Introduction
Racial and ethnic disparity in healthcare system has been a topic attracting attention across various fields of research. To start with social scientists have been in the forefront to explain and analyze how socially driven factors have exacerbated healthcare outcome among minority segments of the society. The incongruities and imbalances in the treatment of various racial and ethnic groups in the society have proliferated up to including universal sectors such as healthcare. Minority groups still face stereotypes and discrimination in the healthcare system; a factor that explains increased negative healthcare outcomes among the minorities segments. Recent researches have narrowed the focus to examine the experiences of pregnant minority women in the healthcare system. The research has been necessitated following recent statistics on maternal deaths in the United States whereby the minorities have been disproportionately affected. Giving birth has been amounted to a death sentence among the racial and ethnic minority groups due to the various pregnancy and postpartum complications. However, most of these complications are preventable; which explains why the whites have experienced less deaths. Which brings the concern of this study whereby following the research I have conducted, I have been able to come up with a hypothesis. The prejudices and discrimination of the racial and ethnic minorities in the healthcare industry is the reason for the increased maternal deaths, mistreatments and negative attitudes on giving birth among these minorities.
Background of the research
Racial and ethnic disparities have had a long history in the United States. Prejudice has been experienced in various social institution with racial minorities experiencing abuse, disrespect, and discrimination. As a result, various aspects of life have been affected including, housing options, economic status, societal treatment, security, and access to healthcare resources. Such socioeconomic injustices and issue have been attributed to the racist attitude imbedded within American culture. Economically disadvantaged segments have struggled to access healthcare resources; also, indigenous communities within the rural areas struggle to reach out health centers for healthcare resources. Despite there being various social welfare programs and policies to carter for the economically disadvantaged and the rural indigenous people by mitigating the social injustices, little has been done concerning the experiences that pregnant racial and ethnic minorities undergo within the healthcare system. Therefore, the big question has been why are the African Americans, Latinas, and other people of color experiencing higher mortality rates than the whites? Moreover, why is such a segment neglected and discriminated against in the healthcare industry? Various researchers have elucidated this topic and scrutinized various related parameters.
Racism and ethnic disparity should be perceived as a matter of civil rights since it has resulted into dire consequences. For instance, Roeder (2019) stipulates that about 700 and 900 expectant mothers die every year in United States; nevertheless, about half a million women experience life threatening postpartum complications. Roeder (2019) adds that most of these deaths can be prevented, however black women suffer disproportionately from the statistics. The implication here is that the healthcare system deliberately allows black other to suffer and die on the basis of their race. Various cases of black mothers experiencing neglection in the healthcare system have been reported. Roeder (2019) presents epitome healthcare neglect for an African American, Shalon Irving, after she delivered by C-section and experienced complications. The clinicians neglect at her needs and attention can be seen when they perceive her symptoms as normal and that she needed to wait. Such neglect is what resulted to the death of Irving despite that she had access to top quality care.
Research
Various scholars have searched the parameters behind why the healthcare system does not value the racial and ethnic minorities as they do for the whites. For instance, women attitudes and preferences towards vaginal and cesarean delivery have been associated with the racial, ethnic, and socioeconomic differences. Attanasio et al. (2017), claims that 32% of about four million women giving birth every year, usually deliver by cesarean. Additionally, cesarean delivery is influenced by race, ethnicity, and socioeconomic status; whereby black women and those with lower socioeconomic status have higher chances of delivering by cesarean. Therefore, there may be a trend behind such a disparity in the delivery mode across different racial, ethnic, and socioeconomic individuals. It also implies that cesarean delivery may be explained by medical conditions only but another variation beyond clinical paradigms. According to Attanasio et al. (2017), complex interplay aspects are the etiology towards cesarean delivery; such factors include clinical practice patterns, hospital environment and culture, practice patterns of the healthcare provider, and preference and attitudes of the woman.
Additionally, patient-clinician relationship and communication play a great role in delivery modes. However, race, ethnic, and socioeconomic minorities do not experience patient centered communication involving decision making in healthcare encounters and therefore not empowered (Attanasio et al., 2017). This results to bias and affects the clinician-patient interaction and interpersonal behavior. Such is backed up by the believe that clinicians have an implicit preference for the white women and perceive black women as not cooperative in the medical procedures. Thus, this believe can be linked with the neglect behind women of color and why maternal deaths among this segment has proliferated disproportionately.
In the following study, Attanasio et al. (2017), examines variation of women’s prenatal attitudes in delivery mode towards racial, ethnic, and socioeconomic differences. The study sample involves 3000 first baby mothers from Pennsylvania. Several timeline interviews were conducted whereby the first happened during the third trimester of their pregnancy, then a month after giving birth, and lastly thirty-six months later after delivery. Moreover, hospital discharge and birth certificate statistics were linked with the responses from interview. The women’s attitude towards cesarean or vaginal delivery were measured using a five-point Likert scale. For instance, statements with preference attitude where used, such as ‘I would like to have my baby by cesarean.’ There after delivery, they were asked concerning their delivery mode; for those who underwent cesarean delivery, they were asked if there was a schedule planned or it came unplanned. Furthermore, several variables were captured such as race, ethnic, and socioeconomic status. Models depicting the interactions between delivery mode and race, ethnicity, and socioeconomic status were estimated.
The results revealed that whites were majority in the research with about 84%, Latina least with 5% while the black women comprise about 7% (Attanasio et al., 2017). Favorable attitudes on vaginal delivery were noted across all the racial groups since the mean value of 4.3 was close to the maximum value of 5. Implying that there was any association in race, ethnic, and socioeconomic disparities with attitude towards vaginal delivery. However, in the adjusted model of planed and unplanned cesarean delivery. Latina and black women were noted to have higher odds of delivering by cesarean than white women (Attanasio et al., 2017). Particularly unplanned cesarean delivery had higher odds among these racial minorities.
We can explain the above outcomes in terms of patient-clinician interaction. Such an interaction can be structured by various social factors such as ethnicity, race, and socioeconomic status. With high quality of patient-clinician communication and decisions that are patient centered, the patient will be empowered and therefore have the type mode of delivery they desire. Such attributes have been linked with the white women than the other racial minorities. Also, the clinician bias is another factor to consider in explaining the prevalence of disparity in handling diverse racial patients in the healthcare system. For instance, the clinician’s beliefs and perceptions towards the socioeconomic status and race of the patient will influence delivery of care and handling of various clinical operations and therefore respective health outcomes. Therefore, the aspect of labor is a significant etiology as to why many black women end up delivering through cesarean section. Moreover, the clinician tends to be quicker to recommending cesarean section delivery to the black women; perhaps this may be to avoid handling labor sections following the clinician’s belief that black women are mostly uncooperative. As a result of cesarean delivery, the associated complications later strike the patient and thus endangering her life.
In another similar study, wide range of attitudes relating to pregnancy among white and black women was examined. This is according to Barber et al. (2015) who concentrates the study among teen women in America. In the study there is also an examination of how racial disparities are mediated by adolescent experiences, family background, and childhood and current socioeconomic status. Barber et al. (2015), speculates that black women have less positive attitudes compared with white women in matter of nonmarital sex, childbearing, and contraception. The comparison differences can be explained by noting the religiosity and socioeconomic status of the two race categories. For instance, in their adolescent stages, the young black women socioeconomically disadvantaged while being more religious as compared to their counterpart whites. However, in their upcoming years, black women are more likely to experience sex without contraceptives; if they become pregnant more positive consequences are expected as compared to whites.
There is another racial disparity noted by Barber et al. (2015) in unintended child bearing, for instance, many pregnancies depicted as unintended have been involved with black women more than the white women. Barber et al. (2015) study focuses on certain life stage, the transition to adulthood. About nine hundred and sixty young women were involved in a Relationship Dynamics and Social Life (RDSL) survey study. Main focus of the study was on general attitudes, individual desires, expectations, and willingness to participate in undesired or unplanned behaviors; these aspects were referred as attitudes. Furthermore, in explaining adolescent’s risky behavior, a prototype or willingness model was deployed (Barber et al., 2015). Thus, race disparity is examined in such aspects as contraception, domains of sex, and pregnancy. Nevertheless, willingness, expectation, attitudes, and desires would affect pregnancy through the association with pregnancy desires and contraceptive or sexual behavior. For example, the desire to avoid pregnancy thwarts the risks associated with pregnancy; this may be either through engagement in sexual or contraceptive behaviors. Conversely, independent attitudes towards contraception and sex and pregnancy desires influence the risk of pregnancy. Three determinants towards pregnancy, contraceptives and sex were depicted to be, family background and adolescent experiences, economic opportunity, and medical experimentations involving forced sterilization among African Americans and socioeconomically disadvantaged individuals (Barber et al., 2015).
In the family background and adolescent experiences, Barber et al. (2015) maintain that attitudes towards contraceptives, pregnancy, and sex are formed during childhood, with childhood experiences varying across various races. For instance, single parenthood is higher among black teens with many experiences of family instability. As a result, black young women engage in early sexual activities with minimum use of contraceptives. Furthermore, the religiosity attribute of the black families explains why they are less involved in contraceptives since these churches oppose contraceptives and sex attitudes. Therefore, the possibility of early non-marital births is profound mostly among the teen black women.
In economic opportunity, Barber et al. (2015) claims that poverty is a solely factor that can influence attitudes towards contraceptive; lack of financial security to cover insurance for the contraceptives thwarts an individual from contraceptive engagement. Black women usually experience higher poverty levels as compared to the white women. Furthermore, aspects of less education, unemployment, few opportunities in employment, discrimination, and poor neighborhoods circulate more among black women. Therefore, such neighborhood acculturalization opposes contraceptive and attitude to pregnancy due ton cost, uncertainty and instability.
In medical experimentation and forced sterilization, Barber et al. (2015) present the debate concerning whether poor black women should bear children. This aspect of experimentation is not determined by socioeconomic status but rather on race. For instance, historical cases of involuntary and lack of informed consent operations on black women making them sterile explains the extend of racism. Furthermore, the Tuskegee study of black men suffering from syphilis is another aspect depicting racial experimentation; as these men were observed closely but not treated. Due to such occasions there has been distrust of contraceptives by African Americans; therefore, less attitudes towards contraceptives. Furthermore, such racial disparities in the attitudes towards sex, contraceptives and pregnancy also influence the mistreatment of black women in the healthcare system.
Fox (2021) integrates biopsychosocial and anthropological theories and methods in addressing mental health among pregnant and postpartum Latina women. The article examines how identity, culture, and social adversity influence maternal mental health, specifically among Latina women. According to Fox (2021), Latina women display higher levels of mood disorders than other women in various ethnic groups; this may be due to stressful conditions induced by cultural stressors such as discrimination and acculturalization. The study focuses on narrowing these trends and aspects among expectant and postpartum women. The study intended to examine how discrimination, acculturalization, and cultural values relates with depression, anxiety, perceived stress, and state of happiness among Latina pregnant and postpartum women.
Fox (2021), utilized first wave comprising of 361 pregnant and postpartum women recruited from south California. Acculturation was measured using the Acculturation Rating Scale for Mexican Americans II (ARSMA II). Cultural values were measured using MACVS subscale while mental health was assessed using the Edinburgh Postnatal Depression Scale (EPDS), used to assess depression levels among maternal prenatal mental health. Anxiety was assessed using State Trait Anxiety Inventory (STAI), lastly discrimination was assessed using prompt information from Perceived Ethnic Discrimination Questionnaire Community Version (PEDQ-CV) (Fox 2021). Other covariates were also considered including, age, socioeconomic status, pregnant versus postpartum, and relationship status. Multiple linear regression was used as an appropriate statistical method. The results were analyzed according to the predictors of interest below.
In acculturalization and mental health, the orientation of American culture was significant with perceived stress model; a negative correlation was noted after adjusting the effects of other predictors (Fox 2021). In the depression model, discrimination was positively correlated while in the happiness model greater Latino and American cultural orientation were significantly positive correlated with happiness. These results imply that different mental health outcomes are predicted by different cultural orientations while discrimination moderated anxiety levels.
Cultural values systems were also observed with their association with the four mental health outcomes. With the perceived stress model, there was no variable contributing to any significant outcome. In state anxiety model, one variable contributed positive significant effect, this was discrimination. The depression model pointed American cultural orientation as the only variable with significant positive prediction while to the negative borderline there was Latino cultural values (Fox 2021). Lastly, for happiness model, Latino cultural orientation contributed positive significance in the borderline.
Additionally, for the cultural value items and mental health outcomes the following observations were noted from the multiple regression models. For instance, in perceived stress model, traditional gender roles values were predicted positively. In the anxiety model, familism predicted some positive significance whereby; familism referent showed higher state anxiety than familism obligation. With the depression model, two variables were predicted positively; independence and self-reliance (Fox 2021). For happiness model, lower happiness levels were associated with traditional gender roles.
The results imply that there is an association between mental health outcome and acculturalization. For example, Latino and American cultural orientation were associate with various benefits; with American culture linked with low perceived stress and greater happiness levels (Fox 2021). The Latino culture was linked with low anxiety and great happiness levels. Furthermore, the role of discrimination has been pointed out precisely; it is altering the relationship between psychological and sociocultural contexts towards realization. For instance, despite that American and Latino cultural orientations have mental health benefits, for the case of Latino lower anxiety is perceived clear following high discrimination.
In another study depicting racial disparity issue within the healthcare system, Altman et al. (2019) discusses the dynamics of information and power and their association with women of color’s experiences while interacting with healthcare providers. According to Altman et al. (2019), women of color are disproportionately affected by poor birth outcomes such as preterm birth; they are two times more likely to experience preterm birth than white women (Altman et al., 2019). These outcomes and complications have been associated with social factors such as discrimination and racism. The clinician stereotypes to the minorities and the perception of such stereotypes by the minorities influence the outcome of negative health outcomes such as preterm birth. For instance, stress and racism experiences exacerbate reproductive outcomes leading to unintended pregnancies, preterm births, and other pregnancy complications (Altman et al., 2019). Moreover, other variable such income inequality, housing disparity, poor living conditions, and education disparities result into a cumulative effect on the outcomes. In the healthcare industry, patient-provider interactions is a significant factors determining the providence quality care and how the patient experiences the care. However, despite that such care should be experienced freely, the healthcare providers are mandated to the system obligation that defines how to provide and hinder care and to who. For instance, patient-provider interaction can be an etiology of empowerment and support to the patient; it may also result to rejection and discrimination leading to a negative outcome (Altman et al., 2019).
Women of color experiences during pregnancy, birth, and postpartum as relating to the healthcare system can be explained through socially driven parameters such as discrimination, abuse, and disrespect. For instance, women of color have attributed their interactions with healthcare provider as disrespectful, lacking autonomy, and exerting sense of inferiority (Altman et al., 2019). For example, the healthcare providers can come up it a critical decision without acquiring informed consent from the patient. This may result in complications that endanger the patient’s life. Therefore, most women of color are not actively involved in the decision-making process or other critical information concerning the pregnancy, delivery mode, or arising complication issue. This implies that the ability to make informed decision and being self-centered in the information acquisition in the healthcare system depicts power; that many women of color have been denied.
In order to thwart women of color the ability to participate actively in healthcare decisions, the providers present biased information that decreases the patient’s ability to get involved (Altman et al., 2019). A good example is concerning the delivery mode, whereby many clinicians would prefer women of color to deliver through C-section to avoid patient-provider interactions during labor. This is the reason why many African American women delivery through C-section as compared to the whites. However, the risk factors associated with C-section delivery usually pose danger to the lives of these minority women. Discrimination and stereotyping women of color by providers involve affirmations such that, they are poor, uneducated, unworthy, and single (Altman et al., 2019). Such stereotypes and prejudices are the reasons for the outcomes such as preterm birth, postpartum complications, and case of death on the mother or the infant.
However, in other parts of the world, like the case of Northwestern Viet Nam, health insurance reform has shown positive results in mitigating economic burden over the poor and ethnic minorities. As Matsubara et al. (2019) depicts, Health Insurance (HI) was introduced to achieve universal health coverage, which is the Sustainable Development Goal 3 (SDG 3). The vulnerable segment has been struggling in accessing healthcare due to financial barriers; an aspect that has led to inequality in Northwestern Viet Nam. The county is currently experiencing two HI; Compulsory Health Insurance (CHI) and Voluntary Health Insurance (VHI). CHI is targeted towards civil employees and those from formal sector, while VHI targets informal sector workers and self-employed persons.
From the study Matsubara et al. (2019) comes to conclusion that the enrollment of HI by the authorities has been successful in covering ethnic minorities from Luong Son district. Additionally, there has been an equitable contribution leading to low amount of out-of-pocket (OOP) within healthcare system for normal delivery and the C-section cases across various income quartiles. Also, Health Insurance supported payment to health resources for various treatments; however, in cases where household income Is low, a financial burden is experienced through transportation and other non-medical payments. Thus, the Insurance cover has played a significant role in mitigating negative health outcomes that can be influenced by healthcare disparity. However, the case of Northwestern Viet Nam is different from the healthcare disparities experienced in United States. In United states racial differences contribute greatly to the healthcare disparities rather than the basis of socioeconomic status.
Conclusion
The prejudices and discrimination of the racial and ethnic minorities in the healthcare industry is the reason for the increased maternal deaths, mistreatments and negative attitudes on giving birth among these minorities. Despite there being various social welfare programs and policies to carter for the economically disadvantaged and the rural indigenous people by mitigating the social injustices, little has been done concerning the experiences that pregnant racial and ethnic minorities undergo within the healthcare system. Various scholars have searched the parameters behind why the healthcare system does not value the racial and ethnic minorities as they do for the whites.
Women of color experiences during pregnancy, birth, and postpartum as relating to the healthcare system can be explained through socially driven parameters such as discrimination, abuse, and disrespect. For instance, women of color have attributed their interactions with healthcare provider as disrespectful, lacking autonomy, and exerting sense of inferiority. Patient-clinician interaction among the racial, ethnic, and socioeconomic minorities has been noted to be uncaring and unsuccessful due to the impeding discrimination and stereotypes articulated towards minority segments by the healthcare providers. It has been noted that most of C-section delivery modes are associated with women of color; this however happens to a neglect by the healthcare providers who avoid interaction during labor. The study has also proved that most of the healthcare providers have preference of white patients other than racial minorities whom they perceive as poor, uneducated, single, and unworthy.
Various interventions are necessary to thwart the vice. For example, in order to mitigate the issue of socioeconomic disparity in the healthcare system, universal health coverages will be necessary. The study has shown the success of health insurance in Northwestern Viet Nam; thus, it can be applied to curb financial barriers in the acquisition of heath resources. However, for the case of racial and ethnic disparities, social consensus and awareness that all people are equal will be the best strategy to curb discrimination. This is because, racism is embedded within the American culture and uprooting it will require starting from within on everybody, before the new equal culture becomes institutionalized.
References
Altman, M. R., Oseguera, T., McLemore, M. R., Kantrowitz-Gordon, I., Franck, L. S., & Lyndon, A. (2019). Information and power: Women of color’s experiences interacting with health care providers in pregnancy and birth. Social science & medicine, 238, 112491.
Attanasio, L. B., Hardeman, R. R., Kozhimannil, K. B., & Kjerulff, K. H. (2017). Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status. Birth, 44(4), 306-314.
Barber, J. S., Yarger, J. E., & Gatny, H. H. (2015). Black-white differences in attitudes related to pregnancy among young women. Demography, 52(3), 751-786.
Fox, M. (2021). Discrimination as a Moderator of the Effects of Acculturation and Cultural Values on Mental Health Among Pregnant and Postpartum Latina Women. American Anthropologist, 123(4), 780-804.
Matsubara, C., Nguyen, T. A., & Murakami, H. (2019). Exploring affordability and healthcare-seeking behaviour for delivery and antenatal care among the poor and ethnic minorities in rural Northwestern Viet Nam. Global Health Action, 12(1), 1556573.
Roeder, A. (2019). America is failing its black mothers. Harvard Public Health, 1-28.
write