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.
 |
| Figure 1 |
 |
| 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:
http://www.childbirthconnection.org/pdfs/maternity_care_in_US_health_care_system.pdf
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:
http://www.consumerreports.org/cro/news/2013/07/will-obamacare-cover-midwives-and-birthing-centers/index.htm
National Center for Health Statistics. (2004). NCHS.
Retrieved from CDC: http://www.cdc.gov/nchs/data/hus/hus04.pdf
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:
http://www.commonwealthfund.org/usr_doc/mead_racialethnicdisparities_chartbook_1111.pdf
