Differences in Hospital Prenatal Care in France: A Qualitative Study within the BIP Research on Racial Implicit Bias in Perinatal Care

Differences in Hospital Prenatal Care in France: A Qualitative Study within the BIP Research on Racial Implicit Bias in Perinatal Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Differences in Hospital Prenatal Care in France: A Qualitative Study within the BIP Research on Racial Implicit Bias in Perinatal Care Priscille Sauvegrain, Marguerite Cognet, Olivia Anselem, Juliette Richetin, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6714783/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract o Background Recent statistics indicate that 24% of live births in France are to mothers who were born abroad. Women born in sub-Saharan Africa (SSA) are especially at risk of maternal and neonatal morbidity and mortality. Intermediate explanatory factors probably include access to and quality of care. We therefore wished to explore the hypothesis of less appropriate care for immigrants resulting from racial discrimination in care encouraged by implicit racial biases that healthcare professionals may carry. The BiP multidisciplinary mixed-methods project sought to explore implicit racial biases among prenatal practitioners in one of the first approaches to this issue in France. The qualitative component presented here aimed to assess whether implicit bias might be producing disparities in prenatal care for pregnant women. o Methods A sociological qualitative study was conducted in three public maternity units in the Paris area, France, among 6 obstetrician-gynaecologists, 6 midwives, 6 anaesthesiologists, and 148 pregnant women. The study is based on audio-recorded prenatal consultations and interviews with practitioners. Consultations and interviews were analysed thematically. o Results The countries of birth and social positions of the participating women were globally similar to those of the pregnant women seen in each maternity unit. The analyses showed that the standard of care was globally high and consultations were slightly longer for immigrant women; explanations provided by health-care practitioners were appropriate to their level of understanding. The prenatal follow-up, when standardised, left little room for differential care. Nonetheless, the tone of voice and the type of jokes showed the salience of the social relations of race and class, beyond the strict framework of the care relationship. A few instances of racism in care were identified and analysed, but their consideration by the institution is non-existent. o Conclusions French research is beginning to produce quantified data on racial discrimination in health care, and this qualitative study provides an in-depth understanding of mechanisms leading to less adequate care (which was not observed to be an everyday occurrence). Despite the inclusion bias inherent in this type of approach, this study produced original results about the differential care of immigrant women during hospital prenatal care and underlines the importance of universal access to care in limiting inequalities. Obstetrics & Gynecology Prenatal care hospital pathway social health inequalities discrimination implicit racial bias maternal health qualitative study immigrant women. Figures Figure 1 Figure 2 Background Recent statistics indicate that 24% of live births in France are to mothers who were born abroad ( 1 ). These immigrant women are, in France as throughout Europe, at higher perinatal and maternal risk than native-born women, with higher rates of hypertensive complications, maternal mortality ( 2 , 3 ), preterm birth, and low birth weight ( 4 ). Women born in sub-Saharan Africa (SSA) are especially at risk of maternal and neonatal morbidity and mortality ( 5 – 7 ). Intermediate explanatory factors probably include access to and quality of care ( 6 , 8 ). Recent studies show the existence of differential care of immigrants (a concept first raised in France by D. Fassin, an anthropologist/physician, and covering both unequal access to care and differential quality of care standards ( 9 )). Specifically, they demonstrate care that is both differential and less appropriate during the perinatal period for women born in SSA ( 10 – 16 ). Further support for this hypothesis comes from an infectious diseases department ( 17 ) and general emergency departments ( 18 ). We therefore wished to explore the hypothesis of less appropriate care for immigrants resulting from racial discrimination in care encouraged by implicit racial biases that healthcare professionals may carry. Racial discrimination in care is a subject underexplored in France, compared with North America where it is at research agenda since decades. Studies from the USA report very strong differences in access to and quality of care received; the differences between Black and White women in health, especially in obstetrics, are much stronger than those reported in Europe ( 19 , 20 ). The issue of racism in obstetrics is much discussed ( 21 ). We conceived this study as an exploration of this topic in France, a country with a different socio-political and historical context, with theoretical universal access to care but limited access to racial data (only country of birth and nationality can be reported, not ethnicity), which makes research on racial disparities difficult. Accordingly, little has been done so far to explore racial discrimination in French health care. This sociological study concerning differences according to migration backgrounds in less appropriate care during hospital-based prenatal care is a component of the BIP research programme (Migrants and differential care in the perinatal period: Effects of implicit bias), designed to address the issue of race-based differential maternity care by mixed methodological approaches ( 22 ). The study reported in this paper aimed, through the use of qualitative methods, to explore the clinical relationship between women from different migration backgrounds and health-care providers to capture the processes potentially producing disparities in the care of pregnant women. Methods This qualitative observational study took place in three Parisian maternity units, with fairly high proportions of immigrant patients and chosen to facilitate contrasts between their catchment areas (centre, eastern and northern Paris). The audio-recording procedure enabled us to study practitioner-patient discussions and the content of prenatal consultations. Self-confrontation interviews with the practitioners involved followed. Audio-recording of consultations : We recruited six obstetrician-gynaecologists, six midwives, and six anaesthesiologists with the three different methods: by a physician/research director in maternity unit A, by the department head in unit B (by email invitation, volunteers contacted us), and directly by the researcher/PI in C (only 1 midwife declined). All consented in writing to participate after full information about the research and its objectives, and to active and stop the audiorecorder. The prenatal care visits recorded were: 1) the first prenatal visit, when women's clinical and obstetric histories and social data are collected; 2) the visit informing women about trisomy 21 screening tests (routinely offered in France and covered by the national health insurance fund; two units combined these with the first-trimester ultrasound scan); and 3) the pre-anaesthesia consultation, mandatory during the third trimester. We approached the 175 women meeting the inclusion criteria: aged 18 or older, consulting for one of the three study visits with a participating practitioner, and speaking French well enough to read and understand the study information and consent forms. Among them, 148 agreed to participate (convenience sample; acceptance rate: 85%), received the necessary information, and provided written consent to the anonymised audio-recording of their consultation. The social science researcher was in the waiting room during the consultations and the audiorecorder was operated by the practitioners. Self-confrontation interviews with practitioners This survey technique began in the field of organizational psychology and was subsequently extended to sociology ( 23 , 24 ). It confronts participants with their own actions and allows them to explain what they did after listening to selected extracts of recordings ( 25 ). The interview guide is available ( see Appendix 1 ); the heart of the interview was the phase of hearing two or three audio excerpts and responding to the analyses. The interviews took place 2 to 4 months after the recorded consultation and lasted between 25 minutes and an hour. Analyses The recordings of the consultations and of the subsequent interviews were anonymised and entered into a software program for treating qualitative data (N’Vivo 12, QSR International). We observed the saturation of the data collected: new themes no longer emerged during the analysis of interviews with practitioners of the last maternity unit. Based on the standards for analysis of content from qualitative studies and reported in Fig. 1, two researchers (PS and MC) jointly coded each track thematically, according to themes usually discussed in these consultations, and each interview according to the interview grid ( 26 , 27 ) We adhered to the COREQ quality criteria for reporting qualitative research (see the checklist in Appendix 2) . Results Population Table 1 summarises the study procedures in each maternity unit and specifically the duration of and health-care providers (HCPs) involved in the consultations we recorded. Table 1 Study procedures in each maternity unit Site Dates Number of HCPs included Ob Midwife Anest No. Consultations observed Maternity unit A Sept. 2018– Jan. 2019 8 2 3 3 70 Maternity unit B Feb–Apr. 2019 6 2 2 2 49 Maternity unit C May–July 2019 4 2 1 1 29 HCPs, healthcare practitioners, Ob, obstetrician; Anest, anesthesiologist Table 2 presents the distribution by parity, country of birth, and social position of the women included in the study. Women recruited at maternity units B and C (respectively located in eastern and northern Paris) were more likely to have been born abroad and to be multiparous and less likely to be managers and professionals than the women recruited at maternity unit A (central Paris). Table 2 Characteristics of the women included in the study, by maternity unit Mater A N = 70 Mater B N = 49 Mater C N = 29 Parity 1 44 (63%) 19 (38%) 13 (45%) 2 17 (24%) 14 (29%) 10 (34%) ≥ 3 9 (13%) 16 (33%) 6 (21%) Country/region of birth* France 45 (65%) 25 (50%) 12 (41%) Europe 8 (11%) 5 (10%) 0 (0%) North Africa 5 (7%) 6 (13%) 6 (21%) Sub-Saharan Africa 9 (13%) 10 (21%) 9 (31%) Others 3 (4%) 3 (6%) 2 (7%) Employment Managerial and professional 34 (49%) 11 (23%) 7 (24%) Intermediate occupations 10 (14%) 12 (23%) 7 (24%) Office workers 14 (20%) 11 (23%) 7 (24%) Crafts workers and shopkeepers 2 (3%) 0 (0%) 0 (0%) Manual workers 0 (0%) 1 (2%) 1 (4%) Farmer 1 (1%) 0 (0%) 0 (0%) Not working 9 (13%) 14 (29%) 7 (24%) Note *: Data available in France: Place of birth and nationality, none about ethnicity Main Results - Longer consultations for immigrant women The table of inclusions incited us to first analyze the consultation time. According to the woman's country of birth, it showed slight longer consultations for immigrant women: the anaesthesiologists saw immigrant women for longer periods than they did women born in France: 55% of the former had visits lasting from 13 to 20 minutes compared with 35% of the latter (and vice versa for the consultations lasting from 7 to 13 minutes), as shown in Fig. 2 . Similarly, for the obstetricians, 70% of whose consultations lasted from 20 to 40 minutes, immigrants were more often seen longer than women born in France. The duration of the consultations with midwives followed the same trend, but are not comparable, because the latter professionals provided various particular services, such as specific consultations for women in situations of social deprivation in maternity B. When asked about the extra length of the consultations in the interviews, practitioners referred to the probable need to translate or to be sure of being understood during consultations: "We manage, we always understand each other. I use Google Translate a lot when we get stuck." (obstetrician #5). Longer consultation times make it possible to safeguard time for discussion and to provide personalized advice, as midwife 2 explained: “I think it's important to connect women with their personal history, prior to migration. These are their roots, and I think it's important for them to draw on them to become mothers themselves.” (midwife #2) - Explanations provided at the pre-anesthesia visit The analgesia consultation was chosen for observation because it is one of the most standardised care procedures in the prenatal pathway. The longer duration among immigrants was observed at each stage (clinical history, clinical examination, diagnosis, and prescriptions). The care nonetheless remained very standardised and the consultations globally rapid. Their contents are prescribed by Public Health Code (Decree of 5 December 1994): patients must be informed about anaesthetic procedures and their risks and benefits. During the self-confrontation interview, anaesthesiologist #6 explained: "- Yes I know, I'm almost reciting a text when I see patients for this consultation. I’ve put together a text that I always deliver at more or less the same rhythm. When I was younger, I did it differently. I adapted more. But since consultations must now be finished in 10 to 15 minutes, I tell myself that this must be fast, concise, and as specific as possible." (Anaesthesiologist #6). Analyses showed that rare complications of epidurals were explained in the most detail to the women who best understood medical discourse and to those with higher social status. - Information provided in obstetrics: the example of trisomy 21 screening tests Practitioners gave women very specific information about these tests and about their right to turn them down. The recordings highlighted the quality of the information provided to the women by the HCPs involved in this study. They adopted simpler words for the women who understood least well, whether this was related to their understanding of the French language (immigrants) or the medical language (those in lower social categories). Thus, midwife #5 started by making sure that women understood that a half a pizza is larger than a quarter of a pizza; and thus, that a risk of 1/250 will be bigger than a risk of 1/10,000. We returned to that in the self-confrontation interview: "I like to ask women that, except obviously when I see they work in computer programming or she's a math teacher … But otherwise, there are plenty of little women, they'll tell you: ‘I don't know, I never understood anything about fractions’." (midwife #5) She also confided that she has progressively standardised her discourse. Observation showed that this left little time for interpersonal variations. - Practitioners speak more loudly to women who don't understand French well The practitioners talked much more loudly to the women who spoke the worst French, as demonstrated by some of the audio recordings. We broached this topic in an interview: "It seems to me listening to the recording that you are speaking more loudly…, to the women who speak French less well. Unless it's the position of the recorder? (Smiles) "Yes, you're right, it's very clear. How do you explain this? I don't know, I hadn't noticed it before. But I can hear that I'm articulating more. I articulate so that she can understand me. " (anaesthesiologist #5) - Social Salience The analyses also showed a number of results that reveal social asymmetries in the care relationship that go beyond the framework of the formal relationships between care providers and patients. These observed trends nonetheless remain somewhat fragile, as they are relatively rare within the recordings. They deserve further exploration and confirmation. We present them in Table 3 . As an example, analysis of the start of consultations revealed differences in the way Professor A greeted his immigrant patients and engaged in intrusive humor that he did not practice with French women. This reveals an implicit racial bias. During the interview, Professor A avoids reacting to this conversation extract (Table 3 ; Excerpt #4) and then insists on his “affection” for these African patients. Table 3 Verbatims illustrating social asymmetries between healthcare professionals and their patients Type of interaction HCP concerned Excerpt (numbered) Standardized salutation Majority E#1 : "- Hello, Madam, I'm Marion*, the one of the consulting midwives here. I'm seeing you today for your first consultation. We're going to set up your file together, now." (midwife #4-P2, Polish woman, housewife, para 2). Familiarity during salutation Mw 5 with an African known patient E#2 : She greeted her warmly and informally, asking for news of the older children: " How are my little ones [mes petits] doing? " Familiarity during salutation Mw 4 with patients who were her peers, white and middle-class. E#3 : She addressed them as "my beautiful one [ma belle]," an expression not found in the discourse of any other clinician. Paternalistic joke Pr A with an African couple E#4 : To a woman whose husband had made it clear in the corridor that the wait was too long (> 2 h) and he was going to leave, Professor A. said: " Why leave? Do you have an appointment with President Macron?" and then he laughed at his joke. Asymmetric tensions that can be expressed in hospital corridors or waiting rooms Ultrasonographist with African patient, para 1, arriving late E#5 : A stentorian voice rings out from the back of a consultation room, with an open door: "Madame Traorrreeeeee."* To me, standing nearby: "That's it, my nerves have had it. - What's happening? - They're not even on time! To the woman: "- So they tell you you're going to have an important sonogram [fetal morphology fetal] and you're not even on time? - But it took us time to get here! - Well then you should have left earlier!!" (The consultation room door slams). Tensions expressed in the medical practice Anesthesiologist #4 with a Comorian patient, para2 E#6 : Her second patient of the afternoon she did not have the file (usually prepared by the administrative team): "- Mrs Ali ! (the time the woman takes to enter: I don't have a file!!) - (to the woman): Mrs Ali*, you don't have a file? I only have one file out of 11, I feel like I'm going to lose my mind! " [Leaves to look for the file, unsuccessfully] … "- Go see at reception and ask them to look for it for you and then come back. - Well, I was with the midwife before, I think it's on the other side. - Yes but I've looked everywhere and I cannot lose a half hour by patient to look for a file. So I'm sorry, I know that it's not your fault but I can't do anything else." (The patient leaved very dissatisfied with her "consultation") *Fictive names - The question of racial discrimination in care? Two particularly conflictual situations were observed during this study, both between white female HCPs and black patients. These practitioners were, in contrast, extremely polite in the interactions with native-born White women. Two dialogues (Table 3 ; excerpts #5 and #6) illuminate the asymmetric tensions that can be expressed in waiting rooms or during consultation. These two practitioners mentioned the disorganisation of their day to justify their irritation (late patient, lost file). Moreover, during interviews, some HCPs reported situations of conflict with some of their patients of colour. Thus, although we had found anaesthesiologist #1 behaved very similarly in each of the consultations, her self-description was quite different: "- Your consultations are very similar from one woman to the next. "- In fact the appointment, it's 10 minutes so if I see they're interested, I am very available for them, if not, I move quickly. But on the other hand if they don't understand, I can stop the consultation at the end of three minutes. It's out of the question for me to do a consultation if the woman doesn't understand anything. … On the other hand, it's harder for me with Arab and African populations: I don't speak their languages. If the Arab women come with their guys, it doesn't bother me to say to them: 'You're not the patient!' I don't hesitate to send them outside. I accept many cultural things, but not that." (anaesthesiologist #1) - Lack of supervisors' support in conflictual situations An sonographer was involved in an argument with Obstetrician #4 reported in Interview, concerning ultrasound scans for an African family. Obstetrician #4 reported this to her department head, who did not intervene (Interview with Ob#4). The situations described above show that inappropriate behaviour is tolerated for practical reasons: essential skills, disorganisation of the care circuit, etc. Discussion Main Results This study of 148 patients in Paris consulting 18 HCPs showed globally similar and highly standardised content delivered to immigrant and native-born women. The professionals tightly controlled the content of care and all of them expressed, during the interviews, their attachment to a quality public service. Accordingly, the differences concern three points. The duration of consultations was slightly longer for immigrants. HCPs simplified their discourse for the women with a poor understanding of French and/or medical terminology, and some practitioners had a way of addressing some patients that reflects racial implicit bias (speaking louder, make jokes or reproaches you wouldn't make to your peers). Strengths and limitations A multidisciplinary steering committee and clinicians were included at several stages of the writing and validation of our protocol. The principal investigator's presentation of the study to women over a seven-month period yielded a high participation rate — 85%, well above our objectives. The fact that she is a midwife facilitated her access to the women and the practitioners. The interviews were both rich and informative because the occupational proximity promoted confidence ( 28 ). We also succeeded in including women with very diverse migratory and social profiles and who were globally similar to the profiles of the women consulting in each unit. The participation of three different medical professions is another originality of this work. The study's greatest limitation is that HCPs knew its objectives and volunteered (as required by the ethics committee). Thus, despite the three different methods used to recruit practitioners, a recruitment bias could have minimised the situations in which differential care was likely to be found. Moreover, the exclusion of seven women who did not speak French (another ethics committee requirement) might have prevented us from obtaining data about some attitudes toward these most vulnerable immigrants. Research beyond this initial exploration would probably require a substantial budget for interpreters. Discussion in the light of the literature Our results confirm that the universal access to hospital-based prenatal care for women fluent in French, born in France or elsewhere, leaves little room for differential care. The more standardised and protocolised the care is (e.g., anaesthesia consultations), the less frequent differential care is likely to be ( 29 ). Studies conducted during delivery and the postpartum period, contexts in which care is less standardised and where the unexpected is most likely to occur, leave much more place for practitioners' cultural or racial biases, which can take the form of differential care ( 15 , 16 , 30 ). We previously showed that women with extremely serious complications of hypertension receive highly standardised management that leaves little room for differential care ( 12 ). Obviously, not all stages of antenatal care can necessarily or usefully be standardised, but these successive studies show the importance of training students and professionals to avoid potentially discriminatory situations. Other non-obstetric studies confirm, as we report here, that the duration of consultation for minority groups differs from that for majority groups, whose consultations are generally shorter ( 31 , 32 ). Some longer consultations are explained by the presence of an interpreter ( 33 ). In our study, HCPs may perceive that these patients require more detailed information to understand. Practitioners speak more loudly to women who do not understand French well, as if to better hold their attention, or as evidence of their annoyance. While audiences at oral presentations at congresses smiled at this finding, it does not, to our knowledge, appear in the literature and merits further exploration, behavioral research in particular. These HCPs handle much of their discourse with very standardised consultations, although their salutations when greeting patients at the start indicate that this moment is less controllable. In their interviews, HCPs confided the personal factors influencing how they care for patients: family history, such as difficult medical situations in their pasts, family traditions of practising medicine or providing health care, or political or religious beliefs guiding them to more altruistic practices. These results are not discussed in this paper but suggest the interest of collecting such data from a larger number of medical professionals in a future project. We observed that practitioners often explained their attitudes in conflict situations by issues related to the organization of care. These issues did not appear in the recorded consultations, which mainly show high-quality care. Nonetheless, several practitioners expressed distance, even annoyance, toward certain groups of immigrant women during the self-confrontation interviews, which thus enabled us to extend our analyses above and beyond the initial recordings and observations. The information to be provided about Down syndrome screening is complex and should be standardised. The epidemiological component of the BIP study showed that immigrants in France are less likely than native women to make an informed choice about foetal trisomy 21 screening ( 14 ). In the same way, a previous study based on interviews with 54 caregivers yielded many information about differential and less appropriate care among African-perceived women ( 34 ). Interviews with HCPs provide an accumulation of experiences, while recordings of consultations allow us to analyse the fact that they rarely take place in the real time of clinical practice. Simultaneously with the discussion about obstetric racism in the United States ( 21 , 35 , 36 ), the French social science literature has been revealing examples of racism in perinatal care ( 37 – 40 ) as in other medical areas ( 41 , 42 ). The disparities in maternal and perinatal morbidity and mortality between groups (racial and/or migrant) appear much stronger in the USA than in France ( 43 – 46 ). Levels of racism and racial segregation are not comparable in the two countries, such as the insurance system. The insurance system which aim to ensure universal access to healthcare in France might constitute a context preventing the influence of discrimination. We must nonetheless stress that when situations of racial discrimination in care are reported up the chain of responsibility, the institutions do not appear to take steps to resolve these conflicts. No training is offered to understand implicit biases and their implications in care relationships, and to help practitioners to deconstruct them, no sanctions applied in case of explicit discrimination. This has already been described in other French institutions ( 47 ). Conclusion The quality of prenatal care appeared to be high in this study, regardless of where women were born. This is an innovative study in France, part of an innovative research programme. Although several limitations restrict the generalisability of our results, we observed both direct and indirect expressions of implicit bias that may affect patient experiences and quality of care. As French teams begin to produce quantitative data on racial discrimination in health care, this qualitative study offers us an in-depth understanding of the mechanisms that lead to care that, while not necessarily commonplace or quotidian, is not adequate either. Improvement in the organisation of care and the working conditions of practitioners could prevent the expression of stereotypes, which seems to be facilitated (or at least excused by) the organisation of obstetric departments. Declarations Ethics approval and consent to participate: The study was conducted in accordance with the principles of the declaration of Helsinki. The INSERM ethics review board approved this study (IRB 00003888, opinion n°18–507) on July 3, 2018, as did the CEREES (Expert committee for health research, studies, and evaluations) on September 6, 2018 (TPS 107121), and the CNIL (National Data Protection Commission) on October 24, 2018 (DR-2018-270). The participating professionals and patients signed written consent forms. A dual circuit for patients' retraction of consent was set up: through the midwife managers in each department and/or through the research teams. No woman retracted her consent. Consent for publication: All authors give their consent to publication Competing interests: The authors declare that they have no competing interests Funding This research was funded by the French National Agency for Research. Grant Funding: This research was funded by the French National Agency for Research. Grant number: ANR-17-CE36-0001. Authors' contributions: PS, MC and EA conceived the study. PS conducted the research (records and interviews), PS and MC performed the analyses, and PS led the writing of the article. Other authors contributed to the implementation of the study and the analysis. All authors read and approved the final version of the article for publication. Acknowledgements: We thank all the women and practitioners who participated in this study, for their time and confidence. We also thank the department heads, managers, and staff of the maternity units where this study took place. Availability of data and materials: The datasets generated and analysed during the current study are not publicly available due to confidentiality reasons but part of them (excluding the recordings) are available from the corresponding author on reasonable request. References Les naissances (2024) en 2023 et en séries longues. État civil - Insee Résultats. INSEE, Paris Harakow HI, Hvidman L, Wejse C, Eiset AH (2020) Pregnancy complications among refugee women: A systematic review. 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Presses de l’EHESP, Rennes, pp 139–154 Blair IV, Steiner JF, Hanratty R, Price DW, Fairclough DL, Daugherty SL et al (2014) An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control. J Gen Intern Med 29(7):987–995 Philibert M, Deneux-Tharaux C, Bouvier-Colle MH (2008) Can excess maternal mortality among women of foreign nationality be explained by suboptimal obstetric care? BJOG 115(11):1411–1418 Meeuwesen L, Harmsen JAM, Bernsen RMD, Bruijnzeels MA (2006) Do Dutch doctors communicate differently with immigrant patients than with Dutch patients? Soc Sci Med 63(9):2407–2417 Johnson RL, Roter D, Powe NR, Cooper LA (2004) Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 94(12):2084–2090 Marin I, Farota-Romejko I, Larchanché S, Kessar Z (2012) Soigner en langue étrangère Jusqu’à la mort accompagner la vie. 4(111):11–19 Sauvegrain P (2013) Des femmes africaines à la mère africaine, en maternité. Migrations Santé 146–147:81–100 Minehart RD, Jackson J, Daly J (2020) Racial Differences in Pregnancy-Related Morbidity and Mortality. Anesthesiol Clin 38(2):279–296 Ukoha EP, Snavely ME, Hahn MU, Steinauer JE, Bryant AS (2022) Toward the elimination of race-based medicine: replace race with racism as preeclampsia risk factor. Am J Obstet Gynecol 227(4):593–596 Blanc J (2021) Racisme et disparités de santé. L’impératif de l’équité en santé. L'Autre 22(3):270–273 El Sauvegrain M, Racioppi A (2022) Comment étudier les discriminations en santé périnatale d’un point de vue socio-anthropologique ? Anthropologie & Santé. ;24 El Kotni M, Quagliariello C (2021) L’injustice obstétricale. Une approche intersectionnelle des violences obstétricales. Cahiers du Genre 71(2):107–128 Virole L (2020) Dispositifs dédiés, effets ambivalents. Emulations - Revue de Sci sociales. (35–36) Cognet M (2020) Les services de santé: lieu d’un racisme méconnu. Racismes de France. La Découverte, Paris, pp 74–86 Braud R (2021) L’ethnicité dans le soin. Perceptions et possibilités d’agir des minorisés. Revue européenne des migrations internationales 37(3):157–178 Gadson A, Akpovi E, Mehta PK (2017) Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Semin Perinatol 41(5):308–317 Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ (2009) Evaluating obstetrical residency programs using patient outcomes. JAMA 302(12):1277–1283 Howell EA (2018) Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol 61(2):387–399 Howell EA, Egorova N, Balbierz A, Zeitlin J, Hebert PL Black-White Differences in Severe Maternal Morbidity in New York City Hospitals. Am J Obstet Gynecol. 2016. Zevounou L (2021) Raisonner à partir d’un concept de « race » en droit français. Revue des droits de l’homme. ;19 Additional Declarations The authors declare no competing interests. Supplementary Files SauvegrainetalBIPsocioCOREQchecklist.docx COREQ check-list InterviewguideVF.docx Interview Guide Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6714783","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":459836177,"identity":"0d50cb46-6cf0-4454-84e9-090b69956081","order_by":0,"name":"Priscille 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Deneux-Tharaux","email":"","orcid":"https://orcid.org/0000-0002-6561-3321","institution":"Inserm","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Deneux-Tharaux","suffix":""},{"id":459836182,"identity":"cdf3b267-cc2c-4a6a-a525-6bd9bd05e638","order_by":5,"name":"Anne rousseau","email":"","orcid":"","institution":"Université Versailles St Quentin","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"rousseau","suffix":""},{"id":459836183,"identity":"f9f02c21-645a-455e-8066-8f6a4062ef84","order_by":6,"name":"Marie-Pierre Bonnet","email":"","orcid":"https://orcid.org/0000-0003-2055-8813","institution":"Sorbonne Université","correspondingAuthor":false,"prefix":"","firstName":"Marie-Pierre","middleName":"","lastName":"Bonnet","suffix":""},{"id":459836184,"identity":"6e0f72a9-264b-4a9c-9861-722b5b312c74","order_by":7,"name":"Elie Azria","email":"","orcid":"https://orcid.org/0000-0002-6159-6253","institution":"Université Paris Cité","correspondingAuthor":false,"prefix":"","firstName":"Elie","middleName":"","lastName":"Azria","suffix":""}],"badges":[],"createdAt":"2025-05-21 09:17:10","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6714783/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6714783/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83438349,"identity":"3f1e7b57-dec0-4db3-b5a2-5aaecc326286","added_by":"auto","created_at":"2025-05-26 08:59:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30158,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe 5 stages of the qualitative analysis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6714783/v1/e5e75fcd04cbae3da5cc36e6.png"},{"id":83439767,"identity":"18b83de9-57a7-402b-a6d4-d0cb985ea190","added_by":"auto","created_at":"2025-05-26 09:15:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40332,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution (in %) of consultation duration (in minutes) for native and immigrant patients by type of professional\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6714783/v1/0ceca84596ae879222daba9c.png"},{"id":83440305,"identity":"11ab3d15-5066-44c8-a5d6-7acc57d9a5e3","added_by":"auto","created_at":"2025-05-26 09:23:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1076101,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6714783/v1/073a823f-5b7c-4c66-9af5-fa4103e0508f.pdf"},{"id":83438348,"identity":"a56d0f20-0cf2-4f87-9761-4af9875b59aa","added_by":"auto","created_at":"2025-05-26 08:59:50","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17735,"visible":true,"origin":"","legend":"\u003cp\u003eCOREQ check-list\u003c/p\u003e","description":"","filename":"SauvegrainetalBIPsocioCOREQchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-6714783/v1/03a65d8331ec245526dfbe6e.docx"},{"id":83438352,"identity":"9c1c1e1b-afa0-462a-8fb8-109d33253682","added_by":"auto","created_at":"2025-05-26 08:59:50","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15618,"visible":true,"origin":"","legend":"\u003cp\u003eInterview Guide\u003c/p\u003e","description":"","filename":"InterviewguideVF.docx","url":"https://assets-eu.researchsquare.com/files/rs-6714783/v1/fcc42015a1b34fb890c0f1d2.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eDifferences in Hospital Prenatal Care in France: A Qualitative Study within the BIP Research on Racial Implicit Bias in Perinatal Care\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eRecent statistics indicate that 24% of live births in France are to mothers who were born abroad (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These immigrant women are, in France as throughout Europe, at higher perinatal and maternal risk than native-born women, with higher rates of hypertensive complications, maternal mortality (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), preterm birth, and low birth weight (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Women born in sub-Saharan Africa (SSA) are especially at risk of maternal and neonatal morbidity and mortality (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Intermediate explanatory factors probably include access to and quality of care (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent studies show the existence of differential care of immigrants (a concept first raised in France by D. Fassin, an anthropologist/physician, and covering both unequal access to care and differential quality of care standards (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)). Specifically, they demonstrate care that is both differential and less appropriate during the perinatal period for women born in SSA (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Further support for this hypothesis comes from an infectious diseases department (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and general emergency departments (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe therefore wished to explore the hypothesis of less appropriate care for immigrants resulting from racial discrimination in care encouraged by implicit racial biases that healthcare professionals may carry. Racial discrimination in care is a subject underexplored in France, compared with North America where it is at research agenda since decades. Studies from the USA report very strong differences in access to and quality of care received; the differences between Black and White women in health, especially in obstetrics, are much stronger than those reported in Europe (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The issue of racism in obstetrics is much discussed (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). We conceived this study as an exploration of this topic in France, a country with a different socio-political and historical context, with theoretical universal access to care but limited access to racial data (only country of birth and nationality can be reported, not ethnicity), which makes research on racial disparities difficult. Accordingly, little has been done so far to explore racial discrimination in French health care.\u003c/p\u003e \u003cp\u003eThis sociological study concerning differences according to migration backgrounds in less appropriate care during hospital-based prenatal care is a component of the BIP research programme (Migrants and differential care in the perinatal period: Effects of implicit bias), designed to address the issue of race-based differential maternity care by mixed methodological approaches (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The study reported in this paper aimed, through the use of qualitative methods, to explore the clinical relationship between women from different migration backgrounds and health-care providers to capture the processes potentially producing disparities in the care of pregnant women.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis qualitative observational study took place in three Parisian maternity units, with fairly high proportions of immigrant patients and chosen to facilitate contrasts between their catchment areas (centre, eastern and northern Paris). The audio-recording procedure enabled us to study practitioner-patient discussions and the content of prenatal consultations. Self-confrontation interviews with the practitioners involved followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAudio-recording of consultations\u003c/strong\u003e: We recruited six obstetrician-gynaecologists, six midwives, and six anaesthesiologists with the three different methods: by a physician/research director in maternity unit A, by the department head in unit B (by email invitation, volunteers contacted us), and directly by the researcher/PI in C (only 1 midwife declined). All consented in writing to participate after full information about the research and its objectives, and to active and stop the audiorecorder. The prenatal care visits recorded were: 1) the first prenatal visit, when women's clinical and obstetric histories and social data are collected; 2) the visit informing women about trisomy 21 screening tests (routinely offered in France and covered by the national health insurance fund; two units combined these with the first-trimester ultrasound scan); and 3) the pre-anaesthesia consultation, mandatory during the third trimester. We approached the 175 women meeting the inclusion criteria: aged 18 or older, consulting for one of the three study visits with a participating practitioner, and speaking French well enough to read and understand the study information and consent forms. Among them, 148 agreed to participate (convenience sample; acceptance rate: 85%), received the necessary information, and provided written consent to the anonymised audio-recording of their consultation. The social science researcher was in the waiting room during the consultations and the audiorecorder was operated by the practitioners.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-confrontation interviews with practitioners\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis survey technique began in the field of organizational psychology and was subsequently extended to sociology (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). It confronts participants with their own actions and allows them to explain what they did after listening to selected extracts of recordings (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). The interview guide is available (\u003cem\u003esee Appendix 1\u003c/em\u003e); the heart of the interview was the phase of hearing two or three audio excerpts and responding to the analyses. The interviews took place 2 to 4 months after the recorded consultation and lasted between 25 minutes and an hour.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalyses\u003c/strong\u003e The recordings of the consultations and of the subsequent interviews were anonymised and entered into a software program for treating qualitative data (N\u0026rsquo;Vivo 12, QSR International). We observed the saturation of the data collected: new themes no longer emerged during the analysis of interviews with practitioners of the last maternity unit. Based on the standards for analysis of content from qualitative studies and reported in Fig.\u0026nbsp;1, two researchers (PS and MC) jointly coded each track thematically, according to themes usually discussed in these consultations, and each interview according to the interview grid (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cp\u003eWe adhered to the COREQ quality criteria for reporting qualitative research \u003cem\u003e(see the checklist in Appendix 2)\u003c/em\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003ePopulation\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the study procedures in each maternity unit and specifically the duration of and health-care providers (HCPs) involved in the consultations we recorded.\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudy procedures in each maternity unit\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSite\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDates\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of\u003c/p\u003e\n \u003cp\u003eHCPs included\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOb\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnest\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003cp\u003eConsultations observed\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternity unit A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSept. 2018\u0026ndash;\u003c/p\u003e\n \u003cp\u003eJan. 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternity unit B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeb\u0026ndash;Apr. 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternity unit C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMay\u0026ndash;July 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eHCPs, healthcare practitioners, Ob, obstetrician; Anest, anesthesiologist\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the distribution by parity, country of birth, and social position of the women included in the study. Women recruited at maternity units B and C (respectively located in eastern and northern Paris) were more likely to have been born abroad and to be multiparous and less likely to be managers and professionals than the women recruited at maternity unit A (central Paris).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of the women included in the study, by maternity unit\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMater A\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMater B\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;49\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMater C\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(63%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(38%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(45%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(24%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(29%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(34%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(13%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(33%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(21%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eCountry/region of birth*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(65%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(50%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(41%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(11%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(10%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(7%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(13%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(21%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(13%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(21%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(31%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(4%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(6%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(7%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003eEmployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eManagerial and professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(49%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(23%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(24%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntermediate occupations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(14%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(23%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(24%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOffice workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(20%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(23%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(24%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCrafts workers and shopkeepers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(3%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eManual workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(2%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(4%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(1%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(13%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(29%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(24%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003eNote *: Data available in France: Place of birth and nationality, none about ethnicity\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eMain Results\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e- Longer consultations for immigrant women\u003c/h3\u003e\n\u003cp\u003eThe table of inclusions incited us to first analyze the consultation time. According to the woman\u0026apos;s country of birth, it showed slight longer consultations for immigrant women: the anaesthesiologists saw immigrant women for longer periods than they did women born in France: 55% of the former had visits lasting from 13 to 20 minutes compared with 35% of the latter (and vice versa for the consultations lasting from 7 to 13 minutes), as shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eSimilarly, for the obstetricians, 70% of whose consultations lasted from 20 to 40 minutes, immigrants were more often seen longer than women born in France. The duration of the consultations with midwives followed the same trend, but are not comparable, because the latter professionals provided various particular services, such as specific consultations for women in situations of social deprivation in maternity B. When asked about the extra length of the consultations in the interviews, practitioners referred to the probable need to translate or to be sure of being understood during consultations:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026quot;We manage, we always understand each other. I use Google Translate a lot when we get stuck.\u0026quot; (obstetrician #5).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eLonger consultation times make it possible to safeguard time for discussion and to provide personalized advice, as midwife 2 explained:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026ldquo;I think it\u0026apos;s important to connect women with their personal history, prior to migration. These are their roots, and I think it\u0026apos;s important for them to draw on them to become mothers themselves.\u0026rdquo; (midwife #2)\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e- Explanations provided at the pre-anesthesia visit\u003c/h3\u003e\n\u003cp\u003eThe analgesia consultation was chosen for observation because it is one of the most standardised care procedures in the prenatal pathway. The longer duration among immigrants was observed at each stage (clinical history, clinical examination, diagnosis, and prescriptions). The care nonetheless remained very standardised and the consultations globally rapid. Their contents are prescribed by Public Health Code (Decree of 5 December 1994): patients must be informed about anaesthetic procedures and their risks and benefits. During the self-confrontation interview, anaesthesiologist #6 explained:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026quot;- Yes I know, I\u0026apos;m almost reciting a text when I see patients for this consultation. I\u0026rsquo;ve put together a text that I always deliver at more or less the same rhythm. When I was younger, I did it differently. I adapted more. But since consultations must now be finished in 10 to 15 minutes, I tell myself that this must be fast, concise, and as specific as possible.\u0026quot; (Anaesthesiologist #6).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAnalyses showed that rare complications of epidurals were explained in the most detail to the women who best understood medical discourse and to those with higher social status.\u003c/p\u003e\n\u003ch3\u003e- Information provided in obstetrics: the example of trisomy 21 screening tests\u003c/h3\u003e\n\u003cp\u003ePractitioners gave women very specific information about these tests and about their right to turn them down. The recordings highlighted the quality of the information provided to the women by the HCPs involved in this study. They adopted simpler words for the women who understood least well, whether this was related to their understanding of the French language (immigrants) or the medical language (those in lower social categories). Thus, midwife #5 started by making sure that women understood that a half a pizza is larger than a quarter of a pizza; and thus, that a risk of 1/250 will be bigger than a risk of 1/10,000. We returned to that in the self-confrontation interview:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026quot;I like to ask women that, except obviously when I see they work in computer programming or she\u0026apos;s a math teacher \u0026hellip; But otherwise, there are plenty of little women, they\u0026apos;ll tell you: \u0026lsquo;I don\u0026apos;t know, I never understood anything about fractions\u0026rsquo;.\u0026quot; (midwife #5)\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eShe also confided that she has progressively standardised her discourse. Observation showed that this left little time for interpersonal variations.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch3\u003e- Practitioners speak more loudly to women who don\u0026apos;t understand French well\u003c/h3\u003e\n \u003cp\u003eThe practitioners talked much more loudly to the women who spoke the worst French, as demonstrated by some of the audio recordings. We broached this topic in an interview:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u0026quot;It seems to me listening to the recording that you are speaking more loudly\u0026hellip;, to the women who speak French less well. Unless it\u0026apos;s the position of the recorder?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e(Smiles) \u0026quot;Yes, you\u0026apos;re right, it\u0026apos;s very clear.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHow do you explain this?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eI don\u0026apos;t know, I hadn\u0026apos;t noticed it before. But I can hear that I\u0026apos;m articulating more. I articulate so that she can understand me. \u0026quot; (anaesthesiologist #5)\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003ch3\u003e- Social Salience\u003c/h3\u003e\n\u003cp\u003eThe analyses also showed a number of results that reveal social asymmetries in the care relationship that go beyond the framework of the formal relationships between care providers and patients. These observed trends nonetheless remain somewhat fragile, as they are relatively rare within the recordings. They deserve further exploration and confirmation. We present them in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAs an example, analysis of the start of consultations revealed differences in the way Professor A greeted his immigrant patients and engaged in intrusive humor that he did not practice with French women. This reveals an implicit racial bias. During the interview, Professor A avoids reacting to this conversation extract (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e; Excerpt #4) and then insists on his \u0026ldquo;affection\u0026rdquo; for these African patients.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVerbatims illustrating social asymmetries between healthcare professionals and their patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eType of interaction\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHCP concerned\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eExcerpt (numbered)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStandardized salutation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE#1\u003c/strong\u003e: \u0026quot;- Hello, Madam, I\u0026apos;m Marion*, the one of the consulting midwives here. I\u0026apos;m seeing you today for your first consultation. We\u0026apos;re going to set up your file together, now.\u0026quot; (midwife #4-P2, Polish woman, housewife, para 2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamiliarity during salutation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMw 5 with an African known patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE#2\u003c/strong\u003e: She greeted her warmly and informally, asking for news of the older children: \u0026quot;\u003cem\u003eHow are\u003c/em\u003e \u003cstrong\u003emy little ones\u003c/strong\u003e \u003cem\u003e[mes petits] doing?\u003c/em\u003e\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamiliarity during salutation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMw 4 with patients who were her peers, white and middle-class.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE#3\u003c/strong\u003e: She addressed them as \u003cem\u003e\u0026quot;my beautiful one [ma belle],\u0026quot;\u003c/em\u003e an expression not found in the discourse of any other clinician.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaternalistic joke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePr A with an African couple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE#4\u003c/strong\u003e : To a woman whose husband had made it clear in the corridor that the wait was too long (\u0026gt;\u0026thinsp;2 h) and he was going to leave, Professor A. said: \u0026quot;\u003cem\u003eWhy leave? Do you have an appointment with President Macron?\u0026quot;\u003c/em\u003e and then he laughed at his joke.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsymmetric tensions that can be expressed in hospital corridors or waiting rooms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUltrasonographist with African patient, para 1, arriving late\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE#5\u003c/strong\u003e: A stentorian voice rings out from the back of a consultation room, with an open door: \u0026quot;Madame Traorrreeeeee.\u0026quot;*\u003c/p\u003e\n \u003cp\u003eTo me, standing nearby: \u0026quot;That\u0026apos;s it, my nerves have had it.\u003c/p\u003e\n \u003cp\u003e- What\u0026apos;s happening?\u003c/p\u003e\n \u003cp\u003e- They\u0026apos;re not even on time!\u003c/p\u003e\n \u003cp\u003eTo the woman: \u0026quot;- So they tell you you\u0026apos;re going to have an important sonogram [fetal morphology fetal] and you\u0026apos;re not even on time?\u003c/p\u003e\n \u003cp\u003e- But it took us time to get here!\u003c/p\u003e\n \u003cp\u003e- Well then you should have left earlier!!\u0026quot;\u003c/p\u003e\n \u003cp\u003e(The consultation room door slams).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTensions expressed in the medical practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnesthesiologist #4 with a Comorian patient, para2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE#6\u003c/strong\u003e: Her second patient of the afternoon she did not have the file (usually prepared by the administrative team):\u003c/p\u003e\n \u003cp\u003e\u0026quot;- Mrs Ali ! (the time the woman takes to enter: I don\u0026apos;t have a file!!)\u003c/p\u003e\n \u003cp\u003e- (to the woman): Mrs Ali*, you don\u0026apos;t have a file?\u003c/p\u003e\n \u003cp\u003eI only have one file out of 11, I feel like I\u0026apos;m going to lose my mind! \u0026quot; [Leaves to look for the file, unsuccessfully] \u0026hellip;\u003c/p\u003e\n \u003cp\u003e\u0026quot;- Go see at reception and ask them to look for it for you and then come back.\u003c/p\u003e\n \u003cp\u003e- Well, I was with the midwife before, I think it\u0026apos;s on the other side.\u003c/p\u003e\n \u003cp\u003e- Yes but I\u0026apos;ve looked everywhere and I cannot lose a half hour by patient to look for a file. So I\u0026apos;m sorry, I know that it\u0026apos;s not your fault but I can\u0026apos;t do anything else.\u0026quot; (The patient leaved very dissatisfied with her \u0026quot;consultation\u0026quot;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e*Fictive names\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch3\u003e- The question of racial discrimination in care?\u003c/h3\u003e\n\u003cp\u003eTwo particularly conflictual situations were observed during this study, both between white female HCPs and black patients. These practitioners were, in contrast, extremely polite in the interactions with native-born White women. Two dialogues (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e; excerpts #5 and #6) illuminate the asymmetric tensions that can be expressed in waiting rooms or during consultation. These two practitioners mentioned the disorganisation of their day to justify their irritation (late patient, lost file).\u003c/p\u003e\n\u003cp\u003eMoreover, during interviews, some HCPs reported situations of conflict with some of their patients of colour. Thus, although we had found anaesthesiologist #1 behaved very similarly in each of the consultations, her self-description was quite different:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026quot;- Your consultations are very similar from one woman to the next.\u003c/p\u003e\n \u003cp\u003e\u0026quot;- In fact the appointment, it\u0026apos;s 10 minutes so if I see they\u0026apos;re interested, I am very available for them, if not, I move quickly. But on the other hand if they don\u0026apos;t understand, I can stop the consultation at the end of three minutes. It\u0026apos;s out of the question for me to do a consultation if the woman doesn\u0026apos;t understand anything. \u0026hellip; On the other hand, it\u0026apos;s harder for me with Arab and African populations: I don\u0026apos;t speak their languages. If the Arab women come with their guys, it doesn\u0026apos;t bother me to say to them: \u0026apos;You\u0026apos;re not the patient!\u0026apos; I don\u0026apos;t hesitate to send them outside. I accept many cultural things, but not that.\u0026quot; (anaesthesiologist #1)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch3\u003e- Lack of supervisors\u0026apos; support in conflictual situations\u003c/h3\u003e\n \u003cp\u003eAn sonographer was involved in an argument with Obstetrician #4 reported in Interview, concerning ultrasound scans for an African family. Obstetrician #4 reported this to her department head, who did not intervene (Interview with Ob#4).\u003c/p\u003e\n \u003cp\u003eThe situations described above show that inappropriate behaviour is tolerated for practical reasons: essential skills, disorganisation of the care circuit, etc.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMain Results\u003c/h2\u003e \u003cp\u003eThis study of 148 patients in Paris consulting 18 HCPs showed globally similar and highly standardised content delivered to immigrant and native-born women. The professionals tightly controlled the content of care and all of them expressed, during the interviews, their attachment to a quality public service.\u003c/p\u003e \u003cp\u003eAccordingly, the differences concern three points. The duration of consultations was slightly longer for immigrants. HCPs simplified their discourse for the women with a poor understanding of French and/or medical terminology, and some practitioners had a way of addressing some patients that reflects racial implicit bias (speaking louder, make jokes or reproaches you wouldn't make to your peers).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003e A multidisciplinary steering committee and clinicians were included at several stages of the writing and validation of our protocol. The principal investigator's presentation of the study to women over a seven-month period yielded a high participation rate \u0026mdash; 85%, well above our objectives. The fact that she is a midwife facilitated her access to the women and the practitioners. The interviews were both rich and informative because the occupational proximity promoted confidence (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). We also succeeded in including women with very diverse migratory and social profiles and who were globally similar to the profiles of the women consulting in each unit. The participation of three different medical professions is another originality of this work.\u003c/p\u003e \u003cp\u003eThe study's greatest limitation is that HCPs knew its objectives and volunteered (as required by the ethics committee). Thus, despite the three different methods used to recruit practitioners, a recruitment bias could have minimised the situations in which differential care was likely to be found. Moreover, the exclusion of seven women who did not speak French (another ethics committee requirement) might have prevented us from obtaining data about some attitudes toward these most vulnerable immigrants. Research beyond this initial exploration would probably require a substantial budget for interpreters.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDiscussion in the light of the literature\u003c/h2\u003e \u003cp\u003eOur results confirm that the universal access to hospital-based prenatal care for women fluent in French, born in France or elsewhere, leaves little room for differential care. The more standardised and protocolised the care is (e.g., anaesthesia consultations), the less frequent differential care is likely to be (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Studies conducted during delivery and the postpartum period, contexts in which care is less standardised and where the unexpected is most likely to occur, leave much more place for practitioners' cultural or racial biases, which can take the form of differential care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). We previously showed that women with extremely serious complications of hypertension receive highly standardised management that leaves little room for differential care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Obviously, not all stages of antenatal care can necessarily or usefully be standardised, but these successive studies show the importance of training students and professionals to avoid potentially discriminatory situations.\u003c/p\u003e \u003cp\u003eOther non-obstetric studies confirm, as we report here, that the duration of consultation for minority groups differs from that for majority groups, whose consultations are generally shorter (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Some longer consultations are explained by the presence of an interpreter (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In our study, HCPs may perceive that these patients require more detailed information to understand.\u003c/p\u003e \u003cp\u003ePractitioners speak more loudly to women who do not understand French well, as if to better hold their attention, or as evidence of their annoyance. While audiences at oral presentations at congresses smiled at this finding, it does not, to our knowledge, appear in the literature and merits further exploration, behavioral research in particular.\u003c/p\u003e \u003cp\u003eThese HCPs handle much of their discourse with very standardised consultations, although their salutations when greeting patients at the start indicate that this moment is less controllable. In their interviews, HCPs confided the personal factors influencing how they care for patients: family history, such as difficult medical situations in their pasts, family traditions of practising medicine or providing health care, or political or religious beliefs guiding them to more altruistic practices. These results are not discussed in this paper but suggest the interest of collecting such data from a larger number of medical professionals in a future project.\u003c/p\u003e \u003cp\u003eWe observed that practitioners often explained their attitudes in conflict situations by issues related to the organization of care. These issues did not appear in the recorded consultations, which mainly show high-quality care. Nonetheless, several practitioners expressed distance, even annoyance, toward certain groups of immigrant women during the self-confrontation interviews, which thus enabled us to extend our analyses above and beyond the initial recordings and observations.\u003c/p\u003e \u003cp\u003eThe information to be provided about Down syndrome screening is complex and should be standardised. The epidemiological component of the BIP study showed that immigrants in France are less likely than native women to make an informed choice about foetal trisomy 21 screening (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the same way, a previous study based on interviews with 54 caregivers yielded many information about differential and less appropriate care among African-perceived women (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Interviews with HCPs provide an accumulation of experiences, while recordings of consultations allow us to analyse the fact that they rarely take place in the real time of clinical practice.\u003c/p\u003e \u003cp\u003eSimultaneously with the discussion about obstetric racism in the United States (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), the French social science literature has been revealing examples of racism in perinatal care (\u003cspan additionalcitationids=\"CR38 CR39\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) as in other medical areas (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The disparities in maternal and perinatal morbidity and mortality between groups (racial and/or migrant) appear much stronger in the USA than in France (\u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Levels of racism and racial segregation are not comparable in the two countries, such as the insurance system. The insurance system which aim to ensure universal access to healthcare in France might constitute a context preventing the influence of discrimination. We must nonetheless stress that when situations of racial discrimination in care are reported up the chain of responsibility, the institutions do not appear to take steps to resolve these conflicts. No training is offered to understand implicit biases and their implications in care relationships, and to help practitioners to deconstruct them, no sanctions applied in case of explicit discrimination. This has already been described in other French institutions (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe quality of prenatal care appeared to be high in this study, regardless of where women were born. This is an innovative study in France, part of an innovative research programme. Although several limitations restrict the generalisability of our results, we observed both direct and indirect expressions of implicit bias that may affect patient experiences and quality of care. As French teams begin to produce quantitative data on racial discrimination in health care, this qualitative study offers us an in-depth understanding of the mechanisms that lead to care that, while not necessarily commonplace or quotidian, is not adequate either. Improvement in the organisation of care and the working conditions of practitioners could prevent the expression of stereotypes, which seems to be facilitated (or at least excused by) the organisation of obstetric departments.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e The study was conducted in accordance with the principles of the declaration of Helsinki. The INSERM ethics review board approved this study (IRB 00003888, opinion n\u0026deg;18\u0026ndash;507) on July 3, 2018, as did the CEREES (Expert committee for health research, studies, and evaluations) on September 6, 2018 (TPS 107121), and the CNIL (National Data Protection Commission) on October 24, 2018 (DR-2018-270). The participating professionals and patients signed written consent forms. A dual circuit for patients' retraction of consent was set up: through the midwife managers in each department and/or through the research teams. No woman retracted her consent.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003e All authors give their consent to publication\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFunding\u003c/strong\u003e \u003cp\u003eThis research was funded by the French National Agency for Research. Grant\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was funded by the French National Agency for Research. Grant number: ANR-17-CE36-0001.\u003c/p\u003e\u003ch2\u003eAuthors' contributions:\u003c/h2\u003e \u003cp\u003ePS, MC and EA conceived the study. PS conducted the research (records and interviews), PS and MC performed the analyses, and PS led the writing of the article. Other authors contributed to the implementation of the study and the analysis. All authors read and approved the final version of the article for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eWe thank all the women and practitioners who participated in this study, for their time and confidence. We also thank the department heads, managers, and staff of the maternity units where this study took place.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to confidentiality reasons but part of them (excluding the recordings) are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLes naissances (2024) en 2023 et en s\u0026eacute;ries longues. \u0026Eacute;tat civil - Insee R\u0026eacute;sultats. INSEE, Paris\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarakow HI, Hvidman L, Wejse C, Eiset AH (2020) Pregnancy complications among refugee women: A systematic review. Acta obstetricia et gynecologica Scandinavica\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEslier M, Azria E, Chatzistergiou K, Stewart Z, Dechartres A, Deneux-Tharaux C (2023) Association between migration and severe maternal outcomes in high-income countries: Systematic review and meta-analysis. PLoS Med 20(6):e1004257\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGodeluck A, Gerardin P, Lenclume V, Mussard C, Robillard PY, Samperiz S et al (2019) Mortality and severe morbidity of very preterm infants: comparison of two French cohort studies. 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Revue Europ\u0026eacute;enne des Migrations Internationales 28(2):81\u0026ndash;100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSauvegrain P (2019) Exploring the hypothesis of discrimination in perinatal health in France: The ethnic term of pregnancy protocol. European Journal of Obstetrics and Gynecology and Reproductive Biology: Elsevier; pp. e140-e1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSauvegrain P, Azria E, Chiesa-Dubruille C, Deneux-Tharaux C (2017) Exploring the hypothesis of differential care for African immigrant and native women in France with hypertensive disorders during pregnancy: a qualitative study. BJOG 124(12):1858\u0026ndash;1865\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNacu A (2011) \u0026Agrave; quoi sert le culturalisme ? Pratiques m\u0026eacute;dicales et cat\u0026eacute;gorisations des femmes \u0026laquo;migrantes\u0026raquo; dans trois maternit\u0026eacute;s franciliennes. Sociologie du travail 53:109\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnselem O, Saurel-Cubizolles MJ, Khoshnood B, Blondel B, Sauvegrain P, Bertille N et al (2021) Does women's place of birth affect their opportunity for an informed choice about Down syndrome screening? A population-based study in France. BMC Pregnancy Childbirth 21(1):590\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinard M, Deneux-Tharaux C, Luton D, Schmitz T, Mandelbrot L, Estellat C et al (2019) Differential rates of cesarean delivery by maternal geographical origin: a cohort study in France. BMC Pregnancy Childbirth 19(1):217\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrebion M, Bonnet MP, Sauvegrain P, Saurel-Cubizolles MJ, Blondel B, Deneux-Tharaux C et al (2021) Use of labour neuraxial analgesia according to maternal immigration status: a national cross-sectional retrospective population-based study in France. 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Presses universitaires de France, Paris, p 243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsieh HF, Shannon SE (2005) Three approaches to qualitative content analysis. Qual Health Res 15(9):1277\u0026ndash;1288\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrauss A, Corbin J (1990) Grounded theory in practice: Procedures, canons and evaluative criteria. Qualitative Sociol 13:3\u0026ndash;21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDespr\u0026egrave;s C (2010) 9. Les femmes enceintes face aux incertitudes de la grossesse. Risque et pratiques m\u0026eacute;dicales. Presses de l\u0026rsquo;EHESP, Rennes, pp 139\u0026ndash;154\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlair IV, Steiner JF, Hanratty R, Price DW, Fairclough DL, Daugherty SL et al (2014) An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control. 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Semin Perinatol 41(5):308\u0026ndash;317\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ (2009) Evaluating obstetrical residency programs using patient outcomes. JAMA 302(12):1277\u0026ndash;1283\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHowell EA (2018) Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol 61(2):387\u0026ndash;399\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHowell EA, Egorova N, Balbierz A, Zeitlin J, Hebert PL Black-White Differences in Severe Maternal Morbidity in New York City Hospitals. Am J Obstet Gynecol. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZevounou L (2021) Raisonner \u0026agrave; partir d\u0026rsquo;un concept de \u0026laquo; race \u0026raquo; en droit fran\u0026ccedil;ais. Revue des droits de l\u0026rsquo;homme. ;19\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"1aa3e623-330a-43cd-9328-1430770d3132","identifier":"10.13039/501100001665","name":"Agence Nationale de la Recherche","awardNumber":"ANR-17-CE36-0001","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Inserm","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prenatal care, hospital pathway, social health inequalities, discrimination, implicit racial bias, maternal health, qualitative study, immigrant women.","lastPublishedDoi":"10.21203/rs.3.rs-6714783/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6714783/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eo Background\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRecent statistics indicate that 24% of live births in France are to mothers who were born abroad. Women born in sub-Saharan Africa (SSA) are especially at risk of maternal and neonatal morbidity and mortality. Intermediate explanatory factors probably include access to and quality of care. We therefore wished to explore the hypothesis of less appropriate care for immigrants resulting from racial discrimination in care encouraged by implicit racial biases that healthcare professionals may carry. The BiP multidisciplinary mixed-methods project sought to explore implicit racial biases among prenatal practitioners in one of the first approaches to this issue in France. The qualitative component presented here aimed to assess whether implicit bias might be producing disparities in prenatal care for pregnant women.\u003c/p\u003e\u003cp\u003e\u003cb\u003eo Methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA sociological qualitative study was conducted in three public maternity units in the Paris area, France, among 6 obstetrician-gynaecologists, 6 midwives, 6 anaesthesiologists, and 148 pregnant women. The study is based on audio-recorded prenatal consultations and interviews with practitioners. Consultations and interviews were analysed thematically.\u003c/p\u003e\u003cp\u003e\u003cb\u003eo Results\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe countries of birth and social positions of the participating women were globally similar to those of the pregnant women seen in each maternity unit. The analyses showed that the standard of care was globally high and consultations were slightly longer for immigrant women; explanations provided by health-care practitioners were appropriate to their level of understanding. The prenatal follow-up, when standardised, left little room for differential care. Nonetheless, the tone of voice and the type of jokes showed the salience of the social relations of race and class, beyond the strict framework of the care relationship. A few instances of racism in care were identified and analysed, but their consideration by the institution is non-existent.\u003c/p\u003e\u003cp\u003e\u003cb\u003eo Conclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFrench research is beginning to produce quantified data on racial discrimination in health care, and this qualitative study provides an in-depth understanding of mechanisms leading to less adequate care (which was not observed to be an everyday occurrence). Despite the inclusion bias inherent in this type of approach, this study produced original results about the differential care of immigrant women during hospital prenatal care and underlines the importance of universal access to care in limiting inequalities.\u003c/p\u003e","manuscriptTitle":"Differences in Hospital Prenatal Care in France: A Qualitative Study within the BIP Research on Racial Implicit Bias in Perinatal Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-26 08:59:46","doi":"10.21203/rs.3.rs-6714783/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d0d85f8-6a03-46b6-967e-cc7ed6d99492","owner":[],"postedDate":"May 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48845461,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2025-05-26T08:59:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-26 08:59:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6714783","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6714783","identity":"rs-6714783","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}