Interview with Carol Sakala, Listening to Mothers in California Lead Researcher

Sakala interview hero.jpgA new report, Listening to Mothers in California, was released last week and there is valuable information for both consumers and birth professionals to be found from this research.  While this is the first survey done at the state level, there have been three prior national Listening to Mothers surveys released in 2002, 2006, and the last national survey in 2013. Listening to Mothers surveys describe women’s childbearing experiences from before pregnancy through the postpartum period, and their views about these matters. They are important because they give voice to the parents' experiences during the childbearing year.  I shared some key highlights and resources available as part of the extensive coverage of this report in an earlier post - "Listening to Mothers in California: New Survey Results Give a Voice to State's Mothers" that you may want to read first.  Today, I interview Carol Sakala, PhD., Director of Childbirth Connection programs at the National Partnership for Women & Families and one of the lead researchers along with Eugene R. Declercq, PhD., professor of community health at Boston University.  I wanted to know more about the survey and had some questions about the research and am grateful for the opportunity to talk with Dr. Sakala about this valuable project and share her answers with you all here.

Sharon Muza: Why is it both important and helpful to examine these issues on a state level? Was California chosen as the first state to be surveyed because of the number of births or another reason?

Carol Sakala: California does have 12% of all births in the nation. However, we carried out the first state-level survey there because the California Health Care Foundation and the Yellow Chair Foundation wanted Listening to Mothers in California survey results to help state stakeholders make a difference for childbearing women and newborns. They recognized tremendous opportunities to improve the quality, experience, and outcomes of care and to improve how families fare throughout and beyond the childbearing year. They understood that the voices and experiences of childbearing women must be front and center in these efforts. 

Relative to the national population, California has important demographic differences, including more Latinas, Spanish speakers, and women born in other countries and fewer Black women. By making the survey questionnaire available in Spanish, we could closely reflect the demographic composition of the state. (Unfortunately, we could not accommodate those who were unable to participate in English or Spanish.) We also customized the survey to shed light on current maternity concerns in the state, such as cesarean overuse and public reporting of hospital performance. This population-based state-level survey provides high-level decisionmakers, advocates and other stakeholders with timely, relevant information that is germane to their population, and also breaks the results down by key subgroups.

Sharon Muza: Where there any results that surprised the research team? Something you learned that was not expected?

Carol Sakala: We included an anxiety screener for the first time and found that symptoms of anxiety appear to be experienced more frequently than symptoms of depression, both during pregnancy and in the postpartum period. The focus on perinatal depression is needed but we also need to address the burden of anxiety for several reasons, including our growing realization that stress during pregnancy is associated with adverse outcomes. In our report, we identified roles for both prevention and treatment of these common maternal mental health conditions.

Overall, most results were similar to our past national results. Of great concern, results for Black women are in line with what we are finding nationally in our surveys and beyond – many instances where their results were on the worst end of the spectrum. I think it’s important for all to understand that Black women most frequently agreed that it is important to avoid unneeded interventions and most frequently expressed interest in mother-friendly forms of care in the future. We must find ways to close the gap between what Black women are getting and what they want.

Sharon Muza: How can the state of California and the health care providers who practice there use this report to improve maternal infant care and outcomes?

Carol Sakala: California is a bellwether state in terms of the level of interest and initiatives underway to improve maternal-newborn care and outcomes. And California is a national leader in the development of toolkits and other resources for maternity care quality improvement, in reversing its rising maternal mortality rate and in efforts to bring down the cesarean rate, including bold policies adopted by Covered California. There are future opportunities for deeper dives in the data that could be of interest to the Medi-Cal program, which funds nearly half of births in the state. We want our rich survey resources to be a catalyst that accelerates the changes California women and families urgently need. 

We hope leaders will respond to the clear preferences women expressed in our survey: three in four agreed and half strongly agreed that birth is a process that should not be interfered with unless medically necessary, yet just 5% of women met the ACOG reVITALize definition of physiologic childbirth. The majority expressed an interest in midwifery care and doula support should they have a future birth, and quite a few expressed interest in use of birth centers and home birth. Yet fewer than one in ten of our respondents had a midwife or a doula and just about 1% in the state had an out-of-hospital birth in 2016 (later data from birth certificates as our study was limited to hospital births). These clear preferences are well aligned with best evidence and call for transformation of care and systems of care. Transformation is possible and our new consensus Blueprint shows the way forward.

Sharon Muza: What should consumers be taking away from this report, especially those who are birthing in California?

Carol Sakala: I think the most important lesson for consumers is the importance of becoming engaged in their care, beginning by carefully choosing their care providers and birth settings and making other consequential decisions. They need to become informed and take steps to get care that aligns with their values and preferences and is best for themselves and their babies.

Sharon Muza: How can childbirth educators in CA (and other places) use the report’s information in their childbirth classes?

Carol Sakala: Childbirth educators can alert women about the disconnect between what women want in childbirth – to avoid unneeded intervention – and what they get in hospitals, which is quite a few interventions overall. They can alert women to safe, underused practices that are often better alternatives for women. Our “overmedicalization” infographic is an important resource for this. One example from our results is delayed hospital admission, which was associated with greatly reduced likelihood of having a cesarean, especially in first-time mothers. 

Childbirth educators can also address some areas of misunderstanding. For example, just one woman in three correctly recognized that quality varies considerably across obstetricians and across hospital maternity units (“practice variation”). And most women who said that they definitely would not consider a midwife should they have a future birth incorrectly felt that doctors provide higher quality care. By contrast, our website summarizes results of systematic reviews comparing the two types of providers, and finds similar or better outcomes and less use of many interventions in women using midwifery versus physician care.

Educators can also address the unmet need we found for midwifery care, doula support and birth center, and home birth, helping women understand more about these forms of care and how to obtain them.

Sharon Muza: Are there plans for other states to be surveyed? If so, where and when?

Carol SakalaThe National Partnership for Women & Families is looking for funding to carry out our fourth national Listening to Mothers survey. And we would welcome the opportunity to adapt the survey for other contexts, such as other states or within a health plan or health system. There are no firm plans for the next survey at this time. 

Note: find a data snapshot with survey highlights, full survey report, issue briefs on experiences of women of color, fact sheets, an infographic and other survey resources at both and The former link also includes an interactive version of the full survey report.

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