Centering Voice and Power: Self-Advocacy and Reproductive Healthcare Experiences Among Black Women

Background and Purpose: The United States continues to experience significant racial disparities in maternal health, with Black women facing disproportionately high rates of pregnancy-related morbidity and mortality. In South Carolina (SC), these inequities persist due to structural racism, organizational barriers, and patient-provider communication disparities. Communication is a modifiable contributor to preventable harm; however, limited research centers Black women’s experiences of voice, power, and self-advocacy within healthcare encounters. Grounded in frameworks of structural racism and patient self-efficacy, this qualitative study examines how Black women navigate communication in perinatal and reproductive healthcare settings. Specifically, this study aims to (1) describe patient-provider communication experiences among Black women and (2) examine self-efficacy related to speaking up, seeking information, and self-advocacy. An exploratory aim examines healthcare professionals’ understanding of self-advocacy and their preparedness to support Black women in clinical settings.

Methods: This community-engaged, formative qualitative study was conducted in SC. Two in-person community listening sessions were held: one with Black women (n = 15) and one with healthcare professionals (n = 9), both recruited through community and professional networks. Participants received a modest incentive for participation. Data were audio-recorded, transcribed, and analyzed using Braun and Clarke’s reflexive thematic analysis. Both deductive and inductive coding strategies were employed, guided by an analytic framework that included structural and institutional racism, organizational factors, provider behaviors, and patient self-efficacy. Analysis followed a six-phase process: familiarization with the data, generating initial codes, constructing themes, reviewing themes, defining and naming themes, and producing the report.

Results: Preliminary analysis identified several key themes:

1. Voice and Trust as Foundational to Care Engagement: Experiences of dismissal, medical gaslighting, not being heard, and impersonal or dehumanizing interactions that undermined trust and shaped care-seeking behaviors.
2. The Labor of Self-Advocacy: Participants described significant emotional and cognitive effort required to speak up, including navigating the threat of perceived stereotypes and fear of being labeled “aggressive.”
3. Power and Structural Constraints in Care Settings: Time pressures and perceived profit-driven healthcare systems limited opportunities for relational, patient-centered communication.
4. Strategies for Being Heard: Participants relied on people in their support system and strategies such as “borrowing someone else’s voice” to strengthen advocacy and mitigate risk.

Preliminary analysis of healthcare professional data suggests overlapping and complementary themes with patient experiences, particularly related to relational communication, trust-building, and structural constraints, as well as provider-specific dynamics such as interprofessional communication and supporting patient self-advocacy.

Conclusions and Implications: Findings highlight the central role of voice and power in shaping maternal healthcare experiences for Black women. Inequities in communication reflect broader structural dynamics that constrain patient agency and contribute to preventable harm. Implications include the need for organizational changes that prioritize relational care and training in anti-racist and trauma-informed communication. Consistent with community-based participatory research principles, organizational changes and interventions to strengthen patient self-advocacy must be co-created with community members to ensure cultural relevance, accountability, and sustainability. Centering community voice in the design and implementation of interventions is critical to advancing maternal health equity and promoting more just, person-centered care systems.