Preterm Birth Prevention in Appalachia: Restructuring Prenatal Care to Address Rural Health Disparities and Establish Perinatal Health Equity

Purpose: This perspective piece reflects off previously published qualitative work to explore (1) themes surrounding equitable prenatal care in Appalachia and (2) strategies to restructure care delivery in a population with disparate rates of preterm birth (PTB). Methods: This study reflects in-depth interviews with 22 Appalachian women who experienced PTB and 14 obstetric providers. Results: Our findings underscore the need for greater cultural humility in prenatal care, heightened awareness of social determinants of health, and strategic planning to establish equity in birth outcomes. Conclusion: Prenatal care must undergo a paradigm shift to include a comprehensive discussion of cultural humility, social disparities, and health equity.

Preterm birth (PTB) is one of the most pressing public health concerns related to maternal-fetal health in the United States. 1 PTB, defined as birth before 37 weeks gestation, is associated with increased maternal morbidity, and places neonates at higher risk of mortality and lifelong disability. 2 PTB complicated *1 in 10 deliveries and accounted for nearly 1 in 5 infant deaths in the United States in 2017. 1 Infants who survive may face a multitude of morbidities, including inadequate pulmonary function, feeding difficulties, cerebral palsy, and developmental delays. 1 Rates of PTB vary substantially by race, ethnicity, socioeconomic status, and rural residency. Disparate outcomes highlight underlying inequities and the array of risk factors contributing to PTB. Reducing rates of PTB among health disparate populations is a critical public health priority. 3 Appalachian women constitute an underserved health disparate population disproportionately impacted by PTB. 4 The March of Dimes consistently assigns Appalachian states a ''failing grade'' in the national PTB Report Card, due to rates of PTB exceeding the national average. 1,4 Appalachian women of childbearing age embody multiple PTB risk factors, including higher-than-average rates of diabetes, hypertension, obesity, intimate partner violence, smoking, and substance use disorder in pregnancy. [5][6][7] Despite known challenges, there is limited research on PTB in Appalachian women. To begin to address this knowledge gap, we conducted a mixed methods study to evaluate PTB risk stratification, prevention, and management approaches in Appalachian Kentucky. This study was approved by the Institutional Review Board at the University of Kentucky. The Consolidated Framework for Implementation Research (CFIR) informed our study design and in-depth interview questions. 8 We engaged multiple stakeholders, including Appalachian women with prior PTB and prenatal care providers in rural Appalachia to understand knowledge and practice, and to identify potential points of intervention. Results from 22 in-depth qualitative interviews with Appalachian women and 14 interviews with obstetric providers were previously published, and revealed complex challenges for PTB prevention in Appalachia. 9 This article reflects on our published work and discusses implications for multilevel interventions.
Interview Themes Regarding Health Equity Cultural humility in prenatal care If we are to address the public health crisis of PTB effectively, providers must use cultural humility, defined as openness to the cultural values and identity of others (Table 1). 10 Approaches such as recognizing the limitations of patient circumstances, avoiding assumptions of patients' situations, awareness of implicit biases and cultural stereotypes, and patient-centric communication are critical to optimizing the patient-provider interaction and patient outcomes. 11 Cultural humility is particularly essential in obstetrics since prenatal care involves sensitive topics, including sexual history and health behaviors (e.g., smoking, substance use, sexual practices), and uncomfortable gynecological procedures. Cultural humility prompts providers to selfcritique personal biases, address power imbalances, and develop partnerships with community members. 12 In interviews, Appalachian patients and obstetric providers highlighted the need for cultural humility in prenatal care (Table 2). Patients emphasized the need for respectful and clear communication with providers. Providers relayed the importance of acknowledging patients' constraints and removing judgment from the clinical setting to reduce patients' feelings of stigma. These insights demonstrate that prioritizing patient physical and psychological comfort during routine prenatal encounters is key to patient-centered care.
Utilizing a social determinants of health framework in Appalachia Greater awareness of social determinants of health (SDoH), the range of social and environmental factors contributing to health, can help providers address disparate health outcomes. 11 The American Medical Association 13 and the American College of Obstetrics and Gynecology 11 have identified SDoH as a vital area of education for physicians. Previous efforts to educate health providers on SDoH have focused largely on socioeconomic and racial health disparities. 14 Health care providers in Appalachia are faced with a complex web of social forces when caring for patients, including persistent poverty, outmigration, and social isolation. 15 There are distinctive aspects of Appalachian culture, including isolation and mistrust of outsiders, that present challenges and complexities in seeking care, navigating the health system, and remaining engaged in care over time. There are also cultural assets, including strong traditions of kinship care, which may be positively reinforced within the patient-provider interaction. Table 2 captures patient and provider insights on challenges and strengths attributable to Appalachian regional culture, and how these characteristics may inform PTB prevention strategies. Participants noted longstanding health disparities preceding pregnancy, the utility of primary care practices, and resilient family structures. Increasing care continuity with a single provider and engaging patients' primary care providers and families may enable obstetric providers to overcome these challenges while embracing the rich and nuanced perspectives Appalachian heritage affords. In addition, clinical efforts to establish perinatal referral networks and increase the accessibility of medication-assisted therapy for opioid use disorder may bolster PTB prevention.

Establishing equity
Efforts to study PTB in Appalachia must also incorporate strategic efforts to alleviate disparities and promote Cultural humility A process through which health care provides commit to lifelong self-evaluation and selfcritique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations. 12

Implicit bias training
Acknowledgment that although cultural stereotypes may not be consciously endorsed, their existence influences how information about an individual is processed and leads to unintended biases in decision-making. 12 Academic detailing The translation of rigorously reviewed evidencebased information into compelling formats readily accessible for dissemination. 23

Medical stewardship
A role which may be taken by the health care sector involves facilitating a multisector focus on SDoH and acting as catalysts to involve people and institutions in the promotion of health equity. 24 SDoH, social determinants of health. It's also important that they honestly listen to the mother.The doctor came in and the first thing out of her mouth was, ''Let me get this straight. You refuse this shot, or you put yourself in your baby at risk for preterm labor because you don't want to get a shot.'' And she was just super like snarky about it. I was so upset that I was scared, and in that situation I felt like I couldn't say anything back to her because I knew she had to do an exam. So it was kind of like if I say something and I make her mad, she's liable to be rough about it, and you're already in a vulnerable situation. I feel like sometimes women, mothers are treated like they don't know what they're talking about. But it's your body. So nobody knows your body better than you do.'' ''I think have a good rapport with their provider and lots of opportunities to see the provider, the same provider, has the best chance of being effective. And that provider needs to have access to tertiary care centers.you have somebody who has preterm labor, and the weather inclement, that it may not be possible for that patient to get to the tertiary care center because of the weather.
So encouraging people to come in and be seen and encouraging them that we don't frown on them coming in.
We want them to come in, because it's a partnership.  Collaborate with local primary care providers to initiate early preterm birth education, screening efforts, and health promotion before conception and early in pregnancy Engage, educate, and empower family members to participate in preterm birth prevention efforts Establish referral patterns with regional high-risk pregnancy (perinatology/maternal fetal medicine) subspecialists who can provide high-acuity care Increase availability and accessibility of substance use disorder treatment and recovery services, with an emphasis on the availability of medication-assisted treatment (MAT) for women with opioid use disorder (OUD) in pregnancy.
(continued) just support the patient, let the other team, the nurses and other support staff sort of.we talk about the social services and a lot of people are very frightened of the social services, they're afraid they're going to take their baby away. That's a big part of what I do is try to reassure them. Otherwise they drop out, refuse to get prenatal care. That's sort of a long answer, but it's a team approach and I support the patient and try to maintain a therapeutic rapport in which the patient really feels like I'm on their side.'' Integrate social and obstetric services to promote comprehensive prenatal care Enact accessible and affordable support structures (e.g., residential facilities, low-cost housing) for families requiring long-term hospitalization PTB, preterm birth.
health equity. Health inequities are differences in health that are systematic, unfair, and avoidable. 16 Equity in health care requires resource allocation be determined by health needs to alleviate such systematic and avoidable differences. 17 Health equity in the context of PTB has specific implications for maternal care. Prenatal care in health disparate populations must be prepared to meet both medical and social needs. 18 Prenatal care models such as group prenatal classes and pregnancy medical homes integrate obstetric and social services, and may advance obstetric health. 18 Prospective studies have demonstrated reduced PTB and maternal psychosocial stress when patients of health disparate communities receive prenatal care with incorporated social services. 19,20 Support for integrated social and obstetric services was echoed by providers ( Table 2). One patient specifically noted challenges in accessing support structures when simultaneously maintaining recovery from substance use disorders.

Strategies for Restructuring Prenatal Care in Appalachia
Implicit bias training Implicit biases, also known as unconscious biases, refer to how common societal experiences create a shared awareness of stereotypes, which subconsciously influence individuals' perceptions and actions. 14 All members of society have implicit biases, including health care providers. 14,21 Past studies have demonstrated implicit biases impact physicians' perceptions and treatment of black individuals, Hispanic individuals, women, elderly individuals, and obese individuals. 14 Such biases have striking consequences for medical decision-making; physician implicit bias is associated with inequities surrounding proper diagnosis, treatment, and communication. 14 Minimal research has focused on implicit bias toward rural or Appalachian patients.
Implicit bias curricula may reveal individual's engrained prejudice, and can make individuals aware of unintended involvement in the perpetuation of discrimination. 22 The importance of implicit bias training is gaining momentum among obstetric health care providers. 23 Future efforts addressing prejudices toward diverse health disparate patient populations, including rural women and Appalachian women, are needed among prenatal care providers. In interviews, most providers did not speak of patients in stereotypical terms. However, some providers' use of stereotypical language suggests underlying biases (e.g., referring to women with substance use disorder as ''drug addicts'' or uneducated patients as ''unlearned''). Enacting implicit bias training may facilitate actionable steps for PTB prevention outlined in Table 2, namely training providers in respectful communication methods and encouraging providers to engage with patients' concerns. Implicit bias training should be incorporated alongside institutional changes to address bias on multiple levels.
Academic detailing Academic detailing (AD) refers to the translation of rigorously reviewed information into compelling formats readily accessible for dissemination. 24 AD is associated with enhanced adoption of evidencebased practices among providers, optimized patientprovider communication, and cost-effectiveness. 24 AD offers a mechanism for educating Appalachian prenatal care providers on SDoH and provides language and educational materials to enhance communication with patients.
Stewardship and the integration of social services. Equity requires providers to act as responsible stewards for their patient population. 25 Stewardship describe the roles which may be taken by health care providers in collaboration with other sectors to promote equitable health care. 25 Revising medical education and training to emphasize SDoH and funding intervention research to address disparities are central priorities for stewardship and the alleviation of maternal and neonatal health disparities. 25 Traditional clinical programming has been largely unidimensional in its focus on medical need, and prenatal care providers are often unequipped to care for social complexity. 18 One provider voiced the hopelessness associated with unmet needs of socially vulnerable patients. When discussing issues of confusion and noncompliance among patients at-risk of PTB, they voiced, ''The ones that don't [comply], the drug addicts and stuff that just show up once in a while and disappear, you can't do anything about that. No matter how much you try.'' Integrating social services alongside prenatal care provides a mechanism for reaching patients whose needs are currently unmet.

Conclusion
In conclusion, prenatal care delivery in Appalachia has needs that will remain unfulfilled unless the focus of clinical care undergoes a paradigm shift. Findings underscore the need for greater cultural humility in prenatal care, heightened awareness of SDoH and health disparities in clinical practice, and strategic planning to establish equity in birth outcomes. Aligned with these principles, research participants have noted actionable steps toward equitable birth outcomes. Steps include enhancing communication methods, building relationships with patients' family and local primary care clinics, enacting accessible support structures for patients requiring long-term care, and integrating social and obstetric services. Strategies, including implicit bias training, AD, and medical stewardship, may be leveraged to achieve these aims.

Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.