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Departments: Expert Opinion: Neonatal

Health Inequity and Social Determinants of Health

Editor(s): Kenner, Carole PhD, RN, FAAN, FNAP, ANEF; Patterson, Natasha PhD, MPH

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The Journal of Perinatal & Neonatal Nursing: April/June 2022 - Volume 36 - Issue 2 - p 109-111
doi: 10.1097/JPN.0000000000000642
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The United Nations Millennium Declaration in 2000 set forth 8 goals to address poverty, disease, illiteracy, environmental degradation, and discrimination again women by 2015.1 Part of this work required monitoring goal progress. By 2015, it became apparent that goals needed to move to sustainability and thus the creation of 17 Sustainable Development Goals or SDGs.2 The SDGs are to be achieved by 2030. Health is at the forefront with emphasis on improving maternal child health equity.2 While much of this work is aimed at low-resourced countries, unfortunately it is very applicable to the United States. Crear-Perry and colleagues3 contend that SDGs have failed to consider the social context and social factors impacting health promotion and preventive care. There are infrastructure and systems issues including structural racism that contribute to health inequities.3 These researchers call for use of a reproductive justice framework “Restoring Our Own Through Transformation (ROOTT) created by Roach4 to move the blame for poor health outcomes from the individual to the system.3

How does the United States perform regarding SDGs? According to the “United States Sustainable Development Report, 2021,” the United States ranked 32nd demonstrating wide variations across states with Southern and Appalachian states having the worst outcomes and New England states the best. For example, New Jersey's SDG Index Rank is 14/50 and in terms of SDG 3 Good Health and Well-Being, New Jersey's deaths by overdose and suicide decreased while HIV prevalence and uninsured status remained a challenge.5 Overall life expectancy and primary healthcare decreased.5 But not one of the states has met or is on track to meet the SDGs by 2030.5 The SDG 10 Reduced Inequalities show moderate improvement in hate group concentration while the Gini Coefficient related to income, racial disparity in rent burden, disability support, and poverty continue to be challenges in New Jersey.5 Why? The poverty, racial and ethnic disparities, and social support are the major factors impacting outcomes.5 The pandemic has exacerbated the situation, sending more people into poverty and reducing access to preventative health services. Climate change and the large divide in the United States on this topic, contributes to a lack of environmental actions in parts of the country that could positively impact health including the maternal child population. Some recommendations to combat the poor SDG US outcomes include rebuilding and strengthening the public health system; embracing climate change policies; and adopting social policies to support racial and ethnic equality.6

The US maternal child health outcomes are the worst of an industrialized nation.7 Maternal mortality rate in 2018 was 17.4/100 000 pregnancies with the rate for Black women standing at 37.1/100 000 pregnancies, 14.7/100 000 pregnancies for White women, and 11.8/100 000 pregnancies for Hispanic women.7 The causes of these deaths vary across the groups. Black women are more likely to have cardiomyopathy than Hispanic women.7 Black women with a college education are more likely to die than White women.7 Alabama, Arkansas, Kentucky, and Oklahoma have the highest maternal deaths in the United States.7 But true state-to-state comparisons are difficult due to the lack of data collected in many states. Black women report higher rates of disrespectful care; not having control of decision making; reduced maternal leave; less psychosocial support after giving birth; and lower rates of exclusive breastfeeding.7

What can and should be done to combat maternal mortality and to improve SDG progress? Some progress has been shown in states that develop maternal review boards but as of 2018, only about half the states had implemented these boards.8 Each state should have these review boards. Other states such as New Jersey are considering the development of maternal child centers in low-resourced areas. The aim of such centers is to increase access to health services including primary care. Other recommendations include improved maternal child data collection in each state; ensuring that the workforce is culturally competent and is aware of unconscious or implicit bias; support respectful care; ensure equitable insurance coverage across all stakeholder groups; and diversify the workforce to mirror demographic/societal changes.8

The US neonatal mortality improved from 2019 to 2020, with the rate moving from 3.69 to 3.61 per 1000 live births.9 This rate is higher than other industrialized nations. These deaths are related to reducing maternal risk factors; obesity, smoking, and alcohol use; access to care; and poverty.10 All of these are related to the need to strengthen access to preconceptual care, primary care, and healthcare in general. Equities in insurance coverage, income, and healthcare delivery call for social policy changes and workforce training around bias and respectful care.

The Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act or the MOMMIES Act was introduced by congresswoman Ayanna Pressley and New Jersey Senator Cory Booker and supported by 21 of their colleagues in May 2021.11 This legislation outlines specific programs and requirements under Medicaid and the Children's Health Insurance Program (CHIP) that pertain to maternal health. One of the most significant changes is to extend postpartum care to 1 year after the birth of the child and another is to provide maternity care “homes” for pregnant and postpartum people to receive comprehensive care and services in one place. This legislation has yet to be signed; it is currently with the committee on finance for review.

In the meantime, New Jersey Governor Murphy signed legislation that focuses on similar requirements and initiatives including but not limited to expanding Medicaid to include coverage for doula care, a newborn home visiting program, and requiring all healthcare professionals who provide perinatal treatment and care to pregnant persons at a hospital or birthing center undergo explicit and implicit bias training. Prior to the new state legislation being signed into law, First Lady Tammy Murphy's office released the Nurture New Jersey Strategic Plan in January 2021.12 The strategic plan, which was developed with the input of all stakeholders including community-based organizations, healthcare organizations, higher education institutions, and pharmaceutical companies, is a robust and comprehensive plan of action for the state.12 It uses the ecological approach, identifying the root causes of the Black maternal health crisis, highlighting the role of racism and social determinants of health, and outlining possible solutions to the problem from each level: individual, interpersonal, organizational, community, and policy. Bringing all of these entities together to combat this problem allows for a more robust plan that is comprehensive.12 The strategic plan outlines responsibilities for each entity.12 Higher education institutions such as The College of New Jersey (TCNJ) have been invited to the table to assist in providing information, partnering with healthcare organizations and community-based organizations, and providing education and training opportunities. The TCNJ Department of Public Health has been involved with facilitation at the annual leadership summits, providing input on the strategic plan as well as the development of a proposed birthing center in Trenton, New Jersey. The department has also hosted a webinar of panelists speaking on the integration of doulas into the medical care team for pregnant people and is currently in the process of developing a doula training program for students in partnership with TCNJ Department of Women and Gender Studies and a community-based organization, Melinated Moms. This organization has been elevating the voices of moms “across the melinated spectrum” and advocating for changes to the systems that continue to marginalize and exclude them.

As previously stated, there are infrastructure and systems issues including structural racism that contribute to health inequities in general and specifically with Black maternal and infant health outcomes. This is a problem throughout the United States. The solutions must be comprehensive, sustainable, and implemented systemwide. The solutions include implementing review boards, expanding Medicaid and CHIP, creating birthing centers, diversifying the workforce, educating healthcare providers, and raising awareness. It is also imperative that all stakeholders be involved in this work, from the planning to implementation to evaluation. Historically, this has not been the practice. Many community-based organizations have not been included in the conversation or in the development of solutions, while they are the ones who have the more direct access to the community and a clear understanding of their needs, challenges, and opportunities. Their input is extremely valuable. In including them, there is also a need to provide them with compensation for their knowledge and experience and funding for the work they will be able to do as a result of whatever strategies are implemented. Policy makers have the opportunity to design and implement legislation to support these efforts at the national, state, and local levels.

The US maternal child population health outcomes must improve. This cannot be done until steps are taken to strengthen the public health system to include preventative services and easy access to care. Identifying and exploring solutions with community stakeholders must include infrastructure and structural racism systems issues. It is no longer acceptable to identify these problems impacting the SDG achievement or health inequities. There must be action and the time is now for change!

—Carole Kenner, PhD, RN, FAAN, FNAP, ANEF
Carol Kuser Loser Dean & Professor
The College of New Jersey
Ewing, New Jersey
Chief Executive Officer
Council of International Neonatal Nurses, Inc (COINN)
Yardley, Pennsylvania
—Natasha Patterson, PhD, MPH
Department of Public Health
School of Nursing, Health, & Exercise Science
The College of New Jersey
Ewing, New Jersey

References

1. World Health Organization. Millennium development goals (MDGs). https://www.who.int/news-room/fact-sheets/detail/millennium-development-goals-(mdgs). Published 2018. Accessed February 25, 2022.
2. World Health Organization. Sustainable development goals (SDGs). https://www.who.int/health-topics/sustainable-development-goals#tab=tab_1. Published 2022. Accessed February 25, 2022.
3. Crear-Perry J, Correa-de-Araujo R, Johnson TL, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health. 2021;30(2):230–235. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020519/. Accessed February 25, 2022.
4. Roach J. ROOTT's theoretical framework of the web of causation between structural and social determinants of health and wellness—2016. Restoring Our Own Through Transformation (ROOTT), https://www.roottrj.org/policy-advocacy. Published 2016. Accessed February 25, 2022.
5. Lynch A, Sachs J. The United States Sustainable Development Report 2021. New York: SDSN. https://us-states.sdgindex.org/. Published 2021. Accessed February 25, 2022.
6. IISD. SDG knowledge hub: experts recommend steps for SDG implementation in the US. https://sdg.iisd.org/news/experts-recommend-steps-for-sdg-implementation-in-the-us/. Published 2021. Accessed February 25, 2022.
7. Commonwealth Fund. Maternal mortality in the United States: a primer. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer. Published 2020. Accessed February 25, 2022.
8. Amankwaa L, Records K, Kenner C, Roux G, Stone SE, Walker DS. African-American mothers' persistent excessive maternal death rates. Nurs Outlook. 2018,66(3):316–318. https://www.nursingoutlook.org/article/S0029-6554(18)30144-1/fulltext. Accessed February 25, 2022.
9. Driscoll AK, Ely DM. Quarterly provisional estimates for infant mortality, 2018-quarter 4, 2020. National Center for Health Statistics, National Vital Statistics System, Vital Statistics Rapid Release Program. https://www.cdc.gov/nchs/nvss/vsrr/infant-mortality-dashboard.htm. Published 2021. Accessed February 25, 2022.
10. America's Health Rankings. America's Health Rankings analysis of CDC WONDER, Linked Birth/Infant Death Files, United Health Foundation, AmericasHealthRankings.org. https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/IMR_MCH/state/ALL. Published 2021. Accessed February 25, 2022.
11. Pressley A, Booker C. Pressley, Booker, colleagues reintroduce MOMMIES Act to promote community-based, holistic maternal health care. https://pressley.house.gov/media/press-releases/pressley-booker-colleagues-reintroduce-mommies-act-promote-community-based. Published 2021. Accessed February 25, 2022.
12. Hogan VK, Lee E, Asare LA, et al. The Nurture NJ Strategic Plan. Trenton, NJ: The State of New Jersey; 2021.
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