Introduction

Introduction

“Before taking this survey I didn’t know I had more options for a better birth giving experience.”

“Thank you for your concern for all women because for us it’s very important to be taken into consideration.”
The Listening to Mothers surveys focus the discussion of maternity care on those who care about it the most: mothers themselves. National Listening to Mothers surveys carried out since 2002 have documented for the first time at the national level many experiences, outcomes and perspectives of childbearing women from before pregnancy through the postpartum period that had been recorded only at the clinical, community or state level – if at all – in the past.

Our Listening to Mothers in California survey was adapted to California needs and opportunities, including current maternity care issues in the state and the distinctive population of birthing women who, in comparison with our national surveys, are much more likely to be Latina and less likely to be Black. For example, in response to concerted statewide policy initiatives to reduce avoidable cesareans, we explored mode of birth and antecedents at length, as well as related care practice recommendations provided by a recent toolkit from the California Maternal Quality Care Collaborative. We oversampled Black women to better understand their views and experiences. We had a racially and ethnically diverse sample, and we were delighted to be able to offer the survey in Spanish for the first time, in addition to English. Responding to the current communications environment, women could complete the survey in either language by themselves on any device or with a trained interviewer. The state-level survey also enabled us to draw a sample from birth certificates and weight the data to be more reflective of the general population of women who were eligible for our study.

The survey research reported here was led by the National Partnership for Women & Families and developed in collaboration with investigators from the University of California, San Francisco (UCSF), Center on Social Disparities in Health, and the Boston University School of Public Health. Quantum Market Research, Inc. administered the survey.

WHO WAS INCLUDED IN OUR SAMPLE, AND HOW WE REACHED THEM

Survey

“Thanks for caring enough to have a survey to ask new moms questions like these.” With the support of the Committee for the Protection of Human Subjects of the Office of Statewide Health Planning and Development and the Vital Statistics Advisory Committee of the California Department of Public Health, analysts at UCSF drew a representative sample of births that occurred from September 1, 2016, through December 15, 2016, from birth certificate files, excluding teens less than 18, women with out-of-hospital births, women with multiple births and non-residents of California. We oversampled Black women, women with midwifery-attended births and those with vaginal births after cesarean to better understand the experiences, outcomes and views of women within these smaller groups.

The survey was conducted from February 22 through August 15, 2017. Mailings (and then emails, text messages and telephone calls, as possible) invited sampled women to participate on their own online using any device or with an interviewer via telephone. All 2,539 survey participants were 18 years or older, could respond to a survey in English or Spanish, and had given birth in a California hospital to a single baby who was living with its mother when the women participated in the survey. We excluded mothers with multiple births, those who gave birth in out-of-hospital settings and women who were not living with their babies, as their experiences differ in important respects from other mothers. Additionally, the numbers that would have been included in the sample would have been too small to analyze as distinct groups. On average, the survey took a bit longer than 30 minutes to complete.

Survey Questionnaire

“It was nice talking about my birth and my experience I had with my baby.” The survey questionnaire, as well as outreach materials inviting sampled women’s participation, were customized to the current state context, pilot tested and refined over several iterations. The complete Listening to Mothers in California survey questionnaire is available at both NationalPartnership.org/LTMCA and chcf.org/listening-to-mothers-CA. Individuals citing Listening to Mothers in California results are encouraged to consult the questionnaire to understand the specific questions posed, choices offered and which groups of women (i.e., the “base”) responded to the questions, whether all mothers or specific subgroups (e.g., questions about experiences with breastfeeding were only asked of mothers who initiated breastfeeding).

Women’s Survey Participation Experience

“Thanks for giving us mothers the opportunity to express our concerns and questions through these surveys ... with a purpose of providing better medical services and be able to have a good experience in the birth of a baby.” Respondents participated from 2 to 11 months after giving birth. Of those who completed the survey, 34% did so online, 28% did so by phone with an interviewer and 39% used both methods (typically starting on their own and finishing with an interviewer). In all, 81% completed the survey in English and 19% in Spanish. There were many indications that Listening to Mothers in California participants were exceptionally engaged in the survey and interested in having their voices heard. This is reflected in their willingness to take more time answering questions than typical survey respondents and the hundreds of women who took the time to respond to open-ended questions, including comments about their appreciation for our effort to systematically understand and share their views and experiences. Many similarly communicated their appreciation to survey interviewers.

Data Weighting

“[I] [h]ope this is a fruitful study, and can improve the childbirth experience for women and babies. I am a physician and did not think there was too much to it before childbirth and only after going through it do I realize how much is uncontrollable during labor/delivery and the emotional rollercoaster/pressures that come with the experience.” To develop a statewide profile of childbearing women aged 18 and older and giving birth to single babies in California hospitals, analysts at UCSF used demographic and other relevant variables from the 2016 Birth Statistical Master File (final file of all certificates for the year) to adjust and weight the Listening to Mothers survey data to the birth file for the full year.

Demographic Profile of Respondents

Despite exclusions, weighted data for our survey participants closely resemble California statewide 2016 birth certificate data in terms of such variables as race/ethnicity, maternal age, birth attendant, mode of birth and number of times the woman had given birth (see Appendix B).

Supplementary Material in Appendices

Appendix A provides a detailed methodology of the survey. Appendix B compares weighted results from birth certificates of our study participants to statewide 2016 results from the Birth Statistical Master File. We also include parallel national birth certificate data for 2016, suggesting some distinctive attributes of the population of childbearing women in California. Appendix C identifies some reasons for discrepancies between our results and some other sources, including some practices for which women’s self-reports may provide more accurate information, for example, due to undercounting in official sources, identified through validation studies.

Reading the Text, Tables and Figures

Percentages may not always add up to 100% because of rounding, the acceptance of multiple answers from respondents, or exclusion of rarely chosen or less germane response categories in reporting.

The term “base” is used to identify the total number of respondents eligible to answer that question. Because many questions are only asked of a subgroup of the sample (e.g., only women who had had labor induction were asked about the reason for the induction), some results may be based on small sample sizes. Caution should be used in drawing conclusions from results based on smaller numbers of women. Readers should also be alert to exactly which population the tables and text refer, because in many cases we probe the data through several layers. Numbers provided for the same base (for example, all women) vary slightly as all eligible women did not respond to every item.

“I’m excited about this research study!” We set the significance threshold for testing group differences at the relatively stringent .01 level. When figures and tables include subgroup comparisons, an asterisk indicates comparisons where the differences are statistically significant at the p < .01 level based on a chi-square test with adjustment for weighting. When comparisons noted in the text are significant at the p < .01 level, this is noted in the text.

Terms for leading race/ethnicity groupings in this and other Listening to Mothers in California reporting align with widely used conventions. “Latina” in our reporting indicates women who identified on the survey as “Hispanic or Latina” (50% of weighted survey respondents). “White” indicates women who identified as “White” and did not select “Hispanic or Latina” (27%). “Asian and Pacific Islander” indicates women who identified as “Asian” or as “Native Hawaiian or other Pacific Islander” and did not select “Hispanic or Latina” (16%). “Black” indicates women who selected “Black or African American” and did not choose “Hispanic or Latina” (5% of weighted responses but oversampled to 9% of unweighted responses to increase our ability to understand this group). Numbers were too small to present data separately for women who selected “American Indian or Alaskan Native,” “something else” (with a write-in response) or who selected more than one race.

In payer analyses, “Medi-Cal” indicates a woman whose 2016 birth was covered by Medi-Cal through a claim in the Department of Health Care Services Management Information System/Decision Support System (MIS/DSS) Warehouse (47% of weighted responses). “Private” indicates a woman who selected a private insurance response choice on the survey (44%) and did not have a paid Medi-Cal childbirth claim. There were too few respondents across other insurance categories to analyze, including less than 1% with no insurance.

Selection of Quotations from Survey Participants

“Thanks for giving me the opportunity to comment on our experience of being a mother.” All women who participated in the Listening to Mothers in California survey were offered three opportunities to provide fully open-ended comments. We asked them to describe (1) the best thing about their experience of giving birth, (2) the worst thing about their experience and (3) anything else they would like to tell us about any aspect of their maternity experience. A remarkable number of women took the time to respond to one or more of these invitations. We received many vivid and moving stories, observations and opinions that bring the women’s experiences to life. Faced with the challenge of selecting comments for this report from among this large and important set of remarks, we gave priority to either contrasting quotes that suggest the range of women’s experiences or those that illustrate notable survey results. Some quotes illustrate a situation of concern for a relatively small proportion of women, but that nonetheless impacts many mothers or babies statewide, since nearly 500,000 women give birth annually California. The quotations in this report reproduce the women’s exact words, though we have in some cases corrected spelling and punctuation. A qualitative researcher is separately analyzing these open-ended responses.

Advisory Council

We convened an advisory council, composed of multi-stakeholder leaders in California and nationally. Council members provided invaluable feedback on a draft of the full questionnaire, which led to many meaningful refinements. We also called on many individual council members to provide specialized types of guidance through the various phases of the project. We look forward to working with council members to share survey results and reporting products and to use survey results to improve policies, programs and practices throughout the state.

Project Responsibility

The National Partnership for Women & Families led this work, in collaboration with investigators from UCSF and the Boston University School of Public Health. Together, this team designed the adaptation of the national Listening to Mothers survey methods to the state-level context. The team prepared applications to the various state agencies and institutional review boards (see below) for approval to carry out the work and gain access to essential data for this project. The investigator team developed the survey questionnaire, with guidance from our advisory council and many childbearing women who provided feedback on iterative versions, and designed the study protocol. This team met regularly throughout the project to assess progress, plan next steps – including those related to the many innovations new to this Listening to Mothers survey – and make decisions.

The UCSF team took responsibility for data management, including designing the sampling plan, overseeing questionnaire programming, and receiving and managing data from all sources (e.g., vital statistics, survey, Genetic Disease Screening Program, Department of Health Care Services). The UCSF team also led the pilot testing of the survey questionnaire and outreach materials directed to sampled women in both English and Spanish. It took the lead on cleaning, coding and weighting the data and producing initial unweighted and weighted frequencies of all measures. That team also independently checked results based on complex coding and carefully reviewed large sections of the report.

Quantum Market Research, Inc. administered the survey, including programming the questionnaire in English and Spanish in Qualtrics, finding and recruiting sampled women, interviewing women who participated by telephone, following up with thank-you gift cards and managing the operations database to track participation status.

Dr. Declercq at Boston University was the lead data analyst. Teams from the National Partnership for Women & Families and Boston University took the lead in developing this report, a digital version of this report and several issue briefs, and collaborated with project officers and California Health Care Foundation and National Partnership communications personnel to develop other survey reporting products.

The Committee for Protection of Human Subjects of the Office of Statewide Health Planning and Development is the IRB of record for this project, and the Human Research Protection Program at UCSF also approved this project. The Vital Statistics Advisory Committee of the California Department of Public Health (CDPH) has approved and provided access to both initial birth certificate data for sampling, contact information of sampled women, and analysis variables and selected variables from the 2016 Birth Statistical Master File for data weighting. The Genetic Disease Screening Program at CDPH approved and provided access to supplementary contact information for sampled women. The Data and Research Committee of the Department of Health Care Services approved and provided access to supplementary contact information for sampled women and, after data collection was complete, analysis variables from the MIS/DSS Warehouse for sampled Medi-Cal beneficiaries.

The California Health Care Foundation and the Yellow Chair Foundation generously funded the Listening to Mothers in California survey. In addition to financial support, project officers with both funders have been engaged in all phases of the development and reporting of the survey, contributing substantively to the quality and success of this work.