African American Women's Maternal Healthcare Experiences: A Critical Race Theory Perspective

Motivations for and experiences of childbirth abroad amongst Nigerian women: A qualitative study

Birth tourism, the practice of a woman travelling out of her country of residence to another country to give birth, is common globally. Despite this, there is limited literature on the motivations and experiences of women who gave birth abroad. This study aims to address this gap by seeking to understand the motivations for and experiences of childbirth abroad among Nigerian women. Using purposive and snowball sampling, 27 Nigerian women who had children abroad were recruited via social media platforms. In-depth interviews were conducted remotely, audio-recorded, transcribed, and analysed thematically. Braun and Clarke's six-step thematic analysis was used, which included data familiarisation, code generation, searching for themes, reviewing themes, defining themes, and producing the report. We found that motivations for seeking childbirth abroad varied based on the mother's desires for their children, needs, and circumstances. These motivations were formed at different times before and after pregnancy and evolved over time. The experience of childbirth abroad is mostly good. However, there are also bad experiences, with some women feeling like they were treated differently because they were "self-paying" patients, "black", or not country residents. The cost of care is deemed exorbitant, but most pay their bills. Support of loved ones around childbirth abroad was considered crucial, although not always available. Through it all, realising the expected and collateral benefits of childbirth abroad made it all worth it. In conclusion, motivation for childbirth abroad varies and evolves. While globalisation, broken health systems, and ongoing sustained economic challenges in Nigeria and similar settings continue to motivate women to seek childbirth abroad, their experiences of childbirth abroad suggest that though it might be greener on the other side, it is not necessarily dark green. Systems are needed to elevate their voices in the public discourse and safeguard them from bad experiences of childbirth abroad.

Black college women's preventive health behaviors: Applications of a Black Feminist-Womanist research paradigm

OBJECTIVE

The researchers applied Lindsay-Dennis' Black Feminist-Womanist research paradigm to Andersen's Behavioral Model for Health Service Use to guide initial research about Black American women's preventive health behaviors.

METHODS

This article highlights this application, using interpretive phenomenological analysis for qualitative questions assessing how 40 Black college women define health and their experiences in health care. This was part of a larger convergent parallel mixed-methods approach in a 2022 cross-sectional online survey.

RESULTS

Participants defined health as a concept involving health literacy, physical and mental health, and being free from health conditions or disease. Regarding health-related lived experiences, negative experiences were more frequently reported than positive experiences. However, many participants reported both positive and negative health care related experiences. Predisposing, enabling, and need factors were all present in qualitative responses.

CONCLUSIONS

This article highlights the fit of a Black Feminist-Womanist research paradigm to Andersen's model to better understand Black women's health experiences and illustrates ways that medical mistrust, health literacy, and past experiences with health care can influence health service use. Areas for future research on barriers and facilitators to preventive care and implications for reducing health disparities are also discussed.

Obstetric racism, a debate under construction in Brazil: perceptions of black women on obstetric violence

This article aims to know the perception of women on obstetric violence from a racial perspective. This was a qualitative study carried out in a public maternity hospital with 25 women in the city of Salvador, Bahia, Brazil. Data were collected through semi-structured interviews and participant observation from November 2021 to February 2022. Content analysis was used to organize the data obtained through the interviews. The results were analyzed through the theoretical contributions of intersectionality, focusing on the interaction between obstetric violence and obstetric racism. The narratives discuss issues of obstetric violence, institutional racism, and how these experiences are permeated by issues of race, gender, and class. Questions related to the feelings of these women regarding the experience of violence at the time of childbirth care were also highlighted. Obstetric racism denies reproductive rights and hinders access to respectful and equitable care for black women.

Healthcare access for pregnant women in a rural developing country context: Formal and informal institutional challenges

This study examines healthcare access for pregnant women in a rural developing country context. Drawing upon institutional theory and Levesque et al's model of access, the study finds pregnant women face challenges both of a formal and informal nature in accessing healthcare. The findings suggest the need for integrated and collaborative workings across formal and informal institutional networks. Theoretically, the study makes two contributions. First, it adds value to institutional theory by incorporating a dimension of access. Second, it builds upon Levesque et al.'s healthcare access framework by highlighting the role and significance of a third dimension-that is informal institutions, in addition to the current two-formal institutions and individual factors.

Healing Health Care Disparities: Development and Pilot Testing of a Virtual Reality Implicit Bias Training Module for Physicians in the Context of Black Maternal Health

Grounded in communication models of cultural competence, this study reports on the development and testing of the first module in a larger virtual reality (VR) implicit bias training for physicians to help them better: (a) recognize implicit bias and its effects on communication, patients, and patient care; (b) identify their own implicit biases and exercise strategies for managing them; and (c) learn and practice communicating with BIPOC patients in a culture-centered manner that demonstrates respect and builds trust. Led by communication faculty, a large, interdisciplinary team of researchers, clinicians, and engineers developed the first module tested herein focused on training goal (a). Within the module, participants observe five scenes between patient Marilyn Hayes (a Black woman) and Dr. Richard Flynn (her obstetrician, a White man) during a postpartum visit. The interaction contains examples of implicit bias, and participants are asked to both identify and consider how implicit bias impacts communication, the patient, and patient care. The team recruited 30 medical students and resident physicians to participate in a lab-based study that included a pretest, a training experience of the module using a head-mounted VR display, and a posttest. Following the training, participants reported improved attitudes toward implicit bias instruction, greater importance of determining patients' beliefs and perspectives for history-taking, treatment, and providing quality health care; and greater communication efficacy. Participants' agreement with the importance of assessing patients' perspectives, opinions, and psychosocial and cultural contexts did not significantly change. Implications for medical education about cultural competency and implicit bias are discussed.

Birth Experience Among Black Women in the United States: A Qualitative Meta-Synthesis

INTRODUCTION

There are striking disparities in perinatal health outcomes for Black women in the United States. Although the causes are multifactorial, research findings have increasingly identified social and structural determinants of health as contributors to perinatal disparities. Maltreatment during perinatal care, which is disproportionately experienced by Black women, may be one such contributor. Qualitative researchers have explored Black women's perinatal care experiences, but childbirth experience data has yet to be analyzed in-depth across studies. The aim of this meta-synthesis was to explore the birthing experience of Black women in the United States.

METHODS

PubMed, Embase, PsycINFO, and CINAHL databases were searched. Inclusion criteria were qualitative research studies that included birth experience data shared by self-identified Black or African American women who had given birth in the United States. Exclusion criteria were reports that did not include rich qualitative data or only included experience data that did not specify the race of the participant (eg, data pooled for women of color). The search began February 2022 and ended June 2022. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to appraise the research. Results were synthesized using content analysis.

RESULTS

Fifteen studies met inclusion criteria. Main themes included (1) trust: being known and seen; (2) how race influences care; (3) preserving autonomy; and (4) birth as trauma.

DISCUSSION

Fragmented care resulted in reports of poor birth experiences in several studies. Open communication and feeling known by perinatal care providers was influential in improving childbirth experiences among Black women; these themes are consistent with existing research. Further prospective research exploring relationships among these themes and perinatal outcomes is needed. Limitations of this report include the use of content analysis and meta-synthesis which may lose the granularity of the original reports; however, the aggregation of voices may provide valuable, transferable, actionable insight that can inform future supportive care interventions.

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review

INTRODUCTION

Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication.

METHODS

We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations.

RESULTS

Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations.

DISCUSSION

Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

Racism and Nursing Leadership in Massachusetts: A Mixed-Methods Study

BACKGROUND

Nursing in the United States has evolved within the same historical context that has reproduced and spread racism worldwide. Nurse administrators are integral to the quality of nurses' practice and play a key role in eliminating racial injustice in places of work.

PURPOSE

Using a feminist and critical race feminist framework, this study examined Massachusetts nurses' experiences of racism in their places of work, focusing on nurse administrators' influence on the nonadministrator (staff nurse) experience of racism experiences before and after George Floyd's death.

METHODS

An investigator-developed, electronic survey was sent to Massachusetts professional nursing organizations for distribution to their members in 2021. Two hundred nineteen nurse respondents completed Likert-scale and open-ended branching logic survey questions to yield the quantitative and qualitative data analyzed for this mixed-methods study.

FINDINGS

Nurse administrators were: 1) more likely than staff nurses to state that policies and meetings to address racism and diversity, equity, and inclusion had taken place before and after George Floyd's murder; and 2) less likely than staff nurses to directly experience racism at the hands of a colleague or a superior. Nurse administrators influence staff nurses' experiences of racism.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015

OBJECTIVE

This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis.

METHODS

Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race).

RESULTS

The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively).

CONCLUSIONS

Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period

Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.

Cultural Marginalization and Mental Health

Cultural marginalization refers to the process of being on the fringe of two distinct cultures. Culture represents the values, beliefs, knowledge, and norms that are common to a group of people. Globalization contributes to an increasingly diverse population and leads to frequent interaction, collaboration, and sharing of space between various cultures. Cultural minority groups experience varied stages of acculturation with the dominant culture which may have an impact on physical and mental health. Understanding the marginalizing experiences of cultural minority groups creates a more accommodating social environment and helps provide culturally safe healthcare experiences for these people.

Trajectories and impact of White mentors' beliefs about racial and ethnic discrimination in a formal youth mentoring program

To examine associations between White mentors' beliefs regarding the presence of discrimination towards Black, Indigenous, and people of Color (BIPOC) individuals and mentoring relationship outcomes, mentors' beliefs about racial/ethnic discrimination were assessed before random mentee assignment and at the end of 9 months of mentoring. White mentors matched with BIPOC youth showed greater increases in beliefs that discrimination limits opportunities for Black Americans. Stronger endorsement of the impacts of discrimination for Hispanic Americans resulted in less youth relationship anxiety when White mentors were matched with White mentees, but not when they were matched with BIPOC mentees. Last, greater increases in beliefs that discrimination limits opportunities for Black Americans resulted in less relationship anxiety for White mentors matched with White mentees, but more relationship anxiety for those matched with BIPOC mentees. Programs should assess and address mentors' racial biases to minimize harm and augment the impact of mentoring programs for all youth.

Provider Characteristics That Hinder Relationships with Black Women in the Perinatal Period

Black women have often reported challenges in their relationships with health care providers during the perinatal period. This study synthesized the findings of qualitative studies to describe health care providers' characteristics that hinder therapeutic relationships with Black women in the perinatal period. A systematic search was conducted and findings from 12 qualitative studies were synthesized using a thematic synthesis approach. Two overarching themes that included seven descriptive themes were discovered. The seven descriptive themes include the following: (1) provides differential treatment; (2) expresses biased attitudes; (3) lacks empathy; (4) limits choices; (5) communicates inadequate health information; (6) provides deficient care; and (7) dismisses concerns. Participants experienced challenged relationships with health care providers who held implicit biases and discouraged them from participating in their care. The findings suggest the importance of confronting implicit biases, promoting a bias-free health care system, and providing quality care that is respectful to Black women in the perinatal period.

Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

OBJECTIVES

To consolidate the available evidence around ethnic minority women's experiences and needs when accessing maternity care.

METHODS

A qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.

RESULTS

Twenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme 'the struggles and fears of ethnic minority women' was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women's needs, and isolation-related impact due to the COVID pandemic.

CONCLUSIONS

Overall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.

Midwives' and Other Perinatal Health Workers' Perceptions of the Black Maternal Mortality Crisis in the United States

INTRODUCTION

This study aimed to identify how perinatal health workers, especially midwives, explained US Black maternal mortality and morbidity and what ameliorative measures they suggested across categories of primary social determinants, health care access, and provider practices.

METHODS

Using a mixed closed-ended and open-ended researcher-designed exploratory survey, 227 perinatal health workers responded to a series of questions probing views of causation and strategies for improvement. The closed-ended responses were summarized. Open-ended responses were analyzed using basic categorical and thematic coding.

RESULTS

Perinatal health workers' responses prominently identified racism as a cause of Black maternal morbidity and mortality, and their recommendations ranged across levels of social determination of health.

DISCUSSION

Results suggest that the views of perinatal health workers, the majority of whom were midwives, are complex and correspond to the problems and solutions identified in the research literature. Midwives and other perinatal health workers are well positioned to help center health equity in perinatal care, through both clinical practice and policy advocacy.

Obstetric racism and perceived quality of maternity care in Canada: Voices of Black women

BACKGROUND

Obstetric racism in healthcare encounters impact on access to quality maternal healthcare for Black childbearing women yet remains underexplored in Canada. Understanding the experiences of Black Canadian women is critical to inform policy and create targeted interventions to address obstetric racism and advanced maternal health equity.

OBJECTIVE

The aim of this study was to explore the experiences of obstetric racism and its influence on perceived quality of maternity care among Black women in Toronto, Canada.

DESIGN

Qualitative research was conducted using a critical qualitative inquiry approach.

METHODS

We conducted a semi-structured interviews with 24 Black women who were pregnant and/or have given birth in the last 3 years. The interviews explored their experiences seeking care during pregnancy/childbirth and perceived quality of care.

RESULTS

Two themes were generated through the process of thematic analysis: (1) Manifestations and Impacts of Obstetric Racism and (2) Strategies for Addressing Obstetric Racism. Narratives of being dismissed, objectified, dehumanized, trauma and paternalism were reflected in the accounts of the participants. These experiences undermined the quality of care, hindered therapeutic relationships and contributed to mistrust.

CONCLUSION

Black women understood the nature and impact of obstetric racism as it relates to the quality of maternal health care, their safety, and well-being. Participants recommended the need for anti-Black racism training specific to caring of Black childbearing women and increasing Black healthcare provider representation in perinatal settings as strategies to address obstetric racism. Investment in Black maternal health research is urgently needed to generate meaningful evidence to inform policy and interventions to advanced maternal health equity.

Perspectives of Maternal Mortality Among Women Who Live in Indiana

OBJECTIVE

To explore the perspectives of women in the lay public in Indiana on the topic of maternal mortality.

DESIGN

Qualitative descriptive design.

SETTING

The state of Indiana.

PARTICIPANTS

Women in the lay public (N = 20) who were recruited from Facebook groups aimed at women with children.

METHODS

We used semistructured phone interviews during which participants described their understanding of maternal mortality and their related experiences. We analyzed the transcribed interviews using content analysis to yield overall themes.

RESULTS

We identified three main themes that described participants' perspectives of maternal mortality: Women Are Not Worried About Mortality Until They Experience Pregnancy Complications, Women Have Limited Information on Maternal Mortality, and Women Often Feel Dismissed During Maternity Care.

CONCLUSION

Our findings suggest that nurses and other health care providers should increase their efforts to effectively communicate about maternal mortality and the associated risk factors and to follow evidence-based guidelines for respectful maternity care.

Confronting Racism in All Forms of Pain Research: A Shared Commitment for Engagement, Diversity, and Dissemination

This third paper in the "Confronting Racism in All Forms of Pain Research" series discusses adopting an antiracism framework across all pain research disciplines and highlights the significant benefits of doing so. We build upon the previous call to action and the proposed reframing of study designs articulated in the other papers in the series and seek to confront and eradicate racism through a shared commitment to change current research practices. Specifically, we emphasize the systematic disadvantage created by racialization (ie, the Eurocentric social and political process of ascribing racialized identities to a relationship, social practice, or group) and discuss how engaging communities in partnership can increase the participation of racialized groups in research studies and enrich the knowledge gained. Alongside this critical work, we indicate why diversifying the research environment (ie, research teams, labs, departments, and culture) enriches our scientific discovery and promotes recruitment and retention of participants from racialized groups. Finally, we recommend changes in reporting and dissemination practices so that we do not stigmatize or reproduce oppressive forms of power for racialized groups. Although this shift may be challenging in some cases, the increase in equity, generalizability, and credibility of the data produced will expand our knowledge and reflect the pain experiences of all communities more accurately. PERSPECTIVE: In this third paper in our series, we advocate for a shared commitment toward an antiracism framework in pain research. We identify community partnerships, diversification of research environments, and changes to our dissemination practices as areas where oppressive forms of power can be reduced.