Instructions provided in the screen shots. And labeled in what order to read the instructions. and link to articles will be sent
Annotated BibliographyResearch Methods
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=hhth20
Health Communication
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hhth20
African American Women’s Maternal Healthcare
Experiences: A Critical Race Theory Perspective
Comfort Tosin Adebayo , Erin Sahlstein Parcell , Lucy Mkandawire-Valhmu &
Oluwatoyin Olukotun
To cite this article: Comfort Tosin Adebayo , Erin Sahlstein Parcell , Lucy Mkandawire-Valhmu
& Oluwatoyin Olukotun (2021): African American Women’s Maternal Healthcare Experiences: A
Critical Race Theory Perspective, Health Communication, DOI: 10.1080/10410236.2021.1888453
To link to this article: https://doi.org/10.1080/10410236.2021.1888453
Published online: 18 Feb 2021.
Submit your article to this journal
Article views: 1642
View related articles
View Crossmark data
https://www.tandfonline.com/action/journalInformation?journalCode=hhth20
https://www.tandfonline.com/loi/hhth20
https://www.tandfonline.com/action/showCitFormats?doi=10.1080/10410236.2021.1888453
https://doi.org/10.1080/10410236.2021.1888453
https://www.tandfonline.com/action/authorSubmission?journalCode=hhth20&show=instructions
https://www.tandfonline.com/action/authorSubmission?journalCode=hhth20&show=instructions
https://www.tandfonline.com/doi/mlt/10.1080/10410236.2021.1888453
https://www.tandfonline.com/doi/mlt/10.1080/10410236.2021.1888453
http://crossmark.crossref.org/dialog/?doi=10.1080/10410236.2021.1888453&domain=pdf&date_stamp=2021-02-18
http://crossmark.crossref.org/dialog/?doi=10.1080/10410236.2021.1888453&domain=pdf&date_stamp=2021-02-18
African American Women’s Maternal Healthcare Experiences: A Critical Race Theory
Perspective
Comfort Tosin Adebayo a, Erin Sahlstein Parcell b, Lucy Mkandawire-Valhmuc, and Oluwatoyin Olukotund
aDepartment of Communication Studies, Towson University; bDepartment of Communication, University of Wisconsin-Milwaukee; cCollege of Nursing,
University of Wisconsin-Milwaukee; dSchool of Nursing, University of Portland
ABSTRACT
Black women are experiencing pregnancy-related complications at a significantly higher rate than women
of other races in the U.S., as Black women are three to four times likely to die from pregnancy-related
complications compared to non-Hispanic White women. Structural barriers and different forms of margin-
alization continue to limit Black women’s access to quality healthcare services. Through critical race
theory, we examine what structural barriers exist in the U.S. healthcare system, one that limits access to
quality care during their prenatal and postnatal doctor’s visits. Using qualitative in-depth interviews, 31
African American women, living in Milwaukee, WI, shared their pregnancy stories. The emergent themes
include, institutionalized care – racially insensitive biomedical approach, race and class – unfair treatment
based on health insurance, and race as a social concept – dismissed pain concerns because you are
a strong Black woman. These themes reveal the experience of racial discrimination toward African
American women through healthcare [communicative] practices that are often times seen as “standard”
practices, albeit marginalizing minority populations.
from this study offer insights for healthcare
providers on communicative practices that foster a racially-safe healthcare environment for African
American women.
Racial disparities in healthcare delivery is well established in
the literature [Centers for Disease Control and Prevention
(CDC), 2019; Creanga et al. (2015); Mkandawire-Valhmu
(2018)]. Numerous studies report that African Americans
receive low-quality care and differential treatment when acces-
sing healthcare services, as a result of their racial identity1
(Cuevas et al., 2016; Dovidio & Fiske, 2012; Keith et al., 2010;
Krieger et al., 2011). Disparities exist for African Americans
and other minority populations, for example, in limited infor-
mation disclosure by healthcare providers (Ryn & Burje, 2002),
verbal dominance by healthcare providers (Ha & Longnecker,
2010), dismissive attitude of healthcare providers toward
patients’ concerns (National Public Radio, 2017), and ulti-
mately, provision of low-quality care (Ward et al., 2013).
Racism and racial discrimination are factors that have been
linked to the delivery and experience of race-based care2 in the
U.S. healthcare system. From the historical events of slavery to
the Tuskegee Syphilis study of 1932 (Scharff et al., 2010) and
the ongoing socio-political discourses that reinforce racial dis-
crimination in the U.S. (Williams & Wyatt, 2015), African
Americans continue to report racial disparities that impact
their health.
Maternal health disparities are a major health concern for
African American women. According to the Centers for
Disease Control and Prevention (CDC) (2019), the maternal
healthcare crisis among African American women is evidence
of health disparities in U.S. society. African American women,
as well as American Indian and Alaska native women, are two
to three times more likely to die from pregnancy-related com-
plications when compared to White women. Sadly, for Black
women, this disparity exists regardless of socio-economic sta-
tus or determinants of health as “[t]he PRMR (the pregnancy-
related mortality ratio) for Black women with at least a college
degree was 5.2 times that of their white counterparts” (Centers
for Disease Control and Prevention (CDC), 2019, para. 6). This
provides strong evidence that the issue of health inequities for
African American women is not solely of a function of social
factors such as socioeconomic status, but rather, it is a complex
problem reflective of structural factors that negatively and
disproportionately impact African American women (Gee &
Ford, 2011; Homan, 2019).
Given the complex nature of maternal health inequities in
African American women, critical theoretical perspectives,
such as the critical race theory, offer an appropriate analytical
lens to deconstruct the unique experiences of African
American women within the U.S. context. Employing
a critical race theory perspective (Delgado et al., 2017) to the
study of African American women’s health is valuable in
exploring and critiquing hegemonic ideologies and structures
that impact the realities and health outcomes of African
Americans. In this study, we sought to unravel how African-
American women make sense of the influence of their racial
identity during maternal healthcare encounters. Specifically,
through their stories, we explored and critiqued manifestations
of racial discrimination in communicative acts of healthcare
providers when providing medical services, with the goal of
CONTACT Comfort Tosin Adebayo cadebayo@towson.edu Department of Communication Studies, Media Center, Towson University, Rm 203, 8000 York Road,
Towson, Maryland 21252, USA
HEALTH COMMUNICATION
https://doi.org/10.1080/10410236.2021.1888453
© 2021 Taylor & Francis Group, LLC
http://orcid.org/0000-0002-1288-2296
http://orcid.org/0000-0001-6922-8108
http://www.tandfonline.com
https://crossmark.crossref.org/dialog/?doi=10.1080/10410236.2021.1888453&domain=pdf&date_stamp=2021-02-17
understanding their participation in the maternal healthcare
crisis in the United States. Further, a secondary objective was to
illuminate how healthcare providers perpetuate institutiona-
lized and structural practices that advance racial discrimina-
tion in the U.S. healthcare system. In the following sections, we
conduct a review of previous studies that have revealed the
myriad problems African American women experience in
accessing the U.S. healthcare system, followed by
a description of our study and findings.
The problem–health disparities, race, and gender
Health disparities have garnered increased attention in the
United States over the past twenty years. However, despite
a significant comprehensive report on health inequities by the
Institute of Medicine and the scholarly discussion that ensued,
ethnic minority communities continue to experience a high
burden of poor health outcomes across a number of health
indicators (Baciu et al., 2017; Institute of Medicine, 2003;
Noonan et al., 2016). For instance, African Americans continue
to be disproportionately impacted by adverse maternal child
health outcomes (Howland et al., 2019; Singh & Stella, 2019).
Compared to White women, African American women are
twice as likely to have a child with low birth weight and one-
and-a-half times more likely to have a preterm birth (Martin
et al., 2017). Similar patterns of disparities in African American
women are seen across other reproductive health indicators
including perinatal loss mortality (Koch & Geller, 2019), and
maternal (Petersen et al., 2019) and infant mortality (Kitsantas
& Gaffney, 2010).
While ongoing efforts are made to comprehensively
delineate the causes of persistent health disparities, growing
evidence points to the effects of a myriad of complex,
multilevel factors rooted in institutionalized discrimination
based on race and gender (Gee & Ford, 2011; Gollust et al.,
2018; Shavers & Shavers, 2006). Their systematic margin-
alization, operationalized through policies, societal prac-
tices, and differential access to resources and power, has
been cited as the distal cause of adverse health outcomes
for African American women (Gee & Ford, 2011; Homan,
2019). Notably, for African American women, the margin-
alization they experience as a result of their racial and
gender identities cannot be analyzed independently of
each other. Strong evidence indicate that the combination
of both racial and gender discrimination that African
American women experience adversely impacts health
through physiological and psychological stress pathways
(Perry et al., 2013). Beyond the differential access to
resources that results from institutionalized discrimination,
understanding the experiences of marginalized communities
during healthcare encounters are a critical component of
unearthing how disparities in health outcomes are pro-
duced within the healthcare infrastructure (Penner et al.,
2014), particularly for African American women who bear
a disproportionate burden of adverse birth outcomes.
Provider-patient communication and the experience of
racial discrimination
Communication occupies a central role in healthcare encounters
(Adebayo et al., 2020). The sensemaking process of healthcare
services is mostly interpreted from the perspective of commu-
nication. In reporting their experiences of racial discrimination
when accessing healthcare services or low-quality care, patients
(regardless of racial identity) have identified communication
factors as key variables when examining experiences of racial
discrimination during healthcare encounters (Cuevas et al.,
2016; Ha & Longnecker, 2010; Raine et al., 2010). For instance,
African Americans have reported poor communication and lack
of expressed respect by healthcare workers (Cuevas et al., 2016).
These findings are similar to many others that have examined
the healthcare barriers of African Americans (Ha & Longnecker,
2010; Mazul et al., 2017).
As evidenced in previous studies (e.g., Cuevas et al., 2016;
Raine et al., 2010), patients also often assess the quality of care
received through the lens of communication; how the provider
related to them, the clarity of the message, the depth of the
message, the content of the message, and the display of inter-
personal connection with the patient. Specifically, the quality of
interpersonal communication between physicians and patients
impacts health outcomes by influencing patient satisfaction,
physician-patient trust, and rapport, willingness to disclose
important health information (Arnold & Boggs, 2019).
Communication functions as a significant tool in shaping the
quality of healthcare services in any context (Abioye Kuteyi et al.,
2010; Ha & Longnecker, 2010). Quality communication, or its
lack thereof, influences patients’ perceptions of the healthcare
system and the services delivered during patient visits. More
specifically, implicit and explicit racial biases thrive through
verbal and non-verbal communication. Studies show that
“Black patients feel less respected by the physician, like the
physician less, and have less confidence in the physician regard-
ing their medical encounters when the physician exhibits greater
implicit racial bias” (Dovidio & Fiske, 2012, p. 948). Moreover,
in the context of maternal healthcare visits, African American
women have reported poor communication along the lines of
rushed interactions, ambiguous word choices, and lack of affec-
tion or empathy (Raine et al., 2010). Evidently, healthcare experi-
ences are communicatively interpreted; hence, analyzing
women’s maternal healthcare experiences as a communication
phenomenon provides an important perspective.
Maternal mortality among African American women
Despite efforts made to unravel and ameliorate racial dispari-
ties in maternal mortality in the U.S., the persistent inequities
in outcomes for African American women remains alarming.
Specifically, non-Hispanic African American women have
higher rates of maternal mortality compared to other ethnic
and racial groups with a two to three-fold increased odds of
dying from pregnancy-related complications when compared
to non-Hispanic White women (Centers for Disease Control
and Prevention (CDC), 2019). One study found that being
2 C. T. ADEBAYO ET AL.
a Black woman with a chronic illness was associated with a two
to three-fold increased odd of maternal mortality in compar-
ison to White women with the same chronic condition (Tucker
et al., 2007).
Arguably, while some evidence exists for the clinical and
pathological causes of maternal mortality in the U.S. (Centers
for Disease Control and Prevention (CDC), 2019; Creanga
et al., 2014), the prevalence of this health problem among
African American women remains a puzzle. Previous studies
have documented the existence of racial and health disparities
in the quality of care received by African Americans when
accessing healthcare services (Krieger et al., 2011).
Consequently, to analyze the U.S. maternal health crisis from
a biomedical perspective with inattention to race and racial
discrimination, as often times reported by the CDC, presents
an incomplete argument. The role of race as an integral factor
in maternal health inequities is evident in extant literature
(Mazul et al., 2017). Race, as a factor in healthcare experiences,
is further illustrated by the reported experiences of prominent
African American women like Shalon Irvings, an
Epidemiologist at the Centers for Disease Control and
Prevention, who passed away weeks after delivery in 2017
(National Public Radio, 2017). Irving’s case was not one linked
to poverty or low education, she had two doctoral degrees;
rather it was linked to racial disparities in quality of healthcare
she received as reports indicate that her health symptoms were
repeatedly dismissed days before her demise (National Public
Radio, 2017).
Similar to Dr. Irvings experience, the African American
maternal health literature is replete with reports of health
symptoms being trivialized or dismissed. Stemming from his-
torical events of slavery, African American women are often
perceived to be “strong” and able to go through hardships and
withstand pain beyond what is considered “normal” (Davis,
2015; Watson-Singleton, 2017). This racial discourse of (per-
ceived) strength negatively impacts African American women
within the healthcare context. The perception of being strong
has been reported to “force” African American women to
internalize their pains and hardships, and healthcare providers
often reinforce this discourse (Collins, 2000; Watson-
Singleton, 2017). The foregoing review provides an overview
of the African American women’s interactions with the health-
care systems. However, beyond the problematic communica-
tion encounters there are structural barriers, otherwise labeled
“standard practices,” that propagate health inequities for
African American women, which is the focus of our study.
Structural barriers in African American women’s maternal
healthcare experiences
In this study, we focus on two main structural barriers con-
fronting African American women during prenatal and post-
natal care: the institutionalized biomedical approach to
maternal care and the structural barrier of public health insur-
ance. The biomedical approach to maternal healthcare is
notorious for its overt focus on Western medicine and proce-
dures in attending to women’s reproductive healthcare needs.
Traditionally, the biomedical approach has been criticized for
disempowering women, since women are the primary
consumers of healthcare services in the United States and
even other parts of the world (Willard, 2005). Particularly
concerning women’s reproductive health, the medical profes-
sion has been critiqued for the medicalization of women’s
experiences, including pregnancy. In this way, the woman’s
body is treated as a machine programmed to perform certain
operations that can be managed when “faulty” to ensure its
appropriate functioning (Andipatin et al., 2019). The domi-
nance of the biomedical approach in healthcare has been found
to result in “the medicalization of normal life events (e.g.,
giving birth, menopause) and an over-reliance on technologi-
cal solutions” (Willard, 2005, p. 135). Consequently, within the
U.S. healthcare system, pregnancy is primarily considered
a medical condition, which needs medical intervention for its
management and treatment.
Given the lived realities of African American women in
U.S. society, the biomedical approach to maternal care further
situates African American women as objects in a system that
denigrates their racial identity and realities. It is important for
healthcare providers to become aware of the reality that “preg-
nancy and its associated biological processes are complex and
expressed in an assortment of ways, they are lived out in
equally complicated sets of social and power relations”
(Andipatin et al., 2019, p. e553). African American women
have unique social and cultural milieu that position them on
the margins of the society. Thus, it is important to understand
how the biomedical approach works to usurp power and
agency from these women based on institutional healthcare
practices that likely do not put racial realities into perspective.
Another notable structural barrier in African American
women’s healthcare access is the type of insurance they carry.
In the United States, an individual’s socio-economic status can
be accurately assessed based on the type of health insurance
(that is, public versus private/employer-sponsored). Public
(also known as state insurance or Medicaid) health insurance
is provided to low-income individuals. For African American
women, using the public insurance is often stigmatized (Allen
et al., 2014; Taylor, 2019); it does not only label them as low-
income, it goes further to limit the access they can have to
healthcare. Studies have shown that one of the challenges that
confront African Americans on public insurance is finding
doctors who accept such insurance plans (Mazul et al., 2017).
For those who are lucky enough to find doctors, they are
treated with suboptimal care while also discriminated against
based on their health insurance (Weech-Maldonado et al.,
2012), including limited breastfeeding support (Thorburn &
De Marco, 2010). These barriers, as they intersect with race and
class, continue to limit African American women’s access to
quality care during this vulnerable time of their lives. Critically
exploring these barriers and their manifestations from a critical
race theoretical perspective provides a holistic understanding
of health inequities common to these women, if we are to
effectively address the U.S. maternal health crisis.
Theoretical framework: Critical race theory
Critical race theory (CRT) is an interdisciplinary theory that
provides a framework for studying the experiences of racially
marginalized populations in the U.S. society. It was developed
HEALTH COMMUNICATION 3
by the collective work of scholars like Derrick Bell, Alan
Freeman, and Richard Delgado (Delgado & Stefancic, 2012).
Though developed by U.S. scholars, the application of the
theory has extended to other parts of the world
(Warmington, 2012). Three basic tenets guide the understand-
ing and application of CRT as discussed by Delgado et al.
(2017). First, CRT functions to critique the idea that racism is
ordinary, that is, normal. This notion of the ordinariness and
normality of racism in the society advances the “color-blind, or
‘formal’, conceptions of equality, expressed in rules that insist
only on treatment that is the same across the board, can thus
remedy the most extreme forms of discrimination” (Delgado et
al., 2017, p. 8). This way, people of color are indiscriminately
ignored or unaccounted for in social policies, “because an
individual (white) person ‘does not see race’ and therefore ‘is
not racist” (Wesp et al., 2018, p. 321). Not only are people of
color ignored in social policies that underserve them, they are
also discriminated against given the hallmark of what is “good”
only resides in whiteness. Second, CRT critiques “interest
convergence” and material accumulation of wealth as a core
manifestation of racism, one that predominantly serves whites
in the U.S. society (Delgado et al., 2017, p. 8). In this regard, as
whiteness is positioned as a property of interest (Ladson-
Billings & Tate, 2006, p. 2006), CRT challenges the hegemonic
functioning of social institutions that advance the interests of
Whites, materially and otherwise. Third, CRT upholds the fact
that race is socially constructed. In other words, ethnic minor-
ity populations are only relevant to the extent to which the
society “endows them with pseudo-permanent characteristics,”
subjecting them to social and power hierarchies (Delgado et al.,
2017, p. 9) where they are relegated to the lowest rungs.
CRT, in its usage, attends to issues of racism, which are
believed to be ingrained in social institutions in the U.S.,
especially in the education sector (Ladson-Billings & Tate,
2006). In its scope, CRT identifies issues of racial injustices
among ethnic minorities as well as unveils the impact of social,
political, and philosophical structures in advancing different
forms of marginalization and injustices toward members of
minority racial groups (Hylton, 2012). Consequently, CRT
allows for a holistic view of racial discrimination as it manifests
systemically, leading to inequities in various sectors of society,
including healthcare.
Within the context of healthcare scholarship, CRT “guides
us in acknowledging the reality of inequality among these
racialized groups and the racist ideology that informs health-
care interactions in our society” (Mkandawire-Valhmu, 2018,
p. 50). It affords healthcare scholars a unique perspective for
understanding the causes of racism in the healthcare system
(Ford & Airhihenbuwa, 2010), as rooted in “standard practices
and structures.” CRT highlights systemic structures that
underserve racial minorities, which in turn advance racism.
Within health communication scholarship, CRT has been used
to study the healthcare experiences of racial minorities like
Hispanics, and African Americans (Vardeman-Winter, 2017).
For instance, in the application of CRT to African American
and Black Hispanics’ healthcare experiences, Freeman et al.
(2017) found that structural racism persists with institutiona-
lized healthcare practices that might not represent the interest
of minority groups. This includes lack of personalized care, as
they reported being treated based on papers and numbers. One
serious implication of these practices that perpetuate racist
ideologies is a deeply-rooted, distrust of healthcare providers
and healthcare practices. While studies like theirs have
employed CRT to unveil how structural racism shape the
experiences of ethnic minority groups within the healthcare
system, there is a dearth of literature that utilizes a similar
approach to analyze structural racism within the maternal
healthcare context.
In this study, CRT provides a lens to critically analyze
the interconnectedness of racial injustice and the maternal
care experiences of African American women. Focusing on
the experiences of African American women will center
their voices while simultaneously recording how race and
systemic racism construct their healthcare realities for
Black women. We used the following question to guide
our work:
RQ: How does racial discrimination manifest in the mater-
nal healthcare narratives of African American women?
Upon the approval of the study by the University of
Wisconsin-Milwaukee IRB (UWM IRB # 19.A.238), the first
author recruited women to participate in qualitative inter-
views through purposive and snowball sampling. Lindlof and
Taylor (2019) argue that qualitative interviews are valuable in
contexts where participants lived experience and worldview
are central to the research questions. Purposive sampling
involves the recruitment of research participants by directly
asking members of groups or populations who fit the research
criteria to participate in the study, while snowball sampling
takes place when individuals are recruited through those who
have participated in a study (Lindlof & Taylor, 2019; Tracy,
2012). In other words, it involves recruitment through refer-
rals – asking research participants to encourage other indivi-
duals (e.g., friends, family members, etc.) who qualify for the
study to participate (Lindlorf & Taylor, 2019).
Announcements were made on Facebook groups and pages
dedicated to moms (e.g., Milwaukee Moms, KidsCycle: NS
Milwaukee area, and African American Breastfeeding net-
work Milwaukee), and the one she created (Black Moms
Maternal Health) for African American women living in the
Milwaukee area.
Study site
Data collection for this study took place in Milwaukee county,
Wisconsin, for close to a year, between March 2019 and
February 2020. Milwaukee presently ranks as the most racially
segregated metropolitan city in the U.S. (Frey, 2018).
Milwaukee also has some of the highest rates of Black infant
mortality (City of Milwaukee Health Department, 2018; Ward
et al., 2013). According to the Wisconsin Department of Health
Services (2019), for the most recent statistics on maternal
health outcomes, maternal mortality rates were five times
higher among African American women compared to non-
Hispanic White women in the city of Milwaukee.
4 C. T. ADEBAYO ET AL.
Participants
Thirty-one African American women participated in this
study, which includes four women who participated in the
pilot study3 for this present research. Participants were
African American women who were currently living in
Milwaukee County and had maternal care experiences with
healthcare providers in the city or surrounding area.
Participants ranged from 20–44 years old and were either
pregnant (n = 6) or had been pregnant within the
previous year (n = 21). Participants also included women
who were part of the pilot study and had been pregnant within
the last ten years (n = 4). The majority of the women were
either pregnant with their first child or had only one child
(n = 16). Ten of the women reported having employer-
sponsored insurance, eighteen reported having state insurance,
one reported not having insurance, while the remaining three
participants did not report their health insurance status. In
reporting their marital relationship status, eight women
reported being married while twenty-three reported being sin-
gle or engaged. For participants who reported their annual
income, ten did not report their income or were currently
unemployed, thirteen had a household income of less than
35,000 USD per year, five reported an income between 36,000
USD and 70,000 USD per year, while three reported an annual
household income between 71,000 USD and 120,000. USD
Semi-structured in-depth interviews
Participants who met the eligibility criteria were interviewed by
the first author, either face-to-face (n= 6) or over the phone
(n= 25). Before the commencement of each interview, the
interviewer read the consent form to the participants, and
consent was established through verbal affirmation for both
face-to-face and virtual participants. Each interview was audio-
recorded and lasted between 50 to 75 minutes.
Participants were asked to narrate their most recent preg-
nancy stories starting from the day they learned of their preg-
nancy until delivery or present (for those who are still currently
pregnant; narrative interview format). Follow-up questions to
clarify meanings and solicit other relevant information based
on their stories and the focus of the study (respondent inter-
view format) were asked. This included descriptive, experience,
typology, and example questions (Spradley, 1979; Tracy, 2012).
In the latter part of the interview, participants answered ques-
tions that solicited information about their perception of the
maternal crisis among African American women. These
include questions on their racial and pregnancy identities.
Upon the completion of the interview, each participant
received a 20 USD Walmart or Amazon gift card.
Reflexivity and positionality
As critical scholars, reflexivity and positionality are key to the
unbiased interpretation of our data, especially when relating
with members of marginalized groups (D’Silva et al.’s, 2016).
Reflexivity focuses on how methodological choices impact the
interpretation of the data (Corlett & Mavin, 2018). Knowing
that truth is socially constructed, it is imperative for researchers
to critically examine how our presence in this research process
impacts the process and ultimately the outcome (Dutta, 2010).
Our culturally diverse team is composed of Black (three) and
White (one) women, from interdisciplinary fields of commu-
nication and nursing. We deliberately prioritized the contribu-
tion of our minority yet diverse voices to the ongoing discourse
of maternal health crisis among African Americans. Our cul-
tural and disciplinary diversity allowed for rigorous and critical
analysis of our data-giving room for careful interpretation and
report of our findings.
Through a pilot study, the first three authors rigorously
assessed the research questions and the interpretation of the
data refining it to remove possible biases in how participants
respond to questions and how we ultimately analyzed the data.
Regarding our positionality, we understand that our lived and
ongoing experiences (via our social locations of race, class,
education, and gender) are capable of influencing our inter-
pretation of the data. As such we deliberately chose to analyze
the data from a theoretical perspective without losing the
diversity that our interdisciplinary and multicultural back-
grounds contribute to the research.
Data analysis
The first three authors conducted the analysis of the data. The
first author took the lead in this process. Data analysis com-
menced during data collection as the first author engaged in an
iterative process of interviewing and reflection. Reflecting on
interviews and reading notes during the process of data collec-
tion are useful practices in making sense of the data at the
preliminary level (Saunders et al., 2018). Following the tran-
scription of the interviews by a third-party service (Temi™
software) and a research assistant, the first author assessed
the 554 pages of transcripts for accuracy. This process included
removing any identifying information from the data while
assigning pseudonyms to participants to further protect their
confidentiality.
In the first stage of coding, we engaged in value coding,
a type of descriptive coding that copiously accounts for parti-
cipants’ “values, attitudes, and beliefs” as it reflects their per-
spective to social issues (Miles et al., 2013, p. 75). This type of
coding is useful for understanding and reporting issues of
identity as it relates to social realities and issues. Since the
study focuses on how the racial identity of Black women inter-
fere with their healthcare experiences and outcomes, employ-
ing this kind of coding was valuable in unveiling the role race
plays in this context. After identifying initial codes (e.g., bio-
medical approach to maternal care, women as machines), we
merged similar codes by categorizing them into themes as they
reflected the tenets of critical race theory issues of racial dis-
crimination propagated by social structures in the U.S. society.
The third author, given expertise in CRT carefully revised the
themes to assess their representation and explanation of CRT.
These include analyzing systemic issues, present in women’s
narratives, and their impact on healthcare encounters. At the
end of this stage, we merged themes that were similar in the
information they provided. In the end, the first author closely
read through the findings again to identify and clarify any form
of ambiguity.
HEALTH COMMUNICATION 5
Findings
In applying critical race theory to African American women’s
maternal healthcare narratives, we highlight dimensions of
racial discrimination present in women’s experiences during
medical interactions and the healthcare practice for maternal
care. One of the central arguments of CRT scholars is that
racial issues and racism are so ingrained in our system and
structures that we fail to perceive them as such-they have
become “normal life” (Delgado & Stefancic, 2012; Ford &
Airhihenbuwa, 2010). As a result of this, the current study
employs CRT to uncover dimensions of racial discrimination
and racism that are present in maternal healthcare “standard
practices,” while demystifying the ideology of color-blind
healthcare system – “the notion of a racially neutral and demo-
cratic social order that works for all people” (López, 2003,
p. 83). Using the three tenets of CRT as guiding lens, three
themes emerged from the analysis: Institutionalized care –
Racially insensitive biomedical approach, Race and class –
Unfair treatment based on health insurance, and Race as
a social concept – Dismissed pain concerns because you are
a strong Black woman. A fourth theme emerged from the
analysis outside of the of CRT’s basic tenets, Distrust –
African American women as charity case.
Institutionalized care – racially insensitive biomedical
approach
One of the basic tenets of CRT is the notion that racism is so
deeply embedded in the fabric of U.S. social and political
institutions that its presence has been normalized and accepted
as “standard practice”. However, women in this study chal-
lenged these standard practices revealing their shortcomings in
advancing a racially insensitive maternal healthcare. Centrally
woven throughout the narratives of women in this study is the
experience of a racially insensitive healthcare system – the
supposed color-blind healthcare. In this context, the institutio-
nalized biomedical approach was criticized for its dominance
in maternal healthcare practice. African American women
challenged this approach as racially denigrating as it has been
structurally positioned as “the” way to provide maternal care
while ignoring other health approaches to providing maternal
care, especially the cultural dimension of health. The narratives
of the women in this study pointed out the lack of considera-
tion for women’s preferences during pregnancy, speaking to
how healthcare providers treated them based on what “text-
books” say, while taking away their racial and cultural presence
in maternal care. They criticized it for its White-centric
method in attending to women’s needs; as the healthcare
practices are mostly viewed from the hegemonic standpoint
of White women, whose experiences mostly form the basis for
healthcare practices during maternal care. When we asked
Beth, a 21-year old mother, to narrate her maternal care
story, she said:
So, from the first time that I found out I was pregnant, I knew right
away that I wanted to have my child at home or at a birthing center.
I know that I wanted it to be as natural as possible and I knew that
I did not really want to go the regular route of going to like the
doctor checkups and stuff . . . .“I want to have this baby at home,
I want to do a natural, I don’t plan a birth in the hospital” . . . .So,
I talked to my doctor about it and he became inconsistent. He said
that I’m high risk and blah blah. And I feel like he started to say that
because I told him about me wanting to birth at home. I feel like as
soon as I told him about that, everything just changed. So, then
they started telling me that I would have to come in every two
weeks and monitor my baby’s growth because I had IUGR, which is
injuring growth restriction. So, they claimed, they told me I was
really high risk. . . . I had told the doctor like, “Well, I’m still gonna
have my baby at home.” And the doctor walked out on me He
never came back in the room . . . I’m like, “Y’all are treating me
wrong. You’re not listening to me. You’re not respecting me. This
is my body, my baby.”
Beth’s narrative shows a rigid biomedical approach to maternal
care, one that subtly rejects other maternal care methods such
as midwifery and home birthing – practices that are historically
and traditionally upheld in the African American community
(Dawley, 2003). Given this dominant biomedical maternal
healthcare practice, African American women are indiscrimi-
nately treated based on a hegemonic model of care, one that
inherently does not account for their unique realities, as with
other social institutions.
The biomedical approach was not only criticized for its
White-centric approach to maternal care, but also for its struc-
tured, one-size fits all approach for Black women. In this
manner, Black women are treated as a monolith based on
“what is generally known about Black health,” rather than
being treated as individuals, further reinforcing the ideology
that they are mere statistics. Rachel, a 23-year-old first-time
mother, shared:
I was diagnosed with gestational diabetes . . . they also diagnosed
me to take baby aspirin. Like no reason. They said that as Black
people, it’s more common to have that preeclampsia . . . I honestly
don’t see why I need to take this. Like I don’t have a history of it.
This is my first pregnancy. So, I’m like, “I’m not taking the baby
aspirin,” but me being me, when they asked me like, “Oh, are you
taking your medicine?” “Yes,” because I don’t want to say no, and
they’d try to diagnose me with something, like, “Well she’s not
taking her medicine, so she probably has this thing.”
Rachel considered this medical push as a hegemonic and
homogenous view about Black women’s health, such that
they are often perceived as having poor health, just as they
are perceived in other contexts (Freeman et al., 2017). She
explained that healthcare providers usually lump African
American women together, without paying attention to
each individual. She said, “Like I don’t have a history of it.
You can’t like, um, basically stereotype me because I’m
African American.” This way, they believe an instance of
illness or behavior in one African American is present with
others. This institutionalized practice further led to the silen-
cing of these women, which is a long-term effect of racism in
our society. Telither, in a similar experience, also encoun-
tered the imposition of medicalized birth by her healthcare
providers. She recalled the reaction of her nurses in the
delivery room when she told them she wanted a natural
birth:
I think the staff pushed more for different directions for my
choices. So, like if I said I want to do a natural birth, they were
like, “Why? Why would you want to go natural? We got drug for
that and you won’t do this” . . . I think they have the assumption
that we don’t know what our bodies are capable of.
6 C. T. ADEBAYO ET AL.
Telither considered her experience as one that invalidates her
ability to make an informed decision about her maternal care.
She attributed this experience to both her racial and gender
identities.
Race and class – unfair treatment based on health
insurance
The interest convergence tenet of CRT was foregrounded as
women reported the influence of their racial identity, as it
intersects with their socioeconomic status, in the quality of
care they received. Unique, a 24-year old pregnant woman, in
her narrative, said African American women begin to experi-
ence differential treatment not only in the quality of care given
to them but even based on the type of insurance they have:
Like when you’re asked what type of insurance you have and you
feel like, “Oh, I have government insurance” and they like look at
you differently or they treat you differently, different from if you
had like private insurance or insurance through an employer or
something like that.”
The fact that Medicaid is only accessible to low-income indi-
viduals, and in Wisconsin a majority of these recipients are
African Americans (Kaiser Family Foundation, 2019), put
these women in a situation where they are constantly disen-
franchised because of the intersections of race and class. While
Medicaid offers benefits for low income individuals, for
African American women, it can function as a reminder of
their disenfranchisement and institutionalized practices that
foster racism. Rachel further evidenced this insurance-based
discrimination in her narrative:
So I feel like, yeah, I feel like this thing [race and class] is definitely
real, they definitely judge you on that. They look at you and it’s like,
“Oh well we’re not going to do much with them. We just gonna
patch them up, get them okay, and throw them out of the door.” . . .
I feel like that’s how they treat African-Americans. You don’t have
the best insurance. A lot of us, don’t get me wrong, we’re in all
different ranks of course, but like I’m in lower class so I can’t afford
to, insurance puts us in different places.
Rachel’s narrative shows both an expression of lament and
distrust in the healthcare system that allows a supposed help
for minority through the prism of Medicaid. The issue even
becomes more complicated because of the racial climate of the
city, where there is evident racial segregation. Shirval articu-
lates how Milwaukee as a city naturally positions African
American women as low class, public insurance patients,
resulting in low quality of care:
Ultimately [the way you are treated] I would say it depends on the
type of insurance you have. And then we are talking about African
American women a lot. And especially here is Milwaukee, if you’re
talking about this region, I feel like there is a lot of African
American women or Black women that’s in poverty and might
need assistance, whether that’s needed, state insurance or whatever
that looks like. And I feel like they are treated differently than
someone with employers insurance . . . they [healthcare providers]
can see or read into my history and find out if you have some form
of education, you know, I feel like that, that, that sometimes they
could make that separation . . . Not to say that I couldn’t be treated
poorly just by looking at me and not knowing anything about me,
but ultimately these people (healthcare provider)], I feel like, it
definitely has a lot to do with, your insurance and what’s the first
thing they see from your records-your socioeconomic status, all of
that.
Without mincing words, Shirval’s narrative unveiled the work-
ings of race and class in the type of treatment African
American get when accessing maternal care. While this is not
new (Allen et al., 2014; Taylor, 2019), women’s narratives, here,
show how covert racial discrimination in the healthcare system
leads to mistrust, and poor treatment, which are factors con-
sistently cited in women’s maternal crisis narratives (National
Public Radio, 2017). Kevris furthered this argument in her
narrative by saying:
I feel like it’s because of our race and the things that we’ve gone
through. In America, there’s always been a difference in, you know,
race, in the color of your skin. You know, it’s always been that way.
Like if you’re white, you have more of a privilege and you are given
more opportunities, you know, but if you’re Black and if your skin
color is Black, no matter if you’re, you know, Black from Africa,
like, have African roots, I feel like you’re still seen as lesser.
Clearly, discourse of systemic racism and the historical events
of slavery and colonization were evident in Shirval’s narrative,
as she attributed African American women’s experiences to
what is considered “normal” in America – the ordinariness of
racism (Delgado & Stefancic, 2012). Consequently, African
American women’s experiences of discrimination in medical
encounters are a reflection of the U.S.’s institutional practices
that underserve racial minorities.
Race as a social concept – dismissed pain concerns
because you are a strong Black woman
Being a Black woman did not only mean differential treatment
for African Americans. For the women interviewed, it also
meant that they had to endure pain beyond what they consid-
ered normal because they were “strong Black women.” Delgado
and Stefancic (2012) explained this ideology as the social con-
struction of race, where African American women are not only
treated based on science but also on how they have been
historically constructed as strong. While this discourse of
strength is traceable to the history of slavery, it has become
a welcomed racial identity marker, even for African American
women themselves. Yet, within the context of healthcare, this
discourse leads to women’s disadvantage (Abrams et al., 2014).
In the current study, this stereotype resulted in the undermin-
ing or dismissing African American women’s concerns, espe-
cially in relation to pain. Sadiat, a 23-year-old first-time
mother, narrated her experience as follows:
At about one in the morning . . . I was just like, I like, this is not
feeling right. I am not comfortable. . . . We went to the ER and
I don’t know if it was because it was late that they just like were not
taking their job seriously, but like the tone of voice, like I said, super
nonchalant . . . disregarding my pain, and I remember one nurse is
just like, “Well yeah, you’re pregnant.” . . . as a doctor, if I’m
explaining my pain to you and the symptoms that I’m having, like
I expect you to take me seriously. I don’t expect you to tell me, “Well
yeah you’re pregnant.” “I know I’m pregnant. That’s why I’m here
explaining my pain to you so I can make sure that my child is okay.”
Similarly, during labor and delivery, Ebony spoke of experien-
cing excruciating pain that was repeatedly dismissed by her
healthcare providers:
HEALTH COMMUNICATION 7
She was like, “No, you’re just being paranoid.” And I was like, “I
still don’t feel well.” She was like, “Oh, you’re fine, you’re fine.” And
I was like, “Something isn’t right.” And then I was telling her like,
“I’m passing these, these chunks of blood clot.” They were like . . .
“You’re fine . . . .” I’m still having problems and, in a strain, even
after taking the narcotics, I’m still like damn pain, cramping bad.
And she was like, “You’re fine. You know, you’re older. That’s why
you know, you’re feeling like this.” And I was like, “That’s not what
this is.” And all I kept telling her, “Something is wrong with [the
baby]. Something is wrong with me.” She’s like, “You’re okay.” So,
two weeks after he was born, I decided to go to the ER, and they
told me that I needed a D & C [Dilation and curettage] because
I still had some of my placenta in me.
Tragically, Ebony lost her baby while also having to go through
emergency surgery following complications post-delivery.
Similarly, Tabithe, a 20-year old mother of one, explained
how she felt healthcare providers perceived African American
women as deceitful about their pain level. When asked about
how healthcare providers perceived pregnant African
American women, she said:
African American woman are seen as lying about what type of pain
we’re in and how bad it hurts. “Don’t tell me how bad I’m hurting.
You are not inside of me.” And that’s how they always come at
you . . . like you’re lying or exaggerating . . . they treat you like
you’re lying or like it’s not that serious.
Tabithe’s story highlights how the dismissal of African
American women’s concerns on the part of healthcare provi-
ders’, exacerbates women’s lack of trust in healthcare providers
and the healthcare system, leaving women feeling disempow-
ered and less-valued.
Distrust – African American women as charity case
Under this theme, African American women expressed how
they felt that their racial identity positioned them as a “charity
case.” Even when healthcare providers provided what they
considered quality care, because of their overall experiences,
they wondered whether healthcare providers genuinely cared
about them and their healthcare needs. In this way, the women
viewed the quality of care provided to them as a favor to help
the “helpless.” Consequently, these women reported that even
“good” care provided to them was often accompanied with the
notion of charity provided by whites to the helpless Blacks. In
Unique’s narrative she said:
I think there’s racism everywhere, but I think there’s racism in the
healthcare system . . . we’re just looked at differently . . . I think
African American women are more looked at as a charity case in
a way. They looked at us like, “It looks better if I help this lady lift
weights because I’m Caucasian and I’m helping somebody different
than me, so it’ll look better on my end if I help her.”
Unique reasoned that the care delivered to African American
women during pregnancy is not aimed at their best interest,
rather as a way that doctors, whom she framed as Caucasians,
foster a positive image for themselves, so as “to look better.”
Zee’s story was similar as she agreed African American women
are often treated as low-class patients:
I just feel like people care about other races than our, than our own
race. Uh, you know, they’re just like, “Well, we don’t care about the
Blacks. Let’s just make sure that other races are okay.” Like, the
Caucasian just make sure they’re okay before we make sure the
African Americans are okay. So, they basically like put us on the
backburner.
Specifically, Zee believes that Caucasians get better treatment at
the expense of African Americans, as African Americans are
treated as inferior, thus, uncared for. In her narrative, Megan
reasoned that African American women are treated poorly
because whites have positioned them as inferior who should
be “helped” When we asked Megan why she had this percep-
tion about doctors, she said:
It’s just, I don’t know, like I never had that problem with a doctor,
but it’s just a thought that crosses my mind too as well. Like, you
know, “You [whites] sit and help us, but you feel like we just
beneath y’all, like we don’t deserve it.” Like they think, some not
all, but some doctors could possibly think, “We shouldn’t have to
help because this money [for your healthcare] expenses is coming
out of our pockets, we got to help y’all. We really don’t want to.
Megan, similar to other women in this study, reasoned that the
problem of maternal crisis among African American women is
rooted in systemic racism, to control the Black population so
that whites may continue to dominate them. While this per-
ception may be subjective, it exemplifies a bigger issue of
mistrust in the healthcare system.
The Study’s findings show how racial identity impacts
healthcare access and experiences for African American
women during pregnancy, labor and delivery and in the post-
partum period. Through implicit and explicit biases, healthcare
providers’ communicative acts were identified as racially deni-
grating and discriminatory toward women.
Communication stands at the core of women’s narratives when
reporting their experiences of racism in the way maternal
healthcare services were provided to them. Communication
strategies, acts, and dynamics culminate to form the platform
through which racial discrimination is enacted and perceived
(Kreps, 2006). Studying maternal healthcare experiences from
a communication perspective helps to center the voices of
women, and CRT helps to uncover ways in which structural
racism is communicatively enacted.
In revealing structural practices that inherently advance
racial discrimination in the healthcare system, the biomedical
approach was critiqued in women’s narratives. The biomedical
structure of the U.S. healthcare system, as an institutionalized
form of racism, paves the way for the denigration and the
dismissal of African American women’s choices in maternal
care. Ultimately, the biomedical approach, as a healthcare
“standard” practice, creates a space that dehumanizes women,
rendering them incapable of making decisions that concern
their own health and the health of their babies. Functioning in
a hegemonic healthcare system, positions healthcare providers
as the only ones who can make decisions on behalf of women,
through structured practices that are not tailored to meet
women’s unique needs, leaving African American women feel-
ing incapacitated and dehumanized (Freeman et al., 2017).
Through the interest convergence tenet of CRT, our data
reveals how the supposed help for the minority groups further
places them on the margins of society for less than optimal care
8 C. T. ADEBAYO ET AL.
during pregnancy. Racial discrimination manifests through
healthcare providers’ disposition toward public insurance,
that is, Medicaid, as women consistently reported discrimina-
tory treatment based on their type of insurance. In some cases,
they were denied care, when the care requested was deemed by
a provider as being unnecessary. Again, CRT helps to uncover
how systemic practices aimed at promoting health equities are
disguised forms of racial discrimination because of the way
they are enacted.
CRT further enabled us to see how dominant cultural
norms, especially socially constructed racial and gender expec-
tations, negatively impact African American women’s maternal
care (Freeman et al., 2017). The cultural notion of women as
“natural endurers” of pain alongside the racial stereotype of
Black women as extraordinarily strong impacted how African
American women’s pain was perceived and managed, espe-
cially during labor and delivery. African American women
are indeed often perceived as possessing extraordinary ability
for putting up with pain (Davis, 2015; Stewart, 2017; Watson-
Singleton, 2017). The strong Black woman, a cultural dis-
course, evolved from the historical experiences of African
American women as they assumed different roles (wives,
mothers, breadwinners, activists; Parks, 2010; Woods-
Giscombé, 2010) during the era of slavery, and was developed
as a coping discourse to upend the notion of promiscuity or
“baby mamas” ascribed to African American women (Parks,
2010). This discourse has been found to work to the disadvan-
tage of African American women especially in the healthcare
setting (Ashley, 2014; Woods-Giscombé, 2010). Perceived for
their supernatural strength, African American women have
continued to experience a disenfranchised form of healthcare,
one that undermines or dismisses their concerns as patients
within the healthcare setting. The dismissal of pain under the
stereotype of being strong is a major theme of maternal crisis
narratives from Black women in the United States (National
Public Radio, 2017). Until healthcare providers begin to con-
front implicit biases toward African American women, women
will continue to experience implicit racism in maternal care
and poor maternal health outcomes for African American
women will persist.
Distrust in the healthcare system has been a long-standing
experience of African Americans, traceable to the Tuskegee
study of 1932 and many more unethical treatment of Blacks
in medical research (Scharff et al., 2010). As a result of this,
women in this study also reported the same perception, albeit
not because they were discriminated against. They already had
an existing perception that the healthcare system, just like any
other social institution in the U.S., is set up against them, and
to their disadvantage. Consequently, even when healthcare
providers are putting up their best practice, there is still some
level of distrust in the way those services are perceived (Durant
et al., 2011). This may lead to unwillingness to comply with
healthcare providers’ recommendations (Adebayo et al., 2020)
This experience shows how damaging systemic racism can
impact patient relationship with their healthcare providers.
Consistent with the argument of Kreps (2006), communication
functions as the tool for uncovering racial disparities in the
healthcare. Similarly, our study reveals that the enactment of
structural racism and different institutional practices that
marginalize minority groups are communicatively performed.
For instance, the women who reported different forms of racial
discrimination made sense of them through the way their health-
care providers communicated to them both verbally and non-
verbally. Essentially, communication is not merely a way through
which we make sense of healthcare practices, it is the primary
platform of operation for provider-patient relationships in every
form.
In identifying the role of communication in healthcare
context, health communication scholars can be positioned
to address these issues through communication concepts
(Parker & Kreps, 2005). Our study has led to the develop-
ment of important knowledge about healthcare practices
that underserve African American women, which include
ignoring women’s concerns under the guise of standard
practice and structural racism. As evidenced in our study,
the continuation of these practices lead to medical mistrust
and in some cases fatal complications, exacerbating poor
maternal and infant health outcomes.
Study implications for healthcare providers and health
communication scholars
Findings from this study show that healthcare providers
may not be aware of some standard practices in the health-
care system that inherently underserve African American
women. Thus, we suggest that policies that are developed
by healthcare administrators should target the needs of
African American women, as well as other minority popu-
lations. To create a healthcare system that serves African
American women, healthcare providers and administrators
should continuously receive training in intercultural aware-
ness, addressing issues such as racism, health inequities
among minority population, as may be manifested in
healthcare institutional practices.
In communication scholarship, our study’s findings contri-
bute the body of knowledge confirming the central influence of
communication in healthcare delivery, as women in this study
identified their experience of racial discrimination in health-
care structures and practices, they made sense of them through
communication. In reporting how healthcare providers per-
ceive them, African American women consistently reported
communicative acts, both verbal and nonverbal, as indicators
of how they are perceived. Communication functions at the
heart of healthcare delivery. Specifically, with the end goal of
addressing maternal mortality crisis among African American
women, communication scholars are better positioned to iden-
tify communication markers, discourses that may significantly
affect healthcare processes, including the interpretation of
healthcare providers’ attitudes toward patients.
Racial discrimination is not only existent in the health
system. It is everywhere; in universities, in workplaces, and
in health care. As such, issues of racial disparities should be
treated from an intersectional perspective, through active
collaboration between individuals and groups from different
sectors of society. Facilitating such intersectoral collabora-
tion that will effectively address racial health inequities, is
an important research focus for future community engage-
ment research.
HEALTH COMMUNICATION 9
1. In this study, we do not use the terms “Black” and “African
American” interchangeably. Whenever the term “Black” is used,
we are referencing all people of African descent, including African
Americans, while the use of African Americans specifically speaks
to African Americans in the United States (See American
Psychological Association, 2019, p. 143).
2. This is a type of healthcare delivery that displays healthcare dis-
parities based on racial differences, especially between Black and
white patients (Goodman et al., 2016).
3. We conducted a pilot study to explore if both Black immigrant
women and African American women share similar maternal care
experiences. The findings showed that African American women’s
experiences are different from that of Black immigrant women. We
included the data of the African American women who partici-
pated in the pilot
This work was supported by the Department of Communication,
University of Wisconsin-Milwaukee [N/A].
Comfort Tosin Adebayo http://orcid.org/0000-0002-1288-2296
Erin Sahlstein Parcell http://orcid.org/0000-0001-6922-8108
Abioye Kuteyi, E., Bello, I., Olaleye, T., Ayeni, I., & Amedi, M. (2010).
Determinants of patient satisfaction with physician interaction: A
cross-sectional survey at the Obafemi Awolowo University Health
Centre, Ile-Ife, Nigeria. South African Family Practice, 52(6),
557–562. https://doi.org/10.1080/20786204.2010.10874047
Abrams, J. A., Maxwell, M., Pope, M., & Belgrave, F. Z. (2014). Carrying
the world with the grace of a lady and the grit of a warrior: Deepening
our understanding of the “strong Black woman” schema. Psychology of
W o m e n Q u a r t e r l y , 3 8 ( 4 ) , 5 0 3 – 5 1 8 . h t t p s : / / d o i . o r g / 1 0 . 1 1 7 7 /
0361684314541418
Adebayo, C. T., Walker, K., Hawkins, M., Olukotun, O., Shaw, L.,
Sahlstein Parcell, E., Dressel, A., Luft, H., & Mkandawire-Valhmu, L.
(2020). Race and Blackness: A thematic review of communication
challenges confronting the Black community within the U.S. health
care system. Journal of Transcultural Nursing: Official Journal of the
Transcultural Nursing Society, 31(4), 397–405. https://doi.org/10.1177/
1043659619889111
Allen, H., Wright, B. J., Harding, K., & Broffman, L. (2014). The role of
stigma in access to health care for the poor. Milbank Quarterly, 92(2),
289–318. https://doi.org/10.1111/1468-0009.12059
American Psychological Association. (2019). Publication manual of the
American Psychological Association (7th ed.).
Andipatin, M. G., Naidoo, A. D., & Roomaney, R. (2019). The hegemonic
role of biomedical discourses in the construction of pregnancy loss.
Women and Birth, 32(6), e552–e559. https://doi.org/10.1016/j.wombi.
2019.03.006
Arnold, E. C., & Boggs, K. U. (2019). Interpersonal relationships e-book:
Professional communication skills for nurses. Elsevier Health Sciences.
Ashley, W. (2014). The angry Black woman: The impact of pejorative
stereotypes on psychotherapy with Black women. Social Work in Public
Health, 29(1), 27–34. https://doi.org/10.1080/19371918.2011.619449
Baciu, A., Negussie, Y., Geller, A., & Weinstein, J. N. (2017). The state of
health disparities in the United States. In J. N. Weinstein, A. Geller,
Y. Negussie, & A. Baciu, National Academies of Sciences, Engineering,
and Medicine Eds., Communities in action: Pathways to health equity
(pp. 57–98). National Academies Press (US).
Centers for Disease Control and Prevention (CDC). (2019). Pregnancy
mortality surveillance system. https://www.cdc.gov/reproductivehealth/
maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
City of Milwaukee Health Department. (2018). City of Milwaukee
2015–2017 infant mortality rate (IMR): Data brief. https://city.milwau
kee.gov/ImageLibrary/Groups/healthAuthors/ADMIN/PDFs/Reports/
IMRDataBrief2015-2017
Collins, P. H. (2000). Black feminist thought: Knowledge, consciousness,
and the politics of empowerment (2nd ed.). Routledge.
Corlett, S., & Mavin, S. (2018). Reflexivity and researcher positionality. In
C. Cassell, A. L. Cunliffe, & G. Grandy (Eds.) The Sage handbook of
qualitative business and management research methods (pp. 377–398).
Sage. https://doi.org/10.4135/9781526430212
Creanga, A. A., Berg, C. J., Ko, J. Y., Farr, S. L., Tong, V. T., Bruce, F. C., &
Callaghan, W. M. (2014). Maternal mortality and morbidity in the
United States: Where are we now? Journal of Women’s Health, 23(1),
3–9. https://doi.org/10.1089/jwh.2013.4617
Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, F. C., &
Callaghan, W. M. (2015). Pregnancy-related mortality in the United
States, 2006–2010. Obstetrics & Gynecology, 125(1), 5–12. https://doi.
org/10.1097/AOG.0000000000000564
Cuevas, A. G., O’Brien, K., & Saha, S. (2016). African American
experiences in healthcare: “I always feel like I’m getting skipped
over. Health Psychology, 35(9), 987–995. https://doi.org/10.1037/
hea0000368
D’Silva, M. U., Smith, S. E., Della, L. J., Potter, D. A., Rajack-Talley, T. A.,
& Best, L. (2016). Reflexivity and positionality in researching
African-American communities: Lessons from the field. Intercultural
Communication Studies, 25(1), 94–109. https://web.uri.edu/iaics/files/
XXV1%E2%80%93D%E2%80%99SILVA-SMITH-DELLA
Davis, S. M. (2015). The “strong Black woman collective”: A developing
theoretical framework for understanding collective communication
practices of Black women. Women’s Studies in Communication, 38(1),
20–35. https://doi.org/10.1080/07491409.2014.953714
Dawley, K. (2003). Origins of nurse-midwifery in the United States and its
expansion in the 1940s. Journal of midwifery & women’s health, 48(2),
86–95. https://doi.org/10.1016/s1526-9523(03)00002-3
Delgado, R., & Stefancic, J. (2012). Critical race theory: An introduction.
University Press.
Delgado, R., Stefancic, J., & Harris, A. (2017). Critical race theory: An
introduction. New York University Press.
Dovidio, J. F., & Fiske, S. T. (2012). Under the radar: How unexamined
biases in decision-making processes in clinical interactions can con-
tribute to health care disparities. American Journal of Public Health, 102
(5), 945–952. https://doi.org/10.2105/AJPH.2011.300601
Durant, R. W., Legedza, A. T., Marcantonio, E. R., Freeman, M. B., &
Landon, B. E. (2011). Different types of distrust in clinical research
among Whites and African Americans. Journal of the National Medical
Association, 103(2), 123–130. http://dx.doi:10.1016/s0027-9684(15)
30261-3
Dutta, M. J. (2010). The critical cultural turn in health communication:
Reflexivity, solidarity, and praxis. Health Communication, 25(6–7),
534–539. https://doi.org/10.1080/10410236.2010.497995
Ford, C. L., & Airhihenbuwa, C. O. (2010). Critical race theory, race
equity, and public health: Toward antiracism praxis. American
Journal of Public Health, 100(1), S30–S35. https://dx.doi.org/10.2105/
AJPH.2009.171058
Freeman, R., Gwadz, M. V., Silverman, E., Kutnick, A., Leonard, N. R.,
Ritchie, A. S., Reed, J., & Martinez, B. Y. (2017). Critical race theory as
a tool for understanding poor engagement along the HIV care con-
tinuum among African American/Black and Hispanic persons living
with HIV in the United States: A qualitative exploration. International
Journal for Equity in Health, 16(54), 1–14. https://doi.org/10.1186/
s12939-017-0549-3
Frey, W. (2018). Black-White segregation edges downward since 2000, census
shows. https://www.brookings.edu/blog/the-avenue/2018/12/17/black-
white-segregation-edges-downward-since-2000-census-shows/
Gee, G. C., & Ford, C. L. (2011). Structural racism and health inequities:
Old issues, new directions. Du Bois Review: Social Science Research on
Race, 8(1), 115–132. https://doi.org/10.1017/S1742058X11000130
10 C. T. ADEBAYO ET AL.
https://doi.org/10.1080/20786204.2010.10874047
https://doi.org/10.1177/0361684314541418
https://doi.org/10.1177/0361684314541418
https://doi.org/10.1177/1043659619889111
https://doi.org/10.1177/1043659619889111
https://doi.org/10.1111/1468-0009.12059
https://doi.org/10.1016/j.wombi.2019.03.006
https://doi.org/10.1016/j.wombi.2019.03.006
https://doi.org/10.1080/19371918.2011.619449
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
https://city.milwaukee.gov/ImageLibrary/Groups/healthAuthors/ADMIN/PDFs/Reports/IMRDataBrief2015-2017
https://city.milwaukee.gov/ImageLibrary/Groups/healthAuthors/ADMIN/PDFs/Reports/IMRDataBrief2015-2017
https://city.milwaukee.gov/ImageLibrary/Groups/healthAuthors/ADMIN/PDFs/Reports/IMRDataBrief2015-2017
https://doi.org/10.4135/9781526430212
https://doi.org/10.1089/jwh.2013.4617
https://doi.org/10.1097/AOG.0000000000000564
https://doi.org/10.1097/AOG.0000000000000564
https://doi.org/10.1037/hea0000368
https://doi.org/10.1037/hea0000368
https://web.uri.edu/iaics/files/XXV1%E2%80%93D%E2%80%99SILVA-SMITH-DELLA
https://web.uri.edu/iaics/files/XXV1%E2%80%93D%E2%80%99SILVA-SMITH-DELLA
https://doi.org/10.1080/07491409.2014.953714
https://doi.org/10.1016/s1526-9523(03)00002-3
https://doi.org/10.2105/AJPH.2011.300601
http://dx.doi:10.1016/s0027-9684(15)30261-3
http://dx.doi:10.1016/s0027-9684(15)30261-3
https://doi.org/10.1080/10410236.2010.497995
https://dx.doi.org/10.2105/AJPH.2009.171058
https://dx.doi.org/10.2105/AJPH.2009.171058
https://doi.org/10.1186/s12939-017-0549-3
https://doi.org/10.1186/s12939-017-0549-3
https://www.brookings.edu/blog/the-avenue/2018/12/17/black-white-segregation-edges-downward-since-2000-census-shows/
https://www.brookings.edu/blog/the-avenue/2018/12/17/black-white-segregation-edges-downward-since-2000-census-shows/
https://doi.org/10.1017/S1742058X11000130
Gollust, S. E., Cunningham, B. A., Bokhour, B. G., Gordon, H. S., Pope, C.,
Saha, S. S., Jones, D. M., Do, T., & Burgess, D. J. (2018). What causes
racial health care disparities? A mixed-methods study reveals variability
in how health care providers perceive causal attributions. Inquiry: The
Journal of Health Care Organization, Provision, and Financing, 55,
1–11. https://doi.org/10.1177/0046958018762840
Goodman, M. S., Gilbert, K. L., Hudson, D., Milam, L., & Colditz, G. A.
(2016). Descriptive analysis of the 2014 race-based healthcare dispa-
rities measurement literature. Journal of Racial and Ethnic Health
Disparities, 4(5), 796–802. https://doi.org/10.1007/s40615-016-0281-5
Ha, J. F., & Longnecker, N. (2010). Doctor-patient communication: A
review. The Ochsner Journal, 10(1), 38–43. https://doi.org/10.1043/
TOJ-09-0040g.1
Homan, P. (2019). Structural sexism and health in the United States:
A new perspective on health inequality and the gender system.
American Sociological Review, 84(3), 486–516. https://doi.org/10.1177/
0003122419848723
Howland, R. E., Angley, M., Won, S. H., Wilcox, W., Searing, H., Liu, S. Y.,
& Johansson, E. W. (2019). Determinants of severe maternal morbidity
and its racial/ethnic disparities in New York City, 2008–2012. Maternal
and Child Health Journal, 23(3), 346–355. https://doi.org/10.1007/
s10995-018-2682-z
Hylton, K. (2012). Talk the talk, walk the walk: Defining critical race
theory in research. Race Ethnicity and Education, 15(1), 23–24.
https://doi.org/10.1080/13613324.2012.638862
Institute of Medicine. (2003). Unequal treatment: Confronting racial and
ethnic disparities in health care. The National Academies Press. https://
doi.org/10.17226/12875
Kaiser Family Foundation. (2019). Medicaid coverage rates for the none-
lderly by race/ethnicity. https://www.kff.org/medicaid/state-indicator
/nonelderly-medicaid-rate-by-raceethnicity/?currentTimeframe=
0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%
22asc%22%7D
Keith, V. M., Lincoln, K. D., Taylor, R. J., & Jackson, J. S. (2010).
Discriminatory experiences and depressive symptoms among African
American women: Do skin tone and mastery matter? Sex Roles, 62
(1–2), 48–59. https://doi.org/10.1007/s11199-009-9706-5
Kitsantas, P., & Gaffney, K. F. (2010). Racial/ethnic disparities in infant
mortality. Journal of Perinatal Medicine, 38(1), 87–94. https://doi.org/
10.1515/jpm.2010.014
Koch, A. R., & Geller, S. E. (2019). Racial and ethnic disparities in preg-
nancy-related mortality in Illinois, 2002–2015. Journal of Women’s
Health, 28(8), 1153–1160. https://doi.org/10.1089/jwh.2018.7557
Kreps, G. L. (2006). Communication and racial inequities in health care.
American Behavioral Scientist, 49(6), 760–774. https://doi.org/10.1177/
0002764205283800
Krieger, N., Kosheleva, A., Waterman, P. D., Chen, J. T., & Koenen, K.
(2011). Racial discrimination, psychological distress, and self-rated
health among us-born and foreign- born Black Americans. American
Journal of Public Health, 101(9), 1704–1713. https://doi.org/10.2105/
AJPH.2011.300168
Ladson-Billings, G., & Tate, W. F. (2006). Toward a critical race theory of
education. In A. D. Dixson & C. K. Rousseau (Eds.), Critical race theory
in education: All God’s children got a song (pp. 11–31). Routledge.
López, G. R. (2003). The (racially neutral) politics of education: A critical
race theory perspective. Educational Administration Quarterly, 39(1),
68–94. https://doi.org/10.1177/0013161X02239761
Martin, J. A., Hamilton, B. E., Osterman, M. J., Driscoll, A. K., &
Mathews, T. J. (2017). Births: Final data for 2015. National vital statis-
tics reports: From the Centers for Disease Control and Prevention,
National Center for Health Statistics, National Vital Statistics System.
https://stacks.cdc.gov/view/cdc/43595
Mazul, M. C., Ward, T. C., & Ngui, E. M. (2017). Anatomy of good
prenatal care: Perspectives of low income African-American women
on barriers and facilitators to prenatal care. Journal of Racial and Ethnic
Health Disparities, 4(1), 79–86. https://doi.org/10.1007/s40615-015-
0204-x
Miles, M. B., Huberman, A. M., & Saldaña, J. (2013). Qualitative data
analysis. Sage.
Mkandawire-Valhmu, L. (2018). Cultural safety, healthcare and vulnerable
populations: A critical theoretical perspective (1st ed.). Routledge.
https://doi.org/10.4324/9781315708706
National Public Radio. (2017, December 7). Black mothers keep dying after
giving birth. Shalon Irving’s story explains why. https://www.npr.org/
2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-
shalon-irvings-story-explains-why
Noonan, A. S., Velasco-Mondragon, H. E., & Wagner, F. A. (2016).
Improving the health of African Americans in the USA: An overdue
opportunity for social justice. Public Health Reviews, 37(12), 1–20.
https://doi.org/10.1186/s40985-016-0025-4
Parker, R., & Kreps, G. L. (2005). Library outreach: Overcoming health
literacy challenges. Journal of the Medical Library Association, 93(S1),
S81–S85. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1255757/
pdf/i0025-7338-093-04S-0081
Parks, S. (2010). Fierce angels: The strong Black woman in American life
and culture. One World.
Penner, L. A., Blair, I. V., Albrecht, T. L., & Dovidio, J. F. (2014). Reducing
racial health care disparities: A social psychological analysis. Policy
Insights from the Behavioral and Brain Sciences, 1(1), 204–212.
https://doi.org/10.1177/2372732214548430
Perry, B. L., Harp, K. L., & Oser, C. B. (2013). Racial and gender dis-
crimination in the stress process: Implications for African American
women’s health and well-being. Sociological Perspectives, 56 (1), 25–48.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783344/pdf/
nihms492047 .
Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K.,
Shapiro Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/
ethnic disparities in pregnancy-related deaths—United States,
2007–2016. Morbidity and Mortality Weekly Report, 68(35), 762–765.
http://dx.doi.org/10.15585/mmwr.mm6835a3externalicon
Raine, R., Cartwright, M., Richens, Y., Mahamed, Z., & Smith, D. (2010).
A qualitative study of women’s experiences of communication in
antenatal care: Identifying areas for action. Maternal Child Health
Journal, 14(4), 590–599. https://doi.org/10.1007/s10995-009-0489-7
Ryn, M. V., & Burje, J. (2002). The effect of patient race and socio-economic
status on physicians’ perceptions of patients. Social Science & Medicine,
50(6), 813–828. https://doi.org/10.1016/S0277-9536(99)00338-X
Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B.,
Burroughs, H., & Jinks, C. (2018). Saturation in qualitative research:
Exploring its conceptualization and operationalization. Quality &
Quantity, 52, 1893–1907. https://doi.org/10.1007/s11135-017-05748
Scharff, D. P., Mathews, K. J., Jackson, P., Hoffsuemmer, J., Martin, E., &
Edwards, D. (2010). More than Tuskegee: Understanding mistrust
about research participation. Journal of Health Care for the Poor and
Underserved, 21(3), 879–897. https://doi.org/10.1353/hpu.0.0323
Shavers, V. L., & Shavers, B. S. (2006). Racism and health inequity among
Americans. Journal of the National Medical Association, 98 (3),
386–396. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576116/
pdf/jnma00190-0078
Singh, G. K., & Stella, M. Y. (2019). Infant mortality in the United States,
1915–2017: Large social inequalities have persisted for over a century.
International Journal of MCH and AIDS, 8(1), 19–31. https://doi.org/
10.21106/ijma.271
Spradley, J. P. (1979). The ethnographic interview. Waveland Press.
Stewart, C. P. (2017). The mule of the world: The strong Black woman and
the woes of being “independent”. Knots: An Undergraduate Journal of
Disability Studies, 3, 31–39. https://jps.library.utoronto.ca/index.php/
knots/article/view/29187
Taylor, J. (2019). Racism, inequality, and health care for African
Americans. The Century Foundation. Retrieved on August 27, 2020,
from https://tcf.org/content/report/racism-inequality-health-care-
african-americans/?session=1&session=1&agreed=1
Thorburn, S., & De Marco, M. (2010). Insurance-based discrimination
during prenatal care, labor, and delivery: Perceptions of Oregon
mothers. Maternal Child Health Journal, 14(6), 875–885. https://doi.
org/10.1007/s10995-009-0533-7
Tracy, S. J. (2012). Qualitative research methods: Collecting evidence,
crafting analysis, communicating impact. Wiley & Sons.
HEALTH COMMUNICATION 11
https://doi.org/10.1177/0046958018762840
https://doi.org/10.1007/s40615-016-0281-5
https://doi.org/10.1043/TOJ-09-0040g.1
https://doi.org/10.1043/TOJ-09-0040g.1
https://doi.org/10.1177/0003122419848723
https://doi.org/10.1177/0003122419848723
https://doi.org/10.1007/s10995-018-2682-z
https://doi.org/10.1007/s10995-018-2682-z
https://doi.org/10.1080/13613324.2012.638862
https://doi.org/10.17226/12875
https://doi.org/10.17226/12875
Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity
Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity
Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity
Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity
https://doi.org/10.1007/s11199-009-9706-5
https://doi.org/10.1515/jpm.2010.014
https://doi.org/10.1515/jpm.2010.014
https://doi.org/10.1089/jwh.2018.7557
https://doi.org/10.1177/0002764205283800
https://doi.org/10.1177/0002764205283800
https://doi.org/10.2105/AJPH.2011.300168
https://doi.org/10.2105/AJPH.2011.300168
https://doi.org/10.1177/0013161X02239761
https://stacks.cdc.gov/view/cdc/43595
https://doi.org/10.1007/s40615-015-0204-x
https://doi.org/10.1007/s40615-015-0204-x
https://doi.org/10.4324/9781315708706
https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why
https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why
https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why
https://doi.org/10.1186/s40985-016-0025-4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1255757/pdf/i0025-7338-093-04S-0081
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1255757/pdf/i0025-7338-093-04S-0081
https://doi.org/10.1177/2372732214548430
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783344/pdf/nihms492047
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783344/pdf/nihms492047
http://dx.doi.org/10.15585/mmwr.mm6835a3externalicon
https://doi.org/10.1007/s10995-009-0489-7
https://doi.org/10.1016/S0277-9536(99)00338-X
https://doi.org/10.1007/s11135-017-05748
https://doi.org/10.1353/hpu.0.0323
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576116/pdf/jnma00190-0078
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576116/pdf/jnma00190-0078
https://doi.org/10.21106/ijma.271
https://doi.org/10.21106/ijma.271
https://jps.library.utoronto.ca/index.php/knots/article/view/29187
https://jps.library.utoronto.ca/index.php/knots/article/view/29187
https://tcf.org/content/report/racism-inequality-health-care-african-americans/?session=1%26session=1%26agreed=1
https://tcf.org/content/report/racism-inequality-health-care-african-americans/?session=1%26session=1%26agreed=1
https://doi.org/10.1007/s10995-009-0533-7
https://doi.org/10.1007/s10995-009-0533-7
Tucker, M. J., Berg, C. J., Callaghan, W. M., & Hsia, J. (2007). The
Black-White disparity in pregnancy-related mortality from 5 condi-
tions: Differences in prevalence and case-fatality rates. American
Journal of Public Health, 97(2), 247–251. https://doi.org/10.2105/
AJPH.2005.072975
Vardeman-Winter, J. (2017). The framing of women and health
disparities: A critical look at race, gender, and class from the
perspectives of grassroots health communicators. Health
C o m m u n i c a t i o n , 3 2 ( 5 ) , 6 2 9 – 6 3 8 . h t t p s : / / d o i . o r g / 1 0 . 1 0 8 0 /
10410236.2016.1160318
Ward, T. C., Mazul, M., Ngui, E. M., Bridgewater, F. D., & Harley, A. E.
(2013). “You learn to go last”: Perceptions of prenatal care experiences
among African American women with limited incomes. Maternal and
Child Health Journal, 17(10), 1753–1759. https://doi.org/10.1007/
s10995-012-1194-5
Warmington, P. (2012). ‘A tradition in ceaseless motion’: Critical race
theory and Black British intellectual spaces. Race, Ethnicity and
Education, 15(1), 5–21. https://doi.org/10.1080/13613324.2012.638861
Watson-Singleton, N. N. (2017). Strong Black woman schema and psy-
chological distress: The mediating role of perceived emotional support.
Journal of Black Psychology, 43(8), 778–788. https://doi.org/10.1177/
0095798417732414
Weech-Maldonado, R., Hall, A., Bryant, T., Jenkins, K. A., & Elliott, M. N.
(2012). The relationship between perceived discrimination and patient
experiences with health care. Medical Care, 50(9 Suppl 2), S62–S68.
https://doi.org/10.1097/MLR.0b013e31825fb235
Wesp, L. M., Scheer, V., Ruiz, A., Walker, K., Weitzel, J., Shaw, L.,
Kako, P. M., & Mkandawire-Valhmu, L. (2018). An emancipatory
approach to cultural competency: The application of critical race, post-
colonial, and intersectionality theories. ANS. Advances in Nursing
Science, 41(4), 316–326. https://doi.org/10.1097/ANS.0000000000000230
Willard, B. E. (2005). Feminist interventions in biomedical discourse: An
analysis of the rhetoric of integrative medicine. Women’s Studies in
Communication, 28(1), 115–148. https://doi.org/10.1080/07491409.
2005.10162486
Williams, D. R., & Wyatt, R. (2015). Racial bias in health care and health:
Challenges and opportunities. JAMA, 314(6), 555–556. https://doi.org/
10.1001/jama.2015.9260
Wisconsin Department of Health Services. (2019). Maternal mortality and
morbidity. https://www.dhs.wisconsin.gov/mch/maternal-mortality-
and-morbidity.htm
Woods-Giscombé, C. L. (2010). Superwoman schema: African American
women’s views on stress, strength, and health. Qualitative Health
Research, 20(5), 668–683. https://doi.org/10.1177/1049732310361892
World Health Organization. (2014). Global health expenditure database.
Retrieved March 5, 2020, from http://apps.who.int/nha/database/
Country_Profile/Index/e
12 C. T. ADEBAYO ET AL.
https://doi.org/10.2105/AJPH.2005.072975
https://doi.org/10.2105/AJPH.2005.072975
https://doi.org/10.1080/10410236.2016.1160318
https://doi.org/10.1080/10410236.2016.1160318
https://doi.org/10.1007/s10995-012-1194-5
https://doi.org/10.1007/s10995-012-1194-5
https://doi.org/10.1080/13613324.2012.638861
https://doi.org/10.1177/0095798417732414
https://doi.org/10.1177/0095798417732414
https://doi.org/10.1097/MLR.0b013e31825fb235
https://doi.org/10.1097/ANS.0000000000000230
https://doi.org/10.1080/07491409.2005.10162486
https://doi.org/10.1080/07491409.2005.10162486
https://doi.org/10.1001/jama.2015.9260
https://doi.org/10.1001/jama.2015.9260
https://www.dhs.wisconsin.gov/mch/maternal-mortality-and-morbidity.htm
https://www.dhs.wisconsin.gov/mch/maternal-mortality-and-morbidity.htm
https://doi.org/10.1177/1049732310361892
http://apps.who.int/nha/database/Country_Profile/Index/e
http://apps.who.int/nha/database/Country_Profile/Index/e
Literature review
The problem–health disparities, race, and gender
Provider-patient communication and the experience of racial discrimination
Maternal mortality among African American women
Structural barriers in African American women’s maternal healthcare experiences
Theoretical framework: Critical race theory
Method
Study site
Participants
Semi-structured in-depth interviews
Reflexivity and positionality
Data analysis
Findings
Institutionalized care – racially insensitive biomedical approach
Race and class – unfair treatment based on health insurance
Race as a social concept – dismissed pain concerns because you are a strong Black woman
Distrust – African American women as charity case
Discussion
Study implications for healthcare providers and health communication scholars
Notes
Funding
ORCID
References
https://onlinelibrary.wiley.com/action/showCampaignLink?uri=uri%3A138f23c6-48df-45ae-8d30-9fdec6e10b53&url=https%3A%2F%2Fffntest.com%2Fhcp%2Fprofessional-resources%2F%23quiz&pubDoi=10.1111/jmwh.13102&viewOrigin=offlinePdf
Journal of Midwifery & Women’s Health www.jmwh.org
Original Research
Listening to Women: Recommendations from Women of
Color to Improve Experiences in Pregnancy and Birth Care
Molly R. Altman1,2, CNM, PhD, MPH , Monica R. McLemore2,3, PhD, MPH, RN , Talita Oseguera3, CNM, MSN,
Audrey Lyndon4, PhD, RN , Linda S. Franck 2,3, PhD, RN
Introduction: Women of color are at increased risk for poor birth outcomes, often driven by upstream social determinants and socially structured
systems. Given the increasing rate of maternal mortality in the United States, particularly for women of color, there is a pressing need to find
solutions to improving care quality and access for racially marginalized communities. This study aims to describe and thematically analyze the
recommendations to improve pregnancy and birth care made by women of color with lived experience of perinatal health care.
Methods: Twenty-two women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit
organization participated in semistructured interviews about their experiences receiving health care during pregnancy and birth. Interviews were
audio-recorded and transcribed, and transcripts were analyzed using thematic analysis to highlight recommendations for improving perinatal
care experiences.
Results: Participants shared experiences and provided recommendations for improving care at the individual health care provider level, includ-
ing spending quality time, relationship building and making meaningful connections, individualized person-centered care, and partnership in
decision making. At the health systems level, recommendations included continuity of care, racial concordance with providers, supportive health
care system structures to meet the needs of women of color, and implicit bias trainings and education to reduce judgment, stereotyping, and
discrimination.
Discussion: Participants in this study shared practical ways that health care providers and systems can improve pregnancy and birth care expe-
riences for women of color. In addition to the actions needed to address the recommendations, health care providers and systems need to listen
more closely to women of color as experts on their experiences in order to create effective change. Community-centered research, driven by and
for women of color, is essential to improve health disparities during pregnancy and birth.
J Midwifery Womens Health 2020;65:466–473 c© 2020 by the American College of Nurse-Midwives.
Keywords: patient-centered care, racism, continuity of patient care, decision making, thematic analysis
INTRODUCTION
Women of color are at increased risk for poor birth outcomes,
such as preterm birth and low birth weight, irrespective
of income or other sociodemographic factors.1-3 Multiple
factors have been implicated in these disparities at the indi-
vidual level, often driven by upstream social determinants
and socially structured systems.4-7 Given the increasing rate
of maternal mortality in the United States, particularly for
women of color, there is a pressing need to find solutions to
improving care quality and access for racially marginalized
communities.8,9
1University of Washington School of Nursing, Seattle,
Washington
2Preterm Birth Initiative, University of California San
Francisco, San Francisco, California
3University of California, San Francisco School of Nursing,
San Francisco, California
4New York University Rory Meyers College of Nursing, New
York, New York
Correspondence
Molly R. Altman
Email: mraltman@uw.edu
ORCID
Molly R. Altman https://orcid.org/0000-0002-0453-0469
Monica R. McLemore https://orcid.org/0000-0001-6539-4256
Audrey Lyndon https://orcid.org/0000-0003-2215-4273
Linda S. Franck https://orcid.org/0000-0003-4291-9181
There is increasing evidence that health care system fac-
tors play a role in the health care experience and pregnancy
and birth outcomes for women of color.10-12 In the con-
text of pregnancy and birth, women of color have repeatedly
shared that they are not listened to and/or that their concerns
are ignored.13-17 Although women seek trustworthy and re-
spectful care, not receiving such care can compound stress
and discourage access to necessary services.13,18,19 Women
of color have rarely been directly asked about their prefer-
ences and ideas for patient-provider and health care system
improvement.14 As experts on their experiences, women of
color have the ability to share insightful knowledge about their
own health, which can guide health care systems to better sup-
port and respect people of color through the pregnancy and
birth experiences.20
As part of a larger study exploring experiences inter-
acting with health care providers during pregnancy, birth,
and postpartum,21 women of color in San Francisco de-
scribed how providers’ power influenced what information
was shared in the context of respect, autonomy, and decision
making. Participants also provided recommendations for how
the health care system could be improved to better support
women of color. The purpose of this report was to describe
and thematically analyze what participants shared as
issues
with the current health care system and their described rec-
ommendations for change.
466 1526-9523/09/$36.00 doi:10.1111/jmwh.13102 c© 2020 by the American College of Nurse-Midwives
https://orcid.org/0000-0002-0453-0469
https://orcid.org/0000-0001-6539-4256
https://orcid.org/0000-0003-2215-4273
https://orcid.org/0000-0003-4291-9181
mailto:mraltman@uw.edu
https://orcid.org/0000-0002-0453-0469
https://orcid.org/0000-0002-0453-0469
https://orcid.org/0000-0001-6539-4256
https://orcid.org/0000-0001-6539-4256
https://orcid.org/0000-0003-2215-4273
https://orcid.org/0000-0003-2215-4273
https://orcid.org/0000-0003-4291-9181
https://orcid.org/0000-0003-4291-9181
✦ Women of color provided recommendations for improving care during pregnancy and birth, aimed toward change in both
individual interactions with health care providers and the larger health care system.
✦ Providing person-centered care and valuing a person’s lived experience are key to improving trust for women of color.
✦ Ensuring access to racially concordant care by supporting more health care providers of color through education and in
the workforce has the power to improve the experience and outcomes for women of color.
✦ Centering the experiences of those affected by health disparities is key for improving pregnancy and birth outcomes.
METHODS
Detailed methods for the larger project have been de-
scribed elsewhere.21 In brief, the research team recruited self-
identified women of color from a community-based organi-
zation in San Francisco, California, that provides health and
wellness services to families with low income. One-to-two–
hour semistructured interviews were conducted with women
from 6 weeks to one year postpartum. These interviews were
transcribed verbatim and then analyzed using constructivist
grounded theory methods.22,23
For this secondary analysis, the interview transcripts were
further analyzed using thematic analysis techniques as de-
scribed by Braun et al24 to identify issues with the health
care system and associated recommendations for health care
improvement that women provided in response to a prompt
within the interview guide. Transcripts were read thoroughly
for additional content specifically related to recommenda-
tions for health care providers or health care systems. Ini-
tial codes were generated and then analyzed within and
across transcripts to form preliminary themes. The prelim-
inary themes and subthemes were then further developed
with illustrative exemplars from transcripts. Themes and sub-
themes were then named and defined. The secondary analy-
sis was performed by 2 members of the research team (first
and third authors), with findings reviewed and commented
upon by the larger team. Reflexivity included continued as-
sessment of researcher positionality within the context of how
women responded to the interview prompt (all researchers
had nursing and/or nurse-midwifery training, with 2 identify-
ing as Black and 3 as white). Human participants’ approval was
granted by the University of California, San Francisco. All par-
ticipants provided informed consent prior to interviews and
received a $50 gift card for their time and involvement.
Of note, although the authors recognize that not all
birthing persons identify as women, the participants in this
study all identified with she and her pronouns and the titles
woman and mother. For this reason, the authors use these
terms in the context of this report of research findings.
RESULTS
Twenty-two women of color participated in the larger study,
and all were included in this analysis. Participants self-
identified as African American or Black (non-Hispanic)
(8), Latina or Hispanic (4), Native American (1), Asian
(3), and multiracial or mixed race/ethnicity (6). Those who
identified as multiracial or mixed race/ethnicity used the
following descriptions: Black/Hispanic (2), Black/Samoan
(1), Black/Filipino (1), white/Latina (1), and other (Chero-
kee/White/Puerto Rican) (1). Participants were aged between
23 and 39 years and had a total of 55 birth experiences. All par-
ticipants received support services at the community-based
organization (such as case management, childcare, and finan-
cial assistance).
Participants described their pregnancy and birth expe-
riences and highlighted ways to improve individual patient-
provider interactions with different types of health care
providers, including obstetricians, nurse-midwives, nurses,
and medical residents. Additionally, they described interac-
tions with several different clinics, hospitals, and health sys-
tems, both public and private, providing recommendations at
the systems level for improving care (Table 1).
Interacting with Individual Health Care Providers
Participants shared insight around interacting with health
care providers and recommendations for health care improve-
ment, including the following subthemes: spending quality
time, relationship building and making meaningful connec-
tions, individualized person-centered care, and partnership in
decision making.
Spending Quality Time
Participants strongly desired that health care providers spend
quality time with them during the course of their appoint-
ments and during their hospital experience. Quality time, in
this context, was defined as time in which participants felt they
were given adequate time and attention from their providers
to feel valued and listened to. Many participants shared expe-
riences of being rushed by providers and inadequate time to
receive individualized care. The experience of being rushed
was often interpreted negatively as a value judgment, in which
their time and needs were less worthy than those of other peo-
ple: “It was like more, ‘Oh, okay. Let’s just hurry up and get her
over with and push her out,’ you know what I mean?”
Participants felt seen and cared for when health care
providers spent time at the bedside, particularly in the con-
text of understanding that providers had competing job du-
ties and limited time. One participant shared that, when in a
particularly stressful moment during her labor, “ …my doc-
tor just came beside me, rubbed my head and says, ‘It’s going
to be okay.’ [ …] She took that one little second to come calm
me down. And that’s what I liked.” That “one little second”
Journal of Midwifery & Women’s Health � www.jmwh.org 467
Table 1. Recommendations, Concerns Addressed, and Proposed Actions Curated from Participant Interviews
Recommendation Concerns addressed Proposed actions
Interactions with individual health care providers
Spending quality time Wanting to not feel rushed Have longer visit length with longer face-to-face times
with providers
Wanting physical time with providers Make eye contact
Wanting to be seen and heard Use reflective listening techniques
Relationship building Wanting an emotional connection Get to know patients as individuals
Wanting to be known and familiar to providers Take notes to remember at subsequent visits
Wanting providers to start and participate in
genuine conversation
Include questions about life, well-being
Value patients’ experiences
Individualized
person-centered care
Wanting to be treated as a person Show respect and dignity
Wanting to know that their health, not just their
fetus’s health, mattered
Focus on both patients, not just fetus
Wanting providers to factor in external influences
and barriers into care
Inquire about and address social determinants of health,
particularly structural impacts such as poverty,
housing, and transportation issues that may affect care
Increase knowledge of impact of social determinants
of health on outcomes and access
Partnership in decision
making
Wanting experiences and knowledge to be valued
and respected
Honor patient stories and lived experience as equal to
theoretical knowledge
Wanting autonomy in decision making Provide all information and support patient decisions
Use informed consent for all professional touch and
procedures
Interactions with the health care system
Continuity of care Wanting to see same providers who know them Use patient panels or other continuity models
Not wanting to have to repeat history and story Have mechanism for sharing details across providers
Provider racial and ethnic
concordance
Needing providers who look like them and have a
shared cultural identity to feel safe
Support education and recruitment of providers of color
across all levels of care
Wanting a more diverse workforce, as there are
few providers of color available
Recruit from historically Black colleges and universities
Precept and/or mentor students of color
Support career fairs at high schools in diverse
neighborhoods
Health system structure
issues
Needing a less fragmented care system; wanting
services consolidated in one location
Streamline services and referral systems to reduce
burden on patients
Add services to existing locations
Needing consistency in insurance coverage and
recommended care, in response to having
recommended care not a covered benefit
Push for comprehensive insurance coverage for all
recommended maternal health services through
lobbying and policy change
Wanting appointment scheduling and time spent
in appointment reflecting needs and barriers
faced by people of color
Provide opportunity for evening and weekend
appointments
Remove late penalties
Provide flexibility in appointment times
Provider education Needing more effective implicit bias trainings Review your own implicit biases
(https://implicit.harvard.edu/implicit/education.html)
Incorporate antiracism trainings into education and
workplace settings
(Continued)
468 Volume 65, No. 4, July/August 2020
https://implicit.harvard.edu/implicit/education.html
Table 1. Recommendations, Concerns Addressed, and Proposed Actions Curated from Participant Interviews
Recommendation Concerns addressed Proposed actions
Needing revisions of textbooks and coursework
that perpetuate structural racism
Choose texts that address structural racism and the
colonial impacts on health care education
Write to publishers of outdated texts to request
necessary changes
transformed her experience in a positive light. Time spent
face-to-face with providers, particularly in the setting of be-
ing listened to and heard with empathy, was seen by women
of color as a valuable mechanism for building trust and mutual
respect.
Relationship Building and Making Meaningful Connections
Participants in this study shared a desire for a connection
with, to know and be known by, and to have a sense of
shared humanity recognized by their health care providers.
For many participants, making connections and building rela-
tionships took the form of having casual, yet meaningful, con-
versation about shared interests or experiences. One partici-
pant recommended providers start and participate in genuine
conversations:
I could sit and I could talk to somebody [ …] “Oh, you
know, hey. How’re you? You have kids too?” and stuff. And
so that’s what gets people a little bit more comfortable [ .. .]
Like just starting a conversation … and it’s just genuine,
you know?
Similarly, participants shared a desire to be known by their
health care providers, as one participant defined as knowing
names and history: “I think when you bring your child to a
doctor it should be someone who knows your child’s name, al-
ready knows what’s going on with the baby, and gets personal.”
Interactions were meaningful for women when providers con-
veyed a sense of empathy and compassion, particularly in
ways that created emotional connection. One participant, who
recently gave birth to her second child, shared this when de-
scribing the lack of compassion she felt from her provider:
When you’re talking to someone about their child, even if
you don’t have kids, having that compassion and under-
standing and emotional connection, empathy and sympa-
thy for someone that is dealing with the care of their child
and the well-being, that is what I think was lost [from the
interaction].
Participants identified actions health care providers could
take to build relationships and create connection, including
sharing commonalities, taking time to know and see individ-
uals as persons, and hearing their concerns with empathy and
compassion.
Individualized Person-Centered Care
Alongside spending time and feeling connection with health
care providers, participants wanted to receive care that was in-
dividualized for them and included person-centered interac-
tions. Participants needed to be recognized as a person who
was valued and whose knowledge was respected. As one par-
ticipant shared, a lack of individualized care and connection
had a direct impact on hope and shared decision making: “So,
if you’re talking to me as though I’m just a number, you’re tak-
ing away my hope of my baby. Don’t feed me lies, but don’t
take away from my hope or take away from me helping you
in the care.” Participants wanted to know that their health
and wellness, not just their unborn fetus’s, mattered to their
providers. A mother of 2 children shared this about her pre-
natal care experience: “They were more concerned about the
pregnancy, not really [ …] me as a person. I’m not just a car-
rier. Be concerned about me too.”
Participants felt that factors external to the health care sys-
tem often influenced how care was accessed and received, and
they noticed when health care providers recognized these in-
fluences and made room for individualized care. One partic-
ipant described her positive experience with a provider who
recognized her unique needs and supported her:
So, I’m often late because I just have so much to deal with
3 little children. So, like if I’m late to an appointment and I
call they’re like, “Yeah, she’s still wanting to see you.” And
I know that’s not always the case with a lot of doctors. She’s
just very supportive and she takes the time to go kind of
above and beyond.
Person-centered care that recognized people as fully hu-
man, not numbers or vessels, but also as valued individuals,
was considered essential to providing a care experience in
which patients felt hopeful, included, and honored.
Partnership in Decision Making
Participants wanted not only to be heard and respected but
also to be included in decision making throughout their care
experience. Having their knowledge respected was valued by
many of the participants: “I think that the doctors should
listen to us more, you know? Some of us do kind of know
what our babies need.” Participants expected autonomy and
decision-making power, to be treated with respect, and care
that was individualized to their own needs: “ … it’s making
sure that the patient has their needs met and their requests
honored. Like allowing somebody to make their own deci-
sions and be autonomous and, you know?”
Autonomy and decision-making power during pregnancy
and birth were highly valued by participants and were ex-
pected as part of the relationship with health care providers.
When these rights were not afforded to them, participants felt
disempowered and frustrated, which then decreased trust in
individual providers and even in the health care system.
Journal of Midwifery & Women’s Health � www.jmwh.org 469
Interacting with the Health Care System
Participants identified system-level barriers, such as frag-
mented care, insurance problems, and discrimination that
they perceived adversely affected their care, and highlighted
several health system–level recommendations for improv-
ing care for women of color. The dominant subthemes in-
cluded continuity of care, racial concordance with health
care providers, supportive health care system structures to
meet the needs of women of color, and implicit bias train-
ings and education to reduce judgment, stereotyping, and
discrimination.
Continuity of Care
Consistency of health care providers and continuity of care,
which provides the time and space needed for relationship
building, was highlighted as an important factor to improve at
the systems level. Many participants highlighted experiences
in which they needed to tell their story repeatedly to differ-
ent people, only to not see the same providers again; there
was a sense of disruption to care and lessened quality of care
provision:
I don’t like they are different nurses or doctors. They don’t
know what happened the previous visit. So, when they
asked me is she okay, I don’t know. [ .. .] I don’t know if she’s
better than the last visit because you don’t know.
Participants highlighted how health care provider consis-
tency allowed for relationship building and increased individ-
ualized care. One participant shared her experience with mul-
tiple providers and struggling with wanting less exposure for
her newborn:
You [shouldn’t] have to get used to the 5 different peo-
ple during your 2-day stay. So, give one nurse these rooms
and another nurse these [other] rooms. [ .. .] It’s just a
brand new baby. You don’t want all these people handling
your baby, first off. Even though they’re nurses, it doesn’t
matter.
Inconsistency in health care providers created an envi-
ronment for many participants that increased mistrust of
provider knowledge and feelings of vulnerability in having to
share their story repeatedly. Participants saw the connection
between continuity of care and ability to build relationships
with providers, which opened up opportunity to increase trust
and connection.
Health Care Provider Racial and Ethnic Concordance
Women of color in this study highlighted the importance of
having a health care provider who looks like them and under-
stands their lived experience as part of their care team. Partic-
ipants shared feeling safer and more connected with providers
of color and noted feeling suspicious and/or fearful of receiv-
ing judgment from white providers:
When I see somebody who is of color, we have more of
a connection without even saying anything to each other.
And so it’s like, “Oh, okay,” you know? It’s so different,
and then when somebody that is Caucasian comes in, I
don’t know. It just—everything just feels so dry like really
short,—you know what I mean? [ .. .] That’s how I feel with
some of the Caucasians—because of the experience that I’ve
been through.
Participants highlighted the need for diversification of the
health care provider workforce. One participant shared her
observation that it is difficult to find providers of color and
that there is a need to have more available to communities:
Well, maybe just that I mean it would be great if there were
more doctors across like a spectrum of different identities;
more people in the medical profession because it can be eas-
ier to get or to feel a sense of equality if there’s just more di-
versity in general. It is sometimes hard to run into like Black
women doctors as regularly as it is other folks. I think that
would be awesome if there were just more.
Women of color in this study found difficulty in connect-
ing with white health care providers, and they often expressed
fear of judgment and potential or actual experiences of dis-
criminatory care. By connecting with providers of color who
shared commonalities of experience and/or an understand-
ing of marginalization, participants felt more comfortable and
therefore were more trusting of the care they received.
Supportive Health System Structures
Participants highlighted a need for health care systems to be
supportive and adaptable for the specific needs of women of
color, particularly related to co-location of services, insurance
transferability, flexibility for appointment times, and wanting
to see efforts toward reducing implicit bias within the health
system. When patients had to travel to different locations for
various aspects of care, there was increased potential for ex-
acerbation of illness for patients, especially those with limited
resources. One participant described a need for better access
to multiple services during her high-risk pregnancy:
I feel if you knew I was high risk then you should have
helped me with whatever resources I needed, not sending
me to another doctor for my blood pressure medicine, not
sending me to another psychologist when I’m stressed, run-
ning me all over the place.
Along with wanting co-located services, issues around in-
surance coverage and not having recommended care as a cov-
ered benefit arose for several women. One participant who
relocated during her pregnancy, but whose public insurance
restricted her to one particular county, needed her insur-
ance coverage to match care recommended by health care
providers:
It would just be nice if you could make sure that what I’m
getting is what I’m getting and that I don’t have to come
back for another BS appointment and be told that I’m not
covered and have to come back next time.
Not only was denial of care frustrating, the time taken to
travel repeatedly to a different county for care served as an
additional barrier to receiving appropriate care.
Participants also wanted health care providers to be con-
siderate of time, both in scheduling clinic appointments and
470 Volume 65, No. 4, July/August 2020
in having to wait to be seen. Despite immense efforts, partici-
pants’ caregiving responsibilities, employment commitments,
and transportation issues sometimes affected their ability to
arrive on time for appointments with consistency. Requesting
leniency for when delays occurred and participants could not
arrive exactly at their appointment times was common:
You know, getting around, transportation and stuff like that
and trying to get here and there, and it’s just like I have to
be seen every week. You need to have some kind of consid-
eration if I’m a little late.
Education to Reduce Judgment, Stereotyping, and
Discrimination
An important subtheme that emerged regarding recommen-
dations for health services was aimed at addressing stereotyp-
ing, judgment, and discrimination that existed at both indi-
vidual and system levels for women of color. As shared by one
participant regarding bias and equitable treatment:
Just like how they would treat the next person that they
see every day. Don’t see me for somebody different. I’m a
human being just like you. You’ve made mistakes. Just be-
cause of my mistakes are a little bit different than yours
doesn’t mean that you’re different than I am, you know?
[ …] It doesn’t matter what color you are. Everybody has
to be treated the same way.
In reflecting on their individual struggles around in-
equitable care as patients and a desire to decrease racism and
discrimination in health care settings, participants recom-
mended implicit bias training and education for all health care
workers. One participant shared her recognition that health
care providers are not adequately trained to deal with their bi-
ases:
It’s really interesting to recognize that maybe there isn’t
enough training to try to deal with those biases in these
professions before they’re actually out there in the field, ac-
tually like implementing their biases in ways that like re-
ally affect people. [ .. .] I doubt there’s substantial diversity
training.
Furthermore, participants recommended trainings that
moved beyond lecture and brought in lived experience:
[Training shouldn’t be] like just one day where you go and
listen to some statistics. Like make you listen to stories. Like
you need to interact with actual people to recognize that
there is no one type of one like person, not all of this kind
of person are going to be this way. [ .. .] So, if doctors are
coming in with their own set of discriminatory beliefs then
that’s going to have an impact on their patients.
Participants disputed the idea that medical and nursing
education in the United States is free from bias and recom-
mending updating textbooks to better reflect diversity and
reduce prejudicial teaching. One participant described how
many biases in education are likely introduced through text-
books that represent structural racism and othering:
I mean that starts in school. It starts with the chapter in
your book that’s like, “Oh, this is how to greet an African
American.” It’s like, “Here’s how to greet a Hispanic per-
son. This is what Hispanic people believe.” [ .. .] And I’m
like, “No, wait. That’s not what I think at all.” You know?
Like that’s crazy. It starts with the books. Like that chapter
needs to go.
DISCUSSION
Participants in this study highlighted several recommenda-
tions for improvement in patient-provider interactions, in-
cluding spending time engaging with patients, connecting
and building relationships, providing individualized women-
centered care, and being open to a true partnership in deci-
sion making. Systems-level recommendations included hav-
ing opportunity for continuity of care, health care provider
availability that allows for racial concordance, and support-
ive health services structures that enable women of color to
more easily and effectively receive needed services. As judg-
ment and discrimination played a role in participants’ experi-
ences, health system recommendations also included training
for providers and removing biased language from textbooks
and coursework.
Many of the recommendations shared by participants
have support in the existing literature. Evidence in support
of person-centered care is extensive, particularly in the repro-
ductive health arena.25-29 Elements of person-centered care,
including individualized care, communication, creating part-
nerships in autonomy and decision making, and building re-
lationships, are well documented as ways to improve the ex-
perience and quality of health care, especially with women
of color.14,29,30 Respectful perinatal care, in relation to ex-
periences of respect, autonomy, and mistreatment, has also
been extensively studied and reported upon.14,26,30 Systems-
level issues such as fragmented care, inflexible schedules, and
long wait times are widely known as issues in the current
health care system, often disproportionately affecting people
of color.13,31 Potential solutions that have been shown to im-
prove care experience include care navigation and an empha-
sis on continuity of care.32-34
The presence of racism and discrimination in participant
encounters was not surprising and illuminates a disturbing
reality that participants still experience multiple perva-
sive episodes of discriminatory care. The fact that several
participants brought up the need for health care provider
training, without knowledge that these trainings exist and
are considered a compulsory part of continuing education
for most health care facilities, further demonstrates how
trainings often do not effect change in behavior.35,36 Other
modalities for reducing judgment and discrimination in
providers are needed to create spaces where women of color
feel safe to receive care. Experience-based co-design is one
promising participatory approach that aims to change health
systems by employing patient experience as a tool to inform
changes in health care policy and clinical practice.37,38
Racial concordance and the availability of health care
providers of color have been documented as a modality for
increasing trust and respect for people of color.39,40 Learn-
ing and practicing environments are often perceived as un-
safe and unsupported because of discrimination across pro-
fessional relationships and the burden of often being the only
Journal of Midwifery & Women’s Health � www.jmwh.org 471
learner or provider of color.41,42 Furthermore, like patients of
color who desire race concordant care, learners of color do not
see themselves reflected in the faculty in predominantly white
institutions, which provide the majority of health care train-
ing programs.43 There is a great need for increasing opportu-
nity and decreasing barriers for people of color to succeed and
thrive as providers, not only for providers themselves but also
for patients who deserve unbiased and compassionate care.
A major strength of this study is the diverse sample of
women of color from varying backgrounds who were able to
provide their insight from within several health care systems.
In addition to racial and ethnic diversity, the study includes 55
birth experiences across a wide range of health care providers,
clinic structures, and hospitals in the Bay Area. Limitations in-
clude generalizability because of the small locality and sample
size. The use of thematic analysis within secondary analyses
has its own limitations, such as bias related to the original in-
terview methodology and research questions; however, mea-
sures were taken to avoid these pitfalls, and developed themes
were confirmed by multiple authors in separate analyses.24
Despite these limitations, the experiences of these participants
are insightful and provide actionable steps for improving the
health care experiences for women of color during pregnancy
and birth.
Participants in this study shared specific and practical
ways in which health care providers can improve pregnancy
and birth care for women of color. In addition to the direct
implications of these recommendations, there is a need to lis-
ten closely to the voices of women of color as experts on their
experiences in order to create effective and actual change.
Community-centered research driven by and for women of
color is essential to improve health disparities around preg-
nancy and birth.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
This research was supported by the University of California,
San Francisco Preterm Birth Initiative Transdisciplinary Post-
doctoral Fellowship, funded by Marc and Lynne Benioff and
the Bill and Melinda Gates Foundation. We thank our com-
munity partnering organization, Homeless Prenatal Program,
and the participants who shared their stories and experiences
to advance health equity. This work was presented in part
at the American Public Health Association’s Annual Meeting
& Expo (November 2018, San Diego, CA) and the Ameri-
can College of Nurse-Midwives Annual Meeting & Exhibition
(May 2019, Washington, DC).
REFERENCES
1.Bowleg L. The problem with the phrase women and minorities: in-
tersectionality – an important theoretical framework for public health.
Am J Public Health. 2012;102(7):1267-1273.
2.Braveman PA, Heck K, Egerter S, et al. The role of socioeconomic fac-
tors in Black-White disparities in preterm birth. Am J Public Health.
2015;105(4):694-702.
3.Davis DA. Reproductive Injustice: Racism, Pregnancy, and Prema-
ture Birth. New York: New York University Press; 2019.
4.Burris HH, Hacker MR. Birth outcome racial disparities: a result
of intersecting social and environmental factors. Semin Perinatol.
2017;41(6):360-366.
5.Rosenthal L, Lobel M. Explaining racial disparities in adverse birth
outcomes: unique sources of stress for Black American women. Soc
Sci Med. 2011;72(6):977-983.
6.Wallace M, Crear-Perry J, Richardson L, Tarver M, Theall K. Separate
and unequal: structural racism and infant mortality in the US. Health
Place. 2017;45:140-144.
7.Wallace ME, Green C, Richardson L, Theall K, Crear-Perry J. “Look
at the whole me”: a mixed-methods examination of black infant mor-
tality in the US through women’s lived experiences and community
context. Int J Environ Res Public Health. 2017;14(7):E727.
8.Neggers YH. Trends in maternal mortality in the United States. Re-
prod Toxicol. 2016;65:72-76.
9.Kennedy HP, Cheyney M, Dahlen HG, et al. Asking different ques-
tions: a call to action for research to improve the quality of care for
every woman, every child. Birth. 2018;45(3):222-231.
10.Shavers VL, Fagan P, Jones D, et al. The state of research on
racial/ethnic discrimination in the receipt of health care. Am J Pub-
lic Health. 2012;102(5):953-966.
11.FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a sys-
tematic review. BMC Med Ethics. 2017;18(1):19-37.
12.Blair IV, Steiner JF, Fairclough DL, et al. Clinicians’ implicit eth-
nic/racial bias and perceptions of care among Black and Latino pa-
tients. Ann Fam Med. 2013;11(1):43-52.
13.Salm Ward TC, Mazul M, Ngui EM, Bridgewater FD, Harley AE.
“You learn to go last”: perceptions of prenatal care experiences
among African-American women with limited incomes. Matern
Child Health J. 2013;17(10):1753-1759.
14.McLemore MR, Altman MR, Cooper N, Williams S, Rand L, Franck
L. Health care experiences of pregnant, birthing and postpartum
women of color at risk for preterm birth. Soc Sci Med. 2018;201:127-
135.
15.Cuevas AG, O’Brien K, Saha S. African American experiences in
healthcare: “I always feel like I’m getting skipped over.” Health Psy-
chol. 2016;35(9):987-995.
16.Lori JR, Yi CH, Martyn KK. Provider characteristics desired by African
American women in prenatal care. J Transcult Nurs. 2011;22(1):71-
76.
17.Yee LM, Simon MA. Perceptions of coercion, discrimination and
other negative experiences in postpartum contraceptive counseling
for low-income minority women. J Health Care Poor Underserved.
2011;22(4):1387-1400.
18.Giurgescu C, Banks A, Dancy BL, Norr K. African American women’s
views of factors impacting preterm birth. MCN Am J Matern Child
Nurs. 2013;38(4):229-234.
19.Nuru-Jeter A, Dominguez TP, Hammond WP, et al. “It’s the skin
you’re in”: African-American women talk about their experiences of
racism. An exploratory study to develop measures of racism for birth
outcome studies. Matern Child Health J. 2009;13(1):29-39.
20.Verbiest S, Tully K, Simpson M, Stuebe A. Elevating mothers’ voices:
recommendations for improved patient-centered postpartum. J Behav
Med. 2018;41(5):577-590.
21.Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I,
Franck LS, Lyndon A. Information and power: women of color’s expe-
riences interacting with health care providers in pregnancy and birth.
Soc Sci Med. 2019;238:112491
22.Schatzman L. Dimensional analysis: notes on an alternative approach
to the grounding of theory in qualitative research. In Maines DR, ed.
Social Organization and Social Process: Essays in Honor of Anselm
Strauss. New York: Aldine de Gruyter; 1991:303-314.
23.Clarke AE. Situational analyses: grounded theory mapping after the
postmodern turn. Symbolic Interact. 2003;26(4):553-576.
24.Braun V, Clarke V, Terry G. Thematic analysis. In: Rohleder P, Lyons
AC, eds. Qualitative Research in Clinical and Health Psychology.
Basingstoke, UK: Palgrave MacMillan; 2014;24:95-114.
472 Volume 65, No. 4, July/August 2020
25.Rubashkin N, Warnock R, Diamond-Smith N. A systematic review of
person-centered care interventions to improve quality of facility-based
delivery. Reprod Health. 2018;15(1):169-191.
26.Vedam S, Stoll K, McRae DN, et al; Changing Childbirth in British
Columbia Steering Committee. Patient-led decision making: measur-
ing autonomy and respect in Canadian maternity care. Patient Educ
Couns. 2019;102(3):586-594.
27.Hunter A, Devane D, Houghton C, Grealish A, Tully A, Smith V.
Woman-centred care during pregnancy and birth in Ireland: the-
matic analysis of women’s and clinicians’ experiences. BMC Preg-
nancy Childbirth. 2017;17(1):322-333.
28.de Labrusse C, Ramelet AS, Humphrey T, Maclennan SJ. Patient-
centered care in maternity services: a critical appraisal and synthesis
of the literature. Womens Health Issues. 2016;26(1):100-109.
29.Mazul MC, Salm Ward TC, Ngui EM. Anatomy of good prenatal
care: perspectives of low income African-American women on barri-
ers and facilitators to prenatal care. J Racial Ethn Health Disparities.
2017;4(1):79-86.
30.Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers sur-
vey: inequity and mistreatment during pregnancy and childbirth in the
United States. Reprod Health. 2019;16(1):77-95.
31.Hanson JD. Understanding prenatal health care for American In-
dian women in a Northern Plains tribe. J Transcult Nurs. 2012;23(1):
29-37.
32.Austad K, Chary A, Martinez B, et al. Obstetric care navigation: a new
approach to promote respectful maternity care and overcome barriers
to safe motherhood. Reprod Health. 2017;14(1):148-156.
33.Perdok H, Verhoeven CJ, van Dillen J, et al. Continuity of care is an
important and distinct aspect of childbirth experience: findings of a
survey evaluating experienced continuity of care, experienced quality
of care and women’s perception of labor. BMC Pregnancy Childbirth.
2018;18(1):13-22.
34.Phillippi JC, Holley SL, Payne K, Schorn MN, Karp SM. Facilita-
tors of prenatal care in an exemplar urban clinic. Women Birth.
2016;29(2):160-167.
35.Shepherd SM. Cultural awareness workshops: limitations and practical
consequences. BMC Med Educ. 2019;19(1):14-23.
36.Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence
education for health professionals. Cochrane Database Syst Rev.
2014;(5):CD009405.
37.Sharpe AN, Waring GJ, Rees J, McGarry K, Hinshaw K. Caesarean sec-
tion at maternal request–the differing views of patients and healthcare
professionals: a questionnaire based study. Eur J Obstet Gynecol Re-
prod Biol. 2015;192:54-60.
38.Kenyon SL, Johns N, Duggal S, Hewston R, Gale N. Improving the
care pathway for women who request caesarean section: an experience-
based co-design study. BMC Pregnancy Childbirth. 2016;16(1):348-
361.
39.Abbyad C, Robertson TR. African American women’s preparation
for childbirth from the perspective of African American health-care
providers. J Perinat Educ. 2011;20(1):45-53.
40.Shen MJ, Peterson EB, Costas-Muñiz R, et al. The effects of race
and racial concordance on patient-physician communication: a sys-
tematic review of the literature. J Racial Ethn Health Disparities.
2018;5(1):117-140.
41.Wren Serbin J, Donnelly E. The impact of racism and midwifery’s lack
of racial diversity: a literature review. J Midwifery Womens Health.
2016;61(6):694-706.
42.Kennedy HP, Erickson-Owens D, Davis JA. Voices of diversity in mid-
wifery: a qualitative research study. J Midwifery Womens Health.
2006;51(2):85-90.
43.Meyers LC, Brown AM, Moneta-Koehler L, Chalkley R. Survey of
checkpoints along the pathway to diverse biomedical research faculty.
PLoS One. 2018;13(1):e0190606.
Journal of Midwifery & Women’s Health � www.jmwh.org 473
Title:More than a “Number”: Perspectives of Prenatal Care Quality from Mothers of Color and
Providers
Authors’ Names and Affiliations:
Sheryl L. Coley, DrPH1,2, Jasmine Y. Zapata, MD, MPH3,4, Rebecca J. Schwei, MPH2,5, Glen
Ellen Mihalovic, BS2, Maya N. Matabele2,6, Elizabeth A. Jacobs, MD, MAPP2,7, Cynthie K.
Anderson, MD, MPH
8
1 Health Disparities Research Scholars Program, University of Wisconsin Madison,
Madison, WI
2 Department of Medicine, University of Wisconsin Madison, Madison, WI
3 Department of Pediatrics, University of Wisconsin Madison, Madison, WI
4 Preventive Medicine and Public Health Residency Program, University of Wisconsin Madison,
Madison, WI
5 BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison,
Madison, WI
6 University of Wisconsin Milwaukee, Milwaukee, WI
7 Dell Medical School, University of Texas Austin, Austin, TX
8 Department of Obstetrics & Gynecology, University of Wisconsin Madison, Madison, WI
Corresponding Author:
Sheryl L. Coley, DrPH
University of Wisconsin Madison School of Medicine and Public Health
610 Walnut Street, WARF Building 9th Floor, Suite 95
7
Madison, WI 53726
Phone: 919-698-070
9
Email: scoley2@wisc.edu
Acknowledgments
The authors thank Drs. Jennifer Edgoose, Deborah Ehrenthal, and Jonas Lee for comments in the
early design of the study. Thanks goes to Ryan Garske for work in preliminary analyses. This
project was supported, in part, by the following sources: National Institute of Child Health and
Human Development (NIH/NICHD) Research in Health Disparities Program, grant
5T32HD049302; University of Wisconsin-Madison Departments of Obstetrics and Gynecology,
© 2017 published by Elsevier. This manuscript is made available under the Elsevier user license
https://www.elsevier.com/open-access/userlicense/1.0/
Version of Record: https://www.sciencedirect.com/science/article/pii/S1049386717301044
Manuscript_a9812a600a4d977022985324c53d793d
https://www.elsevier.com/open-access/userlicense/1.0/
https://www.sciencedirect.com/science/article/pii/S1049386717301044
Medicine, Family Medicine and Community Health, and Pediatrics; University of Wisconsin
Health Innovation Program, School of Medicine and Public Health from The Wisconsin
Partnership Program, and the Community-Academic Partnerships core of the University of
Wisconsin Institute for Clinical and Translational Research (UW ICTR) through the National
Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. This content is
solely the responsibility of the authors and does not necessarily represent the official views of the
NIH nor NICHD. These funding agencies had no input with data collection, analyses, nor writing
of this manuscript for this study.
Declaration of Conflicting Interests: The authors have no conflict of interest in the data
collection, analyses, nor writing of this manuscript.
Dr. Coley had full access to all the data in the study and takes responsibility for the integrity of
the data and the accuracy of the data analysis.
1
Title: More than a “Number”: Perspectives of Prenatal Care Quality from Mothers of Color and
Providers
Abstract:
Introduction: African-American mothers and other mothers of historically underserved
populations consistently have higher rates of adverse birth outcomes than White mothers.
Increasing prenatal care use among these mothers may reduce these disparities. Most prenatal
care research focuses on prenatal care adequacy rather than concepts of quality. Even less
research examines the dual perspectives of African-American mothers and prenatal care
providers. In this qualitative study, we compared perceptions of prenatal care quality between
African-American and Mixed-Race mothers and prenatal care providers.
Methods: Prenatal care providers (n=20) and mothers who recently gave birth (n=19) completed
semi-structured interviews. Using a thematic analysis approach and Donabedian’s conceptual
model of health care quality, interviews were analyzed to identify key themes and summarize
differences in perspectives between providers and mothers.
Findings: Mothers and providers valued the tailoring of care based on individual needs and
functional patient-provider relationships as key elements of prenatal care quality.
Providers
acknowledged the need for knowing the social context of patients, but mothers and providers
differed in perspectives of “culturally sensitive” prenatal care. Although most mothers had
positive prenatal care experiences, mothers also recalled multiple complications with providers’
negative assumptions and disregard for mothers’ options in care.
Conclusions: Exploring strategies to strengthen patient-provider interactions and communication
during prenatal care visits remains critical to address for facilitating continuity of care for
2
mothers of color. These findings warrant further investigation of dual patient and provider
perspectives of culturally sensitive prenatal care to address the service needs of African-
American and Mixed-Race mothers.
Introduction
Racial disparities in adverse birth and obstetrical outcomes between African-American and
White mothers are well-documented (Bryant, Worjoloh, Caughey, & Washington, 2010;
Hamilton, Martin, Osterman, Curtin, & Mathews, 2015; US Office of Minority Health, 2012).
African-American mothers are also consistently less likely to receive adequate prenatal care in
comparison to White mothers nationwide (Bryant et al., 2010; US Department of Health and
Human Services, 2013), and they are approximately 2.3 times more likely than non-Hispanic
White mothers to either initiate prenatal care late in the third trimester or not obtain prenatal care
at all (US Office of Minority Health, 2012). Although research is inconclusive about how
prenatal care reduces birth outcome disparities (Walford, Trinh, Wiencrot, & Lu, 2011), previous
studies found associations between inadequate prenatal care utilization and adverse outcomes in
preterm births, low birth weight births, and neonatal mortality (Cox, Zhang, Zotti, & Graham,
2011; Kitsantas & Gaffney, 2010).
Despite the extensive research on prenatal care, fewer studies investigate concepts of prenatal
care quality and perspectives of African-American mothers. Most studies primarily focus on
adequacy of prenatal care use with limited attention to content or quality of care (Alexander &
Kotelchuck, 2001; Sword et al., 2012). Few studies (Handler, Raube, Kelley, & Giachello, 1996;
Lori, Yi, & Martyn, 2011; Mazul, Salm Ward, & Ngui, 2017; Wheatley, Kelley, Peacock, &
Delgado, 2008) focus on perspectives of prenatal care quality from African-American mothers
3
and other mothers of color. Studies that focus on mothers of color have not simultaneously
explored providers’ perspectives on prenatal care quality. Only one study (Dahlem, Villarruel, &
Ronis, 2014) that examined interpersonal communication found that quality patient-provider
interactions between African-American mothers and their providers were positively associated
with trust that mothers had toward providers and satisfaction with prenatal care. Given that the
delivery and receipt of prenatal care is a reciprocal process between providers and mothers, more
research is needed to assess differences in priorities for health care quality between these groups
for increasing quality patient-provider interactions.
As disparities in quality of care persist between African Americans and Whites (Agency for
Healthcare Research and Quality [AHRQ], 2015), and African-American mothers report more
adverse experiences with prenatal care than White mothers (Wheatley, Kelley, Peacock, &
Delgado, 2008), it is important to understand and address factors that underlie these differences.
One factor that might contribute to disparities could be differences in perceptions of person-
centered care, defined as care that “ensures that each person and family is engaged as partners in
their care quality” (AHRQ, 2015). Given ongoing advocacy for further examination of patient-
provider-system interactions in prenatal care (Alexander & Kotelchuck, 2001; Mazul, Salm
Ward, & Ngui, 2017) and current attention to decrease disparities in person-centered care,
elements that African-American and other mothers of color identified as aspects of prenatal care
quality should be further explored rather than a simple focus on quantity.
In this qualitative study, we compared perceptions of prenatal care quality between African-
American and Mixed-Race mothers and maternal care providers. Using Donabedian’s (1988)
model of health care quality to inform findings, we examined perceptions regarding aspects of
quality related to prenatal care structure and processes with focused attention to patient-provider
4
interactions and perspectives on person-centered care. As a second research aim, we compared
perceptions of prenatal care quality between privately-insured and Medicaid-insured mothers to
identify differences in perceptions between mothers of differing socioeconomic circumstances
(SES) using insurance type as an indicator.
Methods
Study setting and recruitment
This study took place in Southern Wisconsin, a state that ranks high in racial disparities in
adverse birth outcomes between African-American, Mixed-Race, and White mothers (March of
Dimes, 2016; Onheiber & Pearson, 2012, Wisconsin Department of Health and Human Services,
2016). From March 2015 through December 2016, fourteen clinics served as recruitment sites,
including private and academic medical centers and federally qualified health centers offering a
variety of prenatal care services with individual, group, and midwifery care.
Through purposive sampling, we recruited a diverse range of prenatal providers by provider type
and mothers who varied by education, insurance status, and number of children. Based on
previous qualitative research recommendations (Creswell, 2013), we initially sought to recruit
thirty mothers and providers to obtain saturation. Thirty-nine mothers and providers were
recruited through flyers at clinics and community events, emails through clinic and community
list serves, and snowball recruitment in which participants who completed the study recruited
other mothers and providers. We selectively recruited African-American mothers because the
largest racial disparities in birth outcomes exist between African-American and White mothers.
We also included mothers who self-identified as Black or African American and one or more
other races (i.e. Native American or White) given the social complexities that could occur with
5
Mixed-Race identities (Harris & Sim, 2002; Rockquemore, Brunsma, & Delgado, 2009; Storrs,
1999). Eligible mothers met the following criteria: childbirth within 6 months of study
recruitment, age 18 years old and over at the time of their infants’ birth, had one or more prenatal
care visits during pregnancy, residency within the county throughout the pregnancy, and delivery
at a hospital within the county. Eligible prenatal providers included active obstetrics and
gynecology (OB/GYN) physicians and residents, family medicine physicians and residents,
nurse-midwives, and nurse practitioners. The University of Wisconsin Madison institutional
review board deemed this study exempt from IRB review under section 45 CFR 46.101(b)(2).
Data collection
The first author conducted all interviews in-person using semi-structured interview guides.
Demographic information was collected from participants through self-report before their
interviews (Table 1). Given the importance that insurance has for women to obtain prenatal care,
we used the insurance variable to categorize women into privately-insured and Medicaid-insured
groups to assess differences in perceptions between mothers.
As in previous research (Salm Ward, Mazul, Ngui, Bridgewater, & Harley, 2013; Sword et al.,
2012), the interview guides included open-ended questions such as “How would you describe
quality prenatal care?”, allowing the interviewer to incorporate an inductive approach and
mothers and providers to express views in their own words. For maximizing relevance of study
findings to clinical and community program needs, open-ended questions stemmed from
previous research (Salm Ward et al., 2013; Sword et al., 2012; Wheatley et al., 2008) and
discussions with physicians and program managers of two African-American community-based
prenatal support organizations in Wisconsin. Topics explored through the questions include
6
initiation of prenatal care, barriers and facilitators to getting visits, communication between
mothers and providers, nurses, and ancillary staff, and education on prenatal topics as
recommended by the American College of Obstetrics and Gynecologists (ACOG). Analyses for
interview transcripts occurred in tandem with new interviews, and new questions were developed
to inquire about new concepts that emerged. Data saturation was reached when the last 2
interviews for providers and mothers did not generate new concepts for investigation.
Each interview was conducted in spaces convenient to the participants in clinics, mothers’
homes, or library rooms. All participants gave verbal informed consent before each interview
and received $25 gift cards in appreciation for their time. To protect study participants’
identities, interview guides did not have questions about personal information (ex. Name,
birthdate), and participants were given subject ID numbers for identifiers during data analyses.
Each interview lasted approximately 30-45 minutes, was audio-recorded, and transcribed
verbatim.
Analyses
The five-member analysis team used thematic analysis techniques (Boyatzis, 1998) for
identifying key themes and patterns in the interview transcripts. This type of qualitative analysis
gives the flexibility to incorporate inductive analysis based on participants’ voices and deductive
analysis along with codes stemming from previous studies. A preliminary codebook was
developed using a priori codes from previous research (Sword et al., 2012). Additional codes
were then established using an inductive approach in which the first maternal and provider
interview transcripts was read in full for content, then open-coding techniques were used to
assign conceptual codes to meaningful segments of text. This coding scheme was applied for the
7
remaining interviews with additional codes established as new concepts emerged from the
interviews.
To establish coding reliability, the analysis team took the following steps (Boyatzis, 1998). Two
members coded each transcript as one of the most common ways of establishing reliability. Each
analysis team member first independently read transcripts and coded interviews using the
codebook. Inter-rater reliability was checked through calculating percentage agreement of
themes between coders before the coding teams met for consensus. The consensus meetings then
occurred to discuss coding discrepancies and discuss changes to the codebook based on
additional themes that emerged.
Next, we identified and compared recurring themes between and within groups of mothers and
providers using memos, data matrices, and consensus meetings. Differences in mothers’
experiences were explored by their categorization as “privately-insured” or “Medicaid-insured”.
Differences in providers’ experiences were assessed by provider type. NVIVO was used as a
data retrieval tool for coding. An audit trail was maintained of coding decisions and theme
identification and comparison throughout the analysis process.
To enhance relevance of our findings to current prenatal care quality research (Sword et al.,
2012), emergent themes were mapped to broader categories that reflect Donabedian’s (1988)
conceptual model of health care quality. Although conceptual frameworks are not widely used in
qualitative research, they can be used for applied research like this study that focuses on policy-
driven outcomes (Pope, Ziebland, & Mays, 2000). The Donebedian model proposes that three
main constructs constitute health care quality: 1) structure, which refers to the environmental
context where care is provided (i.e. clinic resources, medical organization of care), 2) process,
8
which encompasses technical and interpersonal aspects on how providers care for patients, how
patients receive care, and patient-provider interactions, and 3) outcomes, which refers to patient
health status measures related to health care and satisfaction of care received. Illustrative
quotations were extracted from the transcripts for each construct.
Results
Table 1 provides the demographics of providers (n=20) and African-American and Mixed-Race
mothers (n=19) who participated in the study. Table 2 maps the following themes identified from
the interviews with Donebedian’s health care constructs of structure, process, and outcomes.
Most themes related to the process construct, specifically patient-provider interactions.
Construct 1: Structure
Mothers and providers agreed that “quality prenatal care” includes care being accessible
throughout the pregnancy period regarding appointment availability and clinic resources. One
family medicine doctor noted:
I think it needs to be accessible both in terms of having [it] in a physical facility that’s going
to be convenient for the patient… in terms of economics, having insurance that’s going to
cover everything, and then with available appointments, being able to get in.
Some mothers and providers also valued care that unifies the prenatal care process with
childbirth and postpartum care. One Mixed-Race mother commented on the segmented
organization of maternal care:
9
I feel like [maternal care is] a very fragmented process… it would be so nice if it was like,
I’m going to help you through this process of becoming a parent … it feels very fragmented
and un-unifying when I think what you want is care that unifies you and your baby.
Differences in other structural elements of health care quality emerged between providers and
mothers. Although mothers did not mention benefits to team approaches to prenatal care
delivery, providers viewed access to good clinic teams as important aspects of prenatal care
quality, as these family medicine and OB/GYN doctors note:
I think having a team approach with some nurses who are dedicated to coordinating things,
the physician assistant and the team approach, in some ways, it spreads out the workload, but
it also doesn’t put the burden on one person. And so then I think things don’t get dropped.
I also think having a good clinical staff is important because the physician tends to be very
busy with not only prenatal care but also GYN care…
Structural barriers to prenatal care for mothers included scheduling issues with clinic staff, with
this problem recalled more than transportation issues hindering prenatal care access. More
Medicaid-insured mothers experienced structural issues than privately-insured mothers, as
exemplified by this African-American mother’s experience:
[OB/GYN doctor] always told me that if you miss an appointment, call right away and get in
that week. So one time I did miss an appointment, and I called to reschedule it, and [clinic
staff] told me that it was only an annual check visit, we don’t have anything this week, why
don’t you just come in your next appointment…
10
Construct 2: Process
When describing “quality prenatal care” relative to visit activities, themes emerged relative to
patient-centeredness, communication of testing and options, and cultural competence or
sensitivity.
Patient-Centeredness
Providers and mothers overwhelmingly valued care characteristics that indicate a patient-
centered approach which include: compassionate care that is tailored to the mothers’ needs,
functional relationship built between mothers and providers, effective providers’ responses to
patient questions, prenatal education for mothers to be well informed, and care that encompasses
the “whole woman.” One midwife explained:
We try to treat the entire woman and her family, so we’re very much family-centered care, as
well. So we look at all of, many socioeconomic factors when we’re looking, when we’re
doing, providing the prenatal care.
As an example of compassionate care, one Mixed-Race mother expressed appreciation for her
OB/GYN doctor who tailored her care with empathy concerning her past experiences with
miscarriages:
I think there was a level of understanding there where [OB/GYN doctor] put herself in my
shoes and could maybe empathize with how I was feeling about the pregnancy based on our
previous history and like based on how things started there.
11
Cultural Competence (Sensitivity)
Although both groups agreed on an overall picture of patient-centered prenatal care, perspectives
differed on how this care translates into practice, particularly regarding “cultural competence” or
“cultural sensitivity.” Some providers had skeptical views about cultural competence:
I don’t have any “cultural competence”… whether we’re talking about a different culture like
a different ethnic background or we’re talking about a different culture like different
socioeconomics, if you are my patient, I don’t know what your background is or what your
challenges are until we talk about it.
Although mothers value providers who treat patients on a case-by-case basis, mothers want
providers to learn of needs specifically affecting mothers of color, as this African-American
mother explains:
Culturally sensitive is being aware of if you have a sickle-cell patient, for example, really
doing your homework on the emotional side of what it means to have sickle cell, the
prevalence of it in the African-American community.
Mothers also felt that lack of providers’ cultural competence could lead to implicit bias and
erroneous assumptions that providers make about mothers. One Mixed-Race mother described
her experience with her perinatal care team:
It’s not even on their wavelength of how, based on implicit bias, or whatever, they may treat
someone differently…It’s not a part of their everyday conversation when it should be, or
their thought process. For them, they know what statistics tell them. You know what I mean?
It’s, we’re numbers and not people.
12
The need for culturally competent or culturally sensitive care appeared to have greater value to
mothers, specifically care where providers do not make assumptions or have judgments about
their social or economic circumstances. In comparing Medicaid and privately-insured mothers,
providers’ negative assumptions were noted almost entirely among the privately-insured African-
American and Mixed-Race mothers rather than Medicaid-insured mothers:
A lot of times there was an assumption. Like [providers] just assumed that I was on
BadgerCare [Medicaid]. I’m like, uh no, I’m not actually. You know, I have my own plan…
So I think quality is, don’t treat me like the way you treated the other women on
BadgerCare…
Testing and Options
Overall, mothers’ perceptions of prenatal care quality centered on interpersonal processes of
prenatal visits. In contrast, providers concentrated more on activities that constitute “quality
prenatal care” based on American College of Obstetrics and Gynecology (ACOG) standards,
such as completion of required tests and communicating information to the patient. One
OB/GYN doctor commented:
Quality prenatal care from our perspective, from the physician’s perspective, is making sure
that each patient has had all the lab testing that they need as part of the pregnancy… So to
provide quality care, every patient has to have that information because if there is something
amiss, we need to figure it out.
Although most mothers acknowledged the need for testing, mothers also expressed the need for
providers to communicate options in care and the ability to provide consent without coercion.
Pressure to consent to optional tests and procedures caused great concern for mothers. This
13
mother experienced pressure to complete an unwanted test, which prompted her to switch
providers:
She just kind of kept pushing [genetic testing]. And I asked her, why do you do that with
women where you try to, you know, get them to do tests, and they opt out of it? And her
response was, you know, so that way if you wanted a choice to terminate that pregnancy,
then you can have that choice… That’s why I don’t, that’s why I stopped seeing her.
Construct 3: Outcomes
Both groups agreed that “quality prenatal care” should result in satisfaction of mothers in the
care experienced. Some providers also noted the importance of providers being satisfied with the
care given, as one OB/GYN doctor notes:
I feel like it’s so much better when the patients are happy with the care that they’re getting,
but we’re also happy with the care that we are providing them.
However, some mothers felt dissatisfied with the overall process of care they received when
continuity of care unexpectedly dissolved for labor and delivery and/or postpartum, as one
mother expressed:
I kind of felt a little bit disconnected towards the end of the pregnancy with [provider]. I
know she was busy too, but she wasn’t even at my birth, so I kind of felt like all that time that
we spent… I didn’t really have any closure, you know, with the support that I had.
Another aspect of prenatal care quality for mothers affecting the overall satisfaction of care is the
inclusion of postpartum educational topics such as breastfeeding and contraception. Upon further
14
reflection on mothers’ prenatal and postpartum visits, several expressed dissatisfaction when
their inquiries on postpartum topics were not adequately addressed:
[Provider] did talk about birth control like towards the end, and, (pause) you know, just gave
me some options. But it was kind of, I don’t know, that part was kind of like, how you say it,
it wasn’t as in depth of a conversation… I didn’t feel as sure when I left that appointment as to
what I wanted to do.
Discussion
These findings support the notion that African-American and Mixed-Race mothers and prenatal
care providers have some shared understanding of what constitutes prenatal care quality.
However, important differences include contrasting viewpoints on the importance of cultural
sensitivity and communication of standards of prenatal care while respecting mothers’ value on
having options. The AHRQ US National Healthcare Disparities Report annually documents
racial and ethnic disparities in health care along four concepts: person-centered care, safety,
effectiveness, and timeliness, and our study contributes to the literature by highlighting potential
disparities in patient centeredness.
We also found that privately-insured and publicly-insured mothers of color differed in structural
and process elements of care in which they emphasize negative experiences. As previous
research indicated (Wheatley et al., 2008), Medicaid-insured mothers in this study reported
structural issues with prenatal care access as exemplified by complications of scheduling
appointments with clinic staff. In contrast to previous findings (Attanasio & Kozhimannil, 2015),
privately-insured mothers in our study perceived more problems with negative assumptions and
disrespect during prenatal interactions. These problems for privately-insured mothers relate to
15
the process aspects of prenatal care quality rather than structural elements. The possibility exists
that higher SES mothers have different expectations of care and may view certain provider
interactions differently than lower SES mothers (Attanasio & Kozhimannil, 2015). Future
research can investigate to what extent perspectives within African-American mothers differ
based on SES characteristics; these differences may influence their perspectives of care and may
need direct intervention to enhance perceived quality.
Findings from this study indicate unique differences in perceptions of quality between mothers
and providers, particularly perspectives on cultural sensitivity which might be a relevant aspect
of patient centeredness and overall quality for African-American and Mixed-Race mothers.
Thus, concepts related to cultural sensitivity could be further explored for assessing prenatal care
quality among mothers of color and providers. Racial discordance between mothers and
providers might have also influenced perceptions of quality. Eighteen out of twenty providers in
our study were White. This percentage of White providers is representative of the lack of
diversity in prenatal care providers in the US. Patient-provider communication, trust, and
satisfaction is lower in race-discordant patient-provider relationships (Cooper et al., 2003;
Johnson, Roter, Powe, & Cooper, 2004), and racial discordance may have influenced mothers’
perceptions of their care in this study. The emerging relationships between patient-provider
racial concordance, health care satisfaction, and adherence to recommended care warrant further
attention in research (Dovidio et al, 2008; Earnshaw et al, 2016), and understanding these
relationships is especially relevant in communities where racial discordance between patients
and providers is common.
Our study had some limitations. Because recruitment was targeted to one Midwestern county,
mothers and providers in this study might not represent those in other healthcare settings.
16
Notably, all mothers had either Medicaid or private insurance. Uninsured patients generally
report worse experiences in care (Fiscella & Sanders, 2016), including more barriers in
communication problems (Attanasio & Kozhimannil, 2015). In addition, we recognize that using
insurance status as an indicator for SES may not fully account for differences based on other
socioeconomic factors. Because our provider sample included few midwives or nurse
practitioners and most mothers received care from OB/GYN doctors, our findings primarily
address OB/GYN care. Future studies could dually explore patient and provider perspectives
within family medicine and midwifery care. Finally, data collection was limited to one postnatal
interview per mother, and recall bias could have influenced their recollection of prenatal events.
Future studies can incorporate multiple interviews during prenatal and postpartum periods to
capture thoughts about care during pregnancy and compare to overall experiences.
Implications for Practice and/or Policy
For addressing healthcare disparities, improving mothers’ satisfaction with prenatal care, and
encouraging early initiation and continuity of care for mothers, providers should continue to
focus on ways to enhance patient-provider communication in delivering tailored and culturally
sensitive care. Our findings suggest that many barriers related to prenatal care could be
addressed by strategies to enhance patient-provider communication between providers and
mothers of color. Specifically, these results indicate that prenatal care should encompass more
strategies to enhance provider understanding of patients’ social and cultural context.
Several strategies for assessing patient context and incorporating cultural sensitivity might
facilitate communication between providers and mothers of color, given time limitations for
visits. ACOG (2014) recommendations include patient-centered interviewing, cultural sensitivity
17
training for providers, and strategies to improve shared decision making between mothers and
providers. Improvements to enhance assessments of patients’ social and contextual
circumstances at the initial prenatal visit could facilitate patient-provider communication
throughout pregnancy. Initiatives to increase racial diversity among prenatal providers would
enhance cultural sensitivity toward mothers of color. Also, doula support (Kozhimannil,
Vogelsang, Hardeman, & Prasad, 2016) and alternative prenatal care models such as
CenteringPregnancy© (Ickovics et al., 2011; Lathrop, 2013) can be further explored for
enhancing culturally sensitive prenatal education and support and increasing adequacy of visits
for mothers of color.
Conclusion
Given the continued racial disparities in adverse birth outcomes, developing a shared
understanding of “quality prenatal care” remains important for mothers of color and providers to
collaborate for optimal maternal health and birth outcomes and continuing care postpartum.
Further exploration of attitudes that affect patient-provider interactions is therefore warranted to
improve provider understanding of interpersonal communication, provider training, and patient
education (Thornton, Powe, Roter, & Cooper, 2011). Understanding gaps between patient and
provider perceptions and experiences with prenatal care is critical for the continual improvement
of clinical services and culturally sensitive approaches to prenatal care delivery for mothers of
color.
18
References
Agency for Healthcare Research and Quality. (2015). 2015 National Healthcare Quality and
Disparities Report and 5th Anniversary Update on the National Quality Strategy.
Retrieved July 6, 2017 from
https://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html.
Alexander, G. R., & Kotelchuck, M. (2001). Assessing the role and effectiveness of prenatal
care: history, challenges, and directions for future research. Public Health Reports,
116(4), 306-316.
American College of Obstetricians and Gynecologists. (2014). Effective patient–physician
communication. Committee Opinion No. 587. Obstetrics & Gynecology, 123, 389-393.
Attanasio, L., & Kozhimannil, K. B. (2015). Patient-reported communication quality and
perceived discrimination in maternity care. Medical Care, 53(10), 863-871. doi:
10.1097/mlr.0000000000000411
Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code
development. Thousand Oaks, CA: Sage Publications, Inc.
Bryant, A. S., Worjoloh, A., Caughey, A. B., & Washington, A. E. (2010). Racial/ethnic
disparities in obstetrical outcomes and care: Prevalence and determinants. American
Journal of Obstetrics & Gynecology, 202(4), 335-343. doi: 10.1016/j.ajog.2009.10.864
Cooper, L. A., Roter, D. L., Johnson, R. L., Ford, D. E., Steinwachs, D. M., & Powe, N. R.
(2003). Patient-centered communication, ratings of care, and concordance of patient and
physician race. Annals of Internal Medicine, 139(11), 907-915.
19
Cox, R. G., Zhang, L., Zotti, M. E., & Graham, J. (2011). Prenatal care utilization in Mississippi:
racial disparities and implications for unfavorable birth outcomes. Maternal and Child
Health Journal, 15(7), 931-942. doi: 10.1007/s10995-009-0542-6
Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five
approaches (3rd ed.). Thousand Oaks, CA: Sage.
Dahlem, C. H., Villarruel, A. M., & Ronis, D. L. (2014). African American women and prenatal
care: Perceptions of patient-provider interaction. Western Journal of Nursing Research.
doi: 10.1177/0193945914533747
Donabedian, A. (1988). The quality of care. How can it be assessed? Journal of American
Medical Association (JAMA), 260(12), 1743-1748.
Dovidio, J. F., Penner, L. A., Albrecht, T. L., Norton, W. E., Gaertner, S. L., & Shelton, J. N.
(2008). Disparities and distrust: The implications of psychological processes for
understanding racial disparities in health and health care. Social Science & Medicine,
67(3), 478-486. doi:http://dx.doi.org/10.1016/j.socscimed.2008.03.019
Earnshaw, V. A., Rosenthal, L., Cunningham, S. D., Kershaw, T., Lewis, J., Rising, S. S., . . .
Ickovics, J. R. (2016). Exploring Group Composition among Young, Urban Women of
Color in Prenatal Care: Implications for Satisfaction, Engagement, and Group
Attendance. Women’s Health Issues, 26(1), 110-115.
doi:http://dx.doi.org/10.1016/j.whi.2015.09.011
Fiscella, K., & Sanders, M. R. (2016). Racial and ethnic disparities in the quality of health care.
Annual Review of Public Health, 37, 375-394.
20
Hamilton, B. E., Martin, J. A., Osterman, M. J., Curtin, S. C., & Mathews, T. J. (2015). Births:
Final data for 2014. Hyattsville, MD: National Center for Health Statistics.
Handler, A., Raube, K., Kelley, M. A., & Giachello, A. (1996). Women’s satisfaction with
prenatal care settings: a focus group study. Birth, 23(1), 31-37.
Harris, D. R., & Sim, J. J. (2002). Who is multiracial? Assessing the complexity of lived race.
American Sociological Review, 614-627.
Ickovics, J. R., Reed, E., Magriples, U., Westdahl, C., Rising, S. S., & Kershaw, T. S. (2011).
Effects of group prenatal care on psychosocial risk in pregnancy: Results from a
randomised controlled trial. Psychology & Health, 26(2), 235-250.
Institute of Medicine. (2010). Future Directions for the National Healthcare Quality and
Disparities Reports. Washington, DC: National Academies Press.
Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. A. (2004). Patient race/ethnicity and
quality of patient-physician communication during medical visits. American Journal of
Public Health, 94(12), 2084-2090.
Kitsantas, P., & Gaffney, K. F. (2010). Racial/ethnic disparities in infant mortality. Journal of
Perinatal Medicine, 38(1), 87-94. doi: 10.1515/JPM.2010.014
Kozhimannil, K. B., Vogelsang, C. A., Hardeman, R. R., & Prasad, S. (2016). Disrupting the
Pathways of Social Determinants of Health: Doula Support during Pregnancy and
Childbirth. Journal of the American Board of Family Medicine, 29(3), 308-317. doi:
10.3122/jabfm.2016.03.150300
21
Lathrop, B. (2013). A systematic review comparing group prenatal care to traditional prenatal
care. Nursing for Women’s Health, 17(2), 118-130. doi: 10.1111/1751-486x.12020
Lori, J. R., Yi, C. H., & Martyn, K. K. (2011). Provider characteristics desired by African
American women in prenatal care. Journal of Transcultural Nursing, 22(1), 71-76. doi:
10.1177/1043659610387149
March of Dimes. (2016). 2016 Premature Birth Report Cards. Retrieved February 17, 2017 from
http://www.marchofdimes.org/mission/prematurity-reportcard.aspx.
Mazul, M.C., Salm Ward, T.C. & Ngui, E. M. J. (2017). Anatomy of Good Prenatal Care:
Perspectives of Low Income African-American Women on Barriers and Facilitators to
Prenatal Care. Journal of Racial and Ethnic Health Disparities, 4(1), 79-86.
doi:10.1007/s40615-015-0204-x
Onheiber, P., and Pearson, K. (2012). Wisconsin health facts: Racial and ethnic disparities in
infant mortality. Fact Sheet P-00144-2012. Wisconsin Department of Health Services.
Retrieved June 10, 2016 from https://www.dhs.wisconsin.gov/publications/p0/p00144-
2012
Pope, C., Ziebland, S., & Mays, N. (2000). Analysing qualitative data. BMJ : British Medical
Journal, 320(7227), 114-116.
Rockquemore, K. A., Brunsma, D. L., & Delgado, D. J. (2009). Racing to theory or retheorizing
race? Understanding the struggle to build a multiracial identity theory. Journal of Social
Issues, 65(1), 13-34.
22
Salm Ward, T. C., Mazul, M., Ngui, E. M., Bridgewater, F. D., & Harley, A. E. (2013). “You
learn to go last”: Perceptions of prenatal care experiences among African-American
women with limited incomes. Maternal and Child Health Journal, 17(10), 1753-1759.
doi: 10.1007/s10995-012-1194-5
Storrs, D. (1999). Whiteness as stigma: Essentialist identity work by mixed-race women.
Symbolic Interaction, 22(3), 187-212.
Sword, W., Heaman, M. I., Brooks, S., Tough, S., Janssen, P. A., Young, D., . . . Hutton, E.
(2012). Women’s and care providers’ perspectives of quality prenatal care: a qualitative
descriptive study. BMC Pregnancy Childbirth, 12, 29. doi: 10.1186/1471-2393-12-29
Thornton, R. L. J., Powe, N. R., Roter, D., & Cooper, L. A. (2011). Patient–physician social
concordance, medical visit communication and patients’ perceptions of health care
quality. Patient Education and Counseling, 85(3), e201-e208.
US Department of Health and Human Services. (2013). Maternal, infant, and child health.
Healthy People 2020 Topics & Objectives. Retrieved March 21, 2015 from
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
US Office of Minority Health. (2012). Infant Mortality and African Americans. Retrieved July 6,
2013 from
http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=51&ID=3021
Walford, H. H., Trinh, S., Wiencrot, A., & Lu, M. C. (2011). Chapter 8: What is the role of
prenatal care in reducing racial and ethnic disparities in pregnancy outcomes? In A.
Handler, J. Kennelly & N. Peacock (Eds.), Reducing Racial/Ethnic Disparities in
23
Reproductive and Perinatal Outcomes: The Evidence from Population-Based
Interventions (pp. 152-180). New York, NY: Springer.
Wheatley, R. R., Kelley, M. A., Peacock, N., & Delgado, J. (2008). Women’s narratives on
quality in prenatal care: A multicultural perspective. Qualitative Health Research,
18(11), 1586-1598.
Wisconsin Department of Health Services, Division of Public Health, Office of Health
Informatics. (2016). Wisconsin Interactive Statistics on Health (WISH) data query
system. Retrieved October 19, 2016 from http://dhs.wisconsin.gov/wish.
Table 1. Demographic Characteristics of Providers and
Mothers
Providers
(N=20)
Mothers
(N=19)
Provider Type a
OB/GYN Doctor 8 17
Family Medicine Doctor 8 2
Midwives 2 1
Nurse Practitioner 2 3
Race
Black / African American 1 15
Mixed-Race b 1 4
White 18 0
Gender
Female 14 19
Male 6 n/a
Years of Experience
4 Years or More 15 n/a
Less than 4 Years 5 n/a
Age
18-24 n/a 2
25-34 n/a 13
35 or More n/a 4
Parity
1 or more Older Children n/a 10
None / First-Time Mother n/a 9
Education
High School Graduate n/a 4
Some College n/a 4
Bachelor Degree or More n/a 11
Insurance Status
Private Insurance n/a 10
Medicaid (BadgerCare) n/a 9
a Note for total exceeding 100% for provider type for mothers: Some mothers had more than 1
type of provider during recent pregnancy which is reflected in the numbers and percentages.
b Mixed Race refers to participants that self-identify as two or more races / ethnicities. Only one
provider self-identified as White and an Asian ethnicity. Mixed-Race mothers self-identified as
Black or African American and White and/or Native-American.
Table 2. Donebedian (1988) Concepts and Themes from Interviews
Concepts Providers Mothers
Structure: Clinic resources and
medical organization of care
Accessibility of appointments
and clinic resources
Availability of appointments
Team approach with providers
and staff
Connection of care prenatally
through postpartum
Process: Provider and patient
activities during visits
Patient-centered care tailored
to the individual
Compassionate care
Cultural competency /
sensitivity
Testing by medical standards Choosing options without
pressure
Outcomes: Patient satisfaction
of care and health outcomes
Mothers’ satisfaction of care Satisfaction with continuity
Satisfaction of communication
with postpartum topics