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Reproductive Health volume 16Article : 77 Cite this article. Metrics details. Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations.

Patient-deed items included indicators of verbal Seeking hispanic stud 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.

One in six women Context of care e. Experiences of mistreatment differed ificantly by place of birth: 5. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, Regardless of maternal race, having a partner who was Black also increased reported mistreatment. 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. Peer Review reports. Global health experts agree that how people are treated during childbirth can affect the health and well-being of mother, child, and family, but very little is known about experiences of care among childbearing populations in the United States.

In this study, community members worked with researchers to de a survey that would capture their lived experiences of care during pregnancy and childbirth, including seven types of mistreatment by health providers or health systems. We collected information across the country including from communities of colour, and women who planned to give birth at home or in a birthing center.

Of the women who filled out the survey, one in six Among all participants, being shouted at or scolded by a health care provider was the most commonly reported type of mistreatment 8. Some women reported violations of physical privacy 5. Women of colour, women who gave birth in hospitals, and those who face social, economic, or health challenges reported higher rates of mistreatment. Rates were also increased in women who had unexpected events like cesareans or transfer from community to hospital care; and women who disagreed with a health care provider, about the right care for themselves or the baby, reported the highest rates of mistreatment.

High quality, respectful maternity care is a global priority [ 1 ].

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Four of the standards emphasize care that demonstrates respect, dignity, emotional support, and a systemic commitment to a patient-led, informed decision-making process. The International Federation of Gynecologists and Obstetrics, the International Confederation of Midwives, the International Pediatric Association, and the White Ribbon Alliance have prioritized the WHO quality care standards, and protection of human rights in childbirth, as essential to optimizing birth outcomes [ 3 ]. A traumatic birth can have serious impact on postnatal mental health and family relationships.

Short-term consequences of adverse experience of care include pain and suffering, and long-term consequences cited in the international literature include post-traumatic stress disorder, fear of birth, negative body image, and feelings of dehumanization [ 4567 ]. In addition to these outcomes, fear of disrespect Seeking hispanic stud abuse, and loss of autonomy have been cited as drivers for planned unattended home births, and reduce uptake of care, even among women with known risk factors [ 8 ]. Indeed, such mistreatment is itself an adverse outcome as it constitutes a violation of basic human rights [ 9 ].

While ificant disparities in maternal and newborn outcomes are reported across populations in the United States US [ 12 ], very little is known about whether mistreatment is a component of these adverse outcomes. To understand experiences of childbirth care, especially among communities of color and those who choose to deliver in community settings, service users partnered with NGOs, clinicians, and researchers, to conduct the Giving Voice to Mothers GVtM —US study. To date, evaluations of respectful maternity care RMC have focused primarily on monitoring care during hospital births in low-resource settings [ 61314 ].

However, childbearing women from high and middle resource countries have also reported negative experiences during hospital births, including being ignored, belittled or verbally humiliated by healthcare providers, having interventions forced upon them, and being separated from their babies without reason or explanation [ 7151617 ]. Many of them did not consent to interventions such as episiotomies. Violations of their dignity, privacy, and confidentiality were common.

Women said that care providers did not listen to them, doubted their perceptions and feelings, ignored their wishes, imposed their will on women, and made them feel guilty or like failures [ 17 ]. Few investigators have examined whether experiences of RMC differ by sociodemographic factors, but one U. Bohren and colleagues examined qualitative and quantitative evidence from 65 studies on the mistreatment of women during childbirth in health facilities across 34 countries, representing diverse geographical and economic settings. The investigators identified multiple examples of disrespect and human rights violations experienced by women giving birth, ranging from physical and verbal abuse, to a lack of supportive care, to neglect, discrimination, and denial of autonomy [ 13 ].

Sincenumerous authors have responded to the Bohren typology, noting a lack of global evidence on the topic [ 24252627 ]. Some investigators have adapted the typology to qualitative studies of the prevalence and characteristics of mistreatment in low resource countries [ 14 ], but none to date have applied the typology to assess experience of care in high resource countries, and none have assessed the seven domains in a quantitative survey.

Notably, while the lived experience among study participants provided the descriptive data that informed the Bohren typology, none of the studies included in the systematic review used a patient-led approach to item development. Patient experience indicators of quality and safety are now routinely collected at institutions in other areas of medicine, yet patient-deed instruments that can assess the impact of experience of maternity care remain scarce.

In this paper, we introduce a set of patient-deed indicators of mistreatment that align with the typology proposed by Bohren et al. We present from a large national survey that utilized these items to examine how women in the US overall, and among key subgroups, report on mistreatment during pregnancy and childbirth.

In addition, we examine the relationships between race and mistreatment in the context of factors that are frequently related to health inequity. The concept of intersectionality is rarely considered during de, analysis or interpretation of public health studies [ 28 ]; we aimed to address this gap in this study. Inusing a community-based participatory research process [ 2930 ], we convened a multi-stakeholder team to launch Giving Voice to Mothers GVtM-USa study of maternity care experiences of women who experienced pregnancy in the United States between and The only national study on experience of maternity care in the US was limited to women who planned hospital births, had limited information on differential experiences by race, and did not measure mistreatment [ 23 ].

Hence, our team, comprised of community members, clinicians, community health service leaders, and researchers deed a study on quality of maternity care as experienced by pregnant persons from 4 communities of colour African American, Indigenous, Hispanic, and Asian who gave birth in any location, as well as women who planned to give birth in homes and freestanding birth centers. All participants reviewed an informed consent form before deciding whether they wanted to participate in the online survey.

The GVtM Steering Council recruited community agency leaders and service providers to adapt a survey instrument, developed by service users to study maternity care experiences in British Columbia, Canada [ 313233 ], to the United States context. The validated instrument explored four domains including: preferences for care, interactions with care providers, role in decision-making, and access to care options. Following consultations with the communities they serve, the GVtM Steering Council identified, drafted, or adapted additional items from the literature that assess non-consensual care, disparities in access, social determinants, and institutional racism [ 3435 ].

Some items had been used to measure disrespect and abuse in low resource countries and were adapted for application to the US context [ 35 ]. The community agencies NGOs then recruited 57 women from the target populations to review the draft, and subsequently 31 community Seeking hispanic stud, with representation from all target populations, served on an expert panel to formally content validate the adapted instrument.

They rated each item on a 4-point ordinal scale for clarity, relevance, and importance and provided narrative commentary. We retained, revised, or discarded items based on best practice guidelines for content validation [ 36 ]. They also adapted the Perceptions of Racism PR scale [ 34 ] to be inclusive of all study populations. They provided detailed answer options that reflected their lived experience. Most questions had pre-defined Likert response options, but the survey instrument also included several open-ended questions to allow participants to provide explanatory detail.

It was translated and back translated into a Spanish version, and both versions were mounted on an online platform that allowed for branching to questions adapted for participants who experienced pregnancy loss, and for those who were currently pregnant. Women who experienced at least one pregnancy in the United States between andincluding those currently pregnant, could participate. Of the women who completed or partially completed the survey, some participants skipped questions and others did not finish the survey, resulting in variable denominators for each section.

Because we compare variables that appear across the entire survey, we restrict our analysis to the women who completed the survey. Details on sample delineation are in Fig. All partners participated in evidence-based strategies for recruitment of traditionally marginalized groups, including social networking and venue-based sampling [ 373839 ].

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We used strategies to ensure strong representation of women of colour, and women who planned a birth at home or at a freestanding birthing center. To achieve our goal of robust sampling from women of colour and those who chose home and birth center births, based on the rates of participation to date, halfway through the data collection period we closed the survey to women who identified as White and who gave birth in a hospital, but kept it open to other participants.

NCDA Stebleton, Jehangir \u0026 Collins Presentation MOV file0 3

In New York State data collection was embedded in an established ongoing statewide maternity care evaluation project led by one of the NGO partners, Choices in Childbirth. The Steering Council recognized that this was likely to lead to oversampling from a single state; hence, they initially considered launching the study as a New York State pilot study to demonstrate feasibility and generate enough data to highlight need for national follow up. However, community members served by the distributed NGOs and clinicians on the team felt strongly that they wanted the GVtM study to be open to participants from rural, urban, and suburban contexts across the United States.

They felt that social media recruitment had the greatest potential for securing comparative data from a wide range of service users. Hence, to respect an authentic, patient-oriented participatory research process, the survey was distributed nationally. Content validation resulted in new patient-deed and patient-validated items to measure mistreatment in childbirth that align with the dimensions codified by Bohren Table 1 [ 13 ]. Of note, the community members on the Steering Seeking hispanic stud and the women who participated during the expert content validation stage endorsed these items without knowledge of the Bohren systematic review in progress, yet their lived experience resonated with the typology.

Specifically, the mistreatment items measure the following domains: physical abuse, sexual abuse, verbal abuse, neglect and abandonment, poor rapport between women and providers, loss of confidentiality, and lack of supportive care. Community members also elected to include the MADM autonomy and MOR respectand an adapted Perceptions of Racism scale [ 34 ] that measure other domains in the Bohren typology: stigma and discrimination, failure to meet professional standards of care, lack of informed consent, and loss of autonomy.

The focus of the current paper is application of mistreatment items that describe patient experience of provider behaviors. Subsequent reports will focus on analysis of data related to the mistreatment domains of autonomy and respect eg. Accordingly, the team deed a complex but respectful and realistic approach to collecting and coding this set of items.

Respondents could self-identify and provide considerable detail about their identity, selecting multiple descriptors under 13 pre-defined. For analysis, we recoded this variable into mutually exclusive see Additional file 1 : Table S1. We created a comprehensive composite index that measures low SES, taking into family income below the federal poverty threshold based on before tax family income and household size. In the low SES category, we also counted respondents who reported that their heat or electricity was turned off during or in the year before pregnancyinability to buy enough food or meet financial obligations; and respondents who reported receiving a housing subsidy, assistance from Indian Health Services or a state health plan, Temporary Assistance for Needy Families TANFfood stamps, WIC food vouchers or money to buy food.

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We coded respondents with one or more of the indicators of low SES as 1; and respondents that did not report any of the indicators as 0. Women who reported one or more of the indicators of social risk were coded as 1; women did not report any social risk indicators were coded as 0.

We also created composite indices that measure elevated pregnancy risks and newborn health problems. A description about how these indices were derived can be found in footnotes below the tables. To describe the overall prevalence of mistreatment in the study population, we calculated the proportion of women who experienced each of the seven types of mistreatment and what proportion experienced any mistreatment i.

We used logistic regression to quantify the relationship between mistreatment and the variables described above. To elucidate the intersectional relationships between maternal race and other factors that are linked to mistreatment, we examined the relationship between race and mistreatment within of other sociodemographic and context of care variables.

Within e. Larger differences between groups indicate larger disparities in mistreatment by race. To report illustrative details provided in open-ended text boxes, community and research team members verified the applicability and resonance of the Bohren framework and recommended that we include the voices of mothers by identifying exemplars based on the Bohren typology.

Three team members independently reviewed the text boxes and came to consensus about representative quotes, which were then reviewed and approved by the community partners. The majority of participants Participants from all 50 states completed the survey see Fig. The majority of participants received prenatal care from midwives Fewer women of colour had prenatal care by midwives eg. Additional file 1 : Table S2 displays socio-demographic characteristics for the participants, the participants included in the analysis of mistreatment items.

Being shouted at or scolded by a health care provider was the most commonly reported type of mistreatment 8.

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Fewer women reported violation of physical privacy 5. Very few women reported physical abuse, sharing of their personal information without consent, or healthcare providers threatening them in other ways see Table 2. Indigenous women were the most likely to report experiencing at least one form of mistreatment by healthcare providers Women who identified as White were least likely to report that they experienced any of the mistreatment indicators Differences in mistreatment by race were pronounced for some indicators.

For example, twice as many Hispanic and Indigenous women as compared to White women reported that health care providers shouted at or scolded them. Likewise, Black women, Hispanic women, Asian, and Indigenous women were twice as likely as White women to report that a health care provider ignored them, refused their request for help, or failed to respond to requests for help in a reasonable amount of time see Table 4.

Overall, White women with a White partner reported the least mistreatment Bi-racial couples experienced less mistreatment when the woman was White as opposed to Black. However, for some indicators of Seeking hispanic stud eg. Young women were also more likely to report physical abuse by providers compared to older women Additional file 1 : Table S5.

Multiparous women reported lower rates of mistreatment on all indicators see Additional file 1 : Table S6compared with women who were first-time mothers.

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