What About Social Justice? Advocating for Maternal Health Equity

by Dr. Veronica Hardy, LCSW

     Over the past year (2021-2022), reproductive justice has been in both media and legal spotlights. In 2022, we witnessed the overturning of Roe v. Wade (1973), thus stating that persons do not have a constitutional right to abortion. To gain further insight for social workers about this landmark decision, please visit Dr. Allan Barsky’s recent article, Ethics Alive! Abortion Care and Social Work After Dobbs, published by The New Social Worker.

     We have not only witnessed these contemporary legal proceedings, but also continue to confront race-based maternal health disparities across healthcare systems. The Centers for Disease Control (2022) reports pregnancy-related mortality rates (2016-2018) as 41.4 pregnancy-related deaths per 100,000 live births Non-Hispanic Black, 26.5 Non-Hispanic American Indian or Alaska Native, 14.1 Non-Hispanic Asian or Pacific Islander, 13.7 Non-Hispanic White, and 11.2 Hispanic. Maternal health disparities in the United States represent a longstanding history of injustice exemplified through ethnic misrepresentations of historically marginalized groups as unfit humans and reproductive oppression such as forced sterilizations.

     For example, historical and continuing forms of reproductive oppression have been communicated through documentaries such as No Mas Bebes (2016), produced by the Public Broadcasting Service (PBS). This documentary highlights Mexican women with immigrant status who were, unknown to them, sterilized by doctors during childbirth throughout the 1960s and 1970s.

     As social workers trained to work across systems, including healthcare environments, we need to ask: What about social justice in maternal health?

     According to the U.S. Department of Health and Human Services (2022), health equity is defined as, “…the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, ...” (USDHHS, 2022, para. 5). As noted by Saluja and Bryant (2021), a comparison shows that U.S. maternal mortality rates are showing an increase, while there is a decrease globally, with annual numbers noted as “700 women die because of pregnancy or delivery complications in the United States” (para. 1). 

     Maternal health equity is impeded by structural racism, which includes codified forms of discrimination through policies and practices that impact multiple societal systems, including healthcare (American Medical Association, 2021). As a result, in contrast to the definition of health equity, research has shown that many healthcare professionals, including social workers, have race-based implicit biases toward historically marginalized groups that affect services, including patient-provider interactions, interventions, and treatment outcomes (Hall et al., 2015).

     To highlight the effects of implicit bias and racial disparities in maternal health, Charles Johnson has engaged in multiple speaking events to promote awareness about raising his children after the loss of his wife, Kira Johnson, after childbirth. Mr. Johnson shares his experience in seeking help for his wife when noticing bleeding and other complications post-childbirth. However, he and his wife were both misled that outcomes were normal, and her presenting issues were not a priority. This further communicates the emotional impact of loss on the father, as noted by Henke (2019), and broader familial and community systems in witnessing the effects on infant and maternal mortality rates. Further, research has shown that racial disparities across systems contribute to symptoms of depression, anxiety, posttraumatic stress, and even suicide attempts and substance use (Allen et al., 2020; Gone & Trimble, 2012; Elias et al., 2012).

     According to The National Association of Social Workers Code of Ethics (NASW Preamble, 2021, Revised), social workers have an ethical responsibility to:

...enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.... Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living.... Social workers promote social justice and social change with and on behalf of clients....

     Therefore, as social workers, what are ways we can promote social justice in maternal health systems? Let’s consider ways to advocate for change across the micro, mezzo, and macro levels of practice.

Micro Level Change—Confront Through Education 

     Research has identified training programs as an effective tool toward building knowledge, creating change in perceptions toward diverse populations, and promoting inclusive practices (Stargell et al., 2020). Saluja and Bryant (2021) define implicit bias as:

 …thoughts and feelings that exist outside of conscious awareness and subsequently can affect human understanding, actions, and decisions unknowingly. These biases cause attitudes about other people based on personal characteristics, including, but not limited to, age, race, and ethnicity. (p. 270)

     Implementing implicit bias awareness activities is an initial step in confronting maternal health disparities. One example of an implicit bias training is that developed by The Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University. This training is titled Implicit Bias Module Series and consists of five self-paced online learning modules. Implementing such trainings in healthcare settings, as well as in the curriculum of health professions, can be a beneficial starting point for creating change in maternal health systems.

Mezzo Level Change—Build Collaborative Community Efforts  

     As noted by Johnson, Cobb, and Pettiford (2022), engaging in collaborative opportunities that include persons “with lived experience, communities, and organizational partners” can aid in promoting social justice practices in maternal health (p. 334). For example, Blue Cross Blue Shield, a major healthcare coverage provider, launched a national initiative to promote maternal health. This has included the development of strategic action steps that healthcare and other service organizations can implement to promote maternal health. These steps are in alignment with the racial equity lens definition and recommendations from maternal health advocates (Johnson, Cobb, and Pettiford, 2022), which include building community collaborations to uncover and confront factors that create and sustain disparities, honoring the voices of survivors in decision-making, and developing culturally responsive maternal health services. 

     Further examples of organizations promoting change within communities are: EMBRACe, The University of North Carolina at Pembroke, and Nurse-Family Partnership. These are just a few organizations implementing creative ways to promote maternal health equity that could be adjusted and replicated across communities.

Macro Level Change—Evaluate Organizational and Broader Policies  

     In 2021, President Biden issued Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities through the Federal Government. This document communicates the aspiration of equal opportunity in the United States and includes the following statement:

Entrenched disparities in our laws and public policies, and in our public and private institutions, have often denied that equal opportunity to individuals and communities. Our country faces converging economic, health, and climate crises that have exposed and exacerbated inequities, while a historic movement for justice has highlighted the unbearable human costs of systemic racism. (Executive Order 13985, 2021, para. 1)

     As a result, this document encourages the evaluation of agency policies and procedures to determine if there is codified discriminatory language that perpetuates inequities in practice. Further, this executive order promotes the exploration of barriers to access benefits, opportunities, and services. This builds upon the idea of analyzing policies and practices through what is referred to as a racial equity lens. Key practices proposed through the racial equity lens include evaluating race and ethnicity data to determine if disparities exist, uncovering the underlying factors that create and sustain disparities within the health care system, and intentionally targeting racial disparities when brainstorming and implementing solutions (Philanthropic Initiative for Racial Equity & GrantCraft, 2007, pp. 2-3). 

     As a social worker, you are trained to work across levels of practice to promote change and confront systems that create and sustain oppression. The maternal mortality rate is showing increase in the U.S. with evidence of racial disparities. Pertaining to maternal health equity, what will you do to promote social justice?

References

Allen, J. O., Watkins, D. C., Mezuk, B., Chatters, L., & Johnson-Lawrence, V. (2020). Mechanisms of racial health disparities: Relationships between coping and psychological and physiological stress responses. Ethnicity & Disease, 30(4), 563–574. https://doi.org/10.18865/ed.30.4.563

American Medical Association. (2021). Glossary of terms: What is structural racism? https://www.ama-assn.org/delivering-care/health-equity/what-structural-racism​

Centers for Disease Control. (2022). Pregnancy mortality surveillance system. https://tinyurl.com/yc8654wd

Elias, B., Mignone, J., Hall, M., Hong, S. P., Hart, L., & Sareen, J. (2021). Trauma and suicide behaviour histories among a Canadian indigenous population: An empiri cal exploration of the potential role of Canada’s residential school system. Social Science Medicine, 74(10), 1560-1569.

Executive Order No. 13985. (2021, January 20). Executive order on advancing racial equity and support for underserved communities through the federal government. https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/

Gone, J. P., & Trimble, J. E. (2012). American Indian and Alaska Native mental health: Diverse perspectives on enduring disparities. Annual Review of Clinical Psychology, 8, 131-160. 

Hall, W., Chapman, M., Lee, K., Merino, Y., Thomas, T., Payne, B., Eng, E., Day, S., & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among healthcare professionals and its influence on healthcare outcomes: A systematic review. American Journal of Public Health, 105(12), 60-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638275/​

Henke, L. M. (2019). 10 facts about pregnancy after loss. https://pregnancyafterlosssupport.org/facts-about-pregnancy-after-loss/ 

Johnson, J. L., Cobb, S. M., & Pettiford, B. (2022). North Carolina’s 2022–2026 perinatal health strategic plan: Addressing perinatal health inequities across the life-course. North Carolina Medical Journal, 83(5) 330-336.

National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Philanthropic Initiative for Racial Equity & GrantCraft. (2007). Grantmaking with a racial equity lens. https://racialequity.org/wp-content/uploads/2018/11/grantmaking1.pdf

Saluja, B., & Bryant, Z. (2021). How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States. Journal of Women’s Health, 30(2), 270–273. https://doi.org/10.1089/jwh.2020.8874

Stargell, N., Jones, S., Akers, W., & Parker, M. (2020). Training school teachers and administrators to support LGBTQ+ students: A quantitative analysis of change in beliefs and behaviors. Journal of LGBT Issues in Counseling, 14(2), 118-133.

U.S. Department of Health and Human Services. (2022). Press release: CMS proposes policies to advance health equity and maternal health, support hospitals. http://www.hhs.gov/about/news/2022/04/18/cms-proposes-policies-advance-health-equity-maternal-health-support-hospitals.html​

Dr. Veronica L. Hardy has a PhD in Counselor Education and Supervision, a Master of Social Work degree, Bachelor of Arts in Social Welfare, and clinical social work license in North Carolina. She is currently a professor of social work at The University of North Carolina at Pembroke and adjunct faculty member within the Clinical Mental Health Counseling Program at Saint Joseph’s University in Philadelphia, PA. Dr. Hardy stresses engagement within the community and serves as an anti-child sex trafficking advocate and has co-authored peer-reviewed journal articles such as Domestic Minor Sex Trafficking: Practice Implications for Mental Health Professionals and Commercial Sexual Exploitation of Adolescents: Gender-Specific and Trauma-Informed Care Implications. She also focuses her efforts toward promoting racial equity in K-12 schools by training school support personnel. She is facilitating a grant focusing on racial health equity and has provided multiple keynote presentations focusing on race-based trauma.

She embraces opportunities to mentor fellow social workers and academic professionals. She serves as a mentor to junior faculty, focusing on the tenure and promotion process. Furthermore, she created and facilitates a mentorship group via Facebook titled The Social Work Lounge. To learn more about Dr. Hardy, please visit www.drveronicahardy.com.