Health Equity Issue
The primary issue is that there are existing racial/ethnic disparities in pregnancy-related mortality, seen across the nation. This report will focus specifically on New York City (NYC). According to the latest available government report, there were 273 pregnancy-associated deaths in NYC, 115 (42%) of which were pregnancy-related complications over a period of 4 years. That is a slight increased from 252 deaths the prior 4 years. Although the pregnancy-related mortality ratio (PRMR) decreased by 44% to 18.9 per 1000, live births, including decreases among Black and Latina women, Black non-Latina women were 8 times more likely to die from pregnancy-related causes. Leading causes of pregnancy-related deaths were cardiovascular (25.2%) and embolism (21.7%), while the primary non-pregnancy-related cause was substance use (40.7%) (New York City Department of Health and Mental Hygiene, 2020).
The NYC government and health agencies recognized that there are racial and ethnic inequalities that persist which led to poor health outcomes and pregnancy-related mortality. A range of factors contribute to the issue including structural racism as well economic oppression, pregnancy discrimination, and poverty; all of which can impact the maternal health before, during, and after pregnancy. Racism creates barriers which limit access to healthcare, safe housing, and other key institutions.
A chilling statistic is that if black women were to receive care and deliver in the same hospitals (or same level of quality and access) as the majority of white women, the maternal morbidity rate for the demographic would decrease by 47.7% (New York State Taskforce on Maternal Mortality and Disparate Racial Outcomes, 2019). The racial disparities in pregnancy-related mortalities is a nationwide issue that is health workers, officials, and agencies are aware of, but it remains especially prominent in highly urbanized areas such as NYC which typically house the largest racial/ethnic minority communities.
Policy Environment
The policy environment around the issue is complex as it relates both to healthcare, but also a range of other socioeconomic legislation over decades that have consistently left racial/ethnic minority communities and populations behind. Health inequities stem from social, economic, environmental, and structural disparities. Baciu et al. (2017) identify two root causes, the first being the systemic and institutional mechanisms of distribution of power which inequitable across lines of race, gender, and class. The second is the unequal allocation of power and resources such as goods and services which manifests in inequitable conditions known as social determinants. Health and structural inequities are the primary causes, leading to systematic differences in the availability, quality, physical access, and affordability of healthcare to minorities historically.
The concept is extremely complex and includes the influence of multiple factors, and there is no one legislation that was either the cause of the issue nor can fix it. Policy first and foremost should be targeted at improving the urban neighborhood environments, providing access to clinics, healthy foods, green spaces, public transit, education while reducing environmental factors such as displacement, exposure to toxic waste, eliminating food deserts.
The issue requires mechanisms of social support and cohesion since the social environment interacts with features of the physical environment (Baciu et al., 2017). Despite seemingly broad, all these aspects are interrelated to impact the issue at hand which is racial disparities in pregnancy-related mortalities. If a woman is educated, she is able to take a better approach to family health planning, which would be possible if there is access to a local clinic, that can be reached by public transportation. A pregnancy would also be healthier if there is access to nutrient rich food and limited exposure to pollution and toxins. All the community elements inherently work together to impact health status of an individual and at the population level.
It can be argued that the policy approach to the issue has to be from both ends, stemming from the community and federal levels. The community level addresses the specific practical concerns of the disparities, such as healthcare access, clinics, and quality of care. Meanwhile, at the federal level, more systemic factors such as lack of insurance, Medicaid, and other broad healthcare and economic factors can be addressed.
Example in the News
A news story published in Vice accounts for the story of Amber Rose Isaac, a black woman who died during a c-section while giving birth as a result of health complications experienced during pregnancy. Isaac who lived in Bronx, NYC was feeling symptoms of fatigue and deteriorating health, but was only offered telehealth appointments and no diagnosis due to the combination of the COVID-19 pandemic and racial disparities. Eventually through the help of a local midwife, she got bloodwork done to determine she had a dangerously low platelet count, having HELLP syndrome which is a serious pregnancy complication. However, because it was caught so late, she did not receive help and died (Kipnis, 2021).
The primary connection to the health equity issue is that it provides a concrete example of how racial minority women face barriers in receiving quality healthcare. The article highlights that the pandemic does cause problems for everyone, but it only exacerbated the racial inequity issue. The article states an important quote, “Black people are not believed when we experience symptoms, when we say we’re in labor, when we say we know what’s best for our bodies” (Kipnis, 2021, par. 11).
It is reflective of the general healthcare system which fails to provide the resources and support. The article also provides a quote from an activist which also contributes to the framing of the article, that if the woman was white, she would likely to be alive because doctors inherently pay more attention and are willing to give more resources to white people rather than racial/ethnic minorities. The article relies mostly on anecdotal evidence but also inserts statistical data both in NYC and nationally regarding the pregnancy-related mortalities, as well as offering quotes from stakeholders in the community regarding the issue.
Framing
The framing of the issue is best portrayed as racial/ethnic minorities face systemic and structural barriers in receiving community and healthcare resources, which in turn contributes to a disproportionate number of outcomes in a vital statistic as pregnancy-related mortality.
Values
- Equality – a system of values where there is equal treatment of all people. Regardless of race or location, one should have the access to a similar level of healthcare, especially living in one of the biggest cities of one of the richest and industrialized countries in the world.
- Justice – historically racial minorities, particularly African Americans, have been oppressed in the U.S. with widespread institutional and structural racism. In the modern day, these communities deserve the investment and attention to have the same opportunities and benefits as everyone else.
- Fairness – it is terrifyingly unfair that racial disparities persist at such levels, and innocent lives are lost, even if these people work to contribute to society and face the same issues that all American families do, they are also consistently left behind.
Emotions
- Despair and anger – at the thought that such unfairness persists and little can be done about it because of how ingrained racism and disparities are into the system, even in healthcare which is supposed to be equitable.
- Compassion and thoughtfulness – people should seek to understand the struggles that these families and women are undergoing, and how inherently helpless they are against the systemic barriers. The communities need help at all levels of governance.
- Need for change – change is not easy, but the evidence provided and lost lives show that if the culture of the country is to survive, radical shifts have to occur.
Narrative
The narrative that is best told around this issue are individual people encountering examples of the systematic disparities which lead to the despairing outcomes of losing their lives in pregnancy-related mortalities. The focus should be on the individual and communities that are drowning in a large system which is racist and cruel, also ranging from bad individual actors to whole barriers such as high costs, lack of access, and deteriorating quality of care.
The narrative should drive the desperation factor, making the reader feel the similar helplessness that women and families affected by the issue feel, but also demonstrate that it is possible to make meaningful change through advocacy and proper policy. Furthermore, it needs to be highlighted that the issue is not just a matter of economics or society, but culture – the U.S. has sustained a culture of racial divides and disparities through its modern history, and that inherently needs to change in order for a difference to be made in minority communities not just in regard to healthcare but multiple factors.
Messaging
- Structural racism creates disparities in pregnancy-related and maternal deaths in urban areas around the country.
- When an African American pregnant woman asks for help, why do doctors turn to help the white woman instead? Pregnancy-related mortality is not just another statistic, it is a failure of the system.
- When the racial/ethnic minority rate of pregnancy-related deaths in your city is 8 times higher than those of white individuals, you must start asking questions.
- Communities of color need help and deserve the same as everyone else, why are they left behind with fewer schools, clinics, parks, and busses? These may be all separate issues, but a pregnant woman in NYC will be affected differently by these just because of her race and place of residence.
- Policy cant fix racism, but it can control it and provide equitable access to healthcare for those who need it, empowering racial/ethnic minorities that are consistently left behind.
Storytelling
Sha-asia Washington was a happy young woman that lived in Brooklyn, she was a joy to everyone around her. She was 9 months pregnant, and unbeknownst to her, her fiancé Juwan was planning to propose after she gave birth, to make their child a part of their happy celebration. On a sunny day in July, she was admitted to the hospital for a routine stress test. Sha-asia was already past her due date, so the hospital decided to keep her for observation until she eventually went into labor. Despite feeling unwell, with unusually high blood pressure, and Sha-asia asking for help, the doctors simply offered her an epidural to release the pain.
It was a careless approach meant to simply dismiss her concerns. Sha-asia was not a medical professional, and she placed her trust in the doctors. In the end, it is unclear what killed her, the epidural or the doctors not doing enough. Sha-asia went into cardiac arrest and an emergency c-section was done to save her newborn daughter. Instead of receiving a call about the happy news of delivery, the Washington family and Juwan received one that shook their lives to the core. Another example, another life, another statistic in the grim reality which is named New York’s ‘third pandemic,’ the racial disparities in pregnancy-related and maternal mortalities.
The story is based on true events with some fictional elements added.
Op-ed
What if I told you that the U.S. has double the ratio of pregnancy-related and maternal deaths than most other high-income countries. We are ranked 55th in the world. Not only that, in our most famous city, the NYC, a black woman is 8 times more likely to die of pregnancy-related complications than a white woman. Maternal deaths such as these are a key indicator for modern healthcare systems, and ours spells disaster, with an obvious hint of racism tacked on. The statistics are consistently demonstrating disparities across more than two decades, highlighting that this is a national concern, crisis, and embarrassment not just for NYC but for the United States.
It is an issue that stems from the systemic racism of America’s troubled past. It is the 21st century, and the nation is facing the reckoning of decades of structural disparities, with healthcare being at the core of it. Poverty and racism are inextricably linked, as it reflects on hospital quality data. Obstetric care quality in clinics is directly linked to location, and minority neighborhoods are at a disadvantage. An expert on birth equity, Dr. Crear-Perry notes, “racism fuels power imbalances that subsequently create barriers to access to healthcare, safe housing, and other institutions” (New York City Department of Health and Mental Hygiene, 2020).
Science and healthcare have long proven that health determinants go beyond the lifestyle choices of an individual but their environment as well. Black neighborhoods are more likely to have toxic exposure, more polluted while having less parks, schools, and stores with fresh and healthy foods. Even if all that’s taken out of the picture, and a minority family does have access to healthcare, they continue to face challenges. It has been scientifically and anecdotally proven that African Americans are less likely to be believed by physicians, and may not receive certain services or receive poorer quality of treatment (Hoffman et al., 2016). Unfortunately, racial bias is highly prevalent at multiple levels of healthcare, ranging from access to health to treatment, to financial aspects of being able to find coverage.
Despite a dedicated taskforce created by Gov. Cuomo in 2019 and federal awareness of the issue by the CDC, little is being done to address the underlying causes. Hospital systems in NYC are attempting to mitigate the issue to an extent by integrating more training programs for professionals specializing in pregnancy and labor delivery, as well as general racial-bias awareness programs. However, this is not enough.
There needs to be concrete and specific change in policy, both at the city and federal levels. NYC government needs to ensure that minority communities are not left behind and have the same services and protections as predominantly white neighborhoods. Meanwhile, federal policy should be targeted at creating inclusive healthcare and funding for those areas that aim to enhance key indicators of health including that of pregnancy-related mortality. Similar to how causes of this issue are multifaceted and complex, so must be the policy solutions.
In the end, we must remember that this is not an issue of healthcare or politics and economics, but an issue of humanity. People are dying, and again and again experts agree that the majority of these deaths are preventable. However, these mothers never receive the help they need because our society has inherently built itself on structural racism that puts up roadblocks to both, individuals coming to doctors as well as efforts to provide funding for clinics in minority communities.
The issue goes deeply in the country’s fight against structural racism and reflects another set of casualties which are victims of an unjust and unfair system. The United States should strive to move on from its divided and racist past. Tt can be done by helping those in need and avoid the racial disparities in relatively easily preventable pregnancy-related mortalities, just like the rest of the world does it.
Private Sector and Public-Private Partnership Solutions
The private sector has a unique way of approaching problems, finding market-based and innovative solutions for specific needs. While historically, the private sector has been seen as a either a for-profit endeavor afforded by the select few or a funding stream of corporate philanthropy for public-private partnerships, it can play a much more active role. The first solution that can be provided by the private sector is its supply chains, ensuring that women have access to facilities, trained personnel, and medicines – particularly in underserved neighborhoods. Private sector typically can deal with supply-chain bottlenecks, human resource gaps, and financial issues better than their government counterparts.
The private sector can also use its innovation to improve access and quality of care. For examples, for areas where reproductive care was lacking, Philips was able to develop a handheld ultrasound device which could be used by health workers in home visits, and then share the images to trained technicians in hospital settings. Through developing technology, remote support is possible to improve diagnostics and other digital solutions to make sure that the minority neighborhoods and its mothers receive medical attention (Devex Editor, 2019)
In terms of public-private partnerships, the private sector brings the efficiency and expertise which the public sector lacks, potentially in the long-term allowing to innovate the structure and financing of the health systems solutions to achieve greater healthcare availability, participation, as well as innovation (Devex Editor, 2019). A wide range of opportunities are available for public-private partnerships to increase access to healthcare needs which is the primary issue of maternal health in NYC.
There are options of the city and state government contracting out clinics, both permanent locations as well as potential make-shift or mobile locations in community areas which can provide reproductive and child health services. The contracting out can be done to both not-for-profit organizations as well as for-profit ones, to fill the gaps in health provision. There is also a possibility of a social franchising model, where the public clinics are operated across vulnerable neighborhoods across the city based on a franchising model of expansion but providing medical services as a non-profit organization would working with local partners and relying on corporate funding (USAID, 2015).
Advocacy and Communication Plans
The key to advocacy is to support and promote the rights of patients in healthcare and improving the capacity of community health resources. Therefore, it is a combination of political and economic factors that influential in reducing disparities. The key objectives for the advocacy are based on data that racial disparities in pregnancy-related mortality are preventable via access to care, quality of care, and prevalence with subsequent treatment of chronic diseases. Both public and primary health should aim at management of chronic diseases. Furthermore, it is necessary to ensure access to quality care including specialists during all stages of family health and pregnancy.
Finally, there is a need to address systemic factors of a lack of healthcare coverage and preventive coordinated care gaps in areas with high minority populations (Petersen et al., 2019). These elements are largely addressed though policy and legislation, some at the city and state level particularly focusing on public health and providing access. Other systemic factors are more of a national issue.
Key partners in this issue can be progressive female legislators that support the cause and have the influence to create change starting with the local level. Politicians such as Rep. Alexandria Ocasio-Cortez (NY) and Sen. Elizabeth Warren (MA) among many others have expressed vocal support for racial and women’s rights and have significant media influence. Bringing this issue to their attention and partnering with them on comprehensive legislation that addresses the necessary concepts may be effective.
Of course, public support would be necessary, as this is not an issue that is widely known or considered even with news stories about it. Although it is another cog in the unfortunate but evident mechanism of racial disparities in the United States, with healthcare being significantly affected, public perception needs to massively shift before systemic changes can be adopted. This can be done through a strong and effective media and social media advocacy campaign.
References
Baciu, A., Negussie, Y., Geller, A., et al. (Eds.). (2017). Communities in action: Pathways to health equity. National Academies Press. Web.
Devex Editor. (2019). Maternal health: The next frontier for private sector engagement. Devex. Web.
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296–4301. Web.
Kipnis, V. (2021). The pandemic is killing black mothers. VICE. Web.
New York City Department of Health and Mental Hygiene. (2020). Pregnancy-associated mortality in New York City, 2011-2015. Web.
New York State Taskforce on Maternal Mortality and Disparate Racial Outcomes. (2019). Recommendations to the governor to reduce maternal mortality and racial disparities. Health NY. Web.
Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/ethnic disparities in pregnancy-related deaths — United States, 2007–2016. MMWR. Morbidity and Mortality Weekly Report, 68(35), 762–765. Web.
USAID. (2015). Ending preventable maternal mortality. Web.