Nicole* remembers a lot about the birth of her first child: the contractions coming one after the other, hearing his first cries, the joy of holding him in her arms for the first time.
She also remembers calling for a nurse who was slow to show up. Then, there was the doctor who walked into her hospital room, began an exam without introducing herself, and then told Nicole—without explanation—that her baby could die if she didn’t accept the medication right now. She recalls the wave of humiliation and anger she felt, overhearing “these people have too many kids” and other disrespectful comments from hospital staff.
Sharon,* an OB-GYN, describes a typical day in her working life: patients she’s never seen before, arriving already in labor without health records; patients with a clear vision of how they want to give birth but getting pushback from short-handed nurses and pressure from administrators; and patients doubting her judgment and asking if the more junior (male) clinician in the room could give his opinion.
Their experiences are typical of what dozens of women of color and their providers reported in recent interviews with a team of researchers examining the culture of modern maternity care in the United States. Columbia University’s Averting Maternal Death and Disability (AMDD) program in New York and Black Mamas Matter Alliance in Atlanta are leading the project, with support from Merck for Mothers.
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The study focuses on attitudes, behaviors, and perceptions of care. The goal: to gain insight into why too many Black women in the United States are dying from pregnancy-related causes.
These issues cannot be properly understood without considering the complex dynamics of distrust between marginalized communities and health systems. This distrust threatens to undermine every effort to tackle the U.S. maternal health crisis—a crisis characterized by alarming rates of preventable deaths and disproportionately high risks for Black women, who nationally are dying at a rate of three to four times higher than white women, regardless of income or education. On maternal mortality, the United States ranks 46th in the world, the worst record among high-income countries.
Last year, tennis player Serena Williams grabbed headlines by recounting the dismissive treatment she experienced after childbirth. But far more often, distrust works corrosively to sabotage implementation of even the most well-meaning, evidence-based biomedical interventions. And this distrust cuts both ways.
Against this backdrop, our researchers set out to answer three key questions: What kinds of mistreatment do women experience during childbirth in a hospital setting? What are the key drivers: Was it personal to the individual caregiver, a reflection of how a hospital is organized and managed, or the result of misguided policy? How prevalent is the problem?
The team’s findings, to be published in full later this year, are drawn from focus group discussions with 85 women recruited by community organizations in New York and Atlanta. Virtually all participants were women of color and had delivered a baby within the past two years. Researchers also interviewed male partners; doulas; and nearly 100 doctors, nurses, and administrators from several public and private New York City hospitals.
The women recounted incidents ranging from verbal abuse and ineffective or condescending communication to outright discrimination and racism. Some experiences were characterized as a failure to meet professional care standards or linked to outdated hospital practices like not allowing women to get up and move around during labor.
Providers reported witnessing many of the same things. Maternal health providers reported working in a fragmented health system that undermines the potential of developing trusting one-on-one relationships with patients throughout a pregnancy. They described difficult work environments, pressures and frustrations on the job, including being short-staffed, overwhelmed by the sheer number of patients, and lacking management support. These conditions prevented fidelity to routine protocols, allowing biases to influence behavior, and put providers on the defensive.
In the United States, not only may Black women bring their own personal history of mistreatment to the childbirth experience, but they also receive care in a system that still often reflects the painful history of reproductive injustice that dates back to institutionalized slavery and Jim Crow-era discrimination in health care. This is the barrier through which many women hear a physician’s advice, feel a nurse’s touch, and interpret an administrator’s expression or tone of voice. This cycle of mutual distrust feeds on itself, fostering cynicism, burnout, lapses in quality care, and preventing pregnant women from seeking medical care when they need it.
The upshot is this: In a system that is failing so many mothers and providers, blaming individuals is not the answer. Both women and providers are feeling defeated. We need to work together to build empathy from all sides. Through our research, we learned that provider-patient relationships need to be strengthened to encourage shared decision-making and support continuity of care; that health-care workers need tools to eliminate harmful biases; and that patients need more information on their rights during childbirth. We also need to make space for communities to identify, tap, and strengthen their own cultural and social resources, calling for collective action within communities, facilities and across the broader health system.
We are on the precipice of transformation thanks to the courage of so many Black women who are sharing their stories. Their voices, their experiences, and their solutions must define what we do next.
*Names and identifying details have been changed to protect confidentiality.