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. Author manuscript; available in PMC: 2023 Mar 7.
Published in final edited form as: J Transcult Nurs. 2022 Nov 2;34(1):83–90. doi: 10.1177/10436596221130798

“We Experience What They Experience”: Black Nurses’ and Community Health Workers’ Reflections on Providing Culturally Specific Perinatal Health Care

Roberta Hunte 1, Gita R Mehrotra 1, Susanne Klawetter 1
PMCID: PMC9990696  NIHMSID: NIHMS1878828  PMID: 36321733

Abstract

Introduction:

Black perinatal health workers are part of a tradition of Black people fighting for the well-being of Black communities. The purpose of this article is to better understand the unique experiences of these professionals.

Method:

Descriptive qualitative research was used to understand Black providers’ experiences in a culturally specific perinatal public health program. A focus group was conducted with seven nurses and community health workers, and thematic analysis was used to analyze the data.

Results:

Three themes emerged: (a) shared lived experience and parallel process between staff and clients; (b) navigating multiple shifting gazes between clients, public health department, and medical systems; and (c) reproductive justice and community care characterize a culturally informed approach.

Discussion:

Findings revealed strengths and complexities facing Black nurses and community health workers in their roles. More work is needed in education, practice, and research to better prepare and support nurses and community health workers in culturally specific settings.

Keywords: maternal and child health, cultural groups, Black, African American, public health policy, qualitative research

Black midwives, doulas, and traditional healers were historically the caretakers of Black families during reproduction. By the 1940s, birth became more incorporated into hospitals and the domain of doctors, pushing midwives out of the birthing process. As a result, community-based, Black-led reproductive care has become critical to providing the holistic care for Black families that was lost when birth moved from the home into hospitals (Davis, 2019; Hays, 2016). Currently, Black nurses and community health workers provide community-based perinatal care, which mirrors the care traditionally provided by Black midwives and doulas. Their experiences and work are critical contributions to the reproductive well-being of Black families.

Maternal and infant health inequities within the Black community are long-standing and well documented (Kothari et al., 2017; March of Dimes, 2021; Murphy & Liu, 2022; Petersen et al., 2019). Black midwives locate the causes of these inequities in the realities of systemic racism, the epigenetic legacy of slavery, the embodiment of racism-related trauma, and cultural loss through community displacement (Bridgeman-Bunyoli et al., 2022). Racism-related stress compounds Black people’s embodied experience of pregnancy and parenting (Hunte et al., 2022). As such, Black reproduction can be understood as a site of both racial oppression and anti-racist struggle for the survival and autonomy of the Black family (Hays, 2016).

The movement for reproductive justice addresses the needs and rights of all people to own their sexual and reproductive lives. Undergirded by a human rights framework, the tenets of reproductive justice assert the right to have a child or not, parent children in a sustainable environment, and bodily autonomy (Ross & Solinger, 2017). It is critical that perinatal care providers uphold these tenets in their efforts to provide patient-centered care that empowers vulnerable populations.

Health care providers must have a strong cultural and contextual understanding of Black communities, including considerations of racial, gender, and class oppression, to effectively meet the needs of Black families and pregnant people (Mullings & Wali, 2001). Black people benefit from perinatal care that includes access to services, resources and information, and companionship (Nypaver & Shambley-Ebron, 2016). Black midwives and community health workers state that Black-centered, anti-racist, and reproductive justice frameworks critically shape their interventions in serving Black families (Bridgeman-Bunyoli et al., 2015, 2022; Goode & Bernardin, 2022). These approaches also provide psychological empowerment and a sense of racial and cultural awakening among Black health care professionals (Bridgeman-Bunyoli et al., 2015).

Research consistently demonstrates that racial concordance is critical to patient experiences and perinatal health outcomes. A systematic review examining the effect of racial concordance on patient–physician communication found that when working with White providers, Black patients experienced second-rate communication, lower patient participation, and fewer opportunities for collaborative decision-making than White patients (Shen et al., 2018). Racial concordance, implicit bias training, and supportive health care systems geared toward the needs of people of color have been recommended to improve maternal health outcomes (Altman et al., 2020).

Despite evidence that racial concordance and culturally specific programming are important for Black perinatal health, little research has focused on the lived experiences of Black health care providers. Understanding how these professionals experience their work, address the reproductive needs of Black birthing people, and advocate for structural change is critical to improving Black perinatal health outcomes. The purpose of this article is to explore the experiences of Black nurses and community health workers who are working within Black communities to better understand their lived experiences, and the unique, complex dynamics of their community-based work.

Method

Design and Setting

This article describes a qualitative study of Black health care providers’ experiences in a culturally-specific perinatal public health program, the Healthy Birth Initiatives (HBI). Our use of qualitative methods intervenes in the exclusion and erasure of Black people as community and content experts, and instead elevates and honors their perspectives, knowledge, and experiences (Scott, 2021). This analysis emerged from a larger study conducted in 2019 that explored racism-related stress among Black people who are either clients or staff of HBI, and a more detailed accounting of study methodology also is included in that paper (Hunte et al., 2022). In this analysis, we specifically asked, “What are the experiences of Black nurses and community health workers serving Black people in a culturally-specific perinatal care program?” This study was approved by the researchers’ university and study site’s county institutional review boards. All participants provided written consent.

HBI utilizes racial concordance as a key component of its adaptation of the Nurse-Family Partnership, a perinatal and early childhood support program that provides home-visiting nurses during the prenatal and postpartum periods (Nurse-Family Partnership, 2022). The majority of HBI’s staff identify as Black and provide perinatal health care and support to Black families in the Portland metropolitan area. Portland, Oregon, where HBI is located, is the largest city in a predominantly rural state. The city and state have large White majority populations and relatively little racial diversity compared with other regions in the United States. Admitted to the United States in 1859 as a “whites-only” state (Bates et al., 2014; Imarisha, 2015), Oregon has a long and painful history of anti-Black racism and has been identified as a flashpoint for racist, White nationalist extremism even prior to the racial justice protests that occurred in response to the murder of George Floyd. Remnants of the state’s beginnings shape its structures, institutions, and systems and individuals’ experiences within these settings (Bates et al., 2014; Imarisha, 2015). The persistence of systemic and structural racism has led Oregon’s most populous county to declare racism a “public health crisis” (Multnomah County, 2021).

Sample

This analysis is based on data from one focus group conducted with HBI health care providers (n = 7) who identified as Black women and worked directly with clients as nurses (n = 4) and community health workers (n = 3). Participants were recruited through HBI program events, emails, texts, and fliers posted at HBI’s office. Participants were compensated for their participation.

Data Collection and Analysis

The focus group was conducted by the first author, a Black reproductive justice advocate and scholar who is a faculty member at a large public University. As she had a relationship with HBI, the organization had approached her to conduct research relevant to their work. The focus group took place on-site at HBI in a private location. Participants were asked to reflect on the impact of racism-related stress, effectiveness and limitations of perinatal health interventions, and experiences with racial concordance in their work. The focus group lasted approximately 80 min and was audio recorded and transcribed for analysis. We conducted a thematic analysis using an inductive approach guided by our research question (Braun & Clarke, 2006). Each co-author independently reviewed the transcript and assigned codes to reflect salient ideas. We met as a group to discuss and reconcile codes, and our reactions to the data. We subsequently organized codes into categories, which we then condensed and refined into themes. We prioritized themes related to Black health care providers’ lived experiences of delivering culturally specific perinatal care. Participants did not give feedback on identified themes.

Results

The following themes emerged from our analysis: (a) shared lived experience and parallel process between providers and clients; (b) navigating multiple shifting gazes between clients, public health department, and medical systems; and (c) reproductive justice and community care characterize HBI’s culturally informed approach. Results show the numerous, complex dynamics Black health care providers encountered in their work, and the specialized knowledge they used to effectively deliver culturally specific care.

Shared Lived Experience and Parallel Process

HBI nurses and community health workers identified as Black women, identities they shared with the majority of their clients. Participants described the overt and subtle forms of racism they encountered in their communities, health care systems, and the workplace. Nurses and community health workers also explained how shared lived experiences as Black women contributed to the effectiveness of their work with clients.

Racism Is a Through Line.

Participants discussed their experiences of racism as Black women and often reflected on parallel lived experiences with their clients. These experiences challenged the false notion of separateness between a client and their health care provider. Nurses and community health workers carried ongoing concern about the impacts of racism on themselves, their families, and their communities.

Participants also reflected that the wisdom and knowledge they brought to their work was developed through the training and professionalization process of becoming health care providers, the actual work of serving clients, and from lived experiences of being Black women. Speaker 2 spoke about being a Black woman in the context of racism:

There’s this heaviness all the time, whether it’s just going to the store, or being in the work environment, or even with your home, and your family…We look like the people we’re actually serving, so we experience what they experience. We have first-hand knowledge of it. Most of the stuff we do and teach and learn is kind of what we’ve learned throughout the days of being here or in our own lives.

Meaningful Work Despite Compounding Stressors.

Participants discussed the compounding stress of supporting Black clients in crisis while also being affected by racism, engaging in anti-racism advocacy in their work, and encountering the realities of what it is to be a Black woman in the broader community. Nurses and community health workers described racist experiences in the professional realm. Examples included being stereotyped as less qualified for their jobs, encountering surprise or suspicion of their intelligence, being the only Black person in high-level meetings, and experiencing fatigue and frustration with the slowness of structural change. Participants discussed how the day-to-day realities of their work affected their capacity to be present and engaged with clients at times. Speaker 4 described this accumulated racism-related stress:

You’re dealing with your own racism going into a home visit, and then now that client is dumping their stuff on you, and it’s like, “Okay, well, I came here with my own baggage, and now I have to carry your baggage out of here.” … It makes it difficult to even be present, sometimes, because it’s a lot. It’s a lot to carry around.

Even with the stressors of doing this work, participants unanimously expressed their commitment to it. All of them expressed that they felt inspired by their work and some even described it as a calling, their passion, or their purpose. As Speaker 2 shared, “I love it. I love the people. It’s the best work out there … I enjoy my job. But … it’s a lot.” Despite the challenges, participants agreed that it was meaningful for them to be in a predominantly Black work environment and that they felt more supported by their colleagues than if they worked in a primarily White space.

Community Knowledge Expedites Trust.

Nurses and community health workers highlighted how shared identities and experiences in the broader community helped them gain trust and legitimacy with clients. Providers were able to quickly connect deeply with clients and learn about their medical and personal contexts. This often allowed them to know more about the clients than the clients’ physicians located in more mainstream or traditional medical settings (e.g., community health clinics or hospitals). Participants’ abilities to relate to clients at the intersection of race and gender made the work productive, helped develop intimacy with clients, and fostered knowledge of clients’ experiences that was often not the case within mainstream perinatal services. As Speaker 5 noted,

The fact that we look like them, we’re able to get all kinds of information. Sometimes clients just need to purge and to release some of that stress that they’re feeling…That in itself is freeing up space for them to cope… they might not have ever told anybody, or certainly not a care provider, half the stuff they tell us.

In their work with clients, participants balanced their knowledge of what they believed clients ultimately needed with where clients currently were at in their journey toward well-being. All participants described a version of this delicate balance, which intensified when their personal experiences of systemic racism mirrored those of clients. Speaker 9 explained, We know that feeling of helplessness that they have, where they feel like they can’t do for themselves, comes from the society telling them all their lives that they can’t do for themselves, you’ll never be anything. But at the same time, we have to find a balance of where we know when we have to step back, because then sometimes if you don’t, then it’s almost like their problem becomes your problem, and you’re spending more time trying to fix their problem for them than they’re willing to put in.

Navigating Multiple Shifting Gazes

Participants described complex dynamics they faced as they interacted with clients and medical systems. Black staff shared identities with their clients as Black women; however, their professional capacity gave them more status compared with their clients. Participants often used their position to act as a buffer between clients and mainstream medical systems. Participants spoke about the complicated experience of being viewed through the shifting gazes of clients, the county’s public health system, and medical providers.

Contending With Dual Roles and Complex Boundaries.

HBI is a trusted bridge between the Black community and public health and medical systems. Yet, participants shared how their positions as HBI health care providers and community members presented boundary challenges. Given the relatively small Black population in Oregon, they experienced both opportunity and risk in providing services to people they knew in the community. Participants understood that clients genuinely enjoyed working with them, but also recognized their position of power as health care professionals within a larger system. This sometimes resulted in a sense of both connection and distance in these relationships. For example, in their professional roles, participants could still report their clients to the Department of Human Services (DHS) for child abuse and neglect concerns. Working in a small community required skill-building around maintaining confidentiality and preserving the sanctity of the client–provider relationship within the community. Speaker 2 said, “Our families are in this program. I have family members in this program, so I hear it, and I see it and I go through it myself.”

Toll of Code Switching.

When talking about their professional lives, participants shared how their experiences with racism varied as they moved through their workplaces and the toll that took on them. They also described the shifting or code-switching that occurred for them as they navigated between their predominantly Black work team and the broader public health and medical systems. Speaker 3 explained,

When you leave HBI, you step out of this world and go to the rest of the health department. It’s that white world. So then we have to put on our other hat to be able to engage in a way that they deem appropriate.

Proving Value in a Scarcity Environment.

Because HBI is situated within the county’s public health system, securing funding is always a concern and the program is in competition with the broader medical system for resources. As a result, participants felt that they had to constantly justify the importance of their work to a variety of stakeholders, including medical providers and the county public health department. Participants expressed passion for their work, but factors like low-quality office space and competition for resources brought down morale. HBI’s physical space was a particular point of contention as the county appeared to prioritize HBI low on the list to receive a better space despite building improvements within other areas of their division. Participants noted that limited resources in their facilities negatively impacted how clients viewed their work. Speaker 9 noted how this felt like a form of second-rate treatment:

When you look at how the county’s building a new building and every other department gets to go to some new … place, I feel like Black people always get left with whatever’s leftover.

Although the community and county purport to greatly value HBI, the county’s annual budget constraints, politics, and bureaucratic processes nonetheless impact the program. Participants explained that HBI’s staff and Black leaders within the county constantly had to advocate for funding. They sometimes encountered the perception from workers in other divisions that HBI received funding merely because it was a Black program rather than because it provided effective and necessary services to address disparities in Black maternal and infant health outcomes. Participants wanted all people within the county public health department to value and advocate for the health and well-being of Black people. Speaker 9 talked back to the assumption that HBI receives funding only because it is a Black program:

I would like a system change. That when they look at us, that they don’t see us as, “That program that’s going to get funding just because they’re a Black program.” As if they don’t know the health disparities we have … we’re getting it because our babies are dying. Our women are dying.

In addition to fighting for program funding, HBI nurses and community health workers experienced economic costs on an individual level. Participants explained that HBI nurses are paid less than if they worked for mainstream health care systems. They often chose to work in the program because of shared values and a desire to do community work, but they wanted equitable pay and greater incentives for providers to work in culturally specific programs.

Approaches That Center Reproductive Justice and Community Care

HBI nurses and community health workers discussed their unique, holistic approach to delivering perinatal care. Their services were grounded in community care and reproductive justice principles while also providing advocacy within the mainstream public health and medical systems.

Balancing Practice Frameworks.

HBI is a part of both the mainstream health care system and the Black community. Consequently, their work requires a delicate balance between two practice frameworks: holistic, community-oriented/based reproductive justice and professionalized health services. Historically, the mainstream health care system has contributed to unethical and harmful behavior toward Black people. In contrast, HBI upholds reproductive justice principles by meeting Black families where they are at and supporting them to make the most informed health, reproductive, and parenting choices possible. Speaker 9 described HBI’s approach:

When you go to the regular PCP (primary care provider) … it’s about what they want for you. Whereas when you work with us, it’s about what you want for yourself, your goals, and how we’re going to work with you and help you achieve those goals. Because it’s about you. It’s not about what I want.

Understanding Structural Racism and Integrating Anti-Racism Advocacy.

Participants explained that physical health during the perinatal period is only one aspect of keeping children and families safe. They understood the multiple impacts of systemic racism on Black people’s health beyond the medical domain or the experience of pregnancy. Participants explained that HBI’s approach included addressing racism, advocating for policy change, and building client capacity to advocate for themselves and their families. Participants believed that one of HBI’s most powerful interventions is anti-racism advocacy on behalf of and alongside Black people. They described modeling and teaching advocacy skills to clients in terms of navigating interactions with the medical system, recognizing disparate treatment, and interrupting harms they were experiencing. As Speaker 2 said, “A lot of times we’re put as just another home visiting program, but we’re not just another home visiting program. We’re affecting policy change. We’re advocating for clients.”

Discussion

Results of this study elucidate the unique experiences of Black nurses and community health workers who provide culturally specific perinatal services to Black families. Participants’ narratives illustrate the strengths and complexities of having shared lived experiences with clients. Given their roles, Black nurses and community health workers sometimes saw themselves as situated to buffer clients from racism and other harms in the health care and public health systems. However, they also felt the personal and professional impacts of racism within these systems and in the larger society. This is consistent with previous research that suggests that the more professionalized Black people are, and the more that they move outside of their Black communities within the workplace, the more discrimination they may face (Jones & Shorter-Gooden, 2004). However, working with HBI provided a more supportive environment for Black providers and made room for their professional development. HBI providers have great love for the work while also acknowledging the toll that it takes on them as Black women and the economic trade-off they made to work in a culturally specific program. These findings mirror those of Smith et al. (2022) who found in a study of Black community–based organizations that Black providers acknowledged the importance of racial concordance as a protective factor for Black patients, as well as challenges to their expertise engaging with medical and public health systems.

Black nurses and community health workers were affected by the compounding nature of racism-related stress. Not only were they holding the traumas and race-related impacts felt by clients, but Black providers were also experiencing their own forms of intersectional oppression as Black women living in society and working in health care systems. Findings here are consistent with previous research that emphasizes the compounded nature of racism-related stress for Black women and the physical, mental, and emotional toll on their well-being (Chinn et al., 2021; Prather et al., 2018).

Narratives from participants emphasized the value of collective, community-based approaches to perinatal care that is in contrast to more individualistic approaches often implemented in dominant culture health care systems (Bridgeman-Bunyoli et al., 2022; Mullings & Wali, 2001; Parker, 2021; Smith et al., 2022). Our findings align with Black birthing advocates who center their work in an anti-racist and reproductive justice work (Bridgeman-Bunyoli et al., 2015, 2022; Goode & Bernardin, 2022; Hays, 2016). In providing care that is racially congruent, relationship-based, and connected to the daily lived context of clients’ lives, HBI providers interrupt medical mistrust and racism that contributes to Black pregnant people’s invisibility in health care (Davis, 2019; Smith et al., 2022).

Implications

Our study findings have important implications for supporting culturally specific providers and programs in a range of contexts. Recommendations here are a synthesis of ideas put forward by participants as well as our structural and systemic analysis based on study findings.

Self-Care, Community Care, and Professional Support

Nurse and community health workers’ narratives make evident that Black providers doing work in their own communities face unique stressors. Thus, approaches to self-care and community care must be more robust for Black people working within culturally specific spaces. The compounded stress they experience necessitates intentional community support, structural mechanisms to support self-care within organizations, and professional support for providers to prioritize their own well-being. Therefore, workplace wellness strategies, policies, and supports should be built into program design and implementation—including job descriptions, work hours, and pay scale—to help mitigate burn-out and exhaustion for Black providers. Finally, developing racially concordant mentorship can be a useful support to provide meaningful professional development for Black, Indigenous, Latinx, and Asian, Asian American, and Pacific Islander providers who are navigating complicated dynamics of identity, multiple gazes, well-being, and community needs.

Funding and Resources

Participants emphasized the importance of adequate resources to support culturally specific work. Our findings reinforce that funders should operate from the assumption that communities know what they need and can build strategies to meet these needs. To be effective, interventions should mirror existing culturally and community-based support systems and must take into account the timelines, context, and needs of a specific community. Participants’ reflections also support other scholars and practitioners who have called for the development and implementation of culturally responsive models that are collectivist, relational, and community-centered (Mullings & Wali, 2001; Parker, 2021). For Black people, holistic pregnancy and parenting supports often go beyond the nuclear family and effective interventions must support a variety of actors.

HBI nurses and community health workers also spoke repeatedly about the ways that lived experience and insider knowledge of the community-enhanced effectiveness in their work with patients/clients. As such, valuing lived experience, including being bicultural and bilingual, as central to job qualifications means including these as skills in job descriptions and providing appropriate compensation for culturally specific providers.

Education

Findings from this study illustrate the numerous, complex dynamics Black health care providers encountered in their advocacy and service provision, and ways that their lived experiences shaped their work with clients. Consequently, it is important that considerations of the strengths and unique challenges of working within one’s own racial/cultural community must be meaningfully integrated into educational curriculum in order to support providers of color with the tools needed to do community-specific work. Despite more attention to discussions of diversity and oppression within health care–related educational programs, curricula can often assume that providers are members of dominant culture groups and those receiving services are not (Mehrotra et al., 2019). As such, BIPOC students and providers can be marginalized in these discussions and may not have opportunities for professional development that centers their experiences. Black providers’ narratives open up important perspectives that are relevant for healthcare professionals to consider as they enter the field. Participants in this study also noted the importance of recruiting more people of color into culturally specific work. As such, more professional pipelines must be developed to recruit and retain people of color in health care training programs and jobs to promote culturally reflective and responsive services (see, for example, Carter et al., 2015; Fuchs et al., 2016; Schultz et al., 2011).

Research

Further research is needed to better understand the complexities of racial concordance in health care contexts and in culturally specific programs. Additional research may also look at diverse people of color communities to better understand dimensions, strengths, and potential challenges of racial concordance in various racial/ethnic communities and in diverse geographic contexts. Research in this domain can ultimately be used to support culturally specific programs and educational curricula for health care practitioners of color.

Limitations

This qualitative study was limited to a specific geographic context—a mid-sized predominantly White city on the west coast of the United States; therefore, findings here are not generalizable. Settings with different demographics may yield additional perspectives about the questions raised here. In addition, the study relied on focus groups that may have affected what participants were able or willing to disclose in front of their colleagues.

Conclusion

This study explored the experiences of Black nurses and community health workers who deliver services in a culturally specific perinatal health care program. Several key themes emerged: (1) shared lived experience and parallel process between staff and clients; (b) navigating multiple shifting gazes between clients, public health department, and medical systems; and (c) reproductive justice and community care characterize a culturally informed approach. This research adds to knowledge about culturally specific services and provides a foundation for future research that can continue to explore the unique experiences of service providers that have shared lived experiences with service users with whom they are working.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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