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Commentary

Using Retrofit, Reform, and Reimagine to Advance Toward Health Equity

McLemore, Monica R. PhD, MPH, RN, FAAN

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The Journal of Perinatal & Neonatal Nursing: April/June 2022 - Volume 36 - Issue 2 - p 99-102
doi: 10.1097/JPN.0000000000000639
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Abstract

In 2019, SARS-CoV-2 (corona virus, shortened to COVID-19) emerged as a novel viral illness with multiorgan involvement that has killed an estimated 5 million people around the world.1 The COVID-19 global pandemic shuttered the economies of multiple countries and has exposed long-standing inequities that are associated with structural racism and divestment from crucial public health infrastructure. The COVID-19 pandemic has laid bare the core issues that intersect the social, clinical, and structural determinants of health. It is within this context that anecdotal accounts that informed consent, reproductive autonomy, and basic principles of health equity are being violated due to the need to balance-scarce resources and flatten the curve. It makes sense that pregnancy and childbirth would become ground zero in the United States for where these violations would occur, since childbirth remains the primary reason people are hospitalized each year in the United States.2

However, prior to the emergence of COVID-19, a Black maternal health (BMH) crisis3 had been well documented and in fact, many of the interventions and expansions of care, sought as a remedy to the BMH crisis, were operationalized due to COVID-19. For example, prior to COVID-19, clinicians could not work across state lines despite national licensure, the Centers for Medicare & Medicaid Services would not reimburse for telehealth visits, and auxiliary maternity units were not accessible as viable options outside of hospital-based birth; COVID-19 response temporarily removed these barriers.

The purpose of this commentary is to provide an overview of the current landscape for childbearing families and pregnancy-capable people and a call to action toward the courage to align health and human services that support improved health outcomes. The commentary is broken into 3 parts. First, the framework of retrofit, reform, and reimagine is developed to provide a conceptual framework that supports a shared language. Second, the current landscape is juxtaposed on the framework of retrofit, reform, and reimagine to connect the dots for health equity. The final discussion section ends with a call to action that demonstrates a bold roadmap for birth workers, clinicians, nurses, doulas, physicians, and other clinical health services providers to coconstruct paths to human services that should resolve health inequities.

RETROFIT, REFORM, AND REIMAGINE

Throughout my long clinical and research career, it had been difficult to articulate why reproductive health, rights, and justice were unable to align toward shared goals. After ruminating on the fundamental problem, I developed a framework that would help me, and others understand that we all were not having the same conversation and therefore could not work on shared solutions. From this thinking the framework of retrofit, reform, and reimagine was generated, which is not linear, but circular. Table 1 provides the following definitions from the Merriam-Webster Dictionary.4

Table 1. - Merriam-Webster definitions for retrofit, reform, and reimagine
Retrofit—transitive verb Reform—transitive verb Reimagine
1: To furnish (something, such as a computer, airplane, or building) with new or modified parts or equipment not available or considered necessary at the time of manufacture 1a: To put or change into an improved form or condition
1b: To amend or improve by change of form or removal of faults or abuses
1: To imagine again or anew especially: to form a new conception of: RE-CREATE
2: To install (new or modified parts or equipment) in something previously manufactured or constructed 2: To put an end to (an evil) by enforcing or introducing a better method or course of action
3: To adapt to a new purpose or need: MODIFY (retrofit the story for a new audience) 3: To induce or cause to abandon evil ways (ie, reform a drunkard)
4a: to subject (hydrocarbons) to cracking
4b: to produce (gasoline, gas, etc) by cracking

The framework of retrofit, reform, and reimagine is helpful when discussing the complex social and clinical condition of pregnancy, particularly given the outcomes of pregnancy (ie, abortion, adoption, parenting, and surrogacy) have been the subject of study. Midwives have historically viewed birth as a normal physiologic5 process while obstetricians have viewed birth as a clinical risk that needs to be medically managed. This difference in foundational understanding facilitates the confusion of retrofit, reform, and reimagine in terms of what is possible and necessary interventions that will improve health outcomes. For example, current discussions about increasing access to midwifery services for birthing people at risk for poor outcomes have not included the need to retrofit the existing pathways to diversify the workforce or to reform the location of birth settings. These discussions are superficial at best and harmful at worst. Whereas the simplest solution to achieve this goal is in the reimagine sphere, which would require the redistribution of resources based on need6 and develop midwifery programs at Historically Black Colleges and Universities that already have Schools of Nursing, Medicine, or Public Health. Using this framework is a rapid method to assist multiple stakeholders in establishing which conversation is being held and what positionality or stance each person has while having said discussion. This approach should result in a shared strategy to align effort, resources, and skills to build superior interventions and programs as opposed to continuing to talk past each other resulting in no real action.

CURRENT LANDSCAPE

Within this commentary, I use Dr Camara Jones' definition of health equity, which “is the assurance of the condition of optimal health for all people.”6 To make significant advancement toward health equity, particularly in the care of pregnant-capable people and childbearing families, it is important to map the current landscape. First, there is rampant reproductive injustice across the sexual and reproductive health spectrum. Attacks on the bodily autonomy of pregnant-capable people take many forms from the forced sterilization7 of individuals in Immigration and Customs Enforcement (ICE) detention, to abortion restrictions that do nothing to improve safety,8 patient mistreatment9 combined with maternal morbidity and mortality, bathroom bills and other trans-exclusionary policies.10 It is necessary to affirm that reproductive justice11 should be the goal of any and all people who serve the public across the lifecourse. It will be essential to having shared conversations given these challenges and potential opportunities particularly in light of newly identified resources in the Build Back Better framework12 and the Momnibus13 that both have significant implications for the care economy and childbearing families.

Criminalization of pregnant-capable people

Examples from ICE detention and the horrific conditions of carcerally involved pregnant people have historically been discussed in the context of criminal justice14 and not patient safety. Until recently, data were not readily available on pregnant-capable and their health outcomes.15 A retrofitted discussion of these issues would involve interventions to improve the care of carcerally involved pregnant-capable people and consistency in the services offered. A reform discussion would test out community-based transition programs aimed at reducing recidivism (cycling in and out of jails and/or prisons). A reimagined conversation would begin from the idea that pregnant-capable people should not be incarcerated in the first place.

Patient mistreatment and clinician burnout

Research has shown that patient mistreatment is unfortunately a significant factor for Black, indigenous, and people of color (BIPOC) and/or White people partnered with BIPOC individuals.9 Additionally, clinician burnout has been well documented in research studies16; however, these 2 phenomena are not discussed as they should be. Patient mistreatment and clinician burnout are 2 sides of the same coin because the structures in which we attempt to provide care need reimagination. Some of our workplaces are inhumane and work neither for the people we serve, nor those of us who work within them. Nurses have made attempt to retrofit and reform workplaces to accommodate patients and families including examples such as Family Integrated Care,17 and group prenatal care and parenting classes.18 However, true reimagination will require understanding what the people we serve want and need—paired with clarity of what we want and need, and then creating new structures and models of care.

Language

Clear communication is one hallmark of quality care. Specific to health equity, it matters what language is used in the clinical environment, reporting of research, education and teaching, and policy. Reproductive health, rights, and justice are consistently conflated, when each has a unique definition and these terms exemplify retrofit, reform, and reimagine. The reproductive rights framework historically has been based on universal legal protections for women and sees these protections as rights. This perspective is a retrofit grounded in ensuring or expanding rights to pregnant-capable people. The reproductive health framework emphasizes the very necessary reproductive health services that historically women have needed. However, provision of these services in a compartmentalized medical or clinical context is a reform that responds to the erroneous default standard of human19 (ie, men) grounded in patriarchy. Reproductive justice “is a positive approach that links sexuality, health, and human rights to social justice movements by placing abortion and reproductive health issues in the larger context of the well-being and health of women, families and communities because reproductive justice seamlessly integrates those individual and group human rights particularly important to marginalized communities.”11,20 These distinctions matter particularly when it comes to language as inclusivity and precision are important for clinical decision-making and legal protections. Use of pregnant-capable people, childbearing families, sperm-producing individuals, and people with uteruses is more accurate and mitigates harmful errors that have been caused using short-sighted heuristics like gender.21

DISCUSSION AND CALL TO ACTION

Given what is at stake, the following call to action is grounded in understanding that retrofit, reform, and reimagine are all necessary to achieve health equity. I believe the current and future perinatal workforce has the brilliance, opportunity, and courage to partner with impacted communities to center their needs, desires, and wisdom to improve health outcomes. It will take bold leadership to declare that we need rigorous scientific and clinical innovation and a robust social safety net to resolve health inequities and to achieve health equity. This truth requires a call to action: First, public health, clinical health services provision, and community engagement must be aligned in our efforts. Next, significant investments of humans, money, space, and time will be necessary to make strides toward health equity and this cannot be achieved in one grant, one project, one hospital, or clinic. Adjusting our expectations about population-level health outcome improvements will be the work of clinicians, educators, funders, and policy makers. Finally, everyone needs to appreciate that health equity work is long term and includes retrofits of existing structures as well as reforms, but we must also instill the need to reimagine reproductive health, rights, and justice within the current and future workforce.

References

1. World Health Organization. COVID19 Statistics. https://covid19.who.int/
2. McLemore MR. COVID-19 is no reason to abandon pregnant people. https://blogs.scientificamerican.com/observations/covid-19-is-no-reason-to-abandon-pregnant-people/. Accessed April 24, 2020.
3. The 116 Congress of the United States. House of Representatives. Black Maternal Health Caucus Momnibus. https://blackmaternalhealthcaucus-underwood.house.gov/Momnibus.
4. Merriam-Webster. “Retrofit, reform, and reimagine. Merriam-Webster.com. Accessed December 3, 2021.
5. Supporting healthy and normal physiologic childbirth: a consensus statement by ACNM, MANA, and NACPM. J Perinat Educ. 2013:22(1):14–18.
6. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Roundtable on the Promotion of Health Equity; Forum for Children's Well-Being: Promoting Cognitive, Affective, and Behavioral Health for Children and Youth; Keenan W, Sanchez CE, Kellogg E, et al, eds. Achieving Behavioral Health Equity for Children, Families, and Communities: Proceedings of a Workshop. Washington, DC: National Academies Press (US); 2019.
7. BBC News. ICE whistleblower: Nurse alleges “hysterectomies on immigrant women in US.” https://www.bbc.com/news/world-us-canada-54160638. Accessed December 3, 2021.
8. Nash E. For the First Time Ever, U.S. States Enacted More Than 100 Abortion Restrictions in a Single Year. Guttmacher Institute. https://www.guttmacher.org/article/2021/10/first-time-ever-us-states-enacted-more-100-abortion-restrictions-single-year. Accessed December 3, 2021.
9. Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. doi:10.1186/s12978-019-0729-2.
10. GLSEN. 4 Big Problems With Anti-Trans Bathroom Bills—and How You Can Help. https://www.glsen.org/blog/4-big-problems-anti-trans-bathroom-bills-and-how-you-can-help. Accessed December 3, 2021.
11. Ross L, Sollinger R. Reproductive Justice: An Introduction. Oakland, CA: University of California Press: 2017.
12. The White House. Build Back Better Framework. https://www.whitehouse.gov/build-back-better/. Accessed December 3, 2021.
13. Congress.gov. H.R.959 Black Maternal Health Momnibus Act of 2021. https://www.congress.gov/bill/117th-congress/house-bill/959. Accessed December 3, 2021.
14. National Advocates for Pregnant Women. Statements. https://www.nationaladvocatesforpregnantwomen.org/media_type/statements/. Accessed December 3, 2021.
15. Sufrin C, Beal L, Clarke J, Jones R, Mosher WD. Pregnancy outcomes in U.S. prisons, 2016-2017. Am J Public Health. 2019;109(5):799–805. doi:10.2105/AJPH.2019.305006.
16. Colbenson GA, Ridgeway JL, Benzo RP, Kelm DJ. Examining burnout in interprofessional intensive care unit clinicians using qualitative analysis. Am J Crit Care. 2021;30(5):391–396. doi:10.4037/ajcc2021423.
17. Franck LS, O'Brien K. The evolution of family-centered care: from supporting parent-delivered interventions to a model of family integrated care. Birth Defects Res. 2019;111(15):1044–1059. doi:10.1002/bdr2.1521.
18. Rising SS, Quimby CH. The Centering Pregnancy Model: The Power of Group Health Care. New York, NY: Springer Publishing: 2016.
19. Bray SRM, McLemore MR. Demolishing the myth of the default human that is killing Black mothers. Front Public Health. 2021;9:675788. doi:10.3389/fpubh.2021.675788.
20. Ross L. Understanding Reproductive Justice: Transforming the Pro-Choice Movement. https://www.law.berkeley.edu/php-programs/centers/crrj/zotero/loadfile.php?entity_key=6NK5BUG9.
21. Stroumsa D, Roberts EFS, Kinnear H, Harris LH. The power and limits of classification—a 32-year-old man with abdominal pain. N Engl J Med. 2019;380(20):1885–1888. doi:10.1056/NEJMp1811491.
Keywords:

health equity; reform; reimagine; reproductive health; reproductive justice; reproductive rights; retrofit

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