Chapter 1: Care Team and Place of Birth

Prenatal and Childbirth Maternity Care Providers

Comparative Quality Information About Prospective Care Maternity Providers and Hospitals

More than 1 in 3 women reported she had found information to compare the quality of prospective maternity care providers (40%) or hospitals (38%). Of those who found information, large majorities used it to help make care arrangements (see Figure 1). There were no appreciable differences on information seeking by race/ethnicity or insurance status.

About one-third (32%) of women sought information about the cesarean rate of hospitals where they might have their baby. First-time mothers with private insurance (46%) were more likely than first-time mothers with Medi-Cal (35%) or experienced mothers with private insurance (26%) to seek information on cesarean rates (p < .01). Of those women who sought such information, most (86%) reported being able to find it.

Choice of Maternity Care Provider for Prenatal Care

“I loved that I could choose my doctor and he listened. ... With my other 3 babies I was on Medi-Cal. I had VERY limited choices of doctors.”

We asked women if they had a choice of prenatal care providers, and a large majority (80%) indicated they did have a choice, while 19% indicated they had a provider assigned to them, and 1% reported having received no prenatal care from a maternity care provider. Women with Medi-Cal coverage were twice as likely (26% to 13%; p < .01) as women with private insurance to report not having had a choice. Latina (23%) and Black women (23%) were more likely than White women (12%) to report not having had a choice (p < .01) (Figure 2).

“I took a lot of time to research the best hospital to deliver a baby at. I went to three different hospital orientations before I decided on one hospital. Then I selected an OB-GYN who is affiliated with the hospital I selected.” The proportion of Black women with private insurance who lacked choice in maternity care providers (18%) was similar to that of White women with Medi-Cal (20%). Women who indicated they did not have a choice of prenatal provider were less likely to report having an obstetrician (71%) than those who reported having a choice (83%) and more likely to report having a midwife (10%) or nurse practitioner (9%) than those with a choice (midwife 7%, nurse practitioner 5%) as their primary prenatal provider (p < .01). (In the context of hospital births in California, midwives were essentially all certified nurse midwives, CNMs; birth certificates of survey participants indicate 381 CNMs, one RNM and one LM.)

Prenatal Care Providers

A large majority (80%) of women reported having an obstetrician as their main prenatal care provider, followed by a midwife (7%), nurse practitioner or nurse (5%), a doctor (but they were uncertain of the type) (4%), a family physician (2%) or physician assistant (1%) (Figure 3). When comparing demographic groups, Asian and Pacific Islander women (88%) had the highest rate of prenatal care with obstetricians, while White women (12%) had the highest rate of care with midwives, and Black women (8%) were most likely to rely on nurses who were not midwives as their prenatal care provider (p < .01).

Birth Attendant

“After seeing a midwife for 9 months, I had a random doctor I never met deliver the baby.” When asked who delivered their baby, respondents most commonly cited obstetricians (73%), followed by a doctor of an unknown type (13%) and a midwife (9%) (Figure 3). When examined by race/ethnicity, clear differences emerged. Obstetricians were consistently the most common birth attendants, but their usage varied from 81% among Asian and Pacific Islander mothers to 67% among Latina mothers (p < .01). Midwives most commonly attended the births of White women (11%) and women with private insurance (12%), and especially White women with private insurance (14%) (p < .01). Few women definitively reported having had a family physician as their birth attendant (1%). Having had a birth attendant who was a doctor of unknown type was much more common among Latina women (18%) and Black women (16%), as was identifying “other” attendant.

Consistency of Type of Maternity Care Provider Between Prenatal Care and Birth

“The only part that I wish was different was I wish my doctor was available during birth.” Did women have the same type of provider for prenatal care and their birth? The answer depends on the type of provider they primarily had for their prenatal care. If their prenatal care provider had been an obstetrician (80%) or a doctor of some type (65%), the answer was typically “yes.” In the case of midwives, a plurality (44%) of women with a midwife for prenatal care had a midwife birth attendant, though 35% had an obstetrician attend their birth. Regarding smaller categories of prenatal providers (e.g., family doctors, nurses or physician assistant), an obstetrician or doctor of unknown type usually attended the birth (Table 1).

Use of and Interest in Various Types of Maternity Care Providers and Doulas

Preference for a Specific Type of Prenatal Care Provider

“I switched providers around 32 weeks so I could be cared for by a midwife at [hospital name]. ... My husband and I chose to drive an hour each way to my appointments so I could have the best prenatal care and the birth experience I knew I would get there. I did not like either of the options I had in my town as both were very medically involved in the birth process.” We asked women how important it was for them to have had the type of provider they had for prenatal care. Among the main providers of prenatal care, a large majority with obstetricians as prenatal care providers thought it was “very” or “extremely” important to have had an obstetrician (81%), while majorities felt it was “very” or “extremely” important to have had a midwife (54%) or family doctor (53%). Family physicians, physician assistants and nurse practitioners had distinctive patterns, based on smaller numbers (p < .01 for preference differences by provider) (Figure 4).

“I loved my OB-GYN. She was kind, patient and allowed me to make all the decisions. Care was top notch.”

“I initially wanted a midwife, a doula and a birth center. Insurance wouldn’t cover this so we went with the traditional OB and hospital route.”
When asked if they would have preferred a different type of prenatal provider, 12% of respondents indicated they would have. Not surprisingly, this was a more common response among women who reported they didn’t have a choice of provider (21%) than among those who did (9%) (p < .01). The desire for a different type of provider was greatest among those who had a nurse who wasn’t a midwife (43%) or family doctor (33%) and least common when the mother reported having a midwife (14%) or obstetrician (8%) as her prenatal provider (p < .01). When asked which type of prenatal provider they wished they could have had, the most common response was midwife (47%) or obstetrician (30%).

Of the subset of women (12% of sample) who would have preferred a different type of prenatal provider, the most common preference among those who had used obstetricians was midwife (71% who preferred another type). Among women who had used a midwife (84% who preferred another type), family doctor (76%) and nurse (68%), the most common preference was for an obstetrician.

Barriers to Use of Midwives

“Most frustrat[ing] for me is that I always wanted midwifery care for the birth of my child, but my insurance didn’t offer it.” We investigated reasons for not using midwives under two conditions. First, we asked women who indicated they would have preferred a midwife for their prenatal care why they didn’t have one, and the responses are shown in Figure 5. The most common reason, insurance concerns (56%), could be related to both inadequate knowledge and access issues such as incomplete panel directories and out-of-network practices. Other selected reasons appeared to be related to inadequate knowledge, including uncertainty about access to medical care if needed (16%) and lack of clarity about access to midwifery care in hospitals (13%) and to availability of epidural analgesia with midwifery care (11%). Other responses reflected lack of access: another type of provider had been assigned (27%) or a midwife was not available (25%). Finally, 1 in 4 (25%) felt they needed a doctor due to health problems.

“My health insurance covered midwives but they were out of network so would be much more expensive than an OB-GYN.” We also asked women how open they would be to having a midwife (with doctor care as needed) as their provider for a future pregnancy. Among those who definitely would not want a midwife (27%), we asked about possible reasons, and their responses are shown in Figure 6. The leading responses were based in beliefs that doctors provide higher quality care (63%) and handle emergencies better (60%).

“Everyone was telling me to get an OB-GYN, I didn’t know what to do as this was my first one. I wasn’t aware of a midwife.” Two responses revealed additional knowledge deficits about midwifery: simply not knowing much about midwives (36%) and not realizing that midwives practice in hospitals (13%). About 2 in 5 (42%) women indicated that they already have a preferred provider, who is not a midwife. And about 3 in 10 (30%) identified having health problems that are best handled by a doctor.

Midwife for a Future Birth

In response to how open respondents would be to having a midwife as their maternity care provider (with doctor care if needed) for a future pregnancy, a majority (54%) indicated they would either definitely want a midwife (17%) or would consider a midwife (37%). Overall, six times as many women (54%) reported an interest in having a midwife as their maternity care provider should they have a future pregnancy than actually experienced a midwife as their birth attendant (9%). When broken down by race/ethnicity, the contrast between actual and desired care was greatest among Black women – 66% open to the idea in contrast to just 6% who had had a midwife birth attendant. Asian and Pacific Islander women expressed the least interest (48%), which was still six-fold greater than their actual use. The interest of women covered by Medi-Cal and private insurance was similar (54%–55%), though about twice as many privately insured as Medi-Cal-covered women had actually used midwives (Figure 7). Overall, 27% would definitely not want a midwife in the future, and 20% were not sure. Among women who had had a midwife as their 2016 birth attendant, 84% were open to the idea of using one again, while among those who had had an obstetrician, 49% were open to using a midwife in the future (52% among women with a vaginal birth).

Support from a Doula

“Our doula was the best thing about the care we got and I suspect the birth would have been drastically different without her support, influence, intervention and care.” We described a labor doula as “a trained labor companion who gives comfort, emotional support, and information during birth. A doula does not provide medical care.” We asked women if they had received support from a doula during their recent birth experience. We asked those who reported receiving such support whether the labor doula had also provided support during pregnancy and after the woman had returned home after the birth. Overall, 15% indicated they received this support during labor, but we have concerns about this figure.

Use of labor doulas – as hired by families and through community- and hospital-based programs – appears to be growing in the United States. Our previous national survey found that 6% of women reported using labor doulas in 2011–2012. Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved 27 February 2018, from here. Given that insurance coverage of doula support is extremely limited at this time and community- and hospital-based programs are not available in many communities, we tried to better understand this result. Survey telephone interviewers clarified that the doula role is not widely known in Latin America, and Spanish-speaking respondents in particular sometimes conflated this role with care provided by other personnel, such as a nurse or midwife. The interviewers observed that younger mothers appeared to have greater familiarity with the doula role than older mothers. This is supported by reported labor doula use by the language selected for completing the survey: 11% of those who chose the English version versus 33% who chose Spanish. Similarly – looking at primary language spoken at home – 9% speaking English reported labor doula use versus 32% of Spanish speakers. Those selecting other home language options also reported rates that appear to be elevated: 17% Asian, 16% English and Spanish equally, and 14% other. Thus, we caution about our survey’s overall doula results. We suggest that the rate found among respondents who usually speak English at home (9%) is closer to actual doula use in California in 2016. We use this group for further doula analyses in this report, with notes indicating the analyses are based on this subgroup.

“I wish more information on midwives and doulas were available throughout pregnancy.” Looking at breakdowns limited to survey respondents who usually speak English at home, 4% reported having doula support prenatally, while giving birth and postpartum; 2% prenatally and while giving birth; <1% while giving birth and at home afterward; and 2% solely while giving birth.

Limiting further breakdowns to survey respondents who usually speak English at home, use of a labor doula ranged from 15% among Black women to 3% among Asian and Pacific Islander women (p < .01) and was 11% among Medi-Cal beneficiaries versus 8% in women with private insurance (p < .01) (Figure 8).

Doula for a Future Birth

“Next birth I would love to have a doula and be better prepared mentally.” We asked respondents, “If you have a future pregnancy, how open would you be to having the support of a doula (trained labor companion) while you are giving birth?” Again, as noted above, limiting this analysis to respondents who generally speak English at home, overall, 57% expressed an interest in having doula support in the future, stating that they either definitely would want this (18%) or would consider it (39%) – about four-fold greater interest than actual use. Across race/ethnicity groups, interest ranged from that of Black women – 27% would definitely want a doula – to Asian and Pacific Islander and White women – 16% would definitely want a doula (p < .01). Both women covered by Medi-Cal (55%) and by private insurance (59%) expressed substantial interest (p < .01) (Figure 9). Overall, 29% would definitely not want a doula in the future, and 14% were not sure.

Among English-speaking women who had reported using a doula in this birth, 84% were open to using one in a future birth versus 46% of English speakers who did not use a doula for their recent birth. 50% of women who had a cesarean in their recent birth were open to the idea of a doula in a subsequent one, while 61% of those with a vaginal birth were.

Interest in Out-of-Hospital Birth Settings

“I believe more options for a non-hospitalized midwifery type practice should be available to low-income families.”

“I would have been at a birth center with a midwife in a heartbeat if this had been an affordable option for us. I wish there had been coverage for these alternatives.”

“Wish Medi-Cal let you choose birth place instead of hospital in area.”
We limited our sample to women with hospital births. However, we asked respondents how open they would be to both birth center and home birth if they give birth in the future. Birth certificates indicate that 0.03% of women in California gave birth in a freestanding birth center, and 0.07% gave birth at home in 2016,* figures that are lower than the national average and notably lower than nearby states such as New Mexico, Oregon, Utah and Washington. Respondents expressed much greater interest in these options in the future compared with actual statewide use.

Freestanding Birth Center for a Future Birth

Overall, 40% expressed interest in a future birth center birth: 11% would definitely want this, and 29% would consider it. This interest greatly exceeded actual statewide use recorded in birth certificates. Black women expressed greatest interest in a future birth center birth (14% definitely, 34% consider), followed by White, Latina, and Asian and Pacific Islander women (p < .01). Interest among women covered by Medi-Cal was somewhat greater (only 34% definitely did not want it) than women with private insurance (47% definitely did not want this option) (p < .01) (Figure 10). Overall, 42% would definitely not want a birth center birth, and 19% were not sure.

Home Birth for a Future Birth

“I would like to have my babies at home but do not want to pay for a midwife/home birth and then also have to pay for a hospital visit if a transfer is needed.” Overall, 22% expressed interest in a future home birth: 6% would definitely want this, and 15% would consider it. This interest greatly exceeded actual use in California in 2016, as recorded in birth certificates. Black women expressed greatest interest in a future home birth (8% definitely, 21% consider), followed by Latina (7%, 17%), White (7%, 14%) and Asian and Pacific Islander women (3%, 9%) (p < .01). Interest among women covered by Medi-Cal was considerably greater (8% definitely, 18% consider) than women with private insurance (p < .01) (Figure 11). Overall, 66% would definitely not want a home birth, and 12% were not sure.

Knowledge About Practice Variation

“As I can see now, choosing the right hospital to deliver my baby [is important]. My first was delivered at [hospital name] and I had excellent care. The second time around I delivered at [different hospital name], and the help was not good at all.” We were interested in learning whether survey participants are aware of practice variation in maternity care. We asked women whether they think the quality of maternity care is generally the same for all obstetricians in their area. About one-third (34%) recognized that quality can vary greatly, while 34% stated that the quality of maternity care is pretty much the same, and 32% were not sure.

We also asked women whether they think the quality of maternity care is generally the same for all hospital maternity services in their area. A similar proportion (34%) again indicated that there can be big differences, while slightly more (37%) responded that the quality of maternity care is pretty much the same, and 29% were not sure.