Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean

Abstract

Objective High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S. Methods Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother’s Autonomy in Decision Making Scale; MADM). Results Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician. Conclusion Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.

Maternal and Delivery Characteristics and Self-Reported Perceived Control During Labor

“…This finding is surprising given the ample literature suggesting that there are differences in quality of care provided to Black individuals. 15–19 However, we note that this finding, which exists in the setting of a randomized trial conducted at academic medical centers, may not reflect findings in the general community and may be nonsignificant because of type II error. In addition, we note that greater perceived pain was associated with lower Labor Agentry Scale scores, and there is ample literature suggesting that Black birthing individuals experience less optimal control of their intrapartum and postpartum pain.…”

“…Patient experiences are multifaceted, and although other studies have reported findings generally similar to ours, they also have provided additional insight with regard to the suboptimal experiences for individuals from communities with historical disadvantage such as people of color and of low economic status. 16–19,28,29…”

“…Patient experiences are multifaceted, and although other studies have reported findings generally similar to ours, they also have provided additional insight with regard to the suboptimal experiences for individuals from communities with historical disadvantage such as people of color and of low economic status. [16][17][18][19]28,29 This analysis included a large diverse sample of nulliparous people at low risk. The findings represent perceived control during childbirth based on Labor Agentry Scale scores among people receiving care in the United States, which is important considering that many similar studies examined international populations, who may differ in important ways from a U.S. population with regard to attitudes, beliefs, and preferences during the birth experience.…”

“I was able to take it back”: Seeking VBAC after experiencing dehumanizing maternity care in a primary cesarean

“…We conducted in-depth analyses of narratives collected as the primary qualitative portion of a mixed-methods study exploring contemporary experiences of pregnancy and birth after cesarean across the U.S. Detailed study methods and preliminary results have previously been reported ( Basile Ibrahim, Vedam, Illuzzi, Cheyney, & Kennedy, 2022 ; Basile Ibrahim, Knobf, et al, 2020). In brief, following Institutional Review Board approval (Yale University IRB protocol #2000021384), an online, self-administered questionnaire was created, validated with 20 women who had given birth within the previous 5 years, and distributed via the Qualtrics platform (Provo, UT).…”

Racial and ethnic disparities in psychological care for individuals with FASD: a dis/ability studies and critical race theory perspective toward improving prevention, assessment/diagnosis, and intervention

“…The prenatal period is a pivotal juncture for preventing AEPs ( 41 ). BIPOC women are less likely than White women to receive prenatal care ( 42 ) and experience disparities in respect and autonomy within healthcare settings ( 43 ) potentially contributing to underutilization of services ( 44 ). Regarding receipt of evidence-based prenatal education, the literature is mixed.…”