Disparities in Autonomy during Pregnancy in Canada: Findings from the national RESPCCT Study

To date, the discourse on bodily autonomy has been narrowly focused on contraception and abortion and needs to be expanded to include experiences of agency during pregnancy and birth. Disrespect and mistreatment are widely reported in low resource countries but very little is known about experiences of perinatal care in high resource countries and how to improve care for minoritized populations. MethodsWe examine experiences of autonomy in decision-making during pregnancy among people who were pregnant in Canada between 2009 and 2022, using a large national dataset of patient-reported experiences and outcomes that were collected via a cross-sectional online survey. We measured autonomy with a globally validated patient-reported experience measure, the My Autonomy in Decision-Making (MADM) scale. To assess variations in autonomy by identity or life circumstances, we conducted multivariable regression analyses, controlling for pregnancy year, repeat observations, and place of residence and stratifying by model of care (physician or midwife-led). In a separate analysis, we tested contextual factors such as onset of prenatal care, length of appointments, and model of care (physician-led or midwife-led) that might reduce disparities in autonomy among minoritized childbearing people. FindingsDiverse participants (n=5389) reported on 7049 interactions with healthcare providers. In the adjusted models, autonomy scores were significantly lower among those with high school education or less (physician-led care: IRR=0.86, 95 % CI: 0.82-0.92; midwife-led care: IRR=0.93, 95% CI: 0.88-0.98) and newcomers to Canada (physician-led care: IRR=0.97, 95 % CI: 0.93-0.99). Scores were higher among pregnant people with majorized identities and circumstances, i.e. those who reported low discrimination (physician-led care: IRR=1.21, 95 % CI: 1.15-1.26; midwife-led care: IRR=1.06, 95% CI: 1.02-1.11), no disability (physician-led care: IRR=1.07, 95 % CI: 1.02-1.13; midwife-led care: IRR=1.04, 95% CI: 1.00-1.09), no need for social services (physician-led care: IRR=1.11, 95 % CI: 1.04-1.19; midwife-led care: IRR=1.13, 95% CI: 1.06-1.21), identified as heterosexual (physician-led care: IRR=1.10, 95 % CI: 1.06-1.15; midwife-led care: IRR=1.03, 95% CI: 1.01-1.06), Cis gender (midwife-led care: IRR=1.08, 95% CI: 1.01-1.16), and had sufficient income to meet financial obligations (physician-led care: IRR=1.18, 95 % CI: 1.11-1.24), compared to the reference groups. Several modifiable factors were linked to higher autonomy, including early entry into prenatal care, sufficient time during prenatal appointments, and midwife-led care. Midwife led care was the only contextual factor that was associated with significant increases in autonomy scores for minoritized people. ConclusionsSelf-determination, including the ability to lead decisions during pregnancy, birth and the postpartum period, is a reproductive right, yet minoritized communities reported significant loss of autonomy. Differences persisted across models of care, pointing to structural inequities in patient-led decision-making during pregnancy.