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Review
Communication Between Pregnant People of Color and
Prenatal Care Providers in the United States: An Integrative
Review
Amy H. Goh1,CNM,MPhil ,MollyR.Altman
2, CNM, PhD, MPH , Lucinda Canty3, CNM, PhD,
Joyce K. Edmonds1,4,PhD,MPH,RN
Introduction: Racism and discrimination negatively affect patient–provider communication. Yet, pregnant people of color consistently report
being discriminated against, disrespected, and ignored. The purpose of this integrated review was toidentify studies that examined communication
between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication.
Methods: We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were
eligible for inclusion if they reported on primary research conductedin t he United States, were written in English, and focused on patient–provider
communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic,
Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were
included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins
Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and
organized into 3 a priori categories: factors, outcomes, and recommendations.
Results: Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then iden-
tified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, con-
tinuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly,
culturally congruent care, provider training, and workforce development were categorized as recommendations.
Discussion: Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to
midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research
about digital prenatal health communication is necessary to ensure equitable prenatal care.
J Midwifery Womens Health 2024;69:202–223 c2023 The Authors. Journal of Midwifery & Women’s Health published by Wiley Periodicals LLC
on behalf of American College of Nurse Midwives (ACNM).
Keywords: professional-patient relations, health communication, patient-centered care, prenatal care, health equity, congruent care
INTRODUCTION
Patient–provider communication has been identified as one
of the hallmarks of quality person-centered care and is rooted
in respect, quality relationships, and communication.1,2
Person-centered care is characterized by proficient communi-
cation between patients and health care providers, involving
1Boston College Connell School of Nursing, Boston College,
Chestnut Hill, Massachusetts
2School of Nursing, University of Washington, Seattle,
Wash i n g ton
3College of Nursing, University of Massachusetts Amherst,
Amherst, Massachusetts
4Harvard T.H. Chan School of Public Health, Harvard
University, Boston, Massachusetts
Correspondence
Amy H. Goh
Email: amy.goh@bc.edu
ORCID
Amy H. Goh https://orcid.org/0000-0003-1645-2979
Molly R. Altman https://orcid.org/0000-0002-0453-0469
Joyce K. Edmonds https://orcid.org/0000-0002-0465-9043
shared decision-making that considers the individual’s pref-
erences in order to attain the best possible outcomes and care
experiences.3,4 Researchers have demonstrated that outcomes
such as satisfaction with care are influenced by quality com-
munication and person-centered care.5,6 In pregnancy, opti-
mal communication has been shown to increase satisfaction
with care, decrease anxiety, and increase motivation for health
behavior change.7,8 Pregnant individuals who actively engage
in communication with their health care providers and advo-
cate for themselves are more likely to receive comprehensive
health information and report a sense of being respected.9
In 2001, the Institute of Medicine’s Crossing the Qual-
ityChasm:ANewHealthSystemforthestCenturypro-
vided guidelines for improving the relationships between pa-
tients and health care providers, bringing national attention to
the association between quality communication and person-
centered care.10 Despite the publication of this seminal report
2 decades ago, historically marginalized populations, includ-
ing pregnant people of color, have continued to report poor
communication with their prenatal care providers.11,12 In fact,
researchershaveconsistentlyfoundthatBlackpregnantpeo-
ple experience racism and are discriminated against, disre-
spected, not listened to, and ignored.13–15
202 1526-9523/09/$36.00 doi:10.1111/jmwh.13580
c2023 The Authors. Journal of Midwifery & Women’s Health published by Wiley Periodicals LLC on behalf of American College of Nurse Midwives (ACNM).
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited and is not used for commercial purposes.
✦A complex interplay exists in patient–provider communication in the United States that is influenced by provider behaviors
and the experiences of pregnant people across racial and ethnic groups.
✦In interactions with their health care providers, many pregnant people of color experienced interpersonal racism, lack of
information, disrespect, lack of trust, and diminished influence in decisions, resulting in missed appointments and reduced
satisfaction with the care received.
✦Culturally and linguistically congruent prenatal care is needed to improve communication between pregnant people of
color and their prenatal care providers.
Previous systematic reviews conducted outside of the
United States have explored patient–provider communi-
cation during labor and reported improved patient safety
after provider trainings on communication.16,17 Likewise, US
researchers have explored interventions to improve relation-
ships between birthing people of color and their perinatal
care providers.18 However, these reviews did not specifically
examine communication between pregnant people of color
and their prenatal care providers.
Thus, this integrated review aimed to evaluate find-
ings from studies that examined communication between
pregnant people of color and their prenatal care providers.
Specifically, the review (1) identified studies about com-
munication between prenatal care providers and pregnant
people of color, defined as those who identified as Black,
African American, Hispanic, Latina/x/e, Indigenous, Ameri-
can Indian, Asian, Asian American, Native Hawaiian, and/or
Pacific Islander American; (2) analyzed the findings through
a description of factors in and outcomes of communica-
tion between pregnant people of color and their prenatal
care providers; and (3) summarized recommendations to
improve communication provided by pregnant people of
color.
The authors recognize the considerable variation in lived
experiences among pregnant people of color from different
races, nationalities, economic backgrounds, geographies,
and other intersectional identities. However, a goal of this
review was to capture the shared experiences among pregnant
people from diverse backgrounds in their relationships with
health care providers in a system whose perinatal workforce
is predominantly White. We also acknowledge the different
histories among communities of color and the pervasive
influence of racism across various societal levels, particularly
for Black pregnant people. With this understanding of the
different levels of racism, we desired to examine racism col-
lectively to get a broader understanding of how it significantly
affects the experiences of individuals from communities of
color.19
METHODS
Whittemore and Knafl’s methodology was used for this inte-
grative review.20 We c o n d u cte d s earc h e s i n Pub M e d , Emb a s e,
CINAHL, and PsychINFO using the following search terms:
pregnancy,prenatal care,antenatal care,Black,African Ameri-
can,Hispanic,Latina,Asian American,Pacific Islander,Native
American,BIPOC,people of color,patient-provider communi-
cation,patient-provider relationship,person-centered care.
We included reports of primary qualitative, quantitative,
or mixed-methods research studies that were conducted in the
United States, were written in English, focused on patient–
provider communication, and included a majority of pregnant
or postpartum people of color. Articles published from March
2001, following the release of the Crossing the Quality Chasm
report,10 to March 2023 were included. We excluded proto-
cols, stand-alone abstracts, opinions, book reviews, books,
dissertations, and editorials as well as studies that described
only provider perspectives, intervention studies, and studies
that focused on communication about a specific topic, such
asgenetictesting.Althoughwerecognizetheimportanceof
patient–provider communication within the context of re-
spectful perinatal care, we intentionally chose to exclude stud-
ies that primarily focused on this broader concept. The intent
of this investigation was to prioritize specific aspects of com-
munication that were not comprehensively addressed in those
studies.20
The Covidence systematic review management software
was used throughout the review process,21 and results of the
screening and selection process are presented in a Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) diagram (Figure 1). We conducted an initial search
and removed duplicates, and then 2 reviewers (A.H.G. and
M.R.A.) independently screened articles by title and abstract.
A.H.G. and M.R.A. discussed a selection of articles for full-
text review and found no conflicts. A.H.G. conducted the full-
text review of included articles. A.H.G. and J.K.E. analyzed
the findings. A.H.G., M.R.A., J.K.E., and L.C. developed the
manuscript.
A total of 3015 records were identified from the database
searches, 871 duplicates were removed, and a title and abstract
screening was conducted on 2142 records from which 1992
were excluded, resulting in 150 records. A full-text review was
conductedon146records,asthefulltextof4articleswasun-
able to be retrieved. During the full-text review, 120 articles
were excluded. The remaining 26 articles were included in the
review.
Data were extracted from each included article and sum-
marized in a table of evidence (Table 1). The following data
were abstracted: author, study design and purpose, sample and
location, and main findings. We assigned analytic categories
and rated the level of evidence and quality for each included
article. The ratings scale from the Johns Hopkins Evidence-
Based Practice model was used to rate the level of evidence
Journal of Midwifery & Women’s Health rwww.jmwh.org 203
Ta b l e 1 . Tabl e o f E v i d e n c e
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Adebayo et al25
2022
Describe pregnancy and birth
experiences
Qualitative in-depth
interviews
conducted by
telephone or face
to face
31 African American women
who were pregnant (n =6)
or had been pregnant within
they(n=21) or within the
past 10 y (n =4)
Milwaukee, Wisconsin
Four themes emerged.
Three themes were derived using the critical race theory
framework: (1) institutionalized care—racially insensitive
biomedical approach, (2) race and class—unfair
treatment based on health insurance, and (3) race as a
social concept—dismissed pain concerns because you are
astrongBlackwoman.
The fourth theme was (4) distrust—African American
women as charity case.
III-B
Agbemenu et al41
2021
Describe perceptions of
protective factors and
strategies to avoid obstetric
interventions
Community-based
participatory
research
40 Somali refugee women
(duration of pregnancy
and/or time postpartum not
stated)
Franklin County, Ohio
Four themes emerged: (1) intentionally not seeking prenatal
care, (2) changing hospitals and/or providers when care
has commenced, (3) delayed hospital arrival during labor,
and (4) outright refusal of care.
Thefirstthemeandsomeofthesecondthemefocusedon
prenatal care; the last 2 themes related to labor and birth.
Lower prenatal care usage among Somali pregnant people
compared with those born in the United States due to
poor experiences and distrust. Since 9/11 there has been
increased discrimination against Muslim Americans,
creating more barriers, fear, and distress.
Otherpointsthatcameupwerewithholdinginformation
due to lack of trust and fear, preference for female
midwives, and feeling disempowered to make decisions.
Participants felt their bodies were on display due to
female genital cutting.
III-B
(Continued)
204 Vol u m e 6 9, No . 2 , Mar c h / Ap r i l 2 024
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Altman et al26
2019
Describe pregnancy, birth,
and postpartum
experiences
Qualitative
open-ended,
semistructured
interviews
22peoplewhowere6wkto11
mo postpartum,
self-identified African
American or non-Hispanic
Black (n =8), Hispanic or
Latina (n =4), American
Indian (n =1), Asian (n =3),
andmultiracialormixed
race/ethnicity (n =6) who
identified as Black/Hispanic
(n =2), Black/Latina (n =1),
Black/Filipina (n =1),
White/Latina (n =1), or
Cherokee/White/Puerto
Rican (n =1)
San Francisco, California
Four themes emerged:
(1) Dominant perspective—power and privilege in
patient–provider information exchange. Participants
noted that providers would package information to
influence decision-making.
(2) Conditions that influenced information exchange—it
was important for participants to establish relationship
with providers and for providers to acknowledge power
and privilege in the patient-provider relationship.
(3) Contextual factors influencing patient–provider
interactions. Participants described discrimination based
on race, income, education and/or insurance; barriers
such as racially/ethnically concordant care; short visits;
different providers; and demonstration of power over the
patient.
III-B
Aye rs et a l42 2018 Describe experiences,
perceptions, beliefs of
prenatal care
Community-based
participatory
methods
43 postpartum Marshallese
women
Arkansas
Thebarrierstoprenatalcarewereinsurance,transportation,
and language.
Additional social cultural barriers were lack of
understanding, social stigma (shame, embarrassment,
and discrimination), and fear.
Lack of interpreters; even those who spoke English had
difficulty with medical terminology.
The quality of care was poor as participants reported not
being heard and encountering rude providers.
Additionally, they feared being judged by providers due to
their age or not having a partner; participants expressed
fear of not understanding the provider.
III-B
(Continued)
Journal of Midwifery & Women’s Health rwww.jmwh.org 205
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Barnettetal
46
2022
Understand experiences of
women of color during
pregnancy and birth
Qualitative focus
group
31 women of color who gave
birth after 2016: Black
(n =25), Hispanic (n =4),
and mixed race (n =2)
Franklin County, Ohio
Seven themes were identified: lack of knowledge, mental
health, communication with providers, support systems,
representation, social determinants of health, and
discrimination and stigma.
III-B
Baxley and
Ibitayo27 2015
Explore perceptions of trust
and communication with
providers
Qualitative,
semistructured
interviews
13 pregnant first- and
second-generation Mexican
women
Texas
The following themes emerged: seen as a person,
personalized/friendly and caring, tell everything, be
direct, speak their language, and exhibit cultural
knowledge.
III-B
Bergman and
Connaughton28
2013
Explore expectations and
understanding of
patient-centered care
amongst Hispanic prenatal
care patients
Qualitative,
in-depth,
open-ended
interviews
48 pregnant Hispanic women
from Mexico (n =36),
Honduras (n =4), El
Salvador (n =3), Costa Rica
(n =1), Argentina (n =1),
Guatemala (n =1),
Nicaragua (n =1), and the
United States (n =1)
Care received at Journey Health
Services, a large Midwestern
health care organization
Five themes emerged: (1) una relación amable (friendly
relationship), (2) la atencion médica efectiva (effective
medical care), (3) español hablado (the Spanish language
spoken), (4) comprensión de la información
(understanding the information), and (5) eliminación del
racismo (elimination of racism).
42% of participants felt that one of the most important
aspects of patient-centered care was having a friendly
relationship as demonstrated by providers making eye
contact, smiling, having patience, and greeting patients.
Nonverbal and verbal racist actions were detrimental to
developing good relationships for 10% of participants.
III-B
(Continued)
206 Vol u m e 6 9, No . 2 , Ma r c h /Ap r i l 2 02 4
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Coley et al29 2018 Describe patients’ and
providers’ perceptions of
prenatal care
Qualitative
semistructured
interviews with
open-ended
questions
19 African American and
mixed-race African
American women who were
less than 6 mo postpartum
20 prenatal care providers
including obstetricians
(n =8), family medicine
physicians (n =8), midwives
(n =2), and nurse
practitioners (n =2)
Southern Wisconsin
Four themes emerged: (1) structure, defined as the
organization and structure of prenatal resources and care;
(2) process, defined as patient-centered care; (3)
communication around options/tests and cultural
competence; and (4) outcomes, defined as satisfaction
with prenatal care and outcomes.
III-B
Dahlem et al47
2015
Survey patient–provider
communication,
discrimination, patients’
trust in providers, prenatal
care satisfaction, and
adherence to selected
prenatal health behaviors
Descriptive,
cross-sectional
study
204 pregnant African American
women
21 providers: obstetricians
(n =20) and physician
assistant (n =1)
Southeastern Michigan
Participants had high levels of trust in providers and were
satisfied with their prenatal care.
Participants reported taking provider recommendations
(adherence rates 85%-100%) in all categories except
meeting with a social worker.
Behaviors that were most cited were providing bloodwork,
having healthy diet, going for ultrasounds, and taking
prenatal vitamins. Participants who had a higher
patient–provider communication score reported
increased satisfaction with prenatal care and trust in
provider.
III-B
(Continued)
Journal of Midwifery & Women’s Health rwww.jmwh.org 207
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Edmonds et al40
2015
Describe the value and
importance of prenatal
care, motivations to attend
prenatal care, barriers to
care, services to facilitate
attendance, and creation of
a prefect prenatal care
model
Five 2-h focus
groups using
community-based
participatory
research methods
22 pregnant and postpartum
African American women
Philadelphia, Pennsylvania
Motivations to attending prenatal care were learning how
fetus is doing and feeling anxious if appointments were
missed.
Primary sources of support were family.
Barriers were insurance and transportation.
A strategy proposed was sharing information about all
resources available.
A strong finding was the dissatisfaction with the
relationship participants had with their providers, seeing
multiple providers, medical students, trainees, and feeling
disrespected.
Participants liked the midwifery model of care and
relationships they had with nurses and clinic staff.
Ultrasounds were an important topic for participants as well.
III-B
Fitzgerald et al30
2016
Describe satisfaction with
prenatal care, barriers to
care, use of information
received during care, and
how improvements could
be made
Phenomenological
inquiry; 2 focus
groups in Spanish
8pregnantHispanicwomen
Louisville, Kentucky
Three major themes emerged: (1) la angustia (anguish), (2)
el anhelo (yearning), and (3) la identidad (identity).
Participants expressed fear around pregnancy, birth, and
postpartum.
They also desired more information around pregnancy and
expectations.
Lastly, participants worried about poor care due to the
language barrier.
Some also felt discriminated against, and others were placed
insituationswheretheyfelttheyhadtogiveuptheir
cultural norms.
III-C
(Continued)
208 Vol u m e 6 9, No . 2 , Ma r c h /Ap r i l 2 02 4
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Fuentes-Afflick
et al48 2014
Survey communication,
decision-making, and
interpersonal style
Cross-sectional
quantitative
analysis
1243 postpartum women
(birthplace of participants:
32.9% Mexico, 20.2%
Latin/South America, 6.8%
Asia, 40.1% United States)
Care received at Kaiser
Permanent Northern
CaliforniaMedicalCenteror
San Francisco General
Hospital
Non–privately insured and less acculturated women
reported better prenatal care experiences than US-born
andprivatelyinsuredwomen.
Largest variation in scores was in the patient-centered
decision-making domain, where non–US-born and
uninsured women reported higher decision-making
scores than US-born and privately insured women.
Uninsured women who had preterm or low-birth-weight
neonates reported lower mean scores of social supports.
III-B
Gramling et al31
2004
Describe experiences of
perinatal care and birth
Qualitative; 7
individual
interviews, 27
people in one
focus group
African American women
(n =28), White women
(n =5), and Asian American
women (n =1) who were
inpatient antepartum,
postpartum, or attending
prenatal appointments
Care received at a 520-bed
hospital in southeastern
United States
Three barriers to family-centered perinatal care were (1)
lack of coordination of services, (2) patient–provider
relationships, and (3) access to services and transport.
The facilitators of family-centered perinatal care were (1)
perceived response to patient at high risk, (2)
health-related support outside the hospital, and (3)
special resources.
III-B
Hanson32 2012 Describe prenatal care
experiences
Qualitative,
open-ended,
semistructured
interviews
58 postpartum American
Indian/Indigenous women
One tribe in Northern Plains
Three themes emerged: (1) communication barriers; (2)
institutional barriers; and (3) other barriers such income,
abuse, depression, substance use, transportation, work
schedule, scheduling appointments, seeing male provider.
Participants suggested culturally appropriate prenatal and
parenting education in addition to a class with traditional
elder.
Participants also desired more options for pregnant and
newly postpartum people who desire treatment programs
for substance use.
III-B
(Continued)
Journal of Midwifery & Women’s Health rwww.jmwh.org 209
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Korenbrot et al49
2005
Examine whether prenatal
health promotion and
psychosocial services are
associated with
interpersonal care
(communication,
decision-making,
interpersonal style) and
satisfaction with prenatal
care
Quantitative
one-time
telephone survey
in English or
Spanish
363 pregnant women: African
American (n =132),
non–US-born Latina
(n =96), US-born Latina
(n =65), and White (n =70)
California
Acquiring education on health promotion was associated
with higher quality interpersonal processes of care.
Completing assessment of one’s psychosocial state was
associated with improved interpersonal processes of care.
Communication and interpersonal style were significantly
associated with satisfaction with care.
Receiving education on health promotion and having
psychosocial assessments were significantly associated
with satisfaction with care.
III-B
Lori et al33 2011 Describe desired
characteristics of prenatal
care providers
Qualitative
descriptive focus
group interviews
(2 group 5, one
group 12)
22 pregnant African American
women
Southeastern Michigan
Four themes emerged: (1) demonstrating quality
patient–provider communication, (2) providing
continuity of care, (3) treating women with respect, and
(4) delivering compassionate care.
III-B
Mazul et al43 2017 Examine perspectives of
African American women
of low income on barriers
and facilitators to receiving
prenatal care in an urban
setting
Qualitative focus
groups
31postpartum(nomorethan
one y) African American
women
Southeastern Wisconsin
Themainthemeswerestructuralbarriers,psychosocial
stress, and attitudes and perceptions.
Barriers to obtaining prenatal care included structural
barriers such as transportation and insurance, negative
attitudes toward prenatal care, perceived poor quality of
care, unintended pregnancy, and psychosocial stressors
such as overall life stress and chaos.
Facilitators of prenatal care included positive experiences
such as trusting relationships with providers, respectful
staff and providers, and social support.
III-B
(Continued)
210 Vol u m e 69, N o . 2, Ma r c h /Ap r i l 2 02 4
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
McClellan and
Madler44 2022
Describe the lived
experiences of Mongolian
immigrants seeking
perinatal care in the United
States
Interpretative
phenomenology
12 postpartum Mongolian
women
6 different states in the United
States
Four themes emerged: (1) searching for support, focusing on
the importance Mongolian women place on strong
emotional support during pregnancy; (2) communication
and education, focusing on relationships with providers
and other health care workers; (3) comparing and
contrasting the health care systems, exploring differences
in the care systems of Mongolia and the United States;
and (4) traditions worth keeping, reviewing valued
cultural practices the women wished to continue
observing in their new country.
III-B
McLemore et al34
2018
Describe pregnancy
experiences of women who
are at high risk for preterm
birth
Secondary analysis
of focus group
data (5 groups in
English, one in
Spanish)
54 self-identified Black,
Hispanic/Latina, and
mixed-race pregnant and
postpartum women
Oakland, San Francisco, and
Fresno, California
Five themes emerged: (1) disrespect, (2) stressful
interactions, (3) inconsistent social support, (4) unmet
information needs, and (5) perceived competence and
confidence in parenting and newborn care.
Participant recommendations to improve systems included
respectful care, listening to patients, and birth plans.
Additionally, participants suggested an increase in providers
of color, improved communication among services and
providers, nonjudgmental care even with history of child
protective services involvement.
III-B
(Continued)
Journal of Midwifery & Women’s Health rwww.jmwh.org 211
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Phillippi et al35
2016
Describe the interface of
patients with staff and
certified
nurse-midwives/nurse
practitioners in a prenatal
clinic with low preterm
birth rates
Qualitative
descriptive,
semistructured
interviews
50 pregnant people:
White/Hispanic (n =22),
White/non-Hispanic
(n =16), Black or African
American (n =8), and Asian
(n =4)
Davidson County, Tennessee
The biggest facilitator of access to prenatal care was
connecting with providers and staff, and this also
contributed to quality, personalized care.
Connection was one of the big themes as participants were
able to overcome barriers if they knew they would be
treated well and get the care they needed.
The 4 aspects of connecting were (1) clinic needed to be
convenient to attend; (2) clinic and providers needed to
be compatible with culture, needs, and beliefs; (3)
providers needed to be competent; and (4) providers
needed to communicate well to form a connection.
III-B
Roman et al36
2017
Describe perinatal care
experiences of
Medicaid-insured women
Qualitative; 3 focus
groups
21 pregnant or postpartum (less
than one y) people, 91%
African American
Michigan
Four themes emerged: (1) pursuit of prenatal care by
recognizing pregnancy, making it work, and getting there;
(2) experiences of traditional prenatal care, which was
described as wasting time and leaving with nothing,
although the most important aspects were knowing the
participant and caring; (3) enhanced prenatal and
postnatal care with subthemes of acknowledging the need
for help, challenges of letting caregivers in and engaging
in mental health care, and relating to community health
workers; and (4) women’s health, a missed opportunity,
definedasskippingpostpartumvisits,goingtothe
emergency department postpartum, and not knowing
about contraception.
Twoglobalthemeswerecommunicationwithprovidersand
perceived socioeconomic and racial bias.
III-B
(Continued)
212 Vol u m e 6 9, No . 2 , Ma r c h /Ap r i l 2 02 4
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Seo et al37 2014 Describe experiences of
pregnancy and birth
Qualitative
interpretive
phenomenological
study
15womenborninSouthKorea
who gave birth within the
past 5 y
7statesintheUnitedStates:
West (n =10), South (n =2),
Northeast (n =2), Midwest
(n =1)
Four themes emerged: (1) feeling lost in the health care
environment where language was a barrier and feeling
socially isolated, (2) having limited choices during
childbirth when it came to choosing providers or hospital
and relying on providers to make decisions, (3) holding to
Korean traditions and expecting cultural sensitivity, and
(4) learning through childbirth when there was
information seeking and support to bridge the gap
through online support and social networks.
III-B
Shaffer38 2002 Describe factors influencing
access to prenatal care
Qualitative,
open-ended
interviews with 5
questions, in
person or over the
phone
46 pregnant Hispanic women
from Guatemala (n =30)
and Mexico (n =16)
Location not specified
Main factors influencing access to prenatal care were having
aproviderwhospokeSpanishanddemonstratedcultural
sensitivityandtheavailabilityofappointmenttimestofit
transport availability and nonworking hours.
III-B
Sheppard et al39
2004
Describe health care
experiences that influence
trust among women who
belong to a minority group
or have low income
Qualitative; 4 focus
groups with
guiding questions
and demographic
questionnaire
33 pregnant and postpartum
(less than one y) women:
African American (n =23),
White (n =6), Hispanic
(n =2), and multiracial
(n =2)
Location not specified
The common factors associated with patient trust are
communication, continuity, caring, competence, and
institutional and structural factors, which all lead to
satisfaction with care and adherence to physician
recommendations.
Participants reported that they felt they were not heard, felt
information was being withheld, and did not understand
non–native English-speaking providers.
Theydesiredtoseethesameproviderandappreciatedwhen
providers showed empathy.
Competence was based on misinformation and not
necessarily physician knowledge.
Structural factors such as discrimination based on insurance
also decreased trust in provider.
III-B
(Continued)
Journal of Midwifery & Women’s Health rwww.jmwh.org 213
Ta b l e 1 . (Continued)
Author (Year of
Publication) Study Purpose Design and Method Sample and Location Results
Level of
Evidence and
Qualitya
Tan d o n e t a l 50
2005
Describe respect and
communication
experiences during
pregnancy
Mixed methods,
semistructured
interviews
427 postpartum women:
Hispanic (n =125),
White/non-Hispanic
(n =197),
Black/non-Hispanic
(n =73), and Haitian
(n =32)
Palm Beach County, Florida
86% of Hispanic participants felt that providers/nurses (80%
for staff) treated them with respect during prenatal care
appointments.
The percentages of respectful care were lower than for
Hispanic participants compared with non-Hispanic
participants.
27% experienced language/communication problem with
providers during prenatal care.
The odds of having communication problems were
significantly higher for Hispanic participants compared
with non-Hispanic participants.
Hispanic participants felt that care was not patient centered
due to lack of respect from physicians, nurses, and office
staff in addition to communication problems with
physicians and nurses.
III-B
Wheatly et al45
2008
Examine prenatal care
experiences of primiparous
women with low income
Qualitative focus
group
87 postpartum (less than one y)
women: Mexican, Puerto
Rican, African American,
and White
Chicago, IL
Participants cited both negative and positive aspects in each
of following areas in their discussions around
patient-centered care: listened carefully, explained things,
showed respect, spent enough time.
III-B
aLevels of evidence (I-V) and quality (A-C) from the Johns Hopkins Evidence-Based Practice model rating scale.
214 Vol u m e 69 , N o. 2, M a rc h / Apr i l 2 0 24
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Diagram of Identification, Screening, and
Inclusion
(I-V) and quality (A-C).22 The majority of the included stud-
ies were qualitative, and, therefore, we used mapping as part of
a memoing technique to synthesize and identify the themes.23
Mapping creates a visual overview of the analysis whereby one
can connect themes and form boundaries around them. One
of the functions of memoing is to extract meaning from the
data by producing definitional statements that compare and
contrast concepts.23 After a thorough review of each article,
memos were created to document key observations. These
memos were analyzed to identify recurring themes, which
were subsequently organized to gain a deeper understanding
of their interconnections.
The therapeutic model in psychology, which is the ba-
sis of person-centered therapy, indicates that there are several
key conditions, or factors, leading to outcomes such as self-
actualization and feeling understood.24 Following this model,
the collected data were categorized into predefined factorsand
outcomes. Furthermore, an additional predefined category
was created to encompass the recommendations derived from
theanalysis.Factorsweredefinedasfacilitating,hindering,or
influencing communication between pregnant people of color
and their prenatal care providers. Outcomes were defined as
participants’ self-reported communication experiences with
prenatal care providers. Recommendations were defined as
proposed actions to improve patient–provider communica-
tion.
RESULTS
We included 26 articles, of which 22 were qualitative
studies,25–46 3werequantitativestudies,
47–49 and one was
a mixed-methods study.50 Eleven of the included articles
used focus group or interviews,31,33,34,36,39–43,45,46 3useda
community-based participatory approach,40–42 and 3 were
phenomenological qualitative studies.30,37,44 Twoofthein-
cluded studies had a quantitative cross-sectional study
design.47,48 All of the included studies were rated as nonex-
perimental studies (III) of good quality (B), with one excep-
tion. One study was rated III-C (low quality) due to a limited
sample size that hindered data saturation.30
Sample sizes ranged from 8 to 1243 participants. Ages of
theparticipantsrangedfrom15to77years.Twostudiesin-
cluded participants who were not restricted by age or the
number of years that had passed since giving birth, as these
studies did not impose any specific inclusion criteria regard-
ing participant age or postpartum duration.32,41 Eleven studies
were conducted in the Midwest,25,28,29,32,33,36,41,43,45–47 6 studies
in the South,27,30,31,35,42,50 4 studies in the West,26,34,48,49 and
one study in the Northeast.40 Two studies included partici-
pants from several states,37,44 and 2 studies did not specify a
location.38,39
Eight studies included pregnant people
only,27,28,30,33,35,38,47,49 12 studies included people in the
postpartum period,26,29,32,34,37,42–46,48,50 and 6 studies included
Journal of Midwifery & Women’s Health rwww.jmwh.org 215
pregnant and postpartum people.25,31,36,39–41 Of the 26 studies
in the review, 2 studies also included health care workers (ie,
midwives, nurse practitioners, obstetricians, family physi-
cians, nurses, student nurses, doulas, interpreters, service
coordinators, volunteers).29,47
Six studies described the experiences of self-identified
Black or African American participants.25,33,36,40,43,47 One
study examined self-identified African American or Black
and mixed-race participants.29 Five studies described the ex-
periences of Hispanic or Latina/x/e participants.27,28,30,38,50
One study described the experiences of Indigenous/American
Indian participants.32 Ten studies described the experi-
ences of individuals from a range of diverse racial and
ethnic groups.26,31,34–36,39,45,46,48,49 Two studies described the
experiences of majority immigrant individuals,35,48 and 5
studies described the experiences of one racial or ethnic
group: Korean,37 Marshallese,42 Mexican,27 Mongolian,44 and
Somali41 participants. As this review pertains to health com-
munication, direct quotations were taken from included stud-
ies to give voice to the experiences of pregnant people of color
(Table 2).
Overarching Themes
Two overarching themes, racism and discrimination and un-
met information needs, were relevant to both factor and out-
come categories. These themes also provided several recom-
mendations and will be discussed separately.
Racism and Discrimination
Racism was defined as receiving poor treatment because of
one’s race or ethnicity at various levels, from the interper-
sonal to structural. In 8 studies, pregnant people of color re-
ported racism as both a factor hindering effective communi-
cation and an outcome of the experience of communicating
with prenatal care providers.25,26,28,30,34,36,42,43 Participants in
2 studies reported multiple accounts of interpersonal racism
that included both verbal and nonverbal acts.25,28 In a qual-
itative study examining patient–provider interactions among
22 women of color in California, one participant noted be-
ingrushedandtreatedpoorlyduringprenatalvisitscom-
pared with other patients whom she noticed were treated
with kindness.26 Likewise, structural racism against Black
birthing people was highlighted through the reinforcement
of obstetrician-led prenatal care in hospitals when a partici-
pant was prevented from having a home birth.25 Adebayo et
al explain that the denial of community and midwife-attended
birth, traditionally used by African American birthing people,
demonstrates the persistent institutional racism that exists in
perinatal care.25
Participants in other studies also reported that racism
posed significant barriers to effective communication with
their health careproviders, leading to lack of trust, stressful in-
teractions, and poor quality of care.25,26,34 However, they also
shared that beyond experiencing racism, they encountered
discrimination based on their intersecting social identities af-
ter engaging in communication with prenatal care providers.
Six studies showed that participants felt intersecting that
factorsofraceandpovertycausedproviderbiasandpoor
treatment.25,26,34,39,43,46 Six studies reported instances of dis-
crimination based on insurance type, particularly Medicaid
coverage, underinsurance, and lack of insurance.25,26,36,39,43,46
Discrimination against pregnant people of color was also re-
ported based on lack of English language proficiency,28,30,34,44
not being married,26,34,42,46 education,26,34 and age.34,46
Unmet Information Needs
Unmet information needs refer to instances when pregnant
individuals expressed a desire for more pregnancy-related
content or had unanswered questions regarding pregnancy-
related results or issues. This definition is consistent with the
research conducted by McLemore et al, a qualitative study of
54 pregnant and birthing people of color at risk for preterm
birth.34 McLemore et al identified unmet information needs
as a major theme, meaning that participants did not receive
information about why clinical decisions were being made.34
Participants in 9 studies discussed unmet information
needs.26,36,37,39,40,43–46 In6ofthesestudies,pregnantpeople
of color described prenatal care providers as not sharing in-
formation due either to apathy or to the perception that par-
ticipants would not understand the information.36,37,39,43,44,46
Three studies indicated that because participants did not
receive information from their prenatal care providers, in-
formation needs were met by online communities, family,
or friends.36,37,39 Three studies highlighted unmet informa-
tion needs concerning public health insurance.26,37,43 There
were several other reasons why information needs were not
met: perception that participants were not asking the right
questions,36,46 prenatal care providers not being in the room
long enough,36 and race.26 As a result of inadequate in-
formation, participants were fearful32 and unprepared for
birth46 and went along with provider recommendations with-
out comprehending decisions.37
Factors
The following themes were identified as factors that fa-
cilitated, hindered, or influenced communication between
pregnant people of color and their prenatal care providers:
provider behaviors, language barriers, structural barriers,
provider type, continuity of care, and fear.
Provider Behaviors
Providerbehaviorsweredefinedasactionsorcommuni-
cation styles that either facilitated or hindered commu-
nication. Nine studies identified specific communication
qualities that pregnant and postpartum people of color
desired.27,28,33,35,36,39,43,45,46 Participants consistently described
wanting personalized, direct, and thorough explanations
and to feel that prenatal care providers were friendly and
empathetic.27,28,33,35,36,39,43 In addition, participants identi-
fied the following desired provider behaviors: asking ques-
tions and giving time to ask questions,28,33,35,36,43 making
eye contact,28,33,46 being friendly through actions such as
making small talk and creating a relaxed environment,27,29,35
smiling,27,28,33 greeting pregnant people properly,27,28 and be-
ing patient.28,45 In contrast, participants in 9 studies described
216 Vol u m e 69, N o . 2, Ma r c h /Ap r i l 2 02 4
Ta b l e 2 . Participant Quotations Illustrating Themes
Theme Quotation
Overarching themes
Racism and
discrimination
… to eliminate racism. Taking Hispanic and Latino patients more into consideration because there are so many of
them.28(p796)
“I’m still gonna have my baby at home.” And the doctor walked out on me. He never came back in the room …
I’m like, “Y’all are treating me wrong. You’re not listening to me. You’re not respecting me. This is my body, my
baby.”25(p1140)
I was unfortunately laid off from my job in February so therefore my insurance changed, and I had to switch over
to government insurance. His [the provider] entire attitude completely changed when I switched over to the
[Medicaid Managed Care plan name redacted] insurance. Where my visits were him being - minutes in
the room with me, they ended up being a minute, minutes and he refused to answer any of my questions
regarding my pregnancy.46(p7)
Unmet information needs Ididn’tknowmuch[medical knowledge] so I just followed what I was told. The doctors are experienced. They
didn’t ask me to choose between things and didn’t explain about things in length either. They just told me to do
this because it’s about time, then I did. I didn’t have enough information, and actually the medical system was
unfamiliar.37(p311–312)
Factors
Provider behavior They just ask you questions, like how you feeling, did anything change, do you have any questions. All that let me
know they care and they are trying to help you and the baby.43(p83)
As for some places, they are rude and difficult to work with. Like I said earlier, when I was pregnant with one of
my daughters, back when there were a few Marshallese families here, when I went to seek maternal care, they
were being rude and not wanting to help us in any way.42(p1072)
Languagebarrier Idon’treallyspeakthelanguage,soIjustkeepquiet.…Theyaren’tniceinsomeclinic.It’sawfulbecauseI
personally feel discriminated against.…I understand a little, and they are laughing and talking, and I know
becausetheysay,‘Spanish,’andIaskwhyaretheylikethat?Butohwell,Ihavetoignoreit.Butitis
sad.30(p467)
Structural barriers Now, that’s awful! Trying to get in touch when you’re going to a prenatal center and you’re trying to call to talk to
your doctor but you don’t talk to your doctor. You try to leave a message with the nurse and the nurse isn’t
there because the nurse is doing their job in the clinic. And so you got to leave a message on the answering
machine to the nurse so she can get to the doctor and the doctor might call you back. Then again nurse might
call you back. That’s just too awful. They tell you they’ll call you back by :. Sometimes they get back in
touch with you and sometimes it might be the next morning but it’s late. I don’t get it.31(p45 )
Provider type I had nurse-midwives … every single appointment, she would just come and sit with me. Any question I had to
ask her, she would just sit there and answer all my questions.45(p1593)
Continuity of care The only problem with the [place of care] is that the only time you get to see the doctor is when you are very close
to delivery time. I don’t think that is good because you need to get on a personal level with your doctor if he is
going to deliver your baby.39(p488)
Fear I didn’t go to the doctor … really, why should I go? For what? Because I am scared of what they can do to me. I
will get there, and the doctor will bring some students into the room without even asking me. I have heard from
my friends and sisters that this is what they do.41(p6)
Outcomes
Disrespect I feel the baby move, she’s like: No, you’re not, you’re not even that far along … If I told her I’m in pain, something
don’tfeelright,she’salwayslike:Oh,no,no,you’renot.ShealwaystoldmeI’mwrongateverything.Ididn’t
like that.36(p589)
Trus t I want to be able to trust. If they show me good behavior then I’d be willing to talk more. But if they won’t show
megoodbehaviorIwouldn’twanttotalktothem.I’dprettymuchwanttogotosomeoneelse.Iwouldn’tbe
asking any questions. Their behavior would stop me talking or saying something that I should say because if the
provider was good to the participant, then she would be open and trust them.27(p392)
(Continued)
Journal of Midwifery & Women’s Health rwww.jmwh.org 217
Ta b l e 2 . (Continued)
Theme Quotation
Decision-making power So, why not communicate with me your concerns while you have me in the office instead of going behind my back
and chattering all my mental—all my providers, the nurse, all of them, the social workers, all communicate
witheachother.They’reateam.So,ifoneknows,theyallknow.So,iftheywouldjusttellmeifIwasapartof
the team (laughs), which I’m not—they […] want to have this paternal relationship with me when they should
be working with me, not thinking they’re doing something in my best interest.26(p7)
Missed appointments There is no … type of relationship built up between the mother and anyone in the staff. And I think that you
knowmighthavealottodowithwhytheydon’tgoback.32(p7)
Satisfaction with care The staff is really friendly and, you know, open to questions and, you know, not cold, always warm. So that’s
always good. That’s why I choose this place because I have had great experience with coming here prenatally
and delivering with them.35(p165)
undesired specific communication behaviors that included
prenatal care providers appearing busy or rushed or not ta king
the time to explain concepts,29,31,32,44,46 having no desire for
personal connection,36,37,40,44 and appearing not to care.43,46
Language Barriers
Language barriers were defined as difficulty in communicat-
ing due to lack of a shared language between a participant
and health care provider. Most participants in studies that in-
cluded a majority of immigrant participants highlighted lan-
guage barriers as a hindrance to communication.30,37,38,42,44,50
Participants who spoke English as an additional language
desired prenatal care providers who spoke their native lan-
guage and had cultural knowledge of their countries of
origin.27,29,38 In 8 studies, participants reported that inter-
preters, doulas, and cultural brokers who spoke their same
language helped to improve communication with their pre-
natal care providers.28,30,32,37,38,41,42,50
Three studies described the negative emotions that preg-
nant and postpartum migrants experienced as a result
of the inability to communicate with their prenatal care
providers.30,38,42 Participants in 2 studies expressed concern
about the quality of care and fear of receiving substandard or
culturally inappropriate care because the y could not speak En-
glish or were not fluent.30,42
Structural Barriers
Structural barriers were defined as institutional or systemic
issues that prevented quality communication between preg-
nant people of color and their prenatal care providers. Thir-
teen studies reported structural barriers associated with
communication.26,31,32,34,36–40,42–44,46 Structural factors influ-
encing communication included the following: difficulty
getting public health insurance,26,34,36,37,39,40,42–44,46 difficulty
with transport,26,31,32,36,38,40,42,43 wait time to see prenatal
care providers,26,31,32,36,40,43 inflexible times and length of
appointments,26,32,39,43 location,26,31,43 and overbooking and
inefficient staff.39,43 In contrast, a cross-sectional study by
Fuentes-Afflicketalfoundthatwomenwithnonprivateinsur-
ance had higher ratings of overall prenatal care experiences,
including communication with prenatal care providers.48 Ad-
ditionally, a qualitative study of 50 pregnant people of color re-
ceiving care at the same clinic in Tennessee reported no prob-
lems with wait times, location, or appointment times.35
Provider Type
Provider type was defined as the characteristics or qualifica-
tions of prenatal care providers that facilitated or hindered
communication. Five studies discussed a variety of provider
types such as certified nurse-midwives, obstetricians, family
medicine physicians, residents, nurse practitioners, and
physician assistants. Participants in 3 studies expressed a
preference for midwifery care.32,40,41 One study found that
thereweremorepositiveremarksaboutnurse-midwives
compared with physicians, such as that nurse-midwives took
thetimetolisten.
45 Additionally, participants in 2 stud-
ies expressed a strong desire for only female prenatal care
providers.30,32 Three studies with diverse samples highlighted
participants’ desires for racially concordant care.26,34,46 Nine
studies indicated pregnant people of color’s preference for
prenatal care providers who either were culturally congruent
or understood the pregnant person’s culture.27–30,35,37,38,44,46
Continuity of Care
Continuity of care was defined as seeing the same prena-
tal care provider for multiple prenatal visits or through-
out the entire pregnancy. There were 5 studies that empha-
sized the importance of continuity of care to facilitate qual-
ity communication; participants in these studies preferred to
have a single prenatal care provider follow them through-
out the pregnancy.33,39,40 Lack of continuity of care led to
pregnant people of color repeating themselves or hearing the
same questions from prenatal care providers.26,33,36,40 See-
ing the same prenatal care provider consistently led to trust
and satisfaction of care,26,33 whereas lack of continuity of
care felt impersonal26,40 and did not allow for a trusting
relationship.32,39
Fear
Fear was defined as being afraid of certain aspects of pre-
natalcaredelivery.Threequalitativestudiesthatexamined
218 Vol u m e 69, N o . 2, Ma r c h /Ap r i l 2 02 4
different aspects of the prenatal care experiences of preg-
nant people found fear to be a factor in communications
with prenatal care providers.30,41,42 In a qualitative study of
43 Marshallese birthing people living in the United States,
participants feared communicating with their prenatal care
providers as they were afraid of hearing about adverse out-
comes of their pregnancies.42 Their fear was also tied to
embarrassment around their adolescent or advanced-age
pregnancies.42 Inaqualitativestudyof31pregnantpeopleof
color by Barnett et al, lack of information about pregnancy
and birth caused fear.46
Outcomes
Outcomes were defined as participants’ self-reported commu-
nication experiences with prenatal care providers. The fol-
lowing outcomes were identified: disrespect, trust, decision-
making power, missed appointments, and satisfaction with
care.
Disrespect
Disrespect was defined as having concerns dismissed or
not being heard.37,47 Nine studies found disrespect to
be an outcome of communication with prenatal care
providers.25,26,34,36,39,40,45,46,50 In a qualitative study of 87
primiparous women with low income, disrespect was de-
scribedasprenatalcareprovidersbeingrudeormean
and yelling.45 Seven studies reported pregnant people
of color not being listened to or having their concerns
dismissed.26,36,39,40,43,45,46 In 5 studies, disrespect was found
to be rooted in racism.25,26,28,34,41 In a mixed-methods study
of 359 pregnant people by Tandon et al, Hispanic pregnant
people were less likely to report that prenatal care providers
treated them with respect during prenatal visits compared
with those identifying as non-Hispanic (odds ratio, 0.29; 95%
CI, 0.10-0.86).50 In contrast, only one study reported that
participants felt respected during communications with their
prenatal care providers.35
Trus t
Trust was defined as a perception of the prenatal care
provider’s reliability and truthfulness. Findings from 7 stud-
ies revealed a strong correlation between communication
and trust, indicating that trust or mistrust can be an out-
come of the quality of communication between prenatal
care providers and pregnant individuals.25,27,32,33,39,41,47 Two
studies highlighted that provider behavior such as spend-
ing time with patients led to trust.27,46 Misinformation
and conflicting information from different prenatal care
providers led to mistrust.39 One cross-sectional analysis of 204
African American pregnant women demonstrated that qual-
ity patient–provider communication was predictive of partic-
ipants’ greater trust in perinatal care providers.47
Decision-Making Power
Decision-making power was defined as agency in choos-
ing certain interventions or options during pregnancy. Par-
ticipants in 5 studies noted that communicating with pre-
natal care providers led to decision-making power or lack
of power.26,34,35,41,48 Studies demonstrated lack of decision-
making power due either to how options were presented26,29
or to lack of understanding.36,37,41
Missed Appointments
Missed appointments were characterized as instances when
pregnant individuals intentionally avoided or failed to at-
tend their scheduled prenatal care visits. The 6 studies exam-
ined found that poor communication and strained relation-
ships with health care providers contributed to these missed
appointments.27,28,32,39,41,43 Missed appointments were linked
to fear of judgment,26,42 past negative experiences (personal or
those of family or friends),32,39,41 and no or poor relationship
with prenatal care providers.32,43
Satisfaction With Care
Satisfaction with care was defined as the level at which partici-
pants were pleased or not pleased with their care during preg-
nancy. Fourteen studies discussed satisfaction of care as an
outcome of positive communication. Dissatisfaction with care
was linked to poor relationships with prenatal care providers
and to provider behaviors in 6 studies.29,36,39,40,43,45 Dissatis-
faction was directly linked to distrust,27,32,39,47,49 linguistic dis-
cordant care,28,38 andlackofcontinuityofcare.
33,39 Out of the
14 studies, only 2 studies indicated the majority of participants
being satisfied with care.31,35
Recommendations
Recommendations were defined as suggested actions to en-
hance patient–provider communication, and the analysis
identified 3 key themes: culturally congruent care, provider
training, and workforce development.
Culturally Congruent Care
There were 9 studies that emphasized the importance of
racially and culturally congruent care, which refers to having
ahealthcareproviderwhosharesthesameraceandlanguage
in addition to possessing an understanding of one’s culture
and background.26–30,34,35,37,38,44,46 To address language bar-
riers, recommendations included use of interpreters, doulas,
community health workers, and individuals who serve as cul-
tural brokers.33,4 0,42 Another suggestion focused on alterna-
tive models of prenatal care that for some can be more cul-
turally congruent, such as group prenatal care like Center-
ing Pregnancy, as well as integrating prenatal care with com-
munity programs like Healthy Start.29,31,33,37,41 Additional rec-
ommendations involved providing health education materials
and classes in various languages.31,33
Provider Training
Although researchers in 2 studies specifically asked par-
ticipants to provide recommendations for how to im-
prove patient–prov ider communication and relationships,32,34
Journal of Midwifery & Women’s Health rwww.jmwh.org 219
participants across 6 studies recommended implement-
ing trainings for prenatal care providers on communica-
tion and cultural competence to improve communication
quality.28,29,32,38,41,47 Participants in 2 studies recommended
specific trainings on racism and implicit bias.25,26 An addi-
tional recommendation emphasized the need for communi-
cation training, particularly on how to listen to patients.34,46
Finally, implementing shared decision-making was a recom-
mendation for improving communication about pregnancy-
relatededucationandtopics.
29,37,48
Workforce Development
Three studies made recommendations on offering and in-
creasing access to midwifery care.32,40,41 Participants in a qual-
itative study by Agbemenu et al stated that midwives are
needed to specifically reduce cesarean birth rates among So-
mali birthing people.41 Four studies also made recommenda-
tions to diversify the perinatal workforce.26,27,30,50
DISCUSSION
This integrative review presents a comprehensive examina-
tion of factors and outcomes that have influenced commu-
nication between prenatal care providers and pregnant indi-
viduals of color. Additionally, recommendations aimed at en-
hancing the quality of communication are made by many of
the included studies. Patient–provider communication is in-
tertwined with racism, provider behaviors, disrespect, trust,
andsatisfactionwithprenatalcare.
Racism and discrimination emerged as an overarching
theme associated with communication between prenatal care
providers and pregnant individuals of color. Previous studies
have extensively documented instances of racism that nega-
tively affect the communication dynamics between pregnant
individuals and their prenatal care providers.11,51,52 Areview
encompassing 12 qualitative studies focusing on the relation-
ships between Black women and prenatal care providers iden-
tified several characteristics that impede these relationships,
including differential treatment, biased attitudes, lack of em-
pathy, limited choices, inadequate health information provi-
sion, substandard care, and dismissal of concerns.53 These
findings align with our own research, which revealed similar
patterns pertaining to provider behaviors, racism, discrimina-
tion, unmet information needs, and decision-making power.
Research indicates that foreign-born individuals of color
generally experience improved pregnancy and birth outcomes
compared with their US-born counterparts.54 However, our
findings diverged from the existing literature, as pregnant
individuals who were immigrants consistently reported lan-
guage barriers, fear, and discrimination, which can all lead to
poor birth outcomes. Some feared that the inability to effec-
tively communicate would result in suboptimal care. Fear of
mistreatment and discrimination was found in several stud-
ies with immigrant participants, consistent with reviews de-
scribing the prenatal and birth experiences of US immigrant
individuals.55 One scoping review on the experiences of preg-
nant people of color with low income found communica-
tion with perinatal care providers to be a major theme, with
subthemes including listening, provider responses, discrimi-
nation, and language barriers.56 Similarly, a mixed-methods
study examining a diverse sample of 55 women in Florida
foundthatthemajorityofHispanicwomendelayedentryinto
prenatal care and were hesitant to communicate with health
care providers due to fear of discrimination.57
Respect and trust were often related to satisfaction with
care. This finding is consistent with several studies that have
demonstrated direct associations between person-centered
care and communication, respect, trust, and satisfaction.58,59
A cross-sectional survey analysis of 209 Black birthing people
who had given birth within the past 2 years found that person-
centered communication resulted in increased satisfaction
with care.60 Mediators in the relationship between communi-
cation and quality of care during birth were participants’ trust
in their perinatal care providers and feeling respected. Almost
halfoftheparticipantsreportedfeelingdisrespected.
60 In this
review, studies demonstrated both satisfaction and dissatisfac-
tion with care.
Strengths and Limitations
The inclusion of studies from diverse racial and ethnic groups
allowed for a more comprehensive examination of patient–
provider communication. Articles were selected by 2 authors
in a rigorous coding process. The studies included in the anal-
ysis exhibited heterogeneity in terms of populations and study
methodologies. None of the included studies addressed the
gender identity or sexual orientation of participants or the
potential effect of homophobia and/or transphobia on com-
munication with prenatal care providers. Furthermore, none
of the included studies discussed communication via tele-
health or patient portals, additional methods of information
exchange that may enhance or impede patient–provider com-
munication.
Reflexivity
We recognize the potential for bias based on our positional-
ity and therefore present it here: A.H.G. is a cisgender Asian
American woman who is a certified nurse-midwife, doctoral
student, and midwifery educator. M.R.A. is a queer, cisgender
White woman who is a certified nurse-midwife, researcher,
and educator. L.C. is a cisgender African American nurse
scholar, certified nurse-midwife, and associate professor of
nursing. J.K.E. is a cisgender White woman who is a public
health nurse-scientist and associate professor of nursing.
Implications for Practice, Education, and Research
On an institutional scale, suggestions for enhancing commu-
nication between prenatal care providers and individuals of
colorincludetrainingforprenatalcareprovidersincultural
humility and recognizing implicit bias.29,34 It is imp ortant for
prenatal care providers to recognize their own implicit bi-
ases and how they affect communication.66 Additional recom-
mendations are to increase education on racism, implicit bias,
and respectful perinatal care.61,62 Drawing from our findings,
the concept of intersectionality, which involves the combined
impact of various social categories in shaping systems, must
also be incorporated into professional health care education.34
220 Vol u m e 6 9, No . 2 , Ma r c h /Ap r i l 2 02 4
Improvements in communication and information ex-
change are needed to address unmet information needs of
pregnant people of color and empower them in decisions. Us-
ing a shared decision-making approach when interventions
and care options are offered and attending to pregnant peo-
ple’s racial and ethnic identities as part of their experience are
crucial.63 Providing communication that aligns with the in-
formation needs of pregnant individuals of color in an empa-
thetic manner; fostering trust, respect, and personalization;
and facilitating effective shared decision-making can effec-
tively address the issues of poor communication highlighted
in this review. It is important to conduct further research to
explore how health care providers communicate in the digital
realm, considering the growing use of telehealth and patient
portals. Understanding how access to these communication
modalities can contribute to the quality and equity of perina-
tal care is crucial for future investigations.
At the interpersonal level, communication may be im-
proved by first recognizing and examining the power dy-
namics that exist in patient–provider relationships.26,31 This
is consistent with recommendations from studies that exam-
ine the intersection of race and class.64,65 This will further help
achieve optimal communication between pregnant people of
color and their prenatal care providers.
It is essential to acknowledge systemic racism and histor-
ically rooted oppression and privilege within the relationship
between the pregnant person of color and their perinatal care
provider.66 The fields of midwifery and obstetrics are predom-
inantly made up of White providers,67,68 further emphasiz-
ing the need for education programs and hiring practices to
embraceanantiracistframeworkandcommittodiversifica-
tion of the workforce. Evidence has shown that pregnant peo-
ple of color find racially concordant care optimal for quality
communication.26,34 Thus supporting and building models of
care that are led by Black midwives who prioritize racial con-
cordance are essential.61 Central to this strategy is providing
support for student midwives of color through scholarships
and mentoring, particularly as racism can deter the initiation
and completion of midwifery education, as found in a cross-
sectional survey of 799 midwifery students of color by Mehra
et al.62 When racially and culturally concordant prenatal care
is unavailable, doulas who look like or have shared lived
experiences with their clients can improve patient–provider
communication.69 Doulas improve the pregnancy experience
and facilitate self-advocacy and communication with perina-
tal care providers.70
CONCLUSION
It is evident in this review that pregnant people of color con-
tinue to face challenges in their communication with prena-
tal care providers. Racism and discrimination, along with un-
met information needs, are prominent concepts in patient–
provider communication. Two decades ago, the Institute of
Medicine report highlighted issues with patient communica-
tion with an imperative for health care providers to improve;
however, little has changed. Our findings hold significance in
guiding future research endeavors and informing interven-
tions aimed at enhancing patient–provider communication
for pregnant people of color.
ACKNOWLEDGMENTS
We would like to thank Dr. Erin George for her support and
edits to this manuscript. Amy H. Goh is grateful for support
from the A.C.N.M. Foundation, Inc., and the March of Dimes
Graduate Scholarships.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
REFERENCES
1. Effective patient–physician communication. Obstet Gynecol.
2014;123(2 pt 1):389-393. doi:10.1097/01.aog.0000443279.14017.12
2. American College of Nurse-Midwives philosophy of midwifery.
American College of Nurse-Midwives. https://www.midwife.org/
Our-Philosophy-of-care
3. Agency for Healthcare Research and Quality. Chartbook on
Person- and Family-Centered Care.AgencyforHealthcareRe-
search and Quality; 2018. https://www.ahrq.gov/research/findings/
nhqrdr/chartbooks/personcentered/pfcc.html
4. Afulani PA, Altman MR, Castillo E, et al. Development of the
person-centered prenatal care scale for people of color. Am J Obstet
Gynecol. 2021;225(4):427.e1-427.e13. doi:10.1016/j.ajog.2021.04.216
5. Rathert C, Wyrwich MD, Boren SA. Patient-centered care and
outcomes. Med Care Res Rev. 2012;70(4):351-379. doi:10.1177/
1077558712465774
6. Wolf DM, Lehman L, Quinlin R, Zullo T, Hoffman L. Effect
of patient-centered care on patient satisfaction and quality of
care. JNursCareQual. 2008;23(4):316-321. doi:10.1097/01.ncq.
0000336672.02725.a5
7. Nicoloro-SantaBarbara J, Rosenthal L, Auerbach MV, Kocis C,
Busso C, Lobel M. Patient-provider communication, maternal anx-
iety, and self-care in pregnancy. Soc Sci Med. 2017;190:133-140.
doi:10.1016/j.socscimed.2017.08.011
8. Delaney AL, Singleton G. Information and relationship functions
of communication between pregnant women and their health
care providers. Commun Stud. 2020;71(5):800-822. doi:10.1080/
10510974.2020.1807376
9. Guendelman S, Broderick A, Mlo H, Gemmill A, Lindeman D. Lis-
tening to communities: mixed-method study of the engagement of
disadvantaged mothers and pregnant women with digital health
technologies. JMedInternetRes. 2017;19(7):e240. doi:10.2196/jmir.
7736
10. Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the st Century. National Academy Press; 2001. doi:10.
17226/10027
11. JanevicT,PivergerN,AfzalO,HowellEA.“Justbecauseyouhave
ears doesn’t mean you can hear”—perception of racial-ethnic dis-
crimination during childbirth. Ethn Dis. 2020;30(4):533-542. doi:10.
18865/ed.30.4.533
12. OkoroON,HillmanLA,CernasevA.“Wegetdoubleslammed!”:
Healthcare experiences of perceived discrimination among
low-income African-American women. Wom e n s Heal t h ( L o n d ) .
2020;16:174550652095334. doi:10.1177/1745506520953348
13. Davis DA. Reproducing while Black: the crisis of Black maternal
health, obstetric racism and assisted reproductive technology. Re-
prod Biomed Soc Online. 2020;11:56-64. doi:10.1016/j.rbms.2020.10.
001
14. Canty L. The lived experience of severe maternal morbidity among
Black women. Nurs Inq. 2022;29(1):e12466. doi:10.1111/nin.12466
15. Scott KA, Britton L, McLemore MR. The ethics of perinatal care for
Black women. J Perinat Neonatal Nurs. 2019;33(2):108-115. doi:10.
1097/jpn.0000000000000394
16. Chang YS, Coxon K, Portela AG, Furuta M, Bick D. Interventions to
support effective communication between maternity care staff and
Journal of Midwifery & Women’s Health rwww.jmwh.org 221
women in labour: a mixed-methods systematic review. Midwifer y.
2018;59:4-16. doi:10.1016/j.midw.2017.12.014
17. Lippke S, Derksen C, Keller FM, Kötting L, Schmiedhofer M, Welp
A. Effectiveness of communication interventions in obstetrics—a
systematic review. Int J Environ Res Public Health. 2021;18(5):2616.
doi:10.3390/ijerph18052616
18. Alexander K, Clary-Muronda V. A scoping review of interven-
tions seeking to improve aspects of patient–provider relationships
involving Black pregnant and post-partum people. JAdvNurs.
2023;79(5):2014-2024. doi:10.1111/jan.15537
19. Ford CL, Airhihenbuwa CO. The public health critical race
methodology: praxis for antiracism research. Soc Sci Med.
2010;71(8):1390-1398. doi:10.1016/j.socscimed.2010.07.030
20. Whittemore R, Knafl K. The integrative review: updated method-
ology. JAdvNurs. 2005;52(5):546-553. doi:10.1111/j.1365-2648.2005.
03621.x
21. Covidence systematic review software. Veritas Health Innovation;
2022. https://www.covidence.org
22. DangD,DearholtS,BissettK,AscenziJ,WhalenM.Johns Hop-
kins Evidence-Based Practice for Nurses and Healthcare Profession-
als: Model and Guidelines. 4th ed. Sigma Theta Tau International;
2022.
23. Birks M, Chapman Y, Francis K. Memoing in qualitative research.
JResNurs. 2008;13(1):68-75. doi:10.1177/1744987107081254
24. Raskin N, Rogers C. Person-centered therapy. In: Wedding
D, Corsini RJ, eds. Current Psychotherapies. Cengage Learning;
2005:130-165.
25. Adebayo CT, Parcell ES, Mkandawire-Valhmu L, Olukotun O.
African American women’s maternal healthcare experiences: a crit-
ical race theory perspective. Health Commun. 2022;37(9):1135-1146.
doi:10.1080/10410236.2021.1888453
26. Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I,
Franck LS, Lyndon A. Inform ation and power : women of color’s e x-
periences interacting with health care providers in pregnancy and
birth. Soc Sci Med. 2019;238:112491. doi:10.1016/j.socscimed.2019.
112491
27. Baxley SM, Ibitayo K. Expectations of pregnant women of Mexi-
can origin regarding their health care providers. JObstetGynecol
Neonatal Nurs. 2015;44(3):389-396. doi:10.1111/1552-6909.12572
28. Bergman AA, Connaughton SL. What is patient-centered care
really? Voices of Hispanic prenatal patients. Health Commun.
2013;28(8):789-799. doi:10.1080/10410236.2012.725124
29. Coley SL, Z apata JY, Schwei RJ, et al. More than a “number”:
perspectives of prenatal care quality from mothers of color and
providers. Womens Health Issues. 2018;28(2):158-164. doi:10.1016/j.
whi.2017.10.014
30. Fitzgerald EM, Cronin SN, Boccella SH. Anguish, yearning,
and identity. JTranscultNurs. 2016;27(5):464-470. doi:10.1177/
1043659615578718
31. Gramling L, Hickman K, Bennett S. What makes a good family-
centered partnership between women and their practitioners? A
qualitative study. Birth. 2004;31(1):43-48. doi:10.1111/j.0730-7659.
2004.0273.x
32. Hanson JD. Understanding prenatal health care for American
Indian women in a Northern Plains tribe. JTranscultNurs.
2012;23(1):29-37. doi:10.1177/1043659611423826
33. Lori JR, Yi CH, Martyn KK. Provider characteristics desired by
African American women in prenatal care. JTranscultNurs.
2011;22(1):71-76. doi:10.1177/1043659610387149
34. McLemore MR, Altman M R, Cooper N, Williams S, Rand L, Franck
L. Health care experiences of pregnant, birthing and postnatal
women of color at risk for preterm birth. Soc Sci Med.2018;201:127-
135. doi:10.1016/j.socscimed.2018.02.013
35. PhillippiJC,HolleySL,PayneK,SchornMN,KarpSM.Facilita-
tors of prenatal care in an exemplar urban clinic. Wo m e n B ir th.
2016;29(2):160-167. doi:10.1016/j.wombi.2015.09.007
36. Roman LA, Raffo JE, Dertz K, et al. Understanding perspectives of
African American Medicaid-insured womenon the process of peri-
natal care: an opportunity for systems improvement. Matern Child
Health J. 2017;21(suppl 1):81-92. doi:10.1007/s10995-017-2372-2
37. Seo JY, Kim W, Dickerson SS. Korean immigrantwomen’s lived ex-
perience of childbirth in the United States. J Obstet Gynecol Neona-
tal Nurs. 2014;43(3):305-317. doi:10.1111/1552-6909.12313
38. Shaffer CF. Factors influencing the access to prenatal care by His-
panic pregnant women. JAmAcadNursePract. 2002;14(2):93-96.
doi:10.1111/j.1745-7599.2002.tb00097.x
39. Sheppard VB, Zambrana RE, O’Malley AS. Providing health care to
low-income women: a matter of trust. Fam Pract. 2004;21(5):484-
491. doi:10.1093/fampra/cmh503
40. Edmonds BT, Mogul M, Shea JA. Understanding low-income
African American women’s expectations, preferences, and prior-
ities in prenatal care. Fam Community Health. 2015;38(2):149-157.
doi:10.1097/fch.0000000000000066
41. Agbemenu K, Banke-Thomas A, Ely G, Johnson-Agbakwu C.
Avoiding obstetrical interventions among US-based Somali mi-
grant women: a qualitative study. Ethn Health. 2021;26(7):1082-
1097. doi:10.1080/13557858.2019.1613519
42. Ayers BL, Purvis RS, Bing WI, et al. Structural and socio-cultural
barriers to prenatal care in a US Marshallese community. Matern
Child Health J. 2018;22(7):1067-1076. doi:10.1007/s10995-018-2490-
5
43. MazulMC,WardTCS,NguiEM.Anatomyofgoodprenatalcare:
perspectives of low income African-American women on barriers
and facilitators to prenatal care. J Racial Ethn Health Disparities.
2017;4(1):79-86. doi:10.1007/s40615-015- 0204-x
44. McClellanC, Madler B. Lived experiences of Mongolian immigrant
womenseekingperinatalcareintheUnitedStates.JTranscultNurs.
2022;33(5):594-602. doi:10.1177/10436596221091689
45. Wheatley RR, Kelley MA, Peacock N, Delgado J. Women’s narra-
tives on quality in prenatal care: a multicultural perspective. Qual
Health Res. 2008;18(11):1586-1598. doi:10.1177/1049732308324986
46. Barnett KS, Banks AR, Morton T, Sander C, Stapleton M, Chisolm
DJ. “I just want us to be heard”: a qualitative study of perina-
tal experiences among women of color. Wom e n s Healt h ( L o n d ) .
2022;18:17455057221123440. doi:10.1177/17455057221123439
47. Dahlem CHY, Villarruel AM, Ronis DL. African American women
and prenatal care: perceptionsof patient–provider interaction. Wes t
JNursRes. 2015;37(2):217-235. doi:10.1177/0193945914533747
48. Fuentes-Afflick E, Odouli R, Escobar GJ, Stewart AL, Hessol NA.
Maternal acculturation and the prenatal care experience. JWomens
Health. 2014;23(8):688-706. doi:10.1089/jwh.2013.4585
49. Korenbrot CC, Wong ST, Stewart AL. Health promotion and psy-
chosocial services and women’s assessments of interpersonal pre-
natal care in Medicaid managed care. Matern Child Health J.
2005;9(2):135-149. doi:10.1007/s10995-005- 4871-9
50. Tandon SD, Parillo KM, Keefer M. Hispanic women’s percep-
tions of patient-centeredness during prenatal care: a mixed-
method study. Birth. 2005;4(32):312-317. doi:10.1111/j.0730-7659.
2005.00389.x
51. JulianZ,RoblesD,WhetstoneS,etal.Community-informedmod-
els of perinatal and reproductive health services provision: a justice-
centered paradigm toward equity among Black birthing communi-
ties. Semin Perinatol. 2020;44(5):151267. doi:10.1016/j.semperi.2020.
151267
52. Chambers BD, Arabia SE, Arega HA, et al. Exposures to structural
racism and racial discrimination among pregnant and early post-
partum Black women living in Oakland, California. Stress Health.
2020;36(2):213-219. doi:10.1002/smi.2922
53. Renbarger KM, Phelps B, Broadstreet A. Provider characteris-
tics that hinder relationships with Black women in the peri-
natal period. West J Nu r s R e s . 2023;45(3):215-225. doi:10.1177/
01939459221120390
54. Adegoke TM, Pinder LF, Ndiwane N, Parker SE, Vragovic O,
Yarrington CD. Inequities in adverse maternal and perinatal out-
comes: the effect of maternal race and nativity. Matern Child Health
J. 2022;26(4):823-833. doi:10.1007/s10995-021-03225-0
222 Vol u m e 6 9, No . 2 , Ma r c h /Ap r i l 2 02 4
55. da Santiago M CF, Figueiredo MH. Immigrantwomen’s perspective
on prenatal and postpartum care:systematic review. J Immigr Minor
Health. 2015;17(1):276-284. doi:10.1007/s10903-013- 9915-4
56. Wishart D, Alvarez CC, Ward C, Danner S, O’Brian CA, Simon
M. Racial and ethnic minority pregnant patients with low-income
experiences of perinatal care: a scoping review. Health Equity.
2021;5(1):554-568. doi:10.1089/heq.2021.0017
57. Reid CN, Fryer K, Cabral N, Marshall J. Health care system barri-
ers and facilitators to early prenatal care among diverse women in
Florida. Birth. 2021;48(3):416-427. doi:10.1111/birt.12551
58. Afulani PA, Phillips PB, Aborigo MRA, Moyer PCA. Person-
centred maternity care in low-income and middle-income coun-
tries: analysis of data from Kenya, Ghana, and India. Lancet.
2019;7(1):e96-e109. doi:10.1016/s2214-109x(18)30403- 0
59. Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Moth-
ers study: inequity and mistreatment during pregnancy and child-
birth in the United States. Reprod Health. 2019;16(1):77. doi:10.1186/
s12978-019-0729-2
60. ZhuangJ,GoldbortJ,Bogdan-LovisE,BresnahanM,ShareefS.
Black mothers’ birthing experiences: in search of birthing justice.
Ethn Health. 2023;28(1):46-60. doi:10.1080/13557858.2022.2027885
61. Jeffers NK, Canty L, Drew M, et al. Beyond “patient-provider race
matching.” Black midwives clarify a vision forrace-concordant care
to achieve equity in Black perinatal health: A commentary on “Do
Black birthing persons prefer a Black health care provider dur-
ing birth? Race concordance in birth”. Birth. 2022;50(2):267-272.
doi:10.1111/birt.12720
62. Mehra R, Alspaugh A, Joseph J, et al. Racism is a motivator and
a barrier for people of color aspiring to become midwives in the
United St ates. Health Serv Res. 2023;58(1):40-50. doi:10.1111/1475-
6773.14037
63. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic
bias among health care professionals and its influence on
health care outcomes: a systematic review. Am J Public Health.
2015;105(12):e60-e76. doi:10.2105/ajph.2015.302903
64. Alio AP, Dillion T, Hartman S, et al. A community collaborative
for the exploration of local factors affecting Black mothers’ expe-
riences with perinatal care. Matern Child Health J. 2022;26(4):751-
760. doi:10.1007/s10995-022-03422-5
65. AltmanMR,McLemoreMR,OsegueraT,LyndonA,FranckLS.
Listening to women: recommendationsfrom women of color to im-
prove experiences in pregnancy andbirth care. JMidwiferyWomens
Health. 2020;65(4):466-473. doi:10.1111/jmwh.13102
66. Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race
lens to relationship-centered care in pregnancy and childbirth: an
antidote to structural racism. Birth