Annotated bibliography for research methods class

Title: More than a “Number”: Perspectives of Prenatal Care Quality from Mothers of Color and

Providers

Authors’ Names and Affiliations:

Sheryl L. Coley, DrPH1,2, Jasmine Y. Zapata, MD, MPH3,4, Rebecca J. Schwei, MPH2,5, Glen

Ellen Mihalovic, BS2, Maya N. Matabele2,6, Elizabeth A. Jacobs, MD, MAPP2,7, Cynthie K.

Anderson, MD, MPH8

1 Health Disparities Research Scholars Program, University of Wisconsin Madison, Madison, WI

2 Department of Medicine, University of Wisconsin Madison, Madison, WI

3 Department of Pediatrics, University of Wisconsin Madison, Madison, WI

4 Preventive Medicine and Public Health Residency Program, University of Wisconsin Madison,

Madison, WI

5 BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison,

Madison, WI

6 University of Wisconsin Milwaukee, Milwaukee, WI

7 Dell Medical School, University of Texas Austin, Austin, TX

8 Department of Obstetrics & Gynecology, University of Wisconsin Madison, Madison, WI

Corresponding Author:

Sheryl L. Coley, DrPH

University of Wisconsin Madison School of Medicine and Public Health

610 Walnut Street, WARF Building 9th Floor, Suite 957

Madison, WI 53726

Phone: 919-698-0709

Email: [email protected]

Acknowledgments

The authors thank Drs. Jennifer Edgoose, Deborah Ehrenthal, and Jonas Lee for comments in the

early design of the study. Thanks goes to Ryan Garske for work in preliminary analyses. This

project was supported, in part, by the following sources: National Institute of Child Health and

Human Development (NIH/NICHD) Research in Health Disparities Program, grant

5T32HD049302; University of Wisconsin-Madison Departments of Obstetrics and Gynecology,

© 2017 published by Elsevier. This manuscript is made available under the Elsevier user license https://www.elsevier.com/open-access/userlicense/1.0/

Version of Record: https://www.sciencedirect.com/science/article/pii/S1049386717301044 Manuscript_a9812a600a4d977022985324c53d793d

Medicine, Family Medicine and Community Health, and Pediatrics; University of Wisconsin

Health Innovation Program, School of Medicine and Public Health from The Wisconsin

Partnership Program, and the Community-Academic Partnerships core of the University of

Wisconsin Institute for Clinical and Translational Research (UW ICTR) through the National

Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. This content is

solely the responsibility of the authors and does not necessarily represent the official views of the

NIH nor NICHD. These funding agencies had no input with data collection, analyses, nor writing

of this manuscript for this study.

Declaration of Conflicting Interests: The authors have no conflict of interest in the data

collection, analyses, nor writing of this manuscript.

Dr. Coley had full access to all the data in the study and takes responsibility for the integrity of

the data and the accuracy of the data analysis.

1

Title: More than a “Number”: Perspectives of Prenatal Care Quality from Mothers of Color and

Providers

Abstract:

Introduction: African-American mothers and other mothers of historically underserved

populations consistently have higher rates of adverse birth outcomes than White mothers.

Increasing prenatal care use among these mothers may reduce these disparities. Most prenatal

care research focuses on prenatal care adequacy rather than concepts of quality. Even less

research examines the dual perspectives of African-American mothers and prenatal care

providers. In this qualitative study, we compared perceptions of prenatal care quality between

African-American and Mixed-Race mothers and prenatal care providers.

Methods: Prenatal care providers (n=20) and mothers who recently gave birth (n=19) completed

semi-structured interviews. Using a thematic analysis approach and Donabedian’s conceptual

model of health care quality, interviews were analyzed to identify key themes and summarize

differences in perspectives between providers and mothers.

Findings: Mothers and providers valued the tailoring of care based on individual needs and

functional patient-provider relationships as key elements of prenatal care quality. Providers

acknowledged the need for knowing the social context of patients, but mothers and providers

differed in perspectives of “culturally sensitive” prenatal care. Although most mothers had

positive prenatal care experiences, mothers also recalled multiple complications with providers’

negative assumptions and disregard for mothers’ options in care.

Conclusions: Exploring strategies to strengthen patient-provider interactions and communication

during prenatal care visits remains critical to address for facilitating continuity of care for

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mothers of color. These findings warrant further investigation of dual patient and provider

perspectives of culturally sensitive prenatal care to address the service needs of African-

American and Mixed-Race mothers.

Introduction

Racial disparities in adverse birth and obstetrical outcomes between African-American and

White mothers are well-documented (Bryant, Worjoloh, Caughey, & Washington, 2010;

Hamilton, Martin, Osterman, Curtin, & Mathews, 2015; US Office of Minority Health, 2012).

African-American mothers are also consistently less likely to receive adequate prenatal care in

comparison to White mothers nationwide (Bryant et al., 2010; US Department of Health and

Human Services, 2013), and they are approximately 2.3 times more likely than non-Hispanic

White mothers to either initiate prenatal care late in the third trimester or not obtain prenatal care

at all (US Office of Minority Health, 2012). Although research is inconclusive about how

prenatal care reduces birth outcome disparities (Walford, Trinh, Wiencrot, & Lu, 2011), previous

studies found associations between inadequate prenatal care utilization and adverse outcomes in

preterm births, low birth weight births, and neonatal mortality (Cox, Zhang, Zotti, & Graham,

2011; Kitsantas & Gaffney, 2010).

Despite the extensive research on prenatal care, fewer studies investigate concepts of prenatal

care quality and perspectives of African-American mothers. Most studies primarily focus on

adequacy of prenatal care use with limited attention to content or quality of care (Alexander &

Kotelchuck, 2001; Sword et al., 2012). Few studies (Handler, Raube, Kelley, & Giachello, 1996;

Lori, Yi, & Martyn, 2011; Mazul, Salm Ward, & Ngui, 2017; Wheatley, Kelley, Peacock, &

Delgado, 2008) focus on perspectives of prenatal care quality from African-American mothers

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and other mothers of color. Studies that focus on mothers of color have not simultaneously

explored providers’ perspectives on prenatal care quality. Only one study (Dahlem, Villarruel, &

Ronis, 2014) that examined interpersonal communication found that quality patient-provider

interactions between African-American mothers and their providers were positively associated

with trust that mothers had toward providers and satisfaction with prenatal care. Given that the

delivery and receipt of prenatal care is a reciprocal process between providers and mothers, more

research is needed to assess differences in priorities for health care quality between these groups

for increasing quality patient-provider interactions.

As disparities in quality of care persist between African Americans and Whites (Agency for

Healthcare Research and Quality [AHRQ], 2015), and African-American mothers report more

adverse experiences with prenatal care than White mothers (Wheatley, Kelley, Peacock, &

Delgado, 2008), it is important to understand and address factors that underlie these differences.

One factor that might contribute to disparities could be differences in perceptions of person-

centered care, defined as care that “ensures that each person and family is engaged as partners in

their care quality” (AHRQ, 2015). Given ongoing advocacy for further examination of patient-

provider-system interactions in prenatal care (Alexander & Kotelchuck, 2001; Mazul, Salm

Ward, & Ngui, 2017) and current attention to decrease disparities in person-centered care,

elements that African-American and other mothers of color identified as aspects of prenatal care

quality should be further explored rather than a simple focus on quantity.

In this qualitative study, we compared perceptions of prenatal care quality between African-

American and Mixed-Race mothers and maternal care providers. Using Donabedian’s (1988)

model of health care quality to inform findings, we examined perceptions regarding aspects of

quality related to prenatal care structure and processes with focused attention to patient-provider

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interactions and perspectives on person-centered care. As a second research aim, we compared

perceptions of prenatal care quality between privately-insured and Medicaid-insured mothers to

identify differences in perceptions between mothers of differing socioeconomic circumstances

(SES) using insurance type as an indicator.

Methods

Study setting and recruitment

This study took place in Southern Wisconsin, a state that ranks high in racial disparities in

adverse birth outcomes between African-American, Mixed-Race, and White mothers (March of

Dimes, 2016; Onheiber & Pearson, 2012, Wisconsin Department of Health and Human Services,

2016). From March 2015 through December 2016, fourteen clinics served as recruitment sites,

including private and academic medical centers and federally qualified health centers offering a

variety of prenatal care services with individual, group, and midwifery care.

Through purposive sampling, we recruited a diverse range of prenatal providers by provider type

and mothers who varied by education, insurance status, and number of children. Based on

previous qualitative research recommendations (Creswell, 2013), we initially sought to recruit

thirty mothers and providers to obtain saturation. Thirty-nine mothers and providers were

recruited through flyers at clinics and community events, emails through clinic and community

list serves, and snowball recruitment in which participants who completed the study recruited

other mothers and providers. We selectively recruited African-American mothers because the

largest racial disparities in birth outcomes exist between African-American and White mothers.

We also included mothers who self-identified as Black or African American and one or more

other races (i.e. Native American or White) given the social complexities that could occur with

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Mixed-Race identities (Harris & Sim, 2002; Rockquemore, Brunsma, & Delgado, 2009; Storrs,

1999). Eligible mothers met the following criteria: childbirth within 6 months of study

recruitment, age 18 years old and over at the time of their infants’ birth, had one or more prenatal

care visits during pregnancy, residency within the county throughout the pregnancy, and delivery

at a hospital within the county. Eligible prenatal providers included active obstetrics and

gynecology (OB/GYN) physicians and residents, family medicine physicians and residents,

nurse-midwives, and nurse practitioners. The University of Wisconsin Madison institutional

review board deemed this study exempt from IRB review under section 45 CFR 46.101(b)(2).

Data collection

The first author conducted all interviews in-person using semi-structured interview guides.

Demographic information was collected from participants through self-report before their

interviews (Table 1). Given the importance that insurance has for women to obtain prenatal care,

we used the insurance variable to categorize women into privately-insured and Medicaid-insured

groups to assess differences in perceptions between mothers.

As in previous research (Salm Ward, Mazul, Ngui, Bridgewater, & Harley, 2013; Sword et al.,

2012), the interview guides included open-ended questions such as “How would you describe

quality prenatal care?”, allowing the interviewer to incorporate an inductive approach and

mothers and providers to express views in their own words. For maximizing relevance of study

findings to clinical and community program needs, open-ended questions stemmed from

previous research (Salm Ward et al., 2013; Sword et al., 2012; Wheatley et al., 2008) and

discussions with physicians and program managers of two African-American community-based

prenatal support organizations in Wisconsin. Topics explored through the questions include

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initiation of prenatal care, barriers and facilitators to getting visits, communication between

mothers and providers, nurses, and ancillary staff, and education on prenatal topics as

recommended by the American College of Obstetrics and Gynecologists (ACOG). Analyses for

interview transcripts occurred in tandem with new interviews, and new questions were developed

to inquire about new concepts that emerged. Data saturation was reached when the last 2

interviews for providers and mothers did not generate new concepts for investigation.

Each interview was conducted in spaces convenient to the participants in clinics, mothers’

homes, or library rooms. All participants gave verbal informed consent before each interview

and received $25 gift cards in appreciation for their time. To protect study participants’

identities, interview guides did not have questions about personal information (ex. Name,

birthdate), and participants were given subject ID numbers for identifiers during data analyses.

Each interview lasted approximately 30-45 minutes, was audio-recorded, and transcribed

verbatim.

Analyses

The five-member analysis team used thematic analysis techniques (Boyatzis, 1998) for

identifying key themes and patterns in the interview transcripts. This type of qualitative analysis

gives the flexibility to incorporate inductive analysis based on participants’ voices and deductive

analysis along with codes stemming from previous studies. A preliminary codebook was

developed using a priori codes from previous research (Sword et al., 2012). Additional codes

were then established using an inductive approach in which the first maternal and provider

interview transcripts was read in full for content, then open-coding techniques were used to

assign conceptual codes to meaningful segments of text. This coding scheme was applied for the

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remaining interviews with additional codes established as new concepts emerged from the

interviews.

To establish coding reliability, the analysis team took the following steps (Boyatzis, 1998). Two

members coded each transcript as one of the most common ways of establishing reliability. Each

analysis team member first independently read transcripts and coded interviews using the

codebook. Inter-rater reliability was checked through calculating percentage agreement of

themes between coders before the coding teams met for consensus. The consensus meetings then

occurred to discuss coding discrepancies and discuss changes to the codebook based on

additional themes that emerged.

Next, we identified and compared recurring themes between and within groups of mothers and

providers using memos, data matrices, and consensus meetings. Differences in mothers’

experiences were explored by their categorization as “privately-insured” or “Medicaid-insured”.

Differences in providers’ experiences were assessed by provider type. NVIVO was used as a

data retrieval tool for coding. An audit trail was maintained of coding decisions and theme

identification and comparison throughout the analysis process.

To enhance relevance of our findings to current prenatal care quality research (Sword et al.,

2012), emergent themes were mapped to broader categories that reflect Donabedian’s (1988)

conceptual model of health care quality. Although conceptual frameworks are not widely used in

qualitative research, they can be used for applied research like this study that focuses on policy-

driven outcomes (Pope, Ziebland, & Mays, 2000). The Donebedian model proposes that three

main constructs constitute health care quality: 1) structure, which refers to the environmental

context where care is provided (i.e. clinic resources, medical organization of care), 2) process,

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which encompasses technical and interpersonal aspects on how providers care for patients, how

patients receive care, and patient-provider interactions, and 3) outcomes, which refers to patient

health status measures related to health care and satisfaction of care received. Illustrative

quotations were extracted from the transcripts for each construct.

Results

Table 1 provides the demographics of providers (n=20) and African-American and Mixed-Race

mothers (n=19) who participated in the study. Table 2 maps the following themes identified from

the interviews with Donebedian’s health care constructs of structure, process, and outcomes.

Most themes related to the process construct, specifically patient-provider interactions.

Construct 1: Structure

Mothers and providers agreed that “quality prenatal care” includes care being accessible

throughout the pregnancy period regarding appointment availability and clinic resources. One

family medicine doctor noted:

I think it needs to be accessible both in terms of having [it] in a physical facility that's going

to be convenient for the patient... in terms of economics, having insurance that's going to

cover everything, and then with available appointments, being able to get in.

Some mothers and providers also valued care that unifies the prenatal care process with

childbirth and postpartum care. One Mixed-Race mother commented on the segmented

organization of maternal care:

9

I feel like [maternal care is] a very fragmented process… it would be so nice if it was like,

I'm going to help you through this process of becoming a parent … it feels very fragmented

and un-unifying when I think what you want is care that unifies you and your baby.

Differences in other structural elements of health care quality emerged between providers and

mothers. Although mothers did not mention benefits to team approaches to prenatal care

delivery, providers viewed access to good clinic teams as important aspects of prenatal care

quality, as these family medicine and OB/GYN doctors note:

I think having a team approach with some nurses who are dedicated to coordinating things,

the physician assistant and the team approach, in some ways, it spreads out the workload, but

it also doesn’t put the burden on one person. And so then I think things don’t get dropped.

I also think having a good clinical staff is important because the physician tends to be very

busy with not only prenatal care but also GYN care…

Structural barriers to prenatal care for mothers included scheduling issues with clinic staff, with

this problem recalled more than transportation issues hindering prenatal care access. More

Medicaid-insured mothers experienced structural issues than privately-insured mothers, as

exemplified by this African-American mother’s experience:

[OB/GYN doctor] always told me that if you miss an appointment, call right away and get in

that week. So one time I did miss an appointment, and I called to reschedule it, and [clinic

staff] told me that it was only an annual check visit, we don't have anything this week, why

don't you just come in your next appointment...

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Construct 2: Process

When describing “quality prenatal care” relative to visit activities, themes emerged relative to

patient-centeredness, communication of testing and options, and cultural competence or

sensitivity.

Patient-Centeredness

Providers and mothers overwhelmingly valued care characteristics that indicate a patient-

centered approach which include: compassionate care that is tailored to the mothers’ needs,

functional relationship built between mothers and providers, effective providers’ responses to

patient questions, prenatal education for mothers to be well informed, and care that encompasses

the “whole woman.” One midwife explained:

We try to treat the entire woman and her family, so we're very much family-centered care, as

well. So we look at all of, many socioeconomic factors when we're looking, when we're

doing, providing the prenatal care.

As an example of compassionate care, one Mixed-Race mother expressed appreciation for her

OB/GYN doctor who tailored her care with empathy concerning her past experiences with

miscarriages:

I think there was a level of understanding there where [OB/GYN doctor] put herself in my

shoes and could maybe empathize with how I was feeling about the pregnancy based on our

previous history and like based on how things started there.

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Cultural Competence (Sensitivity)

Although both groups agreed on an overall picture of patient-centered prenatal care, perspectives

differed on how this care translates into practice, particularly regarding “cultural competence” or

“cultural sensitivity.” Some providers had skeptical views about cultural competence:

I don't have any “cultural competence”… whether we're talking about a different culture like

a different ethnic background or we're talking about a different culture like different

socioeconomics, if you are my patient, I don't know what your background is or what your

challenges are until we talk about it.

Although mothers value providers who treat patients on a case-by-case basis, mothers want

providers to learn of needs specifically affecting mothers of color, as this African-American

mother explains:

Culturally sensitive is being aware of if you have a sickle-cell patient, for example, really

doing your homework on the emotional side of what it means to have sickle cell, the

prevalence of it in the African-American community.

Mothers also felt that lack of providers’ cultural competence could lead to implicit bias and

erroneous assumptions that providers make about mothers. One Mixed-Race mother described

her experience with her perinatal care team:

It’s not even on their wavelength of how, based on implicit bias, or whatever, they may treat

someone differently…It’s not a part of their everyday conversation when it should be, or

their thought process. For them, they know what statistics tell them. You know what I mean?

It’s, we’re numbers and not people.

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The need for culturally competent or culturally sensitive care appeared to have greater value to

mothers, specifically care where providers do not make assumptions or have judgments about

their social or economic circumstances. In comparing Medicaid and privately-insured mothers,

providers’ negative assumptions were noted almost entirely among the privately-insured African-

American and Mixed-Race mothers rather than Medicaid-insured mothers:

A lot of times there was an assumption. Like [providers] just assumed that I was on

BadgerCare [Medicaid]. I'm like, uh no, I'm not actually. You know, I have my own plan…

So I think quality is, don't treat me like the way you treated the other women on

BadgerCare...

Testing and Options

Overall, mothers’ perceptions of prenatal care quality centered on interpersonal processes of

prenatal visits. In contrast, providers concentrated more on activities that constitute “quality

prenatal care” based on American College of Obstetrics and Gynecology (ACOG) standards,

such as completion of required tests and communicating information to the patient. One

OB/GYN doctor commented:

Quality prenatal care from our perspective, from the physician's perspective, is making sure

that each patient has had all the lab testing that they need as part of the pregnancy… So to

provide quality care, every patient has to have that information because if there is something

amiss, we need to figure it out.

Although most mothers acknowledged the need for testing, mothers also expressed the need for

providers to communicate options in care and the ability to provide consent without coercion.

Pressure to consent to optional tests and procedures caused great concern for mothers. This

13

mother experienced pressure to complete an unwanted test, which prompted her to switch

providers:

She just kind of kept pushing [genetic testing]. And I asked her, why do you do that with

women where you try to, you know, get them to do tests, and they opt out of it? And her

response was, you know, so that way if you wanted a choice to terminate that pregnancy,

then you can have that choice… That's why I don't, that's why I stopped seeing her.

Construct 3: Outcomes

Both groups agreed that “quality prenatal care” should result in satisfaction of mothers in the

care experienced. Some providers also noted the importance of providers being satisfied with the

care given, as one OB/GYN doctor notes:

I feel like it's so much better when the patients are happy with the care that they're getting,

but we're also happy with the care that we are providing them.

However, some mothers felt dissatisfied with the overall process of care they received when

continuity of care unexpectedly dissolved for labor and delivery and/or postpartum, as one

mother expressed:

I kind of felt a little bit disconnected towards the end of the pregnancy with [provider]. I

know she was busy too, but she wasn't even at my birth, so I kind of felt like all that time that

we spent… I didn't really have any closure, you know, with the support that I had.

Another aspect of prenatal care quality for mothers affecting the overall satisfaction of care is the

inclusion of postpartum educational topics such as breastfeeding and contraception. Upon further

14

reflection on mothers’ prenatal and postpartum visits, several expressed dissatisfaction when

their inquiries on postpartum topics were not adequately addressed:

[Provider] did talk about birth control like towards the end, and, (pause) you know, just gave

me some options. But it was kind of, I don't know, that part was kind of like, how you say it,

it wasn't as in depth of a conversation... I didn't feel as sure when I left that appointment as to

what I wanted to do.

Discussion

These findings support the notion that African-American and Mixed-Race mothers and prenatal

care providers have some shared understanding of what constitutes prenatal care quality.

However, important differences include contrasting viewpoints on the importance of cultural

sensitivity and communication of standards of prenatal care while respecting mothers’ value on

having options. The AHRQ US National Healthcare Disparities Report annually documents

racial and ethnic disparities in health care along four concepts: person-centered care, safety,

effectiveness, and timeliness, and our study contributes to the literature by highlighting potential

disparities in patient centeredness.

We also found that privately-insured and publicly-insured mothers of color differed in structural

and process elements of care in which they emphasize negative experiences. As previous

research indicated (Wheatley et al., 2008), Medicaid-insured mothers in this study reported

structural issues with prenatal care access as exemplified by complications of scheduling

appointments with clinic staff. In contrast to previous findings (Attanasio & Kozhimannil, 2015),

privately-insured mothers in our study perceived more problems with negative assumptions and

disrespect during prenatal interactions. These problems for privately-insured mothers relate to

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the process aspects of prenatal care quality rather than structural elements. The possibility exists

that higher SES mothers have different expectations of care and may view certain provider

interactions differently than lower SES mothers (Attanasio & Kozhimannil, 2015). Future

research can investigate to what extent perspectives within African-American mothers differ

based on SES characteristics; these differences may influence their perspectives of care and may

need direct intervention to enhance perceived quality.

Findings from this study indicate unique differences in perceptions of quality between mothers

and providers, particularly perspectives on cultural sensitivity which might be a relevant aspect

of patient centeredness and overall quality for African-American and Mixed-Race mothers.

Thus, concepts related to cultural sensitivity could be further explored for assessing prenatal care

quality among mothers of color and providers. Racial discordance between mothers and

providers might have also influenced perceptions of quality. Eighteen out of twenty providers in

our study were White. This percentage of White providers is representative of the lack of

diversity in prenatal care providers in the US. Patient-provider communication, trust, and

satisfaction is lower in race-discordant patient-provider relationships (Cooper et al., 2003;

Johnson, Roter, Powe, & Cooper, 2004), and racial discordance may have influenced mothers’

perceptions of their care in this study. The emerging relationships between patient-provider

racial concordance, health care satisfaction, and adherence to recommended care warrant further

attention in research (Dovidio et al, 2008; Earnshaw et al, 2016), and understanding these

relationships is especially relevant in communities where racial discordance between patients

and providers is common.

Our study had some limitations. Because recruitment was targeted to one Midwestern county,

mothers and providers in this study might not represent those in other healthcare settings.

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Notably, all mothers had either Medicaid or private insurance. Uninsured patients generally

report worse experiences in care (Fiscella & Sanders, 2016), including more barriers in

communication problems (Attanasio & Kozhimannil, 2015). In addition, we recognize that using

insurance status as an indicator for SES may not fully account for differences based on other

socioeconomic factors. Because our provider sample included few midwives or nurse

practitioners and most mothers received care from OB/GYN doctors, our findings primarily

address OB/GYN care. Future studies could dually explore patient and provider perspectives

within family medicine and midwifery care. Finally, data collection was limited to one postnatal

interview per mother, and recall bias could have influenced their recollection of prenatal events.

Future studies can incorporate multiple interviews during prenatal and postpartum periods to

capture thoughts about care during pregnancy and compare to overall experiences.

Implications for Practice and/or Policy

For addressing healthcare disparities, improving mothers’ satisfaction with prenatal care, and

encouraging early initiation and continuity of care for mothers, providers should continue to

focus on ways to enhance patient-provider communication in delivering tailored and culturally

sensitive care. Our findings suggest that many barriers related to prenatal care could be

addressed by strategies to enhance patient-provider communication between providers and

mothers of color. Specifically, these results indicate that prenatal care should encompass more

strategies to enhance provider understanding of patients’ social and cultural context.

Several strategies for assessing patient context and incorporating cultural sensitivity might

facilitate communication between providers and mothers of color, given time limitations for

visits. ACOG (2014) recommendations include patient-centered interviewing, cultural sensitivity

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training for providers, and strategies to improve shared decision making between mothers and

providers. Improvements to enhance assessments of patients’ social and contextual

circumstances at the initial prenatal visit could facilitate patient-provider communication

throughout pregnancy. Initiatives to increase racial diversity among prenatal providers would

enhance cultural sensitivity toward mothers of color. Also, doula support (Kozhimannil,

Vogelsang, Hardeman, & Prasad, 2016) and alternative prenatal care models such as

CenteringPregnancy© (Ickovics et al., 2011; Lathrop, 2013) can be further explored for

enhancing culturally sensitive prenatal education and support and increasing adequacy of visits

for mothers of color.

Conclusion

Given the continued racial disparities in adverse birth outcomes, developing a shared

understanding of “quality prenatal care” remains important for mothers of color and providers to

collaborate for optimal maternal health and birth outcomes and continuing care postpartum.

Further exploration of attitudes that affect patient-provider interactions is therefore warranted to

improve provider understanding of interpersonal communication, provider training, and patient

education (Thornton, Powe, Roter, & Cooper, 2011). Understanding gaps between patient and

provider perceptions and experiences with prenatal care is critical for the continual improvement

of clinical services and culturally sensitive approaches to prenatal care delivery for mothers of

color.

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Table 1. Demographic Characteristics of Providers and Mothers

Providers

(N=20)

Mothers

(N=19)

Provider Type a

OB/GYN Doctor 8 17

Family Medicine Doctor 8 2

Midwives 2 1

Nurse Practitioner 2 3

Race

Black / African American 1 15

Mixed-Race b 1 4

White 18 0

Gender

Female 14 19

Male 6 n/a

Years of Experience

4 Years or More 15 n/a

Less than 4 Years 5 n/a

Age

18-24 n/a 2

25-34 n/a 13

35 or More n/a 4

Parity

1 or more Older Children n/a 10

None / First-Time Mother n/a 9

Education

High School Graduate n/a 4

Some College n/a 4

Bachelor Degree or More n/a 11

Insurance Status

Private Insurance n/a 10

Medicaid (BadgerCare) n/a 9

a Note for total exceeding 100% for provider type for mothers: Some mothers had more than 1

type of provider during recent pregnancy which is reflected in the numbers and percentages.

b Mixed Race refers to participants that self-identify as two or more races / ethnicities. Only one

provider self-identified as White and an Asian ethnicity. Mixed-Race mothers self-identified as

Black or African American and White and/or Native-American.

Table 2. Donebedian (1988) Concepts and Themes from Interviews

Concepts Providers Mothers

Structure: Clinic resources and

medical organization of care

Accessibility of appointments

and clinic resources

Availability of appointments

Team approach with providers

and staff

Connection of care prenatally

through postpartum

Process: Provider and patient

activities during visits

Patient-centered care tailored

to the individual

Compassionate care

Cultural competency /

sensitivity

Testing by medical standards Choosing options without

pressure

Outcomes: Patient satisfaction

of care and health outcomes

Mothers’ satisfaction of care Satisfaction with continuity

Satisfaction of communication

with postpartum topics