Perspectives of Certified Nurse-Midwives and Physicians on Structural and Institutional Barriers that Contribute to the Reproductive Inequities of Black Birthing People in San Francisco

AbstractBackground: Black birthing people in the United States disproportionately endure adverse experiences and outcomes during pregnancy and childbirth compared to those of any other racial or ethnic groups. Research confirms that structural and interpersonal racism rather than race are the underlying root causes responsible for the inequities in perinatal and reproductive health outcomes facing Black birthing people and families. Purpose: The purpose of this study was to determine how care model informs and affect how racism is perpetuated in institutional perinatal and reproductive health care through a case study analysis focused on physicians and certified nurse midwives’ perspectives of how racism affects their Black birthing patients’ experiences and outcomes. Objectives: To determine provider perspectives of structural- (e.g., transportation, housing) and institutional (e.g., policies, practices) barriers contributing to reproductive health inequities among Black birthing people and families in San Francisco. To determine if and how models of care inform providers and how these perspectives vary among provider types (e.g., midwife, physician). Setting: Two hospitals (one public community hospital in academic partnership and one University hospital) in San Francisco, California. Participants: Twenty-four Perinatal Providers (Certified Nurse Midwives [n=7] and Physicians [n=17]) recruited by “Dear Clinician” letters and voluntarily participated in interviews. Methods: Critical Race Theory, Reproductive Justice and the Midwifery theory were combined to conduct a secondary thematic analysis of existing qualitative data from Community Racial Equity and Training Interventions and Evaluation of Current and Future Healthcare Clinicians Study. Audio files, transcripts, and field notes provide the data for this analysis. An iterative process was used to determine the influence of professional identity, model of care, and other factors that contribute to provider perceptions about health equity. Results: Thematic analysis resulted in the identification of five themes, namely: racism as a co-morbidity; healthcare systems inability to address the needs of Black birthing people; healthcare systems prioritizing providers over patients is a failed system; patients are the experts in the optimal healthcare model; and benefits of interdisciplinary teams grounded in Reproductive Justice. One finding from this study is that both physicians and midwives expressed a need for a new care model and a new system of care delivery. Implications: With these findings, our team proposes a modification of the midwifery model for application by all provider types that could radically shift perinatal reproductive health care. Using a human rights approach to perinatal care, critical race theory, Reproductive Justice-informed midwifery theory may be operationalized by all perinatal and reproductive health care providers, not only midwives, to move racial health and justice forward in a way that serves and honors all birthing people. The clinical implications of this work are wide and may range from but are not limited to the creation of algorithms of how to address racism in the healthcare environment, to patient satisfaction tools built into electronic medical records that trigger provider accountability, to doulas available to all and covered by all insurance types, to patient navigators dedicated to the safety and experience of patient, to community tools like participant-led perinatal reproductive health support groups, community advisory participants in research, and apps such as the Irth© app to report which providers are considered safe for Black birthing people (https://irthapp.com/)