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Health Communication

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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.

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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.

  • Findings
  • 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.

  • Literature review
  • 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?

  • Method
  • 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.

  • Discussion
  • 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

  • Notes
  • 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

  • Funding
  • This work was supported by the Department of Communication,
    University of Wisconsin-Milwaukee [N/A].

  • ORCID
  • Comfort Tosin Adebayo http://orcid.org/0000-0002-1288-2296
    Erin Sahlstein Parcell http://orcid.org/0000-0001-6922-8108

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    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

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    https://doi.org/10.1097/ANS.0000000000000230

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    https://doi.org/10.1080/07491409.2005.10162486

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    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

    • Abstract
    • 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).

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    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

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    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

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