Introduction

New research: Giving Voice to Mothers: A national survey of the experiences of care during and after pregnancy and childbirth in the US focused on the experiences of birthing women of color who were planning to birth out of the hospital, defined as “community births”. These community births were planned to occur in either a freestanding birth center or at home.  The demographics of these two group (people of color and community births) are traditionally underrepresented in past research projects focused on personal experiences, such as the Listening to Mothers studies did.

It is important to understand the experiences of families of color who have the highest risk of maternal and neonatal mortality and morbidity rates.  As the rates of out of hospital births rise, those experiences also need to be captured. This study aims to assess both of these circumstances.

What makes this study unique is that the 200-question survey was designed by women from the communities that were participating in the survey. This population decided what to study, selected the questions and did the recruitment of study participants.  They were supported by the Birth Place Lab team in successfully achieving their goals.

While the final report has not yet been released, pending final review and collaboration with community researchers, the Executive Summary is available now.

Who participated in the study?

The demographics of the participants where interesting.  Almost half the participants came from just four states and almost all of the respondents in the study spoke English and were well educated.

• 2700 women living in the United States
• 56% were between the ages of 31 and 39 at the time of birth.
• 14% were pregnant when they responded to the survey.
• 90% were born in the United States and spoke English in the home.
• 80% had completed post-secondary education.
• 29% of the respondents came from New York.
• 8% of the respondents came from California.
• 5% of the respondents came from Washington.
• 4% of the respondents came from Texas.
• 33% of the respondents reported an annual income of less than 50,000.
• 15% of the respondents were Black, 10% were Hispanic, 3% were indigenous, 5% were Asian and 66% were white.
• 71% of the women received care by midwives while 26% of women receiving care from obstetricians. White women were more likely to use a midwife than people of color.
• Half of the respondents had a community birth and half gave birth in the hospital.  White women were more likely to have a community birth.
• The cesarean rate amongst all respondents was 14% (19% Black vs 12% white.)

What did the respondents share about their experiences?

Study participants were asked what was important to them during maternity and newborn care, with the most common response being a trusting relationship with a health care provider who was a good match with their own values and preferences, along with remaining together with their baby after birth.  They also wanted time to have all their questions answered, and having the support people of their choice present during their labor and birth.

Most Black women reported that while it was important to have continuity of care with their health care provider, they did not receive this.  Additionally, Black women wanted to have control about the decisions surrounding their care, but in actuality, they did not have decision-making authority as frequently as white women.

Many women had a difficult time finding a care provider who shared their ethnicity or race, with people of color having the most difficulty.

Black and Indigenous women were both had more social determinants of health and more likely to have their needs go unmet or unserved.

80% of those who chose a community birth were criticized or judged for their birth place choice by the public, family, health care providers and friends.

Many of the Black, Indigenous, and people of color respondents indicated they would have liked to have had a doula at their birth, but did not.

One in six people reported at least one type of mistreatment during their experience.  This mistreatment included providers shouting or scolding them, threatening to withhold treatment or threatening them to accept unwanted treatment.  Women who identified as white were least likely to report mistreatment.

One-third of women who received an episiotomy during birth were not asked for consent prior to the procedure. Black and Asian women were least likely to be consulted before the episiotomy.

When treatment was declined, white women were more likely to have their wishes respected while women of color shared that the treatment or procedure was performed anyway.

Overall, when care was provided by a midwife, privacy, dignity, and respect were more likely during their care. Lower rates of respect, dignity, and privacy were reported by women of color.

Women of color were more likely to be pressured into interventions, including continuous electronic fetal monitoring, labor augmentation, a cesarean, and an epidural.

Women of color, younger women and women giving birth for the first time were more likely to have less autonomy in decision-making during their experience.  When a midwife was the care provider or a community birth was planned, there was more autonomy for all.

When study respondents were with a midwife, they were more likely to have immediate skin-to-skin contact with their newborn and to receive support with breastfeeding initiation.

Research take-aways

It is important to recognize that the research indicators used in this investigation were identified by the service users themselves.  This is the first study of its kind to do this.  When birth occurred in a hospital, adverse experiences were more likely to occur. Those people with more social, economic or health challenges also faced more adverse experiences.

Women of color were more likely to experience all types of mistreatment, loss of autonomy, discrimination and less likely to receive care from their preferred provider. Verbal abuse, rights to information and autonomy were present and more likely for people of color.

It was clear that all respondents, regardless of race, received a more optimal experience, and experienced less mistreatment when they planned a community birth or had a midwife as the primary care provider.

In the United States, fewer than 2% of births occur in a community setting.  For those birthing in the hospital, (98% of all US births) 30% experienced mistreatment.  Women of color, especially Black women were most at risk of receiving mistreatment and substandard care.

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