Disparities in Mistreatment During Childbirth

Abstract

Importance: Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US.

Objectives: To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences.

Design, setting, and participants: This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months' post partum. Data were collected from January 1, 2021, to March 31, 2022.

Exposures: Demographic, social, clinical, and birth characteristics that have been associated with patients' health care experiences.

Main outcomes and measures: Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs.

Results: The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being "ignored, refused request for help, or failed to respond in a timely manner" (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous.

Conclusions and relevance: This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Figure 1.. Prevalence of Types of Mistreatment During Childbirth

Study measures reflect self-reported responses by postpartum individuals 12 to 14 months after having a live birth. Detailed survey questions are included in eTable 1 in Supplement 1. Percentages and 95% CIs were weighted to be representative of the 7 sample jurisdictions and to account for the Postpartum Assessment of Health Survey and Pregnancy Risk and Monitoring System nonresponse and sampling design. Error bars indicate 95% CIs.

Figure 2.. Unadjusted Associations Between Any Mistreatment and Patient Characteristics

Study measures reflect self-reported responses by postpartum individuals 12 to 14 months after having a live birth. Odds ratios (ORs) and 95% CIs were weighted to be representative of the 7 sample jurisdictions and to account for the Postpartum Assessment of Health Survey and Pregnancy Risk and Monitoring System nonresponse and sampling design. P values indicate the statistical significance of differences in the odds of reporting any item on the Mistreatment by Care Providers During Childbirth scale relative to the reference group based on unadjusted survey-weighted logistic regressions. Only characteristics with statistically significant comparisons are shown. IPFV indicates intimate partner or family violence; LGBTQ, lesbian, gay, bisexual, transgender, queer; PHE, public health emergency; and SUD, substance use disorder. ^aBefore or during pregnancy.