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Abstract

Background:

Racial disparities are evident in maternal morbidity and mortality rates globally. Black women are more likely to die from pregnancy and childbirth than any other race or ethnicity. This leaves one of the largest gaps in women’s health to date.

Objectives:

mHealth interventions that connect with women soon after discharge may assist in individualizing and formalizing support for mothers in the early postpartum period. To aid in developing an mHealth application, Black postpartum mothers’ perspectives were examined.

Design:

Utilizing the Sojourner Syndrome Framework and Maternal Mortality & Morbidity Measurement Framework, group interview discussion guides were developed to examine the facilitators and barriers of postpartum transitional care for rural Black women living in the United States to inform the development of a mobile health application.

Methods:

In this study, seven group interviews were held with Black mothers, their support persons, and healthcare providers in rural Georgia to aid in the development of the Prevent Maternal Mortality Using Mobile Technology (PM³) mobile health (mHealth) application. Group interviews included questions about (1) post-birth experiences; (2) specific needs (e.g. clinical, social support, social services, etc.) in the postpartum period; (3) perspectives on current hospital discharge processes and information; (4) lived experiences with racism, classism, and/or gender discrimination; and (5) desired features and characteristics for the mobile app development.

Results:

Fourteen out of the 78 screened participants were eligible and completed the group interview. Major discussion themes included: accessibility to healthcare and resources due to rurality, issues surrounding race and perceived racism, mental and emotional well-being in the postpartum period, and perspectives on the PM³ mobile application.

Conclusion:

Participants emphasized the challenges that postpartum Black women face in relation to accessibility, racism and discrimination, and mental health. The women favored a culturally relevant mHealth tool and highlighted the need to tailor the application to address disparities.

Keywords

Black women maternal health disparities mental health mHealth postpartum rural health

Introduction

Disparities in childbirth and maternity among US Black women (henceforth Black women) are gaining widespread attention. In southern states like Georgia, Black women are three times as likely to experience pregnancy-related death in comparison to White women.¹ To mitigate this public health issue, it is crucial to understand the fundamental causes of heightened maternal morbidity and mortality risk among Black women. There exists a limited pool of health systems and public health interventions that address disparities in postpartum care for Black women. Given the rapid growth of mobile health (mHealth) applications as sources of health information, coupled with the critical importance of the postpartum period for preventing adverse maternal health outcomes, optimizing postpartum care and addressing barriers to care for Black women via mHealth technology is needed for bolstering maternal health equity. Current literature presents minimal information on the effects of Black women’s experiences in clinical settings relative to childbirth.² The scant amount of research in this area explains the limited scope of health systems and public health interventions fit to combat inequities in postpartum care endured by Black women. Our qualitative study fills this gap in the discourse by exploring the facilitators and barriers to postpartum transitional care for rural Black women—a population disproportionately affected by inequities in childbirth and maternity—to inform the design of an mHealth application. In this study, postpartum transitional care refers to the provision of medical, emotional, and practical support to women and their newborns during the period immediately following childbirth and extending into the early weeks of postpartum recovery. Moreover, we define Black women as women of the African diaspora living in the United States, who are of reproductive age and recently gave birth within the last year.

Background

Issues of race and perceived racism

Over the last decade, maternal mortality rates in the United States have significantly decreased, but not for Black women.^1,2 Black women are three to four times more likely to die than White women even under the same conditions—an alarming disparity that has proven to be the widest gap in women’s health.³ This inequity is commonly referred to as the Black maternal mortality crisis and stems from various forms of racism embedded within society. One of those is perceived racism which denotes experiences of biased and discriminatory attitudes that involve explicit (i.e. racial slurs and violence) or subtle behaviors (i.e. microaggressions, racial profiling).⁴ Experiences of perceived racism often do not begin during pregnancy but are an accumulation of life experiences from birth.

Racism is an important aspect of maternal health as it often impacts mothers even before they learn of their pregnancy. Starting from childhood, Black women have reported encounters with racism that lead them to become vigilant in healthcare settings;⁵ consequently, many Black women receive fewer resources needed for optimal health. For instance, some healthcare providers hold false beliefs about biological differences between Black and White people. This includes the idea that Black people have a higher tolerance for pain⁴ which negatively impacts the maternal healthcare Black mothers receive and increases their risk of maternal mortality. Racism also invokes barriers in provider–patient communication, decreased self-efficacy and a lack of prenatal, perinatal, and postnatal education. All in all, experiences of racism are known to contribute to excessive chronic stress; thus, significantly impeding a Black mother’s ability to enjoy a healthy pregnancy and delivery.⁶

Black maternal health in Georgia

Georgia is currently ranked 48th for maternal mortality in the United States.⁷ Black women residing in Georgia have the highest risk for adverse maternal outcomes, with a staggering 66.6 deaths per 100,000 live births, compared to 18.1 for Hispanic women and 43.2 for White women.¹ Regrettably, an estimated 90% of pregnancy-related deaths in Georgia are preventable.¹ Factors contributing to this problem involve a lack of healthcare insurance and access among reproductive-aged women, lower socioeconomic status as well as discrimination.⁸ Moreover, Black women are more likely to report being ignored or disrespected by their healthcare providers when seeking treatment for pregnancy-related complications.⁹ The inattention to Black women’s pregnancy-related concerns is a key reason why this group is 60% more likely than White women to suffer from childbirth complications like preeclampsia.¹⁰ Preeclampsia—known as high blood pressure during or after childbirth—is fatal without proper treatment and is the leading cause of maternal death among Black women.¹¹

Geographic location

Geographic location prevents Black mothers, particularly in rural Georgia counties, from receiving the maternal healthcare services they require. In rural Georgia, Black mothers experience 126.7 deaths per 100,000 live births, compared to 78.3 deaths among White women.⁹ Rural areas compared to urban areas have fewer medical specialties, unreliable Internet access, and fewer provider options. In 2019, of the 109 rural counties in Georgia, 93 lacked a hospital labor and delivery unit, and 75 did not have an OBGYN.¹² This leaves rural Georgia mothers without a birthing facility close to their home. Thus, forcing them to travel miles away for prenatal care and hospital delivery services. Limited access to maternal healthcare services because of hospital closures and physician shortages restricts women’s access to care throughout as well as after their pregnancies. Especially, for low-income Black women who are disproportionately burdened by these circumstances.

Disparities in mental and emotional well-being during pregnancy

For many women, pregnancy is physically, mentally, and emotionally challenging. In fact, about 40% of Black mothers in the United States develop adverse maternal mental health conditions.^12
–14 Inequities in economic stability, neighborhood environment, healthcare, community context, and education hinder Black maternal mental health.^15,16 Literature suggests racism and gender oppression create further systems of disadvantage that perpetuate anxiety or depression among Black women.^17
–19 For example, implicit bias and stereotyping lead to culturally incompetent maternal healthcare which drives adverse Black maternal mental health outcomes.^15,20,21 The mental health of mothers has implications for infant growth and development.^22
–24 Therefore, addressing Black maternal mental health is imperative for bolstering quality of life among Black families.

Importance of mHealth to improve Black maternal health outcomes

Given that Black women in the United States inequitably face negative pregnancy-related issues on top of additional health disparities imposed by the COVID-19 pandemic, public health efforts must focus on the creation of innovative, sustainable, and culturally sound interventions. As highlighted by Gourlay,²⁵ community-based doula programs demonstrate promising outcomes for Black mothers by providing tailored support from individuals embedded in the same cultural context as the families they serve. Similarly, in the realm of home visiting, telehealth and virtual platforms have proven pivotal in maintaining continuity of care and ensuring that the benefits of home visiting programs extend to a broader demographic while accommodating the unique cultural needs of families. The White House’s Blueprint for Addressing the Maternal Health Crisis²⁶ mentions telemedicine and technology as tools to address the maternal health crisis. Likewise, analysis of federal legislation suggests that implementation of provider training such as implicit bias training, investing in digital tools, and refined data collection processes as potential avenues to improve maternal health outcomes in underserved communities.

Previous research highlights mHealth as a useful tool for advancing sexual and reproductive outcomes.^27
–29 Guendelman et al.³⁰ sought to understand Internet utilization among disadvantaged, first-time pregnant women and women with young children, and they found that 97% of participants utilized the Internet to seek health information. As an important note, researchers discussed the importance of addressing disparities in mobile phone and Internet access for the use of digital health to be effective for all people. mHealth technology refers to the use of technological devices to promote specific health behavior and provide resources and data. With mHealth, users can monitor their health and attend virtual healthcare appointments. mHealth technologies include smartphones, tablets, and wearable devices.^31,32 Through automated text messages and notifications personalized for each participant, specific interventions can be created with mHealth technology, such as our PM³ application. Our central hypothesis is that use of PM³ app will significantly benefit the health and wellbeing of women during their postpartum period as evidenced by lower rates of comorbid conditions that provoke hospital readmission and higher rates of survival. Such interventions have the potential to be remarkably helpful for Black women living in rural areas with limited access to postpartum health resources. mHealth interventions may benefit these women’s health and well-being during a critical time.

Objectives

Mobile phone applications have grown increasingly popular as sources of health information. By examining the perspectives of Black postpartum mothers, we aimed to assist in developing an mHealth application that connects with women soon after discharge, providing personalized and formalized support in the early postpartum period.

Design

Developing group interview discussion guides based on the Sojourner Syndrome Framework and Maternal Mortality & Morbidity Measurement Framework, we aimed to explore the facilitators and barriers of postpartum transitional care for rural Black women in the United States. This information informs the development of the mobile health application.

Conceptual and theoretical frameworks

Sojourner syndrome

To adequately address the myriad of underlying factors that impact the health of Black women, a theory that elucidates the intersectionality of race, class, and gender is pivotal. In this study, we use the Sojourner Syndrome theoretical framework to better understand how the hierarchies of race, gender, and class operate in the lives of Black women and interact to produce health consequences.³³ As a framework, Sojourner Syndrome primarily considers the constellation of class, race, and gender oppression Black women face, intensifying their risk of adverse health outcomes. However, this framework also recognizes Black women’s multidimensional roles and social identities, as well as their ability to foster resilience in the face of these oppressions.

In addition, Black women’s lifelong chronic overexposure to stress, social disadvantages, and oppressive systems and structures at the intersections of sexism, racism, and classism can increase the risk of perinatal and reproductive morbidity and, secondarily, women’s postpartum mental health problems. Given this harsh reality, it is imperative that the literature that informs research on Black studies and women’s reproductive health explore the relevance of sociopolitical issues linked to experiences with racism and, thus, the enhanced physical implications of that stress on a child-bearing woman. As such, we use Sojourner Syndrome as a lens to better understand the findings, shaping the view and interpretation of the narratives presented.

Maternal mortality and morbidity measurement framework

In 2012, the World Health Organization (WHO) undertook an initiative to standardize the definition, conceptualization, and assessment of maternal morbidity. This initiative culminated in a conceptual framework, namely the Maternal Morbidity Measurement (MMM) Framework.³⁴ The MMM is a multilevel framework that examines all elements that contribute to maternal morbidity and emphasizes the subsets of measurements required to encompass everything significant to women, healthcare providers, and policymakers.

By utilizing the MMM framework, our work investigates the intricacies of social determinants of health that lie at the intersection of culture, class, race, gender, environmental settings, and policies. The MMM draws our attention to the postpartum period as an extended duration of time following pregnancy that spans beyond the traditional 6-week post-birth timeline. Because many women face gaps in healthcare provision but still require continuity of primary care beyond the customary 6 weeks postpartum, this framework is also expected to have important implications for healthcare interventions and programs.

Methods

This study examined the facilitators and barriers to postpartum transitional care for rural Black women to inform the development of the PM³ mobile application. A vast majority of pregnancy apps focus on prenatal support rather than postpartum support,^35,36 and to our knowledge, there is little to no research centering mHealth use during the postpartum period among rural Black women. Therefore, PM³ is curated by and alongside Black women to ensure that their collective and nuanced pregnancy experiences are embodied by the platform.³⁷ Key features of the PM³ prototype include health self-monitoring, goal setting, groups (social networking) as well as access to maternal healthcare services.

Recruitment for this study took place in areas defined as rural and underserved by the Georgia House Rural Development Council and having a Black population greater than 20%.³⁸ To inform the development³¹ of a mobile health application and a postpartum continuum of care model, we conducted group interviews with Black rural mothers (n = 14) over Zoom from June 2021, through October 2021. While we initially intended to conduct focus groups, our protocol required amendment as recruitment of mothers was limited in these areas. Study participants were considered eligible if they were English-speaking, self-identified as African American/Black, were 18 years of age or older, gave birth to a child within the 12 months prior to enrollment and able to give consent. Individuals who did not meet this specific eligibility criteria were excluded from the study. To ensure that the research amplified and reflected the target population’s needs, a Community Advisory Board (CAB) was established (n = 12).

Recruitment

The CAB consisted primarily of rural Black postpartum women (n = 6), representatives of community partner organizations (n = 3; SOWEGA Rising, Black Mammas Matter Alliance, Tri-County Rural Health), and healthcare providers (n = 3; WellStar West Georgia Medical Center, Georgia Department of Public Health, Georgia OBGYN Society). CAB members developed a locally, culturally, and contextually appropriate, non-coercive recruitment and enrollment process by providing education on maternal health and screening. Participants were also recruited passively through word of mouth and by posting flyers at establishments Black women frequent. Recruitment took place in three areas of Georgia defined as rural and underserved by the Georgia House Rural Development Council. Albany, LaGrange, and Waynesboro were selected as they have Black populations that exceeded 20% of the total population.³⁸

Survey and data collection

Prior to participating in group interviews, participants completed a short screener to determine eligibility. If eligible, the participant completed a brief self-administered survey containing close-ended sociodemographic questions and reproductive history and provided written consent before engaging the 1 to 2-hour group interview. Trained members of the research team served as moderators for discussions. Group interviews were conducted and recorded via Zoom and stored for review and transcription by the study team. The moderator used a semistructured discussion guide to garner a rich contextual understanding of participants’ perceptions and beliefs regarding their lived experiences, further elucidated by Sojourner Syndrome and MMM frameworks. Discussions included questions about but not limited to (1) post-birth experiences; (²) specific needs (e.g. clinical, social support, social services, etc.) in the postpartum period; (3) perspectives on current hospital discharge processes and information; and (4) lived experiences with regards to racism, classism, and/or gender discrimination (5) desired features and characteristics for the mobile app development. Thematic saturation was achieved in this study. Participants who completed the group interviews were compensated with a $30 gift card. Information collected from participants remained confidential and anonymous throughout the study and was secured by the principal investigators.

Data analysis

Transcriptions and interviewer notes were uploaded into Dedoose, a mixed-methods research application developed at UCLA.³⁹ Analysis of the data began with classification efforts to code and collect data, in line with the constant comparative analysis method.⁴⁰ This coding technique requires researchers to iteratively examine new data against existing data to develop themes and patterns that provide a wholistic understanding of social phenomena. To ensure consistency, coding was verified by five team members trained in qualitative methods. Final analysis compared data within and across codes. Major themes were determined by the magnitude of code application for each code, and code co-occurrence was also assessed. Supporting quotations were extracted verbatim from the data and shared with the CAB before use in dissemination. This manuscript was prepared in accordance with COREQ guidelines.

Results

A total of 78 women were screened in the study. Of the 78, 14 mothers (18%) were eligible and participated across 7 group interviews. Group interviews last approximately 1 h and ranged from 1 to 3 participants with an average of two participants per group. All participants self-identified as Black or African American (n = 14). Almmost 78% of the participants were between the ages of 25 and 34 years old (n = 9) and living in Albany, GA (n = 10). Figures 1 and 2 display the participants’ locations and ages, respectively. Recruitment efforts for LaGrange and Waynesboro were limited due to restrictions caused by the COVID-19 pandemic and poor or unavailable phone reception.

Figure 1.

Location of participants.

Figure 2.

Ages of participants.

Study team members identified four major themes upon the completion of data analysis, shown in Figure 3: access to healthcare, issues of race and perceived racism, mental/emotional well-being, and mHealth in relation to Black maternal health.

Figure 3.

Prominent themes found across focus groups.

Healthcare access: rurality and information

Mothers expressed several concerns regarding their rural residence preventing them from accessing healthcare services and other resources relevant to the care of their infants. They felt as though their rural towns did not have enough healthcare facilities to accommodate them or the population. Mothers shared that they frequently traveled great distances in order to receive the support they required. For example, one mother recounted a time when she struggled to find a baby formula her doctor instructed her to feed her newborn:

There was one day where I went to go get some formula from Walmart, that’s here in my town, and they did not have the formula that I needed. So I actually had to go 30 minutes away, to get the formula that I needed. I had to go to another town to get the formula that I needed. So that’s a challenge for me living in a rural area.

Furthermore, mothers wanted to receive more information post-birth from hospital staff regarding mental health providers located within a reasonable driving distance. One of the mothers experienced postpartum depression and shared that she felt hesitant to pursue treatment due to the lack of providers in her area. She said, “I mean, I’m getting help now. But I have to travel three hours to get that help. I have to travel all the way to Atlanta, just to get that help.” Another mother also did not receive the mental health support she needed from her doctors and recommended that hospitals make the mental health of new mothers more of a priority:

I actually would have loved to have access to a psychiatrist afterwards. Especially for that first week. Just you know how they automatically have you take the baby to the doctor, that first couple of days after they’re born or you’re out of the hospital. I feel like they should do that for the mother as well. . . That would have helped out a lot.

Issues of race and perceived racism

Several of the mothers mentioned feelings of discrimination, fear, and neglect as a result of their race, which impacted the care they received. Participants adamantly discussed a lack of communication and comfort with their providers throughout pregnancy and delivery. The women felt this was largely due to their race and the provider’s inability to relate to them and express genuine interest in their thoughts. When prompted, one mother discussed her preference for a Black provider, stating

I just feel like it’s, I’m able to be more relatable and open up I feel like they understand a little bit better. And, honestly, during labor, I honestly wish I did, I don’t think I would have felt like, hey, I need to hurry up and push this baby out.

In addition to communication barriers, mothers felt inferior when speaking to White providers. Many mothers shared stories where they experienced discrimination and racism from their providers and other staff. One mother communicated her frustrations with feeling unheard during labor. She asked her provider to respect her wishes and not allow students in the room, but her request was ignored. She shared

I feel like we go unheard like, the statistics, that is true. Because if I was white. . . Excuse me, a white person or white woman saying she don’t want the student, the student wouldn’t have ever come back in. . . So, it’s like oh whatever.

A number of the mothers also expressed fears they had which were worsened by inattentive and biased providers and supporting staff. One mother shared

When I switched, I had a white doctor. And she tried to talk me into getting a hysterectomy, mind you I’m young. So, when I did my research on hysterectomies . . . I voiced my opinion, and she didn’t like it. But I don’t see you talking to the white patients like this. I only see you with an attitude with us . . . with us it’s rushed.

Another commonality among the mothers was their fear of dying during and/or after birth. Some mothers shared sentiments comparable to one mother who said:

That day my doctor was not on call it was a black lady who delivered my child . . . if it would have been my doctor that day, I just don’t feel like I would have been alive. I just don’t . . . She did the necessary things that she had to do in order to keep me alive.

Mental health

Mothers discussed mental health stigma as a barrier to accessing postpartum transitional care. Mental health is a taboo topic in many Black communities; therefore, many mothers were hesitant to share mental health experiences during their postpartum phase. Group interviews highlighted that although having a child is deemed a joyous experience in a woman’s life, the mental and emotional toll of the changes a mother goes through is often discounted. Other mothers shared their willingness to freely discuss their postpartum mental health to bring awareness to the public health issue. One mother was met with opposition as she stated:

A year before I got pregnant, we had a miscarriage, and I did not take care of myself during that time and so that’s why being diagnosed with depression before and I didn’t tell people, so it was like, postpartum with this one. It’s like, no, I’m being honest. And people are like, how dare you talk about this, or you know like, Black women don’t talk about this like we just go with the flow like no, this is what it is. This is what it is. I’m not hiding behind it. I’m not hiding behind this no more.

Quite a few mothers felt as though they did not have the space to be transparent about their experience, not only due to stigma but also to the “strong Black woman” stereotype. This ideology perpetuates the notion that Black women are resilient against harsh realities. For example, one mother articulated:

They expect us to just be strong. In general. They don’t expect us to, well, not they, you know, we say we’re strong, we can do it, we can do it, you’re a black woman pull it together because we always have to . . . And the fact that we always have to be strong no matter what, that played a huge part because I kept telling myself, you’re strong, you’re stronger than your mind is telling you, you’re stronger than you crying, waking up crying. What are you waking up crying for? Like, I tried to beat myself up. Because I was really mentally ill . . . I had to come to the realization you need help, and it is okay.

MHealth and Black maternal health

Participants were shown a video demonstrating a prototype of the PM³ mobile application and were asked about their initial thoughts and suggestions for the mobile application. The “groups” feature of the application was widely talked about, as one participant mentioned:

I like the groups that she was able to join even though the people are not there—the technology where having people, even virtually, or digitally to support you and things.

Support systems, composed of individuals with similar life experiences, was a common theme brought up during the group interviews. Participants shared how mHealth applications could help them connect with other individuals bases on shared interests or feelings. For instance, one mother explained:

With me being a Black woman—with two Black boys, with all this police brutality going on with our Black kids. I would want to speak to someone who has like-minded insights as me. And hear their insight, even possibly try to see what we can do to prevent our boys growing up and dealing with this.

Finally, participants mentioned that the PM³ mobile application could help them to prioritize their mental health. One participant stated:

They help you stay positive as well, especially with going through mental health. And for me, it keeps me positive with me reading something that’s positive, I’m constantly seeing it. Most people have their phone 24 hours a day, and they’re looking at their phone. So, it’s always good to be able to go on there to see something positive instead of always looking at negative information.

The prototype of the PM³ mobile application was positively received, and mothers were highly interested in having an application like on their mobile devices for their own personal use.

Discussion

The shortage of healthcare providers in rural Georgia, combined with the lack of resources and pertinent information provided to the mothers post-birth, contributed to the poor health outcomes they experienced. Healthcare providers must consider the additional needs of Black new mothers to ensure their physical and mental recovery post-birth as well as the health of the baby. Abiding by the “strong Black woman” narrative causes many to suffer in silence, which prematurely deteriorates one’s physical and mental health. While one participant realized that asking for help was not a sign of weakness, many others have not and feel the need to confront the challenges of postpartum life on their own. All in all, the experiences shared in the group interviews corroborate the need to normalize conversations about mental health in the Black community, particularly concerning psychological conditions following childbirth in rural Black women.

This study was unique in the fact that it served as an opportunity to amplify the voices of Black women, specifically. Each of the mothers’ stories demonstrates the need for standardized postpartum care, including, but not limited to, hospitals employing more Black healthcare providers, and for providers to learn and practice more racially inclusive, trauma-informed, respectful, patient-centered care. According to several participants, two positive aspects of residing in a rural area include being closer to family and living in a small community. The commonness of the mothers’ stories, although they are located across different cities, proves that these experiences are not isolated events. When mothers experience feelings of fear and neglect, the patient-provider relationship is strained. This makes mothers less likely to discuss complications with providers and to maintain their and the baby’s health.

Furthermore, this study presented an opportunity to solicit feedback on a postpartum care mHealth application made by and for Black women. Participant comments on PM³ reiterated the importance of critical mass, or when an application garners a big enough audience for it to be self-sufficient off user-generated content; especially, for the groups feature.⁴¹ Given that participants liked the idea of the app providing access to a virtual support system, our research team plans to embed additional community building activities within the app. For instance, participants may be prompted to share a list of things they wish someone had told them about becoming a mother or post the last picture they took before giving birth. In consideration of the mental health feedback, regularly sharing content and initiating dialogue that celebrates Black motherhood and empowers Black women will continue to be a priority for PM³. In this sense, the mHealth application will serve as a counterspace, or a community where the “cultural histories, experiences, and values of [Black people] are not dismissed, but are affirmed and validated,” as a means for promoting mental wellbeing.^42,43

Limitations

Recruitment took place during the COVID-19 pandemic which limited our visibility in the community, limited our reach, and increased barriers for effective communication with rural participants. Many participants did not have access to devices or networks to participate in Zoom calls. Given the limited number of participants it is possible that our data may reflect the perceptions of only a portion of rural populations; however, thematic saturation has been obtained based on literature which states that, “across 16 tests using various approaches to saturation, the sample size for saturation ranges between 5 and 24 interviews.”⁴⁴ Likewise, we were able to reach a point in interviews where the mothers’ perspectives began to overlap and many of the themes that were discussed were repeated. Better methods of recruiting and access to participants are necessary to further examine the effects of mHealth interventions on the experiences of postpartum Black mothers.

Conclusion

Our research highlights the realities of the postpartum experiences of Black women living in rural Georgia. Black rural mother who participated in the study shared common reports of neglect and/or discrimination from their healthcare providers, a lack of resources pertinent to their well-being post-birth, and the need for increased connection with other mothers. From the narratives provided, we have identified core elements of mothers’ descriptions of their postpartum experience. Participants in the group interviews reported several themes consistent with those found in the literature on disproportionate Black maternal mortality rates. Notably, a lack of healthcare providers and resources located within rural settings, medical mistrust due to race discordant patient–physician relationships, and stigma surrounding mental health in the Black community were all discussed as barriers to healthcare and contributing factors to poor maternal health outcomes.

The results of this research also exhibit the importance of race in the postpartum experience and how race can affect patients’ communication with healthcare providers. Several participants mentioned race discordance which made it more difficult to communicate with their providers resulting in incidences of discrimination, racism, and an overall feeling of being dismissed. Mental health was another widely discussed topic during the group interviews. The mothers explained the stigma around mental health being an obstacle which made them reluctant to speak about their mental health struggles, largely due to the “strong Black woman” stereotype that is so pervasive in American society. These discussions highlighted the significance of normalizing dialogue about Black women’s mental health during the postpartum period.

Considering the multiple barriers to equitable postpartum healthcare driving the stark racial/ethnic disparities in maternal mortality, mHealth is a technological solution to this critical public health issue. Feedback obtained on the PM³ mobile application demonstrates its potential to foster culturally responsive and relevant social support among Black mothers.^45–47 Future research should explore the varying social supports (i.e. instrumental, informative, appraisal and emotional) mHealth offers postpartum Black women. Moreover, the feedback we solicited on the PM³ mobile application has implications for the role of mHealth in safeguarding postpartum mental health among Black women. Mental health applications are growing in popularity, yet forthcoming studies are needed to explore their use in preventing of adverse postpartum mental health among Black women. The information shared in the group interviews is valuable because it stems from participants’ personal experiences of being Black women in rural Georgia during their postpartum period. These findings are directly aligned with the target population of the PM³ mobile application and indicate the necessity for tailored mHealth tools.

Supplemental Material

sj-docx-1-whe-10.1177_17455057241239769 – Supplemental material for Using mHealth to reduce disparities in Black maternal health: Perspectives from Black rural postpartum mothers

Supplemental material, sj-docx-1-whe-10.1177_17455057241239769 for Using mHealth to reduce disparities in Black maternal health: Perspectives from Black rural postpartum mothers by Natalie Hernandez-Green, Morgan V Davis, Oluyemi Farinu, Kaitlyn Hernandez-Spalding, Kennedy Lewis, Merna S Beshara, Sherilyn Francis, LeThenia Joy Baker, Sherrell Byrd, Andrea Parker and Rasheeta Chandler in Women’s Health

Footnotes

Acknowledgements

The authors thank the mothers, support people, and healthcare providers who participated in the group interviews, as well as the community partners who helped conduct them.

Declarations

ORCID iDs

Oluyemi Farinu

Kaitlyn Hernandez-Spalding

Supplemental material

Supplemental material for this article is available online.

References

Maternal Mortality Review Committee. 2018-2020 maternal mortality report. Atlanta, GA: Georgia Department of Public Health, June 2023, https://dph.georgia.gov/document/document/maternal-mortality-2018-2020-case-review/download

McLemore

Altman

Cooper

, et al. Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth. Soc Sci Med 2018; 201: 127–135.

Essien

Molina

Lasser

KE.

Strengthening the postpartum transition of care to address racial disparities in maternal health. J Natl Med Assoc 2019; 111: 349–351.

Clark

Anderson

Clark

, et al. Racism as a stressor for African Americans: a biopsychosocial model. Am Psychol 1999; 54(10): 805–816.

Martin

Montagne

Nothing protects Black women from dying in pregnancy and childbirth. ProPublica 2017; 7: 2017.

Liu

Glynn

LM.

The contribution of racism-related stress and adversity to disparities in birth outcomes: evidence and research recommendations. F S Rep 2022; 3(2 Suppl.): 5–13.

United Health Foundation. 2016 health of women and children report. Minnetonka, MN, 2016, https://assets.americashealthrankings.org/app/uploads/hwc-fullreport_v2.pdf

Singh

GK.

Maternal mortality in the United States, 1935-2007: substantial racial/ethnic, socioeconomic, and geographic disparities persist. US Department of Health and Human Services, Health Resources and Services . . ., 2010, https://ntrl.ntis.gov/NTRL/dashboard/searchResults/titleDetail/PB2011103529.xhtml

Yale Global Health Justice Partnership. When the state fails: maternal mortality & racial disparities in Georgia. New Haven, CT, 2018, https://law.yale.edu/sites/default/files/area/center/ghjp/documents/ghjp_2018_when_the_state_fails-_maternal_mortality_racial_disparity_in_georgiarev.pdf

10.

Fingar

Mabry-Hernandez

Ngo-Metzger

, et al. Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014, https://pubmed.ncbi.nlm.nih.gov/28722848/ (2017).

11.

US Preventive Services Task Force. Screening for hypertensive disorders of pregnancy: US preventive services task force final recommendation statement. JAMA 2023; 330(11): 1074–1082.

12.

Delima

Michels

Qiu

Lowering preventable maternal deaths in rural Georgia. J Sci Policy Gov 2020; 17(2), https://www.sciencepolicyjournal.org/article_1038126_jspg170205.html

13.

National Partnership for Women & Families. Black Women’s maternal health: a multifaceted approach to addressing persistent and dire health disparities. Washington, DC: National Partnership for Women & Families, 2018, https://nationalpartnership.org/wp-content/uploads/black-womens-maternal-health-2018.pdf

14.

Hoffman

Trawalter

Axt

, et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA 2016; 113(16): 4296–4301.

15.

Thapa

Mainali

Schwank

, et al. Maternal mental health in the time of the COVID-19 pandemic. Acta Obstet Gynecol Scand 2020; 99(7): 817–818.

16.

Destine

Brooks

Rogers

Black maternal health crisis, COVID-19, and the crisis of care. Fem Stud 2020; 46(3): 603–614.

17.

UPMC Western Behavioral Health. Mental Health Challenges Black Mothers Face, 2020, https://share.upmc.com/2020/07/black-maternal-mental-health/ (accessed 29 December 2023).

18.

Matthews

Morgan

Davis

, et al. Pathways to equitable and antiracist maternal mental health care: insights from Black women stakeholders: study examines pathways to equitable and antiracist maternal mental health care. Health Aff 2021; 40(10): 1597–1604.

19.

Estriplet

Morgan

Davis

, et al. Black perinatal mental health: prioritizing maternal mental health to optimize infant health and wellness. Front Psychiatry 2022; 13: 807235.

20.

Crear-Perry

Correa-de-Araujo

Lewis Johnson

, et al. Social and structural determinants of health inequities in maternal health. J Womens Health (Larchmt) 2021; 30(2): 230–235.

21.

Davis

DA.

Reproducing while Black: the crisis of Black maternal health, obstetric racism and assisted reproductive technology. Reprod Biomed Soc Online 2020; 11: 56–64.

22.

Taylor

JK.

Structural racism and maternal health among Black women. J Law Med Ethics 2020; 48(3): 506–517.

23.

Glover

Can you hear me?: how implicit bias creates a disparate impact in maternal healthcare for Black women. Campbell L Rev 2021; 43: 243.

24.

Parker

Reframing the narrative: Black maternal mental health and culturally meaningful support for wellness. Infant Ment Health J 2021; 42(4): 502–516.

25.

Gourlay

Blue Cross Blue Shield: The Health of America. Data show community-based doulas improve outcomes for Black mothers, 2022, https://www.bcbs.com/the-health-of-america/healthequity/data-show-community-based-doulas-improve-outcomes-black-mothers/ (accessed 29 December 2023).

26.

The White House. White House blueprint for addressing the maternal health crisis. Washington, DC, June 2022, https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf

27.

Fernandez

Copenhaver

Vawdrey

, et al. Smartphone use among postpartum women and implications for personal health record utilization. Clin Pediatr (Phila) 2017; 56(4): 376–381.

28.

Guerra-Reyes

Christie

Prabhakar

, et al. Postpartum health information seeking using mobile phones: experiences of low-income mothers. Matern Child Health J 2016; 20(Suppl. 1): 13–21.

29.

Osma

Barrera

Ramphos

Are pregnant and postpartum women interested in health-related apps? Implications for the prevention of perinatal depression. Cyberpsychol Behav Soc Netw 2016; 19(6): 412–415.

30.

Guendelman

Broderick

Mlo

, et al. Listening to communities: mixed-method study of the engagement of disadvantaged mothers and pregnant women with digital health technologies. J Med Internet Res 2017; 19(7): e7736.

31.

Dugas

Gao

Agarwal

Unpacking mHealth interventions: a systematic review of behavior change techniques used in randomized controlled trials assessing mHealth effectiveness. Digit Health 2020; 6: 2055207620905411.

32.

Rowland

Fitzgerald

Holme

, et al. What is the clinical value of mHealth for patients. NPJ Digit Med 2020; 3: 4.

33.

Mullings

The sojourner syndrome: race, class, and gender in health and illness. Voices 2002; 6(1): 32–36.

34.

Filippi

Chou

Barreix

, et al. A new conceptual framework for maternal morbidity. Int J Gynec Obstet 2018; 141: 4–9.

35.

Sardi

Idri

Redman

, et al. Mobile health applications for postnatal care: review and analysis of functionalities and technical features. Comput Methods Programs Biomed 2020; 184: 105114.

36.

Tucker

Villagomez

Krishnamurti

Comprehensively addressing postpartum maternal health: a content and image review of commercially available mobile health apps. BMC Pregnancy Childbirth 2021; 21(1): 311.

37.

Jackson

Sehgal

Baur

Benefits of mHealth co-design for African American and Hispanic adults: multi-method participatory research for a health information app. JMIR Format Res 2022; 6(3): e26764.

38.

United States Census Bureau. Quickfacts: Georgia, 2021, https://www.census.gov/quickfacts/fact/table/GA/PST045222 (accessed 7 December 2023).

39.

Salmona

Lieber

Kaczynski

Qualitative and mixed methods data analysis using Dedoose: a practical approach for research across the social sciences. Thousand Oaks, CA: SAGE, 2019.

40.

Strauss

Corbin

Basics of qualitative research : techniques and procedures for developing grounded theory. 2nd ed. Thousand Oaks, CA: SAGE, 1998.

41.

Oliver

Marwell

Teixeira

. A theory of the critical mass. I. Interdependence, group heterogeneity, and the production of collective action. Am J Soc 1985; 91(3): 522–556.

42.

Beasley

Tunstall

Blackmon

, et al. Make space, take space: an exploration of academic counter-spaces for Black collegiate women. In: Cain-Sanschagrin

Filback

Crawford

(eds) Cases on academic program redesign for greater racial and social justice. Hershey, PA: IGI Global, 2022, pp. 1–21.

43.

Manalo-Pedro

Mackey

Banawa

, et al. Learning to love ourselves again: organizing Filipinx/a/o scholar-activists as antiracist public health praxis. Front Public Health 2022; 10: 958654.

44.

Hennink

Kaiser

BN.

Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med 2022; 292: 114523, https://www.sciencedirect.com/science/article/pii/S0277953621008558

45.

Anderson-Lewis

Darville

Mercado

, et al. mHealth technology use and implications in historically underserved and minority populations in the United States: systematic literature review. JMIR mHealth and uHealth. 2018; 6(6): e8383.

46.

Dorst

Anders

Chennupati

, et al. Health information technologies in the support systems of pregnant women and their caregivers: mixed-methods study. Journal of medical Internet research. 2019; 21(5): e10865

47.

Sakamoto

Carandang

Kharel

, et al. Effects of mHealth on the psychosocial health of pregnant women and mothers: a systematic review. BMJ open. 2022; 12(2): e056807.

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