Trina Salm Ward , MSW

1. “You Learn to Go Last”:Prenatal Care Experiences in a Sample of Low-Income African-American Women in Milwaukee Trina Salm Ward, MSW UW-Milwaukee Zilber School of Public Health, Center for Urban Population Health, UW-Milwaukee College of Health Sciences Mary Mazul, CNM UW-Milwaukee Zilber School of Public Health, Wheaton Franciscan Healthcare Co-Authors: Amy Harley, PhD, Faculty Advisor, UW-Milwaukee Zilber School of Public Health & Center for Urban Population Health Emmanuel Ngui, PhD, UW-Milwaukee Zilber School of Public Health & Center for Urban Population Health Farrin Bridgewater, BA, Center for Urban Population Health & UW-Milwaukee Dept. of Educational Psychology Wisconsin Health Improvement and Research Partnerships Forum September 21, 2012

2. Objectives The learner will be able to: • Articulate a brief review of the racial disparities in birth outcomes in Milwaukee and the role of prenatal care. • State at least one example of institutional, personally mediated and internalized racism found in our study. • State one area for further study regarding perceived racism and prenatal care in Milwaukee.

3. The Problem • Overall Infant Mortality Rate was 10.4 per 1,000 live births between 2008-2010 • Whites: 5.1 • African-Americans: 14.3 • Hispanics: 8.4 • Wisconsin Dept. of Health Services (WISH), 2012 The disparity between Milwaukee’s infant mortality rates for African Americans and whites is one of the worst in the nation.

4. The Problem Source: Milwaukee FIMR

5. The Role of Prenatal Care • Access to early, high quality, and continuous prenatal care can play a role in identifying and addressing factors that affect disparities in birth outcomes. ACOG & AAP, 2007

6. The Role of Prenatal Care • In Milwaukee between 2007-2010: • of the 296 African-American infant deaths that occurred, 30.1% were to mothers who received late or no prenatal care, compared to • 11.7% of the 60 white infant deaths that occurred during that same period WDHS, 2012; FIMR, 2010

7. The Role of Racism? • Institute of Medicine’s 2003 Unequal Treatment report documented racial disparities in the quality of health care received • US has a long history of racism that has had far reaching effects on every aspect of life, including racial disparities in birth outcomes • Resulting in distrust of the health care system and providers • While studies have examined the link between life time experiences of racism and birth outcomes, there has been a dearth of evidence regarding the perceptions of racism during prenatal care

8. Racism • A social construct that refers to institutional and individual practices that create and reinforce oppressive systems • Perceptions of racism in the health care setting can influence compliance with health care provider advice, satisfaction with care, and outcomes of care

9. Jones’ Theoretical Framework for Racism • Personally-mediated • Differential assumptions and actions • Internalized • Acceptance of negative messages • Institutionalized • Differential access to opportunities of society Jones, 2000

10. Study Purpose To examine the presence and nature of racial discrimination during prenatal care from the perspectives of African American women.

11. Methods • Community-engaged • Focus groups and individual interviews • Sampling • African-American • ≥ 18 years • Infant ≤ 1 year • ≥ 1 PNC visit

12. Methods • Discussion guide • Transcript-based thematic analysis • Study was reviewed by the University of Wisconsin-Milwaukee Institutional Review Board

13. Sample Population • N = 31 • 6 focus groups • 2 individual interviews • African-American • 12th grade or less education • Unemployed, looking for work • Single • <$11,000 annually • Had PNC in 1st trimester • Medical Assistance • Mean Age: 24.4

14. Results • Discrimination based on: • Insurance and/or income status • Race • Lifetime experiences of racial discrimination

15. Discrimination based on insurance/income • “They look at the medical assistance card as lower class…versus if I came in here and said I wanted to be seen today and just take money out of my pocket...They’ll see you right away and probably cater to you.”

16. Discrimination based on race • “The hospital scares me. So I don’t sleep, I just sit up and watch everything they do. ‘Cause there might be somebody that don’t like you and just come in there and do something to you while you ain’t paying attention.”

17. Lifetime experiences of racial discrimination • “Racism don’t come with the hospital and the babies and stuff. That’s our time of love and joy, we just had our babies, we got a new part of the family. Racism will come out in our daily lives while we’re trying to live our lives.”

18. Discussion • Perceived being treated differently • Many described discrimination based on income level or insurance type • Consistent with other studies • Fit within Camara Jones’ theoretical framework of racism • Institutionalized • Personally-Mediated • Internalized

19. Institutionalized Racism • “…So when we go to the doctor, this doctor over here that has [medical assistance] has 100 people on his schedule cause he’s trying to make the same thing as the Caucasian [clinic] on the other side of the street who is only having 50 people that day. So, now that our children are coming out with a low birth weight… So, why are you so alarmed when you’re giving us low rate health care…”

20. Personally-Mediated Racism • “It’s not gonna change. It’s not, cause it’s been like this forever. You learn to go last. No matter how much people talk about it, it is the same. And then a lot of people, they try to smile in your face, ‘oh, we ain’t like that, we ain’t like that.’ Yes it is, it’s been like that forever…That’s how it is.”

21. Internalized Racism • “….I don’t like the black people poking my baby, I like the white medical assistants…they know what they’re doing” • “It’s like they [white people] grow up into having everything…They got the long hair, we got the nappy hair…blue eyes, we get the stupid brown eyes…I’m just saying, how’d they get the pretty hair and the pretty eyes…”

22. Limitations • Racial discrimination was introduced by facilitator in study purpose • We purposely recruited from the YWCA because it served our population of interest • YWCA’s mission is “undoing racism”

23. Next Steps/Future Research • Further analysis • Changes in delivery of care • Sharing women’s stories • PNCC providers, FIMR, Nurses….

24. Conclusions: A better understanding • Women’s perceptions of racial discrimination can influence: • PNC utilization • Outcomes • Provider practices and interactions can: • Be perceived as discriminatory by clients • Influence PNC use

25. Implications for clinicians and researchers • Find opportunities to hear patients’ perspectives • Opportunities to help them feel more empowered • Culturally-sensitive care • “Unlearning Racism: Tools for Action” (YWCA of Greater Milwaukee) • Qualitative methods as a useful investigative tool

26. Anatomy of “Good” Prenatal Care from our sample’s perspectives

27. Acknowledgements We gratefully acknowledge the following supporters of this project: The generosity of the women who participated in our focus groups and shared their stories with us. The support and collaboration of the YWCA of Greater Milwaukee’s Allison Scheff (Job Developer), Martha Barry, PhD (Racial Justice Director), Lisa Boyd (Chief Operating Officer), and Jennifer de Montmollin (W-2 Director). Samantha Perry, MPH, CHES, UW Population Health Institute and Mary K. Madsen, PhD, UW-Milwaukee College of Health Sciences Funding and resources from the Children’s Community Health Plan, the Center for Urban Population Health, and the YWCA of Greater Milwaukee to support this project.

28. Questions? Trina Salm Ward, MSW tsalm@uwm.edu (414) 229-5155 Mary Mazul, CNM Mary.mazul@wfhc.org (414) 447-2275