Overuse of medical procedures has been identified as a significant issue in maternity care, with nearly a third of births delivered by cesarean section, and over 20% of births following an induction of labor. Yet limited research has examined the relationship between pregnant women and their providers and how this shapes decision-making and care utilization in childbirth. Moreover, women are not all at equal risk of receiving an unnecessary medical procedure such as a cesarean during childbirth; recent studies suggest that Black women and less-educated women actually have higher rates of cesarean delivery than their White and more-educated counterparts, after accounting for medical complications, but the reasons for this are not understood. Using two sources of survey data from women who recently gave birth, I examined 1) the role of the patient-provider relationship in use of labor induction and cesarean delivery, and 2) whether aspects of the patient-provider relationship account for race/ethnicity and socioeconomic status (SES) differences in use of these procedures. Data were from the Listening to Mothers III survey (N=2,400) for analyses of communication quality during prenatal care and perceived discrimination during the birth hospitalization, and the First Baby Study (N=3,006) for analyses of involvement in decision-making. While I had hypothesized that positive characteristics of the patient-provider relationship would be associated with lower use of labor induction and cesarean delivery, I found that patient-reported communication quality in prenatal care was not associated with use of either procedure, and that women who experienced discrimination during their birth hospitalization were less likely to deliver by unplanned cesarean. Women who felt more involved in decision making regarding their delivery had lower odds of labor induction and lower odds of cesarean delivery, but the reduction in odds was similar regardless of whether the procedures were performed without a definitive indication (i.e. those more likely to represent overuse). None of the aspects of the patient-provider relationship that I examined mediated the relationship between race or SES and cesarean delivery. However, involvement in decision making was associated with larger reductions in odds of cesarean delivery among Black women than among White women. Communication quality, involvement in decision making and respectful treatment of patients (i.e. lack of discrimination) are necessary for patient autonomy and building trust in the patient-provider relationship; however, my findings suggest that improving these aspects of the patient-provider relationship may not reduce overuse of medical procedures specifically. However, increasing involvement in delivery decision making could have the potential to reduce racial/ethnic disparities in cesarean delivery. Strategies aimed at increasing the prevalence of patient-centered care need to be adapted and implemented for the maternity care context – particularly the intrapartum context – and executed alongside strategies targeting reduction in use of unnecessary procedures.
University of Minnesota Ph.D. dissertation.June 2016. Major: Health Services Research, Policy and Administration. Advisors: Donna McAlpine, Katy Kozhimannil. 1 computer file (PDF); x, 269 pages.
Characteristics of the Patient-Provider Relationship and Use of Labor Induction and Cesarean Delivery.
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