131 The Lived Experiences of African American Women Regarding Their Prenatal Care

131

The Lived Experiences of African American Women Regarding Their Prenatal Care

by

.

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Public Health

/

July 2024

Abstract

The practical manifestation of health inequality can cause a severe societal problem for the African American community. African American women are at risk of their lives and often live in abject poverty. The purpose of this qualitative hermeneutic phenomenological design study is to understand the personal viewpoint and perspective of the lived experiences of African American women regarding their prenatal care experiences. The research question used to guide this study was: What are the perceptions of African American women regarding their prenatal care experience in Southern New York? Using a semi-structured interview to gather data, the responses of 10 participants were analyzed using thematic analysis. Three themes emerged during data analysis to address this question – (a) interactions with prenatal care personnel were limited or rushed but rarely discriminatory, (b) overall experiences of prenatal care quality was mixed, and (c) racism and lack of cultural sensitivity were perceived as general problems confronting African American women in prenatal care. Research findings provide important information regarding the experiences of African American women in prenatal care, indicating the need for enhanced diversity in the healthcare system to mitigate racism and discrimination against minority women such as African American women. The study outcome can help healthcare stakeholders develop important policies and programs to enhance equity in healthcare systems.

The Lived Experiences of African American Women Regarding Their Prenatal Care

by

.

Doctor of Public Health, Walden University 2023

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Public Health

/

August 2023

Dedication

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Table of Contents

List of Figures vi

Chapter 1: Introduction 1

African American Women and Prenatal Care 1

Background 10

Problem Statement 11

Purpose 12

Framework Theoretical 13

Kleinman’s Explanatory Model 14

Critical Race Theory 15

Research Questions 16

Nature of the Study 17

Definitions 17

Assumptions 19

Scope and Delimitation 19

Limitations 20

Significance (Social Change) 21

Summary 21

Chapter 2: Literature Review 23

Introduction 23

Theoretical Foundations 25

Review of the Literature 28

Quality of Pre-Pregnancy and Prenatal Care for African American Women 28

Factors Affecting Perceptions and Experiences of African American Women in Pre-Pregnancy and Prenatal Care 32

Perceptions of Patient-Provider Interactions 42

Prenatal Care for High-Risk Women 46

The Future of Pre-Pregnancy and Prenatal Care for African American Women 49

Summary 55

Chapter 3: Research Method 57

Methodology 57

Research Design and Rationale 58

Role of Researcher 61

Participants 62

Instruments 63

Interview Questions 65

Data Analysis Plan 67

Issues of Trustworthiness 70

Ethical Procedures 71

Summary 72

Chapter 4: Results 74

Introduction 74

Setting 74

Participants 74

Data Collection 75

Data Analysis 75

Evidence of Trustworthiness 79

Results 80

Theme 1: Interactions with Prenatal Care Personnel Were Limited or Rushed but Rarely Discriminatory 81

Theme 2: Overall Experiences of Prenatal Care Quality Were Mixed 85

Theme 3: Racism and Lack of Cultural Sensitivity Were Perceived as General Problems Confronting African American Women in Prenatal Care 89

Chapter 5: Discussion, Conclusions, and Recommendations 93

Interpretation of Findings 94

Theme 1: Interactions with Prenatal Care Personnel Were Limited or Rushed but Rarely Discriminatory 94

Theme 2: Overall Experiences of Prenatal Care Quality Were Mixed 96

Theme 3: Racism and Lack of Cultural Sensitivity Were Perceived as General Problems Confronting African American Women in Prenatal Care 99

Limitations of the Study 100

Recommendations for Future Research 102

Implications 103

Implications for Positive Social Change 103

Theoretical Implications 104

Recommendations for Practice 105

Conclusion 106

References 107

List of Tables

Table 1. Sub-temes, or Initial Codes 76

Table 2. Grouping of Related Initial Codes into Preliminary, Emergent Themes 77

Table 3. Finalized Naming of the Three Preliminar Themes 78

List of Figures

Figure 1. Kleinman’s Explanatory Model of Illness: Individual Perceptions 15

Figure 2. Hermetic Circle 61

Chapter 1: Introduction

African American Women and Prenatal Care

African American women in the United States face significant health inequities directly correlated to maternity care. African American and low-income women are 2 to 5 times more likely to die in childbirth or experience severe maternal morbidity than their White counterparts (Creanga et al., 2017). Prenatal care is essential to reduce maternal deaths and morbidity. Nevertheless, prior work has demonstrated that African American women, particularly those with low socioeconomic status living in urban areas, face significant barriers to high-quality care, including lack of transportation, financial constraints, structural racism, and explicit discrimination. Pre-existing prenatal care delivery structures that require continual in-person contact in clinical settings can exacerbate these barriers. Thus, prenatal care in its current form may create difficult challenges for African American women particularly those with low socioeconomic status, and stand to benefit the most from receiving this vital health service.

To provide the best perinatal care, it’s important to prioritize the patient’s experience. This includes establishing trusting relationships with healthcare providers who prioritize the patient’s needs and offer consistent care. To achieve this, healthcare providers should receive more training on informed consent, bodily autonomy, and communication. The resources for maternal and birth care should be interactive and engaging to improve patient knowledge. Patients should be able to select a provider who understands and respects their cultural background. It’s also crucial to create innovative educational tools and classes led by care providers of color, with proper representation in outreach and educational materials. These are some of the recommendations from the Giving Voice to Mothers (GVtM) -US study by Vedam et al. (2019).

The Giving Voice to Mothers study explored the inequities and mistreatment encountered by pregnant women and mothers during gestation and delivery in the United States (Vedam et al., 2019). This study, led by a multi-stakeholder team comprised of service users, NGOs, clinicians, and researchers, aimed to grasp the lived encounters of maternity care in diverse people. The study employed an online cross-sectional survey to collect participant data, integrating patient-designed items that focused on indicators of mistreatment like oral and bodily abuse, freedom, prejudice, failure to fulfill proficient benchmarks of care, inadequate connection with providers, and inadequate circumstances in the health system. The preponderance of mistreatment was investigated regarding various aspects, comprising race, socio-demographics, mode, place of birth, and care context.

Findings from the GVtM study exemplify the degree of mistreatment women undergo during pregnancy and childbirth. Disturbingly, one in six women documented encountering one or more forms of mistreatment, for instance, loss of autonomy, verbal abuse, and being disregarded or denied help. The care context, like the mode and place of birth and contrasts of opinion, is likened to advanced reports of mistreatment. Notably, the study demonstrated substantial disparities, with women of color, especially those with low socioeconomic status, undergoing more elevated rates of mistreatment (Vedam et al., 2019).It is paramount to acknowledge this study is not an isolated endeavor but part of a broader body of research addressing the perceptions and experiences of black women during prenatal care. For instance, Zhang et al. (2021) examined the intersection of intimate partner brutality, prenatal anxiety, and drug use among expectant Black women. Yoder and Welch (2018) conducted a narrative assessment on midwifery and antenatal care for Black women, highlighting the importance of culturally sensitive care. Welch et al. (2022) explored establishing Black-led birth centers to manage health inequities, while Taylor (2020) delved into the consequence of structural racism on maternal health among Black women.

The United States is one of only 13 countries in the world where the rate of maternal mortality is now higher than it was 25 years ago. Between 2018 and 2021, the number of maternal deaths in the U.S. increased each year from 658 to 1,205, representing a maternal mortality rate increase of 17.4 per 100,000 to 32.9 deaths per 100,000 live births (Hoyert, 2023). During the same period, the maternal mortality rate for non-Hispanic Black women increased from 37.3 to 69.9 deaths per 100,000 live births. Therefore, it is important to consider these issues critically and explore how social-economic inequalities influence maternal care (Altman, et al., 2019; Salmond & Dorsen, 2022).

Among developed countries, the United States has the highest infant mortality rate (IMR), where, in 2021, the IMR was 543.6 infant deaths per 100,000 live births (Xu et al., 2022). An infant born in the United States is three times more likely to die than a baby born in Japan (World Health Association, 2016). Although there has been a decline in the overall IMR in the United States, a disparity gap has arisen between the infants of Black/African American women and their White / European American counterparts. The IMR in Southeast Queens communities among African American women was twice that of European American women residing in the Borough of Queens (New York City Department of Health and Mental Hygiene [NYCDHMH], 2014).

There is epidemiological data on the incidence/prevalence of certain conditions that can complicate pregnancy (Hoyert, 2022). For example, African American women have higher rates of inflammation than other groups of women, which increases their risk of perinatal outcomes (Saadat et al., 2022). Inflammation during pregnancy can harm the immune system of the baby and the mother (Goldstein et al., 2020; Han et al., 2021a). When the mother’s immune system is damaged, preterm birth and pre-eclampsia are often the result (Sawyer, 2021). Han et al. (2021b) found that environmental stressors and social stressors combined with the mother’s inflammation may have an impact on the baby’s developmental process indicating neurodevelopmental disorders when the baby is older. Depression during pregnancy occurs in 12% of pregnant women, though African American women experience depression more often than other races/ethnicities (Centers for Disease Control and Prevention, 2020; Mukherjee et al., 2016). Stress has been connected to adverse birth outcomes in African American women, which is much higher than in White women. Stress and inflammation increase the risk of depression which is a factor in preterm birth (Cruz et al., 2019; Saadat et al., 2022). Intimate partner violence (IPV), substance use, and cigarette smoking are related to low birth weight, preterm birth, and infant mortality, especially for African American women (Zang et al., 2021). However, more research is needed to identify the mechanisms related to both fetal and maternal outcomes (Saadat, et al., 2022). Intimate partner violence is a form of stress; if experienced before a woman becomes pregnant, the risk of depression is higher (Saadat, et al., 2022).

Stressors such as perceived racism by Black pregnant women impact their immune system negatively and can result in infection and, in turn, low weight at birth for babies (Chambers et al., 2020). Racism is a chronic stressor related to both low birth rate of the baby and preterm birth (Braveman et al., 2017; Dominguez, 2010; Dominguez et al., 2008a). The definition of racism is “as a perceived threat formed on an immutable characteristic often central to a person’s identity, resulting in unfair treatment based on a person’s physical attributes including skin color” (Chambers et al., 2018, p. 1). Stress from racism involves worry, denigration, discrimination, and racism in which a person internalizes the messages therein. Racism can occur at work, home, school, and in the community at large (Braveman et al., 2017; Earnshaw et al., 2013; Wallace et al., 2015). According to Chambers et al. (2020), “It is well known that Black women report higher levels of stressors at multiple timepoints across pregnancy compared to women of all other racial and ethnic groups” (para. 1). High levels of racism that Black women experience may impact maternal outcomes negatively. Furthermore, stress stemming from racism is related to the onset of early labor and preterm births (Braveman et al., 2017; Earnshaw et al., 2013; Nuru-Jeter et al., 2009).

Structural racism in the United States involves practices such as redlining, thus limiting access to quality education, and housing, and disparities in incarceration, wealth, and employment (Bailey et al., 2017; Mehra et al., 2017; Ncube et al., 2016). Research has continually shown that when Black pregnant women experience structural racism, adverse birth outcomes are related (Chambers et al., 2018; Mehra et al., 2017; Ncube et al., 2016). Stress in the form of microaggressions often experienced by African American and Latino women have been documented in the healthcare environments that have a detrimental impact especially in the form of barriers and well-being due to the correlation with anxiety and depression (Cruz et al., 2019).

A study of the mental health of African American women during pregnancy revealed an ardent desire for more access to healthcare professionals who are aware of white supremacy, racially conscious, and understand racial issues about health equality (Kemet et al., 2022). Arandomized control study found that cognitive behavior therapy groups that utilized the Mastery Lifestyle Intervention with African American and Latino prenatal pregnant women were effective and ought to be included as a routine adjunct (Ruiz et al., 2022).

The use of labor neuraxial analgesia for vaginal delivery was found to decrease the risk of severe maternal morbidity (Guglielminotti et al., 2022). The findings suggested that increasing access to higher utilization of labor neuraxial analgesia might help decrease severe maternal morbidity and improve maternal health outcomes in the US (Guglielminotti et al., 2022). Lower labor neuraxial analgesia use has been continually reported among racial and ethnic minorities, the uninsured, and low-income obstetric women (Butwick et al 2018). While an estimated 80% of White women get labor neuraxial analgesia nationwide, only 70% of African American women get labor neuraxial analgesia compared to 65% of Latino women. Furthermore, an estimated 75% of pregnant women of all races and ethnicities who have health insurance get labor neuraxial analgesia while only 50% of uninsured pregnant women receive the analgesia (Butwick et al., 2018).

The Centers for Disease Control and Prevention (CDC, 2020) reported that African American women tend to have higher rates of several chronic conditions and therefore are at a higher risk for maternal mortality and morbidity. The leading causes are hemorrhage, sepsis, hypertensive disorders associated with pregnancy, thrombotic pulmonary, and other types of embolism (CDC, 2020). Despite that, these risk factors do not account for severe maternal morbidity, entirely (Leonard et al., 2019).

Many women do not go to even one postpartum visit, which has the potential to contribute to maternal morbidity and this can be a factor in preventing a smooth transition to their well-being in the future (Attanasio et al., 2020). The Presidential Task Force on Redefining the Postpartum Visit and Committee on Obstetric Practices (2018) explained that the second gynecology appointment after giving birth should take place in the 12 weeks and should include an evaluation of the physical, social, and psychological well-being of the women. Research has shown that women attend postpartum appointments based on insurance, socio-demographics, and clinical characteristics (Danilock et al., 2019). Research also showed that African American and Latinx women versus White women and those who have Medicaid versus those who have private insurance are less likely to receive sufficient and well-timed preventive care in general (Taylor et al., 2020). Moreover, postpartum studies conducted in the US have shown that inequities regarding postpartum care content were widespread across all states, which poses a serious disadvantage to women. Nonetheless, examinations based on only one identity dimension may understate the scope of disparities (Interrante et al., 2022).

Furthermore, racial differences in minority rates among women of color can be traced back to healthcare inequality in the United States. Growing healthcare inequalities in America were investigated by Mourey, Besser, and Williams (2021), who looked at the fundamental community, medical, and system-wide causes. According to the results, eradicating health inequality will necessitate shifting the primary objective of studies beyond health inequalities and onto achieving racial justice through the elimination of structural discrimination. This study marked the beginning of a new phase of productive research that resulted in the establishment of the Office of Minority Health in 1986. (Mourey et al., 2021). First, racism is one of the most significant contributing factors that need to be evaluated and accounted for to ensure comprehensive healthcare coverage for African American women (Zambrana, 2004). Black women face more preventable deaths when compared to White women. Studying this in other ways shows that pregnancy rate, the death span, and income also vary and are co-related with education (Kiley, 2016).

African American women also experience a higher rate of problems during childbirth compared to White women. African American women’s pregnancy difficulties are not a passing issue; they stay with them throughout their lives. Even though persons of color and low-income individuals are disproportionately affected by care inequities, their experiences have been largely ignored in research on the delivery of prenatal care. So, clinicians and healthcare executives lack the vital information necessary to adapt prenatal care to the needs of underprivileged communities. Human-centered design (HCD), an approach to reimagining processes from the perspective of the end user, has led to the development of new prenatal care models that are more practical for patients and health care workers (HCWs). While human-centered design (HCD) shows promise as a strategy for reimagining prenatal care for low-income and African American patients’ specific needs, the vast majority of HCD work to date has been conducted with White, high-income populations in privileged academic care settings.

African American women face severe reproductive healthcare issues that include a higher rate of unintended pregnancies. As of June 2022, abortion is no longer legal in the United States. However, some states have passed legislation to keep abortion available (Messerly, 2022). A study in southern New York found that African American women were less likely to receive contraceptives than Latino and White women. Access to abortion is limited for African American women, and they are more likely to experience the effect of abortion at various stages of pregnancy due to stigma (Biggs et al., 2020; Moseson et al., 2019).

Discrimination and implicit bias were found to be a common experience of Black women often manifesting in healthcare workers not believing the severity of symptoms, so treatment was not sufficient (Bryant, 2021; Hatton, 2022). Obstetric care standards were often not adhered to even though they were central to the incidence of preventable deaths. Williams et al. (2019) mentioned the need for a greater understanding of racism in healthcare and the need to address racism as vital to the improvement of maternal healthcare. Both Alio et al. (2022) and Clay (2022) stated that understanding the experiences of pregnant Black women is needed to develop better practices and interventions to better serve this population.

Background

The New York State Department of Health (NYSDOH 2019) reported in 2019 that New York State is facing a challenge with higher maternal mortality rates, ranking 23rd in the country. In 2014-2016, the NYS maternal mortality rate was 18.9 deaths/100,000 live births which was 1.7 times the Healthy People 2020 target of 11.4/100,000(New York Department of Health, 2014). The mortality gap disproportionately impacting African American women only gets larger when looking at the NY-specific rate where African American women experience 51.6 mortalities per 100,000 live births compared to 15.9 mortalities per 100,000 live births among white women in 2014-2016 (New York State Expert Panel on Postpartum Care, 2021). Although rates have decreased, the racial disparity persists, with recent maternal mortality rates at 40.2 deaths per 100,000for African American women compared to 12.7 deaths per 100,000 for White women (Crandall, 2021).

Among the most recent cohort of pregnancy-related and pregnancy-associated deaths (2014), over half of the pregnancy deaths occurred within a week of the end of pregnancy (66.7%). The largest proportion of deaths occurred the day after the end of pregnancy (45.5%) (New York State Expert Panel on Postpartum Care, 2021). The top six causes of pregnancy-related deaths, regardless of timing, identified during the most recent cohort reviewed (2012-2014) included embolism (not cerebral) 23%, hemorrhage 17%, infection 17%, cardiomyopathy 11%, cardiovascular problems 7%, and hypertensive disorders 6% (New York State Expert Panel on Postpartum Care, 2021). Therefore, a cause for concern for many postpartum individuals is the significant barriers to obtaining and maintaining health insurance coverage, especially during the postpartum period.

While this creates a substantial barrier in many other states, New York has an extensive collection of insurance coverage options that ensure most birthing individuals can maintain coverage after their pregnancy. Among those individuals who gave birth in 2018 and received NYS Medicaid Coverage based on pregnancy eligibility, 90% of enrollees maintained public insurance coverage for six months postpartum (New York State Expert Panel on Postpartum Care, 2021). Of those who maintained enrollment in public insurance plans, 73% of enrollees-maintained Medicaid coverage. Of the 27% who lost Medicaid coverage, 62.5% moved into a public insurance option (i.e., Essential Plan or Child Health Plus), 2% enrolled in Qualified Health Plans, and the remaining 36% (approx. 9,000 individuals) lost coverage. Almost two-thirds, or 62% of those enrolled in Medicaid based on pregnancy eligibility-maintained Medicaid coverage for 12 months after the end of their pregnancy. Of the consumers who lost Medicaid coverage in the 7-12 months postpartum, 36% moved into another public health option.

Problem Statement

There is a problem in the healthcare of African American women. African American women are three times more likely to die during pregnancy and childbirth than non-Hispanic White women (Chalhoub & Rimar, 2018). Another study found that prenatal healthcare African American women participants received did not meet their needs based on their perceptions (Peahl et al., 2022). Supportive collaboration with other team members from the community was recommended. Healthcare should also be tailored to the individual and be offered in more convenient locations (Peahl et al., 2022).

A possible cause of this problem is racial inequities in the healthcare of African American women during pregnancy (Clay, 2022; Pabayo, et al., 2019; Ramraj et al., 2019; Salahuddin, Matthews et al., 2022). Further studies on the topic of racist experiences in maternal healthcare are needed (Mehra et al., 2020). This study seeks to expand on the quantitative findings of the Giving Voice to Mothers study and others like it by engaging participants in a qualitative hermeneutic phenomenological study to fill the gaps in perceptions of maternal care.

Purpose

The purpose of this qualitative hermeneutic phenomenological design study is to understand the personal viewpoint and perspective of the lived experiences of African American women regarding their prenatal care experiences. The emphasis of this research is to provide context for the interpretation of the research findings concerning racial and cultural differences in pregnancy. I am also aiming to better understand the psychological and social phenomena of African American Women’s perspective of their prenatal care experiences who have received prenatal care in Southern New York. The study population is all African American women from Southern Queens, New York.

The theory guiding this study is the Critical Theory of Race (CRT) (Bell, 1992; Delgado &Stefancic, 2017) as it is African American Women’s perspective of their prenatal care experiences. Data was collected by individual interviews to be analyzed thematically.

According to Rowley (2001), research that captures the experiences and ideas shared by African American women provides a unique insight into the lives and the communities in which they live. Self-definition, self-evaluation, and self-identification through voice have been themes for the African American community since the 1890s. The voices of this community provide insight into the interrelatedness of their health, education, social opportunities, moral character, cultural values, and general social betterment (Hogue, Hoffman, & Hetch, 2001). Until recently, the literature did not contain basic descriptive information about the self-defined experiences of pregnancy among African American women and their families (Rowley, 2001),

Patricia Collins (2000) noted that by placing African American women, their voices, and their thoughts in the center of research, researchers can move beyond the traditional epidemiologic reductionist framework and take on a Black feminist approach. Black Feminist thought provides African American women the opportunity to have a voice organization from their own experiences (P.H. Collins, 1986).

Framework Theoretical

The study was conducted with two theoretical approaches that explore African Americans’ lived experience with prenatal healthcare of women. The theoretical approach defined the various factors and philosophical approaches to the issue. The underpinning of the theoretical approaches discussed with women’s healthcare includes social and cultural experiences. Kleinman’s Explanatory Model of Illness and Critical Theory of Race (CRT) were explained and provided a framework that supports the current research.

Kleinman’s Explanatory Model

According to the theoretical approach study under Kleinman’s explanatory model shows the model of illness. This model emerged in the 1970s and allowed scholars to be medical and experience different diseases patients face (Kleinman, 1978). These factors show that the model provided is used to explore the patient’s experience, which has better access to healthcare differently. Patients provide some foundations that explore the patient experience with healthcare patient satisfaction. The cultural perspective tells that patients need to provide clinicians and treat patients from different perspectives. Kleiman’s explanatory model of illness is used for development that helps healthcare providers recognize cultural factors. These issues explain the complete healthcare model in some dimensions. The impacts of healthcare department recognize the social and cultural impacts to robust the patient’s condition.

Figure 1 shows that observation and experiences are based on the personal condition of illness. There are specific issues that women face during pregnancy, and the explanatory model explains this better. African American women have severe illnesses during pregnancy that view how diseases are dangerous for long-term health conditions.

Figure 1
Kleinman’s Explanatory Model of Illness: Individual Perceptions

This study used the hermeneutic phenomenological method research design which is based on individual reality and interconnectedness of social and cultural dimensions. Using Kleinman’s theoretical model this study explored how African American women are suffering from barriers in pre-natal healthcare.

Critical Race Theory

CRT recognizes that racism is not biological but socially constructed, permanent, and normal, and is institutionalized in policy, societal, and educational systems (Bell, 1992; Delgado &Stefancic, 2017). Therefore, people of Color are in a subordinate position, so CRT users counter-storytelling to give them power (Bell, 1992; Delgado & Stefancic, 2017. CRT can address the combination of racism and power while empowering employees to examine structures conducive to racial healthcare disparities that include mental healthcare (DeNard et al., 2017). CRT can be used to challenge attitudes about race that are often within a person and systems of society (Harris et al., 2020).

Exploring African American women’s experiences related to the issue of pre-natal healthcare due to racism, discrimination, and inequalities is the aim of the study. A systematic approach is needed to assess the issues that have created the conditions under which pregnancy of African American women has become a severe health crisis. CRT provided a foundation to understand why this is much more prominent in African American women compared to other segments of society.

Racism is directly linked to society as certain factors under which the health system works. These issues need to be addressed so that particular issues may be addressed under a health program developed for all rather than only some particular people. African American women face health issues because of the fractured health system, as there are higher death rates in African American women than in White women, yet that is only one of the reasons for the disparity.

In the study, CRT provided a theoretical lens to understand approaches that can be used to challenge bias, privilege, and positionality in the analytical process of contextualizing and addressing the lived experiences of the barriers faced by African American women during pre-natal healthcare in Southern New York.

Research Questions

The purpose of the research is to examine the lived experiences of African American women regarding their prenatal care.

RQ1- Qualitative: What are the perceptions of African American women regarding their prenatal care experience in Southern New York?

Nature of the Study

This dissertation is a qualitative study that aims to explore the prenatal care experiences of African American women in Southern New York. The researcher used a general qualitative design and open-ended interview questions as the primary data collection method. Through thematic analysis, the study identified social barriers to access to care and potential solutions to mitigate these barriers.

Qualitative research is an inquiry that enables researchers to uncover and chronicle specific population perceptions and actions by representing or signifying them in richly descriptive written forms. Qualitative research allows one to describe how and why people feel, think, act, or react in a specific setting, such as time, place, or circumstances that may not seem apparent or they may not be aware of. Ravitch and Carl (2021) declared how qualitative research uncovers these descriptives through epistemology. The researcher stated that epistemology is a philosophical assumption of qualitative research that expresses how one sees, identifies, and learns information. “How we view and gain knowledge as well as know what you know” (Ravitch & Carl, 2021, p. 5).

Definitions

Bias is a preference or inclination that restricts impartial judgment and is the same as prejudice (Sue, et al., 2007).

Discrimination is based on prejudice that can be either conscious or unconscious, that a person prefers one group over another regarding services, goods, or opportunities (Sue et al., 2007).

Healthcare disparities refer to the differences in the distribution of health determinants or health status between groups of people (World Health Organization (WHO), 2018). Health disparities are well-documented and costly (CDC, 2013).

People of Color is a term referring collectively to people who have a background that stems from Africa, Asia, Native America, and Latinx countries.

Pregnancy-related death means the woman died while pregnant or within one year of the end of pregnancy from a pregnancy complication. It is a chain of events that originated from pregnancy or a condition that was unrelated to aggravation by the physiologic effects of being pregnant. The death may have a temporal relationship to pregnancy, which is causally related to pregnancy or the management of pregnancy (Davis et al., 2019).

Prejudice is a preconceived judgment about a group of people or an individual that denotes negative bias.

Preterm birth (PTB) refers to a woman giving birth earlier than 37 weeks of gestation (Ely & Driscoll, 2020).

Preventable death: A death is deemed preventable if there was at least some chance of the death being avoided by one or more reasonable changes to the patient, community, provider, facility, and/or systems connected to the death (Davis et al., 2019).

Racialization refers to the process of marginalizing and categorizing people based on their race. Race is a social construction concept and thus depends on the existence of social dominion and the power of the dominant group in society (Smedly & Smedley, 2008).

Stereotype refers to blanket expectations and beliefs about those who belong to a certain group that an oversimplified opinion, uncritical judgment, or prejudiced attitude that are typically negative and based on little information (Sue et al., 2007).

Assumptions

The fundamental assumption of hermeneutic phenomenological (HP) research is that there are several perspectives or interpretations. Van Manen (2014) argued that HP is focused on several perspectives of the participants or the research subjects. Therefore, I assumed that those who have vastly different backgrounds including culture will have varying experiences.

I also assumed that participants related to my study would be easy to locate and would be willing to participate. My assumption is directly related to obtaining data for this study. Another assumption is that the participants would respond truthfully and honestly.

Scope and Delimitation

The participants were African American women who have gone through at least one pregnancy, are between the ages of 18 to 50, and received their pre-natal healthcare from one hospital in Southern New York. This study did not include participants who have received healthcare from other facilities in Southern New York as it is not feasible. The choice of utilizing a case study methodology means other possibilities concerning the findings. The researcher has also limited this study to answering the research questions with two theoretical perspectives that were adopted, the choice of participants and the theoretical framework.

Limitations

One of the limitations of the study is that it relies on the perspective and lived experiences of pregnant and postpartum mothers. While the objective of the study is to capture their subjective understanding of the services offered, emotions rather than the reason might influence the reliability of the data. Recruitment of enough respondents was challenging as some mothers may be unwilling to participate in the study. Potential participants were assured of confidentiality, and interviews were scheduled based on their availability and convenience to encourage many to participate. There are also some limitations of this study related to prenatal care of African American women who received healthcare from one hospital in Southern New York. Only one group of women was included, that of African American women between the ages of 18 and 50.There may be other women, or even other African American women older or younger, or others who received pre-natal healthcare at other similar facilities that have not been included, Due to this study being a qualitative case study, inferences cannot be made, nor can correlations, so there may be alternative explanations that could be valid. Furthermore, case study findings are only suggestive and cannot be generalized elsewhere.

Significance (Social Change)

This study is significant because knowing the perceptions and experiences of postpartum mothers using pre-pregnancy and prenatal services may help in creating knowledge that informs appropriate interventions to improve utilization and pregnancy outcomes among African American women. The healthcare experiences faced by African American women during pregnancy is an important topic. Sharp racial discrimination and disparities in treatment, even in the health sector, is an issue African American women frequently deal with. This service crisis further enlarges the interdisciplinary approach that the importance of healthcare for all is a genuine issue.

This study may have particular significance for African American women who are pregnant and seeking pre-natal healthcare. Healthcare professionals could use the information from the findings to provide better healthcare for African American women, so outcomes can improve. African American women believe that their health and the health of their babies are affected by the disrespect and discrimination they experience in interactions with healthcare professionals (McLemore, 2018).The information shared or withheld by healthcare professionals was found to influence issues such as the power dynamic between the professional and patient (Altman et al., 2019).In addition, contextual factors such as judgment toward the patient and bias can also have an impact on the interactions between healthcare professionals and patients (Altman et al., 2019).

Summary

There are multifaceted issues regarding the pregnancies of African American women and the worsening infant mortality rate (Altman et al., 2019; Howell, 2018; Howell, 2018). African American women are more likely to be at risk of death during pregnancy problem because of the weak socioeconomics and lack of quality healthcare (Creanga et al., 2014).

The practical manifestation of health inequality can cause a severe societal problem for the African American community. African American women are at risk of their lives and often live in abject poverty (Howell, 2018). Health, medical facilities, and health insurance can play a vital role in preventing complications during pregnancy (Hall, 2015). The lack of mental healthcare can also play an important role in redressing the deteriorating condition of healthcare for mothers in the African American community.

Chapter 2 is a literature review of relevant prior research to the study. Prenatal care is particularly focused on since it is the closest related. However, other aspects of African American women’s pregnancy are also included to provide a wide-ranging understanding of the problems.

Chapter 2: Literature Review

Introduction

Pre-pregnancy and prenatal care can help women avoid difficulties and learn about crucial steps they can take to safeguard their babies and have a successful pregnancy. Disparities in healthcare outcomes between ethnic, cultural, and socioeconomic classes are exacerbated by disparities in prenatal care access and utilization (Okeh et al., 2015). Prenatal care research typically looks at the relationship between the frequency and timing of prenatal visits and demographic parameters, including the woman’s age, schooling, race, socioeconomic background, financial status, or geographic location. While usage statistics can be used to determine when women began their healthcare and whether they attended appointments regularly once they started, these studies do not evaluate the quality or substance of prenatal care, nor do they illustrate why women do not use the treatments that are provided to them (Okeh et al., 2015). Use cannot be equated with access due to the lack of accessibility to available services. Low-income women may live in areas without access to healthcare or public transit. Unless women are asked, it is troublesome to tell which of these elements has the biggest impact on them or how they interact. The woman’s lived experience of obtaining treatment, such as personal hurdles, wait times for consultations, or other explanations they do not initiate or sustain care, cannot be revealed by utilization data (Coll et al., 2017).

The inequity of healthcare for minority women who were pregnant was so appalling that the Biden-Harris Administration specifically highlighted the situation as part of the first national gender strategy in the history of the United States (The White House, 2021).Noting that Native American and Black women are disproportionately impacted the administration called for unprecedented investments in healthcare (The White House, 2021). In addition, the CDC found two-thirds of the deaths that were related to pregnancy in the United States are preventable and said they require immediate action (Davis et al., 2019).

Based on research published in 2013, this literature review investigates African American women’s perceptions of pre-pregnancy prenatal care. A review of the research on prenatal care access is offered to help physicians and other healthcare professionals better understand the process, including women’s perspectives on prenatal care access.

To frame the subject and conduct the literature study, Galvan’s method was employed. The keywords “prenatal care,” “pre-pregnancy care,” and “access” were used to search the PubMed, ERIC, ProQuest, and CINHAL databases. Only studies from the United States were included in the review due to disparities in healthcare systems between nations. Initially, only sources published after 2013 were examined. A review of procedures for integrity and appropriateness was included in the analysis. Research that derived findings regarding access to prenatal care usage data was separated from literature and studies that surveyed women about their perceptions of access were included.

Theoretical Foundations

The purpose of this qualitative hermeneutic phenomenological design study is to better understand the psychological and social phenomena of African American Women’s perspective of their prenatal care experiences who have received prenatal care in Southern New York.

Critical race theory (CRT) was initially founded in the United States in the 1970s and 1980s (Bell, 1995; Gillborn &Ladson-Billings, 2009; Tate, 1997). At that time, the pioneers of CRT sought to use the framework to target oppressive laws by exposing different incidences of racial inequalities embedded in US policies. Derrick Bell, Kimberlé Williams Crenshaw, Richard Delgado, Lani Guinier, Mari Matsuda, and Patricia Williams were the foundational scholars of CRT.

The theory evolved and has been used in different settings to understand the influence of the intersectionality of race and gender and the representation of women in different fields such as education, business, and other social institutions (Daftary, 2020). CRT offers a theoretical lens for examining how deeply entrenched racism has become the fabric and identity of the culture of people of Color in the United States. Bell (1995) Crenshaw (1995), Delgado and Stefanic (1993), and Ladson-Billings (1995, 2021) agree there are five major constructs of CRT:

Racism is an ordinary and regular phenomenon in society.

Race is a social construct.

Interest convergence promotes self-interest.

Narratives and storytelling can be used to express or challenge Eurocentric ideologies.

The notion that Whites have been recipients of civil rights legislation.

Whiteness as owners of property is based on the historical enslavement of Black people who were considered human capital, and property (Harris, 1993; Leary & Robinson, 2017). Enslavement included extreme abuse, exploitation, rape, as well as psychological warfare to build the wealth of White Americans (Harris, 1993; Leary & Robinson, 2017). Whites were superior in every way and could not be enslaved (Harris, 1993). The White supremacist ideology still provides White people systematic advantages in employment, housing, health, education, and healthcare even though race is socially constructed speciously (Bhopal & Ablibhai-Brown, 2018).

CRT, as utilized by Ladson Billing (1998), was aimed at education, yet some of the same points apply to the area of healthcare. Ladson Billing’s (1998) CRT emphasized cultural relevance, and the objective was to liberate Black people’s educational environments that were systematically racist. Culture was also highlighted in the study, combined with the five main tenets of CRT.

There has been a great deal of criticism recently about CRT (Kaplin et al., 2021). “Conservative activists are believed to be distorting this theory to ban it” (Morgan, 2022, p. 35). There are at least 28 states as of July 2021 that have either passed or legislation restricting what teachers can teach about race (Ray & Gibbons, 2021). The fact is, CRT is not taught in K-12 schools at all, yet it has caused controversy because there are programs that may be dropped wherever CRT is banned. For example, teachers can be fined $5,000 for students being taught to feel guilty about their race in Arizona (Pitzl, 2021). Some teachers and other school personnel have resigned over the issue (Kaplin et al., 2021). Those who stay and teach the “honest history” of the United States have been promised they will be defended in court if they are punished for their teaching practices by the American Federation of Teachers (Binkley, 2021). However, teachers do not feel safe though they want to do the right thing for the best learning of their students (Kaplin et al., 2021). Yet they do not want to upset students or parents either (Kaplin et al., 2021). American history can be taught in a balanced and inclusive manner while incorporating accurate facts about the past, thereby socializing children to become loyal, proud American citizens (Kaplin et al., 2021). However, CRT has become a substitution for “state-sanctioned racism” (Karni& Haberman, 2021).

CRT has become the “latest boogeyman they can use to scare people into thinking America’s children are being “indoctrinated” by “leftist teachers” (Power, 2021, para. 2). Power (2021) counted the number of times Fox News mentioned the phrase critical race theory in the entire year of 2020 114 times. However, from March to the middle of June, the network mentioned CRT 1,900 times. Some Republican state legislators have even succeeded in banning the teaching of CRT (Morgan, 2022; Power, 2021). An illusion is being spun that CRT is being taught in K-12 schools, but the reality is it is not (Morgan, 2022; Power, 2021). Fox News has exaggerated the lie that CRT teaches that one race is “inherently superior to another,” but that is not what it teaches (Power, 2021, para. 3). Examples of what guests on Fox News have said about CRT have crossed over into the absurd. Newt Gingrich said the people behind CRT “want to brainwash your child,” Tucker Carlson called it “a cult,” while Miranda Devine said it would “warp the minds of American children” and “is a recipe for social upheaval and mental illness” (Power, 2021, para. 4). Understanding how White supremacy is maintained will help in the dismantling procedure. Contrary to the belief of some people, CRT is not taught in K-12 schools, although conservative activists have been successful in banning it in many states by misrepresenting the meaning (Morgan, 2022).

CRT provided a foundation and theoretical lens to explore the prenatal care experiences of African American women in Southern New York. In the study CRT is especially applicable through the five constructs particularly that racism is an ordinary and regular phenomenon in society, race is a social construct, and that narratives and storytelling can be used to express or challenge Eurocentric ideologies. The process in the study is expected to give African American women an opportunity to tell their stories in their voices. The findings can be used to challenge bias, privilege, and positionality in the analytical process of contextualizing and addressing the lived experiences of the barriers faced by African American women during pre-natal healthcare in Southern New York.

Review of the Literature

Quality of Pre-Pregnancy and Prenatal Care for African American Women

In the United States, Black women have poor pre-pregnancy and prenatal health outcomes. Access to health insurance is another factor causing the disparities in the quality of care received by African Americans and their Caucasian counterparts. According to Oribhabor et al. (2020), the Affordable Care Act (ACA) made significant progress in increasing the number of people with healthcare insurance, as more than 20 million people have gotten insurance since the law was passed. Taylor (2020) explained that the Affordable Care Act helped millions of African Americans get access to improved healthcare, but it did not eradicate mother and newborn mortality disparities. African American women still have limited access to quality healthcare due to their socioeconomic situations limiting their ability to afford insurance (Williams & Cooper, 2019). Even with the insurance, the researchers noted that those in rural and other underserved areas lack physical proximity to specialized prenatal caregivers, which continues to put them at risk. In such areas, access to maternity wards, OB-GYNs, and other related professionals is limited, which means the women cannot access regular pre-pregnancy and prenatal care when they need it. However, women, there are also other factors impacting the disparities that African American women experience during pregnancy.

To ensure effective prenatal and postnatal care outcomes, patients and providers must establish a relationship. Ineffective communication and interaction between pregnant women and healthcare providers has harmed pregnancy outcomes in the United States (Bush et al., 2017). This issue could lead to misdiagnosis or delayed diagnosis of pregnancy problems. As a result, timely reporting or referral of high-risk cases to professionals or high-level healthcare professionals to take the necessary actions is hampered.

Shahin et al. (2020) posit that despite the advances in maternal health promotion technologies over the last decade, the Maternal Mortality Rate (MMR) in the United States has steadily increased. The authors noted that pregnancy is a unique and essential time for most women, but they face that period of their lives with a lot of fear and uncertainty. This is supported by Herring et al. (2016), who claim that there are certainly a lot of unknowns when it comes to labor and delivery, but non-Caucasian women’s perspectives on preparing for the prenatal journey to the end are typically overlooked. The marginalization, stigmatization, and stereotypes they face in this regard are caused by the racism they must endure in American society. The differences between the life experiences of pregnant Caucasian and African American women merit renewed interest in the cause of the differences so that a solution can be found to address them.

Preparation for motherhood is a crucial step for women during the pre-pregnancy and prenatal stages. Szumilewicz et al. (2013) provided essential insights into the experiences of these women before and during pregnancy. Women look for role models to guide them through the process from their older female relatives or, in places where they had none, someone who could hold the place of a mother to them, such as an older female neighbor, Similarly, Barimani et al. (2017) noted that role models are in charge of supporting women through the pregnancy process as well as teaching them how to be good mothers. In this regard, role models oversee supporting women through the pregnancy process as well as teaching them how to be good mothers (Leech et al., 2014). The women even reported feeling safe and comfortable under the care of their spouse, mother, sister, or any female relative. Notably, this is very different from the experience of Caucasian women at the time as many had access to the services of professionals in the field, which gave them better chances of a successful or at least less problematic pregnancy experience.

Physical activity is also important during pregnancy especially while preparing for natural childbirth was the focus of a study by Szumilewicz et al., (2013). Insights were provided by the participants about their experiences during delivery and the course of labor. The findings showed that healthcare providers need to provide detailed instruction during appointments as there may be individual issues that need to be taken into consideration. Intervention research trials are needed globally to establish guidelines about physical activity (Barakat et al., 2013). This topic is also important during breastfeeding because if there is not enough calcium for both mother and baby, bone resorption and infant growth can occur impeding breastfeeding as can the amount of physical activity. There are also times during and after pregnancy that physical activity is recommended to be adjusted and these have been established by the Society of Obstetricians and Gynecologists of Canada (SOGO) Clinical Practice Obstetrics Committee, the Executive and Council of SOGO, and the Board of Directors of the Canadian Society for Exercise Physiology (Barakat et al., 2020).

It is essential to understand if pre-pregnancy and prenatal care quality has changed for African American women. According to Chalhoub & Rimar (2018), the situation has not changed since studies by the Centre for American Progress showed that African American women are thrice as likely to die during pregnancy and childbirth as non-Hispanic White women. The authors attribute this to the continuous refusal by the American healthcare system to listen to the health concerns of African American women. In the United States, racial inequities continue to raise risk factors for Black women, since they are more likely to suffer from hypertension, anemia, and gestational diabetes (Leonard et al., 2019). These illnesses require special care but are often not addressed in African American women and may result in high maternal mortality (Chalhoub & Rimar, 2018). The study refuted other factors such as smoking and drug abuse that have previously been attributed to high maternal mortality among African American women. This shows that the problem lies in the whole American social system that makes African Americans predisposed to specific health conditions and a healthcare system that does not consider the implications of these conditions on the pregnancy journey (Chalhoub & Rirma, 2018).

There are also serious consequences for the infant when women do receive qualitative healthcare during pregnancy. Clay (2021) explored the trends in Black/White infant mortality rates (IMR) in the United States between 2007 and 2016 based on maternal age, marital status, education, and access to prenatal care. Secondary data from the CDC and descriptive statistics were used in the study. The results showed that IMRs for non-Hispanic Blacks had declined faster (15.8%) relative to non-Hispanic whites (13.5%). Even though non-Hispanic Backs have registered better rates in terms of IMRs, racial disparities persist with Black people lagging (Clay, 2022). Other research has found similar results (Pabayo, et al., 2019; Ramraj et al., 2019; Salahuddin, Matthews et al., 2022).

Factors Affecting Perceptions and Experiences of African American Women in Pre-Pregnancy and Prenatal Care

Various factors influence the perceptions and expectations of African American women regarding pre-pregnancy and prenatal care. These include low income, family and friends, discontinuity of care, delay in seeking care, racial microaggressions, and other barriers. In this section, each of these factors were discussed as they are relevant to the study.

Low Income

Low income is a leading factor influencing these perceptions of African American women. The research by Edmonds et al. (2015) found that the level of income influenced the perceptions of African American women on the quality of care they needed. Such women from low economic backgrounds have low expectations of the quality of care they need to ensure their safety and the child. Many low-income women, especially first-time mothers, do not see a professional before becoming pregnant (Tuomaien et al., 2013). Those who see a professional and those who experienced complications in a previous pregnancy want to know if it is safe to be pregnant again (Rose et al., 2019). Minimal prenatal care is also the norm in such communities where they feel they do not need to visit the clinic more regularly than advised by peers and family. The services are expensive, and therefore, they must minimize the expenses as much as possible.

Family and Friends

Edmonds et al. (2015) added that the study participants mentioned their family and friends as the primary motivation for seeking prenatal care. Factors like the well-being of the baby and their health come second. Despite their fears that missing prenatal care appointments may cause complications for the baby, parents must consider other factors such as insurance and transportation before selecting whether to use the services (Davis-Floyd et al., 2020).According to the scholars, the visits to the clinic involve being instructed and critiqued by the providers on what they are doing wrong but never taking time to listen to the needs of the pregnant mothers. African American women wish that they are treated more humanely during such visits (Attenuation& Hardeman, 2019). Without the right amount of motivation and support, many of these mothers fail to do what is required of them for their well-being and that of the baby.

Discontinuity of Care

Healthcare workers who provide care during pregnancy should be aware of health disparities and how to address them. According to Scott et al. (2019), these guidelines are equally relevant to newborn and perinatal health practitioners and public health professionals, as discrepancies in neonatal and prenatal health may be a result of maternal health inequities. In their research, Sommers et al. (2016) mention discontinuity of care is a major reason why African American women from low-income families do not seek prenatal care. Some of the respondents in this study claimed that the provided only followed the chart and asked repeated questions during every visit, which they did not deem the most effective approach.

While providers may view this as a basic routine that is important for measuring progress, it does not help connect with the patients to understand their specific needs (Yoder & Hardy, 2018). Patients claimed this approach made them feel like “paper patients,” as the providers cared about the records and not the actual patients. Other patients in this study cited negative experiences with trainees. While they agreed on the importance of the trainees’ learning, some were concerned about redundancies and errors in the provision of care by trainees. The mistakes by trainees give patients a bad experience as they have to be checked multiple times for the same issue.

Delay in Seeking Care 

Delay in seeking care is another persistent factor affecting prenatal care among African American women. Research by Warri and George (2020) sought to understand the reasons they initiate antenatal care late. African American women lowly value early antenatal care because, for them, pregnancy is a regular health condition that does not have to be regularly checked (Herring et al., 2016). Such mothers do not even seek pre-pregnancy care and preparation unless they had a complication in their previous pregnancy. They are less motivated to start prenatal care early because of positive experiences with earlier pregnancies or with other women in their families (Tekelab & Berhanu, 2014). This was combined with other factors such as the high cost of services, distance to health centers, and poor road networks, making it difficult for them to start prenatal care early. There is also a perception of a lack of support from relatives and friends who do not believe it is essential to seek antenatal care early.

Racial Micro Aggressions

African American women face discrimination when seeking pre-pregnancy and prenatal care. Often discrimination takes the form of microaggression. Microaggressions were defined by Sue et al. (2007) as “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group” (p. 273). However, micro-aggressions that occur in the environment impact minorities and their identity so a strong connection to one’s ethnic group and thereby a sense of belonging can act as a buffer against racism (Wong, 2003; Sue, 2003; Sue et al., 2019). For example, excluding decorations in the office of a person’s racial identity therefore minimizing that person’s cultural connections with their community.

Vedam et al. (2019) carried out a cross-sectional survey on the experiences of diverse populations in maternity care. The researchers sought to understand issues such as verbal and physical abuse, autonomy, discrimination, poor relationships with providers, and poor environmental conditions in the hospitals as a source of poor services. When assessing interactions between patients and caregivers of different races, there were more cases of abuse of women of color seeking prenatal care (Attanasion & Hardeman, 2019). For instance, it was revealed that 27.2% of women of low socioeconomic status reported being mistreated compared to 18.7% of White women of low socioeconomic status. Additionally, the research found that regardless of the mother’s race, if the partner was Black, it increased the chances of being mistreated. Marti (2018) established that discrimination and abuse of women of color in American hospitals has harmed their pre-pregnancy and prenatal care experiences, as well as their perceptions of the same. These women would rather wait until the pregnancy is several months old before seeking prenatal care to avoid being mistreated for as long as possible.

Other Barriers

Women face different barriers in seeking prenatal care in the United States. Research by Meyer et al. (2016) looked at these issues in three dimensions- societal, maternal, and structural. From a societal perspective, a lot of women may not seek prenatal care for unintended pregnancies. This is because of the stigma associated with it. While this problem affects all women across the board, women of Color are the most affected because of their background. Women from low-income homes may try to postpone their initial prenatal visit as long as possible because they believe they are burdening their families with the pregnancy (Goodman et al., 2013). At the maternal dimension, this researcher cited fear of medical procedures, depression, and the belief that prenatal care is unnecessary as significant barriers to accessing prenatal care. This is also based on their background and lack of motivation from their close family and friends to start visiting the hospital for prenatal care. The structural dimension, which includes long wait times, provider language and attitude, and a lack of proper facilities in their places of residency, also has an impact on women of color (D’Angelo et al., 2016). These structural barriers also affect Black women disproportionately because they are a marginalized group in the US, and even those who seek prenatal care are treated poorly by the providers.

Alio et al. (2022) focused on obtaining descriptions of experiences of the multiple factors that contribute to disparities between Black women and White women concerning maternal mortality and morbidity. The study was conducted using a community-based participatory methodology where the participants become co-researchers and collaborate to help shape the study. Black mothers met in Listening Sessions in Rochester, New York, and talked about their experiences with healthcare professionals. The data was coded into themes and subthemes. The factors that were identified by Black women mother participants revealed multi-level factors impacting their experiences as expected (Alio, et al., 2022; Maskrey, 2019). The four levels were systematic, interpersonal, individual, and clinical/healthcare. However, the most important factor was communication between patients and healthcare professionals. Healthcare professionals’ behaviors and discriminatory attitudes, along with maternal health literacy, were important in the interactions. Maskrey (2019) in a similar study found that healthcare professionals tend to overestimate their communication skills whenever patients see the interaction as inadequate. Communication breakdowns lead to poor outcomes and delays in determining medical conditions and diagnosis (Ibrahim, et al., 2019). These factors are not specific to Rochester, New York, they are nationwide. Therefore, better understandings about the experiences of Black women while they are pregnant are needed to inform interventions, practice, and research (Alio, et al., 2022).This is an opening in the literature to which the study can contribute.

Mehra et al. (2020) used an Ecosocial and intersectional framework as well as a biopsychosocial model of health to understand Black pregnant women’s experiences of gender racism during pregnancy. Data was collected through semi-structured interviews with 24 black pregnant women in New Haven, Connecticut. Women were asked about their experiences with pregnancy, experiences with gender racism, and concerns related to pregnancy and parenting Black children. Grounded theory techniques were used to analyze the data. Women experienced gender-based racism during pregnancy, racist pregnancy stigmas in the form of stereotypes that stigmatized Black motherhood and devalued Black pregnancy (Mehra, et al., 2020). In addition, women reported encountering assumptions from healthcare professionals that they were low-income, single, and had multiple children, regardless of their socioeconomic status, marital status, or parity. Women encountered a racist pregnancy stigma in everyday life, healthcare, social services, and housing, making it difficult to complete tasks without an exam. Many experienced stresses stemming from the racial stigma of pregnancy (Mehra, et al., 2020). To counteract these stereotypes, women used a variety of coping responses, including positive self-definition. Racialized pregnancy stigmas may contribute to poorer maternal and infant outcomes through limited access to quality healthcare and barriers to health services, resources, social support, and poorer mental health. Interventions to fight racist pregnancy stigma and its adverse consequences include anti-bias training for healthcare and social care professionals, screening for racial stigma in pregnancy as well as providing evidence-based coping strategies. The creation of pregnancy support groups and the development of a broader societal discussion that values Black pregnant women will also most likely help diminish gender racism(Mehra, et al., 2020).

The COVID-19 pandemic contributed to the rise in out-of-hospital births that took place either at home or in free-standing birth centers (Davis-Floyd et al., 2020). Other changes occurred also. Davis-Floyd et al. (2020) found that doulas (support persons for pregnantpersons), and the partners of the pregnantwomen were often excluded from the rooms where birth happened. This practice left women unsupported even though there was a lack of PPEs for hospital personnel in addition to guidelines that were provided were unclear. Many pregnant women made swift decisions to have out-of-hospital births at this time. Some decided out of fear and others had been considering it and the pandemic gave them a little push to decide. However, there was much controversy about out-of-hospital births even though it has been debated for years.

Davis-Floyd et al. (2020) tracked some of the discussions and presented all sides of the issue from doctors who were definitely against out-of-hospital births to doulas and midwives who had long-standing practices of helping women give birth at home and in birthing centers. The medicalization of birthing had come to the fore when Hurricane Katrina occurred over a decade before the COVID-19 pandemic stifled normal life worldwide. Yet, nothing was done to prepare for the next disaster after Katrina so the medical community was not prepared to address so many patients at the time. Some advocated for a relaxation of regulations to allow midwives to practice during the pandemic while others exaggerated the risks of out-of-hospital births to women trying to decide where to give birth.

New York and some other states did relax restrictions on practicing midwives as they did for nurses crossing state lines to help with the onslaught of rapidly rising admissions to hospitals due to the pandemic. Much of the information in this article is data gathered from members of the Council on Anthropology and Reproduction, REPRONETWORK, which included doulas, midwives, obstetricians, and other birth practitioners. Maternity wards were restricting who could be a support person so women had to choose between their partner and their doula. Mistreatment and racism were reported from mothers giving birth in hospitals. Midwives were accused of not staying abreast of the latest information for safety measures, and not being connected to others in the community such as nearby universities even though many hospital personnel lacked PPEs. One key contagion site was the hospitals.

Racism in maternity care has been documented by many researchers (Davis D.-A. 2019; Rapp 2019; Valdez & Deomampo, 2019). Others have shown that supporting doula care for women of Color improves women’s empowerment and agency in institutional maternity care in the US where hospital personnel are predominantly White (Bakal & McLemore, 2021). As stated by Davis-Floyd et al. (2020), “The unequal access to safe and high-quality maternity care within the US has only been exacerbated by the COVID-19 virus” (p. 420).

This study focused on African American women and other women who were survivors of abuse about their chosen preference to have a planned out-of-hospital (OOHB) birth, or an unassisted birth (UAB) with no midwife or other healthcare professional birth attendant (Sperlich & Gabriel, 2022). Few studies have focused on Black women who choose OOHB, and little is known about why they choose OOHB. Previous studies have demonstrated that women who have experienced childhood physical or sexual abuse may give priority to having a sense of autonomy and control during giving birth. Sperlich and Gabriel (2022) recruited 18 women who had an OOHB or UAB and who were either Black and/or survivors of trauma to participate in the study. Data was collected by individual interviews. The transcriptions of these interviews were analyzed using a grounded theory technique. The findings showed that women may choose OOHB or UAB due to experiencing prior trauma, or because they feel discriminated against by healthcare professionals (Sperlich & Gabriel, 2022). The discrimination they experiencedwas viewed by the participants as happening due to skin color, age, pregnancy, weight, or some other health condition, and choosing OOHB or UAB allowed them to have more control during the procedure of giving birth. Understanding the role prior trauma and discrimination play in choices about giving birth may assist healthcare professionals in considering bodily autonomy, anti-racism, physical and emotional safety, and independence as major components in their interactions with women who are pregnant and giving birth (Sperlich & Gabriel, 2022). Although the study is focused on Black women’s prenatal care in a hospital, they may have considered giving birth in out-of-hospital situations such as a home birth or a birth center so understanding their choices is important.

Perceptions of Patient-Provider Interactions

Patient-provider interactions also cause disparities in healthcare outcomes. This is a problem that mainly faces racial/ethnic minorities in the US. There are many factors involved in the interactions between patient and provider but many of the issues are related to bias, prejudice, and discrimination. In general, it appears that there is evidence for racial problems to arise from many different aspects of healthcare with pre-natal care being one. Therefore, this section will first present some of the studies related to healthcare for minorities in generalized healthcare situations and then some that are specially tailored to focus on prenatal care.

The purpose of Gollust’s et al. (2018) study was to understand healthcare professionals’ points of view about the causes of disparities associated with race in a mixed-methods study. Data was collected by a survey completed by healthcare professionals from three Veterans Health Administration sites, and interviews in addition to reviewing the literature of prior studies. The findings showed that some physicians realized they were biased and reflected on it, while others did not. For example, one patient who was African American said the staff was racist and the physical was initially annoyed by the patient. Yet, the physician learned about the experiences of racism this patient had endured by establishing a relationship. Another was a White physician who revealed that the relationship with an African American patient reminded him of his own biases based on race. There was also an African American physician who went to the emergency room for back pain and received racially biased treatment. Gollust et al. (2018) concluded that a multidimensional approach was needed to reduce healthcare disparities that included the patient’s circumstances, and the provider’s circumstances, in addition to factors on a systems level.

In another study conducted in a Veterans Administration facility, van Ryn and Fu (2003) found that even though healthcare professionals had good intentions some had a paradoxical attitude concerning mental healthcare. Some especially, valued intersectional identity in their patients and thought that professionalism and good intentions protected them against racism (van Ryn& Fu, 2003). This study aimed to determine if healthcare professionals contributed to differences in care based on race/ethnicity culminating in institutional discrimination. The evidence suggests that motivation and awareness are a necessity for a person to exert control over stereotypes; they are not sufficient (van Ryn& Fu, 2003). However, Goldberg et al. (2020) found that there are fewer disparities when military service was noted at the beginning of mental health treatment.

Communication is also an area that has an impact on interactions between women of Color. Dahlem et al. (2015) conducted a cross-sectional study to examine the perspectives of African American women on patient-provider interactions. This study measured two primary factors, communication, and perceived discrimination, during prenatal visits. A multiple regression analysis revealed that communication between the patient and provider positively impacted the patient’s trust in the provider and patient satisfaction. However, while analyzing the experience of African American women seeking prenatal, Altman et al. (2019) revealed that they do not have effective communication and interaction with the providers. Moreover, McLemore et al. (2018) established that a lack of active listening skills, not asking psychological questions, and not explaining diagnoses affect the experience of Black women seeking prenatal care. These patients cited a lack of clear communication from the provider, which affected how they understood their situation and their motivation to go back to the clinic.

Khemani (2020) provided essential insights on the same topic. The researcher studied racial inequality in the United States healthcare system which has potential consequences for maternal mortality among African American women. According to the research, racial bias is experienced as soon as a woman of Color enters a healthcare facility, from how they are received to their interactions with the providers. This study was focused on the field of reproductive health, which affects African American women’s mortality and morbidity rate. Through investigating the discrepancies in the overall experience of African American women seeking pre-pregnancy and prenatal care, the research is supported by Gavin et al. (2018) who found that there is implicit bias to the extent of the quality of caregivers assigned to them. According to Flanagan et al. (2018), this is common in cases where African American women are seeking specialized care and end up with unaddressed complications because of the quality of care they receive in hospitals. The author noted that women of Color have specific needs that need to be addressed by the care providers, but these are often ignored based on their color. As a result, Black women have a bad experience seeking prenatal care, resulting in poor postpartum outcomes for women.

Interactions between minority patients and healthcare professionals were researched by Sim, et al. (2021) who conducted a literature review on the topic to attain common themes to synthesize explanations and perspectives. Analysis was applied using coding of the articles and was limited to only quotes from patients and healthcare professionals to portray the minority experience regarding the delivery of healthcare. The findings showed that not only is racial bias still operating in healthcare facilities, but biases are also not limited to the United States as several other countries published research included(Sim, et al., 2021). Healthcare professionals often labeled minority patients as being less compliant about their treatment. These same healthcare professionals tended to blame healthcare disparities and unsuccessful treatment on the behaviors of minority patients and did not concern themselves with unequal treatment arising from racism. Healthcare professionals saw minority patients’ reports about racism as misinterpretation of innocent interactions as racist due to encounters in the past that they had experienced or that they were just oversensitive. Many minority patients reported a lack of sympathy from healthcare professionals (Sim, et al., 2021). There were also reports of minority patients playing the race card unnecessarily meaning they were trying to obtain sympathy or special treatment due to their race. However, there is evidence that minorities experience micro-aggressions when they are in healthcare facilities (Sim, et al., 2021). These types of perceptions by healthcare providers may stem from a lack of responsibility and their inaction to address their biases. Exclusion of minority patients from some therapies may contribute to medical treatment that is inadequate and may stem from pigeonholing by healthcare professionals(Purtzer & Thomas, 2019).Sim et al. (2021) suggested healthcare professionals not only take implicit bias assessments, for example, the Implicit Association Test but self-reflect to help in detecting their bias behaviors as a first step. Ireland, Australia, Israel, the United Kingdom, Spain, and the United States have all developed programs to improve racial equality healthcare for minorities.

Prenatal Care for High-Risk Women

Women from ethnic and racial minority groups birth their babies in hospitals that have higher rates of severe maternal morbidity in addition to hospitals that are of lower quality(Dagher & Linares, 2022). According to the CDC (2020), Black women are nearly four times more likely to die when pregnant than their White and Latina counterparts. Black women have higher rates of chronic conditions that make them at higher risk for maternal mortality and morbidity (CDC, 2020). The leading causes are due to sepsis, hemorrhage, hypertensive disorders that are related to pregnancy, and thrombotic pulmonary or another embolism (CDC, 2020).Even so, these risk factors do not account fully for severe maternal morbidity(Leonard et al., 2019).Black women have difficulties attaining appropriate prenatal care as well as postpartum care in addition to experiencing poor communication with their health professionals (Howell, et al., 2020).If Black women gave birth to their babies in the same hospitals where White women give birth, the Black severe maternal morbidity rate would decrease by 47.7%, or from 4.2% to 2.9%.

Previous research has established that all women of Color are among high-risk populations as they have special needs not being adequately addressed in the healthcare system. According to Byerley and Haas (2017), increased satisfaction in care will lead to greater adherence from African American mothers. The inequality experienced by African American women accessing pre-pregnancy and prenatal care can be addressed through group prenatal care (GPC). Scott et al. (2019) noted that this group approach gained popularity in healthcare provision for pregnant women and showed considerably good results. Based on the approach, McDowell (2020) was able to substantiate improved health outcomes for women who went through the GPC. For instance, the researchers found a reduction in preterm birth among low-income and African American women as their attendance at GPC increased.

Further, Trudnak et al. (2013) stated there was an increase in the level of satisfaction with care among this group due to increased knowledge about pregnancy and following other guidelines by the professionals. There were even improvements in other health outcomes among these women. Fewer pregnant women with diabetes require treatment with medication after undergoing GPC (Francis et al., 2019). Those who had to go on with their insulin dose took more diminutive than their dose before the intervention. Women who smoke weed even after knowing they are pregnant were more likely to quit the behavior through GPC (Zadzieslki et al., 2018). This showed that high-risk women got a lot of benefits from engaging in group prenatal care. This is because the approach allows women to come together and form a support system to help each other receive prenatal care and even gain knowledge on pregnancy.

African American women have continued to experience poor prenatal healthcare due to the lack of action from those responsible. In their investigation, Pendergrass (2020) established that the result has been an increasing death rate related to pregnancy and childbirth. However, the researcher noted that this is a problem that can be overcome if the proper measures are taken. Policymakers, healthcare providers, and communities can all work together to improve the quality of prenatal and postnatal care (Kearns et al., 2016). The first recommendation the research offers is expanding and maintaining access to healthcare coverage. Statistics show that only the majority of Black women of reproductive health have no health insurance (Prather et al., 2018). Even those with insurance have experienced coverage gaps at different times of their lives. In this regard, policies need to seek the expansion of coverage so that more women can access prenatal care. The second recommendation that the researcher gave was the provision of patient-centered care that is responsive to Black women’s needs (Pendergrass et al., 2020). In essence, Black women need to receive prenatal care that is respectful safe, and culturally competent because they have specific problems to be addressed.

Addressing the social determinants of health is crucial for pre-pregnancy and prenatal care, especially among African American women. Yoder and Hardy (2018) discovered that these social determinants have different effects on health outcomes across races and ethnicities. One major impediment is racism, which has historically resulted in poor health outcomes for African American women seeking prenatal care (Prather et al., 2018). By addressing such issues, it will be possible to improve Black maternal health outcomes. Furthermore, Williams and Cooper (2020) posited that investing in healthcare quality improvement and safety efforts will go a long way toward ensuring that Black women receive the care they require to live better lives. Improving safety and quality also entails improving communication and the patient-provider relationship. These are essential determinants of health outcomes of African American women.

The Future of Pre-Pregnancy and Prenatal Care for African American Women

The United States is increasingly becoming racially diverse, and this must be reflected in the provision of healthcare. Wren Serbin and Donnelly (2016) predicted a future where the specific needs of women of Color in prenatal care would be adequately addressed. This prediction is based on research carried out on the increasing diversity of healthcare professionals. It has become paramount for healthcare facilities to ensure personnel that reflect the community they serve. These researchers noted that hospitals have been making many efforts towards being more diverse to achieve cultural competence. This is supported by Gadson et al. (2017), who note that the American health sector is making efforts to explore the social determinants of racial/ethnic disparities in prenatal care. While the researchers noted that there is still a long way to go before all the goals of equality in prenatal care are achieved, the steady progress noted is in the right direction. The efforts made include engaging those at risk to understand their specific needs and how they can be adequately addressed in the healthcare system (Gadson et al., 2018). The essence of the changes is not only to improve experiences but also to change the perceptions of African American women regarding pre-pregnancy and prenatal care services because their participation and adherence are required.

One program that has made a difference in the birth-related death rate is named Birth Detroit (Welch, et al., 2022). It is based on a model that is not only community-informed but led by African American women while utilizing evidence-based approaches to provide healthcare for pregnant women before and after birth. Birth Detroit opened to provide community midwifery prenatal care in the city of Detroit (Welch, et al., 2022). Evidence-based does not mean using only quantitative research that is a White supremacist research model, but instead is based on integrative processes, consciousness-raising, and lived experiences research studies. Services stem from the values of equity, love, safety, justice, and trust. Birth Detroit is a blueprint developed by Black women to change the inequities of both mother and child in Black communities. “While every pregnancy is unique, the racialization of pregnancy for Black women has long been one of the most reliable predictors of negative maternal and infant health outcomes in the United States” (Welch, et al., 2022, p. 4). Their adopted mantra is “We are no longer asking you to save our lives” (Welch, et al., 2022, p. 14). This is an example of a model that could be adapted to other locations with a community of interested nurses and midwives striving to address health inequity.

Suarez (2020) highlighted the tremendous changes in the transition from midwifery to obstetrics, discrimination against corporate midwives, the ongoing impact of medical racism, the consequences of legislation, the marginalization of Black midwives in midwifery organizations, the proliferation and activism of radical Blacks Birth Organizations, Black Midwifery and Maternal Experiences, and the Improved Birth and Maternal Outcomes through Midwifery Care. Most important was that the public, politicians, and doctors needed to listen to radical Black birth attendants and mothers about their lived experiences(Suarez, 2020). The goals of the radical Black midwifery organizations include raising awareness of different birth options for Black mothers, addressing the history of medical racism, promoting, and supporting Black women who become midwives, and activism for medicine and especially the state. Society can increase support for birth justice by supporting and centering radical Black birth organizations. Some ways to do this may include public pressure on the healthcare industry and the state to implement changes for greater access to care through Medicaid and private insurance, increased funding for more Black midwives through local and state grants to Black birthing organizations, and more by and large actively calling for and working to change racism in the United States(Suarez, 2020).

There are other programs for the birthing of babies for Black women. Support has also been expressed by the American Medical Association (AMA) (2020). “The AMA recognizes that racism in its systemic, structural, institutional, and interpersonal forms is an urgent threat to public health, the advancement of health equity, and a barrier to excellence in the delivery of medical care.” The hope is that medical professionals and medical schools will embrace discourse on the topic which would have the potential to mitigate medical racism regarding Black mothers and midwives (Suarez, 2020).

Involvement of patients and the public is now recognized to be a necessity to conduct good research (Frank, et al., 2018). Patient and public involvement in research priority setting and funding decisions is only now being recognized as important, and approaches for doing so are promising. This protocol describes the Research Prioritization by Affected Communities (RPAC) protocol and the results, and outcomes of adopting it with women at high socio-demographic risk for birth at preterm. The objective was to directly involve women in identifying and prioritizing questions about pregnancy, birth, and neonatal care, as well as treatment so that their views could be integrated into research priority setting by both funders and researchers (Frank, et al., 2018). The RPAC protocol may be utilized to meaningfully involve under-represented groups at high risk for specific health problems, or those who face disproportionate problems of disease, in strategy and funding priority setting for research(Frank, et al., 2018).

African American women have the highest incidence of premature birth (PTB) (Berkowitz, et al., 2022). Black women experience PTB 1.55 (14.39%) times higher than White women (Ely & Driscoll, 2020; Martin et al., 2019). Disparities and inequities of preterm birth have persisted for minority women for decades ( (Brase et al., 2021; Lonhart, et al., 2019; Martin et al., 2019). Upstream factors, including neighborhood context, may be key contributors to this increased risk. This study examined the relationship between neighborhood quality, as defined by the Healthy Places Index, and PTB in Black women who lived in Oakland, California, and gave birth between 2007 and 2011 (N=5418 women, N=107 census tracts)(Berkowitz, et al., 2022). We found that women living in higher-quality neighborhoods had a 20% to 38% lower risk of PTB compared to women living in lower-quality neighborhoods, regardless of confounders. The results have implications for place-based research and interventions to address racial inequalities at PTB. The study results suggest that living in a more holistically defined, higher-quality neighborhood may help reduce the risk of black women developing PTB(Berkowitz, et al., 2022). For Oakland neighborhoods, the results identify areas for potential citywide assessment and policy intervention to address persistent racial inequalities in PTB. Our results also underscore the importance of examining and intervening on multiple intersecting dimensions of neighborhood quality.

Cities across California can access the publicly available HPI and its component domains to better understand the relationships between neighborhood quality and health outcomes such as PTB in their areas. Such efforts are necessary to advance research and practice to address health inequalities impacted by the places in which women live (Berkowitz, et al., 2022).Other studies have found a relationship between physical environmental factors and PRB, also (Braveman, et al., 2021; Hawthorne, 2019). Place may also be a factor in the study.

The number of obstetricians and gynecologists in the United States is declining, so investments are necessary to expand the maternity care workforce pipeline, particularly nurse midwives, doulas, nurse practitioners, physician assistants, family physicians, and community health workers (National Academies of Sciences Engineering and Medicine, 2020). Doing so may increase the diversity, distribution, and quantity of maternal care. Although midwives constitute an important, safe, and cost-effective part of maternity care, notably in rural areas, impediments to the practice of midwifery endure across the country (Douthard et al., 2021).

Prenatal care is often provided by midwives (Michel & Fontenot, 2022). Craft-Blacksheare and Kahn (2022) conducted a study of the perception of the African American Maternal Mortality Crisis in the United States which found that midwives’ and other perinatal health workers can be leaders in reaching the goal of ascertaining healthcare equity. To accomplish equity suggestions were to listen more carefully to clients, use evidence-based practices, increase the number of birth centers, expand the number of multispecialty provider groups, provide racial and cultural sensitivity training, and recruit more providers of Color, and midwives and other perinatal health workers have a wide-ranging understanding of the possible remedies and multidimensional causes for the high rate of Black maternal mortality (Crafe-Blacksheare & Kahn, 2022).

It is critical to address the wide differences in regulation, certification, and licensing of maternity care professionals in the United States. In addition to clinicians, increasing the quantity of community health workers, public health practitioners, and scholarly researchers in the maternal morbidity and mortality field is necessary for the expansion of functional Maternal Mortality Review Committees, community-based maternity care, and implementation of the national research agenda (Chakhtoura, et al., 2019). It is vital to extend Medicaid to cover one year postpartum nationwide. Pregnant women living in high-income countries with universal insurance are not denied healthcare before, during, or after pregnancy contributing to reducing the maternal mortality ratio in other countries (National Academies of Sciences Engineering and Medicine, 2020).

Summary

Pregnancy is unique for most women, but many face that experience with fear and uncertainty. The disparities between White and African American women deserve renewed engagement regarding the sources of the differences so that a solution can be found. Much of the fear for African American women can be attributed to the continuous refusal by professionals in healthcare to listen to their health concerns. This indicates that the problem most likely lies in the whole American social system that makes African Americans predisposed to specific health conditions and a healthcare system that does not investigate the consequences of these conditions on pregnancy. Access to health insurance is another determinant factor related to the disparities in the quality of healthcare received by African American women (Davis et al., 2019). Various factors influence the perceptions of African American women during their pre-pregnancy and prenatal healthcare. Women from low financial backgrounds tend to have low expectations of the quality of healthcare they need to ensure their well-being and that of their babies. Without good motivation and support, most of these mothers fail to do what is necessary for their well-being and that of the baby. Microaggressions, discrimination, and even abuse are common experiences of African American women when seeking pre-pregnancy and prenatal care (Attanasio& Hardeman, 2019; Martin et al., 2019; Valdez & Deomampo, 2019). There are many studies documenting racism in maternity care (Davis, 2019; Rapp, 2019; Valdez & Deomampo, 2019). Marti et al. (2019) recognized that discrimination and abuse of women of Color in the hospital in the United States have harmed their pre-pregnancy and prenatal care experiences, as well as their understandings and insights of the same. Chapter 3 is next and will explain in detail the methodology of the study that will be utilized.

Chapter 3: Research Method

Methodology

This study aims to explore the prenatal care experiences concerning the barriers faced by African American women, regarding their prenatal care experiences at one hospital in New York City. This chapter will discuss the methodology utilized, which includes several sections explaining the topic. The first section states the research question after defining the phenomenon that is being explored. The research tradition will be discussed next, followed by a definition of the central phenomenon of the study. The role the researcher will play in the study is explained, revealing professional and professional relationships with the participants. The bias of the researcher is presented, along with how those biases will be managed, to not interfere with the research process. Ethical issues as applicable to the researcher and study are discussed next, and how each ethic will be addressed is explained. The methodology presented includes the choice of participants, the instrument used for data collection, and the procedures for recruiting, participation, and data collection. The data analysis plan is then presented. A discussion of the trustworthiness of the study will include credibility, transferability, dependability, and conformability. A full presentation of the ethical procedures of the entire study will be explained in detail, as are the other sections so that the study is replicable to another researcher. The chapter ends with a summary and introduction to chapter 4, which will present the results of the study.

Research Design and Rationale

RQ1- Qualitative: What are the perceptions of African American women regarding their prenatal care experience in Southern New York?

The central phenomenon in this study is that of the perceptions of African American women regarding their prenatal care experiences, especially considering factors such as discrimination from healthcare providers, discrimination, microaggressions, and abuse, among those with social, economic, or health challenges and other negative experiences that have occurred when seeking prenatal healthcare. Many authors have documented these types of experiences (Attanasio& Hardeman, 2019; Davis, 2019; Marti et al., 2019; Martin et al., 2019; Rapp, 2019; Valdez & Deomampo, 2019).

This qualitative study used a qualitative method to explore the perceptions of African American women regarding their prenatal care experience in Southern New York. Using qualitative research means the researcher is interested in the experiences of the participants to understand their perspective of the phenomenon (Renjith et al., 2021; Yin, 2015). Qualitative studies are exploratory and are often used in healthcare research (Renjith et al., 2021). Using a quantitative method would not answer the research question, as statistics are generated and are not needed in this study. Themes were developed from the data to answer the research question (Braun & Clarke, 2013; van Manen, 2016). No categories of codes or themes are predetermined in thematic analysis. A continual comparison of data with prior data is used to search for commonalities and discover new themes that emerge from the collected data (Braun & Clarke, 2013; van Manen, 2016).

A hermeneutic phenomenological design was implemented to better understand the psychological and social phenomena of African American Women’s perspective of their prenatal care experiences. Phenomenological research originated with Husserl, who lived in the 19th century but stemmed from phenomenology philosophy (Kafle, 2011). Essentially, phenomenology is an umbrella term that comprises both the philosophical movement and several different research approaches (Kafle, 2011). The essence of the experience of the participants is what the researcher strives for (Creswell & Poth, 2018; Mousakas, 1994). Researchers use this type of approach when they want to understand the meanings and the nature thereof (Finlay, 2009). Phenomenology, according to Van Manen (2016), is the best approach to research a phenomenon as a lived experience while simultaneously questioning the way a person experiences the world. I chose the phenomenological design because I want to give voice to African American women’s experiences of prenatal care experiences in Southern New York.

The hermeneutic phenomenological design affords researchers access to contextual data and meanings that surface from the lived-in and lived-through healthcare experiences of participants (Crowther et al., 2016; Paley, 2016). This approach was not born from one single author but is a research paradigm with four key ingredients. The first is metaphysics, and when considering the approach of their study a researcher is influenced by their ontological and epistemological foundations and then their values (Greenbank, 2003). Ontology is concerned with the reality that from this perspective an individual by an individual according to the situation and is multiple, not a single reality (Kafle, 2011). Epistemology means knowledge that will be contributed to knowledge itself and is subjective.

The hermeneutic phenomenology approach was chosen because the researcher is interested in the perceptions of African American women regarding their prenatal care experience in Southern New York. The participant’s experiences are the main object of the research, and this approach takes into consideration not only the personal, unique experience of the individual but also the context in which that experience takes place. There is an interaction that occurs with the context that has an impact on the experience. The findings depict the commonalities of the participants of the phenomenon (van Manen, 2016). The researcher does more than just describe the phenomenon; they also use their judgment to interpret the phenomenon (Mousakas, 1994).

Figure 2 depicts the hermetic circle of analysis that consists of reading, reflective writing, and interpretation (Lavery, 2003).

Figure 2

Hermetic Circle

Note: From Hermeneutic phenomenological research method simplified” by N. P. Kafle (2011), Bodhi: An International Journal, 5. https://doi.org/10.3126/bodhi.v5i1.8053 p. 195. Reprinted with permission. Copyright 2011 Bodhi: An International Journal.

Role of Researcher

The role of the researcher in this qualitative hermeneutic phenomenology study is multiple. The researcher did not only develop the interview questions based on prior literature but also conducted the interviews and interpreted them. In qualitative research, the researcher is considered an instrument (Creswell & Poth, 2018). Many new researchers assume they have no biases even though they are using their lens to collect and analyze data (Fusch & Ness, 2015). However, all social research contains both the researcher’s and the participant’s biases or worldviews, whether intentional or not. The better a researcher can recognize their own biases and worldviews, the better they will be to hear and interpret the behavior of others along with their reflections (Fusch & Ness, 2015). The researcher’s experiential and cultural background contains values, ideologies, preconceived ideas, and biases that can have an impact when data is saturated. Therefore, I kept a journal throughout the research process noting biases and my worldview when they surface in my consciousness to mitigate them, for as stated by Fusch and Ness (2015), this “is a key component for the study (p. 1411). This allowed me to listen carefully to what the participants are saying so I can comprehend their perspective of their experiences instead of my own.

Participants

The population of a study is the number of people that live in a specific country. In the study that took place in the United States, the target population consists of African American women who have received their prenatal care in Southern New York. A sample was drawn from the target population by the technique known as purposeful sampling. In purposeful sampling, participants are judged by the researcher to have experienced the phenomenon to provide information that cannot be attained from other sources (Maxwell, 2012). The participants essentially warrant inclusion. The strength of purposeful sampling is that is low cost, is not time-consuming, is convenient, and is an excellent choice for exploratory research (Taherdosst, 2016). However, the weakness is the inability to generalize to other settings (Taherdosst, 2016).

A sample of participants was chosen on these criteria. They must self-identify as African American women who received prenatal care in Southern New York City. All participants was over the age of 18 and were able to articulate their experiences as well as be willing to share them. Any education level was included, whether single or married does not exclude them either. What excluded them from participating in the study is obtaining their healthcare from Southern New York over five years ago. They must also speak English, as the interviews were conducted in English. Moustakas (1994) emphasizes that choosing participants based on the set criteria is important and the criteria should always be adhered to.

Phenomenological research only needs a small number of participants, as Creswell and Poth (2018) suggested a minimum of 3 up to 15 participants. I recruited a minimum of 10 participants to ensure saturation of codes from the data. Two of the participants underwent interviews to establish that the interview questions will solicit the data required to answer the research question and that the interview questions are clearly understood. Potential issues with comprehension were discussed with the dissertation committee and interview questions were revised, as necessary.

Instruments

For my planned research design, I needed to conduct individual in-depth telephone interviews with African American women regarding their perspective on their prenatal care experiences within hospitals in the OB/GYN labor and delivery department in Southern New York. Primary data were necessary to explore the perceptions of the experiences of African American mothers. The World Health Organization’s Research Group on the Care of Women in Childbirth reviewed the research on RMC in-depth in 2015. Quantitative and qualitative data from 65 studies on the abuse of women in childbirth in healthcare settings in 34 countries with varying socioeconomic profiles were analyzed by Bohren and colleagues. From verbal and physical assault to a lack of supportive care to neglect, prejudice, and denial of autonomy, the investigators found several instances of disrespect and human rights breaches encountered by women during childbirth. The authors identified “mistreatment” as a phenomenon with a wide range of manifestations and defined it along seven dimensions, including but not limited to the following: failure to meet professional requirements of care; failure to establish rapport among women and providers; poor conditions and constraints presented by the health systems; physical abuse; sexual assault; verbal harassment; and prejudice. They suggested that this typology be used by future researchers to evaluate the efficacy of interventions and/or to better understand the incidence and impact of abuse across jurisdictions or groups. There has been a flood of responses to the Bohren typology since 2015, with several authors pointing out the dearth of worldwide evidence. Though the typology has been adapted by some researchers for use in quantitative studies of the incidence and profile of mistreatment in low-resource countries, no one has yet used it to evaluate the quality of care provided in high-resource settings, nor have they conducted a qualitative analysis of the seven domains comprising the typology (Bohren, 2016).

Interestingly, while the descriptive data that supported the Bohren typology came from participants’ actual lives, not a single study in this systematic review relied on a patient-led approach to item construction. Based on what we know about what works best in patient-oriented outcome research, those who have experienced the “mistreatment” in question may best define and explain it. Patient-designed measures that may assess the influence of the experience of maternity care are still limited, even though indicators of quality and safety based on patients’ experiences are now routinely gathered at institutions in other fields of medicine. As noted in Chapter 1, there are different studies involving a multi-stakeholder team to explore the diverse experiences of women, especially in maternity care. For instance, Vedam et al. (2019), explored how pregnant women and mothers experience inequities and mistreatment during pregnancy and delivery. Their findings show that most women experience significant cases of mistreatment particularly those with low socio-economic status. These findings resonate with Taylor’s (2020) study which explored how structural racism affected maternal health among African American women. In another study, Zhang et al. (2021), investigated the correlation between IPV, prenatal anxiety, and drug use among black pregnant women.

On this note, my study asked these questions to delve deeper to further explain or expound on those prior findings.

Interview Questions

Would you explain to me your experience during pre-natal care? Anything you want to share is ok.

Do you think you received the best care possible during your prenatal appointments? Can you give me an example?

Did you experience discrimination from your providers that you are willing to share? Can you give me an example?

Did you experience discrimination from other healthcare staff during your prenatal appointments? Can you give me an example?

What would it look like if you could have your ideal birth experience?

Did you ever feel fear in any situation related to healthcare and your pregnancy? Please explain with examples to help me better understand.

How would you explain the stress you experienced during your pregnancy?

Do you believe discrimination and prejudice continue to be a barrier to the healthcare of Black women? If so, please explain why you believe this to be so.

Have you experienced any verbal or physical abuse from your healthcare providers?

During your prenatal care, were treatments forced upon you or withheld by your healthcare providers? Can you give me an example?

Is there anything else you would like to share with me about your prenatal care before we quit the interview?

After the Walden University Institutional Review Board (IRB) has approved the study, I requested to post flyers at clinics in Southern New York and on social media. I used snowball sampling as women who express interest in participating may know other women who fit the criteria for participation. The flyers and social media posts had my contact information (both email and phone).

After volunteers contacted me, I returned their inquiries the same way they contacted me. For example, if they called me on the phone, I would return the phone call, and if they emailed me, I would email them. I thanked them for volunteering and then tell them a little about the study and ask about audio recording the interview. I then asked if they had any questions for me. If they are still interested, I asked for their mailing address to send them a copy of the consent form (see Appendix A) to sign and a few demographic questions to ensure they meet the criteria for participating. These questions asked about each criterion. When I received the consent back, I reviewed the demographic information, and if they fit into the criteria, I contacted them to set up a time to conduct the interview. I used my cell phone on speaker to audio record the interview, which is expected to last between 45 and 60 minutes. I used a tape recorder to back up the recording in case the cell phone does not record the interview.

After each interview, I transcribed the interview using the NVivo app for iPhone. The same procedure as outlined was used for each interview. Interviews continued until saturation was reached. According to Fusch and Ness (2015), saturation is reached when no new data is forthcoming. When saturation has been reached, I contacted everyone else on the list and thank them for volunteering. Interview data were transcribed and were provided to the participants for confirmation of transcript accuracy. When all interviews are transcribed, and members checked, I moved forward with the data analysis.

Data Analysis Plan

The data generated by the interviews is expected to answer the research question as the interview questions were developed while considering the research question, the methodology, the setting in which the study takes place, the characteristics of the participants, and prior literature. The ontology of the researcher was also considered when forming the interview questions, as the researcher has some impact on the data even though the goal is minimization. As there is only one research question, the focus is maintained and emphasized in the endeavor.

Data analysis took the form presented by van Manen (2016) while maintaining a reflective stance throughout the process. In the journal, I kept an ongoing record of reflections while going back and forth between the data and the reflections, crosschecking, comparing, and contrasting findings in the research text. This aids in maintaining faithfulness to the constructs developed by the participants, thus grounding interpretations in the data and authenticity.

Six steps for analysis were developed from hermetic and phenomenological principles (van Manen, 2016). Each was identified and explained for understanding and clarity of the method. Implementing the steps one at a time was interspersed with recordings in the journal as suggested by Lincoln and Guba (2000).

The first step is immersion in which the researcher organized the dataset into texts (van Manen, 2016). This is accomplished by the iterative reading of the texts, while preliminarily interpretations are made to facilitate coding. Authenticity must be maintained, so interpretation does not mean making assumptions about the meaning of the text.

The second step is understanding, meaning identifying the participants’ constructs while maintaining faithfulness in the original text (van Manen, 2016). This step was accomplished using NVivo software for accuracy and speed. No further tasks are required.

The third step is an abstraction that consists of identifying the constructs made by the researcher. The constructs are then organized into sub-themes (van Manen, 2016). This is accomplished by recordings in the journal and attention paid to the text. Interpretation is not necessary as these were constructs of the researcher.

The fourth step is a synthesis, and the development of the themes (van Manen, 2016). The sub-themes are grouped into themes. Further elaboration on the themes can now take place while simultaneously maintaining authenticity by reflecting in the journal. The themes are then compared across sub-discipline groups.

The fifth step is the illumination and illustration of the phenomena (van Manen, 2016). This is where the themes that were identified in step four are linked with passages from prior literature for support, understanding, and clarification purposes. The aim is to reconstruct the interpretations into story narratives. The stories need to be clear and understandable, while prior literature is used to illustrate, endorse, and advocate for the original text. This forms the reports of the findings that will be discussed in chapter four.

The objective of phenomenological data analysis is to “transform lived experience into a textual expression of its essence – in such a way that the effect of the text is at once a reflexive re-living and a reflective appropriation of something meaningful” (van Manen, 2017, p. 36). The key is the essence which means there is a combined core meaning of what the participants explained and shared. There is not one essence but multiple essences, and through combining the participant’s core essences are enhanced due to the multiplicity of the perspectives of reality. These essences can be thought of as core meanings of the interview answers (Benner, 1985; van Manen, 2016). It is a process of reducing the manifold interpretations into a single understanding that represents the entire theme (Young, 2006). Situations where there is only one code that has not been encompassed into a theme are not an essence and will be deleted for the singularity does not contain commonalities shared by the participants.

Issues of Trustworthiness

According to Lincoln and Guba (1985), the trustworthiness of a study involves actions the researcher needs to implement. Trustworthiness is composed of credibility, dependability, confirmability, and transferability in qualitative studies. Credibility means that the findings and interpretations are reasonable according to the participants (Lincoln & Guba, Naturalistic inquiry, 1985). Do the results accurately reflect the reality as seen by the participants? Transferability refers to the applicability of results, due to the comparability of contexts. Are the conditions similar enough to make insights applicable? Reliability refers to accounting for factors of instability and change within the natural context in which the study takes place (Lincoln & Guba, Naturalistic inquiry, 1985). Confirmability is the ability to authenticate the internal coherence of data, findings, interpretations, and recommendations. Document the researcher as an instrument and potential sources of bias.

To establish trustworthiness, certain actions must be taken by the researcher (Lincoln & Guba, Naturalistic inquiry, 1985). The first is prolonged engagement, which means researchers must invest adequate time to learn about the culture, build trust with stakeholders, understand the scope and target phenomena that are being studied, and test for misinformation or misinterpretations due to researcher or informant bias. This ensures credibility, as well as internal validity (Lincoln & Guba, Naturalistic inquiry, 1985). The second is constant observation, which means that the data collection process continues to allow for the identification and evaluation of salient factors and investigation in sufficient detail to separate relevant (typical) from irrelevant (atypical). This also ensures credibility and internal validity.

Peer debriefing refers to the researcher engaging in analytical discussions with neutral colleagues, such as colleagues who have not been involved in the study during the research process, to ensure credibility and internal validity (Lincoln & Guba, Naturalistic inquiry, 1985). Members verify the accuracy of data to ensure an accurate representation of the participants’ perspectives. This also ensures credibility and internal validity. Thick, rich descriptions portray the methods, context, and participants in sufficient detail so that others who might want to replicate the study at a different site can reconstruct the results (Lincoln & Guba, Naturalistic inquiry, 1985). This ensures transferability or external validity. Keeping an audit trail means that the researcher documents the processes and products of data reduction, analysis, and synthesis; methodological process notes; reflective notes; and instrument development. This ensures reliability, corroboration, reliability, and objectivity. Keeping a reflective journal means the researcher’s notes and documentation of the researcher’s thinking throughout the research process. This assures credibility, transferability, reliability, confirmability, or dependability (Lincoln & Guba, Naturalistic inquiry, 1985).

Ethical Procedures

The researcher adhered to all ethical standards, beginning with obtaining approval from Walden University IRB. Participants received an informed consent form before the interviews, clearly explaining the study and their rights, including their right to withdraw from the study at any time without incurring any consequences. Participants were able to ask questions about the study and receive answers to their questions from the researcher before participation.

All collected data were labeled with a number instead of the name of the participant to protect confidentiality. Any possible identifying information was also deleted from the transcripts. Privacy was ensured by the researcher conducting the interviews in private. Both recorded interviews and hard copies of transcripts will be kept in a locked cabinet to which only the researcher has the key. All information concerning this study that is on the computer will be password protected, as will any copies kept on a thumb drive, which will also be kept in the locked cabinet.

Minimal risk for the participants is expected, mainly limited to feeling psychologically uncomfortable about answering questions regarding their prenatal care experiences at the New York Hospital Center, most likely involving medical discrimination and racism.

Summary

This study used the hermeneutic phenomenological method research design, which is based on individual reality and the interconnectedness of social and cultural dimensions (Benner, 1985; Paley, 2016; van Manen, 2016; Young, 2006). Hermeneutics is an interpretation method that deals with problems that occur when addressing meaningful human actions or products, especially texts (Benner, 1985; Paley, 2016; van Manen, 2016; Young, 2006). Hermeneutics has a long tradition because the issues it deals with have been dominant in human life and have continuously and consistently called for reflection (Paley, 2016). Interpretation is a pervasive activity that unfolds whenever people strive to capture the interpretations that they consider significant. Hermeneutics can provide a guide to solving problems of interpretation by offering a toolbox based on solid empirical evidence. In its historical development, hermeneutics has addressed specific problems of interpretation in disciplines such as theology, jurisprudence, and literature (Clay, 2022; Ely & Driscoll, 2020; Paley, 2016).

Chapter 4: Results

Introduction

The purpose of this qualitative hermeneutic phenomenological design study was to understand the personal viewpoint and perspective of the lived experiences of African American women regarding their prenatal care experiences. The emphasis of this research was to provide context for the interpretation of the research findings concerning racial and cultural differences in pregnancy in Chapter 5. The research question used to guide this study was: What are the perceptions of African American women regarding their prenatal care experience in Southern New York City?

This chapter includes a presentation of the results that emerged from conducting the data collection and data analysis procedures described in Chapter 3. The following sections are included in this chapter: (a) setting, (b) demographics, (c) data collection, (d) data analysis, (e) evidence of trustworthiness, (f) results, and (g) summary.

Setting

The interviews were conducted by telephone. I used a cell phone with the audio on speaker, being recorded by a handheld digital audio recorder. There were no personal or organizational conditions at the time of the study that would have affected the participants or should affect the interpretation of the results.

Participants

The participants were 10 women who self-identified as African American and who received prenatal care in Southern New York City within the last five years. All participants were over the age of 18. Any education level or marital status was included.

Data Collection

A one-to-one interview was conducted with each of the 10 participants. The setting of data collection was the telephone. The interviews were audio-recorded using a handheld digital audio recorder. The average duration of the interviews was approximately 45 minutes. There were no deviations from the data collection procedures described in Chapter 3, and no unexpected circumstances were encountered during data collection.

Data Analysis Process

The researcher chose van Manen (2016) approach as the preferred approach to analyzing the qualitative data collected in the study, titled ‘The lived experiences of African American women regarding their prenatal care experience’. The researcher preferred to use a van Manen (2016) approach to analyze the collected data from the ten interviewees, which included ten African American women who have undergone at least one pregnancy, ages 18–50, in regards to their prenatal care experiences in Southern New York. Six steps for analysis was developed from hermetic and phenomenological principles (van Manen, 2016). The first step was immersion in which the researcher organized the dataset into texts (van Manen, 2016). This is accomplished by the iterative reading of the texts, while preliminarily interpretations were made to facilitate coding. According to van Manen, (2016) authenticity must be maintained, so interpretation does not mean making assumptions about the meaning of the text.

The second step was understanding, meaning identifying the participants’ constructs while maintaining faithfulness in the original text (van Manen, 2016). This step was done using NVivo software for accuracy and speed. Here is a sample of some initial codes obtained from this step.

Initial Codes

No. of participants

Coding Refrences

Overall satisfaction with childbirth experience

3

3

Overcrowded hospital environment

1

1

Overwhelmed towards the end of pregnancy due to frequent hospital visits and procedures

1

1

Pre-natal care was sataisfactory given the limited resources the hospital had

1

1

Rushed interactions with the doctor by the healthcare staff

1

1

Unproblematic child birth experience

2

2

Acknowledges a limitation in resources despite the doctors and nurses trying their best to provide the best prenatal care

1

1

Care given healthcare quality being influenced by the insurance cover

2

2

Constant cancellation of appointments due to doctor’s unavailability

1

1

Dissatisfied with the doctor’s punctuality

1

1

Limitations in healthcare due to hospital business and overwrking of nurses

1

1

Long waiting times for appointments

2

2

The third step is an abstraction that consists of identifying the constructs made by the researcher. The constructs are then organized into sub-themes (van Manen, 2016). Here is a sample of some sub themes obtained during this step.

Subthmes

No of participants

Coding References

1. Experiences during pre-natal care

10

23

2. Care received during your prenatal appointments

10

20

3. Discrimination from prenatal healthcare providers

10

11

4. Dicrimination from other healthcare staff during pre-natal appointments

10

11

5. Ideal birth experience

10

15

6. Fear in any situation related to healthcare and pregnancy

9

10

7. Stress experienced during pregnancy

10

12

8. Discimination and prejudice continue to be a barrier to the healthcare of Black women

8

8

9. Experience of verbal or physical abuse from healthcare providers

10

12

10. Forced or withheld treatments by healthcare providers

9

12

11. Further information about prenatal care

1

1

The fourth step is a synthesis, and the development of the themes (van Manen, 2016). The sub-themes are grouped into themes. Here is a table showing the grouping together of different subthemes to form the main themes.

Theme / Subthemes

No. of participants

Coding References

Theme #1 Prenatal experience, assessment of whether best care was received and ideal birth experience

10

57

1.1 Prenatal experience

10

29

1.2 Prenatal best care experience

9

12

1.3 Ideal birth experience

10

15

1.4 Suggested strategies to improve prenatal experience

1

1

Theme #2 Discrimination and Prejudice experiences and barriers to healthcare

10

29

2.1 Provider discrimination experience

10

11

2.2 Other healthcare staff discrimination experience

10

10

2.3 Discrimination and prejudice experienced as barriers to healthcare

8

8

Theme #3 Negative emotions during pregnancy

10

36

3.1 Fear experience during pregnancy

9

12

3.2 Stress experience during pregnancy

10

24

Theme #4 Abuse experiences during prenatal care

10

21

4.1 Verbal or physical abuse from provider experience

10

10

4.2 Forced or withheld treatment experience

9

11

Following the fourth step of van Manen, (2016) data analysis approach, further elaboration on the themes can now take place while simultaneously maintaining authenticity by reflecting in the journal. The fifth step is the illumination and illustration of the phenomena (van Manen, 2016). This is where the themes that were identified in step four are linked with passages from prior literature for support, understanding, and clarification purposes. The aim is to reconstruct the interpretations into story narratives. The stories need to be clear and understandable, while prior literature is used to illustrate, endorse, and advocate for the original text. This forms the reports of the findings that will be discussed in chapter four.

Findings

The main themes that emerged from the analysis included:

Prenatal experience, assessment of whether the best care was received and ideal birth experience

Discrimination and Prejudice experiences and barriers to healthcare

Negative emotions during pregnancy

Abuse experiences during prenatal care.

The table below shows the description of each of the four main themes.

Theme

Description

Theme #1: Prenatal experience, assessment of whether best care was received and ideal birth experience

This theme represents the prenatal experiences shared by the interviewees and the views of the interviewees on whether they received the best care possible during their prenatal appointments.

Theme #2 :Discrimination and Prejudice experiences and barriers to healthcare

This theme represents interviewees’ experiences with discrimination and prejudice from providers and other healthcare staff and the barriers associated with such discrimination in healthcare

Theme #3 :Negative emotions during pregnancy

This theme represents negative emotions such as fear and stress experienced by the interviewees during pregnancy and the causes of such emotions

Theme #4 :Abuse experiences during prenatal care

This theme represents different forms of abuse experienced by the interviewees during prenatal care including verbal or physical abuse and forced or withheld treatment

Theme #1: Prenatal experience, assessment of whether best care was received and ideal birth experience

This theme represented the different experiences, assessments of whether the best care was received, and the ideal birth experience by the interviewed respondents. The different sub themes that contributed to the development of this theme are shown in the table below

Theme / Subtheme

No. of participants

Coding References

Theme #1 Prenatal experience, assessment of whether best care was received and ideal birth experience

10

57

1.1 Prenatal experience

10

29

1.2 Prenatal best care experience

9

12

1.3 Ideal birth experience

10

15

1.4 Suggested strategies to improve the prenatal experience

1

1

1.1 Prenatal Experience

After going through the data analysis process, a pattern of shared meaning emerged among the codes hence contributing to the development of the subtheme of prenatal experience. This subtheme represented the different experiences of African American women during prenatal care. This subtheme had three more subcategories that aided in explaining the different prenatal care experiences of the interviewees as shown in the table below.

Subtheme, subcategories &codes

No.of Participants

Coding References

1.1 Prenatal experience (Subtheme)

10

29

1.1.1 Childbirth experience(Subcategory)

5

9

Challenging childbirth experience (Codes)

1

1

The feeling of being compelled to adhere to certain standards during childbirth

1

1

Mixed experiences during childbirth

1

1

Satisfaction with childbirth experience

4

4

Unproblematic childbirth experience

2

2

1.1.2 Experience with hospital visits (Subcategory)

5

14

Cancellation of appointments due to doctor’s unavailability (Codes)

1

1

The feeling of being burdened by multiple hospital visits toward the end of pregnancy

1

1

Long waiting appointment times

4

7

Overcrowded hospital environment

2

2

Rushed interactions with healthcare professionals

3

3

1.1.3 Communication issues and lack of concern from healthcare staff (subcategory)

3

5

Dissatisfied with communication from healthcare staff (codes)

2

2

Unconcerned healthcare providers

3

3

Experienced healthcare issues during pregnancy

1

1

1.1.1 Childbirth experience

This subcategory represented the experiences of the interviewees when giving birth. The interviewees shared diverse experiences when giving birth. From the analysis, it was evident that the majority of the interviwed African American Women were satisfied with their childbirth experience as four of the interviwed women stated that:

P3

My giving birth was fine. I did not have. Much complain.

P4

but. I think it was overall fine. Thank you.

P8

My prenatal care was ok, the doctor and nurses did the best with the limited resources they had at that time.

P9

My experience of giving birth to my child was ok no problem

From the qualitative thematic analysis, it was evident that two of the women from the interview had unproblematic childbirth experiences as they stated (Byrne, 2022):

P9

My experience of giving birth to my child was ok no problem.

P10

My experience of giving birth to my child was ok no problem

Only one respondent was unsure about her childbirth experience hence the mixed reactions as she stated:

P4

Pregnancy was fine. Giving birth was a little challenging. The healthcare providers were helpful.

From the analysis, it was evident from one respondent that she was made to adhere to certain hospital-given standards through her statement which states:

P4

However, at times I feel that given birth I was forced to adhere to certain standards,

1.1.2 Experience with hospital visits

This subcategory represented experiences of the interviewees during their hospital visits for prenatal care. This was the most prominent subcategory under the prenatal experience subtheme with 14 coding references from 5 interviewees.

One of the main experiences highlighted by the interviwees related to hospital visits during appointments was long wait times with four respondents stating that:

P1

waiting to see the doctor was very long

P2

The stress I felt was because of the long waiting time the doctors was always busy

P6

And I guess they knew that I was always annoyed because the wait time also was very lengthy. So it made me very uneasy having to sit and wait for so long.

At best, or for the most part, because again, I am pregnant and I have to wait. For a long time to see the. Doctor or to be registered? Or whatever is going on. So I was always annoyed.

P7

the time the appointment time was long and loud

Another prominent experience with hospital visits highlighted by three of the interviewees was rushed interactions with healthcare professionals

P1:

yes the interaction what the healthcare professional spell rushed at all times

P2

the staff is always rushing me around

P4:

I did feel rushed always because the clinic was always crowded.

Two of the interviewees also identified the overcrowded hospital environment as a major experience during hospital visits.

P1

the clinic was always over crowded

P2

The hospital is always very crowded

Other experiences with hospital visits identified by the interviewees included:

Cancellation of appointments due to doctor’s unavailability

P6

Yes, my appointments were oftentimes. Twice a week, I would have to canceled because the doctor had other deliveries. So times my appointment was cancelled by the nurses because the doctor was out of the office.

The feeling of being burdened by multiple hospital visits toward the end of pregnancy

P7

at the end of the pregnancy I was always at the hospital for something or the other labs sons gram nutritional classes the specialist it was just too much

1.1.3 Communication issues and lack of concern from healthcare staff

This subcategory represented interviewees experiences with communication issues and lack of concern from the healthcare staff during their prenatal care. After going through the qualitative analysis process, a pattern of shared meaning emerged from the codes that contributed to the development of the communication issues and lack of concern from the healthcare staff subcategory.

The subcategory was visually presented in the following hierarchy chart to show the most dominant code distribution.

Three of the interviewees indicated that they experienced unconcerned healthcare providers stating:

P1

Yes, my experience giving birth in southern Queens is not of the best I believe the staff could have been a little bit more helpful in me understanding my prenatal care my schedule my doctor time and availability.’

P5

Believe that you know the hospital could. Be bitter. The cleanliness of the hospital, I believe. The staff during my previous up here, the staff there. Was a strike. Or something was going on at the hospital. So, they everyone was preoccupied and somewhat distracted.

P6

My experience of giving birth my experience of giving birth was. Not of the best. The healthcare provider, I believe was not concerned about my complaints that I experience to them my pregnancy. I did not feel this they were listening to me as a pregnant patient. My complaints were not being heard. As such, my delivery was very difficult I think hours. In the labor and delivery.

From the analysis, it was evident that two of the interviewees were dissatisfied with communication from the healthcare staff stating:

P1

Yes, my experience giving birth in southern Queens is not of the best I believe the staff could have been a little bit more helpful in me understanding my prenatal care my schedule my doctor time and availability.’

P6

My experience of giving birth my experience of giving birth was. Not of the best. The healthcare provider, I believe was not concerned about my complaints that I experience to them my pregnancy. I did not feel this they were listening to me as a pregnant patient. My complaints were not being heard. As such, my delivery was very difficult I think hours. In the labor and delivery.

1.1.4 Experienced healthcare issues during pregnancy

Another prenatal experience by the interviwees was healthcare issues during pregnancy as stated below by one of the respondents:

P7

It was not fun I was not well during my pregnancy I had gustation diabetes and my leg was swollen and it was during the summer

1.2 Prenatal best care experience

From the qualitative analysis, a pattern also emerged from the codes in the data to form the prenatal best care experience subtheme. This subtheme represented thoughts of the interviwees on whether they received the best prenatal care during appointments.

Four of the interviewees acknowledged that there was a limitation of resources in hospitals despite the doctors and nurses trying their best to provide the best prenatal care

P2

They needed another doctor to help with all the pregnant patient.

P3

Best care possible under the circumstances yes with the hospital being so busy and the nurses being overworked

P5

Best care possible yes you get what is available to you in your neighborhood the hospital needed a lot of improvement.

P8

As I mentioned the doctors and nurses did their best with the limited resources that they had it could have been better.

From the qualitative thematic analysis, it was evident that the quality of prenatal care the Black women received was entirely dependent on the kind of insurance cover they had as two of the interviewees responded (Labra et al., 2020).:

P3

yes, you get what your insurance is paying for.

P7

The best care possible under the circumstances yes with the hospital being so busy and the nurses being overworked yes you get what your insurance is paying for.

Two of the respondents said that they were satisfied with the prenatal care as is evidenced by their statements that they had the best prenatal experience from the below excerpts:

P9

Ah, it was fine

P10

Ah, it was fine.

Two of the respondents reported their birth experience as being unsatisfactory based on the following statements:

P2

No, if the doctor is always late or is tending to another patient in the delivery room then the pregnant women is constantly waiting for her.

P6

My interaction with the healthcare professional was Not professional because I was pregnant and I was annoyed because I was not feeling well most of the time. And I guess they knew that I was always annoyed because the wait time also was very lengthy. So it made me very uneasy having to sit and wait for so long.

One of the interviewees noted that there is a need for additional medical staff to cover the deficit that is there to better the childbirth experience as evidenced by the following excerpt:

P2

They needed another doctor to help with all the pregnant patients.

From the analysis, it was discovered that one of the respondents said that she experienced suboptimal prenatal care due to busy healthcare staff as she stated:

P4

Overall, I believe the care I received could have been better given the situation all of the nurses were very busy trying to help everyone.

1.3 Ideal birth experience

From the analysis, the codes with similar semantics and meaningfulness were merged to come up with the ideal birth experience subtheme. This subtheme represented interviwees responses in regards to what their ideal birth experience would be or look like. The table below shows the codes contributing to the emergence of this subtheme

Subtheme/codes

No. of participants

Coding References

1.3 Ideal birth experience

10

15

Concern about medical staff compensation and workload

1

1

Cost concerns about home birth

1

1

Desire for adequate staffing during birth

1

1

Desire to be surrounded by understanding & considerate people towards pregnant women

1

1

Desire to give birth in a better hospital with better care

6

6

Low expectations and contented with what the hospital has hence does not fancy an ideal birth

1

1

Preference for home birth with own personal healthcare team

2

2

Prefers to have her birth in a different hospital

2

2

From the analysis, it is depicted by six interviewees on how they feel about what their ideal childbirth experience would look like. The majority of the respondents from the interview desired to have their ideal birth in a better hospital with better care as depicted in the following excerpts to support the findings:

P1

I cannot say because I have lived all my life in this neighborhood, but I think that would be a better hospital with better staff

P10

I would probably have had my baby in a better hospital that provides better care.

P3

I believe my ideal birth experience would have been to have my baby in a better area and a better hospital.

P4

My ideal birth experience would not have been much just a better hospital

P6

It would look like probably having a hospital in a better neighborhood with better doctors. Better staff.

P9

I would probably have had my baby in a better hospital that provided better care.

From the analysis, it was also discovered that two of the respondents described their ideal childbirth experience would be if they had their birth at home with their healthcare team to tend to them. This is evident from the following excerpts from the text data:

P1

or an at home birth with my own doctor and nurse.

P7

It would have been to have my baby in a better area and a better hospital.

Further from the analysis, it was discovered that two of the respondents described their ideal birth experience would be giving birth in a different hospital as stated by the two respondents in the following excerpts:

P2

My ideal birth experiences would be to have my baby at a private hospital with lots of doctors and nurses who is not under paid and overworked.

P5

It would have been at another hospital.

Other ideal birth experiences shared by the respondents included

Low expectations and contented with what the hospital has hence does not fancy an ideal birth

P8

I do not and did not expect much from the hospital in this life you get what you get

Desire to be surrounded by understanding & considerate people towards pregnant women

P6

People that understood that when you’re pregnant, you cannot be just sitting and waiting for hours. That would be my ideal experience.

Desire for adequate staffing during birth

P2

My ideal birth experiences would be to have my baby at a private hospital with lots of doctors and nurses who is not under paid and overworked

1.4 Suggested strategies to improve the prenatal experience

This subtheme related to suggestions to improve the prenatal care experience by the interviwees.

From the analysis, only one interviewees suggested a strategy to improve the prenatal care experience stating that there was need for more healthcare professionals in hospitals

P2

No, I believe the hospital needs more nurses and doctors, thank you for doing this research

Theme #2: Discrimination and Prejudice experiences and barriers to healthcare

This theme represented the interviewees’ experiences with discrimination from healthcare providers and other healthcare staff and the barriers associated with such discrimination in the healthcare system. The different sub themes that led to the development of this theme included: provider discrimination experience, other healthcare discrimination experience, and discrimination and prejudice as barriers to healthcare as depicted in the following mind map.

2.1 Provider discrimination experience

After reviewing the codes, the researcher was able to bring together codes that had the same semantic and interpretative meaningfulness that enabled the researcher to develop the provider discrimination experience subtheme. This subtheme represented discrimination experienced by the Black women from the healtcare providers during their hospital visits for pre-natal care.

From the analysis, the researcher found out that the majority of the interviewed women (seven) did not experience any discrimination from the healthcare providers as evidenced in the following excerpts:

P1

I did not experience any discrimination from anyone

P10

No discrimination from my doctor no.

P2

No discrimination from anyone

P3

No. I did not experience any discrimination from my providers.

P7

No. I did not experience any discrimination from my providers.

P8

No discrimination

P9

No discrimination from my doctor no

On the other hand two of the interviewees said that they experienced discrimination from their healthcare provider through uncomfortable comments and remarks as stated below:

P4

Yes she sometimes said why are you having this baby how are you going to care for this baby and then she would say it as though she was making a joke with me but her comments made me very uncomfortable

P5

Yes, very settled discrimination comments about not having proper insurance to cover the cost of the care I was receiving.

Other provider discrimination experiences identified by the interviewees included:

Perception of mutual hostility and dismissiveness with the healthcare professional

P6

Discrimination by healthcare professionals. The healthcare professionals always thought that I had an attitude and I always thought that they had an attitude. So it was, you know, the feeling, I guess it was always mutual. And because we were not happy with each other so it appeared as though we were always angry at each other or they were very settled. And somewhat dismissive. And I was angry.

Feeling that pregnancy-related conditions are not put into consideration

P1

However, I believe they must take into consideration the women’s condition of being pregnant and they are unwell from time to time.

The above excerpts and codes can be summarised using the below hierarchy chart to show the distribution of the codes under the provider discrimination subtheme.

2.2 Other healthcare staff discrimination experience

This subtheme represented discrimination experienced by the Black women from the healtcare staff during their hospital visits for pre-natal care. The table below shows the different codes under this subtheme.

Subtheme/ codes

No . of participants

Coding References

2.2 Other healthcare staff discrimination experience

10

10

Absence of discrimination from healthcare staff

5

5

Experienced discriminatory comments from the healthcare staff

2

2

Perception of not being listened to due to dissatisfaction

1

1

Presence of discrimination based on the kind of insurance coverage

2

2

This is the most occurring code in this subtheme as evidenced by the following excerpts from the data showing that most of the interviwees did not experience discrimination from other healthcare staff.

P1

No, I did not experience any discrimination from my the healthcare staff.

P2

No no discrimination from anyone else

P3

No. I did not experience any discrimination from my providers.

P7

No. I did not experience any discrimination from my providers.

P8

No discrimination from other healthcare staff.

Based on data analysis, it was evident to the researcher that two of the respondents from the interview stated that they experienced discrimination from healthcare staff based on their kind of insurance coverage as stated below:

P9

Yes, sometimes I did think because of my insurance does not pay much for my care so you get what you are paying for?

Two of the interviewees also indicated that they experienced discriminatory comments from the healthcare staff stating:

P4

Discrimination yes she would make comments about my insurance being paid by the state and they do not pay much to the doctor for the care she was providing and that she was working too hard to help the black community.

P5

Yest question about my baby father is he working why am I always alone a my visits

The thematic analysis showed that one respondent experienced discrimination through her not being heard while she was pregnant as shown in the excerpt below (Braun & Clarke, 2019):

P6

No, I do not think I was listening to it because again. I was very a very unhappy pregnant person.

2.3 Discrimination and prejudice experienced as barriers to healthcare

This subtheme represented interviewees belief about discrimination and prejudice as a barrier to healthcare of Black women. The following table is a representation of the codes that contributed to the development of this subtheme.

Subtheme/codes

No. of participants

Coding References

2.3 Discrimination and prejudice experienced as barriers to healthcare

8

8

Lack of knowledge regarding discrimination and prejudice in healthcare for Black women

1

1

Persistent discrimination as a barrier to healthcare for Black women

7

7

Seven of the interviewees perceived persistent discrimination as a barrier to healthcare for Black women. The following excerpts from the data show this:

P1

I believed discrimination and prejudice continue to be a problem in America society as it relates to black women and black people in general.

P3

Discrimination will always be a problem for black people and especially women because the other race is always trying to keep us down.

P4

Yes discrimination and prejudice will always be a problem in America because of the racist white people we have to interact with everyday some are very settled and some are very bold with the level of discrimination

P5

Discrimination would always be a problem in this country.

P6

Discrimination and prejudice goes handin hand I do not think that it is a big problem but it is happening sometimes for everyone not only black women.

P7

Discrimination will always be a problem for black people and especially women because the other race is always trying to keep us down.

P8

Discrimination, yes but life was and continues to be the way it was designed.

From the analysis, it was discovered that one of the respondents lacked knowledge about whether discrimination and prejudice remained a barrier to health care as she stated:

P2

I really cannot answer that question I do not know what to say about that.

Theme #3 : Negative Emotions During Pregnancy

This theme represented the negative emotions such as fear and stress that the interviewees experienced during their pregnancy and the causes of such emotions. The main subthemes contributing to the development of this theme included: fear experience during pregnancy and stress experience during pregnancy as shown in the mind map below.

3.1 Fear Experienced During Pregnancy

This sub theme represented interviewees fears related to healthcare and their pregnancy. The table below shows the codes that contributed to the development of this subtheme. The codes represent the direct responses of the participants.

Subtheme

No. of participants

Coding References

3.1 Fear Experienced During Pregnancy

9

12

Absence of fear or feeling of being unsafe

5

5

Experience of being scolded and having an attitude toward the staff

1

1

Fear of having a baby

2

2

Fear related to safety concerns during hospital visits

1

1

Financial strain

2

2

Unsure if she experienced discrimination

1

1

Most of the interviewed women expressed a lack of fear and never feeling unsafe during their pregnancy as they they stated:

P1

not never felt unsafe or fear

P10

No discrimination no fear this is the people we see daily because they work in our neighborhood

P4

Fear no I did not feel fear during my pregnancy.

P5

No I did not feel feer

P8

No, I did not feel any fear

Of the interviewed women, two acknowledged that they had fear of having a baby as they stated:

P3

Yes, bringing a new life into this crazy world was fearful for me

P7

Yes, bringing a new life into this world finances and better housing and family support was fearful for me

From the interviews, two of the interviewees indicated that they had a fear resulting from them lacking money as there was an incoming baby.

P3

a lack of finances at that time needing better housing and family support was fearful for me.

P7

Yes, bringing a new life into this world finances and better housing and family support was fearful for me

One of the interviewed women felt fear when she was making her hospital visits as she stated:

P2

Well sometimes I did feel fear because of the drug addicts who were coming to the same hospital for treatment I walked from my house to the hospital and in the snow I feared sometimes that I would fall in the snow

3.2 Stress Experienced During Pregnancy

This sub theme represented the causes of stress among the interviewees during their pregnancy .

Motherhood journey

The motherhood journey in general was highlighted as a source of stress among the interviewees. The interviewees identified different elements of the motherhood journey as a source of stress including:

Stress of having a baby

Majority of the women in the interview at some point when pregnant faced the stress of having a baby. This is evident through the following excerpts:

P1

and so distress was you know somewhat intense at times.

P10

I experience alot of stress because of the unknwn a new baby

P3

Again, bringing a new life into this crazy world was fearful for me

P5

Stress of the unknown and of having a baby is stressful managing work and other children as well.

P7

Again, bringing a new life into this crazy world was fearful for me

P9

I experience a lot of stress because of the unknown a new baby my living situation

Handling Multiple Responsibilities During Pregnancy

The researcher also discovered from analysis that, at some point during pregnancy, two of the interviewed women faced stress arising from having to handle multiple responsibilities in the house during pregnancy. The following excerpts from the data clearly show this:

P4

The stress was real having to manage other children my job my doctors’ appointments was very stressful.

P5

The stress of the unknown and of having a baby is stressful managing work and other children as well.

Becoming a mother

One of the interviewees expressed that she was stressed during pregnancy as she was afraid of becoming a mother she stated:

P1

The stress and distress I felt during my pregnancy was intense because of the certainty of being a mother having a baby and so distress was you know somewhat intense at times.

Four interviewees viewed their state of finances as a stressing factor when they were pregnant as they stated:

P10

I experience alot of stress because of the unknwn a new baby my living situation my family situation my finances that was very stressful

P3

a lack of finances at that time needing better housing and family support was fearful for me.

P7

a lack of finances at that time needing better housing and family support was fearful for me

P9

I experienced a lot of stress because of the unknown a new baby my living situation my family situation my finances that was very stressful.

Two of the interviewees indicated that the need for better housing conditions were a significant cause of stress during their pregnancy.

P3

a lack of finances at that time needing better housing and family support was fearful for me.

P7

a lack of finances at that time needing better housing and family support was fearful for me

Again, the researcher discovered from the analysis that two of the interviewed women had stress as a result of them seeing the need to improve or change their current living situation since there was an incoming baby as they stated:

P9

I experience alot of stress because of the unknwn a new baby my living situation

P10

I experience a lot of stress because of the unknown a new baby my living situation

One of the interviewees indicated that they experienced stress during their pregnancy because of being ignored by healthcare providers.

P2

I felt stressed because she did not have enough time to listen to my problems related to my pregnancy.

Again from the analysis, the researcher discovered that one of the intervieweed women was stressed during pregnancy due to the way the society treats Black women in any situation even when they are pregnant as she stated:

P6

Black women are treated very poorly when they’re pregnant, even when they’re not pregnant. We are treated poorly by our family by society by our spouses that can cause a lot of stress also having a new baby is stressful.

One of the interviewed African-American women stated that during her pregnancy she did not experience any stress and continued with her normal life as usual as she stated:

P8

I did not experience any stress. My life back then was my life I took one step at a time to make it better so no stress.

Theme #4 : Abuse Experiences During Prenatal Care

This theme represented the different forms of abuse experienced by the interviewees during their prenatal care including verbal or physical abuse, and forced or withheld treatment by their healthcare provider or other healthcare staff. The two main sub themes that contributed to the emergence of this theme are shown the table below.

Theme/ subthemes

No. of participants

Coding References

Abuse experiences during prenatal care

10

21

4.1 Verbal or physical abuse from provider experience

10

10

4.2 Forced or withheld treatment experience

9

11

4.1 Verbal or physical abuse from provider experience

This subtheme focused on whether the interviewees experienced any form of abuse when pregnant during their hospital visits. All the interviewed women did not experience any for of abuse while at the hospital either from their healthcare provider or other healthcare staff. The following excerpts show what they stated:

P1

No, I did not experience any verbal or physical abuse.

P10

Like what no verbal or physical abuse is that a thing no not at allI.

P2

No I did not experienced and physical abuse

P3

No verbal or physical abuse from anyone.

P4

No verbal or physical abuse.

P5

No

P6

No not physical abuse however I felt as though the provider was always talking to me about my anger and the staff was not happy with me.

P7

No verbal or physical abuse from anyone.

P8

No verbal or physical abuse.

P9

No physical or verbal abuse

4.2 Forced or withheld treatment experience

This sub-theme focused on the interviewees views of whether any medical treatments were forced or withheld from them by their healthcare providers during prenatal care.

Subtheme

No. of participants

Coding References

4.2 Forced or withheld treatment experience

9

11

Did not experience forced or withheld treatment from healthcare providers

5

5

Experienced differing medication approaches by the healthcare provider

1

1

Forced medical operation

3

3

Forced treatment through prescriptions by the healthcare provider

2

2

Five of the interviewees stated that they did not experience forced or withheld treatment from healthcare providers.

P1

No I do not think so I tried to everything they asked me to do just for the health of my baby

P10

I don’t think so.

P2

No treatment was ever forced or withheld from me.

P5

No

P9

I don’t think so.

In contrast, three of the interviewed women stated that they had forced medical operations by healthcare providers.

P3

I believe we could have waited a while longer before opting for a c section

P4

a C-section were forced on me

P7

I believe we could have waited a while longer before opting for a C-section

Two of the women shared that they were forced to take unnecessary medications that they thought they did not necessarily need as they stated:

P3

Yes, I believe I did not need the vitamins the doctor prescribed for me

P7

Yes, I believe I did not need the vitamins the doctor prescribed for me

Chapter 5: Discussion, Conclusions, and Recommendations

The purpose of this qualitative hermeneutic phenomenological design study was to explore the perspectives of the lived experiences of African American women regarding their prenatal care experiences. This study aimed to offer the interpretation of the research findings regarding cultural and racial differences in pregnancy. This study was significant in the healthcare professionals understand the psychological and social phenomena of African American Women’s perspective of their prenatal care experiences who had received prenatal care in Southern New York. The study population was African American women from Southern Queens, New York. Through thematic analysis, the researcher identified social barriers to access to care and potential solutions to mitigate these barriers.

The study findings underscored that the social barriers to access to care included limited interactions with prenatal care personnel, OB-GYNs, and lab technicians, or interactions that were rushed but rarely discriminatory. While some participants indicated that they experienced no stereotyping from their prenatal care personnel, a minority of participants indicated that they perceived some signs of discrimination from prenatal care staff. The findings also revealed mixed perceptions regarding prenatal care quality.

Whereas some participants acknowledged a lack of disagreement with their providers’ care recommendations, and they never felt unsafe when receiving prenatal care, other participants reported that they did not feel they received the best prenatal care possible. However, the minority acknowledged receiving the best possible prenatal care in a better hospital with better service. Racism and lack of cultural sensitivity were perceived as general problems confronting African American women in prenatal care. According to participants, prenatal care providers, in general, lacked cultural sensitivity concerning African American patients. Further, the findings indicated that participants perceived racism as an issue confronting African American women patients in prenatal care. Chapter 5 presents the interpretations of findings, limitations, recommendations for future research, implications for positive social change, and recommendations based on the study findings. The chapter concludes with a study conclusion.

Interpretation of Findings

The research question used to guide this study was: What are the perceptions of African American women regarding their prenatal care experience in Southern New York? Three themes emerged during data analysis to address this question, as follows: (Theme 1) interactions with prenatal care personnel were limited or rushed but rarely discriminatory, (Theme 2) overall experiences of prenatal care quality were mixed, and (Theme 3) racism and lack of cultural sensitivity were perceived as general problems confronting African American women in prenatal care. The following sections present a discussion and interpretation of findings concerning the literature.

Theme 1: Interactions with Prenatal Care Personnel Were Limited or Rushed but Rarely Discriminatory

Crucial to the prenatal care experience in Southern New York is the interaction with prenatal care personnel, which is often limited but rarely discriminatory. The findings revealed that the participants’ interactions with their OB-GYNs, prenatal care staff, and lab technicians as brief and often rushed, but rarely as discriminatory. A minority of the participants indicated that they did not face stereotypes and discrimination during their interactions with healthcare providers in prenatal care. Despite some participants indicating having not experienced racism and stereotypes, some participants highlighted that they faced racism and discrimination in their communication and interactions with prenatal care providers. Research findings suggest that African American women in prenatal care faced stereotypes and racism from prenatal care providers. The study findings provide insight that helps in addressing research questions and research problems by identifying discrimination as a challenge faced by African American women in their interaction with healthcare providers.

The current study findings are consistent with previous literature which indicated that African American women’s health could be impacted by the racism they experience in interactions with prenatal care providers (McLemore, 2018). While some participants held that they did not experience stereotyping during their interaction with healthcare providers, previous research indicated that interaction with healthcare professionals resulted in racism and discrimination against African American women patients (Altman et al., 2019). The discrepancy in findings could be due to different factors including diverse settings and sample sizes used in these studies.

Similar to current study findings regarding interaction with care providers, past research indicated that the most important factor was communication between patients and healthcare professionals (Maskrey, 2019). Healthcare professionals’ behaviors and discriminatory attitudes, along with maternal health literacy, were important in the interactions (Maskrey, 2019). Communication breakdowns lead to poor outcomes and delays in determining medical conditions and diagnosis (Ibrahim et al., 2019). The current study findings confirm previous research by establishing that interaction between prenatal care providers and African American women in prenatal care is impacted by racism and discrimination including stereotyping. In previous literature, researchers established that the relationship with African American patients is mired with biases based on race as African American physicians receive racially biased treatment from prenatal care providers (Goodman, 2013). The current study results provide insight into the issues facing African American women in their interactions with prenatal care personnel.

Theme 2: Overall Experiences of Prenatal Care Quality Were Mixed

The current study findings indicate that although most participants reported not having felt unsafe when receiving prenatal care, some participants highlighted that they never felt having received the best prenatal care possible. However, a minority of the participants reported that they did receive the possible prenatal care. On the other hand, seven out of ten participants felt that they never had an objection to the treatments suggested by their prenatal care providers. It can be noted from the participant’s view that providing higher quality care to private insurance holders would translate to a significant form of discrimination towards providers.

However, participants perceived that this discrimination was based on the type of insurance rather than the race of the patient. Participants did not express their reason for attributing the discrimination they perceived to have experienced to the economic motives of the health care providers. Despite the majority of the participants indicating that they did not receive the best quality care, the minority highlighted having received the best care possible. This theme addressed the study problem and the research question by providing great insight regarding the overall mixed experiences of prenatal care quality received by patients in Hospitals.

Similar to the current study findings, previous research has also demonstrated that patient-provider interactions also cause disparities in healthcare outcomes, a problem that mainly faces racial/ethnic minorities in the US (Goodman, 2013). Current research findings confirm previous research which revealed that there are many factors involved in the interactions between patients and providers but many of the issues are related to bias, prejudice, and discrimination (Goodman, 2013). Some participants in the current study indicated that they did not feel they received the best prenatal care possible. This finding concurs with past research findings which demonstrated that African American women have continued to experience poor prenatal healthcare due to the lack of action from those responsible (Pendergrass, 2020).

Due to increased racism and discrimination among prenatal care providers, there was an increased death rate related to pregnancy and childbirth among African American women patients (Kearns et al., 2016; Pendergrass, 2020). Policymakers, healthcare providers, and communities can all work together to enhance prenatal and postnatal care quality for African American women by expanding and maintaining access to medical coverage (Kearns et al., 2016). Addressing the social determinants of health is crucial for pre-pregnancy and prenatal care, especially among African American women. One major impediment is racism, which has historically resulted in poor health outcomes for African American women seeking prenatal care (Prather et al., 2018). Racism and discrimination align with current research findings that discrimination including economic discrimination and racial discrimination contributed to negative experiences among African American women especially those from low-income status. Healthcare professionals often label minority patients as being less compliant about their treatment as they tend to blame healthcare disparities and unsuccessful treatment on the behaviors of minority patients and do not concern themselves with unequal treatment arising from racism (Sim, et al., 2021).

Consistent with current study findings, previous literature indicated that healthcare professionals saw minority patient’s reports about racism as misinterpretation of innocent interactions as racist due to encounters in the past that they had experienced or that they were just oversensitive (Sim, et al., 2021). Many minority patients reported a lack of sympathy from healthcare professionals (Sim, et al., 2021). The current study results disconfirm the findings from previous research which revealed that African American women still have limited access to quality healthcare due to their socioeconomic situations limiting their ability to afford insurance (Williams & Cooper, 2019; Taylor, 2020).

One significant finding in the current study indicated that providing higher quality care to private insurance holders would translate to a significant form of discrimination towards providers. Even with the insurance, African American women in rural and other underserved areas lack physical proximity to specialized prenatal caregivers, which continues to put them at risk (Williams & Cooper, 2019; Taylor, 2020). In such areas, there can be limited access to access to maternity care departments, OB-GYNs, and other related professionals is limited, which means the women cannot access regular pre-pregnancy and prenatal care when they need it (Williams & Cooper, 2019; Taylor, 2020). The current research findings provide greater information regarding the different experiences of African American women regarding prenatal care in the healthcare system.

Theme 3: Racism and Lack of Cultural Sensitivity Were Perceived as General Problems Confronting African American Women in Prenatal Care

The current research findings indicated that racial/ethnic discrimination as well as lack of cultural sensitivity was perceived as general challenges facing African American women in prenatal care. The participants reported that, generally, prenatal care providers were culturally insensitive concerning African American patients. In addition, racism was also perceived as a problem facing African American women patients in prenatal care. According to the participants, racism existed and would continue to exist as African American women are always discriminated against based on their skin color, which highlights systemic racism as a pervasive issue encountered by African American women patients in prenatal care. In this regard, the findings suggest that racism and cultural insensitivity among prenatal care providers is a significant challenge to African American women patients receiving high-quality prenatal care. The findings under this theme addressed the research problem and the research question by identifying racism and lack of cultural sensitivity as general problems encountered by African American women in prenatal care.

The current study findings have also been reported in other studies. Previous studies highlighted that to accomplish equity suggestions include listening more carefully to clients, using evidence-based practices, increasing the number of birth centers, expanding the number of multispecialty provider groups, providing racial and cultural sensitivity training due to lack of cultural sensitivity among prenatal care providers (Chambers et al., 2018; Mehra et al., 2017; Ncube et al., 2016). Recruiting more providers of Color, midwives’ and other perinatal health workers have a wide-ranging understanding of the possible remedies and multidimensional causes for the high rate of Black maternal mortality (Crafe-Blacksheare & Kahn, 2022). Confirming current research findings on lack of cultural sensitivity and racism among prenatal care providers, previous research revealed that when Black pregnant women experience structural racism due to increased racism and lack of cultural sensitivity among providers, adverse birth outcomes are related as prenatal care providers lack cultural competency to understand African American women’s challenges (Chambers et al., 2018; Mehra et al., 2017; Ncube et al., 2016). Current research outcomes contribute to the previous empirical literature by establishing that racism and lack of cultural sensitivity were perceived as general issues facing African American Women in prenatal care

Limitations of the Study

One of the limitations of this study was that it relied on the perspectives and lived experiences of pregnant and postpartum mothers. While the objective of the study was to capture their subjective understanding of the services offered, emotions rather than the reason might have influenced the reliability of the data. Recruitment of enough respondents was challenging as some mothers were unwilling to participate in the study. Potential participants were assured of confidentiality, and interviews were scheduled based on their availability and convenience to encourage many to participate.

There were also some limitations of this study related to prenatal care of African American women who received healthcare from one hospital in Southern New York. Only one group of women was included, that of African American women between the ages of 18 and 50. There may be other women, or even other African American women older or younger, or others who received pre-natal healthcare at other similar facilities that had not been included, Due to this study being a qualitative case study, inferences could not be made, nor could correlations, so there might be alternative explanations that could be valid. Furthermore, case study findings are only suggestive and cannot be generalized elsewhere.

The researcher also limited this study to answering the research questions with two theoretical perspectives that were adopted, the choice of participants and the theoretical framework. This indicates that the findings would be bound within the constructs of the two theoretical perspectives. Limiting the study to specific theoretical perspectives could limit its application to other theoretical perspectives in the future as different theoretical perspectives have their assumptions, limitations, and biases. Further, the use of limited theoretical perspectives constitutes bias and incomplete understanding of the topic or the phenomenon of the research study.

Recommendations for Future Research

The recommendations for future research were based on the limitations of this study. This study was limited to the perspectives and lived experiences of pregnant and postpartum African American mothers. Failure to include pregnant and postpartum mothers from other races would indicate limited transferability of the research outcomes to other populations as only one group of women was included, that of African American women between the ages of 18 and 50. Based on this limitation, the researcher recommends that future researchers should consider including other postpartum mothers in examining their experiences of prenatal care.

This study was also limited bya qualitative hermeneutic phenomenological design. Due to this study being a qualitative hermeneutic phenomenological study, inferences could not be made, nor could correlations and small sample size be used, so there might be alternative explanations that could be valid. Furthermore, case study findings are only suggestive and cannot be generalized elsewhere. In this regard, future research should be conducted using a quantitative research design to permit inferences and correlations of variables using a larger sample size and enhance the generalizability of the research findings to a broader population of postpartum mothers in New York the United States.

The study was limited to two theoretical perspectives and one setting. Limiting the study to specific theoretical perspectives and one setting could limit its application to other theoretical perspectives and populations in other locations in the future as different theoretical perspectives have their assumptions, limitations, and biases as with different locations having diverse conditions. Thus, there is a need for further research to investigate the experiences of prenatal mothers using different theoretical perspectives and diverse settings other New York to enhance the generalizability of findings to different locations and theoretical perspectives.

Implications

Implications for Positive Social Change

The study had various implications for social change. This research’s findings would help in creating knowledge that informs appropriate interventions to improve utilization and pregnancy results among African American women in New York. The healthcare experiences faced by African American women during pregnancy are an important topic. The findings indicated discrimination and stereotyping from prenatal care staff against African American women. Sharp racial discrimination and disparities in treatment, even in the health sector, is an issue African American women frequently deal with. This service crisis further enlarges the interdisciplinary approach that the importance of healthcare for all is a genuine issue. Thus, healthcare organizations would use the study findings to address cases of discrimination among prenatal care staff by promoting diversity through establishing diversity training programs as the findings indicated that lack of cultural sensitivity was perceived as a general problem encountered by African American Women in Prenatal Care.

This study would have particular significance for African American women who are pregnant and seeking pre-natal healthcare. Healthcare professionals could use the information from the findings to provide better healthcare for African American women, so outcomes can improve. African American women believe that their health and the health of their babies are affected by the disrespect and discrimination they experience in interactions with healthcare professionals (McLemore, 2018). The information shared or withheld by healthcare professionals was found to influence issues such as the power dynamic between the professional and patient (Altman et al., 2019).In addition, contextual factors such as judgment toward the patient and bias can also have an impact on the interactions between healthcare professionals and patients (Altman et al., 2019). As a result, healthcare professionals would enhance their interaction with postpartum mothers to improve service delivery

Theoretical Implications

CRT was used to guide this study. The CRT targets oppressive laws by highlighting various instances of racial inequalities within policies in the United States (Derrick Bell et al., 1980). CRT provided a foundation and theoretical lens to examine the prenatal care experiences of African American women in Southern New York. In the study CRT is especially applicable through the five constructs particularly that racism is a normal and regular phenomenon in society, race is a social construct, and that stories and storytelling are used to challenge Eurocentric philosophies.

The CRT construct of racism and regular phenomenon in society can be used to explore the intersectionality of gender and race in prenatal care experiences among African American women. CRT can also be used to establish race as a social construct and the need for cultural sensitivity to mitigate structural problems within the healthcare sector. The aspect of some participants receiving the best care while others not receiving better prenatal care can reflect convergent interests among care staff and patients, thus increasing racial disparities in the provision of healthcare services. The CRT construct of storytelling has been addressed by the findings including the narratives by participants regarding their experiences of prenatal care. Research findings concerning limited cultural sensitivity among prenatal care providers offer some great insights into the perspective of African American women regarding prenatal care experiences.

Recommendations for Practice

The findings revealed that racism and lack of cultural competence are the issues facing African American women in prenatal care. Based on this finding, training and development programs on cultural diversity should be adopted by healthcare organizations to address the various challenges faced by African American women with postpartum status. Yoder and Welch (2018) highlighted the need for training and development on different cultures to help care providers offer equal services regardless of patient’s racial and cultural backgrounds.

Diversity should be promoted in the healthcare system by implementing various policies including mandatory inclusion of African American women in recruitment of healthcare staff. This could help healthcare organizations mitigate racism against African American women in prenatal care. Employing prenatal care of color would provide enhanced cultural diversity in the provision of prenatal care among healthcare professionals, thus leading to increased and improved care quality. Wren et al. (2016) recommended the adoption of diversity training programs to promote a future where the needs of African American women in prenatal care would be sufficiently resolved. The current research findings have contributed to the previous literature by establishing various challenges facing African American women in accessing prenatal care.

Conclusion

The purpose of this study was to understand the personal viewpoint and perspective of the lived experiences of African American women regarding their prenatal care experiences. African American women feel unsafe when receiving prenatal care. Although the research provides significant insight regarding prenatal care services received by African American women, there were mixed findings as reported by participants. While some participants denied having received the best prenatal care, other participants acknowledged receiving the best possible prenatal care in a better hospital with better service. Racism and lack of cultural sensitivity were perceived as challenges facing African American women in prenatal care as prenatal care providers lacked cultural sensitivity concerning African American patients. Research findings provide important information regarding the experiences of African American women in prenatal care, indicating the need for enhanced diversity in the healthcare system to mitigate racism and discrimination against minority women such as African American women. The study outcome can help healthcare stakeholders develop important policies and programs to enhance equity in healthcare systems.

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Appendix A

Consent Form

You are invited to participate in a research study aimed at understanding the prenatal experiences of African American women in Southern New York. This form is part of a process called “informed consent” to allow you to understand this study before deciding whether to take part.

This study seeks 10 -15 volunteers.

This study is being conducted by a researcher named Alison Edinboro, who is a Doctoral student at Walden University.

Study Purpose:

The purpose of this study is to understand the personal viewpoint and perspective of the lived experiences of African American women regarding their prenatal care experiences in Southern NewYork City.

Procedures:

This study will involve you completing the following steps:

To complete a confidential audio recording interview via the telephone this process would take 40-60 minutes

To complete the demographic questionnaire will take about 5 to 8 minutes

Here are some sample questions:

Would you explain to me your experiences during pre-natal care? Anything you want to share is ok.

Do you think you received the best care possible during your pre-natal appointments. Can you give me an example?

Did you experience discrimination from your providers that you are willing to share?

Did you experience discrimination from other healthcare staff during your prenatal appointment? Can you give me an example?

What would it look like if you could have your ideal birth experience?

Voluntary Nature of the Study:

Research should only be done with those who freely volunteer. So, everyone involved will respect your decision to join or not.

If you decide to join the study now, you can still change your mind later. You may stop at any time. Please note that not all volunteers will be contacted to take part.

Risks and Benefits of Being in the Study:

With the protections in place, this study would pose minimal risk to your wellbeing. Being in this study could involve some risk of minor discomforts that can be encountered in daily life such as sharing sensitive information. The consent form will consider the information risks of breach of confidentiality or loss of privacy, emotional or psychological risks of guilt, confusion, fear, depression, stress, or triggers of past emotional experiences. If you feel uncomfortable and you would like to talk to someone you can call:

New Horizon Counseling Centers (516) 569 6600

This study offers no direct benefits to individual volunteers. The aim of this study is to provide knowledge on the aspects of prenatal care that African American women go through, and the appropriate interventions required to improve their pregnancy outcomes. Once the analysis is complete, the researcher will share the overall results by emailing you a summary.

Payment:

$20.00 Dunkin Donut Gift Card

Privacy:

The researcher is required to protect your privacy. Your identity will be kept confidential, within the limits of the law. The researcher will not use your personal information for any purposes outside of this research project. Also, the researcher will not include your name or anything else that could identify you in the study reports. If the researcher were to share this dataset with another researcher in the future, the dataset would contain no identifiers so this would not involve another round of obtaining informed consent. Data will be kept secure by locking it in a cabinet, and data on the computer would be password protected. Data will be kept for a period of at least 5 years, as required by the university and then destroyed.

Contacts and Questions:

You can ask questions of the researcher by email alison.edinboro@waldenu.edu or telephone if you want to talk privately about your rights as a participant or any negative parts of the study, you can call Walden University’s Research Participant Advocate at 612-312-1210. Walden University’s approval number for this study is IRB will enter approval number here. It expires on IRB will enter expiration date.

You might wish to retain this consent form for your records. You may ask the researcher or Walden University for a copy at any time using the contact info above.

Obtaining Your Consent

If you feel you understand the study and wish to volunteer, please indicate your consent by returning a completed consent form by email to Alexis Edinboro:

Email: ______________________________

Appendix 2: Code Book

Name

Description

Theme #1 Prenatal experience, assessment of whether best care was received and ideal birth experience

This theme represents the prenatal experiences shared by the interviewees and the views of the interviewees on whether they received the best care possible during their prenatal appointments.

1.1 Prenatal experience

Experiences of the interviewees during their prenatal care

1.1 Childbirth experience

Experiences of the interviewees when giving birth

Challenging childbirth experience

The feeling of being compelled to adhere to certain standards during childbirth

Mixed experiences during childbirth

Satisfaction with childbirth experience

Unproblematic childbirth experience

1.2 Experience with hospital visits

Experiences faced by the interviewees during their hospital visits for prenatal care

Cancellation of appointments due to doctor’s unavailability

The feeling of being burdened by multiple hospital visits toward the end of pregnancy

Feeling burdened by the multitude of hospital visits, ranging from labs, ultrasounds, and nutritional classes, towards the end of pregnancy

Long waiting appointment times

Overcrowded hospital environment

Rushed interactions with healthcare professionals

1.3 Communication issues and lack of concern from healthcare staff

Communication and concerns between the interviewees and the healthcare staff during their prenatal care

Dissatisfied with communication from healthcare staff

Unconcerned healthcare providers

Experienced healthcare issues during pregnancy

1.2 Prenatal best care experience

Thoughts of the interviewees on whether they received the best prenatal care appointments

Limited pre-natal care resources in the hospital

Acknowledges a limitation in resources despite the doctors and nurses trying their best to provide the best prenatal care

Need for additional medical staff to accommodate all the patients

The quality of prenatal care received is influenced by the type of insurance coverage

Satisfied with the prenatal care received

Suboptimal prenatal care due to busy healthcare staff

Unsatisfied with pre-natal care received

1.3 Ideal birth experience

Interviewees responses in regards to what their ideal birth experience would be or look like

Concern about medical staff compensation and workload

Cost concerns about home birth

Desire for adequate staffing during birth

Desire to be surrounded by understanding & considerate people towards pregnant women

Desire to give birth in a better hospital with better care

Low expectations and contented with what the hospital has hence does not fancy an ideal birth

Preference for home birth with own personal healthcare team

Prefers to have her birth in a different hospital

1.4 Suggested strategies to improve the prenatal experience

Suggestions by the interviewees to improve the prenatal care experience

Need for more healthcare professionals in hospitals

Theme #2 Discrimination and Prejudice experiences and barriers to healthcare

This theme represents interviewees’ experiences with discrimination and prejudice from providers and other healthcare staff and the barriers associated with such discrimination in healthcare

2.1 Provider discrimination experience

Discrimination experienced by Black women from the healthcare providers during their hospital visits for prenatal care.

Absence of any discrimination experience

Experienced uncomfortable comments and remarks from the healthcare provider

Feeling that pregnancy-related conditions are not put into consideration

Perception of mutual hostility and dismissiveness with the healthcare professional

2.2 Other healthcare staff discrimination experience

Discrimination experienced by Black women from the healthcare staff during their hospital visits for prenatal care.

Absence of discrimination from healthcare staff

Experienced discriminatory comments from the healthcare staff

Perception of not being listened to due to dissatisfaction

The presence of discrimination based on the kind of insurance coverage

2.3 Discrimination and prejudice experienced as barriers to healthcare

Interviewees believe that discrimination and prejudice a barriers to healthcare for Black women.

Lack of knowledge regarding discrimination and prejudice in healthcare for Black women

Persistent discrimination as a barrier to healthcare for Black women

Theme #3 Negative emotions during pregnancy

This theme represents negative emotions such as fear and stress experienced by the interviewees during pregnancy and the causes of such emotions

3.1 Fear Experienced During Pregnancy

Interviewees’ fears related to healthcare and their pregnancy.

Absence of fear or feeling of being unsafe

Experience of being scolded and having an attitude toward the staff

Fear of having a baby

Fear related to safety concerns during hospital visits

Financial strain

Unsure if she experienced discrimination

3.2 Stress Experienced During Pregnancy

Interviewees’ cause of stress experience during their pregnancy?

Absence of feeling any stress during pregnancy

Better housing conditions

Current living situation

The feeling of being unheard during appointments

Financial strains

Motherhood journey

Stress from the interviewees resulting the responsibilities of motherhood

Becoming a mother

Handling multiple responsibilities during pregnancy

The stress of having a baby

Societal treatment of Black women even when pregnant

Support from family

Theme #4 Abuse experiences during prenatal care

This theme represents different forms of abuse experienced by the interviewees during prenatal care including verbal or physical abuse and forced or withheld treatment

4.1 Verbal or physical abuse from provider experience

Interviewees’ perception of whether or not they have experienced any verbal or physical abuse from their healthcare providers.

Did not experience physical or verbal abuse

4.2 Forced or withheld treatment experience

Interwees beliefs and perceptions of whether any medical treatments were forced or withheld from them by their healthcare providers.

Did not experience forced or withheld treatment from healthcare providers

Experienced differing medication approaches by the healthcare provider

Forced medical operation

Forced treatment through prescriptions by the healthcare provider

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