In United States, childbirth accounts for the majority of hospital admission for both Medicaid and commercial payers programs with approximately four million births registered every year (Howell et al., 2013). Obstetrics complications are not uncommon and the quality of care during childbirth is a major determinant of such outcomes (Coeytaux, Bingham & Strauss, 2011). For years, owing to the fact that 99% of maternal mortality were registered in low-and middle-income countries, an assumption has been made that maternal deaths is an issue of developing countries and not a problem of industrialized nations. It was not until, data released by United Nations in 2010 ranked US 50 th worldwide for maternal deaths. Moreover, in that release, the US maternal mortality ratios were greater than nearly every country in Europe, and some nations in Middle East and Asia (Coeytaux, Bingham & Strauss, 2011). This was ironical for a nation like US whose expenditure on maternal health (about US$85 billion annually) exceed that of other nations and even other departments which offer hospitalization care within the same country. According to Howell et al. (2013) more than half of maternal deaths can be prevented. Therefore, such high statistical figures on maternal mortality in US is a question of human right failure and not a public health affair (Coeytaux, Bingham & Strauss, 2011).
In United States, to a larger degree has witnessed disparities in maternal mortality with regards to racial-ethnic groups. It has been recorded that black women have a three-to-fourfold higher risk of dying from pregnancy-related deaths than white women (Creanga et al., 2015; Creanga et al., 2012; Howell & Zeitlin, 2017). Creanga et al. (2015) reports a strikingly higher and obstinate racial-ethnic disparities in the United States with regards to severe maternal morbidity and pregnancy-related mortality. Given the reality of statistical figures of high maternal mortality rate, therefore the big question: Is it agreeable that African American women are dying more in childbirth in hospitals more than any other race? Why are women having natural home births? Are there disparities between African American women in different parts of America? Is there racism in hospitals? Owing to high maternal deaths, some commentators have argued that African American women accounts for the majority of high maternal deaths following their deaths during childbirth in the American hospital. Drawing on issues of more death among African American women during childbirth, this paper aims to include a detailed and critical discussion on this assertion in relation to preference to natural home birth and racism in hospitals.
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African American Women and Other Races of Women
A report by the Institute of Medicine on health discrepancies has shown that racial and ethnic minorities are more unlikely to receive quality health services in addition to missing vital procedures (Grobman et al., 2015). Presently, the Center for American Progress has been investigating the troubling differences in maternal mortality among African American women. The center has established that African American women have a three-to-fourfold higher risk of dying from childbirth than non-Hispanic white women. Moreover, education and other socioeconomic status do not offer any protection against this inequality (Chalhoub & Rimar, 2018). The primary driving factors for these disparities are racism and sexism (Cristina & Jamila, 2018). Despite the advancement in health insurance coverage under the umbrella of Affordable Care Act (ACA), multitudes of African American women are still without insurance cover. Furthermore, accessibility of high quality and personalized care are still lack among the women of color who have insurance (Chalhoub & Rimar, 2018; Howell et al., 2013). Notably, the performance of black-serving hospitals were pitiable than non-black-serving hospitals with regards to 6 out of eleven indicators of safety (Ly et al. 2010).
Disparities exist in the risk factors associated with pregnancy (like gestational diabetes, anemia and hypertension) among various racial-ethnic groups (Chalhoub & Rimar, 2018). According to Chalhoub & Rimar (2018), these risk factors have been aggravated among African American women by stress linked to insufficient health care and racial inequalities which are incompatible with the needs of these women. Many women of color particularly low income earners are still unable to access reproductive health services in spite of the extension brought by ACA and Medicaid. Reason given has been funding and restriction deficits. These variables makes them susceptible to pregnancy related risk factors (Chalhoub & Rimar, 2018). Chalhoub & Rimar (2018) assert that inadequate attention to the medical needs or experiences of African American women by health care providers has contributed to the majority of obstetric complications or maternal deaths. Pragmatism of the implications of this inequality has been seen in narratives where healthcare system failed to pay attention to African American women’s medical needs. Dr. Shalon Irving’s story is a typical illustration of such narrative ( Nina & Renee, 2017). Dr. Shalon, “an epidemiologist at the Centers for Disease Control and Prevention and a lieutenant commander in the US,” died soon after giving birth – cause of death being hypertension.Cultural barriers have been linked to hindrance to access to high quality healthcare among many patients in the minority ethnic group despite an increment in diversity and training of the healthcare providers. African American women have utilized doulas and midwives to counter these barriers (Chalhoub & Rimar, 2018).
Majority of non-Hispanic black women who died from pregnancy related deaths were less educated, younger, unmarried and started visiting antenatal care clinics in the second or third trimester (Creanga et al., 2015). Greater levels of preexisting medical conditions which complicates pregnancy are seen more in blacks than white women (Creanga et al., 2015; Howard, 2017). According to Tucker et al. (2007) the higher “risk of death for black women does not simply reflect a greater risk of an underlying complication occurring.” Moreover, in black women compared to white women, no substantially greater prevalence for the five major obstetric conditions, “preeclampsia, eclampsia, obstetric hemorrhage, abruption and placenta Previa,” that are leading causes of maternal mortality. Nevertheless, black women had a two-to-threefold risk of dying than white women who had similar obstetric complications (Tucker et al., 2007). Notably, the risk of death among African American increases with age. Creanga et al. (2012) assert that race and age were significant determinants of maternal mortality among black women of US natives. Coeytaux, Bingham & Strauss (2011) assert that the notion that black women have greater prevalence of diseases justifying the racial and ethnic disparities in obstetric outcomes do not hold water, but affirms that black women are unlikely to obtain beneficial healthcare necessary to subvert death.
Natural Home Births
Black women constitutes the minority of women who deliver at home regardless of the adoption of home birthing among women of other races. Moreover, proponents who seek natural births at home, motivations include ancestral connection ( TheGrio, 2011 ). Numerous organizations exists which actively advocates for natural birth among the African-American women. Examples include Mamas of Color Rising , Black Women Birthing Justice , and Black Women Birthing Resistance . The agenda by these organization is to teach women of color about what transpire in their body in the course of pregnancy or delivery ( ( TheGrio, 2011 ) .
On the contrary, a significant rise in the figures of home births have been reported in US (Cheyney et al., 2014). Majority of which is constituted by white women. However, in the early 20 th century, most white women delivered in hospitals (Maxwell, 2009) . Notably, natural home births used to be an affair of women of color during then. This was a necessary evil since these women were segregated from medical system on the ground of racism. It was not a smooth ride to cause a shift from home to hospital birth for women of color. African American women had to traverse the barricades of racial discrimination to attain the modern medical services (Maxwell, 2009). Consequently the rate of natural home birth declined among African Americans overtime (Zielinski, Ackerson & Low, 2015).
Popularity for home birth is attributed to the craving to have control over ones delivery, the desire to avoid unnecessary procedure done one body such as C-section or episiotomy (Zielinski, Ackerson & Low, 2015). According to Zielinski, Ackerson & Low (2015) the driving factor for unnecessary C-section is the fear of lawsuits where doctors who rather perform surgery at the expense of waiting for progress of labor with all the uncertainty that surrounds spontaneous vaginal delivery (SVD). Longer hospital stay following C-section with risk of sepsis, hemorrhage and adverse effects of anesthesia are discouraging elements attributed to hospital delivery. Moreover, baby born via surgical route develop more respiratory complication than those delivered via SVD not forgetting lactation problems associated with C-section (Zielinski, Ackerson & Low, 2015).
Recently, it’s been reported that many Black women are opting for natural home births (Mea, 2018). Persistent abuses of women of color during childbirth in hospitals has been the motivational factor for adoption of home birthing approaches. There is desire by women of color especially the elite, to turn the tables upside down by beating the odds relating to high maternal mortality indices among them (Mea, 2018)
African American Women in Different Parts of America
In California, African American women have a tenfold risk of dying from cardiovascular condition during pregnancy or at delivery with an overall four times risk of dying from pregnancy related deaths (Main et al., 2015). A similar higher index is witnessed in Chicago. The disparity in terms of pregnancy related deaths, indicated a relative risk of 3.7 for black women compared to white women (Rosenberg et al., 2006). Rosenberg et al. (2006) assert that persistence in this disparity cannot be explained by medical status alone.
One of the richest cities, San Francisco, marked by innovation in health care also projects similar trends in disparities (Casimir, 2018). According to Casimir (2018) five out of the ten of the recently reported maternal deaths in the city were black women. The irony is that African Americans constitute only six percent of the population. Agreeably, racial discrimination has been the associated factor for the adverse maternal outcomes in blacks; prejudices in the maternity wing is a causal factor for such mortality (Casimir, 2018). These racial prejudices have brought enormous stress in the bodies of black women.
Hafner (2018) reports that black women die during childbirth at a rate that is three times that of women of other race in Virginia. This racial difference in mortality has no association with the disparity in education, income or class. “Implicit biases, historical mistrust in the medical system and access to good care” are linked to the association (Hafner, 2018).
Racial diversity is a reality in United States. Persistence in disparities in maternal health among races have been documented (Creanga et al., 2015; Creanga et al., 2012; Howell & Zeitlin, 2017). Whites account for more than 90% of certified nurse-midwives in the US health system in spite of the support for diversification in workforce (Wren & Donnelly, 2016). Racism surrounds clinical practices in midwifery given the lack of racial diversity which reflects negatively in the lives of women of color (Wren & Donnelly, 2016). Evidently, adverse maternal outcomes cuts across black women of various socioeconomic status including women of higher status which is a pointer to the influence of institutional racism (Campbell, 2018). In essence, the tendency is to view women culturally while disregarding their complaints which is a great lack of objectivity in the medical practice (Campbell, 2018).
Davies (2018) comments that racial influence inexplicably affects the nature of care received by women during delivery. Inherent biasness of racism may cause some medical professionals to utilize less time when serving women of color or offer less efficacious care or even dismiss their complaints. Moreover, the level of pain among black women has been ignored by these practitioners (Davies, 2018). The story by Serena Williams is just but among the few. Numerous stories from African American women gathered by “NPR and ProPublica,” indicated that these women are usually disrespected, dismissed or devalued by the medical caregivers (Davies, 2018). Davies (2018) emphasized that the plight of black women has been compounded by biasness and discrimination amidst the preexisting inequality. Despite the mileage brought by ACA, black women have higher likelihood of being uninsured before being pregnant and is a major hindrance in accessing the necessary postpartum care (Davies, 2018). As emphasized by Nina & Renee (2017), black women continues to obtain low quality care irrespective of their socioeconomic status, education level or age as was the case of Dr. Irving. Therefore, the deep rooted agenda is racism not economic or educational levels (Davies, 2018).
Conclusion and Recommendation
A gap has been reported in the obstetric outcomes among women of different races in US. Disparities have been documented with regards to pregnancy-related deaths with black women having a three-to-fourfold risk of dying during childbirth in American hospitals. These racial-ethnic disparities traverse the entire United States. Higher socioeconomic status, education level or income do not protect African American women from such high maternal deaths. Quality of care accorded to black women has been implicated as the cause of higher death rates. However, the principle driving factor for higher maternal deaths are racism and sexism.
Bridging the gap in quality of health care, offering adequate insurance coverage, promoting diversification in the field of midwifery, confronting the sting of racism and addressing women of color with dignity and respect while being sensitive to their complaints would significantly help in lowering the racial-ethnic disparities of pregnancy-related deaths. Evidently, eradicating discrepancies facing poor women and women of color primarily is the way forward. There is need to offer equitable and high quality maternal healthcare. However, disparities will not be eliminated by the improvements in healthcare system alone
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