Tina Bloom


June 2008

Document Type


Degree Name



Oregon Health & Science University


Health disparities in maternal-child outcomes (preterm birth, low birthweight, infant mortality, and maternal mortality) are substantial, well documented, and in many cases, growing worse. Many research approaches have focused on single risk factors, yet many risk categories (e.g., minority status, socioeconomic status, violence, substance abuse, and mental health issues) overlap substantially. Further, stress and discrimination are potentially common factors to risk categories, but their role in maternal-child health disparities is not well understood. This mixed-method, participatory research study aimed to address this gap by describing the experience of pregnancy and early motherhood among a sample of diverse, primarily low-income mothers. The study focused on mothers’ experiences of stress and discrimination related to race, socioeconomic status, violence, mental health issues, and/or substance use, using an intersectional framework to understand how these factors overlapped and intersected. A mixed-methods survey with demographics, six quantitative measures and qualitative interview probes was developed from literature review. The unique perspective and expertise of participants in the study was privileged in the design of the study questions and in the interpretation of the findings. Eight low-income mothers (lay advisors) evaluated the survey for appropriateness, completeness, understandability, and offensiveness, and additional questions were added in a collaborative revision process with lay advisors. Measures were the Detroit Area Study Discrimination Questionnaire (DAS-DQ), Perceived Stress Scale (PSS), Center for Epidemiologic Studies Revised Scale (CESD-R), Posttraumatic Stress Checklist Civilian Version (PCL), My Exposure to Violence measure (MyETV), and Danger Assessment (DA). These measures described women’s lifetime exposures to discrimination, perceived stress levels, depressive and PTSD symptoms, and lifetime exposures to violence. Semi-structured qualitative interview questions covered the same domains, as well as asking participants to describe their priorities for information and support for mothers. Twenty-four participants took part in the interviews. All were low-income mothers who were currently pregnant and/or had given birth in the past three years, and were recruited from WIC clinics, a low-income health clinic, and Healthy Start sites in the metropolitan Portland area. Interviews were conducted in women’s homes or private and safe settings of their choosing, e.g., coffee shops or cafes. Women were compensated for their time at each interview. The investigator administered quantitative measures followed by the qualitative questions; the qualitative interview portion of the interview was audiotaped and transcribed. Quantitative measures were analyzed for descriptive purposes, with frequencies, means, standard deviations, and ranges of scores reported. Qualitative data were analyzed and coded using a qualitative descriptive approach. A priority was describing experiences of stress and discrimination associated with risk categories for poor maternal-child outcomes, and how these categories of risk overlapped and intersected. Mothers’ priorities for support and information to ameliorate the impact of stressors was also a priority. Interviews continued until data saturation was reached. Study findings were returned to lay advisors for discussion, interpretation, and revision. Mothers in the sample were very low income, with over half under federal poverty guidelines, and financial difficulties were the most prevalent stressor. Violence exposures across the lifespan were extremely high, as were levels of depressive and posttraumatic stress disorder symptoms. Six themes emerged from the qualitative analysis: 1) stress impacted women’s health negatively; 2) the various stressors in women’s lives intersected in complex ways; 3) childhood socioeconomic status impacted adult stress levels and health; 4) health care providers played a clear role in mitigating or exacerbating mothers’ difficulties; 5) many mothers feel isolated and alone, and this compounds their stress tremendously; and 6) women feel that they can generally find information and resources for themselves, but most identify connecting with other mothers with similar lives, difficulties, and interests as important to reduce the impact of stress. Vulnerable mothers who have multiple risk categories for poor maternal-child outcomes feel that stress has a substantial impact upon their health. Risk factors and stressors overlap in women’s lives substantially, and the intersectional framework is a useful lens for examining these complex relationships. Health care providers can be extremely important in addressing stress in women’s lives; adopting the trauma-informed care model is one way to provide the empathetic and connected care that vulnerable women need from their caregivers. A key aspect of this model is the facilitation of connections between women, which was a high priority for mothers in this sample. The CenteringPregnancy model, a model for group prenatal care, may be one way to help facilitate such connections in the health care setting, and the concept was appealing to mothers interviewed. Future research is needed to explore the impact of such interventions on mothers’ health outcomes.




School of Nursing



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