Racial Discrimination, Disrespectful Care, and Health Inequities: Examining Impact and Reimagining Solutions Restricted; Files Only
Jean Louis, Roseline (Spring 2025)
Abstract
Racism and discrimination in healthcare remain significant and pervasive problems in the United States, disproportionately affecting Black people and contributing to widespread health disparities. These experiences are not just isolated incidents; they are tied to systemic inequities that lead to worse health outcomes, increased chronic disease burdens, and lower life expectancy for Black people compared to their white counterparts.
Nowhere is this crisis more evident than in maternal health, where Black birthing people face disproportionately higher rates of severe maternal morbidity and mortality and are 2.5 times more likely to die from pregnancy-related causes than non-Hispanic White birthing people. For every maternal death, 75 to 100 more birthing people experience a severe maternal morbidity (SMM) outcome in the United States (U.S.). SMM has surged over 200% in the past decade, and Black birthing people are at a 70% higher risk of experiencing SMM compared to their White counterparts. Factors underlying racial disparities remain poorly understood, with most studies documenting that differences persist after adjustment for sociodemographic status, preexisting health status, and clinical characteristics.
Manuscript I is a post-hoc analysis that examines the association between perceived discrimination and self-reported health status among three racial/ethnic groups. Black and Hispanic participants were more likely to experience discrimination than White respondents while seeking healthcare, and any experience of racial discrimination in healthcare settings was associated with poor health status across all racial/ethnic groups.
Manuscript II is a quantitative study examining the association between experiencing racial discrimination and disrespectful care from healthcare providers and the likelihood of experiencing an SMM outcome. Approximately 30-50% of nurses, midwives, and physicians provided racially discriminatory and disrespectful maternity care, and the odds of experiencing an SMM outcome were three times higher for participants who experienced disrespectful care from any provider compared to those who did not experience disrespectful care.
Manuscript III is a qualitative study exploring the perinatal experiences and clinical outcomes of Black birthing people, some of whom experienced SMM, to identify ways racially discriminatory and disrespectful care impacts adverse health outcomes. Three overarching themes emerged: Adverse Outcomes Have Roots, Legacies of Racism and Disrespect, and Reimagining Maternal Healthcare.
Table of Contents
Chapter 1: Research Protocol
Introduction ............................................................................................................................................... 2
Conceptual Framework ............................................................................................................................. 4
Research Question and Study Aims ........................................................................................................ 12
Outline of the Dissertation ...................................................................................................................... 13
References ............................................................................................................................................... 13
Chapter 2: Reported Racial Discrimination in Healthcare Settings and Impacts on Health Outcomes in a Racially Diverse Sample in the United States: Findings from the Behavioral Risk Factor Surveillance System
Abstract ................................................................................................................................................... 27
Background ............................................................................................................................................. 28
Methods .................................................................................................................................................. 29
Results ..................................................................................................................................................... 32
Discussion ............................................................................................................................................... 35
Limitations .............................................................................................................................................. 35
Conclusion .............................................................................................................................................. 39
References ............................................................................................................................................... 41
Chapter 3: Characterizing Exposure to Racially Discriminatory and Disrespectful Maternity Care: Impacts on Severe Maternal Morbidity Outcomes Among Black Women and Birthing People in the United States
Abstract ................................................................................................................................................... 45
Background ............................................................................................................................................. 46
Methods .................................................................................................................................................. 50
Results ..................................................................................................................................................... 54
Discussion ............................................................................................................................................... 57
Limitations .............................................................................................................................................. 60
Conclusion .............................................................................................................................................. 61
References ............................................................................................................................................... 63
Chapter 4: “They Are Not Advocates for Us”: Black Women’s Disrespectful and Racially Discriminatory Maternity Care Experiences in The United States Health care System
Abstract ................................................................................................................................................... 72
Background ............................................................................................................................................. 73
Methods .................................................................................................................................................. 75
Results ..................................................................................................................................................... 78
Discussion ............................................................................................................................................... 88
Limitations .............................................................................................................................................. 92
Conclusion .............................................................................................................................................. 93
References ............................................................................................................................................... 98
Chapter 5: Summary and Conclusions
Summary of Results .............................................................................................................................. 106
Conclusion ............................................................................................................................................ 109
References ............................................................................................................................................. 111
List of Tables
Participant Characteristics of Each Race or Ethnic Group, 2014 BRFSS .................................................. 32
Association between race/ethnicity, racial salience, experiencing racial discrimination in healthcare and report of physical symptoms ....................................................................................................................... 33
Association between race/ethnicity, racial salience, experiencing racial discrimination in healthcare and report of emotional symptoms .................................................................................................................... 33
Association between race/ethnicity, racial salience, experiencing racial discrimination in healthcare and report of fair or poor health status ............................................................................................................... 34
Association between experiencing racial discrimination in healthcare and report of health outcomes by race or ethnic group .................................................................................................................................... 35
Participant Characteristics by Severe Maternal Morbidity Outcome ......................................................... 55
Type and Number of Severe Maternal Morbidity Outcomes Experienced by Sample ............................... 56
Level of Racial Discriminatory & Respectful Maternity Care by Provider Type ...................................... 56
Association Between Experiencing Severe Maternity Morbidity Outcomes & Racially Discriminatory & Respectful Maternity Care from Any Provider (Physician, Midwife, Nurse) and Nurse (Only) ................ 56
Qualitative Participant Demographic Characteristics ................................................................................. 78
Meta Theme 1 - Adverse Outcomes Have Roots ........................................................................................ 95
Meta Theme 2 - Legacies of Racism and Disrespect .................................................................................. 96
Meta Theme 3 - Reimagining Maternal Health Care .................................................................................. 97
List of Figures
The Ecological Systems Theory of Black Racial Health Inequities ............................................................. 4
The Ecological Systems Theory of Black Health Disparities – Aim 2 ....................................................... 50
The Ecological Systems Theory of Black Racial Health Inequities – Aim 3 ............................................. 75
Qualitative Interview Guide ........................................................................................................................ 77
List of Appendices
Appendix 1: Aims 1&2 IRB Approval ..................................................................................................... 113
Appendix 2: Aim 2 Screener for Severe Maternal Morbidity with Simplified Terms and Examples ...... 115
Appendix 3: Aim 3 Qualitative Interview Guide ...................................................................................... 116
About this Dissertation
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File download under embargo until 22 May 2026 | 2025-04-30 10:41:26 -0400 | File download under embargo until 22 May 2026 |
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