Why Understanding Black Women’s Beliefs About Motherhood Can Help Improve Reproductive Health Care

Chanel, now a middle-class mother of one, is just one of many women who have used abortion to end a pregnancy. “In college,” she explained, “I had two abortions and I had them not because I didn’t want to be a mother but because I wasn’t ready. I wanted to finish school and I just felt like I was too young… [M]y mother really stayed on me about not having kids and I saw what it was like for her to have kids at such a young age and to be unmarried… I never wanted to do that.” Researchers can distill Chanel’s lived experience down to the briefest of statistics: Black woman, college-educated; three pregnancies, one child. But her candid testimony sheds needed light on the complexities of personal choices about pregnancies. When I interviewed her, Chanel made it clear that her abortions were her own decision. But such decisions are always made by women in the context of external forces that constrain their options.

Decades of previous research have illuminated the significant racial and economic disparities that affect women who seek access to reproductive health services. Black women, especially, bear the brunt of socioeconomic and political factors that impede their full autonomy in making reproductive choices. Much has been made of data from the Guttmacher Institute showing that abortion rates for Black women are almost three times higher than for white women, and that unintended pregnancies are nearly twice as frequent for Black women. Meanwhile, abortions are increasingly concentrated among poor women, who accounted for nearly half of all abortions according to the latest available 2014 data.

What might create more favorable and equal conditions for Black women dealing with reproductive health issues? Studies have suggested many possible solutions – including better sexual health education for young people; expanded health insurance coverage; and increased access to reproductive care, including all forms of contraception, abortion care without stigma, and quality pre- and post-partum care for mothers and children. Many scholars are now also probing the ways in which institutional racism undercuts good health care for Black women.

Effects of Wealth, Class on Black Women’s Ideas about Motherhood

Although a focus on collecting and analyzing systematic data contributes to our overall understanding of women’s reproductive decisions and consequences, my research using in-depth interviews seeks to fill gaps left by previous studies. Discussions about abortion and contraception for Black women, I find, are often influenced by Black communities’ understandings of the centrality of motherhood in the reproductive life course. A richer understanding of the importance of motherhood to the Black community may help researchers and policymakers provide resources and programs grounded in the realities of Black women’s reproductive lives.

My conversations with research participants highlight the role of class in Black women’s definitions of motherhood and interpretations of “choice.” For poor and lower-class women, womanhood is deeply imbued with the value of motherhood. These women largely approach motherhood as destiny rather than as one choice among many. In contrast, upper- and middle-class women grapple much more with the “hows” and “whens” and “with whoms” – with the mechanics of fitting motherhood into their lives. Kim, a young working-class mother of one, explained that her own mother controlled some of her early reproductive health choices: “When I was younger my mom put me on [birth control] and said it was for my periods.” In contrast, Mia, a 33-year old middle-class women with no children, described a more deliberate decision to avoid pregnancy: “Kids are expensive… It’s cheaper to take birth control than have the kid. [laughter] so um yeah I’ll just keep taking birth control until I hit the lottery.” Both women exercised reproductive autonomy by taking birth control, but only the higher-income woman expressed the feeling that preventing pregnancy was her own choice to make.

Including Understandings of Motherhood in Reproductive Health Policy

As they make reproductive decisions, Black women struggle with expectations and obligations about motherhood. Devising policies that take account of community expectations and constraints may help reduce unintended pregnancies, increase access to reproductive healthcare services, and improve health outcomes for Black women. Exploring the meaning of choices made by Black women can reveal how variously situated women make different decisions. This, in turn, will allow more equitable provision of reproductive services.

My work begins to paint a detailed picture of Black women’s reproductive health journeys. But more research remains to be done. To combat the obstacles Black women face, we must interrogate and supplement quantitative data with qualitative explorations of personal experiences and beliefs. Data and interviews so far suggest a number of useful steps to be taken by key stakeholders ranging from policymakers to doctors:

  • Increase access to insurance to reduce the financial burden of preventing pregnancies or bearing children.

  • Foster cooperation among researchers, clinicians and educators – to improve understandings of beliefs important to the Black community, including ideas about motherhood and the meaning of womanhood. Such understandings can help providers improve the dissemination and reception of reproductive health education and services in the Black community.

  • Earmark funding for more research about the ways Black women in various social positions understand their reproductive lives. And encourage studies that encourage community participation and place a central emphasis on hearing Black women’s voices.

Black women make all sorts of reproductive choices, from using birth control to having abortions to raising babies. As their stories reveal, every choice is influenced by social class and the expectations of their families and communities. Researchers and advocates who want to improve reproductive health outcomes for Black women would do well to listen to what Black women have to say and view individuals’ choices as profoundly shaped and limited by social circumstances and cultural ideas and expectations.

What Drives Racial and Ethnic Disparities in Prenatal Care for Expectant Mothers?

Prenatal care — health care for pregnant mothers — is one of the most commonly used forms of preventive health care among women of reproductive age. Prenatal care represents an important opportunity to detect, monitor, and address risky health conditions and behaviors among expectant mothers that can impact birth outcomes.

Both delayed prenatal care (i.e., care initiated after the first trimester of pregnancy) and inadequate prenatal care are associated with poor infant health outcomes such as low birth weight. Although researchers continue to debate precise causal effects, studies suggest that prenatal care brings important benefits — including reductions in maternal smoking, lower rates of preventable pregnancy complications like high blood pressure, and better management of the mother’s weight after giving birth. Furthermore, mothers who initiate care earlier are more likely to take their infants to well-baby visits after their babies are born.

As with other forms of healthcare, we see significant racial/ethnic disparities in access to and use of prenatal care. Although researchers have explored overall disparities in health outcomes rooted in differences in health insurance coverage, education, family income, and county-level poverty, more remains to be learned about how such factors affect various racial/ethnic inequalities.

Such knowledge is critical for achieving national public health goals and for addressing gaps in health outcomes for pregnant women. My research explores this area and can point to solutions that can improve and equalize health care for various groups of women and their children.

Disparities in First Trimester Initiation and Adequacy of Prenatal Care

My research quantifies how various factors contribute to gaps in prenatal care among non-Hispanic white, non-Hispanic black, and Hispanic women. By combining county-level U.S. Census data with rich data on children born in 2001 from the Early Childhood Longitudinal Study, I am able to pinpoint factors that typically cannot be considered simultaneously. For example, I can explore the effects of both maternal access to transportation and the availability of physicians in various counties.

My results reveal significant disparities among black, Hispanic, and white mothers in terms of the start of prenatal care in the first trimester of pregnancy. Although approximately 89 percent of whites initiate care during the first trimester, only 75 percent of black mothers and 79 percent of Hispanic mothers do so. Mothers from these groups also experience disparities in the adequacy of prenatal care they receive. Approximately 79 percent of non-Hispanic whites experience at least adequate prenatal care, while only 68 percent of Hispanic mothers and 69 percent of black mothers receive adequate care. What explains these differences? Here are the key findings from my research:

  • Socioeconomic characteristics like education, family income, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children explain far more of the racial/ethnic gaps in prenatal care than any other factors. These factors explain over half of black–white disparities and nearly half of Hispanic–white disparities in first trimester prenatal care initiation. Socioeconomic characteristics also explain far more of the racial/ethnic gaps in prenatal care adequacy than any other group of factors (although these factors account for considerably more of the black-white gap than the Hispanic-white gap).

  • Maternal health and characteristics of pregnancies (such as maternal age and number of previous pregnancies) explain 8.8 percent of black-white differences and 8.7 – 9.7 percent of Hispanic–white differences in the timing of the start of care in the first trimester. But differences in the adequacy of care are not related to maternal health or pregnancy characteristics.

  • Types of insurance coverage – whether women are covered by Medicaid, private insurance, or have no coverage — explain similar small percentages of differences in the timing of first trimester care, but again do not account for gaps in the adequacy of care.

  • The location of prenatal care facilities – in physicians’ offices and public health clinics — explained 4.7-6 percent of black–white gaps in timing of the start of care and 2.9-4.9 percent of Hispanic–white disparities. Location of care explained about 8.3 percent of black–white gaps in the adequacy of care but did not explain Hispanic-white gaps.

  • Maternal behaviors like smoking and state of residence and count-level conditions did not significantly contribute to racial and ethnic disparities in the initiation of prenatal care. But the availability of local gynecologists and state of residence did help to narrow black–white gaps in the adequacy of prenatal care, although these factors did not influence gaps in the adequacy of care between Hispanics and whites.

Addressing Socioeconomic Factors to Improve Prenatal Health

My research suggests that large and persistent socioeconomic disparities are primary contributors to racial/ethnic gaps in the timing and adequacy of prenatal care. This finding is not surprising — pregnant women with lower incomes and levels of formal education often do not have the resources necessary to obtain care early and often. However, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children made a difference for pregnant women, suggesting that this public program can help meet the financial needs that remain an important barrier to timely and adequate prenatal care.

My findings suggest that policymakers should endeavor to help disadvantaged populations gain expanded access to healthcare. Medicaid expansions through the 2010 Affordable Care Act provide one promising intervention. Although such expansions target childless poor and near-poor adults, women who receive coverage prior to pregnancy can end up enrolling earlier in prenatal care; and they can obtain continuing help with the management of chronic health problems, potentially improving outcomes when their babies are born.

Ultimately, as my research shows, reducing economic inequality may help to close racial and ethnic disparities in prenatal care. Read more in Tiffany L. Green, “Unpacking Racial/Ethnic Disparities in Prenatal Care Use: The Role of Individual-, Household-, and Area-Level Characteristics,” Journal of Women’s Health 27, no.9 (2018).

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