Table 4.

Moving through the Cycle to Respectful Care.

Cycle Phase	Definition	Actions
Waking Up	In the Cycle to Respectful Care, this waking up might include a critical incident of racism, discrimination, or mistreatment in the healthcare facility. Providers are made aware of the incident through patient reports, disparities data, or mandates to address disparate outcomes through implicit bias training or a quality improvement initiative. The American College of Obstetrics and Gynecologists (ACOG) ACOG AIM Patient Safety Bundles [25] and quality improvement initiatives are resources for hospitals and health systems that may illuminate racist and discriminatory care in order to prompt this Waking-Up phase.	Due to the urgency of growing maternal inequities in the United States, hospitals, healthcare systems, and policy makers have taken action to mandate implicit bias training thereby initiating the Waking-Up process rather than waiting for maternal care staff to Wake-Up on their own. The Cycle to Respectful Care begins when an individual observes or experiences the world differently than s/he has in the past.
Getting Ready	Getting Ready is the point at which individuals move from exclusively internal work to application in how they interact with and speak to others. This can be achieved through reviewing evidence-based research, attending anti-racist workshops, training on various topics, and building connections with others. This phase can include challenging beliefs in our worldview, medical education, and consciousness raising.	In preparation of the practice of valuing Black mothers more intensely, healthcare providers become conscious and make note of thoughts, language, and actions to see if they are consistent with newly established beliefs or they can be dismantled [18]. This intrapersonal section requires us to develop a repertoire of skills and tools that will serve us throughout the rest of the Cycle. These skills are built with others in Reaching Out.
Reaching Out	Reaching Out describes the ways in which an individual solidifies a new understanding of Respectful Care. Providers, who are educated about their biases, can identify the behaviors they exhibit that influence care and treatment for patients they are biased towards. Communication and information sharing become more important to the provider, to show themselves more trustworthy [5]. Overall, curiosity about the impact of social determinants on patients’ lives can help providers build empathy and understand others. Small shifts in behavior communicate a level of respect to Black mothers, that impacts their experience. This Reaching Out phase moves us from the internal work to the truly interpersonal within the provider community.	In this phase, a person begins to incorporate their new ideals and knowledge into their everyday interactions, observing the response of others in their life to their new perspective. It is imperative to practice the new skills with others, test expressing new views, vocalize uncertainty instead of staying silent, and examine ideals through reflection and introspection, and seek out a greater range of differences than before. This Reaching Out phase provides strategies to practice the ways in which new worldviews will be met by patients.
Implementing with Provider Community	The Provider Community phase of the Cycle to Liberation contains two components: conversing with those who possess similar social identities and those who are different to build coalitions [18]. The interpersonal phase of the respectful care process is marked by a change in the value of others. This phase is characterized by the creation of an ongoing dialogue where views are exchanged, people are listened to and valued, and the process of seeing others’ points of view as making sense and having integrity, even if they are very different from our own, begins. An integral part of this dialogue is exploring differences, clarifying them, erasing assumptions, and replacing them with firsthand contact and good listening. Building a solid provider community for respectful care means that small groups within institutions come to a common understanding of respectful care for Black mothers. These individuals will begin to conduct themselves differently in ways that impact their colleagues.	Addressing the provider community consists of two steps: (1) dialoguing with people who are like us for support and (2) dialoguing with people who are different from us for gaining understanding about oppression. Patients’ culture, religion, fears, and hopes for their birth experience, must be discussed. It is useful to collectively create guidelines on normalizing best practices that are not standardized, like visitation policies or emerging anti-racism tools [26]. The Black mothers in the study suggested that provider accountability is shown either to the health system itself or to the patient. It is socialized in the provider community to build trust with the patient, such that the patient adheres to clinical guidance. It is not socialized in the provider community to be responsive to the knowledge, words, birthing needs, and priorities of the patient as an autonomous decisionmaker in the birthing experience [27]. The Institute for Healthcare Improvement (IHI) Framework [28] and AIM Patient Safety Bundle Reduction of Peripartum Racial/Ethnic Disparities are resources for organizational self-evaluation for accountability and equity of care to guide health systems and hospitals through this phase.
Coalescing with Local Community	The Coalescing phase is where the actions of the organized coalitions and groups begin to disrupt oppressive systems and create change [18]. It is vital during this phase to realize the collective work of the cohesive group is greater than individual actions. Once obstacles have been ameliorated, one can address factors that maintain racial inequities by joining forces with the broader community beyond that of the hospital facility or healthcare system [27].	Working in a true collaborative manner means that providers are culpable in ensuring patients are well when they are outside of the direct care and oversight of the care facility. Providers, who have coalesced with their patients’ communities are able to ensure patients leave with access to resources to meet biopsychosocial needs. This may require large systems to power map structures and processes for health equity in their locations. This phase is intended to disrupt the status quo and for members of coalitions to take a stand with their beliefs. Consistent with existing quality improvement efforts, this phase also aligns with the IHI Framework sections four and five [28], National Quality Forum’s domains of health equity [27] and the ACOG AIM Patient AIM Patient Safety Bundle Reduction of Peripartum Racial/Ethnic Disparities [29]. The actions in this phase of the Cycle lead to collective work to create change in structures, assumptions, philosophy, rules, and roles
Creating Change	The Creating Change phase of the cycle includes redesigning health services to create new culture and norms that reflect the public’s collective identity [30], resulting in new assumptions, new structures, new roles, and new rules consistent with birth equity. Establishing health equity as a strategic priority and challenging structures, greatly enhances efforts to critically transform systems. Another way to create a culture of respectful care is to improve methods of accountability so that providers can have critical conversations amongst themselves, this involves taking leadership risks and becoming a beacon of change. Critical transformation takes place when organizations make conscious collective decisions for all policies for a collaborative structure rather than hierarchical. The new assumptions, rules, roles and structures must be cultivated.	Creating Change for respectful care means transforming institutions and creating a new culture [31]. Centering the voices and experiences of the group most impacted by the inequity is of greatest importance. Institutional change also depends on an assessment of institutional policies, clinical practices, and structures undergirding the system. Mentorship from identified birth equity champions within the facility or dismantling structures of power in and around quality improvement projects are legitimate activities to create change [5,32]. Tools for assessments include the Institute for Healthcare Improvement tools, National Quality Forum’s health equity domains [27], AIM tools and the strategy of applying the Brooks Equity Typology assessment [33] described in the R4P framework [34].
Maintaining	Maintaining is a phase where all the previous changes become routines in the life of the person, and that people in this phase of the system support each other, to hold one another accountable for maintenance of the change [18]. Moving towards a respectful and anti-racist practice necessitates that institutions challenge structural racism and other intersecting oppressive systems (e.g., ableism, classism, ethnocentrism, homophobia, sexism, transphobia- and shift power in resources, leadership, and policies) [10]. In order to succeed, change needs to be strengthened, monitored, and integrated into the ritual of daily life. Just like anything new, it needs to be nurtured, learned again “debugged,” and modified as needed. Maintaining includes a paradigm shift in medical training and competencies for respectful and anti-racist care models [10]. There must be an ongoing commitment and investment of resources from leadership and systems to maintain Respectful Maternity Care initiatives.	Providers are under extreme pressure and responsibility. Taking care of themselves and others on the care team helps them to avoid burnout and desensitization from repeated issues. Individual providers can help maintain systems change by advocating for institutional, local, state, and federal policies that impact social determinants [30], structural racism [35,36] and healthcare overall. They may be trained to advocate or exercise their inherent knowledge of the administrative or legislative process. Advocacy within the healthcare facility would be helping establish a governance structure and process for health equity, including hiring a diverse staff. Quality improvement efforts of any kind must address racial equity and bias to impact care. The Institute for Healthcare Improvement Achieving Health Equity: A Guide for Health Care Organizations provides guidance on this process [28].