Table 6 Interview results by category, theme, and exemplar quote

Perinatal Disparities

Access to Care

“where I feel I see a lot of disparity is not having access to insurance that really decreases the quality of care. There are a lot of restrictions in terms of where patients can go with specific types of insurance or if they don’t have insurance at all.”

“that’s where they offered it.”

“my insurance had canceled because of my age and then she wanted me to pay out of pocket.”

“…and then once you get to doctor's appointments, Oh my God, Scheduling. Because it's like… today is December 7th. Well, [they] have a doctor's appointment for February the second.”

“I live out South. So I'm like an hour ride to the North side. So when you tell me, Oh, I can't be seen. And I'm going to go all the way that back south to make a new appointment to come all the way back up North. That's just a no, no. Yeah. Especially when I'm on public transportation.”

“I would [be] sitting up in front for two whole hours… it feels like I have the carve out my whole entire day”

Racism

“racism and discrimination in the healthcare system… Black women not being listened to in the context of pain or discomfort. When they make those expressions sometimes they’re ignored and other times they are told it’s not that big of an issue. That issue in particular is something that has been happening even in the early days of the study of obstetrics and gynecology—we can sort of track back these institutional practices of healthcare providers where Black women’s pain and discomfort is ignored. It’s unfortunate we continue to see those same patterns today and there have been clear examples where that has actually led to maternal death for Black women.”

“I suggest to have someone there that can help advocate for you just based off what African-American women have been going through in hospitals.”

“I’ve met some [providers] that just … don't care. They don't listen to you. They just say, this is this and this is your only option.”

“constantly telling everyone the doctors,[ everybody], that something’s not right and no one's listening to me.”

“ to be ignore[d] for that long, … that's what really troubled me.”

“A lot of the times with healthcare workers, you know, you just feel powerless sometimes because you know, they're the doctor and you're not”

“… A lot of the times with healthcare workers, you know, you just feel powerless sometimes because you know, they're the doctor and you're not….”

Resources

“Particularly for low-income Black women, having the resources and support to link with social services they need, whether it’s transportation, housing, nutrition support, and mental health challenges and how and when women can access those support services can be a cause for anxiety.”

“so I was laid off, my job due to the virus… I had to continue to pay every time I had a prenatal visit, I had to pay $40”

Trust

Importance of Trust

“trust is the most core fundamental value that’s missing.”

“If I didn't trust them, I would not go… if I can't trust you, I know you're going to kill me… it may seem funny, but realistically, yeah.”

“And to know that like I was able to have someone that was able to inform me, educate me, or especially on things that I didn't know, and to answer my questions…. It was definitely uplifting.”

Establishing Trust

“if we talked more about trust – do you trust and feel respected by your healthcare provider – having that uncomfortable conversation can help the psychological fear of [physicians not looking out for their best interests]”

“she made sure that she was present”

“I've been going to them in the same doctor before I actually did get pregnant.”

Change initiatives

Patient Education

“…orient them and prepare them for [breastfeeding] because often people don't understand that, you know, might be really difficult. You might have a hard time, it might take a lot of work. You don't produce enough milk, you're going to feel guilty.”

“I feel like when a doctor can talk to me, explain things to me…, then yeah. I can trust you when you tell me … next time I see you [I] want to have this or that.”

Patient Advocates

“A lot of these positive examples [initiatives] from my perspective have largely come from community based perinatal support organizations like midwifery care or community-based doulas… they are centering Black women and other women of color in healthcare practice. What I have seen that has been key in their work is that they center women of color and their experiences.”

“I feel very supported by my doula and how she's set up. Like she even came to my home to do her own prenatal visits with me. It was part of her package. So she does prenatal visits. She of course will support me during and after labor and postpartum. She's gonna still help me with breastfeeding

“I think the best is to have a doula. Get a doula. They help, they help a lot. Cause there's a lot of stuff you're not going to understand.”

Services and Resources

Beneficial Services

“I’ve had patients that have done the moms group and absolutely loved it. They were really invested, motivated, they got a lot of information.”

“everything will be needed and it’s best to get it when it's, you know, provided for you.”

“they also provided and offered a virtual, like pregnancy plan where like, I can take pregnancy classes with other people online and everything.”

“[they] went above and beyond and faxed [the company] all my appointments to make it easier for me. To ensure that I had a ride there whenever my appointment was, and I didn't have to call them every time I needed a ride.”

Addressing patient Needs via Navigation

“I can’t say that for any individual patient that I refer to either of these things that I’m able to see the outcome.”

Social Determinants of Health

Effect on Care

“particularly for low-income Black women, having the resources and support to link with social services they need, whether it’s transportation, sometimes housing can be a big issue, nutrition support, these are all issues that are related to health.”

“I was the only aware that it was provided, like after baby was born just for the baby where they, you know, informed me that no, you know, you can get it now. It's also for you too. And once I started getting it, it was a big benefit because, it provided fruits, vegetables, stuff that, that I wanted at that time.”

Best Suited to Screen

“I feel like whoever the patient trusts, like whoever [healthcare worker] feels like they’re building rapport with that patient and asking those questions are going to yield meaningful answers.”

“I was telling her my situation about me not working and everything with the job. So she recommended me to apply for County care, like a medical card… She gave me the information, I applied online and then I got the card within like two to three weeks.”

Screening Frequency

“So if I’m implementing a screening questionnaire, that’s not a waste of my time because the information is important, but I don’t think it’s an optimal use of my time.”

Perinatal Care Practices

Time Devoted to Patient Care

“I think we should extend our hours every day instead of just two days a week.”

“But most importantly, it was just, they gave you the things in the tools you needed to know,”

Cultural Competency

“You have providers who are not accustomed to working with African American patients who don’t always understand dialects/lingo and don’t utilize language that patients can always understand, which can have a major impact on patient education and their understanding of what exactly their medical condition is.”

“So I know by now what should be going on with my body when I'm pregnant.”

“brush up on the newest things that's going on in our, you know, in our world to, you know, be basically be aware of the new stuff and you know, each generation’s change.”

“not … even when you think you’re a veteran mom, you think you know, but you don't cause everything changes over the years”

Mental Health

“Some of the cultural stigma around mental health and strong black woman syndrome… can really be a barrier in terms of acknowledging that there are challenges [mental health] and that we should talk to someone.”

“prenatal care is seeing to it that I am all around taken care of physically and emotionally”

Expectations for Labor and Delivery Education

“I think a lot of expectations in labor and postpartum we should address ahead of time, globally for patients, but especially for patients that might not have as much trust in the health system… maybe around 30, 32 weeks, labor wise, here’s all the things that might happen. These are things that could potentially go wrong and what might happen so if it does, you’re not completely blindsided. Here are things you should feel empowered to request.”

“Only thing that was shocking was that I had to get induced, so my water bag had just bust. I didn't know, like the pain was just going to come out the blue like that”