Associations of Midwife-Attended Birth with Medicalization of Childbirth, Autonomy in Care, and Maternal Mistreatment in Hospital Settings: A Cross-Sectional Study of Responses to Listening to Mothers in California 2018 Survey

Abstract

Background: Over-medicalized childbirth in the United States is increasing, prioritizing efficiency of managing specific diagnosed symptoms over autonomy and preferences of the birthing parent. While medical interventions can be lifesaving in many circumstances, they may be overemployed, creating long-lasting health implications for the parent and infant. Midwife-attended birth offers an alternative personalized model of birth that addresses these concerns. This study investigated associations of midwife-attended birth (labor and delivery) in relation to uptake of interventions, autonomy of care, and mistreatment during care. Methods: Study participants consisted of Listening to Mothers in California 2018 survey respondents, mothers (n=2,500) who gave birth to a singleton baby between September 1 and December 15, 2016. Exposure was defined as labor and delivery care attended by a midwife. Outcomes were composite measures of interventions received during labor and delivery (overmedicalization defined as 8 or more interventions), pressure (at least once) to undergo specific interventions during intrapartum care, and mistreatment (at least once) by healthcare personnel. Outcome-specific unadjusted and adjusted logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CIs). Adjusted models included variables for race, ethnicity, insurance type, and income. Results: Average maternal age of participants was 29.4 years (SD: 5.72). About half (53.1%) of the deliveries were paid for by private insurance, while the other half (46.2%) were mostly paid for by Medi-Cal. Plurality of participants were white (46.8%), non-Hispanic or Latina (55.3%), married or living with someone as though married (59.7%), with some college education but no degree (25.0%), and had household income between $16,000 and $32,000 before taxes (24.9%). Overall, 248 (12.8%) had midwife-attended birth. Higher percentages of participants with midwife-attended birth were White, married, with graduate education, privately insured, and have higher income, compared with participants without midwife-attended birth. Participants with midwife-attended birth had lower prevalences of over-medicalized birth (18.1% vs. 21.4%, p-value=0.280), pressure to undergo unwanted medical interventions (41.9% vs. 45.3%, p-value=0.357), and mistreatment during childbirth (12.5% vs. 17.8%, p-value=0.047). Compared with participants without midwife-attended birth, participants with midwife-attended birth had 20% lower (aOR:0.80; 95% CI: 0.55-1.15) odds of over-medicalized birth, 21% lower (aOR=0.79, 95% CI: 0.60-1.04) odds of experiencing pressure to undergo unwanted medical intervention during birth, and 24% lower (aOR=0.76, 95% CI 0.5-1.12) odds of mistreatment by maternal care providers, though estimates were not statistically significant. Conclusion: Birthing individuals with midwife-attended intrapartum care had 20-24% lower rates of over-medicalized birth, pressure to undergo unwanted medical interventions, and mistreatment during birthing care, although associations were not statistically significant.