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Health Disparities & Equity

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Equitable Healthcare System

In order to have an effective, equitable and sustainable healthcare system for all Americans we must first evaluate how healthcare policies actually work and how we wish them to work differently. In the Institute of Medicine’s landmark treatise entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” the opening paragraph states:

Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patient’s insurance status and income, are controlled. The sources of these disparities are complex, rooted in historical and contemporary inequalities, and involve participants at several levels.”

Health Disparities and Inequities 

Disparities occur on all levels: between income groups, disparities by education, racial/ethnic disparities, and disparities in access to and quality of health care.

A health disparity/inequality is a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies; it is a difference in which disadvantaged social groups (such as the poor, racial/ethnic minorities, women, or other groups which have experienced social discrimination) systematically experience worse health or greater health risks than more advantaged social groups. Pursuing health equity means pursuing the elimination of such health disparities/inequalities. [Paula Braveman, MD, MPH, citation 3 below]

Racial and ethnic disparities in infant and maternal mortality and morbidity have been consistently documented in the United States but the causes of these disparities are poorly understood. Nonetheless they persist. For example, babies born to African American and American Indian mothers are twice as likely as babies born to White mothers to have low birth weights and to die before their first birthdays. Vulnerable and marginalized women of all races and ethnicities are also at risk. For example, women who have not finished high school are three times as likely as women who have completed college to lack prenatal care during the first three months of pregnancy. 

Often in the United States, those mothers and infants who need high quality healthcare and practitioners most are least likely to have access to them.

Health Equity

Equity is an ethical principle, closely related to human rights principles. The ethic of health equity asserts that each person has a right to the highest attainable standard of health as indicated by the health status of the most socially advantaged group. 

Health equity is a new idea for most people. It’s not hard to grasp, but it does require us to reframe the way in which health differences are usually presented and perceived. People tend to attribute health differences to behaviors, genes or nature and inevitability: “That’s just the way things are.” True, some outcomes are random or result from accidents of nature or individual pathology. Health equity concerns those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable – and thus inherently unjust and unfair. [http://www.unnaturalcauses.org/.]

Midwives Can Make a Difference 

No matter what setting in which a a midwife practices, s/he will encounter individuals who are experiencing disparities in health.

Midwives are in a prime position to advance women's health by being creative, vigilant and resourceful in assessing and addressing health disparities and inequities. Midwives must consider broad public health policies that addresses the full spectrum of a woman's health care needs in the childbearing years, and beyond. 

How High Quality Data on Midwifery Care Can Help

The intensifying need for high-quality, accessible and cost-effective maternity care systems is accompanied by the need for comprehensive data on the role of care models and birth settings in reducing health disparities and improving outcomes for all childbearing women. The MANA Division of Research maintains a data registry on normal, physiologic childbirth that can facilitate research agendas aiming to address health equities in childbearing, including the impacts that midwife-led care can have on maternal child health outcomes for women and their families. The data collection tool is attuned to issues of diversity and vulnerabilities in health, and aims to collect data on a multitude of demographics, care practices and health outcomes so as to understand how midwifery models of care may help to improve health experiences for vulnerable populations.

For example, the MANA Stats project collects data on states that allow for Medicaid coverage of midwifery services; when combined with other demographics and health outcomes data (e.g., low birth weight, prematurity, mode of delivery) collected in the registry, researchers can examine the question of whether Medicaid reimbursement increases the diversity of women who have access to midwifery services and associated care outcomes. Similarly, the registry includes information on rural/urban location, race/ethnicity, socioeconomic status and other variables that are known social determinants of health.

Through the maintenance of a national, comprehensive data registry on normal, physiologic birth and midwife-led care, the MANA Statistics project is paving the way for understanding the how the midwifery model of care in home and birth center settings can contribute to national health equity in childbearing outcomes and practices. 

References for this section

1. Copies of Unequal Treatment: Understanding Racial and Ethnic Disparities in Health Care are available for sale from the National Academy Press; call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP home page at www.nap.edu. The full text of this report is available at http://www.nap.edu/catalog/10260.html

2. Home Birth Summit 2011: Common Ground Statement 3: We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes. This system provides culturally appropriate and affordable care in all settings, in a manner that is acceptable to all communities. We are committed to an equitable educational system without disparities in access to affordable, culturally appropriate, and acceptable maternity care provider education for all communities.  http://www.homebirthsummit.org/outcomes/common-ground-statements.

3. Braveman P. Health disparities and health equity: Concepts and measurement. Annu Rev Public Health 2006;27:167–94.

4. Unnatural Causes: Is Inequity Making Us Sick? A seven-part documentary series exploring racial & socioeconomic inequities in health. http://www.unnaturalcauses.org/.