Exploring Maternal Health of African American Women in

South King County

PRINCIPAL INVESTIGATOR
University of Washington,
Public Health Department
Undergraduate Researcher
[email protected]
Potential Collaborative Partner(s)

Families of Color

YWCA Healthy Birth Outcomes

King County Public Health Maternity Support Services (MSS)

Black Mamas Matter Alliance

Abstract

This project aims to empower the voices of pregnant or recently pregnant African

American women in South Seattle as a way to explore the causes of continued disparities in

maternal health outcomes. Using qualitative research methodologies including interviews and

participant observation, this study will collect the stories and experiences of African American

mothers and mothers-to-be in order to inform new guidelines for health practitioners and

government programs.

Description and Purpose

Introduction

Denene Millner is an award-winning journalist and New York Times best-selling author.

She is also a mother, who gave birth for the first time in 2015. Denene gave birth in a renowned
teaching hospital in upper Manhattan, where she spent an extra $800 to receive the “Cadillac

birthing experience”: a private room, a complimentary congratulatory meal of two steak and

lobster dinners and champagne for two and a special waiting area for family and friends. Yet, in

the words of Denene, “the moment my baby took her first breath, her mother was treated like

a 14-year-old drug-addicted welfare queen, there to push out yet another daddy-less baby”.

The nurses tested her baby for drugs without Denene’s consent. She was immediately placed in

post-birth room with three other women and their newborns, even though she paid for the

private room. Once in her mold infested private “suite”, Denene was left alone for nine hours

with no idea how to breastfeed, no diapers for her baby, and no idea of how to take care of her

post-birth body; whether it was ok for her to walk, wash herself, go to the bathroom. The

nurses verbally expressed their surprise that the man beside Denene during the whole ordeal

was her husband. (Millner 2012).

Denene is living proof that no matter how much money, insurance, or education an

African America woman has, she receives poorer care when delivering her baby. This narrative

makes one wonder where else within the system this disparity must exist. If a black woman is

treated this way at the very end of her pregnancy, what is the level of prenatal care and

instruction she receives? How is the medical system responsible for creating the shocking

statistic that black women are 3 to 4 times more likely to die from pregnancy than white

women? Denene’s story speaks to the pervasive nature of racism within our society that

undoubtedly flows into the medical institutions that are meant to heal. How many other stories

are out there with no platform to be heard? What knowledge must we be lacking from the

silence?
 This proposal aims to answer these questions and more through the collection and

dissemination of stories untold. The African American women who receive unnecessary

Cesarean sections, who’s babies are born with lower weights and who are ultimately at greater

risk of dying from disparate access to maternal health need to be consulted as experts capapble

of informing effective solutions.

Research Purpose

The purpose of this research study is to investigate the determinants of maternal health

for African American women in South Seattle.

Guiding Questions

What are the major sources of stress for pregnant African American women?

Are there maternal health needs within the community that are not being addressed?

What are the formal and informal support systems (friends, family, health services, etc.) in

place for pregnant African American women?

Has the daily experience of racism intersected with the stress of pregnancy for these women?

Do the research partners identify necessary changes to the maternal health services currently

available?

What is currently working well within healthcare settings during the pregnancy and birth

process?

Community/Population of Interest

I will be working with African American women who are either pregnant or under 3 months

postpartum and live within South King County (in order to include Renton residents). The study

aims to involve between 20-30 participants (also referred to as research partners) with no age
limits. This is my target population because African American women experience maternal

mortality rates that are three to four times higher than white women in the United States

(Singh 2010). While the data presumably includes African immigrants within the categories of

“black” or “African American”, this proposal is too limited to include immigrant populations as

well (for further discussion see limitations section). These statistics aren’t available in King

County, but following the rate of infant mortality and preterm births as indicators of overall

maternal health, African American women are disproportionately negatively effected (Public

Health Seattle and King County 2015).

Setting

The ideal collaborative partner for this study would be a small community-based

organization that provides health services and support for mothers within South Seattle or

Renton. Both the perspectives of women who are currently pregnant and those who have

recently given birth are desired to give current and retrospective insight. Families of Color

organizes parenting groups including a “Black Moms” group and would provide access to

women of a middle to high socioeconomic class who have recently given birth. A partnership

with the YWCA Healthy Birth Outcomes program would give access to low-income mothers-to-

be throughout their pregnancy experience. Both of these organizations have main offices

located in South King County. I envision these collaborations as a way to gain access to

communities of African American mothers and pregnant women and to serve as a basis for

recruitment of women to involve within the study. King County Public Health currently offers

Maternity Support Services (MSS) to women on Medicaid and has several locations throughout
the target area of interest. A collaboration with this program may be helpful in examining

where current efforts are lacking or failing some women.

This study will begin within the community organizations I outlined as potential

partners. I will employ two methods to gain entry into these organizations. For collaboration

with King County Public Health I will approach the executive directors and gain their approval

and then work to connect to influential nurses, social workers or other important members of

the program. This “top-down” approach is necessary within this institution because of the

governmental ties and bureaucratic nature of the Public Health Department. These key

stakeholders do not have to be medical or health professionals, but it is extremely important

that research partners trust them fully. This is important to ensure that potential research

partners within each community are not deterred by my association with a system they do not

trust.

In the community organizations I identified I will use a different approach. I will enter as

a volunteer, which puts me closer to the mothers and in a position of equality rather than

superiority. While preventing some intimidation or apprehension because of my presence, my

role as a volunteer will also give back to the organizations and community that I am partnering

with.

Once enough partners have been recruited, the research setting will move into

whatever is most comfortable for them. Working with this population especially, it is very

important to me that the participants choose the setting where one on one interviews will take

place, whether this is their home, a public meeting space, or at the university. The ideal setting

would be somewhere with relative privacy that is not completely isolated from the outside
world in order to make the research partners feel more at ease with minimal distractions. One

example would be a meeting room in a library. This is the kind of location where focus groups

will most likely take place because they need to be easily accessible and centrally located.

Research partners will also be compensated for their time in the form of connection to health

services or monetary incentive such as a gift card.

Significance

This research is important because it empowers the voice of a community so often

silenced. To my knowledge all the data of maternal health in Seattle is quantitative. I am not

aware of work being done to elevate the voices and knowledge of the women who’s lives or the

lives of their children are often at risk. The current public health initiatives are not successfully

decreasing the gap in maternal health between black women and white women. We need to

treat these communities as containing the solutions and not just the problem. If equity in

maternal health for black women is possible, it can only be through the involvement of

communities most negatively impacted. The ultimate goal for this research study is to inform

the creation of new guidelines for health care professionals, public health workers and other

community organizations providing maternal health support. This is only a starting point for the

launch of major reforms. No pregnant woman or infant should die in a country where billions of

dollars are spent on health care. The fact that these deaths and negative health outcomes

disproportionately affect women of color is abhorrent. More work desperately needs to be

done to end these “stupid deaths” (Farmer 2008).

Maternal health indicators show a sharp disparity between African American and white

mothers that transcends socioeconomic class and geographic lines. Nationwide, black pregnant

women die 3 to 4 times more often than white women (Singh 2010). Black women cannot buy

their way out of dying, as was exhibited in a 2010 study by the U.S. Department of Health and

Human Services, which found that the health disparities between African American and white

women persist at high, middle and low income levels (Singh 2010). Many of the traditional

social determinants of health are influenced by the daily experience of racism: housing, political

participation, education and food access to name a few. The confluence of racism and sexism

places extraordinary stressors on black women that have real health consequences.

Discrimination increases the risk of stress, depression, common cold, hypertension,

cardiovascular disease, breast cancer and mortality (Silverstein 2013). When mere anticipation

of racism is enough to trigger a stress response, it’s no surprise that women of color have

higher instances of these chronic diseases (Zahra 2017). Higher risks of pregnancy

complications are associated with chronic diseases such as hypertension, diabetes, and chronic

heart disease (Pregnancy Mortality Surveillance System 2017). Black women die 9.9 times more

often than white women from pregnancy-induced hypertension (Berg et.al 2015). In King

County, African American pregnant women have higher percentages of gestational diabetes,

obesity and hypertension (Public Health Seattle and King County 2015). Black mothers in King

County also report three times more stressful life events than white women (ibid).

Inherent racial biases are present within the very medical system that provides care to

these women as well. A recent study published in 2016 found that doctors believe African
American people can handle more pain and prescribe less pain killers as a result (Hoffman, Kelly

M. et al. 2016). Another report published by Amnesty International found evidence of

“discrimination and inappropriate treatment” from medical professionals (Amnesty

International 2011). Besides negative health consequences, this systemic racism fosters distrust

between patients and doctors.

Public health experts agree that the United States can end maternal mortality and

morbidity and have established the clinical interventions necessary to prevent and manage

pregnancy complications (Center for Reproductive Rights 2016). Research has shown good

prenatal care, skilled attendants during birth, and postnatal care are required to produce good

maternal health outcomes (ibid). It appears as though the answers already exist. What research

into developing these clinical interventions don’t address is the intersection of racism and

health disparities. There is not enough research being conducted based on the experiences of

pregnant women that goes beyond the numbers and medical charts. These experiences are

uniquely geographical as well. While much work has been done in Southern states, the

experience of women living in the cities of the north needs to be added to the narrative field

(ibid).

Research Methodology

I will begin with participant observation as an introduction to potential research

partners and to the community. By entering the space as a passive participant, I will learn about

the culture and experiences of the women so that I will be better informed, conscious of

community norms, and have the community’s needs in mind when conducting interviews. The

intent behind this approach is that I present myself as open-minded and recognize gaps in my
own knowledge, yet use my position of privilege within the university to elevate and empower

their narrative. I want the women to know that their knowledge is powerful and that as a

research I don’t want to “use” it for solely personal gain. The goal is always to produce

something that the community wants and needs. The perfect setting for employing this initial

methodology would be the “Black Moms” parenting group organized by Families of Color. In

the institutions I enter as a volunteer, I will move towards “observant participation” as much as

makes sense for the particular context (Johnson 106-7).

After establishing connections and trust through participant observation, I will identify

individuals who are interested in contributing further as “research partners”. It is important to

me to label these women as partners and not participants. I am not an expert in this issue or

within this community and I want the product of this research to be directly shaped and

informed by the women it will benefit. After identifying these women, I will conduct informal,

semi-structured interviews using an interview guide with questions that “allow for interviewees

to share and narrate distinct experiences” (Johnson 82). Many of the questions I wish to ask

follow a life history model of interviewing. I’ll start with broad, open-ended prompts such as

“Tell me about your life and how it’s changed since being pregnant/giving birth”. The interview

process will thus begin unstructured and broad to build rapport with the interviewee and put

them at ease (Johnson 88). The questions will progressively get more specific and delve into

sensitive topics. The majority (if not all) of the questions will be open-ended enough to elicit

stories and allow for follow-up questions (Johnson 85). I will conduct enough interviews to

reach saturation, which I define as the point when no new insight is gained because the ideas

have been expressed in previous interviews.

experiences and discussion of key issues” and to incite discussion around conflicting opinions

that emerged within the interviews (Johnson 83. The space of a focus group can be

empowering for the research partners as a concrete realization that there are others who face

the same challenges.

The interviews, participant observation and focus groups will generate qualitative data

that needs to be analyzed to identify patterns and themes within the stories and knowledge

contributed by the research partners. This will be accomplished through open coding of the

data to avoid assumptions and biases brought in through closed coding (Johnson 123). The

codes I use to break down the data will follow in vivo coding, or using research partners’ words

and phrases as codes, as much as possible to further eliminate bias (Johnson 124). I will look for

ideas and patterns that speak to gaps in health care support services, common maternal health

issues, and interventions that have made positive change. This will help identify overarching

themes that should be included in the final list of recommendations to health care institutions

and policy makers. As part of this initial cycle of coding I will use “collective coding” to compare

my own interpretation of a transcript to that of someone directly involved within the

community (Johnson 132). Collective coding will produce a list of common codes to use in

subsequent data sources that are agreed upon by both the research team and the community

partners. This is an important part of remaining conscious of my positionality as a researcher

and ensuring that analysis is meaningful to the community itself. Following the initial coding, I

will conduct coding cleanup to rename, reduce, and merge codes and organize them into broad

categories (Johnson 124). Then I will engage in at least one additional cycle of coding to
examine similarly coded data for themes, patterns and divergent voices (Johnson 124). Initial

findings will be shared with research partners and relevant stakeholders as part of “member-

checking” the analysis (Johnson 131).

The write-up of findings generated from analysis will take several forms. First, for health

care providers and policy makers, the findings of this study will be compiled into a toolkit

following the format of the “Black Mamas Matter toolkit” produced in June 2016 by the Center

for Reproductive Rights in partnership with members of the Black Mamas Matter Alliance. The

toolkit will include a list of resources, recommendations for health care professionals, a policy

framework and research overview that are specifically focused on South King County. It will

differ in at least one critical way from the example created by the Center for Reproductive

Rights. Much of the research that has been conducted around racial disparities in maternal

health focus almost entirely on quantitative data to appeal to the medical and public health

communities as legitimate research. This proposal looks to the stories of the African-American

women for knowledge and must present these voices and narratives as uniquely able to

demonstrate the issues of disparity and inequality that plague maternal health access in this

country. I cannot present these stories as mere examples of how the data is founded in real-life

experiences.

While the goal of this research is to transform the quality of maternal health care

African American women receive by appealing directly to medical institutions and policy

makers, it should also have a transformative effect on the research partners themselves. The

first way I will ensure that these women are rewarded for their invaluable knowledge

contribution is through compilation of a list of resources for health information and free
services ranging from child care to continuing education and parenting groups. I will also host a

“culminating event” for research partners, their family members, and community members

that weren’t directly involved in the project as a way to report back to the community (Johnson

140). This event will foster discussion around research findings that might offer important

feedback to the research team, but it should also be an event where appreciation to the

community is expressed.

Limitations

Perhaps the biggest limitation of this research proposal is my limited access to the

community of interest. I have no connection to the potential collaborative partners or key

stakeholders that could foster a relationship to the women I would like to interview. In order to

build this connection, I might have to start at the top of the leadership for some organizations

and work my way down to the pregnant women themselves. This poses potential problems

from allying myself with leadership members who participants don’t like and immediately

entering the space from a position of authority. I also have no personal experience with

pregnancy or the experience of blackness. As a white woman from a university setting, I have a

level of privilege that could potentially prevent meaningful conversations and research

partnerships with these women. I will have to work hard to overcome differences in life

experience and to show the research partners that I have only the best intentions with this

study. Many of these differences in levels of understanding and experience could be bridged by

engaging in volunteer work with the organizations before expanding my role into that of a

researcher. Elaborate.
 Another limitation of this proposal is its definition of African American women as

excluding those with immigrant status. This categorization is necessary given the different

experiences within the health care system of an immigrant black woman and a non-immigrant.

Including both populations would require more time, more funds and more bodies to help

analyze data. There would have to be careful representation of the differences in barriers to

access and necessary interventions for each population. Unfortunately, this proposal does not

have the capacity to extend to both groups. However, it would be fairly simple to amend this

proposal to look specifically at immigrant populations. This would make a wonderful follow up

research project and is an area for needed further exploration.

Amnesty International. Deadly Delivery: The Maternal Health Care Crisis In The USA. London,
2017, https://www.amnestyusa.org/files/pdfs/deadlydelivery.pdf.

Barnes, Zahra. "8 Health Conditions That Disproportionately Affect Black Women." SELF. N.p.,
2017. Web. 18 Aug. 2017.

Berg, Cynthia J. et al. "Preventability Of Pregnancy-Related Deaths." Obstetrics & Gynecology

Center for Reproductive Rights. Research Overview Of Maternal Mortality And Morbidity In The
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/Health-of-Mothers-and-Infants-by-Race-Ethnicity.ashx.

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