Chapter 4: Respectful and Disrespectful Treatment

Respectful and Disrespectful Treatment

“I loved giving birth. I felt like the nurses and midwife respected my choices and wanted to take good care of me and my baby. The midwife really took her time stitching up my tear, and carefully explained what she was doing after the baby was born. They protected my ‘golden hour’ with my daughter.” Globally, there is increased concern with the extent of disrespectful treatment of childbearing women, and recognition that no country is immune from this. Concerns include whether childbearing women are treated with dignity, are free from discrimination, receive high-quality information, have their preferences honored, and do not experience physical or emotional mistreatment. Some of these concerns arise in previous chapters, for example, that many women did not have a choice of their prenatal care provider (Chapter 1), that most women with an episiotomy did not have a say in whether to have that procedure (Chapter 2) and that women with one or two past cesareans received imbalanced information about birth options in their recent pregnancy (Chapter 3).

This chapter reports on several additional items included in our survey to investigate respectful and disrespectful treatment of childbearing women.

Perceived Bias in Care

“They didn’t respect our religion or our religious practices at all.” We asked women, “During your recent hospital stay when you had your baby, how often were you treated unfairly because of your race or ethnicity?” We also repeated the question in terms of the language a woman spoke and type of health insurance she had or because she didn’t have health insurance. A very large majority of respondents (95–96%) indicated that they had not experienced such a behavior during their hospital stay. However, when broken out by subgroups, some differences emerge.

Bias Related to Race and Ethnicity

“[The worst part of our childbirth experience was] the racial comments that they would make to my husband.”

“Women giving birth should be treated with respect no matter their skin color.”
While only 4% of women overall reported being treated unfairly because of their race or ethnicity during their hospital stay, part of that small portion was driven by less than 1% of White women reporting such treatment. A total of 11% of Black women reported being unfairly treated based on their race or ethnicity, while 8% of Asian and Pacific Islander women and 5% of Latinas identified experiencing unfair treatment as a result of their race or ethnicity. White women had a clear advantage with none reporting “usually” or “always” (p < .01) (Figure 39).

Bias Related to Language

“The worst thing was that there were nurses that didn’t speak Spanish and I couldn’t communicate with them.” To explore perceived bias related to language spoken, we grouped respondents by their reports about the primary language spoken at home. Approximately 13% of women who spoke an Asian language and 10% of women who primarily spoke Spanish reported being treated unfairly during their hospital stay because of their language, followed by 9% of women who selected “some other language.” English speakers rarely cited a problem (2%) (p < .01) (Figure 40).

“The nurses kind of get annoyed because one doesn’t speak English and that makes one feel uncomfortable.” We offered versions of the survey in English and Spanish and with English- and Spanish-speaking interviewers, so we heard from Spanish speakers who might not be able to communicate in English in health care settings. The largest perceived bias – those who spoke an Asian language at home – is striking because these survey respondents were able to participate in English. This raises the question of whether the concern associated with Asian-language speakers would have been greater had we been able to include speakers of Asian languages who could not participate in English.

Bias Related to Insurance

“They were just rude about my insurance.”

“With my first child I had Medi-Cal and with my third child I had private PPO Insurance. Quality of care and doctors’ interest in patient was different.”

Women with Medi-Cal coverage were far more likely than women with private insurance (9% versus 1%) to say that they had experienced unfair treatment in the hospital because of the type of insurance they had or lack of insurance (p < .01). Expressing nearly as much concern as Medi-Cal beneficiaries, and greater rates of “always” and “usually” experiencing insurance-related bias, were women who were unable to more precisely describe their insurance source (not shown). Too few women reported being uninsured to analyze them as a subgroup in this case (Figure 41).

Harsh Language and Rough Handling

“The OB wasn’t my original. It was some random lady I didn’t know and was extremely rude.”

“One nurse I had was extremely rude and callous towards me and was very rough while checking my cervix.”

“When I was talking to my anesthesiologist, he was very rude and he basically told me I couldn’t have an epidural because I was too fat.”
Overall, 8% of women reported that a nurse or maternity care provider used harsh, rude or threatening language during the hospital stay for childbirth, while 8% reported experiencing rough handling from a maternity care provider or nurse at this time. In general, there was little variation when we broke the “harsh language” question down by race/ethnicity, language, natality, payment source, age and parity. However, there was some variation in reporting of “rough handling.” Figure 42 shows the results for the two questions broken down by race/ethnicity. A small proportion (4%) of women reported experiencing both forms of ill treatment. The rate was slightly higher for Black women (7%) and for Asian-language speakers (6%) (p < .01) than White women or Latinas.

Perceived Pressure to Have Interventions

“The worst thing is I felt like I was being pressured into decisions.” Given a large majority of women indicated a wish to avoid unneeded childbirth interventions (Chapter 2) and parallel growing concern among maternity-related clinical professional societies and policy makers about the extent of overused procedures, we asked women whether they had experienced pressure to have several consequential interventions: labor induction, epidural analgesia and cesarean birth. A limitation is that we are unable to judge whether a recommended procedure would likely provide a benefit in individual cases.

“I didn’t like how my doctor was trying to pressure me into a C-section and getting my tubes tied.” Survey respondents reported experiencing pressure from health professionals to have interventions. Overall, 14% of women experienced pressure to have their labor induced, and 12% of women who labored experienced pressure to have an epidural (we excluded women with planned cesareans from the epidural analysis, as epidural is considered an optimal form of analgesia for this group). More than 1 in 10 women (11%) experienced pressure to have a cesarean, although this varied considerably depending on whether she had had a previous cesarean. Among women with no previous cesarean, 9% experienced pressure to have a cesarean, while among women with a previous cesarean, 24% experienced pressure to have a cesarean.

“Great experiences with [hospital name]. Very competent and caring prenatal care and labor and delivery nurses. Never sensed I’d be pushed to do something (interventions) I didn’t want.” Rates of intervention varied for women who did and did not experience pressure. Overall, 40% of survey respondents experienced attempted labor induction. However, this varied greatly by whether the women reported experiencing pressure from a health professional to have this procedure (34% with no pressure, 75% with pressure) (p < .01) (Figure 43). Overall, 75% of women who labored had an epidural. However, this varied by whether women reported experiencing pressure (71% with no pressure, 77% with pressure). Among all respondents, 31% had cesareans, and this varied as well by pressure experience (25% with no pressure, 75% with pressure) (p < .01). Among women with no prior cesarean, the variation was greater (15% with no pressure, 60% with pressure). Among women with one or more past cesareans, both those with no pressure (85%) and those with pressure (88%) were highly likely to have a cesarean.

Respectful Care: Autonomy, Support and Communication

“I felt like I was able to have my labor progress the way I wanted, without anyone telling me what I should do. I got support when I asked for specific things, and even got help from a nurse on a good position as I was pushing.” We asked women about three forms of respectful care that women should expect to receive from hospital staff while giving birth: (1) whether staff encouraged them to make decisions about how their birth would progress, (2) supported them well and (3) communicated well. Overall, respondents were quite favorable about their care, with 76% to 92% agreeing strongly or agreeing somewhat that they had experienced such care. In the results that follow, we focus on the “disagree” responses as well as the “neither agree nor disagree” responses, as not being able to definitively agree that care had been respectful.

Encouraged Decisions About Childbirth Progress

“Nurses and midwife as well as my OB-GYN doctor always provided me with extra information to feel comfortable about every step they had to take or do.” Overall, about 3 in 4 respondents agreed that the delivery room staff encouraged them to make decisions about how they wanted their birth to progress. Shown below are those who could neither agree nor disagree, disagreed somewhat and disagreed strongly. In significance testing, Medi-Cal beneficiaries had less decision-making autonomy than women with private insurance (p < .01) (Figure 44).

Felt Well Supported

“We are a queer family and my partner is transgender, even though we saw staff reading our birth plan that stated I was Mom and [partner name] was Dad, they still referred to my husband as ‘she.’” Overall, about 9 in 10 respondents agreed that they felt well supported by the staff during their labor and birth. Shown here are those who could neither agree nor disagree, disagreed somewhat and disagreed strongly, overall by race/ethnicity and payer subgroups (Figure 45). Despite the visual variation, numbers are small and subgroups showed no significant differences.

Experienced Good Communication

“[The best part was] clear communication on expectations, outcomes, and care.”

“[The worst part was] miscommunication and not having time for me to discuss my opinions.”
Overall, about 9 in 10 respondents either agreed strongly or agreed somewhat that the staff communicated well with them during labor. Shown here are those who could neither agree nor disagree, disagreed somewhat and disagreed strongly, overall and by race/ethnicity and payer subgroups. Medi-Cal beneficiaries rated communication worse than women with private insurance (p < .01) (Figure 46).