“Thanks for listening to mothers. We often get forgotten about.”
Listening to Mothers in California is a statewide, population-based survey, in English and Spanish, of the experiences, outcomes and views of women who gave birth in California hospitals in 2016. This survey joins a series of national
The Committee for the Protection of Human Subjects of the California Office of Statewide Health Planning and Development approved our research and the evolution of our work. We developed, field tested and refined a roughly 30-minute questionnaire covering the prenatal through postpartum and newborn periods. We drew a representative sample from birth certificate files, excluding teens younger than 18, women with out-of-hospital births, women with multiple births and nonresidents of California. We oversampled Black women, women with midwifery-attended births and women with vaginal birth after cesarean to better understand the experiences and views of these groups.
“It is nice to have a voice and to be heard and is nice to have a study to improve the health of babies and mothers.” We developed, field tested and refined outreach materials to encourage participation. We invited sampled women to participate through a series of mailings with elements of informed consent, information about how to participate and an offer of a gift card for survey completion. We followed up with nonrespondents by mail, telephone, text message and email, as available, using contact information from multiple sources. Respondents could complete the survey in English or Spanish, by themselves using any device or via telephone with a trained interviewer. Further exclusions at the point of contact were women who were unable to participate in English or Spanish and whose babies were not living with them at that time. Participants completed the questionnaire when their babies were between 2 and 11 months old.
Our survey results from 2,539 women were weighted for the target population, including correction for oversampled groups, using the 2016 Birth Statistical Master File of all births in California. Despite the exclusions, our results closely align with statewide 2016 results on many basic variables. We largely report survey results, but investigators also had access to birth certificates of survey participants and, for respondents with births covered by Medi-Cal, several analysis variables from the state’s Management Information System/Decision Support System Warehouse. Appendix A provides detailed information about the survey methodology.
Just a fraction of women reported receiving no prenatal care, and about 1 in 5 had no choice of prenatal care provider. In the case of both maternity care providers and hospitals for giving birth, about 4 women in 10 said they found information about the quality of prospective options. Nearly all who found information in turn used the results to inform their choice of care arrangements. The great majority of women had obstetricians for both their prenatal care and their birth attendant: fewer than 1 in 10 had a midwife (who was in essentially all cases a certified nurse midwife [CNM], in the context of hospital births) for prenatal care and as birth attendant.
We looked at barriers to midwifery care, both why women who would have liked such care did not have it, and why women would definitely not be interested in such care. Misunderstandings about this care and lack of access to it were important barriers. We estimate that about 1 woman in 10 had the support of a labor doula who, in some cases, also provided support in pregnancy and/or at home after the birth.
We asked women about their interest – should they give birth in the future – in using several types of care, and found considerable unmet needs. Proportions of women who said they would definitely want to have or would consider a midwife and also a doula far exceeded the proportions that used midwives and doulas for their recent births. While all survey participants gave birth in hospitals, we similarly asked about interest in giving birth in a freestanding birth center as well as at home, should they give birth in the future. Proportions of women who would definitely want to use, or would consider, these birth settings greatly exceeded the proportions that actually used these birth settings in the state in 2016 (based on birth certificate data). For all of these care options, Black women consistently were on the highest end of the range of interest among race/ethnicity groups, and women with Medi-Cal had greater interest in out-of-hospital birth settings than women with private insurance.
About 1 respondent in 3 recognized that the quality of maternity care can vary widely across different hospitals and different obstetricians. The rest were divided almost evenly between those who felt that quality is pretty much the same or were not sure.
We asked women how much they agreed or disagreed with the statement, “Birth is a process that should not be interfered with unless medically necessary.” About half agreed strongly and another quarter agreed somewhat versus fewer than 1 in 10 who disagreed. Displaying responses to this question across three national surveys and this statewide survey suggests rapid changes in women’s views about avoiding unnecessary intervention in a 15-year time span.
In contrast to these preferences, we found extensive use of interventions around the time of birth. For example, 2 in 5 women experienced attempts to induce labor, with more than 1 in 3 solely for reasons that are not supported by high-quality evidence. About 3 in 10 women were told near the end of pregnancy that their babies might be getting quite large. These women were more likely to experience induced labor, yet more than 4 in 5 gave birth to babies that were within the normal weight range at birth. We found that most women were admitted to the hospital in early labor, when the likelihood of having a cesarean was great, versus relatively few later in labor, when the likelihood of having a cesarean was exceptionally low. Both women who gave birth vaginally and women with cesarean births had high rates of interventions. Use of pain medications was high, with 3 in 4 experiencing regional analgesia (epidural or spinal). About 1 in 6 respondents used no pain medication. Use of some well-recognized drug-free measures such as showers and tubs was limited. About 1 in 3 women did not experience any drug-free measures for pain relief.
Looking at overall patterns in these care experiences, we found most women tended to have many interventions around the time of birth, and we include a table summarizing those measured. We found that nearly half of respondents experienced five or more of 10 consequential interventions around the time of birth. We found an apparent cascade effect among first-time mothers who labored at term and use of three major interventions. Those with neither labor induction nor epidural analgesia had almost no cesarean births, nearly 2 in 10 with either one of these had cesareans, and 3 in 10 with both had cesareans. Using a consensus definition of clinical professional societies, we calculated experience of “physiologic childbirth” – labor that starts on its own at term, proceeds without pain medications or medicine to stimulate labor, and ends with vaginal birth not assisted with vacuum extraction or forceps. While this is perhaps the birth experience that many women would like, we found that just 1 in 20 respondents had such a birth.
Overall, 3 in 10 respondents gave birth by cesarean, and 7 in 10 had vaginal births. Cesareans were almost evenly divided between initial or “primary” cesareans and repeat cesareans largely attributed to the fact of the past cesarean rather than a new indication. Women with midwives as prenatal care providers were considerably less likely to have a cesarean birth than women with obstetrician prenatal care providers, overall and also when looking just at more comparable low-risk first-birth cesareans.
About 6 of 7 women with one or more cesareans in the past again gave birth by cesarean. Nearly half who had a repeat cesarean were interested in planning a vaginal birth after cesarean (VBAC). However, about half who were interested said they had not had the option to plan a VBAC, mostly due to refusals by providers and hospitals rather than current health concerns. White women had twice the rate of VBAC as Black women, and women with midwives as prenatal care providers were far more likely than women with obstetricians to have a VBAC.
We asked women with one or two past cesareans a validated sequence of questions to understand decision-making experiences. Those who had had a discussion with their care providers about a possible repeat cesarean reported receiving skewed information and recommendations favoring the procedure rather than a VBAC. Just 1 in 10 women who had such discussions had a VBAC, compared with 3 in 10 who did not have such a discussion.
We asked whether the women had experienced unfair treatment during their hospital stay for childbirth because of their race or ethnicity, because of the language they spoke or because of the kind of insurance they had or their lack of insurance. Most participants did not identify such concerns. Among the small numbers identifying concerns, there were significant differences within subgroups showing clear advantages for White women, English-speaking women and women with private insurance relative to their counterparts.
We also asked whether during the hospital stay for birth the women had experienced harsh language and rough handling from personnel. Nearly 1 in 10 responded affirmatively to each of these, with little variation across many variables with respect to use of harsh language and slightly more variation with respect to rough handling. Women who were Black or primarily spoke an Asian language at home were more likely than White women or Latinas to report both types of ill treatment.
We also looked at pressure to experience several major interventions: labor induction, epidural analgesia in laboring women and cesarean birth. About 1 in 10 reported pressure to have an epidural, and to have a cesarean, while experience of pressure to have labor induction was somewhat higher. Women who had labor induction and who had cesarean birth were more likely to have experienced pressure than those who did not.
Finally, most women reported that they had been granted autonomy in decisions about how their birth would proceed, had been well supported and had experienced good communication during the hospital stay for giving birth. However, women covered by Medi-Cal were more likely to identify concerns in all three areas than women with private insurance.
Overall, 1 woman in 10 did not have any postpartum office visit. Women with Medi-Cal coverage were more likely than women with private insurance to have no visits. Black women had the highest number of visits, perhaps reflecting a greater burden of morbidity at this time. Among women with postpartum visits, 2 or more in 3 reported having been asked about several important issues during this period.
Compared with women with private insurance, women with Medi-Cal coverage were less likely to have sources of both emotional and practical support since the birth of their babies, with nearly 1 in 5 saying that they never had either source of support.
About 1 woman in 3 planned to stay home with their babies. Within 4 months of the birth, more than 4 in 5 women with a paid job at the time of the survey reported they were working for pay. Among women who assumed a paid job, fewer than half said that they had stayed home as long as they liked.
About 2 in 3 respondents intended to exclusively breastfeed as they came to the end of their pregnancy, and about 6 in 10 were doing so a week after the birth. Nearly all women felt that the hospital staff had been quite supportive of breastfeeding. About 6 in 10 women who were breastfeeding at 1 week and not at the time of the survey reported not having breastfed as long as they liked. Overall, fewer than 3 in 10 respondents who participated at six or more months after giving birth met the consensus recommendation of leading health professional organizations for exclusive breastfeeding for the first 6 months.
Fully 4 in 5 Medi-Cal beneficiaries reported no out-of-pocket costs for maternity care providers and hospital care. However, more than 1 woman in 3 with private insurance reported costs between one and five thousand dollars, with 1 in 7 citing costs above this range.
We included in our questionnaire the Patient Health Questionnaire for Depression and Anxiety (PHQ-4). This validated, widely used screening tool has subscales for depression and anxiety, and the composite is a marker for severity of psychological distress. Respondents completed the questions with reference to “in the past 2 weeks” (i.e., in the postpartum period) as well as, among prenatal topics, “during your recent pregnancy.” One woman in five screened positive for anxiety prenatally, and 1 in 10 screened positive for anxiety postpartum. About 1 in 10 screened positive for depression prenatally, and this figure dropped several percentage points in the postpartum period. About 1 in 10 scored as experiencing moderate psychological distress and about half that as experiencing severe distress during pregnancy. The postpartum measure for psychological distress resulted in levels that were about half that of prenatal distress. There was a tendency for higher proportions of Black women to screen positive and have symptoms of anxiety and depression and to score as having greater severity of psychological distress at both time periods in comparison with other racial/ethnic groups. These achieved significance in the case of prenatal anxiety, depression and moderate or severe psychological distress. With the exception of postpartum anxiety, there was a tendency for a higher proportion of women with Medi-Cal coverage to screen positive for the conditions during pregnancy than women with private insurance, and this achieved significance in the case of prenatal depression.
Many women reported receiving counseling or treatment for emotional or mental well-being. Women were more likely to receive such help if they had positive screens or with increasing severity of psychological distress. However, most women facing apparent challenges with these conditions did not receive standard types of help.