Our recent study finds: the patient-provider relationship is a key factor in shaping perinatal quality of care, with downstream effects on both mom and baby

A new study from the Center for Early Relational Health’s Marissa Lanoff, MA, shows that perceived quality of perinatal care shapes mothers’ healthcare experiences, with potential lifelong impacts on families.

The experience of healthcare affects our health

Science is now confirming what we have long felt: relationships between patients and their care providers really matter. It’s not just meeting clinical standards that impacts well-being; the patient’s subjective experience plays a significant role in health outcomes. And that’s especially important in perinatal care, where outcomes impact not just one person, but two.

A new paper from the Center for Early Relational Health analyzed mothers’ firsthand accounts to look specifically at this interpersonal aspect of perinatal care. Led by Marissa Lanoff, MA, the study found that patient-provider interactions had lasting impacts on how moms felt about their care more than two years after giving birth. 

Underscoring the link between quality of care and trust in medical institutions, the data indicate that many of today’s young families, especially those who had their babies starting in 2020, may have had negative experiences. That’s critical, because negative birth experiences can impact outcomes like stress, depression, breastfeeding, and even the developing relationship between a mother and infant — with potential lifelong impacts for both. 

“This finding has major implications for practice and policy,” says Center Director Dr. Dani Dumitriu. “It’s concerning, but it’s also unexpectedly hopeful: we might not be able to control whether a mom experiences a medical complication, but quality of care is related to aspects of relationships that we may be able to change: like feeling supported and in control, a provider’s communication style, earned provider trust, and feeling respected by those around you.”

This study strengthens a growing body of research on the importance of the birth experience in shaping future health outcomes, and crucially widens the scope of that importance to include patient-centered care throughout pregnancy and the postpartum period. Because what happens during this critical developmental window can profoundly affect well-being for moms and babies.

An unexpected opportunity to study the impacts of critical perinatal risk factors

The study illuminates an urgent need for practice and policy changes that address the drivers of perceived quality of care. And the most impactful place to start is known risk factors for this especially vulnerable population: care disruption and the compounding effects of toxic stress. 

The uncertainty of the pandemic created an unprecedented opportunity to study firsthand accounts of these risk factors. Birth plans and preparation are known to reduce maternal stress and protect against adverse birth outcomes — but when our COMBO Initiative began enrolling pregnant moms in early 2020, perinatal care had been dramatically disrupted. All over the country, moms were having to change their planned birth location, be separated from their partners and support systems, and even be separated from their newborns after delivery.

“Of course, these disruptions resulted from hospitals striving to protect everyone’s health during a time of enormous uncertainty,” Marissa says. “But policy in this area can become very personal. People make decisions about what happens to your baby or who’s allowed to be with you in labor, and losing these very basic forms of autonomy can be detrimental.” 

Mandated newborn separation, for example, worsened maternal depression and anxiety symptoms. That’s why COMBO mobilized so rapidly in 2020, generating the science needed to reverse those separation policies. With that policy reversal, we were able to help reunite millions of families.

“But we could only do that once we had the science,” says Marissa. “It’s hard to navigate everyone’s best interest in a crisis. There wasn’t any evidence when these decisions initially had to be made, so we didn’t have evidence-based recommendations. That’s not the clinicians’ or hospitals’ fault — they were also wading through this landscape of ever-changing medical guidance and policy shifts. But those changes left many families feeling stressed, scared, and alone.”

How can this science make a lasting difference for families?

Disrupted care and negative birth experiences during this time worsened maternal outcomes including mental health, stress, and birth-related post-traumatic stress disorder (PTSD). And because maternal-infant health is a two-way street, that can also impact a child’s well-being — as well as vital aspects of their developing relationship. 

One of our recent studies (co-authored by Marissa) showed that birth satisfaction correlates with bonding and emotional connection in the first year of life, with potential lifelong implications. Notably, it wasn’t medical risk (like an unplanned cesarean or a NICU stay) that impacted these relational outcomes; it was mom’s subjective experience of provider communication and feelings of safety. 

Meanwhile, an earlier COMBO study found that infants born between March and December of 2020 showed differences in temperament and neurodevelopment at 6 months. That may well be the result of maternal stress, a key risk factor for fetal and infant development that rose dramatically starting in 2020. But lower perceived quality of care can in itself increase maternal stress, resulting in a kind of domino effect, as Dani explains: “If mom doesn’t feel listened to or doesn’t trust her provider, that can be extremely stressful. Then, even if it’s no one’s fault, that baby is now growing in an environment of heightened stress, which we know can impact their development even years down the line.” 

These findings have critical implications for the way we support parents and children — especially when so many of today’s young families had their babies during this time of disrupted care and heightened stress.

A frontline physician in the newborn nursery, Dani saw firsthand the impacts this profoundly stressful environment had on both new moms and providers. “It’s important to think about how we, as perinatal clinical providers, can reframe our approach with families so that they feel safe, listened to, and understood,” she says. “How can we not just better treat, but actively prevent negative birth experiences and the consequences of disrupted care — which continue to this day for many families.”

Breaking down research silos to meet families real-world needs 

Meaningfully improving subjective quality of care hinges on understanding patients’ firsthand experiences. Even when care meets objective clinical standards, families’ felt experiences influence whether they trust their providers, heed their advice, and seek care again. For pregnant patients, that is doubly important.

To understand the modifiable aspects of the patient-provider relationship that shape quality of care — and how we might leverage them to improve health outcomes — our team did something crucial: they interviewed moms directly. 

“It is essential to include the communities we’re studying in the conversation, rather than making decisions on their behalf,” says Marissa. “It helps us ask better questions, get to findings that reflect their experiences, and hopefully influence policy change to implement the things that directly support families.”

The interviews confirmed that giving birth between 2020-2021 worsened families’ perinatal healthcare experiences — and illuminated specific domains of the patient-provider relationship that led to this decreased perception of care quality.

These experiences include struggling to receive timely and adequate care; delayed, uncivil, or rushed communication; language barriers (moms frequently noted the absence of in-person translators, a reliance on virtual translation, and uncertainty about whether their words or their provider’s words were accurately conveyed); feeling stereotyped or unfairly judged; and having difficulty finding a provider who understood their lived experience.

"This might sound disheartening, but it’s actually good news,” says Marissa. “If we can work backwards, these areas then become things we can change. This kind of evidence helps us get to what might actually work in the real world: gathering moms’ firsthand accounts points a compass toward relational experiences we can now begin to address to improve perinatal healthcare.”

One clear theme that emerged from the mothers’ accounts was discrimination. That’s concerning for many reasons, including the fact that even one experience of health care discrimination is associated with higher levels of birth-related PTSD and postpartum stress. 

Many moms struggled to say whether negative provider interactions stemmed from pandemic-related disruptions, discrimination, or both (an ambiguity the paper terms the Murky Waters phenomenon). These “Murky Waters” are significant for maternal health, as research suggests that ambiguous forms of discrimination can produce greater stress than overt acts because of this uncertainty. 

With the perinatal window being such a critical period for both maternal well-being and fetal development, these experiences may have multi-generational health implications: it is well established across pre-pandemic studies that discrimination can impact not only maternal health, but also serious infant outcomes like preterm birth, low birth weight, and physiological markers of stress.

“The pandemic didn’t create these problems,” Marissa says, “it exacerbated them and made them impossible to ignore. Strong provider-patient relationships are foundational to high-quality care, yet moms in our study faced this ‘double jeopardy’ of pandemic-related healthcare strain and discrimination-based stress.” 

But she also says something wonderful came out of these interviews: “It can be so hard to talk about difficult experiences in pregnancy, birth, and motherhood. But here, you have all these moms describing a collective experience. So to me, this paper communicates that you’re not alone.”

So what can we do to better support these vital parent-provider relationships?

This study builds on a growing body of research with enormous potential to support young families. We’re learning so much about the power of parent-child relationships to architect well-being. And now, we’re seeing that parent-provider relationships matter too: for moms, babies, and the health-promoting connection between them. 

The pandemic was a time of stress and fear for providers, too, who were caring for patients while facing tremendous personal risk. “It’s not ‘us versus them,’” Marissa emphasizes. “Providers are also not often included in designing these systems, and there are lots of things that get in the way of them being able to develop the relationships they hope for with their patients. Understanding how our systems falter during vulnerable times, and how that affects health, can help us ultimately redesign these systems to really work for both families and the clinicians who care for them.”

After all these interviews, the impression Marissa was left most strongly with was resiliency: “These mothers experienced so much hardship and stress — and yet they had this unbelievable resiliency. They advocated for themselves in medical spaces; they found ways to connect with their communities and support each other.” 

“It is absolutely vital to look not only at the deficits of this time, but also to ask: what went right,” Marissa urges. “How did people stay resilient in the face of these hardships, sometimes even turning them into positive change?” Ultimately, that’s the foundation of our strengths-based research: uncovering the science behind how we can all build resiliency, with relationships at the core.

Want to Learn More?

Back to top