Editor’s Note: This month’s feature written by Dr. Lisa Marie Jones, DBH, is installment 2 of a 3 part series by CGI Faculty was written in response to the article that follows. Reading this first will undoubtedly provide some context and insight. Thank you.
Goodman, B. (2017, November 20). Death By Birth: Bearing the Burden of Maternal Mortality. Retrieved November 16, 2017.
Maternal Health Equity
By Lisa Marie Jones DBH, M.Ed, HS-BCP
With the United States leading the world in healthcare research and spending twice as much on healthcare than any other developed nation, Americans should be the healthiest people in the world; yet, we are not. Health is the multidimensional relationship between social environment, mental health, physical well-being, functional needs, quality of life, and the ability to adapt, self-manage, and recover; it is the holistic state of well-being and maternal mortality rates are a good gauge in determining of the overall health of a population (Huber, 2011) (Wilson & Cleary 1995) (WHO, 1948). Tragically, 700 women in the United States die annually of preventable pregnancy or delivery related complications (CDC, 2017). Global pregnancy-related deaths have decreased significantly over the past few years; however, the maternal mortality rate in the United States has increased by more than 25% and has even doubled in certain states like Texas (Carroll, 2017). Goodman (2017) described a perfect example of this disheartening statistic in a recent article about the preventable pregnancy related death of a Black-American mother living in Texas. Health disparities of specific vulnerable populations result in the U.S. having worse health outcomes than any other developed nation, with ethnic/racial minorities and low-income populations being the most susceptible. For example: the maternal mortality among Black American women is three times higher than the national rate for all women (Kane, 2013).
Goodman (2017) attributed fragmented healthcare systems, lack of access to quality maternal care, and unequal treatment of the under-insured as possible causes of the maternal mortality increase in the United States but health challenges faced by women are complex and there are many contributing factors. These factors are called Social Determinants of Health and they directly impact quality of life, functioning, and health outcomes of women and their infants and children. Many determinants of maternal health are not related to individual biology or genetics and are outside of an individual’s control or personal choice. Along with the factors suggested by Goodman, access to quality reproductive and lifespan healthcare, provider bias, poverty, racism, founded patient mistrust of providers, availability of transportation, neighborhood safety, and access to physical activity and fresh fruits and vegetables are highly correlative to maternal health outcomes (Braveman, 2011).
The same healthcare system that relies primarily on female healthcare providers is deficient in caring for the needs of these same women (WHO 2016). Along with U.S. healthcare system’s focus on providing insurance coverage for and attending to the medical needs of newborns at the expense of the mother’s healthcare needs (Goodman, 2017), other systemically oppressive and politically motivated factors lead to maternal health disparities. For example: in an attempt to defund Planned Parenthood, the family-planning budget in Texas was reduced and many of the clinics providing reproductive health services were closed or forced to reduce their services (Carroll, 2017). Physician or provider bias is another pervasive source of the system’s unresponsiveness to the healthcare needs of women. This bias is usually unintentional and unconscious but it drives differences in treatment related to race, gender, and social class. Inequality in treatment of pain, referrals to specialists, and unnecessary surgical removal of body parts has been well documented. Viewing female reproductive organs as “potentially disease-producing and useless after childbearing age”, providers show a preference for saving diseased male reproductive organs over non-diseased female reproductive organs. Male reproductive organs are removed as a last resort; yet, medically unnecessary total hysterectomies are recommended even when disease is not present (Hensling, 2017). Hysterectomies are the second most common surgery among women in the United States with the most common surgery being childbirth by cesarean delivery (C-section). While C-sections have successfully treated rare birthing complications, profit and convenience have motivated the increase of iatrogenic risks by medicalizing routine healthy childbirth with procedures, like unnecessary cesarean deliveries (Kapinos, 2017).
Maternal health begins where a mother is “born, lives, learns, works, plays, worships, and ages” (Healthy People 2020). Maternal health does not begin when a mother receives her first prenatal check-up or even when she finds out that she is pregnant; it is shaped by a life time of experiences that begin with the earliest exposures to social conditions. Chronic exposure to these conditions causes the body to continuously adapt to psychosocial changes and antagonistic environments which wreaks havoc on the body. The cumulative embedding of the negative effects of chronic stress over a life time is called allostatic load. Allostatic load is highly correlated to low societal status, perceived racial discrimination, and poverty; it impacts the health of the mother and shapes the health of an infant before she/he is even born. (APA, 2017).
Improving maternal health is a social and political imperative that would benefit the economy and overall health of society (Africa Progress Panel, 2010). Health systems have focused primarily on the physical aspects of maternal care during pregnancy, which is too-little-too-late. Cost-effective life-span interventions can be identified by understanding how specific risks related to age, gender, and race at each phase of life contribute to maternal health. The implementation of culturally informed biopsychosocial interventions in integrated health and community settings at each stage can reduce health disparities in infant and maternal mortality, benefit the economy, reduce healthcare expenditures, and improve the overall health of the U.S. population.
All women in the U.S. deserve clinically and culturally competent quality care with equal health decision opportunities regardless of their gender, level of income, education, occupation, or ethnicity. Investing in maternal health should be a U.S. policy decision making priority.
Africa Progress Panel (2010) Maternal Health: Investing in the Lifeline of Healthy Societies & Economies. Policy Brief
American Psychological Association (2017) Health Disparities and Stress
Braveman, P. (2011) Social Determinants of Health: Coming of Age. Annual Review of Public Health 32: 381-398
Caroll, A. (2017 Why Is US Maternal Mortality Rising? Jama Forum. Retrieved from https://newsatjama.jama.com/2017/06/08/jama-forum-why-is-us-maternal-mortality-rising/
Center for Disease Control and Prevention (2017) Pregnancy-Related Deaths. Reproductive Health. National Center for Chronic Disease Prevention and Health Promotion. Retrieved fromhttps://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm
Goodman, B. (2017, November 20). Death by Birth: Bearing the Burden of Maternal Mortality.
Healthy People 2020 (2017) Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Washington, DC: U.S.
Henslin, J. M. (2017). Social problems: A down-to-earth approach. 12th Edition. Pearson Higher Education.
Huber, M., Knottnerus J., Green L., Horst, H., Jadad, A., & Kromhout D, et al. (2011) How should we define health? BMJ. 2011; 343: d4163.
Kane (2012) Health Costs: How the U.S. Compares with Other Countries. PBS. Retrieved fromhttps://www.pbs.org/newshour/health/health-costs-how-the-us-compares-with-other-countries
Kapinos, K., Yakusheva, O., & Weiss, M. (2017). Cesarean deliveries and maternal weight retention. BMC Pregnancy and Childbirth. 17
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Wilson, I., Cleary, P. (1995 Linking Clinical Variables with Health-Related Quality of Life: A Conceptual Model of Patient Outcomes. JAMA. 273(1):59–65.
World Health Organization (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946 and entered into force on 7 April 1948. Geneva, Switzerland: World Health Organization.