I was 7 months pregnant when I walked into my OB/GYN's office for my monthly appointment with a list of questions and concerns to bring up with my doctor. After talking to the nurse and having some blood work done, I was shown into the exam room. When the doctor came in, she asked how I was doing.
"I'm in pain," I began. I ran down my issues: pain in my pelvis, constipation, hemorrhoids, and my hesitancy to take iron pills the nurse said I needed because my iron was low.
"Your iron is low?" The doctor asked in a surprised voice.
"Yes. I'm anemic," I answered, annoyed. "It was low at the start of my pregnancy, but a little over the required threshold. Now it's under."
"Oh," she said, surprised again. "I didn't see that in your chart, let me look again."
She flipped through the manila envelope with my medical information tucked inside, found the numbers to confirm what I'd told her, then looked back at me with a blank stare before finally saying, "Oh, your numbers are low."
I stared at her, waiting for her to offer a solution or at least more information about the symptoms I'd just shared. Neither came. Instead, she said, "These are the things that happen during pregnancy. You just have to go through it. Your baby's doing well, and after delivery you'll get back to normal, too."
I was dissatisfied. Angry, really, that she had dismissed my concerns. In her eyes, I felt like nothing more than a host for the baby growing in my body and not a full person.
Her dismissal reminded me of the many disparities Black women face during their pregnancy and birth journeys: the assumption that we have a higher pain tolerance; the staggering numbers that show we are more likely to develop pregnancy-related complications, including preeclampsia, hypertension, and gestational diabetes; the heartbreaking pregnancy-related mortality ratios for Black, Native American, and Alaska Native women.
As I stood in line to make my next appointment, I wondered, "Should I find a Black woman to be my doctor instead of coming back here?"
I was looking for empathy, compassion, clear information, care, and concern — qualities of a culturally competent physician.
What it means to provide culturally competent care — and why that's so important
Culturally competent care respects the beliefs and values of all patients, no matter their race, ethnicity, sexual identity, or religious background. A culturally competent physician is not necessarily someone who shares your background — but they understand the "why" behind health disparities that may affect you and can accommodate your wishes (or, if not medically possible, at least listen to and try to understand those wishes).
Working with a culturally competent medical team is an important first step in ensuring a mom has a healthy pregnancy and a safe delivery — especially for Black women, who are more likely to face barriers to quality care that have driven the maternal death ratio to a whopping 44.8 per 100,000, which is about 3 times higher than it is for white women.[1]
There are many complicated reasons why Black moms are more likely to experience poor outcomes than white moms, but a lot of them boil down to racism. Research around racism in maternal health care is sobering — Black women face:
- More frequent medical mistreatment. Roughly 30% of Black, Hispanic, and multiracial women reported experiencing mistreatment during pregnancy or delivery, with respondents saying their healthcare provider ignored them, violated their privacy, yelled at them, and more.[2]
- Higher rates of C-section. The latest statistics from March of Dimes reveal Black women are more likely to give birth via C-section, at a rate of over 37%, compared to white women, who receive them at a rate of roughly 31%.[3]
- Compounded risks. Maternal mortality and morbidity rates are about three times higher for women who had C-sections compared to those who had vaginal deliveries.
But it isn't just Black moms who benefit from a culturally competent care team. Anyone who's part of a marginalized group benefits from working with a physician who is open and understanding of their needs. LGBTQ patients, for example, are twice as likely as non-LGBTQ patients to report negative experiences while receiving health care, according to a recent survey by KFF.[4] And for patients with limited English proficiency, research has found that having a practitioner who speaks the patient's primary language is associated with fewer medical errors and better outcomes.
For people with disabilities, a culturally competent provider is also critical to ensuring a healthy pregnancy. Monika Mitra, Ph.D., director of the Lurie Institute for Disability Policy and an associate professor at Brandeis University, says women with disabilities are often stigmatized, discriminated against, and discouraged from having children. For these women, she says, culturally competent care may mean finding a practitioner who can treat them with the same level of care as a patient without disabilities, as well as someone experienced with the patient's specific disability.
Chanelle Wimbish, a senior clinical research specialist who lives in Maryland, suffered a spinal cord injury in 2009 when a car struck her in a hit-and-run accident. Wimbish has some feeling below her breastbone, but she uses a wheelchair. At the time of this interview, she was 7 months pregnant and said finding competent care has been about accessibility.
"Having access to a wheelchair scale was the biggest thing I really had to advocate for early on in my pregnancy," Wimbish says. "They would ask me questions, take my blood pressure at the beginning of each visit, and then just ask me if I knew my weight. I said, 'Well, there's no wheelchair scale for me to be weighed?' Like, I'm not going to go my whole pregnancy and not be weighed."
Wimbish worked out a plan with her practitioner to arrive early for prenatal appointments; she now enters a different area of the hospital to use a wheelchair scale, one of only a few in the entire complex. Aside from having to advocate for this, though, she says she feels confident and safe with her providers because of the open dialogue they allow during each visit.
"I never feel like they're trying to rush to get to another patient," she says. "There always seems to be a little downtime where I can think, I can write my notes, and I can make sure I've asked all my questions."
A culturally competent OB/GYN, midwife, or doula also facilitates effective cross-cultural communication. "When someone understands our cultural preferences, without [needing] a long-winded explanation or convincing, it gives us a wonderful place to start to ensure that the birth experience is going to be well aligned with our expectations," says Karen Dale, R.N., market president of AmeriHealth Caritas District of Columbia.
Dale notes that a culturally competent provider will also help patients decide how they want to tailor their birth experience (such as hiring a doula, delivering in a hospital or birthing center, or creating a birth plan) and then advocate to ensure those preferences are honored whenever medically possible.
"Cultural competence is certainly one component," she says. "However, there's so much more about building trust, being treated with dignity, and having your preferences honored and celebrated versus denigrated that improves the overall experience."
How to find a culturally competent provider
Spotting the signs of a culturally competent practitioner places the initial burden on the patient. In shouldering this responsibility, a mom-to-be has to educate and advocate for herself.
One way to begin the search process is to look up facilities or hospital systems highlighted by the Lown Hospitals Index for Social Responsibility, which ranks hospitals on social responsibility and evaluates nearly 4,000 hospitals on their performance across health outcomes, value, and equity.
Interviewing potential prenatal care providers is another way to ask questions and get a sense of how their practices operate.
"To the extent that it's covered by insurance, or someone can afford it, I strongly recommend that people interview at least a couple of different providers," says Dale.
She suggests asking them three questions:
- What is your rate of C-sections?
- What procedures don't you do?
- What types of support and relationships can you provide throughout the birth experience?
Dale says that these questions can help moms-to-be learn how long their provider will allow them to labor before suggesting a C-section and under what circumstances a C-section will be suggested.
It’s also worth asking potential providers:
- Are you open to a team model of care with either a midwife or doula?
- Can you provide access or a referral to a nutritionist?
- Are any digital tools, such as remote patient monitoring, available?
It's about more than racial concordance
When looking for a practitioner, it's important to keep in mind that culturally competent care does not necessarily mean that your doctor must have the exact same background as you, says Oluwatosin Goje, M.D., an OB/GYN at the Cleveland Clinic and member of the What to Expect Medical Review Board.
Racial concordance — when your health care provider shares the same racial or ethnic background as you — has been found to improve health outcomes for Black patients, but it’s not required for culturally competent care.[5] Any practitioner can offer culturally competent care as long as they are open to meeting their patients where they are and bringing comfort, acceptance, and understanding into their practice.
It’s also possible to have a nonsupportive provider who shares your background.
"A culturally competent doctor for a Black pregnant patient can be a 60-year-old white man," Dr. Goje says. "He just needs to have some knowledge and skill set about the people, because if people are not comfortable with you, then half of the message you want to give them, they won't take."
Dr. Goje shared a story of a provider she knows in private practice. "Most of his patients are Hispanic," she says. "He is not Hispanic. Guess what he did? Everybody who works in that office is Hispanic."
Akela Lee, a mother of two in Jacksonville, Florida, had two miscarriages before the birth of her son this past February. Even though she is Black, her doctor is a white woman who she trusts implicitly.
"I stressed the fact of wanting to see only her, because a lot of times when you are pregnant, they want you to see every doctor in the office, and I did not want to do that because of what I had gone through," Lee says. "I stressed, 'Are you the one who's going to deliver my baby?' and she reassured me multiple times that she was the one who would be delivering the baby, whether she was on call or not."
Lee's doctor made good on her promise, coming in when she was not on call to deliver her baby via emergency C-section.
"I freaked out to the point where I brought up the Black mortality rate," Lee says. "I screamed out, 'I don't want to die, I don't want to die.' ... And she came over that blue curtain ... She said, 'You're not gonna die. You're going home. Your baby is going home. Everything will be okay.'"
Her doctor's reassuring bedside manner helped Lee stay calm. Soon after, she welcomed her healthy baby boy.
Lee says that her experience highlighted just how important it is for moms-to-be to feel comfortable with their doctor. "If you're just unsure about your doctor and you feel like you're not being heard, it's okay to find another physician that will listen to you," she says. "I don't care how far you are in your pregnancy. Don't sit in a situation where you're uncomfortable."
This is advice I'm following myself. After my 7-month appointment, I decided not to go back to the doctor I felt was dismissive of my needs. Instead, I sought out another physician in my group practice who took the time to answer my questions and address my concerns. I have requested that I only see this doctor or one other with whom I have a prior relationship for the remainder of my pregnancy.
My new practitioner has been patient with me, answering all of my questions (even when I ask the same ones multiple times), reassuring me that my baby is doing well, and explaining in detail why certain procedures can or can't be done for the safety of myself and my daughter.
Most importantly, I have felt more comfortable, seen, and heard — and advocating for myself in this way has made me feel like I can maintain more control over my birth experience.
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