One Hundred Intentional Acts of Kindness Toward a Pregnant Woman: Building Reproductive Social Capital in Los Angeles

Abstract

This article describes the development of an innovative community-based program, One Hundred Intentional Acts of Kindness toward a Pregnant Woman^© (100 Acts), which seeks to increase reproductive social capital for pregnant women in south and central Los Angeles communities. Reproductive social capital includes features such as networks, norms, and social trust that facilitate optimal reproductive health within a community. 100 Acts was designed and developed by the Healthy African American Families project, using community participatory methods, to increase local community and social network support for pregnant women. Dialog groups with pregnant women identified specific actions that families, friends, and strangers might do to support pregnancies. Participants primarily wanted emotional and instrumental support from family and friends. From strangers, they wanted respect for personal space and common courtesy. Based on these results, the 100 Acts was created for use in the Los Angeles community. 100 Acts encourages and engages active participation from community members in promoting healthy pregnancies. By seeking to increase community-level reproductive social capital, 100 Acts shifts the provision of social support during pregnancy from a high-risk approach to a population approach. 100 Acts also establishes new social norms about how pregnant women are valued, treated and respected.

Introduction

In the United States, Black infants have significantly higher mortality rate than White infants.¹ A significant portion of this disparity is attributable to the near two-fold increase in low birth weight (LBW, <2500 grams) and preterm births (<37 completed weeks gestation), and the near three-fold increase in very low birth weight (VLBW, <1500 grams) and very preterm births (<32 completed weeks gestation), among Black infants.¹

Growing evidence suggests that maternal psychosocial stress is an important risk factor for LBW and preterm birth.^2–4 Maternal stress can cause increased release of norepinephrine and cortisol, which then activates placental corticotropin-releasing hormone (CRH) gene expression, thereby precipitating the biological cascade leading to the onset of preterm labor.⁵ Stress can also alter immune function, leading to increased susceptibility to intraamniotic infection or inflammation.⁶ Additionally, stress may induce high-risk behaviors as coping responses.⁷ These associations between stress and preterm birth have led some investigators to ascribe African Americans' excess prematurity risk to excess exposures to psychosocial stress.⁷ Several studies suggest that African American women may experience more psychosocial stress before and during pregnancy than White women.^8,9

Social support has been proposed as a means of addressing maternal psychosocial stress, with an ultimate goal of reducing LBW and preterm births.¹⁰ Current psychosocial interventions in public health most often take the form of case management and home visitation. The results of these interventions have been quite mixed.¹¹ A Cochrane review found that programs offering additional social support during pregnancy were not associated with significant reductions in LBW or preterm birth rates.¹¹

An important criticism of previous psychosocial interventions is that they may not offer the types of social support needed to buffer against the chronic social stressors pervasive in African American women's daily lives. Instead of relying solely on monthly or weekly home visits by public health nurses, interventions also should strengthen the capacity of the partner, family, peers, neighbors, and the community at large to provide social support, particularly emotional and instrumental support, for pregnant women.

Social capital goes beyond social support to describe the degree of social connectedness within a community or society. It was first proposed by Putnam to refer to those features of social organization such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit.¹² Social capital is characterized by: 1) the existence of community networks; 2) civic engagement; 3) local identity and a sense of solidarity and equity with other community members, and: 4) trust and reciprocal help and support. Several studies have linked social capital to health disparities, including disparities in infant mortality.¹³

Reproductive social capital can thus be defined as features of social organization, such as networks, norms, and social trust that facilitate reproductive health within a community. With respect to pregnancy, it describes the degree of social connectedness of the pregnant woman to her community. Reproductive social capital is characterized not only by the number of neighbors a pregnant woman can turn to for help and support, but also by the ways in which a community treats a pregnant woman. For instance: Does the community provide safeguards and resources for pregnant women? How actively engaged is the community in promoting healthy pregnancy? Do community members feel a sense of solidarity with the pregnant woman and of responsibility for the wellbeing of that pregnancy? And most fundamentally, what kinds of community support do pregnant women want and receive? In this article we describe a community-based program created to increase reproductive social capital within a local African American community.

Program Description

Healthy African American Families (HAAF) is a non-profit, community-based organization which addresses poor health outcomes for Black infants and families in Los Angeles. It began in 1992 as a community-academia-government research partnership to study the experience of pregnancy among African Americans. Specifically, its goal was to generate a new understanding of potential health risk factors, and therefore resiliency, among pregnant African Americans by using ethnographic research to explore lifestyles, barriers, and assets of the community. This understanding would then provide a foundation for the development of subsequent interventions. HAAF and the other outcomes of this work are described in greater detail elsewhere in this issue.^14,15

The One Hundred Intentional Acts of Kindness toward a Pregnant Woman^© program (100 Acts) was conceived and developed by HAAF as part of a community-based media campaign to increase social support and decrease psychosocial stress for pregnant African American women in the south and central Los Angeles communities.¹⁶ Earlier ethnographic research conducted by HAAF indicated that psychosocial stress was a common occurrence during pregnancy for African American women, and that psychosocial stress might be reduced by strengthening pregnant women's social support network, which includes not only families and friends, but also the community at large.¹⁵ In discussions with community members, the need for a media campaign that gave visual and verbal prompts on providing positive support to pregnant women was identified.^15,16

The 100 Acts campaign was developed in a series of dialog (focus) groups with fifty-five pregnant or postpartum African American women who were recruited from local clinics, community-based organizations, and faith-based organizations. In the initial six groups, participants were asked to name five things you wish someone close to you would do (would have done) to make your pregnancy better and five things a stranger could do (could have done) to make your pregnancy better. The HAAF staff and consultants then collated, sorted, and identified themes within the proposed acts. Redundant acts were consolidated. The draft acts were then presented to follow-up dialog groups (9 total), composed of the original participants, for review and final selection. For the final Acts, a balance of positive and negative actions were sought as well as preservation of original language. This project was approved by the University of California Los Angeles institutional review board.

The most common request among group participants was for emotional support. About half (53%) of the participants wished that someone close, particularly their husband or partner, could be more supportive (eg, “I wish my baby's father would have been more involved,” “be there for my pregnancy,” “give more encouragement,” “be more understanding to my emotional swings,” “be more interested in [my] pregnancy,” and “don't argue with me”). Participants asked for physical expressions of emotional support, such as walking (16%), talking (15%), or massages (9%). Participants wanted instrumental support from someone close, such as help with preparing meals (26%), housecleaning (22%), transportation (22%), and childcare (11%). Twenty-two percent of women wanted their partners, families, or friends to attend prenatal care appointments with them.

From strangers, participants had more don't's than do's on their list. The most common request was “don't talk to me/leave me alone” (26%), followed by “don't touch my belly/stomach” (16%). Other “don't's” included “don't smoke/use drugs around me” (13%), “don't stare at me/talk about my weight” (11%), and don't say negative things about the pregnancy, labor and delivery, or life (eg, “don't say … how bad it is to be pregnant,” “don't talk about the pain of having a c-section or … labor and delivery experiences,” “don't say my life is over”) (9%). On the do list, the most common request was to “give up their seat for me” (24%), followed by “ask, `can I help you with anything”' (11%). Eleven percent of participants asked that strangers be respectful, polite, and encouraging while 7% asked for a simple smile. Several participants asked for other forms of support, such as “carry my bags,” “open doors,” and “bring me some water.” One participant asked for help to “give me my job back,” while another wished strangers would “pray for me and [my] unborn baby.”

Based on the responses from the dialog groups and other HAAF partners, a list of 100 intentional acts of kindness were compiled (Figure 1). These were then distributed within the community to increase awareness of the 100 Acts in multiple domains in the community.¹⁷ Fans with the 100 Acts listed on one side and HAAF contact information on the other were distributed to local churches, beauty and barber shops, and health care clinics. Fans were also shared with local and state health departments. Other dissemination strategies, such as posters, billboards, advertisements on buses and at bus stops, business cards, and web page were identified and await funding. One Hundred Intentional Acts of Kindness Toward New Mothers^© and One Hundred Acts of Kindness Toward Oneself^© were subsequently developed using similar methods.

Fig 1.

100 Intentional Acts of Kindness Toward a Pregnant Woman

The 100 Acts were presented to the local community during a HAAF community conference.¹⁸ Evaluative feedback from conference participants indicated that the intent of the 100 Acts was clear to 77% (81/105) of attendees. Eighty-six percent (89/104) of attendees indicated they would give the Acts to a client or family member.

Lessons Learned

100 Acts offers several important public health lessons. First, the social support that pregnant women want from families, friends, and strangers is not typically provided through public health case management or home visitations. Most pregnant women said they wanted consistent, daily emotional and instrumental support (eg, “ask me if I need anything”, “take a walk with me”) from family and friends. They wanted strangers to show common courtesy, including respect for personal space and avoid prying (eg, “ask permission to touch my belly”), and simple acts of kindness (eg, “offer me your seat on the bus,” “allow me to go ahead of you in line”). These acts of kindness from families, friends, and even strangers may help buffer against the chronic stressors experienced daily, and may help prevent activation of the body's physiologic response to stressors that could lead to preterm labor.^3–6 100 Acts represents a paradigm shift in providing social support during pregnancy from a high-risk approach to a population approach.¹⁹ The next wave of psychosocial interventions during pregnancy will require continued thinking innovatively outside the box about not only how to address psychosocial stress among high-risk individuals, but also how to strengthen the capacity of families, friends, and communities to provide social support to pregnant women.

Second, 100 Acts has the potential to not only increase social support at the individual level but also to help create reproductive social capital at the community level. Asking for acts of kindness from families, friends, and even strangers strengthens social connectedness to pregnant women in their community. It establishes new social norms about how pregnant women are valued, treated and respected. It encourages and engages conscious, active participation from community members in promoting healthy pregnancy for all women. Healthy African American Families believes it takes a village to have a healthy baby. While acts of kindness do not alone address structural issues such as housing, employment and discrimination that are the source of chronic stressors for many pregnant African American women,²⁰ they may create a sense of solidarity and collective efficacy in the community that can then be mobilized into political action.

Third, 100 Acts demonstrates the power of participatory action research (PAR). PAR uses a series of core principles and values, among which is a shared commitment to actively engaging those who live in the community and whose lives are affected by the issue under study in every phase of the research process.²¹ In PAR there is a co-learning between scientific researchers and community members, as equal partners, to create knowledge necessary for local change.²¹ 100 Acts was created by such processes. While academic partners contributed theories, resources, and technical assistance, 100 Acts was driven from the outset by community partners in its conception, design, implementation, and evaluation. Preliminary evaluation results indicate community acceptance and utilization of the 100 Acts.

100 Acts may be an important first step toward increasing reproductive social capital and reducing psychosocial stress for pregnant African American women in south and central Los Angeles communities. Moreover, while 100 Acts was developed for use in a local African American community, the acts are not culturally specific and are easily transferable to any racial/ethnic community.