The purpose of this thesis is two-fold: it attempts to develop a feminist theory of health and health care of women and moves beyond the political economy theory of health and health care grounded in Marxist principles. Secondly, it attempts to apply these feminist theoretical principles, incorporating the methodology of historical materialism, to a specific historical situation - that of African women in Natal/Zululand in the nineteenth century. The thesis is divided into three parts. The first provides an overview of the political economy of health and the Marxist theory on which it is based. The second section deals specifically with feminist theoretical concerns: particularly the need to incorporate the concept of gender and the sexual division of labour into analysis of the position of women in society. In addition, it focusses on women's particular health needs and attempts to incorporate these into a feminist theory of health and health care. The third part examines the health and health care of African women in pre-colonial Natal/Zululand by focussing on their role in procreation and production, and changing health patterns and health care under colonial rule. / Thesis (M.A.)-University of Natal, Durban, 1990.

Problem to be addressed: Stillbirth is a major public health problem. The stillbirth burden is on a par with newborn deaths. The stillbirth rate measures not only a substantial portion of the global and national burden of mortality, but also equity and quality of care for women’s and children’s health. Reducing the numbers of these deaths requires an understanding of why they occur, yet approximately one-third of stillbirths are unexplained, even in settings with high-quality autopsy and placental examination, while deaths considered to be explained are usually ascribed to single, proximal causes. An important limiting factor for efforts to reduce the large and inequitable stillbirth burden has been insufficient research into conditions that could inform prevention strategies and reduce inequity.1 2 Substantial evidence exists for associations between structural racism, maternal stress, and adverse pregnancy outcomes, yet research focusing on stillbirth is sparse, particularly at the ends of the causal spectrum—macro-level structural conditions and mechanisms. Several studies have called for research on possible biological mechanisms by which racism, racism-related stress, and stillbirth may be associated, including epigenetic mechanisms.3-6 The most recent review of causes of racial disparities in stillbirth rates in the U.S. recommended that researchers take a multi-domain approach, considering not just individual-level risk factors, which have been relatively well-studied, but also upstream factors such as institutional racism, and biological mechanisms such as epigenetic modification. The objective of this dissertation was to explore evidence that could help to explain persistent racial disparities in stillbirth. The specific aims were: 1. To review the literature on racial disparity in stillbirth rates; 2. To assess whether structural racism can help to explain racial disparity in stillbirth rates in New York City; and 3. To assess whether maternal stress is associated with stillbirth, whether stress is associated with methylation of stress-related genes, whether methylation is associated with stillbirth, and whether there is evidence that methylation of stress-related genes mediates associations between stress and stillbirth. Materials and methods used: For Aim 1, we carried out a scoping review of the literature in five databases (PubMed, Scopus, Cinahl, Embase, PsycInfo) to identify all reports including stillbirth rates stratified by race in the U.S., mapping exposures and effect modifiers (“domains of analysis”) and authors’ comments on racial disparity in stillbirths (“domains of explanation”) into one of eight domains (race, genetic, fetal, maternal, family, community, healthcare system, and structural). We defined Stillbirth Disparity Ratios (SDRs) as the ratio of the stillbirth rate in a racial/ethnic minority group to the stillbirth rate in white individuals. Selected SDRs were extracted from each report, as were all SDRs for Black/white comparisons. For Aim 2, we modelled associations between four measures of structural racism and stillbirth in all non-Hispanic (NH) Black and white singleton births in New York City between 2009 and 2018. Exposures were four Public Use Microdata Area (PUMA)-level measures of structural racism (Indices of Dissimilarity, Isolation, and Concentration at the Extremes (ICE), and an Educational Inequity Ratio) constructed from U.S. Census American Community Survey data. Using multilevel logistic regression, we first tested for interaction between race and structural racism in relation to stillbirth. For structural racism measures that interacted with race, we estimated odds ratios for stillbirth separately in 221,925 NH Black and 325,058 NH white births. Race-specific models were further stratified by maternal age. For Aim 3, we assessed associations between maternal stressors and stillbirth in 183 non-anomalous full-term singleton births (63 stillbirths and 120 livebirths) from the U.S. Stillbirth Collaborative Research Network. Measuring maternal stress with two hypothesized stressors, an Index of Significant Life Events and an Index of Disadvantage, we assessed associations between maternal stressors and stillbirth in our sample, and then whether maternal stressors and stillbirth were associated with differential methylation of 1,191 CpGs on five stress-related genes (BDNF, FKBP5, HSD11B2, IGF2, and NR3C1). Finally, we assessed whether methylation mediates associations between stressors and stillbirth. Conclusions reached: For Aim 1, we found 95 reports presenting stillbirth rates stratified by race/ethnicity in the U.S. We found evidence of increased risk of stillbirth in Black as compared to white births in the majority of the 83 reports with the necessary data. Among the 1143 Black-white SDRs that we extracted, the median SDR was 1.67, with 74% of SDRs showing evidence of disparity. Family and community factors, healthcare system factors, and structural factors were commonly used as domains of explanation (20-38% of reports), but rarely (family/community, structural, 4-5%) or never (healthcare system) used in analysis. The most commonly used domains of analysis—fetal and maternal factors including gestational age, maternal age, education, and prenatal care—do not appear able to explain the observed racial disparities. Gaps in the literature include a paucity of studies examining the possible role of health system, community, and structural factors in Black-white disparity in stillbirth rates, and limited data on other types of racial disparities in stillbirth rates, including Hispanic and Native American births. For Aim 2, we found that structural racism as measured by ICE and Isolation was associated with stillbirth in NH Black but not NH white mothers. This would seem consistent with our hypothesis that structural racism may help to explain racial disparity in stillbirth rates; however, the associations we observed were not in the expected direction. Specifically, NH Black mothers living in PUMAs with a high concentration of privilege had 90% greater odds of stillbirth in comparison to those living in PUMAs with a high concentration of disadvantage (ICE quintile 5 vs 1), and NH Black mothers living in PUMAs that were the most isolated had 40% lower odds of stillbirth in comparison to those living in PUMAs that were the least isolated (Isolation tertile 3 vs 1). We suggest that while the measures we used (ICE and Isolation) do help to explain the Black-white disparity in stillbirth rates, our results raise questions about the way these measures operationalize structural racism, meriting further investigation. For Aim 3, we found that having two or more vs no items in the Index of Disadvantage (“Disadvantage”) was associated with more than fourfold greater odds of stillbirth (95% CI 1.58, 12.93). We found no association between the Index of Significant Life Events and stillbirth. We found that 32 out of 1,191 CpGs on five stress-related genes were differentially methylated with respect to stillbirth, and six CpGs were differentially methylated with respect to Disadvantage. Methylation at two CpGs on IGF2 and one on HSD11B2 (cg02097792, cg12283393, and cg19413291, respectively) mediated the association between Disadvantage and stillbirth. Research on causes is a critical component of stillbirth prevention and reducing the inequitable distribution of this public health burden. Limited understanding of causes at both “ends of the spectrum”, from upstream distal factors to mechanisms, has likely contributed to slow progress on prevention.7 8 This dissertation contributes to science and public health by providing researchers with data to support new lines of inquiry, e.g., into associations between structural racism and stillbirth, and for methylation as a mechanism of effect, that should help to improve our understanding of causes. Our research may also support health policy makers who now have additional data to illustrate the adverse health outcomes of structural racism in the U.S. Finally, it may help the parents and other family members of stillborn babies who continually seek to understand “why”.

The effects of a multifaceted weight loss program on the body weight, body composition, plasma variables, and nutrient intakes of 50 obese black women were investigated. Subjects were between 20 and 51 years of age, with an average BMI of 34.5 (range = 23.6 - 57.3). Subjects attended nutrition education/behavior modification classes once per week for three months. Thirty-five of the women attended 80% or more of the classes (NU). Twenty-eight women attended 30% or more of the low-impact aerobic exercise classes that were offered three days per week, for six months. An average 2.2 kg weight loss was observed for the whole study group, as body fat fell, and lean body mass increased by 2.1% of total body weight. Slightly greater changes were observed in the group that exercised consistently, as well as those who regularly attended nutrition classes, but not in either of the groups which more sporadically attended exercise or nutrition classes. Significant reductions in plasma total cholesterol, HDL-Cholesterol, HDL₂-Cholesterol, and insulin were observed for the group of 50 subjects. Significant reductions in plasma TC occurred in both the SE (attended between 30 to 70% of exercise sessions) and SN ( < 80% attendance of nutrition classes) groups. Plasma LDL-Cholesterol followed the same pattern as plasma total cholesterol but there were no significant differences. Exercise appeared to mitigate decreases in plasma HDL-C. Significant reductions in total Kcal, including CHO, protein, fat (including saturated, polyunsaturated, and monounsaturated fatty acids), dietary cholesterol, and sugar were noted for the study group. A weight-loss program which included diet, nutrition education, behavior modification, stress management and exercise was effective in producing favorable changes in body composition, plasma variables, and dietary components in obese black women over six months, with a high degree of variability in motivation and participation. / Master of Science

Existing research on health disparities in breast cancer is heavily focused on outcomes for poor or low-income women. Little is known about the experience of privately insured Black breast cancer patients that have moderate to high SES. As a result, the present study was conducted to learn more about their experiences. It examines differences in physician prescribing of two breast cancer pain treatments, peripheral nerve block (PNB) and opioids, for Black and White women with like levels of health insurance coverage and socioeconomic status (SES). Three specific questions are addressed: 1. What, if any, race-based disparities exist in usage of PNBs at time of total mastectomy? 2. What, if any, race based disparities exist in the prescription of opioids for postoperative pain following total mastectomy? 3. What, if any, changes have occurred in the frequency of orders placed for PNBs and prescription opioids over time, to treat postoperative pain resulting from mastectomy? A cross-sectional designed was used relying on an existing national dataset, Optum Clinformatics Data Mart. The study period was January 1, 2012, through December 31, 2019. Study results revealed that while moderate to higher SES Black women have equitable access to PNB and opioids - a kind of shield from long established physician bias against Black women – this protection is quite porous. They still do not have open and ready access to PNB as a more advanced pain treatment. Nor do they have assurance that they are protected from the overprescribing of opioids, a class of drugs with serious and well-known safety risks. Therefore, on the surface, it appears that equity and racial inclusion are hallmarks of physician prescribing of postoperative breast cancer pain treatment. However, further interrogation reveals that ‘separate and somewhat equal’ is a more accurate characterization of their prescribing practices, based both on race and SES.

This study addressed the long-standing crisis of Black severe maternal morbidity in the U.S., while the COVID-19 pandemic led to even worse outcomes. The purpose of the study was to identify significant predictors of the quality of patient-provider relationships during a birth hospitalization. The sample of Black women (N=182) gave moderate ratings for quality of patient provider relationships, and for level of trust, rapport, and communication with providers. Providers were rated as having a fair level of cultural sensitivity, competence, and humility—while 30.2% rated them as poor. For experiences of racism, discrimination and inequities in service delivery, combining categories of a “few times” and “many times,” 53.3% felt racially stereotyped or treated like a racial stereotype, 52.5% were treated with less respect than a White woman would have been, 39.7% were verbally abused or yelled at, 43.8% were scolded, ridiculed, mocked, and shamed, 47.2% felt belittled and put down, 42.7% felt threatened, coerced, lied to, and manipulated, and 46% felt their pain was not managed the same way as for a White woman. Women entered the hospital with risk factors of cardiovascular disease (20.3%), hypertension (23.6%), obesity (18.1%), and diabetes (13.7%). Further, 74.2% had COVID-19 in the past two years, 25.8% had long COVID-19, 34.1% had COVID-19 during their pregnancy, and 34.1% had COVID-19 at delivery. Medical events during their delivery hospitalization included hemorrhage (40.7%), blood clot (25.3%), and a hypertensive disorder of pregnancy (25.3%). Women had high rates (over 75%) of past year depression, anxiety, and trauma—with 68.1% receiving counseling; and higher rates (over 85%) the year post-partum—with 76.9% receiving counseling. Noteworthy significant predictors of a higher quality of patient-provider relationships were higher education, higher trust/ rapport/ communication with providers, and lower global racism/ discrimination/ inequities during service delivery—while entering the hospital with lower risk factors for pregnancy-related complications (69.8% of variance predicted). The study contributes to literature on the crisis of severe maternal morbidity for Black women in the U.S, as well as factors that need to be addressed to reduce it, while offering a cache of culturally appropriate measures for ongoing research.

Depression is one of the most widespread and disabling mental health disorders affecting adults worldwide, and Black women bear a disproportionate burden of this disorder. With its varied symptom presentation, depression can be difficult to diagnose. In addition, Black women may be less likely to report symptoms due to cultural stigma. The purpose of this dissertation is to examine the associations between social determinants of health and depressive symptoms using DNA methylation data and machine learning to predict depressive symptoms in Black women. Chapter 2 contains two comprehensive literature reviews: a scoping review of machine learning methods used to analyze omics data to classify depressed cases and healthy controls and a concept analysis of depression in Black mothers. Chapter 3 examines associations between social determinants of health, depressive symptoms, and DNA methylation. Chapter 3A focuses on socioeconomic deprivation; Chapter 3B focuses on perceived income inadequacy; and Chapter 3C identifies differential methylation associated with depressive symptoms. Chapter 4 utilizes supervised machine learning algorithms to predict depressive symptoms and perform feature selection. These chapters show the harmful effects that perceived discrimination can have on the mental health of Black women. Additionally, the results indicate that DNA methylation is associated with depressive symptoms, an area which requires further research.

This study takes the concept of ubuntu, which means humanness and applies it to healthcare issues in general, and women's health, in particular. Ubuntu is based on the reality of interdependence and relatedness. It is a philosophy or way of life that finds its roots and meaning in humanity. The values espoused in ubuntu emphasize caring, sharing, reciprocity, co-operation, compassion and empathy in recognition that for human beings to develop, flourish and reach their full potential, they need to conduct their relationships in a manner that promotes the well-being of others. The values championed in ubuntu are what inform and shape African cultural, social, political and ethical thought and action. / Thesis (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2007.

The study explored the body image of Professional Black South African women, cultural expectations, and their experiences in Westernised working milieus, utilising a phenomenological approach and qualitative exploratory design, located within Constructionism. Data were collected through purposive sampling (and snowballing) through individual face-to-face voice-recorded semi-structured interviews with 11 participants in/around Gauteng. Analysis was done through content analysis utilising thematic networks (Attride-Stirling). Major findings: Western values have influenced participants; Lower weight and thinness do not automatically correspond with assumptions about HIV/AIDS, instead correspond with healthier lifestyle choices; Body shape not weight or size was the prominent area of focus for most participants; Clothes size determines perception of overweight; Overweight has consequences. Forty-five per cent of participants were content with their bodies, 18% dissatisfied/unhappy, 18% satisfied, one happy, one apathetic. Tswanas were generally smaller-figured; Zulus, Northern Sotho/Pedi, Xhosa in general traditionally expected full-bodied women. Overt expectations in the workplace were not found. / Psychology / Master of Arts (Psychology)

The study explored the body image of Professional Black South African women, cultural expectations, and their experiences in Westernised working milieus, utilising a phenomenological approach and qualitative exploratory design, located within Constructionism. Data were collected through purposive sampling (and snowballing) through individual face-to-face voice-recorded semi-structured interviews with 11 participants in/around Gauteng. Analysis was done through content analysis utilising thematic networks (Attride-Stirling). Major findings: Western values have influenced participants; Lower weight and thinness do not automatically correspond with assumptions about HIV/AIDS, instead correspond with healthier lifestyle choices; Body shape not weight or size was the prominent area of focus for most participants; Clothes size determines perception of overweight; Overweight has consequences. Forty-five per cent of participants were content with their bodies, 18% dissatisfied/unhappy, 18% satisfied, one happy, one apathetic. Tswanas were generally smaller-figured; Zulus, Northern Sotho/Pedi, Xhosa in general traditionally expected full-bodied women. Overt expectations in the workplace were not found. / Psychology / M.A. (Psychology)