Callous Care for Pregnant Patients, Particularly Those of Color
CDC: HCWs need training on implicit bias, stigma
With maternal mortality rates on the rise in the United States, a new report comes as an unwelcome complication — and, in part, an explanation for the disturbing trend: Many women feel disrespected and even experience verbal abuse during their pregnancy and delivery care, the CDC reported.
The CDC analyzed data from the PN View Moms survey, an opt-in consumer poll of U.S. mothers with children younger than age 18 years living at home. Administered in April 2023, the option to complete the survey online was shared with 7,607 women. Overall, 2,407 mothers responded.
“The survey examined maternity care experiences, including satisfaction with care, experiences of mistreatment and discrimination, and whether respondents held back from asking questions or discussing concerns with healthcare providers,” the CDC reported in an unsettling new Vital Signs report.1
Wanda Barfield, MD, MPH, FAAP, director of CDC’s Division of Reproductive Health, addressed some of these issues at a press conference.
“When we talk about mistreatment, we’re talking about receiving no response to requests for help, being shouted at or scolded, not having their physical privacy protected, and being threatened with withholding treatment or made to accept unwanted treatment,” Barfield reported. “This report found that one in five women surveyed experienced mistreatment during their maternity care. Those numbers were higher for certain groups of women who reported experiencing mistreatment. Thirty percent were Black, 29% were Hispanic, and 27% were multiracial women.”
According to the CDC report, the percentage breakdowns of all women reporting mistreatment included:
- 10% were ignored by healthcare workers or saw their requests for help refused;
- 7% were shouted at or scolded by healthcare workers;
- 5% reported their physical privacy was violated;
- 5% were threatened with withholding of treatment or forced to accept treatment they did not want.
A neonatologist, Barfield said she has witnessed thousands of interactions between healthcare workers and mothers during pregnancy, delivery, and postpartum care.
“Not all of that care was respectful,” Barfield noted. “As a mother and as a Black woman, I was fortunate to have an obstetrician/gynecologist who saved my life and the life of my son because he respectfully listened to my concerns while I was pregnant. Yet this report provides evidence that many women are having experiences that are truly unacceptable.”
If you think this is the one patient group healthcare workers would not mistreat, think again. Early this year, Emory Hospital Midtown in Atlanta fired four labor and delivery nurses after they mocked their patients on a video posted on social media. They cited irritations or “icks” their patients did, including incredibly, one when mothers ask how much their newborn weighs “when it is still in their hands.” Another nurse complained, “When we’ve already told you to push the call light, but every five minutes your family members come up to the front desk asking for something else.”2
Discriminatory Care
In the CDC survey, about 40% of Black, multiracial, and Hispanic mothers reported discriminatory treatment by healthcare workers in labor and delivery.
“[This was] discrimination for reasons such as race, ethnicity, skin color, age, and weight,” Barfield said. “These experiences also vary by insurance status. Women with no insurance or public insurance reported more mistreatment during maternity care than people with private insurance.”
Feelings of marginalization and intimidation also were reported on the CDC survey. “Effective communication between pregnant and postpartum women and their healthcare providers can make it more likely that there will be accurate, timely diagnoses for any complication so that they can get treatment,” Barfield explained. “Yet unfortunately, 45% of women reported holding back from asking their questions or discussing their concerns with their healthcare providers.”
Common reasons cited on the survey for this reticence included:
- Told by friends or family that what they were feeling was normal;
- Not wanting to make a big deal out it;
- Embarrassed to talk about it;
- Concerned their healthcare provider would think they were difficult;
- Thinking their healthcare provider seemed rushed;
- Not feeling confident they knew what they were talking about.
“We want patients to be comfortable sharing their health concerns with their providers, whether nurses, physician assistants, or doctors,” Barfield said. “It’s critical that we help care providers in the room make sure that they’re taking the time to build trust by actively listening and being culturally aware of the people we’re serving.”
Previously, the CDC reported Black women are three times more likely to die from a pregnancy-related cause than white women. “Multiple factors contribute to these disparities, such as variation in quality healthcare, underlying chronic conditions, structural racism, and implicit bias,” the CDC noted.3
In 2021, 1,205 women died of maternal causes in the United States, compared with 861 in 2020 and 754 in 2019. The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. According to CDC data, 31% of pregnancy-related deaths happen during pregnancy, 36% during labor and delivery, and 33% in the year after pregnancy.
“Despite having one of the most advanced health systems in the world, the U.S. currently has the highest pregnancy-related death rate among developed nations,” wrote Asima Ahmad, MD, MPH, a reproductive endocrinologist. “It’s simple: Pregnant women are not receiving the appropriate level of medical care. Racial and ethnic disparities only worsen the situation, resulting in poor birth outcomes and more deaths for minorities.”4
80% of Deaths Preventable
Indeed, the CDC estimates 80% of most pregnancy-related deaths are preventable, Debra Houry, MD, MPH, CDC’s chief medical officer, said at the press conference.
“Despite our technology, despite our advancements, women still are reporting that they’re not being listened to and that they’re not receiving respectful care,” Houry said. “The survey data from our report show that many women report mistreatment and discrimination during maternity care. This is unacceptable.”
These negative healthcare encounters may make pregnant women reluctant to seek care across the spectrum of prenatal, pregnancy, and postpartum.
Houry said there are too many examples of Black women — including a CDC colleague — who voiced some concern about their pregnancy to no avail. In a manner of speaking, they were not heard. For this reason, the CDC has created a website called “Hear Her” that chronicles the stories of pregnant women. (For more information, see the related story in this issue.)
“CDC’s own Dr. Shalon Irving was one of these women,” Houry said. “She was a lieutenant commander in the U.S. Public Health Service and an advocate for eliminating health disparities. In 2017, she died weeks after delivery due to high blood pressure, despite continuously visiting her healthcare providers, where she kept insisting something was wrong and was being dismissed.”
How can these incidents be prevented? “We know that actions like hiring and retaining a diverse workforce and providing healthcare provider trainings on unconscious bias and stigma can help improve the quality of care,” Houry explained.
CDC currently supports 39 states and one U.S. territory for a program called Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM). The program supports “maternal mortality review committees,” which investigate deaths related to pregnancy to identify prevention opportunities. These committees can also identify racism and discrimination during reviews, Barfield explained.
The American College of Obstetricians and Gynecologists made the following recommendations for OB/GYNs and other providers to improve patient-centered care and decrease inequities in reproductive healthcare by:
- “Inquiring about and documenting social and structural determinants of health that may influence a patient’s health and use of healthcare;
- Maximizing referrals to social services to help improve patients’ abilities to fulfill these needs;
- Providing access to interpreter services for all patient interactions when patient language is not the clinicians’ language;
- Recognizing that stereotyping patients using presumed cultural beliefs can negatively affect patient interactions, especially when patients’ behaviors are attributed solely to individual choices without recognizing the role of social and structural factors.”5
REFERENCES
- Mohamoud YA, Cassidy E, Fuchs E, et al. Vital Signs: Maternity Care Experiences — United States, April 2023. MMWR Morb Mortal Wkly Rep 2023;72.
- Jackson R. Hospital nurses no longer employed after viral TikTok mocking expecting mothers. 11 Alive News. Dec. 12, 2022.
- Centers for Disease Control and Prevention. Working together to reduce Black maternal mortality. April 3, 2023.
- Ahmad A. America has the highest maternal mortality rate among developed nations — and it’s on the rise. Here’s why we are facing a pregnancy health crisis. Fortune. May 14, 2023.
- Ades V, Goddard B, Ayala SP, et al. ACOG Committee Opinion No. 729: Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstet Gynecol 2018;131:1162-1163.
With maternal mortality rates on the rise in the United States, a new report comes as an unwelcome complication — and, in part, an explanation for the disturbing trend: Many women feel disrespected and even experience verbal abuse during their pregnancy and delivery care, the CDC reported.
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