# “To me, it was overwhelming”: a mixed methods study of maternal healthcare in a marginalised community in New York City, guided by the person-centered care framework for reproductive health equity

## TL;DR

This study explores how maternal healthcare is affected by social and community factors in a marginalized New York City community, highlighting disparities and barriers during the pandemic.

## Contribution

The study applies the Person-Centered Care Framework to maternal healthcare in an underserved U.S. population, revealing pandemic-related disparities and community-specific barriers.

## Key findings

- Over half of pregnant individuals received inadequate prenatal care, with disparities among younger women, Black women, Arabic-speaking women, and those who smoked.
- Barriers to care included telehealth challenges, immigration status, and low health literacy.
- Quality of care issues included poor patient-provider communication and inconsistent care delivery.

## Abstract

The Person-Centered Care Framework for Reproductive Health Equity (PCC) elucidates drivers of health disparities: community determinants, health-seeking behaviours and quality of care. Limited studies assess person-centered maternal healthcare in underserved populations. Racial and ethnic disparities in maternal health were exacerbated by the COVID-19 pandemic. We applied PCC to evaluate factors influencing maternal healthcare at two public hospitals in NYC before and during the pandemic. We conducted mixed-method, community-engaged research using PCC. A cross-sectional study using EHR data from 5330 pregnant individuals in 2019 assessed factors related to inadequate maternity care utilisation. Qualitative research in 2020 explored perceptions of maternal health equity, barriers, and healthcare quality through 17 in-depth interviews and five focus group discussions with postpartum women, clinicians, and community-organisation staff. Among 3181 women, 90% had public insurance, and 95% were people of colour. Using the Adequacy of Prenatal Care Utilisation index, 1648 (51.8%) received no or inadequate prenatal care and 1267 (40%) lacked postpartum care. Women aged 18–24, Black women, Arabic-speaking women and those who used tobacco during pregnancy appeared more likely to experience inadequate care. Qualitative data identified community-level determinants, namely health literacy and economic status. Health-seeking barriers included social distancing, telehealth and immigration status. Quality of care issues included disruptions in healthcare delivery, patient-provider experience and continuity of care. Findings indicate disparities in maternal healthcare utilisation, which are likely downstream effects of broader social inequities. Addressing these disparities requires rights-based, community-informed policies that guarantee equitable, respectful and accessible maternal care for all.

The Person-Centered Care Framework for Reproductive Health Equity (PCC) aims to improve maternal care by focusing on the needs and experiences of people giving birth. It looks at issues like access to and use of healthcare, community support and the quality of care received. There has been limited use of this framework to assess reproductive health equity amongst marginalised groups outside of low- and middle-income countries. Since the COVID-19 pandemic made racial and ethnic disparities in maternal health worse, it is important to study its effects closely. We studied maternal healthcare at two NYC public hospitals. We used the PCC framework before and during the pandemic. In 2019, we collected data from 5330 pregnant people. We also interviewed new mothers, healthcare providers and community staff in 2020. Our research found that most of the 3181 new mothers were women of colour with public insurance. Many lacked postpartum care, and over half received poor prenatal care. Inadequate care seemed more common among younger women, Black women, Arabic-speaking women and women who smoked during pregnancy. Barriers to care included: (1) lack of health awareness, (2) financial hardships, (3) social isolation, (4) challenges with telehealth and (5) immigrant status. Problems with the quality of care included: (6) poor communication between patients and doctors and (7) not getting consistent care. The results show differences in how women use maternal healthcare, which are likely caused by larger social issues. To fix these disparities, we need policies that are equitable and involve the community.