Including the patient voice when addressing racial disparities in maternal health

Experts have spent recent years trying to better understand and address significant racial disparities and inequities in maternal health. 

The data is alarming: Black and low-income people are two to five times more likely to die in childbirth or experience severe maternal morbidity than those who are white.

But one important voice has largely been missing from the conversation: the patients themselves.

“Although certain populations face significant maternal health care inequities, their views have mostly been absent from prenatal care delivery research and we’ve lacked important information to redesign care to better meet their needs,” said lead author Alex Peahl, M.D., MS.c., an obstetrician-gynecologist at University of Michigan Health Von Voigtlander Women’s Hospital and co-director of the Michigan Plan for Appropriate, Tailored Healthcare in Pregnancy, also known as MiPATH.

“Our goal was to center the voices of Black pregnant people in Detroit and the people who care for them to inform our ongoing efforts to redesign prenatal care and make it more effective and equitable.”

To capture some of this patient experience, Peahl and colleagues interviewed 19 pregnant people who were Black and from a lower income household from two clinics in Detroit as well as 19 healthcare workers who cared for them, including Obgyns, midwives, doulas and community health workers.

Among the questions asked: what barriers were preventing them from getting proper prenatal care during pregnancy? How could pregnancy care be improved from their perspective?

Some recurring themes emerged from responses, which were published in JAMA Network Open, including the view that the inconvenience of appointments overrode perceived benefits and that the approach to prenatal care was too standardized to be meaningful.

As one participant said “[the doctor] is just going to check the heartbeat and it’s going to be like 10 minutes. No, I’m not going to waste my gas. Back then I was surviving.”

Another person described clinic care as a “cookie cutter” approach that didn’t address their specific concerns.

Prenatal care is an important target to reduce maternal deaths and morbidity, Peahl says, but previous research suggests that Black people, particularly those with low socioeconomic status living in urban areas, face significant barriers to high quality care. Challenges may include lack of transportation, financial constraints and structural racism.

“Prenatal care in its current form that requires frequent in-person visits may actually exacerbate barriers for those who may benefit the most from receiving this important health service,” she said.

Peahl said she and colleagues have already incorporated the new feedback into efforts to redesign prenatal care locally and nationally, reflected in new prenatal care recommendations that emerged from the COVID-19 pandemic and call for greater use of telemedicine and fewer in-person visits during pregnancy.

The ideal prenatal care model outlined by participants, Peahl says, includes services tailored to each person’s comprehensive needs and preferences, including screening for and managing existing health conditions that could lead to pregnancy complications and guidance about pregnancy, childbirth, the postpartum period and parenting.

Participants also wanted help with non-medical factors impacting their ability to engage with the health system during pregnancy, including resources like housing and transportation as well as social support.

“We need to listen to patient voices in our communities to help shape new care models that address persistent inequities in prenatal care and outcomes,” Peahl said.

Additional authors include Michelle Moniz, M.D., MSc.; Michele Heisler, M.D. M.P.A.; Aalap Doshi, M.S.; Gwendolyn Daniels, D.N.P., M.S.N.; Martina Caldwell, M.D., MSc.; Vanessa Dalton, M.D., M.P.H.; Ana De Roo, M.D., MSc.; Mary Byrnes, Ph.D.

Disclosures: Peahl is a consultant for Maven Clinic.

Study cited: “Experiences with prenatal care delivery reported by income and by health care workers in the U.S., a qualitative study," JAMA Network Open. DOI: 10.1001/jamanetworkopen.2022.38161