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Vital Signs: Maternity Care Experiences — United States, April 2023
Weekly / September 1, 2023 / 72(35);961–967
On August 22, 2023, this report was posted online as an MMWR Early Release.
Yousra A. Mohamoud, PhD1; Elizabeth Cassidy, MPH1; Erika Fuchs, PhD1; Lindsay S. Womack, PhD1; Lisa Romero, DrPH1; Lauren Kipling, PhD1; Reena Oza-Frank, PhD1; Katharyn Baca, PhD1; Romeo R. Galang, MD1; Andrea Stewart, PhD1; Sarah Carrigan, MPH1; Jennifer Mullen, MPH1; Ashley Busacker, PhD1; Brittany Behm, MPH1; Lisa M. Hollier, MD1; Charlan Kroelinger, PhD1; Trisha Mueller, MPH1; Wanda D. Barfield, MD1; Shanna Cox, MSPH1 (View author affiliations)
View suggested citationSummary
What is already known about this topic?
Maternal deaths increased in the United States during 2018–2021, with documented racial disparities. Respectful maternity care (e.g., preventing mistreatment, communicating effectively, and providing care equitably) can be integrated into strategies that aim to improve quality of care and reduce pregnancy-related deaths.
What is added by this report?
Approximately one in five mothers overall, and approximately 30% of Black, Hispanic, and multiracial mothers reported mistreatment (e.g., violations of physical privacy or verbal abuse) during maternity care. Approximately 40% of Black, Hispanic, and multiracial mothers reported discrimination during maternity care, and 45% of all mothers reported holding back from asking questions or discussing concerns with their provider.
What are the implications for public health practice?
Approaches to improving respectful maternity care include multilevel interventions involving health systems, providers, patients, and communities.
Abstract
Introduction: Maternal deaths increased in the United States during 2018–2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths.
Methods: CDC analyzed data from the PN View Moms survey administered during April 24–30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care.
Results: Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider.
Conclusions and implications for public health practice: Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.
Introduction
From 2018 to 2021, the maternal death rate in the United States increased from 17.4 to 32.9 per 100,000 live births (1). Native Hawaiian and other Pacific Islander, Black, and American Indian and Alaska Native persons have the highest rates of pregnancy-related deaths.* Approximately 80% of pregnancy-related deaths are preventable.† Preventing pregnancy-related deaths requires a multilevel approach that includes ensuring quality care for all pregnant and postpartum persons (2). Standards of quality maternity care include respectful maternity care (3), defined as “care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth” (4). Respectful, equitable, and supportive care is included as a component in all Alliance for Innovation on Maternal Health (AIM)§ patient safety bundles to improve person-centered and equitable care. Negative experiences during maternity care are more prevalent among women from some racial and ethnic minority groups (5). Maternal mortality review committees have identified discrimination as one factor contributing to pregnancy-related deaths (6,7). The concepts of mistreatment, engaging with effective communication, and discrimination have been used to evaluate respectful maternity care (8). CDC analyzed data from the PN View Moms survey, an opt-in consumer audience panel survey of U.S. mothers with children aged <18 years living at home. The survey examined maternity care experiences, including satisfaction with care, experiences of mistreatment and discrimination, and whether respondents held back from asking questions or discussing concerns with health care providers.
Methods
CDC obtained data from Porter Novelli through a subscription license. No personally identifying information was included in the data file provided to CDC. The option to complete the PN View Moms survey online was shared with 7,607 opt-in panel members¶; 2,407 (32%) mothers responded. The survey was administered in English during April 24–30, 2023. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.** The analysis was conducted using data from 2,402 respondents (five respondents aged ≥65 years were excluded). Respondent characteristics were described, including respondent age, race and ethnicity,†† highest level of educational attainment,§§ health insurance during delivery,¶¶ and age of the youngest child living at home.
Respondents were asked about their maternity care experiences during pregnancy or delivery of their youngest child. Satisfaction with care was defined as a response of very or somewhat satisfied with maternity care.*** Any mistreatment during maternity care was measured using seven validated questions to determine mistreatment (5), such as violations of physical privacy, ignoring requests for help, or verbal abuse. Satisfaction with care and mistreatment experiences were summarized overall and stratified by race and ethnicity and health insurance at time of delivery. Respondents were asked about experiences of discrimination while receiving maternity care and could select multiple reasons for the discrimination they experienced, such as race, ethnicity, skin color, age, or weight†††; these estimates were tabulated and presented overall and by race and ethnicity. Holding back from communicating questions or concerns during maternity care was evaluated by asking “During your pregnancy or delivery of your youngest child, did you hold back from asking questions or discussing your concerns for any of the following reasons” (with an option to note if they did not hold back). Respondents could select one or more reasons for holding back from communicating questions or concerns. Descriptive statistics were calculated using Stata software (version 17.0; StataCorp). No inferential statistical analyses were performed.
Results
Nearly two thirds of respondents (65.5%) reported that their youngest child was aged ≥5 years (Table 1). More than two thirds (69.6%) of respondents were White, 10.7% were Black, 10.2% Hispanic, 4.8% Asian, 2.8% multiracial, and 1.5% American Indian, Alaska Native, Native Hawaiian, or Pacific Islander. More than half of respondents (56.5%) were privately insured, and 32.6% were insured by Medicaid at the time of delivery of their youngest child. Overall, 90.5% of respondents were satisfied with the care they received during pregnancy (Table 2). Approximately one in five (20.4%) respondents reported experiencing at least one type of mistreatment. The most commonly reported experiences of mistreatment were being ignored by health care providers, having requests for help refused, or not responded to (9.7%); being shouted at or scolded by health care providers (6.7%); having their physical privacy violated (5.1%); and being threatened with withholding of treatment or being forced to accept treatment they did not want (4.6%). Among respondents who reported any mistreatment, 75.1% were satisfied with the care they received during pregnancy. Black, Hispanic, and multiracial respondents reported the highest prevalences of mistreatment (30.0%, 29.3%, and 27.3%, respectively). Among insurance categories, 28.1% of respondents with no insurance and 26.1% of those with public insurance at the time of delivery reported mistreatment.
Overall, 28.9% of respondents reported experiencing at least one form of discrimination during maternity care (Table 3), with highest prevalences reported by Black (40.1%), multiracial (39.4%), and Hispanic (36.6%) respondents. Overall, the most commonly reported reasons for discrimination were age (10.1%), weight (9.7%), and income (6.5%); reasons varied by race and ethnicity. For example, among Black respondents, the most common reasons were weight (13.2%), race, ethnicity, or skin color (12.9%), and age (12.8%). Among multiracial respondents, the most common reasons were age (16.7%), difference in opinion with caregivers about the right care for oneself or one’s baby (12.1%), race, ethnicity, or skin color (10.6%), income (10.6%), and substance use (10.6%). Among Hispanic respondents, the most common reported reasons for discrimination were age (11.4%), weight (10.2%), and income (8.9%).
Approximately one half (44.7%) of all respondents reported holding back from asking questions or discussing concerns with their provider during maternity care (Table 4). The most common reasons included thinking that what they were feeling was normal (28.8%), feeling embarrassed and not wanting to make a big deal (21.5%), having someone close tell them it was normal (21.2%), and worrying that their maternity care provider might think they were being difficult (20.7%).
Discussion
Approximately one in five surveyed women reported mistreatment and approximately 30% reported discrimination during maternity care. These experiences were more common among Black, Hispanic, and multiracial mothers. Approximately one half of respondents reported holding back from discussing questions and concerns during maternity care. These findings highlight the gaps in delivering respectful maternity care and underscore the need for improvement. Respectful maternity care is a component of quality care and can be integrated into broader strategies to reduce pregnancy-related deaths (3).
Although approximately 90% of respondents reported satisfaction with maternity care received, this estimate was lower among those who experienced mistreatment. Women might report satisfaction with the maternity care received overall and concurrently recall discrete instances of mistreatment. Women who feel safe, supported, and respected are more likely to have positive pregnancy experiences (9). Higher patient-centered maternity care scores are associated with lower risk for pregnancy complications (10). Improving respectful maternity care can improve the experiences of mothers during pregnancy and delivery care.
Negative maternity care experiences might influence health care utilization; for example, experiences of racial discrimination are associated with less than adequate prenatal care and not receiving a postpartum visit (11). Evaluation of measures of respectful maternity care, the impact of interventions to improve respectful care, and the effectiveness of respectful maternity care interventions on maternal health outcomes in U.S. settings is needed (8). Studies outside of the United States have found that multilevel interventions that include approaches to improving health system practices and policies, addressing health care provider attitudes and behaviors, and engaging the local community have significantly improved respectful maternity care (12).
Health care systems can encourage a culture of respectful maternity care by implementing training for health care providers on recognizing unconscious bias and stigma, shared-decision making, improving interactions and communication with patients, and cultural awareness.§§§,¶¶¶,**** The AIM patient safety bundles, which are standardized practices used in birthing facilities to reduce severe illness and death, all include the provision of safe, respectful, equitable, and supportive care. Perinatal quality collaboratives, which are state or multistate networks of teams working to improve the quality of care for mothers and babies, have implemented quality improvement initiatives to address birth equity and improve respectful care.††††,§§§§ Routine measurement of patient experiences of respectful care can guide the development, implementation, and evaluation of initiatives to improve respectful care and their contribution toward improving patient outcomes (8).
Engaging patients with effective communication is a component of respectful care. Nearly one half of respondents reported holding back from asking questions or discussing concerns with their provider during maternity care. The most common mistreatment experience reported by mothers was a health care provider ignoring them, refusing their request for help, or not responding to their request for help. The Hear Her campaign¶¶¶¶ provides resources for pregnant and postpartum women and their support networks to share concerns with providers and to recognize urgent maternal warning signs that signal an immediate need to seek care. The campaign also promotes the need for providers to actively listen to their patients’ concerns and provide culturally appropriate, respectful care. Clinical organizations representing health care providers have highlighted the importance of providing respectful maternity care to improve outcomes for mothers and children by ensuring effective communication and shared decision-making with patients and their families and strengthening coordinated care teams (13).
This analysis found variation in mistreatment during maternity care by race, ethnicity, and insurance status at time of delivery. Black, Hispanic, and multiracial mothers reported the highest prevalences of experiencing any discrimination during maternity care. Experiences of racial discrimination are associated with pregnancy complications (14), and bias and stigma related to obesity and low income during obstetric care have been documented (15,16). The equitable delivery of respectful patient-centered maternity care has been proposed as one strategy to reduce disparities in maternal mortality (17). Recruitment and retention of providers with diverse backgrounds that mirror the population served, midwifery models of care, and doulas have been shown to improve patient experiences for racial and ethnic minority groups (2). For example, doula support is associated with higher levels of respectful care (measured by experiences related to decision-making, support, and communication during childbirth), particularly for mothers who are publicly insured and identify as members of certain racial and ethnic groups (18). Engaging community-based organizations can raise awareness of respectful care and identify opportunities to incorporate respectful care into initiatives aiming to reduce disparities in pregnancy-related deaths (2,19). Maternal mortality review committees can identify racism and discrimination during reviews of pregnancy-related deaths and develop recommendations for prevention (20), providing critical data for centering health equity and reducing disparities.
Limitations
The findings in this report are subject to at least seven limitations. First, the survey was opt-in, did not use probability sampling, and was not weighted; thus, these data are likely not representative of the U.S. birthing population. Second, the participation rate was <50%, and some subgroups comprised a small number of respondents. Third, because experiences were self-reported, the responses are subject to social desirability bias. Fourth, only maternity care experiences for the youngest child were evaluated, and experiences might have differed for other births or pregnancy outcomes. Fifth, most women were reporting on experiences during the pregnancy or delivery of a child aged ≥5 years; such responses are subject to recall bias and might not represent more recent experiences. Sixth, data for race were collected using a combined category for all American Indian, Alaska Native, Native Hawaiian, and Pacific Island mothers, precluding further disaggregation. Finally, because the survey was fielded in English only, these data do not include the maternity care experiences of those not fluent in English.
Implications for Public Health Practice
Improving respectful care is an important component of strategies to reduce pregnancy-related deaths. Health care systems can implement quality improvement initiatives to standardize care and support providers with training on discrimination, stigma and unconscious bias, cultural awareness, and communication techniques in the context of broader quality improvement initiatives. Health professionals interacting with patients at all points of maternity care play a role in improving patient experiences during maternity care and providing respectful maternity care equitably. Health communication campaigns and community engagement can include the perspectives of patients, families, and communities to raise awareness to incorporate the components of respectful maternity care, as well as how pregnant and postpartum women and their support system can communicate their questions and concerns. These campaigns and community engagement can also encourage providers to listen to and address their patients’ concerns.
Corresponding Author: Yousra A. Mohamoud, [email protected].
1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm† https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html
§ https://saferbirth.org/patient-safety-bundles/
¶ PN View Moms surveys are designed by Porter Novelli Public Services. They are programmed and fielded by Big Village (https://big-village.com/insights/caravan-omnibus-surveys/) using opt-in panel members from the Lucid platform (https://luc.id/quality/). Data quality checks are incorporated during both sampling and survey administration. Lucid uses a variety of tracking measures to confirm respondent identity and prevent duplicate responses.
** 45 C.F.R. part 46; 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d), 5 U.S.C. Sect. 552a, 44 U.S.C. Sect. 3501 et seq.
†† PN View Moms survey is not a federal data collection. Race and ethnicity data were categorized in the following manner based on the way data were collected: Hispanic includes all persons who selected Hispanic ethnicity. Race categories are non-Hispanic. White includes White, Middle Eastern, and North African. Black includes Black or African American, Caribbean American, and African. Asian includes Asian American, South Asian, East Asian, and Southeast Asian. Porter Novelli collects race data using the category “Indigenous American/First Nations,” which includes Native American, American Indian, Alaska Native, Pacific Islander, and Native Hawaiian, and is referred to in this report as “American Indian, Alaska Native, Pacific Islander, or Native Hawaiian.” Multiracial includes respondents that selected more than one race; another race includes those who did not select any race or ethnicity categories.
§§ Highest level of formal education completed at time of survey was defined as less than high school, high school diploma or equivalent, or more than a high school diploma. More than a high school diploma includes respondents with some college education, an associate degree or technical school, a bachelor’s degree, a master’s degree, or a professional degree or doctorate.
¶¶ Private insurance includes respondents with health insurance from the Healthcare.gov Healthcare Marketplace and Tricare or other military insurance; public insurance includes those on Medicaid, Medicare, Indian Health Service, or any other tribal insurance; and no insurance includes respondents who did not have insurance at any time during their youngest child’s birth and those who self-paid.
*** Respondents rated their overall satisfaction with the care they received during their pregnancy or delivery of their youngest child as 1) very satisfied, 2) somewhat satisfied, 3) neither satisfied nor dissatisfied, 4) somewhat dissatisfied, or 5) very dissatisfied.
††† Respondents were asked, “While getting health care during your pregnancy or delivery with your youngest child, did you experience discrimination or were you prevented from doing something, hassled, or made to feel inferior because of any of the following?” Reasons included race, ethnicity or skin color, disability status, immigration status, age, weight, income, sexual orientation, religion, language or accent, type or lack of health insurance, difference in opinion about right care for mother or baby, substance use, involvement with the justice system (jail or prison), and other reason.
§§§ Institute for Perinatal Quality Improvement. Speak Up Program. https://www.perinatalqi.org/page/SPEAKUP
¶¶¶ Association of Women’s Health, Obstetric and Neonatal Nurses Respectful Maternity Care Implementation Toolkit 2022. https://www.awhonn.org/respectful-maternity-care-implementation-toolkit/
**** TEAMBIRTH, Ariadne Laboratories. https://www.ariadnelabs.org/delivery-decisions-initiative/teambirth/
†††† Oklahoma Perinatal Quality Improvement Collaborative Team Birth Initiative. https://opqic.org/teambirth/
§§§§ Illinois Perinatal Quality Collaboratives Birth Equity. https://ilpqc.org/birthequity/
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* Survey was administered in English during April 24–30, 2023.
† Percentages might not sum to 100 because of rounding.
§ PN View Moms survey is not a federal data collection. Race and ethnicity data were categorized in the following manner based on the way data were collected: Hispanic includes all persons who selected Hispanic ethnicity. Race categories are non-Hispanic. White includes White, Middle Eastern, and North African. Black includes Black or African American, Caribbean American, and African. Asian includes Asian American, South Asian, East Asian, and Southeast Asian. Porter Novelli collects race data using the category “Indigenous American/First Nations,” which includes Native American, American Indian, Alaska Native, Pacific Islander, and Native Hawaiian, and is referred to in this report as “American Indian, Alaska Native, Pacific Islander, or Native Hawaiian.” Multiracial includes respondents that selected more than one race; another race includes those who did not select any race or ethnicity categories.
¶ Private insurance includes respondents with health insurance from Healthcare.gov Health Insurance Marketplace and Tricare or other military insurance; public insurance includes those on Medicaid, Medicare, Indian Health Service, or any other tribal insurance; and no insurance includes respondents who did not have insurance at any time during their youngest child’s birth and those who self-paid.
** Highest level of formal education completed at time of survey was defined as less than high school, high school diploma or equivalent, or more than a high school diploma. More than a high school diploma includes respondents with some college education, an associate degree or technical school, a bachelor’s degree, a master’s degree, or a professional degree or doctorate.
†† https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
* PN View Moms survey is not a federal data collection. Race and ethnicity data were categorized in the following manner based on the way data were collected: Hispanic includes all persons who selected Hispanic ethnicity. Race categories are non-Hispanic. White includes White, Middle Eastern, and North African. Black includes Black or African American, Caribbean American, and African. Asian includes Asian American, South Asian, East Asian, and Southeast Asian. Porter Novelli collects race data using the category “Indigenous American/First Nations,” which includes Native American, American Indian, Alaska Native, Pacific Islander, and Native Hawaiian, and is referred to in this report as “American Indian, Alaska Native, Pacific Islander, or Native Hawaiian.” Multiracial includes respondents that selected more than one race; another race includes those who did not select any race or ethnicity categories.
† Private insurance includes respondents with health insurance from Healthcare.gov Health Insurance Marketplace and Tricare or other military insurance; public insurance includes those on Medicaid, Medicare, Indian Health Service or any other tribal insurance; and no insurance includes respondents who did not have insurance at any time during their youngest child’s birth and those who self-paid.
§ Survey was administered in English during April 24–30, 2023.
¶ Respondents rated their overall satisfaction with the care they received during their pregnancy or delivery of their youngest child as: Very satisfied, somewhat satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, and very dissatisfied.
** No respondents.
†† Question was asked as, “Did you experience any of the following issues or behaviors during your pregnancy or delivery of your youngest child?” https://pubmed.ncbi.nlm.nih.gov/31182118/
* Respondents were asked, “While getting health care during your pregnancy or delivery with your youngest child, did you experience discrimination or were you prevented from doing something, hassled, or made to feel inferior because of any of the following?”
† PN View Moms survey is not a federal data collection. Race and ethnicity data were categorized in the following manner based on the way data were collected: Hispanic includes all persons who selected Hispanic ethnicity. Race categories are non-Hispanic. White includes White, Middle Eastern, and North African. Black includes Black or African American, Caribbean American, and African. Asian includes Asian American, South Asian, East Asian, and Southeast Asian. Porter Novelli collects race data using the category “Indigenous American/First Nations,” which includes Native American, American Indian, Alaska Native, Pacific Islander, and Native Hawaiian, and is referred to in this report as “American Indian, Alaska Native, Pacific Islander, or Native Hawaiian.” Multiracial includes respondents that selected more than one race; another race includes those who did not select any race or ethnicity categories.
§ Survey was administered in English during April 24–30, 2023.
¶ Respondents were allowed to select more than one reason for the discrimination they experienced.
** No respondents.
* Survey was administered in English during April 24–30, 2023.
† Respondents who selected this option were not asked about reasons for holding back from asking questions or discussing concerns with a health care provider.
§ Respondents could select more than one reason. Percentages were calculated using the overall number of persons who reported a reason for holding back from asking questions or discussing concerns with a health care provider (n = 1,073) as the denominator.
Suggested citation for this article: Mohamoud YA, Cassidy E, Fuchs E, et al. Vital Signs: Maternity Care Experiences — United States, April 2023. MMWR Morb Mortal Wkly Rep 2023;72:961–967. DOI: http://dx.doi.org/10.15585/mmwr.mm7235e1.
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