Differences in hospital prenatal care between immigrant and native women in France: a qualitative study within the BiP research on racial implicit bias in perinatal care

Abstract

Background

As of 2023, 25.5% of live births in France are from mothers who were born abroad. Women born in sub-Saharan Africa are especially at risk of maternal and neonatal morbidity and mortality. Intermediate explanatory factors probably include access to and quality of care. The BiP multidisciplinary mixed-methods project sought to explore implicit racial biases among prenatal practitioners as one of the first approaches to this issue in France. The qualitative component we present here aimed to explore the clinical relationship between women from different migration backgrounds and healthcare providers as well as possible racial-based differential care in the setting of prenatal care.

Methods

A sociological qualitative study was conducted in three public maternity units in the Paris area among 6 obstetrician-gynaecologists, 6 midwives, 6 anaesthesiologists, and 148 pregnant women. The study was based on audio-recorded prenatal consultations and self-confrontation interviews with practitioners. Consultations and interviews were analysed thematically.

Results

The countries of birth and social positions of the participating women were globally similar to those of the pregnant women seen in each maternity unit. The content of care was globally controlled by healthcare providers and consultations were slightly longer for immigrant than native women; the explanations they provided were appropriate to women’s level of understanding. The prenatal follow-up, when standardised, left little room for differential care. Nonetheless, the tone of voice and the type of jokes showed the salience of the social relations of race and class, beyond the strict framework of the care relationship. A few instances of racism in care were identified and analysed, but their consideration by the institution was non-existent.

Conclusions

French research is beginning to produce data on racial discrimination in healthcare, and this qualitative study provides an in-depth understanding of mechanisms leading to less adequate care, which was not an everyday occurrence. Despite the inclusion bias inherent in this type of approach, this study produced original results about the differential care of women who are immigrant during hospital prenatal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08750-w.

Background

As of 2023, 25.5% of live births in France are from mothers who were born abroad [1]. In France as in Europe, these women are at higher perinatal and maternal risk than native-born women, with higher rates of hypertensive complications, maternal mortality [2–4], preterm birth, and low birth weight [5]. Women born in sub-Saharan Africa (SSA) are especially at risk of maternal and neonatal morbidity and mortality, with a risk ranging from 2 to 5 times higher than that of native women [6–8]. However, this increased risk does not apply to all immigrant women. In particular, the risk of severe maternal morbidity is not increased for women from North African countries [3; 8] versus women from SSA countries. Furthermore, women born in SSA countries represent 33.5% of the highly diverse group of women born abroad who give birth in France. Women born in North Africa represent 30.5%, those born elsewhere in Europe 13%, those born in Asia 11% and others (a very heterogenous group of women born elsewhere in the world and grouped in most available studies) 12% of such women [1]. Intermediate explanatory factors probably include access to and quality of care [7, 9]. Recent studies show the existence of a differential care of immigrants, a concept first raised in France by D. Fassin, an anthropologist/physician, and covering both unequal access to and quality of care [10]. Specifically, these studies demonstrate care that is both differential and less appropriate during the perinatal period for women born in SSA versus women born elsewhere in Europe, North Africa, and other areas [11–17].

The hypothesis of differential care is further supported by a study conducted in an infectious disease department, where an analysis of 1,944 patients revealed that those born in SSA were less likely to receive reduced-drug antiretroviral therapy as compared with those born in France. These disparities in prescription practices could not be fully explained by differences in clinical or biological profiles [18]. Another recent French study based on a survey involving 1,563 healthcare professionals, addressing healthcare delivered in general emergency departments, demonstrated that the characteristics of simulated patients influenced prioritization decisions. Specifically, Black patients were less likely to receive emergency care than their White counterparts [19]. Discrimination in healthcare can be defined as any differential treatment—intentional or unintentional—based on a patient’s real or perceived origin, which results in reduced access to, or quality of, care [20].

Studies from the United States report very strong differences in access to and quality of care received. Perceived racial identity can influence the quality and nature of healthcare interactions. Healthcare providers may unconsciously adapt their communication, decision-making, and even clinical management according to patients’ perceived race or ethnicity [21, 22]. The differences between Black and White women in health, especially in obstetrics, are much larger than those reported in Europe [23, 24]. As an example, college-educated Black birthing individuals are 5 times more likely to die from pregnancy-related causes than college-educated White birthing individuals [25, 26]. In France, despite existing disparities, the gap is less pronounced but is only measured for immigrant women: recent data indicate that women born in SSA have a maternal mortality rate approximately twice that of women born in France [8]. Several factors may explain these differences, including the universal healthcare system in France, differences in the social and historical context of race, and varying levels of structural racism. However, the persistence of disparities in both contexts highlights the need for continued research and targeted interventions.

We aimed to explore the hypothesis of less appropriate care for certain groups of women who are immigrants and discrimination in care in the French setting, where the topic is underexplored, as compared with North America, where it has been in the research agenda for years [23, 27]. The socio-political and historical context in France has shaped regulations that limit the collection of ethno-racial data, which explains why research on racial disparities in care is limited.

We conceived the BiP research program (Migrants and differential care in the perinatal period: Effects of implicit bias) as an exploration of racial-based differential care in France by mixed methodological approaches, bringing together (1) epidemiological analysis of existing datasets to detect care disparities (e.g., trisomy 21 screening, epidural use, caesarean delivery, preeclampsia management [15, 17, 28]) and (2) national web-based psychosocial study among health care providers (HCPs) using an Implicit Association Test and clinical vignettes to assess biases and their potential impact on care [28]. The present study constitutes the third component of this research program. It aimed to mobilize qualitative sociological approaches to explore the clinical relationship between women from diverse migration backgrounds and healthcare providers and to examine the existence of differential care in the setting of prenatal consultations.

Methods

This qualitative observational study took place in 3 Parisian maternity units, with fairly high proportions of immigrant patients and chosen to facilitate contrasts between their catchment areas (centre, eastern and northern Paris). First, we assessed consultations between HCPs and patients, then conducted informant interviews with HCPs. This study is grounded in intersectionality theory [29], which provides a lens to examine how gender, social class, and migration background intersect to shape women’s experiences in prenatal care. This perspective allows us to capture the complexity of overlapping social determinants and their influence on healthcare trajectories. In addition, we drew on the literature on social health inequalities [30] and implicit bias [31] to conceptualize key constructs such as healthcare access, discrimination (in that differential care is an action of treating differently), and racial bias. These frameworks guided the construction of our thematic analysis grid and the interpretation of our results.

Audio-recording of consultations

We recruited 6 obstetrician-gynaecologists, 6 midwives, and 6 anaesthesiologists in 3 different ways: a physician was appointed as study leader by her department head in maternity unit A, the department head in unit B emailed invitations and volunteers contacted us, and HCPs were directly recruited by the researcher (PS) in unit C (only 1 midwife declined). All consented in writing to participate after receiving full information about the research and its objectives (as required by the ethics committee). The prenatal care visits recorded were (1) the first prenatal visit, when women’s clinical and obstetric histories and social data are collected; (2) the visit informing women about trisomy 21 screening tests (routinely offered in France and covered by the national health insurance fund; 2 units combined these with the first-trimester ultrasound scan); and (3) the pre-anaesthesia consultation, mandatory during the third trimester. We approached the 175 women who were ≥ 18 years old and consulting for one of the 3 study visits with a participating practitioner. Participants were required to have sufficient command of French to understand the study information and provide informed consent, as mandated by the ethics committee. Language proficiency was assessed by the researcher during the initial presentation of the study. We excluded women who were unable to understand the explanation or who declined participation. Although all included participants understood the study information, the levels of French proficiency varied and could not be formally graded. Overall, 148 women agreed to participate (convenience sample; acceptance rate: 85%), received the necessary information, and provided written consent to the anonymised audio-recording of their consultation. The sociology researcher was in the waiting room during the consultations and the audiorecorder was activated and stopped by the practitioners.

Self-confrontation interviews with practitioners

This survey technique began in the field of organizational psychology and was subsequently extended to sociology [32, 33]. It confronts participants with their own actions and allows them to explain what they did after listening to selected extracts of recordings [34]. The interview guide is available (see Appendix 1). The heart of the interview was the phase of hearing 2 or 3 audio excerpts selected by 2 authors (PS and MC) that best corresponded to their research questions and submitting them to the caregivers interviewed so that they could respond and explain their statements or actions retrospectively. The interviews took place with PS 2 to 4 months after the recorded consultation and lasted from 25 min to 1 h.

Analyses

The recordings of the consultations and the subsequent interviews were anonymised and entered into a software program for treating qualitative data (N’Vivo 12, QSR International). Data saturation was reached after analysing consultations and interviews from maternity units A and B. We continued analysing consultations and interviews conducted at maternity unit C, but no new themes emerged during this phase [35]. On the basis of the standards for analysis of content from qualitative studies and reported in Fig. 1, two researchers (PS and MC) jointly coded each track thematically, according to themes usually discussed in these consultations, and each interview according to the interview grid [35, 36].

Fig. 1.

The 5 stages of the qualitative analysis

We adhered to the COREQ quality criteria for reporting qualitative research (see the checklist in Appendix 2).

Results

Line-by-line coding of 148 audio-recorded consultations of 18 HCPs and the thematic comparison of the sequences corresponding to mandatory clinical information (history-taking, explanation of screening tests, pre-anaesthesia information) showed that clinicians followed the same structured script across patients, independent of migration background. The professionals tightly controlled the content of care, and all of them expressed, during the interviews, their attachment to a quality public service. However, some differences in care provided to immigrant and native-born women still emerged from this study and concerned 3 points, detailed below. These analyses are summarized in Table 1.

Table 1.

Main themes identified in the qualitative analysis

Theme	Description	Variation between immigrant and native-born women?
Structure of consultations	Sequence of mandatory steps (history, clinical measures, explanation of tests, prescriptions)	No – Highly standardised across all groups
Content of information	Mandatory explanations (T21 screening, pregnancy follow-up, anaesthesia risks/benefits)	No – Same clinical content delivered to all women
Adaptation of language	Simplification of vocabulary, reformulation, checking comprehension	Yes – More frequent for women with lower French proficiency
Consultation duration	Time spent in each stage of the visit	Yes – Slightly longer for immigrant women
Greeting and initial interaction	Opening expressions, level of formality, warmth of initial contact	Yes – More formal and standardised greetings for most patients; occasional increased warmth for socially similar patients; sometimes more distant or paternalistic tone with immigrant or socially disadvantaged women
Tone of interaction	Volume, rhythm, articulation	Yes – Louder or slower speech when perceived language barrier
Humour / familiarity	Informal comments, jokes, terms of endearment	Yes – Variable and sometimes reflecting perceived social distance
Conflict management	Reaction to lateness, missing files, organisational stress	Yes – Occasional asymmetries, sometimes racialised

Population

Table 2 summarises the study procedures in each maternity unit and specifically the number of HCPs involved in the consultations we recorded.

Table 2.

Study procedures in each maternity unit

Site (maternity unit)	Dates	included HPC				Audio-recorded consultations
		Ob	Midwife	Anest	Total	First consult	Echo or consult with HT21 test proposition	Pre-anesthesia consult	Total
Unit A	Sept. 2018–Jan. 2019	2	3	3	8	23	12	35	70
Unit B	Feb–Apr. 2019	2	2	2	6	18	11	20	49
Unit C	May–July 2019	2	1	1	4	12	7	10	29

HCPs healthcare practitioners, Ob obstetrician, Anest anesthesiologist, Consult consultation

Table 3 presents the distribution by parity, country of birth, and social position of the women included in the study. In total, 82 women were native-born and 66 were immigrants. Women recruited at maternity units B and C (located in eastern and northern Paris, respectively) were more frequently born abroad and multiparous and were less frequently managers and professionals than women recruited at maternity unit A (central Paris).

Table 3.

Characteristics of the women included in the study, by maternity unit

		Unit A N = 70		Unit B N = 49		Unit C N = 29
Parity	1	44	(63%)	19	(38%)	13	(45%)
	2	17	(24%)	14	(29%)	10	(34%)
	≥ 3	9	(13%)	16	(33%)	6	(21%)
Country/region of birth*	France	45	(65%)	25	(50%)	12	(41%)
	Europe	8	(11%)	5	(10%)	0	(0%)
	North Africa	5	(7%)	6	(13%)	6	(21%)
	Sub-Saharan Africa	9	(13%)	10	(21%)	9	(31%)
	Others	3	(4%)	3	(6%)	2	(7%)
Employment	Managerial and professional	34	(49%)	11	(23%)	7	(24%)
	Intermediate occupations	10	(14%)	12	(23%)	7	(24%)
	Office workers	14	(20%)	11	(23%)	7	(24%)
	Crafts workers and shopkeepers	2	(3%)	0	(0%)	0	(0%)
	Manual workers	0	(0%)	1	(2%)	1	(4%)
	Farmer	1	(1%)	0	(0%)	0	(0%)
	Not working	9	(13%)	14	(29%)	7	(24%)

Professionals direct the content of care

Longer consultations for immigrant than native women

Consultations were slightly longer for immigrant than native-born women according to the type of professional consulted: anaesthesiologists saw immigrant women for longer periods than they did women born in France: 55% of the former versus 35% of the latter had visits lasting from 13 to 20 min (and vice versa for the consultations lasting from 7 to 13 min) (Fig. 2).

Fig. 2.

Distribution of consultation duration (in minutes) for immigrant and native-born women by type of professional

Similarly, for obstetricians, two-thirds of whose consultations lasted from 20 to 40 min, immigrants were more often seen for longer durations than were women born in France. The duration of consultations with midwives followed a similar trend, although consultation times were longer for immigrant women as compared with those by other HCPs, attributable to the organisation of targeted sessions for women in socially vulnerable situations and immigrants in maternity ward B. When asked about the extra length of the consultations in the interviews, practitioners referred to the probable need to translate or to be sure of being understood during consultations:

“We manage, we always understand each other. I use Google Translate a lot when we get stuck.” (obstetrician #5).

Longer consultation times allow for safeguarding time for discussion and providing personalized advice, as midwife 2 explained:

“I think it’s important to connect women with their personal history, prior to migration. These are their roots, and I think it’s important for them to draw on them to become mothers themselves.” (midwife #2).

Anesthesiologist #1 noted that consultations with immigrant women occasionally took longer because she communicated with them in their native languages. Notably, she was the only participant to mention fluency in multiple languages, including English, Spanish, Romanian, and Italian.

Standardized communication in pre-anaesthesia consultations

We chose the pre-anaesthesia consultation for observation because it is one of the most standardised care procedures in the prenatal pathway. Consultations were longer for immigrant than native-born women at each stage (clinical history, clinical examination, diagnosis, and prescriptions). Nonetheless, the care remained standardised and the consultations globally rapid. Their contents are prescribed by Public Health Code (Decree of 5 December 1994): patients must be informed about anaesthetic procedures and their risks and benefits. During the self-confrontation interview, one anaesthesiologist explained:

“Yes I know, I’m almost reciting a text when I see patients for this consultation. I’ve put together a text that I always deliver at more or less the same rhythm. When I was younger, I did it differently. I adapted more. But since consultations must now be finished in 10 to 15 minutes, I tell myself that this must be fast, concise, and as specific as possible.” (Anaesthesiologist #6).

Analyses showed that rare complications of epidurals were explained in the most detail to the women who best understood medical discourse and to those with higher social status.

Tailored explanations in obstetric consultations: the case of trisomy 21 screening

The information provided in obstetrics should have been at the heart of our analyses, but in practice, this information is offered in multiple places: in private medical laboratories and in hospitals during the first consultations or combined with the first ultrasound. Practitioners gave women very specific information about these tests and about their right to turn them down. The recordings highlighted the quality of the information provided to the women by the HCPs involved in this study. They adopted simpler words for the women who understood least well, whether this was related to their understanding of the French language (immigrants) or the medical language (those in lower social categories). Thus, one midwife started by ensuring that women understood that a half a pizza is larger than a quarter of a pizza; and thus, that a risk of 1/250 will be bigger than a risk of 1/10,000. We returned to that in the self-confrontation interview:

“I like to ask women that, except obviously when I see they work in computer programming or she’s a math teacher … But otherwise, there are plenty of little women, they’ll tell you: ‘I don’t know, I never understood anything about fractions’.” (midwife #5).

She also confided that she has progressively standardised her discourse. Analyses showed that this left little time for interpersonal variations.

Social dynamics and implicit bias in patient-provider interactions

Louder speech as a response to Language barriers in consultations

The practitioners talked much more loudly to the women with lower proficiency in French than to other women, as demonstrated by some of the audio recordings. We broached this topic in an interview:

• “It seems to me listening to the recording that you are speaking more loudly…, to the women who speak French less well. Unless it’s the position of the recorder?

• (Smiles) “Yes, you’re right, it’s very clear.

• How do you explain this?

• I don’t know, I hadn’t noticed it before. But I can hear that I’m articulating more. I articulate so that she can understand me. " (anaesthesiologist #5).

Exploring social differences through initial greetings in consultations

A number of results revealed social asymmetries in the care relationship that went beyond the framework of the formal relationships between care providers and patients. Regardless, these observed trends remained somewhat fragile because they were relatively rare within the recordings. They deserve further exploration and confirmation. We present them in Table 4.

Table 4.

Verbatims illustrating social asymmetries between healthcare professionals (HCPs) and their patients

Theme and type of interaction	HCP concerned	Excerpt (numbered)
Greeting and initial interaction_ Standardized salutation	Many participants	E#1: “Hello, Madam, I’m Marion*, the one of the consulting midwives here. I’m seeing you today for your first consultation. We’re going to set up your file together, now.” (midwife #4-P2, Polish woman, housewife, para 2).
Greeting and initial interaction_ Familiarity	Mw 5 with an African known patient	E#2: She greeted her warmly and informally, asking for news of the older children: “How are my little ones [mes petits] doing?”
Greeting and initial interaction_ Familiarity	Mw 4 with patients who were her peers, white and middle-class.	E#3: She addressed them as “my beautiful one [ma belle],” an expression not found in the discourse of any other clinician.
Humour / familiarity Paternalistic joke	Pr A with an African couple	E#4: To a woman whose husband had made it clear in the corridor that the wait was too long (> 2 h) and he was going to leave Pr A. said: “Why leave? Do you have an appointment with President Macron?” and then he laughed at his joke.
Conflict management Asymmetric tensions that can be expressed in hospital corridors or waiting rooms	Ultrasonographist with African patient, para 1, arriving late	E#5: A stentorian voice rings out from the back of a consultation room, with an open door: “Madame Traorrreeeeee.“* To me, standing nearby: “That’s it, my nerves have had it. - What’s happening? - They’re not even on time! To the woman: “So they tell you you’re going to have an important sonogram [fetal morphology] and you’re not even on time? - But it took us time to get here! - Well then you should have left earlier!!” (The consultation room door slams).
Conflict management Tensions expressed in the medical practice	Anesthesiologist #4 with a Comorian patient, para 2	E#6: Her second patient of the afternoon she did not have the file (usually prepared by the administrative team): “Mrs Ali ! (the time the woman takes to enter: I don’t have a file!!) - (to the woman): Mrs Ali*, you don’t have a file? - I only have one file out of 11, I feel like I’m going to lose my mind! [Leaves to look for the file, unsuccessfully] … - Go see at reception and ask them to look for it for you and then come back. - Well, I was with the midwife before, I think it’s on the other side. - Yes but I’ve looked everywhere and I cannot lose a half hour by patient to look for a file. So I’m sorry, I know that it’s not your fault but I can’t do anything else.” (The patient left very dissatisfied with her “consultation”)

*Fictitious names. E exerpt; Mw midwife, Pr professor of medicine

Midwife #5, very experienced, had an appointment during the study with an African woman (para 4), whose preceding pregnancies she had already followed. She greeted her warmly and informally, asking for news of the older children (Table 4; Excerpt #2). However, for midwife #4, familiarity was reserved for patients who were her peers, French and middle-class (Table 4; Excerpt #3). In contrast, the other HCPs, younger, framed their consultations in a manner close to the one below (Table 4; Excerpt #1).

Professor A greeted his immigrant patients with low socio-economic background and engaged in intrusive humor that he did not practice with French women. This may reveal an implicit racial bias. During the interview, Professor A avoids reacting to this conversation extract (Table 4; Excerpt #4). He also evaded our question about the familiarity underlying this type of “off-the-cuff” remark and then insists on his “affection” for his African patients. Indeed, further observations revealed that he cares for them in a paternalistic way. For years, he has been providing standard gynecologic care to some immigrant women in precarious situations, ensuring continuity of care and sparing them the cost of private consultations.

One of the 3 HCPs born in an Overseas Department described herself in interview as a “citizen of the world”, approaching patients who are immigrants as equals most often:

“For me, diversity is an integral part of society. I grew up on Reunion [Island] and I think that I don’t even necessarily see differences between people. I love in Paris, in the city and in our maternity ward, this richness of the diversity of the population.” (midwife #3, self-confrontation interview).

Accordingly, what we can call the margins of care — that is, the tone used, the types of humour used, the salutations and greetings — show salience of social relations that go beyond the framework of the formal relationships between care providers and patients. Finally, we found few situations of conflict during this research.

The question of Racial discrimination in care?

We observed 2 particularly confrontational situations during this study, both between White female HCPs and SSA patients. In contrast, these practitioners were extremely polite in the interactions with native-born women. Two dialogues (Table 4; excerpts #5 and #6) illuminate the asymmetric tensions that can be expressed in waiting rooms or during consultation.

These 2 practitioners mentioned the disorganisation of their day to justify their irritation (late patient, lost file). Nonetheless, they reserved a very polite welcome to their White French patients: “Hello, ladies and gentlemen, I am Dr Dubois*, an anesthesiologist. Welcome. So you are Madame Gustave*?” (anesthesiologist #4-P2: woman born in France, nullipara, teacher). (*Fictitious names). After her departure from the department and despite our repeated requests, we were unable to conduct a confrontation interview with anesthesiologist #4.

Moreover, during interviews, some HCPs reported situations of conflict with some of their immigrant patients. Thus, although we had found that anaesthesiologist #1 behaved similarly in each of the consultations, her self-description was quite different:

“Your consultations are very similar from one woman to the next.

“In fact the appointment, it’s 10 minutes, so if I see they’re interested, I am very available for them; if not, I move quickly. But on the other hand if they don’t understand, I can stop the consultation at the end of 3 minutes. It’s out of the question for me to do a consultation if the woman doesn’t understand anything. … On the other hand, it’s harder for me with Arab and African populations: I don’t speak their languages. If the Arab women come with their guys, it doesn’t bother me to say to them: ‘You’re not the patient!’ I don’t hesitate to send them outside. I accept many cultural things, but not that.” (anaesthesiologist #1, self confrontation interview).

Lack of supervisors’ support in conflictual situations

A sonographer was involved in an argument with Obstetrician #4 reported in an interview, concerning ultrasound scans for an African family. Obstetrician #4 reported this to her department head, who did not intervene (Interview with Ob#4). Obstetrician #3, who holds a leadership role in one of the departments of Maternity Unit B, also spoke about this type of situation during the confrontation interview. He explained that one of his colleagues—a renowned ultrasound specialist in Paris—was so helpful in accommodating patients late in the evening that he preferred not to challenge her or raise concerns about potentially disrespectful behaviour toward women from SSA.

The situations described above show that inappropriate behaviour is tolerated for practical reasons: essential skills, disorganisation of the care circuit, etc.

Discussion

Main results

This study of 148 patients in Paris consulting 18 HCPs showed globally similar and highly standardised content delivered to immigrant and native-born women. The professionals tightly controlled the content of care, and all of them expressed, during the interviews, their attachment to a quality public service. Accordingly, the differences concern 3 points. The duration of consultations was slightly longer for immigrant than native-born women. HCPs simplified their discourse for the women with a poor understanding of French and/or medical terminology. These first 2 types of results tended to point to “positive” differentiated care because it is tailored to the individual patient even if they reveal asymmetries in the social relationship that is healthcare. Nevertheless, some practitioners had a way of addressing some patients that may reflect racial implicit bias (speaking louder, make jokes or reproaches you would not make to your peers), and the moments of greeting at the beginning or end of consultations deserve to be explored further and confirmed. To our knowledge, this notion has not been previously documented in the literature.

Strengths and limitations

We included a multidisciplinary steering committee and clinicians trained within the French public healthcare and academic system at several stages of the writing and validation of our protocol. The principal investigator being a midwife and a sociologist facilitated her access to the women and practitioners. Her presentation of the study to women over a 7-month period yielded a high participation rate — 85%, well above our objectives. The interviews were both rich and informative because the occupational proximity promoted confidence [37]. None of the investigators had a personal lived experience of migration; however, some authors are children of immigrants. This positionality may influence our sensitivity to issues of discrimination and our interpretation of subtle interactional dynamics. To minimise these effects, data coding and thematic interpretation were performed collaboratively across disciplines, ensuring reflexive discussion of potential biases throughout the analysis.

We also succeeded in including women with very diverse migratory and social profiles and who were globally similar to the profiles of the women consulting in each unit. The participation of 3 different medical professions is another originality of this work.

The study’s greatest limitation is that HCPs knew its objectives and volunteered. Thus, despite the 3 different methods used to recruit practitioners, a recruitment bias could have minimised the situations in which differential care was likely to be found. Moreover, the exclusion of 7 women who did not speak French might have prevented us from obtaining data about some attitudes toward these most vulnerable immigrants. We highlight the methodological constraints encountered when researching differential care in France. The prohibition on collecting data concerning race, ethnicity, or religion—enshrined in Article 1 of the French Constitution—rooted in the republican ideal of universal citizenship, prioritises individual equality over group identity. This principle restricts research into racial discrimination and may contribute to the minimisation of its existence. Although the 20th century has seen the use of ethno-racial data for unethical and even criminal purposes, it can also be used to combat discrimination. Therefore, a strict framework could be established for collecting and using such data for this purpose.

Furthermore, research regulations that require specific information about the research topic to be provided in advance to respondents (in this case, HCPs) are likely to promote inclusion bias. These regulations should evolve so as to optimise research on discrimination without infringing on the rights of those participating in it.

Nonetheless, our research program illustrates how mixed methods can yield valuable insights within this regulatory framework. In interpreting our findings, one must distinguish between migration background, socio-economic position, and racialisation, which are overlapping but not interchangeable dimensions. Because French regulations prohibit the collection of ethno-racial data, our analysis cannot document race as a category; instead, it captures how certain interactions may become racialised through providers’ perceptions of patients’ origin, language, or appearance. Clarifying these intersecting processes allows our results to contribute to broader discussions on unequal treatment in perinatal care without inferring racial identity from country of birth. This approach contributes to the advancement of knowledge in a context of restricted data access and offers a replicable model for future studies.

Discussion in the light of the literature

Our results highlight that hospital-based prenatal care for women fluent in French, born in France or elsewhere, leaves little room for differential care. At the individual level of the care relationship, the less standardised and protocolised the care (e.g., pre-anaesthesia consultations in this study), the grater the differential care [21]. These patterns were evident in the epidemiological component of the BiP program, particularly regarding the decision-making process for performing caesarean sections during labour [16], as well as the provision of information enabling informed choices about trisomy 21 screening [15]. In contrast, within the more standardised domain of anaesthetic care—specifically concerning epidural analgesia during labour—no differences were observed in the delivery of care between immigrant and native-born women [17]. Delivery and the postpartum period, contexts in which care is less standardised and when the unexpected is most likely to occur, leave much more place for practitioners’ cultural or racial biases, which can take the form of differential care [16, 38]. We previously showed that women with extremely serious complications of hypertension receive highly standardised management that leaves little room for differential care [13].

As we report here, other non-obstetric studies confirm that the duration of consultation for minority groups differs from that for majority groups, whose consultations are generally shorter [22, 39]. Some longer consultations are explained by the presence of an interpreter [40]. In our study, HCPs may perceive that these patients require more detailed information for understanding, which is quite protective for women, and we consider this differential care as “an increase in care standards”, as described by Fassin [10] .

Nevertheless, practitioners speak more loudly to women who do not have sufficient proficiency in French, as if to better hold their attention or as evidence of their annoyance, but this result probably reflects a bias against them. Audiences at oral presentations at congresses smiled at this finding, but it does not, to our knowledge, appear in the literature and merits further exploration, behavioural research in particular.

These HCPs handle much of their discourse with very standardised consultations, although their salutations when greeting patients at the start indicate that this moment is less controllable. In their interviews, HCPs confided the personal factors influencing how they care for patients: family history, such as difficult medical situations in their past, family traditions of practising medicine or providing healthcare, or political or religious beliefs guiding them to more altruistic practices. These results are not discussed in this paper but suggest the interest of collecting such data from a larger number of medical professionals in a future project. Although subgroups differed sociodemographically (e.g., women born in SSA were more often multiparous and socially disadvantaged than native women), these differences did not translate into clearly distinct patterns of differential care in our observational material. This finding reinforces the conclusion that standardisation of prenatal care reduces the likelihood of subgroup-specific disparities, even within a diverse migrant population.

At the organisational level, practitioners often explained their attitudes in conflict situations by issues related to the organization of care. These issues appeared rarely in the recorded consultations, which mainly show high-quality care and explanations. Nonetheless, several practitioners expressed distance, even annoyance, toward certain groups of women who are immigrants. The self-confrontation interviews therefore enabled us to deepen and expand our analyses beyond what was possible from the initial recordings. In the same way, a previous study based on interviews with 54 caregivers yielded much information about differential and less appropriate care among African-perceived women versus other women [41].

Simultaneously with the discussion about obstetric racism in the United States [23, 42, 43], the French social science literature has been revealing examples of racism in perinatal care [44–47] and in other medical areas [48, 49]. The disparities in maternal and perinatal morbidity and mortality between groups (racial and/or migrant) seem much stronger in the United States than in France [50–53]. Unlike our study, these studies do not incorporate real-life observations or qualitative insights from clinical interactions, which limits the possibility of comparisons. Levels of racism and racial segregation are not comparable in the 2 countries. The insurance system in France, which aims to ensure universal access to healthcare, might constitute a context preventing the influence of major discrimination. However, when situations of racial discrimination in care are reported up the chain of responsibility, the institutions do not seem to take steps to resolve these conflicts. No training is offered to understand implicit biases and their implications in care relationships or help practitioners deconstruct them and no sanctions applied in case of explicit discrimination. This situation has been described in other French institutions [54]. Although our study does not directly measure structural racism, it provides micro-level observations that help contextualise it. Finally, national restrictions on collecting ethno-racial data shape what can be identified and acknowledged as discrimination. Taken together, these findings illustrate how structural features of the French system can both constrain and obscure racialized dynamics in care.

Conclusion

The analyses does not show major differences in quality of prenatal care between women who are immigrants and native-born women in France, although we could not include women who did not speak French in the study for ethical reasons. These results may be linked to the protective French system that theoretically allows universal access to prenatal care. Although several limitations restrict the generalisability of our results, in a few situations, we observed expressions of implicit bias that may affect patient experiences and quality of care. This qualitative study offers an in-depth understanding of the mechanisms that lead to care that although not necessarily commonplace or quotidian, might be not adequate either. These qualitative findings align with the epidemiological component of our research programme, which similarly highlights disparities in care. Results from the psychosocial study are forthcoming and will further enrich our understanding of these mechanisms. Obviously, not all stages of antenatal care can necessarily or usefully be standardised, but our results show the importance of training students and professionals to avoid potentially discriminatory situations.

Authors’ contributions

PS, MC and EA conceived the study. PS conducted the research (records and interviews), PS and MC performed the analyses, and PS led the writing of the article. Other authors contributed to the implementation of the study and the analysis. All authors read and approved the final version of the article for publication.

Funding

This research was funded by the French National Agency for Research. Grant no.: ANR-17-CE36-0001.

Data availability

The datasets generated and analysed during the current study are not publicly available due to confidentiality reasons but part of them (excluding the recordings) are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the principles of the declaration of Helsinki. The INSERM ethics review board approved this study (IRB 00003888, opinion no. 18–507) on July 3, 2018, as did the CEREES (Expert committee for health research, studies, and evaluations) on September 6, 2018 (TPS 107121), and the CNIL (National Data Protection Commission) on October 24, 2018 (DR-2018-270). The participating professionals and patients signed written consent forms. A dual circuit for patients’ retraction of consent was set up: through the midwife managers in each department and/or through the research teams. No woman retracted her consent.

Consent for publication

All authors give their consent to publication.

Competing interests

The authors declare no competing interests.