By Carolyn Crist

(Reuters Health) – Women who decline certain procedures – such as cesarean delivery or immediate cord clamping – during childbirth are more likely to report being treated poorly during their hospital stay, a U.S. study finds.

The new mothers said the discrimination they perceived from staff could have been related to their health insurance status, race and ethnicity, or their difference of opinion with the healthcare provider, the study authors report in the journal Social Science and Medicine.

“We’ve seen an increasing push in the last couple of decades for patients to take a more active role in their care, and discrimination is the antithesis of that, which undermines trust and good communication with the doctor,” said lead study author Laura Attanasio of the University of Massachusetts Amherst School of Public Health and Health Sciences.

“For some women, pregnancy and birth may be the first time they’ve experienced intensive contact with the health system,” she told Reuters Health in a phone interview. “What happens there could influence their interactions going forward.”

Attanasio and a coauthor analyzed data from the Listening to Mothers III survey, an online questionnaire of 2,400 women who gave birth in U.S. hospitals in 2011-2012. The researchers looked at the relationship between declining care during a childbirth hospitalization and reported discrimination, as well as reasons for the perceived poor treatment.

Although the survey asked women if they had declined any type of care for themselves or their baby, the researchers note some of the specific procedures that women sometimes opt-out of during childbirth are cesarean sections, intravenous analgesia, epidural and episiotomy – where a surgical cut is made to enlarge the vaginal opening. For the baby, new mothers may also decline formula supplementation, antibiotic eye ointment, vitamin K injection and the hepatitis B vaccine.

The research team found that women ages 18 to 24 were most likely to decline care, as were first-time mothers and those with graduate education, pre-existing conditions such as hypertension or diabetes or cesarean births.

Those who declined care were five times more likely to report poor treatment due to race or ethnicity during their hospitalization, and they were four times more likely to report poor treatment due to insurance status or having a different opinion from a provider. For instance, researchers found a significant link between Latin ethnicity, declining care and perceived insurance-based discrimination. Black women were more likely overall, and twice as likely as white women, to cite discrimination based on a difference of opinion about care.

“We know that physicians are human beings with their own experiences and biases, whether implicit or explicit, and the healthcare environment in the U.S. is challenging for both patient and provider now,” said Tina Sacks of the University of California, Berkeley School of Social Welfare.

“Women have hopes, dreams and desires for the life-changing time of childbirth,” she told Reuters Health by phone. “Being able to have agency during that time is important, especially for racial and ethnic minorities who have experienced a lack of autonomy or power to make their own decisions.”

Medical schools have begun initiatives to change the conversation and reduce health disparities, Sacks said, though it may take time. For now, women may want to consider finding a support person who can help develop a birth plan and act as an advocate during appointments and childbirth.

“Having someone to help you navigate all the people you will encounter helps take some of the stress and strain of dealing with a complex health system off of you,” said Linda Franck of the University of California, San Francisco Preterm Birth Initiative.

“Group prenatal care is an excellent way to get both great quality prenatal care as well as built-in learning and peer support,” Franck, who wasn’t involved in the study, said by email. “For mothers who have experienced poor treatment in maternity care, join others who are on a mission to change this situation and use your voice to help drive change.”

SOURCE: Social Science and Medicine, online May 20, 2019.