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Abstract

Introduction:

Freestanding and in-hospital (alongside midwifery units [AMUs]) birth centers are evidence-based innovations for low-risk pregnancies that promote positive maternal and infant outcomes. However, racial and income inequities in birth center access exist. This study aims to describe the preferences and self-reported needs of Black pregnant people related to the implementation and adoption of a planned AMU within a safety-net hospital where participants were receiving prenatal care.

Methods:

In-depth qualitative interviews were conducted with a convenience sample of low-risk pregnant people who identified as Black and were receiving prenatal care in a safety-net hospital. A semi-structured questionnaire based on the Health Equity Implementation Framework (HEIF) was used to understand participant priorities and preferences for implementation of an AMU. Rapid qualitative analysis was employed.

Results:

Interviews with 15 participants were conducted. Themes were identified within each of the HEIF patient-level domains. Cross-cutting themes include autonomy in decision-making about birth setting, the need for comprehensive, unbiased birth center information, strong relationships with staff, high-quality communication, and recommended adaptations to AMU infrastructure.

Discussion:

Results contribute new information about the multidimensional aspects of patient autonomy and perceptions of safety related to maternity care services overall for Black birthing people. Patient recommendations for operational practices, physical infrastructure, and information sharing about AMU birth setting options can promote implementation success and increase access to choice in birth settings.

Health Equity Implications:

Findings can promote health equity across care settings by demonstrating the importance of relationship-based care, patient autonomy, and strong provider communication skills. For birth center care models, both freestanding and AMUs, this study contributes information about practices that can diversify access and adapt care models to serve all birthing people.

Keywords

midwifery birth center alongside midwifery unit health equity implementation science qualitative research

Background and Significance

Racial inequities in maternal health outcomes for Black birthing people in the United States are large and persistent. Compared with White birthing people, Black individuals experience rates of maternal mortality and severe morbidity that are 2.5–4 times higher.¹ They are also more likely to undergo unnecessary cesarean births, less likely to breastfeed, and more frequently exposed to nonconsented procedures.^2–4 In addition, Black birthing people report lower levels of respectful care, autonomy, and overall satisfaction with their birth experiences.⁵ Addressing these inequities requires a fundamental transformation of maternity care systems to advance health equity—ensuring that all birthing people and infants have the conditions necessary for optimal health.⁶

Accredited birth centers offer an evidence-based approach to advancing maternal health equity. These wellness-oriented, home-like settings are associated with fewer cesarean births, lower rates of preterm birth and low birth weight, higher breastfeeding rates, greater satisfaction, and higher rates of respectful care compared with traditional hospital settings.^7–13 Care typically includes extended prenatal visits, continuous labor support, active monitoring with hospital transfer as needed, early postpartum and newborn care with discharge up to 8–12 h postpartum (often starting at 4 h), and intensive follow-up through early home visits and phone calls.¹⁴

Birth centers operate in two models: (1) freestanding birth centers, which are independently owned, out-of-hospital facilities; and (2) AMUs, which are hospital-owned centers located within the hospital but distinct from standard labor and delivery units.^14,15 We use the general term “birth center” to include both models, as they serve medically low-risk individuals in environments designed to support physiological birth. Midwives provide most birth center care. The midwifery model—grounded in health promotion and relationship-centered practice—is associated with lower intervention rates, higher rates of vaginal birth, and reduced costs.^16,17 It also emphasizes respect, continuity, and trust within patient–provider relationships.^18,19

Despite strong evidence demonstrating that midwifery and birth center care are safe, effective, and equitable, Black birthing people and low-income populations continue to face limited access to these models.²⁰ In 2022, midwives attended 10.2% of births among Black birthing people compared with 13.3% among White birthing people.²¹ Although Black birthing people account for 14.2% of U.S. births, they comprise only 11.9% of birth center births.²² States with higher proportions of Black births tend to have fewer midwives across all birth settings.²³ Although several freestanding birth centers nationwide focus on culturally responsive care for Black communities—emphasizing emotional safety and equity in access—there remains a limited understanding of Black birthing people’s priorities for the design and implementation of AMUs.^7,24,25

This study addresses this gap by building on qualitative research on Black birthing people’s experiences with freestanding birth centers and extending it to AMU models.^7,24–27 Guided by the Health Equity Implementation Framework (HEIF), we elicited Black birthing people’s perspectives to inform the planning and design of an AMU within a safety-net hospital.^28,29 We chose this framework because its theoretical foundation was well aligned with the qualitative research question “What are the preferences and self-reported needs of Black pregnant people related to the implementation and adoption of an AMU within a safety-net health system?” Because community engagement and co-design strengthen the equity impact and sustainability of health innovations, this study centers Black birthing people’s voices to advance racial health equity in AMU design.³⁰

Methods

Overview

This descriptive qualitative study employed in-depth, semi-structured interviews to explore the preferences and self-reported needs of Black birthing people regarding the adoption and implementation of a planned AMU in a safety-net hospital. The HEIF guided both data collection and analysis. Results are reported using the Consolidated Criteria for Reporting Qualitative Research.³¹ The team included three investigators—the PI, a White cisgender midwife researcher fluent in Spanish, and two midwife coinvestigators, one of whom identifies as a Black immigrant female cisgender educator and researcher who is fluent in Haitian Creole and another who identifies as a White cisgender midwife researcher who is fluent in Spanish. Additionally, two research assistants participated, both of whom identify as Black cisgender females. Interviews were conducted by the assistants (K.M., S.T.) and one coinvestigator (T.C.). All investigators contributed to the analysis.

Setting and participants

The study was conducted in a prenatal clinic at Boston Medical Center (BMC), a safety-net hospital serving approximately 1,500 prenatal patients annually. Among these, about half identify as Black and 20% as Hispanic; 85% are insured by Medicaid. Midwives provide prenatal care for approximately 50% of patients, all of whom give birth at BMC. Inclusion criteria were: (1) medically low-risk pregnancy using standard birth center eligibility criteria³² (no hypertension, diabetes, prior cesarean, active substance use disorder, or planned epidural); (2) 24–40 weeks’ gestation; (3) self-identified Black race; (4) fluency in English, Haitian Creole, or Spanish; and (5) receipt of prenatal care in the study clinic. Exclusion criteria included care by maternal–fetal medicine specialists and ages younger than 18 or older than 45 years.

Recruitment

A convenience sample of 15–20 participants was targeted to achieve thematic saturation.³³ Using the electronic medical record and provider schedules, we identified 66 people who met the inclusion criteria. We sent opt-out letters to those individuals. After 2 weeks, we approached people who had not opted out either during clinic visits or by phone if they were not reachable during a visit. We were able to contact 24 people to confirm eligibility, describe the study, and offer participation. Of those, 18 people agreed to participate, and 15 completed the interview. Participants were provided with a $50 ClinCard (gift card) as compensation. The study was approved by the BMC and Boston University Medical Campus Institutional Review Board.

Data collection

An interview guide was developed using HEIF constructs and prior literature on health equity in maternity care and birth centers (Supplementary Data S1). Topics included knowledge of birth centers, preferences for care encounters, risk perceptions, and the influence of sociopolitical and economic factors. A plain-language slide presentation provided an overview of birth center characteristics at the beginning of the interview (Supplementary Data S2).

Interviews were conducted between July and September 2024, in person or via Zoom, according to participant preference. Sessions lasted 30–45 min, were audio recorded, and de-identified. One interview was conducted in Haitian Creole by a bilingual coinvestigator and was professionally translated; all others were in English. Data were stored on a secure, HIPAA-compliant institutional drive.

Analysis

Rapid qualitative analysis (RQA) methods were used, a validated approach suited for timely policy and practice dissemination.³⁴ In brief, an initial codebook was derived from the HEIF domains related specifically to patient-level determinants of implementation outcomes (Supplementary Data S3).^28,29 The constructs within each domain were chosen from the HEIF and relevant constructs related to birth center care models noted in the literature.^7–13,28 Two coders independently coded two interviews and compared coding to establish interpretive consensus. The interview guide and codebook were then refined, and a third interview was jointly coded by five coders to reach further consensus and develop a templated summary table. The remaining interviews were coded individually. The research team then met regularly to compare coding, discuss discrepancies, and reach consensus on the final code application. Themes and quotes were extracted from the template of individual findings into consolidated summaries using an Excel matrix to identify themes across the sample. We determined thematic saturation was reached when interviews no longer contributed new information to structured summary templates, consistent with an RQA approach.³⁴ An electronic audit trail and memos documented coding decisions. Lack of participant response inhibited the study team from completing member checking.

Results

Participants

A total of 15 pregnant people were interviewed (Table 1). The majority (n = 11, 73.3%) were aged 20–34 years and nulliparous. Fifty-three percent (n = 8) were insured by Medicaid and 47% (n = 7) by commercial insurance. Eighty percent (n = 12) were employed. Ethnicities included African, Black American, Haitian, and other Caribbean. Of the 15 participants, 14 (93%) identified as cisgender females, and 1 (7%) person declined to answer. Midwives provided prenatal care for 53% (n = 8) of the sample.

Table 1.

Participant Demographics

Characteristic	n (%)
Age
• 18–20 years	0 (0)
• 20–34 years	11 (73.3)
• 35+ years	4 (26.7)
Parity
• Nulliparous	10 (66.7)
• Multiparous	5 (33.3)
Insurance
• Medicaid	8 (53.3)
• Commercial	7 (46.7)
Ethnicity
• Black American	3 (20.0)
• African	6 (40.0)
• Haitian	4 (26.7)
• Caribbean (not Haitian)	2 (13.3)
Employed
• Yes	12 (80.0)
• No	3 (20.0)
Prenatal provider type
• Midwife	8 (53.3)
• Physician	2 (13.3)
• Nurse practitioner	1 (6.7)
• Mixed	4 (26.7)
Gender identity
• Cisgender, female	14 (93.3)
• Unknown/Not stated	1 (6.7)

Themes

Our themes follow the HEIF domain structures relevant to patient perspectives (Fig. 1). These include factors related to the health care innovation (the AMU), preferences and needs related to clinical encounters, patient-level cultural factors, and societal factors specifically impacting patient perspectives. Table 2 illustrates the themes and supporting quotations in detail.

FIG. 1.

Health Equity Implementation Framework codes.

Table 2.

Preferences and Needs Related to Implementation of an Alongside Midwifery Unit in a Safety-Net Setting

Health Equity Implementation Framework domain	Theme	Supporting quotes
The health care innovation
Knowledge of birth centers and AMUs	Birth center models are unfamiliar	“Back in my country… you just might be like, ‘okay, so I don’t wanna go to tde hospital’ so…they just… call a midwife… who just comes …like at home, you know. Especially in my country…they do it … at home for less (cost)… and the hospital is always more. So that’s how I see it.” (ID 07)
The clinical encounter
Relationship with birth center staff	Being known by birth center staff promotes trust	“Having a go-to person there...like a midwife that’s gonna receive your case …so you can talk to them straight up. Because I feel like I’ve had issues with...meeting ...like 4 different midwives …in 4 different times, and every time ...even when you call…you have to explain yourself...explain, repeat yourself... If I could get someone who’s on the same page as me (that) will be nice... If you need something, or if you have to book your appointment, or if you have to get like (your) cervix checked, and then you call. You have to explain yourself...every time, cause you’re getting different people...if it’s an emergency, you need to speak to someone who’s on the same page as you.” (ID 03)
Relationship with birth center staff	Culturally and racially concordant staff decrease worry about discrimination	“Black women are nervous about giving birth and being taken seriously. And they think that having someone that looks like them would just make them feel more comfortable and make them feel heard and seen.” (ID 11)
Quality of communication with birth center staff	Needing to feel heard in the clinical encounter	“She listen(s) to me. She’s a good midwife … She pay(s) attention to me when I come. …she listen(s) careful to understand me.” (ID 09)
	Needing to feel welcomed in the birth center	“I think the first thing will be how we welcome the person…if you don’t give them the welcome they deserve, they won’t enjoy the experience.” (ID 02)
	Multilingual staff are important for communication with non-English speakers	“My first (provider) here was a Haitian (provider) and it made all the difference for her to speak my language...just being able to communicate and understand without having to...get lost in translation...I was more comfortable...speaking with her about certain things. The flow was so much easier. I felt like I was being understood. I didn’t have to struggle to, you know, communicate.” (ID 12)
	Providers who are knowledgeable about providing birth center care are needed	“I felt like my questions were being answered thoroughly, and (my midwife) was knowledgeable. Yes, that makes me feel very safe.” (ID 12)
	Accessible, unbiased, and complete health information about birth centers is needed	“Sometimes it (verbal information) could be delivered wrong, or it being misconstrued so...having a pamphlet with the same facts that’s consistent so that everybody can get that same information and there’s no blurring lines...the thing is, for me, if this person is biased, if they are like ‘we have this birth center but its new’ and like kinda put a shade on it, for me that would be a bad delivery.” (ID 15)“I believe that the pregnant woman should have a brochure listing all the types of deliveries offered by (the hospital) so she can choose the type of delivery she prefers.” (ID 02)
Patient factors
Perceptions of safety and risk	Complete information about the birth center promotes a sense of safety about the birth center	“I think feeling safe giving birth in a birth center will depend on how they present the orientation before my delivery. That’s why I believe an orientation during pregnancy is important.” (ID 02)
	A birth center within the hospital campus felt safer	“I like the whole…setting of, you know, feeling at home, being comfortable in the birth center while it’s still being safe, like it’s you’re at home. But you’re still safe, which is nice.” (ID 11)“The fact that like, if if it gets escalated and like, it, turns high risk, and that the hospital is also like right there, and like as a choice as well.” (ID 10)
	Participants need flexible postpartum discharge options	“… my main concern is like going home and then I’m sent home too early, essentially and not all the proper tests are I guess, done on either me or the baby to make sure that we’re both okay… when I go home, I’m most likely not gonna sleep. So that’s another concern with like the 8 to 12 h, even if it’s 24 h.” (ID12) “There is no problem, its ok to go home [early]. Everybody is waiting at home to see the baby!” (ID 09)
Family and friends’ involvement in care	Autonomy related to accompaniment in labor is desired	“That’s why I wanna be in a birth center, so I can have whoever in the room, a circle of women.” (ID 05)
Cultural preferences for birth center care	Participants need autonomy and support related to cultural practices	“I think that if the person wants to (follow cultural traditions), they can do it. They don’t need the hospital’s permission to do so. It’s their decision after giving birth if they want to use their cultural method.” (ID 02)“I might be Muslim...you cannot force me into your own way when I’ve said I can’t do this.” (ID 04)
	Participants need access to doulas for emotional support and advocacy	“I think doula and midwife are important for birth because, like I said before, we need emotional support from a doula. And the midwife…to support with the medical … thing that they know with that knowledge …I think both are so important in the birth.” (ID 13) “I think having like a (doula) definitely makes me feel safe because of the advocacy part of it, which I feel like with having a midwife I’m already getting that advocacy, anyway, like I’m not too worried about that. But like an added layer.” (ID 12)
	Participants want access to birth center community-facing activities	“For instance, where I come from…the women go through the classes. They tell them what to do…before you give birth…That would be nice if they could do that. Bring women together and talk, pregnant women.” (ID 04)
Preferences for the use of technology in childbirth	Participants generally approach labor and birth as a physiological event that can be supported by a low-stress environment	“Trusting yourself and your body. Like we’re made to do this. We’ve done this many times before there were hospitals successfully... so like don’t let the world, social media, and people’s negative opinions scare you.” (ID 05)“At a birth center …(you) will be…comfortable, because you will be with family and you’re not gonna see everything. I’m scared of seeing too (much) medical equipment. When I saw that, I (felt) like I’m between death or life. Yeah, that made me very stressed.” (ID 13)
	Participants also want technology to be available if it is needed	“I think it (labor interventions) are somewhat important because you never know.” (ID 02)
	Above all, participants want to give fully informed consent when interventions are used	“I don’t really know like the risk of … medical intervention and stuff like that, like I think I had Pitocin with my daughter, but I didn’t really know what it was or what it does….I read that it makes your contractions like 10 times worse. People are not really well informed about these things, you know.” (ID 11)“I have a right to say I don’t want the treatment.” (ID 09)
	Participants want access to tubs for labor pain management	“The birthing tub is extremely important, I think, to be able to have the water birth option would have been so great. “I find that…water is one of the things that helps me calm down.” (ID 12)
Perceptions of racism	Participants need to feel heard in their experience specifically as Black birthing people	“I’ve experienced …not being valued or heard, and it … made me feel unsafe. I feel like it’s hard for me to even be comfortable with being treated by a provider that I genuinely feel like I can’t trust, and I feel like for pregnancy…. It’s such a vulnerable time that if I’m not feeling valued, heard in my experience, then I feel like it’s just not a positive experience. I’m just gonna be freaking out the whole time about things that I really shouldn’t be freaking out about, like trusting my provider.” (ID 12)
Perceptions of racism	Doulas and racially concordant staff promote a sense of emotional safety for Black birthing people	“We are just more complicated beings, and now higher rates of just negative things going wrong… having somebody who looks like you in the room, it’s just another thing to be comforted by in such a, it’s a beautiful but, also a traumatic experience, so to have anything you need to keep you calm is good.” (ID 05)“…I think it should be illegal as a Black woman to not have a doula.” (ID 05)
Societal influence
Social determinants of health (sociopolitical forces)	Participants need insurance coverage to access birth centers	“At first I did want to give birth in a birthing center because… I wanted to have a water birth. That was the initial goal, but it was…really complicated to get that. I felt like I didn’t know how to navigate it with my insurance to know if it’s being covered or not.” (ID 12)“in an ideal world I would have loved to give birth at home but obviously money is a big factor in that cause not a lot of insurance covers it and then the next step would’ve been a birth center, but there’s not one around.” (ID 10)
	Participants need robust postpartum infrastructure, including home social support	“That’s why the sleep was so important to me (before discharge) because there’s no like guarantee that there’s gonna be any support. Partners gonna go back to work. Everybody’s going to work. I’m gonna be home alone with the baby navigating that like alone. So it’s kind of like for me, it’s yeah. The support at home is like one of the biggest concerns for me probably.” (ID 12)“a doula in the home, at least for the 1st couple of days, or a week, or something they’d be helpful for sure. Just less stress the day after…you just feel more comfortable at home. And also, they can just see how everything like how you can acclimate it at home.” (ID 11)
	Participants need case management services to address material and social service resources	“Oh, it would be so nice to have [a social worker] at the birth center. ..yes…having case workers or social workers. Cause. I feel like that’s what I needed the most.” (ID 12)
The built environment (physical structures)	Participants need physical structures that are culturally familiar and inclusive	“…Art, probably on the wall that represents like a bunch of things around the world. And it’s just not replicating, like one specific area of the world, or something. Things that you can look at and be like ‘Oh, I feel connected to that.’” (ID 03)“I think that if I were to build such a center, I would design each room based on a different culture from one another. When you enter a room, it will be adapted to fit your culture so that you feel comfortable, if that’s what you want… (in) Haiti, I always have handcrafted lamps. I (would) include one, even if it’s just for decoration and not for lighting.” (ID 02)
The built environment (physical structures)	Participants need robust postpartum infrastructure, including home clinical support	“It’s difficult to leave the house right after giving birth: I mean if they send the person home after 8 h, then I feel like making them leave the house the next day. It’s kind of awful. If they can have a visiting person at home, that’d be good.” (ID 13)“I spoke to my sister about…childbirth, and we have 2 different experiences…Her husband was there. He didn’t know what to do, but then she had…a midwife that came in because she lives in London… I think they come in and they speak to you at the home. And she said it was very helpful to have somebody like that that understand what you’re going through.” (ID14)

AMUs, alongside midwifery units.

Innovation factors

Knowledge of AMUs

Participants were largely unfamiliar with birth centers and AMUs, highlighting limited awareness of these care models. Of the 15 participants, 5 (33%) of our sample had some idea of the concept of birth centers. Two said they had heard of them but did not know much about them, and two others said they did not know about birth centers, but when they heard the description said it sounded like home birth in their country of origin. One participant had hoped to use a birth center because she wanted a water birth, but there was not one in her geographic area.

The clinical encounter

Relationship with AMU staff

The majority of participants (n = 9; 60%) emphasized that feeling known by their providers was essential to positive care experiences. Continuity of care across the pregnancy, birth, and postpartum periods fostered trust and safety, aligning with AMUs’ personalized, relationship-based model. Racially diverse staff and racially concordant midwives were valued for reducing concerns about bias, though some participants prioritized compassion and clinical competence over racial concordance.

Quality of communication with AMU staff

Participants emphasized that feeling heard by AMU staff is essential to a positive birth experience. Active listening, empathy, and friendliness were identified as key provider competencies that foster trust and respect. One participant described how her midwife’s attentiveness made her feel valued, whereas others noted that not being listened to in prior experiences of care eroded trust, reflecting broader experiences of racism in health care. A welcoming attitude—expressed through compassion, eye contact, and small acts of hospitality—was highly valued. Participants also stressed the importance of multilingual, clinically competent staff to ensure effective and safe communication.

Preferences for information sharing centered on autonomy and transparency (Fig. 2). Participants desired unbiased, standardized written materials in a clear compare-and-contrast format, supplemented by frequent and accessible opportunities for discussion. Educational content should include newborn care, postpartum recovery, lactation, emergency procedures, pain management, and cost and insurance information. Trusted sources included prenatal care providers, peer educators, and midwives affiliated with the AMU. Participants also valued opportunities for AMU tours and online information through the hospital or social media platforms.

FIG. 2.

Goals, content, timing, and sources of information for birth center education: Themes related to preferences and strategies.

Patient-level factors

Perceptions of safety and risk

Participants reported a need for accessible and complete health information about the AMU to feel safe. They felt this undiscovered model of care requires intentional and thorough information sharing. Additionally, most participants felt that the location of an AMU within the hospital walls promoted a sense of safety, as compared with community birth. Early postpartum discharge (8–12 h postpartum) was unfamiliar to most participants, and they had questions about both the safety and the comfort of early discharge. A few participants with strong family support felt happy with the idea of early discharge. Although participants had different individual needs related to support during labor, the importance of autonomy in choosing labor support was also a common theme.

Family and friends’ involvement in care

Participants had different preferences related to having friends and family members present at birth, but most noted that they wanted autonomy to decide who would be with them. Community involvement in birth was desired by some participants, and they described a need for more people than would typically be permitted in a hospital setting. Others felt only the partner should be present and that limits on visitors in the hospital setting were not an issue.

Cultural preferences for AMU care

Participants emphasized autonomy and respectful communication regarding cultural and religious childbirth practices. Access to doulas emerged as a key theme, with many viewing doulas as enhancing emotional safety and complementing midwives’ clinical roles. Participants also valued AMUs offering community-oriented activities, such as prenatal classes, to foster connection and support.

Preferences around the use of technology

Participants viewed birth as a normal process unless complications arose and preferred to avoid routine interventions. They valued decision-making autonomy and fully informed consent, with access to technology if needed. Most desired natural childbirth, emphasizing birthing tubs for comfort, whereas others appreciated the flexibility to access hospital care for epidural pain relief if needed.

Perceptions of racism

Perceptions of racism in health care were woven through several of the above constructs. Participants expressed the importance of feeling heard, specifically in their experience as Black birthing people. The relationship between being heard and having trust in the health care system was evident. The role of the doula in promoting emotional safety during birth and the importance of racially concordant staff were specific strategies mentioned by participants to buffer experiences of racism.

Societal influences

Sociopolitical forces and physical structures

Sociopolitical forces are one of the external contextual components of the HEIF framework that influence implementation success and model adaptation needs. In our study, participants articulated the need for three categories of socioeconomic support. First, participants reported that insurance coverage of birth centers, along with easily accessible information related to coverage, is critical to the decision to use a birth center model. Second, some participants needed additional postpartum social support to make early discharge feasible. Participants noted that doula support in the home could play an important role in this period. Last, some participants reported that case managers for navigation of material resource needs are an important part of holistic prenatal care.

Physical structures

Physical structures, including the material and built conditions of the AMU facility, are another external contextual factor in the HEIF framework that can influence implementation. The built environment of an AMU, including its location and physical design, relates to sociopolitical forces to the extent that it responds to the birthing person’s experience of personal power, values, and socioeconomic needs in health care. Participants shared that the AMU facility design could reduce stress and promote confidence in physiological birth. For example, many participants reported the need for tubs in the birth rooms to cope with labor. Two stated that they specifically wanted the choice of having a water birth. Participants also articulated a preference for décor that was culturally familiar and inclusive. Another participant recommended cultural décor that could be adaptable to the preferences of the birthing person.

Postpartum infrastructure that promotes safety and comfort after early discharge was also noted as an important tangible environmental need. Rather than clinical facilities such as hospital rooms and clinics, participants articulated the importance of the home setting for postpartum care in order to promote physical recovery of the birthing person and the newborn. As previously mentioned, doula presence in the home for social support is also a potentially beneficial component of postpartum infrastructure in the home setting. Although not specifically physical structures, doula and midwife home care provides infrastructure to support the home care site.

Strategies for addressing preferences and needs

Table 3 offers strategies for how midwives and hospitals can integrate our findings into the implementation planning of AMUs to promote health equity. Using a published inventory of implementation science strategies drawn from the literature,³⁵ this table presents ways in which identified needs and preferences can be integrated into model design. Although a formal mapping method was not used, the strategies may be useful to promote rapid implementation of birth center models of care.

Table 3.

Potential Alongside Midwifery Unit Implementation Strategies to Address Participant Needs and Preferences

Theme	Potential strategies for addressing theme
Wanting to feel known by birth center staff	Implement continuity of care models and/or opportunities in pregnancy for patients to meet all midwives who attend birth
Needing to feel heard in the clinical encounter	1. Identify and prepare communication champions to support active listening skills among staff 2. Provide education and training for staff on active listening 3. Implement appointment and medical record systems that allow for time to elicit and document patient values and perspectives
Needing to feel welcomed in the birth center	1. Develop a “welcoming” routine for visits and labor admission 2. Train staff in communication strategies to help people feel welcomed
Multilingual staff are important to participants	1. Hire multilingual staff 2. Train staff to work with linguistically diverse people and use interpreters effectively
Participants need providers who are knowledgeable about providing birth center care	1. Include access to midwives with experience in birth centers 2. Implement standardized midwifery training in birth center care
Participants need accessible and complete health information	Implement in-depth, comprehensive education on what to expect in the birth center (see Fig. 2 for details)
Participants need culturally and racially concordant staff to decrease worry about discrimination	1. Ensure access to racially/culturally concordant staff to decrease worry about maltreatment 2. Implement staff training and support structures with accountability metrics to ensure clients feel heard and to eliminate bias in decision-making
Participants need to feel they are giving fully informed consent	Provide comprehensive information about potential interventions (prenatally and during labor) (see Fig. 2 for related education points)
Autonomy related to accompaniment in labor	Implement policies that allow patients to bring their chosen support companions without requirements or limitations
Participants need flexible postpartum discharge options	Offer flexible postpartum stay options, including: (1) standard birth center early discharge with in-depth prenatal preparation and robust home support; (2) transfer to postpartum inpatient unit
Participants need access to doulas	Educate about and refer to doula care services for emotional support and to address concerns of medical racism
Participants receiving care in a safety-net hospital prefer a birth center located within the hospital	Provide information about the geographic proximity to hospital services
Participants need autonomy and support related to cultural practices	Create organizational norms where patients can practice their cultural traditions as they desire
Participants want access to birth center community-facing activities	Implement supportive and informative community-facing opportunities
Participants need a low-stress built environment that promotes confidence in physiological birth	Build a home-like environment with: (1) a large bed; (2) an opportunity to cook personal food; (3) a relaxing atmosphere (light, nice entrance, dim lights, music)
Participants need physical structures that are culturally familiar and inclusive	Design the space to include multicultural décor and art of mothers/parents and babies; consider portable multicultural “decoration kits” for labor rooms that parents can choose when they are admitted to the birth center
Participants want tubs for labor comfort	Install tubs for comfort in labor and birth
Participants need robust postpartum infrastructure, including home clinical support	Provide home postpartum visits for clinical assessment and support
Participants need robust postpartum infrastructure, including home social support	Provide in-home doula support options for those with early discharge
Participants need insurance coverage to access birth centers	1. Provide insurance coverage for birth center services 2. Disseminate birth center insurance coverage information that is easily accessible to pregnant people
Participants need case management services to address material and social service resources	Create access to case workers for material and social service resource navigation needs

Discussion

Application of the HEIF addresses a key gap in the literature by highlighting the multidimensional aspects of autonomy prioritized by Black birthing people—dimensions extending beyond shared decision-making (see Table 2). Participants emphasized provider qualities such as active listening, friendliness, and hospitality as behaviors that foster engagement and agency. Flexibility in allowing family and friends during labor supported community participation, whereas the valued role of doulas reflected a broader view of advocacy as central to autonomy. Participant recommendations also underscored transparent, consistent information sharing as essential to informed consent and decision-making authority. These findings elevate the importance of a holistic experience of self-determination in childbirth to Black birthing people.

Participants in the present study also defined safety holistically, encompassing comprehensive health information, emotional safety in provider relationships, and home-like, welcoming environments, in addition to positive clinical outcomes (see Tables 2 and 3). Evidence demonstrates that freestanding accredited birth centers achieve excellent results, including lower rates of preterm birth, low birth weight, and cesarean delivery, and higher rates of respectful communication compared with hospitals.^7–13 Participants in this study perceived the AMU model as providing an additional layer of safety due to its hospital location. This finding aligns with the HEIF’s focus on how physical structures and service location shape equitable implementation. By addressing geographic and financial barriers to freestanding birth center access, along with cultural preferences for birth care, the HEIF highlights the structural significance of the AMU model as an equity-promoting redesign of perinatal care, particularly for populations served by safety-net health systems.

Because all participants received prenatal care in a safety-net hospital system, their perspectives may reflect specific contextual influences, such as financial insecurity, fewer social support resources, and less exposure to evidence-based information about birth center care models. Prior research suggests that perceptions of out-of-hospital birth safety are similar for Black and White birthing people.³⁶ Another study found that Black postpartum individuals were more likely than other racial or ethnic groups to desire future birth center care.³⁷ Importantly, early discharge emerged as a significant concern, as noted in Table 2. Standard birth center practice includes discharge up to 8–12 h postpartum, followed by home visits within 24 h and daily follow-up calls. Participants expressed apprehension about complications at home, as well as a desire for additional rest, although many were reassured by early home visits. This finding is a new addition to the evidence on birth center preferences and an underexplored topic in the literature. It highlights the need for further study related to perceptions of postpartum safety, postpartum and newborn care preparation needs, and preferences related to discharge timing.

Another novel finding noted in Table 2 was the limited awareness of birth center and AMU models among individuals receiving care in safety-net settings. Because 97% of births in the United States occur in hospital settings, most people have not been exposed to this model.²¹ As a result, community education is critical for increasing utilization of evidence-based birth center models (see Fig. 2). This study underscores the importance of culturally responsive education and outreach to build awareness, trust, and engagement among Black birthing people specifically.

Some findings from this study also reinforce prior research identifying key priorities among Black birthing people in maternity care, including the importance of trusting provider relationships, feeling heard and respected, racial and cultural concordance with staff, and access to doula support (see Tables 2 and 3).^{24–27,38–44} Consistent with other studies, participants identified barriers to birth center use such as concerns about complications requiring hospital transfer, cost, and insurance limitations.²⁶ Reported facilitators mirrored those found elsewhere, including an emphasis on autonomy, culturally responsive care, and support for physiological birth.^24–27

Limitations include the single-site design. All participants received care at an urban safety-net hospital site, and most saw a midwife for prenatal visits. Participant perspectives may therefore reflect specific contextual influences, such as knowledge of midwifery care or lack of access to resources. This may limit the transferability of findings to settings where patients are not exposed to midwives or those who have greater access to material resources and social support that make postpartum home care more appealing. Furthermore, two-thirds of participants were nulliparous. Perceptions of safety and care priorities may differ for multiparous individuals, whose preferences may be shaped by prior birth experiences, and may influence the transferability of our findings to this group. Future studies can consider oversampling multiparous participants to ensure representation from experienced birthing people. Finally, although the study aimed to include linguistically diverse participants, no eligible Spanish-speaking individuals elected to participate.

Implications for health equity

The lessons from this study are broadly applicable for improving health equity across maternity care settings. All facilities can benefit from adopting practices that promote relationship-based care, uphold birthing-person autonomy in multiple dimensions, and strengthen communication skills that prioritize active listening and emotional safety. Both hospital-based AMUs and freestanding birth centers can use these insights to diversify access and adapt care models to reflect the communities they serve. Additionally, co-designed community education about AMUs can effectively increase awareness and help diverse families understand the scope and value of birth center models of care.

Authors’ Contributions

T.C.: Conceptualization, funding acquisition, methodology, data collection, analysis, and writing—editing. K.M.: Data collection, analysis, and writing—editing. J.M.-S.: Conceptualization, funding acquisition, methodology, analysis, and writing. K.R.: Conceptualization, funding acquisition, analysis, and writing—editing. S.T.: Data collection, analysis, and writing.

Footnotes

Acknowledgments

The authors would like to thank the participants for their insights and time. They are also grateful to the Boston University Center for Implementation Science, including Dr. Kirsten Austad and Kayla Jones, for their consultation service.

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

The study was funded by the BMC’s Health Equity Accelerator Seed Grant. The funder had no role in the design of the study, collection, analysis, or interpretation of data or in the writing of the article.

Supplemental Material

Abbreviations Used

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Supplementary Material

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Co-Designing Alongside Midwifery Units to Promote Maternal Health Equity: A Qualitative Study with Black Pregnant Individuals Receiving Prenatal Care in a Safety-Net Hospital Setting

Abstract

Introduction:

Methods:

Results:

Discussion:

Health Equity Implications:

Keywords

Background and Significance

Methods

Overview

Setting and participants

Recruitment

Data collection

Analysis

Results

Participants

Themes

Innovation factors

Knowledge of AMUs

The clinical encounter

Relationship with AMU staff

Quality of communication with AMU staff

Patient-level factors

Perceptions of safety and risk

Family and friends’ involvement in care

Cultural preferences for AMU care

Preferences around the use of technology

Perceptions of racism

Societal influences

Sociopolitical forces and physical structures

Physical structures

Strategies for addressing preferences and needs

Discussion

Implications for health equity

Authors’ Contributions

Footnotes

Acknowledgments

Author Disclosure Statement

Funding Information

Supplemental Material

Supplemental Material

Supplemental Material

Abbreviations Used

References

Supplementary Material