports the methodology of this study with its tenet that Africana women (including
African American women) must create their own criteria for assessing their realities, both in thought and action. Critical Race Theory is a race-conscious approach to inquiry that is based on structural determinism and antiessentialism. Structural determinism posits that culture influences life context. Societal norms, beliefs, and practices define the context of one’s life, and once in place, are difficult to reestablish even if they are found to be crippling for some groups of people. Antiessentialism posits that individuals cannot be reduced into categories such as race, gender, or class but instead suggests that the combined experience of all categories are greater than the sum of the parts. Thus, the combined experience of being an African American woman in a society with a history of racism, sexism, and classism provides a unique lens through which one may view the perpetuation of health disparities. Sociopolitical structures that may contribute to meaningfulness of prenatal care must be explored. Historically, African American women are spiritual and share a strong sense of sisterhood and community (HudsonWeems, 1993/2004). Churches are common meeting grounds for sharing norms and beliefs. Knowledge is bequeathed to future generations orally through the use of storytelling. Elders are respected as the “knowers.” Hence, a community approach that included Elders was needed to critically examine cultural strengths that enhance health and sociopolitical barriers that may create and perpetuate differences in health outcomes such as infant mortality. Group discussion through the use of photovoice promotes critical pedagogy aimed at generating knowledge and transforming this new knowledge into power-sharing actions (Wang, 1997) that may reduce infant mortality disparities. Reducing disparities in health is ultimately a matter of social justice, the cornerstone of Critical Race Theory.
Methodology The method used for this study was CBPR using the photovoice approach. This collaborative approach to inquiry involves both the researcher and community members in the research process, with all parties taking ownership of the newly generated knowledge that can be translated into action to serve the community (Israel, Eng, Schulz, & Parker, 2005). Photovoice is a process by which people take pictures of a phenomenon of common interest or concern. Photovoice, an action research strategy based on health promotion principles, facilitates a diversity of perspectives to define and improve social, political, and ultimately health in groups of people (Wang, 2006). Photovoice has been used in multiple studies in varying contexts. It was used by Stedman-Smith, McGovern, Peden-McAlpine, Kingery, and Draeger (2011) to explore maternal knowledge of ways that children are exposed to pesticides. Mothers in the study were better able to identify the pesticide problem, became more aware of how
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Nypaver and Shambley-Ebron pesticide exposure affects health, and identified strategies to reduce pesticide exposure. Another study used photovoice to engage and empower immigrants in a Canadian town to identify and correct barriers to their health and well-being (Hague & Eng, 2011). According to Wang (2006), Photovoice enables people to connect the community to larger social audiences to advocate for community concerns and issues. The purpose of photovoice in this study was to: (1) enable the participants to take photographs to illuminate persons, places, and things that support pregnant women in their community; (2) promote critical dialogue about supportive care during pregnancy; (3) identify barriers to supportive prenatal care for African American women; and (4) reach change agents who have potential to remove identified barriers to support pregnancy in the community. The research questions were: Research Question 1: What are the ways that African American women care for themselves during pregnancy? Research Question 2: What are cultural meanings of prenatal care for African American women? Research Question 3: How does culture influence how African American women care for themselves during pregnancy? Research Question 4: What systems are currently in place to support African American women during their pregnancies? Research Question 5: What are the sociopolitical, economic, and personal barriers that hinder African American women from receiving meaningful care during pregnancy?
informed consent, (2) introductions, (3) study purpose and explanation, (4) outline of the photovoice project, (5) importance of attendance, (6) camera mechanics and photography tips, (7) photography ethics, and (8) ground rules for photovoice discussions. Before arriving at Sessions 2 through 5, participants took pictures that represented people, places, or things in their community that served as supports or barriers to meaningful care during pregnancy. At each session, the researcher downloaded the pictures onto a computer one at a time and projected onto the screen at the head of the meeting table. The researchers guided the discussion using the SHOWeD technique (Wang, 2006) which consists of the following questions: (1) What do you SEE? (2) What is HAPPENING? (3) How does this relate to OUR lives? (4) WHY do these issues exist? and (5) What can we DO about these issues? This resulted in dialogue as the women discussed, listened, and learned from multiple perspectives about the assets and barriers to meaningful prenatal care in their community. Topics were discussed until saturation was achieved. All discussions were audio recorded and the researcher took field notes to provide context for the discussion. Participants also kept reflective journals about the pictures they had taken. The various methods of collecting data (triangulation) were purposeful to strengthen credibility of the data.
Data Analysis
The study community was an urban housing project in the Midwest which is 90% African American and home to 4,500 families, the majority of whom earn below the federal poverty level. Meetings took place in a room in the community’s elementary school. African American women, less than 65 years of age, who were either currently pregnant or had been pregnant in the past were recruited for the study, through flyers posted in the community. Eleven women consented to be in the study, however, four were lost to attrition for various reasons including family emergency, lack of transportation, and scheduling conflicts. Table 1 provides the characteristics of the sample.
Data were analyzed using the constant comparative method, whereby data were coded, sorted, organized, and categorized to abstract conceptual themes (Glaser & Strauss, 1967). Trustworthiness of the study was assessed through Lincoln and Guba’s (1985) evaluation of credibility, transferability, dependability, and confirmability. The researcher listened to audiotape recordings by sessions, read and reread the transcriptions, journals, and field notes. The researcher then coded the transcribed data by session, segmenting data into portions of conversations about a particular idea. The HyperRESEARCH (Researchware, 2012) data management software was used to organize the data. To ensure intercoder reliability, a second researcher coded the data and both were compared for congruency. Codes were continually compared and categories formed. Data were finally abstracted to arrive at five themes. The researcher met with the participants in the community after data analysis was complete. Member checking was conducted to ensure credibility. The participants confirmed accuracy of the identified themes, conclusions, and recommendations. The researcher and participants disseminated findings at a community event.
Procedure
Researcher Reflexivity
The photovoice project consisted of six weekly sessions, culminating with a photo exhibit. The first session included (1)
To enhance trustworthiness of the study, the researcher acknowledges her own values, bias, and multiple influences
Institutional review board approval was obtained prior to recruitment of participants and initiation of the study. The researcher obtained informed consent of participants.
Sample and Setting
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Table 1. Characteristics of the Sample. Age (years) Range M ± SD Age at first pregnancy (range) Age at first pregnancy (M ± SD) Pregnancies (number) Range M ± SD Children (number) Range M ± SD Prenatal care Number of women who received prenatal care Number of women reporting missing one or more prenatal care visit Time of delivery Number of women who delivered a preterm infant Number of women who delivered term infant Infant birth weight Range M ± SD Education Education beyond high school Less than high school graduate General educational development Yearly earned income Range M ± SD Number of women reporting no earned income
28 to 55 42.7 ± 9.52 17 to 21 18.5 ± 1.49 2 to 5 2.71 ± 0.76 2 to 4 2.76 ± 0.57 7 7
1 6
5 lbs 3 oz to 9 lbs 6 lbs 6.9 oz ± 1.32 4 2 1 $0 to $25,000 $8,198 ± 10,024.85 3
Participant photographs and dialogues are displayed in Table 2 through Table 6.
Access to Care The first theme, Access to Care included subthemes of “Transportation” and “Wait” depicted in photographs by Participants #1 and #2, respectively. The participant who took “Transportation” from the interior of her home stated that there were buses and cars parked outside and within walking distance of her home, yet they were often unavailable to her for various reasons. The majority of the participants agreed that the primary form of transportation in their neighborhood is the bus, yet the cost to use it is often prohibitive. The second photograph titled “Wait” sparked reflective dialogue among the participants with all agreeing that prenatal care is important for good pregnancy outcomes, yet once at the facility that provides this care, most had encountered long waiting times to see a health care provider. The women stated that it was difficult and uncomfortable to sit in the waiting room, often with their other children, for long periods while pregnant to finally be seen for a short rushed visit.
Soul Nourishment Soul Nourishment, “the intangible psychosocial nourishment and support that is fundamentally needed by all women” (Nypaver, 2013, p. 95) was the next theme derived from the data. This theme resonated with the participants as spirituality in the form of God, Church, and Bible. Participant #3 photographed pages in the Bible and titled it “Life.” “I had a strong family and strong spiritual family that helped sustain me mentally and emotionally” (Participant #4).
Companionship she brings to the research process and data analysis. The researcher brings a health care provider perspective, having worked as a nurse–midwife for the past 15 years. She has the acute belief that there is an inherent inequality in the provider–client relationship whereby providers “instruct” “patients” based on standards of practice. Using a CBPR approach enabled her to explore perspectives of meaningful care during pregnancy from the women themselves. Because she could only bring her own perspective as a health care provider, she had to iteratively check with participants that her interpretations were in line with their experiences. By doing so, she was able to explore the answers to the research questions more authentically.
Companionship was another theme abstracted from the data. All the women were single mothers yet all desired companionship. The photograph titled “Empty” was taken by Participant #1 to depict this feeling.
Findings
The Future
Five themes were abstracted from the data. They were the following: (1) Access to Care; (2) Soul Nourishment; (3) Companionship; (4) Help Me, Teach Me; and (5) The Future.
The theme The Future expressed the need to build self-worth, self-esteem, and sense of life purpose for African American girls. Many of the participants voiced that young women
Help Me, Teach Me Help Me, Teach Me emerged as a theme as participants described their need for information and education about health in general, but specifically care and resources for pregnant women. “Many Questions, No Answers” was taken by Participant #1 to illustrate unawareness or resources during her pregnancy.
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Nypaver and Shambley-Ebron Table 2. Theme 1: Access to Care. Photographs
Dialogue The photograph titled “Transportation” was taken by Participant #1 from the interior of her home. She stated that there were buses and cars parked outside home yet not available. Most of the participants agreed that the primary form of transportation in their neighborhood is the bus, yet the cost to use it is often prohibitive. “There’s buses going up and down the street all day, but you can’t afford to get on one and sometimes you can get there but you can’t get home” (Participant #1).
Transportation Participant #2 took a photograph which she titled “Wait.” All participants agreed that prenatal care is important for good pregnancy outcomes, yet they often had to wait long periods of time to see their health care provider. They stated that it was difficult and uncomfortable to sit in a waiting room for long periods while pregnant to finally be seen for a short rushed visit. “I waited three hours to talk to the doctor for a five minute visit. That’s all he had because he was rushing through it because he was already behind” (Participant #2). Participant #5 admitted that if she was feeling well on the day of her prenatal care visit, rather than waiting a long time to be seen, she would choose not to attend this short visit. “Waiting” resulted in: “prenatal care visits getting missed, early childhood visits getting missed, and family planning visits getting missed” (Participant #6).
Wait
Table 3. Theme 2: Soul Nourishment. Photograph
Dialogue
Life
Soul Nourishment, defined as “the intangible psychosocial nourishment and support that is fundamentally needed by all women” (Nypaver, 2013, p. 95) was the next theme derived from the data. The women in this study discussed the relationship between physical and mental health. For them, physical health was perceived to be dependent on mental health. They made a clear distinction between the needs of the physical body and the needs of the spirit or soul. Examples they provided for bodily needs included water, food, and shelter. Examples of soulful needs were reported as family, spiritual, and emotional support. Soul Nourishment resonated most often with the participants as spirituality in the form of God, Church, and Bible. The participants reported that care during pregnancy should not be based solely on physical, medical care, but rather on intangible supportive care that nourishes the soul to achieve mental health. Participant #3 photographed pages in the Bible and titled it “Life.” “I had a strong family and strong spiritual family that helped sustain me mentally and emotionally”(Participant #4). Participant #3 explained that for her, this picture illustrated a parallel between new life within a pregnant woman and new life that the “Word of God” can provide resulting in a peaceful, calming effect. “Pregnant women need to ‘sit down’ and enjoy peaceful time. The baby can tell if you’re in a bad mood . . . kind of like tight cramps” (Participant #2). Several women reported that they found great strength in their belief in God while pregnant even when they felt alone and unsupported. All of the women believed that if spirituality was strengthened during pregnancy, this would lead to increased positive maternal and fetal emotions that would enhance physical well-being.
with higher self-esteem are confident with a purpose in life, can envision their future and set life goals that may include reproductive planning. Participant #3 took the photograph she titled “Train Up A Child.”
Discussion Data from this study support that African American women care for themselves and other pregnant women by attending to their physical, emotional, spiritual, and social needs (Soul Nourishment and Companionship). Prenatal care is valued as providing positive pregnancy outcomes but in order for it to be utilized, it must be meaningful. Meaningfulness is enhanced
by physical, psychosocial, and spiritual care rather than just an established number of prenatal care visits with a health care provider, a practice of the current biomedical model of care. In addition, adequate time must be allotted with unrushed health care providers ensuring vital exchange of knowledge between both parties and to provide the opportunity of building relationships where information exchange is trustworthy. Short, rushed prenatal care visits may not provide the opportunity to gather adequate information that is needed about pregnancy and motherhood nor may it allow time to build genuine, trusting relationships between patients and health care providers. Findings add to the body of knowledge that African American women are more likely to engage in early and continuous pre-
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Table 4. Theme 3: Companionship. Photograph
Dialogue Companionship was another theme abstracted from the data. All the women were single mothers yet all desired companionship. The photograph titled “Empty” was taken by Participant #1 to depict this feeling.
Empty
“There’s a pregnant belly. No health care, no support, no spiritual foundation, just alone and pregnant . . . ” (Participant #1). Even though many of the participants had support from spiritual families and friends, they knew of many African American women who were pregnant and alone.
Table 5. Theme 4: Help Me, Teach Me. Photograph
Dialogue Help Me Teach Me emerged as a theme as participants described their need for information and education about health in general, but specifically care and resources for pregnant women. The participants defined community resources as people, places, and things in their community that support women during pregnancy. They identified the community health center, local churches, a mobile van that provides prenatal education, the Women, Infants, and Children Program and Healthy Start Program as helpful resources in which they were aware of. However, they felt there were more resources that they were not aware of. “Many Questions, No Answers” was taken by Participant #1 to illustrate unawareness during her pregnancy.
Many Questions, No Answers
“Some people see the world like that. They see this big infrastructure, this big city and they don’t know, they feel lost.” “It’s out there but you just don’t know where to go. So I had to get out there and find other things that could help me” (Participant #1). The general consensus of the photovoice group was that most of the knowledge each obtained about their own pregnancies was learned from friends and family members and to a lesser extent health care providers.
natal care if it is meaningful for them, especially if it is relationship-centered care (Dahlem et al., 2014; Massey, Rising, & Ickovics, 2006) The themes Soul Nourishment and Companionship revealed that culture played a role in how African American women cared for themselves during pregnancy, how they received care, and how they cared for other pregnant women. Consistent with African Womanism Theory (HudsonWeems, 1993/2004), spirituality, sisterhood, Elder respect, and mothering/nurturing by others were important for the care of pregnant African American women. Soulful care is the term that this author uses to describe the intangible forms of care: spiritual care, social care (relationships), and psychological care (emotions), all of which are tightly interwoven according to the data from this study. Religion was identified as the most common form of spiritual care. The practice of religion brings people of faith together in common meeting spaces increasing the potential to build social support networks. Having historical roots from Africa, spirituality is a predictor of maternal, fetal, and infant health
(Jesse, Graham, & Swanson, 2006; Jesse & Reed, 2004; Mueller, Plevak, & Rummans, 2001). The participants identified intergenerational exchange of cultural beliefs and practices as the main source of advice about pregnancy and motherhood, particularly from their mothers, grandmothers, and elders. Cultural care involved companionship and formation of strong female support systems mainly with family members, friends, and spiritual families. According to the data from this study, African American women feel a deep-felt sense of obligation to serve as mentors, educators, and role models for youth and other pregnant women. Data from this study support the notion that African American women strive to care for themselves during pregnancy by creating time and spaces for peace and relaxation. There was common belief that this practice facilitates mental health, which in turn increases physical health that may lead to healthier pregnancy outcomes. The themes Access to Care, Help Me, Teach Me, and Companionship, identified both supportive systems and barriers for pregnant African American women seeking
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Nypaver and Shambley-Ebron Table 6. Theme 5: The Future. Photograph
Dialogue The theme The Future expressed the need to build self-worth, self-esteem, and sense of life-purpose for African American girls. Many of the participants voiced that young women with higher self-esteem are confident with a purpose in life, can envision their future and set life goals that may include reproductive planning. Participant #3 took the photograph she titled “Train Up A Child.”
Train Up A Child
All the participants agreed that it is everyone’s responsibility to teach young girls about their self-worth. If they have a sense of self-worth, they can begin to dream and set goals for their lives. They will begin to “believe that they can achieve their life goals” (Participant #4). Having experienced a teenage pregnancy, Participant #6 stated that she did not have self-esteem instilled in her when she was a child . . . “as far as my mom sitting me down telling me you’re a beautiful young lady, you somebody, you got a purpose in life, that did not happen.” Therefore, since she saw no life purpose she did not set goals and plan for her future. “Most people who set goals are people that are consistently focused not on just the present but the future and people who are focused on just the present find a lot of things happen in their lives unplanned such as unplanned pregnancies” (Participant #3). “I’ve see a lot in African American families, a lot of pregnancies that were not planned” (Participant #7).
meaningful prenatal care. Supportive systems ranged from local churches to a mobile prenatal care education van, and a community health care clinic. These venues have the potential to supply education about pregnancy, provide physical care, and enhance social support networks. Previous studies have demonstrated that social care has a positive effect on health outcomes (Ickovics et al., 2007; Ickovics et al., 2011; Jesse et al., 2006; Robertson, Aycock, & Darnell, 2009), whereas a lack of social support contributes to social stress which may be a major contributor to the excess risk for PTB among African Americans (Goldenberg, Culhane, Iams, & Romero, 2008; Rowley, 2001). Access to Care is hindered by lack of or poor transportation, lack of child care services, lack of adequate health care coverage, and long waiting times to see health care providers were barriers that hinder African American women from receiving meaningful care during pregnancy. Kitsantas, Gaffney, and Cheema (2012) reported that women who live in urban areas and have two or more barriers to care are twice as likely to initiate late prenatal care. Furthermore, inadequate health care coverage may prevent preconception and intraconception care, an opportune time for detecting and controlling chronic illnesses that are associated with poor pregnancy outcomes. Preconception and intraconception care provides an opportune time for disease prevention and health maintenance to achieve optimal health before a pregnancy exist. Last, the theme, The Future, identified the need to build self-worth and self-esteem in young women. Consistent with
the action portion of CBPR methodology, two of the participants were instrumental in forming and sustaining two separate girls-mentoring groups in their community, one at a local church and the other at the elementary school.
Limitations Limitations of this study were the focused sample, inclusion of participants from only one urban neighborhood in Ohio and a sample that did not include pregnant women. Samplings in several urban areas may have yielded more diverse findings. In addition, the sampling did not include women who were pregnant. Although pregnant women were targeted for recruitment, none enrolled. The perspective of meaningful care from a pregnant woman may be quite different from women recalling care they received during past pregnancies. Future studies using a CBPR approach with a larger sampling that included pregnant African American women along with those who have given birth in the past may yield richer data.
Conclusion This photovoice project empowered African American women to express their perceptions of meaningful care during pregnancy. Despite considerable body of literature devoted to prenatal care, there is very little written about what constitutes meaningful care for pregnant African American women. This study is unique because it captured
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Journal of Transcultural Nursing
perceptions of meaningful prenatal care from African American women who had experienced care in their past. The data support the belief that meaningful care is different from the standardized biomedical model of care because of unique psychosocial and spiritual needs of African American women in this study. Results revealed that prenatal care must be more encompassing of the psychological and social systems that support pregnant women, not merely the act of attending prenatal care visits with a health care provider. Perhaps, adequacy of prenatal care should not be measured by when and how many visits a woman attends but rather by the quality by which it is delivered, quality that satisfies cultural needs (Nypaver, 2013). Findings from this study, which came from the target population themselves, can be used to inform culturally appropriate prenatal care that aims to improve utilization of care and pregnancy outcomes.
Implications for Future Research and Practice The findings from this study have important implications for the care of pregnant African American women. First, different culturally congruent models of prenatal care need to be examined, implemented, and tested through intervention studies. These models of care must include broader views of preventative services such as preconception care, education, and psychosocial support. Although group prenatal care is not a new concept, limited studies on Centering Pregnancy have demonstrated increased patient satisfaction, social support, and infant birth weights, while decreasing the risk for PTB (Ickovics et al., 2007). Replication studies are needed in African American populations. Due to limited health care accessibility, future intervention research is needed to test delivery of prenatal care in alternative settings. One setting may include mobile units in neighborhoods identified as having high IMRs. Perhaps group prenatal care in a church or mobile van in at-risk neighborhoods may decrease barriers that limit access to care, while strengthening social networks. Redesigning models and settings for prenatal care may have the potential to decrease infant mortality among African Americans. Acknowledgments The authors wish to thank Ms. N, Ms. L, Ms. J, Ms. A, Ms. P, Ms. D, and Ms. T for their contribution in many stages of this work and for sharing their stories.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This
research was funded by the Dean’s New Investigator Research Award, College of Nursing, University of Cincinnati.
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