Research and Professional Literature to Inform Practice for March/April 2024

Mindfulness-based childbirth and parenting (MBCP) programs have been gaining in popularity as the broader mindfulness movement has grown. However, like many health and wellness supports, MBCP takes time and support to use in birth and parenting and is, therefore, less accessible to many marginalized individuals who may benefit from the skills learned. Indeed, prior work to pilot test this MBCP involved a group of women who were primarily White and well-resourced and had private health insurance.1 Group health care visits, including CenteringPregnancy (CP), offer unique opportunities to explore a topic that requires a greater allotment of time than a typical one-on-one prenatal appointment. Prior work in California with Black pregnant women found that participants had great difficulty identifying and then reaching mental health support during pregnancy. These participants were open to the idea of using group care as a vehicle for mental health support.2 To reach more marginalized communities during the prenatal period, the CenteringPregnancy with Mindfulness Skills (CP+) was created and piloted in a small pragmatic, quasiexperimental pilot trial. Researchers hypothesized that individuals who participated in the CP+ group would experience less postpartum depression and a host of other mental health-related outcomes, such as greater mindfulness, less postpartum anxiety, and healthier psychological functioning. To test these hypotheses and see if such a program was feasible, acceptable, and led to equal or greater satisfaction with care, participants aged 18 to 35 were recruited from a midwife-led CP program in California. At this clinic, all pregnant patients were automatically enrolled in group prenatal care but could opt out if they desired one-on-one care delivery. Additionally, those with high-risk pregnancies would concomitantly attend CP with additional one-on-one visits. Individuals who spoke English or Spanish, were enrolled in CP, and planned a hospital birth within the specified geographic area were included. Individuals who had previously participated in CP; had formal training in meditation, yoga, or other mind-body practices; or had specific health conditions (type 2 diabetes, HIV, serious mental health disorder, etc) were excluded. A total of 163 individuals were referred to the program, with a final sample of 49 participants enrolled in the study, below the target enrollment of 72. Of the 49, 24 were enrolled in the control group, which consisted of routine CP, and 25 individuals were enrolled in the experimental group, which consisted of CP+. Approximately two-thirds of participants selected Spanish for the prenatal groups, and the remaining third selected English. Most participants (90%) identified as women of color (including 65% Latina). Due to the logical constraints of conducting group perinatal visits, researchers were unable to randomly assign individuals to groups, so a quasiexperimental approach was used. Pairs of groups were assigned a 1:1 distribution, meaning for every 2 Spanish-language CP groups, one assigned to CP+ and the other to CP. Participants were provided with transportation vouchers, snacks, and incentives totaling $150 for their participation. Data were collected 3 times total: baseline upon starting CP, third trimester (28-32 weeks' gestation), and postpartum (6-10 weeks after birth). At baseline, no group differences were noted in outcome variables of interest and sociodemographic factors, except for income, with the CP+ group having a higher income than those in the control group. For the primary outcome, those in the experimental group (CP+) scored lower mean (SD) for postpartum depression (4.90 [4.06]), as measured by the Edinburgh Postnatal Depression Scale, than those in the control group (8.68 [5.39]) after controlling for baseline depression scores and family income. The difference in scores was statistically significant, with Cohen's d = 0.80 indicating a large effect size. The researchers also found that those in the CP+ group had greater improvements in dispositional mindfulness, depression symptoms, perceived stress, and negative emotions than those in the control group if they either (1) had higher baseline levels of mindfulness or (2) lower levels of depression, anxiety, or negative emotions. Thus, CP+ seemed to benefit those who had better psychological well-being at baseline than did CP. Attrition, or participants who left the study, was similar between the experimental and control groups, which suggests that mindfulness-based changes were broadly acceptable and did not negatively influence retention. Furthermore, all CP+ participants rated their practice as helpful, with the highest rankings occurring in the third trimester. Open-ended responses from participants highlighted how mindfulness training helped them reduce stress during pregnancy and feel more present and centered in their bodies. Furthermore, many participants spoke of how the mindfulness training helped them remain calm while parenting a crying infant and realize that there's no ideal way to parent. This study suggests that incorporating MBCP into existing CP programs could be a meaningful way to reduce postpartum depression. These findings are consistent with other mindfulness-based traditions, which have been repeatedly shown to reduce depression at similar rates to psychotropic medications.3,4 Furthermore, the individuals who received this intervention represent many intersecting disadvantaged identities. Individuals in this study were experiencing poverty (n = 44), homelessness (n = 2), or an unstable living situation (n = 16) during their pregnancy and, therefore, had a very high emotional burden at baseline. That these findings were identified among individuals from a marginalized population is promising and hopeful but also underscores the limits of an intervention in a setting of great need and lack of social and structural support. Those already engaged in group prenatal care may want to consider incorporating mindfulness training into group education. MBCP requires training and ongoing mindfulness practice by the instructor to both ensure fidelity of the intervention and best support patients learning mindfulness and experiencing its full benefit. This should not be a drawback, however, because mindfulness practice has important benefits for health care providers.5 Most reproductive health organizations in the United States define abortion as "an intervention (or medication) intended to terminate a pregnancy so that it does not result in a live birth."1 However, in public conversation, what constitutes an abortion and how we talk about abortion are deeply intertwined with abortion stigma.2,3 How people understand and define abortion, as well as other reproductive health outcomes, is critical for collecting accurate data and ensuring individuals have access to the evidence-based, supportive health care that they need.4,5 In a post-Dobbs world, the public is growing increasingly more aware of the many reasons a person may need or want abortion care. However, little research focuses on how we understand, define, and consider these various life circumstances. To better understand how individuals define abortion and how their understanding of abortion might impact their access, utilization, or experiences of care, researchers conducted a mixed-method study using novel data collection methods. Qualitative data collection involved 2 parts. In the first section, participants were given a stack of cards that described different reproductive health experiences, such as "had a surgical abortion" or "took emergency contraception," and were asked to place the cards into one of 3 piles. The 3 piles were an answer to the question "is this an abortion?" and were labeled "yes, definitely," "no, definitely not," or "maybe, it depends." They were also asked to describe how and why they sorted the cards into the categories they selected. In the second part of the interview, the participants were read 8 vignettes that presented different scenarios about a reproductive health experience, with small variations made regarding gestational age, contraceptive use, and the type of abortion procedure. Again, participants were asked if they considered the experience to be an abortion and why they made that determination. For the quantitative survey, the card sorting activity and vignettes were converted to survey questions with the same 3 options to the query about whether this described an abortion (yes, no, maybe). Participants for the qualitative interviews were recruited from an urban area in New Jersey and a suburban area in Wisconsin to ensure that the study findings did not reflect state-specific findings. In total, 64 individuals between the ages of 18 and 49 participated, 29 from New Jersey and 35 from Wisconsin. The survey was distributed nationally and used quota sampling to ensure it was nationally representative by race and ethnicity, region, and age. In total, 2009 individuals responded to the survey. Quantitative results showed a general pattern of agreement among participants; however, there was disagreement for every reproductive health experience on the survey. For example, 5% of participants answered yes, definitely to considering a stillbirth an abortion, 13% answered yes to missing a menstrual period, and 22% of participants felt that taking emergency contraception was an abortion. A quarter of participants responded that taking abortion pills obtained online or having a surgical abortion was "not an abortion." Additionally, none of the answers elicited a uniformly decisive response, with anywhere from 8% to 35% of participants answering "maybe, it depends" to the scenarios. This survey's findings indicate high levels of ambiguity regarding how abortion is classified. Qualitative findings provided a much-needed exploration into how and why participants conceptualize and understand abortion, especially in relation to other pregnancy-related care like miscarriage management. The first finding was ambiguity about how one determines when a pregnancy begins and how this knowledge influences if something is an abortion. For example, one scenario involved a person taking an herbal supplement after a late period and getting a heavier-than-normal period a week later. Many felt that if a pregnancy had been considered by a home pregnancy test and a clinic visit, then the person's actions would constitute an abortion. Formal pregnancy recognition was deemed a critical aspect of whether one's actions constituted an abortion. The second theme centered on understanding the person's intention and choice regarding ending a pregnancy. For some participants, even if a person was unsuccessful in ending a pregnancy, what they had undertaken was an abortion because ending the pregnancy was their intention. In the other direction, many participants vocalized hesitation in labeling something as an abortion if there was a medical reason, such as a reduction in a triplet pregnancy or in the setting of a lethal fetal anomaly. A third finding centered on exploring concepts like natural and unnatural as it relates to pregnancy. For example, many respondents understood miscarriage as something that happens naturally and does not involve an intervention. Removal of the products of conceptus via abortion pills, such as in the vignette of an individual with heavy bleeding at 5 weeks of pregnancy, was seen by many participants as unnatural and, therefore, an abortion because expulsion did not happen on its own. Furthermore, miscarriage management was hard to define for many participants who seemed hesitant to call something an abortion if it was not desired by the pregnant person. This theme carried over somewhat to the fourth theme, which centered around the lack of health literacy regarding pregnancy experiences. This theme was seen frequently in participants discussing the management of an ectopic pregnancy and emergency contraception. Participants were confused about whether an ectopic pregnancy could result in a live birth and whether it was dangerous for a pregnant person. Although about half of the participants identified correctly that emergency contraception prevents pregnancy, many others saw taking emergency contraception as an abortion. One participant said, "Plan B is to get rid of a baby. I mean, that's—that's how I feel about it." Other participants conflated abortion pills and emergency contraception or acknowledged that they were not clear on the difference. Still others labeled a stillbirth as an abortion, unsure of how or if to distinguish it from miscarriage or abortion. The quantitative and qualitative findings from this study highlight the varied, incongruous, and scientifically unfounded ways that individuals may understand and define abortion. A focus on one's intentions and choices influenced perceptions of abortion. However, participants tended to view choices from a very narrow range. Little consideration was given to one's broader life circumstances,6 but was overwhelmingly focused on the health of the pregnancy and fetus. A desire to stratify abortions based on the circumstances was clear, with some abortions, such as a reduction for triplets, seen as inherently different. In these instances, the influence of abortion stigma likely influenced participants' hesitation to call some experiences an abortion. Implicit and explicit in the data was an understanding of abortion as a negative and stigmatizing word, an experience to avoid. This socially accepted understanding means that the full breadth and depth of abortion care, and abortion bans, are misunderstood. Although this misunderstanding results in delayed or avoided services, the ramifications in a post-Dobbs era are especially problematic. Furthermore, although health care terminology must be as clear and accurate as possible, it is also important to center the desires and beliefs of individuals. A person's definition of pregnancy and abortion may indeed be very personal and important to them. For instance, a person who deeply believes conception happens during sex may understand emergency contraception to cause an abortion. Although this is inconsistent with how pregnancy is formally defined, it is nonetheless important that an individual's ability to act in accordance with their own beliefs be honored. Bodily autonomy is not solely reserved for those seeking abortion services but is important for all people throughout the many circumstances they will navigate throughout their lives. Paid family leave of 12 weeks or more is the standard in every industrialized country in the world except the United States.1 Currently, approximately 1 in 4 employees have access to paid family leave. Unpaid leave is more widely available due to the Family Medical Leave Act (FMLA), but the lack of salary renders this protection almost meaningless for families who are economically marginalized.2 The benefits of paid family leave are well documented—paid leave is associated with higher rates of breastfeeding initiation, lower rates of intimate partner violence, an increase in pediatric visit attendance and receipt of newborn vaccination, and a lower rate of maternal suicide.3,4 This patchwork system, made up of paid leave supported by insurers, employers, or government; unpaid job protection; and uneven usage or flexibility of banked sick and vacation time, has been a difficult topic to meaningfully study. To better understand the nuance related to paid leave and health outcomes, researchers used data from a national database and a rigorous ranking system. Individual data were collected as part of the Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System (PRAMS) study, which is a state-based mail and telephone survey measuring behaviors, attitudes, and health conditions among individuals who have recently given birth.5 Rankings of state parental leave policy were developed by the National Partnership for Women and Families. Scores were based on four categories of state laws regarding both private and public-sector employees. These categories represented laws that (1) expanded FMLA, (2) allowed workers to accrue paid sick time off, (3) allowed the ability to flexibly use sick time for a new child, and (4) provided unemployment insurance benefits to people who have left their jobs to care for a sick or disabled family member or partner. The highest score possible was 190, and scores from individual states ranged from 160 (Massachusetts) to 0 (Alabama, Idaho, Michigan, Mississippi, Nebraska, North Dakota, South Dakota, Utah, and Wyoming). State scores were then trichotomized into low (0-24, n = 26 states), medium (25-74, n = 9 states), and high (75 or greater, n = 8 states) paid family and medical leave coverage. Study participants totaled 143,131 individuals who had singleton live births between 2016 and 2019. Because PRAMS is a probability sample, or a sample selected in such a way that it is representative of the larger population, the sample is representative of more than 7 million individuals living in the 43 states and the District of Columbia who report data to PRAMS.5 A little more than half of participants (53.5%) represented states with little or no family leave, a fifth (20.5%) were from states with some paid leave, and just over a quarter (26.2%) were from states with the most generous paid leave. Breastfeeding was defined as any occurrence of breastfeeding, without regard to exclusivity, at 6 months postpartum or at the time of survey completion. Results from this study showed that state breastfeeding prevalence was positively correlated to a state's paid leave score (r = 50.34; P = .02). Prevalence of breastfeeding increased by 7% to 8% among those living in states scoring a medium and high level for paid leave. When looking only at breastfeeding among individuals whose births were covered by Medicaid, researchers observed a 17% and 32% higher likelihood of breastfeeding in states with medium and high paid leave, (adjusted incidence rate ratio [aIRR], 1.17; 95% CI, 1.11-1.24; and aIRR, 1.32; 95% CI, 1.25-1.39) compared with those in low paid leave states. Postpartum depression was measured using a 2-question screener6 and individuals who answered "often" or "always" were defined as having postpartum depression. Prevalence of postpartum depression showed a strong negative correlation with paid leave scores, with many states with the lowest paid leave scores having a greater than 15% to 20% prevalence of postpartum depression. Prevalence of postpartum depression decreased less precipitously than breastfeeding, with states rated as medium or high paid leave scores showing a 2% reduction in prevalence. When looking at those whose births were covered by Medicaid, there were significantly lower odds of postpartum depression symptoms among individuals living in states with the highest level of paid leave (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94). Postpartum visit attendance rates showed a smaller but significant positive correlation with paid leave scores, with many of the states in the low level of leave score having a postpartum attendance rate below 90%. Those living in states with medium levels of paid leave had the highest rates of postpartum visit attendance (92.17%). Among those whose births were covered by Medicaid, there was a small difference in postpartum visit attendance between those living in states with the lowest paid leave and those scoring at medium level (aIRR, 1.03; 95% CI, 1.01-1.04). Regression analysis to test the significance of state policy while controlling for individual participant characteristics indicated continued significant improvement in outcomes as paid leave support levels increased. Those living in states with medium and high levels of support had 8% and 9% higher likelihoods of breastfeeding at 6 months postpartum, respectively (aIRR, 1.08; 95% CI, 1.07-1.10; and aIRR, 1.09; 95% CI, 1.07-1.11). Those living in states with medium levels of state support had 10% lower odds of experiencing symptoms of postpartum depression compared with those living in states with the lowest level of support (aOR, 0.90; 95% CI, 0.85-0.96) and were slightly more likely to attend their postpartum appointment (aIRR, 1.01; 95% CI, 1.01-1.02). However, in states with the highest levels of paid level there was not a statistically significant difference in outcomes when controlling for participant characteristics for both postpartum depression and postpartum visit attendance. Interestingly, there was a small difference in the prevalence of breastfeeding, postpartum depression, and postpartum visit attendance between states with medium and high levels of paid leave. After controlling for participant characteristics, differences were negligible or nonsignificant. These findings suggest that, at least for the outcomes of breastfeeding, postpartum depression, and attendance to prenatal visits, states doing the least in terms of paid leave may not need to undergo a total overhaul of their leave system to support new families most effectively. If these states can adopt the policies of those states that fall within the medium level of paid leave, their residents may experience a meaningful increase in postpartum wellness. The fact that statistically significant differences were noted among individuals whose births had been covered by Medicaid indicates that these improvements will likely be experienced by those most vulnerable, an important goal for health equity and birth justice. Midwives and other perinatal care providers should use data like these in their state and national-level advocacy work because continued inaction and piecemeal solutions are a choice policymakers continue to make. Screening for cervical cancer has changed rapidly over the past several decades, currently consisting of cervical cytology (known as a Pap test), human papillomavirus (HPV) DNA testing, or a combination of the 2 based on an individual's age and risk factors.1 HPV DNA testing was first approved 2 decades ago to triage atypical squamous cells of undetermined significance cytology and approved for stand-alone testing in 2015.2 However, due to the recent nature of the screening recommendations, we have little information about the long-term impacts of HPV screening on cervical cancer incidence and mortality. To examine the effects of HPV screening on incidence and mortality, researchers used longitudinal data from a randomized HPV screening trial in Finland. Thanks to a government program launched in 1963, Finland has a well-established cervical cytology program nationwide and, as a result, has one of the lowest incidences of cervical cancer in the world.3 This large-scale randomized controlled trial included more than 236,000 individuals randomized with a 1:1 ratio to either primary HPV or cytology screening arm. The trial was conducted from 2003 to 2013, and follow-up information was collected through the end of 2020. In total, 3.5 million person-years of follow-up identified 129 cervical cancers and 32 cervical cancer deaths in the cytology arm, 139 cervical cancers and 32 cervical cancer deaths in the HPV arm. Thus, the cumulative incidence of cervical cancer was similar in both screening arms, with mortality rates slightly but not significantly higher in the cytology arm of the trial. These results indicate that HPV screening alone is similarly effective to cytology in identifying cervical cancer and preventing death. Importantly, HPV screening is more objective than cytology and allows for self-sampling. In the United States, cervical cancer screenings and resulting incidence and mortality are not equitably experienced across race, ethnicity, income, and insurance status.4 Furthermore, mistrust and distrust in health care providers and health systems impact the willingness of many to seek cervical cancer screenings.5-7 HPV-only screening offers an effective way to allow individuals and groups who may be hesitant to seek care or need barriers to care removed a novel way to screen for cervical cancer. There are numerous papers and clinical guidelines that provide advice and recommendations for treating pregnant people who have opioid use disorder (OUD) during pregnancy and in the postpartum period. There is far less guidance, however, on ensuring that pregnancy and postpartum care, in particular postpartum pain management, is not itself a starting point for OUD. It is well-established that exposure to opioids after surgery, for example, is a risk factor for OUD.1,2 Despite the recommendation to use a stepwise, multimodal approach to postpartum pain management that does not rely heavily on opioids,3 opioids are commonly prescribed after operative and vaginal birth in the United States. A study done in Tennessee found that 89% of individuals filled an opioid prescription following an operative birth, and 53% did so following a vaginal birth.4 To better understand how new opioid prescriptions given postpartum influence the incidence of OUD, researchers in Ontario, Canada used publicly available birth and controlled substance data. They identified 982,666 births that fit inclusion criteria (eg, gestational age of 35-42 weeks, both neonate and mother discharged alive within 7 days from birth, and one record per birth), of which 135,361 individuals, or 13.8%, filled an opioid prescription within 7 days of discharge after birth. Opioids varied by birth, with codeine being prescribed most after vaginal birth (35.9%), whereas oxycodone was most prescribed after operative birth (40.9%). Among those prescribed opioids after birth, 1282 (10.8 of 1000 births) individuals met the definition of new persistent opioid use during the first year postpartum, equaling approximately 1% of those who gave birth in Ontario. Notably, rates of new persistent opioid use were higher after vaginal (308, 16 of 1000) compared with operative (974, 9.8 of 1000) birth. The authors identified several modifiable factors that were strongly associated with a higher risk of persistent opioid use, including a higher dose of the initial medication prescribed and concomitant prescription of a benzodiazepine. Additionally, those with a history of substance use disorder were at greater risk for persistent opioid use postpartum. With a 1% incidence rate, birth does appear to represent a lower risk for persistent opioid use than many surgeries.2 However, 3.6 million births occur in the United States every year, so even a small risk may carry devastating implications.5 Long-acting reversible contraception (LARCs) were once heralded as helping usher in the end of unplanned pregnancy. Increasingly, researchers, activists, and patients have highlighted how the emphasis on a particular method or clinical outcome (eg, planned vs unplanned pregnancy) can come at the expense of patient autonomy and agency.1 However, the promotion of LARC methods over other contraceptive methods, especially to individuals from marginalized groups, continues to be well documented.2-4 The majority of these data are qualitative and provide an important glimpse into how patients understand and explain efforts by providers to promote LARCs. However, given the recent understanding of the phenomenon of LARC pressure, little research has explored prevalence and sociodemographic variables of who is more or less likely to experience LARC pressure by health care providers. New data collected as part of the 2021 Delaware and Maryland Survey of Women (SoW) provide some of the first population-level data on LARC pressure. The SoW is a cross-sectional population-representative household survey of reproductive behavior and attitudes of women aged 18 to 44. Data were collected from web and mailed-based surveys offered in English and Spanish, with a full sample of 4063 participants in Delaware and 3078 in Maryland. To answer questions specifically about pressure to use and keep LARCs, 2 sample subsets were used. The first sample included participants who were currently using a LARC (n = 1058), and the second sample included both current and previous LARC users (n = 1788). One in 4 current LARC users (26%) reported experiencing pressure to get a LARC, and 11% of ever users report feeling pressure to keep their LARC. Certain groups were much more likely to experience pressure, namely young women (aged <25 years) who had already given birth (87%). However, no significant differences in LARC pressure were noted by race and ethnicity, education, health insurance status, or household income. Thus, except for young parous women, experiences of LARC pressure were spread relatively evenly across the sample. Additionally, 1 in 10 current or previous LARC users reported experiencing pressure to keep their LARC. Again, young parous women were much more likely to experience pressure to keep their LARC (54%), as well as those who identify as Hispanic (17% vs 9% for non-Hispanic White women) and those who are economically disadvantaged (as measured by education level, income, and insurance status). To explore the impact of LARC pressure, researchers looked at linkages between LARC pressure and an individual's response to the statement "I can get [contraception] without seeing a doctor or going to a clinic." A LARC user who experienced pressure to keep their LARC was more than twice as likely as someone who did not experience the same pressure to answer the above question as being an "extremely" important feature of the contraceptive method (42% vs 18%). These population-level data are an important first glimpse at both the frequency with which individuals experience pressure to use and, to a lesser extent keep, a LARC method and how this pressure may influence their subsequent contraception method. Providing patient-centered contraceptive counseling necessitates listening to and acting upon the wishes, priorities, and needs of the patient.1