Public Health Critical Race Praxis in Maternal Health Occupational Therapy: A Framework for Race-Conscious Research and Intervention

In occupational science, motherhood is understood as a complex and multifaceted activity that is crucial for nurturing children and significantly influences the well-being of both mother and child (Berger et al., 2020). Mothering includes various tasks across physical, emotional, social, and cultural dimensions and is influenced by supports and barriers, such as social support systems, economic conditions, and societal norms (Lim et al., 2022). Occupational therapy practitioners must account for these variables to promote occupational well-being during the transition to motherhood.

As the United States faces a maternal health crisis (Beck et al., 2023; McSpedon, 2024), it is essential for maternal health occupational therapy practitioners to harness their unique role in addressing the factors fueling this issue. The United States has the highest maternal mortality rate among industrialized nations (Agency for Healthcare Research and Quality, 2022). The Centers for Disease Control and Prevention (2023) reports that Black birthing people are disproportionately burdened by this crisis. They are also three to four times more likely to die and two to three times more likely to experience short- or long-term morbidity from pregnancy-related causes than their White counterparts (Julian et al., 2020; Njoku et al., 2023; Taylor, 2020). These adverse maternal health outcomes are profoundly influenced by structural racism and health care bias (Bose, 2023; Njoku et al., 2023; Taylor, 2020).

Systemic racism, which involves practices that perpetuate or exacerbate unfair disparities in power, resources, or systemic racist conditions, is deeply ingrained in various aspects of society, including health care, housing, employment, and education (Bose, 2023; Delaney et al., 2021; McSpedon, 2024). Health care bias refers to the conscious or unconscious prejudices and partialities that influence the judgment and behavior of health care professionals, often leading to disparities in client treatment and outcomes (Julian et al., 2020; Taylor, 2020). Systemic racism and implicit bias, which are amorphous and pervasive in nature, infiltrate every level of health care, creating invisible barriers that perpetuate inequities and undermine the well-being of Black birthing people. In addition, race evasiveness (color-blindness)—the avoidance or denial of racial categories and issues—prevents meaningful discussions of and actions to address racial disparities, leading to persistent systemic barriers and inequitable health outcomes for Black birthing people (Bailey et al., 2017; Dayo et al., 2023; Njoku et al., 2023).

Occupational therapy practitioners are uniquely positioned to develop research and interventions that mitigate the compounded effects of systemic racism, implicit bias, and race evasiveness in maternal health; however, there has been minimal focus on how these experiences affect Black mothers’ personal and family lives (Parnell, 2023). It is critical for occupational scientists and practitioners to cultivate a strong sense of race consciousness to transition to thought processes that center the voices and experiences of Black birthing people. The purpose of this column is to promote the use of the Public Health Critical Race Praxis (PHCRP) framework to inform race-conscious, culturally affirming, and antiracist approaches to maternal health research and interventions in occupational therapy.

The PHCRP is a framework for analyzing the complex interplay among race, health, and structural inequities through a race-conscious lens (Ford & Airhihenbuwa, 2010). This approach emphasizes the importance of acknowledging race as a social construct and assists researchers and practitioners in examining, explaining, and addressing racial factors that affect health. It also highlights the importance of process factors, such as the power imbalances and implicit biases between research participants and researchers (Ford, 2016). The PHCRP framework enlists an approach to center the lived experiences of Black birthing people and acknowledges historical and contemporary injustices. It challenges the status quo and aids in addressing disparities, dismantling oppressive systems, and establishing antiracist practices in maternal health occupational therapy. It also offers occupational therapy practitioners the opportunity to develop race-conscious research strategies that can inform evidence-based interventions that actively work to dismantle oppressive systems.

The PHCRP framework embodies a sophisticated, semistructured background that excels in addressing racial equity with notable methodological rigor, making it particularly effective for confronting health inequities (Ford & Airhihenbuwa, 2010) in fields such as maternal health occupational therapy. At its core, this methodology is grounded in race consciousness, which fundamentally shapes its approach to research and intervention. This core is embedded in an integrated methodology that combines theoretical frameworks, experiential data, scientific inquiry, and proactive intervention strategies. The PHCRP framework is structured around four main foci and enhanced by 10 guiding principles. In examining maternal health occupational therapy, the core methodology, foci, and principles enable a comprehensive and systematic exploration and amelioration of the root causes of maternal health disparities. This scientific approach ensures that all aspects of research and clinical practice are critically aligned with an understanding of racial dynamics and their profound impact on health outcomes.

Race consciousness is crucial for the effective investigation of the impact of racism on health disparities. This involves acknowledging and understanding the complexities of racialization and emphasizing a realistic perspective on racism and individual roles within its systemic structure (Ford & Airhihenbuwa, 2010). This heightened awareness of racial dynamics is essential, particularly in contemporary settings, where race-evasive ideologies frequently mask the realities of racial stratification. For instance, in maternal health occupational therapy, race consciousness could guide further evaluation and understanding of the varied lived experiences and specific needs of Black birthing people, which frequently go unaddressed in both the design and application of research and health care practices (Black Mamas Matter Alliance [BMMA], 2019). The experiences of Black birthing people are often simplistically equated to those of their White counterparts (Njoku et al., 2023). In addition, it is vital to recognize and address the complex layers of intersectional oppressions—including factors such as ability, citizenship, class, education, gender identity, race, and sexuality—that distinctly affect the health of Black birthing people (BMMA, 2019). For a truly equitable approach, researchers and practitioners must adopt a race-conscious lens to ensure that the experiences of Black birthing people are central in creating research and interventions that are genuinely responsive to their unique needs.

The PHCRP framework is structured around four central foci: (1) contemporary patterns of racial relations, (2) knowledge production, (3) conceptualization and measurement, and (4) action. Each focus plays a critical role in dissecting and addressing the layers of racism embedded in health care systems and practices (Ford & Airhihenbuwa, 2010). In the context of maternal health, the four central foci can guide race-conscious efforts in research design, methodology, data collection, and assessment selection, as well as intervention planning.

The first focus area, contemporary patterns of racial relations, urges researchers to examine systemic racism and current social dynamics that affect maternal health outcomes. For instance, maternal health occupational therapy researchers might explore how racial bias in health care settings affects the prenatal care experiences of Black mothers and identify specific systemic barriers that impede equitable care.

The second focus, knowledge production, challenges traditional research paradigms that may perpetuate racial biases by advocating the inclusion of diverse perspectives in research design and interpretation. Occupational therapy practitioners can use this approach in the area of maternal health to critically analyze the existing literature and frameworks for bias and to develop new studies and interventions that better reflect the realities of Black birthing people, ensuring a diverse and comprehensive understanding of health narratives that challenge mainstream perspectives.

The third focus area, conceptualization and measurement, stresses the importance of developing culturally relevant assessment tools that recognize and measure the unique experiences of racialized groups. In the context of maternal health occupational therapy, this could involve creating or adapting assessment tools and intervention strategies that accurately reflect and address the specific needs and experiences of Black birthing people, considering the nuances of their lived experiences and the intersectional oppressions they face.

The fourth focus, action, translates research findings into concrete actions and policy recommendations aimed at dismantling systemic barriers in health care. For maternal health occupational therapy, this means implementing interventions that are informed by the specific findings of PHCRP-oriented research, such as programs tailored to support the maternal health of Black birthing individuals, addressing both medical and socioeconomic factors in a culturally affirming manner.

By integrating these four foci, the PHCRP framework provides an informed mechanism that helps occupational therapy practitioners deeply engage with the systemic issues that influence maternal health disparities. This approach not only enhances the effectiveness of therapeutic interventions but also aligns with broader efforts to ensure equity and justice in health care outcomes.

The PHCRP framework is supported by 10 principles that guide researchers and practitioners in addressing racial disparities within health care through a critical and comprehensive lens (Ford & Airhihenbuwa, 2010): (1) race consciousness, (2) primacy of racialization, (3) race as social construct, (4) ordinariness of racism, (5) structural determinism, (6) social construction of knowledge, (7) critical approaches, (8) intersectionality, (9) disciplinary self-critique, and (10) voice. These principles challenge traditional, often race-evasive approaches to public health research and practice, urging an acknowledgment of race as a social construct and a determinant of health. They range from fostering race consciousness to recognizing the ordinariness of racism and the structural determinism that perpetuates health disparities. These principles advocate a deep understanding of how racial dynamics manifest within societal structures, influence knowledge production, and affect health outcomes.

In parallel with the focus areas, several principles of PHCRP resonate with the foundational components of maternal health occupational therapy research. Race consciousness and intersectionality both highlight the importance of acknowledging the impact of race and other intersecting identities on maternal health outcomes. This is a necessary perspective because it requires a thorough consideration of how these factors affect occupational engagement and health. Structural determinism aligns with the profession’s emphasis on environmental factors, acknowledging the profound influence of societal structures on health outcomes. Moreover, both critical approaches and voice advocate challenging traditional narratives and ensuring the inclusion of the voices of Black birthing people, which is essential for developing culturally affirming interventions in occupational therapy. Table 1 provides descriptions of race consciousness, structural determinism, intersectionality, and voice; ways these principles can uniquely inform maternal health occupational therapy research; and practice implications.

Integrating the PHCRP framework into maternal health occupational therapy necessitates the enhancement of cultural responsivity, emphasizing the integration of race consciousness into research promoting informed evidence-based interventions tailored to diverse racial groups, especially Black birthing people. Occupational therapy practitioners should collectively advocate policies and actions that combat systemic racism, health care bias, and race-evasive practices and oppression by facilitating longitudinal and participatory research to understand the long-term effects of racism on Black maternal health outcomes and mothering. Community engagement and the inclusion of Black birthing people in the development and application of research are crucial if the field is to ensure that interventions are relevant and grounded in the real-world experiences of those receiving occupational therapy services. We urge occupational therapy practitioners to critically reevaluate existing practices to ensure they do not perpetuate racial biases but instead promote a just and inclusive health care environment that improves outcomes for all clients.