Unrecognized and Unheard: Experiences of Black Mothers Navigating the "Good NICU Mother" Ideal Across the Preterm Birth Continuum.

Background: Black mothers who experience preterm birth and neonatal intensive care unit (NICU) hospitalization face intersecting structural and institutional challenges that shape their early maternal experiences. While racial disparities in maternal and neonatal outcomes are well documented, less is known about how racialized narratives of Black motherhood are enacted across everyday perinatal care interactions. Grounded in the principles of respectful maternity care (RMC), this study examines how Black mothers navigate birth, neonatal transport, and NICU hospitalization, and how institutional expectations of the "good NICU mother" shape maternal identity and legitimacy within these settings. Methods: This qualitative study used a reflexive thematic analysis of in-depth interviews with five Black mothers whose very preterm infants (24-28 weeks' gestational age) required neonatal transport to a tertiary NICU in South Carolina. Interviews were conducted during or shortly after the infant's NICU hospitalization and analyzed using Braun and Clarke's six-phase approach. Findings were contextualized using an adapted National Institute on Minority Health and Health Disparities research framework. Results: Three phases of experience were identified: (1) preterm labor and initial contact with the healthcare system, (2) preterm birth at a referral hospital and neonatal transport, and (3) the postpartum period during NICU hospitalization. Across all three phases, participants described dismissal of their concerns, constrained communication, limited agency, and physical and emotional mistreatment - experiences that directly conflict with the core principles of RMC. The "good NICU mother" emerged as a regulatory standard - defined by constant bedside presence, emotional composure, breastmilk production, and fluency in medical terminology - that participants were evaluated against but structurally unable to meet. For Black mothers, these expectations intersected with racialized assumptions about maternal competence and responsibility, intensifying experiences of surveillance and scrutiny. Conclusions: Institutional systems of perinatal care function as sites where maternal legitimacy is interpreted and evaluated, often in ways that undermine RMC for Black mothers. Extending RMC principles beyond labor and delivery into neonatal intensive care settings is essential for achieving equitable, dignity-centered care. Structural reforms to visitation policies, documentation practices, and communication standards are needed across the full perinatal continuum.