Listening to Mothers

Childbirth requires many choices: between a vaginal birth or a Caesarean section, whether or not an episiotomy is necessary, whether to take an epidural or not. The difference between responsive maternal care and care that overlooks a woman’s needs, wants, and feelings is sometimes as simple as giving patients the power to make these choices. But implicit bias toward patients, whether based on socioeconomic status, race, or ethnicity, often leads medical professionals to overlook some patients’ ability to make informed healthcare decisions.

Eugene Declercq and team wanted to know whether type of insurance coverage influenced pregnancy-related care and women’s feelings of agency and respect. The Listening to Mothers in California survey was a statewide effort conducted in 2016 to measure how women who gave birth in California felt during their pregnancy.

The researchers found wide differences in perceptions of choice and agency. Medi-Cal, California’s Medicaid program, recipients reported not having the choice of provider for pregnancy and childbirth twice as often as women with private insurance. They also saw obstetricians as their prenatal providers less often, and were given the option of whether to have an episiotomy less commonly. During childbirth, women with Medi-Cal reported feeling pressured to have an epidural more often yet were actually less likely to receive an epidural than other women. After giving birth, women with private insurance received postpartum visits within the standard eight-week time period more often. When women with Medi-Cal did receive these visits, providers more frequently neglected to ask about postpartum depression.

During childbirth, women with Medi-Cal reported feeling pressured to have an epidural more often yet were actually less likely to receive an epidural than other women.

The sum of these findings equals a system where women on Medi-Cal have less autonomy and receive inferior care compared to privately insured women. Other researchers have also reported that Black women and lower income women, two groups more likely to rely on Medi-Cal, have poorer outcomes and less control over their medical care than wealthier, white, native-English-speaking patients.

Improving Medicaid standards will likely improve pregnancy-related care for everyone, regardless of their insurance. By improving training and standards for providers who see Medicaid patients, the quality of care that non-Medicaid patients receive similarly improves. In other situations, addressing deficiencies in Medicaid coverage improved the care of all patients in a given area—even if they had better insurance than Medicaid—while also closing disparities between insurance providers.

Considering the notably poor maternal health outcomes in this country, work needs to be done to improve women’s healthcare experiences. One vital step is to have healthcare professionals meaningful engage with these kinds of data and examine their implicit biases. California passed the California Dignity in Pregnancy and Childbirth Act in 2019 to mandate implicit-bias training in response to one cause of maternal health disparities. But more efforts are needed.

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