Mothers' Experiences of Institutional Betrayal during Childbirth and Postpartum Mental Health Outcomes

Purpose: Emerging research suggests that betrayal by healthcare institutions could explain how negative birth experiences may lead to postpartum mental health disorders. The current study is the first to examine the role of experiencing institutional betrayal during childbirth (failure of a health system to meet a mother’s expectations in a way that harms the mother) in the prediction of and causal pathways to poor postpartum mental health outcomes for mothers in the US.

Participants & Methods: Mothers who had given birth in the last 3 years in the US as of June 2021 were recruited online. Participants (n = 612; 72% White; 100% women; median age between 27 and 36 years) responded to Qualtrics survey questions about their birth experiences, including adverse medical events, negative birth experiences, and experiences of institutional betrayal.

Data Analysis: Multiple logistic regression analysis was used to examine if experiencing instances of institutional betrayal (i.e., having procedure that was more painful than expected, not being notified of test results, etc.) significantly predicted postpartum mental health condition. Hierarchical regressions were used to examine whether institutional betrayal is a moderating variable, and R’s mediate package was used to determine if institutional betrayal mediates the causal pathway between negative birth experiences and poor postpartum outcomes.

Results: 48% of respondents experienced at least once instance of Institutional Betrayal, and their average number of IB experiences was 1.9 (SD = 1.10, max=5). Mothers who experienced institutional betrayal compared to those who didn’t were more likely to have been diagnosed with any postpartum mental health condition (p < 0.001). Experiencing more institutional betrayal instances increased a mother’s odds of a postpartum mental condition by 1.54 times (p < 0.005). Institutional betrayal was not a moderating variable, but it was a mediator between negative birth experiences and poor postpartum mental health outcomes.

Discussion: These findings can inform interventions to prevent poor postpartum mental health outcomes at the level of the individual patient as well as at the level of the healthcare system or institution. Further research should focus on postpartum mental health and birth equity by developing an additional adaptation of the IB questionnaire for childbirth for mothers of color, recruit a sample of mothers of color, and conduct analyses into causal pathways to postpartum mental health disorders for that population.