Background:
In the United States, differences in adverse perinatal outcomes between Caucasian women and women of colours are well-documented(33,46–48), and persist even when controlling for socio-economic status and access to quality prenatal care(33,49). Some policy makers and public health experts attribute this to concomitant disparities in wages, housing, and safe environments. However, researchers have proposed that institutional racism and lack of access to birth care options may be a factor. At the same time women from many high resource countries report that place of birth and midwife-led care can affect their sense of autonomy and respect, and access to physiologic birth, resulting in optimal outcomes.
Method:
Community members worked with clinicians, NGO leaders, and researchers to design a study on quality of maternity care as experienced by pregnant persons from communities of colour (African American, Native American, and Latina) and those who planned to give birth in homes and birth centers. The final online survey instrument was content validated by community members, piloted, and distributed across the US. Items included previously validated quality measures including the Mothers Autonomy in Decision Making (MADM) scale, the Mothers on Respect index (MORi); and the Perceptions of Racism (PR) scale. Descriptive statistics were calculated to describe access, experience, and outcomes; and regression analyses linked MADM and MORi scale scores to respectful care and autonomy (adjusting for differences in sociodemographics, risk profile, type of provider, and place of birth).
Results
Of the total sample (N3275), 37.3% were women of colour (Black, Hispanic, Native, other), and 18% Medicaid recipients. Women of colour had significantly lower MADM scores, and 20.5% were not satisfied with their role in decision making. Women with low MORi scores reported pressure by health professionals to accept interventions [(6.8 %) epidurals, (15.8 %) inductions, (11.1%) caesarean]. Reported discrimination due to a difference in opinion with providers was more common (17%) among women of color. Women of colors and low-income women (i.e. maternity care was paid for through Medicaid) were more likely to report disrespectful treatment from care providers and were more likely report being pushed into accepting options for care. Midwife-led care was associated with higher MADM scores than physician-led care, across birth settings.
Discussion
Our large community-based participatory research project elicited detailed and unprecedented information about disparities in the nature and experience of maternity care among marginalized populations. MADM, MORi, and PR scores varied significantly by race, socioeconomic status, place of birth and type of provider with cumulative effects on increased disrespect and loss of autonomy. Women who experienced midwifery care, especially when births completed at home or in birth centers, reported greater sense of autonomy in decision making but experiences of discrimination and disrespect were significantly increased among women of colour regardless of type of provider or birth setting.
Conclusion Our patient-led study confirms that marginalized women in the US experience less respectful maternity care, and reduced access to options for physiologic birth care. Data suggest that type of provider and place o
1. Studies that integrate knowledge from a range of scientific approaches and/or perspecti
