Mistreatment in Childbirth is Common, Especially Among the Disadvantaged

Lack of respectful maternity care culminating in mistreatment in childbirth is a regular occurrence in the U.S., according to researchers at Columbia University Mailman School of Public Health. Until now, experiences of this mistreatment have not been well documented. The findings are published in JAMA Network Open.

To estimate the prevalence of mistreatment by care providers in childbirth, the researchers collected survey data from a representative sample of people who had a live birth in 2020 in New York City and the six states of Kansas, Michigan, New Jersey, Pennsylvania, Utah, and Virginia. They used a validated scale to ask participants to report whether they had experienced a set of specific types of mistreatment by health care providers during childbirth. They used this data to identify the most common types of mistreatment and the demographic, social, and clinical characteristics associated with those experiences. 

The study—the first to use representative multi-state data to examine mistreatment in childbirth in the U.S.—found that mistreatment by health care providers during childbirth affected more than one in eight people with a live birth in the study states and New York City in 2020. The highest rates of mistreatment occurred among people who were unmarried; Medicaid-insured; LGBTQ-identifying; obese; with a history of a substance use disorder, mood disorders, or intimate partner and family violence; as well as those who had an unplanned Cesarean birth.

“Many of our results suggest that pervasive structural social stigma permeates the birth experience and shapes how care is received,” said Chen Liu, MS, research associate in Columbia Mailman School’s Department of Health Policy and Management and first author. “For example, we found that LGBTQ-identifying individuals were twice as likely to experience mistreatment, driven by higher rates of feeling forced to accept unwelcome care or being denied wanted treatment. These findings align with prior work demonstrating poorer birth outcomes among sexual minorities.”

The most common forms of mistreatment were being “ignored, refused request for help or failure to respond in a timely manner" (experienced by 7.6 percent of birthing people), being “shouted at or scolded” by health care providers (4.1 percent), and having health care providers threaten “to withhold treatment or force you to accept treatment that you did not want” (2.3 percent).

Negative experiences during childbirth can have long-term consequences for birthing people, including post-traumatic stress disorder, negative body image, feelings of dehumanization, and changes in future reproductive decisions. Discrimination and structural racism, which may manifest as mistreatment in childbirth, are also major drivers of the stark disparities in maternal mortality and morbidity in the U.S..

“Mistreatment in childbirth has been widely documented in low- and middle-income countries, but this study shows that respectful maternity care is an important quality metric that we should also be tracking in the United States,” said Jamie Daw, assistant professor in Health Policy and Management and senior author. "Reporting on these experiences is the first step to addressing them, holding health care providers accountable, and developing effective interventions to improve respectful maternity care.”

There remains scant evidence on effective interventions to improve respectful maternity care in the U.S. on a large scale. However, Daw noted that “policymakers are currently focused on improving maternal health and promising initiatives such as Medicaid reimbursement for doula care and new ‘birthing-friendly’ hospital designations could make a difference.” 

As the study notes, the researchers only examined mistreatment during childbirth, and it is possible that birthing people in the sample also experienced mistreatment during pregnancy or the postpartum period. “No one should experience mistreatment during what is one of the most important moments of their life. We hope this study is a call to action for implementation and evaluation of patient-centered interventions to address structural health system factors that contribute to these negative experiences,” noted Liu.

Co-authors are Kristen Underhill, Cornell Law School; Janice J. Aubey, NewYork-Presbyterian/Columbia University Medical Center; Goleen Samari, University of Southern California Keck School of Medicine; and Heidi L. Allen, Columbia University School of Social Work.