Racial disparities in severe maternal morbidity (SMM) and mortality persist across the United States.1–5 The Centers for Disease Control and Prevention reports that the maternal mortality rate for Black patients was almost triple that of White patients: 69.9 deaths compared with 26.6 deaths per 100,000 live births.6 Historically, maternal deaths have been significantly higher in the South and lower in the Northeast.7 Alabama has the third worst maternal mortality rate (34.6/100,000 live births) in the nation, behind Arkansas and Kentucky.8 A 2020 report from the Alabama Maternal Mortality Review Committee noted that 86.3% of maternal deaths in the state had multiple contributing factors, including patient or family-, practitioner-, and health care systems–level factors.9

Racial disparities in maternal health outcomes in the United States reflect numerous factors, including racism.10–12 Race itself is not a biological indicator but rather an indicator of exposure to disadvantage and discrimination that can affect factors that influence Black patients' health status and quality of life, including quality of care.13,14 Research into the role of racism is needed to overcome racial disparities in SMM and maternal mortality. There is a need to provide contextual information to better understand the potential influence of factors beyond the individual patient—including community-, health care practitioner–, maternity services–, and system-level factors—associated with maternal health outcomes as postulated in Howell's conceptual framework, which is guiding this study.1

Our multidisciplinary team aimed to identify multilevel determinants of racial disparities in SMM and maternal mortality in Alabama. Our primary research objective was to determine which factors contribute to racial disparities in SMM and maternal mortality in Alabama. To achieve these objectives, we performed a qualitative study including a diverse group of maternity service health care practitioners and administrators who shared perspectives about how health care practitioner and maternity services factors contribute to disparities in maternal health outcomes. A secondary objective was to identify potential strategies and solutions to address racial disparities in Alabama.

METHODS

We used the Consolidated Criteria for Reporting Qualitative Research Studies checklist to present our study methods and results.15 IRB approval was received from the University of Alabama's IRB (IRB-30006402).

The investigators developed a semistructured interview guide using Howell's conceptual framework1 on racial and ethnic disparities in SMM and maternal mortality, which identifies pathways that contribute to racial and ethnic disparities in SMM and maternal mortality (see Appendix 1, available at https://links.lww.com/AOG/D345, for interview guide). We added a level to the framework to highlight the characteristics of maternal health services at health facilities as being distinct from health care practitioner and system levels (Fig. 1). The interview guides focused on the experiences of Black cisgender women.

Fig. 1.:

Multideterminant levels and factors contributing to racial disparities in severe maternal morbidity and maternal mortality.

Two trained and experienced qualitative interviewers (the first and second authors) conducted the interviews. Pilot interviews were conducted in November 2020 with two volunteers to determine the appropriateness of the questions and to adjust the interview guides as needed.16 The volunteers were a Black obstetrician and a Black doula. The interview guide was revised on the basis of feedback from the pilot interviews.

We engaged key informants, including study coinvestigators, to help identify and recruit potential participants.17 We selected participants according to their roles in provision of care to racially and ethnically diverse pregnant or postpartum patients in Alabama and aimed to achieve variation in race, type of practitioner, type of organization, and role in services. The number of required participants for each practitioner type was not predetermined.

Potential participants were contacted by email and phone. When a participant expressed interest in participating, recruitment letters explaining the objectives of the study and informed consent forms were sent by email to the identified participants. We obtained signed written and verbal consent from participants before the interviews. Recruitment and interviews were conducted between January and March 2021. No relationship was established with the participants before the interviews were started.

We conducted key informant interviews virtually using Zoom videoconferencing software (https://zoom.us/). Each interview lasted about 90 minutes and was one-on-one between an interviewer and a participant. Audio recordings and transcripts of the interviews were generated by the Zoom videoconferencing software. After each interview, the interviewers engaged in reflexivity by making notes about their thoughts and the participant's responses and drafting postinterview memos after each interview.18 The research team held regular debriefing meetings to discuss emerging themes, areas for further probing in future interviews, and data saturation. Demographic data, including age, sex, occupation or employment position, and race and ethnicity, were collected by self-report from the participants at the end of each interview. Participants received a $20 incentive on interview completion. All interview recordings, transcripts, and memos were deidentified and stored in a secured electronic folder.

We adopted a thematic analysis approach using a two-stage analytical procedure involving open and selective coding.19,20 Using the interview guides, pilot transcripts, and pilot field memos, we developed a codebook with broad and fine coding schemes.21 Transcripts and field memos were coded and analyzed with NVivo 12. With oversight from a senior investigator, the two interviewers initially double coded six transcripts to establish agreement and to discuss areas of disagreement. This iterative process established reliability of the final coding framework. Consequently, each of the two interviewers was a primary coder for 10 transcripts and a secondary coder (reviewing the coding of the primary coder) for three. Thematic analysis was performed to uncover recurring patterns and themes, including primary and subthemes, that informed the narrative.19 Subgroup analysis was done to explore and compare differences among our diverse group of participants.22 The team decided a priori to have a minimum of 20 interviews and to otherwise stop interviews when thematic saturation had been reached.

RESULTS

Overall, 37 potential participants were contacted; 17 declined participation, and 20 interviews were completed. After 20 interviews, thematic saturation had been reached. Ninety percent of participants were female. Appendix 2, available online at https://links.lww.com/AOG/D345, presents demographic characteristics of the participants. The sample included a diverse group of practitioner types, with 60.0% identifying as clinical obstetric health care practitioners. Seventy percent of the health care practitioners worked with patients in urban areas of Alabama, and 30.0% worked with patients in mixed urban and rural areas of Alabama. The majority (55%) of the interviews were racially concordant.

Participants recounted personal and second-hand experiences pertaining to health care practitioner and maternity services factors. Primary themes that emerged at the health care practitioner level included implicit bias and explicit racism, lack of communication and lack of positive patient–health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes at the maternity services level included lack of accessibility of care, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Each primary theme had several subthemes highlighting key factors contributing to racial disparities in maternal health outcomes, which are summarized in Table 1. The majority of the themes were the same across subgroups. The main differences in subgroup findings were in the suggested strategies.

Table 1.:

Illustrative Quotes on Health Care Practitioner–Level and Maternity Services–Level Factors Contributing to Racial Disparities

There was consensus among participants that health care practitioner racial bias posed a serious health risk to Black patients. Participants unanimously spoke on health care practitioners’ racism, implicit racial biases, and their stereotypes and assumptions about Black patients (Table 1, quote 1), including incorrect assumptions that Black patients did not feel pain, had children with different or multiple partners, and used illicit drugs. An example was shared of how male partners of Black patients were sometimes treated disrespectfully by health care practitioners (Table 1, quote 2).

“…outright ignoring their male partner who is there to support them to be a physical support but is not included in there.” (Doula, female, Black) (Table 1, quote 2).

One participant noted that racial bias is an uncomfortable topic to broach with health care practitioners because it requires self-reflection (Table 1, quote 3).

Participants generally agreed that establishing positive patient–health care practitioner relationships and trust is necessary for better maternal health outcomes. However, some factors such as socioeconomic status and power dynamics may hamper the development of this relationship (Table 1, quote 4). It was noted, however, that health care practitioners can acquire the requisite skills to foster better interactions with Black patients (Table 1, quote 5).

Multiple participants noted that health care practitioners of a different race may not be “culturally competent” in their interactions with Black patients, thereby creating barriers to care (Table 1, quote 6).

“I’m White and I serve a mainly predominantly African American patient population and…when we as providers are not as culturally competent, we won't ask the right questions…” (Physician, female, White) (Table 1, quote 6)

Participants spoke about the influence of variations in health care practitioners' clinical knowledge and experience. Although some participants perceived that the health care practitioners' places of training and work experience may positively contribute to maternal health outcomes, others did not think this was the case.

“…I don't necessarily perceive that years of experience informs or doesn't inform attitudes towards racial disparity so much as what that person's life experience has been…” (Physician, female, White) (Table 1, Quote 7)

Others emphasized the need for health care practitioners to consistently follow clinical guidelines and standardize care to improve patient outcomes (Table 1, quotes 8 and 9).

“If we're going to go to the literature, one of the things that has been defined is if clinical guidelines are followed consistently regardless of race, that we would have different outcomes.” (Doula, female, Black) (Table 1, quote 9)

One participant expressed her concern that the health care practitioners' training curriculum is outdated and may result in provision of racially discriminatory care (Table 1, quote 10).

“It goes back to how they are being taught in school. Most of the doctors that are being taught in school are still being taught on a curriculum that is, I feel, outdated…I’ve talked to a nurse before, and she even says she read it in her book that it says Black women or Black people in general don't feel pain. Yes, this [is] in a textbook…Like they are still being taught these things in these textbooks and I feel like all of that needs to be updated…” (Certified Lactation Counselor, female, Black) (Table 1, quote 10).

Participants shared their concerns about the quality of maternity care services provided to Black patients. They perceived that right from their first contact at the health facility during a pregnancy, Black patients were often not listened to and tended to have their concerns dismissed. Others noted that prenatal care does not address the chronic lifelong stress of Black patients and that they generally appeared to receive a lower standard of care (Table 1, quotes 11–13).

“We don't get listened to. When we say that we're in pain, or when we say that we need something, or something doesn't feel right, it gets dismissed.” (Certified Lactation Counselor, female, Black) (Table 1, quote 11)

A theme of lack of continuity and coordination of care covered several issues, including fragmented prenatal care, related to the type of insurance coverage available to many Black patients (Table 1, quote 14). Participants also felt that the lack of continuity of care hampers the formation of interpersonal relationships between pregnant individuals and health care practitioners.

One participant observed that drug screening is not uniformly administered to both White and Black patients in maternity hospitals (Table 1, quote 15). Participants also recounted that during the coronavirus disease 2019 (COVID-19) pandemic, restrictive visitor policies were put in place at various maternity hospitals, and Black patients were more likely to be adversely affected by these policies (Table 1, quote 16).

Participants observed a shortage of Black maternity care health care practitioners. They shared their views that patient–health care practitioner racial concordance fosters comfort and ease of sharing information and communication (Table 1, quote 17). Participants also observed that an interdisciplinary approach is important to leverage different strengths. They reported lack of obstetric services and maternity practitioner shortages in rural areas of Alabama, with some patients having to travel to neighboring counties for obstetric care (Table 1, quote 18).

Participants recounted how barriers encountered by Black patients, particularly those of low socioeconomic status, impede their access to health care, including inflexibility of the appointment system in some health care facilities (Table 1, quote 19).

Participants shared strategies that they felt could potentially reduce racial disparities in maternal health outcomes in Alabama. These included racial and interdisciplinary diversity in the maternity workforce, practitioner trainings, and specific evidence-based interventions that were deemed feasible, effective, and acceptable to health care practitioners and facilities providing maternal services.

Most participants expressed the need for a more racially diverse and interdisciplinary workforce for maternity services provision in Alabama, noting that it would reduce health care practitioner implicit racial bias and racism (Table 1, quotes 20–22).

Implicit racial bias and diversity training for health care practitioners was suggested by participants. Some felt that bias training would be more effective and acceptable to health care practitioners if it was a requirement for state licensure or malpractice insurance (Table 1, quote 23). Similarly, cultural sensitivity training was advocated for by participants (Table 1, quote 24).

Suggested evidence-based strategies included group prenatal care, use of early warning signs criteria, simulation training, coordinated care, disparities dashboards, digital solutions, and adoption of effective strategies from other states and countries.

Participants suggested group prenatal care as an acceptable strategy to both health care practitioners and patients that could provide important benefits to Black patients (Table 1, quote 25). Clinical participants were more knowledgeable about the effectiveness and feasibility of clinical interventions such as patient safety bundles (Table 1, quote 26), quality measures, and disparities dashboards (Table 1, quote 27). Pregnancy-related digital applications were suggested across participant types because of the ubiquity of smartphones, which could promote easy access to health information and improve patient–practitioner communication. Nonclinical participants favored the adoption of home visits as an evidence-based and effective strategy to reduce disparities (Table 1, quotes 28 and 29).

DISCUSSION

We identified health care practitioner– and maternity services–level factors contributing to racial disparities in SMM and maternal mortality in Alabama, as well as strategies to address them. Our study adds to current literature on racial disparities in maternal health outcomes in the United States. Facility-based and community-based maternity health care practitioners had consensus on the majority of the factors identified, particularly practitioner racial bias and racism, lack of cultural sensitivity, poor coordination of care, workforce shortages, and the need for a more racially diverse and interdisciplinary maternity care workforce. Nonclinical health care practitioners such as doulas and Certified Lactation Counselors were more inclined to recommend community-based interventions such as home visits and doula services as strategies to improve maternity outcomes. Black health care practitioners, particularly Certified Lactation Counselors and doulas, were more likely to assert that Black patients were not listened to or that their concerns were dismissed. This was echoed by some White community-based health care practitioners.

Our participants perceived that Black patients were racially discriminated against by clinical health care practitioners and nonclinical staff alike. This aligns with a previous study in Alabama23 that found that White nonclinical and clinical staff had higher levels of explicit bias toward Black patients than White patients. This implies that such individuals may engage in discriminatory acts against Black patients.23 Although implicit bias education has been prioritized for health care practitioners across the United States to enhance awareness about and to reduce practitioner racial bias, there are conflicting results on the influence of implicit bias on the provision of health care.24–29 Research30 shows that awareness of personal bias may not change after bias education, possibly because these trainings are not followed up with any effective debiasing strategy.31,32

Consistent with current research, our participants described how patient–health care practitioner racial and cultural concordance may promote better quality and more respectful care for Black mothers.12 Participants also advocated for group prenatal care as an effective strategy for improving pregnancy outcomes and providing supportive care for Black patients.33–35 In 2019, Alabama had only five group prenatal care sites with only 1.4% of pregnant individuals in Alabama participating.36

Findings should be interpreted within study limitations. Our study was conducted in early 2021 during the COVID-19 pandemic and after seminal events such as George Floyd's death.37,38 These events may have influenced our participants' unanimous identification of health care practitioner racial bias as a major contributor to racial disparities in maternal health outcomes. Our participants were intentionally limited to people providing pregnancy-related care to racially and ethnically diverse patients. Racial discordance with the interviewer may have affected some participants' willingness to openly share their views on racism. However, we believe that our reflexivity in data analysis helped to reduce biases in data interpretation in that we noted any existing biases on our part and critically examined our assumptions about the study topic. Although health inequities may also affect a wide range of Black people of different sexes, this study focused on care for Black cisgender women. We acknowledge the possibility of selection bias because participants were purposively selected. Furthermore, we acknowledge that many of the participants worked with lower-income patients; thus, their perceptions may not necessarily apply to Black patients of middle and higher socioeconomic status. We also had few male participants and few participants practicing in rural areas. Our study findings may not be widely generalizable because we focused only on Alabama.

Our study has several strengths. It uncovers the unique perspectives of health care practitioners in the U.S. Deep South. We examined racial disparities through the inclusion of both traditional and nontraditional maternity care health care practitioners such as doulas and Certified Lactation Counselors who interact more closely with Black patients living in both urban and rural communities. Generally, our participants provide maternity care to racially and ethnically diverse populations. However, Certified Lactation Counselors and doulas were more likely to have low-income clients compared with the clinical health care practitioners. The community-based participants (30%) had substantial personal and informal interactions with Black patients. Many of the clinical health care practitioners and government public health agency participants provide care to patients from all over Alabama, which informed their broad perspectives on the study topic.

In conclusion, health care practitioner factors and quality of maternity services appear to contribute to racial disparities in maternal health outcomes in Alabama, and evidence-based, multifaceted strategies are required to address them. Future research should examine the effect of combining quality improvement measures with bias and cultural sensitivity trainings, as well as community-based approaches, as strategies for reducing racial disparities in maternal health outcomes in Alabama and similar health care settings.31

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