Equity in Perinatal Services
Participants in this study were clear about their preferences for care during pregnancy and childbirth, but there were marked differences in their ability to access their preferred care depending on where they lived or who they were.
Key Findings
The following factors were rated as important or very important by more than 90% of participants:
Leading decisions about pregnancy, birth, and baby care
Having a trusting relationship with my care provider
Having a doctor or midwife who is a good match for what I value and want for pregnancy and birth care
Not being separated from baby after birth
Having enough time to ask questions and discuss options for care
Having support people of my choice present for labor and birth
Knowing the midwife/doctor who will care for me during birth
Choice of birth place (home, birth center or hospital)
Half of the participants reported that when deciding who they wanted care from, they considered their previous birth experiences, and information from books, websites, and friends.
Indigenous women listed their grandmothers and sisters as important sources of information more frequently compared to other groups.
For 1 in 3 people, doctors provided most of their prenatal care. A small number of people saw nurse practitioners, nurses or physician assistants. Black and Hispanic women were, compared to other demographics, most likely to report an obstetrician as their primary prenatal care provider. Of those who changed care providers during pregnancy, a quarter changed because of a preference for birth setting (home, birth center, hospital), and 1 out 5 changed seeking options for care that their first doctor or midwife did not offer.
If you found out that a close friend or family member was pregnant, what would be the most important advice you could give them?
“Get to know how your care provider works; what are their policies during birth, what are the statistics of the hospital you will be birthing at, press your provider for details (how many of your patients’ births did you induce last year, how many successful VBACs did you attend last year), and change providers if you don't like the answers. The birthing room is not the time to find out that you don't agree with your provider.”
Self-identified as White, had a hospital birth with a midwife in New York
Most respondents said that having time to build relationships and trust with their providers was very important to them.
Half of respondents (n=1088, 49.9%) said that they always or almost always saw the same person for their prenatal care, one in three (n=735, 33.7%) saw two or three different people during prenatal care, and 359 (16.5%) said that four or more different people shared their prenatal care.
Continuity of care provider varied by maternal race, with 74.4% of White women reporting that their lead prenatal care provider also attended their birth, compared to 64.2% of Black women, 65.8% of Latina women, 69.1% of Asian women and 70.6% of Indigenous women.
Continuity of care also varied by the type of provider: 56.3% of women who had a physician had the same person who provided prenatal care attend their birth, compared to 78.7% of midwifery clients.
What was the best thing about your care?
"Comfort, trust, peace of mind. Every midwife appointment felt like going to visit a friend. I trusted that she always wanted what was best for me, the baby, and my family. I was at peace because I knew she was experienced and very educated in the work she does."
Self-identified as Black, had a homebirth with a midwife in California
Midwife clients reported longer appointments than physician clients.
More than 95% of Black women said it was important or very important to them to have enough time to ask questions and discuss options for care, yet they were the most likely to have very short prenatal appointments (10-15 minutes).
Length of Prenatal Appointments, Stratified by Race
Regardless of setting, most women reported using position changes, showers or tubs, physical support like massage and birth balls to help with comfort during labor. Midwifery clients were more likely to report that they did not use any pain medication during labor compared to women who were under the care of a physician.
People who were Black, Hispanic, and Indigenous found it harder to find a provider to attend a community birth than did people who were white.
People who were Black, Hispanic, and Indigenous found it harder to find a provider to attend a community birth than did people who were white.
"I had little to no options… no doula, no birthing centers, no midwives. There was one hospital and that was it."
Self-identified as biracial, gave birth with an obstetrician in a hospital
"I had little to no options… no doula, no birthing centers, no midwives. There was one hospital and that was it."
Self-identified as biracial, gave birth with an obstetrician in a hospital
If there is one thing you could change, what would it be?
Notably, 96.8% of women who had a community birth with a midwife did not use any pain medications during labor, compared to 53.6% of women who had a hospital birth with a midwife, compared to 32.7% who birthed at the hospital with a physician.
If there is one thing you could change, what would it be?
“I did the best I could. I wish I didn't need the epidural, but I did need it. I wish it wasn't so strong so I could have given birth in a different position from laying on my back. I also wish I would have had access to a bath. Maybe I wouldn't have needed the epidural if I could have gotten some relief from the tub. But my hospital room didn't have one even though I was told it would.”
Self-identified as European and American Indian, gave birth in an in-hospital birth center with a midwife in Maryland
What was the best thing about your care?
Most women named their partner as their main labor support person, but Black women more often reported having other family members than any other group. In comparison to White or Asian women, Black and Indigenous women were both less likely to know what a doula is and to have the support of one.
What was the best thing about your care?
“The support I got from my husband and Doula during labor and after baby was born was the best. My Doula also did a postpartum visit to check on how I was doing and how baby was feeding, which was very supportive and helpful.”
Self-identified as Black, had a hospital birth with an OB in Arizona
People know what they need to have a healthy pregnancy. They identified things like counselling for mental health, access to a state health plan, and WIC food vouchers; but they also reported that they got almost no help from their doctors or midwives to secure these supportive services.
Racialized service users have significantly more unmet needs when compared to white women. Black and Indigenous women are two to three times more likely to have unmet needs. They were also more likely to have providers make assumptions about their needs for support.
Proportion of service users who needed the following services or resources, and proportion who received help from their doctor or midwife to access them
Here is what women said about inequity, choices, and services:
What was the worst thing about your care?
"A black woman OB's negativity toward my unmedicated birth inquiries and a Latina OB's decision to have me stay overnight at the hospital with an unnecessary IV because she wanted to leave work early, are what made me leave the practice. Being a woman of color is not enough, but if they were midwives, I doubt they would have those problems. I didn't like being talked at. I'm an engineer; I need things to make sense. And I want it (our choices) to be explained to other women too."
"I was offered WIC [the Women, Infants, and Children's program, which assists new mothers and babies with supplemental food and nutrition] repeatedly though I explained that I did not qualify. I believe it was because I am Latina and my partner Black that we were repeatedly offered WIC."
If you found out that a close friend or family member was pregnant, what would be the most important advice you could give them?
“Find your own way. Research your options and do not be afraid to do something differently from your family or friends if it is what you are drawn to. Be sure to research the current rates of Caesarean sections while making your choice. Consider homebirth and midwifery care for the comfort they give and the autonomy that you can have. Hire a doula to help you remain focused and calm and to be your support. Your body is built to do this, and you can do it, so try not to fear.”
Self-identified as White, had a homebirth with a midwife in New York