When it comes to childbirth, a new major survey of more than 2,500 women in California finds a significant disconnect between the maternity care they want and the care they end up getting. The results of Listening to Mothers in California, released today, reveal what is and isn’t working with maternity care in the Golden State, including significant differences by race, ethnicity, and insurance status.

The survey was conducted in 2017 by a broad team led by the National Partnership for Women & Families. The California Health Care Foundation was the lead funder. The research is based on the highly respected and widely cited Listening to Mothers national surveys, and this marks the first time the survey has been conducted at the state level and in Spanish. The team also oversampled Black women to better understand their experiences. Related resources delve into important subtopics, including issue briefs focused on disparities in maternity care experienced by Black, Latina, and Asian and Pacific Islander women.

Seeking Less Intervention, Getting More Instead

According to the survey, women report receiving too many interventions that are, according to research, unwanted and unneeded. For example, 74% of Californian mothers agree that childbirth should not be interfered with unless medically necessary, yet only 5% gave birth with no medical intervention. The survey found that Black and Latina women and women with Medi-Cal coverage held this belief most strongly.

Among the findings:

• One in three women overall, and more than one in four women with low-risk pregnancies, gave birth by cesarean section (c-section). Both rates are higher than recommended by experts at the World Health Organization and in California.
• Four in ten women reported that a health professional tried to induce their labor by using medicine or other methods to try to cause labor to start. Three-quarters of women who felt pressured to have labor induced in this way ended up having the procedure.
• While only 9% of women had a midwife as their birth attendant, 17% said they would definitely want one, and 37% said they would consider one for a future birth. Research consistently finds that midwives provide high-quality, cost-effective, and satisfying care.
• An estimated 9% of respondents used a labor doula during childbirth. However, 57% expressed interest in doula care should they have a future birth, with Black women showing the greatest interest.

“The results of Listening to Mothers in California underscore that women are not receiving the kind of care they seek during childbirth,” said Debra L. Ness, president of the National Partnership for Women & Families. “The message is loud and clear: Women want greater access to proven, high-value forms of care, including greater access to midwives, doulas, and birth centers. Unfortunately, these options are not nearly as available as they should be. We need to improve maternity care and policies for women in California as well as nationwide.”

Large Disparities for Black Women
While the survey finds room for improvement in care and outcomes across all groups of women, the disparity between Black and white women is particularly stark:

• A c-section rate of 42% for Black women compared to 29% for white women
• A vaginal birth after cesarean (VBAC) rate for Black women that is half the rate for white women (8% compared to 16%), although VBAC rates were extremely low across the board
• More frequent reporting of symptoms of anxiety and depression (30% prenatal anxiety compared to 20% for white women; 20% prenatal depression compared to 10% for white women)

Undertreatment of Depression and Anxiety
Perinatal mood and anxiety disorders are the most common medical complications of pregnancy and childbirth (these include prenatal and postpartum depression, anxiety, and, in extreme cases, postpartum psychosis). Left undetected and untreated, these conditions can lead to negative health outcomes for the mother. They can negatively affect the mother-child bond and the child’s long-term physical, emotional, and developmental health. Additionally, the financial cost of untreated maternal mental health conditions can be significant (for example, more use of emergency care services, and lost days at work).

Survey respondents were more likely to report symptoms of anxiety (21%) than depression (11%) during pregnancy. Only one in five women who reported symptoms of anxiety or depression before giving birth got help, and only one in three with symptoms did so after they had their baby.

“We know what works with childbirth in this country, we just aren’t doing it,” said Stephanie Teleki, PhD, director of learning and impact at CHCF. “The status quo for too many California women, particularly Black mothers, is care that produces poor outcomes, is not in keeping with their preferences, and is often needlessly expensive. That needs to change.”

Additional Resources
A variety of related resources are available at www.nationalpartnership.org/ltmca and www.chcf.org/listening-to-mothers-ca, including:

• The full survey report
• Issue briefs on the experiences of women of color
• A data snapshot with slides highlighting findings from the survey
• An infographic on the overmedicalization of childbirth
• Fact sheets on maternal mental health, c-section, and care arrangements
• Documentary videos featuring stories from patients and providers
• The questionnaire

About the California Health Care Foundation
The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.