Respectful Care for All: A Midwifery Practice and Policy Imperative

A recent research report from the Centers for Disease Control and Prevention (CDC) caught my attention and spurred further reading and reflection.¹ This report should push all of us to action to assure that all recipients of perinatal care feel well cared for and able to discuss any topic with their care providers.

The authors of this CDC study described overall maternity care experiences using survey data from more than 2000 mothers who are part of an opt-in community panel. The study revealed that 1 in 5 women (20%) reported mistreatment during childbirth in the United States.¹ That rate was close to 30% for Black, Hispanic, and multiracial respondents. In addition, nearly 30% of respondents reported discrimination of some type, including age, weight, and income. Furthermore, nearly half of respondents reported not asking a question or addressing a concern with their provider.¹

The CDC report is only the latest study to address this problem. Other recent research, including research led by midwives, reports the existence of mistreatment in perinatal care in the United States and offers additional information by birth location and provider type. A survey of more than 2000 women, using patient-designed items, revealed that 1 in 6 (17%) identified some type of mistreatment. Only 5% of those who gave birth in community settings (home or freestanding birth center) identified mistreatment compared with 28% who gave birth in hospitals. As in the CDC study, mistreatment was reported more often by women of color. Mistreatment was less common when midwives were the main prenatal care provider.² A secondary analysis of the same study focused on place of birth and intrapartum provider type among participants who gave birth in their planned location. For this subset of 1290 respondents, mistreatment was less likely for those giving birth in community settings with midwives compared with physicians in hospital settings. Although autonomy was greater for respondents cared for by midwives in hospitals, reported mistreatment was not different compared with those cared for by physicians in hospitals.³

Authors of a qualitative analysis of nearly 100 birth stories from 61 participants, analyzed using previously determined domains of mistreatment, found descriptions of mistreatment in 42.7% of narratives. Most instances were classified as poor rapport, such as poor communication, loss of autonomy, and lack of supportive care; none were physical or sexual abuse.⁴ In an effort to identify health care clinician behaviors that exemplify respectful maternity care, researchers examined the literature within a combined set of rights for respectful care during labor and birth. Specific examples of identified clinician respectful behaviors included providing only clinically indicated and evidence-based care, avoiding harmful care practices, protecting clients from abuse, providing honest information and obtaining consent for care, providing culturally respectful care, using understandable language, and treating all clients with equal respect, among other examples.⁵

The World Health Organization stated, “Every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination.”^6(p1) In the United States, supported with federal funding, the Alliance for Innovation on Maternal Health (AIM) created a series of evidence-based patient safety care bundles to improve maternity care outcomes. With the goal to add Respectful maternity care to the existing AIM bundle safety framework of Readiness, Recognition, Response, and Reporting, the Agency for Healthcare Research and Quality has recently undertaken a systematic review to define and identify measures of respectful maternity care in order to inform practice and policy, ultimately identifying strategies to improve care, especially to individuals from disadvantaged populations.⁷

Midwives are ideally situated to lead the charge to eliminate mistreatment and disrespect in perinatal care. Midwifery professional guidelines demand a high level of quality care for all patients. As midwives, we pride ourselves on providing patient-centered and individualized care for all. The American College of Nurse-Midwives (ACNM) philosophy statement supports “the basic human rights of all persons” including the right of individuals to have health care providers “that demonstrate respect for human dignity, individuality, and diversity among groups; act without bias or discrimination; and actively seek to disrupt systems of power and privilege that cause harm.”⁸ Further, a hallmark of midwifery practice is the “Promotion of person-centered care for all, which respects and is inclusive of diverse histories, backgrounds, and identities.”⁹

Every person deserves basic human respect when seeking health care; actions must be taken at the individual, group, and system levels to improve the outcomes reported. Individually, clinicians can ask themselves how they can be respectful, open, and engaged with what their patients need in every encounter. When observing instances of disrespectful care or mistreatment, address the situation respectfully with colleagues and patients. Most clinicians aim to provide good care and will appreciate hearing that their interactions may be perceived as disrespectful. In group practice settings, raise these questions to the practice level, implementing efforts to improve communication among colleagues and with patients while seeking their input. Midwives must continue work at the system level, assuring that administrators implement policies that allow the full expression and practice of midwifery care within hospital settings³ and prevent those that may allow mistreatment and disrespect, while explicitly demonstrating that all are welcome and will be treated with respect. System-level messages must be clear that respectful care and communication are expected in all settings.

It is also time to add an explicit ACNM Core Competency related to providing respectful midwifery care, expanding beyond the existing Hallmark. Likewise, the Accreditation Commission for Midwifery Education accreditation criterion requiring curricular content on bias and health disparities can be expanded to include provision of respectful care.¹⁰

Midwives have a voice and a platform from which to lead in eradicating disrespect in perinatal care. Our actions, individually and collectively, will speak the loudest and contribute to real change in people's perinatal care experiences and future research outcomes.