Every Mother Counts: listening to mothers to transform maternity care.

More than a decade ago, the United Nations Human Rights Council passed a resolution recognizing maternal health as a human right. Subsequently, global advocates mobilized to establish the right to respectful maternity care, which has since been formally recognized by the World Health Organization and endorsed by more than 90 international, civil society, and health professional organizations. Despite widespread acknowledgment of this right, traditional approaches to maternity care do not adequately address aspects of quality care that are highly valued by mothers and birthing people, such as respect, dignity, and shared decision-making, and high numbers of women and birthing people worldwide continue to experience disrespect and mistreatment during childbirth. Efforts to reduce maternal mortality have historically overemphasized clinical approaches while failing to listen to mothers and pregnant people, threatening patient autonomy, and contributing to persistent racial disparities and high levels of preventable maternal mortality. This article shares the birth story and evolution of Every Mother Counts, an organization dedicated to making pregnancy and childbirth safe, respectful, and equitable for every mother, everywhere, and provides tangible examples of how storytelling and listening to women-in film, media, research, advocacy, education, and patient care-can serve as powerful vehicles to create awareness of maternal health issues and transform our maternity care system into one that centers mothers in labor and childbirth and elevates equity and birth justice. There are concrete steps that every participant in the maternity care system can take to help make respectful, equitable care a reality, including implementing patient-reported experience measures as part of standard clinical practice, using individualized care plans and shared decision-making tools in patient care, and developing a grievance process to address instances of disrespectful care and mistreatment. Most importantly, we can listen to mothers, women, and birthing people, hear their concerns, and act promptly to provide the care and support that they deserve.

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

BACKGROUND: Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality. METHODS: We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains. RESULTS: Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28). CONCLUSION: Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

BACKGROUND: Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study. METHODS: Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables. RESULTS: Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment. CONCLUSION: This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health.

Continuous labor support by a trained doula has proven benefits and is recognized as an effective strategy to improve maternal and infant health, enhance engagement and satisfaction with maternity care, and reduce spending. Community-based doula programs can also reduce or eliminate health disparities by providing support to women most at risk for poor outcomes. The most effective way to increase use of this evidence-based service would be to eliminate cost barriers. Key recommendations identify numerous pathways to pursue Medicaid and private insurance coverage of doula care. This comprehensive and up-to-date inventory of reimbursement options provides the doula, childbirth, and quality communities, as well as policy makers, with many approaches to increasing access to this high-value form of care.

How Doula Care Can Advance the Goals of the Affordable Care Act: A Snapshot From New York City.

Doula care meets each of the triple aims of the Affordable Care Act: improving health outcomes for all, improving the experience of care, and lowering costs by reducing non-beneficial and unwanted medical interventions. Cost is the greatest barrier to use of doula support. Reimbursement for doula services by private insurance, Medicaid, and Medicaid managed care organizations would significantly increase access to doulas. Widespread availability of doula care could significantly reduce cesarean rates, and increased access to community-based doula programs could reduce entrenched health disparities.