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OHSU leads national effort to define, evaluate standards for respectful maternity care

Amid U.S. crisis in maternal morbidity, death, researchers establish starting point for standard of care, accountability
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OHSU researchers Amy Cantor, M.D., M.P.H., center, and Ellen Tilden, Ph.D., C.N.M., right, aim to better define and measure respectful maternity care and develop a standard of care and accountability across health systems. (OHSU/Christine Torres Hicks)
OHSU researchers Amy Cantor, M.D., M.P.H., center, and Ellen Tilden, Ph.D., C.N.M., right, aim to better define and measure respectful maternity care and develop a standard of care and accountability across health systems. (OHSU/Christine Torres Hicks)

Oregon Health & Science University is leading national research efforts to determine the role that respectful maternity care, known as RMC, plays in improving the poor and worsening health outcomes for those who are pregnant and postpartum in the United States.

The study, funded by the by the Agency for Healthcare and Quality Research at the U.S. Department of Health and Human Services and published today in the Annals of Internal Medicine, aims to establish a better understanding of RMC, how it is defined and measured, and whether implementing RMC has an effect on important health outcomes for those who are pregnant — especially those at risk for experiencing health inequities.

Amy Cantor, M.D., M.P.H.
Amy Cantor, M.D., M.P.H. (OHSU)

“We are facing a growing maternal health crisis in this country, especially among Black women, with racism and implicit bias from health care providers being a significant contributing factor,” said Amy G. Cantor, M.D., M.P.H., associate professor medical informatics and clinical epidemiology, family medicine and obstetrics and gynecology in the OHSU School of Medicine and principal investigator and lead author of the study.

Maternal morbidity and death are worse in the U.S. than in all other high-income countries, and the U.S. Department of Health and Human Services, or HHS, reports overall maternal health continues to worsen and maternal health disparities continue to grow. Emerging research suggests disrespectful care during childbirth contributes to these problems.

“Addressing this crisis will require bold policy solutions and significant health care system reform, but we can’t create long-lasting, meaningful change without a clear vision of what respectful maternity care looks like,” Cantor said. “This work provides a much-needed starting point to develop that standard of care and accountability across health systems.”

Maternal health crisis

It is safer to be pregnant and give birth in all other high-income countries, as well as many moderate-income countries, than to be pregnant and give birth in the United States. This negatively affects the entire childbearing population, with the greatest impact on Black women.

The Centers for Disease Control and Prevention found that Black women are up to three times more likely to die from pregnancy-related complications than white women. They are also more likely to experience life-threatening conditions like preeclampsia, postpartum hemorrhage and blood clots and pregnancy-related complications like preterm birth and low birth weight.

These issues have persisted for generations due to longstanding failures to pursue adequate reproductive health research, policy and innovation, compounded by structural and systemic racism across health care settings.

In 2020, HHS launched a department-wide effort to improve maternal health outcomes, with RMC being critical to the effort. However, there was no universal definition of RMC; defining RMC and its components, as well as identifying tools to measure and implement safe and respectful care, was paramount to informing future program goals and addressing this national public health crisis.

OHSU researchers were awarded a $520,000 grant by Agency for Healthcare and Quality Research, or AHQR, a division of HHS focused on improving the safety and quality of health care. AHRQ commissioned the work as part of this federal initiative, and the systematic review was also included as a key component of the White House Blueprint for Addressing the Maternal Health Crisis.

This research will be used by federal and non-federal agencies, clinicians, patients and policymakers to help inform a clearer understanding of RMC and its effectiveness on maternal and infant health outcomes and patient experiences.

Giving birth with dignity, autonomy

In a systematic review, the research team identified 12 RMC frameworks and isolated key components and themes to inform consensus around a universal definition.

Two main concepts were identified: disrespect and abuse, which focus on recognizing mistreatment during the birth experience; and rights-based, which includes reproductive justice, human rights and antiracism.

Additionally, there were overlapping themes that researchers focused on, including freedom from abuse, consent, privacy, dignity, communication, safety and justice.

The team developed a definition using the data collected; through consideration of the history and concepts within the frameworks and their overlap; and with input from clinical and content experts:

Respectful maternity care: An approach to maternity care that honors the dignity, personhood, autonomy, and preferences of birthing people; prevents disrespect, mistreatment, or abuse toward individuals who are using maternal care services; and provides a practical paradigm for the delivery and receipt of peripartum care through a rights and reproductive justice-based framework.

Researchers say this work will have widespread impacts on health systems, clinicians and patients.

Ellen Tilden, Ph.D., C.N.M.
Ellen Tilden, Ph.D., C.N.M. (OHSU)

“Research tells us that ‘delay, denial and dismissal’ are key drivers of U.S. maternal morbidity and mortality and these drivers directly tie to issues of respect,” said Ellen L. Tilden, Ph.D., C.N.M., associate professor of nurse-midwifery in the OHSU School of Nursing and of obstetrics and gynecology in the OHSU School of Medicine, and co-investigator of the study.

“Disrespectful maternity care can include unconsented procedures, poor communication, and failure to listen or respond to concerns or symptoms. Unfortunately, these patient experiences are all too common,” Tilden said. “This work is an important step, but we still have a long way to go. It’s critical that clinicians, health system leaders and policymakers continue to work together and take intentional, tangible actions to improve the health of mothers and birthing people in this country.”

Researchers note there are additional factors to consider in RMC, and say concerted efforts need to be made to address the effects of obstetric trauma, violence and racism.

“We really want to encourage care teams to understand the prevalence of prior and potential trauma and its effect on the birth experience,” Cantor said. “Ultimately, we are working to build a health system where everyone is heard, listened to and provided the safe, respectful care they deserve.”

This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00006). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

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