Negotiating Patient-Provider Power Dynamics in Distinct Childbirth Settings: Insights from Black American Mothers
2. Empirical and Theoretical Background
3. Materials and Methods
4.1. Care and Power Asymmetries: Experiential Narratives
Originally when I had my first child, I wanted either a home birth or a birthing center that had more of a home-like feel, but insurance was that deciding factor.(Lila, Hospital)
It does not give me peace to be at home while having a baby, having the complications I had with my first and then the experience with my second … I’d rather be at a place where If I’m going to do it natural, great. But if something goes wrong, they’re right there.(Giselle, Military Hospital and Unintentional Home)
I really think the hospitals are for sick people. And so why go there if you’re perfectly healthy? I feel like doctors are trained to handle the worst-case scenario, and I don’t know if they really know how to be present and to assist a natural healthy birth.(Tara, Birth Center and Home)
I had to stop listening to NPR and I had to stop reading books. I’m like, “Nope, they’re [obstetricians and hospital staff] going to kill me. I’m not going to hospital.” This is why delivering at home is much better.(Brooke, Home)
She [midwife] honestly felt like an older sister. She spoke with me whenever I needed it. Now, looking back at it without the pregnancy hormones, I’m like, “Oh my gosh! [Laughs.] The amount of time she spent with me!” So, I’m not going to say like she was my counselor in the sense that she was giving me like that type of advice, but she definitely counseled me. She spoke with me…She was my midwife for the first pregnancy [miscarriage] and so she’s very familiar with that. So, she’s very caring. She’s very loving. She checked in on me. She let me vent. She assured me of things. She’s very reassuring. She was just always there when I needed her.(Brooke, Home)
With a [medical] provider, I feel like a number. I feel like they don’t know who I am or what I want for myself, or my baby, or my birth.(Sam, Military Hospital and Home)
I just know that for Black moms, you will never be treated like your White friends. Don’t expect to get the same treatment. I made that mistake thinking because I am someone educated, and I was informed about the birth process and everything, it wasn’t like I was going into it with no knowledge at all, and this [nonconsensual cesarean section] still happened to me. I know other moms and I’ve heard their stories or read their stories and it’s all the same, it comes down to a provider who just lacks compassion.(Megan, Hospital)
You can have a woman of color that delivers and a non-woman of color that delivers, but say the woman of color delivered an hour before and she’s waiting on her food. Her tray comes up and they’ll give it to the other lady first. They just make her keep waiting. And epidurals, it’s time for an epidural, this woman of color was ready first then somebody else comes in and they’ll give it to her instead. Even though her [woman of color] stuff is ready to go.(Kelly, Hospital and Home)
And then, when she took her hand out [of the cervix], my water broke. And I thought, did she do that or? And so, I was excited, but I knew inside she did that on purpose, and Jamie’s face was like “crap,” almost like she had seen this done before.(Giselle, Military Hospital and Unintentional Home birth)
They [midwife and doula] start taking my clothes off and they got me in the tub, and … that’s when my husband got there and he freaked out and was like, “Why is she in the tub? This is not her birth plan. She was very specific about what she wanted this time.” And they said, “It’s okay. She’s too far along. She’s crowning. We need to just do it, or she’s going to have him in the car.”(Giselle, Military Hospital and Unintentional Home birth)
They just came in the room like snapping their fingers at me. I had an epidural. Telling me to get up and get on my knees. Nobody helped me. I’m like “I need help, I can’t hold myself up,” nobody was helping me. Nobody was listening to me at all. They did not try, if they were claiming they tried for ten minutes to stop the decels [decelerations in fetal heart rate] they did not. They were just like, “Oh this is happening” and I’m being wheeled into a cesarean that I did not consent to.(Megan, Hospital)
Emotionally, I was like just out of it because I’m like saying “I don’t want this.” Then I was like I better be quiet or they’re going to put me under, so I just laid there, and I was just done. I was like, nobody is listening to me. So, if I keep talking and trying to advocate for myself, they’re just going to shut me up. So, I didn’t say anything else.(Megan, Hospital)
I’m sitting there and I’m telling the doctors like, “Something doesn’t feel right” and they’re like, “Well, just wait,” because I ended up going into birth in their shift change, the nurses’ shift change. They’re like, “Well, just wait cause the new nurses are going to come be in here for you.” I’m like, “No, I’m trying to tell you something is not right, right now.” So, literally an hour passed. Nobody’s coming and I’m hitting the red button cause I’m like something is not right. Well, I’m hitting the call button and they’re just like, “Well, just wait. Your new nurses are clocking in.” And so, the nurse who was my nurse for my first son, she was absolutely amazing, comes in and she’s like, “Hey! Do you remember me?” And I’m like, “Yeah, I remember you,” And she’s like, “I saw your name on board and I was wondering was this you?” And she’s like, “How’re you doing?” I was like, “I’m good. Are you my nurse?” She’s like, “No, I’m not. I’m training today, but I just wanted to come say hi. Is everything fine?” I said, “No. Something doesn’t feel right.” She said, “Well, do you mind if check you? I’m not your nurse, but do you mind?” And I’m like, “No. Please do.” So she sticks her hand up there to check and she goes hitting the red button, the emergency button. All these doctors start flying in. They’re rushing me straight to the surgery room. She has to keep her hand there the entire time while they’re doing the C-section. I think they called it a prolapse cord. And they literally had like told me had she not had gone that my baby could’ve died, had a whole other hour passed. I was so livid because I was like “I kept telling ya’ll something was not right. Something was not right,” but then again, they thought I was on Medicaid when I had come into the hospital. It wasn’t until I was like “I had did all my paperwork. I’m already registered with you all. I don’t understand why you all keep thinking I’m on Medicaid.” I think it’s just because I’m Black.(Lindsey, Hospital)
He just walked in as soon as he was ready to help me with the placental extraction, he walked in and grabbed my cord, wrapped around his hand twice, braced two fingers on my pubic bone, and then pulled, and just pulled my placenta right out. I thought I’m going to die. I just thought right then, I was like he’s going to pull my uterus right out like you’re not supposed to do this. So, it hurt. There’s like nothing, you know, no one could have stopped him anyway.(Roberta, Home)
They immediately gave me something to take the edge off. They were very tentative, and the nurse let me hold her the whole time [laughter]. She even stayed after her shift to make sure I was okay.(Ashley, Hospital)
When I went in and I asked them, “Can I have something for pain while I wait for the epidural?” They gave me 500 mg of Tylenol, which I’m a nurse, and I’m just like, “Why even give this to me?” So, there is that. I was vomiting from the pain and they wouldn’t even give me a tissue to wipe my face or a throw-up bag. They let me labor with no pain medication, no supervision for several hours. I kept asking, you know, for a doctor, for assistance.(Ashley, Hospital)
With my second, I tried to stand up because they wouldn’t give me any pain medicine. So, I was like I do know if I stand up I feel better. You know? And they were like, “No, lay down.” They wouldn’t let me do anything. Like not even normal pain management, like non-pharmaceutical.(Ashley, Hospital)
I did not feel in control. I felt like I had to kind do what they said, to be quite honest. Even though things got better the second time, I was still intimidated by requesting “Can I get up and go to the bathroom?” “Can I sit in a shower?” I felt intimidated asking those questions.(Lila, Hospital)
I feel like I almost have fallen in love with my midwives. They brought me my babies safely and they make sure to check up on me. They’re so encouraging and empowering. You know, after I had my babies, they called me Superwoman and they said that I was amazing to have not torn delivering these babies, and just really made me feel good about myself.(Tara, Birth Center and Home)
I’m really trying to get out there that these particular midwives are not … they’re “medwives.” They’re not natural-minded at all. They didn’t trust the birth process, they didn’t make me feel emotionally safe with them or anything and when I looked at my medical records, it looks like they gave me medication without my consent before the cesarean, so there’s that too.(Megan, Hospital)
The midwife that was on call before the shift change had told me that my cervix was swollen and to take a Benadryl because that would help. I didn’t question that because she’s a midwife. I was like well, you know, the midwife is telling me to do this, so I guess I should do it because they’re a midwife and they’re not an OB [obstetrician]. Not that all OBs are bad, but you kind of believe the midwives more over an OB. That was another mistake on my behalf there.(Megan, Hospital)
I went with midwives because they tend to be more lenient when it comes to natural birth and not having interventions. I had an entire birthing plan that I wrote out and it included no interventions … I didn’t really consider artificially breaking my water as an intervention, but I see now how even that even when you’re in labor can be detrimental to the natural birthing process. I honestly think that she just thought that she could be done quicker with me if she broke my water.(Trina, Hospital)
They were great on my follow-up care, to the point where I paid for six weeks of care, but they had me scheduled for an informal visit just so that I can come back and meet with my main midwife who was actually my doula with my daughter. She was on vacation at my last visit and they really wanted continuity of care.(Tara, Birth Center and Home)
After the baby was born she’s [obstetrician] like, “Oh, okay. Bye. Congrats,” and we didn’t see her again.(Kim, Hospital)
4.2. Resistance: Power Contested and (Sometimes) Subverted
I told him I didn’t want any blood. I told him I didn’t want to be induced. I told him I didn’t want any Pitocin, and I gave a whole “this is what I did not want” speech and he was like, “okay, okay, okay.”(Kim, Hospital)
She [the obstetrician] told me, “If you’re not dilated by Friday, then I’m going to induce you.” And I said, “No, you’re not going to induce me.” She’s like, “I’m going to have to.” I’m like “Why? I’m not even 40 weeks by then.” So, it wasn’t even my due date yet, and she said, “If you’re not dilated by this date, I’m going to induce you.” And I said “No, it’s not happening. You’re not going to induce me, I don’t care what you say. You’re not going to induce me.” And so, I said, “I’m going to find any natural labor inducing things that I can do.” Pineapple juice and all those things, walking around. Whatever, sex. I was like let me try anything that I can, because I’m not going to get induced. I don’t want that.(Amber, Hospital)
Because of income disparities, home birth is less of an option for a lot of, especially, Black women. To me, I don’t view money as something that I will allow to control my outcome. To me, I would rather go into debt to be safe on something, especially something as big as birth and have the birth that I want. It’s important to be in a place where I’m comfortable and feel okay doing this. This is a big deal. This isn’t just go wake up and go buy [a] car from somewhere. This isn’t go to Walmart and pick up some food. This is a big deal. Women die. If your kid fell from three stories high and was alive, but you didn’t have the money and you needed care for them, you wouldn’t mess around about that. You’d put it on every credit card you have, and tell the hospital to bill me later, whatever, fix my kid. I think it [birth] should be the same.(Roberta, Home)
My husband and my doula were very… kind of like at my beck and call almost. If I was like, “Okay, I need to get on the floor.” They rushed to get me on the floor. If I needed to walk around, they were the ones advocating, “No. You said she could have a wireless monitor. She needs this wireless monitor.” All that kind of stuff. Even when they put me on Pitocin, you have to be on a monitor all the time. They [husband and doula] were like, “That’s fine, but it needs to be wireless, though.” I think that they really helped me, and whatever I wanted, for the most part, was able to be done.(Debra, Hospital)
That was one of the final reasons why I decided I will not deliver there, because I was not satisfied with the care that doctors were giving me. They told me, when I go into labor, “Yes, a student will deliver you. No, you do not have the choice to the midwives or to request the doctor on staff. You have to have a student” or a resident I should say. That was my deciding factor. I should have a choice. As a medical provider myself, I’m all for learning. I’m all for having residents there, and being involved and giving them a chance, but I also have to be accountable for my own experience, and my own health care, and if I did not feel comfortable with the teachers, there was no way I could feel comfortable with the residents and because they said I didn’t have a choice, I said, “Well, I won’t be coming here.”(Lila, Hospital)
Nobody told me that there are bad doulas and midwives. Nobody talks about that in the birth community and I realize that in Texas, at least the area I was in, the birth community is very hush-hush about the bad doulas and providers as far as OBs and midwives. I’m not saying, “trash them online,” but at least put the information out there like “I had a bad experience with so and so.” There are so many things that other moms who aren’t minorities are never going to experience in their lives. Ever.(Megan, Hospital)
Conflicts of Interest
Appendix A. Interview Guide
- (a) To begin, can you generally tell me about your birthing experience(s)? [Most memorable aspects.]Pregnancy and Prenatal Care
- (a) During your most recent pregnancy, how did you feel physically? (b) And how did you feel emotionally? (c) What actions, if any, did you take to prepare for the birth?
- (a) What influenced your decision to give birth at [location]? (b) Influence of financial considerations?
- (a) How did you choose your midwife or obstetrician? (b) How would you describe your relationship with your obstetrician/midwife before becoming pregnant? (c) How did your relationship with your midwife/obstetrician differ from relationships you have with other healthcare professionals you’ve encountered? (d) What have others said about your care provider, if you’re aware of others’ views?
- (a) How was the quality of your prenatal appointments (information, duration, etc.)? [Typical visit.]
- (a) Before you gave birth, what did you feel was most important during your labor and birth experience? (b) In what sort of environment did you want to give birth and why? (c) Did you want a certain type of delivery (vaginal or cesarean)? Why? (d) Who did you want to be present at your most recent delivery, and why? (e) What kind of comfort measures, if any, did you plan to use during your delivery (e.g., bath tub, squat bar, medical pain management, rocking chair)?Labor and Birth
- (a) Describe your labor support team. (b) What forms of support did you receive during childbirth, and how did that work out for you (positive, negative, mixed experiences of support)?
- (a) Will you recount in detail your most recent birth experience? (b) Some women describe their actual birth experience as being much different than what they wanted or planned. How did this work out for you? [Probe for environment, comfort measures, support team, mode of delivery.]
- (a) Was your care provider present during labor and delivery? (b) Did you feel like you could ask them questions? (c) How would you assess your care provider (positives, negatives)?
- (a) Describe your participation during your labor and delivery experience. (b) What decisions did you make during your labor and delivery experience? (c) Describe ways that you felt (1) in control and (2) not in control during your birth experience? (e) Overall, were your wishes and intentions honored?
- (a) What happened as soon as baby was born? (b) What was your initial reaction after giving birth?
- (a) Reflecting on your childbirth experience, what were you happy with and what would you change?Postpartum
- (a) What role did your care provider play in your postpartum experience? (b) How was your follow-up visit with them? (c) Do/did you plan to keep in touch with your care provider? (d) If you have another baby, will you have them as your care provider? Why or why not?
- (a) Would you recommend [location/provider] to your friends? Why or why not? (b) What advice would you offer expectant mothers in relation to their upcoming birth experience and care provider?Follow-Up
- (a) Do you think that it’s dangerous or risky to give birth? (b) If so, what are the dangers and risks?
- (a) What do you think about maternal healthcare in your community? (b) What are the main problems/challenges that women face? (c) What could be done to improve the situation?
- (a) What have you heard, if anything, about maternal mortality risks in Texas? (b) From what sources have your learned of this information? (c) Are you aware of any racial disparities regarding maternal mortality rates in Texas? If so, please describe them. (d) What actions, if any, have you taken in light of information you’ve heard about maternal mortality risks of women in Texas?
- Looking back on your most recent birth experience, were there any conflicts, tensions, or disagreements between you and your care provider? If so, please describe them and their resolution.
- Do you have any final thoughts or comments you’d like to share regarding your birth experience or your interactions with your care providers?
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|Name 1||Race-Ethnicity||Relationship Status||Educational Level||Household Income||# of Children||Birth Location||Mode of Delivery|
|Roberta||Black, White||Married||High school||$30–40,000||2||Home||Vaginal|
|Giselle||Black, Haitian||Married||Master’s||$40–60,000||4||Military Hospital, Home (Unintentional)||Vaginal|
|Sam||Black||Divorced||Master’s||$40–60,000||2||Military Hospital, Home||Vaginal|
|Kelly||Black||Married||Master’s||>$100,000||3||2 Hospital, 1 Home||Vaginal|
|Lindsey||Black||Married||Associate’s||>$100,000||4||Hospital||1 Vaginal, 3 Cesareans|
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West, R.; Bartkowski, J.P. Negotiating Patient-Provider Power Dynamics in Distinct Childbirth Settings: Insights from Black American Mothers. Societies 2019, 9, 45. https://doi.org/10.3390/soc9020045
West R, Bartkowski JP. Negotiating Patient-Provider Power Dynamics in Distinct Childbirth Settings: Insights from Black American Mothers. Societies. 2019; 9(2):45. https://doi.org/10.3390/soc9020045Chicago/Turabian Style
West, Rachel, and John P. Bartkowski. 2019. "Negotiating Patient-Provider Power Dynamics in Distinct Childbirth Settings: Insights from Black American Mothers" Societies 9, no. 2: 45. https://doi.org/10.3390/soc9020045