Purpose: African American women have nearly twice the rate of preterm birth (PTB) and low birth weight (LBW) compared to European American women (Mathews, 2013; Strutz et al., 2014) and twice the infant mortality rate (Mathews, 2013; Willis, 2014)). This disproportionate rate of adverse birth outcomes persists despite controlling for factors such as maternal education (Schoendorf et al., 1992), socioeconomic status (SES; Berg et al., 2001) and prenatal care and health behaviors (Hogan et al., 2012; Goldenberg et al., 1996). Research suggests that the ways in which African American women experience and cope with stress and distress may partially explain the disproportionately high rate of adverse birth outcomes in this group. Specific race and gender-related stressors, in addition to stress related to socioeconomic status (Austin & Leader, 2000), may contribute to psychological distress and stress-related physiological outcomes that lead to adverse birth outcomes (Dominguez, 2011; Giscombe & Lobel, 2005). Substantial evidence links psychological distress (anxiety and depressive symptoms) during the perinatal period (onset during pregnancy and up to one year postpartum) to adverse birth outcomes (Stewart, 2006; Dunkel Schetter, 2011; Accortt et al., 2015). These outcomes are strikingly more common among African American mothers and their infants (Rosenthal & Lobel, 2011). Additionally, in comparison to European American women, African American women experience a disproportionately high rate of stress-related health problems (Geronimus et al., 2010). Studies have indicated that when African American women experience anxiety or depression, the impact is more severe as evidenced by greater number of days missing work or school and impact on quality of life and well-being (Williams, 2007). The experience of stress, psychological distress and self-care behaviors that African American women use to reduce the impact of these factors on their health status warrants further examination given the potential implications on adverse birth outcomes. Superwoman Schema (SWS; Woods-Giscombe, 2010) and network-stress (NS; Woods-Giscombe et al., 2015) are culture-bound factors that have been proposed as contributors to psychological distress in African American women and may help to explain this disparity despite maternal education level, SES or prenatal care and health behaviors. The SWS framework posits that historical and sociocultural events in the United States related to race and gender have resulted in African American women feeling compelled to take on a superwoman role (Woods-Giscombe, 2010). This superwoman role may involve a perceived obligation to manifest an image of strength, a perceived obligation to suppress emotions, a perceived obligation to resist vulnerability, a determination to succeed even in the face of limited resources, and an obligation to help others before themselves. Network-stress refers to the perceived stress related to stressors in the lives of family members, friends, or other loved ones (Woods-Giscombe et al., 2015). SWS and NS are potentially important, yet underexplored, factors in stress-related adverse birth outcomes in African American women. Research suggests that NS should be examined when developing culturally relevant stress management interventions for African American women to help them cope with their stress and distress (Woods-Giscombe, 2010). Complementary health approaches (such as mindfulness and mindful self-compassion) have been linked to reductions in stress and psychological distress (Chiesa, 2014; Keng, 2012; Neff, 2013). Moreover, it has been postulated that complementary health approaches could contribute to an appropriate intervention aimed at changing perceptions and coping mechanisms of stress as well as reducing psychological distress-related adverse birth outcomes in African American women (Woods-Giscombe & Gaylord, 2014; Woods-Giscombe & Black, 2010). While there are studies that have explored the use of complementary health approaches during pregnancy (Goodman et al., 2014; Taylor et al., 2016), and there are studies that have shown complementary approaches can result in decrease distress in African Americans (Woods-Giscombe et al., 2016), there are very few studies that have examined complementary health approaches in African American women specifically (Woods-Giscombe & Black, 2010; Zhang & Emory, 2015). For this reason, efforts should be undertaken to explore the development of culturally relevant and specific complementary health approaches for this population. To promote integration of such an intervention into healthcare, women’s primary care providers (such as nurse-midwives, obstetrician/gynecologists and nurse-practitioners) are key targets given the integral role they play during women’s healthcare decision making throughout the reproductive years. While researchers have begun to examine culturally relevant interventions to reduce stress-related perinatal outcome disparities, none have integrated SWS and NS, or provider-focused strategies and few have integrated complementary health approaches. Therefore, this research study explores and describes African American women’s experiences during the perinatal period to examine if there are any perceived associations between women’s descriptions of SWS, NS and their women’s healthcare resources with psychological distress and self-care during this critical period. The purpose of this study is to gain a better understanding of the individual and perceived factors that may contribute to the persistent ethnic disparities in African American women’s birth outcomes. This research study is novel because it is the first study to position African American women’s perspectives in the forefront of understanding the problem. It is also unique in that it is the first study to combine and integrate the theoretical concepts of SWS and NS to understanding the potential factors that have previously been overlooked when evaluating stress, stressors and distress in perinatal African American women. In addition, this study assesses the acceptability of complementary health approaches (mindfulness and mindful self-compassion practices) and women’s perspectives concerning communication with healthcare providers regarding their experiences of and strategies to manage psychological distress.
Methods: Thematic analysis of the data was performed utilizing Atlas.ti® analysis software. Transcripts were read and reread to get a sense of the essential features of the interviews and served as an opportunity to get a sense of the whole. Initial codes were generated then refined and combined as themes were identified.
Results: Analysis of the qualitative interviews confirmed the hallmark characteristics of SWS as explicated in Giscombe’s 2010 study which examined stress in African American women. However, this study also elucidated unique findings regarding the individual stressors that are rooted in the lived experience of being African American and pregnant or postpartum that may contribute to women’s stress, psychological distress and self-care behaviors. The participant’s indicated that a stress management intervention that incorporates mindfulness would be an acceptable approach to help them cope with their stress. The majority of the participants indicated that their women’s primary care providers did not address their stress during the perinatal period and that they would have liked them to. Additionally, the theme of self-care neglect was quite prominent with many women indicating that they often neglected their own self-care needs in order to prioritize the care of others.
Conclusion: This study suggests that there are individualized stressors that are unique to the African American women’s experience that impact their stress and self-care behaviors during the perinatal period. This research has the potential to impact the way in which researchers and women’s primary care providers understand the perspectives of perinatal African American women as it relates to stress and psychological distress. The results of this study will be used to inform and develop a culturally relevant, mindfulness-based stress management intervention for perinatal African American women as well as the development of a stress assessment tool for women’s primary care providers to use when providing care for this population.
