The Continued Mistreatment of Women During Pregnancy and Childbirth

Abstract

Mistreatment of women during pregnancy and childbirth continues to define our American way of birth in spite of decades of awareness and concern. The Giving Voice to Mothers study identifies the incidence of mistreatment of childbearing women in the United States, the factors that increase a woman's risk of being mistreated including socio economic and racial characteristics, place of birth, and health-care provider. This editorial highlights the study findings, the role of the current maternity care system in perpetuating inequality and mistreatment, and calls on all stakeholders to create a culture that cares for women with respect and dignity. The editor also describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote, support, and protect natural, safe, and healthy birth.

In 1958, Ladies Home Journal published “Cruelty in Maternity Wards” (Schultz, 1958). The report from nurses and mothers about abusive care during labor shocked the American public. Mistreatment included hitting, abusive language, withholding medication, and restraining women. The report shook the country and was the impetus for childbirth reform including childbirth education, the right to informed consent and informed refusal, changes in hospital policies that allowed family members with women in labor and at birth, and eventually abandoning the use of twilight sleep.

Fifty years after “Cruelty in Maternity Wards” was published, Goer (2010) asked what, if anything, had changed. Goer made a strong case for ongoing mistreatment of childbearing women including verbal and physical abuse, failure to provide supportive care, denial of the right to informed decision-making, and punishment for attempting to refuse interventions. Goer posited that mistreatment in pregnancy and childbirth in the United States continues because of factors inherent to hospital social culture and called for all stakeholders to work together to bring about systematic reform.

In 2016, World Health Organization (WHO) researchers released Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. The document identifies seven dimensions of mistreatment that have adverse impacts on quality and safety: physical, sexual or verbal abuse, discrimination, neglect, poor rapport, loss of confidentiality, and lack of supportive care. These dimensions capture the evidence-based findings of research on mistreatment in pregnancy and childbirth. The Giving Voice to Mothers Study is the first U.S. national survey that specifically addresses women's experiences related to mistreatment, autonomy, and respectful care (Vedam et al., 2019). The recently published “The Giving Voice to Mothers Study: Inequality and Mistreatment during Pregnancy and Childbirth in the United States” (Vedam et al., 2019) reports the findings specific to women's experiences of provider behaviors related to the WHO mistreatment dimensions of verbal and physical abuse, rapport with the provider, and discrimination.

The Giving Voice to Mothers Study is groundbreaking in several ways. Unlike previous national studies of childbearing women's experiences, the sampling was designed to insure that the experiences of a diverse population of women were heard, including African American, Indigenous, Hispanic and Asian women, as well as women who gave birth in community settings. The study is groundbreaking in another sense. There was community participation, with women who had given birth joining the researchers in planning the study, developing the survey questions, and interpreting study results.

“The Giving Voice to Mothers: Inequality and Mistreatment during Pregnancy and Childbirth in the United States” reports the findings specific to women's experiences of provider behaviors related to verbal and physical abuse, rapport with the provider, and discrimination. The researchers looked at mistreatment by race, socioeconomic factors, type of birth, place of birth, and context of care. Almost 18% of the women who completed the survey reported experiencing mistreatment that included being shouted at, scolded, threatened, and refused help. Only 5% of women who gave birth out of hospitals reported mistreatment versus 28% of women who gave birth in hospitals. Women whose primary care giver was a midwife were less likely to report mistreatment. Mistreatment was also far less common for women who had a vaginal birth versus a cesarean. White women, women over 30 years of age, and multiparous women were less likely to be mistreated. For women with low socio-economic status, there was marked inequality between women of color and White women, with 28% of women of color reporting mistreatment compared with 19% of White women. Mistreatment was amplified for all women by unexpected interventions (e.g., transfer to the hospital or cesarean) and in situations when the woman and her provider disagreed.

In summary, being White, giving birth outside the hospital, and being cared for by a midwife were protective. Women of color, women under 30, women having a cesarean, and women giving birth in a hospital cared for by obstetricians were more likely to experience mistreatment.

The findings of this study highlight the value of giving birth outside the hospital and with care provided by midwives. The findings also highlight the fact that when women rock the boat by disagreeing with their provider they are likely to be punished. And, the findings support previous research that there are marked inequalities in care with women of color more likely to experience mistreatment.

What can we learn from midwifery care and birth outside the hospital? Both are characterized by mutual respect and trust that develops over the course of the pregnancy (Lothian, 2013). The midwife values physiologic birth and women's ability to give birth and this become the foundation for women's autonomy and shared decision-making. The maternity care system needs to embrace these values and develop policies and protocols that reflect a deep understanding of physiologic birth and women's ability to give birth safely and joyfully when supported and treated with respect and dignity.

There needs to be a sea shift in thinking and doing at a systems level. “The Blueprint for Advancing High Value Maternity Care through Physiologic Childbearing” (Avery et al., 2018) provides detailed, evidence-based guidelines for creating the changes that need to happen to increase quality and safety for women and their babies.

Vedam and her team have made a major contribution to our understanding of the incidence of mistreatment in the United States and the factors that increase women's risk of mistreatment. It is well past time to put a stop to inequality and mistreatment of pregnant and childbearing women.

IN THIS ISSUE

In this issue's “Celebrate Birth!” column, Rachel Furr recalls the home birth of her first child. Her story exemplifies the power of birth when a mother is supported to listen to her body and labor on her own terms. She praises the comfort of home birth and the respect of midwifery care. She emerges from the other side of her birth empowered and transformed, ready to embrace motherhood.

Also in this issue, authors Link, Tinius, Maples, and Logsdon share the results of their study designed to improve self-efficacy and teaching about postpartum depression by perinatal nurses in a rural setting. Guided by Self-Efficacy Theory, the results of this replication study indicated perinatal nurses' postpartum depression teaching behaviors were associated with: self-efficacy related to postpartum depression teaching; social persuasion by a supervisor; prior mastery of teaching on other postpartum care topics; and vicarious experiences of observing peers teach about postpartum depression. Perinatal nurses with positive attitudes toward receiving psychological help were more likely to provide postpartum depression education.

In an article on discussing the benefits of continuous labor support, Murn describes the implementation of an educational program designed to enhance nursing practice of continuous labor support and provide skills to enhance clinical practice.

In order to improve breastfeeding outcomes in Egypt, El-Ghany et al. present the results of their important survey measuring knowledge, attitudes, and practices of providers and staff at Al-Zahraa University Hospital, Cairo, Egypt, regarding the Baby-Friendly Hospital Initiative and the International Code of Marketing Breast Milk Substitutes. Four hundred eight providers and staff members who care for breastfeeding mothers and babies were randomly selected to assess their knowledge, attitudes, and practices regarding the Baby-Friendly Hospital Initiative. Although the majority of the participants scored above 50% on the knowledge and attitude questions, on the practice questions only less than half scored above 50%. These results indicate that attention should be focused on developing practice guidelines and monitoring outcomes since knowledge and attitude were found to be adequate.

Also in this issue Japanese authors Hishikawa, Kusaka, Fukuda, Kohata, and Inoue discuss links between anxiety or nervousness and disturbance in the progress of birth based on the adaptive standpoint of human behavioral evolutionary biology. They build a compelling case for how anxiety or nervousness in pregnant women may increases the risk of dystocia. To support a safe and healthy birthing process, childbirth educators, other health-care professionals, and pregnant women require an in-depth understanding about the disruptive effects of anxiety or nervousness on birth progress.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.