Maternal mortality is a marker of national health and well-being. While far too many have the perception that our country offers excellent healthcare and fear universal healthcare will destroy our superior structure, the reality is that the United States has unacceptably high maternal mortality rates, and for decades has had the worst maternal and child health outcomes of all industrialized countries in the world (Reddy et al., 2021). More then 20 women die for every 100,000 women giving birth, and that has increased by 27% since 2000 (Margerison et al., 2022). An estimated 60% of U.S. maternal deaths are preventable (Reddy et al., 2021). If we look at how we care for those who suffer social inequalities, there is really very little pride to be claimed. Our healthcare is also the most expensive in the world for no other reason than greed.
Black women, in particular, experience maternal morbidity and mortality rates several times higher than other groups, and have for my entire career. In fact, I am not aware of a single maternity provider who is ignorant to this as it is at the forefront of our educational programs. We also know that #racism is the cause of these outcomes, not socioeconomics, not education, not higher health risks, and not age. We can not put this responsibility on Women of Color. Rather, it is our healthcare system and our culture that owns the blame.
Our healthcare system is simply not in line with the needs of women and children; it is much more reflective of the priority, or lack thereof, our culture holds for various populations of people. I've written about racism, discrimination, and the challenges of the LGBQT community within healthcare. I've also written about domestic violence and that nurses have the highest rate of suicide among all professions. I have stated for years that pro-life legislature will reach far beyond protecting the life of a little one in the womb, and compromise women themselves and their own health and safety. Today we are seeing that prediction unfold, the result of a patriarchal society.
As clinicians, we know what needs to be done to fix these poor outcomes. We know we have to become more aware, so the popular mindset in which a white person says they "don't see color," therefore they are not racist, is exceedingly naive and grossly ignorant. We must see color. We must recognize gender inequality. We must pay attention. More than awareness though, we need to adjust and we need to provide assistance to these groups. We have to align our care to their needs, and we must get active and advocate. Raising your "not racist" or "not a misogynist" card seems a very progressive step when you are steeped in the misogyny mindset, and because you don't broadcast your ideals that women are incompetent, hysterical, and feeble-minded, doesn't actually demonstrate tangible progress for those who are #oppressed. Fewer overt jokes and minimizing crude behaviors does not equate to implementation of interventions and policies that can remediate and eliminate inequalities in healthcare. You have to actually move, do something, speak up, risk something - like your own comfort.
I get it though; we all know how quickly one gets pushed out of an organization when they speak up about #injustice. I know, I've done it; more than once. These structures and systems date back to the founding of this nation and its economy on principles of racial, class, and gender hierarchy. It's the same reason nurse practitioners today work under restrictive licenses within half of the states in our nation, because nurses have always been predominantly female and therefore deemed subservient to the point of having to stand when a physician, historically almost always male, walks in the room and needs a chair.
As nurse practitioners and nurse midwives demonstrate outcomes just as good, if not better, than their physician colleagues, and are the preferred provider among consumers, this poses threat to the physician. In spite of a plethora of evidence to the contrary, physicians continue to report to lobbyists that their supervision is absolutely critical for public safety. This perception doesn't exist though for other clinical professions such as optometrists, audiologists, and dentists who are also not physicians, yet have prescription authority and they even use their title doctor without controversy. Each of these other professions though, have long been male dominated professions, so the real difference here is the perception that women should not lead or hold any authority. This has long been established social rule for our society, since the very beginning of our democracy. It's misogyny. It's the patriarchy.
The distribution of #power in our culture, within our healthcare system, is based on outdated concepts. This system draws lines by race, by class, and by gender. We have always done that; remember Jim Crow, the GI Bill, and redlining, even mass incarceration? Need I remind you that within my lifetime, banks could refuse women a credit card or could require that her husband cosign. Women could get fired for being pregnant until the end of the 1970s. It wasn't even until the mid-1970s that women were permitted to sit in the jury in all states because we were thought to be too fragile to hear unwholesome details of crimes. Yale, Princeton, Harvard, Dartmouth, and Columbia would not admit a female student until the 1970s-1980s.
Is it no surprise then that the nurse is the only clinician with restrictions on her practice? Is it no surprise that healthcare, otherwise dominated by women is expected to work without proper personal protective gear in a pandemic, but we receive no accommodations for our sacrifice? Nurses can't even file charges against those who physically harm them on the job because it is an expectation of our role, an expectation not assumed of police officers who were offered military warfare during the pandemic to fight the people they are suppose to protect. These inequalities are reflective of the patriarchy and all of these injustices within the system, funnels down upon those for which we provide care. Women and children, our entire healthcare infrastructure, will continue to suffer until we address the real issue.
Men have decided that a woman with a pregnancy outside her uterus can not abort that pregnancy to save her life, but ironically, when this pregnancy kills her, it will be prior to this fetus being able to sustain life without her. The woman, nor the child, were actually ever the priority. Prosecutors have begun criminalizing women for wanted pregnancies, who seek care, but ultimately miscarry. It won't take long before women will no longer be allowed epidurals in childbirth because there is absolutely no benefit to the child and only risk. How does one even give informed consent to an unborn child? Not a huge stretch for a prosecutor to charge a woman, or her anesthesiologist, in these scenarios. This discussion and the reach of these laws goes deep into the really scary abyss of potential ways they could be used to advance the patriarchy and admittedly, these are unfolding in our society much quicker even than I anticipated.
Women must bear children if children are to exist, yet there are no accommodations for this burden; no matter the joy this blessing offers, there is no ignoring that this responsibility also creates significant burden. The woman's risk of dying after she becomes pregnant increases in the next year, and while many receive disability when unable to work, women are not financially supported by their community when they need to pause their employment to birth and recover, nor care for their very vulnerable newborn. The men who participated in creating this pregnancy are in no way responsible for the burden women assume, because this sacrifice is assumed. The lack of paid family leave in our country is a public health crisis and we are only one of two industrialized countries, along with Papua New Guinea, that does not have a national policy guaranteeing paid leave to new parents (Crear-Perry et a., 2023). This fact alone has been associated with high risk for suicide, homicide, and drug related deaths in women within their childbearing year and year following birth (Margerison et a., 2022).
The 1993 Family Medical and Leave Act provides for unpaid leave, but almost half of the U.S. workers are not eligible, and many cannot afford time off without pay anyway (Crear-Perry et al., 2023). Many countries around the world are offering 6 months paid maternity leave as standard practice, and paid parental leaves have demonstrated improved women's economic outcomes and reduced infant mortality. What we ignore is that our society will divert money previously allocated to support women and children, to building new football stadiums because again, there remains an unequal distribution of power.
Our generation did pretty well at teaching little girls that they can be and do whatever they want, but we sure didn't prepare our boys for supporting their sisters. Girls grew up and simply did more and assumed more responsibility. That responsibility though, the burden, was not redistributed among this generation of boys. If this is the framework for which boys and girls shape their perceptions, then can we really recover these poor outcomes in healthcare? Will physicians recognize this break down in collaboration between physicians and nurses is really about misogyny? Will our culture recognize that not protecting and caring for women, who birth our future, will ultimately become our greatest travesty?
If you're in the "not all men" crowd, consider that it is enough men to be absolutely critical to women's health. Eight percent of women who die during their childbearing year do by homicide, almost always by their male partners (Margerison et al., 2022). And again remember that the United States leads the industrialized world in maternal mortality. The consequences of patriarchy are malignant beyond what our culture is currently willing to recognize.
American College of Nurse Practitioners. (2023). Quality of nurse practitioner practice. https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice
Crear-Perry, J., Correa-de-Araujo, R., Johnson, L. T., McLemore, M. R., Neilson, E., & Wallace. M. Social and structural determinants of health inequalities in maternal health. Journal of Women's Health, 30(2), 230-235. doi:10.1089/jwh.2020.8882
Margerison, C. E., Roberts, M. H., Gemmill, A., & Goldman-Mellor, S. (2022). Pregnancy-associated deaths due to drugs, suicide, and homicide in the United States, 2010-2019. Obstetrics & Gynecology, 139(2), 172-180. doi: 10.1097/AOG.0000000000004649
Reddy, S., Patel, N., Saxon, M., Amin, N., & Biviji, R. (2021). Innovations in U.S. health care delivery to reduce disparities in maternal mortality among African American and American Indian/Alaskan Native women. JPCRR, 8(2), 140-145.