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. Disclosures The YWCA provided in-kind recruitment support, meeting space, and childcare The YWCA’s mission is “undoing racism” Funded in part by the Children’s Community Health Plan

3. 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.

4. 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

5. Source: Milwaukee FIMR

6. 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

7. 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

8. 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

9. 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

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

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

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

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

14. Discussion Guide Main Questions What did you like about the prenatal care you received for this baby? What didn’t you like about the prenatal care you received? How would you know you were getting good prenatal care? What was hard for you about getting good prenatal care? Probing Question Do you think race had anything to do with this?

15. Demographic Characteristics (N = 31) Characteristic#% Race/Ethnicity Black or African American2993.5% Hispanic26.5% Missing13.2% Highest Level of Education 11 th grade or less722.6% 12 th grade/GED1238.7% Some college825.8% Associate Degree26.5% Bachelor’s Degree26.5% Current Employment Status a Employed full-time2 6.5% Employed part-time2 6.5% Student (part-time)2 6.5% Unemployed, looking2477.4% Unemployed, not looking13.2% Marital Status Single2683.9% Married13.2% Divorced13.2% Living with a partner39.7% Income Level Under $10,999/year2787.1% $11,000-$29,999/year412.9% Month Prenatal Care Began This Pregnancy 1 st month722.6% 2 nd month929.0% 3 rd month825.8% 4 th month39.7% Missing412.9% Number of Prenatal Visits 1-5 prenatal visits39.7% 6-10 prenatal visits26.5% >10 prenatal visits1754.8% Missing929.0% Health Insurance Medical Assistance2890.3% Private insurance13.2% No insurance13.2% Missing13.2% Mean Age: 24.4 (range 18-41 yrs) Mean # of Pregnancies: 2.9 (range 1-6)

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

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

18. 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.”

19. 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.”

20. 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.”

21. 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

22. 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…”

23. 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.”

24. 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…”

25. 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”

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

27. 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 Conclusions: A better understanding

28. 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

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

30. 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.

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34. Health Issues/Disability “I get these bad migraines and then my doctor gave me some type of medicine…it just makes me drowsy.” [meaning she can’t take it when caring for her child, working, etc.] Limited Family Support “I have a family that’s not supportive at all so I got to do what I got to do.” Stressful Childhood “Me and my mom, we never really had a mother- daughter relationship…my father was in and out of prison his whole life…my mom used to always tell us, ‘y’all gonna be just like him…you gonna be just like your daddy, you ain’t never gonna be nothing, you gonna be always in prison.’” Life Stress Finding Employment “They say ‘go to school,’ the commercials every day, ‘go to school,’ ‘go to school.’ I done been to school for this, and this, and this and that, and I still don’t have a career. That’s my stress, that’s my worry.” Lack of Stable Housing “I’m just staying there for the sake of my kids. And all, everyday I wake up, I’m like, ‘should I go to a shelter?’” Poverty “If I pay all my rent and all this, I’m not going to have no money left. I always had like a hundred and some dollars left, but I still had my first son and I had to buy him pull-ups and stuff like that.” Long Work Hours “We have so much stress because we’re trying to work 10 hour days to make sure we feed our kids.” “It’s like I don’t see my kids until 11:00 at night, that’s ridiculous.” State Assistance System Issues “I hate going there…you can’t even call, you don’t even know who your worker is, you can’t call them, you’ve got to take a number and wait for three hours. That is so unbelievable.” “I dropped [paperwork] off in February. Just this month [May] they cut me off of assistance. I didn’t even know…I’m calling for a cab to fill a prescription and they’re like ‘you don’t have [insurance].’ So then I call [the office] and they’re like, they got the signature form but they didn’t update the case. “ Neighborhood Safety “Especially in the summer time, it’s always drunks walking up the street, prostitutes, crack heads asking you for change, all that other type of stuff.“ Limited Friendship Network “There’s a lot of drama out there…with their baby daddies, baby daddy wanna talk to her so she wanna fight her – type of stuff. That’s why I don’t get into none of that…As long as you keep to yourself and not get into no argument with no female out there then you’ll be okay….because as soon as you get to know somebody you’ll get into some stuff.” Domestic Violence “Me and my oldest daughter have to go to court because he’s stupid and we - he get drunk and always wanna fight somebody do I’m pressing charges against him.” Unhealthy Coping Behaviors “It’s hard to kick the [smoking] habit when you got other things going on in your life.” Child Care Issues “Everybody got jobs, ain’t nobody got no time to be babysitting no baby.” Salm Ward & Mazul, 2011

35. Transportation 100% Schedule 62.5% Prenatal Care Vitamins 62.5% Safety of Clinic 50% Phone 37.5% Exhaustion 25% Perceptions of Poor Care 75% Discrimination 100% Life Stress 100% Communication 62.5% Unplanned Pregnancy 75% Finding Provider (Insurance) 62.5% Waiting Time 75% Salm Ward & Mazul, 2011 Barriers to Prenatal Care