“I Cannot Believe That This Is Really What Is Happening”: Understanding Birthing Experiences of Vulnerable Women In Texas.

Background & Purpose
Maternal mortality—defined as death during pregnancy or within one year postpartum from pregnancy-related causes—remains a critical public health issue in the United States, with higher rates in Texas (28.2 per 100,000 live births) compared to the national average (23.2). Disparities are especially pronounced for Black women, who experience mortality at rates 2–3 times higher than White women. While quantitative research identifies structural determinants of maternal health inequities, less is known about how these forces are experienced and navigated in everyday life. This study advances rigorous, community-centered inquiry by examining how people who give birth in Texas perceive health risk, understand their health status, and engage resources during pregnancy and postpartum. We ask: (1) How do perceptions of health risk shape care-seeking? (2) How is health status understood? and (3) How are behaviors interpreted as health risks or protective actions?

Methods
We conducted 25 semi-structured interviews with individuals who experienced birth complications within the past 12 months. Participants were recruited using convenience and snowball sampling through community-serving organizations. The sample was racially diverse (44% Black, 32% Latina, 24% White; mean age=28). Most women were employed, had a high school degree or higher and had insurance prior to pregnancy and during childbirth. Data collection and analysis happened concurrently through 2 phases. Interviews were analyzed using team-based coding informed by matrix of domination theory, with iterative, structural analystic memoing and consensus-driven theme development supported by Atlas.ti.

Results
Three central themes illustrate how structural conditions shape maternal health beliefs and behaviors. First, Baby Comes First: participants made healthcare decisions based on perceived infant needs and the constraints of their healthcare access, often delaying care for themselves unless symptoms were severe. Second, Health Beliefs Are Shaped by the Birthing Process: participants relied on medical providers as trusted authorities during pregnancy, but a lack of continuity in postpartum care created gaps in guidance, leading many to seek information from informal sources such as the internet. Health was consistently framed as baby-centered, reinforcing feelings of responsibility and self-blame, particularly when complications arose. Third, Anticipated Racism Acts as a Buffer: participants—especially Black women—described anticipating discriminatory treatment and proactively modifying their care-seeking strategies, including selecting racially concordant providers, to mitigate harm.

Conclusion and Implications
Findings demonstrate how structural inequities are reproduced through the intersection of healthcare access, institutional discontinuity, and internalized expectations of motherhood. Our findings suggest that maternal health behaviors are not solely individual choices but are shaped by constrained options, anticipated bias, and fragmented systems of care. Policy and clinically driven efforts to reduce maternal mortality must move beyond individual-level interventions to address continuity of care, culturally responsive practices, and structural conditions that shape both access and decision-making.