 So right now, I will quickly introduce our speakers. We have three speakers to do justice to this topic, titled Variation in Caesarean Bet Amongst Asian Betting People within the American Association of Bet Centers for Immaculate Data Registry. I'll quickly introduce Ami, I'll go Ami first. Ami is a certified nurse midwife and a PhD candidate at Boston College here in the US. She has been a midwife for over a decade and has worked in variety of settings from a vet center to a large academic teaching hospital. She's a Nigerian faculty at Thomas Jefferson's University Midwifery Program and also works for the Digital Health Company, Ufia Health. Ami is on the American Association of Bet Centers Board of Directors and is on the Commonwealth of Massachusetts, Asian, American and Pacific Islanders Commission. Thank you Ami for joining us today. I'm now the second speaker is a master's and public health student at the University of Arizona. She's a graduate intern at the American Association of Bet Centers and currently works as a microbiologist. She's a Vietnamese American and was born and raised in Arizona. Welcome. And lastly, Dia, Dia is a current MPH candidate and the University of Arizona at the University of Arizona and completing an internship with the American Association of Bet Centers. She has focused her work primarily on minority maternal health ranging from South Asian to indigenous mothers who have been beds utilizing Western medicine. She has worked towards providing culturally informed support at post-PSI and organization providing support for post-partum depression and anxiety and research on post-partum depression and help seeking behavior among mothers in India. As an incoming medical student she aims to improve maternal care for people of color by enhancing interprofessional collaboration between midwives and the physician. So at this point, I'll hand over the mic to Amy. Hi, thank you so much for that introduction. So as you can see, we have our presentation here. I'm so sorry, Jumi, I'm unable to advance the slides. Jumi. How about now? Are you able to now? Yeah, you should be able to. Yeah, there it goes. Okay, so first I'm going to talk about our positionality, all of us will and then we'll go and get into the backgrounds. Anna will give us the methods and then we'll go into the results, conclusion and acknowledgments. So in terms of my positionality, May is a month that I can celebrate all my intersection identities because in the United States, we celebrate Asian American and Pacific Islander Native Hawaiian Heritage Month. And I'm proud to say that I'm a child of immigrants from Korea. Today we also celebrate International Day of the Midwife and that's why we're here and I've had the privilege of working as a certified nurse midwife for the past 10 years within a birth center and hospitals in the Boston area. Lasting next Wednesday, I celebrate the birth of my daughter and the first time I became a mother. I'm also married with two children who are born at the Cambridge Birth Center. My name is Dia and I was born in India to a single mother and raised in Canada who inspired my interest in maternal health. So currently I am residing in California. I've always been very, very passionate about maternal health among minority populations. And so I'm looking forward to speaking to all of you and sharing our research today. So I have a broad interest in maternal and child health epidemiology and as well as infectious disease and epidemiology. So as Jimmy introduced us earlier, I'm part of the American Associations of Birth Centers intern, part of the internship program. And so I'm glad to be presenting here today and going back my positionality, I'm Vietnamese American and I currently reside in Arizona. So yeah, my parents are immigrants from Vietnam. So I was first, I'm part of the first generation born here. To get into the background, currently in the United States there's about 18 million Asians and Asians-American Americans. Though Asians are categorized often into one group, as you can tell by this table, there actually is a wide range of origin groups, ethnicities. You can see the breakdown here. This was from the US Census from 2016 to 2020. Births amongst Asians and Asian-Americans in the United States have declined over the past several years, which is actually true for many racial groups and ethnicities, but overall Asians account for about 7% of total births in the United States. So the CDC, the Central for Disease Control, National Vital Statistics System, which is a comprehensive national database of all births and deaths in the United States, they release a birth outcomes report annually. This report from all the births from 2021 was published last, this past January, and they found that there are several outcomes that actually place Asians at lower of sexual risk compared to other racial and ethnic groups. An example is they have the highest rates of initiation of prenatal care in the first trimester. They have the lowest rates of obesity, lowest rates of smoking. And another study found that actually they have lower rates of hypertensive disorders of pregnancy. One of the conditions that actually place Asians and Asian-Americans at higher risk, for example, for Caesarean birth, what we're talking about today are the higher rates of gestational diabetes. In the National Vital Statistics System report from 2021, which I mentioned earlier, 16.1% of Asians had a diagnosis of gestational diabetes, which has actually doubled the national average. Another finding from the National Inpatient Sample database from 2016 to 2018 also found a separate disparity amongst Asians and other racial and ethnic groups is that they had the highest rates of intra-amiotic infection, which many of us know as choreo, choreo-amiunitis and also pre-labor rupture of membranes. So we're here today to talk about Caesarean birth and based on this report from 2021, they found that Asians have the second highest rates of Caesarean birth in the United States. And actually I went back and surveyed several of those reports in the past five years and it continued to stay sort of in the same place Asians did have and Asian-Americans had the second highest rates of Caesarean birth for the past five years. Additionally, this report and other studies that have been done have found that Asians are actually the lowest utilizers of midwives. And as you can see from this table as well, they actually are the lowest utilizers of community birth. Here specifically is home birth, but there's actually been other studies done looking at birth center birth two and they were also low utilizers of birth center births as well. And because this conference is looking at midwives and we're here to celebrate midwives, some will provide a little bit of context of the midwifery workforce. The United States certified midwives and certified nurse midwives workforce is predominantly white. Based on the data from the American Midwifery Certification Board from 2021, it found that only 10.8% of midwives identified as a person of color and 1.7% of midwives identified as Asian. I'll now pass it on to Anna. All right, so going on to our methods for this analysis, we used data from the American Association of Birth Centers, perinatal data registry from the years 2007 to 2021. We used data specifically on Asian birthing people and did a logistic regression analysis. And then we also categorized the data into a few categories, including low risk birthing people or low risk as well as community birth eligible or people who gave birth at a hospital community. And then the last category was on people who had cesarean births. And this can either be primary or repeated cesarean births. And then the low risk group is defined as people who had a vertex singleton pregnancy that lasted longer than 36.6 weeks. And the other group that I mentioned earlier, the community birth eligible group is a subset of the low risk group. And it's defined as people who are qualified for community birth admission based on the commission for accreditation of birth center standards. And this is inclusive of people, of birthing people who chose hospitals in the absence of medical indication or in other words, elective hospitalization. And then the community birth eligible excludes any preexisting medical history, any previous pregnancy histories, prenatal complications in the current pregnancy as well as anti-natal medical referrals and admission status exclusions. And then here in showing some of the significant results that we found in the analysis, initially we found the odds of cesarean births among multi-paras birthing people were actually 1.6 times higher compared to people who had non-paras pregnancies. And then additionally, birthing people within the community birth eligible group, they actually had an adjusted odds of cesarean births that was higher than people in the low risk and total populations. And then as you can see the highlighted odds ratio here of 1.554 or 1.6 rounded among the multi-paras birthing people was higher than that of the non-paras birthing people in the total population. And then the other second significant result we found was that among adjusted cesarean odds, people in the community birth eligible group had a higher odds ratio of 1.539 compared to people who were in the total or low risk population groups. And then moving along, we also found that non-paras birthing people in the community birth eligible group had a cesarean birth that was 1.5 times higher compared to the low risk and total populations. And then among the community birth eligible groups, people who were admitted to the hospital actually had higher adjusted odds of cesarean birth compared to low risk and total population samples. And so multi-paras birthing people also had a higher adjusted odds of cesarean births compared to people who with, compared to non-paras birthing people. Then here on the tables represented, we see that the adjusted odds among the non-paras birthing people within the community birth eligible group had higher odds than people in the low risk and total populations of non-paras birthing people. And then additionally, people who were community birth eligible, you can see that. And they were, people who were in the community birth eligible group and were also admitted to the hospital had higher adjusted odds of cesarean births. And then we also found that multi-paras birthing people had a higher adjusted odds of cesarean births compared to non-paras people. You can see that here. And next I'll pass it on to Dya. Hey, so the research that we conducted is the first to examine Asian pregnancies and clinical birthing outcomes from the AABC perinatal data registry, which makes it a vital addition to the current literature on this population. Our results did indicate that we had higher odds of cesarean birth among non-paras people and the community eligible group, which are comparable to current literature that we also looked at. Furthermore, it is determined that there may be healthcare disparities due to socioeconomic status from implicit bias and discrimination within the healthcare system, trauma during the birthing process and just cultural differences among patients. So similar to our results, a secondary analysis on the perinatal data registry found that multi-paras birthing people who were eligible for community center birth, but then elected for hospitalization had a five times higher odds of cesarean birth. Then multi-paras who elected to give birth at the community center. So this really indicates that a greater risk of cesarean birth in hospitals, there is a greater risk of cesarean birth in hospital settings and it needs further exploration. Furthermore, similar to our findings, a cross analysis of all US births in 2016 found that multi-paras Asian birthing people who were in spontaneous labor or induced labor and this excluded repeat cesarean births had higher rates of cesarean birth compared to white counterparts, which again, further implies that there are differences in birthing outcomes between racial groups. When you take socioeconomic status into consideration, we looked at the listening to mothers in California survey, which determined that Asian and Pacific Islander birthing people who utilized public insurance, which is known as MediCal, were three times as more likely to report being mistreated within the hospital system. This really suggests that having an intersectional identity increases the risk of minority birth during their labor experience and can impact health outcomes as well. So we also looked at cultural differences that can determine cesarean births being higher in certain racial groups. These may be due to previous birthing experiences and this was primarily found in a study that looked at multi-paras mothers in China who were more likely to elect for cesarean birth over vaginal birth compared to their null paris counterparts. This was also found in another study where elective cesarean birth was higher due to traumatic deliveries or child loss after vaginal birth among Thai women. Apart from having a traumatic experience, there might be differences in cultural or religious beliefs that do motivate Asian people to elect for cesarean birth. So for example, it was determined that Korean and Chinese beliefs indicate that an auspicious life for the baby may be based on their date of birth, which may explain higher elective cesarean births amongst this population. So in conclusion, again, this study is the first to examine and analyze birthing outcomes amongst Asian birth givers included in the AABC perinatal data registry. It indicates that there are clear perinatal outcomes and inequities experienced by Asian birthing people and there's definitely a need for data disaggregation based on racial and ethnic groups and perinatal outcomes in the United States as well that there is a need to evaluate the low utilization of midwifery care and community births amongst the Asian population. Lastly, it is vital to acknowledge that racial and ethnic and cultural differences can lead to healthcare disparities, which must be acknowledged when midwives or other healthcare workers provide care to Asian birthing people or people of color in general. And I will pass it back to Amy. So lastly, we just like to give a few shout outs. The first one is to the American Association of Birth Centres Foundation Research Grant, which was able to fund our research. A big, big thank you and acknowledgement to Dr. Diana Jolie, who is actually on listening now. She was our mentor and had helped to really facilitate or being able to do this secondary analysis. An additional contributor contributed to the research was Debbie Soman, who is a PhD architect. She's an architect but a PhD student. But thank you very much for the presentation. I don't know if we'll have questions in the charts. Okay, Dr. Cecilia Jolie said, this finding with multi-powers is so unusual. It's not what they found in the AABC study, examining the outcomes of individuals with obesity, receiving care at these birth centers, but they didn't divide by racial groups, which is what you are looking at. You are looking at this population, Asian, Tibetan people. Thank you very much. So I have a question maybe before other people can send in any question or comments, okay. What can be done to reduce the CS rates among, so we can see that there's some disparity there. What can be done to reduce the CS rates among Asian or Tibetan people? Okay, so Dr. Cecilia is saying that the sample had too few Asians to look at them separately. I know that's quite obvious. Thank you. So what can, let's talk a little bit about that, to reduce the rates among Asian, Tibetan people. Yeah, we can go for it. Sure, Jimmy, thank you. And to respond to Dr. Jebett, I mean, I think the sample as you know, it sounds like you of course know the PDR pretty well, but the sample is also limited. So there are limitations in our study. But if you also look in terms of the sample and the group that we used, it was both primary and repeat Caesarean births. And there actually have been studies, actually the study that Dia talked about, that looked at the Robson catastrophic categories for Caesarean birth, the Valdez study had found that I think it was the Robson 2B category, which is being, I'm sorry, I forget which category it was, but it was essentially looking at the one for breach, which as we know is an indication for Caesarean often. Asians were the highest to actually elect for a breach Caesarean due to breach. In addition, I think that there's other factors that might play into it as well. So I don't know if that helps to answer or just respond to your question. And I don't know if anyone, Anna or Dia, I don't know if you wanna address Jumi's question or I'm happy to continue. Just to add on in terms of looking at how to reduce Caesarean birth amongst Asian people or even minorities in general, I think it's really important to provide adequate knowledge and resources because when you look at immigrant populations, they may not know the consequences of Caesarean birth as long-term consequences that come with having a Caesarean birth. So really as a provider, providing enough information so they can make informed decisions that would be really, really important. Having those conversations while also taking their cultural perspectives into consideration would be vital. Yeah, and just to add on real quick, I think a big barrier is probably with language, especially with Asian languages, like dialects and tones, and I think it's important to be conscientious about that as a resource or interpreters or translators because I personally, I think as I've witnessed it with my parents as well, where language is a big barrier to in healthcare. Yeah, well, thank you very much. And I think the midwife comes into play in some of these ideas we have training. The midwife has a significant role to play to help the woman to understand the system, how to better access the care. And I think, yeah, thank you so much. Dr. Javid said this belief is especially as a date of death is something she experienced in Florida with families from India and China. They practiced shot until they found a group that would shadow its caesarean on the best day. Any hints on dealing with clients holding those belief? So we have a comment from Dr. Javid in the chat specifically about families from India and China. I don't know what are your thoughts about this? I mean, I think it's going back to talking about much what Deanna and Anna talked about. And again, I know it's hard because, as I mentioned, only a little over 1% of midwives in the United States are Asian, but it's finding a cultural and linguistical concordant provider. And I know that we are really trying to do that within our midwifery workforce. But I think that if you look at the population of births like 7% versus the 1%, we're clearly not even close. But I think that would be the first step is really trying to promote students who are interested in midwifery, get the word out, and then really helping to shape those providers to be able to work with those communities, specific communities. But it is difficult. I mean, I think just people from any country who come with different beliefs. And it's also a lot about, I know for example, myself in Korea, the Caesarean rate is extremely high. So it's about Asians, but also Asian Americans, right? You have immigrant groups that come over that have who think that Caesarean birth is completely normal and there's nothing wrong with it. Or I mean, again, it's not that it's not normal, but it's just that there aren't repercussions of from Caesarean birth. So I think it's about finding a provider that the patient feels comfortable with and then ultimately giving the evidence, which I'm sure is what we all do as providers, but hopefully we can continue to work towards increasing the number of Asian midwives in this country. Just to add on, I totally agree with what Amy said, a big first step that we definitely need to make is to get more midwives who are people of color and actually increase representation. So our patients feel more included in seeing and heard. So that's like a major first step, but I did wanna add as a person of color myself and seeing my own family experiences, there is a little bit of mistrust that comes when you look at like the Western medical system or when you have a provider that might not look like yourself. So there's definitely, like even if you don't have providers who are like you, it's really important to increase collaboration with maybe leaders of that community who have an understanding of Western medicine, but can also speak to patients on that religious or cultural aspect and have a really happy medium where you're combining best of both worlds through a collaborative practice with cultural leaders as well as midwives or physicians to provide that care and informed evidence to those patients, so yeah. Anna, do you have any thoughts to share before we close? So yeah, Dr. Jibbit, I agree with you. Okay, go on please. No, I was just gonna say, I think Amy and Dia really said that really well, especially the collaboration part. Yeah, because I think like we can't do it alone having multiple people from multiple disciplinaries coming together like working as a team, I think will be the best kind of like method going forward with in terms of including the best practice we can for patients or people and being inclusive of their culture and like their perspective as well. So Nidhi, thank you very much ladies. Thank you everyone. Yeah, Dr. Jibbit said, I agree that all of North America has a huge need to educate more midwives from Asia with even that cultural background. All those different cultural groups need to be represented and just increase the diversity, making it more easy, comfortable for women to relate and just identify with their providers. Thank you very much.