A first of its kind survey of California mothers about their birth concerns and outcomes offers two findings: Health providers often don’t listen to mothers about their birth preferences and African American women are the least likely to be listened to.
Disregarding input from pregnant women increases the risk of death and complications for the mothers and their babies.
“We know what works with childbirth in this country, we just aren’t doing it,” said Stephanie Teleki, director of maternity investments at the California Health Care Foundation, which funded the survey. “The status quo for too many California women, particularly black mothers, is care that produces poor outcomes, is not in keeping with their preferences, and is often needlessly expensive. That needs to change.”
The National Partnership for Women & Families began its national Listening to Mothers surveys in 2002. The California survey is the first statewide one the organization has conducted, collaborating with researchers from UC San Francisco and the Boston University School of Public Health. The report is based on completed surveys by over 2,500 healthy women who gave birth to a single baby in a California hospital in 2016.
Key findings include:
- Four in 10 women reported that a health professional tried to induce labor by using medicine or other methods. Three-quarters of women who felt pressured to have labor induced in this way ended up having the procedure.
- While only 9 percent of women had a midwife as their birth attendant, 17 percent said they would want one, and 37 percent said they would consider one for a future birth.
- About 9 percent of respondents used a labor doula—a non-medical birth assistant—during childbirth. But 57 percent expressed interest in doula care for a next birth. African American women showed the greatest interest.
While African American women give birth to only about 5.5 percent of the babies born in California each year, their disparities compared to other groups are high. California statistics show:
- A C-section rate of 42 percent for African American women compared to 29 percent for white women.
- A vaginal birth after cesarean rate of 16* percent for African American women compared with 8 percent for white women.
- More frequent reporting of symptoms of anxiety and depression. About 30 percent of African American women reported prenatal anxiety, compared to 20 percent of White women. And 20 percent of black women faced prenatal depression, compared to 10 percent of white women.
“The results of Listening to Mothers in California underscore that women are not receiving the kind of care they seek during childbirth,” said Debra L. Ness, president of the National Partnership. “Women want greater access to proven, high-value forms of care, including greater access to midwives, doulas and birth centers. Unfortunately, these options are not nearly as available as they should (be).”
Ashia Ezekiel 22, an African American writer, lives in Los Angeles and had her daughter Yaara, eight months ago. She didn’t seek out prenatal care until her sixth month of pregnancy and didn’t meet the doctor who would deliver her baby until her ninth month.
Feeling uncomfortable with the doctor, Ezekiel chose another hospital for delivery. After 12 hours of labor, she asked for an epidural, but was told the baby’s heart rate was concerning—and then Ezekiel felt pressured to have a C-section.
“The baby is fine and healthy, but I felt then and feel now that if I could have had a midwife or doula, someone who could have helped me change positions to reduce pain and perhaps change the heart rate, I might not have needed the C-section,” she said.
Work is already underway in California to reduce the level of C-sections and Covered California, the state’s health insurance exchange, has told insurers to drop hospitals that don’t have C-section rates below** 23.9 percent of low-risk births by 2020.*** The California Health Care Foundation hopes to empower women to discuss C-sections with their doctors. In addition to the survey, the foundation launched a consumer campaign last month called My Birth Matters.
Teleki said the foundation is already engaging insurers, along with other partners, about overuse of C-sections and the new survey data gives them “other points of engagement including the disparities among African American women and mental health concerns.”
Coincidentally, just as the survey data was released, Malia Cohen, president of the Board of Supervisors in San Francisco announced a new free doula program for low-income women that will begin next year in the city. The project, to be privately funded and run by the city’s public health department, will first train women to become doulas, with a special focus on recruiting African American and Pacific Islander women, since data shows birth and maternal disparities for both those groups.
“It’s quite simple,” said Cohen. “The goal is to reduce and ultimately eliminate infant and maternal mortality.”
Ambitious, but possible, said Jonathan Fuchs, director of the Center for Learning and Innovation in Public Health at the San Francisco Department of Public Health and Director, Collective Impact, UCSF California Preterm Birth Initiative. Fuchs said the doula program has several goals, including supporting women before and after birth to help reduce the rate of preterm births in the city, as well as to see if women can earn a living working as doulas.
Doulas will be paid $1,800 per birth. Fuchs cites a 2016 study in the journal Birth that found that doulas could reduce preterm and C-section births and by doing so save about $1,000 per birth.
“We want to see if we can have an impact on the system itself, to try to address the legacy of racism, so we are acknowledging that,” he said. “We’re identifying strategies to train providers to address unconscious bias and to help doctors with cultural competency and responsive care to women giving birth. It’s a promising strategy and an empowering one for a community.”
*An earlier version of this story put the rate at 18 percent.
** An earlier version of this story said C-section rates above 23.9 percent.
***An earlier version of this story omitted “low-risk births.”