Sunday, November 2, 2014

The Social Inequality of Childbirth in America



Academic thesis on childbirth and social justice

African American Babies are 2-3x as likely to be born too soon, too small, too sick to survive.  African American Women are 3-4x as likely to be harmed or die during childbirth. (National Center for Health Statistics, 2004) (See Figure 1)  The prevalence of these health disparities are largely related to socioeconomic factors and access to proper healthcare. (Committee on Health Care for Underserved Women, 2005) (See Figure 2)

Childbirth is the very base of our humanity; it has lasting impacts on both the mother and the baby in terms of physical and mental health as well as a strong influence in the health of society that influence generation after generation. By improving health outcomes at birth, health outcomes for life can also be improved. In 2010, the United States spent $111 billion for pregnancy, delivery and newborn, 47% of which were billed to Medicaid (Childbirth Connection, 2012), all while ranking 60th for maternal mortality and exhibiting racial disparities in healthcare outcomes for African American women and babies. This paper will explore three models of social justice and how they each view this issue and what they would propose as a solution to the social inequality of childbirth in America. Evaluated in this thesis will be the social philosophies of libertarianism, utilitarianism and egalitarianism.
childbirth, social inequality
Figure 1

healthcare, childbirth,
Figure 2

Libertarian Philosophy, John Locke & Robert Nozick

The Libertarian philosophy focuses on the protection of self-ownership through civil rights. Philosophers John Locke and Robert Nozick assumed that all free agents have control rights, rights to compensation, enforcement rights, rights to transfer and ownership rights. According to Locke and Nozick, the government’s involvement in civil, economical and social matters should be limited. (Encyclopedia Britannica)  
A libertarian would see the prevalence of health disparities, socioeconomic factors and healthcare access, and view it as a circumstance that individuals could negotiate and be in control of rather than an issue where laws and government should intervene. Maryn Leister, traditional birth attendant and founder of Indie Birth, is a strong advocate of “women own birth”. There is a definite lack of care prior to pregnancy and as Leister argues, a lack of self-education and responsibility that sums up the problem as a strong libertarian would perceive it.
Locke would look at the ethnic disparities and the contract between healthcare providers and their patients and say, “if you’re unhappy with your contract, renegotiate it” and “if you’re not going to do anything about it, then don’t complain about it.”  It’s imperative that women practice self-prenatal care prior to conception in order to be set up for a healthy pregnancy and the libertarian would focus on the basic rights women are entitled to that would encourage them to practice self-ownership and examine this prenatal care they practice with themselves. Leister argues that traditional prenatal care in America is not working. (Leister, 2013)  She goes on to say that healthcare, such as that covered by today’s Affordable Care Act, is not improving birth outcomes.  In looking at the statistics we can see that since 1990, birth outcomes in American have exceedingly declined (Woods, 2008)  despite increasing interventions and excessive prenatal care in low risk pregnancies. “If prenatal care were a drug, it would not be approved by the FDA for efficacy.” (Strong, 2002)

Utilitarianism, Jeremy Bentham & John Stuart-Mill

Utilitarianism holds that an action is morally right if its consequences lead to happiness, noting that everyone’s happiness counts the same. With the utilitarian philosophy, Jeremy Bentham and John Stuart-Mill focus on the greater good, even if it may mean that a minority will suffer for the greater happiness.
Philosophers Jeremy Bentham & John Stuart-Mill would argue that the racial disparities in health outcomes for African American women and their babies could be fixed by care providers caring for the patients equally regardless of race or economic status; by providing care from a patient-centered approach and practicing under oath, the greater good would be served. Normative Ethics takes this particular issue a step further, noting the “impact that choosing the greatest good will have over the minority that will be negatively impacted…. That it is unavoidable that a minority will suffer for the greater happiness.” (Encyclopedia Britannica) When looking from the macro perspective, one would see an alarming disproportion of excessive healthcare costs, increasing poverty levels and bad outcomes, ranking the United States 60th in the world for maternal mortality rates – meaning 59 other countries are doing it better. (Reich, 2014)  While acknowledging that “black and Hispanic patients report lower confidence and less trust in their specialist than white patients… and that distrust of the medical community may also prevent the delivery of truly patient-centered care (Woods, 2008), the utilitarian philosophy does not overlook the higher maternal mortality rates for African American women, and the risks for their babies, but insists that equality is necessary to improve healthcare for all.
Under the utilitarian philosophy, the responsibility would shift from the woman over to the government and her provider. The Affordable Care Act (ACA) is an example of a utilitarian response to the problem of racial disparities in America. Under the ACA, signed into law under the Obama administration in March 2010 and enforced beginning January 2014, pregnant women have better access to health care. Under the ACA, health insurance companies are required to cover expectant women and “health plans may no longer discriminate against different types of health providers who are practicing in line with their professional licensing.” (Metcalf, 2013) 

 Social Justice Theory, John Rawls

            Strict Egalitarianism recognizes that economic disproportions is what creates the framework for society and a degree of inequality is normal for a society to function.  Furthermore, the difference principal of egalitarianism says “Liberty and opportunity, income and wealth, and the bases of self-respect – are to be distributed equally unless an unequal distribution of any of all of these goods is to the disadvantage of the least favored.” (Encyclopedia Britannica)
            Rawls would argue that this social inequality is due to a lack of tangible resources. While the Affordable Care Act has created the opportunity for these low income minorities to be covered 100%, many states have refused to expand Medicaid. (Reich, 2014) By limiting women’s access to healthcare prior to pregnancy, preventative measures and eliminating health clinics, with poverty rates are rising, we are giving these minorities excuses to not take responsibility for their own health; this increases the gap between what they have needs for and what they have access to.
            Rawls argues that the socioeconomic bar is set from the bottom and by benefiting those of lower socioeconomic status, meeting them where they are with healthcare access and education, we increase the level of benefit for all. An egalitarian response, stemming from the necessity of burdens of different economic distributions across society, would be to expand the access of free health clinics and for childbirth educators, social workers, doulas and the like, to provide free or reduced services for these at risk women.

Conclusion and Editorial

Something as intrinsically primal as birth cannot be fixed by government intrusion. The libertarian view makes the most sense, arguing that individual people should have the freedom to be responsible for their own births and health regardless of race or class.  Acknowledging that good health is a very important part of pregnancy and childbirth it is important to recognize that education and self-ownership are going to achieve that over government mandated health care (utilitarianism) or enabling people to become a result of their socioeconomic status or racial grouping (egalitarian response).  
To support the argument of birth being primal, I would like to bring forth the concept of the limbic system and its responsibility for primal learning. Limbic imprint creates how and why humans emotionally make decisions. “A baby absorbs information about the outside world from the moment of conception, including the moment of conception.” (Vitalis, 2014)  According to Elena, founder of Birth into Being, the problems with birth and neglected children began generations ago; she goes as far as to suggest this as a response to slave labor – subservient people who passed on this limbic imprinting of “learned helplessness”. 
We all have genetic memory of our foremothers being sold to their husbands before they even reached a childbearing age; or traded for some kind of commodity – women were currency. And it’s very difficult to give birth in ecstasy and pleasure if you are a slave in your husband’s household. (Tontetti-Vladimirova, 2014)
Taking into account the theory of the limbic system, genetic history and the history of slavery of African Americans, one may be bold enough to say, this is where their lesser health outcomes stem from. Any outward forces, such as those that may be suggested by egalitarian or utilitarian philosophies, can only make things worse as other interferences with birth have done.  More important than access to healthcare prior to conception and prenatally, is access to education and self-ownership. The libertarian philosophy I associate with, would challenge the providers, insurance companies and governments surrounding these women to allow them the civil rights to take birth into their own hands, having healthy pregnancies and even healthy moments of conception that would lead to more positive birth outcomes. Leister argues that most birth complications can be traced back into nutrition during pregnancy. (Leister, 2013) Both midwifery experts encourage women to take a conscious look at where they come from and own those issues, making decisions for their own healthcare, claiming responsibility for the outcomes they desire. This isn’t to say that health care isn’t necessary or situations in childbirth don’t arise – understanding your own healthcare and taking an active role as to deciding when to seek outside help is important – but first, women need to understand birth itself and what it was meant to be. (Leister, 2014) As a culture, if Americans didn’t place so much responsibility of their own health into the hands of care providers, preventative care – in the terms of healthy living – would prevail.
            The utilitarian response is difficult to support because while the ACA is in writing a “moral” response to creating equal opportunity, it in fact is not affordable to many of the working class, thus widening the gap between economic classes and in that sense becomes more of an egalitarian reaction. While the idea of socialized health care and equal opportunity for all is a potentially positive & moral solution, America is failing miserably at executing anything even close to that, while in fact limiting access to what could be better health care. In terms of better healthcare for childbearing women, if we take the focus off of preconception and place it onto the birth itself, in looking at European countries who have better outcomes, we see that the care is largely provided by midwives. Under the ACA, health plans may no longer discriminate against different types of health providers who are practicing in line with their professional licensing.” (Metcalf, 2013) – Rather than expanding access to a variety of providers, choice has been limited by the government interfering and deeming which “professional licensing” is appropriate to provide care and mandating what interventions and routine steps must be met. However, at the end of the day, is it really the health care during childbirth or that of before conception? As I’ve stated, I believe that birth is intrinsically primal and is best left undisturbed, agreeing with Leister- that nutrition, and Elena- that emotional well-being, are the primary sources for healthy pregnancy and birth. “Under a psychosocial interpretation, these health inequalities are due to negative emotions and engendered by perceptions of relative disadvantage.” (Lynch, 2005)

 Works Cited

Childbirth Connection. (2012, December). United States Maternity Care Facts and Figures. Retrieved from Childbirth Connection:
Committee on Health Care for Underserved Women. (2005). Racial and Ethnic Disparities in Women's Health. American College of Obstetricians and Gynecologists, No. 317.
Leister, M. (2013). Breaking Tradition in Prenatal Care [Recorded by Taking Back Birth]. Sedona, AZ.
Leister, M. (2013). Pregnancy Nutrition Made Simple [Recorded by Taking Back Birth]. Sedona, AZ.
Leister, M. (2014). What the System Never Told You About Undisturbed Birth [Recorded by Taking Back Birth]. Sedona, AZ.
Lynch. (2005). Hierarchy Makes You Sick. In W. Bottero, Stratification: Social Division and Inequality (p. 195). New York: Routledge.
Metcalf, N. (2013, July 3). Will Obamacare Cover Midwives and Birthing Centers? Retrieved from Consumer Reports:
National Center for Health Statistics. (2004). NCHS. Retrieved from CDC:
Reich, R. (2014, May 12). How the Right Wing is Killing Women. Robert Reich.
Strong, T. (2002). Expecting Trouble: What Expectant Parents Should Know about Prenatal Care in America.
Encyclopedia Britannica (2014). Social Philosophy: Models of Social Justice. Class Handout.
Tontetti-Vladimirova, E. (2014, August 25). ReWilding Our Birth Experience. (D. Vatalis, Interviewer)
Woods. (2008, March). Racial and Ethnic Disparities in U. S. Health Care: A Chartbook. Retrieved from The Commonwealth Fund:


No comments:

Post a Comment

Contact info

Jennifer Valencia | Labor & Postpartum Doula | 928.300.1337


Blog Directory