Maternal Mortality in the United States Dissertation

Introduction

Maternal health amongst black women continues to be an issue of concern despite the technological and medical advances witnessed over the years. This makes them prone to a higher maternal mortality rate. According to Ai-ris and Collier (2019), the World Health Organization defines maternal mortality as the mother’s death during pregnancy or within forty-two days after the termination of a pregnancy. Statistical data drawn from the Centers for Disease Control (CDC) shows that African American women have a probability of three to four times succumbing to maternal complications than women from other racial backgrounds. According to their estimates, in forty-two out of every 100,000 live births, a black woman dies, representing a figure much higher than that of White-American and Asian-American women (Owens, & Fett, 2019). This disparity is caused by a wide range of issues against black women. These issues include limited access to healthcare, lower socioeconomic status, and the presence of preexisting conditions in the form of chronic complications like hypertension and cardiovascular diseases. There are also systematic barriers such as sexism, racism, and economic inequality that black women have not overcome. These also play a prominent role in negatively impacting black women’s maternal health (Fang et al., 2000; Hausmann et al., 2010). In general, these factors indicate the existence of significant disparity in maternal health between members of the Maternal health Black, Asian, and ethnic minority groups (BAME).

Research shows that the mother’s level of education plays a role in their maternal health. Since black women are, in general, less likely to graduate from high school and college than their white counterparts, this contributes to their higher mortality rate. Another factor contributing to poor maternal health in African American women is abortion access. According to Dunger (1998), black women are more likely to get unintended pregnancies and are three times more likely to try an abortion than white women. The geographical location or the environment where the mother lives play maternal health. Due to economic disparity, most black people live in urban areas where medical facilities may be less available since they do not pay as much taxes as those in affluent neighborhoods. It is difficult to assess the impact on other BAME groups at the moment, but the disparity trend is evident.

A poor socioeconomic standing forces millions of BAME people to live in poor neighborhoods where basic facilities like clean water and decent housing may not be available. Additionally, security in some of those neighborhoods is compromised, which means that if a mother goes into labor at night, she may be afraid to get out or risk being attacked. In their study seeking to determine the impact of geographical location on maternal mortality rate, Ai-ris and Molina (2019) found that mothers in the most-deprived areas bore a hundred and twenty percent higher mortality risk than those in the most affluent neighborhoods. That is a worrying statistic that shows that whether a mother lives or dies during or soon after the pregnancy is a factor of her socioeconomic status.

This paper will look into the mortality rate issue among BAME women from the science/mathematical and ethical/cultural perspectives. It will look at how the available data show the existence of discrepancies and the moral or cultural issues that contribute to them. It will also offer solutions to the problems that have been identified. This paper will consider four significant factors: access to healthcare, socioeconomic status, predisposed and preexisting conditions, and racism.

Background

Maternity care policy in the UK stipulates the right of every mother to receive information that is evidence-based which allows for safe and informed choice, to be treated with kindness, respect, and dignity, care should be compassioned, woman-centered, tailored to the individual needs, and delivered in a way that it enhances woman’s experiences throughout the birth continuum (NHS England, 2016). However, the principle of such policy does not reflect clinical practice for every woman accessing maternity services in the UK (NHS England, 2016). Henderson, Gao, and Redshaw (2013) found ethnic minority women experienced significantly worse care than their white counterparts, with problematic themes around care provision, healthcare system, cultural needs, and midwife–woman relationships. The national survey of maternity care highlights significant gaps during pregnancy; BAME women were more likely to report lack of information during the antenatal period, lack of choice in place of birth, negative attitudes of healthcare professionals, and increased likelihood of being left alone during delivery (NHS England, 2016). Therefore, such variations in maternity care outcomes and the service provision disproportionately impact the Black, Asian, and ethnic minority groups (BAME) (Garcia et al., 2015; Knight et al., 2019).

Triennial UK national analysis of maternal morbidity and mortality found Black women have a fourfold higher risk of death and double the risk of death for Asian and Other minority ethnic groups than White women (Knight et al., 2021; Jacques and Jackson, 2020). The latter has remained statically unchanged for the past decade (Knight et al., 2021; Jacques and Jackson, 2020). Infants’ outcomes are of similar differential concern, with BAME women at an increased risk of preterm birth (birth before 37 weeks of pregnancy), stillbirth (born without signs of life after 24weeks of pregnancy), neonatal death (baby death within 28days of life), and low birth weight infant (birth weight less than 2500g) (Nair, Knight, and Kurinczuk, 2016, DH, 2007, Lewis, 2004). Maternal mortality in New York is two to three times higher in black women than other races, which constitutes approximately twelve percent of maternal deaths in the state. Westwood (2020) posits that black women die from maternal complications four times higher than white women. Peek et al. (2011) credit this considerable difference in mortality rate to factors that include poverty among black communities and lack of health access and coverage for black women.

The nation made significant steps in closing the health accessibility gap when it passed and mandated the Affordable Care Act (Obamacare) in 2009. However, the plan may not cover the wide range of checkups that mothers need to ensure that they are in good maternal health. The solution to healthcare access lies in a government intervention program, similar to Bush; ‘No Child Left Behind,’ that makes sure that all mothers are given an equal chance at proper maternal healthcare. This will lower the maternal mortality rate in the United States and African American women. In the case of unwanted pregnancies, Dunger (1998) posits that the government ought to make birth control available to women of child-bearing age at an affordable cost. This will avert most deaths resulting from abortion and delayed antenatal care.

Socioeconomic Factors

As noted earlier, black people, and especially black women, are at an economic disadvantage due to much lower wages. On top of sexism and racism, black women are more likely than women from other races to have a lower level of education. Socioeconomic status plays a crucial role in determining health outcomes. However, Marie et al.’s (2020) research show that race is the most vital factor that affects maternal mortality. In general, having a higher level of education across all races leads to better, less strenuous jobs and income. Black women are, therefore, at an added disadvantage due to a lower level of education, which limits their job options and the benefits that come along with such jobs as healthcare coverage, maternity leave, family leave of absence, and so on. To stay afloat with their bills and other responsibilities, they may be forced to work late into their pregnancies or soon after giving birth. This risks their health and may even lead to death. According to Chiu (2018), these social and economic inequalities adversely affect black women’s ability to access good education, get good jobs, afford safe neighborhoods, and access clean drinking water. He opines that black women are impacted by racism in America more than any other demographic group.

Another socioeconomic factor that affects the maternal mortality rate is the mother’s marital status. According to Berg et al. (2003), maternal mortality was higher in unmarried mothers than married ones. Ai-ris & Molina (2019) posit that a woman’s available status can increase her chances of maternal mortality by up to 50%. Since the slavery era, the black family structure has been fragile for centuries. Various studies have shown that although black men constitute about thirteen percent of the American male population, they account for thirty-five percent of all incarcerated men. This phenomenon of absentee fathers leaves a lot of mothers with the economic, emotional, and psychological burden of raising children alone, raising their stress levels. These black women’s obligations and stress become precarious during pregnancy, leading to preeclampsia and subsequent high blood pressure (Singh, 2020; Shavers et al., 2012). This raises their chances of losing life, contributing to the higher mortality rate among African American women.

To find solutions to the carnage of maternal mortality rate, some experts have suggested controlled home birthing as a viable solution. As it stands, the American healthcare system and institutions have either refused or been unable to reduce maternal mortality in black women because of racism and socioeconomic factors. However, Chervenak et al. (2013) observe that if provided with the proper education and financial empowerment, controlled home birth is a significant intervention to reduce maternal mortality in black women. This would involve women being educated on living a healthy lifestyle that mitigates birth-related complications. A certified midwife is brought in to oversee the process and ensure that the woman delivers safely at home at the time of delivery. For this option to work, the expectant mother must be healthy enough, as determined by a qualified physician, and under the supervision of a certified midwife (Chervenak et al., 2013). This will allow black women to avoid poor and discriminative care at health facilities and offer them a more affordable service. Even though this method is being suggested to black women, it is available to women of all races. The caveat here is the need to have the woman determined as healthy enough by a physician, which will require working health insurance coverage. Therefore, all these factors must be considered simultaneously to ensure that the mother and her unborn child’s health are fully considered before the due date.

Intersectionality Framework

Intersectionality and its Constituent Parts

Lines, elements, and categories intersect to create intersectionality. As an analytical tool, it is valid. The intersection of two (or more) of these aspects attempts to extend the feminist agenda by investigating these other ‘power’ dimensions: class, racism, sexuality, and disability “Diving into the wreck: Exploring intersections of sexuality, “Race,” gender, and class in the Dutch cultural archive” (2014) states that “specific intersections, hierarchies, and elaborations” are not predetermined. “The connections between various elements and modalities of social relations and subject forms,” as stated by (Crenshaw 2019, p. 1111). The goal of intersectionality is to liberate women from the shackles of their social contexts.

Individualism: Intersectionality aims to answer the question of “Who?”

What does the term ‘woman’ mean? To wit, female researchers confront an uphill battle in domains that claim objectivity and reality. Feminisms of the poststructuralist and postmodern eras converged in this way. Poststructuralist feminists see women as a product of their self-perception and the social context in which they live. According to Foucault, a person can be both an active and passive subject, depending on their social setting (“Author, subject, structure: Lacan contra Foucault,” n.d). It’s challenging to diminish the meaning and subordinate practices since the subject have various resistance spots. Feminism in poststructuralist feminism does not believe in a single, fixed core of identity within each individual.

Postmodern feminists, on the other hand, believe that gender, race, and class are all intertwined. Classifying one’s experiences, self-image, and social milieu is next to impossible (Lépinard 2014). Social class, sexuality, and gender all interact to create symbolic violence and practical injustices that are difficult to overcome (ibid). In light of this, we can better understand the intricacies of our identities. What does it mean to do to “articulate” race, class, and gender? An organized system of categories can decrease the complexity and immensity of the landscape.

There is a movement to identify specific points of intersection for women in many categories (Lépinard, 2014). In contrast, this implies a preference for a particular analytical type’s properties above others. A British African middle-class heterosexual woman, for example, feels one component of race, class, sexuality, and gender. Personal tales are incredibly potent because they show only one facet of a multifaceted social structure.

Human Complexity versus Societal Categorization

Given their complexity, it’s not surprising that social categories frequently fall short of truly capturing the human experience. To “meet the demands of complexity,” intersectionality is stated to link several types of classifications (McCall, 2005). A person’s social class is defined by the people they interact with. To maintain social order, social categories are imposed. In some circumstances, social classifications like “Muslim” or “Woman” form a hierarchy (assumed via socialization processes). There are many ways social categories might be deconstructed from an elemental creature to a manufactured one (ibid). They are rearranged according to other classes. So that things can be done, cited, copied, and abused. Values, rather than socioeconomic status, are to blame for creating social hierarchies (Crenshaw, 2019). Crenshaw suggests a shift of power from one category to another. Foucauldian concepts of power are used here as a source of oppression and new discourses within the subject. To discover power clusters and the contexts in which they present themselves may prove more difficult than locating their manifestation within hegemonic discourses of gender, race, or class. The extent of inequity is another argument made by McCall: She believes it can assist her in identifying subordination in all of its manifestations, from the simplest to the most complex. When it comes to social injustice, there is no one-size-fits-all solution. In the past, mild inequality was defined as a substantial difference between the mean and the median. They come in a variety of sizes (McCall, 2005).

Defeats to a New Way of Thinking

When it comes to women’s experiences, intersectionality is a powerful tool. Risks abound, though, due to the project’s size and complexity. Gender, class, and race terminology are prominent concerns in feminist studies outside of the United States and Western Europe. The term “gender” is not used in every language. Theorizing women’s experiences in a system with varying cultural notions of gender is complex and dangerous. Several factors make it challenging to describe race in English, such as its complex social and biological roots. All of the same students. Overtones of “social class” include cultural, academic, and political. Division and injustice are created and perpetuated through categorization. To keep up with the ever-changing world, feminist analysis and the social sciences, in general, are constantly tweaking their categories.

Using the same categories is necessary to identify social category crosses. Stifling categorization may inhibit intersectional innovation. It is a word that criticizes the way homogenized social concepts are often related before being carefully separated. Aside from these considerations, concerns emerge about how to document the complexity of each analytical kind. It is challenging to study gender, race, class, and other aspects because of their different magnitudes and relevance (McCall, 2005). In some cases, peer-reviewed journals may reject lengthy research reports because of their word and page limits. A growing number of monographs released by academic and scholarly publishers capture the breadth and complexity of intersectional study (ibid).

Intersectionality may be hindered more by inconsistencies in methodology than by theoretical frameworks or topics. Studies in transdisciplinary are hampered by disciplined feminist research methodologies (McCall, 2005). Different approaches should be considered to achieve sufficient interconnectedness. However, other feminist researchers have used intersectionality in studies that have nothing to do with distinct forms of subordination.

Methodology

Scoping review

The research is to conduct a scoping review to map out the evidence based on the issue of racism in NHS maternity care for BAME women. Scoping review was considered appropriate for this research to outline the breadth of literature, the types, and potential gaps and develop future research (Boland, Cherry, and Dixon, 2017). Historically gender gap in medical research is a recognized phenomenon (Scott et al., 2018). However, this disparity is amplified in BAME women, who are less likely to partake in or be included in scientific research than white groups (Smart and Harrison, 2016). This disparity highlights the significance of this review for developing future primary research.

The review uses qualitative methodology with an interpretivist theoretical perspective to investigate the research questions. Qualitative methods emphasize descriptive data (text, audio, or visual) rather than numerical interpretation (Bryman, 2016). Ryan and Bernard (2000) suggest that the recurring characteristic of qualitative research lies in method design, specifically the iterative, flexible, and cyclical nature in answering the research question and adapting the strategy based on the emerging evidence. On the other hand, the interpretive paradigm assumes that human inquiry is intersubjective and shaped from the individual historical and cultural settings (Crotty, 1998). At the same time, reproductive health oppressions exist in historical, political, and social-economical contexts and manifest in societal structures, reinforcing maternal inequity (Taylor, 2020). Therefore, interpretive research allows for exploring such interlinked social phenomena holistically and provides an understanding of the livid experience rather than abstract generalization (Alasuutari et al., 2018). The latter is commonly seen in opposition to the positivism paradigm (Crotty, 1998)

Research questions

• Q1. How do accounts of racism within the NHS affect childbirth experiences for Black, Asian, and minority ethnic women?
• Q2. How does the NHS currently address racial inequalities for Black, Asian, and minority ethnic women during childbirth?

Aims

His work aims to explore the current research and literature that seeks to understand the multiple experiences of racism and childbirth in the NHS and what is being done to address racial inequalities to inform future primary research.

The objectives are:

1. To carry out a scoping review of the literature by searching across seven databases, including grey literature and information published by NHS and government bodies.
2. To thematically analyze for themes and trends emerging from the evidence and identify gaps in the literature, informing future research.
3. To present BAME women’s narratives, inform clinical practice, improve health outcomes and experience, ultimately eliminate inequity in maternity care.

A significant disparity in mortality and morbidity outcomes exists for this group, historically attributed biological and socioeconomic factors as a cause (Knight, 2019). Arguably, disparate care provision linked to racial bias also causes unjustifiable harm in experience and outcome (Hoffman et al., 2016). The resulting data can provide greater insight into the connection between intersecting racial bias and the impact on BAME women’s lived experiences and the quality of care to understand their reality better and identify tangible public health strategies to eliminate such disparity.

Data Collection

Several academic databases were searched including: PubMed, Cochrane library, NHS evidence, MIDIRS, PsycINFO, MEDLINE, and CINAHL Plus with Full Text. These databases were selected due to the ability to access various medical information, as well as statistical data. These databases focus in particular on the provision of articles focused on clinical practice. It is especially important that through them you can also find data relevant to various social and ethnic groups of the population. The most significant factor is also the fact that the database data allows for keyword searches, which is the basis of the research.

The search strategy for the academic literature adopted key terms using Boolean operators ‘AND’ and ‘OR’ to improve focus in the literature search (Stern et al., 2014). Key terms listed below were used to generate relevant articles, which meet the breadth of the available literature required for scoping review ( Arskey and O’ Malley, 2005). Using Boolean operators like AND and OR, Dearholt and Dang (2012, p. 76) discovered that inserting searches in parentheses was the most successful searching technique. Patient outcomes or quality care and staffing ratios and “emergency department” appear to be the most relevant terms in the CINAHL database. It gave a total of 27 items, four of which were related to my search. There were over 12,000 results retrieved in CIHAHL using (nurse AND patient AND ratio), many of which were relevant but not specific enough Your Last Name 13 for my needs. I used the terms “emergency department” and “emergency room” to reduce my search results. A total of 780 relevant articles were found by using this search strategy. The same search terms were used in the Medline database to get relevant results. There were 341 hits when searching for “emergency department” and the key terms “patient outcomes” and “quality care” together.

Table 1. Key words

Non-academic literature was also included by Public Health England and the NHS, which address health inequalities specific to maternity care in the UK. To ensure the most accurate results, LoBiondo-Wood and Haber (2014, p. 290) recommend that nursing research measurement tools be valid and dependable. Inaccurate results are the outcome of using incorrect measurements. When conducting an experiment or study, you must ask yourself whether or not you can repeat the experiment with fresh volunteers in the same conditions and achieve the same results as before (Dearholt & Dang, 2012, p. 105). According to Dearhold and Dang (2012, p. 103-104), validity is defined as the degree to which a researcher can be confident in their findings. Whether or not the research outcomes fit the method’s requirements is determined by whether or not the experiment’s validity is considered (LoBiondo-Wood & Haber, 2014, p. 292). The validity of your study’s findings is verified by verifying that the conclusions you draw from your research have a direct connection to what you saw. Is the conclusion showing that the relationship had been established when there was not, or did the conclusion demonstrate that there was no relationship developed when there was? (Dearhold & Dang, 2012, p. 103). Whether or not an experiment’s results may be attributed to its treatments or the subjects’ behavior resulting from participating in a study (Dearhold & Dang, 2012, p. 103). If the result holds for other people, in other places, and at different times when conducting the same study, it is considered externally valid.

Construction validity is a final consideration, and it examines if a study measures what it set out to. The author/ability of investigators to translate their thoughts into measures is determined by construct validity (Dearhold & Dang, 2012, p. 104). While it may be challenging to sort through all the material offered, it’s important to remember that quality research is just as crucial as validity. Before implementing the findings, the analysis must be thoroughly analyzed. The Johns Hopkins Nursing Evidence-based Practice (JHNEBP) process can identify the quality and amount of research evidence. Dearhold and Dang (2012, p. 108) give two JHNEBP tables, one to apply a level and evaluate the strength of research evidence and the other to calculate the quality rating and apply a grade.

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria to retrieve relevant articles within a manageable timeframe was vital. Determining set criteria provides the reader with a clear outline, set limitations, and allows for explicability by others (Stern et al., 2014). For the academic literature the main criterion for inclusion is the matching of the belt by keywords, as well as the content of the relevant content. Exclusion for academic literature is an insufficient sample of the study population, as well as a lack of connection with current NHS practices. For gray literature, the inclusion criterion is also the content of relevant content, primarily statistical data required for research. The exclusion criterion is to focus on the general health population rather than on ethnic minorities.

A narrative review of the abstract, reading, and indepth reading of the literature and further reference searching of those selected, improved article selections. Studies published in full text, English language and peer reviewed journals based in the UK, between 2010-2021 were eligible for inclusion. This chosen in order due to the relevance of current UK maternity care provision. Similarly grey literature including government and NHS policies were included. Obstetric complications in pregnancy or postpartum either linked to biological or social determinants of health such as demographics, employment or financial status that do not correlate with the research question or aims were excluded.

Data Analysis

Data charting by use of excel spreadsheet across heterogeneous studies allowed for extraction of the relevant information of the reviewed literature. Key themes, which emerge across the studies are presented in table format and individual narratives, in line with qualitative research. Latter to ensure and facilitate complete, transparent and consistent reporting of the literature.

Limitations of Scoping Review

In the first place, the scoping review is not a complete review of the existing literature, but rather lays the foundation for future research. Within the framework of this method, it is important to identify the main concepts and trends in order to outline the topic more clearly. Compared to a systematic review, this factor is a limitation of scoping review, but it is also a feature of this approach. Additionally, this method takes into account both qualitative and quantitative data, which assumes a mixed analysis of information. In this regard, the analysis of the data is less in-depth and allows only superficial conclusions to be drawn and the identification of existing gaps. However, the primary goal of scoping review is precisely this result, which represents the approach as an initial stage in the formation of the research methodology.

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