Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Awotwi-Pratt, Stephanie
Master of Arts - MA
University of British Columbia
Black women in the United States die of pregnancy-related causes at a three times higher rate than white women, regardless of the mother’s socioeconomic status. Systemic medical racism contributes to high morbidity and mortality rates among Black populations. Currently, there is a lack of race-based data collected in Canada. Given there is evidence of medical racism experienced by Black women in the United States, Black Canadian women may experience medical racism within the Canadian healthcare system. This study aims to understand how Black Canadian women navigate and manage obstetric racism in reproductive healthcare contexts. Trauma-informed intersectional feminist research practices empower and encourage Black women to share their experiences. Qualitative descriptive was used to understand how Black women experience medical racism. Black women living in Canada actively participated in twenty-five in-depth one-on-one interviews. Five themes include: 1) Black women anticipate experiencing some form of discrimination given the known health inequalities in the U.S., 2) healthcare providers consistently dismiss Black women’s pain. 3) healthcare providers’ perception of Black women affects their care, 4) increased need for Black representation in reproductive healthcare providers, and 5) patient-centred care improves Black women’s wellbeing. This study findings show that, despite implementing strategies to overcome racism and discrimination, participants still endure forms of systemic racism. Healthcare providers need to be aware that Black women experience health disparities due to a providers’ personal bias and the systemic barriers that exist in the healthcare system. Healthcare providers must understand that Black women may withhold health information to protect themselves from negative stereotypes. Healthcare providers need training on cultural safety to recognize their implicit biases and to provide safe and equitable care. Recruiting medical professionals who reflect racially underrepresented backgrounds will help to address systemic barriers in healthcare. The evidence suggests that Black Canadian women experience medical obstetric racism even with a successful pregnancy and delivery. The Canadian healthcare system must be aware of these issues and advocate for Black Canadian women to reduce instances of medical racism.
NAVIGATING MEDICAL RACISM: HOW BLACK CANADIAN WOMEN EXPERIENCE REPRODUCTIVE HEALTHCARE IN CANADA by Stephanie Awotwi-Pratt B.Sc., University of British Columbia (Okanagan), 2018 B.A., University of British Columbia (Okanagan), 2022 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE COLLEGE OF GRADUATE STUDIES (Interdisciplinary Studies) (Power, Conflict, and Ideas) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) December 2024 © Stephanie Awotwi-Pratt, 2024 ii The following individuals certify that they have read and recommend to the College of Graduate Studies for acceptance a thesis entitled: Navigating Medical Racism: How Black Canadian Women Experience Reproductive Healthcare in Canada submitted by Stephanie Awotwi-Pratt in partial fulfillment of the requirements of the degree of Master of Arts. Dr. Marie Tarrant School of Nursing Supervisor Assistant Professor Rishma Chooniedass School of Nursing Co- Supervisor Dr. Margaret Carlyle, Irving K. Barber Faculty of Arts and Social Sciences Supervisory Committee Member Dr. Heather Latimer, Irving K. Barber Faculty of Arts and Social Sciences Supervisory Committee Member Dr. Laura Meek, Irving K. Barber Faculty of Arts and Social Sciences University Examiner iii Abstract Black women in the United States die of pregnancy-related causes at a three times higher rate than white women, regardless of the mother’s socioeconomic status. Systemic medical racism contributes to high morbidity and mortality rates among Black populations. Currently, there is a lack of race-based data collected in Canada. Given there is evidence of medical racism experienced by Black women in the United States, Black Canadian women may experience medical racism within the Canadian healthcare system. This study aims to understand how Black Canadian women navigate and manage obstetric racism in reproductive healthcare contexts. Trauma-informed intersectional feminist research practices empower and encourage Black women to share their experiences. Qualitative descriptive was used to understand how Black women experience medical racism. Black women living in Canada actively participated in twenty-five in-depth one-on-one interviews. Five themes include: 1) Black women anticipate experiencing some form of discrimination given the known health inequalities in the U.S., 2) healthcare providers consistently dismiss Black women’s pain. 3) healthcare providers’ perception of Black women affects their care, 4) increased need for Black representation in reproductive healthcare providers, and 5) patient-centred care improves Black women’s wellbeing. This study findings show that, despite implementing strategies to overcome racism and discrimination, participants still endure forms of systemic racism. Healthcare providers need to be aware that Black women experience health disparities due to a providers’ personal bias and the systemic barriers that exist in the healthcare system. Healthcare providers must understand that Black women may withhold health information to protect themselves from negative stereotypes. Healthcare providers need training on cultural safety to recognize their implicit biases and to provide safe and equitable care. Recruiting medical professionals who reflect iv racially underrepresented backgrounds will help to address systemic barriers in healthcare. The evidence suggests that Black Canadian women experience medical obstetric racism even with a successful pregnancy and delivery. The Canadian healthcare system must be aware of these issues and advocate for Black Canadian women to reduce instances of medical racism. v Lay Summary Black women are likely to experience racism when they interact with healthcare providers. Participants in this study reported experiencing discrimination when seeking reproductive healthcare. In one-on-one qualitative interviews with 25 participants, the study revealed five central themes: 1) Black Canadian women anticipate experiencing discrimination due to the known health disparities, 2) Providers often dismiss the pain experienced by Black women, and 3) Black women acknowledge how healthcare providers perceive them. 4) Black women strategize to navigate potential threats of discrimination within medical spaces, 5) patient-centred care is important to minimize discrimination. Based on the results of the study, Black women experience medical racism despite taking steps to prevent difficult interactions with providers. Therefore, to prevent obstetric racism, healthcare providers must advocate for Black women in reproductive healthcare spaces. vi Preface To preface, Stephanie Awotwi-Pratt wrote this Master of Arts thesis in its entirety without using any Generative artificial intelligence. This thesis was also edited and supported by supervisors Dr. Marie Tarrant and Rishma Chooniedass RN MN, as well as committee members Dr. Margaret Carlyle and Dr. Heather Latimer. Stephanie Awotwi-Pratt conducted, analyzed, transcribed, and coded all 25 one-on-one qualitative research interviews with Black Canadian women and supervisors and committee members reviewed a couple of coded transcripts for consistency. Stephanie Awotwi-Pratt is the sole contributor to this thesis work and research. The University of British Columbia Behavioural Research Ethics Board with the approved application number H23-01589. This thesis or research study does not include any copyright materials. vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary .................................................................................................................................v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables………………………………………………………………………………..……x Acknowledgements ...................................................................................................................... xi Dedication .................................................................................................................................... xii Chapter 1: Introduction ................................................................................................................1 1.1 Key Concepts…………………………………………………………………….....1 1.2 Purpose of the Study ................................................................................................ 5 1.3 History of Slavery in North America and the field of Obstetrics and Gynecology...6 1.31 Case of Diana Bastain ............................................................................................. 8 1.32 Case of Marie- Joseph Angélique .......................................................................... 8 1.33 Lucy Anarcha and Betsey ....................................................................................... 9 1.4 Autonomy and Agency in Healthcare ..................................................................... 11 1.41 Henrietta Lacks and the Tuskegee Syphilis experiments ..................... 12 1.5 Conclusion .............................................................................................................. 14 Chapter 2: Literature Review .....................................................................................................15 2.1 Obstetric Racism .................................................................................................... 15 2.2 Implicit Biases in the Delivery of Care ................................................................. 18 2.3 Reproductive Justice ............................................................................................. 22 Chapter 3: Methods .....................................................................................................................27 viii 3.1 Recruitment Process .................................................................................................... 29 3.2 Ethical Considerations and Confidentiality ............................................................... 31 3.21 Potential Risks and Benefits of the Study ...................................................... 31 3.3 Qualitative Interview Procedures ................................................................................ 32 3.31 Managing Research Data .............................................................................. 32 3.32 Data Analysis ................................................................................................ 33 3.33 Coding ........................................................................................................... 34 3.4 Positionality of Researcher ........................................................................................ 34 3.5 Trauma Informed Intersectional Feminist Approaches .............................................. 37 3.6 Inductive Research Analysis of Qualitative Research Data ....................................... 38 3.7 Summary of Methods .................................................................................................. 39 Chapter 4: Findings .....................................................................................................................41 4.1 Effects of Known Health Disparities .......................................................................... 42 4.2 Dismissal of Pain ........................................................................................................ 47 4.3 Navigating Interactions with Healthcare Providers .................................................... 53 4.4 Increased Representation in Reproductive Healthcare ............................................... 55 4.5 Patient-centred care to enhance health and wellbeing ................................................ 60 4.6 Summary of Research Findings ................................................................................. 63 Chapter 5: Discussion and Conclusion ......................................................................................65 5.1Anxieties Given Black Health Inequities……………………………………………..65 5.2 Dismissal of Black Women’s Pain…………………………………………….…….67 5.3 Navigating Interactions with Healthcare Providers………………………………….68 5.4 More Black Representation in Healthcare Providers Is Needed……………………..68 ix 5.5 Strategies to Avoid Experiencing Obstetric Racism…………………...…………….70 5.6 Recommendations……………………………………………………………………71 5.7 Strengths and Limitations……………………………………………………………72 5.8 Reflection and Reflexivity…………………………………………………….…..…73 5.9 Conclusion……………….…………………………………………………….….…74 Bibliography .................................................................................................................................75 Appendices ....................................................................................................................................84 Appendix A: Consent Form ................................................................................................ 84 Appendix B: Recruitment Poster ......................................................................................... 91 Appendix C: Master’s Research Interview Questions ......................................................... 92 Appendix D: Undergraduate Research Award Interview Questions .................................... 96 Appendix E: Resources for Black Canadian Women ........................................................... 98 x List of Tables Table 1 25 Black Canadian Women’s Participant Information…………………….41 xi Acknowledgements This thesis could not have been completed without the support and guidance of my supervisors, Dr. Marie Tarrant and Rishma Chooniedass, RN, MN, throughout this thesis work. To each of my two committee members, Dr. Margaret Carlyle and Dr. Heather Latimer, I thank you for individually mentoring me and collectively providing meaningful feedback and generous support, which has contributed to the completion of this thesis. I have learnt a lot and, through all of your guidance, been able to craft my voice amongst meaningful scholarship in this field geared towards anti-racism in healthcare. I also want to thank my sister, Jacklyn Awotwi-Pratt, for believing in me, for the value of my work and its contributions and for how this work is meaningful for Black Canadian women like us. I also want to thank all the Black Canadian women who participated in this project and who have generously supported and contributed to this thesis. I want to thank you for allowing me to hear your stories and for trusting me to share them. xii Dedication I dedicate this MA thesis to my loving sister, Jacklyn Awotwi-Pratt. You have taught me to dig deep within myself and to stay ruthlessly determined and committed to creating the change I want to see in this world. I also dedicate this thesis to my younger self. Thank you, God, for being my rock and ever-present help, you are my everything. Thank you for placing this passion and research in my heart. 1 Chapter 1: Introduction Black women’s reproductive healthcare experiences are underexplored in Canada. In the United States (U.S.), race-based data suggests a direct correlation between obstetric racism and high incidence of Black maternal and infant death rates (Blackstock, 2024; Cooper Owens, 2017; D. A. Davis, 2019; D. Davis, 2019; Maynard, 2017). In 2023, the US Centre for Disease Control and Prevention (CDC) reported that "Black women are three times more likely to die of pregnancy-related causes than white women," regardless of the mothers' socioeconomic status (CDC, 2024). In Canada, the maternal mortality rate in 2021 was 8.16 per 100,000 live births and rose to 12.22 in 2023. It is not known, however, what the maternal mortality rate is among Black Canadian women (Government of Canada, 2023). Overall, this data does suggest that maternal death rates in Canada are increasing (Government of Canada, 2023). Black Canadian maternal mortality rates in Canada remain unreported, and the current statistical data does not identify potential causes of high maternal mortality rates (Government of Canada, 2023). There is also a significant degree of "colourblind[ness]" in how Canada reports healthcare data, especially as it relates to reproductive healthcare outcomes (Dayo et al., 2023). Canada's lack of race-based data erases the current maternal mortality rates and poor reproductive healthcare outcomes of Black women (Government of Canada, 2023). 1.1 Key Concepts The Black population within Canada consists of immigrant populations and those born in Canada, which comprise approximately 3.5% of the population (Dryden & Nnorom, 2021). There are two types of racism that affect Black populations in Canada today: racism and systemic racism. 2 Racism is defined as the intolerance and discrimination of a group based on their racial identity (Johnson, 2018; Maynard, 2017; Satzewich, 2011). Systemic racism refers to the mechanisms that are embedded in society and institutions, like medicine, that perpetuate discrimination and oppress racialized groups based on their race (Dryden & Nnorom, 2021) . Black populations are affected by anti-Black racism, which is rooted in a history of colonialism. Dryden and Nnorom (2021) assert that it is necessary to define anti-Black racism specifically to describe and demonstrate how medical professionals in Canada treat Black patients and how this affects their healthcare experiences and outcomes. Anti-Black racism is a specific form of racism, rooted in the history and experience of enslavement, that is targeted against Black people, people of African descent (Dryden & Nnorom, 2021). Anti-Black racism continues to permeate American and Canadian healthcare systems and negatively impact Black patient health outcomes because of the embedded institutional colonial violence and oppression of Black people (Cooper Owens, 2017; D. Davis, 2019; Dryden & Nnorom, 2021; Maynard, 2017; Prather et al., 2018; Roberts, 1997). In healthcare, racism can manifest overtly or covertly within specific fields like Obstetrics and Gynecology (OBGYN) (Blackstock, 2024; D. Davis, 2019; Roberts, 1997). Overt racism in medicine is more explicit and can manifest in patient and healthcare provider interactions, such as when Black patients' concerns are 3 consistently dismissed, or they are denied pain medication when they ask for pain relief (Blackstock, 2024). Covert racism is more insidious and systematic and plays out in the negative stereotypes and assumptions that healthcare providers unknowingly project when interacting with Black patients (Blackstock, 2024). Covert racism is more subtle and shows up in the unconscious actions and attitudes of medical professionals. Healthcare practitioners have beliefs, backgrounds, and biases which may unintentionally influence their clinical practice (Blackstock, 2024). The term obstetric racism is also central to understanding how discrimination manifests in specific healthcare fields, like obstetrics and gynecology. Obstetric racism is the gendered violence experienced by marginalized women that results in them feeling ignored, dehumanized, and mistreated by a medical professional during their pregnancy, labour, and delivery (D. Davis, 2019). Two key terms that indicate the effects of colonial violence on Black patient healthcare outcomes today include bodily autonomy and agency (Kapsalis, 1997; Roberts, 1997). Bodily autonomy is the legal right to freely control a person's body and reproductive future (Roberts, 1997). According to Hacker and Moore (2010) autonomy is […] [the right to] exercise autonomy, an individual must be capable of effective deliberation and be neither coerced into a particular course of action nor limited in her or his choices by external restraints" (p. 7) 4 Healthcare providers continue to hold authority and determine the health outcomes of patients (Roberts, 1997). Although a lack of bodily autonomy may be assumed to be in the past, marginalized and Black women still constantly negotiate their rights within reproductive healthcare settings (Roberts, 1997). Autonomy is a person's ability to make informed decisions about their health without any external interference on their right to choose their care (Hacker et al., 2010). Agency, on the other hand is defined by the United Nations Population Fund (UNPF) is: "the right to the autonomy of our bodies means that we have the power and agency to make choices, without fear of violence or having someone else decide for us. It means being able to decide whether, when or with whom to have sex. It means making your own decisions about when or whether you want to become pregnant. It means the freedom to go to a doctor whenever you need one" (United Nations Population Fund State of World Population 2021, p. 7). Agency is the freedom to act and the ability to decide your future (Kapsalis, 1997; Roberts, 1997). Autonomy and agency provide context to the umbrella term reproductive justice and how it shapes Black women's reproductive health (Wade, 2023). Broadly, reproductive justice aims to improve Indigenous, Black, and women of colour’s access to reproductive healthcare, like legal abortions (Wade, 2023). One such example of activism is reproductive justice, which has its roots in second-wave feminism from groups like SisterSong (1997) in South America (Wade, 2023). This research will explore how Black Canadian women experience medical obstetric racism in the reproductive healthcare context and how Black Canadian women reclaim their agency and autonomy over their bodies in reproductive healthcare spaces. 5 1.2 Statement of Problem This section will address how systemic racism is present in the Canadian healthcare system today and continues to affect Black Canadian women and their reproductive healthcare (Coen-Sanchez et al., 2022; Dryden & Nnorom, 2021). To understand the Canadian healthcare system, one must acknowledge the legacies of settler colonialism, including forced assimilation and violence perpetrated against Indigenous people in Canada. While this history cannot be directly compared to the enslavement of Black peoples, the history and legacies of violence against Indigenous peoples are interrelated (Dhaliwal, 2019; Turpel-Lafond et al., 2020). The In Plain Sight Report, a report from British Columbia (BC) on Indigenous-specific racism in healthcare, found that systemic and overt racism in healthcare to be the leading cause of health complications, poor health, and, in some cases, death (Turpel-Lafond, 2020). This report revealed the entrenched biases and failures of the healthcare system to provide adequate care to Indigenous people in BC (Turpel-Lafond et al., 2020). I must acknowledge that this history of colonialism and systemic racism enacted on Indigenous people is evident in the Canadian healthcare system so that I can address Black racism. It is impossible to cover the complete history of enslavement and how it has shaped the outcomes of Black Americans and Canadians to date. In section 1.3, I provide three key examples of the practice of slavery and systematic oppression of Black enslaved people in American and Canadian contexts. Finally, in section 1.4, I will outline three examples of medical and scientific practices that highlight the importance of bodily autonomy and agency in healthcare. 6 1.3 History of Slavery in North America and the Field of Obstetrics and Gynecology This section provides a brief history of colonialism in America and Canada and how it constructed norms about race and racial differences that continue to impact medical interventions on Black patient health outcomes today (Blackstock, 2024; Maynard, 2017; Roberts, 1997). I will focus on how colonialism continues to take root in current medical discourses when assumptions about enslaved Black women continue to permeate the current medical consciousness (Roberts, 1997). Within modern Canadian reproductive health, legacies of colonial violence are consistently overlooked, although medical discourses continue to perpetuate around race (Maynard, 2017; Roberts, 1997). Race is the physiological traits that are also based on an individual’s geographical location this concept gained traction in the 15th century (Chowdhury & Madden, 2021; Maynard, 2017). The category of race reaffirmed white European assumptions about Black and racialized bodies in medicine and created racial distinctions (Maynard, 2017; Roberts, 1997). Race was used as a justification for colonial violence and reproductive exploitation of enslaved Black people (Maynard, 2017; Roberts, 1997). Blackness was a category used by white colonists in North America to justify the enslavement of Black people (Roberts, 1997). Racial ‘pseudoscience’ took root in scientific and medical discourses in the late eighteenth and nineteenth centuries, and debates formed around humans’ skeletal and skull size proportions as markers of intelligence, social status, and racial inferiority (Blackstock, 2024; Kapsalis, 1997; Roberts, 1997). Myths and stereotypes were created and used to justify slavery and the torture of enslaved African people, including notions that Black people were biologically different or subhuman, less intelligent, had a greater tolerance for pain, and were not to be trusted, among 7 many others (Dryden & Nnorom, 2021). The Black enslaved body was viewed as inherently biologically durable and destined for harsh labour (Roberts, 1997). Therefore, when anatomists, physicians, and scientists of the colonial period collaborated to construct truths about the Black body as biologically inferior, it justified their violent practices of enslavement of Black people in America and Canada (Blackstock, 2024; Kapsalis, 1997; Roberts, 1997). Medical interventions performed on the enslaved Black body not only created a climate of routine medical violence but also reinforced racial hierarchies that justified the continued violence against Black people (Kapsalis, 1997; Roberts, 1997). Medicine was the primary conduit to perpetuate racial differences in the colonial period and was used to differentiate those of Black African descent from white Europeans (Blackstock, 2024). Biological differences are the physical variations in physical observable traits among different people of different races. Biological differences played a role in how Black people historically were treated based on scientific racist beliefs about people in the 19th century (Blackstock, 2024, p. 78; Chowdhury & Madden, 2021; Schiebinger, 1986). In the colonial era, Canada also participated in the ownership of enslaved Black women as an asset to acquire free labour and generate wealth in Canada (Maynard, 2017). Between 1671 and 1834, historians have estimated that there were 4,200 enslaved peoples in Canada; two-thirds of those enslaved were Indigenous, while the rest were Black (Kentner, 2020, p. 7). 1.31 Case of Diana Bastain To illustrate Canada's history of colonialism and violence against enslaved Black women, I will analyze the cases of Diana and Marie-Joseph Angélique (Cooper, 2007, 2017). These cases 8 illustrate the reproductive violence and labour imposed on them by their white Canadian slave owners. In 1792 Diana Bastian, a 15-year-old enslaved Black Canadian girl, was raped by George More a prominent councilman in Nova Scotia, became pregnant and subsequently died in childbirth (Cooper, 2017). Bastain experienced reproductive violence in the colonial period that went ignored in historical accounts (Cooper, 2017). In documented accounts unearthed in recent years, she was sexually assaulted, gave birth, and died soon after childbirth (Cooper, 2017). Historical documents omit the physical violence and assault of Bastian, and her eventual death underscores the atrocities enacted against the lives of enslaved Black women historically in Canada (Cooper, 2017). Bastian's case exemplifies the little agency and autonomy of enslaved Black women and girls. Sexual violence and reproductive injustices were forced on her by George More, the white slave owner, which highlights how violence was routinely perpetrated. Bastain, whom today we consider to be underage, was sexually and physically assaulted and was not given any legal rights or support despite the brutality of the crime (Cooper, 2017). 1.32 Case of Marie-Joseph Angélique Canada's history of slavery is also evident in Afua Cooper's (2007) book The Hanging of Angélique, which indicates that it was routine for enslaved women to experience sexual violence at the hands of their white slave masters. Cooper (2007) provides one example of slavery in the Canadian context with Angélique, whose case was the first legally documented evidence about the enslavement of Black people in Canada. 9 Marie-Joseph Angélique was recorded in court documents as having started a fire in what is now Montreal in 1734 (Cooper, 2007). Angélique was one of the first recorded court cases representing the violent murder of an enslaved Black woman in what was then New France in the 1700s (Cooper, 2007). Angélique was tortured into submission, tried, hanged, and found guilty of burning her slave owner's house even though no evidence was gathered of the crime (Cooper, 2007). Angélique's story was reported yet concealed, juxtaposing Canadian historical benevolence and denial of slavery in its history (Cooper, 2007). This case emphasizes Canada's history of slavery and the lack of legal autonomy experienced by enslaved Black people (Cooper, 2007, pp. 28-132). Since Angélique had no legal right to defend herself (as an enslaved person), it highlighted how the Canadian judicial system could routinely charge and execute enslaved people for being disobedient (Cooper, 2007). In both cases, Bastian and Angélique highlight Canada's dark past of slavery and the well-documented evidence of the assault and physical violation inflicted upon enslaved Black women and girls of the colonial era (Cooper, 2007; Cooper, 2017). 1.33 Lucy, Anarcha, and Betsey Black enslaved women's bodies were sites of social capital, but also the producers of free labour through forms of sexual violence by their white enslavers to procure children that would fuel the colonial economic machine in America and Canada (Cooper Owens, 2017; D. A. Davis, 2019; Roberts, 1997). Terri Kapsalis' (1997) book, Public Privates: Performing Gynecology from Both Ends of the Speculum, examines the American history of slavery and reproductive medicine in the colonial era. Gynecological practices were routinely used on Black enslaved 10 women in America in the colonial period and contributed to the development of the field and to gynecological tools still used today, like the vaginal speculum (Kapsalis, 1997). The violent use of Black enslaved women as producers of free labour for colonists in America is detailed by slave owner and founder of the field of Obstetrics and Gynecology in America, James Marion Sims' book The Story of My Life (1894) explores the barbaric medical experimentational practices conducted in the colonial period on the likes of enslaved Black women Lucy, Anarcha, and Betsey (Kapsalis, 1997; Sims, 1894). Lucy, Anarcha, and Betsey were enslaved Black women operated on by Dr. James Marion Sims in his makeshift backyard hospital from 1845 and 1849 in Montgomery, Alabama (Kapsalis, 1997, p. 6). Vesicovaginal fistulas (VVF) was the primary condition Lucy, Anarcha, and Betsey were treated for by Sims without any anesthesia or pain medication, thus fueling the myth that enslaved Black women did not experience pain (Hartman, 2008; Kapsalis, 1997). According to the accounts in Sims' (1894) book, all three women were never consensually treated for or cured of their conditions (Kapsalis, 1997). Black enslaved women were racially pathologized within the rapidly developing fields of obstetrics and gynecology, as the field provided leverage for colonists to justify the violence committed against the enslaved (Kapsalis, 1997). In the American colonial period, if enslaved Black women were unable to produce children, the slave owners would take them to physicians who would operate on and otherwise ‘treat’ their reproductive illnesses (Kapsalis, 1997; Sims, 1894). Sims created a climate of medical oppression, violence, and condemnation of enslaved Black women (Kapsalis, 1997; Sims, 1894). Sims also constructed myths about the Black enslaved female body, their pain, and their inherent racial inferiority, as he systematically 11 performed trial-and-error operations to determine so-called justifiable reasons that enslaved Black women should experience differential ‘treatment’ from white women (Kapsalis, 1997). Black enslaved women's reproductive health and sexuality were referred to as "brute," "savage," and the opposite of what at the time was considered white Christian morality (p. 41). These three cases showcase how Black enslaved women in North America were denied reproductive freedom, agency, and autonomy throughout their lives. Although the field of Obstetrics and Gynecology developed in America based on the routine violation of Black enslaved women's agency and autonomy, Canada also shared a dark history of unjustly violating and perpetrating violence against enslaved people (Cooper, 2007, 2017). 1.4 Autonomy and Agency in Healthcare In this section, I will address how autonomy and agency are in constant negotiation within medical contexts. I will present two cases to illustrate how the autonomy and agency of Black patients continued to be squandered and violated after the end of slavery and how healthcare continued to suppress Black patient agency and perpetuate racism and white supremacy (Blackstock, 2024; Maynard, 2018). The first is the unethical use of Henrietta Lacks' biological cells by medical physicians and biomedical scientists to treat other viral and cancerous diseases (Blackstock, 2024; Reverby, 2009; Roberts, 1997, p. 152). 1.41 Henrietta Lacks and the Tuskegee Syphilis experiments Henrietta Lacks, also known as Loretta Pleasant, was diagnosed with cervical carcinomas in situ in 1951, changing the course of biomedical history (Skloot, 2010). Referred to today as HeLa cells, the "immortal" human cells, Lacks’ cells advanced research in polio vaccine, in-vitro fertilization, and cancer (Skloot, 2010, p. 1). Despite the financial and medical success of the 12 HeLa cells in biomedical research, Lacks and her family did not consent to the use of her cells and never received any monetary compensation for the exploitation of her body and cells for further scientific research (Skloot, 2010). Lacks's case highlights the routine use and misuse of her cells by clinicians and scientists at Johns Hopkins University (Skloot, 2010). Lacks was from a poor Black community in Roanoke, Virginia and lived on what once was the same tobacco plantation her family was enslaved on (Skloot, 2010). In the 1960s, segregation laws and racial tensions were fraught in America when Lacks' cells were taken while she was being treated for cervical cancer and later used for medical research purposes (Skloot, 2010). During treatment, medical providers and scientists discovered that her cells could reproduce indefinitely, which was timely since they were looking for cells to use in experimental treatments for diseases like cancer and viral infections (Skloot, 2010). Given the historical connection to Lacks’ family, who were direct descendants of slaves, it is telling how the same healthcare system that once exploited and violated enslaved Black women would also target the cells of a Black woman like Lacks (Skloot, 2010). Lacks' case illustrates how Black patients' autonomy in medical spaces is limited by racially driven power imbalances between the healthcare provider and the patient. There is also evidence of medical abuses and the suppression of Black patient agency and autonomy in the case of the Tuskegee Syphilis experimentation in Alabama on Black African American males (Blackstock, 2024; Reverby, 2009). 13 The Tuskegee Syphilis experiments were a study between 1932 and 1972 that aimed to address the cause of syphilis among Black men in America; biomedical researchers targeted almost 600 poor Black men living in Macon County in Alabama (Reverby, 2009). Participants in the study were not treated or informed of their syphilis condition (Reverby, 2009). Spanning 40 years the public health system and physicians targeted vulnerable Black African Americans with a promise of syphilis treatment who were not treated despite penicillin becoming a readily available cure in the 1940s (Reverby, 2009). The study also continued to perpetuate racial stereotypes about the sexual health and well-being of African Americans at the time (Reverby, 2009). The ongoing legacies of the Tuskegee Syphilis experiment have contributed to African American communities’ growing mistrust of medical research, healthcare providers, and vaccines (Reverby, 2009). The experiments also highlight past medical injustices and the impetus for ongoing movements for racial equity in healthcare (Reverby, 2009). These cases also explain why Black patients are skeptical about healthcare providers today, as healthcare providers have historically and routinely viewed them as 'willing' test subjects to exploit (Blackstock, 2024; Roberts, 1997). A recent study revealed that Black Canadians have less confidence in the COVID-19 vaccines, which traces back to medical discrimination and violence rooted in historical legacies of colonial medical violence and experimentation (Cénat et al., 2024; Reverby, 2009; Skloot, 2010; Washington, 2006) claim that the persistent inequities and medical discrimination faced by Black Canadian communities in Quebec and Ontario are contributing factors to increased rates of deaths and infections from the COVID-19 virus (Cénat et al.,2024). The experiences of Henrietta Lacks and the lives affected 14 by the Tuskegee Syphilis experimentation underline why Black patients are hesitant about relying on a medical system that perpetuates anti-Black racism and white supremacy (Reverby, 2009; Skloot, 2010). 1.5 Conclusion Healthcare and medicine within the American and Canadian contexts have historically failed Black patients through legacies of discrimination and poorer overall health outcomes (Blackstock, 2024; Maynard, 2017). The remnants of colonialism that once minimized Black enslaved people’s agency and autonomy continue to affect Black patient’s mistrust of the healthcare system (Maynard, 2017). In this chapter, I outlined key concepts to situate the importance of this study among other developing research and concepts like anti-Black racism, systemic racism, overt and covert racism and bodily autonomy and agency (Blackstock, 2024; D. Davis, 2019; Dryden & Nnorom, 2021). I also addressed the history of slavery and provided exemplars in both America and Canada (D. Davis, 2019; Murray de Lopez, 2018). This section situates the importance of research addressing the systemic oppression of Black people by the healthcare system. 15 Chapter 2: Literature Review In this chapter, I will explore the current literature on obstetric racism, anti-Black racism in healthcare, implicit biases in treatment practices in reproductive healthcare, and reproductive justice. The literature suggests that further research is needed to understand the impact of systemic racism on Black Canadian patients who access reproductive healthcare in Canada. This section aims to identify the current literature on obstetric racism, anti-Black racism, and reproductive justice. 2.1 Obstetric Racism Davis (2019) situates obstetric racism at the “intersections of obstetric violence and obstetric racism” (p. 561). Obstetric violence is defined as a violation of a woman's reproductive health rights that causes women trauma, harm, and pain during pregnancy and childbirth (Murray de Lopez, 2018). Violence in the field of obstetrics includes insults, denial of pain medication, lack of consent when administrating treatment, threats and intimidation made by healthcare providers, and coercive enforceable methods of administrating medicine (Davis-Floyd et al., 2023; Murray de Lopez, 2018). Obstetric violence does not specify race and instead focuses on poor treatment practices conducted by healthcare providers (Davis-Floyd et al., 2023; Murray de Lopez, 2018). The term obstetric racism accounts for the historical legacies of oppression, discrimination, and violence enacted on Black enslaved women, and today, this continues to affect Black women's interactions with medical professionals during the perinatal period (D. Davis, 2019). These intersections of race and gender shape the treatment of Black women by medical professionals. 16 A study of 50 Black women receiving assisted reproductive technologies (ART) found that Black women are vulnerable to obstetric racism (Davis, 2020). Some barriers include structural racism, financial barriers to accessing technologies like ART, and anticipating potential threats of discrimination when interacting with reproductive healthcare providers (Davis, 2020). Stereotypes about Black women having high fertility play a part in dismissive, neglectful, and intentional harm caused by providers who do not take Black women’s infertility seriously (Davis, 2020). ART is one example of how structural racism permeates obstetric and gynecological spaces in the U.S. (Davis, 2020) Structural racism is tied to institutional policies and practices that reinforce racial inequities and exclude racialized groups and manifests in health research data (Dayo et al., 2023). Canada, unlike the U.S. and the U.K., continued to ignore the effects of systemic and structural racism that persists in the treatment of Black women and manifests in discriminatory behaviour, mistreatment, microaggressions and even death (Dayo et al., 2023; Kanter et al., 2020). A Canadian study interviewed 24 Black women living in the Greater Toronto Area (GTA) and explored their experiences of obstetric racism (Boakye et al.,2023). Participants stated that they felt: “invisible and unheard, being ignored and neglected, feeling objectified and devalued, feeling dehumanized and disrespected, experiencing paternalism and loss of agency, feeling mistreated and traumatized, and feeling stigmatized and discriminated” (p. 4). This study revealed that obstetric racism is present in Canadian healthcare. Recently, there has been a focus on maternal mortality rates among Black women and people of colour (Davis-Floyd et al., 2023; van Daalen et al., 2022). For instance, the rates of maternal mortality among Black women in the U.S. and U.K. are high, indicating that racial 17 discrimination is linked to health inequities among racialized people. A systematic review reported that Black and Indigenous women had two to three times higher mortality rates than white women in the U.S (van Daalen et al., 2022). This study also found that mortality rates for Black women are two to four times higher than for white women in the U.K. (van Daalen et al., 2022). Another study from the US indicated that 60% of pregnancy-related deaths are preventable and that women of colour, including Black and Native American (Alaskan women), are “3.3 and 2.5 times more likely to die from pregnancy-related causes than White women, respectively” (Sutton et al., 2021, p. 229). Eurocentric and Western cultural ideals fuel “patriarchal healthcare systems” that perpetuate the normalization of male, white healthcare providers who have the power to decide and control the health outcomes of women and marginalized people (Coen-Sanchez et al., 2022). A U.S. study with 11 young Black mothers between the ages of 19-23 found that Black mothers experienced stress, racism, and discrimination when seeking obstetric care (OjiNjideka Hemphill et al., 2023). The findings suggest that Black women have a mistrust of the medical system stemming from their routine experiences of trauma and stress while pregnant (OjiNjideka Hemphill et al., 2023). This study also showed that Black women adopted methods to resist obstetric racism with the concept of obstetric resistance (OjiNjideka Hemphill et al., 2023). These methods include finding trusted, credible health advocates concerned with maintaining the Patriarchal Healthcare Systems are when medicine as an institution uphold patriarchy and the domination of male perspectives, health issues, and ideals, which poorly effects women’s health, issues, and adverse chronic problems (Coen-Sanchez et al., 2022). 18 patient's rights. This study identified that the patient's family members, like mothers, played the role of advocate alongside a trusted healthcare provider like a nurse or doctor (OjiNjideka Hemphill et al., 2023). Obstetric resistance is the mechanisms Black and or racialized women employ to ressist threats of racism and dsicrimination by relying on health advocates and providers they trust with their medical treatment (OjiNjideka Hemphill et al., 2023, p. 1). Obstetric resistance directly responds to patients who feel disempowered and lack autonomy (OjiNjideka Hemphill et al., 2023). Participants explained that family members or people who participants felt were trustworthy advocates contributed to fewer instances of obstetric racism (OjiNjideka Hemphill et al., 2023). 2.2 Implicit Biases in the Delivery of Care Reproductive healthcare providers may implicitly or explicitly enact medical racism in their interactions with racialized patients (Hall et al., 2015; Hirsh et al., 2015; Kanter et al., 2020; Maina et al., 2018; Sim et al., 2021). A systematic review of 23 articles (including 1,006 participants from the U.S., U.K., Australia, Canada, and Hong Kong) identified barriers affecting marginalized patients (Hall et al., 2015). These barriers included poor communication, problems accessing healthcare, viewing patients as noncompliant, and differing cultural obstacles, all contributing to power imbalances between patients and healthcare providers. Implicit bias, including covert racism, was found to be present in all of the studies, which contributed to the inequities among dark-skinned patients in the U.S. (Hall et al., 2015). 19 A review of 37 U.S. studies found that healthcare providers who display “higher implicit biases” have increased health disparities with “pain management and empathy” when interacting with racialized patients (Maina et al., 2018, p. 219). The authors also found that across multiple healthcare specialties and from varying levels of training (residents and physicians) have an implicit bias against Black and dark-skinned patients, which resulted in poor health outcomes and negative interactions (Maina et al., 2018). However, Black health practitioners are less likely to exhibit implicit biases when compared with white and other racialized practitioners (Maina et al., 2018). Kanter et al. (2020) described these biases experienced by patients from healthcare providers as microaggressions. Microaggressions are the unintentional behaviours or comments that marginalize racialized groups (Kanter et al., 2020). They are experienced by Black and people of colour to reaffirm whiteness as the norm (Kanter et al., 2020). A study found that microaggressions emerge when a Black patient is anxious about facing a negative interaction with a non-racialized healthcare provider (Kanter et al.,2020). Black patients may disengage based on prior negative health experiences with a provider or general mistrust of the healthcare system (Kanter et al.,2020). The results of the study suggest that “[m]edical providers may be more likely to exhibit bias with patients of color in specific racially charged moments during medical encounters” (p. 1). Racial disparities, therefore, stem from persistent microaggressions enacted by their healthcare providers (Kanter et al., 2020). Microaggressions include verbal insults, diagnosing based on stereotypes, and showing a lack of interest in patient’s concerns (Kanter et al., 2020). 20 A systemic review addressed health disparities among Black and Hispanic women in the U.S. and their interactions with providers like obstetricians and gynecologists (OBGYNs) and found broader factors that influence reproductive healthcare services, including difficulty accessing health insurance and access to trusted providers (Sutton et al., 2021). Structural racism is the unequal access and inequitable opportunities to systemic institutional resources like education and healthcare (Sutton et al., 2021. Disproportionately, racialized groups are more likely to have inadequate resources to access healthcare in the U.S. (Sutton et al., 2021). One study reviewing unregulated treatment practices used by medical residents and clinicians in 12 virtual (white/Black) patients found that explicit and implicit racial biases contributed to poor administration of patient pain with opioids (Hirsh et al., 2015). The study found negative stereotyping influenced pain management decisions (Hirsh et al., 2015). For instance, a provider would under-prescribe medication to a Black patient based on the belief that they are more likely to become drug addicts (Hirsh et al., 2015). A similar study assessed the pain management of 25 Black premenopausal women living in the southern U.S. from the time they reported pain to the time of treatment for their condition (Thorpe et al., 2022). The study revealed that Black patients who poorly communicated their pain were more at risk of chronic pain related to their reproductive health (Thorpe et al., 2022). Healthcare providers and obstetrician-gynecologists (OBGYNs) assumed that Black women lacked knowledge about their bodies and sexual health and that they were uneducated about their pain management (Thorpe et al., 2022). Healthcare providers often invalidated Black women’s concerns about their pain and health. 21 Scholars have identified that Black women experience chronic pain more than any other race in the U.S., and this is exacerbated during pregnancy and birth (Cousin et al., 2022; Mander & Tocher, 2011; Martis, 2020; Thorpe et al., 2022). Black women are less likely to be given pain medication and are more likely to experience chronic pain (Cousin et al., 2022). A study of 2400 women found that participants experienced discrimination when treated for their chronic pain. Specifically, 90% of participants reported gendered inequities, and Black women had higher risks of pain and disabilities related to their chronic pain (Cousin et al., 2022). Although Cousin et al. (2022) assessed the effects of chronic pain issues broadly, the study reveals strong evidence that the healthcare system in the U.S. routinely delays diagnosis, dismisses Black women’s chronic pain, and under-prescribes Black women’s pain medication for chronic health conditions. Another study focusing on postpartum opioid pain management among racialized women (Hispanic, Black, and non-Hispanic) in the U.S. found that race played a role in poor pain treatment methods of women dealing with postpartum pain issues (Badreldin et al., 2019). The study also found that despite non-Hispanic Black and Hispanic U.S. women reported a pain score of “5 or higher” (indicating experiences of extreme pain), they were consistently underprescribed pain medication. These findings provide evidence that despite the attempt to standardize pain measurements, racialized patients continue to be undertreated (Badreldin et al., 2019). Much research has been done to understand how Black patients experience racism; however, there is also evidence showing that Black and racialized health care providers also experience racism (Williams et al., 2023, (Hall et al., 2015; Hirsh et al., 2015; Kanter et al., 2020; Maina et al., 2018; Sim et al., 2021; Sutton et al., 2021).). Blackstock (2024) highlights the lack of Black medical students gaining admission into medical school and describes her time at 22 Harvard Medical School, where only 10% of students were Black. Blackstock (2024) described her experiences of racism as a student such as feeling dismissed and ignored, and being treated poorly by her white professors. Increasing the number and retention of Black physicians in the U.S. would improve equitable health outcomes for Black and racialized patients (Williams et al., 2023). Limited research has examined how Black and racialized reproductive healthcare providers experience racism in their profession. One study found that Black, Indigenous, and or people of colour (IBPOC) experience racism working in the field of midwifery in Ontario, Canada (Aseffa et al., 2023). Findings from the study indicate that greater racial diversity among healthcare providers improves the care, delivery, and treatment of patients who identify as IBPOC (Aseffa et al., 2024). The study suggests that healthcare providers must also reflect the patients they support (Aseffa et al., 2024). The race demographics currently in Canadian reproductive healthcare indicate a disproportionately low representation of IBPOC healthcare providers (Aseffa et al., 2024). The Association of Ontario Midwives (AOM) (2024) found that “19% of AOM” professionals identify as IBPOC, and “34% of people in Ontario” identify as a racialized minority (p. 52). Increasing the representation of racialized healthcare providers is part of the principles of reproductive justice, which advocates for more equity and inclusion in healthcare (Wade, 2023). 2.3 Reproductive Justice Reproductive Justice is central to the successful health and well-being of patients, especially those from underrepresented groups (Wade, 2023). Reproductive justice was created by one of the founders of SisterSong, an American (Southern) based organization used to improve and advocate for institutional policies to improve reproductive health access for 23 marginalized Black and Indigenous communities (SisterSong, n.d.; Ross, 2017; Wade, 2023, p. 68). After second-wave feminism, reproductive justice was created to improve the lives of IBPOC patients in the U.S. (Wade, 2023). As sexual and reproductive health was discussed more in the 1960s and 70s, reproductive justice advocates called for better sex education, adequate access to contraceptives and reproductive healthcare (Wade, 2023). Reproductive justice challenges oppression and is only enacted when there is economic, social, and political equity among racialized populations (Ross, 2017; Wade, 2023). Reproductive justice frameworks are central to human rights issues and are at the core of debates related to IBPOC women’s reproductive health in the U.S. (Luna, 2020). The three core aims summarized by SisterSong include: all women have the right to decide their birth and conditions of how they will deliver their child, all women have the right to decide whether she has a baby or not and know their health options to prevent or terminate a pregnancy (Luna, 2020). Also, women have the human right to have access to and receive social support to maintain a safe environment for their child(ren) without fear of violence from the government (Luna, 2020). All the tenets of reproductive justice highlight its efforts to protect the agency and autonomy of Black women accessing reproductive healthcare services safely in the U.S. (Luna, 2020; Ross, 2017; Wade, 2023). In Canada Action Canada for Sexual Health and Rights (aka Action Canada) is an organization that provides information about sexual health and reproductive healthcare (e.g., abortion care and general information about sexual health) (Action Canada | Action Canada for Sexual Health and Rights, n.d.). Action Canada does not provide reproductive health services specifically for Black women, but they focus on providing equitable forms of sexual health for all people, including racialized populations. 24 Canada is complicit in reproductive injustices, which is a “polite […] form of racism” that continues to affect marginalized patients and their overall health outcomes (El-Mowafi et al., 2021). The authors argue that the current assumptions in healthcare are that “white[ness] is normal,” other racialized groups are the exception, and that equity and accessibility are equal for everyone (El-Mowafi et al., 2021, p. 2). El-Mowafi et al. (2021) argue that reproductive justice, like intersectionality, has its roots in social justice and human rights advocacy. Intersectionality is a critical feminist framework and practise with its roots in social justice. Cho et al. (2013) define intersectionality as “a heuristic term to focus attention on the vexed dynamics of difference and the solidarities of sameness in the context of antidiscrimination and social movement politics” (p. 787). Intersectionality is vital to understanding how IBPOC women are unique in their experiences and social identities and can experience certain privileges or discrimination and oppression differently depending on differences in class, gender, age, and sexuality (Cho et al., 2013; El-Mowafi et al., 2021). IBPOC women experience trauma and oppression variably depending on their intersectional social identities (Coen-Sanchez et al., 2022). A young Black woman with a poor socioeconomic background may experience more stereotypes when compared with a mature Black woman with higher socioeconomic standing (Cho et al., 2013; Coen-Sanchez et al., 2022). Nonetheless, regardless of a mother’s socioeconomic status, she has an equal likelihood of experiencing discrimination (D. Davis, 2019). To address systemic racism, Coen-Sanchez et al. (2022), like other scholars researching reproductive justice, in response are adopting this framework by hiring more IBPOC doulas, physicians, and midwives. Reproductive justice is also a movement for change that encourages and supports women and girls to actively 25 voice their concerns about their reproductive care (Coen-Sanchez et al., 2022). Systemic targeting of IBPOC women through coercive sterilization has contributed to legacies of reproductive health disparities (Coen-Sanchez et al., 2022). A Canadian example of this was the decades-long forced sterilization of Indigenous women living in rural areas of the country with coercive abortions, tubal ligations and prolonged use of contraceptives (Coen-Sanchez et al., 2022). Sterilization among Black populations in the U.S. is extensively documented as compared to Canada. Before the 1980s, the U.S. government overtly sterilized Black women for medical experimentation (Ross, 2017). Sterilization then transitioned into covert forms where the U.S. government coerced Black women to voluntarily participate in sterilization campaigns aimed at providing long-term low-barrier chemical procedures with drugs like Norplant, Depo-Provera, and copper IUDs (Ross, 2017). This chapter has explored the importance of reproductive justice, implicit biases in reproductive healthcare treatments of Black patients, and how medical (obstetric racism) contributes to negative health outcomes for Black women in Canada and the U.S. Reproductive justice is imperative for health equity, accessibility for all, and addressing systemic and overt racism enacted by healthcare providers. Implicit biases continue to persist in the stereotyping of Black patients as difficult, noncompliant, and able to withstand extreme pain, which all result in negative health consequences for them (Hall et al., 2015; Kanter et al., 2020; Maina et al., 2018; Prather et al., 2018; Sim et al., 2021). The current literature suggests Black women in Canada and the U.S. are navigating obstetric racism when seeking reproductive healthcare treatment (Boakye et al., 2023; D. Davis, 2019). Understanding the cause of racism, oppression, and discrimination that cause, in some extreme cases maternal mortality, is vital to the successful 26 treatment of Black patients (D. Davis, 2019). The literature discussed in this chapter lays a comprehensive foundation for the current health climate treatment of Black patients in the Canadian reproductive healthcare system. Chapters 4 and 5 of this thesis in the Findings and Discussion section will discuss interview transcriptional data and findings from 25 qualitative interviews with Black Canadian women from British Columbia, Ontario, and Manitoba. 27 Chapter 3: Methods This chapter explores the methods and theoretical frameworks applied in this research study. I adopted a critical race feminist theoretical framework and a qualitative descriptive design in this research. Critical race theory examines how social institutions perpetuate racial inequality, discrimination, and oppression and aims to dismantle systemic racism using a social justice lens (Wing, 1997). Critical race feminism, like intersectionality, examines how social inequality shapes the experiences of individuals based on their social location (Wing, 1997). Social categories, such as race, age, gender, class, and educational background shaped participants’ experiences and affected how they navigated social institutions. This feminist framework also problematizes structural inequality affecting women of colour). Instead of viewing a participant as one-dimensional or focusing on one part of a person’s social location, in this research study, I engaged with intersectionality as a framework to understand the complexity of people’s identities and lives (Shramko et al., 2019). Intersectionality is a framework to understand how an individual intersects with multiple socio-political identities and locations (Cho et al., 2013). Kimberlé Crenshaw is the earliest theorist to define intersectionality within a social justice perspective to address how discrimination toward Black women differs considerably from other marginalized groups (Crenshaw, 1991). Researchers use critical race theory as a framework to review qualitative research data to understand how institutions perpetuate oppression based on socio-political factors, such as race, gender, age, and class (Wing, 1997). Critical race theory centres marginalized voices to seek perspectives from those that are traditionally underrepresented in qualitative research (Crenshaw, 28 1991; Wing, 1997). In this research study, I examined how medical reproductive settings and challenges the unequal power dynamics that decentre Black patient voices. This framework also challenges dominant narratives that serve to reinforce stereotypes, discriminatory behaviour, and unequal power within institutions like medicine (Wing, 1997). By fostering an equitable research environment centred on participants’ narratives, I integrated critical race theory into interviews. I framed research around participant’s experiences and used probing questions to guide discussions rather than interrogating participants for specific information. I also analyzed the data using critical race as it was a tool to focus on the effects of racism and race on the individual. I understood how medicine as an institution perpetuates racial inequity and oppression. Qualitative descriptive is used to capture the meaning of a particular social phenomenon (Kim et al., 2017). Qualitative research was adopted in this study to understand the experiences of participants, patient interactions with providers, and the impacts of the healthcare system on the individual (Kim et al., 2017). Qualitative data included semi-structured interviews, which remained open-ended and flexible and were guided by probing questions (Kim et al., 2017) Quantitative research does not capture the experiences of Black women, their voices, and their perspectives. Current quantitative research addresses reproductive healthcare outcomes related to discrimination and oppression by focusing on the considerably higher maternal mortality rates of Black women in the U.S. (D. Davis, 2019). Qualitative research is helpful when little is known about an issue or problem as it elaborates on missing information (Miles et al., 2014). Qualitative description is a framework used to describe health-related phenomena in healthcare. This analysis also understands situations and interactions among patients and healthcare providers in their “natural state” (Kim et al., 2017, p. 24). 29 Qualitative research methods involve continuous engagement with participants throughout the research process, centring participant voices and providing enriched data analysis to find potential reoccurring themes (Berg, 1998; Denzin & Lincoln, 2013; Miles et al., 2014). In this study, I applied this approach by leaving room for participants to share their experiences without interrupting. Qualitative data unearths “naturally occurring” and “ordinary events in natural settings” (Miles et al., 2014, p. 30). In this study, participants reported meeting for the Zoom interviews in a comfortable location (in their homes) where they could confidently share their stories. This qualitative method explores the “lived experiences” of participants and draws meaning from these interactions with their healthcare providers (Miles et al., 2014, p. 30). In interviews, participants would talk through their traumas with me and process the events to understand them better. 3.1 Recruitment Data collected in this research study came from my Undergraduate Research Award project in 2021 master’s research conducted in 2023-24. In 2021, I conducted a total of 15 interviews, and for this Master of Arts study, I collected 10 interviews, making it a combined total of 25. As approved by the UBC Okanagan Ethics Board (H23-01589), I collected data from two separate but closely related projects. The Undergraduate research project focused on the general experiences of Black women in Canadian reproductive healthcare contexts and this master’s research understands how they navigate medical obstetric racism. The inclusion criteria for both projects were the same. Eligible participants included English-speaking Black Canadian women, 18 years or older, who immigrated to Canada within the last 20 years or who were born in Canada (and identify as Black Canadian), and who currently reside in Canada. Eligible participants had to have given birth in Canada and to have had perinatal and postnatal experiences. 30 I used social media to recruit participants by engaging with Black Canadian community groups on Facebook. I also reached out to community groups like Black Caucuses to attract a diverse pool of participants from varying backgrounds and professions. I used a digital recruitment poster to display information about the study, eligibility criteria, and UBC contact information. Then, I uploaded the poster to community groups and Facebook pages (see Appendix B). Additionally, I recruited participants by implementing snowball sampling, where participants shared information about the study with other potentially interested and eligible individuals (Noy, 2008). In some cases, participants shared their experiences of the study with friends and family, who also expressed interest and reached out via email or social media. This expanded the participant pool and allowed a wider reach of Black women from varying communities and locations across Canada. Noy (2008) claims that snowball sampling is integral to the qualitative recruitment process as it allows researchers to access communities that are otherwise difficult to reach and increases variability in participants. This was true for this study. Throughout the recruitment process, my focus was to minimize any fraudulent participants who did not meet the minimum requirements of the research study from participating. There were screening processes, which included a brief conversation via email or phone to verify participant identity and ensure they met the eligibility criteria (Sefcik et al., 2023). Qualitative research risks attracting fraudulent participants based on the honorarium, so a potential participant may misrepresent themselves for financial gain (Sefcik et al., 2023). I applied the screening tools throughout the recruitment process and avoided including fraudulent participants in this research study to maintain research standards (Sefcik et al., 2023). 31 3.2 Ethical Considerations and Confidentiality Those who participated in this research study signed consent forms approved by the University of British Columbia (UBC) Okanagan Ethics Board H21-00692 (Undergraduate Research Award project in 2021) and H23-01589 (included the combination of both Undergraduate Research Award and master’s research Study in 2023-24) (See Appendix A). Participants were allowed to choose a name they wanted to be referred to in the interview to facilitate participants’ autonomy when sharing their experiences and to ensure confidentiality. In all data collection, including transcriptional data, I used pseudonyms. The data was stored on a password–protected computer (including password-protected Word documents) on a UBC server. As per UBC Okanagan Ethics, the principal investigator and graduate researcher (Stephanie Awotwi-Pratt) will continue to store the data for a minimum of five years. There were no conflicts of interest in this research. Throughout the study, I followed UBC Okanagan’s ethical guidelines and policies. There were ethical considerations made to protect the privacy and information of participants and to minimize harm. Participants reviewed the consent form and were given opportunities to ask about confidentiality and ethics, including the use of pseudonyms used to protect their personal information throughout the study. 3.21 Potential Risks and Benefits of the Study This research study was considered low risk, and to mediate any risks, participants were given mental health support resources specific to reproductive health contexts to review after interviews were conducted (See Appendix C). The purpose of the study was to provide participants with the opportunity to reflect on their experiences and interactions with medical practitioners in Canada and to engage with their past with healthcare providers reflexively. Participants mentioned 32 post-interview how cathartic and reflexive the experience was, and the interview was one of the few times they could describe their pregnancy and childbirth. Participants were always given opportunities throughout the interview and research process to withdraw from the study if they chose to. Participants could review their transcripts after one-on-one interviews with the researcher. The study considered how some participants may have found some questions to be upsetting, frustrating, or stressful, but it was made clear that participants did not need to answer if they felt uncomfortable. An honorarium of a $25 gift card or voucher was given to each participant after the interview was concluded as a token of appreciation for their time. 3.3 Qualitative Interview Procedures I initially reviewed the fifteen transcripts to get a sense of the data after interviews were conducted during my Undergraduate Research Award study (See Appendix D for Undergraduate Research Award Interview Questions) and ten interview transcripts in the research for this thesis (Awotwi-Pratt, 2021). Using a semi-structured questionnaire (See Appendix C), I conducted one-on-one interviews with Black Canadian women across Canada via UBC Zoom, using a UBC account, ensuring that the data was on servers located in Canada. I gave participants the option to keep their cameras on or off, depending on their personal preferences. A moderator mediated the verification of participants’ names and identities through social media accounts and once verified within Black social groups, and I also communicated with participants before our oral interviews. All interviews were audio recorded. The video recordings were not accessed or used in this research study as specified in the ethics application. Qualitative interviews lasted between 60 to 90 minutes. Participants were asked about their experiences with pregnancy, labour, and delivery within reproductive healthcare settings like hospitals and how that has shaped them as Black 33 Canadian women and mothers. Interview questions and prompts included questions such as: Tell me about your experiences with healthcare providers. Did your experiences or interactions with your healthcare provider affect how you navigated the healthcare system throughout your pregnancy? If so, how? Questions guided the interviews, and this study focused on how participants managed potentially racist interactions with medical providers. 3.31 Managing Research Data Data was managed using a UBC Okanagan server and organized using naming systems, such as RMR###, to arrange and indicate the participant transcriptional data. Throughout the research process, the researcher protected the confidentiality and personal information of participants by storing all research data on the UBC server only. Coding data were stored in a separate document on the UBC server SharePoint folders. NVivo12 was not used in this study, rather, themes and coded data were generated manually by reviewing the transcripts line by line and gathering commonalities and themes from and within the data. 3.32 Data analysis Data analysis was a reflexive process of reassessing and analyzing the qualitative research data for trends and patterns. I adopted a thematic data analysis approach to analyzing research data (Bloomberg & Volpe, 2019; Charmaz, 2014). First, open coding was used to familiarize myself with the transcriptional data (Charmaz, 2014). Second, I looked for relationships within the data, referred to as axial coding, which builds on the initial observations made in the qualitative interview data (Bloomberg & Volpe, 2019; Charmaz, 2014). Third, I was selective about the transcriptional data, focusing on specific sections of the interview transcripts to organize them into themes (Bloomberg & Volpe, 2019; Charmaz, 2014). As a methodological practice, I actively engaged with the data after the preliminary data collection by analyzing it shortly after recording 34 it with the participants. Throughout the research process, I consistently compared other transcriptional data collected from all 25 participants. Interviews were transcribed verbatim to include pauses, laughter, or any interruptions in speech. I used the ‘naturalism’ process to transcribe exactly what was said in interviews (Oliver et al., 2005). However, to present the data clearly, the quotes in Chapter 5 are ‘denaturalized’ meaning that the verbal expressions were removed without undermining the meaning of the participant’s words (Oliver et al., 2005). The URA research study is related to the Master’s research study since both studies addressed the strategies Black women used to avoid experiencing discrimination. Although the URA focused on maternal health experiences, themes highlighted the unintentional and intentional strategies Black women used throughout pregnancy and birth. 3.33 Coding After coding the transcripts, themes were generated from the research data gathered. The initial coding included “open coding” and then “focused coding” throughout data collection (Charmaz, 2014, p. 478; Saldaña, 2016). “Open coding” initially sorts and organizes initial data into general groups that develop into “focused coding,” which specifies concepts, themes, and trends across interview transcriptional data (Charmaz, 2014, p. 478). For credibility, the principal investigators reviewed the transcripts and coded two interview transcripts to verify consistency in coding. Coding research data and reviewing the transcriptional data are how themes, patterns, and consistent trends were generated. 3.4 Positionality of Researcher As a Black Canadian woman who has not given birth, my positionality was crucial to the success of this research study. Cultural access and the ability to understand participant perspectives contributed to the conversational style and relaxed interview format. Even though I 35 have not given birth, my familiarity with reproductive health and knowledge of the medical field from prior university education supplemented the health-related jargon participants introduced in interviews. I chose this research study based on my interests in reproductive healthcare and knowing of a Black woman like Serena Williams, who experienced complications after giving birth (“Serena Williams Tells Scary Story of Childbirth Complications,” 2018). Her story inspired me to pursue this research study. Williams explained how she felt overlooked by medical providers, and this story ignited discussions about Black women’s maternal health in the U.S. and Canada (“Serena Williams Tells Scary Story of Childbirth Complications,” 2018). Since I also have Ghanaian ancestry and can speak and understand Twi, some participants who identified as Ghanaian felt more comfortable sharing their experiences because I had the cultural context to understand them. My lived experience as a Black woman afforded me an insider perspective on the lives of other Black women; this commonality gave me an enriched and empathetic understanding of their experiences of medical (obstetric) racism. Given my daily experiences of navigating racism, and microaggressions, I was able to identify and characterize the issues that affect Black patients who participated in this study. Intersectionality was essential in this research study as I understood the layered effects of oppression and the diversity of Black experiences (Crenshaw, 1991). I know the diaspora of shared experiences Black women have based on diverse factors such as age, socioeconomic status, and class complicate their experiences with the Canadian healthcare system. Throughout the research process, I continued to interrogate my positionality and examined my own biases and assumptions about how and why Black women may experience racism and oppression when seeking reproductive healthcare treatment. As a researcher who identifies with the racial identity of participants, I aimed to foster a space of empowerment and 36 encouraged participants to feel safe sharing their experiences and stories. I balanced academic research rigour while valuing emotional narratives from participants throughout the qualitative research interviews. My interdisciplinary background in sciences, social sciences, and the humanities was instrumental in building the contextual foundations for this research. I was equipped with an understanding of how historical legacies of oppression and violence inform present realities for Black Canadian women. My social science background aided in interrogating how institutions and systems like medicine play a role in standardizing norms about Black patients based on racialization. This context was important throughout the research process from the interviews to data analysis. The interview process, including asking participants about their experiences, was a chance for participants, who had not previously been able to discuss what happened during their pregnancy and childbirth, to reflect and hold space for their perspectives and knowledge. Participants stated that participating in this research was therapeutic and that participating in this research was one of the few opportunities for them to describe and reflect on their pregnancy and childbirth experiences and to feel that their perspectives were acknowledged and validated. One of my goals in this research study is to make ethical considerations to maintain respect, support, and integrity throughout interactions with participants. My goals in this research study were to uplift, empower and advocate for systemic changes in healthcare that support the positive health outcomes for Black Canadian women. Empowering participants does not just include recording data for the research study but also highlights their agency, autonomy, and resilience despite confronting discriminatory medical practices. 37 This research study was continually developing and shaping discourses surrounding systemic racism in reproductive healthcare contexts. The goal of this research was to provide a deeper look at how medical (obstetric) racism shaped the experiences of Black Canadian women to change future medical policies and practices and contribute to equity in reproductive healthcare. By highlighting the voices and experiences of Black women, I seek to dismantle structures and institutions that perpetuate racial disparity and discrimination that result in extreme cases of maternal mortality (D. Davis, 2019). This research aims to bring awareness to the unique health disparities and challenges Black women face in Canada, which is impacted by my identity as a Black woman. Based on my perspective, I am uniquely placed to produce research that is impactful to Canadian reproductive health research while also contributing to reproductive justice and racial equity. 3.5 Trauma Informed Intersectional Feminist Approaches To best support Black Canadian women who participated in the study as they disclosed sensitive and traumatic experiences in interviews, I adopted trauma-informed intersectional feminist approaches (Shramko et al., 2019). Shramko et al. (2019) highlights the value of adopting a trauma-informed approach since the approach “unearth[s] underlying causes of health inequities” (p. 1). The goal of trauma-informed intersectional approaches is to examine how the social locations of participants, based on socio-cultural factors, such as their race, gender, age, and class, affect how they experience social inequality and medical obstetric racism (Shramko et al., 2019, p. 2). Adopting a trauma-informed approach in healthcare research shaped my interactions with participants for the better (Shramko et al., 2019). I embedded these approaches (Appendix E) throughout the research process, this included sharing health resources after each interview, not 38 interrupting participants as they shared their experiences, and validating their feelings after sharing a traumatic event (Shramko et al., 2019). This approach also minimized power imbalances between participants and me. Interviews felt like conversations among friends rather than question-response style discussions. I remained cognizant of my role as the researcher, only speaking to clarify a point, ask a question, or validate how a participant felt. Trauma-informed intersectional approaches shaped how I asked questions. In some interviews where a particular topic was sensitive to the participant, I would not probe further and ask more about their experiences with a particular provider when they indicated they did not want to answer. This approach honours a participant’s boundaries regarding what they are willing to share and respecting the sensitivities of their experiences. 3.6 Inductive Research Analysis of Qualitative Research Data An inductive approach was used in this research to analyze the raw qualitative research data (Thomas, 2006). This approach required first collecting the research data and then observing any themes, concepts, and trends (Thomas, 2006). Inductive research analysis is a research approach that focuses on multiple detailed readings of qualitative research interview data to generate themes and concepts guided by a theoretical framework (Thomas, 2006). Instead of drawing a hypothesis before the data collection, in this research, I was open to what the participants shared throughout the study to guide the research, making adjustments in data collection using probing questions (Thomas, 2006). I embedded probing questions (Miles et al., 2014) to expand on a particular point the participant shared: What were your experiences with pregnancy in Canada? A probing question in this research study included: please tell me more 39 about your pregnancy visit at the local hospital and your experiences with your healthcare provider(s). Inductive research analysis was imperative to the research process, as it allowed for any surprises in the research data and any new interpretations of the research data (Thomas, 2006). The steps to conduct an inductive research analysis included, first, collecting qualitative research data through one-on-one qualitative research interviews with participants (Thomas, 2006). Second, reading and re-reading the transcribed research data (Thomas, 2006). Third, make short notes after interviews to highlight any initial observations in interviews (Thomas, 2006). Fourth, coding the research data by focusing on general concepts or initial themes observed in the research data (Thomas, 2006). Fifth, after conducting two or three interviews, I looked for any general patterns in the research data. Finally, drawing conclusions and looking for consistency across qualitative interview data. Overall, inductive research analysis allows for the natural emergence of themes in the research data (Thomas, 2006). 3.7 Summary of Methods This research required the use of qualitative descriptive research methods to capture the lived experiences of Black patients experiencing pregnancy and childbirth. In this chapter, I have outlined the importance of qualitative description in this research and critical race theory as an intersectional approach and theory in practice. I have also explored the recruitment process, ethical considerations and confidentiality, and potential risks and benefits of the study to support the health and well-being of participants throughout the research process. In doing so, the interview procedure aligned with trauma-informed practices to reduce harm to participants when sharing their experiences. The management and storing of data remain compliant with UBC Okanagan Human Behavioural Ethics as stipulated in the consent form found in Appendix A. Trauma-40 informed intersectional approaches were also employed to support the well-being of Black Canadian women in their shared confidential, sensitive, and private information about their experiences with healthcare providers. This approach strengthened the rapport between the researcher and the participant throughout the interview process. Inductive research analysis is useful to understand how research data is open to interpretation. The diaspora of Black women’s experiences that will be explored in subsequent chapters indicates how race, gender, class, status, and education influence how participants navigate threats of discrimination in the Canadian reproductive healthcare system. Chapter 4 explores the major findings of the data gathered from the interviews. Chapter 5, the Discussion will explain how the research findings are situated among emerging scholarship. 41 Chapter 4: Research Findings In this chapter, I will describe the findings gathered from 25 qualitative interviews of Black Canadian women living in British Columbia, Ontario, and Manitoba. I gathered five findings from interviews between 2021 and 2024. The five themes from these interviews include: 1) Black women anticipate experiencing medical racism given the known health disparities in the United States and 2) There is consistent dismissal of Black patients’ pain, resulting in a lack of care, 3) Participants adopt strategies to navigate interacting with healthcare providers, 4) A recognized need for Black or racialized representation of healthcare providers, finally, 5) Patient-centered care is integral to the success and well-being of Black patients. Overall, most participants expressed having experienced obstetric racism, poor health outcomes, and dismissal during their pregnancy and or childbirth. Table 1 describes the demographic data collected in interviews. Please note all names mentioned are pseudonyms of participants to protect the identities of those who were interviewed in this research study. Table 1: 25 Black Canadian Women’s Participant Information Number Participant Pseudonym Age (at the time of interview) Location at time of interview 1 Marissa 31 Manitoba 2 Tracey 30 British Columbia 3 Sally 28 British Columbia 4 Cassie 41 Ontario 5 Tamra 32 British Columbia 6 Lebuhang 32 Ontario 7 Shantel 29 Ontario 8 Joanne 24 British Columbia 42 Number Participant Pseudonym Age (at the time of interview) Location at time of interview 9 Reena 37 British Columbia 10 Dori 42 British Columbia 11 Jane 49 British Columbia 12 Vee 26 Ontario 13 Mela 36 Ontario 14 Kelly 30 Ontario 15 Jenny 34 British Columbia 16 Blue 30 British Columbia 17 Glo 24 British Columbia 18 Lala 39 British Columbia 19 Nana Yaa 30 British Columbia 20 Anaya 30 British Columbia 21 J’s mom 31 British Columbia 22 Maya 30 British Columbia 23 Eli 20 British Columbia 24 Claire 27 British Columbia 25 Evadne 44 British Columbia 4.1 Effects of Known Health Disparities Most of the participants expressed feelings of anxiety, stress, and fear about interacting with healthcare providers, knowing that they may be mistreated. Most of the participants shared that they heard from a friend, researched on their own or knew of someone online who was a Black woman and had experienced a negative birthing experience. One participant, J’s mom, who is an OBGYN resident in B.C., shared her anxieties from a healthcare provider perspective but also as a Black woman about to give birth: 43 Like I knew from what I had heard from other Black women in passing that they did not have amazing experiences in the Lower Mainland [J’s mom]. Hearing from other Black women who had poor health experiences brought up feelings of anxiety and stress about the potential dangers of giving birth in B.C. J’s mom shared that she chose to give birth in the hospital she worked in to avoid becoming a maternal mortality statistic: I was like, I don’t want to deliver somewhere where people don’t know me because that would lead to potentially me, you know, being this like a statistic like others that have been treated [J’s mom]. Since Canada does not collect race-based data on Black maternal health, J’s mom refers to the well-known statistical data in the U.S. that document the higher maternal mortality rates of Black women (D. Davis, 2019). J’s mom’s awareness of the high maternal mortality rates in the U.S. was evident based on her professional knowledge of the reproductive healthcare system. Evadne also works in the healthcare industry as a social worker, predominantly in hospitals. With knowledge of the healthcare system and the known treatment of Black women in the U.S., Evadne pre-emptively anticipated a racist or negative interaction with a healthcare provider: I was not necessarily hypervigilant. But I was on guard, and I was anxious. I was more prepared for what I thought might be an uncomfortable experience [Evadne]. 44 Given what she had already witnessed, Evadne explains how she could not relax and enjoy her pregnancy and birth, considering how providers treated other racialized patients in that professional environment. Her remarks illustrate a general mistrust of the healthcare system, where she felt the need to protect herself from any threats of violence that could affect herself or her unborn child. One participant, Lebuhang, who lives in Ontario, experienced racism while giving birth to her first child and indicated that her first-hand experiences were proof that she was vulnerable to medical mistreatment. Lebuhang shares how that caused severe anxiety and stress, especially feeling isolated at doctors’ appointments during COVID-19. Because of COVID, it just felt more stressful [to find] new healthcare providers when you weren’t necessarily expecting to because you’re Black. And last time, I experienced so much racism during my birth [Lebuhang]. Lebuhang is a stay-at-home mother and less knowledgeable about the healthcare system. She felt isolated while she tried to manoeuvre a system that had already treated her poorly. In contrast, Blue was a participant who was aware of the known disparities affecting Black women, so she chose to undertake research on her own and educate herself on the processes of giving birth and ways to have the best experiences possible: 45 And as a Black woman, you know, we are obviously affected a bit more than other races. So, I just wanted to make sure that I had the best possible chance of going through the whole thing: pregnancy and birth [Blue]. Blue hints that she knew Black women are affected more by medical obstetric racism than other racialized groups, so she made sure to inform herself on ways to avoid experiencing anything traumatic. Blue also shared that in our interview, to keep her anxieties at bay, she consulted her mother-in-law, who is a Black midwife working in the U.S. and was also aware of the disparities there. Lala, a dual citizen in both the U.S. and Canada, indicated that she was aware of the statistics in the U.S., so while giving birth in Canada, she chose to listen to her instincts about who to take on as her healthcare provider. I didn’t have a midwife, knowing my instincts were going to be pretty spot on about having a C-section because I knew in the U.S., they plan it [Lala]. With the U.S. as a point of comparison and to reduce her fears about the known health inequities among Black women, Lala strategically chose her healthcare team to avoid having negative health experiences. Eli, comparatively, at the time of our interview, was a university student pregnant with her first child and shared hearing conflicting stories from other women on social media about what her own birthing experiences would be like: 46 I’ve heard this story quite a few times, and like, people are kind of really forcing you to birth in the same position that like the [way] that you see in the movies [Eli]. The reference to people refers to healthcare providers she anticipates will force her to give birth in a position with which she is uncomfortable. This remark highlighted her stress and anticipation of how she would feel managed by her provider. Marissa, who was a new mother and a Ghanian professional living in Manitoba, shared the following: I had a Ghanaian midwife who is in Winnipeg who I had a five-minute conversation with, and I told her that I am worried and I am scared about the process and she said you are going to be fine you know just relax and just do this and you are going to go in and come out and with no issues and no problems. So, I did take her word into consideration, and I felt like I could go in and the fact reassured me that I would be fine [Marissa]. Marissa shared her concerns about experiencing discrimination or oppression when interacting with her providers at her local hospital. She discussed with her care provider, who was of the same nationality as her, to navigate the healthcare system given what she knew about Black maternal health outcomes. Marissa leaned on her midwife and her experience with the healthcare system to anticipate any issues. Given her knowledge of the disparities, she collaborated with her midwife to develop the best plan before giving birth. 47 This section has outlined that whether participants are aware of the adverse health statistics affecting Black women’s reproductive health or not, there is a general sense of anxiety and anticipation when interacting with healthcare providers. Whether providers will adequately manage their pain also affects participants and what they consider a healthy, positive birthing experience, as explored in the next section. 4.2 Dismissal of Pain Most participants in this study indicated that they felt their pain was either ignored, dismissed, or discredited by reproductive healthcare providers at some point. An example of this is Kelly, who shared her experiences at an Ontario hospital when she was pregnant as a teen: I remember being told while I was giving birth by a nurse that I should or should not be able to feel pain. I thought my epidural was not working, but she did this to teach me not to end up pregnant again. And [that] she didn’t want to see me there again. [Kelly]. Unethically and barbarically, a nurse chose to deny basic pain medication out of personal prejudice and judgment. The willingness of a healthcare provider to use their power to deny pain relief and comfort as a means of punishing a patient indicates the extent to which a provider holds power over vulnerable Black patients like Kelly. Healthcare providers can also deny, dismiss, and under-prescribe pain medication in the same way. Jenny’s experience is an example of how her midwife walks away when she asks for pain relief: 48 So, I’m getting sick. She decides to leave the room. So, she gave me some options. She said, you can go on morphine, which is going to be potentially stressful for the baby, or you can take Tylenol and Gravol [Jenny]. After being provided with these options and told that there were no beds available, Jenny’s only option was to take an ineffective medication for pain relief and to go home while her labour was quickly progressing. After being sent away to labour at home, Jenny gave birth to her son on her bathroom floor without pain relief or any medical assistance. The ordeal was so traumatic and stressful that Jenny shared how she felt “discarded” by her midwife when she needed her the most. After enduring a painful labour at home for some time, Marissa, a professional living in Manitoba, was rushed to the hospital. Once there, her providers did not have enough time to administer pain relief, so they gave her a small dosage before she gave birth. Marissa shared the following: But I did get fentanyl, not a lot, but a little to help with the pain, and that was it. I didn’t get it before I pushed because it was too late. So, I felt all the pain, but it was what it was [Marissa]. Although Marissa believed her labour was unproblematic, she expressed how unideal the administration of her pain medication was during her labour. Marissa indicates that she has a high pain threshold and believes that other women may not have been able to endure it, so although she did not receive relief, that did not play a big part in her labour. But like other 49 participants, once they express their pain, it is less likely to be taken seriously by healthcare providers, especially during active labour. In our interview, Sally discussed how she used strategies in the hospital to be taken seriously. Sally had just moved to B.C. from Ontario and was accustomed to a higher level of care in her first pregnancy and birth. After labouring at home for some time and arriving at a hospital where they dismissed her pain concerns, Sally decided to exaggerate her voice to show signs that she was in extreme pain. Like my husband was starting to get really upset and because clearly, I am in pain and there were other women in pain and varying levels of pain, and I am not trying to discount that or anything. But they were just going to brush me off and send me home [Salley]. Sally navigates the healthcare system with the awareness that her pain as a Black woman will be taken less seriously, so to avoid dismissal, she vocalizes her discomfort. These strategies worked and Salley shared that she received pain medication shortly after and was assessed faster for complications which she believed would not have been acknowledged had she not spoken up. Shantel, a graduate student from Ontario, shared her Cesarian-section with her first child as follows: I didn’t appreciate after I’d had the C- section, they had just prescribed Advil and Tylenol as my painkillers and when I went home, I remember, like, suffering [Shantel]. 50 Shantel stated that she suffered extreme pain after birth and received little pain relief or support after undergoing major abdominal surgery. While pregnant with her second child, Shantel was anxious and fearful of undergoing surgery and having to endure the excruciating pain for the second time. Participants like Shantel indicate that whether they gave birth vaginally or via cesarian section, they expected to be under-prescribed, dismissed, or given over-the-counter medication to manage their pain. Shantel was concerned that highlighting her recreational drug use, before becoming pregnant, would affect how providers prescribed medication for her pain postpartum: [When I completed] my pre-registration, I was [honest about using] marijuana, [since I suffer from] migraine[s]…So, I don't know if they were feeling like, they didn't want to prescribe me drugs or something [Shantel]. The stigma surrounding recreational drug use was among the biggest concerns Shantel had. She speculated that providers would under prescribe her drugs. Joanne had similar experiences during a vaginal sweep by her OBGYN that she felt was racist and violated her. Joanne shared the following: I think she was trying to also do a sweep and feel where the head is, and it was just really painful, and really invasive. And I was in pain, and she just wasn’t stopping. I just felt really violated. I felt really uncomfortable [Joanne]. 51 Not only did Joanne feel that her pain was not adequately managed, but she felt persistently violated by her healthcare provider after expressing discomfort. Like Kelly’s experiences, healthcare providers often dehumanize Black patients by dismissing their bodily autonomy during routine procedures. Maya shared her experiences with how providers judged and dismissed her pain after a painful C-section and recovery. The nurses were great, but there were a couple that were more crass. And just because they had seen it a thousand times, they didn’t understand kind of how much pain I was in or why I was [in a wheelchair longer], because they were like, It’s a C-section. They said you should be walking by now [Maya]. Maya provides a unique perspective on the way healthcare providers homogenize Black patients and treat them the same, despite her recovery taking longer. Maya’s pain was more severe than what the nurses were used to seeing and instead of supporting her recovery and attending to her needs, they judged and minimized her pain. Maya expresses later in our interview how “insensitive” and “desensitized” they became about her pain even to the point of refusing to support and treat her. The staff and hospital Maya describes was in an area in B.C. where there are not a lot of Black patients, so race could have played a factor in how she was treated. Finally, Mela, who is a law student living in Ontario with a medical history of pregnancy and birth complications, grew accustomed to dealing with pain and discomfort. 52 After birth and experiencing tearing, no matter how painful it was, I had to soldier on [and toughen up]. I have a lot of kids. I can’t relax. [Mela]. Mela’s resilience is what helped her persevere through the pain after childbirth. Mela also stated that her various personal priorities and obligations required her to manage her pain without relief. However, her last pregnancy caused her to spend most of her pregnancy in the hospital after almost bleeding to death. Mela is indicative of all the participants I have spoken with who are incredibly resilient and strong despite confronting oppression, discrimination, extreme pain, and, in some cases, near death. Participants were constantly dealing with healthcare providers and a healthcare system that continually reflected biases and prejudice toward Black patients. Depending on sociopolitical factors like gender, age, and class, some participants had more extreme experiences of oppression than others. Kelly, because she was a teen mother and had less access to social support and knowledge of the healthcare system, was more vulnerable when compared with participants from higher socioeconomic backgrounds who had access to more support. Participants also shared how they adopted strategies to avoid engaging with any forms of discrimination or racism, as explored in the next section of this chapter. 4.3 Navigating Interactions with Healthcare Providers The third theme that emerged from the data was the awareness Black Canadian women had about being perceived by their healthcare providers, whether positive or negative. Stereotypes about Black women can affect the type of medical care they receive. These 53 assumptions serve to marginalize and discriminate against Black women and adversely affect their care, as demonstrated by the examples in this section. Evadne, who was knowledgeable about the healthcare system and how providers perceive their patients, shares the following: It is a very classist system, and it can also be a very patriarchal system. You know, and so I know how to talk the talk. In terms of ensuring when I enter the system, I'm respected [Evadne]. Evadne shares in our interview about the importance of appearance, mannerisms, and tone to be treated respectfully by providers. According to her, providers in medical spaces have power over the patient’s health outcomes, and respect is earned and contested based on appearance, mannerisms, and tone. Evadne shares how she would ensure she styles her hair professionally, presents herself in respectable clothes, and communicates softly and clearly with her provider to avoid experiencing discrimination. In contrast, Kelly explained the mistreatment and judgment she received from her provider. [My first pregnancy as a teen mother] was a pretty stressful and traumatic experience. I felt that I experienced a lot of ageism just because I was a young mom. And a lot of stereotypes were placed on me [Kelly]. 54 Kelly shared how, as a teenager, she was discriminated against by her provider based on her age and because she had a lack of knowledge about the Canadian healthcare system, given she was a new immigrant from Jamaica. Lebuhang shared her experience of severe pain and bleeding postpartum. She expressed her frustration about having to frequent the hospital to avoid encountering a well-known racist on-call physician at the emergency ward who targeted Black patients. Leb returned at different times of the day to avoid encountering the racist on-call physician: And [there was a] super racist person on-call that day, like, what would I have done? Judged for being Black. But you know, like certain people of colour, like still treat you badly, because you're Black [Lebuhang]. Leb shares in this quote that she tried to avoid any encounters with racist healthcare providers, but because of her rapidly deteriorating condition and other concerns, she received treatment from another on-call physician. Leb’s experience illustrates the lengths some women will go through to have their conditions treated. Despite her discomfort and frustration, Leb was determined to find a provider that would take her concerns seriously. In contrast, Blue also shared that to navigate any racist experiences in a B.C. hospital, she found a woman of colour OBGYN because there were not a lot of Black OBGYNs. She felt that by having a woman of colour as a provider, she would experience fewer complications, trauma, and maternal or infant death. Blue entrusted her health to a provider she believed would not judge her but sympathize with and respect her identity, culture, and background. To seek a provider who shared her racial identity or was a person of colour was an intentional strategy to 55 avoid explaining her experiences, race, and culture to someone who may overlook her and her health concerns. Participants use methods to resist any forms of judgment and stereotyping from healthcare providers. Some expressed presenting themselves as poised, professional, and articulate to receive more respect from the providers. Participants also reflected that by being extra selective about their healthcare providers with similar backgrounds or racial identities, they were less likely to encounter discrimination. 4.4 Increased Representation in Reproductive Healthcare Most participants expressed that having a care provider who is either Black or a person of colour would contribute to a more positive experience and overall satisfaction with their care. Being able to relate to a provider who could empathize with their experience positively affected how they maneuvered through their pregnancy and birth. Cultural competency and the ability to relate to participants' cultural backgrounds, cultural needs, and experiences confronting structural racism influenced their decision to see a provider who identified as Black or was a person of colour. Having a provider who has encountered and experienced racism was important to participants as they were more likely to take their patient’s concerns seriously. Based on Vee’s traumatic experiences with her healthcare provider, who she perceived contributed to the stillbirth of her first child, she intentionally sought a Black dermatologist to treat her daughter’s skin condition. I’m looking for a Black dermatologist. I just don’t take chances with certain things I just don’t want to wait and see [Vee]. 56 Vee discussed how traumatized she was after her previous healthcare experience that resulted in a stillbirth, so she decided to find a Black healthcare provider who could relate to her and her experiences better and that she no longer trusted the healthcare system to treat her fairly. [I went] to my OB’s office, and I remember I was getting out of the car, and I took out the seatbelt, and I felt him kick, and I said like it was a big strong kick that I had not felt in so long. And I said [to her partner] …I just felt a strong kick again, and I said finally he is okay, and that was the last time I felt him. I went into the office, and a very strong feeling came over me. I sat there, and I think that was the moment he died [Vee]. This experience severely traumatized Vee and her family. After Vee’s first pregnancy, she experienced psychological distress, anxiety, and depression. Understandably, Vee was reluctant to trust medical providers; this contributed to her intentional decision to seek Black physicians in the following pregnancy. Reena, in comparison, as someone who lives in B.C. and recognizes that there is a shortage of Black doctors and OBGYNs in the province, settled on a provider who was a person of colour: And, you know, I want to say I did look for that in my search for a suitable provider who was a person of colour, there was one, but there were not many Black OBGYNs that I could find in B.C. So, I decided to stop looking and instead find a person of colour [Reena]. 57 Cassie, who is a mature stay-at-home parent, experienced birth in the U.K. and Canada. She shared that the biggest difference in giving birth in both countries was the benefit of having a Black British midwife who she trusted to take her concerns seriously: Like my midwife in the UK, she was British, but she was of a Nigerian background. I mean, you don’t have to have to be from the same background to have good medical care. But I think all those things just make things far easier [Cassie]. Cassie received better treatment in the U.K. under the care of her Black midwife, who was understanding and tailored her treatment to avoid complications, given preexisting conditions like iron deficiencies. Like Cassie, Joanne also preferred to have a Black healthcare provider. Joanne had her first check-up in Zambia while on vacation, and when she returned to Canada, she felt her experiences were extremely negative in comparison. Comparatively, Joanne shared how comfortable she felt with Zambian providers than those in Canada. You don’t feel like you are going to be mistreated because you’re Black. You just feel comfortable, confident in knowing that, you know, like you’re not going to get bad treatment because of racist people [Joanne]. Experiencing racism was a serious concern for participants like Joanne, and having a Black provider, or at least a provider who shared their cultural experiences and who was 58 knowledgeable about their body, could considerably improve the overall well-being of Black women like her. Jane, who is a psychologist, also remarked on the need for more Black healthcare providers by expressing her opinion that there are white standards in the delivery of care. Jane infers that white women who give birth and are induced before their medically determined due date are the standard to which other racialized women are compared: [There is a] white standard when you deliver. I was shocked to find out that most people [don’t] deliver on their delivery date. [There is] a whole bunch of us that can [deliver past our due date] [Jane]. Norms about how to deliver when were constantly imposed on her throughout her pregnancy. Jane reiterates in this quote that there were assumed norms she felt she had to adhere to as a Black woman with a non-Black provider. Like Joanne, Cassie, and Reena, Lala also felt more comfortable with a Black healthcare provider. So, I went with a doula, and I specifically wanted someone Black or of colour, and I found two, actually, believe it or not [Lala] The shortage of Black physicians in the area is the reason why Lala chose to find at least a Black doula who could advocate on her behalf. Lala expressed that despite having difficulty finding a Black or provider of colour, she saw a non-racialized physician who still took her concerns seriously and supported her throughout her pregnancy and birth. 59 I felt reassured, I felt safe. I felt like my skin colour wasn't an issue. I felt like she just saw me as one of her patients or a regular person. There was no aggression because sometimes you get that undertone when you talk to [healthcare providers]. And no question was stupid [Lala]. Anaya provided a nuanced perspective on the need for a Black healthcare provider by tracing it back to having more pathways for Black midwives and doctors. Despite not having a Black healthcare provider, she expressed her frustrations with the shortage of doctors in general. She referenced innovative ways Black women are supporting one another to find Black providers in their community through the online forum Afiya Collective in B.C.: So, we need more Black midwives, we need more Black doctors and just health care professionals. And here’s a collective called the Afiya Collective making sure that try to centralize Black nurse practitioners, doctors, and paramedical professionals (Afiya Care Collective, n.d.) [Anaya]. Anaya remarks on not just finding a Black healthcare provider but on the systemic barriers Black people face when applying for and gaining admission into medical schools or healthcare professional programs in Canada. To avoid experiencing racism in Canadian healthcare systems, Black women are sharing and centralizing Black health supports and resources to navigate the Canadian reproductive healthcare system. Anaya and other participants reiterate the need for Black patient-centred care, where healthcare providers are cognizant of the racial inequities that affect their health and wellbeing. 4.5 Patient-centred care to enhance health and wellbeing 60 Patient-centred care honours Black women’s knowledge to reduce the overmedicalization of Black women’s bodies. Participants described how some healthcare providers disregarded their lived experiences and cultural background, as well as their Black experiences and bodies, in clinical practice. Another key finding that emerged from the research was the importance of Black patient-centred care embedded in reproductive health practices. Reena eloquently illustrates her approach to navigating medical spaces that center the doctor’s or healthcare providers’ perspectives, knowledge, and medical treatments over the patients’ knowledge of their bodies: I asked what her approach is to people of colour and how that plays a role in decisions that could be life or death in the hospital [Reena]. Reena described the conversation she had with her provider about the best approach to her care, where they worked collaboratively to find the best treatment options, ones that she was comfortable with, and that also respected her cultural beliefs. Comparatively, Vee voices that she does not feel like a person and that the doctors did not acknowledge her perspectives when treated: I feel like the doctors are very aggressive, and they don’t treat me as a person. You are just a body to them and not a person with feelings, and that was pretty high on the list of traumatic things in my labour. That would have made a vast difference in my recovery. They don’t realize the lasting effects they have on your life [Vee]. 61 Vee stated that she felt disempowered and vulnerable during childbirth and how powerful and overbearing doctors can be when treating Black women like her. This approach can leave long-lasting trauma in their lives and bodies. Therefore, centring her voice and perspectives may have made a difference in the outcome of her traumatic stillbirth. Vee’s experience is indicative of the need for a Black provider to treat Black patients with care and sensitivity based on their shared experiences of structural racism and to be empathetic to patients’ concerns like Vee’s. Health advocates and patient-centred support from healthcare providers are also important in the overall outcomes for some participants. Tracey, a stay-at-home mom who hired a midwife in her second pregnancy, stated: If I didn’t have a midwife and didn’t have people advocating for me, I cannot guarantee I would be sitting here and talking to you. But having people there to advocate for me and care, I think I was the only reason I was there and alive [Tracey]. Tracey felt that her experiences, concerns, and fears were acknowledged in her second pregnancy, and her perspectives were centred when it came to deciding the best treatment options. Tracey also reflected on how her midwife was pivotal to the successful delivery of her child and her overall health and safety. Tamara, like other participants in this study, did extensive research to select the best possible reproductive healthcare provider and team for her pregnancy and childbirth. Tamara, who is a naturopathic doctor, shared: 62 And so, I think that for me, it was about working with a team that, of course, would be knowledgeable, but more importantly, that would honour my autonomy through the process [Tamara]. Patient-centred care is essential to the overall success and comfort of the patient, but to Tamara, feeling autonomous, in control, and supported by her midwives was imperative, especially after having poor experiences with doctors and medical staff during an abortion in the U.S. in her early 20s. Maya, who gave birth in British Columbia but works as an actor in the United States, shared how patient-centred care is also essential for patients postpartum. Maya felt fortunate to have midwives advocating for her and focused on providing her with the best care: I would say I was super fortunate to have a midwife because, with everything going on. The OBs are very limited to communicating with you unless they absolutely need to. But I was always able to get my information through the midwives, who would speak to the nurses and look at my charts, and they would come in every hour. [Maya]. Patient-centred care requires the time and energy to listen to patient concerns. In Maya’s case, she recognized how busy the OBGYNs were, so her midwives stood in to translate her concerns to the other medical care providers. Maya, however, felt discarded by the healthcare system that focuses on the mother and baby in childbirth but decenters them postpartum: 63 You don't really get any sort of follow-up… I just wish that there were more check-ins because it really is a huge, huge transition after giving birth [Maya]. Based on participant insights, findings suggest that patient-centred care is imperative to the overall success of Black patients. Participants indicate that clinicians must address their own implicit biases and gatekeeping of medical knowledge of the body to successfully treat Black patients with autonomy and dignity. 4.6 Summary of Research Findings The findings generated from the rich qualitative research data revealed general themes across interviews. Black women feel unheard and dismissed by healthcare providers who perceive Black women to have higher pain tolerances. Despite their socioeconomic status, access to care, and knowledge of the healthcare system, Black Canadian women continue to face challenges including being given the appropriate pain medications to manage their birth and postpartum. Black Canadian women anticipate experiencing some form of discrimination. Black patients are careful to present themselves as competent, vocal, educated, and eloquent when interacting with healthcare providers because they believe they will be treated better. Participants are aware of how oppressive medical spaces can be, so they hire doulas and health advocates to advocate on their behalf. Representation in healthcare providers is also key to the overall success and wellbeing of Black patients. Having a healthcare provider who is reflective of the patient’s racial identity and with the cultural awareness to care for them, made a positive impact. Patient-centred care is also imperative to minimizing the power dynamics at play between a healthcare provider and a patient. When a Black patient has autonomy to decide their care they have overall improved patient outcomes. 64 A common theme across most interviews was that Black Canadian women felt dismissed and less likely to be administered pain relief despite vocalizing their discomfort. These findings are compelling and should start a more extensive discussion about supporting Black women’s well-being, treatment, and care. Anti-Black racism was pervasive in the interactions that participants had with healthcare providers, and this was evidenced in the ways that providers both overtly and covertly discriminated against them. In this chapter, I have outlined the major themes and data. In Chapter 5, I will provide an analysis of the implications of this research. 65 Chapter 5: Discussion and Conclusion Well-documented reproductive healthcare disparities in the U.S. leave Black Canadian women concerned about whether they may also experience the same high maternal mortality rates. Based on the findings in this research, healthcare providers consistently minimize Black women’s pain in childbirth. Healthcare providers, whether intentionally or not perceive Black women poorly and because of these preconceived opinions Black women adopt strategies to separate themselves from the stereotypes to avoid experiencing racism. Representation matters to participants; they recognize the need for their healthcare provider to reflect their own racial identities. This research also identified that Black patient-centred care and anti-Black racism must be part of their care plan. I will discuss each of the preceding findings in detail, supplemented by the current scholarship addressing similar topics related to medical obstetric racism. 5.1 Anxieties Given Black Health Inequities Black Canadian women are fully aware of the health disparities and well-known statistical race-based data that shows that Black women are dying of pregnancy-related causes at a higher rate than white women (Coen-Sanchez et al., 2022; D. A. Davis, 2019). In this study, participants who were also healthcare professionals were aware of the known maternal health disparities documented in the U.S. Participants with high socioeconomic status, more access to resources, and more social power to decide their care were able to navigate the reproductive healthcare system better and were more knowledgeable than someone with a lower socioeconomic status. Intersectionality has been a valuable tool for understanding participants' complex socio-political identities participants have that shape how they navigate the healthcare system. Intersectionality was evident when participants who are healthcare professionals and 66 who are aware of the health disparities experienced by Black women and usually have higher socioeconomic status employ doulas and health advocates to protect themselves from medical racism and discrimination. Coen-Sanchez et al. (2022) expand on this finding regarding the effects of the known health disparities in to illustrate how this not only result in negative health outcomes for Black women but impact their access to adequate health services and resources. Gatekeeping medical knowledge about Black women’s health and restricting their access to medical clinicians is also why Black communities create online resources like the Afiya Collective. Afiya Collective is a website dedicated to providing a list of local B.C. Black healthcare providers that Black patients can choose from. Anxieties about the known health disparities plague Black women and make them hyper-vigilant for any potential threats of violence, racism, and discrimination. Anticipating a racist interaction increases stress, cortisol levels, and anxiety, which negatively affects pregnancy and childbirth (D. Davis, 2019). Racism and anticipatory racism stress (ARS) have known physiological effects on Black people by increasing the chances of chronic health diseases such as autoimmune diseases and lowering life expectancy (Spears et al., 2021). This, I argue, is the primary cause of poor health outcomes for Black Canadian women. The additional stress of encountering a potentially racist provider or experience concerned most participants and later affected subsequent pregnancies, causing high blood pressure and fatigue. So, regardless of the statistical data documented, Black women experience embodied trauma and stress due to systemic and covert racism. Racism can manifest in forms of dismissal, and a consistent finding in this study suggests that their pain is routinely minimized. Strategies of resistance are in direct response to participants who anticipate a racist interaction to reduce stress and give them autonomy over their care. 67 5.2 Dismissal of Black Women’s Pain This research found that Black women’s pain is not adequately managed or addressed. Most participants reported receiving inadequate pain relief, with over-the-counter drugs like Tylenol and Gravol to treat their labour pains, when usually during active labour, an anesthesiologist would administer an epidural for pain relief. This finding correlates with the stereotype and misconception that Black women have high pain tolerances and can endure more pain than white patients because of their “thicker skin” (Blackstock, 2024). This belief is untrue and grounded in a history of medical racism dating back to slavery (Blackstock, 2024, p. 43; Hoffman et al., 2016). Denying patients who need pain medication for severe medical conditions and procedures based on racist assumptions is inherently wrong and could be a determinant of postpartum depression (Floyd James et al., 2023). Implicit and even explicit biases rooted in stereotypes are contributors to the under-prescription of pain medication. Healthcare providers often impose their biases on Black and racialized patients and label them as “drug-seeking” or more likely to become addicts if given narcotics as pain relief (Coen-Sanchez et al., 2022, p. 5). Racial implicit biases are the leading cause of poor Black patient health outcomes. Participants in this study consistently referenced the denial of care, dismissal, and neglect of patient suffering, and this treatment led to misdiagnosis, infant mortality, and maternal distress (Bridges, 2020). The Canadian healthcare system continues to fail Black Canadian women if healthcare providers minimize one of the most painful experiences of their lives (Coen-Sanchez et al., 2022). The belief that Black women should endure pain without medication is a prime example of medical obstetric racism at work and contributes to severe health complications and emotional trauma for the mother. 68 5.3 Navigating Interactions with Healthcare Providers A significant finding of this research is that participants also attempt to distance themselves from negative stereotypes, such as, Black women are not educated enough to understand medical jargon. As identified by participants in the study, they attempted to overcome persistent stereotypes by presenting themselves as professionals so that they would be taken seriously by healthcare providers. Given this concern, Black women are visibly aware of how they are perceived and the system they are negotiating. Often, participants shared how they felt disempowered when interacting with a healthcare provider who was overtly racist towards them, and this made them less likely to share their concerns out of fear of being discriminated against. In this study, Black women shared experiencing microaggressions; to mediate this, they vocalized their concerns to people who would listen, advocate and intervene on their behalf, such as a doula. 5.4 More Black Representation in Healthcare Providers Is Needed Participants recognized that their experiences could have been more positive if their healthcare provider shared the same racial identity as them. A Black healthcare provider creates a sense of trust, familiarity, and cultural safety. Black healthcare providers are well-documented in providing intensive, holistic treatment, and more understanding of culturally safe care will contribute to equitable outcomes for Black patients (M. T. Williams et al., 2022). Participants like Vee shared how, when they interacted with a Black healthcare provider, they felt safer and reassured in their decisions. Participants from B.C. recognized that there are fewer Black people and indicated that just having a person of colour on their obstetric healthcare team would be an additional benefit. Participants also reported the benefits of having a healthcare provider who 69 may have a similar background, experiences of racism, and cultural knowledge to respectfully engage with Black patients and collectively work on the best treatment methods. Anti-Black racism in healthcare starts with more Black healthcare providers being leaders in healthcare initiatives (Maxwell et al., 2024). Equity in healthcare also starts with Black healthcare providers in leadership roles, making key decisions about policies, procedures, and medical school curricula to dispel stereotypes about Black patients in medical practices. A recent article addressing inequity in Canadian healthcare claims that training more Black medical learners about anti-Black racism is the first step to reducing inequity in provider-patient interactions (Maxwell et al., 2024). Qualitative research suggests that Black patients have better healthcare outcomes when treated by Black clinicians (Williams et al., 2023). To address implicit bias and medical obstetric racism, Coen-Sanchez et al. (2022), like other scholars researching reproductive justice-orientated practices, indicate the importance of hiring more IBPOC (Black, Indigenous, and people of colour) doulas, physicians, and midwives (Coen-Sanchez et al., 2022; Maxwell et al., 2024; M. T. Williams et al., 2022). Healthcare providers must prioritize the well-being and care of their patients. This research has focused on the voices of Black Canadian women and how the healthcare system must also centre their experiences and perspectives. The findings of this research indicate that Black women’s knowledge about their bodies, health, and experiences are deprioritized. The over medicalization of birth and women’s bodies in obstetrics and gynecology is one reason participants did not feel autonomous and why their knowledge about their bodies was not prioritized. Medicine has continually been gatekeeping knowledge about the Black body and standardized white patient experiences, which dehumanizes and disempowers the Black and 70 racialized patient and their experiences (Boakye et al., 2023). In this study, participants routinely expressed feeling that their viewpoints are ignored and that they are routinely not included in discussions about their treatment methods. Participants who shared that they had a more positive experience felt that their needs were being addressed, and they worked collaboratively with their healthcare team and provider from pregnancy to childbirth. Patient-centred care also meant factoring in the cultural, religious, and sociopolitical beliefs of the patients who, in some cases, were Christian, recent immigrants, and were not familiar with the Canadian healthcare process. One-third of participants had a career in medicine or health-related fields, so patient-centred care was essential to strengthening and building relationships between themselves and their providers. With the awareness and knowledge of the healthcare system, participants, including a naturopathic doctor, OBGYN resident, nurse, doula, prenatal educator, psychologist, and social worker. These participants understood the importance of speaking up when interacting with a provider and knew what to ask when and when it was appropriate to share information with their providers. Centring Black patients and their wellness is an essential step to reducing occurrences of patient dismissal, discrimination, and mistreatment in administrating care and pain relief (Boakye et al., 2023). 5.5 Participants Adopted Strategies to Avoid Experiencing Obstetric Racism Some participants indicated that one strategy to improve their health experiences was to find healthcare providers who shared their racial identity and were more likely to empathize with their experiences. Overall, despite enlisting ways to avoid experiencing discrimination, all participants experienced medical obstetric racism in some form. Although participants did not specifically refer to this term, their experiences are indicative of being racially targeted and 71 discriminated against. The term obstetric racism is the concept I used to interpret and understand the collective experiences of participants who shared experiencing some form many forms of oppression. The most compelling finding in this study, though, is that having a lower socioeconomic status, less access to medical resources, and lack of education about the medical system, participants were more likely to experience overt and or covert medical obstetric racism. A highly educated Black woman with a doula and or health advocate experiences less racism than a young mother without access to a team of advocates (Sutton et al., 2021). Health advocates play an important role in honouring the patient and their best interests. Advocacy requires that the patient is autonomous and can make clear decisions about their treatment for themselves and consult the provider when needed (Sutton et al., 2021). Therefore, centring the patient rather than the healthcare provider minimizes misdiagnosis and complications since their care is prioritized. 5.6 Recommendations This research study revealed significant gaps in Black maternal health research, particularly from the needs of patients from their providers. Based on the findings of this study and the research data collected, I first recommend that anti-Black racism courses be embedded in health professions’ curricula and that current maternal and child health care providers are required to be educated about the effects of racial biases in health care practice. Second, healthcare providers must focus on advocating for, supporting, and empowering Black women in clinical practice. Third, patient-centred-care is required to decentre the healthcare provider and their knowledge but instead value the patient’s viewpoints about their body and treatment. Fourth, more Black learners need to be admitted into all health professional programs to bridge the gap in cultural competencies in maternal healthcare. Finally, dispelling myths about Black 72 women’s pain in healthcare practices and curricula in Canadian health professional education programs. At a policy level, obstetric racism needs to be addressed for changes to happen at the structural level. Race-based data on Black maternal health needs to be collected in Canada to start discussions about how it is affecting maternal and infant mortality rates. Understanding the root cause of the problem alongside research like this is what will bring awareness and change to Canadian healthcare systems. 5.7 Strengths and Limitations The strength of this study is that I centred on Black women’s experiences drawn from qualitative data. A strength is that I analyzed data from 25 interviews, which was a robust number of perspectives and ranges of experiences. A limitation of this study is that participants did not interact with each other more. In future studies, I would consider having both focus groups and one-on-one interviews to facilitate community building. Another limitation is the sampling of Black Canadian women throughout the interview process. Many participants were from B.C., and in future research, I would explore the possibility of reaching more widely across Canada to ensure representation of the Canadian population. However, the focus on the B.C. healthcare system was the strength of this research because little research focuses on Black maternal health in provinces like B.C. where there are fewer Black populations. A mixed methods approach may be needed to survey how Black women across Canada and in rural versus urban areas are discriminated against based on their geographical locations. To address how the different provincial healthcare systems treat patients based on medical coverage and policies, future research could explore accessibility issues affecting Black women across Canada. Therefore, a holistic view of the participant may be explored in future research to account for 73 how housing, access to care, income level, and social support could influence Black maternal healthcare. 5.8 Reflection and Reflexivity This research and thesis have strengthened my qualitative research methods. Initially, interviews were shorter and less robust since I was learning how to ask probing questions. After my fifth interview, I understood when to ask the specific research questions and how to facilitate a conversational-style interview. This research process has taught me a lot about my community, the resilience of Black women birthing in Canada and the value of research that prioritizes Black women’s viewpoints. After my eighth interview, I felt comfortable with approaching the research process, reflecting after interviews, and building a rapport with participants. I also learnt that more than two-thirds of participants shared that they never had the opportunity to unpack their stories and trauma and that I created a safe space for them to express it, knowing that this research could help others. I was humbled to know that they felt safe sharing the most intimate stories, some of whom had not shared with their own family or friends, so I cherished that time with them. The opportunity to connect and give back to my community was a highlight of this process and inspired me to pursue a career where I continue this work in a similar capacity. The research process was overall rewarding, and I felt validated by my personal experiences as a Black woman with a past of navigating structural and medical racism. I related to the participants on an emotional level, at times, participants referred to me by my nickname, we cried together and shared our experiences, and I felt that I was a part of their lives. Since most participants experienced obstetric racism, I questioned whether I wanted to have children in the future and deal with similar trauma. Even in the most planned birthing process, participants 74 expressed feeling disempowered and out of control. Having seen a loved one experience that firsthand, I am reluctant to put myself through a similar distressing birthing experience. 5.9 Conclusion In this study, I found that Black women do experience medical obstetric racism and attempt to manoeuvre the healthcare system using strategies such as hiring healthcare advocates to protect themselves from medical harm. Qualitative research methods using trauma-informed intersectional feminist approaches were ideal to improve participant well-being and empower them to share their stories. 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New York University Press. ‘ 84 Appendices Appendix A: Consent Form NAVIGATING MEDICAL RACISM: HOW BLACK CANADIAN WOMEN EXPERIENCE REPRODUCTIVE HEALTHCARE IN CANADA Consent Form Study Team: Principal Investigator: Dr. Marie Tarrant Email: marie.tarrant@ubc.ca Principal Investigator: Rishma Chooniedass Email: rishma.chooniedass@ubc.ca Graduate Student Investigator: Stephanie Awotwi-Pratt Masters Student at UBC Okanagan Email: sawotwip@student.ubc.ca Sponsors: This study is being funded by Social Sciences and Humanities Research Council Canada Graduate Student Master’s Scholarship, Finch Family Scholarship, and the Okanagan Graduate Research Scholarship (OGRS). Purpose of the study: The purpose of this study is to include Black Canadian women who sought reproductive healthcare across Canada and who have experienced pregnancy, labour, and delivery. This study focuses on Black Canadian women’s experiences and understanding how Black women reclaim their agency and power during their pregnancy, labour, and delivery in reproductive healthcare 85 systems. Participants will include Black Canadian women 18 years or older who have immigrated to Canada within the last twenty years or that were born in Canada (and identify as Black Canadian) living and residing in Canada. You have been invited to take part in this study, which will help us learn more about how Black Canadian women are treated by healthcare professionals and how it influences the strategies and mechanism of avoiding any potential racist or discriminatory interactions with healthcare providers. We are inviting people like you to take part and share your perspectives. Study Procedures: If you agree to participate in this study, you will be participating in an interview that should last between 60 to 90 minutes. Stephanie Awotwi-Pratt will ask you about your experiences with pregnancy and delivery within healthcare settings like hospitals, and how that has shaped you as a Black Canadian woman and mother. Interview questions will include questions such as: tell me about your experiences with healthcare providers? How do you think you are resisting or preventing something from happening in any way during your pregnancy, labour, and delivery? The interview will be done over UBC’s account for Zoom or in-person depending on the personal preferences of participants. Using a UBC account ensures data is on servers located in Canada. As a part of this study, the audio will be recorded through Zoom or in- person interviews to ensure that we accurately record your responses to the questions. At any point during the interview, you have the right to refuse being recorded. In- person interviews will also be audio recorded with the permission of the participant. Only Dr. Dr. Marie Tarrant, Rishma Chooniedass, and Stephanie Awotwi-Pratt will have access to these Zoom audio recordings and information will be kept confidential. All audio recordings will be transcribed, and we will 86 remove any identifying information. All audio recording will be deleted once transcribed for accuracy and deidentified. Stephanie will then send the transcripts to the participants who express interest when the interview is completed. Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from this study at any time. Participants can also request to review their transcripts. Participants will be able to review transcripts 24-48 hours after interviews are recorded. Study Results: This research is the basis for the student researcher’s MA thesis, which is considered a public document and will be available on the Internet (via UBC’s cIRcle platform). The study results will be published and presented at conferences, but no identifiable names will be included to protect participant confidentiality. The results of the study will also be presented at research conferences and future publications. Participants can email the researchers to read the results of the study and will be sent a copy of the summary of results and transcript if you so choose. All audio recordings will be deleted once the transcripts have been verified for accuracy and deidentified. Potential Risks and Benefits of the Study: Some of the questions may get into areas that you find upsetting, frustrating or stressful. However, you do not need to answer questions that you do not want to answer, or that make you feel uncomfortable. And you can withdraw (stop taking part) in the study at any time. We describe below the steps we are taking to protect your privacy. 87 Participants will be able to review their one-on-one interview. The researchers will send a copy of the interview once it had been transcribed. All audio recordings will be deleted once the transcripts have been verified for accuracy. You can also let us know if you want certain quotations excluded from the research, presentations, and publications. A list of resources (and information about available resources) will be given to you at the end of the session. Potential Benefits of the Study This study will allow participants to reflect on their experiences and interactions with medical practitioners in Canada and engage with their past with healthcare providers in a reflexive way. Confidentiality: Your participation in this study is confidential. We will ensure your confidentiality by removing or altering any identifying information (including names) from transcribed interviews. The data will be stored on a password-protected computer (including password-protected word documents). Data is stored for a minimum of five years following publications and they are stored at UBC. Interview transcripts and consent forms and all other research files will be stored by the PI for up to five years. We will make every effort to protect your confidentiality and privacy. We will not use your name or any information that would allow you to be identified. • As per per UBC policy SC6 all data is required to be stored for a minimum of five years following publications. 88 • Identifying information (digital recordings, consent forms and identification sheet) will be stored separately from the data and will be kept for five years and will then be destroyed by the principal investigator. • The de-identified data will be stored indefinitely and may be reanalyzed in the future as part of a separate project (i.e., secondary data analysis) and or publication. • Audio recordings will be deleted once the transcripts have been verified for accuracy and deidentified. • If you consent, quotations will be used in write-ups/presentations and will not contain information that allows you to be identified. You will be able to vet your quotations by reviewing transcription after the interview (24-48 hrs). If you consent, there is also a possibility that this research data will be used in future research publications and will be submitted to the UBC Okanagan Ethics Board in advance. Will you be paid for taking part in the research Study? You will receive a $25 gift card as an honorarium for your participation in the research study. 89 Contact for Information about the Study If you have questions at any time about the study or the procedures or if you experience adverse effects as a result of participating in this study, you may contact the researcher, Stephanie Awotwi-Pratt via email at sawotwip@student.ubc.ca. You may also contact the principal investigator Dr. Marie Tarrant and Rishma Chooniedass via email at marie.tarrant@ubc.ca and or rishma.chooniedass@ubc.ca Contacts for Information about the Study: If you have any questions or need more information with respect to this study, you may contact the researchers carrying out this study. Contact information is provided above. If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Services toll free at 1-877-822-8598 or the UBC Okanagan Research Services Office at 250-807-8832. It is also possible to contact the Research Complaint Line by email (RSIL@ors.ubc.ca ). Please reference the study number H23-01589. Participation: Your participation in this study is voluntary; you may decline to participate without penalty. You have the right to refuse to answer any question you choose. If you withdraw from the study, you can request to have your data removed/destroyed by emailing the principal investigator and requesting data removal until August 2024. Consent In completing this consent form, please send a signed copy to (sawotwip@student.ubc.ca) and print or save an e-copy for your records. 90 I have read and understand the above information. I have received a copy of this form. I agree to participate in this study. Participant's signature___________________________________Date _________________ Investigator's signature__________________________________Date _________________ 1. I agree that the interview can be audio-recorded. Yes _____ No _____ 2. I would like to review my transcripts prior to my quotes being used in this research. Please send the transcript to this email address__________________________. 3. Yes, I would like to receive a summary of the study’s results. Please send them to this email address _________________________________ 91 Appendix B: Recruitment Poster 92 Appendix C: Master’s Research Interview Questions NAVIGATING MEDICAL RACISM: HOW BLACK CANADIAN WOMEN EXPERIENCE REPRODUCTIVE HEALTHCARE IN CANADA Research Questions Preliminary Mention: • To start, so that you are aware, our discussion today is confidential and private. And if at any point you would like to withdraw from participating in the research study, you can do so. o Do you have any questions or concerns before we start? • Purpose of the study: o The purpose of this study is to include Black Canadian women who sought reproductive healthcare across Canada and who have experienced pregnancy, labour, and delivery. This study focuses on Black Canadian women’s experiences and understanding how Black women reclaim their agency and power during their pregnancy, labour, and delivery in Canadian reproductive healthcare systems. Participants will include Black Canadian women 18 years or older who have immigrated to Canada within the last twenty years or that were born in Canada (and identify as Black Canadian) living and residing Canada. You have been invited to take part in this study, which will help us learn more about how Black Canadian women are treated by healthcare professionals and how it influences the strategies and mechanism of avoiding any potential racist or discriminatory interactions with healthcare providers. We are inviting people like you to take part and share your perspectives. 93 Introductory Questions: • How was your day today? • Can you tell me a bit about yourself? o Where were you born? o How old are you? o How many children do you have? o How old were you when you had your child(ren)? Experiences with Pregnancy Questions: • What I’d like for you to do now is tell me about your experiences with any medical providers throughout your pregnancy. You can begin wherever you like and include or leave out whatever you choose. • Can you tell me what healthcare professionals you saw during your pregnancy? • Tell me about your first time going to the doctor when you were pregnant or thought you were pregnant. • Possible Probes o How did you feel? • How if any did you resist or try to avoid something from happening throughout your pregnancy? o How did they handle it? • Did you change doctor’s when you saw your doctor when you were pregnant if so, why? • Did your experiences or interactions with your healthcare provider affect how you navigated the healthcare system throughout your pregnancy? If so, how? o What type of support system did you have throughout your pregnancy? 94 § What did they do? • Did this change how they went to the doctor or healthcare providers the next time? • Did you find that you avoided doing or saying anything whether negative or positive throughout pregnancy? How so? • How would you describe your interactions with healthcare professionals during pregnancy? Experiences with Labour and Delivery Questions: • What I’d like for you to do now is tell me about your experiences with any medical providers throughout your labour and delivery. You can begin wherever you like and include or leave out whatever you choose. • Where did you give birth? At home? The hospital? • Who was with you when you gave birth? • What city or location did your labour and delivery take place? o If you have had more than one birth, where were they located? • Tell me about your experience(s) with labour in a hospital or reproductive healthcare setting. • Tell me about your experience going to the doctor or your healthcare provider when you were in labour and delivering. • How if any did you try to avoid something from happening throughout your labour and delivery? If so how? • How would you say your recovery and overall well-being were after? • If you could go through labour all over again, would you want things to be different? 95 • How do you feel about the overall experience and what happened? Feel free to explain in your own words and include or leave anything out. Experiences with Other Children Questions (if the participant has multiple children): • What was your second pregnancy like? (What were your other pregnancies like?) • Was it similar or different? How so? • Did you have any positive experiences in one pregnancy as compared to your other pregnancies? How so? • Did you have any difficulties or challenges that were different in comparison to your first pregnancy? How so? • Did you find that you did something in your other pregnancies or birth to avoid anything potentially from happening whether negative or positive throughout your labour and delivery? If so, how? Future Recommendations/ Reflection o What would you have liked to see happen differently in future interactions with medical practitioners? o What would you want to change about your experience to make it better? o What would you like to see change based on your interactions with medical staff throughout your pregnancy, labour, and delivery? Final Questions: • Is there anything that I have not asked you today that you think is important I consider in this research? o How did you feel during this interview? 96 Appendix D: Undergraduate Research Award Interview Questions • Where were you born? • When were you born? • How many children do you have? • How old were you when you had your child(ren)? • Where did you give birth? At home? The hospital? • What city or area did your labour and delivery take place in? • If you have had more than one birth, where were they located? • Could you tell me about your first pregnancy? • Could you tell me about how your pregnancy went? • You can explain in your own words, feel free to include or leave anything out. • What was it like to be pregnant (for the first time)? • How were your experiences during checkups and appointments with Obstetricians and Gynecologists throughout your pregnancy up until childbirth? • Which medical professionals were involved during your labour and delivery? Nurses? Doula? Obstetricians and Gynecologists? 97 • If you have interacted with more than one medical professional, please describe who and how long they were involved in your pregnancy, labour, and delivery. • Tell me about your labour and delivery experience(s) in a Canadian hospital? • How would you say your recovery and overall wellbeing was after your experience during labour and delivery in a Canadian hospital? • If you could go through labour and delivery all over again, would you want things to be different? • How do you feel about your experiences and what happened? • How were your experiences with your first pregnancy? • How were your experiences with the different types of medical professionals throughout your pregnancy/ pregnancies? o Were your experiences different or similar? • Did you experience any difficulties or challenges, in comparison to your first pregnancy, during your labour and delivery in a Canadian hospital? • How did this affect how your labour and delivery went? • Is there anything that I have not asked you today that you would like to discuss? • How did you feel during this interview is there anything that you would like to add? 98 Appendix E: Resources for Black Canadian Women Resources for Black Canadian Women Participants Across Canada Mental Health Support across Canadian Provinces • Alberta o Alberta Health Services: Addiction and mental health • Manitoba o Government of Manitoba: Mental health and community wellness • New Brunswick o https://www.ementalhealth.ca/index.php?m=record&ID=74931 • Newfoundland and Labrador o https://nl.bridgethegapp.ca/youth/info-booth/perinatal-mental-health/ • Northwest Territories o https://www.nthssa.ca/en/services/mental-health-resources-and-supports • Nova Scotia o https://mha.nshealth.ca/en/perinatalmentalhealth • Nunavut o https://www.gov.nu.ca/en/health/mental-health-resources o https://uummati.ca/ • Ontario o https://www.perinatalwellbeing.ca/ o https://www.publichealthontario.ca/en/Health-Topics/Health-Promotion/Maternal-Infant-Health/HHDT • Prince Edward Island 99 o https://www.princeedwardisland.ca/en/information/health-pei/pregnancy-and-postpartum-perinatal-mood-disorders o https://src.healthpei.ca/provincial-perinatal-health-program-formerly-reproductive-care-program • Quebec o https://www.santementaleperinataleqc.com/home-eng • Saskatchewan o https://momsandkidssask.saskhealthauthority.ca/pregnancy-birth-newborns/maternal-mental-health • Yukon o https://postpartumsupportyukon.com/ The Space Belongs to You (British Columbia) o https://thisspacebelongstoyou.com/ o By appointment only o Contact: thisspacebelongstoyou@gmail.com o Referral form: https://docs.google.com/forms/d/e/1FAIpQLSd81c6x5bjjTOXp8hBASJqAvX-OcMbjXn7ByMo3Yx-Bdwzg-A/viewform Wellness to Together (Canada Wide) o https://www.wellnesstogether.ca/en-ca/ o https://www.wellnesstogether.ca/en-ca/resource/hope-for-wellness-online-chat § Online Chat and Call Services 24/7 o Canada wide counselling services including certified counsellors. 100 Women’s Mental Health (British Columbia) o https://womensmentalhealth.ca/?gad=1&gclid=Cj0KCQjw7JOpBhCfARIsAL3bobcB3Iz7-N1j62M2LYsFKKF9hMX1nIsmO0q4UZuF88ILX6viduYzLyIaAuQQEALw_wcB o https://womensmentalhealth.ca/counsellors/ o Support residents living in British Columbia. Virtual Mental Health Supports for B.C. residents o https://www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substance-use/virtual-mental-health-supports o 310Mental Health Support Call 310-6789 for emotional support, information and resources specific to mental health These resources include inclusive and supportive counselling for Black Canadian women who are participating and living in Canada.
Thesis/Dissertation
eng
Interdisciplinary Studies
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Tarrant, Marie
Chooniedass, Rishma
Navigating medical racism : how Black Canadian women experience reproductive healthcare in Canada
Text