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Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston

Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With... Practice Brief Report Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston Rose L. Molina, MD, MPH; Amanda DiMeo, MSc; Leigh Graham, PhD, MBA; Grace Galvin, MPH; Neel Shah, MD, MPP; Ana Langer, MD ABSTRACT Community-based organizations are uniquely positioned to address critical gaps in social support that contribute to in- equities in maternal health. Using a human-centered design process, we held 3 design workshops with members of 15 organizations in Greater Boston, including community-based organizations, allied hospital systems, and public health departments, to assess proposed solutions for gaps in social support services during pregnancy and the first year after childbirth. The workshops focused on solutions to problems that emerged from a mixed-methods research study with community-based organizations that provide social support services; workshop attendees explored facilitators and barriers to implementing solutions. Key considerations included colocation of solutions, shared ownership of program and client data, decision making about triage and referrals, and strengthening coordination of existing programs. Collaborative de- sign workshops surfaced potential solutions to improve coordination of services, which require addressing structural and interpersonal racism in Greater Boston. KEY WORDS: community-based organizations, health care delivery, human-centered design, maternal health, racial equity acial and ethnic inequities in maternal health White individuals, even after adjusting for socioeco- 1,2 persist, with African American/Black and nomic factors. These inequities are a national crisis R Native American individuals experiencing even in states, such as Massachusetts, with relatively worse outcomes when compared with non-Hispanic few maternal deaths and other adverse outcomes. There is growing attention to the postpartum pe- Author Affiliations: Ariadne Labs, Boston, Massachusetts (Drs Molina, riod as a vulnerable moment in the life course for Graham, and Shah and Mss DiMeo and Galvin); Department of Obstetrics & physical, mental, and family health. Gaps in social Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts support during pregnancy and the first year after (Drs Molina and Shah); and Women & Health Initiative, Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Dr Langer). childbirth contribute to these inequities in maternal The authors thank Oby Okafor, Becca West, and Tomi Ojo for their health. Community-based organizations (CBOs) and contributions to the research, community engagement, and design aspects of other allied organizations address critical gaps in so- the project. The authors also thank all collaborators in the design workshops, cial support but may not be adequately coordinated for their contributions to this project, and the study participants, for sharing their experiences with them. to optimize outcomes. The project was financially supported by grant G2019-0034 from The Boston This project launched in 2019 as a partnership Foundation. with The Boston Foundation, The Women and Health The authors have indicated they have no potential conflicts of interest to Initiative at Harvard T. H. Chan School of Public disclose. Health, and Ariadne Labs. We set out to map the This is an open-access article distributed under the terms of the landscape of CBOs in Greater Boston, an area that Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work includes Boston and about 100 neighboring cities and provided it is properly cited. The work cannot be changed in any way or used 5 towns. The project aim was to create solution pro- commercially without permission from the journal. totypes to address the gaps in social support services Correspondence: Rose L. Molina, MD, MPH, Department of Obstetrics & that we identified through prior surveys and inter- Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Kirstein 3, Boston, MA 02215 (rmolina@bidmc.harvard.edu). views (findings to be published separately). This brief Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. summarizes the design thinking process we used to DOI: 10.1097/PHH.0000000000001438 develop solution prototypes. S66 www.JPHMP.com January/February 2022 • Volume 28, Number 1 Supp January/February 2022 • Volume 28, Number 1 Supp www.JPHMP.com S67 Methods could support a solution and what would impede its success. For example, there was an activity in We identified CBOs that provide social support ser- which participants were asked to rank solutions for vices to pregnant and postpartum clients through investment and discuss how to center community professional networks, key informant interviews and engagement in the solutions. Some workshops in- snowball sampling, and publicly available informa- cluded breakout sessions where participants worked tion on Web sites. We analyzed surveys and interviews in smaller groups to brainstorm facilitators and bar- with 21 unique CBOs and other allied organizations riers relevant to the solutions. Participants were also in Greater Boston (findings to be published sepa- encouraged to share new ideas. The output of each rately). We presented these findings at a networking workshop involved a Miro board of virtual “sticky reception of more than 140 CBOs, researchers, policy notes” of ideas and discussion themes. During the makers, and study participants in October 2020. We workshops, we discussed solutions to address the top worked with design thinking experts to develop so- challenges to accessing social support for birthing lution prototypes to close the gaps in social support people of color, as well as facilitators and barriers during pregnancy and the first year after childbirth. relevant to the solutions, and their potential impact In fall 2020, we hosted 3 design workshops over in Greater Boston. Other key considerations included Zoom to cocreate a set of solutions for the gaps iden- Boston’s history with racism, high rates of health care tified in our first phase of work. Participants were coverage in Massachusetts, regional inequality, and invited to attend the design workshops if they (1) variations in local governance across Greater Boston. were on the original list of CBOs invited to partici- 9 We conducted thematic analysis of the output pate in the research study, (2) were identified through from the design workshops and held a final, internal snowball sampling from study respondents, or (3) workshop to review the findings from the former 3 attended the virtual networking reception. Potential workshops. We reviewed the thematic analysis find- participants received an e-mail describing the project ings and integrated themes in the final workshop. and design workshops and replied on the basis of We included experts in design thinking and mater- their availability and interest. Participants did not nal health in Boston to encourage our team to think receive compensation for their participation. Orga- strategically about the best focus for designing a so- nizations did decline to participate, especially given lution to support CBOs and allied organizations. We the concurrent COVID-19 pandemic. Attendance is focused our final workshop on the opportunity to im- reported as follows: design workshop 1: 55 invited prove coordination and collaboration among CBOs and 14 (25%) attended; design workshop 2: 50 in- and allied organizations with a racial equity lens. An vited and 15 (30%) attended; and design workshop equity lens “asks what disparities exist among differ- 3: 64 invited and 6 (9%) attended. Eight CBOs that ent groups; takes into account historical and current participated in the earlier study joined the workshops, institutional and structural sources of inequality; and and 7 CBOs joined because they were engaged in our takes explicit steps to build the social, economic, and networking reception. political power of the people most affected by in- We organized design workshops to achieve 3 goals: equities in order to narrow gaps while improving (1) use interview and survey data to identify high- 10 overall outcomes.” Finally, we conducted organiza- impact opportunities for solution prototypes; (2) 11 tional analysis of the participants, using publicly obtain input from a variety of organizations; and (3) available data to assess common equity considera- assess the usefulness of potential solutions. Ultimately, tions, such as demographic diversity of organizational we aimed to enhance coproduction and ownership leadership, organizational history and mission, and of the solution prototypes through the design work- annual financials for the nonprofit entities as a proxy shops. The first 2 workshops lasted 1.5 hours, and the for size. third and fourth workshops lasted 1 hour. We con- Ethical approval for this research was obtained ducted a structured brainstorming process to generate from the Harvard University Institutional Review new ideas and critically review potential solutions us- Board (IRB) on February 27, 2020 (IRB20-0193). In- ing Stanford University’s Hasso Plattner Institute of formed consent was obtained for all participants in Design (the “d.school”), IDEO’s framework for de- surveys and interviews. 7 8 sign thinking, and Miro, an online collaborative whiteboard platform. Results An expert in design thinking facilitated the work- We included 28 organizations in the research and de- shops and used a virtual whiteboard space on Miro sign phases of the work. The majority (71%; n = 20) for discussion. Throughout the workshops, the facil- of our participants were led or co-led by women or itator encouraged participants to think about what S68 Molina, et al • 28(1 Supp), S66–S69 Design Workshops on Inequities in Pregnancy-Related Social Support gender-expansive people, based on publicly avail- a birth center). One participant emphasized that able data. Of the 28 organizations, 18% (n = 5) were what may appear as an alternative birthing option led or co-led by women or gender-expansive Black to hospitals is historically the primary option for or Indigenous People of Color (BIPOC) based on birth, particularly among communities of color. This publicly available data. Most of the participants had sparked a discussion about the historical context current or historical ties to the health systems within of birth and what tangible steps could be taken to Boston or Massachusetts. Organizations ranged in support all birthing options and ensure equitable out- size and included centers in large health systems comes regardless of a birthing person’s preference to small businesses providing emotional support for for location of birth, such as expanded access to birthing people, among others. The design workshops midwifery care or birthing centers. Participants also included 15 participants from the following sectors: discussed enhanced coverage for doulas and lactation health care (n = 3), public interest or law (n = 3), consultants, recruiting BIPOC doulas, and training public health (n = 2), mental health (n = 2), early doulas in the care of BIPOC individuals. Anti-racism childhood (n = 1), care coordination (n = 1), doula and microaggression training in health care systems care (n = 1), education (n = 1) and housing (n = 1). were key solutions in addressing structural and inter- The Table details solutions, facilitators, and barriers personal racism within Greater Boston. For structural explored in the workshops. Participants highlighted and interpersonal racism within organizations, partic- potential solutions to counter structural and interper- ipants explored paying community members for their sonal racism in Greater Boston, including supporting time in program planning, creating deliberate strate- alternative birthing options (births at home or in gic plans focused on equity, and implementing hiring TABLE Solutions Identified for the Top Challenges to Accessing Social Support Structural and interpersonal racism Solutions: Support alternative birthing Hold doula trainings and workshops in the Greater Boston area options for pregnant and birthing specific to BIPOC people when representation does not Incorporate anti-racism and exist in the health care system microaggression training into the Advocate for policies to enhance health care system coverage for social support providers Facilitators: Acknowledge history and lived experiences of birthing people of color; strengthen informal support networks; invite culture change that is accountable Barriers: Historically restrictive policies in birth center/birth worker accreditation; lack of anti-racist curricula at all professional levels Structural and interpersonal racism Solutions: Provide payments to Offer professional development for within CBOs community members for participating BIPOC staff in programming Implement recruitment and hiring Create a deliberate strategic plan to practices to ensure a diverse address equity workforce Facilitators: Make a plan within the organization that is intentional and measurable, available to the whole organization Barriers: Language is not always accessible for all Lack of coordination of services Solutions: Centralized, coordinated, or Citywide shared data (eg, Web site) collaborative intake systems for social about available social support support needs services and eligibility criteria Coalition that includes community Health navigators at the city level to members and birthing people to ensure help individuals navigate support social support services are prioritized referrals Facilitators: Build up existing networks of services that already exist; obtain necessary human and financial resources to sustain intake systems Barriers: Staff for all necessary roles; identify backbone organization to lead Crosscutting themes • Colocation of multiple solutions: Creating access points to referrals • Shared ownership of data about social support services and eligibility criteria • Who decides about screening and referrals for social support needs • Strengthening and coordinating existing programs to avoid duplication of services and fill gaps Abbreviations: BIPOC, Black, Indigenous, and People of Color; CBO, community-based organization. January/February 2022 • Volume 28, Number 1 Supp www.JPHMP.com S69 parenting exist but are not tied to specific organiza- Implications for Policy & Practice tions. This presents an opportunity to uplift existing programs within the community through better coor- ■ While lack of coordination among CBOs and allied organi- dination with CBOs. zations is not new, there is a growing imperative for public health stakeholders to (1) apply an equity lens in dismantling racism as a key barrier and (2) support people navigating Discussion and Conclusion a vulnerable social transition in starting or growing young Despite a large number of CBOs and allied organi- families. zations providing a range of social support services ■ Workshops organized with human-centered design princi- in Greater Boston, gaps in social support persist ples can increase engagement, generate diverse perspec- for birthing people, particularly in communities of tives and experiences, and enhance solution prototyping. color. During design workshops, participants identi- These principles center the voices of those directly impacted fied potential solutions to the top 3 challenges in the by the outcomes of the project, placing researchers in the provision of social support services. We applied design role of facilitator and participants as the experts, and pri- thinking principles with a racial equity lens to develop oritize a transparent process that shares results directly a solution prototype to enhance coordination and col- back with the participants. This methodology supported the laboration among CBOs and allied organizations in intention to uplift local knowledge and practice. Greater Boston. Our project highlights the value of ■ Organizational analysis with attention to racial equity can design workshops as an important tool for public contextualize recommendations from design workshops by health practice by facilitating engagement with CBOs identifying the perspectives that are represented and those and allied organizations in the solution development that are missing. Such an analysis may reveal the dominance process. In our next phase of work, we will refine the of certain voices or sectors, such as the health care sec- solution prototype for field testing with local partners tor in Greater Boston, and provide an opportunity to reduce and develop instruments to assess its impact. marginalization as we further develop the solution. References 1. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic dispari- ties in pregnancy-related deaths in the United States, 2007-2016. practices and professional development focused on MMWR Morb Mortal Wkly Rep. 2019;68(35):762-765. 2. Petersen EE, Davis NL, Goodman D, et al. Vital Signs: pregnancy- BIPOC staff. Participants discussed both positive and related deaths, United States, 2011-2015, and strategies for negative experiences within organizations in craft- prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep. ing anti-racist policies and cultures. For the lack of 2019;68(18):423-429. 3. Howell EA. Reducing disparities in severe maternal morbidity and coordination of services, participants described po- mortality. Clin Obstet Gynecol. 2018;61(2):387-399. tential solutions including centralized intake systems 4. Ramanadhan S, Viswanath K. Priority-setting for evidence-based (referrals and screening for social services occur at one health outreach in community-based organizations: a mixed- methods study in three Massachusetts communities. Transl Behav point of contact), coalitions that include birthing peo- Med. 2013;3(2):180-188. ple, citywide shared data for referral eligibility, and 5. MAPC Metropolitan Area Planning Council. About MAPC. https:// municipal health navigators. www.mapc.org/aboutus. Accessed June 9, 2021. 6. The Boston Foundation. Addressing inequities in maternal health: Participants also identified opportunities for pro- a spotlight on Greater Boston. https://vimeo.com/468684502. Pub- posed solutions to complement each other, such as a lished October 14, 2020. Accessed June 6, 2021. centralized intake system that links into a health nav- 7. Hasso Plattner Institute of Design. An introduction to de- sign thinking: process guide. https://s3-eu-west-1.amazonaws. igation program, ultimately improving coordination com/ih-materials/uploads/Introduction-to-design-thinking.pdf. Ac- of services. Participants discussed ownership of data cessed June 8, 2021. regarding social services and client eligibility, with 8. Miro. https://miro.com. Accessed June 8, 2021. 9. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res careful attention to building trust with the commu- Psychol. 2006;3(2):77-101. nity and capacity to report out on the data. The locus 10. Williams J, Marxer S. Bringing an equity lens to collective im- of decision making regarding triage and referrals was pact. Collective Impact Forum Resources blog. https://collectivei impactforum.org/sites/default/files/EquityandCollectiveImpact_ also explored, with providers or clients and families UrbanStrategiesCouncil.pdf. Posted August 2014. Accessed or an intermediate agent taking the responsibility for August 12, 2021. referrals. Finally, organizations identified existing re- 11. Silver JK. Be Ethical. A call to healthcare leaders: ending gender workforce disparities is an ethical imperative. https:// sources and coordination mechanisms that could be sheleadshealthcare.com/wp-content/uploads/2018/10/Be_Ethical_ further strengthened, minimizing inefficiency and po- Campaign_101418.pdf. Published September 2018. Accessed tential duplicity. For example, participants explained August 12, 2021. 12. PFLAG. PFLAG National Glossary of Terms. https://pflag.org/ that community support groups for breastfeeding and glossary. Published January 2021. Accessed June 8, 2021. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Management and Practice Wolters Kluwer Health

Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston

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Wolters Kluwer Health
Copyright
© 2022 The Authors. Published by Wolters Kluwer Health, Inc.
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1078-4659
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1550-5022
DOI
10.1097/phh.0000000000001438
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Abstract

Practice Brief Report Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston Rose L. Molina, MD, MPH; Amanda DiMeo, MSc; Leigh Graham, PhD, MBA; Grace Galvin, MPH; Neel Shah, MD, MPP; Ana Langer, MD ABSTRACT Community-based organizations are uniquely positioned to address critical gaps in social support that contribute to in- equities in maternal health. Using a human-centered design process, we held 3 design workshops with members of 15 organizations in Greater Boston, including community-based organizations, allied hospital systems, and public health departments, to assess proposed solutions for gaps in social support services during pregnancy and the first year after childbirth. The workshops focused on solutions to problems that emerged from a mixed-methods research study with community-based organizations that provide social support services; workshop attendees explored facilitators and barriers to implementing solutions. Key considerations included colocation of solutions, shared ownership of program and client data, decision making about triage and referrals, and strengthening coordination of existing programs. Collaborative de- sign workshops surfaced potential solutions to improve coordination of services, which require addressing structural and interpersonal racism in Greater Boston. KEY WORDS: community-based organizations, health care delivery, human-centered design, maternal health, racial equity acial and ethnic inequities in maternal health White individuals, even after adjusting for socioeco- 1,2 persist, with African American/Black and nomic factors. These inequities are a national crisis R Native American individuals experiencing even in states, such as Massachusetts, with relatively worse outcomes when compared with non-Hispanic few maternal deaths and other adverse outcomes. There is growing attention to the postpartum pe- Author Affiliations: Ariadne Labs, Boston, Massachusetts (Drs Molina, riod as a vulnerable moment in the life course for Graham, and Shah and Mss DiMeo and Galvin); Department of Obstetrics & physical, mental, and family health. Gaps in social Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts support during pregnancy and the first year after (Drs Molina and Shah); and Women & Health Initiative, Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Dr Langer). childbirth contribute to these inequities in maternal The authors thank Oby Okafor, Becca West, and Tomi Ojo for their health. Community-based organizations (CBOs) and contributions to the research, community engagement, and design aspects of other allied organizations address critical gaps in so- the project. The authors also thank all collaborators in the design workshops, cial support but may not be adequately coordinated for their contributions to this project, and the study participants, for sharing their experiences with them. to optimize outcomes. The project was financially supported by grant G2019-0034 from The Boston This project launched in 2019 as a partnership Foundation. with The Boston Foundation, The Women and Health The authors have indicated they have no potential conflicts of interest to Initiative at Harvard T. H. Chan School of Public disclose. Health, and Ariadne Labs. We set out to map the This is an open-access article distributed under the terms of the landscape of CBOs in Greater Boston, an area that Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work includes Boston and about 100 neighboring cities and provided it is properly cited. The work cannot be changed in any way or used 5 towns. The project aim was to create solution pro- commercially without permission from the journal. totypes to address the gaps in social support services Correspondence: Rose L. Molina, MD, MPH, Department of Obstetrics & that we identified through prior surveys and inter- Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Kirstein 3, Boston, MA 02215 (rmolina@bidmc.harvard.edu). views (findings to be published separately). This brief Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. summarizes the design thinking process we used to DOI: 10.1097/PHH.0000000000001438 develop solution prototypes. S66 www.JPHMP.com January/February 2022 • Volume 28, Number 1 Supp January/February 2022 • Volume 28, Number 1 Supp www.JPHMP.com S67 Methods could support a solution and what would impede its success. For example, there was an activity in We identified CBOs that provide social support ser- which participants were asked to rank solutions for vices to pregnant and postpartum clients through investment and discuss how to center community professional networks, key informant interviews and engagement in the solutions. Some workshops in- snowball sampling, and publicly available informa- cluded breakout sessions where participants worked tion on Web sites. We analyzed surveys and interviews in smaller groups to brainstorm facilitators and bar- with 21 unique CBOs and other allied organizations riers relevant to the solutions. Participants were also in Greater Boston (findings to be published sepa- encouraged to share new ideas. The output of each rately). We presented these findings at a networking workshop involved a Miro board of virtual “sticky reception of more than 140 CBOs, researchers, policy notes” of ideas and discussion themes. During the makers, and study participants in October 2020. We workshops, we discussed solutions to address the top worked with design thinking experts to develop so- challenges to accessing social support for birthing lution prototypes to close the gaps in social support people of color, as well as facilitators and barriers during pregnancy and the first year after childbirth. relevant to the solutions, and their potential impact In fall 2020, we hosted 3 design workshops over in Greater Boston. Other key considerations included Zoom to cocreate a set of solutions for the gaps iden- Boston’s history with racism, high rates of health care tified in our first phase of work. Participants were coverage in Massachusetts, regional inequality, and invited to attend the design workshops if they (1) variations in local governance across Greater Boston. were on the original list of CBOs invited to partici- 9 We conducted thematic analysis of the output pate in the research study, (2) were identified through from the design workshops and held a final, internal snowball sampling from study respondents, or (3) workshop to review the findings from the former 3 attended the virtual networking reception. Potential workshops. We reviewed the thematic analysis find- participants received an e-mail describing the project ings and integrated themes in the final workshop. and design workshops and replied on the basis of We included experts in design thinking and mater- their availability and interest. Participants did not nal health in Boston to encourage our team to think receive compensation for their participation. Orga- strategically about the best focus for designing a so- nizations did decline to participate, especially given lution to support CBOs and allied organizations. We the concurrent COVID-19 pandemic. Attendance is focused our final workshop on the opportunity to im- reported as follows: design workshop 1: 55 invited prove coordination and collaboration among CBOs and 14 (25%) attended; design workshop 2: 50 in- and allied organizations with a racial equity lens. An vited and 15 (30%) attended; and design workshop equity lens “asks what disparities exist among differ- 3: 64 invited and 6 (9%) attended. Eight CBOs that ent groups; takes into account historical and current participated in the earlier study joined the workshops, institutional and structural sources of inequality; and and 7 CBOs joined because they were engaged in our takes explicit steps to build the social, economic, and networking reception. political power of the people most affected by in- We organized design workshops to achieve 3 goals: equities in order to narrow gaps while improving (1) use interview and survey data to identify high- 10 overall outcomes.” Finally, we conducted organiza- impact opportunities for solution prototypes; (2) 11 tional analysis of the participants, using publicly obtain input from a variety of organizations; and (3) available data to assess common equity considera- assess the usefulness of potential solutions. Ultimately, tions, such as demographic diversity of organizational we aimed to enhance coproduction and ownership leadership, organizational history and mission, and of the solution prototypes through the design work- annual financials for the nonprofit entities as a proxy shops. The first 2 workshops lasted 1.5 hours, and the for size. third and fourth workshops lasted 1 hour. We con- Ethical approval for this research was obtained ducted a structured brainstorming process to generate from the Harvard University Institutional Review new ideas and critically review potential solutions us- Board (IRB) on February 27, 2020 (IRB20-0193). In- ing Stanford University’s Hasso Plattner Institute of formed consent was obtained for all participants in Design (the “d.school”), IDEO’s framework for de- surveys and interviews. 7 8 sign thinking, and Miro, an online collaborative whiteboard platform. Results An expert in design thinking facilitated the work- We included 28 organizations in the research and de- shops and used a virtual whiteboard space on Miro sign phases of the work. The majority (71%; n = 20) for discussion. Throughout the workshops, the facil- of our participants were led or co-led by women or itator encouraged participants to think about what S68 Molina, et al • 28(1 Supp), S66–S69 Design Workshops on Inequities in Pregnancy-Related Social Support gender-expansive people, based on publicly avail- a birth center). One participant emphasized that able data. Of the 28 organizations, 18% (n = 5) were what may appear as an alternative birthing option led or co-led by women or gender-expansive Black to hospitals is historically the primary option for or Indigenous People of Color (BIPOC) based on birth, particularly among communities of color. This publicly available data. Most of the participants had sparked a discussion about the historical context current or historical ties to the health systems within of birth and what tangible steps could be taken to Boston or Massachusetts. Organizations ranged in support all birthing options and ensure equitable out- size and included centers in large health systems comes regardless of a birthing person’s preference to small businesses providing emotional support for for location of birth, such as expanded access to birthing people, among others. The design workshops midwifery care or birthing centers. Participants also included 15 participants from the following sectors: discussed enhanced coverage for doulas and lactation health care (n = 3), public interest or law (n = 3), consultants, recruiting BIPOC doulas, and training public health (n = 2), mental health (n = 2), early doulas in the care of BIPOC individuals. Anti-racism childhood (n = 1), care coordination (n = 1), doula and microaggression training in health care systems care (n = 1), education (n = 1) and housing (n = 1). were key solutions in addressing structural and inter- The Table details solutions, facilitators, and barriers personal racism within Greater Boston. For structural explored in the workshops. Participants highlighted and interpersonal racism within organizations, partic- potential solutions to counter structural and interper- ipants explored paying community members for their sonal racism in Greater Boston, including supporting time in program planning, creating deliberate strate- alternative birthing options (births at home or in gic plans focused on equity, and implementing hiring TABLE Solutions Identified for the Top Challenges to Accessing Social Support Structural and interpersonal racism Solutions: Support alternative birthing Hold doula trainings and workshops in the Greater Boston area options for pregnant and birthing specific to BIPOC people when representation does not Incorporate anti-racism and exist in the health care system microaggression training into the Advocate for policies to enhance health care system coverage for social support providers Facilitators: Acknowledge history and lived experiences of birthing people of color; strengthen informal support networks; invite culture change that is accountable Barriers: Historically restrictive policies in birth center/birth worker accreditation; lack of anti-racist curricula at all professional levels Structural and interpersonal racism Solutions: Provide payments to Offer professional development for within CBOs community members for participating BIPOC staff in programming Implement recruitment and hiring Create a deliberate strategic plan to practices to ensure a diverse address equity workforce Facilitators: Make a plan within the organization that is intentional and measurable, available to the whole organization Barriers: Language is not always accessible for all Lack of coordination of services Solutions: Centralized, coordinated, or Citywide shared data (eg, Web site) collaborative intake systems for social about available social support support needs services and eligibility criteria Coalition that includes community Health navigators at the city level to members and birthing people to ensure help individuals navigate support social support services are prioritized referrals Facilitators: Build up existing networks of services that already exist; obtain necessary human and financial resources to sustain intake systems Barriers: Staff for all necessary roles; identify backbone organization to lead Crosscutting themes • Colocation of multiple solutions: Creating access points to referrals • Shared ownership of data about social support services and eligibility criteria • Who decides about screening and referrals for social support needs • Strengthening and coordinating existing programs to avoid duplication of services and fill gaps Abbreviations: BIPOC, Black, Indigenous, and People of Color; CBO, community-based organization. January/February 2022 • Volume 28, Number 1 Supp www.JPHMP.com S69 parenting exist but are not tied to specific organiza- Implications for Policy & Practice tions. This presents an opportunity to uplift existing programs within the community through better coor- ■ While lack of coordination among CBOs and allied organi- dination with CBOs. zations is not new, there is a growing imperative for public health stakeholders to (1) apply an equity lens in dismantling racism as a key barrier and (2) support people navigating Discussion and Conclusion a vulnerable social transition in starting or growing young Despite a large number of CBOs and allied organi- families. zations providing a range of social support services ■ Workshops organized with human-centered design princi- in Greater Boston, gaps in social support persist ples can increase engagement, generate diverse perspec- for birthing people, particularly in communities of tives and experiences, and enhance solution prototyping. color. During design workshops, participants identi- These principles center the voices of those directly impacted fied potential solutions to the top 3 challenges in the by the outcomes of the project, placing researchers in the provision of social support services. We applied design role of facilitator and participants as the experts, and pri- thinking principles with a racial equity lens to develop oritize a transparent process that shares results directly a solution prototype to enhance coordination and col- back with the participants. This methodology supported the laboration among CBOs and allied organizations in intention to uplift local knowledge and practice. Greater Boston. Our project highlights the value of ■ Organizational analysis with attention to racial equity can design workshops as an important tool for public contextualize recommendations from design workshops by health practice by facilitating engagement with CBOs identifying the perspectives that are represented and those and allied organizations in the solution development that are missing. Such an analysis may reveal the dominance process. In our next phase of work, we will refine the of certain voices or sectors, such as the health care sec- solution prototype for field testing with local partners tor in Greater Boston, and provide an opportunity to reduce and develop instruments to assess its impact. marginalization as we further develop the solution. References 1. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic dispari- ties in pregnancy-related deaths in the United States, 2007-2016. practices and professional development focused on MMWR Morb Mortal Wkly Rep. 2019;68(35):762-765. 2. Petersen EE, Davis NL, Goodman D, et al. Vital Signs: pregnancy- BIPOC staff. Participants discussed both positive and related deaths, United States, 2011-2015, and strategies for negative experiences within organizations in craft- prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep. ing anti-racist policies and cultures. For the lack of 2019;68(18):423-429. 3. Howell EA. Reducing disparities in severe maternal morbidity and coordination of services, participants described po- mortality. Clin Obstet Gynecol. 2018;61(2):387-399. tential solutions including centralized intake systems 4. Ramanadhan S, Viswanath K. Priority-setting for evidence-based (referrals and screening for social services occur at one health outreach in community-based organizations: a mixed- methods study in three Massachusetts communities. Transl Behav point of contact), coalitions that include birthing peo- Med. 2013;3(2):180-188. ple, citywide shared data for referral eligibility, and 5. MAPC Metropolitan Area Planning Council. About MAPC. https:// municipal health navigators. www.mapc.org/aboutus. Accessed June 9, 2021. 6. The Boston Foundation. Addressing inequities in maternal health: Participants also identified opportunities for pro- a spotlight on Greater Boston. https://vimeo.com/468684502. Pub- posed solutions to complement each other, such as a lished October 14, 2020. Accessed June 6, 2021. centralized intake system that links into a health nav- 7. Hasso Plattner Institute of Design. An introduction to de- sign thinking: process guide. https://s3-eu-west-1.amazonaws. igation program, ultimately improving coordination com/ih-materials/uploads/Introduction-to-design-thinking.pdf. Ac- of services. Participants discussed ownership of data cessed June 8, 2021. regarding social services and client eligibility, with 8. Miro. https://miro.com. Accessed June 8, 2021. 9. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res careful attention to building trust with the commu- Psychol. 2006;3(2):77-101. nity and capacity to report out on the data. The locus 10. Williams J, Marxer S. Bringing an equity lens to collective im- of decision making regarding triage and referrals was pact. Collective Impact Forum Resources blog. https://collectivei impactforum.org/sites/default/files/EquityandCollectiveImpact_ also explored, with providers or clients and families UrbanStrategiesCouncil.pdf. Posted August 2014. Accessed or an intermediate agent taking the responsibility for August 12, 2021. referrals. Finally, organizations identified existing re- 11. Silver JK. Be Ethical. A call to healthcare leaders: ending gender workforce disparities is an ethical imperative. https:// sources and coordination mechanisms that could be sheleadshealthcare.com/wp-content/uploads/2018/10/Be_Ethical_ further strengthened, minimizing inefficiency and po- Campaign_101418.pdf. Published September 2018. Accessed tential duplicity. For example, participants explained August 12, 2021. 12. PFLAG. PFLAG National Glossary of Terms. https://pflag.org/ that community support groups for breastfeeding and glossary. Published January 2021. Accessed June 8, 2021.

Journal

Journal of Public Health Management and PracticeWolters Kluwer Health

Published: Jan 1, 2022

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