Disparities in Perinatal Care
Quantitative findings on respect, autonomy, mistreatment and body mass index in a national Canadian survey
BMC Pregnancy and Childbirth, Volume 24, Article 737, Published 8 November 2024, DOI 10.1186/s12884-024-06928-8
What did this study examine?
Weight stigma in healthcare had previously been documented through qualitative studies, patient accounts and surveys of healthcare professionals. What was missing was large-scale quantitative evidence showing whether experiences of maternity care changed systematically across BMI categories.
This study used three patient-reported experience measures to assess autonomy, respect and mistreatment among 3,280 participants in the pan-Canadian RESPCCT survey. It examined whether experiences deteriorated as pre-pregnancy BMI increased and whether BMI remained associated with care experiences after accounting for race or ethnicity, income, education and age.
The findings show a graded pattern: as BMI increased, autonomy and respect declined and mistreatment increased. The analysis also found independent inequities affecting Indigenous Peoples and non-Indigenous racialized participants.
Key adjusted findings
Reduced autonomy
Participants with BMI ≥35 had 45% higher adjusted odds of being in the lowest tier of autonomy scores.
Mistreatment
Participants with BMI ≥35 had nearly twice the adjusted odds of high mistreatment scores.
Indigenous identity
Indigenous participants had more than twice the adjusted odds of high mistreatment scores.
Racialized identity
Non-Indigenous racialized participants had higher adjusted odds of mistreatment.
What is the study’s main contribution?
From reported incidents to measurable population-level disparities
Earlier studies had documented episodes of weight-related disrespect and provider bias. This research asked whether those experiences could be detected systematically in a large national sample using person-centred measures of care.
The results move the evidence beyond isolated accounts. They show that differences in autonomy, respect and mistreatment are visible across BMI categories and persist after statistical adjustment.
How was respectful maternity care measured?
Mothers’ Autonomy in Decision Making
A seven-item measure assessing whether healthcare providers facilitate autonomy and meaningful involvement when discussing care options.
Mothers on Respect Index
A seven-item measure covering comfort asking questions, accepting or declining care, coercion and cultural respect.
Mistreatment Index
An adapted 15-item index capturing different forms of mistreatment and disrespectful behaviour by healthcare providers.
What patterns emerged?
Participants with BMI ≥35 had adjusted odds of 1.45 for low autonomy and adjusted odds of 0.71 for being in the highest autonomy tier, compared with participants in the reference BMI category.
The odds of low respectful-care scores increased progressively across BMI categories. Participants with BMI ≥35 had the largest observed disparity in respectful care.
Adjusted odds of high mistreatment scores increased from 1.45 among participants classified as overweight to 1.79 for BMI 30–34.9 and 1.95 for BMI ≥35.
Indigenous participants had higher adjusted odds of low autonomy, lower odds of high respectful-care scores and 2.26 times the adjusted odds of high mistreatment scores.
Non-Indigenous racialized participants also had higher adjusted odds of low autonomy, lower odds of high respectful-care scores and 1.33 times the adjusted odds of high mistreatment.
Greater income sufficiency and older age were generally associated with better reported care experiences, demonstrating that socioeconomic position also shapes the experience of perinatal care.
Study design
Survey
RESPCCT: Research Examining Stories of Pregnancy and Childbearing in Canada Today.
Sample
3,280 participants with pre-pregnancy BMI ≥18.5 and complete data for the analysis.
Geographic coverage
Experiences of perinatal services reported across Canadian provinces and territories.
Analysis
Multivariable logistic regression adjusting for identity, income, education and age.
Implications for healthcare systems
Measure experiential quality
Health-system performance reporting should not rely only on clinical outcomes, procedures or access. Respect, autonomy, communication and mistreatment are measurable dimensions of quality.
Recognize weight stigma as a quality issue
Weight stigma should be addressed as a patient-safety and healthcare quality concern, not only through individual counselling or weight-management approaches.
Avoid generic approaches to bias
Weight stigma, anti-Indigenous racism and racial discrimination do not operate through identical mechanisms. Each requires specific recognition, measurement and accountability.
Support informed decision-making
Clinical guidance related to BMI should not displace individualized discussion, bodily autonomy, informed consent or the patient’s right to participate meaningfully in decisions.
Publication and policy resources
Published article
Read the open-access peer-reviewed article in BMC Pregnancy and Childbirth.
Open the DOI recordFull article PDF
Download the publisher’s open-access PDF under the article’s Creative Commons licence.
Download the full paperOne-page policy brief
A concise summary of the findings, measures and implications for healthcare quality and equity.
Download the policy briefPublic-facing explanation
Explore how patient-reported experience measures make inequities in perinatal care visible.
Read the LinkedIn articleHealth Equity Research Hub
See related work on pregnancy loss, Indigenous perinatal care, coercion, consent and Canadian health-system access.
Explore the research programmeORCID record
View Nisha Malhotra’s research record and publication identifiers.
Open ORCIDQuestions this research answers
Can weight stigma in maternity care be measured at the population level?
Yes. This study used validated patient-reported measures and national survey data to show that experiences of autonomy, respect and mistreatment changed systematically across BMI categories. The results therefore move the evidence beyond individual accounts of stigma to measurable population-level disparities.
Does higher BMI remain associated with poorer care after adjustment?
Yes. BMI remained associated with autonomy, respect and mistreatment after accounting for race or ethnicity, income, education and age. Participants with BMI ≥35 had 45% higher adjusted odds of low autonomy and 1.95 times the adjusted odds of high mistreatment.
Do weight stigma, anti-Indigenous racism and racial discrimination independently shape care?
The mutually adjusted models indicate that BMI, Indigenous identity and racialized identity each remained associated with poorer experiences. This does not mean the mechanisms are identical. It means each form of inequity remains independently visible in reported care experiences and requires a specific response.
Why are PREMs important for health-system quality?
Administrative data can show whether a service was delivered, and clinical data can show health outcomes. PREMs answer a different question: whether patients were heard, respected, involved in decisions and protected from mistreatment while receiving care.
Does universal healthcare coverage eliminate inequities in maternity care?
No. Universal coverage reduces important financial barriers, but it does not by itself ensure equitable treatment. This Canadian study demonstrates systematic differences in autonomy, respect and mistreatment associated with BMI, Indigenous identity, racialized identity, income and age.
How to cite this research
Malhotra, N., Jevitt, C. M., Stoll, K., Phillips-Beck, W., Vedam, S., & the RESPCCT Study Team. (2024). Weight-based disparities in perinatal care: Quantitative findings of respect, autonomy, mistreatment, and body mass index in a national Canadian survey. BMC Pregnancy and Childbirth, 24, Article 737. https://doi.org/10.1186/s12884-024-06928-8
Licence: The published article is open access under a Creative Commons Attribution 4.0 International licence, subject to the publisher’s terms for included third-party material.