Background Low birthweight (LBW) and preterm birth (PTB) are more common among Black infants than white infants in the United States. Although multiple hypotheses have been proposed to explain elevated rates of PTB and LBW, the perspectives of Black midwives who serve Black communities are largely missing from the literature. Methods Using semi‐structured interviews and focus groups with a purposive sample of midwives (n = 29), we elicited midwives' perceptions of PTB and LBW causation, as well as insights on culturally congruent strategies for prevention. We used consensus coding and reciprocal ethnography to increase the rigor of our analyses. Results Midwives identified three intersecting and predisposing root causes: (1) systemic racism; (2) the epigenetic legacy of enslavement; and (3) ongoing cultural loss. In response to these stressors, midwives recommended variants of two additional themes—(4) community building; and (5) culturally centered care—as essential to reversing mortality trends among Black babies. Discussion Midwives' perspectives, which are supported by relevant literature, provide critical insights that should inform both research and policy aimed at promoting birth justice in the United States and beyond.

INTRODUCTION: Adverse perinatal outcomes among immigrants, refugees, and women of colors in the US are well-documented and persist even when socio-economic background is considered. METHODS: Community members and researchers designed a survey to capture patient-oriented data on maternity care experiences among communities of color. Items included previously validated instruments including the Mothers Autonomy in Decision Making (MADM) scale, the Mothers on Respect index (MORi); and the Perceptions of Racism (PR) scale. The final instrument was content validated, piloted, and distributed across the US. Descriptive statistics describe access, experience, and outcomes; and regression analyses link MADM and MORi scale scores to respectful care and autonomy (adjusting for differences in sociodemographics, risk profile, type of provider, and place of birth). RESULTS: Of the total sample (N=2260), 37.3% were women of color (Black, Hispanic, Native, other), and 18% Medicaid recipients. Women of color had significantly lower MADM scores, and 20.5% were not satisfied with their role in decision making. Women with low MORi scores reported pressure by health professionals to accept interventions [(6.8%) epidurals, (15.8%) inductions, (11.1%) cesarean]. Reported discrimination due to a difference in opinion with providers was more common (17%) among women of color. MADM, MORi, and PR scores varied significantly by place of birth and type of provider. CONCLUSION: Persons of color in the US report receiving less respectful maternity care, and reduced access to options for physiologic birth care. Data suggest that type of provider or place of birth modulates outcomes, and institutional racism may be a contributing factor.

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