African American women and prenatal care: perceptions of patient-provider interaction

Patient-Provider Satisfaction and Communication in U.S. Prenatal Care: A Systematic Review

INTRODUCTION

This is a systematic review on patient-provider satisfaction in U.S. prenatal care by addressing the following research question: What factors influence patient-provider satisfaction during prenatal care?

METHODS

Thirty six online databases were searched for peer-reviewed research from February to September of 2018 using 10 key terms published in English on U.S. populations between the years 1993-2018 on the topic of provider communication skills and patient satisfaction in the prenatal context. Searches yielded 2563 articles. After duplicates were reviewed and eligibility determined, 32 articles met criteria and were included in the final content analysis. All reported study variables were entered into EXCEL, data reported in each study were analyzed by two people for inter-rater reliability and included in the qualitative content analysis. Two researchers also utilized assessment tools to assess the quality of the articles.

RESULTS

Results indicate the importance of good patient-provider communication, that patients have a need for more information on a plethora of topics, and that Hispanic and African American women reported less satisfaction.

DISCUSSION

We recommend that future studies measure potentially significant themes not adequately present in the reviewed studies such as practitioner demographics (e.g. gender, years of experience, or race/ethnicity), mothers under 18 years of age, inclusion of religious minorities, patients with differing immigration statuses, and patients with disabilities.

Impact of telehealth on patient-provider communication in prenatal care for pregnant women from underserved settings

INTRODUCTION

Telehealth has emerged as a promising supplementary modality in prenatal care. However, its impact on patient-provider communication (PPC), especially among pregnant women from underserved settings, requires comprehensive evaluation. This study examined the factors associated with the quality of patient-provider communication during the COVID-19 pandemic among pregnant telehealth users and non-users.

METHODS

Using a cross-sectional study design, 242 women were surveyed (response rate = 23%) regarding their experience with telehealth, quality of PPC, and experiences of discrimination during prenatal care. Multiple regression models were used to identify the factors associated with the quality of PPC during the COVID-19 pandemic. A sub-group analysis explored the factors associated with the quality of PPC separately among telehealth users and non-users.

RESULTS

The majority of the participants were on Medicaid (95%) and self-identified as Black/African American (57.3%). Regression analyses revealed a negative relationship between telehealth use during pregnancy and the quality of PPC (β = -1.13, P = 0.002). Irrespective of the telehealth use, the experience of discrimination was associated with poor quality of PPC among users (β = -3.47, P = .02) and non-users (β = -.78, P = .03), while adjusting for sociodemographic factors and social support during pregnancy.

DISCUSSION

While telehealth offers advantages like convenience, increased accessibility, and continuity of care, challenges in establishing effective PPC in virtual settings have emerged that emphasize the necessity for comprehensive provider training extending beyond technical competencies. The persistent issue of perceived discrimination, impacting PPC across both groups, underscores the necessity to rethink existing strategies of mandatory training to increase providers' knowledge.

Perceptions to Overcoming Barriers to Prenatal Care in African American Women

Pregnancy-related deaths affect African American women at a rate four to five times higher than White women. These deaths occur during pregnancy or up to 1 year after childbirth. Inadequate or delayed prenatal care is a factor associated with poor maternal health outcomes in African American women. Identifying factors that pose as facilitators and barriers to prenatal care is essential in developing interventions aimed at improving maternal health outcomes.

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.

Implementation of cross-sector partnerships: a description of implementation factors related to addressing social determinants to reduce racial disparities in adverse birth outcomes

Introduction

Traditional perinatal care alone cannot address the social and structural determinants that drive disparities in adverse birth outcomes. Despite the wide acceptance of partnerships between healthcare systems and social service agencies to address this challenge, there needs to be more research on the implementation factors that facilitate (or hinder) cross-sector partnerships, particularly from the perspective of community-based organizations. This study aimed to integrate the views of healthcare staff and community-based partner organizations to describe the implementation of a cross-sector partnership designed to address social and structural determinants in pregnancy.

Methods

We used a mixed methods design (in-depth interviews and social network analysis) to integrate the perspectives of healthcare clinicians and staff with those of community-based partner organizations to identify implementation factors related to cross-sector partnerships.

Results

We identified seven implementation factors related to three overarching themes: relationship-centered care, barriers and facilitators of cross-sector partnerships, and strengths of a network approach to cross-sector collaboration. Findings emphasized establishing relationships between healthcare staff, patients, and community-based partner organizations.

Conclusion

This study provides practical insights for healthcare organizations, policymakers, and community organizations that aim to improve access to social services among historically marginalized perinatal populations.

Migrant and native women's perceptions of prenatal care communication quality: the role of host-country language proficiency

BACKGROUND

Despite the potentially significant impact of women-prenatal care provider communication quality (WPCQ) on women's perinatal health, evidence on the determinants of those perceptions is still lacking, particularly among migrant women.

METHODS

We aimed to examine the effect of women's host-country language proficiency on their perceived WPCQ. We analyzed the data of 1210 migrant and 1400 native women who gave birth at Portuguese public hospitals between 2017 and 2019 and participated in the baMBINO cohort study. Migrants' language proficiency was self-rated. Perceived WPCQ was measured as a composite score of 9 different aspects of self-reported communication quality and ranged from 0 (optimal) to 27.

RESULTS

A high percentage of women (29%) rated communication quality as "optimal". Zero-inflated regression models were fitted to estimate the association between language proficiency and perceived WPCQ. Women with full (aIRR 1.35; 95% CI 1.22,1.50), intermediate (aIRR 1.41; 95% CI 1.23,1.61), and limited (aIRR 1.72; 95% CI 1.45,2.05) language proficiencies were increasingly more likely to have lower WPCQ when compared to natives.

CONCLUSIONS

Facilitating communication with migrant women experiencing language barriers in prenatal care could provide an important contribution to improving prenatal care quality and addressing potential subsequent disparities in perinatal health outcomes.

Exploring Patients' Needs and Desires for Quality Prenatal Care in Florida, United States

Background and Objective

High-quality prenatal care promotes adequate care throughout pregnancy by increasing patients' desires to return for follow-up visits. Almost 15% of women in the United States receive inadequate prenatal care, with 6% receiving late or no prenatal care. Only 63% of pregnant women in Florida receive adequate prenatal care, and little is known about their perceptions of high-quality prenatal care. Therefore, the objective of this study was to assess women's perceptions of the quality of their prenatal care and to describe their preferences for seeking prenatal care that meets their needs.

Methods

From April to December 2019, a qualitative study was conducted with postpartum women (n = 55) who received no or late prenatal care and delivered in Tampa, Florida, USA. Eligible women completed an open-ended qualitative survey and a semi-structured in-depth interview. The interview contextualized the factors influencing prenatal care quality perceptions. The qualitative data analysis was based on Donabedian's quality of care model.

Results

The qualitative data analysis revealed three key themes about women's perceptions and preferences for prenatal care that meets their needs. First, clinical care processes included provision of health education and medical assessments. Second, structural conditions included language preferences, clinic availability, and the presence of ancillary staff. Finally, interpersonal communication encompassed interactions with providers and continuity of care. Overall, participants desired patient-centered care and care that was informative, tailored to their needs, and worked within the constraints of their daily lives.

Conclusion and Global Health Implications

Women seeking and receiving prenatal care prefer a welcoming, patient-centered health care environment. These findings should prompt health care providers and organizations to improve existing prenatal care models and develop new prenatal care models that provide early, accessible, and high-quality prenatal care to a diverse population of maternity patients.

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

Black women's experiences with professional accompaniment at prenatal appointments

U.S. public health statistics report dismal Black infant and maternal mortality rates. Prenatal care alone, while essential, does not reduce such disparities.

OBJECTIVES

The purpose of the study was to explore Black women's experiences when a perinatal support professional (PSP) accompanies them to prenatal medical appointments.

DESIGN

This research used a phenomenological approach, using data from in-depth individual interviews to explore the essence of 25 Black women's experiences.

RESULTS

We identified three major themes from the data that together, show that PSPs served as communication bridges for their clients. Clients said their PSPs helped them to understand and feel seen and heard by their medical providers during their prenatal appointments. The third theme was the deep level of trust the clients developed for their PSPs which made the first two themes possible. PSPs' intervention resulted in reduced stress and uncertainty in medical interactions and increased women's trust in their providers' recommendations.

CONCLUSIONS

Including a trusted, knowledgeable advocate like a PSP may be an important intervention in improving Black women's prenatal care experiences, reducing stress associated with medical interactions, and ultimately reducing pregnancy-related health disparities.

Sociodemographic factors and perceived patient-provider communication associated with healthcare avoidance among women with psychological distress

Objective

To establish the extent to which psychological distress influences health avoidance behavior among women, controlling for patient provider communication and sociodemographic characteristics.

Methods

Data from the 2019 Health Information National Trends Survey (HINTS 5, Cycle 3) was analyzed to obtain healthcare avoidance behavior among women aged 18 and older (n = 2788). Weighted descriptive, bivariate, and multivariable logistic regression models were conducted.

Results

Approximately 649 women or 1 in 4 women (26.7% weighted prevalence; 95% Confidence Interval [CI] 0.23%-0.29%) avoided healthcare in the past 12 months. Non-Hispanic white (62.8%) and married (55.4%) women represented a higher proportion of the sample. Bivariate analysis revealed that the odds of reporting healthcare avoidance among women with mild, moderate, and severe psychological distress (Odds Ratio [OR]: 2.26, 95% CI: 1.45-3.53, p = 0.001; OR: 3.88, 95% CI: 2.29-6.56, p < 0.001; OR: 3.08, 95% CI: 1.81-5.23, p < 0.001) was significantly higher compared to those with none-minimal psychological distress. In the adjusted model, women with moderate and severe psychological distress (Adjusted OR [AOR]:3.15, 95% CI: 1.55-6.38, p = 0.002; AOR: 2.24, 95% CI: 1.10-4.92, p = 0.044) were more likely to report healthcare avoidance than those experiencing none-minimal psychological distress. Furthermore, increasing patient-provider communication score (AOR: 0.91, 95% CI: 0.87-0.96, p < 0.001) reduced the likelihood of healthcare avoidance. Among the sociodemographic variables assessed, being younger (18-49 years) and having less than a high school degree significantly increased the chances of avoiding healthcare.

Conclusion

A high proportion of women with psychological distress avoid necessary healthcare. Patient-provider communication quality, increasing age, and being a high school student contribute to healthcare avoidance in women.

Innovation

Strategies to improve health service utilization must address healthcare avoidance by developing effective health communication targeted at women with psychological distress.

An Integrative Review of the Perinatal Experiences of Black Women

OBJECTIVE

To synthesize the current body of evidence regarding the perinatal experiences of Black women.

DATA SOURCES

The databases PubMed, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus were searched with the search terms "African American" (in PubMed), "Black" (in Scopus), or "Black" OR "African American" (in CINAHL) AND "pregnancy" AND "experiences."

STUDY SELECTION

Searches yielded 266 articles published between January 2015 and May 2021. After initial screening, 68 articles were assessed for eligibility, yielding 23 studies that met the inclusion criteria of this review.

DATA EXTRACTION

Studies were reviewed for the perinatal experiences of Black women. Nonresearch articles, systematic reviews, and instrument development articles were removed. Also excluded were articles with a focus on adolescent pregnancy, breastfeeding experiences, and those outside of the perinatal time frame.

DATA SYNTHESIS

Analysis showed that Black women continue to report negative experiences in perinatal care and that these negative experiences spanned various sociodemographic characteristics. Although some Black women described positive interactions, many more expressed dissatisfaction with the lack of education, resources, and continuity in care, as well as poor communication. Additionally, experiences of racism and biases in care, mistrust in the health care system, and doubts of the efficacy or necessity of medical treatments exist.

CONCLUSION

Negative perinatal care experiences and dissatisfaction among Black women remain common. Although Black women desire more holistic, naturalistic, and empowering care, Black women first want safe, respectful care and a health care team that removes biases and racism from its system. More research is needed that includes the voices of Black women to understand these experiences and to develop interventions to improve the perinatal care experience. Nurses and other health care providers providing care in the perinatal period must also listen to, trust, and respect Black women.

Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum

Objectives: Person-centered care has been increasingly recognized as an important aspect of health care quality, including in maternity care. Little is known about correlates and outcomes of person-centered care in maternity care in the United States. Materials and Methods: Data were from a prospective cohort of more than 3000 individuals who gave birth to a first baby in a Pennsylvania hospital. Person-centered maternity care was measured via a 13-item rating scale administered 1-month postpartum. Content validity was established through exploratory factor analysis. The resulting scale had scores ranging from 13 to 54, with Cronbach's alpha of 0.86. Using linear and logistic regression models to control for covariates, we examined associations between participants' characteristics and person-centered maternity care and between person-centered maternity care and postpartum outcomes. Results: Participants had a mean total score of 47.80 on the person-centered maternity care scale. Patient factors independently associated with more person-centered maternity care included older age, more positive attitude toward vaginal birth during pregnancy, and spontaneous vaginal birth. In adjusted models, higher person-centered maternity scale scores were strongly associated with many positive physical and mental health outcomes at 1 and 6 months postpartum. Conclusions: Our findings underscore the importance of person-centered maternity not just due to its intrinsic value but also because it may be associated with both mental and physical health outcomes through the postpartum period. Results suggest that policy efforts are necessary to ensure person-centered maternity care, especially for delivery hospitalization experience.

Relationship with the Father of the Baby and Pregnancy-Related Anxiety among Pregnant Black Women

PURPOSE

Pregnancy-related anxiety may increase the risk of preterm birth. Effective coping strategies and social support may help minimize pregnancy-related anxiety.

STUDY DESIGN

Secondary analysis of cross-sectional data.

METHODS

A sample of 408 pregnant non-Hispanic Black women completed questionnaires between 19 and 31 weeks gestation. Mediation analysis with structural equation modeling was used to explore effects of the relationship with the father of the baby on pregnancy-related anxiety.

RESULTS

Support from the father of the baby was negatively associated with avoidance coping ( r = -.22, p < .001) and pregnancy-related anxiety ( r = - .17, p < .001), whereas conflict with the father of the baby was positively associated with avoidance coping ( r = .37, p < .001) and pregnancy-related anxiety ( r = .29, p < .001). Avoidance coping was positively associated with pregnancy-related anxiety ( r = .34, p < .001). After adjustment, avoidance coping partially mediated the effect of conflict with the father of the baby on pregnancy-related anxiety.

CLINICAL IMPLICATIONS

Discussions with women about management of pregnancy-related anxiety should consider her current social support and coping mechanisms. Providers should offer support and resources on adaptive coping strategies.

Reported information sharing and satisfaction with maternity care providers during the COVID-19 pandemic: Associations with socioeconomic status and shifts to telehealth

BACKGROUND

The COVID-19 pandemic has dramatically affected pregnant people's prenatal care, labor, and delivery experiences. Given these rapid changes, providers have needed to be proactive in sharing information about COVID-19-related care impacts. The purpose of this study was to investigate: (a) Whether patient demographics or disrupted care (eg, canceled appointments and rapid shift to telehealth) is associated with patient-reported information sharing from the providers; and (b) Whether patient-reported provider information sharing or disruptions to care are associated with patient satisfaction with provider.

METHODS

Data come from a convenience sample of 1999 pregnant people living in the United States who completed an online survey between April 16 and May 7 2020.

RESULTS

Thirty-eight percent of participants said that their provider had not discussed how the pandemic would affect their care during pregnancy, labor, or delivery. Participants with lower education, less income, or whose appointments had been canceled or rescheduled because of the pandemic were significantly less likely to report information sharing. Provider satisfaction was significantly lower among participants who did not report information sharing, those who had appointments by way of telehealth, and those who reported that all their appointments had been rescheduled/canceled.

DISCUSSION

At the beginning of the pandemic, there were significant socioeconomic inequities in reported information sharing by the providers, which in turn was negatively associated with provider satisfaction. Providers need to be aware of the role implicit bias may play in information sharing-both generally and during public health crises-and consider ways to reduce the impacts of disrupted care delivery on patient satisfaction. If left unaddressed, perceived poor provider communication and associated low satisfaction with providers could contribute to adverse perinatal outcomes.

Quality and satisfaction with care following changes to the structure of obstetric care during the COVID-19 pandemic in a safety-net hospital in Georgia: Results from a mixed-methods study

Objective

To understand perceived quality of obstetric care following changes to the structure of care in a safety-net institution during the COVID-19 pandemic.

Methods

We conducted a mixed-methods study including a web-based survey (n = 67) and in-depth interviews (n = 16) between October 2020 and January 2021. We present a descriptive analysis of quantitative results and key qualitative themes on reactions to changes and drivers of perceived quality.

Results

Reported quality was high for in-person and phone visits (median subscale responses: 5/5). Respondents were willing to include phone visits in care for a future pregnancy (77.8% (49)) but preferred in-person visits (84.1% (53)). In interviews, provider communication was the key driver of quality. Respondents found changes to care to be inconvenient but acceptable.

Conclusions

To improve satisfaction with changes to care, health systems should ensure that relationship building remains a priority and offer patients information about the reason behind changes.

From a Place of Love: The Experiences of Birthing in a Black-Owned Culturally-Centered Community Birth Center

Introduction

Racial and ethnic disparities in perinatal health outcomes are among the greatest threats to population health in the United States. Black birthing communities are most impacted by these inequities due to structural racism throughout society and within health care settings. Although multiple studies have shown that structural racism and the disrespect associated with this system of inequity are the root causes of observed perinatal inequities, little scholarship has centered the needs of Black birthing communities to create alternative care models. Leaning on reproductive justice and critical race theoretical frameworks, this study explores good birth experiences as described by Black birthing people.

Methods

Thematic analysis of two focus groups and three one-on-one interviews conducted with clients at a Black-owned free-standing culturally-centered birth center (n=10).

Results

We found that Black birthing persons' concerns centered on three main themes: agency, historically- and culturally-safe birthing experiences, and relationship-centered care. Many participants pointed directly to past experiences of medical mistreatment and obstetric racism when defining their ideal birth experience.

Conclusion

Black birthing people seeking care from culturally-informed providers often do so because they have been mistreated, disregarded, and neglected within traditional care settings. The needs articulated by our study participants provide a powerful framework for understanding alternative patient-centered models of care that can be developed to improve the care experiences of Black birthing people in the pursuit of birth equity.

Dental EHR-infused Persona Ontologies to Enrich Dental Dialogue Interaction of Agents

The quality of patient-provider communication can predict the healthcare outcomes in patients, and therefore, training dental providers to handle the communication effort with patients is crucial. In our previous work, we developed an ontology model that can standardize and represent patient-provider communication, which can later be integrated in conversational agents as tools for dental communication training. In this study, we embark on enriching our previous model with an ontology of patient personas to portray and express types of dental patient archetypes. The Ontology of Patient Personas that we developed was rooted in terminologies from an OBO Foundry ontology and dental electronic health record data elements. We discuss how this ontology aims to enhance the aforementioned dialogue ontology and future direction in executing our model in software agents to train dental students.

African American Women's Experiences with Birth After a Prior Cesarean Section

OBJECTIVES

Women who have had a cesarean section (C-section) and become pregnant again may choose to have a planned repeat cesarean delivery (RCD) or vaginal birth after a cesarean (VBAC). This study aimed to characterize the pregnancy and birth experiences of African American (AA) women who had a successful VBAC, failed VBAC, or RCD.

METHODS

Eligible participants (N = 25) self-identified as AA, had a C-section and a subsequent birth(s) in the past 12 years, and were educated past high school. Each participant was individually interviewed via phone call. The Sort and Sift, Think and Shift method was used to evaluate interview transcripts to minimize researcher bias and emphasize the voices of the participants.

RESULTS

The resulting themes included the impact of providers on pregnancy and childbirth satisfaction, the value of autonomy in maternal health decision-making, and the role that racism plays in AA women's birth experiences. Although some participants recalled a positive experience, the presence of limited autonomy, lack of support, and negative experiences with providers indicate that birth after a prior C-section for AA women can be improved.

CONCLUSIONS

Providers should address their own racial biases and utilize the shared decision-making approach when their patients decide between a VBAC and RCD to improve patient satisfaction.

Emotional and Birth Outcomes Associated With Different Types of Prenatal Care for Women With Low Income

This article summarizes findings from the literature on the emotional and birth outcomes of women with low income receiving different types of prenatal care. This literature review included studies published between 2015 and 2020. The results indicated that women with low income have challenging experiences in traditional models of prenatal care. Evidence of improved birth outcomes with nontraditional prenatal care is mixed, but qualitative findings indicate that it is associated with better emotional outcomes for women with low income when compared to traditional prenatal care. Future research should investigate ways to improve the negative interpersonal and structural dimensions that can characterize prenatal care for women with low income.

Perceived Racial Discrimination in the Pregnant African American Population: A Concept Analysis

African American women experience higher lifetime exposure to chronic stressors, such as perceived racial discrimination. Clearly defining perceived racial discrimination in the pregnant African American population has the potential to better explain the phenomenon and how it relates to adverse birth outcomes such as preterm birth. The purpose of this concept analysis is to more clearly define perceived racial discrimination in the pregnant African American population using Rodgers' evolutionary method. Defining the concept of interest has the potential to uncover modifiers that may help close the gap in the Black-White infant mortality rates in the United States.

A new perspective on the maternal mortality disparity

The disparity in maternal mortality rates between ethnicities in the United States is alarming, with Black women at far higher risk of dying than women of other ethnicities. Factors typically thought of as protective in health disparity research are not necessarily protective with maternal mortality. Building upon a social justice framework by utilizing a strength-based focus is needed when addressing this issue to build upon strengths and empower Black women as a part of the solution.

The prenatal triad: The importance of provider-patient communication with expectant fathers throughout the prenatal care process

Previous research has primarily focused on the relationship between providers and expectant mothers as a key element of quality prenatal care. Significantly less attention has been directed toward expectant fathers and the importance of their communication with prenatal care providers and involvement in the prenatal care process. Much of this limited existing literature emphasizes the health benefits including fathers would bring for mom and baby, but rarely is the potential benefit to fathers' health included in the conversation. This discussion aims to highlight the value of this line of research for both communication and medical researchers and consider potential avenues for studying and promoting father engagement in prenatal care.

"I fought my entire way": Experiences of declining maternity care services in British Columbia

BACKGROUND

The 2016 WHO Standards for improving quality of maternal and newborn care in health facilities established patient experience of care as a core indicator of quality. Global health experts have described loss of autonomy and disrespect as mistreatment. Risk of disrespect and abuse is higher when patient and care provider opinions differ, but little is known about service users experiences when declining aspects of their maternity care.

METHODS

To address this gap, we present a qualitative content analysis of 1540 written accounts from 892 service users declining or refusing care options throughout childbearing with a large, geographically representative sample (2900) of childbearing women in British Columbia who participated in an online survey with open-ended questions eliciting care experiences.

FINDINGS

Four themes are presented: 1) Contentious interactions: "I fought my entire way", describing interactions as fraught with tension and recounting stories of "fighting" for the right to refuse a procedure/intervention; 2) Knowledge as control or as power: "like I was a dim girl", both for providers as keepers of medical knowledge and for clients when they felt knowledgeable about procedures/interventions; 3) Morbid threats: "do you want your baby to die?", coercion or extreme pressure from providers when clients declined interventions; 4) Compliance as valued: "to be a 'good client'", recounting compliance or obedience to medical staff recommendations as valuable social capital but suppressing desire to ask questions or decline care.

CONCLUSION

We conclude that in situations where a pregnant person declines recommended treatment, or requests treatment that a care provider does not support, tension and strife may ensue. These situations deprioritize and decenter a woman's autonomy and preferences, leading care providers and the culture of care away from the principles of respect and person-centred care.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth

OBJECTIVE

To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records.

DESIGN

A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group.

SETTING

A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers.

PARTICIPANTS

All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization.

MEASUREMENTS

Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff.

RESULTS

Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample.

CONCLUSION

The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

Geographic, Health Care Access, Racial Discrimination, and Socioeconomic Determinants of Maternal Mortality in Georgia, United States

Over the past decade, the United States has been taking steps to reduce its rising maternal mortality rate. However, these steps have yet to produce positive results in the state of Georgia, which tops the list of all 50 states with the highest maternal mortality rate of 46.2 maternal deaths per 100,000 live births for all women, and a maternal mortality rate of 66.6 deaths per 100,000 live births for African American women. In Georgia, several social determinants of health such as the physical environment, economic stability, health care access, and the quality of maternal care contribute to the high maternal mortality rate. Addressing these determinants will help to reduce the state's maternal mortality rate. This commentary discusses the relationship between social determinants of health and maternal mortality rates in Georgia. It also proposes strategies for reversing the trend. We conducted an ecological study of the relationship between social determinants of health and maternal mortality in Georgia. We searched PubMed and Google Scholar and reviewed 80 English articles published between 2005 and 2021. We identified five key social determinants associated with high maternal mortality rates in Georgia - geographic location of obstetric services, access to health care providers, socioeconomic status, racism, and discrimination. We found that expanding Medicaid coverage, reducing maternal health care disparities among the races, providing access to maternal care for women in rural areas, and training a culturally competent health workforce, will help to reduce Georgia's high maternal mortality rate.

Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians

Background

Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic.

Methods

We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts.

Results

Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians.

Conclusions

This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.

Acknowledging and Addressing Allostatic Load in Pregnancy Care

The USA is one of the few countries in the world in which maternal and infant morbidity and mortality continue to increase, with the greatest disparities observed among non-Hispanic Black women and their infants. Traditional explanations for disparate outcomes, such as personal health behaviors, socioeconomic status, health literacy, and access to healthcare, do not sufficiently explain why non-Hispanic Black women continue to die at three to four times the rate of White women during pregnancy, childbirth, or postpartum. One theory gaining prominence to explain the magnitude of this disparity is allostatic load or the cumulative physiological effects of stress over the life course. People of color disproportionally experience social, structural, and environmental stressors that are frequently the product of historic and present-day racism. In this essay, we present the growing body of evidence implicating the role of elevated allostatic load in adverse pregnancy outcomes among women of color. We argue that there is a moral imperative to assign additional resources to reduce the effects of elevated allostatic load before, during, and after pregnancy to improve the health of women and their children.

"We get double slammed!": Healthcare experiences of perceived discrimination among low-income African-American women

BACKGROUND

On account of their racial/ethnic minority status, class, and gender, African-American women of low socioeconomic status are among the least privileged, underserved, and most marginalized groups in the United States. Generally, African Americans continue to experience poorer health outcomes, in which disparities have been attributed to socioeconomic inequities and structural racism. This objective of this study was to explore the lived experiences of low-income African-American women in interacting with the healthcare system and healthcare providers.

METHODS

Twenty-two in-depth one-on-one interviews were conducted with low-income African-American women. The audio-recorded interviews were transcribed verbatim. An inductive content analysis was performed, using an analytical software, Dedoose® to enabled hierarchical coding. Codes were grouped into categories which were further analyzed for similarities that led to the emergence of themes.

RESULTS

A key finding was the experience of discriminatory treatment. The three themes that emerged relevant to this category were (1) perceived discrimination based on race/ethnicity, (2) perceived discrimination based on socioeconomic status, and (3) stereotypical assumptions such as drug-seeking and having sexually transmitted diseases.

CONCLUSION AND RECOMMENDATIONS

Low-income African-American women experience less than satisfactory patient care, where participants attribute to their experience of being stereotyped and their perception of discrimination in the healthcare system and from providers. Patients' experiences within the healthcare system have implications for their healthcare-seeking behaviors and treatment outcomes. Healthcare personnel and providers need to be more aware of the potential for implicit bias toward this population. Healthcare workforce training on culturally responsive patient care approaches and more community engagement will help providers better understand the context of patients from this population and more effectively meet their healthcare needs.

Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention

HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (M_age = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.

Identifying the Key Elements of Racially Concordant Care in a Freestanding Birth Center

INTRODUCTION

There is empirical evidence that the quality of interpersonal care patients receive varies dramatically along racial and ethnic lines, with African American people often reporting much lower quality of care than their white counterparts. Improving the interpersonal relationship between clinicians and patients has been identified as one way to improve quality of care. Specifically, research has identified that patients feel more satisfied with the care that they receive from clinicians with whom they share a racial identity. However, little is known about how clinicians provide racially concordant care. The goal of this analysis was to identify the key components of high-quality care that were most salient for African American birthworkers providing perinatal care to African American patients.

METHODS

We conducted semistructured interviews (30 to 90 minutes) with clinicians (N = 10; midwives, student midwives, and doulas) who either worked at or worked closely with an African American-owned birth center in North Minneapolis, Minnesota. We used inductive coding methods to analyze data and to identify key themes.

RESULTS

Providing racially concordant perinatal care to African American birthing individuals required clinicians to acknowledge and center the sociocultural realities and experiences of their patients. Four key themes emerged in our analysis. The first overarching theme identified was the need to acknowledge how cultural identity of patients is fundamental to the clinical encounter. The second theme that emerged was a commitment to racial justice. The third and fourth themes were agency and cultural humility, which highlight the reciprocal nature of the clinician-patient relationship.

DISCUSSION

The most salient aspect of the care that birthworkers of color provide is their culturally centered approach. This approach and all subsequent themes suggest that achieving birth equity for pregnant African American people starts by acknowledging and honoring their sociocultural experiences.

Validating a path model of adherence to prenatal care recommendations among pregnant women

OBJECTIVE

To date, no study has reported a diagrammatic path model that involves patient-provider communication on pregnant women's adherence to prenatal care recommendations. To bridge this gap, this study aimed to validate a path model to display the direct and indirect influences on adherence to prenatal care recommendations.

METHODS

A cross-sectional study founded on an evidence-based proposed theoretical framework was conducted among pregnant women (18-45 years) in their second or third trimester (n = 401) in the Midwestern United States. The proposed theoretical framework examined multiple levels of influences. Previously validated instruments were pilot tested and modified. Path analysis was conducted to validate the best-fit path model.

RESULTS

The path model showed shared decision-making and motivation significantly predicted adherence to prenatal care recommendations and accounted for 10% (R²) of the variance. Cultural competency, interaction, perceived discrimination, and satisfaction accounted for 30% (R²) of the variance of shared decision-making. Patient's trust, distrust, and self-efficacy accounted for 5% (R²) of motivation's variance.

CONCLUSION

Our work identified the best-fit path model for adherence to prenatal care recommendations.

PRACTICE IMPLICATIONS

Incorporating findings from this study could assist prenatal care providers in understanding many complex variables affecting prenatal care, ultimately reducing infant mortality.

A qualitative study on rural women's experiences relating to the utilisation of birth care provided by skilled birth attendants in the rural areas of Bongo District in the Upper East Region of Ghana

Background

Increasing skilled attendance during childbirth is well established in literature to play a significant role in averting the many preventable maternal deaths that occur in developing countries such as Ghana. Inadequate utilisation of skilled birth care services in Ghana is believed to be a major hindrance to efforts aimed at improving the health of women, especially during delivery. The purpose of this study was to explore and describe the experiences of rural women regarding the utilisation of skilled birth care provided in the rural areas of Northern Ghana.

Methods

The study adopted a qualitative, exploratory, descriptive research approach, whereby individual interviews, observations and field notes were used to obtain a thick description of women’s experiences regarding the utilisation of skilled birth care services in the rural areas in Ghana. A purposive sampling approach was used to select 20 women who utilised skilled birth care in the rural areas of Bongo District of Ghana. Data collected from the interviews were transcribed verbatim and analysed to identify themes.

Results

The study identified three themes: The women had negative interactions with skilled birth attendants during delivery; women lacked confidence in skilled birth attendants’ abilities; skilled birth attendants disrespected the traditional beliefs of the women.

Conclusion

Most of the participants had negative experiences regarding the utilisation of skilled birth care. There is thus a need to develop strategies that could help address the above concerns of women to facilitate utilisation of skilled birth services in the rural areas in Ghana where there is low utilisation of skilled birth care.

The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment

BACKGROUND

Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies.

METHODS

We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA.

RESULTS

The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality.

CONCLUSION

The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Black Maternal Mortality-The Elephant in the Room

Maternal mortality is on the rise in the United States and it disproportionately affects black women. The reasons for this staggering discrepancy hinge on three central issues: First, black women are more likely to have pre-existing cardiovascular morbidity that increase the risk of maternal mortality. Second, black women are more likely to experience adverse pregnancy outcomes which puts them at risk for developing long-term cardiovascular disease. Third, racial bias of providers and perceived racial discrimination from patients (the elephant in the room) impacts black patients' trust in their providers and the medical community at large. Reducing black maternal mortality involves a multi-tiered approach involving the patient, provider and public health policy.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community

Objectives Pacific Islanders are disproportionately burdened by poorer perinatal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. The aim of this study is to examine Marshallese mothers' beliefs, perceptions, and experiences of prenatal care and to identify potential barriers. Methods Three focus groups were conducted with Marshallese mothers, who were 18 years or older, and living in Arkansas. Focus groups focused on mothers' beliefs, perceptions, and experiences of prenatal care. A thematic qualitative analysis was conducted to identify salient themes within the data. Results The results demonstrated that negotiating health insurance, transportation, and language barriers were all major structural barriers that constrain prenatal care. The social-cultural barriers that emerged included a lack of understanding of the importance of seeking early and consistent prenatal care, as well as how to navigate the healthcare process. The more complicated challenges that emerged were the feelings of shame and embarrassment due to the perception of their age or being unmarried during pregnancy not being acceptable in American culture. Furthermore, the participants described perceived discrimination from prenatal care providers. Lastly, the participants described fear as a barrier to seeking out prenatal care. Conclusions for Practice This study identified both structural and socio-cultural barriers that can be incorporated into suggestions for policy makers to aid in alleviating maternal health disparities among Pacific Islander women. Further research is needed to address the Marshallese mothers' perceived discrimination from maternal health care providers.

More Than a "Number": Perspectives of Prenatal Care Quality from Mothers of Color and Providers

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 semistructured 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 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.

Providers' perspectives of barriers experienced in maternal health care among Marshallese women

PROBLEM

Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care.

PURPOSE

The purpose of this study was twofold: (1) to explore maternal health care providers' perceptions and experiences of barriers in providing care to Marshallese women, and (2) providers perceived barriers of access to care among Marshallese women. This is the first paper to explore perceived barriers to maternal health care among a Marshallese community from maternal health care providers' perspectives in the United States.

METHODS

A phenomenological, qualitative design, using a focus group and in-depth interviews with 20 maternal health care providers residing in northwest Arkansas was chosen.

FINDINGS

Several perceived barriers were noted, including transportation, lack of health insurance, communication and language, and socio-cultural barriers that described an incongruence between traditional and Western medical models of care. There was an overall discord between the collectivist cultural identity of Marshallese families and the individualistic maternal health care system that merits further research.

DISCUSSION

Solutions to these barriers, such as increased cultural competency training for maternal health care providers and the incorporation of community health workers are discussed.

Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey

BACKGROUND

Previous qualitative studies suggest that women with physical disabilities face disability-specific barriers and challenges related to prenatal care accessibility and quality. This study aims to examine the pregnancy and prenatal care experiences and needs of U.S. mothers with physical disabilities and their perceptions of their interactions with their maternity care clinicians.

MATERIALS AND METHODS

We conducted the first survey of maternity care access and experiences of women with physical disabilities from 37 states. The survey was disseminated in partnership with disability community agencies and via social media and targeted U.S. women with a range of physical disabilities who had given birth in the past 10 years. The survey included questions regarding prenatal care quality and childbirth and labor experiences.

RESULTS

A total of 126 women with various physical disability types from 37 states completed the survey. Almost half of the respondents (53.2%) reported that their physical disability was a big factor in their selection of a maternity care provider and 40.3% of women reported that their prenatal care provider knew little or nothing about the impact of their physical disability on their pregnancy. Controlling for maternal demographic characteristics and use of mobility equipment, women who reported that their prenatal care provider lacked knowledge of disability and those who felt they were not given adequate information were more likely to report unmet needs for prenatal care.

CONCLUSIONS

The findings from this study suggest the need for training and education for clinicians regarding the prenatal care needs of women with physical disabilities.

Patient-reported Communication Quality and Perceived Discrimination in Maternity Care

BACKGROUND

High-quality communication and a positive patient-provider relationship are aspects of patient-centered care, a crucial component of quality. We assessed racial/ethnic disparities in patient-reported communication problems and perceived discrimination in maternity care among women nationally and measured racial/ethnic variation in the correlates of these outcomes.

METHODS

Data for this analysis came from the Listening to Mothers III survey, a national sample of women who gave birth to a singleton baby in a US hospital in 2011-2012. Outcomes were reluctance to ask questions and barriers to open discussion in prenatal care, and perceived discrimination during the birth hospitalization, assessed using multinomial and logistic regression. We also estimated models stratified by race/ethnicity.

RESULTS

Over 40% of women reported communication problems in prenatal care, and 24% perceived discrimination during their hospitalization for birth. Having hypertension or diabetes was associated with higher levels of reluctance to ask questions and higher odds of reporting each type of perceived discrimination. Black and Hispanic (vs. white) women had higher odds of perceived discrimination due to race/ethnicity. Higher education was associated with more reported communication problems among black women only. Although having diabetes was associated with perceptions of discrimination among all women, associations were stronger for black women.

CONCLUSIONS

Race/ethnicity was associated with perceived racial discrimination, but diabetes and hypertension were consistent predictors of communication problems and perceptions of discrimination. Efforts to improve communication and reduce perceived discrimination are an important area of focus for improving patient-centered care in maternity services.