“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
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.
The Problem
The disparity between Milwaukee’s infant
mortality rates for African Americans and
whites is one of the worst in the nation.
• 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
Source: Milwaukee FIMR
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
• 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
• 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
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
Jones’ Theoretical Framework
for Racism
• Personally-mediated
• Differential assumptions and actions
• Internalized
• Acceptance of negative messages
• Institutionalized
• Differential access to opportunities of
society
Study Purpose
To examine the presence and nature of racial
discrimination during prenatal care from the
perspectives of African American women.
Methods
• Community-engaged
• Focus groups and individual interviews
• Sampling
•
•
•
•
African-American
≥ 18 years
Infant ≤ 1 year
≥ 1 PNC visit
Methods
• Discussion guide
• Transcript-based thematic analysis
• Study was reviewed by the University of
Wisconsin-Milwaukee Institutional Review
Board
Sample Population
• N = 31
• Single
• 6 focus groups
• <$11,000 annually
• 2 individual interviews
• Had PNC in 1st trimester
• African-American
• 12th grade or less
education
• Unemployed, looking
for work
• Medical Assistance
• Mean Age: 24.4
Results
• Discrimination based on:
• Insurance and/or income status
• Race
• Lifetime experiences of racial
discrimination
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.”
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.”
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.”
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
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…”
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.”
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…”
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”
Next Steps/Future Research

Further analysis

Changes in delivery of care

Sharing women’s stories

PNCC providers, FIMR, Nurses….
Conclusions: A better understanding
• Women’s perceptions of
racial discrimination can
influence:
o PNC utilization
o Outcomes
• Provider practices and
interactions can:
o Be perceived as
discriminatory by clients
o Influence PNC use
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
Anatomy of “Good” Prenatal Care from our sample’s perspectives
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.