Mistreatment and Discrimination in Maternity Care: A CDC Survey of U.S. Mothers, 2023

From 2018 to 2021, the U.S. maternal death rate rose from 17.4 to 32.9 per 100,000 live births. Native Hawaiian and other Pacific Islander, Black, and American Indian and Alaska Native people have the highest rates of pregnancy-related death, and about 80% of those deaths are preventable. Maternal mortality review committees have found discrimination to be one contributing factor.

Respectful maternity care — care that preserves dignity, privacy and confidentiality, is free from harm and mistreatment, and supports informed choice and continuous support in labor — is part of quality care, and part of the strategy to prevent those deaths.

The survey

CDC analyzed the PN View Moms survey, an opt-in online panel of U.S. mothers with children under 18, fielded April 24–30, 2023, in English. 2,402 mothers were included, reporting on the pregnancy and delivery of their youngest child. Most (69.6%) were White; 10.7% were Black, 10.2% Hispanic, 4.8% Asian and 2.8% multiracial. 32.6% had Medicaid at delivery.

What mothers reported

90.5% were satisfied with their pregnancy care — but that fell to 75.1% among those who were mistreated.

Mistreatment

20.4% — about one in five — reported at least one kind:

Discrimination

28.9% reported at least one form — 40.1% of Black, 39.4% of multiracial and 36.6% of Hispanic mothers. The most common reasons overall were age (10.1%), weight (9.7%) and income (6.5%). Among Black mothers, the top reasons were weight (13.2%), race, ethnicity or skin color (12.9%) and age (12.8%).

Holding back

44.7% held back from asking questions or raising concerns with their provider. Top reasons:

• thinking what they felt was normal (28.8%);
• feeling embarrassed or not wanting to make a big deal of it (21.5%);
• someone close telling them it was normal (21.2%);
• worrying the provider would think they were being difficult (20.7%).

Why it matters

Negative experiences can drive people away from care: racial discrimination is linked to inadequate prenatal care and missed postpartum visits, and to pregnancy complications. Women who feel safe, supported and respected have better experiences, and more patient-centered care is linked to fewer complications.

What helps

• Health systems: train providers on unconscious bias and stigma, shared decision-making, communication and cultural awareness; routinely measure patients' experiences of respectful care.
• Patient safety bundles from the Alliance for Innovation on Maternal Health, used in birthing facilities, all include safe, respectful, equitable and supportive care; perinatal quality collaboratives run improvement projects on birth equity.
• Listening: the Hear Her campaign helps pregnant and postpartum women and their families speak up about concerns and recognize urgent warning signs, and urges providers to listen.
• Who gives care: a workforce that reflects the community, midwifery models and doulas improve experiences for racial and ethnic minority groups; doula support is linked to more respectful care, especially for publicly insured mothers.
• Communities and reviews: community organizations can raise awareness, and maternal mortality review committees can identify racism and discrimination in pregnancy-related deaths.

Studies outside the U.S. show that multilevel approaches — health system policies, provider behavior and community engagement — significantly improve respectful care.

Limits

The opt-in, unweighted survey probably doesn't represent all U.S. mothers; fewer than half of those invited took part, and some groups were small. Answers were self-reported, often about a birth five or more years earlier, and only in English.

Sources

Based on Mohamoud YA, Cassidy E, Fuchs E, et al., "Vital Signs: Maternity Care Experiences — United States, April 2023," MMWR volume 72, number 35, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The definition of respectful maternity care is paraphrased from the one the report quotes.