Black people in the U.S. are twice as likely as white people to be coerced into procedures during perinatal and birth care, and to undergo them without their explicit consent, according to a new study by researchers at UBC’s Birth Place Lab and the University of California San Francisco (UCSF). Pregnant people of other minoritized racial identities also experience pressure from providers at higher rates than white counterparts.
The findings, published today in the journal Birth, reveal key contributing factors to the persistent racial inequities in reproductive health in the U.S. The researchers believe this to be the first large study comparing experiences of coercion and consent during pregnancy and childbirth across racial and ethnic identities.
“The coercion and unconsented procedures experienced by Black, Indigenous and people of color (BIPOC) during birth is deeply concerning,” said senior author Dr. Saraswathi Vedam, a professor of midwifery at UBC and lead investigator at the Birth Place Lab. “This illuminates how racism and discrimination affect people’s experiences of care.”
Dr. Vedam says the problem is not unique to the U.S. Her team is currently investigating the differences in birth experiences and outcomes across Canada through a study titled RESPCCT. The research team has collected more than 6,000 survey responses from childbearing people across Canada.
“We know that there are tremendous health inequities in Canada, and that Indigenous, Black and people of color continue to experience racism and discrimination within the health system,” said Dr. Vedam. “Our preliminary analysis of the Canadian data suggests that birthing people here experience many of the same challenges.”
People who had a C-section 30 times more likely to report pressure
For the new paper, the researchers analyzed data from the Giving Voice to Mothers study, which recorded pregnancy and birth experiences of 2,700 people in the U.S. between 2010 and 2016. They examined survey responses from a subset of 2,490 participants who reported experiencing pressure or unconsented procedures or interventions during perinatal care. Of the participants, 34 percent self-identified as BIPOC.
Overall, 31 percent of all respondents reported experiencing pressure to accept perinatal procedures, such as:
Induction—using drugs to speed up labor
Epidurals—injecting anesthesia around the spinal cord to block labor pain
Episiotomy—incision made at the opening of the vagina during childbirth
Fetal monitoring—using tools to monitor and interpret the baby’s heartbeat during labor and birth.
Forty-one percent reported unconsented procedures, including injection before delivering the placenta, episiotomy or breaking someone’s water bag. In addition, 10 percent reported pressure to have a C-section. Notably, participants who had a C-section reported were 30 times more likely to report pressure to have a C-section than those who ultimately had vaginal births.
Providers more likely to listen to white pregnant people when they declined care
Respondents with Black racial identity reported experiencing unconsented procedures during perinatal care 89 percent more frequently and, during vaginal births, 87 percent more frequently than white respondents. People who identified as Asian, Latinx, Indigenous or multiracial reported experiencing pressure to accept perinatal procedures 55 percent more often than white respondents.
“These findings are alarming given the long history of obstetric racism and higher rates of adverse birth outcomes among Black, Indigenous and people of color in the U.S.,” said first author Dr. Rachel G. Logan, a postdoctoral scholar in the UCSF department of family and community medicine. “They suggest that provider pressure and lack of consent processes may be playing a significant role in driving these inequities.”
Though in this sample there was no racial or ethnic difference in the experience of pressure to have a C-section, a higher proportion of Black respondents had the procedure. This is similar to higher rates of C-section found in the U.S. Black population.
Black and white pregnant people declined care at the same rate, yet practitioners were more likely to accept the wishes of those who identified as white and were more likely to proceed with the procedure without consent when people who identified as Black declined care.
Centering health equity and human rights can transform care
The authors say action is needed to transform care experiences and to ensure that health equity and human rights are at the center of care provision. In particular, they recommend incorporating human rights-based frameworks into health professional curricula. In addition, they say health systems and perinatal providers need:
A process for informed decision-making and consent that is free of coercion.
To prioritize engaging in informed choice discussions during intrapartum care to ensure ethical principles are upheld, even during emergencies.
To establish in-service training and certification focused on person-centered decision-making, respectful communication and racial literacy.
“Our findings call for practitioners, health law, and health care systems to face the reality of unconsented care, and to address these illegal and unethical acts,” said co-author Dr. Monica R. McLemore, an associate professor with the UCSF department of family health care nursing.