key: cord-0773674-b6ub4cwj
authors: Basile Ibrahim, Bridget; Kennedy, Holly Powell; Combellick, Joan
title: Experiences of Quality Perinatal Care During the US COVID‐19 Pandemic
date: 2021-08-25
journal: J Midwifery Womens Health
DOI: 10.1111/jmwh.13269
sha: 5844e9e2ff3d293e7ba3f36c66b242f5dbbbabcb
doc_id: 773674
cord_uid: b6ub4cwj

INTRODUCTION: Quality perinatal care is recognized as an important birth process and outcome. During the coronavirus disease 2019 (COVID‐19) pandemic, quality of perinatal care was compromised as the health care system grappled with adapting to an ever‐changing, uncertain, and unprecedented public health crisis. METHODS: The aim of this study was to explore the quality of perinatal care received during the COVID‐19 pandemic in the United States. Data were collected via an online questionnaire completed by people who gave birth in the United States after March 15, 2020. The questionnaire included the Mothers on Respect Index and the Mothers Autonomy in Decision Making validated measures. Low‐quality perinatal care was defined as decreased respect and/or autonomy in the perinatal care received. Responses were geocoded by zip code to determine COVID‐19 case‐load in the county on the date of birth. Multivariate regression analyses described associations between respect and autonomy in decision‐making for perinatal care and levels of COVID‐19 outbreak across the United States. RESULTS: Participants (N = 707) from 46 states and the District of Columbia completed the questionnaire. As COVID‐19 cases increased, participants’ experiences of autonomy in decision‐making for perinatal care decreased significantly (P = .04). Participants who identified as Black, Indigenous, and people of color, those who had an obstetrician provider, and those who gave birth in a hospital were more likely to experience low‐quality perinatal care. Those with a midwife provider or who had a home birth were more likely to experience high‐quality perinatal care in adjusted models. DISCUSSION: Variability in experiences of high‐quality perinatal care by sociodemographic characteristics, birth setting, and provider type may relate to implicit bias, structural racism, and inequities in maternal health and COVID‐19 outcomes for birthing people from marginalized communities.

Respect and communication are integral values in quality maternal and newborn care 1 and respectful perinatal care 2,3 is recognized as an important birth outcome. Yet, during the global coronavirus disease 2019 (COVID-19) pandemic, evidence has surfaced that human rights and respectful perinatal care have suffered [4] [5] [6] [7] as health systems grappled with adapting to an ever-changing, uncertain, and unprecedented public health crisis 6 while providing essential care for families during birth.

The World Health Organization (WHO) and scholars have incorporated respectful maternity care as a central tenet to high-quality perinatal care across birth settings, levels of technology, and resources of the country. 1, [8] [9] [10] Quality mater-nal and newborn care prioritizes the needs of birthing people and their infants. 1 The WHO defines respectful maternity care (hereafter referred to as respectful perinatal care) as that which is "organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth." 10(p3) The WHO guidelines for COVID-19 clinical management state that all pregnant people, including those with suspected or confirmed COVID-19 infection, should have access to high-quality perinatal care that is respectful, person-centered, and skilled. 11 Yet, health system policies in response to the COVID-19 pandemic have deemphasized many aspects of high-quality perinatal care including respect, dignity, informed choice, early skin-to-skin contact with the newborn, and continuous support during labor and birth and have potentially exacerbated harmful birth experiences. 4, 5 Individuals who identify as Black, Indigenous, and people of color (BIPOC) were disproportionately impacted by higher rates of maternal morbidity and mortality [12] [13] [14] in the prepandemic United States. Quality of perinatal care, from preconception to postpartum, is critical to reducing inequities in health outcomes for BIPOC birthing people. 15 BIPOC communities also have higher rates of infection and death from COVID-19. 16, 17 Disparities in maternal mortality and ✦ As US coronavirus disease 2019 (COVID-19) cases increased, birthing persons' autonomy decreased significantly.

✦ People of color were less likely than their white counterparts to experience high-quality perinatal care during the US COVID-19 pandemic.

✦ Participants who had a vaginal birth, a midwife provider, or who gave birth at home or in a birth center were most likely to experience high-quality perinatal care.

morbidity and the disparately high impact of COVID-19 in BIPOC communities are associated with similar preexisting inequities 18 arising from systemic and structural racism, [19] [20] [21] [22] [23] including inequities in the quality of perinatal care. 22 Structural racism is "the totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems (in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, and so on) that in turn reinforce discriminatory beliefs, values, and distribution of resources, which together affect the risk of adverse health outcomes." 19(p1454) To improve perinatal health and COVID-19 related outcomes for individuals from BIPOC communities, it is essential to identify and call out the structural racism that perpetuates these inequities. 20, 22, 24 The US health care system has been deeply strained by the COVID-19 pandemic. 25 Lessons learned during this crisis can help improve care going forward and build resiliency during future public health emergencies. Therefore, this study sought to explore the quality of perinatal care during the COVID-19 pandemic in the United States with a health equity lens.

The results reported here were collected in the preliminary phase of an ongoing, cross-sectional, explanatory sequential mixed-methods study exploring experiences of pregnancy and birth and decision-making about birth setting during the COVID-19 pandemic in the United States. Analysis of the qualitative data is ongoing and will be reported elsewhere.

We developed a cross-sectional web-based self-administered questionnaire in the Qualtrics platform (Qualtrics, Provo, UT). The questionnaire included screening questions to determine eligibility; questions about COVID-19 birth experience, birth setting, and perinatal care provider; the Mother's Autonomy in Decision Making (MADM) scale; 26 and the Mothers on Respect Index (MOR). 27 The online questionnaire was content validated prior to the start of the study by a diverse group of 10 individuals who were pregnant or postpartum community members (n = 4) and/or worked as perinatal care professionals or trainees (n = 6) (eg, providers, nurses, doulas). Based on their feedback, the questionnaire was edited for content, clarity, and sensitivity. The 2 validated instruments included in the survey measure agency in decision-making for perinatal care (MADM scale) 26 and experiences of respectful perinatal care (MOR). 27 Participants rate their ability to state their preferences in decision-making, whether different care options were presented, and if their choices were respected on the 7-item MADM scale. Each item is scored 1 to 6 with a lower score indicating less autonomy; scores range 7 to 42. Participants describe their experiences of respectful care from their perinatal care provider (midwife or physician) and their associated level of comfort in the decision-making process on the 14-item MOR scale. Each item is scored 1 to 6, with a lower score indicating less respect; scores range 14 to 84. Higher scores on each scale indicate greater autonomy and respect when engaging in decision-making during pregnancy and birth. Both MADM and MOR display high reliability and internal consistency when validated in US populations. 26, 27 In the framework for quality maternal and newborn care, respect is a key value. 1 Other key values of quality maternal and newborn care include strong communication, delivering care that strengthens the person's capabilities, and care tailored to the birthing person's circumstances and needs. 1 These aspects of care are measured in the MADM. 26 To capture the general experience of perinatal care and to make the scores on the MADM and MOR more clinically relevant, we created a dichotomous variable capturing the quality of perinatal care experienced. We define quality of perinatal care based on measures of respectful and autonomous perinatal care as measured by the MADM and MOR scales. We created a dichotomous variable of low-quality versus high-quality perinatal care. Participants who scored in the lowest quartile of scores in our sample on the MADM (score <26) and/or MOR (score <65) were categorized as receiving low-quality perinatal care. Those who scored higher than the lowest quartile on both MADM and MOR scores in our sample were categorized as receiving high-quality perinatal care.

Participants who self-identified as any race or ethnicity other than non-Latinx white were categorized into a dichotomous variable as BIPOC and white, non-Latinx participants were categorized as non-BIPOC.

We administered a web-based questionnaire to minimize infection risk and maximize participation rate and geographic diversity. Data were collected from June to November 2020, and each participant provided informed consent prior to completing the questionnaire if they met eligibility criteria. Adults (>18 years of age) who gave birth in the United States after March 15, 2020, were eligible to participate. This study was approved by the Yale University Institutional Review Board (identifier: MOD00032835).

Recruitment was accomplished through a variety of methods. Information about the study and a link to the study webpage was shared in an electronic newsletter to alumni of an advanced practice nursing and midwifery program in the Northeastern United States and to the University's general alumni organization. Information about the study was also shared via social media (Facebook, Twitter, Instagram) through the personal and professional contacts of the research team. Study information was disseminated to professional organizations of doulas, lactation consultants, and childbirth advocacy groups to pass on to their members. We encouraged participants to refer other eligible participants, thereby employing a form of snowball sampling. While the questionnaire was active, we noted a lack of racial and ethnic diversity in our sample and made additional efforts to reach out to BIPOC communities and individuals through social media, the research team's personal and professional contacts, and organizations for BIPOC birth professionals and advocates.

Responses were geocoded by participant-provided zip code in ArcGIS PRO (ESRI, Redlands, CA) to determine county of residence in the week prior to giving birth. The counties were linked to county-level COVID-19 outbreak data 28 to determine the number of positive COVID-19 cases reported in the county on the date each participant gave birth and to calculate case-density using the 2019 population of each county. 29 Descriptive statistics, bivariate, and multivariate regression models were performed in SAS 9.4 for Windows. STROBE guidelines for reporting cross-sectional studies 30 were followed.

A total of 707 participants from 46 states and the District of Columbia completed the questionnaire (Table 1 ) . Most (64%) were between the ages of 25 and 34 years and gave birth to their first (43%) or second (39%) child in 2020. They most commonly gave birth in April (28%), followed by May (19%) and June (14%), and 73% had a vaginal birth. Participants were most likely to identify as white (86%), privately insured (83%), educated at the baccalaureate level (40%) or higher (41%), and to live in the Northeast (31%) or Midwest (31%). Most participants received care from an obstetrician (70%), and 29% were attended by a midwife for their prenatal care and birth. Most gave birth in a hospital (77%) and many gave birth at home (10%).

Bivariate analyses ( Table 1 ) of experiences of high-quality perinatal care varied significantly by race and ethnicity (P = .02), BIPOC identification (P = .007), provider type (P < .001), mode of birth (P = .005), birth setting (P = .001), and satisfaction with experience (P < .0001). Participants who were nonwhite race, identified as BIPOC, had an obstetrician provider, had a cesarean or assisted vaginal birth, gave birth in a hospital, and who were dissatisfied with their experience reported receiving low-quality care more frequently.

Zip codes were available and geocoded for 668 participants ( Figure 1 ) and were included in the regression analyses related to COVID-19 cases. The minimum number of COVID-19 cases in the county of residence on the date the participant gave birth was 0 and the maximum was 139,017. The median number of cases in the county on the date the participant gave birth was 3,049. The maximum density of COVID-19 cases in residence county was 7189 per 100,000 county residents.

Median MADM scores (range, 7-42) were 32 (interquartile range [IQR], [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] and median MOR scores (range, 31-84) were 74 (IQR 65-80). Quartiles were set based on analysis of MADM and MOR scores for this cohort (Table 2). MADM and MOR scores met assumptions for normality based on skewness and kurtosis. In unadjusted and adjusted (adjusted for maternal age, parity, and geographic region) linear regression analyses (Table 3) , birthing people experienced less autonomy in decision-making (MADM scores decreased) as the number of COVID-19 cases in the county increased (adjusted P = .04). For each additional COVID-19 case in the county, the MADM score decreased by 3.6 × 10 −5 points. Experiences of respectful care (MOR scores) were not significantly different as number of COVID-19 cases increased in the county (adjusted P = .06).

Participants described many mandatory changes to their labor, birth, and postpartum care due to the pandemic ( Table 4 ). The most common changes to care were restrictions on the number of support people present during labor and birth (83%) and on the number of postpartum visitors (82%). The next most common changes were setting-based: being restricted to their room while in the hospital (51%) and a shorter postpartum hospital stay (50%). Other frequent changes to care included mandatory COVID-19 testing (45%) and a requirement to wear a mask during labor and birth, regardless of COVID-19 status (34%).

One in 3 participants (33%) indicated they did not experience high-quality perinatal care (Table 1 ). In models adjusted for geographic region, parity, and maternal age, when giving birth during the COVID-19 pandemic in the United States, BIPOC birthing people were 42% less likely to experience high-quality perinatal care than those who identified as white, non-Latinx (adjusted odds ratio [aOR], 0.58; 95% CI, 0.39-0.99; Table 5 ). Participants who had a midwife provider were 3 times more likely to experience high-quality perinatal care than those who had an obstetrician (aOR, 2.98; 95% CI, 1.97-4.53). Participants who gave birth at home had a threefold higher likelihood of experiencing high-quality perinatal care than those participants who gave birth in a hospital (aOR, 3.03; 95% CI, 1.48-6.24). Participants who had a vacuumassisted or forceps-assisted vaginal birth were 61% less likely 

Among our national sample of people who gave birth during the US COVID-19 pandemic, we found that having a home birth and having a midwife as primary perinatal care provider increased the likelihood of experiencing high-quality perinatal care. Furthermore, people who identified as BIPOC and those who had an assisted vaginal birth with forceps or vacuum were significantly less likely to experience high-quality perinatal care. Our findings are similar to the findings of the Giving Voice to Mothers study. 31 In both studies, autonomy and respect were more likely to be compromised for individuals who gave birth in a hospital, who identified as BIPOC, or had an obstetrician as their primary perinatal care provider. The midwifery model of care exemplifies the tenets of quality perinatal care, which are captured in the values of the quality maternal and newborn care framework 1,32 and fall within the definition of respectful perinatal care. 33, 34 Midwifery care is associated with higher rate of vaginal birth, 35 and among our sample, having a vaginal birth and having a midwife provider were each significantly associated with experiencing high-quality perinatal care. Nationally, 10% of all births are attended by midwives and slightly over 98% of women give birth in a hospital. 36 In our sample, 29% of participants were attended by midwives and 10% gave birth at home. This increased use of midwifery care may explain the higher rate of vaginal birth in our sample (73%) compared with the US rate of 68%. 36 The United States is an outlier among high income countries for the high rate of cesarean birth, high rate of maternal morbidity and mortality, and low midwife to physician ratio. 37 Reducing the rate of cesarean birth and promoting normal physiologic birth is a globally recognized means to improving maternal outcomes that is strongly associated with midwifery care. 1 Participants reported many mandatory changes in their care due to the COVID-19 pandemic. A majority of individuals had limitations placed on the presence or number of support people present during labor and birth. Many were separated from their newborns and were limited in their options for pharmacologic and nonpharmacologic pain relief during labor. Sadler and colleagues postulate that mandatory changes to care during the COVID-19 pandemic, such as prohibition on labor support persons, separation from the newborn, and nonmedically indicated interventions, all of which do not achieve the objective of limiting the spread of COVID-19 and decrease maternal autonomy and dignity, are equivalent to obstetric violence. 5 In our study, 1 in 3 participants reported that they did not receive high-quality perinatal care during the COVID-19 pandemic. Participants who identified as BIPOC (racial and ethnic minorities) were less likely to experience highquality perinatal care than white participants, which is similar to experiences reported by BIPOC participants in other studies. 31, 38, 39 The quality of health care received, from preconception through postpartum care, may be a "critical lever for improving outcomes for racial and ethnic minority women." 12(p2) There is significant research showing that experiences of disrespectful care and mistreatment by health care providers, including racism and racial discrimination, are linked to health and specifically to negative birth outcomes for women and infants of color. [40] [41] [42] [43] Lack of high-quality, person-centered perinatal care, poor communication, and mistreatment during labor and birth can create a feeling of distrust of caregivers 44 and stress, anger, and distress in the relationship with their perinatal care provider. 45 Participants in Oparah and colleagues' 2016 study reported numerous instances in which they felt coerced or were denied full informed consent, 45 which indicates lower-quality perinatal care. BIPOC people's experiences of low-quality care exemplified by discrimination, poor communication from providers, and coercion in their reproductive care increase levels of health care system distrust, which contributes to racial disparities in health care. 46 Higher levels of health system distrust have been associated with less preventative health services use among lower-income Black Americans. 47

To our knowledge, this is the first large-scale study to describe individuals' experiences giving birth in the United States during the 2020 COVID-19 global public health crisis. The study's focus on health equity in maternal health corresponds to the latest priorities of the US Surgeon General and Department of Health and Human Services. 48, 49 Although the experiences of our participants occurred during a global health crisis, their mean scores on the MADM and MOR were slightly higher than in a comparable pre-COVID-19 US national sample, 39 and median scores were higher than pre-COVID-19 Australian and German samples. 50, 51 This study is not without limitations, as it is subject to selection bias owing to being a self-administered questionnaire and recruitment through birth advocacy social media sites, midwives, and doula networks. Furthermore, despite repeated attempts to do so, we were unable to recruit a representative percentage of participants from BIPOC communities nor were our participants geographically representative of the entire United States.

We anticipate that there will be future episodes of uncertainty and chaos in public health, related not only to the current pandemic but also to the increasing incidence of health system threats arising from major weather events, large-scale human migration, and changing patterns of infectious disease. The current pandemic has highlighted existing health system weaknesses, including those identified in our study, which demand correction in times of health system disruption as well as in times of normal functioning. Perinatal care, as an essential service, must continue despite uncertainty and strain on the health system. Our finding that 1 in 3 people lacked high-quality, person-centered care points to the need for further training in respectful perinatal care, especially in rapidly changing or uncertain situations. Antiracist, cultural humility, and structural competency trainings for providers and hospi-tal staff 45, 52, 53 can help to lessen the inequities in experiences of person-centered care due to racial discrimination.

This study highlights the need for further research in many areas related to health equity in maternal health. Further qualitative research is needed to understand what women need to feel they are respected and in control of their own health care needs, especially during the important life transition of pregnancy and childbirth. More research is needed, especially with marginalized groups (racial and ethnic minorities, socioeconomically disadvantaged, and rural residents), about the long-term and intergenerational biosocial, physiologic, and psychologic effects of perinatal care that is not person-centered or high-quality, as pregnancy and birth are important and vulnerable transition stages. Additional research to further quantify and measure quality perinatal care is also necessary for comparison across models of care, settings, and health systems.

Policy changes addressing structural racism, which is currently perpetuating inequities in social determinants of health that impact maternal health 54 (residential environment, education, employment, and access to high-quality care), are overdue. 20 Incorporating cultural humility and structural competency into physician, midwifery, and nursing curricula via a national mandate may help to improve rates of implicit bias and discrimination from providers at the outset of their careers. 51, 52 Policy support in the form of amendments to midwifery licensure and supervision regulations, as well as improved reimbursement policies, is necessary to provide additional support for community birth and midwifery care. 35, 37 CONCLUSION During times of uncertainty in public health and strain on the health systems, it is crucial to deliver perinatal care in a respectful manner to avoid trauma, adverse maternal and neonatal health outcomes, and decreased trust and health care use, especially among our most marginalized communities.

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis

Human Reproduction Programme at the World Health Organization. The Prevention and Elimination of Disrespect and Abuse during Facility-Based Childbirth. World Health Organization

Respectful maternity care in the context of COVID-19: a human rights perspective

COVID-19 as a risk factor for obstetric violence. Sex Reprod Heal Matters

Reflecting on equity in perinatal care during a pandemic

Human Rights Violations in Pregnancy, Birth Anda Postpartum During the COVID- Pandemic

Blueprint for Advancing High-Value Maternity Care through Physiologic Childbearing. National Partnership for Women & Families

World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization

World Health Organization. WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience. World Health Organization

Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID- Disease Is Suspected. World Health Organization

Reducing disparities in severe maternal morbidity and mortality

Social determinants of pregnancy-related mortality and morbidity in the united states: a systematic review

Racial/ethnic disparities in pregnancy-related deaths -United States

Reducing disparities in severe maternal morbidity and mortality

Unequal distribution of COVID-19 risk among rural residents by race and ethnicity

Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income

Syndemic perspectives to guide black maternal health research and prevention during the COVID-19 pandemic

Structural racism and health inequities in the USA: evidence and interventions

Examining racism in health services research: a disciplinary self-critique

Community-informed models of perinatal and reproductive health services provision: a justicecentered paradigm toward equity among Black birthing communities

Applying a critical race lens to relationship-centered care in pregnancy and childbirth: an antidote to structural racism

Structural racism and health inequities: old issues, new directions

Improving patient and provider experiences to advance maternal health equity strategies to address inequity during the COVID-19 pandemic and beyond

Addressing inequities in maternal health among women living in communities of social disadvantage and ethnic diversity

The Mother's autonomy in decision making (MADM) scale: patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care

The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth

An interactive web-based dashboard to track COVID-19 in real time

Annual estimates of the resident population for counties

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

Asking different questions: research priorities to improve the quality of care for every woman, every child

World Health Organization. WHO Recommendation on Respectful Maternity Care during Labour and Childbirth. World Health Organization

Respectful Maternity Care: The Universal Rights of Childbearing Women

Mapping integration of midwives across the United States: impact on access, equity, and outcomes

Demographic, socioeconomic, health systems, and geographic factors associated with vaginal birth after cesarean

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

I had to fight for my VBAC": A mixed methods exploration of women's experiences of pregnancy and vaginal birth after cesarean in the United States

An ecological approach to understanding Black-white disparities in perinatal mortality

Racism, health status, and birth outcomes: results of a participatory community-based intervention and health survey

Area racism and birth outcomes among Blacks in the United States

Racial discrimination and adverse birth outcomes: an integrative review

African American women & unplanned cesarean birth

Battling Over Birth: Black Women and the Maternal Health Care Crisis in California, Executive Summary. Black Women Birthing Justice

Prior experiences of racial discrimination and racial differences in health care system distrust

The role of trust in use of preventive services among low-income African-American women

The Surgeon General's Call to Action to Improve Maternal Health. US Department of Health and Human Services; 2020. 49.US Department of Health and Human Services. Healthy Women,Healthy Pregnancies,Healthy Futures: Action Plan to Improve Maternal Health in America. US Department of Health and Human Services

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

Measuring disrespect and abuse during childbirth in a high-resource country: development and validation of a German self-report tool. Research Square

Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education

Structural competency: theorizing a new medical engagement withstigma and inequality

World Health Organization. A Conceptual Framework for Action on the Social Determinants of Health. World Health Organization

The authors would like to thank Miriam Olivares, GISP, GIS Librarian at Yale University for her support of this project. Dr. Basile Ibrahim was supported during the period of data analysis and manuscript drafting by a Rural Health Equity Postdoctoral Fellowship, supported by the Clinical and Translational Science Institute and the Office of Academic Clinical Affairs at the University of Minnesota. It is housed in the Division of Health Policy and Management at the University of Minnesota School of Public Health. The funding for this fellowship comes from the National Institutes of Health's National Center for Advancing Translational Sciences, grant UL1TR002494.

The authors have no conflicts of interest to disclose.