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4 Systemic Influences on Outcomes in Pregnancy and Childbirth
Pages 113-144

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From page 113...
... , systems-level factors can contribute to existing risk factors or create new ones, shaping quality, access, choice, and outcomes in birth settings. These factors include structural inequalities and biases, the social determinants of health, and financing and policy decisions in the health system.
From page 114...
... . In light of these realities, a thoughtful discussion of risk and birth settings must be placed in the context of historical and present-day inequities that may contribute to risk and impede equitable access to birth settings for 1  Asian women have higher rates of low birthweight but lower rates of preterm birth compared with White women.
From page 115...
... . However, out-of-pocket costs or locale may put certain birth settings out of reach for socially or financially disadvantaged populations.
From page 116...
... Low/very low birthweight 9.7 8.1 16.8 9.7 9.7 Interventions Cesarean birth 32.0 30.9 36.0 28.5 33.2 Low-riska 26.0 24.9 30.4 22.8 27.8 Induction of labor 25.7 28.9 23.9 26.7 20.5 Pregnancy-related mortality per -- 13.0 42.8 32.5 14.2 10,000 births Infant mortality rate per 1,000 live 5.8 4.7 11.0 9.2 3.8 births aLow-risk cesarean birth rate is the number of singleton, term (37 weeks or more of gestation based on the obstetric estimate) , cephalic cesarean deliveries to women having a first birth per 100 women with singleton, term, cephalic deliveries.
From page 117...
... SYSTEMIC INFLUENCES ON OUTCOMES IN PREGNANCY AND CHILDBIRTH 117 Native Hispanic Origin Hawaiian or Other Central/ Other/ Pacific All Puerto South Unknown Islander Hispanic Mexican Rican Cuban American Hispanic 24.9 24.8 24.2 24.7 27.4 26.5 24.8 48.7 52.2 50.2 64.2 52.5 50.5 52.9 36.7 52.0 55.1 71.5 43.7 16.9 68.0 77.3 72.1 70.6 82.9 91.4 61.6 79.5 9.7 13.5 10.5 15.8 28.1 18.4 15.7 52.5 72.3 72.0 76.0 82.2 67.7 74.6 19.6 7.7 7.9 6.1 4.2 9.3 7.0 56.2 60.2 61.7 60.1 52.7 54.7 61.6 28.6 28.5 27.1 34.1 43.1 26.9 29.8 6.3 6.7 6.7 1.4 1.6 12.9 3.5 8.9 4.7 4.5 4.4 2.7 5.5 5.1 10.5 9.6 9.4 11.2 9.1 9.1 10.2 8.9 8.7 8.2 11.4 8.6 8.1 9.7 31.0 31.8 30.4 33.9 45.8 31.3 33.9 26.8 25.6 24.0 27.5 39.2 26.0 26.6 17.5 21.6 21.1 24.2 22.6 20.5 22.8 -- 11.4 -- -- -- -- -- 7.6 5.1 5.1 6.5 4.0 4.5 --
From page 118...
... . In the following section, we consider the birthing justice framework of access with the reality of medical and obstetric risk factors, patterned by the social determinants of health.
From page 119...
... Black women see obstetric racism as a threat to positive birth outcomes. In response, some attempt to mitigate their risk of obstetric racism by utilizing midwives and doulas and avoiding the hospital when home and birth center birth services are available (Davis, 2018)
From page 120...
... This raises the critical need to diversify the maternity care workforce, which is discussed at greater length in Chapter 7.
From page 121...
... For example, in addition to stress related to racial discrimination, low-income women of color may experience stress related to limited economic security, limited childcare availability, the cost of health services, inadequate family and social support, the need to continue working during pregnancy to support the family financially, and other psychological stressors, all of which contribute to negative health outcomes (Dominguez et al., 2008; Lobel et al., 1992; Hogue and Bremner, 2005)
From page 122...
... The label "Black," for example, although a social construct and not a marker of genetic difference, has served as a risk factor for almost all poor obstetric outcomes, when in fact, it is racism, not race, that increases Black women's risk. While compounding social disadvantages with financial disadvantage means that low-income women of color face health challenges, it is critically important that membership in a specific perceived racial/ethnic group not be used to over­ determine a given patient's risk assessment such that it alone constrains the birth setting or maternity care provider options made available.
From page 123...
... Doing so would enable women of color, particularly those with elevated medical, social, or obstetric risk factors, to still garner the benefits of woman-centered midwifery models of care and labor support. In summary, racism and racial discrimination, whether manifested in the health care system, through chronic stress, or in reduced access to services, has tangible impacts on the lives of women of color and their families, impacts that are seen in racial/ethnic disparities in adverse birth outcomes.
From page 124...
... . The figure shows the social determinants -- such as housing, transportation, and education -- that influence experiences in the maternity care system for women and infants.
From page 125...
... . Accordingly, women who experience intimate partner violence may be better served in birth settings that allow for greater relationship building between providers and the women they serve.
From page 126...
... Providing social support during pregnancy to women who need it may reduce the risk of such adverse birth outcomes as preterm birth, low birthweight, and postpartum depression (Collins et al., 1993)
From page 127...
... . Women who received these enhanced doula services had lower rates of preterm birth and low birthweight compared with women in the same neighborhood who did not receive those services (Thomas et al., 2017)
From page 128...
... . Employment Status Among social determinants, the workplace and related social policies play a major role in maternal well-being and ability to care for infants (­ ational Partnership for Women & Families, 2018a)
From page 129...
... In one study of 613 low-income pregnant women and teenage girls receiving prenatal care in New York City, housing instability was independently associated with low birthweight, even after controlling for clinical, behavioral, and demographic factors (Carrion, 2015)
From page 130...
... In this section, we explore the innermost circle of our conceptual model, the health system, and its role in the patterns of women's risk in pregnancy and childbirth. The health system, writ large, includes the geographic distribution of the health care workforce; the certification, licensure, and scope of practice of that workforce; the financing of maternity care services; and the resultant access to services for the population.
From page 131...
... Many rural -- and even some urban -- areas lack maternity care providers and hospitals with maternity units. A "maternity care desert," as defined by the March of Dimes, is a county in which maternity care services are limited or absent because of either a lack of services or barriers to a woman's ability to access those services (March of Dimes, 2018a)
From page 132...
... In addition, closures of hospital maternity care units in urban underserved communities often result from high costs and economic pressures. In 2017, for example, the only two maternity care units on the east side of Washington, DC, closed their doors, leaving the predominantly Black and largely low-income population, with limited public transportation services, to find care elsewhere (Itkowitz, 2017)
From page 133...
... . Other systems attempt to address geographic challenges by bringing women to maternity care services.
From page 134...
... . Moreover, it may be beneficial to create models that expand family physicians' participation in maternity care and provision of laborist care within hospital and micro-hospital settings, as well as provide midwifery care for low-risk women in home and birth center settings (Avery et al., 2018)
From page 135...
... . Despite their importance to rural communities, however, family physicians may face challenges in obtaining hospital privileges to perform cesarean births and building collaborative relationships with other maternity care providers (Eden and Peterson, 2018)
From page 136...
... For example, if certified nurse midwives and nurse practitioners were permitted to practice to the full extent of their education and training in all jurisdictions, they could greatly alleviate the shortage of maternity care providers, and could improve access to care for women across the country (see, e.g., Institute of Medicine, 2011; Buerhaus, 2018)
From page 137...
... Created with Mapchart.net. Maternity Care Financing As discussed in Chapter 2, sources of financing for maternity care may include commercial insurance (with some out-of-pocket costs)
From page 138...
... In addition, payment, especially by Medicaid, may not cover the facility fee for birth, so that home and birth center settings, unable to cover their marginal costs, are unable to accept a large proportion of Medicaid patients. This is the case despite documented cost savings and reduction in preterm birth, among other benefits for Medicaid beneficiaries in birth centers, in comparison with similar women receiving maternity care in typical Medicaid care settings (Hill et al., 2018)
From page 139...
... Black women, AIAN women, women of low socioeconomic status, rural women, and immigrant women all face systemic barriers to accessing early and adequate prenatal care (see Table 4-1 presented earlier; see Box 4-1 for discussion of the challenges to accessing materity care among immigrant women)
From page 140...
... found that infants born to Latina immigrant women had a lower incidence of low birthweight and higher average weight at birth compared with infants born to U.S.-born White women in two U.S. states, a phenomenon that has been replicated in other studies of immigrants (Ramraj et al., 2015)
From page 141...
... In the comparison group analysis, participants receiving enhanced prenatal care were matched by risk profile with Medicaid beneficiaries in the same counties receiving usual or nonenhanced prenatal care. Comparative analyses demonstrated significant improvements for women in birth center care compared with usual care for a range of outcomes, including preterm birth (6.3% vs.
From page 142...
... Finding 4-1: Birthing facilities and maternity care providers are un evenly distributed across the United States, leaving many women without access to prenatal, birthing, and postpartum care and choices among options near home. Finding 4-2: Women living in rural communities and underserved urban areas have greater risks of poor outcomes, such as preterm birth and maternal and infant mortality, in part because of lack of access to maternity and prenatal care in their local areas.
From page 143...
... This in turn influences her willingness to seek maternity care and other aspects of access to care. Under­ tanding the role s that nonclinical factors play in determining clinical risk is essential for d ­ eveloping risk-appropriate models of care.
From page 144...
... At the population level, these systemic factors translate into disparities in maternal and neonatal outcomes along lines of race, class, and geography. Other social determinants of health also influence both access and outcomes, including housing, employment status, health literacy and education, transportation, location of services, and location of maternity care professionals.


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