Background: African American women deliver preterm at a rate that is two to three times that of their white counterparts, and after decades of research, this disparity in birth outcomes still remains unexplained. While factors including income, education, neighborhood conditions, infection and stress have all been associated with prematurity, no combination of these factors has explained why the disparity persists. Recently, however, racism-specific stress has emerged as a possible factor contributing to this disparity. This study was designed to learn how preterm birth was explained by African Americans directly impacted by prematurity. Methods: Interviews were conducted with African American women with a history of preterm birth hospitalized for complications with their current pregnancy; the mothers of these women; the fathers of their unborn children; and African American physicians, nurses and medical assistants. A total of 25 recorded interviews were transcribed and analyzed for risk perception, and for explanatory models of risk. Results: With one exception, racism, racism-specific stress and the structural inequalities that impact the incidence of preterm birth for African American families were not acknowledged. All respondents shared a perception that the pregnant woman\u27s behavior was the primary explanation for her continuing experience with prematurity. The informants also agreed that stress and lack of support were strongly implicated in preterm birth. There were, however, differences between the groups. Notably, the competing priorities women faced in their roles as mothers, wives and homemakers, and their moral hierarchies for deciding how to fulfill these cultural roles, were often not recognized by providers. The emphasis by health care providers on gestational age at delivery often obscured the other important concerns that families faced. Additionally, this study found that patients and providers assigned significantly different meanings to risk and harm, and that these differences impacted health behaviors. Conclusions from this study offer a direction for constructing culturally appropriate interventions, including the co-negotiation of risk, and inform best practices for the health care community
