Abstract
Although recent research has examined discrimination in health care, no studies have investigated women's experiences during prenatal or obstetrical care. Analyses of data from the Oregon Pregnancy Risk Assessment Monitoring System showed that 18.53% of mothers reported discrimination by providers during prenatal care, labor, or delivery, most commonly because of age or insurance status. Perceived discrimination was associated with maternal characteristics such as age, marital status, and type of insurance, but not with number of subsequent well-baby visits.
Discrimination in health care has been the focus of a number of studies in recent years.1–10 Research suggests that people experience discrimination when receiving health care on the basis of their race/ethnicity, socioeconomic status, type of insurance, gender, language abilities, or other factors.1–3,5,6,9,10 Studies also suggest that perceived (i.e., self-reported) discrimination in health care is higher among some sociodemographic groups than among others.1–4,6,8–10 Furthermore, greater amounts of such discrimination are associated with less satisfaction with care,5 delayed care and not following doctors’ advice,4 not receiving some preventive health services,9 more hospital admissions,2 poorer mental health,10 greater levels of depression and posttraumatic stress, and poorer general health.5
A few studies have explored women's experiences with discrimination while receiving reproductive health care,6,11–13 but none has specifically examined women's experiences of discrimination while receiving prenatal or obstetric care. We assessed perceptions of discrimination during prenatal care, labor, and delivery among Oregon women. Our purpose was to examine the extent to which Oregon women perceive that health care providers discriminate against them during prenatal care, labor, or delivery; the relationship between maternal and infant characteristics and perceived discrimination; and the association between perceived discrimination during prenatal care, labor, or delivery and the frequency of well-baby visits.
METHODS
We used data from the 1998–1999, 2000, and 2001 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS). Modeled on the multistate PRAMS program of the Centers for Disease Control and Prevention, the Oregon PRAMS collects data about maternal attitudes and experiences before, during, and immediately after pregnancy from Oregon mothers who have recently had a live birth. Data from the 1998–1999, 2000, and 2001 Oregon PRAMS surveys were not collected under a Centers for Disease Control and Prevention protocol.
Mothers who are Oregon residents and whose babies were born in Oregon were sampled with a stratified random sample of birth certificates. African American, American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic mothers were oversampled. Unweighted response rates for 1998–1999, 2000, and 2001 were 64.0%, 73.1%, and 72.1%, respectively. Further details about the Oregon PRAMS are available online.14 We pooled data for the 3 cohorts, resulting in a total sample of 5762 women. The median time from delivery to survey completion was 101 days.
Perceived discrimination in health care was assessed by asking women if they felt they had ever been treated differently by health care providers during prenatal care, labor, or delivery because of their race, culture, ability to speak or understand English, age, insurance status, neighborhood in which they lived, religious beliefs, sexual orientation or lifestyle, marital status, or desire to have an out-of-hospital birth. For each item, response categories were “yes” and “no.” We performed exploratory factor analysis on these 10 dichotomous items with varimax rotation to maximize the variance of the loadings within the factors to allow for ease of interpretation. Two factors with eigenvalues greater than 1 were extracted. However, all items loaded strongly on the first factor (eigenvalue = 5.6), meaning that each item was strongly correlated with that factor. We therefore created 1 scale by summing the 10 items (Kuder–Richardson 20 coefficient = 0.68). Because of its nonnormal distribution, we dichotomized the scale into “any discrimination” versus “no discrimination.”
We generated unadjusted odds ratios to assess the association between maternal and infant characteristics and perceived discrimination. Characteristics that were associated with perceived discrimination at P at less than or equal to .1 were included in a multiple logistic regression. We also performed a multiple logistic regression to determine perceived discrimination's adjusted association with having had 3 or more well-baby visits. A significance level of .05 (2-tailed) was used for all analyses. To ensure that the data were representative of all live Oregon births, we used a weight that is a product of weights accounting for oversampling at the strata level, unit nonresponse, and noncoverage. Further details about the weighting methods for the PRAMS data appear elsewhere.14 All data presented are weighted except where noted.
RESULTS
Nearly one fifth (18.53%) of women reported experiencing discrimination by health care providers during prenatal care, labor, or delivery. Discrimination on the basis of age (8.44%) or insurance status (8.19%) was most common, and discrimination because of sexual orientation (0.96%) or because of the neighborhood lived in (0.96%) was least common. As shown in Table 1, several variables were significantly associated with perceived discrimination.
TABLE 1.
Sample Characteristics and Their Unadjusted Association With Perceived Discrimination During Prenatal Care, Labor, or Delivery: Oregon PRAMS, 1998–1999, 2000, 2001
| Characteristic | Respondents, Unweighteda No. (%) | Perceived Discrimination, % | Unadjusted OR (95% CI) |
| Total | 5762 | 18.53 | |
| Maternal age at delivery, y | |||
| ≤ 19 | 807 (14.01) | 38.53 | 3.43*** (2.58, 4.55) |
| 20–34 (Ref) | 4329 (75.13) | 15.47 | 1.00 |
| ≥ 35 | 626 (10.86) | 19.23 | 1.30 (0.90, 1.87) |
| Maternal education, y | |||
| < 12 | 1538 (27.05) | 24.79 | 1.00 (1.00, 1.02) |
| ≥ 12 (Ref) | 4146 (72.95) | 16.75 | 1.00 |
| Maternal marital status | |||
| Not married | 2109 (36.60) | 30.26 | 2.75*** (2.19, 3.44) |
| Married (Ref) | 3653 (63.40) | 13.64 | 1.00 |
| Maternal race/ethnicity | |||
| White (Ref) | 1956 (33.95) | 18.26 | 1.00 |
| African American | 655 (11.37) | 24.21 | 1.43** (1.13, 1.81) |
| American Indian/Alaska Native | 657 (11.40) | 30.70 | 1.98** (1.59, 2.48) |
| Asian/Pacific Islander | 931 (16.16) | 18.48 | 1.01 (0.81, 1.27) |
| Hispanic | 1563 (27.13) | 17.91 | 0.98 (0.80, 1.19) |
| Maternal residence | |||
| Urban (Ref) | 4061 (79.86) | 17.99 | 1.00 |
| Rural | 1024 (20.14) | 17.71 | 0.98 (0.73, 1.32) |
| Annual household income, $ | |||
| < 15 000 | 1776 (33.70) | 25.79 | 3.48*** (2.36, 5.13) |
| 15 000–29 999 | 1536 (29.15) | 20.98 | 2.66*** (1.79, 3.95) |
| 30 000–49 999 | 979 (18.58) | 17.99 | 2.20*** (1.44, 3.35) |
| ≥ 50 000 (Ref) | 979 (18.58) | 9.07 | 1.00 |
| Received prenatal care during first trimester | |||
| Yes (Ref) | 3891 (70.50) | 17.37 | 1.00 |
| No | 1617 (29.50) | 22.52 | 1.30** (1.10, 1.53) |
| Type of prenatal care provider | |||
| Private physician or HMO (Ref) | 3112 (56.24) | 15.12 | 1.00 |
| Hospital clinic | 1099 (19.86) | 20.88 | 1.48** (1.10, 2.00) |
| Health department | 919 (16.61) | 24.25 | 1.80*** (1.33, 2.43) |
| Other | 403 (7.28) | 36.74 | 3.26*** (2.20, 4.83) |
| HIV test suggested by provider during pregnancy | |||
| No (Ref) | 1974 (38.65) | 17.39 | 1.00 |
| Yes | 3483 (61.35) | 19.67 | 1.03 (0.95, 1.11) |
| HIV test during pregnancy | |||
| No (Ref) | 1751 (37.54) | 15.68 | 1.00 |
| Yes | 3547 (62.46) | 20.95 | 1.01 (0.95, 1.07) |
| Homeless while pregnant | |||
| No (Ref) | 5317 (94.46) | 18.04 | 1.00 |
| Yes | 312 (5.54) | 33.98 | 2.34*** (1.52, 3.61) |
| Unable to pay bills during pregnancy | |||
| No (Ref) | 3854 (68.54) | 14.41 | 1.00 |
| Yes | 1769 (31.46) | 28.49 | 2.37*** (1.88, 2.98) |
| Type of insurance coverage for delivery | |||
| Employer-sponsored (Ref) | 2640 (46.44) | 12.55 | 1.00 |
| Oregon Health Plan | 2580 (45.38) | 25.28 | 2.36*** (1.86, 2.99) |
| Other or none | 465 (8.18) | 30.34 | 3.03*** (2.06, 4.47) |
| Infant birthweight, g | |||
| < 1500 | 1073 (18.62) | 21.27 | 1.20 (0.99, 1.46) |
| ≥ 1500 (Ref) | 4689 (81.38) | 18.38 | 1.00 |
Note. PRAMS = Pregnancy Risk Assessment Monitoring System; OR = odds ratio; CI = confidence interval; HMO = health maintenance organization. Except where noted otherwise, data were weighted to account for oversampling, nonresponse, and noncoverage.
Excludes those who did not know or did not respond.
**P < .01; ***P < .001.
Adjusted odds ratios (Table 2) indicate that reports of discrimination were significantly more likely among young mothers (aged ≤ 19 years) and older mothers (aged ≥ 35 years) than among mothers aged 20 through 34 years, women who were not married versus married women, and those with annual household incomes less than $50 000 compared with those with annual incomes of $50 000 or more. Receipt of prenatal care from a provider other than a private physician, health maintenance organization (HMO), hospital clinic, or health department was also significantly associated with perceived discrimination. In addition, reports of discrimination were significantly more likely among women who were unable to pay bills during pregnancy than among those who had no trouble paying. Reports of discrimination were also significantly more likely among those without employer-sponsored or Oregon Health Plan insurance coverage for delivery compared with those who had employer-sponsored coverage. The Oregon Health Plan is a state-run program that provides health care coverage to low-income Oregonians. By contrast, perceived discrimination was significantly lower among Hispanic women compared with White women.
TABLE 2.
Multiple Logistic Regression Analysis of Perceived Discrimination During Prenatal Care, Labor, or Delivery: Oregon PRAMS, 1998–1999, 2000, 2001
| Characteristic | Adjusted OR (95% CI) |
| Maternal age at delivery, y | |
| ≤ 19 | 2.43*** (1.67, 3.54) |
| 20–34 (Ref) | 1.00 |
| ≥ 35 | 1.91** (1.26, 2.91) |
| Maternal marital status | |
| Not married | 1.79*** (1.30, 2.47) |
| Married (Ref) | 1.00 |
| Maternal race/ethnicity | |
| White (Ref) | 1.00 |
| African American | 0.89 (0.65, 1.22) |
| American Indian/Alaska Native | 1.14 (0.85, 1.53) |
| Asian/Pacific Islander | 1.22 (0.92, 1.61) |
| Hispanic | 0.60** (0.44, 0.81) |
| Annual household income, $ | |
| < 15 000 | 1.76* (1.05, 2.97) |
| 15 000–29 999 | 1.96** (1.22, 3.14) |
| 30 000–49 999 | 1.77* (1.12, 2.82) |
| ≥ 50 000 (Ref) | 1.00 |
| Received prenatal care during first trimester | |
| Yes (Ref) | 1.00 |
| No | 1.10 (0.73, 1.67) |
| Type of prenatal care provider | |
| Private physician or HMO (Ref) | 1.00 |
| Hospital clinic | 1.29 (0.90, 1.85) |
| Health department | 1.40 (0.90, 2.19) |
| Other | 2.96*** (1.83, 4.78) |
| Homeless while pregnant | |
| No (Ref) | 1.00 |
| Yes | 1.38 (0.81, 2.37) |
| Unable to pay bills during pregnancy | |
| No (Ref) | 1.00 |
| Yes | 2.12*** (1.61, 2.79) |
| Type of insurance coverage for delivery | |
| Employer-sponsored (Ref) | 1.00 |
| Oregon Health Plan | 1.11 (0.77, 1.59) |
| Other or none | 1.81* (1.14, 2.88) |
| Infant birthweight, g | |
| <1500 | 0.98 (0.77, 1.23) |
| ≥ 1500 (Ref) | 1.00 |
Note. PRAMS = Pregnancy Risk Assessment Monitoring System; OR = odds ratio; CI = confidence interval; HMO = health maintenance organization. Data were weighted to account for oversampling, nonresponse, and noncoverage.
*P < .05; **P < .01; ***P < .001.
Most mothers received their well-baby care from a private physician or HMO (68.57%), followed by a hospital clinic (15.54%) and a public health department (11.85%). More than half obtained 2 or fewer well-baby visits (53.38%). After adjusting for selected characteristics, perceived discrimination was not significantly associated with number of well-baby visits (Table 3).
TABLE 3.
Multiple Logistic Regression Analysis of Having 3 or More Well-Baby Visits: Oregon PRAMS, 1998–1999, 2000, 2001
| Characteristic | Adjusted OR (95% CI) |
| Perceived discrimination | |
| No (Ref) | 1.00 |
| Yes | 0.81 (0.62, 1.07) |
| Maternal age at delivery, y | |
| ≤ 19 | 0.87 (0.61, 1.25) |
| 20–34 (Ref) | 1.00 |
| ≥ 35 | 0.88 (0.63, 1.23) |
| Maternal marital status | |
| Not married | 1.26 (0.96, 1.66) |
| Married (Ref) | 1.00 |
| Maternal race/ethnicity | |
| White (Ref) | 1.00 |
| African American | 1.06 (0.78, 1.45) |
| American Indian/Alaska Native | 0.96 (0.74, 1.24) |
| Asian/Pacific Islander | 1.02 (0.80, 1.29) |
| Hispanic | 0.95 (0.73, 1.23) |
| Annual household income, $ | |
| < 15 000 | 1.27 (0.87, 1.85) |
| 15 000–29 999 | 1.24 (0.89, 1.72) |
| 30 000–49 999 | 1.17 (0.86, 1.59) |
| ≥ 50 000 (Ref) | 1.00 |
| Received prenatal care during first trimester | |
| Yes (Ref) | 1.00 |
| No | 1.05 (0.82, 1.34) |
| Type of prenatal care provider | |
| Private physician or HMO (Ref) | 1.00 |
| Hospital clinic | 1.13 (0.79, 1.62) |
| Health Department | 1.40 (0.91, 2.14) |
| Other | 1.23 (0.75, 2.01) |
| Homeless while pregnant | |
| No (Ref) | 1.00 |
| Yes | 0.79 (0.48, 1.28) |
| Unable to pay bills during pregnancy | |
| No (Ref) | 1.00 |
| Yes | 0.89 (0.70, 1.14) |
| Type of insurance coverage for delivery | |
| Employer sponsored (Ref) | 1.00 |
| Oregon Health Plan | 1.12 (0.84, 1.49) |
| Other or none | 1.28 (0.84, 1.94) |
| Infant birthweight, g | |
| < 1500 | 2.20*** (1.81, 2.68) |
| ≥ 1500 (Ref) | 1.00 |
| Type of well-baby care provider | |
| Private physician or HMO (Ref) | 1.00 |
| Hospital clinic | 1.09 (0.77, 1.55) |
| Health Department | 1.17 (0.80, 1.73) |
| Other | 1.36 (0.80, 2.32) |
| Baby's age at time of survey | 1.00 (0.99, 1.02) |
Note. PRAMS = Pregnancy Risk Assessment Monitoring System; OR = odds ratio; CI = confidence interval; HMO = health maintenance organization. Data were weighted to account for oversampling, nonresponse, and noncoverage.
***P < .001.
DISCUSSION
Our results indicate that nearly 1 in 5 women in Oregon have experiences during prenatal care, labor, or delivery in which they feel they were treated differently by health care providers because of their age or other characteristics. Our study adds to the growing body of research suggesting that people experience discrimination while receiving medical care.1–13
Type of insurance was associated with perceived discrimination, a result similar to those of other studies.4,9 We found (as did Trivedi and Ayanian9) that discrimination on the basis of insurance status was one of the types of discrimination most frequently reported. The financing of a woman's obstetric care may be an important influence on the quality of her interactions with providers and should be examined more closely.
Receipt of prenatal care from a provider other than a private physician or HMO, hospital clinic, or health department was also associated with more discrimination than was receipt of care from a private physician or HMO. Unfortunately, only 17 of the 403 women who obtained prenatal care from other types of providers gave information about them, and those who did reported a range of provider types (e.g., midwives, a low-income clinic, and a diabetes clinic). Hence, drawing conclusions about this group of women is difficult. Studies that compare the quality of patient–provider interactions by different types of providers could shed light on these issues.
Women who were not married, were 19 years or younger, were 35 years or older, or had annual household incomes of less than $50 000 reported more discrimination than did women who did not fall into these categories. These findings resemble those from a study of African American women that found that younger age and lower income (but not marital status) were associated with perceived race-based discrimination when getting contraceptive services.6 Unmarried women and young women may experience discrimination during prenatal care, labor, and delivery because of stigma associated with nonnormative childbearing (i.e., nonmarital and adolescent childbearing). Similarly, low-income women may experience discrimination because of the impression others have that they are unable to materially provide for a child.
Our results indicate that Hispanic women perceived less discrimination during prenatal care, labor, and delivery than did White women. Previous research on racial/ethnic differences in perceived discrimination has produced mixed findings.1,4,9 A potential explanation for our findings is that Hispanic women in Oregon may be able to access culturally appropriate care and, as a result, are less likely to experience discrimination.
Research has found varying relationships between perceived discrimination and health care utilization.2–5,9 In our study, however, perceived discrimination during pregnancy, labor, or delivery did not significantly lower the odds of having 3 or more well-baby visits. Possibly, women viewed discriminatory experiences as provider-specific, did not expect similar treatment for their children, or were highly motivated for their infant's health. Future research, both qualitative and quantitative, should examine a range of potential patient responses to discrimination, including other behaviors such as timely receipt of prenatal care or use of the same provider for a subsequent pregnancy.
The strengths of our study were the probability sampling and high response rates of the Oregon PRAMS. In addition, the discrimination question asked about differential treatment in a specific situation and about multiple types of discrimination. As a result, the measure is less likely to underestimate exposure to discrimination and is more informative than are questions that are global or ask about one type of discrimination.15
Our study did have some limitations. First, our findings may have limited generalizability because the characteristics and experiences of Oregon mothers may differ from those in other states. For example, Oregon has relatively little racial/ethnic diversity. Second, combining prenatal care, labor, and delivery in 1 discrimination measure could not capture any differences in women's experiences across these settings. Further, the data are retrospective self-reports. A variety of factors may have influenced women's reports of discrimination, including greater awareness of discrimination than women not included in the study, heightened sensitivity to the quality of services, and their current feelings about pregnancy, childbirth, or motherhood.
Our results have provided further support for the need to examine discrimination in the delivery of health care. More specifically, studies that examine women's experiences during prenatal care, labor, and delivery and their consequences in greater depth, from the perspective of women and health care providers, would be especially beneficial for improving the quality of care for women.
Acknowledgments
The authors thank Alfredo P. Sandoval for his work collecting, maintaining, and preparing the Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data and for acting as a resource person, and Kenneth D. Rosenberg for offering the data and reviewing the article. We also thank the Maternal and Child Health Bureau of the US Department of Health and Human Services and the Centers for Disease Control and Prevention for their support of Oregon PRAMS.
Human Participation Protection
This study was approved by Oregon State University's institutional review board.
Peer Reviewed
Contributors
M. De Marco helped plan the analyses, managed the data, completed the analyses, and helped interpret the findings. S. Thorburn originated the study, supervised its implementation, and interpreted the findings. W. Zhao assisted with the study and helped plan the analyses. All authors contributed to the writing of the article.
References
- 1.Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M. Race, ethnicity, and the health care system: public perceptions and experiences. Med Care Res Rev 2000;57(suppl 1):218–235 [DOI] [PubMed] [Google Scholar]
- 2.Bird ST, Bogart LM. Perceived race-based and socioeconomic status (SES)-based discrimination in interactions with health care providers. Ethn Dis 2001;11:554–563 [PubMed] [Google Scholar]
- 3.Public health special report: racial and ethnic discrimination in health care settings. 2001. Seattle, WA: Public Health Seattle and King County; [Google Scholar]
- 4.Blanchard J, Lurie N. R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care. J Fam Pract 2004;53:721–730 [PubMed] [Google Scholar]
- 5.Bird ST, Bogart LM, Delahanty DL. Health-related correlates of perceived discrimination in HIV care. AIDS Patient Care STDS 2004;18:19–26 [DOI] [PubMed] [Google Scholar]
- 6.Thorburn S, Bogart LM. African American women and family planning services: perceptions of discrimination. Women Health 2005;42:23–39 [DOI] [PubMed] [Google Scholar]
- 7.Van Houtven CH, Voils CI, Oddone EZ, et al. Perceived discrimination and reported delay of pharmacy prescriptions and medical tests. J Gen Intern Med 2005;20:578–583 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Schuster MA, Collins R, Cunningham WE, et al. Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care. J Gen Intern Med 2005;20:807–813 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Trivedi AN, Ayanian JZ. Perceived discrimination and use of preventive health services. J Gen Intern Med 2006;21:553–558 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Gee GC, Ryan A, Laflamme DJ, Holt J. Self-reported discrimination and mental health status among African descendants, Mexican Americans, and other Latinos in the New Hampshire REACH 2010 Initiative: the added dimension of immigration. Am J Public Health 2006;96:1821–1828 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Bird ST, Bogart LM. Birth control, conspiracy beliefs, perceived discrimination, and contraception among African Americans: an exploratory study. J Health Psychol 2003;8:263–276 [DOI] [PubMed] [Google Scholar]
- 12.Armstrong KA, Kenen R, Samost L. Barriers to family planning services among patients in drug treatment programs. Fam Plann Perspect 1991;23:264–271 [PubMed] [Google Scholar]
- 13.Oliva G, Rienks J, McDermid M. What high-risk women are telling us about access to primary and reproductive health care and HIV prevention services. AIDS Educ Prev 1999;11:513–524 [PubMed] [Google Scholar]
- 14.Oregon PRAMS: First Year Report, 1998–99, Appendix B: PRAMS 1998–99 Data Collection Methodology. Available at: http://oregon.gov/DHS/ph/pnh/prams/9899/9899appb.shtml. Accessed January 1, 2006
- 15.Krieger N. Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv 1999;29:295–352 [DOI] [PubMed] [Google Scholar]