In class, we learned how to write the introduction and conclusion of the Literature Review section, which includes: Introduction (6 sentences on p. 10a) Review of Literature (u

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 1

Racial Disparities in Healthcare Among Pregnant Women in the United States

Tamifer Lewis

Department of Public Health, Monroe College, King Graduate School

KG604-144: Graduate Research and Critical Analysis

Dr. Manya Bouteneff

December 4, 2022

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RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 2

Racial Disparities in Healthcare Among Pregnant Women in the United States

Introduction

African American, American Indian, and Alaska Native women are up to three times

more likely to die from adverse pregnancy related outcomes, a disparity that increases with age

(Centers for Disease Control and Prevention [CDC], 2019). Researchers found a program which

provided support to African American women through group trainings, entailing of stress

reduction techniques, life skills development, and the building of social support. This enabled

mitigation efforts to be focused and geared around the factors that influence and contributed to

adverse pregnancy outcomes among the minority women within the community, thus reducing

and preventing negative pregnancy outcomes in women of color. In the United States, maternal

mortality and adverse health outcomes persist within the minority community, yet as racial

disparities in healthcare among pregnant women is a current preventable public health concern, it

is vital to understand the determinants of health that influences negative pregnancy related

outcomes in minority women, similar to one of California’s intervention programs, the Black

Infant Health Program (Nichols & Cohen, 2019).

Literature Review

Introduction to Literature Review

Research suggests that racial disparities in healthcare among pregnant women persists in

the United States (Zhang et al., 2013). Due to this continuous occurrence, it is vital to examine

the factors that contribute to the adverse outcomes in maternal health. The literature review

contained only research articles about factors that impacted and influenced disparities in

pregnancy outcomes. Factors that were reviewed were socioeconomic status, public health

insurance, race/ethnicity, and poverty status. The literature review was conducted using EBSCO

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 3

Host and ProQuest databases from the Monroe College Library. The search terms used to

compile pertinent articles were racial disparities maternal health, adverse pregnancy outcomes,

and maternal health outcomes.

Review of Literature

Adverse Pregnancy Outcome Factors

Darling et al. (2021) conducted a study between 2001 and 2018 to examine the efficiency

of qualified interventions in preterm birth, small for gestational age, low birth weight, neonatal

death, cesarean deliveries, maternal care satisfaction, and coast effectiveness programs. A

systematic review was used to collect data from the United States, France, Spain, and the

Netherlands. The studies consisted of mostly non- Caucasian women from low-income

population ranging from 12 to 46 years of age and being between 20 to 32 weeks' gestation.

Interventional programs were implemented into three categories: group prenatal care, augmented

prenatal care, or a combination of both group and augmented prenatal care (Darling et al., 2021).

The researchers found that certain interventions, such as prenatal care and augmented care, or a

combination of both, may decrease adverse outcomes in small-for-gestational-age and preterm

birth, and could aid in increasing maternal care satisfaction. Interventions that worked on

enhancing coordination of care were found to result in providing more effective cost savings.

The researchers also found disparities in the quality of access to care in the vulnerable

population. There was insufficient evidence of suitable quality to confirm that the interventions

were successful at enhancing clinical outcomes in prenatal care for at risk populations (Darling et

al., 2021).

Similar observations were made in a study conducted by Nichols and Cohen (2020),

between 2006 and 2018 to examine the methods used to improve the results of maternal

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 4

mortality in California. The study was conducted using a scoping review to evaluate research on

women and maternal health in the United States. The researchers used information from the US

Maternal Fetal Medicine Network to measure the percentage of studies where pregnant women,

women, and children were the main focus. The researchers also reviewed documentation on

healthcare policies and practices from California’s public health department, healthcare

foundation, and Maternal Quality Care Collaborative. Nichols and Cohen (2020) found that

although the health of fetus and children could be adversely affected by the health of the mother,

the majority of maternal programs in the United States places emphasis on the child. The

researchers also found four areas of concern in women health experiences, both in pre and

postnatal care. The problem areas entailed inadequate investment in women's health, inefficient

quality of care and avoidable caesarean delivers, expanding disparities in minority women and

women living in rural areas, and contradictory collection and distribution of data (Nichols &

Cohen, 2020).

Approaches to Improving Pregnancy Outcomes

In contrast to the preceding studies, Zhang et al. (2013) conducted a study between 2005

and 2007 to calculate the excessive rate of unfavorable outcomes in pregnancy within racial and

ethnic groups. The study also aimed to measure the possibility of Medicaid savings that are

linked to paid maternal care claims resulting from the inequalities that contribute to unfavorable

maternal outcomes. A cross-sectional study using Medicaid Analytic eXtract (MAX) data was

used to gather pregnancy outcome information from inpatient hospitals from 14 states (Florida,

Alabama, Arkansas, North Carolina, Georgia, Louisiana, Kentucky, Mississippi, Maryland,

Missouri, Tennessee, South Carolina, Virginia, and Texas). The study consisted of a little over 2

million patients who were insured with Medicaid and had a delivery code of maternal delivery

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 5

stay. Zhang et al. (2013) found that, with the exception of gestational diabetes, African American

women showed the worst outcomes out of all unfavorable pregnancy outcomes. These disparities

are postulated as being multi-factorial, having causes stemming from complicated experiences

with racism, poverty, and complex healthcare interactions. It was also found that women covered

under Medicaid health insurance were more likely to have consistency in care from prenatal care

through delivery compared to their counterparts. However, due to participation in Medicaid

programs being influenced by reimbursement rates, some providers may choose to stop

accepting Medicaid patients because of reimbursement delays and low payment rates, which

could contribute to negative birth outcomes (Zhang et al., 2013).

Analysis of Literature

In the United States, the persistence of maternal mortality continues to be a problem area

in public health. The contributing factors that impact pregnancy outcomes persist in burdening

the U.S., leading to poor healthcare quality, and increasing health disparities. The studies used in

this literature review each used a different form of research methodology to collect data,

including systematic and scoping reviews and cross-sectional studies. Similarly, Darling et al.

(2021), Nichols and Cohen (2020), and Zhang et al. (2013) have emphasized the correlation

between race/ethnicity and financial status playing a part in influencing quality of care, access of

care, and pregnancy outcomes in pregnant minority women. To mitigate the disparities in

maternal health Darling et al. (2021) and Zhang et al. (2013) suggested that interventions should

be inspected and geared towards determining and eradicating the racial and ethnic disparities that

affect pregnancy-related outcomes. Whereas Nichols and Cohen (2020) suggested focusing on

exploring the distinctive experiences of particular at-risk subgroups of women, such as women in

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 6

prison, who are of childbearing age, and the pregnant women who are less likely to pursue

prenatal care, such as undocumented women.

Discussion

Introduction to Discussion

There is current evidence that racial disparities in healthcare among pregnant women

continues to be a problem in the United States. In an article published by The New York Times

(Rabin, 2019), there has been a persistence and growth in racial disparity throughout the years

despite calls to take action to improve medical care access for women of color. Similarly, in a

study conducted by Nichols and Cohen (2019) mounting disparities continue amid women health

outcomes in the United States, primarily among race and ethnicity and within residents living in

urban and rural areas (Nichols & Cohen, 2019). These disparities directly affect African

American, Alaska Native and Native American Women (Rabin, 2019). When compared to other

high-income countries, the United States has substandard records in maternal health outcomes,

and while the rate of maternal mortality dropped across the world, America's maternal health

outcomes have worsened (Rabin, 2019).

Evidence-Based Recommendation

To reduce the disparities among minority women policy changes have been made.

Federal law enacted the Preventing Maternal Death Act providing states with grants to explore,

examine and investigate pregnancy related deaths for up to one year after the birth of a child

(Rabin, 2019). Also, The American College of Obstetrics and Gynecologists created new

guidelines in treating cardiovascular disease in pregnant women (Rabin, 2019). In 2014 Alliance

for Innovation on Maternal Health (AIM) was developed by the American College of Obstetrics

and Gynecology to collaborate with partners of the states and hospitals to gather information on

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 7

safety measures being taken to improve maternal health outcomes, allowing partners to assess

and track program progress (Nichols & Cohen, 2019). In the study conducted by Nichols and

Cohen (2019), two out of the various programs that California implemented were the Black

Infant Health Program (BIH) and increasing the states income eligibility for pregnant women to

200% of the federal poverty level. With the implementation of these programs, mortality rates

decreased from 22.1% to 8.3% in the best practices toolkit, a program developed for hemorrhage

and high blood pressure during pregnancy. Altogether, California's maternal mortality rate

decreased by above 50% between 2006 and 2018 (Nichols & Cohen, 2019). To prevent negative

pregnancy outcomes in women of color, California used federal funds to develop programs that

focused on African American mothers and the health determinants that are influenced by social

and structural factors. The Black Infant Health Program provided support to African American

women through group trainings, entailing of stress reduction, life skills development, and

building social support (Nichols & Cohen, 2019). Nearly half of the babies born in the United

States are insured under Medicaid which covers the child through the first year of life. However,

in most states, Medicaid provides coverage for the mother until 60 days postpartum, after which

the mother must meet the federal poverty level to be eligible for coverage (Nichols & Cohen,

2019). This exposes the mother to various risks that can adversely affect her health. Expanding

Medicaid access would mitigate the maternal healthcare barriers that affect low socioeconomic

minority women.

Racial disparities in maternal healthcare are a persistent problem in the United States.

African American mothers experience higher adverse pregnancy outcomes and are less likely to

obtain sufficient prenatal care when compared to Caucasian women (Zhang et al., 2013).

Similarly, racial disparities among women of color are made worse by partialities in the

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 8

healthcare that they receive (Nichols & Cohen, 2019). To mitigate racial disparities in maternal

health among minority women it is important to understand the determinants that contribute to

their health outcomes. With increased federal funding, programs can be geared towards

providing quality care to women of color. This can be established by utilizing specific methods

of care that are relatable to those being serviced in the community, providing them with medical

professionals that are culturally competent and adequately trained in servicing underserved

communities, fostering a trusting provider-patient relationship. Nichols and Cohen (2019)

suggest that funding should be used to address the social factors that influence maternal health to

reduce the psychosocial risks in women who may be more vulnerable to adverse pregnancy

outcomes. The pregnancy-related risks of a mother do not end after her child's birth. The

expansion of Medicaid access and coverage would provide a mother with the means of receiving

adequate care during all stages of pregnancy and during the postpartum period, in which she can

still be adversely affected from her pregnancy. It is vital for the federal government to enact

policies requiring states to provide medical coverage to women for one year after the birth of

their child. Providing coverage to various specialties would ensure the mother has efficient

access to care should adverse symptoms develop. Nichols and Cohen (2019) postulated that state

programs should expand Medicaid coverage for women focusing on their healthcare needs

before, during and after pregnancy, paying close attention to women’s health and chronic disease

management, especially to those who have or had high risk pregnancies. Implementing these

programs would develop a foundation in the quality of racial maternal care across all states and

provide cohesion and uniformity in the delivery of care.

Conclusion

RACIAL DISPARITIES IN HEALTH IN PREGNANT WOMEN 9

As seen in one of California’s intervention programs, the Black Infant Health Program

(Nichols & Cohen, 2019), a program which provided support to African American women

through group trainings, which entailed stress reduction techniques, life skills development, and

the building of social support enabled mitigation efforts to be focused and geared around the

influencing factors that contributed to adverse pregnancy outcomes among the minority women

within the community, thus reducing and preventing negative pregnancy outcomes in women of

color. African American, American Indian, and Alaska Native women are up to three times more

likely to die from adverse pregnancy related outcomes, a disparity that increases with age (CDC,

2019). In the United States, maternal mortality and adverse health outcomes persist within the

minority community and as a result racial disparities in healthcare among pregnant women is a

current preventable public health concern, therefore it is vital to understand the determinants of

health that influences negative pregnancy related outcomes in minority women.

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