Stakeholder participants included (n=21) physicians, nurses, social workers/case managers, and national leaders with expertise in Black maternal health. Participant characteristics are described in Table 2. A purposive sample of participants were identified by the study team with the aid of clinical team rosters and professional networks. Participants were recruited via email outreach to community health centers and community-based organizations. Interviews included questions about perspectives on and experiences of working with pregnant individuals (see Appendix B). Respondents shared ideas about the complex nature of improving perinatal care for and establishing trust with Black/AA pregnant individuals, particularly given their lived experiences. One participant stated “…data supports their lived experience…no matter their income…socioeconomic status or their education level…they are treated differently. They’re not listened to, they’re not heard…” Participants also shared considerations for how healthcare teams and systems can improve care. One participant described this process as “…there has to be a fundamental reimagining of how perinatal care is provided. We created it on a flawed belief that women are not capable of birthing on their own and need assistance through either forceps or a hospital…So all of these false beliefs that were taught in medical school and written textbooks are still embedded in how we treat and care for patients.” There is often much emphasis on how clinicians can or should gain trust from patients, but respondents also shared that trust building is bidirectional. For clinicians to gain trust, they must also trust the patients and their decisions. This means seeking to understand patients’ life narratives and contexts, including social supports, family traditions, culture, and beliefs. One participant described how we must rethink trust building by stating “We usually talk about it in the sense of patients trusting their providers. When we work with Black birthing people…they want providers to trust them…that [they] want to have children who are loved and valued as well. And that [they’re] making the best choices and decisions for [their] families.” With heightened trust, respondents felt that there would be a higher likelihood of patients attending appointments, believing the information presented to them, and even “hearing” the information differently, thereby improving health literacy. Underlying many of these discussions was a recognition of the role of racism in healthcare, and how perinatal care improvement cannot be addressed without acknowledging this history and its continuation into present day systems. As one participant stated “So I think given…our long history of distrust of the medical system…for a variety of very valid reasons…I think being able to create that bridge of trust lays the pathways and foundations for behavior change…it creates the opportunity for there to be bi-directional change…it creates the opportunity for that individual to increase their health literacy…because they can actually hear you because they, they believe that the information that you are providing is in their best interest.” Overwhelmingly, stakeholder perspectives aligned with patient perspectives in that clinicians should spend time to understand patients’ goals and needs, respect patients’ choices, and trust their decisions about their own bodies.

Given the importance of listening to patients and building trust to improve communication and health outcomes, the findings from these interviews guided the implementation of trust-building questions at health centers. Participating health centers in the OPTIMIZE study began recruiting patients in June 2021 and built prompts into their electronic health record (EHR) platforms to guide clinicians in critical conversations that would begin trust building. At the first prenatal care visit, EHR flowsheets include prompts to start conversations around patient goals, challenges, concerns, safety issues, and social determinants of health needs. Implementation success will be measured in a variety of ways, including follow up interviews, patient surveys, and medical record abstraction. For example, at the conclusion of the trial, EHR data will demonstrate clinicians’ rate of uptake (e.g., how often clinicians asked and documented trust building questions). Patient participants will also answer survey questions about their experiences of care, including questions about feeling heard and respected. The start of this conversation about patients’ health and life narratives has the potential to increase patient agency. Initiating trust sets the stage for enabling patients and clinical care team members to exchange information and receive follow-up assistance from care coordinators, patient navigators, or other support staff that truly center Black/AA pregnant and birthing persons in a way that routine perinatal care has traditionally failed.