Annotated bibliography for research methods class

Journal of Midwifery & Women’s Health www.jmwh.org Original Research

Listening to Women: Recommendations from Women of Color to Improve Experiences in Pregnancy and Birth Care Molly R. Altman1,2, CNM, PhD, MPH , Monica R. McLemore2,3, PhD, MPH, RN , Talita Oseguera3, CNM, MSN, Audrey Lyndon4, PhD, RN , Linda S. Franck 2,3, PhD, RN

Introduction: Women of color are at increased risk for poor birth outcomes, often driven by upstream social determinants and socially structured systems. Given the increasing rate of maternal mortality in the United States, particularly for women of color, there is a pressing need to find solutions to improving care quality and access for racially marginalized communities. This study aims to describe and thematically analyze the recommendations to improve pregnancy and birth care made by women of color with lived experience of perinatal health care.

Methods: Twenty-two women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit organization participated in semistructured interviews about their experiences receiving health care during pregnancy and birth. Interviews were audio-recorded and transcribed, and transcripts were analyzed using thematic analysis to highlight recommendations for improving perinatal care experiences.

Results: Participants shared experiences and provided recommendations for improving care at the individual health care provider level, includ- ing spending quality time, relationship building and making meaningful connections, individualized person-centered care, and partnership in decision making. At the health systems level, recommendations included continuity of care, racial concordance with providers, supportive health care system structures to meet the needs of women of color, and implicit bias trainings and education to reduce judgment, stereotyping, and discrimination.

Discussion: Participants in this study shared practical ways that health care providers and systems can improve pregnancy and birth care expe- riences for women of color. In addition to the actions needed to address the recommendations, health care providers and systems need to listen more closely to women of color as experts on their experiences in order to create effective change. Community-centered research, driven by and for women of color, is essential to improve health disparities during pregnancy and birth. J Midwifery Womens Health 2020;65:466–473 c© 2020 by the American College of Nurse-Midwives.

Keywords: patient-centered care, racism, continuity of patient care, decision making, thematic analysis

INTRODUCTION

Women of color are at increased risk for poor birth outcomes, such as preterm birth and low birth weight, irrespective of income or other sociodemographic factors.1-3 Multiple factors have been implicated in these disparities at the indi- vidual level, often driven by upstream social determinants and socially structured systems.4-7 Given the increasing rate of maternal mortality in the United States, particularly for women of color, there is a pressing need to find solutions to improving care quality and access for racially marginalized communities.8,9

1University of Washington School of Nursing, Seattle, Washington 2Preterm Birth Initiative, University of California San Francisco, San Francisco, California 3University of California, San Francisco School of Nursing, San Francisco, California 4New York University Rory Meyers College of Nursing, New York, New York Correspondence Molly R. Altman Email: [email protected] ORCID Molly R. Altman https://orcid.org/0000-0002-0453-0469 Monica R. McLemore https://orcid.org/0000-0001-6539-4256 Audrey Lyndon https://orcid.org/0000-0003-2215-4273 Linda S. Franck https://orcid.org/0000-0003-4291-9181

There is increasing evidence that health care system fac- tors play a role in the health care experience and pregnancy and birth outcomes for women of color.10-12 In the con- text of pregnancy and birth, women of color have repeatedly shared that they are not listened to and/or that their concerns are ignored.13-17 Although women seek trustworthy and re- spectful care, not receiving such care can compound stress and discourage access to necessary services.13,18,19 Women of color have rarely been directly asked about their prefer- ences and ideas for patient-provider and health care system improvement.14 As experts on their experiences, women of color have the ability to share insightful knowledge about their own health, which can guide health care systems to better sup- port and respect people of color through the pregnancy and birth experiences.20

As part of a larger study exploring experiences inter- acting with health care providers during pregnancy, birth, and postpartum,21 women of color in San Francisco de- scribed how providers’ power influenced what information was shared in the context of respect, autonomy, and decision making. Participants also provided recommendations for how the health care system could be improved to better support women of color. The purpose of this report was to describe and thematically analyze what participants shared as issues with the current health care system and their described rec- ommendations for change.

466 1526-9523/09/$36.00 doi:10.1111/jmwh.13102 c© 2020 by the American College of Nurse-Midwives

✦ Women of color provided recommendations for improving care during pregnancy and birth, aimed toward change in both individual interactions with health care providers and the larger health care system.

✦ Providing person-centered care and valuing a person’s lived experience are key to improving trust for women of color.

✦ Ensuring access to racially concordant care by supporting more health care providers of color through education and in the workforce has the power to improve the experience and outcomes for women of color.

✦ Centering the experiences of those affected by health disparities is key for improving pregnancy and birth outcomes.

METHODS

Detailed methods for the larger project have been de- scribed elsewhere.21 In brief, the research team recruited self- identified women of color from a community-based organi- zation in San Francisco, California, that provides health and wellness services to families with low income. One-to-two– hour semistructured interviews were conducted with women from 6 weeks to one year postpartum. These interviews were transcribed verbatim and then analyzed using constructivist grounded theory methods.22,23

For this secondary analysis, the interview transcripts were further analyzed using thematic analysis techniques as de- scribed by Braun et al24 to identify issues with the health care system and associated recommendations for health care improvement that women provided in response to a prompt within the interview guide. Transcripts were read thoroughly for additional content specifically related to recommenda- tions for health care providers or health care systems. Ini- tial codes were generated and then analyzed within and across transcripts to form preliminary themes. The prelim- inary themes and subthemes were then further developed with illustrative exemplars from transcripts. Themes and sub- themes were then named and defined. The secondary analy- sis was performed by 2 members of the research team (first and third authors), with findings reviewed and commented upon by the larger team. Reflexivity included continued as- sessment of researcher positionality within the context of how women responded to the interview prompt (all researchers had nursing and/or nurse-midwifery training, with 2 identify- ing as Black and 3 as white). Human participants’ approval was granted by the University of California, San Francisco. All par- ticipants provided informed consent prior to interviews and received a $50 gift card for their time and involvement.

Of note, although the authors recognize that not all birthing persons identify as women, the participants in this study all identified with she and her pronouns and the titles woman and mother. For this reason, the authors use these terms in the context of this report of research findings.

RESULTS

Twenty-two women of color participated in the larger study, and all were included in this analysis. Participants self- identified as African American or Black (non-Hispanic) (8), Latina or Hispanic (4), Native American (1), Asian (3), and multiracial or mixed race/ethnicity (6). Those who identified as multiracial or mixed race/ethnicity used the

following descriptions: Black/Hispanic (2), Black/Samoan (1), Black/Filipino (1), white/Latina (1), and other (Chero- kee/White/Puerto Rican) (1). Participants were aged between 23 and 39 years and had a total of 55 birth experiences. All par- ticipants received support services at the community-based organization (such as case management, childcare, and finan- cial assistance).

Participants described their pregnancy and birth expe- riences and highlighted ways to improve individual patient- provider interactions with different types of health care providers, including obstetricians, nurse-midwives, nurses, and medical residents. Additionally, they described interac- tions with several different clinics, hospitals, and health sys- tems, both public and private, providing recommendations at the systems level for improving care (Table 1).

Interacting with Individual Health Care Providers

Participants shared insight around interacting with health care providers and recommendations for health care improve- ment, including the following subthemes: spending quality time, relationship building and making meaningful connec- tions, individualized person-centered care, and partnership in decision making.

Spending Quality Time

Participants strongly desired that health care providers spend quality time with them during the course of their appoint- ments and during their hospital experience. Quality time, in this context, was defined as time in which participants felt they were given adequate time and attention from their providers to feel valued and listened to. Many participants shared expe- riences of being rushed by providers and inadequate time to receive individualized care. The experience of being rushed was often interpreted negatively as a value judgment, in which their time and needs were less worthy than those of other peo- ple: “It was like more, ‘Oh, okay. Let’s just hurry up and get her over with and push her out,’ you know what I mean?”

Participants felt seen and cared for when health care providers spent time at the bedside, particularly in the con- text of understanding that providers had competing job du- ties and limited time. One participant shared that, when in a particularly stressful moment during her labor, “ ...my doc- tor just came beside me, rubbed my head and says, ‘It’s going to be okay.’ [ ...] She took that one little second to come calm me down. And that’s what I liked.” That “one little second”

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Table 1. Recommendations, Concerns Addressed, and Proposed Actions Curated from Participant Interviews

Recommendation Concerns addressed Proposed actions

Interactions with individual health care providers

Spending quality time Wanting to not feel rushed Have longer visit length with longer face-to-face times

with providers

Wanting physical time with providers Make eye contact

Wanting to be seen and heard Use reflective listening techniques

Relationship building Wanting an emotional connection Get to know patients as individuals

Wanting to be known and familiar to providers Take notes to remember at subsequent visits

Wanting providers to start and participate in

genuine conversation

Include questions about life, well-being

Value patients’ experiences

Individualized

person-centered care

Wanting to be treated as a person Show respect and dignity

Wanting to know that their health, not just their

fetus’s health, mattered

Focus on both patients, not just fetus

Wanting providers to factor in external influences

and barriers into care

Inquire about and address social determinants of health,

particularly structural impacts such as poverty,

housing, and transportation issues that may affect care

Increase knowledge of impact of social determinants

of health on outcomes and access

Partnership in decision

making

Wanting experiences and knowledge to be valued

and respected

Honor patient stories and lived experience as equal to

theoretical knowledge

Wanting autonomy in decision making Provide all information and support patient decisions

Use informed consent for all professional touch and

procedures

Interactions with the health care system

Continuity of care Wanting to see same providers who know them Use patient panels or other continuity models

Not wanting to have to repeat history and story Have mechanism for sharing details across providers

Provider racial and ethnic

concordance

Needing providers who look like them and have a

shared cultural identity to feel safe

Support education and recruitment of providers of color

across all levels of care

Wanting a more diverse workforce, as there are

few providers of color available

Recruit from historically Black colleges and universities

Precept and/or mentor students of color

Support career fairs at high schools in diverse

neighborhoods

Health system structure

issues

Needing a less fragmented care system; wanting

services consolidated in one location

Streamline services and referral systems to reduce

burden on patients

Add services to existing locations

Needing consistency in insurance coverage and

recommended care, in response to having

recommended care not a covered benefit

Push for comprehensive insurance coverage for all

recommended maternal health services through

lobbying and policy change

Wanting appointment scheduling and time spent

in appointment reflecting needs and barriers

faced by people of color

Provide opportunity for evening and weekend

appointments

Remove late penalties

Provide flexibility in appointment times

Provider education Needing more effective implicit bias trainings Review your own implicit biases

(https://implicit.harvard.edu/implicit/education.html)

Incorporate antiracism trainings into education and

workplace settings

(Continued)

468 Volume 65, No. 4, July/August 2020

Table 1. Recommendations, Concerns Addressed, and Proposed Actions Curated from Participant Interviews

Recommendation Concerns addressed Proposed actions

Needing revisions of textbooks and coursework

that perpetuate structural racism

Choose texts that address structural racism and the

colonial impacts on health care education

Write to publishers of outdated texts to request

necessary changes

transformed her experience in a positive light. Time spent face-to-face with providers, particularly in the setting of be- ing listened to and heard with empathy, was seen by women of color as a valuable mechanism for building trust and mutual respect.

Relationship Building and Making Meaningful Connections

Participants in this study shared a desire for a connection with, to know and be known by, and to have a sense of shared humanity recognized by their health care providers. For many participants, making connections and building rela- tionships took the form of having casual, yet meaningful, con- versation about shared interests or experiences. One partici- pant recommended providers start and participate in genuine conversations:

I could sit and I could talk to somebody [ ...] “Oh, you know, hey. How’re you? You have kids too?” and stuff. And so that’s what gets people a little bit more comfortable [ .. .] Like just starting a conversation ... and it’s just genuine, you know?

Similarly, participants shared a desire to be known by their health care providers, as one participant defined as knowing names and history: “I think when you bring your child to a doctor it should be someone who knows your child’s name, al- ready knows what’s going on with the baby, and gets personal.” Interactions were meaningful for women when providers con- veyed a sense of empathy and compassion, particularly in ways that created emotional connection. One participant, who recently gave birth to her second child, shared this when de- scribing the lack of compassion she felt from her provider:

When you’re talking to someone about their child, even if you don’t have kids, having that compassion and under- standing and emotional connection, empathy and sympa- thy for someone that is dealing with the care of their child and the well-being, that is what I think was lost [from the interaction].

Participants identified actions health care providers could take to build relationships and create connection, including sharing commonalities, taking time to know and see individ- uals as persons, and hearing their concerns with empathy and compassion.

Individualized Person-Centered Care

Alongside spending time and feeling connection with health care providers, participants wanted to receive care that was in- dividualized for them and included person-centered interac-

tions. Participants needed to be recognized as a person who was valued and whose knowledge was respected. As one par- ticipant shared, a lack of individualized care and connection had a direct impact on hope and shared decision making: “So, if you’re talking to me as though I’m just a number, you’re tak- ing away my hope of my baby. Don’t feed me lies, but don’t take away from my hope or take away from me helping you in the care.” Participants wanted to know that their health and wellness, not just their unborn fetus’s, mattered to their providers. A mother of 2 children shared this about her pre- natal care experience: “They were more concerned about the pregnancy, not really [ ...] me as a person. I’m not just a car- rier. Be concerned about me too.”

Participants felt that factors external to the health care sys- tem often influenced how care was accessed and received, and they noticed when health care providers recognized these in- fluences and made room for individualized care. One partic- ipant described her positive experience with a provider who recognized her unique needs and supported her:

So, I’m often late because I just have so much to deal with 3 little children. So, like if I’m late to an appointment and I call they’re like, “Yeah, she’s still wanting to see you.” And I know that’s not always the case with a lot of doctors. She’s just very supportive and she takes the time to go kind of above and beyond.

Person-centered care that recognized people as fully hu- man, not numbers or vessels, but also as valued individuals, was considered essential to providing a care experience in which patients felt hopeful, included, and honored.

Partnership in Decision Making

Participants wanted not only to be heard and respected but also to be included in decision making throughout their care experience. Having their knowledge respected was valued by many of the participants: “I think that the doctors should listen to us more, you know? Some of us do kind of know what our babies need.” Participants expected autonomy and decision-making power, to be treated with respect, and care that was individualized to their own needs: “ ... it’s making sure that the patient has their needs met and their requests honored. Like allowing somebody to make their own deci- sions and be autonomous and, you know?”

Autonomy and decision-making power during pregnancy and birth were highly valued by participants and were ex- pected as part of the relationship with health care providers. When these rights were not afforded to them, participants felt disempowered and frustrated, which then decreased trust in individual providers and even in the health care system.

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Interacting with the Health Care System

Participants identified system-level barriers, such as frag- mented care, insurance problems, and discrimination that they perceived adversely affected their care, and highlighted several health system–level recommendations for improv- ing care for women of color. The dominant subthemes in- cluded continuity of care, racial concordance with health care providers, supportive health care system structures to meet the needs of women of color, and implicit bias train- ings and education to reduce judgment, stereotyping, and discrimination.

Continuity of Care

Consistency of health care providers and continuity of care, which provides the time and space needed for relationship building, was highlighted as an important factor to improve at the systems level. Many participants highlighted experiences in which they needed to tell their story repeatedly to differ- ent people, only to not see the same providers again; there was a sense of disruption to care and lessened quality of care provision:

I don’t like they are different nurses or doctors. They don’t know what happened the previous visit. So, when they asked me is she okay, I don’t know. [ .. .] I don’t know if she’s better than the last visit because you don’t know.

Participants highlighted how health care provider consis- tency allowed for relationship building and increased individ- ualized care. One participant shared her experience with mul- tiple providers and struggling with wanting less exposure for her newborn:

You [shouldn’t] have to get used to the 5 different peo- ple during your 2-day stay. So, give one nurse these rooms and another nurse these [other] rooms. [ .. .] It’s just a brand new baby. You don’t want all these people handling your baby, first off. Even though they’re nurses, it doesn’t matter.

Inconsistency in health care providers created an envi- ronment for many participants that increased mistrust of provider knowledge and feelings of vulnerability in having to share their story repeatedly. Participants saw the connection between continuity of care and ability to build relationships with providers, which opened up opportunity to increase trust and connection.

Health Care Provider Racial and Ethnic Concordance

Women of color in this study highlighted the importance of having a health care provider who looks like them and under- stands their lived experience as part of their care team. Partic- ipants shared feeling safer and more connected with providers of color and noted feeling suspicious and/or fearful of receiv- ing judgment from white providers:

When I see somebody who is of color, we have more of a connection without even saying anything to each other. And so it’s like, “Oh, okay,” you know? It’s so different, and then when somebody that is Caucasian comes in, I

don’t know. It just—everything just feels so dry like really short,—you know what I mean? [ .. .] That’s how I feel with some of the Caucasians—because of the experience that I’ve been through.

Participants highlighted the need for diversification of the health care provider workforce. One participant shared her observation that it is difficult to find providers of color and that there is a need to have more available to communities:

Well, maybe just that I mean it would be great if there were more doctors across like a spectrum of different identities; more people in the medical profession because it can be eas- ier to get or to feel a sense of equality if there’s just more di- versity in general. It is sometimes hard to run into like Black women doctors as regularly as it is other folks. I think that would be awesome if there were just more.

Women of color in this study found difficulty in connect- ing with white health care providers, and they often expressed fear of judgment and potential or actual experiences of dis- criminatory care. By connecting with providers of color who shared commonalities of experience and/or an understand- ing of marginalization, participants felt more comfortable and therefore were more trusting of the care they received.

Supportive Health System Structures

Participants highlighted a need for health care systems to be supportive and adaptable for the specific needs of women of color, particularly related to co-location of services, insurance transferability, flexibility for appointment times, and wanting to see efforts toward reducing implicit bias within the health system. When patients had to travel to different locations for various aspects of care, there was increased potential for ex- acerbation of illness for patients, especially those with limited resources. One participant described a need for better access to multiple services during her high-risk pregnancy:

I feel if you knew I was high risk then you should have helped me with whatever resources I needed, not sending me to another doctor for my blood pressure medicine, not sending me to another psychologist when I’m stressed, run- ning me all over the place.

Along with wanting co-located services, issues around in- surance coverage and not having recommended care as a cov- ered benefit arose for several women. One participant who relocated during her pregnancy, but whose public insurance restricted her to one particular county, needed her insur- ance coverage to match care recommended by health care providers:

It would just be nice if you could make sure that what I’m getting is what I’m getting and that I don’t have to come back for another BS appointment and be told that I’m not covered and have to come back next time.

Not only was denial of care frustrating, the time taken to travel repeatedly to a different county for care served as an additional barrier to receiving appropriate care.

Participants also wanted health care providers to be con- siderate of time, both in scheduling clinic appointments and

470 Volume 65, No. 4, July/August 2020

in having to wait to be seen. Despite immense efforts, partici- pants’ caregiving responsibilities, employment commitments, and transportation issues sometimes affected their ability to arrive on time for appointments with consistency. Requesting leniency for when delays occurred and participants could not arrive exactly at their appointment times was common:

You know, getting around, transportation and stuff like that and trying to get here and there, and it’s just like I have to be seen every week. You need to have some kind of consid- eration if I’m a little late.

Education to Reduce Judgment, Stereotyping, and Discrimination

An important subtheme that emerged regarding recommen- dations for health services was aimed at addressing stereotyp- ing, judgment, and discrimination that existed at both indi- vidual and system levels for women of color. As shared by one participant regarding bias and equitable treatment:

Just like how they would treat the next person that they see every day. Don’t see me for somebody different. I’m a human being just like you. You’ve made mistakes. Just be- cause of my mistakes are a little bit different than yours doesn’t mean that you’re different than I am, you know? [ ...] It doesn’t matter what color you are. Everybody has to be treated the same way.

In reflecting on their individual struggles around in- equitable care as patients and a desire to decrease racism and discrimination in health care settings, participants recom- mended implicit bias training and education for all health care workers. One participant shared her recognition that health care providers are not adequately trained to deal with their bi- ases:

It’s really interesting to recognize that maybe there isn’t enough training to try to deal with those biases in these professions before they’re actually out there in the field, ac- tually like implementing their biases in ways that like re- ally affect people. [ .. .] I doubt there’s substantial diversity training.

Furthermore, participants recommended trainings that moved beyond lecture and brought in lived experience:

[Training shouldn’t be] like just one day where you go and listen to some statistics. Like make you listen to stories. Like you need to interact with actual people to recognize that there is no one type of one like person, not all of this kind of person are going to be this way. [ .. .] So, if doctors are coming in with their own set of discriminatory beliefs then that’s going to have an impact on their patients.

Participants disputed the idea that medical and nursing education in the United States is free from bias and recom- mending updating textbooks to better reflect diversity and reduce prejudicial teaching. One participant described how many biases in education are likely introduced through text- books that represent structural racism and othering:

I mean that starts in school. It starts with the chapter in your book that’s like, “Oh, this is how to greet an African

American.” It’s like, “Here’s how to greet a Hispanic per- son. This is what Hispanic people believe.” [ .. .] And I’m like, “No, wait. That’s not what I think at all.” You know? Like that’s crazy. It starts with the books. Like that chapter needs to go.

DISCUSSION

Participants in this study highlighted several recommenda- tions for improvement in patient-provider interactions, in- cluding spending time engaging with patients, connecting and building relationships, providing individualized women- centered care, and being open to a true partnership in deci- sion making. Systems-level recommendations included hav- ing opportunity for continuity of care, health care provider availability that allows for racial concordance, and support- ive health services structures that enable women of color to more easily and effectively receive needed services. As judg- ment and discrimination played a role in participants’ experi- ences, health system recommendations also included training for providers and removing biased language from textbooks and coursework.

Many of the recommendations shared by participants have support in the existing literature. Evidence in support of person-centered care is extensive, particularly in the repro- ductive health arena.25-29 Elements of person-centered care, including individualized care, communication, creating part- nerships in autonomy and decision making, and building re- lationships, are well documented as ways to improve the ex- perience and quality of health care, especially with women of color.14,29,30 Respectful perinatal care, in relation to ex- periences of respect, autonomy, and mistreatment, has also been extensively studied and reported upon.14,26,30 Systems- level issues such as fragmented care, inflexible schedules, and long wait times are widely known as issues in the current health care system, often disproportionately affecting people of color.13,31 Potential solutions that have been shown to im- prove care experience include care navigation and an empha- sis on continuity of care.32-34

The presence of racism and discrimination in participant encounters was not surprising and illuminates a disturbing reality that participants still experience multiple perva- sive episodes of discriminatory care. The fact that several participants brought up the need for health care provider training, without knowledge that these trainings exist and are considered a compulsory part of continuing education for most health care facilities, further demonstrates how trainings often do not effect change in behavior.35,36 Other modalities for reducing judgment and discrimination in providers are needed to create spaces where women of color feel safe to receive care. Experience-based co-design is one promising participatory approach that aims to change health systems by employing patient experience as a tool to inform changes in health care policy and clinical practice.37,38

Racial concordance and the availability of health care providers of color have been documented as a modality for increasing trust and respect for people of color.39,40 Learn- ing and practicing environments are often perceived as un- safe and unsupported because of discrimination across pro- fessional relationships and the burden of often being the only

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learner or provider of color.41,42 Furthermore, like patients of color who desire race concordant care, learners of color do not see themselves reflected in the faculty in predominantly white institutions, which provide the majority of health care train- ing programs.43 There is a great need for increasing opportu- nity and decreasing barriers for people of color to succeed and thrive as providers, not only for providers themselves but also for patients who deserve unbiased and compassionate care.

A major strength of this study is the diverse sample of women of color from varying backgrounds who were able to provide their insight from within several health care systems. In addition to racial and ethnic diversity, the study includes 55 birth experiences across a wide range of health care providers, clinic structures, and hospitals in the Bay Area. Limitations in- clude generalizability because of the small locality and sample size. The use of thematic analysis within secondary analyses has its own limitations, such as bias related to the original in- terview methodology and research questions; however, mea- sures were taken to avoid these pitfalls, and developed themes were confirmed by multiple authors in separate analyses.24 Despite these limitations, the experiences of these participants are insightful and provide actionable steps for improving the health care experiences for women of color during pregnancy and birth.

Participants in this study shared specific and practical ways in which health care providers can improve pregnancy and birth care for women of color. In addition to the direct implications of these recommendations, there is a need to lis- ten closely to the voices of women of color as experts on their experiences in order to create effective and actual change. Community-centered research driven by and for women of color is essential to improve health disparities around preg- nancy and birth.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

ACKNOWLEDGMENTS

This research was supported by the University of California, San Francisco Preterm Birth Initiative Transdisciplinary Post- doctoral Fellowship, funded by Marc and Lynne Benioff and the Bill and Melinda Gates Foundation. We thank our com- munity partnering organization, Homeless Prenatal Program, and the participants who shared their stories and experiences to advance health equity. This work was presented in part at the American Public Health Association’s Annual Meeting & Expo (November 2018, San Diego, CA) and the Ameri- can College of Nurse-Midwives Annual Meeting & Exhibition (May 2019, Washington, DC).

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