Review research and develop research questions

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

Review

CEUThe Impact of Racism and Midwifery’s Lack of Racial

Diversity: A Literature Review Jyesha Wren Serbin, CNM, WHNP-BC, MS, Elizabeth Donnelly, CNM, WHNP-BC, MS

Introduction: The United States is increasingly racially diverse. Racial disparities in maternal-child health persist. Despite national calls for work-

force diversification, more than 90% of certified nurse-midwives are white. This systematic review examines how racism and midwifery’s lack of

racial diversity impact both midwives and their patients.

Methods:Databases were searched in January 2016 for studies that explored 1) racially concordant or racially discordant maternity care provided,

at least in part, by midwives; 2) women of color’s experience of race and discrimination in maternity care provided, at least in part, by midwives;

and 3)midwives of color’s experience of race and discrimination in clinical, educational, and/or professional settings. Studies were excluded if they

were conducted outside the United States, focused on recent immigrant populations, or didn’t have an English-language abstract. Selected studies

were each reviewed by 2 independent reviewers, and data from the studies were entered into literature tables and synthesized for discussion.

Results: A total of 7 studies was retained for review—3 on the experience of patients and 4 on the experience of providers. The studies show

racism is common in midwifery education, professional organizations, and clinical practices. Racism and midwifery’s lack of racial diversity act

as a barrier to people of color completing midwifery education programs and fully participating in midwifery professional organizations. Both

patients and midwives of color identified midwives of color as uniquely positioned to provide high-quality care for communities of color.

Discussion: The midwifery profession and its patients stand to substantially benefit from diversification of the field, which requires addressing

racism within the profession. Structural competency is a new theory that offers an effective framework to guide these efforts.

J Midwifery Womens Health 2016;61:694–706 c© 2016 by the American College of Nurse-Midwives.

Keywords: health status disparities, midwifery, professional organizations, racial disparities, racial diversity, racially concordant care, racism,

structural competency

INTRODUCTION

Maternal and infant health in the United States is in a state of crisis, with morbidity andmortality rates far worse than other developed nations, despite more money spent on maternal- child health.1 In the face of the high-tech, high-intervention, and high-cost obstetric model of care, maternal mortality is increasing.2 Mainstreaming midwifery care has the potential to greatly reducematernal and infantmorbidity andmortality in the United States.3

In addition, racial and ethnic disparities in obstetric and early childhood outcomes are ubiquitous. Compared to chil- dren born to white women, children born to black women are more than 2 times as likely to die before their first birthday.4

Similarly, children born to American Indian/Alaskan Native mothers are 1.5 times more likely to die before celebrating their first year of life.5 Maternal mortality rates are equally if not more troubling: American Indian/Alaskan Native are more than 1.5 times more likely to die from childbirth than white women, andAfricanAmericanwomen are 4 timesmore likely to die than other racial groups.2,5 The disparities have not abated over the years and are even worsening in some states.1,6

The United States faces 2 major challenges in maternal- child health: reducing unnecessary interventions and elimi- nating racial disparities in birth outcomes. Midwifery is suc-

Address correspondence to Jyesha Wren Serbin, CNM, WHNP-BC, MS, Email: [email protected] and Elizabeth Donnelly, CNM, WHNP- BC, MS, Email: [email protected]

cessfully addressing the first problem in the communities it serves.3 It is unclear, however, if the profession is well posi- tioned to bring the reduction in unnecessary interventions to a wider population and to successfully address racial dispari- ties.

A growing body of evidence frommedical research shows that greater racial diversity in the health care workforce will improve access to care and the quality of care for people of color, and is an important intervention to reduce racial dis- parities in health.7 There is limited research, however, into the role of racism and lack of racial diversity in midwifery. This review was undertaken to present the state of the research on the impact of racism and lack of racial diversity on both mid- wifery patients and providers of color.

BACKGROUND

Race and Racism Framework

It is well understood that race is a social construction, not grounded in biologic or genetic differences.8–12 Due to racism, however, the social construct of race does significantly im- pact people’s physiologic health and lived experiences.13,14 In her framework for understanding racism, Camara Jones de- scribes 3 levels: institutionalized, personally mediated, and internalized.15 This article will focus on the first 2 levels. In- stitutionalized racism is defined as “differential access to the goods, services, and opportunities of society.”15(p1212) It is in- extricably woven through institutions, bureaucracies, and so- cial structures such that no individual can be identified as

694 1526-9523/09/$36.00 doi:10.1111/jmwh.12572 c© 2016 by the American College of Nurse-Midwives

✦ Despite a national call for health care workforce diversification, more than 90% of nurse-midwives are white.

✦ Midwives of color are uniquely positioned to provide high-quality care to communities of color.

✦ Interpersonal and institutional racism are significant problems in clinical, educational, and professional settings, and act

as barriers to further diversifying the profession.

✦ Cultural competency is an insufficient framework for approaching health disparities; the emerging theory of structural competency is better suited to guide midwives in understanding and addressing the ways that economics, politics, and racism promote the health and wellness of some, while degrading the health of others.

✦ Midwives should work to create a midwifery profession whose racial demographics mirror that of the populations being served.

responsible. Personally mediated racism is defined as prej- udice, meaning “differential assumptions about the abilities, motives, and intentions of others according to their race,” and discrimination, meaning “differential actions toward others according to their race.”15(p1212) It can be both intentional and unconscious.

The terminology used to describe race in theUnited States evolved from census definitions that were originally devel- oped to promote and maintain the power of the white ruling class.16,17 The terms have changed over time and in response to a wide range of cultural forces.16,17 Recognizing that race is a social construct, this review reflects the language used by study authors when describing race. The reader will there- fore encounter the terms African American and black, which are used to identify similar and overlapping groups of people. This choice wasmade out of respect for the self-identity of the participants and in an attempt to offer the richest level of data and information to the reader.

Midwifery and Racial Diversity

Over the past 2 decades, the membership of the Ameri- can College of Nurse-Midwives (ACNM) has remained more than 90% white.18,19 Only 7% of ACNM members and 5.8% of certified nurse-midwives/certifiedmidwives (CNMs/CMs) recertifying through the American Midwifery Certification Board (AMCB) can be identified as people of color.19 Reflect- ing a more recent trend toward greater racial diversity in the profession, 14.5% of CNMs/CMs certifying with AMCB for the first time can be identified as people of color.19 However, even with the recent influx of more midwives of color, white

people remain dramatically overrepresented in the population of CNMs/CMs.

Meanwhile, the population of the United States is becom- ing increasingly diverse. According to the US Census, non- Hispanic white people made up only 62.2% of the total pop- ulation in 2014, and people of color are predicted to be the majority of the population by 2044.20 Additionally, the pop- ulation served by midwives is more racially diverse than the US population as a whole.21 The racial makeup of midwifery providers does not reflect the diversity of the communities midwives serve.

Based on an extensive literature review conducted in 2006, the US Department of Health and Human Services (Health

Resources and Services Administration [HRSA]) reported that health professionals from underrepresented groups dis- proportionately care for underserved populations and that minority patients tend to receive better interpersonal care in race-concordant interactions (patient and practitioner are of the same race).7 These findings are replicated in themidwifery profession. While the profession as a whole has a long his- tory of service to underserved populations including com- munities of color, midwives of color are more likely to care for people of color than their white counterparts.22 Based on the review, HRSA concluded that greater racial diversity in the health care workforce will improve access to care and the quality of patient-provider interactions for people of color and is an important intervention to reduce racial disparities in health.7

Structural Competency: A New Theory for Engaging

With Racial Disparities and Health Care Workforce

Diversification

For decades, the theory of cultural competency has been the dominant approach to training health care professionals to care for diverse populations. Proponents of cultural compe- tency suggest that provider familiarity with the values, cus- toms, and belief models of various racial/ethnic groups can mitigate health disparities. In practice, however, cultural com- petencymethods often present patients as static embodiments of the dominant culture’s perceptions of their race/ethnicity, perpetuating stereotypes and creating the false sense that clinicians can achieve mastery or a complete knowing of other cultures.23,24 Another significant shortcoming of cul- tural competency is its one-way view focused exclusively on the culture of the patient, family, or community while largely ignoring the culture of the clinicians, care sites, andhealth care institutions.25

In Structural Competency: Theorizing a New Medical EngagementWith Stigmaand Inequality,Metzl andHansen recognize that while trying to understand the culture of oth- ers has importance, limiting the conceptual paradigm to cul- ture alone blinds us to deeper structural forces that confine a person’s agency and produce health disparities.26 The authors propose structural competency as an alternative approach. This model, consisting of 5 core competencies, is defined as the trained ability to understand how symptoms, attitudes, or

Journal of Midwifery &Women’s Health � www.jmwh.org 695

Table 1. Five Skill Sets of Structural Competency

Skill Description

Recognize the structures

that shape clinical

interactions

Consider how economic, social,

and political forces impact the

patient’s presentation and health

history and the interaction

between the patient and

clinician.

Develop an extraclinical

language of structure

Utilize an interdisciplinary

approach to study and

understand how social

structures impact the health of

communities. Relevant

disciplines include critical race

theory, medical anthropology,

sociology, economics, political

science, and urban planning.

Rearticulate cultural

presentations in

structural terms

Develop the capacity to recognize

and describe a clinical

presentation in structural terms,

especially when faced with a

presentation that would typically

be framed as cultural.

Imagine structural

intervention

Conceive of structural

interventions to address

structural barriers to optimal

health.

Develop structural

humility

Recognize that one can never fully

understand how economic,

social, and political forces

impact another’s life and thus

approach all efforts to address

structural inequality with an

open mind and humility.

Source: Metzl and Hansen.26

diseases represent downstream implications of a wide variety of upstream structural systems (Table 1). The structural com-

petency theory asks health care providers to consider how so- cial constructs such as race, class, and gender create stigma and inequality. This allows clinicians to better understand and address theways that economics, politics, and racismpromote the health and wellness of some while degrading the health of others.

Given the lack of racial diversity among midwifery providers, the marked racial diversity of midwifery patients, and HRSA’s findings that a racially diverse workforce is best equipped to serve a racially diverse patient population, this re- view was conducted to identify how racism and midwifery’s lack of racial diversity impacts both midwives and their patients.

METHODS

A literature search was conducted in January 2016 via PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus. Search terms included “nurse-midwives,” “obstetric,” “labor and delivery,” “health care workforce diversification,” “racism,” “health dispari- ties,” “culturally appropriate,” and “cultural diversity.” See Ap- pendix 1 for exact query. A search using the same terms was performed for gray literature. Inclusion was not lim- ited by date of publication. In cases where a thesis pre- ceded a published document, the published document was included.

To be included in the review, studies had to explore one of the following phenomena: 1) racially concordant or racially discordant maternity care provided, at least in part, by mid- wives; 2) women of color’s experience of race inmaternity care provided, at least in part, by midwives; 3) midwives of color’s experience of race in clinical, educational, and/or professional settings. Studies were excluded if they were conducted out- side of the United States, didn’t have an English-language ab- stract, or focused on recent immigrant populations. Explor- ing the impact of racism and lack of racial diversity on recent immigrant populations is complicated by confounding fac- tors such as language barriers, disparate prior access to health care, and documentation status, and is out of the scope of this paper.

All studies were screened by 2 independent review- ers based on title and abstract using Covidence, a sys- tematic review software tool. Many of the full-text re- view studies met multiple exclusion criterion. In these cases one exclusion criterion was assigned based on a hierarchy (Appendix 2).

Selected studies were each reviewed by 2 independent reviewers, and data from the studies were entered into lit- erature tables based on the consolidated criteria for re- porting qualitative research (COREQ) 32-item checklist.27

The tables included aims, theory, data collection and sam- ple selection, participation and setting, analysis, results, re- searcher identity with a focus on racial identity, and key quotes. Results and key quotes extracted by reviewers fo- cused on the themes of racism and lack of racial diver- sity in the midwifery profession. After independent review, the reviewers discussed their findings and consolidated their results.

RESULTS

The original query yielded 9994 studies; 2 additional studies were identified in the gray literature search. Af- ter duplicate citations were excluded, 6223 studies were screened, with 64 proceeding to full-text review. See Figure 1 for a flow diagram of the literature extraction process.

A total of 7 studies met criteria for inclusion in this re- view. Threewere focused on the experience of patients of color (Table 2), and 4 were focused on the experience of midwives of color (Table 3). All 7 were qualitative studies. The follow- ing sections describe the characteristics and findings from the studies grouped by patient or provider.

696 Volume 61, No. 6, November/December 2016

Figure 1. Flow Diagram of Literature Reviewed

Patient Experiences

Study Characteristics

Salam Ward et al (N = 31) and Sawyer (N = 17) both used a combination of focus groups and individual interviews, while Hanson (N = 58) relied solely on individual interviews.28–30

Salam Ward et al and Sawyer investigated the experience of African American women, while Hanson looked at the ex- periences of women from one American Indian tribe in the Northern Plains. Salam Ward et al specifically focused on low-income women, while the sample investigated by Sawyer was predominantly middle class. Hanson’s study did not re- port the income level of the participants; however, the other sociodemographic information suggests an economically di- verse group of American Indian women.

Sawyer’s study was broad in scope and aimed to generally explore the experiences of pregnancy and motherhood for African American women. Hanson had a more narrow focus seeking to specifically understand both barriers to adequate prenatal care and solutions to these barriers. Meanwhile, Salam Ward et al’s study was specifically designed to investi- gate “the experiences of racial discrimination during prenatal care.”28(p1753)

None of the studies focused exclusively on care delivered by midwives. Only one participant in the Sawyer study re- ceived care from a midwife, and the number of participants who received care from midwives in the Salam Ward et al study is unknown. However, almost all of the participants in the Hanson study received care from a nurse-midwife for at

least one of their prior pregnancies. A limitation of all 3 stud- ies is that none of them explicitly investigated the race of the providers.

Study Findings

Both SalamWard et al and Sawyer’s studies explicitly name the experience of racism and discrimination experienced by their study participants, and Sawyer further describes specific cop- ing strategies employed by the women she interviewed. Salam Ward et al found themes of differential treatment and discrim- ination based on race in all focus groups, with participants describing both interpersonal racism and institutional racism in prenatal care. From the data, Salam Ward et al conclude that “African American womenwith limited incomes perceive many provider practices and personal interactions during pre- natal care as discriminatory.”28(p1753) In Sawyer’s study, she de- scribes the context in which the African American women in her study experience pregnancy and the process of becoming a mother as including “having to deal with negativity, stereo- typing, and assumptions about pregnant African American women, and fac[ing] discrimination on a daily basis.”29(p16)

The key quotes provided as examples all describe experiences of discrimination or bias in pregnancy-related health care set- tings. Sawyer goes on to explicitly state, “Health care providers were judged [by study participants] as racist based on their body language, how they acted, and their tone of voice, as well as by what they said.”29(p17) Women in her focus groups described “comfort with [as] a major criteria used in the

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Table 2. Three Qualitative Studies of Patients

Author/Year Aims

Data Collection, Sample

Selection N, Participants, Care Setting Results Researcher Identity

Hanson, 201230 To understand barriers to

adequate prenatal care

among American Indian

women from one tribe

in the Northern Plains

and to investigate

potential solutions.

Individual interviews.

Convenience sample from

which a stratified sample

was chosen from each

district on the reservation

based on the percentage of

total housing units in each

district.

Inclusion criteria: American

Indian women from the

tribe of focus, previous

pregnancy, previous

prenatal care at an Indian

Health Service facility or

clinic.

Exclusion criterion:

Currently pregnant.

58

Aged 18 to 77 years with average of

3.72 previous pregnancies. Less than

half were employed. Half (49.1%)

had some college-level education,

31.6% had a high school diploma,

and the rest had not completed high

school. Half were living with their

partner (50.9%), and half were single

and never married, divorced, or

widowed.

Nearly all respondents saw a

nurse-midwife for � one of their

pregnancies. Race of providers not

described.

Communication barriers included “an

overall lack of trust of physicians,

especially white physicians and

‘modern ways of medicine.’”

Solutions to barriers included an

emphasis on culturally appropriate

education, intervention, and

prevention, including overcoming

communication barriers with

providers.

Race of researcher

unknown, interviews were

conducted by an enrolled

member of the tribe who

had worked previously in

a health care organization,

so rapport and trust were

established.

Sawyer, 199929 To elicit the experiences of

pregnancy and

motherhood for African

American women.

Focus group and individual

semistructured

interviews.

Theoretical sampling was

used to solicit diversity in

age, geographic origins,

education, income, and

health status.

No inclusion or exclusion

criteria stated.

17

First-time African American mothers

in the immediate postpartum period,

aged 23 to 40 years, most were

middle-class, well-educated, and

married or partnered.

Large managed care organization in

California, provider type varied (ie,

physicians, nurse practitioners,

midwives, physical therapists,

counselors, doulas), race of providers

unknown.

Health care providers were judged as

racist based on their body language,

how they acted, and their tone of

voice, as well as by what they said.

“Comfort with” was a major criterion

used in the selection of a provider to

decrease the chance of experiencing

racist attitudes and treatment during

care.

A few stated that they made a

conscious decision to not interpret

an incident as racism.

White Irish American

woman

(Continued)

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Table 2. Three Qualitative Studies of Patients

Author/Year Aims

Data Collection, Sample

Selection N, Participants, Care Setting Results Researcher Identity

SalamWard et

al, 201328 To examine experiences of

racial discrimination

during prenatal care

from the perspectives of

African American

women in a low-income

neighborhood who are

at highest risk for poor

birth outcomes.

Focus groups and

individual interviews.

Convenience sample.

Inclusion criteria:

Self-identified as African

American, aged 18 years

or older, have a child one

year of age or younger,

experienced at least one

prenatal care visit in

Milwaukee, Wisconsin.

31

Black/African American (n = 29) and

Hispanic (n = 2) women, most

receiving medical assistance (n = 27,

type of assistance was not specified).

Care at various sites and from various

types of providers (ie, obstetricians,

midwives, and family physicians),

race of providers unknown.

African American women from

low-income backgrounds reported

perceived discrimination relating to

type of insurance and race in the

receipt of prenatal care, and

experiencing racial discrimination

over the course of their lives.

Institutional racism was highlighted

more than interpersonal racism.

Race of researcher

unknown; groups were

facilitated by an African

American woman (in 2

cases a white moderator

substituted) with a

note-taker (identity not

described) present in the

back of the room.

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Table 3. Four Qualitative Studies of Providers

Author/Year Aims

Data Collection,

Sample Selection N, Participants, Care Setting Results

Researcher

Identity

Goode, 201431 To investigate the

experiences, thoughts, and

feelings of contemporary

black midwives in the

United States.

One-on-one, in-depth

semistructured

interviews.

Snowball sampling

method.

Inclusion criterion:

Black midwives

practicing in the

United States.

22

CNMs (n = 12) and CPMs (n =

10) aged 30 to 80 years, 5 to 45

years of professional experience,

practicing in urban environments

in various states.

Participants attributed poor birth outcomes in

black women to the social operation of

racism.

The relatively low number of black midwives

was attributed to a smear campaign by the

medical establishment and racism and

discrimination on the part of white

midwives.

Black women’s underutilization of midwives

was attributed to social disenfranchisement

and legacies of slavery, segregation, and

forced subservience as domestic help.

Participants experienced professional

organizations as racist environments

unsupportive to communities of color.

Black

Kennedy et al,

200634 To identify what midwives

of color and male

midwives perceive to be

essential to exemplary

midwifery care and

determine if diverse

midwives believe that

their ethnicity or gender

influences their practice

or concepts of exemplary

care.

Individual and group

semistructured

interviews.

Purposive sampling.

No inclusion or

exclusion criteria

stated.

15

CNMs who self-identified as

black/African American women

(4), Asian/Pacific Islander

women (4), Latina women (3),

and white men (4).

Participants believe that their race did impact

their conceptualization of exemplary care

and added to what they were able to offer

their patients.

Many participants reported that racism

toward them and people of color around

them was common with their colleagues

and students and in their workplaces.

Many described experiencing “otherness,”

oppression, and invisibility, and reported

that this treatment resulted in significant

negative consequences.

3 white women

(Continued)

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Table 3. Four Qualitative Studies of Providers

Author/Year Aims

Data Collection,

Sample Selection N, Participants, Care Setting Results

Researcher

Identity

McLaughlin,

201232 To document the

experiences of black

midwives with

direct-entry midwifery

education; explore the

social, cultural, and

structural barriers facing

black women in pursuit of

midwifery training; and

develop a summary of

themes and issues to guide

midwifery educators on

improving their

recruitment, retention,

and graduation of black

students.

Semistructured

interviews.

Snowball and purposive

sampling.

Inclusion criteria: Aged

18 to 65 years,

self-identified as black

or African American,

currently practicing or

recently retired

direct-entry midwife,

currently practicing or

recently retired

direct-entry midwifery

educator or preceptor

to black direct-entry

midwifery students.

9

Aged 30 to 60 years with 5 to 30

years of experience.

Racism significantly impacts black women in

the midwifery profession.

Participants experienced isolation and

discrimination in their education programs

and connected this to attrition rates.

Disenfranchisement of black communities

motivated “many if not all” participants to

become midwives, and 8 of 9 subjects

expressed a commitment to serving the

African American community.

Most (n = 7) focused their work on

decreasing African American maternal and

infant morbidity and mortality.

Participants who were educators instilled this

focus in their students and worked to make

apprenticeships accessible to students of

color.

Japanese

American

Abbyad, 201133 To explore perceptions by

African American health

care providers of ways in

which African American

women prepare for

childbirth and ask

providers about their

personal and professional

experiences with

childbirth.

Semistructured

interviews and focus

groups.

No inclusion or

exclusion criteria

stated.

12

African American (n = 11) and

white (n = 1, inadvertently

invited to participate, only made

one short comment during focus

group); health care providers

practicing in the United States:

6—registered nurses, 4; licensed

vocational nurses, 1; CNM, 1

certified assistant (type of

assistant not specified).

Themes included:

“Traversing an unresponsive system,” in

which African American women are

stereotyped and treated dismissively or

disrespectfully.

“Childbirth classes not a priority,” with

providers reporting that patients express

feeling unwelcome by white participants.

Voiced concerns about differential treatment

of pregnant African American women and

described attempts to positively affect

women they cared for.

Caucasian

researcher took

notes during

focus groups

facilitated by

African

American

moderator.

Abbreviations: CNM, certified nurse-midwife; CPM, certified professional midwife.

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selection of a provider.”29(p17) “Comfort with” described an assessment by patients that they were less likely to experience racism with a given provider.

Hanson, on the other hand, did not explicitly name racism or discrimination in pregnancy-related care. However, she de- scribes a pattern of communication barriers that clearly in- clude dissatisfaction with race-discordant care. She describes the “feeling [among study participants] that the physician did not care about the patient or his or her reasons for seeking care, and an overall lack of trust of physicians, especially white physicians and ‘modern ways of medicine.’”30(p32) Further, Hanson issues a clear call for racially and culturally concor- dant care. She states, “participants . . . proposed an emphasis on culturally appropriate education, intervention, andpreven- tion, [and] suggested classes with a traditional elder woman on pregnancy and health care.”30(p33)

It is unclear if Hanson’s use of the word physician in the above quote is intentionally used to exclude nurse-midwives. Elsewhere in the study, she explicitly contrasts the care re- ceived from nurse-midwives and physicians stating that the respondents had a preference for nurse-midwifery care due to continuity of care, longer visits with more teaching, and more frequent gender concordance. She never describes, however, a mechanism by which nurse-midwifery care is different from the specifically racial critique of “white physicians and ‘mod- ern ways of medicine.’”30(p32)

Finally, an interesting set of findings from both Salam Ward et al and Sawyer relates to the reluctance by partici- pants in both studies to name racism. Salam Ward et al de- vote a full section of their discussion to the topic stating that some “participants [were reluctant] to discuss race with- out a probing question and validation from the rest of the group.”28(p1757) Sawyer describes a similar behavior when she states that her participants both ignored incidences of racism and “made [the] conscious decision to not interpret an inci- dent as racism.”29(p17)

Provider Experiences

Study Characteristics

Goode (N = 22), McLaughlin (N = 9), and Abbyad (N = 12) all focused exclusively on the experience of black providers, while Kennedy et al’s (N = 15) sample included black women, Asian/Pacific Islander women, Latina women, and white men.31–34 All providers in Kennedy’s study were CNMs, Goode’s sample included CNMs and certified profes- sional midwives (CPMs), while participants in McLaughlin’s study were all direct-entry midwives. Abbyad’s sample con- sisted of a range of providers including registered nurses, li- censed vocational nurses, one certified assistant (type of as- sistant not specified), and one nurse-midwife.

Goode and McLaughlin both used individual, semistruc- tured interviews, Abbyad used a semistructured focus group, and Kennedy et al used a combination of in- dividual and group interviews. Kennedy et al’s study was informed by the health care theories of cultural competence and cultural humility while Goode and McLaughlin’s work was informed by other disciplines: black feminist standpoint epistemology and intersection-

ality theory, and phenomenology and critical race theory, respectively.

Goode’s aim was the broadest, exploring the perspectives and experiences of blackmidwives in relation to racial dispar- ities in maternal-child health, midwifery professional organi- zations, demographics of the profession, and more. Abbyad examined the experience of black providers as both providers and recipients of care. McLaughlin focused on understand- ing the experience of black women in midwifery education, including cultural and structural barriers and potential solu- tions to these barriers. The focus of Kennedy et al was the narrowest, investigating whether midwives of color and male midwives believe that their race/ethnicity or gender influ- ences their clinical practice or their concepts of exemplary midwifery care.

Study Findings

Two of the 4 studies on providers included findings on racism in the clinical setting. Kennedy et al’s study reported that racism in clinical settings was common and directed both at the providers who were the participants in the study and other people of color. Abbyad’s study participants reported personal experiences of being stereotyped, dismissed, and de- valued during the maternity care they received and hearing similar stories from the black women they serve.

Three studies, Kennedy et al, McLaughlin, and Goode, explored midwives of color’s experiences in midwifery education; all found racism to be a considerable challenge. Participants in Kennedy et al’s study cited racism and dis- crimination in midwifery education as a significant barrier to people of color applying to and graduating from mid- wifery education programs. McLaughlin noted a number of key themes regarding challenges faced by black student midwives including organizational racism, overt racism from midwifery peers, lack of willing preceptors, and aloneness. Goode’s participants describe a lack of respect and care during their midwifery education. Further, the participants describe a lack of racial diversity among faculty, preceptors, and classmates, which both negatively impacts the content being taught and places undue burden on midwifery students of color, making it harder for them to succeed.

Two studies, Goode and McLaughlin, described experi- ences of racism within professional midwifery organizations. In McLaughlin’s work, participants state that because profes- sional midwifery organizations in the United States are largely run by white women, they lack an understanding of the con- text that many women of color live and work in, leading to the creation of policies that privilege white people over people of color. Goode found that blackmidwives perceive both ACNM and the Midwifery Association of North America (MANA) to be significantly racist organizations. Study participants de- scribed interpersonal and institutional racism, lack of organi- zational support for issues of importance to people of color, and a lack of commitment to racially diversifying the pro- fession. For example, participants reported that while profes- sional midwifery organizations were using the word diversity more frequently, the language was not coupled with action supportive of communities of color. Participants described the way organizations are engaging with the issue of diversity as

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“performance art for white people,”31(p123) in which a simplis- tic narrative of celebrating diversity and being tolerant results in the fetishization of people of color through the consump- tion of ethnic food, clothing, and artifacts. Participants in both studies indicated that racism limited participation and mem- bership by midwives of color in professional organizations.

Participants in all 4 studies shared a commitment to serv- ing patients of color. In McLaughlin and Kennedy et al, par- ticipants expressed a passion for eliminating racial disparities in birth outcomes. Participants in Abbyad’s study expressed great concern about differential treatment of African Ameri- can women who are pregnant. They described feeling called to “take on the mothering role” to patients who lack social support and are “falling through the cracks.”33(p51) Echoing this theme, a participant in Goode’s study says, “When I am working with a black woman, I love on her hard.”31(p157) She then describes some of the ways that she goes the extra mile to nurture and care for her black patients, including things like asking about her children, rubbing her back, and offering food. McLaughlin’s participants reported focusing directly on decreasing African American maternal and infant morbidity andmortality and expressed prioritizing service to theAfrican American community through strategies such as targeted out- reach and accessible fee structures.

Participants in all 4 studies recognized that their racial identity as a person of color strengthened their ability to serve patients of color. As midwives in the Kennedy et al study ex- plained, they possess survival strategies for copingwith racism and discrimination, which give them awareness and strength that they are able to share with their patients and students. As one participant stated, “I’ve become more sensitive, perhaps because of the kinds of racist experiences I’ve had . . . I am less quick to judge, hopefully.”34(p88) Further, the participants in McLaughlin and Goode recognize workforce diversification as central to the goal of building the capacity of midwifery to reduce racial disparities.

Researcher Reflexivity

Researcher reflexivity is an important element in qualitative research that involves considering the relationship and power dynamics between the researcher and study participants, and describing how complications and bias are addressed.27,35 A key component to researcher reflexivity in qualitative stud- ies on race is recognizing that racial concordance between re- searchers and participants can increase access to participants and certain kinds of information, as well as enhance the depth of information provided.36,37

Goode, a black woman, describes how her racial identity shaped her interests, guided her research questions, and fa- cilitated access to her population of study. Of note, 3 study participants asked if Goode was black before agreeing to be interviewed. During the research process, she reports being “treated like a daughter, sister or friend” with participants of- ten using terms such as “‘we,’ ‘us,’ and ‘you know,’” reflec- tive of their sense of shared identity and understanding.31(p 44)

McLaughlin, a Japanese American woman, notes that her identity allowed her to access forums for midwives of color and openly sharing her experiences with racism in these fo- rums may have helped to establish trust among potential re-

search participants. At the same time, the depth and breadth of information shared may have been hindered by her lack of racial concordance with participants.

Three of the studies in which the primary researcher(s) was white or did not state their race (Abbyad, Hanson, and Salam Ward) attempted to establish trust and minimize the negative impacts of racial discordance by having interviews and/or focus groups facilitated by a racially concordant per- son. The remaining 2 studies withwhite researchers (Kennedy et al and Sawyer) did not describe any attempt to address how their white identity might impact the nature and depth of what people of color chose to express to them about race and racism.

DISCUSSION

The studies reviewed here represent a significant contribu- tion to the literature on racism in the profession of midwifery. There are 3 key findings from the studies. First, racism (in- terpersonal and institutional) is commonplace in midwifery education, professional organizations, and clinical practices. Second, racism in midwifery and lack of racial diversity act as barriers to further diversifying the profession. Third, both patients and midwives of color identify midwives of color as uniquely positioned to provide high-quality care for commu- nities of color.

Metzl and Hansen’s theory of structural competency has great utility for analyzing racial disparities. Structural com- petency makes clear that understanding social disparities, including racial disparities, requires utilizing extraclinical theories and thinking in structural terms. For example, by grounding their research in critical race theory, sociology, and black feminist theory, Goode and McLaughlin are the only researchers to identify racism and the lack of midwives of color as an explicitly structural barrier impeding people of color’s access to both high-quality care and midwifery education. Participants in these studies then “imagine struc- tural intervention”27(p 130) through their recommendations to increase the racial diversity of midwives. Additionally, the lens of structural competency enables one to recognize the profession of midwifery as a social structure. When investigating the impact of racism within the structure of midwifery, the distinction between those served and those providing the care dissolves: midwives cannot address racism experienced by their patients without addressing racism experienced by their colleagues and vice versa.

The data are clear that the midwifery profession, mid- wives, and their patients stand to substantially benefit from diversification of the field. More diversity in the provider population would allow patients from Hanson’s study to re- ceive care from a “traditional elder woman”30(p33) during their regularly scheduled clinical visits rather than in supple- mentary classes offered in parallel to clinical midwifery care. Provider diversification would also likely increase the num- ber of providers that patients felt “comfort with”29(p 17) as de- scribed in Sawyer. As people of color themselves, midwives of color are uniquely positioned to understand the economic, political, and social forces affecting the lives and health of the people of color who present to them for care. The data from the studies suggest that the shared experience as targets

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of racism would improve understanding and communication between patients and providers and reduce perceived racial discrimination. Additionally, the research reviewed here gives voice to the themes within themidwifery service pattern data, namely, that midwives of color demonstrate a deep commit- ment to caring for underserved communities. It follows that increasing the racial diversity of midwives is likely to improve access and health outcomes for communities of color.

The data are equally clear that diversification ofmidwifery presents a formidable challenge. First and foremost, racism and lack of faculty diversity in midwifery education programs must be addressed. Participants in the 3 studies that inves- tigated educational institutions found that racism is preva- lent and greatly contributes to the attrition of midwifery stu- dents of color. These findings show that external institutional racism, such as segregated schools and race-based wealth dis- parities, is not the only factor limiting access to the profession for persons of color.

Beyond the educational environment, racism and lack of racial diversity in midwifery professional organizations must be addressed. Professional organizations represent concen- trations of political power, social connections, and financial means. These groups have the power to set national agendas and steer the midwifery movement. Therefore, midwives of color being excluded or alienated from organizations such as ACNM and MANA effectively disenfranchises them, hinder- ing their ability to advocate for their communities and weak- ening organizations that don’t have access to their skills and perspectives. This happened in 2012whenMANA’sMidwives of Color section resigned, stating that they could no longer tolerate the racism in the organization and that “these organi- zations distract us from our true mission”31(p31) of improving maternal and infant health outcomes for US women.

Implications for Future Research

Gaps in the literature exist but should not prevent midwives from acting now to prioritize racial diversification of the pro- fession. Future research should investigate race concordance in midwifery care including the possibility that diversifica- tion may improve the cultural and structural competency of the whole team. Research should include the experiences of patients and providers from a wide range of racial identi- ties including Asian and Pacific Islander, Latino, and Amer- ican Indian as well as, specifically, recent immigrant popula- tions. Best practices for effective recruitment and retention of a racially diverse student population, including research in effective methods of anti-racist education, must be identi- fied. Studyingwhitemidwives’ understanding of racism,white privilege, and health inequity could help guide trainings for white midwives and educators.

CONCLUSION

This systematic review adds to the state of the science, deep- ening the collective understanding of both the pressing need to racially diversify midwifery and the challenges faced when working toward diversification. The need to diversify is made clear by the finding that both patients and midwives recog- nizemidwives of color as uniquely positioned to provide high- quality care for communities of color. This, coupled with the

severe disparities in maternal-child health outcomes experi- enced by communities of color, requires that diversification of the profession be a priority. The results also demonstrate that racism is found in midwifery education, professional or- ganizations, and clinical practices, and it must be addressed in order to effectively diversify the profession. Structural compe- tency offers an effective framework to guide these efforts.

Racism is, unfortunately, woven throughout the eco- nomic, political, and social structures thatmake up theUnited States. The US population shares a moral imperative to work to redress race-based inequalities. Midwives’ calling is even stronger; the profession locatesmidwives as experts at the crit- ical and sensitive periods of pregnancy and childbirth where racism extracts a particularly brutal toll. It is unconscionable that women of color face a significantly elevated risk of losing their life, or the life of their child, from pregnancy and birth. Midwives cannot turn away from this reality and must heed the call to diversify the profession.

AUTHORS

Jyesha Wren Serbin, CNM, WHNP-BC, MS, identifies as brown with West African and European ancestry. She is in clinical practice at Highland Hospital, Alameda Health Sys- tem, in Oakland, California, and at Kaiser Permanente’s Red- wood City Medical Center in California. She is a co-founder of the University of California, San Francisco (UCSF) student nurse-midwives of color group where she serves as a mentor.

Elizabeth Donnelly, CNM, WHNP-BC, MS, identifies as white, with Irish and Scotch-Irish roots. She practices mid- wifery at Kaiser Permanente’s Walnut Creek Medical Center. As a student she served 2 years on the UCSF School of Nurs- ing Diversity in Action Committee, whose aim is to create a welcoming and inclusive community for all students, faculty, and staff.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

ACKNOWLEDGMENTS

The authors are grateful to Tekoa King and Evans Whitaker for their editorial and technical assistance in developing this manuscript.

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Appendix 1: Search Query

(((“Nurse Midwives” OR “Nurse Midwife*” OR “Nurse Mid- wife*” OR Midwife* OR midwife* OR obstetric* OR “prena- tal care” OR “antenatal care” OR intrapartum OR “labor and delivery” OR pregnancy OR pregnant OR childbirth))) AND ((((((((“healthcare workforce diversification” OR “healthcare workforce diversity”)) OR (Workforce AND (“Cultural diver- sity” OR Racism OR “Healthcare disparities”))) OR (((con- cordant or concordance) AND (race OR racial OR races OR ethnicity)))) OR (racism OR “racial disparities” OR “racial disparity” OR “health disparities” OR “health disparity” OR “racial discrimination” OR “race discrimination”)) OR (“cul- turally competent” OR “culturally appropriate” OR “cultural competency” OR “cultural humility” OR “culturally humble care” OR “cultural sensitivity” or “culturally sensitive care”)) OR “patient-provider communication”) OR (diversity OR “Cultural Diversity”))

Appendix 2: Exclusion Hierarchy

1. Full text unavailable 2. Not original research 3. Recent immigrant population

Journal of Midwifery &Women’s Health � www.jmwh.org 705

4. Describing a racial disparity but no data on patient or provider experience

5. Investigated women of color and childbirth but did not investigate the provision of pregnancy-related health care and/or did not address racial identity/racism/concordance in pregnancy-related health care

6. Wrong provider population

7. Provider population unclear

Continuing education units (CEUs) are available for this article as a part of a continuing education theme issue. To obtain CEUs online, please visit www.jmwhce.org. A CEU form that can be mailed or faxed is available in the print edition of this issue.

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