“Giving birth is so beautiful, scary, life changing, and emotional.”

Many stakeholders in California and across the nation are deeply committed to improving maternity care and the well-being of childbearing women and infants. Listening to Mothers in California is a unique source of information about the experiences, outcomes and views of childbearing women, providing a window on many topics that are otherwise unavailable for this population at the state level.

Survey results, presented in this report and through a wealth of related documents, point to a broad policy and practice mandate. Care that most childbearing women want but frequently do not receive is also high-value, evidence-based care that makes wise use of limited resources. All stakeholders must prioritize transforming our maternity care system in this direction. Similarly, after giving birth too many women experienced challenges with adequate time with their babies, breastfeeding, social support and mental health. We must stop failing to meet the needs of childbearing women at a time when they, their infants and families are especially vulnerable.

Beyond overall concerns for childbearing women and their infants lie deeply disturbing disparities by race/ethnicity – most consistently affecting Black women – and by payer, with Medi-Cal beneficiaries disproportionately facing challenges relative to women with private insurance. These inequities compound the harm and failure. Survey results are a call to action.

Listening to Mothers in California results highlight opportunities to close gaps between what women want and what they are experiencing. Notably, the great majority wanted to avoid unneeded interventions around the time of birth, yet experienced high rates of intervention, including the 1 respondent in 3 who gave birth by cesarean. Of special concern was the extent to which women reported experiencing pressure from a health professional to have several types of consequential interventions and the association of pressure with getting the intervention. Relatively few experienced “physiologic childbirth” without major interventions, according to the definition endorsed by leading professional organizations. American College of Obstetricians and Gynecologists. (2017). reVITALize Obstetric Data Definitions. Retrieved 26 March 2018, from here A timely new consensus blueprint for advancing high-value maternity care through physiologic childbearing can guide stakeholders in better meeting women’s preferences and improving care. Avery, M.D., Bell, A.D., et al. (2018). Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing. Washington, DC: National Partnership for Women & Families. Retrieved 14 July 2018, from here

“I’m so happy you’re calling and getting this feedback and I hope this survey does make a change in the maternity care women receive and gives the mothers a voice to be heard to be able to advocate for the kind of childbirth they want to have.” We also found gaps between care and preferences when asking about interest in several high-value care arrangements should women have a future birth. Women identified far greater interest in use of midwifery care and labor doula support than actual use in their 2016 births. And while our survey was limited to hospital births, respondents expressed far greater interest in future use of birth center care and home birth than statewide use of these forms of care in 2016.

Our results further identify opportunities to close gaps between best evidence and professional guidance on the one hand and common patterns of care on the other. For example, survey items measured low use of practices promoted in a recent toolkit Smith, H., Peterson, N., Lagrew, D., & Main, E. (2016). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. California Maternal Quality Care Collaborative. Stanford, CA: California Maternal Quality Care Collaborative. Retrieved 19 October 2017, from here that is being used in many California hospitals to support intended vaginal birth, and identified the low rate of vaginal birth after cesarean, which is not receiving commensurate policy and professional attention.

Survey results identify opportunities to incorporate shared decision-making and high-quality, up-to-date decision aids into maternity care. A validated question sequence applied to one common situation, mode of birth for women with one or two past cesareans, found that current patterns of decision-making align poorly with standards of shared decision-making. Results suggest that, overall, women were steered toward repeat cesarean birth and were not provided with resources to enable informed decisions about this matter.

The survey also identified knowledge gaps among women and the importance of providing better information to enable them to make wise fundamental choices of care provider and birth setting. While a heartening proportion of respondents found and used comparative quality information to make these decisions, the great majority was not aware of the extent of quality variation. There are rich opportunities for further building the skills and knowledge of childbearing women, providing access to better provider-level quality data, providing help navigating this information and making a search for comparative quality information a standard part of the early pregnancy experience. Relatedly, too many women, especially Medi-Cal beneficiaries, reported not having access to a choice of prenatal care provider.

“Just do what you know what’s right. You don’t always have to listen to anyone. It’s your decision at the end of the day.” While postpartum depression is widely recognized as a challenge for childbearing women, we found that many respondents also screened positive for anxiety and that more women appeared to experience symptoms of these conditions during pregnancy than in the postpartum period, based on a respected screening tool for psychological distress with subscales for anxiety and depression. We found that even in the most extreme case of “severe” psychological distress, most women were not receiving the most conventional types of help, counseling and medication.

We also looked at how women were faring in the postpartum period from several other perspectives. Most women who were doing paid work felt that they had not had enough time at home with their babies. Most who had breastfed but were not breastfeeding at the time of the survey felt that they had not fed breast milk as long as they liked – and these two findings are interrelated. Fewer than 3 mothers in 10 met the consensus standard for exclusive breastfeeding to 6 months. Too many never or just sometimes had sources of emotional and practical support since the birth of their babies. Finally, we documented significant out-of-pocket costs for many women with private insurance.

Cutting across all of the issues, survey results also sharpen our understanding of racial/ethnic disparities and present many opportunities to advance health equity. While we identified instances in which each of the commonly cited racial/ethnic groupings fared worst, time and again, results suggest that Black women face the greatest challenges, have the greatest need for better care and most desire access to supportive forms of maternal care. By oversampling Black women, we increased our ability to shed light on the views and experiences of this segment of the childbearing population. Survey results identify many areas where we can and must improve.

Survey results highlight disproportionate challenges facing Medi-Cal beneficiaries. These are multi-factorial, relating to the more vulnerable life circumstances of this group and its care patterns. Through data linkage, we identified women in our survey with a claim for their 2016 childbirth covered by Medi-Cal. The survey thus presents a unique opportunity for an in-depth look at childbearing women covered by Medi-Cal and the care they receive, with gold standard identification of this population and experiences, outcomes and views reported by women themselves. The survey found some advantages in care patterns favoring women with Medi-Cal coverage, others favoring women with private insurance and overall many opportunities for all health insurance providers and plans to drive improvement.

Altogether, Listening to Mothers in California results suggest a need for widespread care transformation to reliably deliver optimal maternal and newborn care. Such transformation could occur through such mechanisms as delivery and payment reform and quality improvement initiatives, performance measurement and accountability, consumer engagement, attention to health professions education and the composition and distribution of the health professions workforce, and research to fill gaps in knowledge. Through these levers, and through stronger paid leave, breastfeeding, mental health and other social policies and programs, we can help ensure that childbearing women and newborns have the care and supports and attain the positive outcomes that they deserve.