UC Davis

Respect is fundamentally important to safe, high quality perinatal care. Zampas et al. (2017) noted within the World Health Organization maternal quality of care framework the need for high quality perinatal care to include being treated with respect and dignity. The right to be free from violence during birth care and have one’s bodily autonomy respected are vital parts of conceptualizing perinatal respect and protecting women’s agency. The impact of the overuse of obstetrical interventions has been a concern in the international maternity health and research community for decades (Bohren et al., 2016; Bowser D, 2010; Garcia, 2020; Sadler et al., 2016, 2020; Zampas et al., 2020). Many obstetric interventions or procedures are unplanned by women and experienced as unexpected, and have been reported as coercion and disrespectful of their agency (Declercq et al., 2014; Ibrahim et al., 2022; Logan et al., 2022; Vedam et al., 2019).In the groundbreaking “Giving Voice to Mothers” (GVtM) study, the most common obstetric procedures women reported being pressured into were continuous electronic fetal monitoring (24%), medications to start or speed up labor (13%), and a Cesarean section for type of delivery (11%) (Vedam et al., 2019). There have been few US studies focused specifically on women’s experiences of respectful maternity care in the context of experiencing pressure to have obstetric procedures (Chinkham et al., 2022). This dissertation includes two studies, the first a quantitative analysis, and the second, a mixed methods study, from a sub-group who experienced pressure to have obstetric procedures. Quantitative and qualitative analyses are included via an integrative feminist and midwifery lens culminating in findings which describe and compare themes derived from open-ended responses in the survey about the worst aspect of the women’s care and/or the one thing they would change from their birth care. Methods The data for this study came from an online survey collecting information from births which occurred in US settings in women who birthed from 2010 to 2016, called the “Giving Voice to Mothers” survey. This study sample of n=1850 included women who were over 18 and reported a live singleton birth, and excluded women who planned a repeat Cesarean section. With the “Mother’s on Respect index” (a.k.a. MORi) score as the dependent variable, two independent variable types were modeled. The first was there any pressure to have an obstetric procedure (yes or no), and the second was a count of procedures experienced. Effect modification modeling was also utilized to clarify interaction effects of birth provider type, maternal race, and ethnicity, and two socioeconomic variables (Socioeconomic Composite scores, and History of Social Risks) on MORi scores. In the second study, a mixed methods analysis of women’s text responses was conducted from the sub-sample of those who were above age 18, had a singleton live birth in the study interval (2010-2016), and reported pressure to have an obstetric procedure (n=640). Finally, some participants answered one or both of two open-ended questions about their birth experiences. The two open-ended questions were, “What was the worst thing about the care you received during your recent birth?” (n=514) and “If you could change one thing about your birth experience, what would that be?” (n=537). Text responses were coded using In Vivo, descriptive, and thematic style coding methods, and Dedoose software (www.dedoose.com). As a multi-level categorization first by codes, then by themes was applied to the text responses. The mixed methods analysis included a quantitative analysis followed by a qualitative analysis, and finally an integrative approach applied to the findings from thematic description and comparison. Results Most of the women in the first study sample were ages 31-39 years (59%) and were comprised of 5% Asian mothers; 14% Black, Non-Hispanic mothers; 3% Indigenous mothers; 9% Latina mothers; and 67% White, Non-Hispanic women. Most women began prenatal care in the first trimester (95%), and multiparity was reported by 60% of the sample. The results showed that both any pressure to have obstetric procedures and rising counts of procedures in patients were consistently associated with lower MORi scores (i.e., less respect). Any pressure to have obstetric procedures was associated with an 8.9-point reduction in the reported MORi score (p < 0.01), and for each additional procedure for which pressure was experienced, the MORi score decreased by 3.8 points (p< 0.01). The main covariate associated with higher MORi scores (or higher respect) was prenatal provider as midwife (β= 4.6; p < 0.01), and the next covariate associated with increased MORi scores was multiparity (β=1.6; p<0.01). Other important covariates associated with lower MORi scores included mode of delivery as Cesarean section, onset of prenatal care in the second or third trimester, a history of social risks, low socioeconomic status (a composite variable), and maternal and/or fetal health complications. Four main themes emerged from analysis of text entries describing the “Worst thing about the birth care received”: Theme 1) lack of support for my decisions and desires during labor & birth (n=283, or 55%); Theme 2) feeling no control (53%); Theme 3) unexpected outcomes after treatment (29%); and Theme 4) ineffective communication with care providers, including physicians, nurses, and midwives. The most frequent theme in response to the question about one thing to change about the birth described the experience of loss of control, for example, the ability of a woman to move into a position of their choice, n=262, 49%, examples of this theme were, “If I want to move, I move”,” If I want to birth, Baby’s out” in the words of one study participant to exemplify a lack of bodily agency as well as bodily control. Participants described having insufficient autonomy with their bodies, emotions, and choices. The theme was endorsed similarly by those who declined care and those who accepted (52% versus 48%; p=0.31). In the second study, 65% (n=334) declined some care offered, and 35% (n=180) accepted the care, for a final n=514 (for those who answered the “Worst thing”). Discussion Respect scores in models that controlled for important perinatal and socio-demographic factors were significantly lower when women reported any pressure to have any obstetric interventions. The magnitude of this association was large, averaging approximately nine points lower, an amount that would make a significant impact on the otherwise high MORi scores in the sample. Additionally, the lack of support during birth care arose as a key theme, describing complex experiences with limited autonomy during their birth care, experiencing unexpected outcomes, and ineffective communication, which were described across both sample subsets, i.e., both those who did and did not accept the interventions. The importance of perinatal respect was paramount to study participants, who noted its impact on asking for or not being asked for permission prior to performing an intervention and generated important descriptive and comparative results detailing the experiences of consent and bodily autonomy being violated. Conclusions Improving the problem of pressure to have obstetric interventions will require education and information sharing as well as a deeper dismantling of obstetric policies and practices that are not aligned with promoting perinatal respect and agency. Of note, having a midwife as a perinatal care provider was a protective finding. Studying how structures and environments of care may decrease perinatal respect is a vital aspect of considering any iatrogenic aspects of harm, including processes and procedures in which maternal agency is questioned or undermined. Ultimately this will assist in developing patient centered respectful maternity. Provider education, including adding to the midwifery workforce, as well as continued ethical and unconscious bias training may support the reduction of perinatal disrespect during birth experiences.