“It was just one moment that I felt like I was being judged”: Pregnant and postpartum black Women's experiences of personal and group-based racism during the COVID-19 pandemic

Abstract

Background

Racial inequities in maternal and child health outcomes persist: Black women and birthing people experience higher rates of adverse outcomes than their white counterparts. Similar inequities are seen in coronavirus disease (COVID-19) mortality rates. In response, we sought to explore the intersections of racism and the COVID-19 pandemic impact on the daily lives and perinatal care experiences of Black birthing people.

Methods

We used an intrinsic case study approach grounded in an intersectional lens to collect stories from Black pregnant and postpartum people residing in Fresno County (July–September 2020). All interviews were conducted on Zoom without video and were audio recorded and transcribed. Thematic analysis was used to group codes into larger themes.

Results

Of the 34 participants included in this analysis, 76.5% identified as Black only, and 23.5% identified as multiracial including Black. Their mean age was 27.2 years [SD, 5.8]. Nearly half (47%) reported being married or living with their partner; all were eligible for Medi-Cal insurance. Interview times ranged from 23 to 96 min. Five themes emerged: (1) Tensions about Heightened Exposure of Black Lives Matter Movement during the pandemic; (2) Fear for Black Son's Safety; (3) Lack of Communication from Health Care Professionals; (4) Disrespect from Health Care Professionals; and (5) Misunderstood or Judged by Health Care Professionals. Participants stressed that the Black Lives Matter Movement is necessary and highlighted that society views their Black sons as a threat. They also reported experiencing unfair treatment and harassment while seeking perinatal care.

Conclusions

Black women and birthing people shared that exposure to racism has heightened during the COVID-19 pandemic, increasing their levels of stress and anxiety. Understanding how racism impacts Black birthing people's lives and care experiences is critical to reforming the police force and revising enhanced prenatal care models to better address their needs.

1. Introduction

Racial inequities in perinatal and child health outcomes persist in the United States (US) (Chambers et al., 2021). Black people are 3–4 times more likely to die in labor or from related complications in comparison to white women and birthing people (Howell, 2018). Infants born to Black people are about two times more likely to be born premature (<37 weeks gestation) and die before their first birthday in comparison to infants born to whites (Dominguez, 2010; March of Dimes, 2022a.; Owens and Fett, 2019; March of Dimes, 2022b). Many studies have shown that these inequities remain when accounting for socioeconomic status (e.g., educational attainment) and medical conditions (e.g., hypertension) (Dominguez, 2010). There is strong research to support that exposure to racism across the lifespan and during pregnancy is the root cause of these inequities (Giscombé and Lobel, 2005).

Racism is a system of oppression structured to distribute opportunity and wealth based on a person's race and ethnicity, which has disadvantaged Black people and communities (Jones, 2000). Racism operates at many levels, shaping and impacting policy, as well as perpetuating socially constructed beliefs about Black people (Jones, 2000). Structural racism, or structured policies, laws, and ideological beliefs that advantage white people's access to opportunity, health, and wealth, results in inequitable opportunity structures, neighborhood environments and conditions, and limits access to individual resources for Black people (Jones, 2000). Structural racism has been associated with preterm birth and infant mortality, while interpersonal racism, defined as the direct and vicarious day-to-day mistreatment experienced personally based on a person's race and/or ethnicity (personal racism) or collective experiences of mistreatment experienced by people of the same racial/ethnic group (group-based racism), has been associated with poor health care experiences, low birth weight, and being born small for gestational age (Chambers et al., 2019; Slaughter-Acey et al., 2019). Research supports that both structural and interpersonal racism (both personal and group) serve as chronic stressors in Black women's lives, negatively changing their physiology over time, and limiting their access to resources including quality prenatal care (Allen et al., 2019; Slaughter-Acey et al., 2013).

The World Health Organization declared a global pandemic in early March 2020, and, nearly two years later, 94.5 million Americans have been infected by coronavirus disease (COVID-19) and over 1 million have died (Center for Disease Control and Prevention, 2020; Ritchie et al., 2020; Sheahan and Frieman, 2020). In parallel, after the onset of the COVID-19 pandemic, the killings of Ahmaud Arbery, George Floyd, and Breonna Taylor further increased awareness of another pandemic, racism, through the unjust violence towards Black people by current and former police officers and US Coast Guard personnel (Laurencin and Walker, 2020; Lemke and Brown, 2020). The Black Lives Matter Movement (BLM) amplified these injustices and we cannot underestimate their emotional and physical toll on Black parents (BlackMatter, 2022). BLM was founded in 2013, seven years before the rise of the COVID-19 pandemic (BlackMatter, 2022). Stark racial inequities in COVID-19 infection and mortality in America have become evident with national estimates of mortality rates being 2.1 times greater among Black people in comparison to their white counterparts (Johnson-Agbakwu et al., 2020). Research supports that these inequities are the direct result of structural racism, as Black populations sit at the intersection of high rates of unemployment and chronic disease, low rates of health insurance, and poor living conditions (Peek et al., 2021). During the height of the COVID-19 pandemic, Black people not only feared dying from a novel infectious disease, but also from targeted police brutality. News and social media exposures of the accumulating deaths of Black people from COVID-19 and by police officers and US Coast Guards intensified the emotional and physical toll these two pandemics individually and collectively had on the Black community (Lemke and Brown, 2020). Furthermore, the COVID-19 pandemic has had harsh implications for pre-existing sexual and reproductive health inequities among Black people, particularly within the context of accessing quality perinatal care (Lemke and Brown, 2020).

Enhanced prenatal care has been identified as a promising intervention to address exposure to complex stressors and reduce racial inequities in perinatal and child health outcomes (Roman et al., 2014, 2017). Enhanced prenatal care models provide traditional components of clinical care, including checking vital signs, monitoring fetal growth, administering care for existing or new health conditions, and providing health education and other pregnancy resources, while also offering psychosocial support and assessment of, and links to resources to address social determinants of health (Roman et al., 2014). Despite the potential benefits of enhanced prenatal care, racism (both structural and interpersonal) is a barrier to accessing prenatal care (Roman et al., 2017). The COVID-19 pandemic highlighted the longstanding impact of racism and discrimination impacting Black people and families’ access to healthcare and social and economic resources, and to live healthy and thriving lives in their communities (Laurencin and Walker, 2020; Wheeler et al., 2021).

To reduce the risk of COVID-19 infection, the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine advised prenatal care providers that a modified schedule of prenatal care may be appropriate, including reducing the number of in-person prenatal care visits, utilizing telehealth when possible, and incorporating home measurement of blood pressure, weight, and other health data during telehealth visits if feasible (Boelig et al., 2020; American College of Obstetricians and Gynecologists, 2020). However, increased use of telehealth might reduce prenatal care access in communities with limited broadband access to healthcare equipment to monitor pregnancy progress (e.g., blood pressure cuffs) (Limaye et al., 2021).

As part of a larger comparative effectiveness study (Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE)) of two forms of enhanced prenatal care (Glow! Group Prenatal Care and individual prenatal care with Comprehensive Perinatal Services Program enhancements) for low-income pregnant people in California's Central Valley, we conducted interviews with 62 individuals who self-identified as Black/African American and/or Latinx and were currently pregnant or had given birth in the previous year. Participants for this qualitative study included EMBRACE study participants and people who had participated in Fresno County's Black Infant Health Program. The goal of the interviews was to gain a nuanced understanding of the prenatal care these individuals had received during the COVID-19 pandemic and to develop a telehealth version of Glow! that would be more appealing to, and better reflect, the needs of pregnant people during and after the pandemic. For this analysis, we used data from the 34 participants who self-identified as being Black only or multiracial with Black as one of their social identities to explore the intersections of racism and the COVID-19 pandemic impact on their daily lives and perinatal care experiences.

2. Methods

2.1. Study design

We used an intrinsic case study approach grounded in an intersectional lens (Stake, 1995). Our case for this study was understanding how racism impacted the labor experiences of Black people with low-income lives and perinatal care experiences during the COVID-19 pandemic. The study was bounded to July–September 2020, as protocols and procedures to access and engage in perinatal care drastically changed during that period. Our case also focused on group (e.g., killings of George Floyd and Breonna Taylor and witnessing discrimination while navigating perinatal care) and personal (e.g., experiences of discrimination while navigating perinatal care) events of racism during this timeframe. This approach was guided by an intersectional framework that posits: (1) people have multiple social identities that intersect and co-depend on one another; (2) there is a need to focus on the perspectives of people who sit at the intersections of historically oppressed social identities; (3) people's individual social identities intersect with historical systems and structures to contribute to health inequities; and (4) people's social identities collectively work together so that no social identity is more important or outweighs another (Bowleg, 2012). In this study, we acknowledge the intersecting social identities of Black people with low incomes, and the oppressive systems that shape access to resources, wealth, and health including racism, sexism, and classism, adding an additional layer of systematic oppression that the COVID-19 pandemic has caused and made visible.

2.2. Ethical considerations

We obtained study approval from Institutional Review Boards at the University of California, San Francisco, and California State University, Fresno.

2.3. Setting and sample

Participants for this qualitative study were purposely recruited in Fresno County, which is home to almost one million residents, of whom people of color are the overwhelming majority (54% Latino, 11% Asian Pacific Islander, and 6% Black/African American) (“U.S. Census Bureau QuickFacts,” n. d.). Approximately 20.5% of the population lives in poverty, limiting their access to affordable housing, clean and safe drinking water, reliable public transportation, open space for their children to play, and healthy, safe jobs that provide a living wage (Central Valley Health Policy Institute, 2015).

When we look at perinatal and child health outcomes for Fresno County, rates for adverse birth outcomes experienced by Black people are significantly higher than for California overall. For example, in 2019, California had an infant mortality rate of 4.2 per 1000 live births, while Fresno County had an infant mortality rate of 5.7 deaths per 1000 live births (March of Dimes, 2022a). Although Black people accounted for only 5.1% of Fresno County births, they accounted for 15.6% of total infant deaths (Central Valley Health Policy Institute, 2015; March of Dimes, 2022c). Similar Black-white inequities are seen in preterm birth rates (14.1% vs. 8.9%) and access to adequate prenatal care (79.4% vs. 87.1%) (March of Dimes, 2022d; March of Dimes, 2022e).

For this analysis, we recruited participants from two populations: (1) individuals who had enrolled in EMBRACE comparative effectiveness study prior to the COVID-19 outbreak; (2) individuals who were receiving services from the Fresno County Black Infant Health (BIH) program. Sixty-two individuals enrolled in the qualitative study, of whom 34 identified as Black or multiracial with Black as one of their races/ethnicities: 12 EMBRACE study participants and 22 BIH clients. Two research team members and one graduate student contacted all potential participants by phone. To ensure comparability of the groups in this analysis, BIH participants were screened using the same inclusion and exclusion criteria we had utilized for the EMBRACE study participants: self-identifying as Black/African American, ≤24 weeks gestation or <7 months postpartum, eligible for Medi-Cal during their pregnancy, and English- or Spanish-speaking. All participants provided consent in person or remotely via DocuSign. We did not ask participants about their gender identity, therefore, we will be using Black birthing people while presenting results.

All participants whose data were included in this analysis reported being U.S. born and their mean age was 27.2 [SD = 5.8]. Approximately three quarters (76.5%) self-identified as Black only and 23.5% self-identified as multiracial/ethnic including Black. Half (47.1%) reported being married or living with a partner. A total of 29.4% of the participants reported monthly household incomes below $1000 while 20.6% reported incomes over $3000 per month. Lastly, 11.7% reported having graduated from college (Table 1 ).

Table 1.

Descriptive characteristics for the analytical sample (N = 34).

Sociodemographic characteristics*	n (%)a
Age, mean (SD), y	27.7 ± 5.2
Racial or ethnic group
Black	26 (76.5)
Bi-racial, mixed race, or multi-racial ethnic with Black as one race/ethnicity	8 (23.5)
Highest level of education
Some high school	6 (17.7)
High school graduate, GED or equivalent	6 (17.7)
Some college, junior college, or vocational school	18 (52.9)
College graduate	4 (11.7)
Relationship status
Married or living with partner	16 (47.1)
Significantly involved with a partner, but not living together	8 (23.5)
Single/not significantly involved	10 (29.4)
Monthly household income
Less than $1000	10 (29.4)
$1000 to $2000	11 (32.3)
$2000 to $3000	4 (11.8)
Over $3000	7 (20.6)
Don't know	2 (5.9)

^aUnless otherwise specified.

2.4. Data collection

We developed a semi-structured interview guide in partnership with the EMBRACE implementation, research, and community engagement teams (see Table S1 in the online supplementary files). Three iterations of the interview guide were administered during the data collection process to ensure we were gathering information to capture birthing people's changing experiences during the COVID-19 pandemic and effective strategies that can be used to improve birthing people with low incomes' telehealth experiences during prenatal care. All interviewers received training in qualitative research methods. All interviews were conducted by racially and ethnically concordant interviewers using the Zoom videoconferencing platform without video. The interviews ranged from 23 to 96 min, and study team members completed field notes after conducting each interview.

2.5. Analysis

All interviews were audio-recorded and professionally transcribed. An inductive thematic analysis approach was used to code and analyze data. A diverse stakeholder team of nine members reviewed field notes and transcripts to develop initial codes. We had a team of nine coders, including five individuals who represented the community, or had trained in community health, and four who were prenatal care providers or had experience facilitating group prenatal care sessions. The study team had no previous personal relationships with the study participants who were recruited from BIH. Because of the longitudinal nature of the EMBRACE study, some of the interviewers interacted with qualitative interview participants during the course of prior quantitative interviews. Team members met on a weekly basis to discuss the coding process, identify emergent codes, and finalize the codebook. Two team members from each coding group (i.e., community representative or community health researcher with a prenatal care provider or facilitator) reviewed and coded each transcript and worked collectively to adjudicate discrepancies and assign final codes.

For this analysis, we focused on responses to questions pertaining to exposures to personal- and group-based racism in the context of the pandemic, including: (1) How has racial and ethnic discrimination impacted your family or community? (2) How has racial and ethnic discrimination impacted you personally? (3) Have you personally been treated unfairly while receiving prenatal care? What experiences or situations made you feel that way? (4) Do you know others who have been discriminated against in your community while receiving their prenatal care? Can you please describe their experience? (5) How have protests for BLM during the COVID-19 pandemic affected your family and community? and (6) How have people in your community been involved with the BLM protest? We also focused on general questions about the impact of COVID-19 on participants' day-to-day lives. Two team members used thematic analysis to review codes and group them into larger themes. Themes were shared with the EMBRACE Study Stakeholder Advisory Group to enhance the trustworthiness of data to support emergent themes. Dedoose software was used to code and manage the data (SocioCultural Research Consultants, 2022). We assigned participants pseudonyms to increase confidentiality. We did not exclusively ask participants a survey question about their gender identity; therefore, we use inclusive language to share study results.

3. Results

Ten of the 34 participants in this analysis were interviewed during their third trimester of pregnancy, and 24 were interviewed between one and six months after they gave birth. These people shared being exposed to structural and interpersonal racism during the COVID-19 pandemic while being quarantined and navigating public spaces and healthcare settings. Five themes emerged from this data analysis: (1) Tensions about Heightened Exposure of Black Lives Matter Movement during the pandemic; (2) Fear for Black Son's Safety; (3) Lack of Communication from Health Care Professionals; (4) Disrespect from Health Care Professionals; and (5) Misunderstood or Judged by Health Care Professionals.

3.1. Tensions about heightened exposure to BLM during the pandemic

Participants described police brutality as a chronic stressor plaguing Black individuals and communities. BLM served as a platform to build awareness about the high incidence of police killings in the Black community. During the pandemic, much of the world was quarantined and witnessed the unjust killings of Ahmaud Arbery, George Floyd, and Breonna Taylor by police officers and white men. Simultaneously, the incidence of, and mortality from, COVID-19 were rising and disproportionally impacting the Black community. Participants in our study shared experiencing close family members dying from COVID and being fearful for their own lives.

My main worries and fears is just catching it … my immune system's already low from the cancer and stuff … My stepmother, she died. She had the same problems that I have, the health problems … My brothers, my sisters, all of them, my dad, they all have it. Their mom ended up dying from it [COVID] a couple of days after she got it. – A 37-year-old Black birthing person who received individual care

While navigating the impact of the COVID pandemic on their community and families, participants in our study described tensions between being fearful and having a sense of relief with the heightened exposure to the BLM. A 29-year-old Black birthing person who received individual care stated: “I am grateful, there's awareness of the situation [unjust killings of Black people by police officers], it has reached a national level. I am grateful for that, bringing national awareness to the situation and not just randomly seeing a video here and there.” These birthing people stated that the issue of unjust police killings in the Black community is not new, yet the COVID-19 pandemic has increased awareness of the issue in non-Black communities.

Some participants expressed concern that this increased awareness might cause additional harm to the Black community, but upon further reflection they felt that it would lead to important changes across the nation and in their own communities. A 24-year-old Black birthing person who received individual care shared:

Honestly, it scared the living crap out of me at first, because I felt like the protesting was agitating people to treat us worse than what they were already treating us, but seeing the outcome of it all, I feel like now we're finally making somewhat of a change or being heard about our demands.

Witnessing police killings of Black people has caused emotional harm to Black people and communities. Participants described not fully understanding how people can discriminate against others based on an innate characteristic such as skin color. These Black birthing people described heightened police killings of Black people as a racial trauma that resulted in feeling hurt and fearful.

All those deaths and all that violence, and that kind of thing that affect us all in a big way because it hurts to see that going on in your community. It's like, ‘Wow. People still feel a certain way about us just because of something that we can't control. Yes, it hurts to see that.‘—A 36-year-old Black birthing person who received individual care

Black birthing people described how systems of oppression such as racism contribute not only to unjust killings of Black people, but also to mental and health issues in the Black community.

The BLM makes me feel [sic] very sad, hurt, angry, disrespected. Feel hated, not really equal. There are so many emotions that come with that. We're all human. We all deserve to respect one another and love one another. We all bleed the same. Our colors may not be the same, but our blood is the same. —A 29-year-old Black birthing person who received group care

Overall, these participants expressed a tension between the racial trauma from witnessing filmed killings of Black people and the sense of relief that there is national and global awareness of this issue.

3.2. Fear for Black Son's safety

Racial trauma related to deaths and violence in the Black community caused by police brutality becomes intensified when one focuses on Black birthing people's intersecting social identities of being Black, a birthing person, and a parent to a Black son. The mass killings of Black men by police officers during the pandemic serve as a constant reminder to Black parents that their sons are perceived by society to be a threat, which puts them in danger each day in private and public spaces. A 32-year-old Black birthing person who received individual care expressed:

I have two sons, it's nerve-wracking and sad. It's alarming paranoia to think like, ‘You just have to protect them in such a manner.’ Really doing [sic] anything, walking down the street trying to jog somewhere … as a parent, as an individual and as a kid, that's just too stressful.

Participants expressed that the unjust killings of Black people by police officers create a collective trauma or worry shared among parents and children.

Birthing people shared that this collective trauma or worry starts the moment they give birth to their sons. A 24-year-old Black birthing person who received individual care described the impact of the worry about the racial discrimination their unborn Black son will experience on her mental health: “A lot [discriminations impact], because now, it's hard for the Black males in some areas, so me giving birth to one and having to raise him in this environment is really scary, and worrisome for me.” A 28-year-old Black birthing person who received individual care shared that this collective trauma and worry that they have for their son, is similar to the fear they have for their husband: “Yes, with my son gone, he's doing stuff that he might not make it back home or my husband might not make it back home if he gets pulled over or something. So, it's always a fear.” Furthermore, these birthing people described taking additional precautions to protect their children, especially their sons, from premature death from homicide committed by a police officer.

Preparing Black boys to avoid being killed by the police is a necessary, yet challenging conversation that Black parents must have with their Black sons, every day. Birthing people reflected on the trauma associated with having these conversations and raising their Black sons for survival. Birthing people shared struggling to identify when is the “right” time to have discussions with their Black sons about racism and police brutality, to equip them with strategies they will need to survive potential interactions with police officers.

I've always said I've never wanted sons … I've always heard of boys getting shot and killed and looked at a certain way. I feel like that's why I never wanted a son, is because I didn't want to have to always be worried about his safety. Now, that I have a son, it's like, at what age am I supposed to explain to him, ‘If you get pulled over, this is what you do. This is how you act. This is how you respond. You need to dress like this because if you dress like this, you're automatically assumed as a gang member or a thug. – A 29-year-old Black birthing person who received individual care

Respondents further stressed that racism, operating through police brutality, strips away Black children's childhood by requiring them to think about ways to increase their safety when interacting with police officers who are supposed to be hired and trained to protect communities.

3.3. Disrespect from healthcare professionals

Participants in our study also shared that they received unfair treatment and harassment while seeking care during pregnancy and birth because of their race/ethnicity, gender, and other intersecting social identities. These stories highlight how oppressive ideologies such as racism and classism shape healthcare professionals’ perceptions and treatment of Black birthing people with low incomes. Healthcare professionals included any individuals working for the clinic, practice, hospital, or other healthcare facilities where the participant received care. Disrespect from healthcare professionals was described as an ongoing issue that Black birthing people encountered when navigating healthcare settings. Despite global rapid changes within perinatal care settings during the pandemic, most facilities in Fresno County remained open and provided in-person care to pregnant birthing people. Birthing people shared that protocols to enter and navigate perinatal care facilities changed and wait times to see providers substantially increased.

When I get there, first I have to check-in, give them my name, birth date. Then they give me a little cup to handle my business in. Then after that I just have to wait. Sometimes the wait can be a little longer than what I expected due to the pandemic. I feel that's the issue that they should understand that. My appointment would be at 10:00 then I'm going to see him close to 11:00. —A 29-year-old Black birthing person who received individual care

Participants also shared restrictions on bringing support persons to appointments was also a challenge. At the start of the COVID-19 pandemic, birthing people were not allowed to bring their partners to prenatal care appointments. Yet, a 27-year-old biracial/ethnic Black birthing person who received individual care shared an interaction with a health care professional who was checking in with her about this change. This Black birthing person felt disrespected by a follow-up question that indicated an assumption that because they were a Black birthing person who looked young, their child's father was not involved.

One time I went in [for a prenatal care appointment], I actually had a nurse tell me, ‘How are you feeling about dad not being allowed in here? Is there even a dad in the picture?’ I looked at her and I said, ‘I'm sorry.’ She was like, ‘Oh, well, you're just really young and I just didn't know if the baby's father was in the picture,’ and I said, ‘Well, why would you assume that he wasn't?’ She just stopped talking to me.

Participants shared that some facilities continued to allow support persons to attend appointments; however, providers showed favoritism to couples of other races/ethnicities. A 23-year-old biracial/ethnic Black birthing person who received individual care expressed: “He [their friend] was able to go to appointments with his pregnant girlfriend, but then, all of a sudden, someone new had … started working there. They told him that he couldn't come anymore, but he had seen the boyfriends of other pregnant moms in the waiting room.”

Participants further shared that exposure to disrespect in healthcare settings came with an emotional toll. A participant expressed seeing healthcare professionals treat them differently in comparison to people of other racial and ethnic groups impacted their emotional health. A 26-year-old Black birthing person who received individual care shared:

In the beginning [of their pregnancy], I was really hungry, and a lot of times, I felt like some of the nurses they were laughing at me because I just kept on asking for food. That really hurt me because I was like, I don't understand why. I mean, everybody else asks for food too. Like other races ask for food too. Why is it funny with me?

Many participants shared they are often publicly disrespected by healthcare professionals when accessing supportive services. Black birthing people further shared that when offered resources, they felt healthcare professionals attempted to force resources on them that did not necessarily match their needs, but rather healthcare professionals’ biases about them as a Black birthing person.

There was a woman in my mommy group that they were trying to force things upon her that she didn't want. She said that they were basically thinking that she was uneducated and didn't know anything. She felt racial discrimination due to that. - A 26-year-old Black birthing person who received individual care

Participants' stories underscore that being a Black birthing person, and of low-income, intensified the amount and kinds of discrimination they received while navigating perinatal healthcare settings.

3.4. Lack of communication from health care professionals

Participants shared experiencing poor communication from health care professionals while seeking prenatal care. Birthing people described poor communication as not being provided information or treatment options after expressing a need, being misread or misunderstood, and receiving care or treatment options that do not align with their expressed care plan. Birthing people expressed asking providers questions about their health and well-being, and not receiving answers that met their needs.

Yes. I would say far as getting my questions answered. It was hard to get an effective answer when I asked questions as far as my health or, "What does this mean? or "How can we fix this? Is there other options?" It wasn't very effective on ways to secure my health and wellbeing. – A 25-year-old Black birthing person who received individual care

Black birthing people shared that poor communication not only impacted their own care, but also the prenatal care their friends and family members received. A 27-year-old Black birthing person who received individual care shared:

Yes. I've heard of family members not being taken seriously with their concerns while they were pregnant. Even after giving birth, having issues, and not being taken seriously until it's bad and they have a horrible infection and things like that.

Black birthing people shared that poor communication from healthcare professionals extended to the birth setting. A 22-year-old Black birthing person who received individual care reported feeling violated during their pelvic exam and frustrated that their birthing plan was not followed. They expressed that they were given Pitocin without their provider first talking with them about options.

I felt like she [the midwife] just went for it [checking the cervix]. It was uncomfortable and I flinched. She was just like, ‘Oh, no. If you're going to be this tense the whole time, you're better off -- you need to just get the epidural,’ because I did go in telling them that I didn't want an epidural … I had barely got in there and it wasn't even 20 minutes and they had called her [the doctor] and told her I was four centimeters dilated and the doctor, without even meeting with me or anything said to put me on Pitocin … I ended up getting it pretty early on [an epidural], which was not in my plan at all. I just feel like she wasn't very encouraging at all.

Birthing people shared that their providers participated in victim-blaming strategies and did not take responsibility for their behaviors. For example, a 22-year-old Black birthing person who received individual care further shared: “Even with pushing, I was doing what she was telling me, and she was just like, ‘Come on. You've got to do.’ Like, ‘basically, you've got to do it better than that.” I was just like, ‘Wait.’” Black people's birthing experiences underscore the overwhelming evidence that healthcare professionals continue to not listen to Black birthing people which results in adverse care experiences and outcomes. Furthermore, healthcare professionals did not always communicate with birthing people to ensure that they were receiving care that met their expectations and that they were partners in the decision-making that impacted their care experiences and outcomes.

3.5. Judged by health care professionals

Participants also reported that when healthcare professionals did listen to them, they responded with judgment. Furthermore, feeling judged by healthcare professionals was identified as a barrier to receiving resources to support a healthy pregnancy and a positive birthing experience. A 25-year-old biracial/ethnic Black birthing person who received group care shared that their provider's personal views on marijuana use during pregnancy interfered with them being referred to resources to support having a healthy pregnancy and baby.

It was just one moment that I felt like I was being judged off of what I was telling her. I was just opening up to her about things that were going on in my life and I felt like I was being judged rather than giving I guess the proper tools or resources. Instead of giving me resources or tools, I felt like I was being judged off of what I was saying.

Similar experiences were shared about treatment received in the birthing setting. A 29-year-old Black birthing person who received individual care shared provider's judgment about them as a Black person impacted the quality of care they received in labor and delivery:

When I went to the emergency room, yes, I feel like they look at me or Black people as in we're just dramatic and we overthink things, but when little Susie over here will get looked at and checked out from A to Z, while they just tell us, "Oh, just drink more water.

A couple further expressed feeling judged upon discharge from labor and delivery. A 30-year-old Black birthing person who received group care expressed that a nurse who had cared for them during their hospitalization told them they could take their baby home in the hospital receiving blanket and was then accused of stealing it by another nurse when leaving the hospital.

It's more of like a discrimination thing we [Her and her partner] felt … One of the nurses, when we were leaving the hospital said, she can have a receiving blanket, but the other nurse, the one that was waiting downstairs, snatched it from her and said, ‘No, you can't have this’ … she felt like she [sic] was trying to steal it, but it was given to her.

The quotes show how oppressive structures of racism and sexism, and tropes of Black birthing people being “thefts,” “crackheads,” and “welfare queens” contribute to healthcare professionals’ judgments about Black birthing people and families.

4. Discussion

Findings from this intrinsic case study show how Black people's pregnancy, birthing, and postpartum experiences were affected by heightened exposure to racism during the COVID-19 pandemic. Taking an intersectional approach highlighted how systems such as racism and classism contribute to racial trauma and healthcare mistreatment among Black birthing people with low incomes during the COVID-19 pandemic. Participants shared stories of the collective trauma and worry from bearing witness to the killings of Black people and fearing for the safety of their Black sons. Coupled with judgment and lack of communication from the health care professionals they interacted with, these birthing people voiced experiencing disrespectful care during their prenatal and birthing care experiences.

Our study is unique in that it explored Black birthing people's lives and perinatal care experiences during the COVID-19 pandemic and the BLM following the unjust killings of Ahmaud Arbery, George Floyd, and Breonna Taylor. Awareness of the unjust violence towards Black people has been amplified by the BLM and we cannot underestimate the emotional and physical toll this has on Black parents (Jaye, 2020). Research supports that exposure to group-based racism, such as witnessing mass killings of Black people by police officers across the life course, contributes to Black women being more prone to symptoms of anxiety and depression during the prenatal period (Orr et al., 2006). A study conducted during the initial wave of the COVID-19 pandemic confirmed that Black women reported higher levels of stress related to personally knowing people who died from COVID-19, and from job loss and economic burdens due to COVID-19, compared to their white counterparts, which are all effects of racism (Gur et al., 2020). Findings from our study provide an account of how police brutality played a role in the multitude of stressors experienced by Black birthing people during the COVID-19 pandemic while acknowledging that Black people were already experiencing a pandemic called racism. Our findings underscore that racism is the underlying cause of healthcare mistreatment and COVID-related anxiety and worry (Elbaum, 2020).

Black birthing people in our study voiced concerns about unmet communication needs, unfair or violent treatment, and being judged by perinatal health care professionals. Their encounters with a fractured healthcare system were described as ongoing and amplified during the pandemic. However, these experiences are not singular and obstetric racism is not unique to the period of the COVID-19 pandemic (Chambers et al., 2021; Davis, 2019). Black women and their bodies have long been victims of harm and medical experimentation at the hands of healthcare professionals and unjust systems (Davis, 2019). Current literature continues to echo similar themes from women of color during pregnancy, labor, and the postpartum period. McLemore et al. described co-occurring experiences of racism, poor communication, and stressful interactions with their obstetric providers among Black and Latinx women and families from Fresno, Oakland, and San Francisco, CA (McLemore et al., 2018).

Black women and families feel the negative impacts of structural racism while accessing and receiving health care (Chambers et al., 2021). An integrative review of 15 studies in the US showed racial discrimination as a strong risk factor for preterm birth and low birth weight (Alhusen et al., 2016). As qualitative research gives space to experiences of Black birthing people, the impact of personal and group-based discrimination on care experiences and birth outcomes becomes undeniable. This study shows how the COVID-19 pandemic can add to experiences of racism in clinical, hospital, and community settings for Black birthing people. The findings stress the need for transformative approaches to improve patient-healthcare professional interactions, focusing on better relationships among Black patients and healthcare professionals (Alhusen et al., 2016). As Hardeman and colleagues have outlined, efforts to improve the clinical encounter must center the experiences of Black birthing individuals, and healthcare professionals must engage in cultural humility and empathy to deepen patient-healthcare professional relationships (Hardeman et al., 2020).

Although healthcare professionals' racial identities were not reported or examined in this study, the findings speak to the salience of racially concordant care and implicit bias trainings as a potential opportunity to improve communication in the clinical encounter for Black patients. For instance, Karbeah et al.‘s findings that many clinicians of color are committed to racial justice and center the Black patient's cultural identity as part of their care indicate that increased investment in providers of color is a promising avenue for improving care experiences (Karbeah et al., 2019). Additionally, Black birthing people's experiences concerning the BLM and the exacerbation of racial tensions during the COVID-19 pandemic highlight the heavy burden Black families carry to cope with these stressors. This presented additional challenges due to the shelter-in-place orders, isolating people from family, friends, and social services (Wheeler et al., 2021). Thus, expanding access to programs like BIH, which aims to support Black perinatal clients with culturally relevant and person-centered services, is essential for supporting resilience.

Birthing people's stories support that these judgments and misunderstandings can result in unfair treatment and inadequate access to resources in prenatal and birth care settings. Furthermore, healthcare professionals' judgment interfered with their ability to listen to the needs and desires of Black birthing people and to treat Black families with respect and integrity.

4.1. Limitations

This study provides a rich exploration of the experience of Black birthing people in Fresno, CA, at the onset of the COVID-19 pandemic, but is limited in generalizability based on the timing of interviews and geographic focus. Our thematic analysis revealed experiences with personal and group-based racism inside and outside of care delivery settings that are not unique to the period of COVID-19. The time period when the interviews were conducted, July–September 2020, may not reflect the specific impacts of the early or later COVID-19 pandemic. Importantly, hospital policies, such as allowing support people at appointments or births, varied by care location and over the course of the pandemic. We did not exclusively ask participants about their gender identity. Further work should explore how Black women and birthing people's, individually and collectively, perceptions of police brutality and the BLM, as well as discrimination in the healthcare system, may have been affected by hospital policy or worsening racial disparities in COVID-19 infection.

4.2. Public health implications

Findings from our study underscore that racism, which negatively impacts Black birthing people's families, care experiences, and communities, has been further exacerbated during the COVID-19 pandemic. Racism has been identified as an ongoing public health crisis that affects multiple societal domains, including healthcare settings. Findings from our analysis underscore the need for police reform, including banning the use of force and maintaining ongoing racial bias trainings for police officers. Our results also emphasize the need for enhanced prenatal care models that provide respectful, antiracist care, and connect birthing people to adequate resources to support healthy pregnancies and births. In addition, our findings call out the need to mandate racial equity trainings for perinatal health care professionals to address interpersonal and structural racism and their impact on the care Black birthing people receive while navigating prenatal and birth settings.

5. Conclusions

Black birthing people disproportionately die at higher rates due to childbirth or related complications in comparison to birthing people of all other racial and ethnic groups. Racism, discrimination, and implicit biases have been identified as key drivers of these inequities. Black birthing people in our study shared that the COVID-19 pandemic highlighted the ongoing racial injustices impacting the Black community stirring up fear for their sons’ safety navigating the world as Black boys. Furthermore, Black birthing people expressed that sitting at the intersection of these two pandemics, racism and COVID-19, impacted their mental and physical health, as well as the accessibility of perinatal care. Participants' stories underscore the ongoing disrespect, judgment, and lack of communication Black birthing people experience while navigating perinatal care settings. As healthcare institutions are realigning to respond to new variants of COVID-19, centering on a racial equity lens is an integral approach to improve the quality of care provided to, and health outcomes of, Black birthing people.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Handling Editor: Blair T. Johnson

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Data availability

Data will be made available on request.