Pregnancy is a critical period of development when stress can have deleterious effects on both the pregnant person and their baby, leading to adverse birth and long-term health outcomes [1,2] that disproportionately affect Black, Indigenous, and Native Hawaiian or Pacific Islander people [3,4]. In the United States, Black infants are twice as likely to be born preterm or with low birth weight compared to White infants [3]. These inequities extend to maternal health, with Black women being 3.3 times more likely to die during or after pregnancy than White women [5]. While rates of adverse outcomes are often obscured by aggregation of data among Asian and Pacific Islander subgroups [6], Native Hawaiian and other Pacific Islander people experience higher rates of low birth weight, preterm birth, and macrosomia [3,7,8]. Even in San Francisco, a wealthy, well-resourced city, the shrinking Black and Pacific Islander populations experience significant inequities in birth outcomes [9]. Black and Pacific Islander pregnant women and people experienced the highest rates of preterm birth, at 12.7% and 8.9%, respectively, in 2014-2016, the last years with enough births to Pacific Islander people to reliably report [10]. Research increasingly indicates that racism—structural, institutional, and interpersonal—is a key underlying driver of these inequities [11,12]. It is unsurprising, therefore, that clinical, educational, and behavioral interventions have failed to meaningfully narrow racialized birth disparities [3,13-15].

Efforts to reduce inequities must address exposure to interpersonal, institutional, and structural racism as the root cause of disproportionate risk [16-19]. Racial inequity in income and wealth is one manifestation of structural racism, with important public health ramifications [16,20]. The racial wealth gap has resulted from a long history of exclusion of Black families from economic opportunity, through a combination of redlining, exclusionary zoning, subprime loans, and “urban renewal” programs, among other tactics [21]. This leaves Black families and other families of color more vulnerable to economic stress during pregnancy. Financial stress may be particularly acute during pregnancy, a period of income volatility when families frequently experience changes in housing, employment, health care, and childcare costs [22]. Indeed, in a nationally representative study of pregnant and postpartum women, over half reported general financial stress [23]. Yet, efforts to directly alleviate poverty and financial stress to address birth inequities are limited. In San Francisco, the median annual income in 2020 for White households was US $146,043, while it was just US $38,862 for Black households and US $90,917 for Pacific Islander households [24], making it the city with the third largest income disparity in the United States [25]. The Insight Center Family Needs calculator estimated the minimum income required to live in San Francisco in 2021 without public or private assistance as US $60,232 for a single adult, US $120,519 for a single adult with 1 preschooler, and US $167,432 for a household with 2 adults, 1 infant, and 1 preschooler [26]. To meet the needs of a family of three, Black and Pacific Islander households would have needed to earn 4 and 2 times their current average incomes, respectively.

Guaranteed income describes the disbursement of unconditional cash to individuals or families in a community without restrictions, allowing flexibility to close gaps where needs are not being met by public benefits programs [27]. Guaranteed income programs offer the potential to address poverty and stress caused by economic racism and the racial wealth gap. Philanthropic funders, cities, and states, including California, are increasingly investing in guaranteed income as a poverty reduction and equity-generating strategy [28]. Emerging findings from the growing research on United States guaranteed income pilots have found that monthly income supplements improve the sense of trust in institutions, dignity, and autonomy and increase savings, without changing spending patterns [29,30]. Magnolia Mothers Trust, a program providing US $1000 per month for 12 months to Black mothers living in federally subsidized housing in Jackson, Mississippi, allowed mothers to save for emergencies, buy food, pay childcare expenses, and prioritize their health [30].

At the time of the Abundant Birth Project’s (ABP) inception, there were no guaranteed income programs in the United States that addressed the critical period of pregnancy. However, evidence from other contexts supported a guaranteed income in pregnancy as a health intervention. A quasi-experimental study among 14,591 pregnant women in Manitoba, Canada, found that an approximately 10% increase in income from a pregnancy income benefit resulted in reductions of low birthweight by 21% and preterm birth by 18% [31,32]. Since the launch of ABP, there has been a proliferation of guaranteed income programs across California, including other programs that target pregnancy [28,33,34].

ABP is a program of Expecting Justice, a Black-led, cross-sector collaborative focused on birth equity in San Francisco that includes mothers, public health professionals, health and social systems partners, and governmental leaders. Expecting Justice uses a collective impact model, which is a process to bring together diverse stakeholders to create a common agenda, establish shared measurement, and foster mutually reinforcing activities for stakeholders [35]. As part of its work to advance birth equity, Expecting Justice is guided by community voice and emphasizes upstream solutions that address the social determinants of health. As defined by the National Birth Equity Collaborative, birth equity is the assurance of optimal birth conditions for all people, with an ongoing effort to address racial and social inequities [36]. The social determinants of health result from the larger systems at play, such as economic policies, racism, and political systems that shape the conditions of daily life and health [37,38]. These frameworks informed the focus on this pregnancy-guaranteed income program as an equity-generating strategy to directly address income insecurity as a social determinant of health by interrupting the pathway from economic exclusion and stress to adverse birth outcomes. Expecting Justice targeted this intervention toward communities most likely to experience preterm birth to help narrow disparities in preterm birth rates. Focusing on the most marginalized aligns with the birth equity framework, emphasizing that targeted support, rather than universal availability, is essential for addressing birth inequities [36].

Expecting Justice entered a community-academic partnership with the University of California, Berkeley, and the University of California, San Francisco, to design and evaluate ABP. We developed the ABP program and evaluation by actively, meaningfully, and intentionally centering the voices and experiences of the communities most affected by the adverse birth outcomes the program seeks to improve. ABP launched in June 2021, with the goal of enrolling 150 Black and Pacific Islander pregnant women and people (including gender-diverse individuals with the capacity for pregnancy) over 18 months.

This paper describes the formative research process, under the co-leadership of community members, used to design ABP.. Our primary objectives were to (1) determine the financial needs of Black and Pacific Islander women and people during pregnancy, and (2) collaboratively design a pregnancy-guaranteed income pilot program with Black and Pacific Islander mothers. We hope that the process and results from the formative research to design ABP will be useful to other researchers, practitioners, and community groups developing interventions to address racial health disparities, including guaranteed income pilot programs.

ABP used shared decision-making and community-centered practices in all phases of the program development and evaluation, by purposely centering the voices of community members with lived expertise [39]. As a community-based participatory research project, ABP recognized that this relationship is dynamic and requires continual effort to rebalance traditional power structures [40]. To support these efforts, 4 community researchers (CRs) served as key members of the community-academic partnership. The CRs are Black and Pacific Islander community members who have lived experience of pregnancy and parenting in the San Francisco Bay Area. They come from a variety of professional backgrounds and have an interest in learning or experience using research methods to advance birth equity. We adopted a shared power structure and decision-making process that included following Expecting Justice’s “expert opinion protocol” for all final decisions. This protocol enabled ABP stakeholders who identified as Black and/or Pacific Islander mothers to have protected time to share their insights with the larger group without contradiction before voting. We also used weighted voting in decision-making to prioritize the perspectives of those who identified as Black and/or Pacific Islander mothers.

The process of designing the ABP program and evaluation involved (1) conducting interviews as part of the needs assessment, (2) a Rapid Assessment Process (RAP) for analysis, (3) a prototype development design sprint, and (4) a usability testing design sprint (Figure 1). The CRs contributed to the full process, bringing expertise from their lived experience with pregnancy and parenting in the Black and Pacific Islander communities: developing research questions, formulating survey and interview instruments, recruiting participants, conducting interviews, facilitating design sprints, interpreting results, and making key program decisions. CRs received training in data collection and analysis supported by the university-based staff, which coupled with the team’s shared power structure, helped to dismantle the hierarchy often present in research institutions that keeps community members out of decision-making processes [41,42]. Expecting Justice also led an ABP working group with birth equity stakeholders, including Black and Pacific Islander mothers, community organization representatives, social service providers, maternal health leaders and researchers, and representatives from health plans to collaborate and provide strategic resources to support program development. The ABP working group met monthly to inform key program design and implementation decisions before, during, and following the formative phase.

The shared decision-making structure with the ABP program and research teams, CRs, and ABP working group led to tangible improvements in research and program design. For example, the CRs voiced concerns that research studies rarely compensate participants in a way that truly values their time. Under their leadership, the team increased the amount of participant remuneration for the interviews and design sprints from US $50 to US $75 and US $100 to US $200, respectively.

To inform ABP’s design, we first conducted interviews to understand the experiences Black and Pacific Islander women and people face during pregnancy in San Francisco. Inclusion criteria were aged 18 years or older, identified as Black and/or Pacific Islander, spoke English, and either currently pregnant or had been pregnant while residing in San Francisco in the past 5 years. Participants were recruited from social media and local community organizations. The CRs closely collaborated on the development of the interview guide to ensure that language and questions would capture appropriate topics in a comfortable environment for participants. We conducted interviews from April to June 2020. The CRs conducted the interviews using a web-based videoconference platform or by telephone. Interviews were recorded and professionally transcribed.

The interview guide addressed stress and financial experiences during pregnancy and experiences with and perception of public benefits programs. We also asked participants for recommendations on the ABP program design, including how much money would alleviate financial stress during pregnancy, how to best distribute the income supplement, and program eligibility criteria and restrictions.

Before conducting interviews, the CRs underwent training in qualitative research methods led by Dr Brittany Chambers, a Black scholar, mother, and community engagement expert. The training included an introduction to asking research questions, qualitative data collection, and interviewing skills. The entire research team went through the training together, building trust and rapport throughout the process. The CRs described the importance of being trained by a researcher from their own communities. Dr Chambers used art-based activities that allowed the CRs to celebrate their stories and the whole team to tap into their imagination and creativity and engage with one another outside of hierarchies. CRs received compensation for their time and expertise in the training.

To identify key topics, we used RAP, an intensive, team-based, iterative analytic approach that uses data triangulation to develop preliminary findings from the perspective of an insider—pregnant and parenting Black and Pacific Islander San Franciscans [43]. RAP is well-suited for qualitative research informing the design of interventions, as it allows for rapid and timely data reduction and ongoing analysis during data collection. We brought together the team, including CRs, program staff, and student research assistants for shared qualitative analysis training. CRs, other research team members, and program staff used summary templates to create a memo for each interview. Members of the research team reviewed memos for consistency. The first step of data reduction involved matching domains from the summary template to interview questions. The domains included concerns about stress and pregnancy, employment, experiences with social services, desired programs and services, feelings about the income supplement, recommended supplement amount, eligibility restrictions, disbursement, recruitment recommendations, and additional financial services. Finally, we used an individual-level data matrix to synthesize key data across participants and identify themes.

The institutional review board of the University of California, San Francisco, approved this study’s protocol (IRB #19-27608, reference #267614). Participants signed consent forms for interviews and design sprints after reviewing them with study personnel. The research team removed identifiers (eg, names) from interview transcripts to deidentify data. Participants received a US $75 gift card incentive for taking part in the needs assessment interviews and a US $200 gift card incentive for participation in each design sprint.

Eight participants from the first design sprint returned in December 2020 to test and provide feedback on all components of the ABP prototypes.

We elicited feedback on example recruitment documents. Participants preferred interest and referral forms that could be completed in 5 minutes or less. They suggested that the ABP website contain a portal to allow applicants to check their status from interest form submission to enrollment. To create a welcoming atmosphere, participants felt it was important for the website to have imagery representing Black and Pacific Islander people. This was especially important for the Pacific Islander participants because few programs tailored outreach specifically to this community. With this in mind, Expecting Justice collaborated with Black and Pacific Islander artists to design outreach materials such as flyers and social media posts. Expecting Justice consulted the San Francisco Pacific Islander Maternal Advisory Board about the best language to use to refer to the Pacific Islander population. They learned that the community felt most comfortable using “Pacific Islander,” “Pasifika,” or “Pasefika”—as opposed to “PI”—and consequently used these terms in their outreach materials. Participants also recommended that individuals be given a small welcome gift once selected. Participants felt that a list of local resources was insufficient in terms of offering support, and instead favored having program staff directly link participants to services (ie, a warm handoff).

During this design sprint, participants expressed concerns about people “misusing” the ABP funds. While we originally wanted to create the lowest documentation burden for applicants, participants in the second design sprint expressed a desire for stricter documentation requirements to ensure eligibility. These preferences mirrored those expressed in the needs assessment interviews and the first design sprint. In addition, participants discussed what would happen in the case of a pregnancy loss.

Participants also weighed in on their willingness to participate in research to evaluate the impact of ABP. They noted the factors that would make them more likely to participate in the research, including transparency in how the results would be used and knowing that the data collection would be conducted by Black and Pacific Islander community members.

Through a community-centered design process, we designed a novel guaranteed income program to center the needs of pregnant Black and Pacific Islander women and people in San Francisco. To our knowledge, no previous studies have qualitatively explored the financial, social services, and pregnancy and parenting experiences of these communities in San Francisco. Our needs assessment interviews revealed significant financial and life stressors experienced by Black and Pacific Islander people during and after pregnancy. Housing insecurity and previous poor experiences with social service programs were underscored by multiple participants. These findings are consistent with a report documenting that increases in San Francisco housing prices led to new concentrations of poverty especially for Black families from 2000 to 2015 [50]. Our findings also align with previous studies that report disproportionate unaffordable housing costs among people of color [51,52]. Additionally, the high cost of living in San Francisco left participants far above the federal poverty line ineligible for social services yet struggling to make ends meet. While all participants were enthusiastic about the potential of a guaranteed income program, they expressed concerns surrounding the eligibility and additional support needed to navigate the benefits system.

These experiences served as the foundation of the ABP prototypes and final program design. This formative process allowed for the establishment of eligibility and verification, supplement amount, disbursement options, and optional case management supports that were directly aligned with community members’ expertise and preferences.

There are several strengths to this community-centered model of formative research and program development. Guaranteed income is a novel public health intervention, and the ABP program contributed to a swell of guaranteed income pilots in California and across the country [53-56]. Integrating community voice and expertise throughout the design process tailored ABP to the needs of the pregnant women and people it aimed to serve. We note that formative research with the CR model and shared decision-making requires more time and resources in the design phase, and institutions and academic hierarchies often do not allow space for this community-engaged work. Nonetheless, we strongly believe that community-centered formative research and program design ensures authentic engagement and leads to more relevant, responsive, and just programs and interventions. Our process can provide a roadmap for other programs to guide community co-design of an intervention.

Our results should also be considered in light of some limitations. Due to the COVID-19 pandemic, the needs assessment interviews and design sprints were implemented through videoconferencing only, and this mode of data collection may have affected the way participants engaged in the sessions. Participants’ experiences of pregnancy and parenting were also likely changed by the pandemic. Additionally, eligibility for the interviews and design sprints included the ability to speak and read English, so these findings may not capture the experiences of non–English-speaking Black and Pacific Islander pregnant people in San Francisco, particularly immigrants.

The model of formative research to design ABP may be useful to other programs centering on community-driven, equity-oriented approaches. Interventions intended to address health equity should include experts with lived experience in the design process. Too often, well-intentioned programs do not meet the needs of recipients or center equity because of a lack of community participation in all elements of design.

The inclusion of CRs as integral members of the ABP staff was key to maximizing community involvement and shared decision-making. Ongoing staff and ABP working group meetings had designated spaces for CRs and community experts to advise ABP program implementation and evaluation design. Using the expert opinion protocol allowed for any ongoing issue to be decided with a consensus that prioritizes lived experience in developing solutions.

ABP aims to directly address the historical disinvestment of Black and Pacific Islander communities in San Francisco and positively impact birth outcomes in these communities through the provision of an unconditional income supplement. The COVID-19 pandemic has disproportionately impacted Black families, further underscoring the vital need for interventions that address structural deficiencies [57]. ABP applied a community-centered approach to design an intervention focused on the communities most impacted by maternal and birth disparities to reduce the effects of the racial wealth gap and economic insecurity among Black women. This novel approach and design process has great promise to reduce inequities in birth outcomes and center health and racial justice in antipoverty programs.