Abstract
Introduction: Black women in the United States face numerous barriers accessing high quality prenatal care. We sought to understand the experience of Black women getting prenatal care in a free faith-based medical clinic and to explore their experiences with staff and clinicians at the clinic.
Methods: From August 2022-January 2023, we conducted qualitative interviews with 14 Black women. Interviews were recorded, transcribed, and coded by 2 researchers. After coding, researchers identified emerging themes through standard qualitative methods. The study was IRB reviewed and approved.
Results: Patients identified meaningful relationships with clinic staff; the impact of a faith-based institution; the complicated relationships with clinicians; and the value of wrap-around services as key aspects of care.
Conclusions: This study highlighted the importance of interpersonal relationships and building trust. Findings support prior research showing Black women’s’ preference for race- and gender-concordant prenatal care and this being an important contributor to trust.
- African Americans
- Ambulatory Care Facilities
- Faith-Based Organizations
- Interpersonal Relations
- Minority Health
- Pregnancy
- Prenatal Care
- Qualitative Research
Background
Disparities in fetal, infant, and maternal mortality are worsening nationally.1–4 In 2021, Black women were 13.5% less likely to receive prenatal care in the first trimester and twice as likely to give birth with no or late prenatal care compared with non-Hispanic White women.2,3 A variety of factors may limit access to care for Black women during pregnancy including culturally inappropriate care, poor treatment in the system related to racism, inconsistent social support, and limited trust in the health care systems which have mistreated or neglected them in the past.5,6
Early access to prenatal care can identify risk factors that lead to morbidity and mortality and may be a vehicle through which disparities can be identified and addressed. Researchers have suggested that non-Hispanic Black women may be more likely to use public safety net clinicians such as free clinics, because they engender trust, offer broader support systems, are in closer proximity to the neighborhoods where Black women live, and have a historic role in the communities they serve.7 However, little is known about how or why these safety net clinics attract and retain Black women for prenatal care. In this study, we interviewed Black women who obtained care through a free Detroit clinic and used qualitative methods to better understand decision making around where to receive prenatal care. Specifically, we queried why women chose a free, faith-based clinic, and factors impacting their experiences with physicians and clinic staff.
Methods
Overview and Objectives
This study used a general qualitative descriptive approach8,9 of reproductive-age Black women in Detroit, Michigan. We recruited patients from Luke Clinic, a free faith-based clinic in Detroit, Michigan which offers prenatal, postpartum, and infant care.10 The clinic is held twice monthly, staffed by a rotating group of family medicine physicians and a consistent group of volunteers with ties to the local communities. Volunteer staff filled all necessary clinic roles including nursing, technicians, ultrasonographer, and medical assistant roles. Clinic staff were composed of individuals of a variety of racial and ethnic backgrounds. The clinic provides wrap-around services including ultrasound, labs, free medications, education, immunizations, insurance navigation, and tangible supplies.
Potential participants were identified by clinic staff, approached by interviewers, or recruited through a flyer. Interviews were conducted until thematic saturation was reached, which was defined as the point when no new codes were needed to adequately represent the data through consensus of the research team. Eligible participants self-identified through verbal response to open-ended questions as Black or mixed-race Black women who were pregnant or within 1 year postpartum at the time of the interview and had at least 1 visit at Luke as a patient before the interview. We limited recruitment to English-speaking women who were born in or had immigrated to the United States more than 15 years ago. We obtained verbal informed consent before the interview and offered a gift card as appreciation for participation.
Data Collection
As validated qualitative interview tools were not available, the research team reviewed existing literature to identify preferred aspects of clinical care for this population and developed a structured interview guide. The guide included background, demographic information, lived experience and preferences, trust in physicians, and an exploration of how clinic services affected decision making processes. The interview questions were piloted with a volunteer participant before the start of the study. Two investigators who identify as Black women medical professionals (and who were not acquainted with any participants) conducted private 15 to 30 minute interviews.
Data Analysis
The interviews were digitally recorded, transcribed, and deidentified. Transcripts were coded through interactive steps informed by inductive-deductive thematic analysis.8 Two team members independently reviewed and annotated transcripts to develop a set of codes, and the full team refined the codes and created a code dictionary. Two transcripts were independently coded by 2 members of the team, blinded to each other's work, until codes achieved at least 85% agreement using Cohen’s Kappa. Two reviewers then applied the codes to all the transcripts, and the team mapped codes to thematic schema. A descriptive matrix was used to synthesize responses.11 Transcribed interviews were coded in Dedoose (www.dedoose.com, v.9.0). The study was deemed exempt after review by our Institutional Review Board.
Results
From August 2022 to January 2023, 14 of 16 invited women participated in interviews. One transcript was excluded from analysis, as review found the woman did not meet all study criteria. All participants self-identified as either ‘Black’ or ‘African-American.’ The average age of participants was 27.2 (± 6.7), range 21 to 40. On average, women had 3 pregnancies and 2 deliveries at the time of the interview. Ten participants were pregnant, and 3 postpartum. Four themes emerged surrounding relationships with clinic staff and physicians, the role of religion and faith, the impact of race on the patient-physician relationship, and the availability of wrap-around services.
Meaningful Relationships with Clinic Staff
Of the thirteen participants, 8 described strong connections with clinic staff and cited this relationship as the primary reason they continued receiving care at the Luke Clinic. (Table 1) Participants noted that they are frequently asked about their needs and subsequently provided with both tangible and emotional support. The phrases “like family” and “safe haven” were used to describe the atmosphere at the clinic. Two women reported that relationships with staff developed during particularly difficult times of their lives, such as after a relationship breakup or an unplanned pregnancy.
Participant Reflections on Meaningful Relationships with Clinic Staff (Total n = 13)
“So, no matter what, I wasn't going back to [Detroit hospital] …here… I was a priority and I mattered. … it was a very rocky time… Coming here was the only time anybody would even ask like, ‘Are you okay?’ So just at that time, it was just the support.” (Participant 11)
The Role of Religion or Faith
No women reported feeling uncomfortable receiving medical care in a church building, though all were initially surprised by the location. (Table 2) While most were ambivalent about the presence of religious symbols, several women reported that the familiar environment made them feel more comfortable.
Participant Comments on the Role of Religion or Faith (Total n = 13)
Complicated Patient-Physician Relationship
All participants reported feeling respected by the physicians, but when asked how much they trusted their physician, most expressed some level of hesitation. Women explained that physicians could be trusted to not cause harm but could not be trusted to care about them as individuals.
Interviewer: “Do you feel like you trust the clinicians here? … To have your best interest at heart and give you good advice and take good care of you?”
Participant: “No, and yes. I don't feel like they have ill intentions towards me, but because of history, I feel maybe my best experience or best what not, would, would not be in their hands specifically.” (Participant 8)
Value of Race-Gender Concordance
Many participants expressed a preference for race-gender concordance with their physician. They felt that a Black woman physician would have a deeper understanding of their health. Some women attributed this to trust, stating that physicians who look like them are more reliable in providing personalized care. (Table 3)
Participant Experiences of a Complicated Patient-Physician Relationship (Total n = 13)
Availability of Wrap-Around Services
All participants appreciated the value of wrap-around services and many stated that this contributed to their feeling cared for by clinic staff, even if they did not need specific services. One participant reported she had found a “family feeling” at the Luke Clinic that she was unable to find in other prenatal care settings.
Discussion
The Black women in this study overwhelmingly endorsed the importance of receiving prenatal care in a context that developed community around them. In line with previous studies, we found that meaningful relationships with clinic staff were a leading explanation for why these Black women chose to receive their prenatal care at a free, faith-based clinic rather than in a standard clinic or hospital setting.
Several studies have described the ideal characteristics of prenatal care for Black women including that physicians emphasize patient-centered care.12,13 Positive interactions with clinicians and staff are a key predictor of satisfaction.14 Our study confirmed that Black women prefer care from clinicians that demonstrate these characteristics and supports previous findings that Black women prefer receiving gender and racially concordant care.15
While another study measuring trust in prenatal care for Black patients highlighted the distinction between interpersonal trust between a patient and clinician versus social trust in an institution or organization, our study is among the first to describe that the patient-physician relationship may not necessarily be the most important factor affecting whether a Black woman will be satisfied with her care and return for future visits.1,6 Even if the patient does not feel that she completely trusts her physician, other factors, including her relationship with clinic staff members, a welcoming environment, and integration of wrap-around services can positively affect her perception of care. Research has also explored numerous social and structural barriers to care for Black women, and clinics that address these issues upfront may be perceived as more trustworthy.14 Pregnant Black women reported social support and faith as important components for managing COVID-19 pandemic stress, and spirituality has repeatedly been shown to be an important coping mechanism for many Black women.16–18
This was a small qualitative study in a faith-based clinic. The close-knit nature of the clinic empowered participants to freely and truthfully share their experiences. The depth and the complexity of their conveyed experiences were a strength of this study.
This study aims to assist teams providing care to Black pregnant women to attract and retain this population. Findings can be used to develop research questions aimed at strengthening the physician-patient relationship and can be practically applied to support the development and maintenance of wrap-around services. While these results begin to characterize the importance of community and relationships in this population, knowledge gaps regarding factors that drive trust-building between patients and physicians still exist. Future research should focus on how to strengthen the physician-patient relationship, especially among gender and racially discordant pairs.
Acknowledgments
The authors wish to thank the clinic patients who graciously offered their perspectives, staff at Luke clinic who allowed us to carry out this study, University of Michigan Poverty Solutions for grant funding, and Ms. Katie Grode who assisted with manuscript preparation.
The corresponding author had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Notes
This article was externally peer reviewed.
Funding: Dr. Gold received funding from Poverty Solutions at the University of Michigan. Dr. Jean received funding from the University of Michigan Medical School Capstone for Impact grant.
Conflict of interest: The senior author serves as the medical director at Luke Clinic. 10% of her salary is funded by Luke clinic and 10% by her department to manage care at Luke. No other author has any conflicts to declare.
- Received for publication March 22, 2024.
- Revision received May 9, 2024.
- Revision received February 12, 2025.
- Revision received April 1, 2025.
- Revision received April 16, 2025.
- Accepted for publication May 27, 2025.
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