How do community advocates address racial inequities in maternity care for Black, African, Caribbean and mixed-Black families? A realist review.

Abstract

Black, African, Caribbean and mixed-Black women face higher maternal mortality and poorer maternity outcomes than white women due to structural, institutional and interpersonal racism. Experiences of coercion, neglect and biased decision-making foster mistrust and disengagement from care. In response, families adopt protective strategies, including using community advocates. Advocates, such as doulas and perinatal support professionals, can provide continuous, culturally tailored support that complements clinical care, improving maternal health outcomes and care satisfaction. To explore how, for whom and in what contexts community advocates address racial inequities in maternity care for Black, African, Caribbean and mixed-Black families. We conducted a realist review, developing initial programme theories and searching MEDLINE, Embase, CINAHL, Maternity and Infant Care, PsycINFO, Global Health, HMIC, Web of Science and grey literature. Sources were included if they examined use of community advocates in maternity care for Black, African, Caribbean and mixed-Black families. Data were analysed to generate and refine context-mechanism-outcome configurations with input from lived experience, policy, practitioner and academic experts. Of 1168 records screened, 46 met inclusion criteria, from the USA, UK, and Canada. Three components emerged: how advocates co-create personalised care, how they are supported and how they are embedded in health systems to influence service improvements. Advocates address racial inequities by building trust, fostering family empowerment and autonomy. Effectiveness depends on formal recognition, fair remuneration, training, mentorship and institutional anti-racism support ensuring independence and accountability. Community advocates can reduce racial inequities in maternity care by co-creating culturally responsive, individualised, non-judgemental and empathetic care with families. Sustained impact depends on adequate support and systemic anti-racism reforms that embed advocates while preserving their independence. CRD42024596506.