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ORIGINAL RESEARCH
published: 17 June 2021
doi: 10.3389/fgwh.2021.655409
Frontiers in Global Women’s Health | www.frontiersin.org 1June 2021 | Volume 2 | Article 655409
Edited by:
Tabassum Firoz,
Yale New Haven Health System,
United States
Reviewed by:
Adanna Chukwuma,
World Bank Group, United States
Bilal Ahmed Usmani,
Aga Khan University, Pakistan
*Correspondence:
Elizabeth A. Mosley
emosley@gsu.edu
Specialty section:
This article was submitted to
Maternal Health,
a section of the journal
Frontiers in Global Women’s Health
Received: 18 January 2021
Accepted: 18 May 2021
Published: 17 June 2021
Citation:
Mosley EA, Pratt M, Besera G,
Clarke LS, Miller H, Noland T,
Whaley B, Cochran J, Mack A and
Higgins M (2021) Evaluating Birth
Outcomes From a Community-Based
Pregnancy Support Program for
Refugee Women in Georgia.
Front. Glob. Womens Health
2:655409.
doi: 10.3389/fgwh.2021.655409
Evaluating Birth Outcomes From
a Community-Based Pregnancy
Support Program for Refugee
Women in Georgia
Elizabeth A. Mosley 1,2
*, Michelle Pratt 3, Ghenet Besera 2, Lasha S. Clarke 2, Heidi Miller 4,
Tracy Noland 4, Bridget Whaley 2, Jennifer Cochran 4, Amber Mack 5and Melinda Higgins 6
1Georgia State University School of Public Health, Atlanta, GA, United States, 2Emory University Rollins School of Public
Health, Atlanta, GA, United States, 3Emory Decatur Hospital, Decatur, GA, United States, 4Embrace Refugee Birth Support,
Clarkston, GA, United States, 5Healthy Mothers, Healthy Babies Coalition of Georgia, Atlanta, GA, United States, 6Emory
University Nell Hodgson Woodruff School of Nursing, Atlanta, GA, United States
Refugee women face numerous and unique barriers to sexual and reproductive
healthcare and can experience worse pregnancy-related outcomes compared with
U.S.-born and other immigrant women. Community-based, culturally tailored programs
like Embrace Refugee Birth Support may improve refugee access to healthcare and
health outcomes, but empirical study is needed to evaluate programmatic benefits.
This community-engaged research study is led by the Georgia Doula Access Working
Group, including a partnership between academic researchers, Emory Decatur Hospital
nurses, and Embrace. We analyzed hospital clinical records (N=9,136) from 2016
to 2018 to assess pregnancy-related outcomes of Embrace participants (n=113)
and a comparison group of women from the same community and racial/ethnic
backgrounds (n=9,023). We controlled for race, language, maternal age, parity,
insurance status, preeclampsia, and diabetes. Embrace participation was significantly
associated with 48% lower odds of labor induction (OR =0.52, p=0.025) and 65%
higher odds of exclusive breastfeeding intentions (OR =1.65, p=0.028). Embrace
showed positive but non-significant trends for reduced cesarean delivery (OR =0.83,
p=0.411), higher full-term gestational age (OR =1.49, p=0.329), and reduced
low birthweight (OR =0.77, p=0.55). We conclude that community-based, culturally
tailored pregnancy support programs like Embrace can meet the complex needs of
refugee women. Additionally, community-engaged, cross-sector research approaches
could ensure the inclusion of both community and clinical perspectives in research
design, implementation, and dissemination.
Keywords: refugees, perinatal health, pregnancy support, birth outcomes, community-based research, doulas
BACKGROUND
Refugee women resettled in the United States (U.S.) face numerous and unique barriers to sexual
and reproductive healthcare, and can experience worse pregnancy-related outcomes than U.S.-born
and other immigrant women (1–8). Historically, the U.S. had the largest refugee resettlement
program in the world, with over 3 million refugees resettled there since 1975—half of whom were
Mosley et al. Evaluating Refugee Pregnancy Support Program
women (9,10). After the 2016 presidential election, U.S.
resettlement numbers dropped to a record low of only 22,000
refugees in 2018 (down from 85,000 in 2016) (11). In turn,
federal funding for refugee resettlement has also been reduced,
endangering refugee-centered programming efforts (12,13).
Approximately one-third of the U.S. refugee resettlement
agencies have been forced to close due to budget shortfalls (13).
The antecedent life experiences of refugee women, combined
with the challenges of a hostile sociopolitical environment in
the U.S., are associated with poorer pregnancy-related outcomes.
Compared with U.S.-born and non-refugee immigrant women,
refugee women begin prenatal care later and have fewer
prenatal visits during pregnancy due to socioeconomic and
language barriers, stigma, culturally insensitive health services,
and other challenges (1,4–6,8). Additionally, a number of
studies have shown that refugee women have higher rates of
labor induction and cesarean delivery (2,14), higher risk of
preterm birth (1,2), lower birthweight babies (1,3), and lower
rates of exclusive breastfeeding (15,16). Although, notably,
some studies have shown inconsistent results—for example,
well-documented advantages in birth outcomes for foreign-
born Latina women relative to U.S.-born women (17) and
other studies that found African refugee women have better
pregnancy outcomes than U.S-born women. Further, previous
studies have found associations between characteristics of refugee
and migrant populations, including race/ethnicity or country of
origin (14,18–20), length of time in the host country (19), parity
(3,20), and maternal age (20) and their maternal and child-health
outcomes. For example, in a systematic review and meta-analysis,
researchers found cesarean birth rates were higher among Sub-
Saharan African and South Asian migrants compared with
non-migrant women, but Eastern European and Vietnamese
migrants had lower rates compared with non-migrant women
(20). In addition to considering factors established as having
an association with maternal and child-health outcomes, the
diverse backgrounds (e.g., country of origin and length of time
in the host country) of refugees can influence maternal and
child-health outcomes.
Considerable literature describes the independent and joint
benefits for healthy mothers and infants of spontaneous (vs.
induced), vaginal (vs. cesarean) delivery at 37 weeks gestation or
more (i.e., full term). For instance, induction of labor is associated
with greater risk of maternal post-partum hemorrhage relative
to spontaneous labor, and with greater risk of fetal stress and
respiratory illness (21). Labor induction is also associated with
a significantly higher risk of cesarean delivery (22), which itself is
linked to acute and chronic complications, including postpartum
cardiac arrest (23). Additionally, the increased risk of morbidity
and mortality among infants born preterm or early term is
also well-known (24–26). Low birthweight (<2,500 g), which
is often a consequence of preterm birth, confers a higher risk
of infant mortality and morbidity (including cognitive deficits
and motor delays) that can extend throughout the life course
(27). Particularly for low birthweight infants, though the benefit
may extend to infants of normal birthweight, evidence suggests
that initiation of breastfeeding within the first day of life is
associated with a significant reduction in the risk of neonatal
mortality as compared with breastfeeding delayed for >24 h after
birth (28).
Community- and evidence-based pregnancy support
programs—ones that provide support for pregnant women
throughout the duration of their pregnancy and the postpartum
period through strategies such as doula support and group
education—have the potential to provide support and improve
connection to culturally appropriate healthcare, but there is
a dearth of evidence on how these programs impact refugee
birth outcomes (29). In a mixed-methods study of the Refugee
Women’s Health Clinic in Arizona, researchers documented
widespread barriers to prenatal care and high approval of the
specialized clinic among refugee women from diverse ethnic
backgrounds but did not assess birth outcomes (30). Another
study of community-based doulas in New York demonstrated
that having a doula of the same ethnic background improved
Burmese refugee women’s self-advocacy during labor and
delivery (31). However, this qualitative study did not measure
associations with maternal and child health outcomes. Similarly,
the participants in a qualitative study of community-based
prenatal services for refugee women in Perth, Australia,
reported improved social support, greater continuity of care,
increased knowledge about pregnancy, greater confidence to ask
questions, and more assistance with other life challenges such
as transportation and language services (32). Finally, a study
with Burmese refugees in Melbourne, Australia, showed that
group-based prenatal care can help women feel more informed,
prepared, and confident; improve social and emotional support;
and build trusting relationships with healthcare providers
(33). But it is still unclear how group-based prenatal care and
childbirth education translate to improved birth outcomes.
To date, evidence on reproductive health disparities and
interventions for refugee women is sparse and incomplete.
As described above, most studies use qualitative or mixed
methods to evaluate the process and experience of refugee
pregnancy support programs. Much less is known about how
these programs quantitatively impact birth outcomes on a large
scale. Additional research is needed to assess programmatic
effects on reproductive health outcomes for refugees in the U.S.
This requires both adequate sample sizes and statistical methods
that can account for the vast diversity of refugee groups.
The current study is a community-engaged, quantitative
evaluation of maternal health outcomes, child health outcomes,
and breastfeeding intentions among the participants of the
Embrace Refugee Birth Support program in Clarkston, Georgia.
Founded in 2010, Embrace Refugee Birth Support (34) is a
comprehensive, culturally tailored pregnancy support program
offered by the non-profit, refugee support organization Friends
of Refugees. The Embrace participants receive 8 weeks of no-
cost, evidence-based childbirth education classes taught in their
language by community liaisons. They are also matched to an
Embrace volunteer, who provides transportation to prenatal and
postnatal visits, continuous support during labor and childbirth,
and social connection. Embrace uses an evidence-based “Healthy
Moms” curriculum (35) for pregnant refugee women that covers
topics including prenatal health, newborn care, and how to
communicate with providers. In our study, we analyze hospital
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Mosley et al. Evaluating Refugee Pregnancy Support Program
clinical records to compare birth outcomes for the Embrace
participants and women who did not participate in the program,
controlling for relevant covariates. We ask the following:
•Do the Embrace participants have improved maternal health
outcomes, including reduced labor induction, vaginal delivery
compared with similar women who did not participate
in Embrace?
•Do the Embrace participants have improved child health
outcomes, including higher birthweight and gestational age at
birth compared with similar women who did not participate
in Embrace?
•Do the Embrace participants have greater likelihood of
breastfeeding intentions compared with similar women who
did not participate in Embrace?
METHODS
Research Approach and Setting
In 2019, the Healthy Mothers, Healthy Babies Coalition of
Georgia (HMHBGA)—a non-profit organization dedicated to
local maternal and child health—convened the Georgia Doula
Access Working Group (GADAWG) (36). The GADAWG
mission is to improve access to full-spectrum doula services in
Georgia, especially for marginalized groups facing the greatest
barriers to high-quality maternal and child healthcare, including
refugees, people of color, and low-income families. This study
is a community-engaged, cross-sector collaboration between
Embrace Refugee Birth Support, Georgia State University School
of Public Health, Emory School of Public Health, Emory School
of Nursing, and Emory Decatur Hospital overseen and supported
by the GADAWG. The members of our research team represent
each of the organizations involved as well as the refugee
communities we serve.
It is important to note that Clarkston, Georgia is a uniquely
diverse community near Atlanta. The town has resettled over
37,000 refugees in the past 25 years, and the current population of
nearly 13,000 is over 31% foreign-born with representation from
150 countries, 760 ethnic groups, and 140 languages all in one
square mile. Emory Decatur Hospital—located only 3 miles from
Clarkston—is where the majority of the Embrace participants
give birth. Inclusive of Clarkston, metro-Atlanta is the ninth
largest metro area in the country at over 6 million residents and
the fourth fastest growing (37). Its population is also diverse with
46% White, 34% Black, 11% Hispanic, and 6% Asian residents.
Yet racial/ethnic and economic inequality persist: Atlanta has the
highest income inequality in the country, 76% of Black children
live in high-poverty neighborhoods compared to 6% of White
children, and Black women are 3 times as likely as White women
to die from pregnancy-related causes (38,39).
All research activities were approved by the Emory University
Institutional Review Board (IRB00109995). The researchers were
trained in research ethics through the Collaborative Institutional
Training Initiative, including human subjects protection.
Data and Measures
To evaluate the Embrace program, we abstracted maternal
clinical records from March 2016 to December 2018 at Emory
Decatur Hospital. There were a total of 9,136 unique clinical
records during this period. We sought to include all covariates
related to refugee maternal and child health outcomes, but we
were limited by the hospital medical records. In the end, we
included the Embrace participation, race and language spoken
(as a proxy for ethnicity), age, parity, insurance status (as a proxy
for socioeconomic status), preeclampsia, and diabetes.
Predictors
Embrace Participation
We used Embrace’s internal program dataset to identify the
names, dates of birth, and delivery dates for the Embrace program
participants during the same period. Those names were cross-
matched with the Emory Decatur Hospital clinical records to
identify the patients who had participated in the pregnancy
support program. We created a new variable called “Embrace
Participation” where the participants were designated 1, and the
non-participants were designated 0. There were 113 Embrace
participants in the sample.
Race and Language Spoken
We operationalized race/ethnicity as the patients’ race and their
primary language spoken at home—both demographics that were
captured in the electronic medical record system. Race included
White, Black, Asian, American Indian, Hawaiian/Pacific Islander,
Hispanic, other, and unknown. The language variable included
over 50 different languages, which we categorized into English,
Burmese/Karen, African languages, Arabic/Egyptian/Aramaic,
and other/unknown. Race and language were highly colinear,
so we created a composite variable Race-Language with
seven categories: White-non-Arabic, Black-African, Black-Other
(reference because this was the largest subsample), Asian-
Burmese/Karen, Spanish-speaking, Asian-Nepali, Asian-Other,
Arabic/Egyptian/Aramaic-speaking, and other/unknown race.
Additional Covariates
Age was measured as a continuous variable in the electronic
medical records. Parity—the number of pregnancies ending in
live births, stillborns, and miscarriages—was measured as a count
variable that included the current birth. There were 24 different
insurance statuses, which we classified into these categories:
public insurance (Medicaid/Medicare) or other (self-pay, private
insurance, military insurance, veteran’s insurance, or other). We
also included underlying maternal health conditions that are
associated with our pregnancy-related outcomes of interest—
pre-eclampsia and diabetes. The variables were dichotomous,
where having the condition was coded as 1 while not having the
condition was coded as 0.
Zip Code
To consider environmental and neighborhood effects on
maternal and child health, we controlled for the patient’s zip
code of residence. Over 300 zip codes were represented in the
Emory Decatur database. We classified these into a categorical
variable: Clarkston (reference), metro-Atlanta (coded as 2),
Georgia outside of metro-Atlanta (coded as 3), and outside of
Georgia (coded as 4).
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Mosley et al. Evaluating Refugee Pregnancy Support Program
Outcomes
Labor Induction
When patients are admitted to Labor and Delivery at Emory
Decatur Hospital, the provider orders indicate whether (1) the
patient was in spontaneous labor or (2) the patient was being
induced (i.e., labor is started through medicine like Pitocin). In
our dataset, spontaneous labor was coded as 0, and induction was
coded as 1.
Cesarean Delivery
When a patient gives birth at Emory Decatur Hospital, the nurses
record whether it was a vaginal delivery or a cesarean delivery
(i.e., by surgical operation). In our dataset, we coded vaginal
delivery as 0, and cesarean delivery as 1.
Gestational Age at Birth (and Full-Term)
The nurses also record the gestational age at birth, which is
measured in weeks and days—either estimated since the last
menstrual period of the patient or confirmed by ultrasound. In
our dataset, we measured gestational age as a continuous variable
in days. We also created a dichotomous variable for full-term
gestational age, which is set at 259 days or 37 weeks (19). We
coded all births before or at 259 as 0 (not full term), and then
coded all births after 259 days as 1 (full term).
Birthweight (and Low Birthweight)
The electronic medical record also includes the birthweight of
the baby in kilograms. In our analyses, we used birthweight
as a continuous measure, and then also created a dichotomous
variable for low birthweight, which is defined as <2.5 kg (19). We
coded low birthweight as 1, and anything at or above 2.5 kg as 0.
Breastfeeding Plans
When patients are admitted to the Labor and Delivery Unit
for birth, nurses ask how they plan to feed their babies. The
feeding intention of the patient is recorded in the electronic
medical record as exclusive breastfeeding, bottle feeding with
formula, or a mixture of both. For this study, we coded exclusive
breastfeeding as 1 and any other feeding plans as 0. Notably, this
variable measures the patient’s intention for breastfeeding, not the
actual behavior.
Analysis
For our analyses, we first looked at descriptive statistics for
the Embrace participants and the comparison group. We then
tested those differences, using the appropriate bivariate tests. For
continuous predictors and outcomes (maternal age, gestational
age in days, and birthweight in kilograms), we used t-tests. For
categorical predictors and outcomes (race language, insurance,
pre-eclampsia, diabetes, zip code, labor induction, cesarean, full
term, low birthweight, and exclusive breastfeeding), we used chi-
squared tests. For parity, which is a count variable, we used a
bivariate Poisson regression.
We then conducted multivariate analyses to test for
differences between the Embrace participants and the
comparison group after controlling for covariates (race-language,
maternal age, parity, insurance status, preeclampsia, diabetes,
and zip code). For the continuous outcomes of gestational age at
birth and birthweight, we used multiple linear regression models.
For the dichotomous outcomes (labor induction, cesarean, low
birthweight, full term, and exclusive breastfeeding), we used
multiple logistic regression models. We then assessed marginal
effects of Embrace participation, using adjusted predicted
probabilities. We checked all assumptions for our regression
models, including multicollinearity. We also conducted Wald
tests to test the hypothesis that Embrace was associated with
changes in the maternal and child health outcomes.
RESULTS
Descriptive Statistics by Embrace
Participation
Demographics and Predictors
We analyzed 9,136 unique clinical records from Emory Decatur
Hospital (Table 1). The majority of the patients in the sample
(62.2%) were Black and spoke a language other than Arabic,
Spanish, or a Bantu African language—most often, English. On
average, the patients in our study were 29 years old, had two prior
births, and were on public insurance (65.8%). There was a small
but important minority of women who had pre-eclampsia (6.9%)
and diabetes (8.6%).
Out of the total sample, 113 (1.2%) patients had participated
in the Embrace program and 9,023 (98.8%) patients were used
for the comparison group. The two groups differed by race and
language spoken (χ²8=598.3, p<0.001), parity (bPoisson =0.4,
p<0.001), insurance (χ²1=45.1, p<0.001, and zip codes (χ²3
=355.3, p<0.001). The Embrace participants were more likely
to be Asian and speak Burmese/Karen or Black and speak African
language. They were also more likely to have higher parity, public
insurance, and live in Clarkston than the comparison group.
Pregnancy-Related Outcomes
There is evidence that the Embrace participants had better
pregnancy-related outcomes than the comparison group (see
Table 2). Labor was induced for 15.0% of the Embrace
participants compared with 24.7% of the comparison group
(p=0.02). Twenty-six percent of the Embrace participants had
cesarean deliveries compared with 33.8% of the comparison
group (p=0.07). Embrace babies had significantly higher
gestational age at birth: 277 days compared with 272 days
in the comparison group (p=0.01), and nearly 94% of the
Embrace babies were born full-term compared with 88.9% in the
comparison group (p=0.05). Only 5.3% of the Embrace babies
were low birthweight compared with 10.1% in the comparison
group (p=0.09). Finally, 62.9% of the Embrace participants
planned to exclusively breastfeed compared with 63% of the
comparison group (p=0.93).
Multivariate Analyses
Regression Models
Results from our multiple logistic regression models similarly
show some significantly improved pregnancy-related outcomes
for the Embrace participants. Table 3 includes our outcomes
of interest: labor induction, cesarean, full-term gestation, low
birthweight, and exclusive breastfeeding intentions. We have
included the total number of observations (n) and the model’s
fit-test statistics (likelihood ratio, LR, and chi-square). All models
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Mosley et al. Evaluating Refugee Pregnancy Support Program
TABLE 1 | Descriptive statistics of the Embrace participants and comparison group at Emory Decatur Hospital from 2016 to 2018.
Descriptor Comparison Embrace Total Statistic p-value
n%n%n%
Total 9,023 98.76 113 1.24 9,136 100 – –
Race and Language*** χ²8=598.30 <0.001
White Non-Arabic speaking 1,370 15.57 2 1.77 1,372 15.4 – –
Black African language 307 3.49 37 32.74 344 3.86 – –
Black-Other 5,537 62.94 5 4.42 5,542 62.2 – –
Asian-Burmese/Karen 360 4.09 34 30.09 394 4.42 – –
Spanish-speaking 325 3.69 0 0 325 3.65 – –
Asian-Nepali 236 2.68 1 0.88 237 2.66 – –
Asian-Other 367 4.17 12 10.62 379 4.25
Arabic-Speaking 85 0.97 9 7.96 94 1.05 – –
Other/Unknown race 210 2.39 13 11.5 223 2.5
Maternal age 28.81 (M) 6.01 (SD) 28.89 (M) 6.20 (SD) 28.81 (M) 6.01 (SD) t9,124 = −0.16 0.88
Parity*** 2.24 (M) 1.45 (SD) 3.24 (M) 2.20 (SD) 2.26 (M) 1.47 (SD) b=0.37 <0.001
Insurance Status*** χ²1=45.1 <0.001
Other Insurance/Self-Pay 3,120 34.59 5 4.42 3,125 34.21 – –
Public insurance: medicaid/medicare 5,901 65.41 108 95.58 6,009 65.79 – –
Pre-Eclampsia†624 6.92 3 2.65 627 6.86 χ²1=3.16 0.075
Accucheck 773 8.57 12 10.62 785 8.59 χ²1=0.60 0.44
Residence zip code*** χ²3=355.30 <0.001
Clarkston, Georgia 937 10.39 75 66.37 1,012 11.08 – –
Metro-Atlanta, Georgia 7,945 88.07 38 33.63 7,983 87.4 – –
Other Georgia 62 0.69 0 0 62 0.68 – –
Outside of Georgia 77 0.85 0 0 77 0.84 – –
The bparity coefficient is from a bivariate Poisson regression due to the count distribution of the parity variable; †p<0.01; *p<0.05; **p<0.01; ***p<0.001.
TABLE 2 | Bivariate statistics by Embrace participation/comparison group at Emory Decatur Hospital from 2016 to 2018.
Outcome Comparison Embrace Total Statistic p-value
n%n%n%
Labor induction* 2,225 24.66 17 15.04 2,242 24.54 χ²1=5.57 0.02
Cesarean delivery†3,041 33.76 29 25.66 3,070 33.66 χ²1=3.27 0.07
Gestational age (days)* 271.69 (M) 18.33 (SD) 276.54 (M) 10.02 (SD) 271.75 (M) 18.26 (SD) t9,009 = −2.76 0.01
Full term gestation†7,929 87.88 106 93.81 8,035 87.95 χ²1=3.7 0.05
Birthweight (kilos)†3.17 (M) 0.75 (SD) 3.30 (M) 0.49 (SD) 3.17 (M) 0.75 (SD) t8,662 = −1.82 0.07
Low birthweight†909 10.07 6 5.31 915 10.02 χ²1=2.81 0.09
Exclusive breastfeeding 5,191 63.33 61 62.89 5,252 63.32 χ²1=0.01 0.93
†p<0.01; *p<0.05; **p<0.01; ***p<0.001.
were statistically significant (p<0.001), indicating we can reject
the null hypothesis that all predictors in the models are equal
to zero.
Relative to the comparison group, the Embrace participants
had 48% lower odds of labor induction (OR =0.52, p=
0.025), and 65% higher odds of planning to breastfeed exclusively
(OR =1.65, p=0.028). The first row corresponds with
Embrace participation (our independent variable). Following
rows correspond with our covariates: race-language, maternal
age, parity, insurance status, preeclampsia, diabetes, and zip
code. Other results, while not statistically significant, also showed
trends in the positive direction. The Embrace participants had
17% lower odds of cesarean delivery (OR =0.83, p=0.411),
49% higher odds of full-term gestational age (OR =1.49, p=
0.329), and 23% lower odds of low birthweight (OR =0.77, p=
0.552). Not shown in Table 3, our results also showed improved
but non-significant improvements in gestational age at birth and
birthweight: a 2.26-day increase in gestational age at birth (b=
2.26, p=0.204) and a 0.06 kg increase in birthweight (b=0.06,
p=0.403).
Holding other variables at their mean, we found that
Embrace participation was significantly associated with a 9-
percentage point reduction in labor induction from 23% (95% CI:
22.7–24.5%) to 14% (95% CI: 0.07–20.6%) and a 10-percentage
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Mosley et al. Evaluating Refugee Pregnancy Support Program
TABLE 3 | Multivariate analyses of pregnancy-related outcomes for the Embrace participants and the comparison group at Emory Decatur Hospital from 2016 to 2018.
Variable Labor induced* Cesarean delivery Full term gestation Low birthweight Exclusive breastfeeding*
n=8,871 n=8,860 n=8,871 n=8,871 n=8,071
LR chi2(17) =44.56 LR chi2(17) =394.11 LR chi2(17) =494.16 LR chi2(17) =422.59 LR chi2(17) =1,051.76
p= ≤0.001 p= ≤0.001 p= ≤0.001 p= ≤0.001 p= ≤0.001
OR p95% CI OR p95% CI OR p95%CI OR p95% CI OR p95% CI
Embrace participation 0.52 0.025 0.29 0.92 0.83 0.411 0.53 1.30 1.49 0.329 0.67 3.34 0.77 0.552 0.33 1.82 1.65 0.028 1.06 2.57
Race and language (reference: black-english)
White, non-Arabic 0.82 0.014 0.70 0.96 0.67 <0.001 0.57 0.77 1.69 <0.001 1.33 2.14 0.47 <0.001 0.35 0.62 3.60 <0.001 2.92 4.44
Black-African 0.65 0.003 0.48 0.87 0.89 0.392 0.69 1.15 1.67 0.019 1.09 2.56 0.61 0.041 0.38 0.98 0.99 0.931 0.76 1.28
Asian-Burmese 0.49 <0.001 0.36 0.67 0.58 <0.001 0.44 0.76 1.72 0.013 1.12 2.65 0.43 0.001 0.25 0.72 0.93 0.564 0.73 1.19
Any-Spanish 0.79 0.076 0.61 1.03 0.78 0.047 0.61 1.00 1.36 0.109 0.93 1.97 0.60 0.023 0.39 0.93 1.03 0.797 0.81 1.32
Asian-Nepali 0.69 0.043 0.48 0.99 1.05 0.73 0.78 1.41 2.20 0.009 1.22 3.96 0.79 0.37 0.48 1.32 0.58 <0.001 0.43 0.78
Asian-Other 0.81 0.118 0.63 1.05 0.77 0.03 0.61 0.97 1.06 0.746 0.75 1.49 1.05 0.803 0.73 1.50 1.14 0.292 0.89 1.47
Any, Arabic 1.10 0.699 0.69 1.74 1.09 0.715 0.70 1.68 1.89 0.12 0.85 4.20 0.93 0.834 0.45 1.89 1.11 0.646 0.71 1.74
Other/unknown race 0.61 0.007 0.43 0.88 0.89 0.434 0.66 1.19 1.36 0.214 0.84 2.19 0.66 0.137 0.38 1.14 1.59 0.005 1.15 2.20
Maternal age 1.04 <0.001 1.03 1.05 1.06 <0,001 1.05 1.07 1.01 0.123 1.00 1.02 0.99 0.077 0.97 1.00 1.04 <0.001 1.03 1.05
Parity 1.17 <0.001 1.13 1.22 0.91 <0,001 0.88 0.94 0.88 <0.001 0.84 0.92 1.05 0.057 1.00 1.11 0.77 <0.001 0.74 0.80
Medicaid insurance 1.13 0.058 1.00 1.28 1.23 0.001 1.09 1.38 1.05 0.528 0.89 1.25 1.20 0.054 1.00 1.44 0.49 <0.001 0.43 0.56
Pre-Eclampsia 1.63 <0.001 1.36 1.95 2.29 <0,001 1.93 2.72 0.17 <0.001 0.14 0.20 5.71 <0.001 4.73 6.89 0.91 0.328 0.75 1.10
Diabetes 1.36 <0.001 1.16 1.61 1.61 <0,001 1.37 1.88 0.55 <0.001 0.45 0.68 1.28 0.039 1.01 1.63 0.77 0.004 0.65 0.92
Zipcode (reference: clarkston)
Metro-Atlanta 1.02 0.878 0.83 1.24 0.97 0.769 0.81 1.16 0.90 0.448 0.68 1.19 1.18 0.276 0.88 1.60 0.96 0.660 0.80 1.15
Other Georgia 1.60 0.121 0.88 2.91 0.96 0.901 0.53 1.75 0.79 0.595 0.33 1.87 1.50 0.388 0.60 3.75 1.65 0.212 0.75 3.62
Outside Georgia 1.34 0.310 0.76 2.34 0.87 0.615 0.50 1.50 0.63 0.203 0.30 1.29 2.05 0.06 0.97 4.35 0.68 0.19 0.39 1.21
*p<0.05 for Embrace participation.
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Mosley et al. Evaluating Refugee Pregnancy Support Program
FIGURE 1 | Marginal effects of Embrace participation on the probability of pregnancy-related outcomes at Emory Decatur Hospital from 2016 to 2018 after adjusting
for covariates. *p<0.05; probabilities are adjusted for race, language spoken at home, parity, maternal age, insurance status, underlying conditions (pre-eclampsia
and diabetes), and zip code.
point increase in exclusive breastfeeding plans (66 vs. 76%)
(Figure 1). Our results also showed non-significant but positive
trends on other outcomes. Embrace participation was associated
with a 4-percentage point decrease in cesarean delivery from
33% (95% CI: 32.1–34.1%) to 29% (95% CI: 19.8–38.2%), a 4-
percentage point increase in full-term gestational age from 89%
(88.6–90%) to 93% (95% CI: 87.1–98.1%), and a 2-percentage
point decrease in low birthweight from 9% (95% CI: 8.1–9.4%)
to 7% (95% CI: 1.4–12.3%).
Our Wald tests indicate that we can reject the null hypothesis
that Embrace participation was not associated with lower
likelihood of labor induction (Wald test χ²1=5, p<0.025) and
greater likelihood of exclusive breastfeeding intentions (Wald test
χ²1=4.83, p<0.028). We cannot reject that null hypothesis for
Embrace participation and cesarean delivery (Wald test χ²1=
0.68, p=0.411), full-term gestational age (Wald test χ²1=0.85,
p=0.329), or low birthweight (Wald test χ²1=0.35, p=0.552).
DISCUSSION
Refugee women are particularly vulnerable to adverse pregnancy
outcomes (2). Community-based pregnancy programs represent
a promising strategy to address some of the challenges refugee
women face when giving birth in a new country. Our study
suggests that one such program, Embrace Refugee Birth Support
in Georgia, might be effectively improving pregnancy-related
outcomes for refugees, particularly reduced labor induction and
increased plans for exclusive breastfeeding. Labor induction is,
in turn, associated with higher gestational age and birthweight
as well as a lower risk of cesarean delivery (22). While exclusive
breastfeeding is associated with health benefits for mothers and
babies across their life courses (28).
A core value of Embrace is cultural sensitivity; through
their programming, education, and birth support, Embrace
seeks to integrate a refugee’s home culture into her birth
experience in America. Additionally, the Embrace volunteers
help alleviate many barriers women face in accessing and
navigating pregnancy-related services, particularly as it relates
to relationships and communication with providers during the
pregnancy, birth, and postpartum periods (40). As highlighted
by Khan and DeYoung (41), culturally sensitive programs
and strategies such as these are needed to assist refugee
women with accessing maternity services that can improve
outcomes. Furthermore, prior studies have demonstrated that
incorporating culturally sensitive strategies has been successful in
addressing barriers, promoting perinatal health service use, and
improving outcomes among pregnant women (29,30). Findings
from our study reinforce the importance of community-based,
pregnancy support programs to improve refugee maternal and
child health.
Given the benefits of breastfeeding to the health and
development of infants, providing culturally relevant education
on breastfeeding is important to improve breastfeeding-related
outcomes among resettled refugee populations (15,16). In
Embrace’s Healthy Babies and Breastfeeding module, community
liaisons teach women about the health benefits of breastfeeding
and navigating challenges with breastfeeding. While we are not
able to directly assess the relationship in our study, previous
studies have found women who attend prenatal classes focused
on breastfeeding had higher intentions to exclusively breastfeed
and were more likely to exclusively breastfeed, compared with
women who did not attend classes (42,43). This may explain the
greater intention to exclusively breastfeed among the Embrace
participants.
Education surrounding obstetrical interventions is critical for
refugee populations, given many refugee women come from
settings and cultures where such interventions are uncommon or
unfamiliar, which may lead to avoiding medical care and distrust
of providers (44–46). As found in another study, childbirth
education may be an effective strategy for reducing elective
inductions (47). Consistent with this finding, our study found
Frontiers in Global Women’s Health | www.frontiersin.org 7June 2021 | Volume 2 | Article 655409
Mosley et al. Evaluating Refugee Pregnancy Support Program
that women who participated in Embrace had a significantly
lower likelihood of labor induction, which, in turn, supports
the findings that the women who participated in Embrace
might have higher gestational age and birthweight as well as
a lower risk of cesarean delivery. Furthermore, during many
births, an Embrace volunteer is present with the moms to
provide continuous support during labor and childbirth and
to advocate for them and serve as a bridge between patient
and provider, especially in instances where interventions are
recommended. Our results align with findings from a systematic
review that found women with continuous support during
birth, including from doulas, were more likely to have a
spontaneous vaginal delivery and less likely to have a Cesarean
delivery (48). However, unlike our study, this review found
that there was no impact of continuous support on the use of
synthetic oxytocin (e.g., induction and augmentation) during
labor or breastfeeding.
Findings from our study have several implications for
providing services for pregnant refugee women and future
research. Participating in culturally sensitive and tailored support
services may have positive influences on refugee women’s
pregnancy outcomes and social support (19,44). Similar
programs can be developed to meet the pregnancy, birth, and
postpartum needs of diverse resettled refugee populations. The
Embrace participant sample was very diverse and can be used
to generalize to many racial/ethnic groups. The Embrace sample
was African (32.7%), Karen/Burmese (30.1%), other Asians who
were not Nepali (10.6%), and Arab refugees (8.0%). Furthermore,
our sample’s diverse countries of origin are comparable to the
resettled refugee population in the US. In Fiscal Year 2020, 35%
of refugees resettling in the US came from Africa, 18% from East
Asia, and 17% from Near East/South Asia (49). Therefore, our
findings may be generalizable to the broader resettled refugee
population in the US.
While the study findings align with Embrace’s program
components, future studies could assess Embrace’s program
evaluation data to discern possible mechanisms through which
the program is improving pregnancy-related outcomes. In
particular, this study was not able to assess how much doula
support women received from Embrace or how many prenatal
visits the Embrace and comparison women attended. Future
research should include dose-response measures to assess those
effects. Additionally, this was an innovative study, using big
data to rigorously evaluate a community-based pregnancy
support program for refugee women, whose health disparities
are particularly difficult to quantify. Previous studies typically
rely on qualitative designs or compare pregnancy outcomes
between refugee and U.S.-born or immigrant populations. Future
studies could adopt a similar design to quantitatively assess
the effectiveness of services across resettled refugee populations.
However, those studies will need to conduct careful power
calculations to ensure the sample sizes are adequate to detect
statistically significant results. Additionally, as found by several
studies, the lack of cultural awareness and receptiveness among
providers to refugee women’s beliefs and practices surrounding
birth creates disconnects between patients and providers and
feelings of fear and marginalization among refugee women
(41,44,50). In addition to birth education for refugee
women, Embrace works closely and establishes relationships
with healthcare providers in the community whom refugee
women regularly see. Through these relationships, Embrace has
worked to provide education, such as Lunch and Learns, for
providers to orient them to the refugee community and different
cultural practices. Future qualitative research is needed with
data collection at the organizational and community levels to
understand provider and community perspectives surrounding
providing pregnancy-related services for refugee women.
Limitations
Our study demonstrates the potential success of Embrace in
pregnancy-related outcomes; however, important limitations
must be noted. For one, women were not randomized into the
Embrace program. Furthermore, causality cannot be established
because we were unable to control for additional potential
confounding factors or temporality. Nevertheless, we have
controlled for a number of covariates that could have possibly
explained the improved outcomes for the Embrace patients.
Another related limitation is that we have no definitive
data on the refugee status of women in the comparison
group. We have made the comparison group as similar to
the Embrace population as possible, but there could still be
underlying unmeasured differences between the two groups.
The use of secondary data from Emory Decatur Hospital
limited which predictors and outcomes we could assess for
this study. For example, data on length of time in the
U.S. were not available for analysis. By using the hospital
records, however, we were able to analyze a large sample,
including the Embrace participants and a comparison group,
using consistent, clinical measurements. Furthermore, due to
limitations on data availability, only data on breastfeeding
intentions were available rather than actual breastfeeding.
Because behavior intentions are the closest predictor of
actual behavior (51), however, this remains an important and
valuable breastfeeding indicator. Finally, these results might not
generalize to Spanish-speaking refugees in the US, given that
there were no Spanish-speaking Embrace participants in this
sample. Nevertheless, Embrace program evaluation data with the
Spanish-speaking participants, who delivered at other hospitals,
indicates the program is similarly valued by and beneficial
for Latinas.
Conclusion
Community-based, culturally tailored pregnancy support
programs like Embrace are needed to meet the complex
needs of refugee women, who are at greater risk of barriers
to maternal health services and negative birth outcomes.
In a time when anti-refugee social contexts and COVID-19
present additional challenges, programs such as Embrace
are especially needed to support refugee women when
navigating health services and giving birth in their new
country. Community-engaged, cross-sector research approaches
like the one we took in this study under the guidance
of Georgia Doula Access Working Group are needed to
ensure community and clinical perspectives are included
Frontiers in Global Women’s Health | www.frontiersin.org 8June 2021 | Volume 2 | Article 655409
Mosley et al. Evaluating Refugee Pregnancy Support Program
in research design, implementation, and dissemination
of results.
DATA AVAILABILITY STATEMENT
The data analyzed in this study is subject to the following
licenses/restrictions: Data come from electronic medical records
and cannot be made publicly available. Requests to access these
datasets should be directed to emosley@gsu.edu.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by Emory University IRB. Written informed
consent for participation was not required for this study
in accordance with the national legislation and the
institutional requirements.
AUTHOR CONTRIBUTIONS
HM, TN, and JC: pregnancy support program development and
implementation. EM, MP, HM, AM, and MH: study design. AM,
HM, TN, and JC: community engagement. EM, MP, HM, TN,
and JC: data collection. EM, MP, BW, and MH: data analysis.
EM, GB, BW, and LC: first draft of manuscript, revisions, and
second draft of manuscript. All authors contributed to the article
and approved the submitted version.
FUNDING
This work was also made possible through the support of
Collaborative for Gender and Reproductive Equity, a sponsored
project of Rockefeller Philanthropy Advisors.
ACKNOWLEDGMENTS
The Georgia Doula Access Working Group, which oversaw
this study, was funded by the United Way of Greater Atlanta
through the Healthy Mothers, Healthy Babies Coalition of
Georgia. Dr. Mosley’s contributions were funded by the Center
for Reproductive Health Research in the Southeast (RISE) and
an anonymous foundation. The team also acknowledges Mary
M. Gullate Ph.D., RN, ANP-BC, AOCN, FAAN, Corporate
Director Nursing Research and Evidence Based Practice, Emory
Healthcare, Atlanta, Georgia for her research guidance and
mentoring.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2021 Mosley, Pratt, Besera, Clarke, Miller, Noland, Whaley, Cochran,
Mack and Higgins. This is an open-access article distributed under the terms
of the Creative Commons Attribution License (CC BY). The use, distribution or
reproduction in other forums is permitted, provided the original author(s) and the
copyright owner(s) are credited and that the original publication in this journal
is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
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