Collaborative Anti-Racist Perinatal Care: A Case Study of the Healthy Birth Initiatives–Providence Health System Partnership

Abstract

This article describes a case study of the partnership between Healthy Birth Initiatives, a community-based organization (CBO) and Black-led public health nurse home visiting program, and the maternal health division of the Providence Health System located in the Pacific Northwest. This study’s purpose was to explore the formation, significance, and impact of this partnership from the perspectives of staff and leadership members from both organizations. We conducted a case study through qualitative interviews with staff, participant observation, and debrief of leadership meetings. We completed a hybrid deductive–inductive thematic analysis of the data, followed by member checking with study participants and other key interest holders. Key facilitators of the CBO–health system partnership included the vital role of leaders in prioritizing the partnership; health system willingness to incorporate new information from the CBO to improve care; and health system utilization of resources to institutionalize changes that emerged from this partnership. Challenges to the CBO–health system partnership included CBO resource limitations; fragmented referral processes and information sharing; and the persistence required to nurture the relationship without formalized roles. This study contributes to the literature by offering staff perspectives on how a CBO–health system partnership formed, successes, early lessons learned, and practical suggestions for how to develop stronger alignment to provide culturally responsive patient-centered care to Black families.

1. Introduction

Racial and ethnic inequities are a defining feature of maternal and infant health in the United States (US), with Black women and infants facing the highest morbidity and mortality rates regardless of socioeconomic status (Ely and Driscoll 2023; Gregory et al. 2024). Black families bear the highest burden of infant death, preterm birth, and low birth weight of any racial group in the US (Matthews et al. 2015). Compared to white women Black women experience 2–3 times the rates of maternal death (Lu et al. 2015). This disparity widens with maternal age and educational attainment such that Black women with a college degree have 5 times the risk of death due to pregnancy-related causes compared to their white counterparts (Petersen et al. 2019). It is important to note that these disparities are caused by racism, not weakness in Black bodies.

Numerous sociopolitical and economic factors contribute to Black maternal and infant health disparities including both historical and current manifestations of structural racism. Scholars have written extensively about the historical roots and ongoing consequences of medical racism (Davis 2018; Mullings and Wali 2001; Roberts 2017). Examples of historical contributors include longstanding patterns of discrimination, denial of care, medical abuse and neglect, misdiagnosis, and coercion. These contributors have facilitated obstetric racism, diagnostic lapses, medical mistrust, and lack of access to necessary reproductive care (Davis 2018). With this history as a backdrop, Black families continue to experience implicit bias in healthcare, inaccessible and limited quality healthcare, medical neglect, and underlying chronic conditions as drivers of persistent maternal and infant health disparities (Petersen et al. 2019).

Two promising strategies for improving the care of Black women and infants include racial concordance and partnerships between health systems and community-based organizations (CBOs). Concordance occurs when patients and providers share the same race or ethnicity. Racial concordance may be associated with improved patient-centered care and patient satisfaction with care, increased adherence to treatment recommendations, and better health outcomes (Altman et al. 2020; Hunte et al. 2023; Shen et al. 2018; Takeshita et al. 2020). Partnerships between health systems and CBOs may address structural determinants of disparities by tapping into culturally specific organizations with whom communities have established trust. However, the literature on best practices for developing and sustaining these partnerships, as well as their impact, is limited (Agonafer et al. 2021; Nandyal et al. 2021). In light of this gap, this article describes a case study of the development, significance, challenges, and future opportunities of a partnership between a culturally specific CBO and a large health system located in the Pacific Northwest. We conclude with recommendations, directly informed by study participants, for practitioners and administrators interested in developing partnerships between CBOs and health systems.

1.1. Study Context

Healthy Birth Initiatives (HBI) is a federally funded county health department nurse-family home visiting program (Multnomah County 2024). HBI utilizes Black community health nurses and community health workers to provide: in-home case management; social support (e.g., respite and mental health services); pregnancy, birth, and newborn classes; nutrition and lactation support; cross-system care coordination; material support (e.g., housing assistance); antiracism training for medical providers; organizing for structural policy change; father engagement services; and client advocacy to address medical racism. Through a relatively small staff of 12, HBI serves around 300 mothers and 250 community members.

HBI functions similarly to a CBO and is well integrated into the local Black community. Similar to other culturally specific CBOs, HBI addresses reproductive oppression by grounding their work in a Reproductive Justice framework (Hunte et al. 2022). Reproductive Justice, a framework developed by Black women in the US and shared broadly, challenges reproductive oppression through supporting the human right of all people to have a child, to not have a child, to parent free of state, community, and environmental violence, and to exercise bodily autonomy (SisterSong n.d.).

Providence St. Joseph Health (Providence) is a large, multi-state health system of over 3000 employees that includes a network of hospitals, clinics, and affiliated health services (Providence 2024). Providence providers identify as nurses, Obstetrician-Gynecologists, Maternal Fetal Medicine specialists, and administrative leadership with clinical backgrounds. This study included care teams and leaders in both Providence and HBI’s perinatal and women’s health services.

HBI predominantly serves Black people residing within Multnomah county, of which Portland is the largest city. Black people make up only 5.8% of Portland’s population (U.S. Census Bureau 2024b) and 2.4% of the state (U.S. Census Bureau 2024a). Due to increased cost of living in Portland, people are moving out of the county to surrounding areas but they still access some perinatal health services in Multnomah County. Providence is not limited to county boundaries to provide care. For many Black people, HBI may be the only Black provider they encounter in their care.

1.2. Partnership Origins

Multiple factors initiated the HBI–Providence partnership. A mutual patient (RH) introduced leaders from both entities to each other in 2017 after learning of their shared commitment to improve Black perinatal care. RH received care through Providence three times and twice through HBI. She was cared for by both entities for pregnancies in 2016 and 2019–2020, respectively. She began working with HBI as a researcher in 2016 to explore the perceptions of racism-related stress on their clients. She has worked with HBI as a researcher since then. That same year, Providence invited HBI to meet with their social work division to improve care coordination. Simultaneously, HBI was actively seeking ways to strengthen their relationship with Providence. Out of these intersections, HBI and Providence leadership began meeting regularly to explore partnership opportunities. The leadership team meetings ranged in size from 3 members on the HBI side and 4 members from Providence. To preserve anonymity and to offer some context, we share the range of positions represented. Members represented HBI nurse leads, program directors, nurses, and the county maternal health division director. Providence leaders represented the divisions of maternal health social work, nursing, maternal and fetal medicine, and women’s health. Over the course of the relationship for HBI, the director positions that changed included program director, nursing director, and county maternal health director. Four members of the Providence team remained steady but two core members were considering retirement and a new position in the future.

Since 2017, HBI and Providence have met quarterly with the following goals: (1) relationship-building between organizations; (2) information-sharing about Black maternal health initiatives; (3) case review and consultation for shared patients/clients, including identification of successes and areas for improvement; and (4) HBI provision of feedback to Providence about community needs and perceptions of policies and practices. Their relationship sustained through the COVID-19 pandemic, and uprising for Black Lives to the present.

In addition to quarterly leadership meetings, HBI meets regularly with Providence social workers, nurses, and physicians at grand rounds. HBI also contributed to the creation of and co-leads a Birth Equity Community Advisory Committee (BECAC) created by Providence to bring hospital staff, CBOs, and doulas into conversation. The BECAC is composed of Providence’s OB/GYN and MFM leadership, OB/GYNs that provide clinic based and hospital support, OB hospitalists, labor and delivery unit nurses, social workers, childbirth educators, and culturally specific community-based organizations—including HBI’s home visiting program and various doula organizations that center communities of color (Black, Indigenous, Latin, and Pacific Islander). BECAC meets quarterly to assess and improve birth outcomes and patient experiences. Disparities in birth outcomes, pregnancy-related morbidities, and respectful care are identified using hospital data and insight from hospital staff and community birth workers. This committee forms recommendations for improving patient experiences that improve the equity of birth outcomes and family inclusion before, during, and after birth-related hospital stays. Providence regularly invites HBI to join the Oregon Perinatal Collaborative and partner in health literacy efforts. Finally, HBI routinely invites Providence to its Community Action Network meetings to present and engage with the local Black community.

2. Materials and Methods

We conducted a case study through qualitative interviews, participant observation, and debrief of leadership meetings to explore three questions: (1) How does the partnership affect Providence policies, provider practices, and perinatal health outcomes? (2) How does the partnership influence cultural responsiveness? and (3) How can the partnership be improved? This study was approved by the Portland State University Institutional Review Board (#227853-18). By cultural responsiveness, we were interested in how the two groups understood and sought to meet the diverse needs, beliefs, values, and preferences of Black patients. Our interdisciplinary study team included members from Black studies (RH), women gender and sexuality studies (RH), social work (SK, KC), public health (MG, DRH), and doula care and community health work (DRH). DRH is a former staff member of HBI. RH is a former client of HBI and patient of Providence. DRH from HBI was a co-chair of the BECAC.

Birth Justice served as a guiding framework for this case study. Birth Justice is a component of the Reproductive Justice framework created in 1994 and maintains that Black people, people of color, immigrants, and LGBTQ+ communities have and continue to experience oppression and trauma related to having and not having children (Voices for Birth Justice 2022). Birth Justice includes culturally responsive and holistic perinatal care across the pregnancy spectrum, including abortion, miscarriage, pregnancy, birth, and postpartum (University of California San Francisco 2025). Birth Justice also includes access to traditional and indigenous care providers and healers—such as midwives, birth workers, and lactation support providers (Southern Birth Justice 2024). Within our inquiry, we were listening for how the needs and desires of Black birthing people and families were discussed, identified, and supported through the partnership.

RH completed in-depth interviews with HBI and Providence staff between 2022 and 2024. Initial interviewees were members of the leadership team at the time. Then, we used purposive sampling by asking organizational leaders to recommend subsequent participants; snowball sampling was used to identify later participants. Each participant was offered a USD 50 Amazon gift card. A total of fourteen participants completed qualitative interviews, with 4 representing HBI and 10 representing Providence. Interviews lasted approximately 60–120 min. In addition, RH collected observational data through attendance of HBI–Providence leadership meetings. Meetings included discussions of individual patient case reviews and observations of partnership problem-solving, partnership qualities like collaboration and mutual respect, and conversations about the social and political experiences of the Black community at the time. RH also met with members of both organizations over this study and debriefed conversations with the research team as the analysis process continued.

Interviews were recorded, transcribed, and checked for accuracy. We uploaded transcripts into Dedoose qualitative software Version 10.0.35 to assist with analysis. We conducted a hybrid deductive–inductive thematic analysis (Fereday and Muir-Cochrane 2006) by first developing a codebook using a priori codes based on the interview guide and research questions, then adding emergent codes. Three research team members comprised the coding team (RH, SK, MG). Two transcripts were triple-coded to test the initial codebook; the remaining transcripts were double-coded. The analysis team met regularly to discuss and reconcile codes. We then collapsed codes into preliminary themes, prioritizing themes that reflected the most frequently used codes and that related directly to our research questions (RH, SK, MG, KC). In addition, observational data informed the analysis and interpretation of preliminary themes, particularly around the relationship differences within the partnership and the leadership and frontline levels. As a form of member-checking (McKim 2023), we shared preliminary themes with study participants and other key interest holders (e.g., Providence and HBI leadership, staff, and BECAC) and incorporated feedback into the final themes.

3. Results

Our analysis produced a set of themes. We grouped these into two categories: (1) partnership facilitators and successes and (2) ongoing challenges. These themes reflect the most frequently used codes of “barriers” and “facilitators.” Themes reflected the importance of leaders committed to equity, the use of case reviews to highlight structural drivers of discriminatory care, and the power of culturally responsive care. Findings also point to ongoing challenges such as barriers to coordinated care, imbalanced resources, and sustainability. Our findings are from the perspective of staff and are focused on what they felt were critical contributors and concerns in developing this type of collaboration.

3.1. Partnership Facilitators and Successes

Our questions asked about how the partnership formed. Several critical factors contributed to the development of the partnership and its positive impacts. We describe these below, accompanied by illustrative participant quotes.

3.1.1. Strong Leaders Deliberately Built the Partnership by Making Bold Decisions, Identifying Priorities, Investing in the Relationship, and Developing a Shared Vision

Participants noted that partnership-building took time, and identifying mechanisms for communication and collaboration enabled power sharing that could disrupt entrenched hierarchies within the health system and care teams. An HBI leader acknowledged that she had not been able to make similar relationships with other health systems as she had with Providence. No other county home visiting program has been able to establish a regular cadence of connecting with health systems around patients they share. As HBI–Providence leaders gained clarity about assets and priorities within each organization, a trusting foundation emerged where feedback was freely given and received. A Providence participant (Prov8) described the work of creating a partner-centric rather than health-system-focused relationship: “This is not a moonshot. You’re not going to walk in the door, sit down at a table and problem-solve. This is little incremental steps … You got to be willing to sit there every single time.” By partner-centric, she and other health system’s members talked about spending time getting to know and trust HBI as a major shift in orientation to collaboration. Time was invested in getting to know each other rather than focusing on how HBI could help the health system. This relationship building was less driven by a specific project objective and more on a desire to know how each other came to do the work they did, how they understood the impacts of racism on care, how they viewed the other, and areas of potential collaboration. HBI staff expressed appreciation for the “genuineness” of Providence’s commitment to ongoing relationship: “They’ve invested time in having their leading staff be a part of this work and be a part of partnering with us so heavily. We really appreciate that and we value that” (HBI4).

Structural factors that helped develop and nurture the partnership included incorporating HBI staff into Providence committees, providing regular opportunities for HBI to interact with Providence leadership, and including HBI staff as valued members of care teams. Eventually, Providence formalized birth and racial equity as a strategic objective; a clear example of this impact is that birth equity is now a standing agenda item in various recurring meetings. One Providence staff (Prov8) discussed how they incorporated learnings from their relationship with HBI into the strategic direction of their organization:

We have formalized birth equity as a strategic objective, all at the highest level of the organization that goes to the community ministry board. The tactics underneath are things like the Birth Equity Advisory Committee, Team Birth, the relationship with HBI…I think that formalizing birth equity as a strategic objective forces the organization to meet those objectives. Those are objectives that are aligned and they are all the way up to the top of the organization. Everybody agrees to those. Then you get the support to continue that kind of work.

3.1.2. Expanding Beyond Individual-Focused Case Reviews Broadened Understanding of the Structural and Historical Drivers of Racism in the US Healthcare System

Prior to the partnership, it was easier for negative Black patient experiences to be seen as “one-off”, exceptional examples rather than systemic patterns. An example could be the misdiagnosis of a Black patient that might have been dismissed as the failure of a nurse or doctor, rather than understood as a sign of a systems failure and obstetric racism (Davis 2019), a contributor to cumulative Black maternal health disparities. HBI providers are well versed in applying a systemic lens to individual cases and offered insights and re-framings as informal training to Providence staff. Understanding broader themes affecting Black maternal health helped both organizations address systemic concerns. Through conversations about individual cases and reflections on broader systemic concerns of the Black community, Providence began to recognize trends in the care of Black patients. As a result, Providence leadership and staff began to place individual cases in the broader context of Black maternal health. HBI regularly gave feedback from the field on the social determinants of health impacting their clients, such as housing and employment insecurity, transportation challenges in accessing care, trauma related to healthcare and the Black community, increasing racial tensions during the Black Lives Matter uprising of 2020, and how these determinants manifested in clinical experiences. Over time, this feedback shifted Providence leadership’s understanding of the issues affecting the local Black community. One Providence staff (Prov7) explained how conversations with HBI simultaneously helped them address individual cases and shift their broader understanding of Black patient experiences:

Early on, our conversations were very much about specific cases. ‘This happened at Providence. It didn’t go well. How do we use this example to try to take some learnings?’ […] Always the kernel at the core of it is using stories, specific examples to help illuminate the themes that have been readily visible to the community, but have been really drowned out within a health system because they’ve come up in one-offs. They haven’t come up as a thematic story.

3.1.3. The Partnership Resulted in a More Culturally Responsive Environment, More Shared Power Within the Healthcare System, and an Improved Dynamic Between Providers and Patients

The partnership strengthened Providence leadership’s awareness of the value of culturally responsive services. Part of how HBI facilitates cultural responsivity is its commitment to racially concordant care. A Providence staff (Prov14) explained:

There’s been so much bad care that our community has faced. A lot of people don’t go to the doctors. There’s a lot of lack of trust in healthcare. Getting to see someone familiar, that naturally just builds a little bit more trust. ‘Oh, someone’s going to speak up for me, someone’s going to support me.’

HBI providers routinely worked with the same clients throughout their pregnancies, whereas Providence providers may only meet the birthing person for short stints of their pregnancy, delivery, or routine visit to the doctor. Shorter, less frequent visits with Providence providers impacts patients ease and familiarity with their providers.

In conversations with Providence, HBI providers discussed safety for Black patients. An example was the differences in how Providence viewed its drug testing policy and feedback HBI gave about the harmful impact of this policy on the community. HBI shared that automatic drug testing or child welfare reporting could increase medical mistrust and be viewed as threatening. DHS overinvolvement and substance use criminalization are outcomes that could come from disclosing substance use or being perceived as a drug user. Black patients were less comfortable submitting to automatic drug testing and did not trust the motivations of providers when asking for screening. Providence ultimately changed its practices and delayed approaching testing around substance use until a relationship had been established between providers and patients.

Providence staff also acknowledged that part of HBI’s role was to help clarify the rationale for treatment recommendations with shared patients. HBI providers set the cadence of visits based on the clients’ preferences; clients often opt to meet with HBI providers weekly, bi-weekly, or monthly and for 1–2 h per visit. The HBI client-led meeting frequency contributes to increased trust between HBI providers and clients. The longer visits—compared to routine hospital and clinic visits which are often bound by hospital policies and insurance requirements—also serve as a bridge for increased trust between clients and their Providence care team. HBI provider visits allow additional time for questions and explanations related to care plans and individualized health education. One HBI staff member (HBI1) described this as a valuable form of health literacy, stating, “They are also educating the families as to the why, because oftentimes, the families don’t seem to know the why behind things happening.” An HBI staff member (HBI4) shared how the relationship increased her ability to advocate for clients and to have her concerns heard more readily. She said:

“I’ve had clients call, […] ‘They’re [Providence providers] talking to me rudely, they’re not helping me, and they’re trying to put me out. I don’t feel ready to go. I just had this C-section and my blood pressure is still high and they’re trying to tell me that I have to go because of my insurance.’ [I reply] ‘I’m on my way.’ I arrive, and next thing you know, the nurse is in, the doctor’s in, lactation is there, the custodians are there. And next thing you know, mom can stay a day. She can stay two days. Now you have a room full of people at your beck and call, just because someone walked in the room. It’s so sad that that’s the case, but it is. The conversations and the way they’re communicated with by the nurses just changes.”

Participants also described how Providence invited HBI to join the policy and advocacy tables they occupied at state, regional, and federal levels, thus increasing the political significance of the partnership. In effect, these actions validated the system-level importance of culturally specific perinatal care to both internal and external audiences. A Providence staff (Prov8) member described how they mutually advocated for and with HBI at the legislative level:

We keep an eye on the bills that are out there and what we can bring forward and advocate on behalf of. One of the first things was the significant morbidity mortality committee that the state set up, and [Providence] and [HBI] were on that group. Part of that was our health system advocating, but also advocating, ‘Hey, someone from Healthy Birth Initiatives might be good to be on that too.’

Further, HBI staff acknowledged the uniqueness of the relationship between HBI and Providence. Many home-visiting programs do not have regular, direct communication with relevant health systems about how care is delivered and received by communities. They believed this access to leadership and providers at different sectors improves care for Black patients through collaborative decision making and prioritizing patient autonomy and respect. One HBI participant (HBI4) said:

In our current relationship with Providence, we really are fortunate and appreciative that we get to have direct conversations with them about things that go well and things that don’t. […] We definitely see the value in it being a direct conversation with providers.

The relationship between Providence and HBI was valuable during the COVID-19 pandemic and the uprising for Black Lives and racial justice in 2020. The pandemic reduced the ability for HBI to go to people’s homes. Providence faced staff shortages and decreased ability to see patients in person. A lot of conversations during this time focused on changing care needs of patients under lockdown and the impacts of racism on Black maternal health. HBI advocated for preventative measures to help people address maternal health risks around preeclampsia and anemia. HBI urged Providence to provide blood pressure monitors for all patients to help address the risk of preeclampsia. HBI saw this as a high need among those in their care. Providence responded and provided blood pressure cuffs for birthing people. Hemorrhage became a focus of Providence leadership and HBI was asked to collaborate with them and a Black led CBO from California on reducing anemia in the Black community. HBI also gave Providence regular feedback on how their COVID-19 hospital policies negatively impacted people. Ongoing discussion helped the leadership team refine and reflect on practices through the lens of cultural responsiveness and patient-centered care. This time fostered stronger connection between the leadership team, but reduced the in person connection of front line staff as HBI did not come into meetings in person in the same way as before. It remains a challenge to come back to the level of in person partnership between the two systems experienced prior to 2020.

3.2. Ongoing Challenges

Interviews with staff also revealed challenges facing the partnership and opportunities for improvement. These findings highlight barriers to the partnership’s long-term goals and its sustainability.

3.2.1. Fragmented Processes Are a Barrier to Coordinated Care

Participants explained that referrals to HBI depended on individual providers who happened to know about HBI and the process of connecting potential clients. Without this insider knowledge and serendipitous timing, patients were unlikely to be connected to HBI services. A Providence physician (Prov2) said: “I have to be the source to push it. It shouldn’t be that. It should be as soon as the person walks in the office, there’s an HBI package for them as part of the new patient information.” Staff turnover at both organizations exacerbated this issue. Providence is a large hospital system with three large hospitals in the region and multiple patient outpatient clinics. Certain hospitals and clinics tend to serve larger numbers of Black patients. The partnership has worked to increase awareness of HBI, but still every practitioner does not know about HBI or how to refer.

Furthermore, privacy restrictions between HBI and Providence delayed the sharing of information even if a patient verbally agreed to coordinated services. At the time of this study, Providence used EPIC while HBI used paper and an internal computer system. Without shared documentation, partners relied on patients to tell them what the other partner was doing. For instance, Providence could refer a patient to HBI, who then calls but is unable to reach the patient, and the patient then tells their provider that HBI did not make contact. This fragmentation contributed to limited knowledge of the other partner’s work, duplication of efforts, and a sense that the partnership was not as strong as people needed it to be.

While leaders within the partnership worked diligently to build relationships and communicate regularly, COVID-19 impacted the frequency of connection and severely reduced in person meetings. A Providence participant (Prov 15) noted how decreased in-person connection weakened the relationship between HBI and Providence frontline staff: “I feel like back in the day, we sometimes would talk about cases and almost do case consults. That hasn’t happened in a very long time. […] I would like to see more collaboration be reignited in terms of case-by-case and for HBI family support workers.”

HBI discussed an increase in the needs of clients during COVID-19 and reduced staff capacity to meet the need. Providence staff expressed some frustration around HBI’s change in capacity. They were careful to not be critical of HBI and expressed a need for HBI to also hear from them when the HBI system made it hard for them to successfully partner on patients’ care. Two way feedback between the groups at the practitioner levels is both necessary and not always possible; this can cause resentments or limit trust of some health system practitioners of the utility of HBI. Providence staff said they did not know what happened when patients left their care. They did not always know if patients were able to connect with HBI. Patients are only under Providence care for a limited time.

3.2.2. Imbalanced Resources and Capacities Between the Partners

There are stark differences in partners’ access to resources, which in turn impacts organizational capacity. Providence has significantly more political power, resources, and staff capacity, while HBI has fewer resources to support a highly distressed community. HBI must justify their funding every grant cycle and staff reductions strain their ability to provide services. HBI’s grant funding further restricts who they can serve; only pregnant individuals are eligible, which limits services for later term and postpartum clients. One Providence staff (Prov13) remarked:

Sometimes you don’t know what you don’t know. If this is your first baby, or if it’s your second, whatever baby, sometimes things change. To have that flexibility to refer to HBI, I don’t know if there’s any possibility of doing that, but that would be great to have that flexibility to refer postpartum. Or even from the hospital just with a fresh new baby if somebody feels like they would want that.

She went on to say this limitation meant that people who would benefit from HBI services could not access them. Providence and HBI wanted to rely on each other to augment some of the social health needs support of patients. Limited resources and diminished capacities to meet the increased needs of patients within both organizations put strain on both organizations. Providence and HBI teams have had conflict between each other. For the most part this conflict when it has arisen has been constructive. Providence has generally responded to concerns raised by HBI with openness and a willingness to learn how their individual- and system-level approaches are impacting Black providers, patients and communities. There are moments where Providence needs to give feedback to the CBO. At the individual level, the CBO can work with the feedback, but at the systems level the limits of resources, capacity, and lack of system-level control within county policies can restrict how responsive HBI can be to concerns of Providence providers.

3.2.3. Partnership Sustainability and Overreliance on Individual Leaders

Thus far, dedicated leaders and key staff from each organization have nurtured and sustained the partnership. Inevitable staffing changes pose a threat to partnership sustainability, underscoring a need to structure the partnership in less people-dependent ways. A key concern at the time of this study was that two of the core founders of the partnership (one from HBI and one from Providence) were leaving the leadership table, and a third leader from Providence was set to retire. A Providence staff (Prov8) said:

I do worry about, is this a people dependent relationship or is this an institutional relationship between two organizations that endures beyond the people? I hope the answer is yes. When Dr. [X] fully retires, would his replacement come in and we would automatically say, ‘Hey, this is part of our relationship. This is part of your role. We have a relationship with HBI. We’d like to introduce you to the team. We’d like you to join us. These are the things that we do. Here’s our meeting notes over the last couple years. Take a look at those, get used to the work we do together and join us.’, and make that just a part of the job expectation.

Participants agreed that some sort of formalization agreement would help institutionalize the relationship. A Providence staff (Prov7) spoke to a collective tension around formalization: “As much as I don’t like to formalize everything […] I do think for something as important and foundational as this, I do think some formality is important.” The partnership takes resources, space and time. There is will for this partnership and an orientation towards it. Both groups have invested staff time in meeting, but there has not been investment in shared space, or shared FTE for staff members.

4. Discussion

Study results describe a partnership between a small, culturally specific CBO and a large health system that was created to improve the perinatal care experience and maternal and infant health outcomes for Black families. As an under-researched health equity strategy, this paper adds to the literature on partnerships between culturally specific CBO and health systems by (1) offering the perspectives of staff directly involved with the CBO–health system partnership, (2) explaining how the CBP-health system partnership was formed, (3) describing the partnership’s early successes and lessons learned, and (4) providing actionable recommendations to other communities interested in developing similar partnerships.

Partnerships between health systems and culturally specific CBOs can improve patient care and outcomes by harnessing organizations’ unique assets to provide holistic care. Partnerships must be grounded in a steadfast commitment to relationships and demonstration of mutual respect and trust for each other’s expertise. Our study found that these commitments were actualized through prioritizing birth equity, regular integrated team meetings, and the development of feedback loops. HBI acted as birth justice advocates for Black families by regularly sharing individual and Black community needs with the hospital system. Their advocacy helped shift hospital leadership focus from the needs of the health system more towards the needs of the patient. HBI’s advocacy shines a light on what is needed for more patient-centered care for Black people. Partnerships like these give access to advocates from underserved communities to influence the beliefs and cultural assumptions of dominant systems.

The results of our study reflect that while challenges exist, partnerships such as the one between HBI and Providence may also create a healthy interdependence. The two entities could live without each other. Both say that their work is improved because of the ways they can augment each other’s care. For large health systems committed to health equity, cultural humility and respect are particularly important qualities to understand and demonstrate as they tap into the credibility and trust that CBOs have established with the community (Hill et al. 2024). Furthermore, health systems can leverage their institutional capital to expand the impact of culturally specific CBOs through policy advocacy, workforce development, and integration of CBOs as equal partners.

The Providence-HBI partnership shows how a CBO can function as a bridge between community and health systems, including through the provision of culturally responsive and racially concordant care (Dagher and Linares 2022). HBI’s integration within care teams helped facilitate better communication and collaborative decision making between providers and Black patients. At the same time, power and resource imbalances between partners can yield negative downstream effects on organizational and staff capacity, and ultimately patient care. Further, the critical role of visionary and skilled leaders in both the health system and CBO highlights the challenge of sustainability in the eventuality of leadership change and shifting organizational priorities. These challenges call attention to the need for more research to identify strategies for more streamlined and sustainable implementation of these unique partnerships.

4.1. Strengths and Limitations

This case study describes a specific, unique partnership from the perspectives of staff members within each respective organization. Not all staff members or stakeholder perspectives are represented. Key findings are not intended to be generalizable and may or may not transfer to other settings. Participants provided insights into how to address ongoing challenges, which we reflect in a set of recommendations for other organizations and partnerships to consider. Further research should include the voices of patients in the care of both partner organizations and longer term data of patient outcomes. We cannot make claims around patient outcomes. We can make claims around how staff perceived the impact of their work due to the partnership.

4.2. Implications and Recommendations

This study has important implications for health systems and CBOs that wish to develop and/or strengthen equity-oriented public health partnerships. Black communities may trust the CBO more than the health system. Building trust and understanding between the CBO and health system can improve the care and experiences of Black patients. Below we offer four specific recommendations.

4.2.1. Recognize, Value, and Leverage the Unique Skills, Perspectives, and Resources That Each Organization Brings to the Partnership

Partners’ unique assets can be strategically mobilized to build each other’s capacity and fill existing service gaps. CBOs may be deeply connected to, and have the trust of, culturally specific communities; CBOs may also be able to bridge cultural and medical knowledge (Hunte et al. 2022; Hunte et al. 2023; Yasmin et al. 2022). These assets position CBOs to share critical feedback with healthcare systems about community members’ care experiences. Health systems have the staffing, facilities, medical knowledge, technology, and resources to offer a wide spectrum of services, along with extensive administrative capacity (e.g., research capabilities and political power). Health systems can financially invest in CBOs and integrate them in the care of shared patients.

4.2.2. Develop a Systematic Referral Process Between the Health System and CBO to Facilitate Shared Access to Patient Information and Improve Care Coordination

Referral processes should be systematized and less dependent on individual providers’ prior knowledge of the CBO. In addition, health systems and CBOs can identify new points of referral, such as referral from hospital admission and postpartum visits. Shared access to patient information may improve care coordination; health systems and CBOs can explore options for shared access while also considering the importance of privacy concerns around data sharing.

4.2.3. Use a Range of Strategies to Secure, Strengthen and Grow the Partnership

Treat collaboration as a necessary component of care by integrating the work of partnership formation and sustainability in each organization’s work plans (Holt et al. 2010). Identify administrative strategies of institutionalization such as formal MOUs and explicit references to the partnership in job descriptions of select positions at each organization. Given the imbalance in power and resources, health systems can consider ways to sustain CBO participation by investing in their financial stability. On a patient care level, explore opportunities for structural integration of the CBO within the health system; for example, a CBO community health worker can be embedded in a health system’s women’s clinics that serve higher numbers of Black patients. A family-centered care lens may be useful for identifying integration opportunities; for example, solidifying coordination of care between perinatal and primary care, and extend and coordinate maternal and infant postpartum care.

4.2.4. Develop the Partnership Using an Implementation Science Research Framework, with a Focus on Sustainability

Implementation science may provide useful frameworks given its aim to assist in the design of public health interventions for implementation and health equity in partnership with health systems and communities (Shelton et al. 2023). Growing interest in implementation science to support the sustainability of public health interventions makes it an appropriate approach for further study.

5. Conclusions

CBOs have key knowledge and access to Black birthing people. We assert that Black providers and birth workers must be understood as part of the solution to address the Black maternal health crisis in the US. Addressing obstetric racism cannot happen without integrating the voices and recommendations of those most impacted by the failings of the health system. CBOs and health systems have the opportunity to work together and shift the culture of care that privileges the knowledge of health systems over that of communities. Partnerships between health systems and culturally specific CBOs are a health equity strategy that may reduce disparities and redress community medical mistrust. Numerous aspects of the HBI–Providence partnership may serve as a model for other organizations and settings: leaders made the partnership a priority; the health system demonstrated willingness to change in light of new information from the CBO; and the health system utilized its resources to institutionalize changes, such as strategic planning and modification of practices across various care teams that serve Black patients. The HBI–Providence partnership also highlights challenges facing health system–CBO collaboration: CBO resource limitations are barriers to their long-term participation, and fragmented referral processes and information sharing hinders realization of the partnership’s full potential. The potential of health system–CBO partnerships to improve care, and ultimately health outcomes, for marginalized communities requires continued research to identify feasible, effective, and sustainable strategies to achieve health equity.