Mistreatment during Childbirth: Impact on Maternal Outcomes and Importance of Provider Perspectives

Background: Dying in childbirth is one of the most common causes of death for women. While maternal mortality rates, defined as deaths per 100,000 live births, have been steadily dropping in most countries worldwide, maternal mortality rates have doubled in the United States in the last twenty years. This commentary examines the various contributing factors to this trend. Me-thods: A literature review was performed using the keywords: maternal mortality, United States, disrespectful maternity care, obstetric violence, provider perspectives, and disparities. Maternal mortality statistics were obtained from the World Health Organization website. Results: Medical factors associated with maternal mortality include increased maternal age and cardiovascular conditions. Social factors include barriers to healthcare access, delays in receiving medical care, reduction in reproductive health services in some states, and non-obstetrical deaths such as accidents, domestic violence, and suicide. Racial inequities and disparities of care are reflected in higher maternal mortality rates for minorities and people of color. Disrespectful maternity care or obstetric violence has been reported worldwide as a factor in delay of lifesaving obstetrical care and reluctance by a pregnant person to access the health-care system. About one in five US women has reported experiencing mi-streatment, varying from verbal abuse to lack of privacy, from coerced procedures to neglect during childbirth. Conclusion: This commentary highlights the importance of inclusion of providers in research on respectful maternity care. Provider burnout, moral distress, limited time, and burden of clinical re-sponsibilities


Introduction
Dying in childbirth is one of the most common causes of mortality for women.According to the World Health Organization (WHO), in 2020, 800 women died each day, or one woman every two minutes, from preventable prenatal, intrapartum, or postpartum-related causes [1].Maternal death is devastating at the individual, family, community, and societal levels.Increased infant and child mortality, reduction in family and community economic opportunities, and poverty are among the direct consequences of each maternal loss [2].The WHO sustainable development goal of maternal mortality reduction emphasizes the importance of attention to this issue and, in general, the causes of death are clear: severe bleeding, infections, high blood pressure during pregnancy, complications from delivery, and unsafe abortion [3].Poor maternal outcomes have been identified as a proxy for gender inequity in both health care and society [4] [5].The underlying factors leading to maternal deaths have been analyzed from both a scientific and a social ecological framework.In a study from India, both individual and systemic factors were identified [6].Individual factors included shame, fear of discrimination, past successful home births, and lack of knowledge of pregnancy complications.Healthcare structural factors included the delay in care due to unavailability of experienced medical staff and equipment.These factors suggest an underlying component of obstetric violence, defined as lack of respectful care as manifested by discrimination, non-consensual care, abandonment, and physical abuse, which has been reported worldwide [7] [8].Disrespectful care has been associated with future avoidance of healthcare facilities for birth [9].However, the suspected association between lack of respectful maternal care or obstetric violence by healthcare providers and poor maternal outcomes including maternal deaths has not been well studied.

Results
While 95% of all maternal deaths occur in low-and middle-income countries (LMICs), the United States faces a growing national crisis of maternal deaths [3] [11].Maternal mortality rates (MMR), defined as rates of death per 100,000 live births during pregnancy and up to one year postpartum, have more than doubled in the United States since the turn of the twenty-first century, making the US one of the few places in the world where maternal mortality is increasing [1] [10].In-hospital maternal deaths decreased for all racial and ethnic groups during 2008 to 2021 in the United States, while severe maternal morbidity increased [12].The discrepancy of increased overall national MMR with a reduced in-hospital MMR suggests improvement of in-hospital care but potential worsening of prenatal and postnatal factors.Four out of five maternal deaths are preventable [13].Twenty-one percent of deaths occurred during the prenatal period while sixty-five percent occurred 1 to 365 days postpartum, identifying the vulnerability to life-threatening events during both pregnancy and in the postpartum period [12] [13].Stark racial inequities underscore the concerning state of maternal health.In 2019, the MMR for Black mothers reached 69.9 deaths per 100,000 live births, compared with 26.6 for white mothers [10].The causes of maternal mortality are complex-increases in the average age and rates of chronic health conditions of US mothers, deferred care due to the COVID-19 pandemic, and improved reporting measures all play a role [14] [15].Non-obstetric causes of death have been increasing.In a US population-based cross-sectional study of over 80 million births from 2000 to 2019, 34.5% of deaths during pregnancy, childbirth, and within 42 days postpartum, were from non-obstetric causes such as transport accidents, accidental poisonings, homicide, and suicide [16].Homicide prevalence was 16% higher during pregnancy or within 42 days postpartum than in nonpregnant females of reproductive age especially in the Black population and exceeded all other causes of maternal mortality by more than two-fold [17].Additionally, maternal mortality rates differ by state, ranging from 14 per 100,000 births in Massachusetts, to 50 per 100,000 births in Indiana, to 72 per 100,000 births in Louisiana.These discrepancies may reflect reproductive healthcare funding restrictions and barriers to healthcare access in different states [18].
One factor that remains understudied in the United States is the experience of birthing individuals during childbirth care.Patient experience of care is not only a crucial quality and outcome metric, but also an important influence on morbidity and mortality outcomes.Emerging research into the treatment of birthing people during childbirth paints a concerning picture.About one in five US women reported experiencing mistreatment during childbirth.Mistreatment can vary from verbal abuse to lack of privacy, from coerced procedures to neglect [19] [20].Racial and ethnic disparities in maternal morbidity and mortality are mirrored in rates of reported mistreatment: Black, Hispanic, and multiracial women are more likely to report being mistreated [19] [20] [21].Inequities worsen when the birthing environment is not attentive to vulnerabilities including race, substance use, trauma history, language preference, educational level, disability, and immigration status [22].The perceived hostile environment of facility-based birth contributes to poor maternal mental health and can cause birthing individuals to avoid care in the future.In a prospective study of 634 nulliparous Black and White persons in their third trimester of pregnancy, 11.5% and 13.1% respectively said they felt safest giving birth out of hospital [23].This avoidance of care has a multigenerational impact.A birthing person's experience during a most vulnerable perinatal period impacts future reproductive choices, as well as future engagement in the medical systems.

Discussion
Pregnancy care is often the first major medical encounter that patients experience; in the United States, it is also a time when many patients can access insurance and medical care they otherwise may not have.For low-income families, Medicaid and public coverage is available to cover routine care and catastrophic expenditure that is not available for non-pregnant persons [24].Given that experiences during childbirth likely influence future interactions with the medical system, we stress the larger importance of respectful maternity care beyond solely the childbirth time frame.In addition, given the increasing out-of-hospital maternal mortality in the United States, all aspects of the medical experience that may prevent a pregnant or postpartum person from accessing life-saving care must be explored and understood.
As research on respectful maternity care continues to develop, it is important not only to champion equity, but also to delve into the root causes of inequity.In particular, the perspectives of physicians, nurses, midwives, and other birthing attendants are vital to a full understanding of the barriers to respectful maternity care.Providers possess unique insights into systemic issues that influence childbirth experiences.Their interactions with patients are shaped not only by individual identities and beliefs, but also by broader societal norms, structural determinants, and health system policies.Their perspectives are therefore crucial to identifying barriers to and designing interventions for respectful maternity care.However, minimal research exists on provider perspectives within the US-existing literature focuses on low-and middle-income countries [25].
While validated tools have been developed to assess patient experiences of obstetric violence, no such survey exists at the provider level.Provider burnout, moral distress, limited time, and burden of clinical responsibilities are known challenges to respectful and comprehensive medical care in general [26] [27].
Participation in studies exploring root causes of disrespectful childbirth care can empower nurses, midwives, and physicians to improve their environment and find solutions [28].Finally, research funding should incentivize the inclusion of providers as key stakeholders in the promotion of respectful maternity care.
To provide equitable, dignified, and just care during childbirth, understanding provider perspectives is crucial.Additionally, the identification of societal and medical infrastructural risk factors leading to the rising maternal mortality rate will allow educational and policy changes.As witnesses to and, unfortunately, arbitrators of mistreatment in childbirth, providers play a key role in the respectful maternity care movement.Their voices-in addition to patient perspectives-must be heard to better understand and dismantle structures that perpetuate birth inequity.

A
literature search was conducted to find relevant publications on maternal mortality and disrespectful maternity care.The search was conducted on the National Center for Biotechnology Information (NCBI) and PubMed (U.S. National Library of Medicine at the National Institutes of Health).The keywords, maternal mortality, United States, disrespectful maternity care, obstetric violence, provider perspectives, and disparities, were used and articles were analyzed for inclusion of healthcare provider perspectives.Maternal mortality statistics were obtained from the World Health Organization vital statistics and from the United States National Center for Health Statistics [1] [10].