Title of Thesis: EXAMINING CONTRIBUTORS TO BLACK MATERNAL HEALTH EXPERIENCES IN PRINCE GEORGE’S COUNTY, MARYLAND Aden T. Eskinder, Alexis C. Nnabue, Christal C. Onyekwere, Isabella H. Battish, Esohe T. Owie, Madison L. Harris, Sidney A. Redwood, and Stephanie M. Fishkin, 2025 Thesis Directed By: Assistant Dean, Office of Public Health Practice and Community Engagement Associate Clinical Professor Dr. Sylvette La Touche-Howard School of Public Health 1 Abstract Black women in the United States face a maternal mortality rate three times that of white women, a disparity mirrored in Prince George’s County, Maryland (Hoyert, 2023; Maryland Department of Health, 2022). In 2019, the Prince George’s County Health Department reported that between 2008 and 2017, Black, non-Hispanic mothers experienced the highest pregnancy-related maternal mortality rate (37.4 deaths per 100,000 live births) in the county (“Maternal Infant and Health Report,” 2019). This study explores how maternal access to healthcare and provider cultural competency training influence maternal health disparities in Prince George’s County. Using a mixed-methods approach, the research team surveyed and interviewed two key populations: Black mothers ages 18-34, residing in Prince George’s County, Maryland, and maternal health providers practicing in the District of Columbia, Maryland, and Virginia (DMV) region. By examining patient-provider interactions and gaps in medical education, this research aims to inform policy and curricular reforms to improve Black maternal health outcomes. 2 EXAMINING CONTRIBUTORS TO BLACK MATERNAL HEALTH EXPERIENCES IN PRINCE GEORGE’S COUNTY, MARYLAND by Team Black Mamas Matter (BMM) Aden T. Eskinder, Alexis C. Nnabue, Christal C. Onyekwere, Isabella H. Battish, Esohe T. Owie, Madison L. Harris, Sidney A. Redwood, Stephanie M. Fishkin 3 Thesis submitted in partial fulfillment of the requirements of the Gemstone Honors Program, University of Maryland 2025 Advisory Committee: Dr. Sylvette La Touche-Howard, Chair Dr. Ndidiamaka Amutah-Onukagha Ms. Elizabeth Marshall Dr. Catherine Maybury Ms. Taylor Palmer Dr. Tracy Zeeger Ms. Emily Deinert, Librarian 4 © Copyright by [Aden T. Eskinder, Alexis C. Nnabue, Christal C. Onyekwere, Isabella H. Battish, Esohe T. Owie, Madison L. Harris, Sidney A. Redwood, Stephanie M. Fishkin] [2025] 5 Acknowledgements We extend our deepest gratitude to Dr. Sylvette La Touche-Howard for her invaluable mentorship, continuous support, and expertise throughout our research journey. We thank Dr. Tracy Zeeger, Dr. Catherine Maybury, and the University of Maryland School of Public Health for providing us with essential resources and opportunities to share our research. Special thanks to Tam Nguyen who was a member of the team in years one and two and made influential contributions to our work. We are grateful to Taylor Palmer and the members of the Prince George’s County Health Action Coalition for welcoming us to informative meetings and supporting the dissemination of our study. Thank you to Dr. Ndidiamaka N. Amutah-Onukagha and the Maternal Outcomes for Translational Health Equity and Research (MOTHER) Lab for supplying instrumental data that helped shape our research. Special thanks to the University of Maryland Capital Region Medical Center and Prince George’s County Memorial Library System for aiding us with participant recruitment. We thank Ms. Elizabeth Marshall for providing us with insightful feedback at our Thesis Conference. We sincerely appreciate the funding support from our generous donors from the University of Maryland Libraries, Launch UMD, and bake sale consumers. We are thankful for Ms. Emily Deinert, our team librarian, whose guidance was immeasurable in establishing a strong foundation for our thesis. 6 Lastly, we are especially grateful to the Gemstone Honors Program, Dr. David Lovell, Dr. Allison Lansverk, Ms. Leslie Lizama, and Ms. Brianna Lucas, for providing us with the opportunity to lead a meaningful undergraduate research project. 7 Table of Contents Abstract 2 Acknowledgements 6 Table of Contents 8 List of Tables 12 List of Figures 13 List of Abbreviations 16 Chapter 1: Introduction 17 Chapter 2: Literature Review 21 2.1 A Historical Overview of Obstetrics and Gynecology in the United States 21 2.2 The State of Maternal Health in the United States 22 2.3 Maternal Health in Prince George’s County, Maryland 25 2.4 Contributing Factors to Black Maternal Mortality 28 2.4.1 Comorbidities 28 2.4.2 Provider Mistrust, Limited Health Literacy, and Barriers to Seeking Health Information 31 2.4.3 Lack of Cultural Competency Training in Maternal Care Provider Training 34 8 2.4.4 Lack of Representation in Doctors 38 Chapter 3: Methodology 40 3.1 Research Questions 40 3.2 Study Design 40 3.3 Sample and Recruitment 41 3.3.1 Sample Criteria 41 3.3.2 Recruitment 42 3.4 Study Procedure 43 3.5 Measures 44 3.5.1 Demographic Variables – Mothers 44 3.5.1 Dependent Variables – Mothers 45 3.5.2 Demographic Variables – Providers 48 3.5.3 Dependent Variables – Providers 49 Chapter 4: Results 51 4.1 Description of the Sample 51 4.2 Descriptive Statistics for Mothers 55 4.2.1 Disparities by Zip Code 61 9 4.2.2 Income Disparities 64 4.2.3 Relationship between Housing Location and Choice of Provider 67 4.2.4 Maternal Care Experiences 69 4.2. 5 Mothers' Health Beliefs 79 4.3 Descriptive Statistics for Providers 89 4.3.1 Cultural Competency Training 89 4.3.2 Work Environment 99 4.4 Qualitative Interview Findings 105 Chapter 5: Discussion 111 5.1 Introduction 111 5.2 Trust Between Providers and Mothers 111 5.3 Maternal Health Care Access in Prince George’s County 115 5.3.1 Seeking Prenatal Care 118 5.3.2 Health Literacy 121 5.4 Cultural Competency Trainings for Providers 123 5.5 Limitations and Strengths 127 5.6 Equity Impact Statement 129 10 5.7 Future Research 129 5.8 Conclusion 131 Appendices 133 References 158 11 List of Tables Table 1: Demographics of Surveyed Mothers (N= 69) 52 Table 2: Demographics of Surveyed Providers (N= 107) 54 Table 3: Most Trusted Sources for Health Information for Mothers 87 Table 4: Provider Response to Questions Indicating Racial Bias 99 Table 5: Self-Reported Interview Participant Experience Demographics 105 12 List of Figures Figure 1: Distribution of Mother Income 56 Figure 2: Distribution of Mother Education 57 Figure 3: Frequency of Mothers Who Share a Racial Identity with Provider 58 Figure 4: Impact of Shared Race on Patient-Provider Interactions 60 Figure 5: Number of Respondents by Zip Code 62 Figure 6: Number of Black Women Between 15-50 Who Gave Birth in the Past Year 63 Figure 7: Median Mother Income by Zip Code 65 Figure 8: Median Mother Income by Zip Code 66 Figure 9: Percentage of Mothers Surveyed Who See an OB/GYN by Zip Code 67 Figure 10: Distribution of Mothers Surveyed Who Received Prenatal Care 69 Figure 11: Distribution of Mothers Who Received Prenatal Care by Income 70 Figure 12: Distribution of Mothers Surveyed Who Received Prenatal Care by Education 71 Figure 13: Extent to Which Mothers Agree/Disagree with Having Personal Barriers, Preventing them from Obtaining Healthcare Services/Information 72 13 Figure 14: Extent to Which Mothers Agree/Disagree with having Personal Barriers Preventing them from Obtaining Healthcare Services/Information by Income 74 Figure 15: Extent to Which Mothers Agree/Disagree with having Personal Barriers Preventing them from Obtaining Healthcare Services/Information by Education 76 Figure 16: Mothers’ Beliefs of when Prenatal Care Should be Initiated after Learning of Pregnancy 79 Figure 17: Mothers’ Beliefs of when Prenatal Care Should be Initiated after Learning of Pregnancy Aggregated by First Pregnancy or Not 81 Figure 18: Mothers’ Overall Prenatal Care Experience Rating 83 Figure 19: Mothers Perception of Provider Attentiveness to Their Concerns 84 Figure 20: Perception of Trust, Comfort, Safety, and Respect with Provider 85 Figure 21: Proportion of Providers with Cultural Competency Training 89 Figure 22: Providers with Cultural Competency Training By Provider Type 90 Figure 23: Time Providers Recorded Spending to Complete Cultural Competency Training 92 Figure 24: Provider Recorded Amount of Time Passed Since Completing Cultural Competency Training 93 Figure 25: Extent to Which Providers Believed They Received Adequate Cultural Competency Training 95 14 Figure 26: Providers’ Identification of the Following Statements as True/False 97 Figure 27: Providers’ Estimate of the Length of a Typical Patient-Provider Interaction 100 Figure 28: Proportion of Time Typically Spent with Patients by Provider Type 101 Figure 29: Challenges Providers Encounter When Delivering Care to Diverse Patient Populations 102 Figure 30: Providers’ Description of their Coworkers 103 Figure 31: Providers’ Description of their Work Environment 104 15 List of Abbreviations DMV: District of Columbia, Maryland, and Virginia OB/GYN: Obstetrician/Gynecologist MUP: Medically Underserved Population NICU: Neonatal Intensive Care Unit BIPOC: Black, Indigenous, and People of Color URM: Underrepresented Minorities MCAT: Medical College Admission Test CVD: Cardiovascular Disease IRB: Institutional Review Board PA: Physician Assistant/Associate NP: Nurse Practitioner 16 Chapter 1: Introduction The maternal mortality rate for Black women living in the United States (U.S.) is two to three times higher than that of white women (Hoyert, 2023; Maryland Department of Health, 2022). While other factors may contribute to this disparity, research has shown the main cause is due to the systematic and interpersonal prejudice ingrained in the U.S. society (Shaya et al., 2023). In most instances, women who have attained higher education levels are proven to have better birthing outcomes; however, this does not hold true when examining across racial demographics (Anthony Jr. et al., 2024). The rate of maternal mortality for Black women with a college degree is 1.6 times higher than white women with less than a high school diploma (Shaya et al., 2023). This trend continues for Black women, regardless of high socioeconomic status and access to healthcare (Shaya et al., 2023). There have been dangerous hypotheses surrounding the disproportionate rates of maternal mortality, suspecting that perhaps the genetic composition of Black women may be the root cause of this discrepancy (Stafford, 2023), however, this has been refuted on several occasions (Duello et al., 2021). Recent studies have also found that compared to Black women born in the U.S., the maternal mortality rate for immigrant Black women was found to be 33% lower (Peredy et al., 2024). A centuries-long history of systemic inequality and discrimination against Black women is a fundamental factor in this disparate outcome (Stafford, 2023). Research finds the myth that Black people have higher pain tolerance has contributed to the mistreatment of Black Americans by healthcare providers who undertreat or dismiss Black patients’ pain symptoms (Hoffman et al., 2016). These myths and 17 stereotypes are especially dangerous considering that due to experiences with racism in social interactions or social institutions, Black women experience higher stress levels, which, in turn, elevates their risks of comorbidities and birth-related complications (Jha et al., 2004; Bond et al., 2021). Structural factors not only adversely impact the health of Black women, but also makes it more difficult for them to gain access to health and health information (Muvuka et al., 2020). According to a recent study, a disproportionate number of women from minoritized racial and ethnic backgrounds live in maternal care deserts, defined as counties with no hospital offering obstetric care and no Obstetrician/Gynecologist (OB/GYN) or certified nurse-midwife providers (March of Dimes, 2020). Previous efforts to increase healthcare accessibility have included universal coverage health insurance programs, such as Medicaid and Medicare; however, without health insurance literacy, these are ineffective at increasing accessibility (Vardell, 2019). Overall, the systemic challenges that Black women face in the healthcare system impact their ability to access quality prenatal and postnatal care that monitors potential risk factors and improves the safety of the childbirth experience. Black physicians have been underrepresented in the healthcare system due to the presence of processes and health professions school admissions criteria that disadvantage Black Americans (Adelman, et al, 2019). In 2021, only 11% of physicians making up the OB/GYNs specialty were Black (Tiako et al., 2021). Standards of “professional” behaviors and appearances, such as those surrounding hairstyles, dress, and speech, are biased toward Eurocentric values and practices (Tiako et al., 2021). Black Americans who do not conform to said Eurocentric 18 standards may be considered less “professional” relative to their white counterparts (Tiako et al., 2021). Medical school curricula has also frequently inappropriately portrayed race as a biological determinant of health rather than as a social construct, which exacerbates provider internalized racism (Amutah et al., 2021). As a result of this literature, there has been a demand for providers to undergo cultural competency and implicit bias training to reduce biases (Mendizabal et al., 2021). Yet, only half of healthcare providers reported undergoing such cultural competency and/or implicit bias training in medical schools in recent studies (Mendizabal et al., 2021). Thus, medical schools perpetuate not only the underrepresentation of Black physicians, – which hinders Black patients’ abilities to feel seen in the healthcare system – but also the continued existence of biases that contribute to the mistreatment of Black patients, such as the dismissal of Black patients’ pain symptoms (Greenwood et al., 2020). As discussed in our literature review, many scholars have documented how physicians’ biases and a lack of accessibility to healthcare providers contribute to racial disparities in maternal health outcomes. There is a lack of research surrounding the impact of cultural competency training on patient-provider interactions. This research is innovative and focuses on hearing from both maternal care providers and Black mothers in Prince George’s County, Maryland. Through an in-depth analysis of the participant surveys and expert interviews with maternal care providers, we explored the healthcare attitudes and patient-provider relationships of Black mothers in Prince George’s County. Our findings also show the impact of cultural competency training on quality of maternal healthcare by provider. Our data sheds light on the needs, concerns, and needed resources for Black women in this area. Results will be 19 made available to the County Council Board of Health and the Prince George’s County Health Department. It is our belief that the recommendations deduced from this data, if implemented, can also ensure that significant strides are made to ensure that Black women are supported before, during, and after pregnancy. 20 Chapter 2: Literature Review A Historical Overview of Obstetrics and Gynecology in the United States The history of maternal health in the United States is rooted in violence and the exploitation of Black bodies as unwilling participants for the advancement of medicine (Holland, 2025; Owens & Fett, 2019). From the forced transportation of enslaved Africans through the Middle Passage to the buying and selling of slaves in the antebellum South, white medical physicians were often present, not to ensure the well-being of enslaved, but to protect the financial well-being of slave owners (Owens & Fett, 2019). When Black enslaved individuals died, their bodies were often used as teaching material in white medical schools or displayed in medical museums (Owens & Fett, 2019). Following the ban of the Transatlantic Slave Trade in 1807-1808, slave owners began to focus on enslaved Black women as a way to increase the enslaved population for economic gain (Owens & Fett, 2019). During this time, midwives played a significant role in Black communities, ensuring that enslaved women could give birth as safely as possible under brutal conditions (National Museum of African American History and Culture, n.d.). White physicians were only summoned for difficult births but even with their involvement, maternal and infant mortality rates remained disproportionately high due to systemic medical neglect (Owens & Fett, 2019). Tragically, these physicians frequently blamed the mothers for these deaths, ignoring the structural conditions that contributed to these outcomes (Owens & Fett, 2019). 21 Enslaved Black women were not only exploited for their reproductive labor but were also subjected to invasive medical experimentation. Their bodies served as the site for the development of procedures still in practice today (Owens & Fett, 2019). For instance, François Marie Prevost, a slaveholding surgeon, pioneered cesarean section surgeries through repeated operations on enslaved Black women (Owens & Fett, 2019). Similarly, James Marion Sims, known as the “Father of Modern Gynecology,” developed obstetric fistula repair techniques by experimenting on enslaved Black women (Holland, 2025; Owens & Fett, 2019). These surgeries were performed without anesthesia, as physicians operated under the racist belief that Black people did not feel pain the same way as white people, a myth that continues to influence medical bias today (Holland, 2025). The early 20th century saw a shift toward institutionalised obstetrics, but this shift often worsened maternal health outcomes. Between 1900 and 1920, the United States experienced the highest maternal mortality rates of the 20th century (Centers for Disease Control and Prevention, 1999). Substandard, unhygienic obstetric practices, combined with the fact that obstetrics was viewed as a lesser field within medicine, were responsible for the deaths of many women (Centers for Disease Control and Prevention, 1999). To fully understand the current Black maternal mortality crisis in the United States, it is crucial to acknowledge the deep and painful connection between American gynecology and slavery. The State of Maternal Health in the United States Each year, 700 U.S. women die due to pregnancy complications (Petersen et 22 al., 2019). This number is likely underestimated due to differences in data collection and reporting across regions (Pham et al., 2020). In comparison to other developed nations, the United States has the highest maternal mortality rate, with a 2018 maternal mortality rate of 17.4 deaths per 100,000 live births. This rate is at least double the rate as compared to other developed countries (Tikkanen et al., 2020) and has only been increasing. According to the National Center for Health Statistics, “the maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births compared with a rate of 20.1 in 2019” (Hoyert, 2023). Additionally, in comparison to other high income countries, the U.S. has one of the lowest supplies of maternal healthcare providers per 1000 live births (Tikkanen et al., 2020). While the maternal mortality rate around the world has decreased by 43%, the U.S. is the only country with a rate that has increased (Korbatov, 2015). The leading cause of maternal mortality in the US are cardiovascular disorders/diseases such as pulmonary embolism (blood clots in the lung) and hypertension (high blood pressure) or a huge loss of blood (Korbatov, 2015). Maternal mortality rates also vary depending on race. For instance, in 2020, the Center for Disease Control and Prevention (CDC) found that “the maternal mortality rate for non-Hispanic Black women was 55.3 deaths per 100,000 live births,” which is an extremely shocking statistic given that this rate is “2.9 times the rate for non-Hispanic White women (19.1)” (Hoyert, 2021). There are many possible reasons for this disparity such as lack of health literacy, accessibility, and/or mistrust in the healthcare system due to potential racial bias as a result of improper medical school curricula (Center for Disease Control and Prevention, 2020). Maternal mortality rates among Black women in the U.S. measure three times 23 higher than maternal mortality rates found among white women, with 44.0 deaths per 100,000 live births compared to 17.9 deaths for 100,000 live births in 2019 (Hoyert, 2021). Causes of this disparity are varied. Black women are more likely to be uninsured and face financial barriers to healthcare (National Partnership for Women & Families, 2018; Biennial Health Insurance Survey, 2017). Black women are less likely to access prenatal care (U.S. Department of Health & Human Services, 2011). Additionally, research shows that Black women are more likely to live in areas that are more segregated by race/ethnicity and/or income levels (Thoma et al., 2019). Residents of neighborhoods that are deprived of resources are less likely to have access to environmental benefits, healthy foods, high-quality and affordable hospitals, and other health-promoting resources (Pirtle, 2020). Regardless of educational attainment, high maternal mortality rates among Black women in comparison to white women persist. For example, among all women with college degrees or higher, Black women have a maternal mortality rate over five times higher than that of white women (Racial/Ethnic Disparities in Pregnancy-Related Deaths , 2023). Additionally, Black mothers with a completed college education or higher have a 1.6 time higher mortality rate than white women with less than a high school diploma (Hill et al., 2024). There are differences in maternal mortality rates for Black women of different socioeconomic statuses, with research finding low-income Black women faring worse due to unemployment or underemployment, low and stagnant wages, lack of health insurance, and insufficient funding for government social services (Wynn, 2019). One study found that “almost 7 percent of non-Hispanic Black women in 2018 did not 24 start prenatal care until their third trimester, and an additional 3 percent report no prenatal care at all.” (Declercq, 2020). Compared to white women, “non-Hispanic Black women were more likely to report: being treated unfairly and with disrespect by providers because of their race, not having decision autonomy during labor and delivery, feeling pressured to have a cesarean section, [and/or] not exclusively breastfeeding at one week and six months” (Declercq, 2020). Maternal Health in Prince George’s County, Maryland The United States Census Bureau reported the state of Maryland’s racial and ethnic makeup in 2024 and the majority of Maryland residents are in the white alone racial category (57.2%). Black alone makes up 31.6% of the state population (U.S Census Bureau, 2024). In 2018, the overall maternal mortality rate for Maryland mothers was 53.5 deaths per 100,000 live births (Maryland Department of Health, 2021). Between 2014 and 2018, among non-Hispanic Black women, the maternal mortality rate was four times as high as the rate for non-Hispanic white women in Maryland (Maryland Department of Health, 2021). This gap has grown larger since 2009 to 2013, when the maternal mortality rate for non-Hispanic Black women was twice that of non-Hispanic white women (Maryland Department of Health, 2021). According to the 2021 Primary Care Needs Assessment, there were 42 Medically Underserved Areas throughout the state of Maryland, which encompasses around 17% of the entire state population. There are a total of 15 Medically Underserved Populations (MUP) in the state, and 11 of Maryland’s 24 jurisdictions have the MUP designation (Maryland Department of Health, 2021). Despite being 25 one of the wealthiest Black counties in the nation, Prince George’s County, Maryland has three of these MUP designations. Within the county, there is a high rate of cardiometabolic syndrome and hypertension, both diseases that disproportionately affect Black people, as discussed previously (Bond et al., 2021). Prince George’s County is Maryland’s second most populous county, with 966, 629 residents (U.S Census Bureau, 2024). The majority of county residents are part of the ‘Black alone’ category (62.98%) (U.S Census Bureau, 2024), the highest percentage for this demographic compared to any other Maryland county (U.S Census Bureau, 2024). Much of the county’s demographics depends on its history. In the nineteenth century, the development of a station for the B&O Railroad, now the MARC Camden Line, as well as a Washington, Berwyn, and Laurel streetcar spurred development and population density (Rowlands, 2018). Today, the beltway dividing the county separates densely populated areas within the beltway from more sparsely populated areas outside of it (Rowlands, 2018). Zip codes within the beltways like 20740 have some of the highest percentages of families living in poverty for the county (between 14.6% to 18.2%) (“Maternal Infant and Health Report,” 2019). The county’s infant mortality rate is approximately 8.9 per 1000 live births, higher than both Maryland’s rate (6.3) and the national average rate (5.9) (Lucero, 2018). Notably, the overall mortality rates in Prince George’s County are almost twice as high as the rates of neighboring counties such as Montgomery County (4.6) (“Maternal Infant and Health Report,” 2019). In Prince George’s County, infant mortality rates are the highest among Black infants, with the Maternal and Infant Health Report performed by Prince George’s County Health Department reporting 26 12.0 per 1,000 is the death rate for Black, non-Hispanic infants in 2019 (“Maternal Infant and Health Report,” 2019).. In comparison, the infant mortality rate for Hispanic infants in the county was 5.0 per 1,000 (“Maternal Infant and Health Report,” 2019). Among mothers in Prince George’s County, Black, non-Hispanic mothers had the highest rate of pregnancy-associated mortality with 37.4 deaths per 100,000 births, compared with the county average of 28.6 deaths per 100,000 births (“Maternal Infant and Health Report,” 2019). These findings emphasize maternal and child health disparities, particularly for Black moms and babies in the county. Access to medical care in Prince George’s County remains an issue. It is estimated that eight out of ten expecting mothers leave the county to deliver their babies due to the lack of obstetric services (Alsobrooks, 2023). This statistic is particularly shocking as Prince George’s County is reported to have the second highest birth rate in the state of Maryland. The limited access to maternal healthcare services in the county has resulted in the dependence on neighboring counties and territories further overwhelming the overall healthcare system. In addition to the shortage of maternal healthcare providers in Prince George’s county, there are only two main hospitals that offer birthing services: University of Maryland (UM) Capital Region Medical Center and MedStar Southern Maryland Hospital Center. Notably, the UM Capital Region Medical Center remains the only Level III neonatal intensive care unit (NICU) available in Prince George’s County, a vital resource for high-risk pregnancies and critically ill newborns. The shortage of obstetric services in the county has been linked to the shortage of licensed obstetric beds, lack of financial resources, and low obstetrician-to-patient ratios. These barriers surely magnify the 27 underlying presence of health disparities, particularly for low-income and communities of color who are disproportionately impacted by the limited access to healthcare. Furthermore, the inadequacy of medical care for particularly Black mothers is quite prominent, with research finding only 28.6% of Black mothers experienced adequate care in comparison to the 36.8% of white mothers. 22.2% of Black mothers reported that they experienced inadequate care, while only 12.6% of white mothers reported as such (“Maternal Infant and Health Report,” 2019). This significant difference in statistics raises the question of whether there are biases or racial disparities in maternal healthcare that alters the experiences mothers of different races hold. Contributing Factors to Black Maternal Mortality Comorbidities Pre-existing health conditions significantly contribute to maternal health disparities, particular in Black women. Compared to women with other racial identities, Black women experience the greatest risk of severe maternal health morbidity and comorbidity (Brown et al., 2018). Conditions include hypertension, diabetes, obesity, diabetes, and heart disease, which are more prevalent and underdiagnosed among Black women compared to white women (Britton et al., 2018; Centers for Disease Control and Prevention (CDC), 2021; Thoma et al., 2019). 28 Hypertension correlates with higher risk of preeclampsia, which is more prevalent among African American parents (CDC, 2022; MedlinePlus, 2018). Preeclampsia is defined as hypertension that occurs after the twentieth week of pregnancy, and it may involve organ damage in mothers and can be life-threatening to mothers and infants (MedlinePlus, 2018). Hypertension is also linked with decreased blood flow to the placenta, slowed/decreased growth of the baby, maternal organ damage, and future risk of maternal heart disease (“Maternal Infant and Health Report,” 2019). These adverse effects result in higher risks of gestational diabetes, preterm delivery, and infant death, among other pregnancy complications (CDC, 2022). Another common pre-existing health condition is diabetes, which is a disease that affects how blood sugar is regulated in the body and during pregnancy it can cause complications to both the woman and the developing embryo (“Maternal Infant and Health Report,” 2019). Both type one and two diabetes in mothers increase the risks of birth defects, stillbirth, preterm birth, obesity, and type two diabetes in children (CDC, 2018). Obesity is also a major risk factor that disproportionately affects Black women more than other racial identities. Research shows that 33.7% of Black mothers are more likely to be obese prior to pregnancy, which can result in detrimental outcomes such as gestational diabetes, hypertension, preeclampsia, cesarean delivery, preterm delivery, large size for gestational age, and infant death. (Driscoll & Gregory, 2020). Another main cause of maternal mortality is heart disease, which can be defined as a health condition that has a profound effect on the function of the heart. Some of the leading causes of maternal mortality include cardiomyopathy and cardiovascular conditions such as coronary artery disease, 29 pulmonary hypertension, acquired and congenital valvular heart disease, vascular aneurysm, hypertensive cardiovascular disease (CVD), Marfan syndrome, conduction defects, and vascular malformations (Bond et al., 2021). These heart-related diseases disproportionately affect Black women, which may be attributed to the fact that Black women face more environmental barriers that lead to higher risk factors yet have less access to preventive care services and timely treatment referrals (Jha et al., 2004). Black women in Prince George’s County face a disproportionate amount of maternal comorbidities. This significantly increases their risks of maternal mortality and other negative birthing outcomes. In 2017, approximately 7% of women in the county experienced diabetes during pregnancy. These rates were shown to increase with age affecting over 10% of women ages 35 and older (Prince George’s County Health Department, 2019). Additionally, nearly 30% of all women were obese before pregnancy and like diabetes these rates also increased with age, affecting one-third of mothers ages 35 and older (Prince George’s County Health Department, 2019). Additionally, 5.9% of Black Non-Hispanic mothers experienced preeclampsia while almost 6% of Black Non-Hispanic mothers experienced pregnancy related hypertension, both of which are associated with severe complications during childbirth (Prince George’s County Health Department, 2019). Between 2008 and 2017, half of pregnancy-related deaths in Prince George’s County were linked to circulatory system diseases and other pregnancy-related conditions (Prince George’s County Health Department, 2019). These findings illustrate that many factors, including provider bias and lack of access to preventive care, contribute to disparities in pre-existing health conditions 30 that shape maternal health inequalities. Hypertension, diabetes, obesity, and heart diseases are only a few pre-existing conditions that play a role in the high maternal mortalities that plaque Black women. Examining their effects on maternal and infant health reveals the role of maternal health morbidities in shaping maternal health disparities. Provider Mistrust, Limited Health Literacy, and Barriers to Seeking Health Information In a study done by Christine Abbyad (2011), the majority of Black women interviewed said their mothers or grandmothers are who they referred to for advice during pregnancy. One woman stated, “And the information I got from my mom when I was pregnant, you know, how to breastfeed, you know, changing diapers, taking care of the circumcision. Things like that I got from my mom” (Abbyad, 2011). Why these women entrust their family members with medical advice rather than a maternal care provider likely stems from mistrust of the system. Another woman interviewed recounted an interaction with her doctor – she had asked her doctor if she was having twins due to her husband being a twin. The doctor dismissed her question, but a few days later, the woman ended up giving birth to twins (Abbyad, 2011). Additionally, many of the participants agreed that the physicians would only provide more information about their pregnancy if they thought their patients were highly educated:“If they feel like you’re not intelligent, if you’re not going to ask questions, they’re not going to tell you a whole lot,” said one woman (Abbyad, 2011). These examples directly correlate to two aspects of this project: access to care and health literacy. Black women should not have to rely on families and friends for 31 health information because it is easier to understand than if it were to come from a professional; instead, professionals should be an accessible resource for Black mothers. Health insurance literacy is a key tenet of healthcare accessibility (Vardell, 2019). Health insurance literacy can be described “as ‘the extent to which customers can make informed purchase and use decisions’” (Vardell, 2019). Healthcare is made accessible in large part by health insurance, which reduces out-of-pocket healthcare costs by providing financial assistance to policyholders (Vardell, 2019). Consumer-directed health plans are different from other health insurance plans: they “have the lowest premium cost” and “a much higher deductible and out-of-pocket limit” (University of Washington Human Resources, n.d.). These low-premium cost options are beneficial, as those without health insurance coverage were seven times more likely to “forgo needed healthcare due to cost” as compared to the insured (Chou et al., 2013). However, a low level of health insurance literacy creates barriers for individuals who cannot evaluate the best healthcare plan from different Consumer Directed Health Plans (CDHPs) (Vardell, 2019). This can result in individuals saving less, and, thus, spending more on healthcare costs (Vardell, 2019). Access to healthcare refers to the availability of services at an affordable cost or no cost at all. In this context, healthcare accessibility refers to “why and how women come to the decision to participate in prenatal care or what women value and prioritize in prenatal care” (Edmonds et al., 2015). There is a strong, positive association between race/ethnicity and healthcare services utilization (Chou et al., 2013). In a study researching why women choose to utilize or not utilize prenatal care 32 services, low-income African-American women were divided into focus groups, where they discussed the impact of having or not having prenatal care, barriers to prenatal care, and others (Edmonds et al., 2015). Aside from health insurance literacy, other barriers to prenatal care cited included “parking costs and ride availability” and “ambivalence and lack of motivation due to unintended and undesired pregnancies” (Edmonds et al., 2015). In another study conducted, researching prenatal care utilization among low-income African American women, 27 of the 126 women had planned pregnancies, while the other 99 did not (Mikhail, 2000). However, the difference between the percentage of women who adequately utilized prenatal care services among those with planned pregnancies and those with unplanned pregnancies was not statistically significant, despite women in the other study citing having an unplanned pregnancy as a reason for not utilizing prenatal care (Edmonds et al., 2015; Mikhail, 2000). These findings illustrate that social structures and personal circumstances interact to shape accessibility to maternal health services. However, race/ethnicity is not separate from all of these factors. For example, educational success is very much influenced by race/ethnicity (Walters, 2001). Since the creation of the common schools in the United States, achievement gaps between Black and white students and between poor and rich students continue to exist (Walters, 2001). Studies on these achievement gaps have found that “the characteristics of schools accounted for little variation in students’ achievement” (Walters, 2001). However, race and income status do play a role in this variation, just as educational achievement does in the odds of having an unintended pregnancy (Kim et al., 2016; Walters, 2001). When adjusting for odds, having a bachelor of art or 33 bachelor of science degree accounted for 11.52% of the difference in the likelihood of having an unintended pregnancy for Black versus white women (Kim et al., 2016). Thus, adjusting for odds resulted in the elimination of some of the influence of race/ethnicity on the likelihood of having an unintended pregnancy, as educational attainment is influenced by race/ethnicity (Kim et al., 2016; Walters, 2001). Looking at the unadjusted odds, which are statistically significant in their difference in the likelihood of having an unintended pregnancy between Black and white women, may provide a more accurate representation of the role race/ethnicity plays in the likelihood of having an unintended pregnancy, as all factors of life are susceptible to be influenced by race, not just educational attainment (Kim et al., 2016). Lack of Cultural Competency Training in Maternal Care Provider Training Medical school affects the healthcare system by shaping not only the demographics but also the cultural competency of healthcare providers. The State of Maryland defines cultural competency as the ability to identify how culture, race, and ethnicity affect medical care; understand how patients' and providers’ attitudes, values, and beliefs impact patient-provider relations; and integrate cultural knowledge and skills into medical care (“Implicit Bias Training,” 2021). Cultural competency is essential to providing high-quality medical care and reducing health disparities (Mendizabal et al., 2021; Purnell et al., 2018; Guzman et al., 2021). Despite evidence in support of physicians cultural competency training, a survey of 1,220 providers in the 10 largest departments at Johns Hopkins University School of Medicine – one of the major healthcare providers in the State of Maryland – found that only 49% of the providers had undergone cultural competency training prior to the survey (Purnell et 34 al., 2018). This finding is corroborated by another study of residents at the University of Pennsylvania’s Department of Neurology, which found that only 56% of residents had received training in cultural competency (Mendizabal et al., 2021). This may help explain findings that healthcare providers ranked “lack of knowledge about a culture or minority group” as one of the greatest barriers to providing culturally competent care and “culture-specific knowledge” as the most desired topic in their training (Rule et al., 2018). Moreover, there is currently no standardized cultural competency training program. This means that even among providers with cultural competency training, there is significant variation in the length and depth of training (Mendizabal et al., 2021). Most providers’ training, if it occurred, took place during medical school (Mendizabal et al., 2021). A survey of 257 residents and faculty members at a large teaching pediatric hospital found that 52% of the respondents had a maximum of 5 hours of training in cultural competency at their medical schools, while 21% reported more than 5 hours of training, and 26% reported uncertainty (Rule et al., 2018). Only 22% of these providers indicated that their medical schools had a cultural competency component in their curricula, suggesting that even within medical schools, there may be no standardized cultural competency curriculum (Rule et al., 2018). Similarly, a study of 15 medical schools in the U.S. found that only 2 schools had courses with “cultural competence” in their names, while other schools promoted cultural competency through coursework not explicitly labeled “cultural competence” or through community-based projects (Guzman et al., 2021). Notably, there is a perception among some medical students that cultural competency is not directly tied 35 to medical care. A medical faculty member stated, “When you label it ‘cultural competence,’ [the students] sort of cross their arms and roll their eyes…but if you say now we’re looking at interventional cardiology, oh by the way… if you have this [patient population] here’s what they get, students, in my experience, are much more interested” (Guzman et al., 2021, p. 896). This may deter medical schools and instructors from using the term “cultural competency” in their education; at the same time, it is important to help students recognize the value of cultural competency in clinical care. Understanding the hidden curriculum — which Cucchiara (2021) defined as the “unofficial messages” reinforced and conveyed in the classroom through rules, routines, and interactions — of medical schools is important in understanding the differences in treatment and health outcomes for Black women in the U.S. A study published in The New England Journal of Medicine identified five domains in which medical school educators misrepresented race in the classroom: semantics, prevalence without context, race-based diagnostic bias, pathologizing race, and race-based clinical guidelines (Amutah et al., 2021). Race was frequently used instead of origin to discuss ancestry, and disease development was discussed without providing background, wrongly depicting race as a risk factor for disease rather than social and environmental factors (Amutah et al., 2021). The study examined over 880 lectures from 21 different courses in one institution’s 18-month preclinical medical curriculum (Amutah et al., 2021). Another study, surveying one semester of first and second-year preclinical lectures, found similar results: of the 102 lecture slides mentioning race, 96% suggested race as a biological risk for disease, 39% noted biological differences 36 between races, and 58% implied biological differences (Tsai et al., 2016). The issue here is that, as a whole, the lecture slides suggest that race is genetic when research suggests that race is not genetic, rather race is a social construct that society has formulated and is commonly misused in biomedical settings (Duello et al., 2021). This misuse of terminology opens room for misdiagnosis, misinformation, and confuses the relationship between health and identity (Duello et al., 2021). Further, darker skin tones are underrepresented in medical school textbooks, and the underrepresentation of racial and skin tone groups in curriculum and media was found to contribute to racial inequality (Louie & Wilkes, 2018; Martin et al., 2016). This underrepresentation can result in misdiagnosis in fields like dermatology, which heavily specializes in skin conditions and diseases. When there is a lack of knowledge, representation, and familiarity in regards to darker skin tones, healthcare providers may face difficulties when making a diagnosis because they are only accustomed to the physical symptoms of those who have lighter skin tones. Underrepresentation of groups in the curriculum sends a message about norms regarding who a medical student may encounter as a patient in the future, informing associations between race and risk for disease (Louie & Wilkes, 2018). Previous research has offered solutions to combat the harmful hidden curriculum embedded in medical schools. One study emphasizes the value of not “oversimplifying” the conversation regarding disease and prevalence (Amutah et al., 2021). While human biological variation exists, smaller categories than race and ethnicity should be used to discuss it and diagnose disease (Amutah et al., 2021). The study recommended standardizing language used to describe race and ethnicity, understanding health in 37 the context of social structure, and employing the most up-to-date research regarding race in the medical school curriculum (Amutah et al., 2021). Lack of Representation in Doctors Hiring doctors from similar backgrounds to those of their patients is crucial in improving healthcare outcomes and experiences for black women. In 2018, it was reported that just 5% of practicing physicians in the United States identified as Black or African American (Association of American Medical Colleges [AAMC], 2019). Additionally, just 9.6% of OB/GYNs identified as Black or African American (AAMC, 2019). Shared racial identities between newborns and their physicians have been associated with a significant reduction in Black infants’ mortality rates (Greenwood et al., 2020). Despite the importance of having a diverse healthcare workforce, Black or African American physicians continue to be underrepresented in both the U.S. healthcare system and medical schools. A survey of 56 OB-GYN residency program directors listed the lack of departmental and institutional diversity as the most commonly reported barriers to recruiting underrepresented minorities (URM) to OB-GYN residency programs (Mendiola, Modest, & Huang, 2021). Black physicians are also underrepresented in medical school leadership, with only 8.6% of medical school deans identifying as Black in a sample of 151 deans (Choubey et al., 2022). When deciding where to apply, Black applicants may perceive a lack of institutional diversity as a lack of commitment to inclusion and tolerance. Diversity in hospitals is crucial as residency applicants increasingly rank institutional diversity as a consideration when deciding 38 where to apply. Researchers studying a sample population of 3,756 medical students pursuing residency found that 81% have seen physicians discriminate against African American patients, and 94% have witnessed physicians talk about their African American patients in an inappropriate manner (Nguemeni Tiako et al., 2021). During clinical rotations, URM students have reported feeling unequal treatment in comparison to their white counterparts (Nguemeni Tiako et al., 2021). The normalization of racism in the learning space opens room for URM to feel no sense of belonging and takes a toll on their motivation to continue when the learning environment does not support their needs. 39 Chapter 3: Methodology Research Questions The two primary research questions of our study were: (1) What are the primary barriers Black mothers in Prince George's County face when seeking maternal healthcare? and (2) How does implicit bias and cultural competency training shape patient-provider interactions? These research questions were addressed using quantitative and qualitative data collected from surveys and interviews of Black mothers, medical students, and maternal healthcare providers. Study Design We followed a mixed method study design through conducting surveys and interviews. Our team created a quantitative survey and qualitative interview questions using the Qualtrics platform. Questions included were based on existing measures and demographics from the Department of Health and Human Services (“Health Care Access and Quality,” n.d.), the March of Dimes (“Prenatal Care Checkup,” 2017), the National Institutes of Health Healthcare Access & Utilization survey examples (“Healthcare Access & Utilization,” 2016), and the National Partnership for Women and Families (“Listening to Mothers III,” 2013). Adjustments were made to fit our survey’s purpose and demographic better. The survey questions for mothers were crafted to explore access to healthcare, patient-provider relationships, satisfaction with care, and birth experiences. In contrast, survey questions for providers were constructed to focus on their professional backgrounds, patient interactions, cultural competency and their approaches to maternal healthcare. We designed the interview 40 questions to deepen our understanding of the survey responses and explore key themes in both groups' experiences with maternal care. The survey and interview questions (See Appendix D) were developed in Fall 2023, with input from relevant experts in the field to ensure cultural relevance and clarity (See Appendix G ). After submitting our proposal to the Institutional Review Board (IRB) (See Appendix H), we received approval in January of 2024. The surveys opened on February 14, 2024 and closed on January 27, 2025. Our interviews were conducted from September 2024 to January 2025. Sample and Recruitment Sample Criteria The eligibility criteria for both the interviews and surveys of Black mothers were: (1) being between the ages of 18 and 34, (2) identify as a Black cisgendered woman, (3) be a resident within an eligible zip code of Prince George’s County, Maryland, (4) be currently pregnant or postpartum, and (5) be proficient (both reading and speaking) in the English language. The final survey and interview eligibility criteria for healthcare providers were: (1) being at least 18 years of age, (2) either a medical student or a healthcare provider currently practicing care for mothers during the prenatal, perinatal, or postpartum periods, and (3) currently studying or practicing in Washington, D.C, Maryland, or Virginia. Specific healthcare professionals eligible to participate in the study included physicians (preferably OB/GYNS), physician assistants/associates (PA), nurse practitioners (NP), certified nurse midwives, or doulas. 41 Recruitment To recruit participants for our study, our surveys were advertised in flyers (see Appendix C) in local libraries, churches, community centers, and medical schools (see Appendix B). We developed a database of over 300 organizations that serve community members in Prince George’s County and surrounding areas, including churches, hospitals, doctors, daycares, libraries, grocery stores, student organizations, and community centers. We also purchased Meta advertisements (Facebook and Instagram) to target a broad audience (See Appendix F), using demographic filtering to reach individuals who met the study's criteria. Additionally, we attended local events around Prince George’s County such as community baby showers, numerous local library events, WIC farmers markets, and lactation support groups (See Appendix E). At each in-person event that we tabled in the community, we provided one or more of the following as incentives and promotional items for our study: stickers, Gemstone Honors Program merchandise, candy, posters and pamphlets describing our research, and flyers with QR codes to recruit community members. We also included a list of relevant resources for mothers and other community members to access and use as needed. At each in-person community event, we interacted with approximately 20 community members, though some events resulted in a larger turnout than others. In addition to tabling events, we also built strong relationships with community partners such as local food banks, WIC offices, and the College Park Aviation Museum. These organizations also partnered with us to help recruit participants, either by sharing our flyers or mentioning our study to potential eligible 42 participants. We also joined the Prince George’s County Health Action Coalition and attended meetings between December 2023 to March 2025 to connect with various community members about our study and our recruitment aspirations. Study Procedure Upon completion of the survey, participants were offered the choice to be entered into a raffle to win money and/or the opportunity to participate in a follow-up qualitative interview to share more about their experiences. For both the mother and provider surveys, participants were asked at the end to select either “I am interested…” or “I am not interested in the raffle, interview, and/or study results…”. If they selected that they were interested, they were redirected to a separate survey to share their email address. To avoid confusion and protect the privacy of the participant’s information, we made sure to mention in the survey that their email address would be collected and stored separately from their survey responses. Additionally, we emphasized that a follow-up was optional and that the participant could opt-out of the follow-up by choosing to not share their email. Survey compensation for mothers and providers were initially determined to be that survey participants interested in the raffle would have the chance to win $25 and we established that there would be a total of 20 winners. On October 10, 2024, we submitted an amendment application to the IRB proposing to compensate all mother participants who completed our survey with a $25 Tango digital gift card. The decision was made to help address lack of survey participation and encourage a higher response rate. By expanding the compensation, we aimed to increase 43 engagement, so we can ensure that the survey accurately reflects our target population. The compensation description for the medical provider survey remained a raffle of 20 randomly selected winners to earn $25 in Tango digital gift cards. Measures Demographic Variables – Mothers Age. Participants self-reported their age in years. ZIP Code. Participants self-reported their five-digit zip code. Income. Participants selected the response that best described their income from the following options: Under $24,999, $25,000 - $49,999, $50,000 - $74,999, $75,000 - $99,999, $100,000 - $124, 999, $125,000 - $149,999, $150,000 - $199,999, $200,000+, Prefer not to say. Household Composition. Participants identified the response that best describes the makeup of their household from the following options: Single parent, Couple in the first pregnancy, Couple in the second/third/subsequent pregnancy, Extended family, Prefer not to say, Other. Gender Identity. Participants self-identified their gender identity by selecting cisgender male, cisgender female, non-binary, transgender male, transgender female, prefer not to say, or other. Sexual Orientation. Participants reported their LGBTQ+ identity, selecting from the following options: Yes, No, Prefer not to say. Education. Participants self-identified their highest level of education by selecting from the following options: No high school diploma/GED, High school 44 diploma/GED, Some college/trade school/Associate Degree, Bachelor’s Degree, Master’s Degree, Doctoral Degree, Prefer not to say. Immigration Status. Participants reported their immigration status by selecting U.S. Citizen, permanent resident, undocumented status, prefer not to say, or other. Insurance. Participants identified their current insurance coverage by selecting one (or more) of the following options: Not covered/Insured, Medicaid, Other private coverage (e.g., through the Maryland Health Connection exchange), Coverage through an employer (e.g., my employer, my spouse’s employer, my parents’ employer), Covered by spouse’s plan, Medicare, Prefer not to say. Pregnancy History. Participants reported if they were in their first pregnancy by selecting yes, no, or prefer not to say. Pregnancy/Postpartum Status. Participants reported their pregnancy outcome or postpartum status by selecting the response that applied to them at the time of survey submission. The response options included: My pregnancy did not result in a live birth, First trimester (0-13 weeks), Second trimester (14-27 weeks), Postpartum (less than 3 months after my baby was born), Postpartum (more than 3 months after my baby was born), Prefer not to say. Dependent Variables – Mothers Maternal Health Care Satisfaction Maternal health care satisfaction was assessed using a 0-100 scale where participants rated their comprehensive maternal health care experience, with higher scores indicating greater satisfaction. Sample questions included: “How would you 45 rate your overall prenatal care experience?” and “How satisfied are you with the number of prenatal visits that you have had?” Patient Provider Similarities Patient-provider similarities were evaluated based on common racial/ethnic identification, gender identity, and religious or spiritual affiliation. In addition to reporting how these commonalities affect their healthcare experiences (Positively, Negatively, No Impact, or Other), participants indicated if they shared these traits with their primary maternal health provider. Perceived Quality of Care The perceived quality of care was evaluated using Likert-scale items (Strongly Agree, Agree, Neutral, Disagree, or Strongly Disagree) that reflect clinician attention, communication efficiency, cultural sensitivity, and the degree to which providers address patient concerns. A set of questions modified from Purnell et al. (2018) focused on certain provider behaviors during maternal healthcare sessions in order to further evaluate provider interactions. Participants indicated if their practitioner routinely (80-100%) takes steps like gathering personal information and background, appropriately addresses them, involves them in treatment planning, and takes cultural considerations into account while having conversations. Statements evaluating participants' access to healthcare resources and services were used to gauge perceived barriers to care. Participants rated their level of agreement with statements, such as "There are personal barriers preventing me from obtaining healthcare services and/or information" and "My maternal health care provider(s) offers me access to useful 46 resources when I need it", using the 5-level Likert scale (Strongly Disagree to Strongly Agree). Attitudes Towards Maternal Health Clinic/Provider Attitudes toward maternal health clinics and providers were assessed to evaluate patient perceptions of trust, comfort, and emotional responses to care. Participants indicated their level of agreement using a 5-point Likert scale (Strongly Disagree to Strongly Agree). Feelings of emotional safety in clinical settings were evaluated through statements such as “I feel comfortable interacting with my maternal healthcare provider(s),” and “I trust my maternal healthcare provider(s).” To assess anxiety associated with maternal healthcare experiences, participants responded to the statement “I feel stressed and anxious when I visit my maternal healthcare provider(s).” Perceived Discrimination or Bias in Care Perceived discrimination or bias in maternal healthcare was assessed to understand the extent to which patients feel they are treated differently due to aspects of their identity, such as race, gender, socioeconomic status, or other personal characteristics. For example, participants used a 5-point Likert scale (strongly disagree-strongly agree) to score their level of agreement with the statement “I feel that I am treated differently due to an aspect of my identity by my maternal healthcare provider(s).” To further assess the impact of perceived bias on patient-provider interactions, participants responded to the question “How often, if ever, do/did you feel that you were treated differently due to any aspect of your identity by your 47 maternal healthcare provider(s)?” with response options ranging from “Never” to “Always”. Health Beliefs The Health Beliefs section was designed to assess participants’ attitudes toward maternal health services and their perceived importance and perceived outcomes for both the parent and child. Participants used a 5-point Likert scale (strongly disagree-strongly agree) to score their level of agreement with the statements “Going to a maternal healthcare provider when one is pregnant is beneficial for the mother,” and “Going to a maternal healthcare provider when one is pregnant is beneficial for the fetus,” using a 5-point Likert scale (Strongly Disagree to Strongly Agree). These items measured the level in which individuals perceived maternal healthcare as essential to a healthy pregnancy. Additionally, to examine beliefs about the role of cultural and familial values in maternal health decisions, participants responded to statements such as “Family and cultural values should be accounted for in health decisions,” and “Maternal healthcare providers should have a strong grasp of a variety of sensitive cultural issues.” Demographic Variables – Providers Provider Profession. Participants reported their role/profession in the maternal healthcare setting from, selecting from the following options: Obstetrician/Gynecologist (OB/GYN), Family Medicine Physician, Nurse Practitioner, Certified Nurse Midwife (CNM), Doula, and Other (Please specify). 48 Dependent Variables – Providers Patient-Provider Communication Patient-provider communication was assessed by measuring the frequency and quality of interactions between healthcare providers and their patients. Participants were asked about the average duration of patient interactions, their time spent checking patients’ understanding of health information, and their confidence in working with culturally diverse patients. For example, participants were asked "How long does a typical patient or client interaction last for you?" Responses were recorded using categorical time intervals (e.g., "10-15 minutes," "More than 30 minutes") or a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher scores indicating more thorough communication and confidence in diverse settings. Cultural Competency and Implicit Bias Awareness Cultural competency and implicit bias awareness were measured by assessing healthcare providers’ perceived knowledge and confidence in addressing cultural issues in patient care. Participants responded to statements such as "I have a strong grasp on a wide array of sensitive cultural issues" and "I have cultural biases that may affect the way I interact with patients or clients.” Additionally, some questions assessed participant’s previous participation in cultural competency training including the duration and recency of such training. Responses were recorded on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher scores indicating greater cultural awareness and self-perceived competency. Implicit biases 49 were further examined using true/false questions designed to assess awareness of racial misconceptions in healthcare. Participants were asked to indicate whether they believed statements such as "Black people age more slowly than white people," "Black people’s nerve endings are less sensitive than white people’s," and ““Black people’s blood coagulates more quickly than white people's." were True or False. The correct answer for all three statements is False. Patient-Provider Similarities Provider demographic factors and perceptions of patient similarity were assessed through questions about the provider’s racial, gender, and religious identity compared to the patients they typically serve. Providers were asked "Do you share the same racial identity as most of the patients or clients you see or work with?" and "How do you think your response to the question above affects your patients' or clients' interactions with you?" Response options included "Yes," "No," "Not sure," and "Prefer not to answer," with follow-up questions evaluating whether perceived similarity or difference impacts provider-patient relationships. 50 Chapter 4: Results The aim of this study was to investigate the maternal care experiences of Black mothers in Prince George’s County. We examined this from the experiences of both Black mothers in Prince George’s County and maternal care providers in the Washington D.C., Virginia, and Maryland (DMV) area. We conducted a mixed-methods study where respondents filled out a survey and then had the option to opt in for an interview to examine their experiences further. The survey for mothers aimed to explore their experiences receiving care from their providers and how they felt in healthcare settings. The survey for providers aimed to investigate how they perceived their patient visits went and their experiences with cultural competency training. The interviews were aimed to further explore these experiences. Description of the Sample A total of 253 survey responses were collected from both mothers (n=133) and providers (n=120), but 176 survey responses met the inclusion criteria. Of the 133 mothers surveyed, 69 mothers met the inclusion criteria since they had a Prince George’s County zip code and were under the age of 35. The Qualtrics survey form accepted any five digit zip code and did not discriminate between Prince George’s County zip codes and other zip codes which resulted in the difference between respondents and eligible respondents. Many respondents provided zip codes from outside of Prince George’s County and were thus ineligible. Out of the 120 providers who completed the survey, 107 met the inclusion criteria. In total, we conducted five interviews with providers. Unfortunately, despite several attempts, there were no follow up interviews conducted with mothers. 51 Table 1 Demographics of Surveyed Mothers Demographics of Mothers (N= 69) Variable Characteristics Frequency (n) Percentage Age 20-22 9 13% 23-25 14 20.3% 26-28 17 24.6% 29-31 16 23.2% 32-34 13 18.8% Income Under $24,999 2 2.9% $25,000-$49,999 15 21.7% $50,000-$74,999 18 26.1% $75,000-$99,999 21 30.4% $100,000-$124,999 11 15.9% $125,000-$149,999 0 0% $150,000-$199,999 1 1.4% Over $200,000 1 1.4% Household Makeup Couple in First Pregnancy 29 42% Couple in Subsequent Pregnancy 28 40.6% Extended Family 9 13% Single Parent 3 4.3% Highest Level of Education No High School Diploma/GED 0 0% High School Diploma/GED 6 8.7% Some College/Trade School/Associate Degree 29 42% 52 Demographics of Mothers (N= 69) Bachelor’s Degree 30 43.5% Master’s Degree 4 5.8% Doctoral Degree 0 0% Type of Insurance Coverage Coverage through an Employer 22 31.9% Medicare 20 29% Medicaid 17 24.6% Other Private Coverage 6 8.7% Covered by Spouse’s Plan 4 5.8% Not Covered/Uninsured 0 0% First Pregnancy Yes 31 44.9% No 38 55.1% Pregnancy Status First Trimester (0-13 weeks) 2 2.9% Second Trimester (14-27 weeks) 18 26.1% Third Trimester (28 weeks and later) 12 17.4% Postpartum 36 52.2% My pregnancy did not result in a live birth 0 0% Prefer Not to Say 1 1.4% Note. Age was measured as a continuous variable that respondents typed in. Income was measured by ranges of $25,000 increments. 53 The range of income for mothers surveyed spanned from under $24,999 to over $200,000. The largest proportions of surveyed mothers were between the ages of 26-28 (24.6%) or 29-31 (23.2%). The majority of mothers had an income level between $75,000 and $99,999 (30.4%). Over 70% of mother’s income ranged between $25,000 and $99,000. At the time of survey completion, 44.9% of respondents were in their first pregnancy and 52.2% were postpartum. The majority of mothers had a highest education level of a Bachelor’s degree (43.5%). Table 2 Demographics of Surveyed Providers Demographics of Providers (N= 107) Variable Characteristics Frequency (n) Percentage Profession Obstetrician/Gynecologist (OB/GYN) 50 46.7% Family Medicine Physician 4 3.7% Nurse Practitioner 8 7.5% Certified Nurse Midwife 10 9.3% Doula 21 19.6% Medical Student 11 10.3% Registered Nurse 1 0.9% Perinatal Mental Health Clinician 1 0.9% Certified Professional Midwife 1 0.9% 54 The only demographic information collected for providers surveyed was profession within maternal care. The surveyed provider population was largely OB/GYNs (46.7%), followed by doulas (19.6%) and medical students (10.3%). 16 respondents selected the “Other” option, including 11 medical students, a registered nurse, a perinatal mental health clinician, and a certified professional midwife. Two doulas also selected the “Other” category– one was also a lactation consultant, while the other was a lactation educator, placenta practitioner, and a certified professional midwife student. Additionally, only two medical students specified their year in medical school: one was an MS1 and the other was an MS4 applying to be an OB/GYN. Descriptive Statistics for Mothers Mothers responded to questions about their income, education, and the race of their provider. Respondents were asked to type in their age and zip code, all other questions were multiple choice- some questions allowed respondents to select all that applied while others restricted respondents to only one answer. 55 Figure 1 Distribution of Mother Income The distribution of respondents' income followed a roughly normal distribution with a minor skew towards lower income. Most respondents had an income between $75,000 and $99,999, followed by between $50,000 to $74,999. Three respondents reported an income under $24,999 and one reported an income over $200,000. 56 Figure 2 Distribution of Mother Education 57 The education brackets on the survey ranged from “Did not finish high school/No GED” to “Doctoral Degree”. Similar to the income distribution graph, the education distribution followed a roughly normal distribution. There were no mothers on either extreme of education– the majority had a Bachelor’s degree, followed by some college/trade school/Associate’s degree. The respondents with the lowest amount of education had a high school diploma or GED while the respondents with the highest amount of education had a Master’s degree. Figure 3 Frequency of Mothers Who Share a Racial Identity with Provider 58 Note. Mothers were asked the following survey question: “Do you share the same racial identity as your main/current maternal health care provider?” This survey question was asked with the intent of learning how sharing or not sharing the same race as your provider influences patient-provider actions. Of the 69 respondents, the majority shared the same racial identity as their provider (41 mothers). 18 mothers did not share the same race as their provider, six mothers had no response, and four selected “Not sure.” 59 Figure 4 Impact of Shared Race on Patient-Provider Interactions Note. Mothers were asked the following survey question: “How does your response to the question above affect your interactions with your provider?” “The question above” referred to the question in Figure 4. 60 Of the respondents who do not share the same racial identity as their provider, 38.9% said this positively impacted their interactions, 38.9% said it had no impact on their interactions, and 22.2% said this negatively impacted their interactions with their provider. Of the respondents who did share the same racial identity as their provider, 52.2% said this positively impacted their interactions, 4.9% said it had no impact, and 43.9% said it negatively impacted their interactions with their provider. Of the four people who were unsure of their provider’s race, half reported this positively impacted their interactions and the other half reported no impact. Mothers who shared the same race as their provider were most likely to indicate this similarity positively impacted their interactions. These mothers were also most likely to indicate their provider’s racial identity negatively impacted their interactions. They were least likely to say their provider’s race had no impact on their interactions. In contrast, respondents who did not share the same race as their provider were the least likely to report a positive impact on their interactions. Disparities by Zip Code In order to qualify for the study, the respondents had to reside in a valid Prince George’s County zip code, as listed in Appendix A. The 2020 5-year American Community Survey data (U.S. Census Bureau, 2020) and the Prince George’s County Maternal Infant and Health Report (“Maternal Infant and Health Report,” 2019) were used to see if results on the state of maternal care for Black moms in the county aligned with existing data, as well as to identify areas in the county where maternal care may be below the standard. 61 Figure 5 Number of Mother Respondents by Zip Code In each zip code of Prince George’s County, the number of responses from mothers ranged between zero to six. We aimed to get responses from any of the 41 zip codes in Prince George’s county. We received respondents from 27 unique zip codes listed in Appendix A, and covered 65.6% of zip codes. The zip codes where most mothers responded were: 20708 (Laurel, MD) with 6 respondents, 20706 (Lanham, MD) and 20607 (Accokeek, MD) with 5 respondents each respectively. In general, survey respondents were from all over the county. 62 Figure 6 Number of Black Women Between 15-50 Years of Age Who Gave Birth in the Past Year Note. Adapted from the U.S. Census Bureau (2020, 5-Year American Communities Survey). We can compare this to 2020 U.S. Census data which has the number of Black women in Prince George’s between the ages of 15-50 who gave birth in the last 12 months by census tract (U.S. Census Bureau, 2020). Census tract and zip code are not the same but the U.S. Census does not have data by zip code, furthermore our data only includes mothers between the ages of 18-34 and the data is from 2020 while our data collection primarily took place in 2024, so there is a difference in populations. In general, we have an overrepresentation of mothers in areas where there was a low number of births in 2020, the southern part of the county which saw low birth 63 numbers in 2020 is where a lot of our respondents came from, the same is true for the northern part of the county. Meanwhile, the central part of the county had the highest number of births in the county in the 2020 Census data but is where minimal numbers of our respondents came from. Income Disparities Along with the number of births we measured income disparities across the county and within surveyed participants. 64 Figure 7 Median Mother Income by Zip Code Note. To find the income of our respondents by zip code, we took the median income from each zip code. We measured income as an ordinal variable where respondents were allowed to select a bracket within which their income falls instead of as a numerical variable, to account for cases with an even number of respondents in a zip code, we found the lower median. 65 Figure 8 Median Mother Income by Zip Code In general, survey respondents had a median income that aligned with the 2020 5-year American Community Survey median income by Census tract in Prince George’s County (U.S. Census Bureau, 2020). The southern part of the county was the richest in both the Census data and our data. Additionally, parts of the county that border the District of Columbia were the poorest in both the Census data and our data (U.S. Census Bureau, 2020). The outer edge of the county, bordering other parts of Maryland, were in the middle of the income distribution, aligned with the Census data and our data (U.S. Census Bureau, 2020). 66 Relationship between Housing Location and Choice of Provider We examined the relationship between the location of where respondents were located and whether that changed how many of them sought care from an OB/GYN. There are only two birthing hospitals in Prince George’s County, one in Clinton, MD which is in the southern part of the county and one in Largo, MD which is in the central part of the county (A Landmark Victory for Obstetric Healthcare Access in Prince George’s County, 2023). Figure 9 Percentage of Mothers Surveyed Who See an OB/GYN by Zip Code 67 For each zip code, we calculated the percentage of respondents in that zip code that saw an OB/GYN. Nearly every zip code had somewhere between 80-100% of respondents who saw an OB/GYN as their provider during their pregnancy. There were minimal zip codes with fewer respondents who did not see an OB/GYN, primarily concentrated in the northern part of the county, though they generally spread throughout the county. However, not seeing an OB/GYN during pregnancy does not necessarily mean the respondent did not receive any care– they might have received care from a doula, midwife, physician’s assistant/associate, or another healthcare professional. 68 Maternal Care Experiences Figure 10 Distribution of Mothers Surveyed Who Received Prenatal Care Note. Mothers were asked the following survey question: “Have you received prenatal care services for your current or most recent pregnancy (e.g., doctors’ visits to check on the baby or you)?” The vast majority of mothers sought prenatal care during their pregnancy. Only five respondents did not receive prenatal care during pregnancy while 64 did receive prenatal care during their pregnancy. All respondents who did not receive prenatal care were in their first pregnancy. 69 Figure 11 Distribution of Mothers Surveyed Who Received Prenatal Care by Income To assess income related barriers impacting mothers who did not receive prenatal care, we sorted the responses indicating if mothers received prenatal care by income. We found that out of the five respondents who did not receive prenatal care, three respondents had an income between $25,000 and $49,000 and two respondents had an income between $75,000 and $99,000. In contrast, all 13 respondents with an income over $100,000 indicated that they received prenatal care. Similarly, the two respondents with an income under $24,999 also received prenatal care. This may indicate an economic barrier to receiving prenatal care. 70 Figure 12 Distribution of Mothers Surveyed Who Received Prenatal Care by Education We then evaluated the barriers impacting mothers who did not receive prenatal care by education level. Out of the five respondents who did not receive prenatal care, four respondents had a Bachelor’s degree and one respondent had a high school diploma or GED. All four respondents with a Master’s degree and all 29 respondents with some college, trade school, or Associate’s degree reported receiving prenatal care. Interestingly, the majority of respondents who did not receive prenatal care were those who earned a Bachelor’s degree. 71 Figure 13 Extent to Which Mothers Agree/Disagree with having Personal Barriers Preventing them from Obtaining Healthcare Services/Information Note. Mothers were asked to express the extent to which they agree/disagree with the following statement: “There are personal barriers preventing me from obtaining healthcare services and/or information.” We then analyzed barriers preventing mothers from obtaining healthcare services. We acquired data for respondents with a high school diploma or GED, some college or trade school or Associate degree, Bachelor’s degree, and Master’s degree. 72 We had no respondents with education lower than a high school diploma or GED and higher than a Master’s degree. A total of 64 respondents answered the question, and five non-responses. 23 respondents (35.9%) were neutral, showing that most respondents did not strongly feel impacted by barriers to accessing care. Additionally, 14 respondents agreed and six respondents strongly agreed that there were barriers preventing them from obtaining healthcare services, reflecting 31.3% of the total responses. In contrast, 16 respondents disagreed and five respondents strongly disagreed, indicating 32.8% of respondents not experiencing barriers that prevent them from obtaining healthcare services. This reflects a diverse distribution of responses, with respondents being evenly divided among those who experienced barriers to obtaining care, those who did not, and those who felt indifferent about the presence of barriers. 73 Figure 14 Extent to Which Mothers Agree/Disagree with having Personal Barriers Preventing them from Obtaining Healthcare Services/Information by Income To further our analysis, we sorted responses by income levels to examine potential barriers preventing mothers from obtaining healthcare services. Out of the two respondents earning under $24,999, both respondents indicated feeling neutral to facing barriers to healthcare services. Among the 12 respondents earning between $25,000 to $49,999 who answered this question, three disagreed, four were neutral, 74 three agreed, and two strongly agreed. Out of the 18 respondents earning between $50,000 to $74,999, two strongly disagreed, three disagreed, four were neutral, six agreed, and two strongly agreed. Among the 17 respondents earning between $75,000 to $99,999 that replied to this question, two strongly disagreed, six disagreed, seven were neutral, three agreed, and one strongly agreed. Out of the 11 respondents earning between $100,000 to $124,999, four disagreed, five were neutral, and two agreed. The one respondent earning between $150,000 to $199,999 strongly disagreed and the one respondent earning $200,000+ was neutral. This analysis shows variability in perceptions of barriers preventing respondents from obtaining healthcare services. We can see that respondents falling into the middle income brackets, specifically respondents in the $25,000 to $49,999 bracket and $50,000 to $74,999 bracket, reflected the highest levels of agreeing to barriers preventing them from obtaining health care services. When looking at the respondents earning between $25,000 to $49,999, 41.7% of respondents agreed or strongly agreed to facing barriers while only 25% of respondents disagreed or strongly disagreed to facing barriers. Similarly, in the $50,000 to $74,999 bracket, 44.4% respondents agreed or strongly agreed to facing barriers while only 27.8% of respondents disagreed or strongly disagreed to facing barriers. In contrast, only 23.5% of respondents in the $75,000 to $99,999 bracket and 18.1% of the $100,000 to $124,999 bracket agreed or strongly agreed to facing barriers. Additionally, no one earning under $24,999, between $150,000 to $199,999, and $200,000+ agreed or strongly agreed to facing barriers. Ultimately, the barrier appears to lie within the middle income range–specifically the $25,000 to $49,999 and $50,000 to $74,999 75 brackets– as these groups show the highest levels of agreement regarding personal barriers that prevent their access to healthcare services and/or information. Figure 15 Extent to Which Mothers Agree/Disagree with having Personal Barriers Preventing them from Obtaining Healthcare Services/Information by Education We then sorted responses by education level to similarly examine barriers preventing mothers from obtaining healthcare services, as done prior. Again, we acquired data for respondents with a high school diploma or GED, some college or trade school or Associate degree, Bachelor’s degree, and Master’s degree. We had no respondents with education lower than a high school diploma or GED and higher than 76 a Master’s degree. Out of the five respondents with a high school diploma or GED who answered this question, two disagreed, one was neutral, and two agreed to experiencing barriers to access healthcare services. Among the 29 respondents with some college or trade school or Associate degree, two strongly disagreed, four disagreed, 10 were neutral, seven agreed, six strongly agreed. Out of the 26 respondents with a Bachelor’s degree that answered this question, two strongly disagreed, nine disagreed, 11 were neutral, and four agreed. Among the four respondents with a Master’s degree one strongly disagreed, one disagreed, one was neutral, and one agreed. These results show slight variability amongst all education levels. There is an evident concentration of agreement to facing barriers for respondents with lower levels of education. We can very clearly see this in respondents with some college or trade school or Associate degree where 44.8% of respondents agreed or strongly agreed to experiencing barriers while only 20.6% of respondents disagreed or strongly disagreed to facing barriers. Interestingly, respondents with a high school diploma or GED the distribution was even, where 40% of respondents agreed or strongly agreed to experiencing barriers and 40% of respondents disagreed or strongly disagreed to facing barriers. For those who earned a Bachelor’s degree only 15.4% of respondents agreed or strongly agreed to experiencing barriers while a larger 42.3% disagreed or strongly disagreed. For those who pursued more education to earn a Master’s degree only 25% agreed or strongly agreed to experiencing barriers while a larger 50% disagreed or strongly disagreed. Ultimately this analysis shows that barriers to obtaining healthcare services are most prevalent within respondents 77 with lower education–specifically the high school diploma or GED and some college or trade school or Associate degree education levels. These groups reported the highest levels of agreement when experiencing personal barriers that prevent them from accessing healthcare services and/or information. 78 Mothers’ Health Beliefs Figure 16 Mothers’ Beliefs of when Prenatal Care Should be Initiated after Pregnancy Note. Mothers were asked the following question: “When do you believe someone should schedule their first prenatal visit after learning about their pregnancy?” Options mothers could select from included: “I don't believe visiting a medical provider during pregnancy is helpful”, “Within the first month,” “Within the first three months,” “Within the first six months.”, “Only during delivery”, and “Not Sure”. 79 Next, we looked into mother’s beliefs initiating prenatal care. The overwhelming majority who received prenatal care during their pregnancy is also reflected in the respondents’ answer to the question on when they believe prenatal care should begin. 67 respondents answered this question, so there were two nonresponses. Not a single respondent selected that prenatal care should begin during delivery nor that visiting a medical provider during pregnancy is not helpful. This means even respondents who did not receive prenatal care during their pregnancy do think it is helpful and important to receive prenatal care. 47.8% of respondents believe that prenatal care should be initiated within the first month of pregnancy, while 23.3% of respondents believe prenatal care should be initiated within the first trimester, and 15.9% of respondents think it should be initiated within the first six months of pregnancy. Generally, the respondents of our survey are inclined to seek prenatal care fairly early on in pregnancy. 80 Figure 17 Mothers’ Beliefs of when Prenatal Care Should be Initiated after Learning of Pregnancy Aggregated by First Pregnancy or Not We looked to see a difference in the beliefs of when prenatal care should be initiated between respondents in their first pregnancy compared to respondents in subsequent pregnancies. There were two nonresponses to the question about when prenatal care should be initiated and both respondents were in their first pregnancy. In general, mothers in their first pregnancy and subsequent pregnancies believe that prenatal care should be initiated within the first month of pregnancy. 51.6% of respondents in their first pregnancy and 44.7% of respondents in subsequent pregnancies believe that prenatal care 81 should be initiated in the first month of pregnancy. Respondents in their first pregnancy differed from respondents in subsequent pregnancies on whether prenatal care should be initiated within three months or six months. 42.6% of mothers in subsequent pregnancies believe prenatal care should be initiated within the first three months compared to 22.6% of mothers in their first pregnancy. Mothers in their first pregnancy are more likely to believe that prenatal care should be initiated within the first six months than mothers in subsequent pregnancies. 19.4% of mothers in their first pregnancy believe prenatal care should be initiated within the first six months compared to 13.2% of mothers in subsequent pregnancies. However, all respondents who believe prenatal care should be initiated within six months are in the minority and respondents who believe that prenatal care should be initiated within the first month are in the majority. 82 Figure 18 Mothers’ Overall Prenatal Care Experience Rating In order to explore our respondent’s prenatal care experiences further, we asked them to rate their overall prenatal care experience on a scale of 0-100 with zero being considered unsatisfactory and 100 being considered outstanding. There were five nonresponses to this question. The rating that received the most responses was 100, with seven respondents saying their prenatal care was outstanding and rating their experience as 100. However, the median and mean rating were 55.5 and 56.6 respectively. In general, the respondents had a normal distribution of prenatal care experience rating with a mean and median around 50, but there is a skew towards a higher rating. The standard deviation of the ratings was 28.1. 83 Figure 19 Frequency of Provider Attention to Mothers and Their Concerns We asked the respondents a series of questions about their prenatal care experiences and relationship with their provider to gain a better understanding of patient-provider interactions. Responses were measured on a five-point likert scale. We asked respondents how often they felt their provider was attentive to them and their concerns, 36.2% of respondents said rarely which 84 was the majority answer. However, the next response that was answered most frequently with 20.3% of respondents was frequently, followed by 17.4% of respondents who said sometimes. In general, respondents tended to avoid extreme answers like always or never which combined together only saw about 19% of respondents. Figure 20 Mother Perceptions of Trust, Comfort, Safety, and Respect with Provider Participants were then asked a series of questions about their feelings on their maternal care provider and respondents were then asked to answer on a five-point likert scale. Participants were first asked their agreement to the statement “I trust my maternal care provider(s)”. Over 50% of respondents 85 either agreed or strongly agreed with this statement and less than 25% disagreed with the statement, furthermore this is the only question where none of the respondents strongly disagreed with the statement. A shift in responses takes place when the statement is changed to “I feel safe and respected in the healthcare setting”. There are three respondents who strongly disagree with the statement and people who disagree or strongly disagree make up about 30% of the respondents, and respondents who agree or strongly agree makeup about 45% of responses. Only 11.6% of respondents strongly agree that they feel safe and respected in healthcare. Less than half of respondents feel safe and respected in the healthcare setting. The last statement participants were asked was “I feel comfortable interacting with my maternal care provider(s)”. 50.7% of respondents strongly agree or agree with the statement about feeling comfortable interacting with their maternal care provider and little over 25% disagreed or strongly disagreed with the statement. In general, respondents reported feeling generally positive about their provider specifically but less so about healthcare as a whole. 86 Table 3 Mothers’ Most Trusted Sources for Health Information Most Trusted Sources for Health Information for Mothers (N= 69) Variable Characteristics Frequency (n) Percentage Trusted Source Family Member 49 13.1% Obstetrician/Gynecologist (OB/GYN) 45 12.0% Primary Care Provider 36 9.6% Religious Leader 23 6.1% Friend 21 5.6% Physician Associate 20 5.3% Registered Nurse 20 5.3% Hospital Website 20 5.3% Certified Professional Midwife 20 5.3% Doula 20 5.3% Clinic Website 20 5.3% WebMD 17 4.5% MayoClinic 17 4.5% Local Health Department 17 4.5% Centers for Disease Control and Prevention (CDC) 17 4.5% Other Physician 12 3.2% Research Journal 1 0.3% 87 Note. Mothers were asked the following survey question: “When you have health-related questions, who do you feel comfortable getting the answer from? Select all that apply.” The majority of respondents selected a family member as their trusted source for health information followed by OB/GYN and primary care provider. Many respondents cited religious leaders, physician’s associates, nurses, MayoClinic, WebMD, hospital websites, and the CDC’s website. One mother wrote in “Research Journal.” 88 Descriptive Statistics for Providers Cultural Competency Training Figure 21 Proportion of Providers with Cultural Competency Training Of the providers surveyed, the majority completed cultural competency training: 81 providers or 81.8% completed this training, while 18 providers or 18.2% of the sample had not. Eight providers did not respond to this survey question. Of the providers who completed cultural competency training, 89 OB/GYNs were most likely to have this training, followed by providers in the other category who were mostly medical students (11 respondents), two doulas, a registered nurse, a perinatal mental health clinician, and a certified professional midwife. Doulas and certified nurse midwives were least likely to have completed a cultural competency training, though the majority of these providers did complete this training. Figure 22 Providers with Cultural Competency Training By Provider Type The majority of cultural competency trainings were short in length: 22 90 providers reported a two to five day training, 17 reported a one to five hour training, and eight reported a one day training. No provider reported their training was in the format of a semester-long course. The “Longer” answer option refers to a training longer than a semester-long course and six providers selected this. Four provider