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-An opening paragraph explaining what the chapter covers

-Design

-Measures, participants, and unit of analysis

-Sources of data

-Data collection and processing

-Delimitation

-Scope

-Closing paragraph reminding what you did in this chapter and what is next coming up

-What did your findings mean?

-What do you want your audience to know?

-What implications does your study offer?

-What recommendations do you have in terms of policy?

-Why is there no national outcry about this issue?

Running Head: MATERNAL MORTALITY IN THE U.S.

MATERNAL MORTALITY IN THE U.S.

THE PARADOX OF HEALTH CARE:

MATERNAL MORTALITY IN THE UNITED STATES

By:

Bibi Alli

Tashiya Baptiste

Joelle Cange

Dana Cortese

Vanessa Dasque

A Master’s Project Presented to the Faculty

Of the School of Business, Public Administration and Information Sciences,

Long Island University, Brooklyn Campus

In Partial Fulfillment of the Requirements for the Degree of

MASTER OF PUBLIC ADMINISTRATION

Dr. Bakry Elmedni

Mentor

Dr. Helisse Levine

Professor

May 201

Acknowledgments

First and foremost, we would like to thank God Almighty for giving us the strength, knowledge, ability, and opportunity to undertake this capstone project and complete it successfully. Without His blessings, this achievement would not have been possible. We would like to convey our heartfelt thanks to our mentor, Dr. Elmedni Bakry, our capstone professor, Dr. Helisse Levine, and to all of the MPA professors for providing their invaluable guidance throughout the course of this project and our careers at LIU-Brooklyn. Thank you for motivating us to work harder, challenging us to think critically, and reminding us that we are the future of public administration. Tomorrow’s change begins with us. To our family and friends, thank you for being our biggest cheerleaders and for the constant love and support. You remind us every day that sky is the limit, and we would not have been able to complete this journey without you. Lastly, we would like to say congratulations to the class of 2018. “It always seems impossible until it’s done.” We made it!

TABLE OF CONTENTS

CHAPTER ONE

Introduction

1.1 Research Problem

1.2 Nature of the Problem

1.3 Significance of the Study

1.4 Methodology

1.5 Study Organization

CHAPTER TWO

Background and Literature Review

2.1 Background

2.2 U.S. Healthcare Policies & Women

2.3 Maternal Mortality: A result of policy failure

2.4 Maternal Mortality and Racial Background

2.5 Health Insurance and Maternal Mortality

CHAPTER THREE

Conceptual Framework

3.1 Health Insurance Status and Maternal Mortality

3.2 Race and Women’s Health

3.3 Assumptions

3.4 Research Questions and Hypotheses

3.5 Key Stakeholders

3.6 Terminology

3.7 Concluding Remarks

CHAPTER FOUR

Methodology

4.1 Research Questions

4.2 Research Design

4.3 Delimitations and Scope

4.4 Measures and Participants

4.5 Data Collection and Processing

4.6 Concluding Remarks

CHAPTER FIVE

Results and Findings

5.1 Results

5.2 Findings

CHAPTER SIX

Discussion and Conclusion

6.1 Discussion

6.2 Recommendations & Conclusion

REFERENCES

APPENDICES

APPENDIX A

Capstone Proposal

APPENDIX B

Annotated Bibliographies

APPENDIX C

125

Project Timetable

125

APPENDIX D

126

Research Grid

126

APPENDIX E

127

Secondary data

127

APPENDIX E.1

131

Literature Synthesis Chart

131

APPENDIX F

138

Resumes

138

APPENDIX G

144

NIH Certificates

144

Abstract

The United States spends the most on healthcare but has the highest maternal mortality rate in the developed world. When inspected further, black women’s contribution to the country’s high maternal mortality rate, is disproportionately greater than any other race. This study examines whether race and health insurance status of women has an effect on maternal mortality rate in the U.S. The dual study was conducted using secondary data, which were collected from America’s Health Rankings 2016 Health of Women and Children Report. The data was analyzed using Pearson’s Correlations. Additionally, 25 peer-reviewed studies were reviewed and organized, to gain a consensus regarding the relation between race, health insurance status and maternal mortality. The results, supported by the qualitative analysis, showed that there is a direct relationship between black women, uninsured women and maternal mortality in the U.S. (p < 0.5). This indicates that there is a disparity when it comes to the health and care of black women in the U.S. Keywords: Maternal Mortality, Health Insurance Status, Race

CHAPTER ONE
Introduction
In 2015, the United Nations (UN) set 17 Sustainable Development Goals (SDGs) to accomplish by 2030 (Sustainable Development Goals Fund, 2016). SDGs built upon the foundation established by the Millennium Development Goals (MDG), which were presented in 1990 (SDGF, 2016). One MDG the UN planned to focus on was reducing the 1990 maternal mortality rate (MMR) of 385 deaths per 100,000 by 75 percent over a period of 15 years (SDGF, 2016). The UN reaffirmed their plan to decrease MMR through the mobilization of the Global Strategy for Women’s, Children’s and Adolescent’s Health 2016-2030 (World Health Organization, 2016). The Global Strategy provides a roadmap for how nations could achieve and provide the highest standards of healthcare for women, children and adolescents (WHO, 2016). This plan was geared towards not only assuring that women receive the necessary care to survive childbirth, but to thrive throughout their lives (WHO, 2016).
According to Tavernise (2016), between 2005 and 2015, the global maternal death rate fell by one third. However, the United States (U.S.) has managed to defy this global trend. A 2010 study by Amnesty International found that maternal mortality is the highest in the U.S. compared to 49 other countries in the developed world. For example, in Australia, which has wealth similar to that of the U.S., the maternal mortality rate decreased by 25% between 2005 and 2015. During the same time period, the U.S. saw a 16.7% rise in MMR (WHO, 2015). Ironically, Howard (2017) states that the U.S. spends more on healthcare than any other country in the world. She also goes on to say that more than two women die every day during childbirth in the U.S. In addition, Bryant and his colleagues (2010), argue that disparities in access to care and quality of care have resulted in varying maternal health outcomes for women of different backgrounds. Literature suggests that insurance status and the racial backgrounds of mothers are precipitating factors in the rising rates of maternal death. The high MMR and high healthcare spending in the U.S. indicates that a paradox exists within the system.
1.1 Research Problem
Although most states in the U.S. provide prenatal care to all women regardless of insurance or race, the country’s high maternal mortality rate is associated with the health insurance status and racial background of mothers. The U.S. spent $60 billion on maternal care in 2012, yet an estimated 1,200 women experienced fatal complications during childbirth (Agrawal, 2015). Additionally, America spent $3.2 trillion on healthcare in 2015, yet the MMR has nearly doubled in the past two decades (Centers for Medicare & Medicaid Services, 2018, WHO, 2015). The umbrella issue of maternal mortality has brought more attention to the inequalities that women of color, specifically black women, face when seeking and receiving care, as well as the overall lack of efficiency of such a costly healthcare system.
The inequality in America’s healthcare system affects millions of families who still cannot afford healthcare. Poor women living in low-income neighborhoods have the least access to quality care, making them more vulnerable to maternal death. Black women are particularly affected by this problem. (Heuser & Karkowsky, 2017). During the years of 2011-2013, 12.7 deaths per 100,000 live births were white women, 14.4 were other races, and 43.5 were black women (CDC, 2017). We designed this study in response to these findings and the apparent paradox in healthcare. This study was conducted to determine whether there is a correlation between high maternal mortality rates in the U.S. and whether it is influenced by the health insurance status and racial background of mothers.

1.2 Nature of the Problem
The issue of maternal mortality has received increasing attention in the past two decades as the U.S. government has failed to curb high maternal mortality rates, despite global progression. Global maternal mortality rates have decreased by 44 percent between 1990 and 2015 (UNICEF, 2015). In 1990 there were a reported 385 maternal deaths per 100,000 live births. That number decreased to 216 deaths in 2015 (UNICEF, 2015). According to Thomson (2016), the U.S. currently spends 17.1 percent of its Gross Domestic Product (GDP) on healthcare costs, however, the country has been unable to decrease its maternal mortality rate. In 1990 there were about 16.9 maternal death per 100,000 live births in the U.S. In 2015 that number increased to about 26.4 deaths (UNICEF, 2015).
The failure of the U.S. government to curtail these high maternal mortality rates has led to an increased focus on how federal funds are being allocated. Policymakers, healthcare providers, and scholars are now focusing their attention on putting an end to preventable maternal mortality. It is important to do so in a timely manner, especially amid the current administration’s attacks on family planning and women’s health policy. An end to the Title X Family Planning program by the Trump administration, “would cut off millions of pregnant women from access to complete and unbiased information about their medical options” (Ota, 2017). If this issue is not resolved soon, matters may only worsen for the fate of American mothers and their children.
It is also important to understand the magnitude of the issue at hand. According to Thomson (2016), U.S. women are three times as likely to die during childbirth than women from the United Kingdom, Germany, and Japan. Thomson (2016) goes on to state that most of these cases, about 60 percent, are preventable. This leads us to believe there is a gross inefficiency in healthcare policy. This issue is also very pertinent, as we believe it violates social justice. Flanders-Stepans (2000) states that black women are two to six times more likely to die due to complications during pregnancy than their white counterparts. In most cases, disparities among different races that exist in access to quality healthcare contribute to these complications. Every human has an unalienable right to life, regardless of race, and should therefore have access to equitable healthcare.
1.3 Significance of the Study
As healthcare costs are projected to rise, it is imperative to aid policymakers in identifying areas of healthcare that need monetary support and attention. At the current rate, researchers predict that national health care spending will reach $5.7 trillion by 2026 (CMS, 2018). The government also estimates that between 2017 and 2026, healthcare expenditures with grow 1.0 percentage point faster than the GDP (CMS, 2018). This study will investigate the driving forces behind high maternal mortality rates in the United States. The qualitative findings in this study, coupled with quantitative statistics play a significant role in determining the elements that sustain maternal mortality. Once these areas are identified, policymakers can focus their attention on extending funds to ensure mothers get the care and support they need for a healthy and happy pregnancy.
Through careful research this study also strives to create awareness of the disparities that exist in healthcare overall, but more specifically in women’s health. By addressing these issues, policymakers and healthcare providers may be inclined to allocate resources into correcting these disparities and putting an end to preventable maternal mortality in the United States. Our research, which explores the factors that contribute to high maternal mortality rates, can help in designing policy proposals for addressing such injustices. Lastly, this study hopes to fill in any gaps in public administration research regarding how socioeconomic factors contribute to maternal mortality rates globally, as well as in the United States.
1.4 Methodology
To determine the relationship between our independent and dependent variables, we conducted a cross-sectional study with a mixed method design. Through the use of peer reviewed articles we performed a systematic review of quantitative empirical studies to determine the general consensus among the literature on maternal mortality in the United States. We also developed a table to organize our secondary data. The data was organized by state, percent of uninsured residents, racial background of mothers, and maternal mortality rate. We then used this data to conduct a Pearson’s Correlation Test for each of our two independent variables to help us identify significant correlations between each variable and our dependent variable, maternal mortality. We performed a state level analysis of uninsured women and black women in 48 states plus the District of Columbia. We analyzed data and research for the year 2016 from sources including the Centers for Disease Control, the U.S Department of Health, and the U.S Census Bureau and America’s Health Rankings.
1.5 Study Organization
This study has been organized into six concise chapters. The first chapter introduces the premise of the research, including the problem statement, the nature of the problem, the purpose and significance of the research, and a brief introduction to the methodology used. Chapter two provides historical background and a detailed review of current literature regarding MMR and its relationship to health insurance status and racial background. The conceptual framework, which explains in depth how each independent variable affects the dependent variable, is presented in the third chapter. The fourth chapter outlines the research methods used to conduct the study, the unit of measure, as well as the resources used to gather data. The results and findings of this research is presented and explained in the fifth chapter. Finally, the study concludes with the evaluation of the results, as well as recommendations for future research.
CHAPTER TWO
Background and Literature Review
We have developed a thorough review of literature within our study to gain a general consensus among scholars and researchers who have published current works in regard to maternal mortality and its relationship with health insurance status and race. Through this literature review we were able to identify several main factors that are related to, and may affect maternal mortality within the United States. This section will speak to five main factors including a brief background of the issue of maternal mortality within the U.S., as well as U.S. policies that have affected women’s health, and how those policies have failed to provide appropriate care for all women. Additionally, we have touched on issues of race and racism, as it affects maternal mortality rates, and how health insurance status may determine a mother’s health outcomes throughout pregnancy.
2.1 Background
There has been a long-standing debate regarding healthcare policy and practice in the United States. Main points of contention have included healthcare expenditures, access to and quality of care, and the idea of universal healthcare (Kronenfeld, Jacobs, Parmet, & Zezza, 2012). The government has struggled with the concept of whether society as a whole or individuals should be held responsible for health costs (Kronenfeld Jacobs et al., 2012). Within the last decade, the debate has only intensified. The introduction of the 2010 Patient Protection & Affordable Care Act (ACA), also referred to as Obamacare, ignited a fervent battle between the Democratic and Republican parties (Irwin, 2017). The passing of the bill, however provided hope that years of political deadlock would end. The ACA promised to extend coverage to 30 million uninsured Americans, while also slowing the growth of healthcare expenditures (Irwin, 2017). Obamacare, however, only led to a greater divide on the subject of American healthcare and increased partisan tensions within the White House.
A key provision of the ACA was the expansion of Medicaid, a joint federal and state health insurance program (“Medicaid expansion & what it means for you,” 2017). Medicaid was designed to provide medical coverage to those with limited income (“Medicaid expansion,” 2017). Under the Act, states were required to amend Medicaid eligibility and cover all adults, ages 18-65, with incomes at or below 138% of the United States poverty level (“Medicaid expansion,” 2017). The previous requirements provided benefits to low-income children, elderly, disabled persons, and pregnant women, but often excluded other low-income adults (Garfield & Damico, 2017). The ACA required that coverage be extended regardless of age, sex, or health status (Wachino, Artiga, & Rudowitz, 2014). In 2012, however, the U.S. Supreme Court ruled that Medicaid provisions were voluntary for states; therefore, some have not expanded the program (Garfield & Damico, 2017).
As of October 2017, nineteen states have chosen not to implement the expansion of Medicaid (Garfield & Damico, 2017). This decision has upheld the disparities in access to care that the ACA sought to diminish. In states that adopted the provision, historical gaps in health insurance coverage were quickly filled (Garfield & Damico, 2017). Ironically, uninsured, low-income adults that are not eligible for Medicaid under the previous laws are concentrated in states that refused Medicaid expansion (Garfield & Damico, 2017). More than 25% of adults that fall into the coverage gap reside in Texas, which refuses to broaden the stipulations of eligibility (Wachino, Artiga, & Rudowitz, 2014). Minority groups living in these areas are directly affected by the lack of progression in health policy. They are less likely to receive the adequate care they need due to lack of Medicaid coverage and face difficulties in accessing low quality health services.
With 2014 health care expenses exceeding $3 trillion, it is difficult to understand why certain groups are still dying due to minor health issues (Mathur, Srivastava and Mehta, 2015). The maternal mortality rate (MMR) in the U.S. is higher than any other developed nation in the world (Molina & Pace, 2017). Other high-income countries have experienced decreases in MMR, while the rate has doubled since 1990 in the U.S. (Molina & Pace, 2017). Despite the growth of healthcare expenditures, racial and socioeconomic inequalities have contributed to growing MMR (Molina & Pace, 2017). In America, low-income mothers, women living in rural areas, and non-Hispanic black women are three times more likely to die during childbirth than white women with median incomes (Molina & Pace, 2017). The high health costs and high maternal death rates indicate a major issue and lack of effectiveness in healthcare policy and implementation.
There is a general assumption that development in medical technology and increased health spending would lead to improved health outcomes, however the U.S. has managed to contradict this idea. The American government spends the most on healthcare than any other country in the world, however not only struggles with tackling MMR, but increasing life expectancy and decreasing rates of infant mortality as well. The U.S. spends approximately $9,237 on healthcare per person, yet only has a life expectancy of 79.1 years (Brink, 2017). The United Kingdom, which spends only $3,749 on healthcare per person has a higher life expectancy of 80.9 years (Brink, 2017). Even though America spends the most, it ranks 12th in life expectancy among twelve of the world’s wealthiest, developed nations (Brink, 2017).
In relation to infant mortality, which is defined as “death within the first year of life,” the U.S. also falls behind (“Infant Mortality in the U.S.,” 2017, p. 1). When compared to other developed countries, the U.S. rate of infant mortality is 71% higher (“Infant Mortality in the U.S.,” 2017). Similar to MMR, infant mortality rates are the highest amongst non-Hispanic blacks (“Infant Mortality in the U.S.,” 2017). The inability of the U.S. government to effectively address these issues and redirect the allocation of funds has left minorities susceptible to preventable deaths. A paradox has appeared in American healthcare; though trillions of dollars is funneled into health spending, gaps and disparities still exist and rates of mortality amongst black infants and mothers remain at unconventionally high rates for one of the most developed nations in the world. In order to gain a better understand of the influencing factors of maternal mortality rates, a thorough review of current literature was conducted. The research included examined how U.S. healthcare policy and its failures have affected women, as well as how racial background and health insurance status have impacted maternal death.
2.2 U.S. Healthcare Policies & Women
Comfort, Peterson and Hatt (2013) acknowledge that in the U.S., health insurance status is tied to health care costs and therefore, cannot be discussed without understanding how the introduction of Medicare impacted the country’s current healthcare spending. Medicare is not the only source that draws on the government’s funding to allocate resources to eligible Americans. Other similar healthcare policies include Medicaid and most recently, The Affordable Care Act (ACA). Results of a 2015 study, which surveyed 8,000 women ages 18 to 39, revealed that 18.2% of the participants had insurance under Medicaid, 69.5% had private insurance, 11.5% were uninsured and the remaining 0.8% had another type of health insurance coverage (Jones & Sonfield, 2016). To understand the healthcare policies that currently exist in the U.S., it is imperative to acknowledge how these policies came to be. The history of American healthcare policies has been complex because of the difficulty to create a standard and equal medical care system for all citizens. Regardless, healthcare policies have always aimed to help vulnerable populations. Today, one of the vulnerable populations affected by healthcare policies are women. In the proceeding section, all healthcare policies developed to help vulnerable populations will be discussed, along with employer-centered coverage for those of the working class.
Employer-centered coverage. One form of healthcare insurance for Americans is employer-based coverage. Appropriately named, this type of coverage is when employers purchase healthcare insurance for their employees. Ginsburg (2008) shows that the employer-based health insurance system was accidental because it was developed “to evade wage controls during World War II,” (p. 676), adding that it still exists because employees prefer it. Many workers prefer this type of coverage because it not only secures their access to healthcare but also their family members (Cubbins & Parmer, 2001). Approximately 44.5 percent of American workers are covered under their employer’s insurance, which leaves the remaining 55.5 percent to seek coverage under privately-purchased insurance, Medicare, Medicaid or the military (Frauenholtz, 2014; Mendes, 2013). Over the last decade, however, the percentage of individuals covered through employer-based coverage has decreased due to the increased cost of healthcare, making it difficult for employers to afford (Ginsburg, 2008). Also, as more women join the workforce with needs differing from the usual male employees, employer-based health insurance would need to be expanded to include coverage for all employees. For women, employer-based insurance would need to consider possible pregnancies and coverage for the mother, along with the infant.
Medicare and Medicaid
. A large portion of Americans who are not covered via their employer receive coverage through Medicare and/or Medicaid. Medicare was implemented in 1966 with the purpose of reducing social and economic inequality between men and women, 65 years or older (Salganicoff, 2015). Since women only comprised 39% of the paid labor force compared to the 81% of men, upon retirement, more women were living in poverty than their male counterparts (Salganicoff, 2015). Also, many women did not have the financial support as they age, especially in areas pertaining to their healthcare coverage because they were dependent on their working husband. However, Medicare did not satisfy all the necessary care for women initially, and still does not today. As pointed out by Salganicoff (2015), with much growth and transitions, Medicare began to cover routine mammography screenings and pap smears to women in 1990 and 1991, respectively. Today, although Medicare has been an effective government intervention, women’s healthcare costs are only partly covered. Medicare has high deductible costs, and does not cover necessities such as hearing aids, eyeglasses, dental care, personal care and extended nursing home stays; all of which becomes out-of-pocket expenses for people covered (Salganicoff, 2015). In 2010, women’s out-of-pocket expenses ranged from $4,173 to $8,574, whereas men’s out-of-pocket costs for the same year ranged from $3,842 to $7,399 (Salganicoff, 2015).
While disparities in Medicare tend to exist among older Americans, Medicaid focuses on reducing the inequality gaps in terms of access to healthcare between financially stable Americans and Americans from low income households (Epstein & Newhouse, 1998). One of the important roles Medicaid has taken on is assisting low-income women with health necessities, especially during pregnancy and childbirth. According to Johnson (2012), more than 12 million (1 out of 10) women in the U.S. are covered under Medicaid. Additionally, the program “finances 40 percent of prenatal care and births” (Johnson, 2012, p. 3). Prenatal care is essential for women. It is important to note that women do not always qualify for Medicaid if their household income is above the poverty line and are also not eligible for Medicare if they are under 65 years of age. Moreover, Legerski (2012) contends that the increasing cost of healthcare has caused American women to either not be able to afford coverage or not qualify for coverage under Medicaid because of the program’s strict financial guidelines. This leaves many women uninsured, creating disparities in healthcare. If an uninsured woman becomes pregnant, she is then covered under Medicaid. However, having previous temporary gaps of coverage can lead to issues during pregnancy.
Gaps in coverage can put the woman at a higher risk of poor health outcomes. As individuals become more aware of the benefits of prenatal care, more women have opted to start paying for Medicaid prior to starting a family. A 2015 report by the Centers for Disease Control and Prevention revealed that nearly one third of women who delivered a live infant in 2009 experienced a change in their health insurance status around the time of pregnancy. The most common pattern found was that women went from being uninsured in the month before pregnancy to having Medicaid coverage until the time of delivery (Centers for Disease Control and Prevention, 2015). To support this statement, Egerter, Braveman & Marchi, (2002) conducted a study of the relationship between the timing of insurance coverage and prenatal care. Using a cross-sectional statewide survey with a sample of 5455 low-income participants, they showed that 45 percent of the women were uninsured before pregnancy. The results also revealed that 21 percent of the women lacked coverage in the first trimester and two percent were uninsured throughout their pregnancy (Egerter et al., 2002, pp. 425-426). Egerter and team (2002) discussed that the period in which the woman does not have insurance coverage may contribute to issues faced during maternity and lack of preventative care is due to affordability factors of healthcare coverage.
The Affordable Care Act. Since the implementation of Medicare and Medicaid, there had not been any relevant changes made to U.S. healthcare policies until The Affordable Care Act (ACA). The ACA was signed into law on March 23, 2010 by President Barack Obama, but was not implemented until October of 2013 (Kantarjian, 2017). The goal of the ACA was to decrease the number of uninsured Americans, at a reasonable cost. This goal was partially achieved, as the ACA expanded insurance coverage by reducing the percentage of uninsured Americans from 18 percent to 12 percent within two years of being put into effect (Chen, Vargas-Bustamante, Mortenson, & Ortega, 2016). This means more than 15 million of the 48 million uninsured Americans gained healthcare insurance under the ACA (Chen et al., 2016). The Act has been a step in the right direction for universal healthcare for all Americans, but particularly has been a success for women. An article by Scientific American (2017) explains that under the ACA, organizations like Planned Parenthood gained block funding towards “routine health services such as gynecological exams, cancer screenings, STD testing and contraception,” (p. 9). Medicaid also received funding to provide better maternity care to uninsured mothers. However, with a new president in office, the ACA is under attack as the new administration has promised to have it repealed and replaced. Heuser and Karkowsky (2017) argue that the potential loss of the ACA under the current administration would lead to budget cuts in women’s healthcare. With limited funding for women’s healthcare, issues like the high maternal mortality rates in the United States will continue to rise.
Driving forces of costs. The growth of technology has contributed to increasing healthcare expenditures in the U.S. Technology has resulted in longer lifespans due to its assistance in the discovery of cures or treatments for many illnesses. Simultaneously, with technology’s growth, healthcare costs have increased as well. Squires (2012) argues that the U.S. uses expensive technology more frequently when compared to other countries. The use of costly equipment for medical procedures has had a reverse domino effect on health insurance prices. The expense for research and invention of more technological advancements has become greater as well. Therefore, the price of healthcare coverage has risen. Even with Medicare and Medicaid assistance, as well as the emergence of the ACA, gaps in women’s healthcare still exist. How could this be? Although these programs are implemented at a federal level and driven by the growth of technology and cost, the driving forces of acceptance differs at a state level.
As previously mentioned, Medicaid expansion is voluntary by state, and so many states are opting out of the program due to high healthcare costs. For example, states like Texas, Oklahoma, Georgia, Florida and Mississippi, which already have the highest rates of uninsured residents, are choosing not to expand Medicaid due to its high costs (Quinn, 2017). Within these states, people who are currently receiving Medicaid will no longer be receiving the associated benefits. Individuals who would meet the qualifications with Medicaid expansion, will not be able to afford insurance coverage under the current market prices and will be uninsured. Ironically, the states that chose not to expand Medicaid will only increase their uninsured population.
To take a case in point, Texas’ rejection of the federal fund to expand Medicaid would have covered over 1 million more of its inhabitants, in addition to already covering half of all births in the state, as well as the care for mothers sixty days after giving birth (Novack, 2017). At a state level, the forces that drive healthcare policies are political party affiliation and ideological worldviews. Texas is heavily Republican and has been associated with conservative outlooks on issues like women’s health. Putting money into caring for women is not a priority. It is not surprising that the latest data shows that Texas has the highest maternal death rate in the U.S., at 32.5 per 100,000 live births in 2015 (Sifferlin, 2018). Ultimately, without funding through federally assistance programs, states like Texas will continue to have high maternal mortality rates as there is no money going into the care for its women.
On the other hand, a predominantly Democratic state’s, such as New York, driving force for health care policies specific to maternity has become the care and well-being of the mothers and their babies. New York was one of the states that supported the expansion of Medicaid eligibility for its residents (Sommers, Baichek & Epstein, 2012). In a study by Lazariu, Nguyen, McNutt, Jeffrey, and Kacica (2017), it was revealed that New York has established an effective prenatal protocol to ensure the care for mothers and babies within its facilities to reduce the risk of the state’s number of maternal deaths. In addition, it was found that Medicaid expansions in New York were associated with a significant reduction in maternal mortality (Sommers et al., 2012). Unlike Texas, New York is more progressive in passing healthcare policies that serve to help its vulnerable population.
Values and healthcare. Lastly, values that are necessary to consider in healthcare policies are the economy, equity and justice. Economically, the U.S. spends a large amount of its Gross Domestic Product (GDP) on healthcare expenditures. Mathur, Srivastava and Mehta (2015) explain that 18 percent of the U.S.’s GDP is used for health care costs for its citizens. To reiterate, that percentage calculates to about $3 trillion dollars, or over $9,000 on each American’s health annually (Mathur et al., 2015). That cost is projected to increase in the upcoming year. According to Mathur and his research partners (2015), 20 percent of the country’s GDP will be spent on healthcare by 2022 and it is estimated that it will continue to rise if appropriate steps are not taken.
Moreover, a major part of the government funding goes to the pharmaceutical industry for developing treatments for diseases, rather than to each citizen’s medical well-being or preventative care. According to Mathur and his colleges (2015), spending on prescription drugs and related pharmaceutical devices “increased from around $61 billion dollars in 1980 to $349 billion dollars in 2011” (p. 2). This massive growth can be credited to the simple price increase of common antibiotics, like doxycycline, which increased from $20 a bottle in 2013 to $1,849 a bottle in 2014 (Mathur et al., 2015). There is a clear inefficiency in how government funds are being allocated. Monetary support needs to be designated to areas that need funding, especially when it comes to women’s healthcare. As shown in other sections, the U.S. has the highest maternal mortality rate among its other developed counterparts. If a majority of its GDP is being spent on healthcare, it’s baffling that it’s women are dying at higher rates.
Unfortunately, healthcare in the U.S. is treated as a business. It is time to consider the values of equity and justice, an image of which the U.S. displays to the world with government innovations like Medicare, Medicaid and the ACA. The purpose of government programs is to aid the socially and economically disadvantaged American, particularly of a certain gender, race and/or socioeconomic class. In reference to the U.S.’s high maternal mortality rate, a 2017 report by Centers for Disease Control and Prevention revealed that black women had the highest pregnancy related deaths, at 43.5 deaths compared to 12.7 and 14.4 (per 100,000 live births) of white and other races of women, respectively. The funding under Medicare, Medicaid and the ACA’s coverage can help women in general but women of color immensely. Not only race but socioeconomic inequities are contributing factors to the high maternal mortality trend (Molina & Pace, 2017). It is only fair for the allocated funds to be used rightfully. It is important to maintain equity and justice in medical care, regardless of race or socioeconomic status.
2.3 Maternal Mortality: A result of policy failure
Motherhood should be a joyful and positive experience, but for many women lack of healthcare coverage can make pregnancy and childbirth a dangerous and frightening struggle. According to the World Health Organization (2016), “about 830 women die from pregnancy or childbirth-related complication around the world every day” (p.1). In 2015, 303,000 women died from preventable causes either during or after childbirth (WHO, 2016). Unfortunately, many government policies have failed to protect the safety of motherhood and our countries rates of maternal mortality continues to rise. This failure, combined with the reality of our current patriarchal government, has ensured that little progression is made in protecting the mothers of our country.
Conceptualization. Current literature has conceptualized maternal mortality in similar ways, however authors have explored the influencing factors of maternal mortality differently. In 2007, the Partnership for Maternal, Newborn and Child Health (PMNCH, 2007) presented a conceptual framework depicting maternal mortality in relation to the continuum of care. PMNCH emphasized a linkage between women seeking consistent care throughout their lifetime and lower maternal death rates (PMNCH, 2007). In this framework, maternal mortality, the dependent variable, was conceptualized as the rate of maternal mortality (PMNCH, 2007). The continuum of care was presented as the independent variable and was conceptualized as the time of care during a woman’s lifetime and the location where care is received (PMNCH, 2007). Time of caregiving was broken down throughout a woman’s lifetime, starting with adolescence and pre-pregnancy, and ending with postpartum care (PMNCH, 2007). PMNCH asserted that early health interventions, such as improving the nutritional intake of young girls and family planning counseling prior to pregnancy, would aid in the reduction of the maternal death rate (PMNCH, 2007). The places of caregiving were presented in three dimensions; health facilities, communities, and households (PMNCH, 2007). PMNCH also stated that through the promotion of healthy home practices, encouraging women to seek care at healthcare facilities, and the integration of the access quality care throughout the community, MMR would be significantly reduced (PMNCH, 2007).
Straying from the traditional conceptualization, Stewart (2006) broadens the context of maternal mortality. The study explores different approaches to improve maternal death rates in Canada. Stewart bases her concept of maternal death not only on obstetric indicators, but also includes deaths due to mental health conditions and violence (Stewart, 2006). The dependent variable, maternal death, is influenced by nutrition, education, poverty, and mental health factors (Stewart, 2006). These factors are described as “nonobstetric” indicators (Stewart, 2006). Stewart asserts that exploring both obstetric and nonobstetric factors, as well as expanding the scope of surveillance of death past the standard 42 days would aid in targeting maternal death (Stewart, 2006).
In their research, Shiffman and Smith (2007) explore why certain global health initiatives receive more political priority than others. The authors shift away from attributing high maternal death rates to socioeconomic and health factors, and instead explain how politics play a major role in how governments tackle the problem (Shiffman & Smith, 2007). Shiffman and Smith link the affects that political acting powers, the comprehension of the detriments of high MMR, the political context, and the characteristics of the issue has on how maternal mortality has been addressed globally (Shiffman & Smith, 2007). Actor power is conceptualized as “the strength of the individuals and organizations concerned with the issue” (Shiffman & Smith, 2007). Acting power can influence the MMR through how political groups and grassroots organizations mobilize to bring attention to the issue and how mechanisms are implemented to address the problem (Shiffman & Smith, 2007). The authors also state that global MMR can be influenced by how the issue is understood and portrayed (Shiffman & Smith, 2007). The way in which governments choose to frame and define the problem and how the public responds influences how policy will be shaped to counter high MMR (Shiffman & Smith, 2007). In addition, the environment in which political acting powers operate, such as global political conditions can impact how governments attack MMR (Shiffman & Smith, 2007). The political climate and policy windows create or prohibit the opportunities to decrease maternal death rates (Shiffman & Smith, 2007). Lastly, the features of the concern of high global MMR, including the severity of the problem, the way MMR is measured and monitored, and how the interventions are explained and implemented will have an impact on the dependent variable (Shiffman & Smith, 2007).
In conclusion, the study found that the global safe motherhood has encountered many obstacles (Shiffman & Smith, 2007). In respect to acting powers, there is no strong, influential global leader to head the initiative, causing a fragmented response to the high maternal death rate (Shiffman & Smith, 2007). There is also inconsistent methods of measurements and interventions, causing a lack of consensus on how to decrease MMR (Shiffman & Smith, 2007) The article goes on to state that the victims of MMR, poor women of color, hold little political power to generate support for the cause (Shiffman & Smith, 2007). Though the political climate has opened windows to allow for the implementation of effective strategies, the world’s governments have not effectively taken advantage of the opportunities to pass impactful policies (Shiffman & Smith, 2007). The research suggests that increased political momentum and a universal consensus on the approach to reducing MMR should be implemented, as well as continued research and refinement of the framework will aid in eliminating this complexity (Shiffman & Smith, 2007).
Patriarchy in Government and Healthcare. The United States can be viewed as a patriarchal society, a general structure in which men hold the positions of power and have more privilege to which women are not entitled. Men typically hold high positions such as the head of government or household, a boss in the workplace, and leader of social groups (Napikoski & Lewis, 2017). For example, the Trump Administration composed of high ranking white men, has attempted to repeal policies implemented to assist in the best outcome for women’s health. Countless women in the United States still lack the opportunity for informed decision-making to ensure that they receive high-quality care (Coeytaux, Bingham, & Strauss, 2011). Though there have been many strides in gender equality in areas such as education and the labor force, women and girls still face crucial health disparities. A World Health Organization (2009) study found that due to patriarchal ideologies, women are typically viewed as subordinates, therefore become more susceptible to mistreatment, leading to high instances of illness and death (p. 9). Though more women are participating in politics, men are still the wielders of power, making them the controllers of the allocation of socioeconomic resources (WHO, 2009). Implicit biases in healthcare are a major driving force in the high rates of disease and maternal mortality amongst women, in particular black women (Blair, Steiner, & Havranek, 2011).
The U.S. government has not taken hasty initiative to address maternal mortality as it has other issues. One can say that the issue is not seen as priority due to lack of consideration for the population affected by this crisis. Women, and more specifically women of color, have endured years of being devalued and considered less than their white, male counterparts. Still, women have yet to gain the respect they deserve to be seen as equal. Today, women make up about one-fifth of Congress; only 19.6 percent and 38.5 percent of those women are women of color (“Women in the U.S. Congress,” 2018). 2017’s Fortune 500 CEOs list included only 32 companies with female CEOs (“Women CEOs,” 2017). The gender wage gap is still present within our society, as woman earn 80.5 cents for every dollar earned by men, and this number is even lower for women of color, at about 63 cents (“Pay Equity & Discrimination,” n.d.; “Women and the Wage Gap,” 2017). And lastly, about 35 percent of women have reported being victims of domestic violence in the United States (“Violence Against Women,” 2015). Additionally, according to Justice Bureau Statistics, African American women experience domestic violence from an intimate partner at rates 35 percent higher than white women.
The Affordable Care Act. The Patient Protection and Affordable Care Act (ACA) was fully implemented in 2014 with the provision to increase access to prenatal care and health insurance (Hope et al., 2017). It has been effective in providing affordable, quality health care to millions of Americans, and especially American women (Gamble & Taylor, 2017). Before the ACA, pregnant women seeking healthcare coverage were turned away because most individual plans did not cover maternity services. Individual plans that did offer coverage ranged in price from $15 to $1600 a month (Ranji, Salganicoff, Sobel, & Rosenzweig, 2017). Additionally, Ranji and her colleagues (2017) state that the ACA Medicaid expansion was implemented to provide continuous coverage to pregnant women who automatically lose coverage 60 days after the birth of their baby. Before the enactment of the ACA, only a few states required coverage for maternal care in the individual insurance market. In fact, eight out of ten health insurance plans failed to cover maternity care at all (Sonfield, 2017). Additionally, this would affect women who opt out of maternity care coverage through their job health insurance coverage thinking they would not need it, only to fall short if they unintentionally become pregnant (Ranji et al., 2017). The ACA has taken strides in narrowing the gap in health insurance coverage. However, under the current administration, these progressions have come to a screeching halt. Despite the critical role of the ACA in securing access to maternity care, Congress has pushed to undo the law’s most critical protections for women concerning personal decisions and family planning (Molina & Pace, 2017).
According to Gamble & Taylor (2017), in May of 2017 the House of Representatives passed the American Health Care Act (AHCA), a bill to repeal and replace critical requirements of the ACA. Gamble and her colleague also state that the Congressional Budget Office (CBO) estimated that 23 million people would lose insurance coverage in the next ten years if passed. In July 2017, the Senate then released its version of the repeal and replace bill, the Better Care Reconciliation Act (BCRA) and if approved, CBO estimated that 22 million people would become uninsured (Gamble & Taylor, 2017). Again, in July 2017, a proposal for the Obamacare Repeal Reconciliation Act was released, which would repeal the ACA entirely with no immediate replacement. CBO estimated that in the next ten years 32 people million would lose their health insurance as a result of such an act (Gamble & Taylor, 2017). The Senate provision to defund Planned Parenthood was also added to the legislation (Gamble & Taylor, 2017). Even though these proposals failed, the ACA faces continuous difficulties, including efforts by the Trump administration to repeal payments to insurance companies that help reduce cost-sharing for low-income people (Molina & Pace, 2017).
What does this mean for American women? The ACA has provided numerous women a range of protection and benefits such as mandatory maternity and newborn coverage, prenatal screening, and breastfeeding support (Sonfield, 2017). Many women have relied on Medicaid rather than private insurance, to cover the cost of pregnancy. Eliminating required maternity coverage would weaken progress made under the ACA, resulting in 23 million fewer people with insurance by 2026 (Sonfield, 2017) Obamacare also provides women with access, free of charge, to contraceptives which allow for family planning and the prevention of unwanted pregnancies (Sonfield, 2017). The Trump administration plans to allow states to opt out of this requirement as well block women from using Medicaid to visit Planned Parenthood Federation of America (PPFA) clinics (Khazan, 2017). Planned Parenthood is an organization which provides reproductive health services to many low-income women across the nation (Ranji et al., 2017). Terminating access to the care provided at PPFA clinics not only removes access to a trusted and available provider but also removes access to essential preventative and reproductive health services that are crucial to proper maternal health outcomes (Gamble & Taylor, 2017). The replace and repeal also abandons the obligation of the coverage of maternal health care under Medicaid (Khazan, 2017). The passage of this bill could not only affect public insurance, but also impact the health benefits that employers provide, limiting the access women have to pre-natal and maternal care (Khazan, 2017). If passed, there could be detrimental effects on the progress made through the ACA, and a spike in negative health outcomes for American women.
2.4 Maternal Mortality and Racial Background
According to the American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women (2015), “projections suggest that people of color will represent most of the U.S. population by 2050” (p. 1). Unfortunately, significant racial and ethnic disparities continue to persist in women’s health and health care within our country. As mentioned earlier, research has shown that maternal mortality disproportionally affects African American women and other women of color. Howard (2017) states that 700 to 1,200 women die each year in the United States from pregnancy or childbirth complications. Additionally, a 2007 study conducted by Tucker, Berg, Callaghan, and Hsia found that black women are two to three times more likely to die from preeclampsia, eclampsia, abprutio placentae, placenta previa, and postpartum hemorrhage, common conditions associated with maternal mortality, than their white counterparts. Many of these health disparities are directly linked to inequities in income, housing, education, and job opportunities (ACOG, 2015). Long-lasting issues of racism and discrimination have influenced individual health in our country and has contributed to our current women’s health crisis.
Lack of national response. All over the world, rates of maternal mortality have decreased significantly. According to the World Health Organization (2015), developed regions have experienced an estimated 2.4 percent average yearly reduction in their maternal mortality rates over the past 25 years. However, we have made it clear several times that the United States has not experienced quite the same trend. However, the issue may be deeper than the government’s inability to allocate proper funds towards an initiative to end preventable maternal mortality within the country. It could be, instead, that dying American mothers are simply not a priority. Fathalla (2006), as cited in the American Public Health Association (2011), states that “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving” (p.1). Furthermore, when one understands that maternal mortality is a greater issue among American women of color than among American white women, it is easier to further realize why the issue may have been ignored for so many years, given the racial climate over the past several decades.
The national response to opioid epidemics in comparison to maternal deaths makes the case in a point. For several decades, health disparities among the black Americans have been largely blamed on the population’s susceptibility to illness (Martin, 2017). New research, however, has indicated that the problem may not so much be race, but instead racism, that is leading to such a disproportionate rate of maternal deaths among black mothers. Systemic issues are instead to blame for the social inequities experienced by African Americans, that has led to their negative health outcomes and unequal access to care. Take the crack and opioid epidemics as an example. During the 1980s, the use of crack-cocaine was rampant among the black community. The epidemic was the biggest story in the news at the time, however, efforts to combat the issue were, needless to say, minimal as a health concern. A very different approach is seen today, as policy-makers work hard to put an end to the opioid epidemic that has ravaged the country; one that has affected mainly the white population.
In the 1980s, lawmakers were swift in implementing an incarceration-based response to the crack epidemic. In 1986 congress passed the Anti-Drug Abuse Act, which established mandatory minimum-sentences for specific quantities of cocaine. The act required a minimum five-year federal prison sentence for distribution of just five grams of crack-cocaine; a much harsher sentence than that required for distribution of powder cocaine, a predominately “white” drug. The distribution of 500 grams of powder cocaine – 100 times the amount of crack cocaine – carries the same sentence (Vagins and McCurdy, 2006, p. i). Instead of working to help those addicted to the lethal drug, the government’s solution was to throw them in prison, further adding to the oppression of black Americans within the U.S.
In comparison, great efforts have been put towards ending the opioid epidemic that has taken the lives of so many Americans; predominately those of Caucasian decent. Devastated by increased prescription and illicit opioid use, abuse, and overdose, governments, both federal and local have put much of their resources into improving access to prevention, treatment, and recovery support services as well as supported research that looks to find alternatives to opioids for pain and new treatment options for individuals plagued by the epidemic (National Institute on Drug Abuse, 2017) On October 26, 2017, President Trump declared the opioid crisis a “Health Emergency,” making the issue a priority for the government and the American people. When the opioid crisis hit rural areas and the Caucasian population, addiction was no longer a crime as it was in the 1980s. Instead, addicted individuals were encouraged to seek help and the burden was shifted to the government to offer the services needed to aid these people in getting back on their feet.
Inequalities among women of color and maternal mortality. The devaluation of many people of color in American History has contributed to the social inequalities that many women of color face during pregnancy and childbirth. Martin (2017) found that differing access to healthy food and safe drinking water, safe neighborhoods and good schools, decent jobs and reliable transportation are all types of social inequities that have stemmed from systemic failures that have plagued this specific population. As mentioned previously, black women are more likely to have chronic conditions such as diabetes, cardiovascular heart disease, hypertension and obesity (Mays et al., 2007), which can cause complications during pregnancy. Many behavioral risk factors that contribute to early disease and death among these individuals are an unhealthy diet, smoking, living in substandard housing or dangerous neighborhoods, and living in communities with environmental hazards (Julion, 2018). Black women are also less likely to be insured than their white counterparts (Martin, 2017). Without routine visits to the doctor, many of these women could have diseases heading into pregnancy that they were unaware of. Martin (2017) goes on to state that many of the hospitals where black women give birth are often products of historical segregation and lower in quality than those where white women deliver.
These issues are amplified by unconscious biases that exist within the medical system. According to Shavers and her colleagues (2012), 74 percent of African Americans, and 69 percent of other non-whites report personally experiencing general race-based discrimination in a medical setting, and has been found to deter these individuals from using available services. Negative racial attitudes and experiences have contributed to the decision of many women of color to delay prenatal services that can lead to better health outcomes for the mother and her child. Experiences with chronic race-based discrimination, both actual and perceived, has also been proven to set off physiological responses such as elevated blood-pressure and heart rate; issues that can lead to further complications during pregnancy (Mays et al., 2007).
2.5 Health Insurance and Maternal Mortality
According to Comfort and colleagues (2013), studies have shown a positive relationship between health insurance and the use of maternal health services. Two out of three studies which examined the effect of health insurance status on maternal mortality found that having health insurance does, in fact, decrease maternal mortality. Maternal health services, which include prenatal care, are essential in ensuring the best health outcomes for both the mother and child. Therefore, it is safe to assume that the lack of maternal health services can contribute to rising maternal mortality rates in the United States. Although prenatal care is provided to all women in most states, women across many low-income neighborhoods and minority backgrounds may not understand the importance of prenatal care and might be unsure of how to access it (Baudry, Gusman, Strang, Thomas, & Villarreal, 2017). Futhermore, Baudry and colleagues (2017) state that this lack of knowledge can result in disproportionate health outcomes for women who are unable to identify warning signs of possible complications during their pregnancies. According to the CDC (2015), nearly a quarter of black women begin prenatal care late in their pregnancy or not at all. This percentage is more than two times higher for black women than their white counterparts. Having health insurance and access to maternal health services prior to pregnancy, during pregnancy, and after pregnancy is the most ideal situation to prevent negative health outcomes for both the mother and child.
Women can gain insurance through their employer, the government, or a private company. Depending on which option is most suitable for their financial situation, the quality and access to care may vary. A 2008 study conducted by the National Women’s Law Center discovered that among more than 3,500 insurance plans sold across the country, only 12% included comprehensive maternity coverage (Sonfield, 2010). In other words, women who opt for private insurance may be able to obtain better benefits and higher quality of care than women who depend on Medicaid (Comfort et al., 2013). The authors further drive this point by stating that there is significant evidence demonstrating the effectiveness of having access to skilled care at the bedside during delivery, a benefit that low-income women will not be able to reap. The thought that all women are not provided the same quality of care based on their insurance is disturbing when you consider the fact that about four in ten U.S births are paid for through Medicaid (CDC, 2015). Seeing that a government program funds almost half of every ten births in the United States, the quality of care provided by Medicaid should be equally beneficial to the mother as the care provided by a private insurance.
Health insurance status. Thankfully, as a result of the Affordable Care Act, opportunities for women to receive health insurance have increased. The ACA requires Medicaid to provide insurance for women throughout their pregnancy, which enables them to use their prenatal care services as a detection and surveillance of pregnancy complications and chronic diseases (Molina, 2017). However, the lack of health insurance coverage prior to pregnancy can play a notable role in exacerbating maternal mortality rates. According to Nour (2008), the consensus among international organizations is that quality care requires services throughout a woman’s reproductive life. Nour’s point is that proper management of a woman’s health before pregnancy is proven to be just as important to the management of a woman’s health during and after pregnancy.
Additionally, many states without Medicaid waivers stop covering these mothers sixty days after delivery (Sonfield, 2010). The author states that this process leaves many low-income women without insurance again, tossing them into a never-ending cycle of moving in and out of insurance coverage. The CDC (2015) reports that women who experienced unstable coverage were more likely to be young, minority, have no higher than a high school diploma, unmarried, and have incomes lower than 200% of the federal poverty level. These factors all serve as barriers to practicing preventative health care and limit a woman’s opportunity to monitor chronic conditions.
Consequences associated with lack of healthcare coverage. The CDC (2015) identified cardiovascular diseases and hypertensive disorders along with a few others as conditions that can put women at risk for poor maternal outcomes. Without insurance, these conditions often go unmanaged and possibly unidentified. A woman with an unmanaged chronic condition is more likely to experience risks during pregnancy and delivery, even if she receives prenatal care somewhere down the line (CDC, 2015). However, the importance of prenatal care is still relevant. Baudry and colleagues (2017) assert that prenatal care interventions appear to be effective in reducing adverse maternal outcomes. Unfortunately, the authors argue that the decision of many states to not expand Medicaid funds has created a coverage gap where people are not poor enough to get Medicaid, yet not financially stable enough to pay for their own insurance or better coverage. It is estimated that 1.1 million women included in the coverage gap could qualify for Medicaid if their states expanded program eligibility (Kaiser Foundation, 2015).
There is a possibility that women in this coverage gap could be left to suffer if the treatment is costly, but there is not enough research to prove it. According to the Kaiser Foundation (2017), women are less likely to be covered through their own job and more likely to be covered as a dependent. The authors emphasize the raised stakes for coverage if a woman were to ever become a widow or divorcee. A loss in coverage can force a woman to forgo medical services, even ones crucial for women’s health such as mammograms and pap tests. Due to the lack of funds to pay for treatment, Weinick, Byron, and Bierman (2005) report that one in six people avoid necessary health care. This includes putting off, postponing, or never seeking medical services, not filling a prescription, and not following the doctor’s treatment plan. Health care providers are increasingly finding themselves in situations where they are concerned about their patient’s ability to pay for the necessary treatment (Weiner, 2001).
Some physicians do what they can to help and others feel that there is no additional help they can provide to patients unable to pay for treatment. Weiner (2001) indicates that some physicians may attempt to under code or waive deductibles for people who cannot afford treatment but those actions mean committing fraud. On the other side of this ethical dilemma, people across the United States have witnessed the dumping of patients from health care facilities into the streets without proper housing placement. Since most health care facilities are run like a business, if a patient lacks the insurance or money to pay for services, the providers may find themselves doing whatever they can to discharge the patient as quickly as possible. It can be assumed that denying health care to a pregnant woman due to lack of insurance can affect the U.S maternal mortality rate, but further research should be collected to determine a significant relationship between the two.
Likely victims of healthcare coverage. According to the CDC (2015), the Pregnancy Risk Assessment Monitoring System concluded that most women who were uninsured just a month before pregnancy were non-white/a person of color. A woman who receives health insurance right before the start of her pregnancy should be taught what her insurance covers, how to utilize it, and the importance of prenatal care. The lack of preventative health care, maternal education, and guidance puts low-income African American women at a higher risk for negative maternal outcomes. The American Public Health Association’s (2011) also points out that since 1950, African American women have consistently had a higher maternal mortality rate than White women. Additionally, many of the communities that these African American women come from have substantial gaps in access to quality health care for pregnant women.
Due to their community’s lack of resources, African American women may attempt looking outside of their neighborhood for health care services. However, Baudry and colleagues. (2017) mention that after trying a health care facility outside of their neighborhood, African American women may be discouraged to continue receiving care because of the negative interactions and discrimination they face in healthcare settings. Studies have shown that implicit bias can affect the care received by a woman of color (Blair, Steiner, & Havranek, 2011). Additionally, the authors state that research suggests African American people receive lower quality and intensity of care than White people even when their insurance is the same. The failure of healthcare providers to listen, respect, and create an appropriate treatment plan for women of color, directly affects their quality of care (Baudry et al., 2017) and can potentially contribute to the maternal mortality rate in the United States.
CHAPTER THREE
Conceptual Framework
In this chapter, we discuss the factors that contribute to the high maternal mortality rates in the U.S. First, we present the conceptual framework, which serves as the road map for this study. Next, we explain the variables we believe are responsible for high maternal mortality within the United States. These variables are health insurance status and racial background of women. Then, we discuss our assumptions, research questions, and corresponding hypotheses. After, we acknowledge the stakeholders to whom this study pertains to and present the key terms we believe are essential to understanding the key issue. Lastly, we conclude with this chapter’s main points.
Figure 3.1 illustrates the relationship between the dependent and independent variables in this study.
Figure 3. 1
The dependent variable is maternal mortality. The aim is to determine whether maternal mortality is affected by the independent variables, which are health insurance status and racial background of American women. Health insurance status is conceptualized as uninsured versus insured. Racial background of American women is conceptualized as white or black women. Moreover, to further understand how the dependent and independent variables will be measured, the following operational definitions are important. Maternal mortality is operationalized as the number of maternal deaths per 100,000 live births. The first independent variable, health insurance status, is measured as the percentage of uninsured women in the state. The second independent variable, racial background of women, will be measured by the percentage of black women in the state, or per capita. Below, Table 3.2 summarizes how each variable will be operationalized.

Figure 3. 2
3.1 Health Insurance Status and Maternal Mortality
In a recent article by Chuck (2017), the reasons behind Texas’ high maternal mortality rates are explored. One of the two major reasons for Texas’ high rates includes a delay in receiving prenatal care until late pregnancy. Novack (2017) explains that the state’s policy makers have rejected a federally funded expansion of Medicaid under the ACA, which would have covered 1.1 million more of their residents. The choice not to expand through the ACA will also affect more than half of all births in Texas that are paid for by Medicaid already. The state’s legislation is focused on extending research efforts, rather than addressing the underlying problem: lack of access to healthcare. Sifferlin (2018) argues that a lack of access to proper healthcare before pregnancy and a push for cesarean section do not properly prepare a woman’s body for birth. This leaves these women more vulnerable to dying during childbirth.
Overall, the U.S. has experienced a decrease in the number of uninsured women. According to a Health of Women and Children Report (2018) by America’s Health Rankings, in 2015 the number of uninsured women was about 20 percent, this percentage dropped to approximately 17 percent a year later. The reason for this decline is due to the ACA, as referenced previously in chapter 2 of this paper. Despite the dip in the number of uninsured, the maternal mortality rate is still high in the country, at almost 20 percent in 2016 (America’s Health Rankings, 2018). There must be another contributing factor that affects maternal mortality. In this study, we deem it to be race.
3.2 Race and Women’s Health
Though women of all races contribute to Texas’ high maternal mortality; black women contribute to the state’s live birth rate at about 10 percent, but contribute to its maternal deaths with more than 25 percent (Chuck, 2017; Hoffman, 2017). These skewed statistics have led researchers to inquire why African American women in Texas are dying at such a high rate during childbirth. In a systematic review and meta-analysis study, regarding racism and health service utilization by researchers Ben, Cormack, Ricci and Paradies (2018), it was concluded that an association exists between race and healthcare outcomes. Overall, racism greatly dictates the trust minorities had in the healthcare system and professionals. Those who experienced racism while receiving care were more likely to delay seeking treatment and reported lower satisfaction and poor perception of quality of care (Cormack et al., 2018). Similarly, D’Angelo, Bryan and Kurz’s (2016) mixed methods study, which examined disparities in prenatal care among Connecticut’s female residents, found that although the participants understood the importance of prenatal care, experiences differed among women of different racial backgrounds. Black/African American women were one of the groups that expressed that they experienced discrimination stating that they did not have any input when it came to their care (D’Angelo et al., 2016).
In addition, Creanga, Berg, Ko, Farr, Tong, Bruce and Callaghan (2014) presented several bar graphs from 1987 to 2009 in the United States. The trend in data depicted the rise of maternal mortality across the nation and also provided the data by reasons for the number of maternal deaths as well as the race of the mothers. The pregnancy related mortality ratio is greater in every year for black women in comparison to white women. Supporting this trend, MacDorman, Declercq and Thomas (2017) analyzed data from 2008-2009 and 2013-2014 to understand the patterns in maternal mortality by socioeconomic characteristics and cause of death in 27 states and the District of Columbia. Their results revealed that there was a 23% increase in maternal mortality during the 5-year period and non-Caucasian women had the greatest increase in maternal mortality (MacDorman et al., 2017). Centers for Disease Control and Prevention (2017) adds more support that race contributes to high maternal mortality rates in the U.S. by pointing out that during the years of 2011-2013, per 100,000 live births, 12.7 maternal deaths were white women, 43.5 deaths were black women, and 14.4 were other races.
3.3 Assumptions
Based on the existing published work about health insurance status, race, and maternal mortality mentioned prior, there are three main assumptions driving this study. The first assumption is that due to implicit bias of healthcare providers, black women do not have equal access to healthcare. Our second assumption is that being uninsured leads to a lack of preventative care. This in turn, leaves women more susceptible to complications during pregnancy. The third assumption is that women who are uninsured before pregnancy are less likely to successfully utilize and navigate prenatal care for optimal maternal outcomes.
3.4 Research Questions and Hypotheses
Along with our assumptions, we also derived two research questions based on research conducted. The first research question examines the relationship between the health insurance status of American women and maternal mortality in the country. The second research question asks about the relationship between the race of women and maternal mortality in the U.S.
With the support of existing literature and studies regarding maternal mortality, null and alternative hypotheses were developed for each study question proposed. In regards to the relationship between health insurance status and maternal mortality, the null hypothesis indicates that no relationship exists between health insurance status and maternal mortality. However, the testing hypothesis states the greater the percent of uninsured women in the state, the greater the number of maternal deaths per 100,000 live births within that state.
Pertaining to the research question that inquires about the relationship between racial background of women and maternal mortality in the U.S, the null hypothesis states that no relationship exists between the racial background of women and maternal mortality. On the other hand, the testing hypothesis suggests that the greater the percentage of black women in the state, the greater the number of maternal deaths per 100,000 live births within that state.
3.5 Key Stakeholders
There are several key stakeholders who the conclusion of this study concerns. We have grouped these individuals into three categories: women, policy makers and health care providers. The aim of this study is double layered. It is not only to increase the level of awareness regarding maternal mortality and how it is affected by insurance status and race. But, also to help create active universal health policies, which will decrease and ultimately eliminate implicit bias that contributes to the U.S.’s high maternal mortality rates.
Women: The main stakeholders of this study are American women, and particularly black American women. Every woman should have the right to equitable healthcare before pregnancy, regardless of race. One of our sub-purposes is to inform women of the benefits of preventative care. Giving birth is a strenuous experience and caring for her body will better prepare women, in the chance that she becomes pregnant. Access to health care is another issue we want to inform the female population about. If she cannot afford healthcare or does not qualify under her state’s guidelines for public health coverage, it is important to take initiative in their government policies. Whether it is taking part in a march, signing or starting a petition, and/or voting, women need to take the lead in the political sphere, especially pertaining to their health.
Policy makers: The driving point of this study is significant for policy makers. As elected officials, they need to consider the best interest of the individuals that voted them in for their role. The funding designated to women’s healthcare should be used effectively and the overall health of all women should be a main priority. As communicated beforehand, allocating resources efficiently in areas of preventative care and health insurance for women through public assistance programs will help with the issue of the U.S.’s high maternal mortality rate.
Healthcare providers: As discussed earlier in this chapter, healthcare providers implicitly are biased to black women. The purpose of this research study is to raise this issue among health care providers and point out that black women are less likely to routinely go to their doctor appointments if they feel discriminated against. Healthcare providers need to be aware that women in general are a vulnerable population and women’s healthcare is a sensitive subject. Therefore, they need to be more mindful and conscious of their language and actions when speaking to women about her prenatal, maternal and overall care.
3.6 Terminology
The following key terms are necessary to gain a better understanding of this study. Definitions are gathered according to the World Health Organization and the U.S Census Bureau.
Maternal mortality rate (MMR): Maternal mortality rate reflects the number of maternal deaths per registered 100,000 live births. There are many factors that contribute to the high maternal mortality rate in the United States but for this study we will explore health insurance status and racial background of mothers.
Maternal death/maternal mortality: Maternal death and maternal mortality can be used interchangeably and is defined as the death of a woman while pregnant or within 42 days of delivery.
Live birth: A live birth is described as the complete expulsion or extraction of a baby from his/her mother. The baby must show evidence of life after the separation, such as the ability to breathe on its own.
Prenatal care (Antenatal care): Prenatal care is the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both the mother and baby during pregnancy. Most states in the U.S provide prenatal care to all women regardless of their health insurance
Race: Race is defined as the way a person self-identifies through one or more of the following social groups
· White, Black or African American, Asian, American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander
For this study, Black or African American women are the main focus.
3.7 Concluding Remarks
In this chapter, we presented and explained the conceptual framework in which the variables in this study are related. The assumptions based on current published work, research questions that this study aims to answer, and hypotheses were discussed as well. After, the key terms and stakeholders were recognized, as it was relevant to supporting the goal in this study. In the next chapter, the methodology to accomplish our study will be discussed.
CHAPTER FOUR
Methodology
Although the maternal mortality rate has significantly declined on a global scale from 1995 to 2015, the United States rate is steadily rising. Prenatal care has been
identified as a key component to ensuring the best health outcomes for both the mother
and child, however not all women receive the same access and quality of care (Blair et
al., 2011). Black women comprise a disproportionate number of maternal
deaths in the United States and it assumed that varying factors such as race and health
insurance status can influence that number. First, we will state the research questions and
hypotheses to further develop the focus of this study. Next, this chapter will discuss the
design of the study and how it will help determine the relationship between health
insurance status, race, and maternal mortality. Finally, we will share the level of analysis,
followed by the description of measures and data collection.

4.1 Research Questions
1. What is the relationship between the health insurance status of mothers and maternal
mortality in the U.S.?
2. What is the relationship between the racial background of women and maternal
mortality in the U.S.?

Hypothesis

H0: There is no relationship between health insurance status and maternal mortality.
H1: The greater the percentage of uninsured women in the state, then the greater the number of maternal deaths per 100,000 live births within that state.
H0: There is no relationship between the racial background of women and maternal
mortality.
H2: The greater the percentage of black women in the state, then the greater the number of maternal deaths per 100,000 live births within that state.
4.2 Research Design
The purpose of this study is to determine the role that health insurance status and
race play in rising maternal mortality rates in the United States. To do this, we conducted
a cross-sectional, state-level study using mixed methods research. According to O’Sullivan, Rassel, and Berner (2008), “A cross-sectional design collects data on all relevant variables at one time” (p. 27). Rather than studying or analyzing a population over a long period of time, cross-sectional studies offer “snapshots” of a population of interest at one point. The design’s greatest value is in describing the relationships among several variables and was used in our study to determine the relationship between each of our independent variables and our dependent variable.
Through the use of peer-reviewed articles, we performed a systematic review of
quantitative studies to identify trends within the existing literature on the topic. Examining this literature has helped to guide our research process in the right direction. The secondary data collected from these quantitative studies, as well as governmental sources and websites, will give readers a more comprehensive understanding of the number of maternal deaths by state and the population who is affected by this issue the most. Some common themes found among the literature on maternal mortality included our variables, racial background and health insurance status, as well as prenatal care, health care expenditures, and policy failures related to maternal health services.
4.3 Delimitations and Scope
There are several factors that contribute to maternal mortality in the United States,
however, to keep our study clear and concise we only focused on health insurance and
race, as well as maternal mortality rates at a national level. This study will not focus on
women who died due to complications from an abortion, the mother’s lifestyle choices,
genetic conditions, education, income, social class, or ethnicity. To provide an overview
of the most recent trends within the United States, we collected data and research from the year 2016. Data from 2016 is the most recent data available.
4.4 Measures and Participants

This study does not include any participants because we are using secondary data,
but our units of analysis are uninsured women and black women within 48 states plus the District of Columbia (2016 maternal mortality rates were unavailable for Alaska and Vermont). Our independent and dependent variables were measured as the following:

Dependent

· Maternal mortality was conceptualized by maternal mortality rate and
operationalized as the number of maternal deaths per 100,000 live births.

Independent

· Health insurance status was conceptualized by insured versus uninsured and
operationalized as the number of uninsured as a percentage of the state
population.
· Race was conceptualized by white women versus black women
and operationalized as the number of maternal deaths of black women
per state.

4.5 Data Collection and Processing
For the qualitative portion of this study, we synthesized 25 peer-reviewed articles to identify the general consensus and common conclusions among the literature on maternal mortality in the United States. To organize this data, we developed a chart with the author of each article’s name, the year of publication, and a brief summary of the study’s findings, we then indicated whether each study spoke to either of our study variables, health insurance status and racial background of women. We collected quantitative data from studies found on government websites such as the Centers for Disease Control, the U.S Department of Health, and the U.S Census Bureau. We then used this data to conduct a Pearson’s Correlation Test for each of our two independent variables. The results of these tests clearly demonstrate the correlations between our variables and maternal mortality within the United States.
4.6 Concluding Remarks
In this chapter we described the actions that will be taken to properly investigate our research questions. Knowing what will be included and omitted, as well as learning how the data was collected and analyzed, will give readers a better understanding of our study and its purpose. In the next chapter, we will discuss the findings and results.

CHAPTER FIVE
Results and Findings

The aim of this chapter is to explore the relationship between uninsured women, black women, and the MMR in the U.S. More specifically, first, the sample used to run quantitative tests will be briefly discussed. Then, the results of the Pearson’s correlation tests will be explained. This will be followed by the qualitative analysis of 25 recent studies on health insurance status, race and MMR.
5.1 Results
The sample consisted of 48 States in the U.S. and the District of Columbia. The MMRs were unavailable for Alaska and Vermont for the year of 2016. The sample as a whole had an average MMR of 20.1 per 100,000 live births (SD = 13.71) ,15.3% uninsured women (SD = 5.45) and 14.3% black women (SD = 8.73). The MMR ranged from 5.80 to 40.70 per 100,000. The state of Massachusetts had the minimum MMR and the District of Columbia had the maximum MMR.
Table 5.1 MMR, Percent of Uninsured and Black Women for 2016
Descriptive Statistics (N = 49)

Variables

MMR

Percent of Uninsured Women

Percent of Black Women

Min

5.80

3.60

.70

Max

40.70

28.30

61.40

20.11

15.33

14.31

8.73

5.45

13.71

Pearson’s Correlation tests were used to examine the relationship between the study variables and MMR.
Health Insurance and Maternal Mortality

The first Pearson’s Correlation test investigated the relationship between health insurance status and maternal mortality. On a scale of zero to one, results indicate that a significant relationship exists between the percent of uninsured women and MMR, r(47) = .357, p <.05, two-tailed. Table 5.2 shows the summary of the first Pearson’s Correlation test. Table 5.2 MMR, Percent of Uninsured Women and Percent of Black Women: Correlations Percent of Uninsured Women Percent of Black Women MMR Pearson Correlation Significance (2-tailed) N .357 .012 49 .394 .005 49 Figure 5.3, which is a scatter plot depicts a positive and moderate correlation between the two variables, suggesting the higher the percent of uninsured women in the state, the higher the MMR. Based on the results, we would reject the null hypothesis. Figure 5.3 MMR and percent of uninsured women were positively correlated, r(47) = .357, p < .05. Figure 5.3 Race and Maternal Mortality The second Pearson’s Correlation test was performed to explore the relationship between the racial background of mothers and MMR. As summarized in Table 5.3, on a scale from zero to one, the results produced indicate that a significant relationship exists between the percent of black women and MMR, r(47) = .39, p < .05, two-tailed. Table 5.3. MMR, Percent of Uninsured Women and Percent of Black Women: Correlations Percent of Uninsured Women Percent of Black Women MMR Pearson Correlation Significance (2-tailed) N .357 .012 49 .394 .005 49 Figure 5.4 shows that the second study variable and MMR have a moderately positive relationship. The results imply that the higher the percent black women in the state, the higher the MMR. Based on the results, we reject the null hypothesis. Figure 5.4 MMR and percent of black women were positively correlated, r(47) = .394, p < .05. Figure 5.4 5.2 Findings A qualitative analysis was also performed during this study. The findings of twenty-five peer reviewed and news articles were reviewed and categorized into three themes. The first theme explored was whether health insurance status affects maternal mortality, despite race. The second theme examined was that race, regardless of coverage, was a driving factor in MMR and finally that both variables impacted MMR in the U.S. Of the twenty-five articles, eight articles attributed MMR to racial background, eight articles stated maternal mortality influenced the rates, and nine articles stated that MMR was impacted by both variables. Figure 5.5 provides a depiction of the distribution of the articles. Based on these results, we would reject the null hypotheses. Figure 5.5 Synthesis of literature attributes cause of MMR to both health insurance status & race Figure 5.5 CHAPTER SIX Discussion and Conclusion The final chapter will provide a general summary of the study and results and relate it to the context of current literature and research regarding maternal mortality rates in the United States. The limiting factors of the study will be explained and recommendations will be proposed to remedy the issue. We also provide actions needed to improve future studies and underlying issues that contribute to high maternal mortality amongst black women in the U.S. 6.1 Discussion Given the lengthy history of racial injustice in the U.S., we began this research with the assumption that socioeconomic status and race were intertwined. In the beginning stages of our research we began to see a paradox emerge, as we found that although the U.S. spends trillions on healthcare, the maternal mortality rate has nearly doubled in the past twenty years (Centers for Medicare & Medicaid Services, 2018, WHO, 2015). We also found that black women are dying at an alarmingly higher rate than their white counterparts. Through our analysis we strived to offer possible explanations for the current maternal mortality crisis within the United States, while simultaneously unveiling injustices that exist within the country’s healthcare system. First, we hypothesized that insurance status would have a direct affect on maternal health outcomes and MMR. We also hypothesized that the racial background of mothers would have an impact on MMR. Our study confirmed both assumptions and also revealed that the main victims of the crisis are black women. It is evident that a woman race is a predictor of maternal health outcomes, as black women are likely to experience maternal death at a significantly higher rate than white women. Our findings proved to be parallel to those of the existing literature that was reviewed earlier in this study. To reiterate, Comfort et al (2013) found a direct, positive linkage between health insurance status and utilization of maternal health services. These findings, in conjunction with our research confirm that the presence of health insurance will increase a mother’s ability to access healthcare, therefore positively impacting the MMR. Tucker et al (2007) concluded that black women are more likely to die from birth complications, affirming our results that there is a significant relationship between the percentage of black women per capita and the MMR of a state. For the sake of this study, race was defined as a social construct, using data on how people self identified. Race is a critical marker of social location, determining the quality of one’s life. A person’s race is a major influencing factor in the interactions they have with institutions, such as the criminal justice system and health care system. The outlawing of slavery in the 1860s did not suddenly free blacks from the oppression they had faced for centuries. For years following the Emancipation Proclamation of 1863, America used Jim Crow laws to continue to disenfranchise the black population and uphold racial segregation (Alexander, 2010). White supremacists routinely terrorized and intimidated black neighborhoods with the senseless lynching of innocent men, women, and children. When the Jim Crow era finally came to an end, officials ushered in a new era of racialized social control: mass incarceration (Alexander, 2010). Racial discrimination is engrained within our country’s foundation, making it less shocking that it has reared its ugly head within our healthcare system. Medical researchers made their most profound discoveries at the expense of their black subjects, often who did not provide informed consent. Dr. Marion Sims, who has been credited as the father of modern gynecology, pioneered the field of gynecological surgery by operating on enslaved black women without anesthesia. A bronze statue commemorating Sims was erected in New York’s Central Park in the 1920s. It was finally taken down in April 2018 only after it became the focus of protests denouncing Sims’ experimentation on black women. The Tuskegee, Alabama Syphilis Experiment which began in 1932, is another notorious example of scientific racism in the US. The subjects were illiterate black men who had contracted syphilis, a sexually transmitted disease that if left untreated would lead to painful and deadly symptoms (Yoon, 1997). Participants were lured into the study under the guise of receiving free healthcare. Many were not treated, even the cure had been discovered (Yoon, 1997). They were subjected to painful spinal taps and procedures and many were denied treatment so that scientists could observe the degenerative progress of the disease (Yoon, 1997). The study ended in 1972, twenty five years after the cure was made available (Yoon, 1997). By then, 128 subjects had died from syphilis or related complications (Yoon, 1997). In addition, forty of the participants’ wives and nineteen children had also been infected (Yoon, 1997). The issue of maternal mortality in the United States is not new, however it is a perfect example of the pervasive racism that still exists within the country. While data shows that the United States has managed to fall behind in decreasing maternal mortality rates, proper resources have yet to be allocated to resolving the issue. In fact, measures have been taken to further hinder women’s chance of receiving proper health care before, during, and after their pregnancy. Many believe the issue has yet to be seen as important by the U.S., due to a lack of consideration for the population affected by this crisis. Black women’s bodies have long been sites of violation and abuse. They endured years of systemic rape during slavery. To highlight the difference from white women, naked black women, such as Sarah Baartman, were put on display as freak shows (Qureshi, 2004). Studies found that most maternal deaths in the U.S. are preventable. Unfortunately, society has yet to make the decision that women’s lives, and even more so, black women’s lives, are worth saving. Women, and more specifically women of color, have endured years of being devalued and considered less than their white, male counterparts. Still, women have yet to gain the respect they deserve to be seen as equal. Today, women make up about one-fifth of Congress; only 19.6 percent and 38.5 percent of those women are women of color (“Women in the U.S. Congress,” 2018). 2017’s Fortune 500 CEOs list included only 32 companies with female CEOs (“Women CEOs,” 2017). The gender wage gap is still present within our society, as women earn 80.5 cents for every dollar earned by men, and this number is even lower for women of color, at about 63 cents (“Pay Equity & Discrimination,” n.d.; “Women and the Wage Gap,” 2017). And lastly, about 35 percent of women have reported being victims of domestic violence in the United States (“Violence Against Women,” 2015). Additionally, according to Justice Bureau Statistics, African American women experience domestic violence from an intimate partner at rates 35 percent higher than white women. Furthermore, black individuals have suffered through years of racial segregation and discrimination. In our literature review, we explored how the crack and opioid epidemics are great examples of the preferential treatment of white individuals within our country. Here one can see two very similar drug epidemics, with two very different national responses. The crack epidemic was met with an incarceration-based response that saw crack users, predominately black individuals, as criminals. Contrastingly, the recent opioid epidemic has been declared a public health emergency by the government, ensuring opioid users, predominately white individuals, receive the help they need to be rehabilitated. Unfortunately, the same disregard for black individuals can be identified in the current maternal mortality crisis as there has been little national outcry on the issue. Based on our analysis of our independent variables, health insurance status and racial background of women, and its effect on maternal mortality in the U.S., we have found that uninsured, black women are dying during or after pregnancy at disproportionate rates when compared to their insured, white counterparts. While there are exceptions, which will be discussed later in this chapter, we believe it is safe to say that black women who have unequal access to appropriate care are the main victims of maternal mortality within the United States, therefore contributing to the idea that demographics play a role in the government’s failure to recognize the issue as a priority. It is unfortunate that while black women are dying giving birth, it is unlikely that this will become a national conversation let alone warrant a policy response and this simply because black women are denied full humanity and their lives are not valued by a society marred with structural racism. 6.2 Recommendations & Conclusion Research on maternal mortality stresses the importance of maternal health services and its connection to better health outcomes for mothers however, the use of health services before pregnancy has been found to be just as important. According to the World Health Organization (2008), the lack of affordable, available, accessible, and quality health care has a large impact on maternal mortality rates (p.1). As we know, in the United States maternal health services are provided for women when they become pregnant but unfortunately many women remain without health insurance prior to and after pregnancy. Although the expansion of Medicaid eligibility under the Affordable Care Act has extended health insurance to many people who were once uninsured, the Kaiser Family Foundation (2018) reports that as of April 2018, nineteen states have not expanded their programs. The refusal of certain states to expand their programs has left millions to suffer within the coverage gap. A change in policy, which would require Medicaid expansion under the Affordable Care Act to exist on a national level like it was originally intended to, would allow millions of women access to preventative health care services and therefore lead to a decrease in the U.S maternal mortality rate. Democratic states are exploring ways to avoid rollbacks in Medicaid, as well as ways to expand insurance past the stipulations of the ACA. Liberal states, such as New York, are taking the necessary steps to address MMR amongst black women. The state government is planning to launch a number of initiatives to curtail high maternal death rates. One progressive measure of this plan is to expand Medicaid to cover doula care (Ferre-Saduri, 2018). Doulas are trained to coach and assist women through pregnancy and childbirth. Recent studies have indicated that a doula’s presence promotes calm, stress free conditions, improved maternal health outcomes and reduced pregnancy complications (Ferre-Saduri, 2018). Doula care can be very expensive, costing approximately $1,500 per birth (Ferre-Saduri, 2018). Expanding this service to low-income mothers could possibly address the healthcare disparities fueling MMR. The state will also create a Task Force on Maternal Mortality and Disparate Racial outcomes, as well as expand programs to educate expectant mothers on prenatal care (Ferre-Saduri, 2018). The Task Force will work with the Maternal Mortality Review board, a team of healthcare professionals, to review each maternal death in New York (Ferre-Saduri, 2018). For future research, it would be insightful to compare maternal mortality rates among states that chose to expand coverage versus those that did not. Since a lack of health insurance is more commonly associated with non-Caucasian women (Garfield & Damico, 2017, p.1), readers would be able to examine the role of both racial background and health insurance status on maternal mortality rates across the United States. It would also be of interest to monitor how New York’s doula pilot program performs, providing a blueprint for other states seeking to extend the service to expectant mothers. The United States use of a third party payment system is the primary reason for such a large coverage gap, however, if the United States provided universal health care to all it’s residents, no coverage gap would exist at all. Women of all racial backgrounds and socio- economic statuses would reap the benefits of quality care and be at less risk for complications during and after childbirth. Additionally, healthcare costs would be lower under universal health care. According to Frank (2017), administrative and advertising costs would significantly decrease and the government would be able to negotiate more affordable terms with service providers (p.1). Metz (2014) agrees with this by emphasizing how much more expensive it is to restrict access and limit care to people rather than providing care to all (p.1). In the meantime, improving data collection on maternal mortality rates in the United States can provide more accurate and useful information on how to combat the issue. Gavin (as cited in MacDorman & Thorma, 2017) reports that data from 2009-2014 show an increase in both maternal mortality rates of women over forty and the number of maternal deaths with nonspecific causes. This leads researchers to believe that there may be data quality issues and Gavin agrees by stating that the data being collected from U.S death certificates may not be the most reliable source to reference because of some imposing factors. In 2003, the U.S death certificate was updated to include the pregnancy question but not all the states implemented the updated certificate at the same time and some states had a pregnancy question that was inconsistent with U.S standards (MacDorman, Declercq, Cabral, & Morton, 2016). Gavin (as cited in MacDorman & Thorma, 2017) lists other possibilities for inaccuracies such as the death not having anything to do with the pregnancy itself or the pregnancy box being selected by accident. If the United States strengthens the systems in place to record, interpret, and analyze maternal mortality, we can begin identifying and targeting the issues plaguing women’s reproductive health. This study confirmed that states with higher populations of uninsured women are more likely to have higher MMR, however recent data shows that maternal death may be more closely related to race. NPR’s Code Switch podcast explored the theory of the weathering effects of racism on black women (2018). The hosts found that encountering discrimination at work, school, the doctor’s office and other aspects of life will increase the levels of stress black women experience (Demby & Meraji, 2018). This, in turn, leads to increased stress levels, higher cortisol levels, the rapid onset of coronary heart disease and high blood pressure (Demby & Meraji, 2018). Research also shows that black women that reported racism during doctor’s visits were more likely to give birth to underweight babies (Demby & Meraji, 2018). There have also been several reports of middle to high class black women suffering from life threatening pregnancy complications. Shalon Irving, a decorated epidemiologist at the CDC, died three weeks after giving birth due to complications of high blood pressure (Demby & Meraji, 2018). Irving, ironically, was researching the detrimental physical effects of discrimination. Serena Williams, a gold medal Olympian and tennis superstar, also recounted her near death experience after giving birth. Williams experienced a pulmonary embolism, causing her caesarean scar to rupture (Villarosa, 2018). Both women had voiced concerns to their doctors prior to the complications arising and both recounted being dismissed. Unconscious racism, or implicit bias, coupled with overt attempts of the current administration to repeal healthcare policy are the fueling factors for high MMR amongst black women. A longitudinal study observing the long term effects of racism on the physical and mental health of populations of color could provide great insight on why they are disproportionately affected by certain diseases, such as high blood pressure. Also, implicit bias tests should be used to help people identify their own prejudices and address them before providing care to diverse populations. Coursework on cultural competency should also be incorporated into healthcare curriculum, to ensure that providers are understanding of the populations they are serving. In conclusion, policy makers are responsible for providing equitable healthcare to all citizens, regardless of race, ethnicity, income or education. The UN global initiatives aimed at addressing MMR are the first in many steps that are needed to eliminate this issue worldwide. The eradication of racial biases through continued efforts and education is needed to ensure that providers address their unconscious prejudices, which will improve care for black mothers and other women of color. Efforts at a global, federal, and local scale should be undertaken to improve the lives of black women and babies. All mothers deserve to enjoy every stage of their pregnancy, including living to raise and love their newborn child. REFERENCES ACOG Committee Opinion No. 649: Racial and Ethnic Disparities in Obstetrics and Gynecology. (2015). Obstetrics & Gynecology, 126(6), e130-e134. doi:10.1097/AOG.0000000000001213 Agrawal, P. (2015) Maternal mortality and morbidity in the United States of America. Bulletin of the World Health Organization, 93, 135. doi: http://dx.doi.org/10.2471/BLT.14.14862 Alexander, M. (2010). The New Jim Crow : mass incarceration in the age of colorblindness. New York: The New Press America's Health Rankings. (2018). Overview | 2018 Health Of Women And Children Report. Retrieved March 20, 2018 from https://www.americashealthrankings.org/learn/reports/2018-health-of-women-and-children-report/overview American Public Health Association. (2011). Reducing US Maternal Mortality as a Human Right. Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/11/15/59/reducing-us-maternal-mortality-as-a-human-right Amnesty International. (2011). Deadly Delivery: The maternal health care crisis in the USA. Retrieved from https://www.amnestyusa.org/wpcontent/uploads/2017/04/deadlydelivery-Oneyear Baudry,E., Gusman, N., Strang, V., Thomas, K., & Villarreal, E. (2017). When the State Fails: Maternal Mortality & Racial Disparity in Georgia. Retrieved from https://law.yale.edu/system/files/area/center/ghjp/documents/ghjp_2018_executive_summary_when_the_state_fails-_maternal_mortality_racial_disparity_in_georgia Ben, J., Cormack, D., Ricci, H., & Paradies, Y., (2018, Dec 18) Racism and health service utilization: A systematic review and meta-analysis. PLoS ONE, 12(12), Retrieved from https://doi.org/10.1371/journal.pone.0189900 Blair, J. V., Steiner, J. F., & Havranek, E. P. (2011). Unconscious (implicit) bias and health disparities: where do we go from here? The Permanente Journal, 15(2), 71-78. Brink, S. (2017, April 20). What Country Spends The Most (And Least) On Healthcare Per Person? Retrieved March 9, 2017, from National Public Radio, Inc.: https://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-country-spends-the-most-and-least-on-health-care-per-person Bryant, A.S., Worjoloh, A., Caughet, A.B., & Washington, A.E. (2010). Racial/Ethnic Disparities in Obstetrical Outcomes and Care: Prevalence and Determinants. American Journal of Obstetrics and Gynecology, 202(4), 335–343. http://doi.org/10.1016/j.ajog.2009.10.864 Centers for Disease Control and Prevention. (2015). Patterns of health insurance coverage around the time of pregnancy among women with live-born infants: Pregnancy risk assessment monitoring system, 29 states, 2009. Retrieved from https://www.cdc.gov/mmwr/pdf/ss/ss6404 Centers for Disease Control and Prevention. (2017, November 09). Pregnancy Mortality Surveillance System. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html Centers for Medicare & Medicaid Services. (2018). Historical National Health Expenditures. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html Chen, J., Vargas-Bustamante, A., Mortenson, K, & Ortega, A.N. (2016). Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act. Medical Care, 54(2), 140-146. Chuck, E. (2017, August 12). Texas Has the Highest Maternal Mortality Rate in the Developed World. Why? Retrieved February 14, 2018 https://www.nbcnews.com/news/us-news/texas-has-highest-maternal-mortality-rate-developed-world-why-n791671 Comfort, A. B., Peterson, L. A., & Hatt, L. E. (2013, December). Effect of Health Insurance on the Use and Provision of Maternal Health Services and Maternal and Neonatal Health Outcomes: A Systematic Review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021700/ Creanga, A.A., Berg, C.J., Ko, J.Y., Farr, S.L., Tong, V.T., Bruce, C., & Callaghan, W.M. (2014). Maternal mortality and morbidity in the United States: Where are we now? Journal of Women’s Health, 23(1), 3-9. doi:10.1089/jwh.2013.4617 Cubbins, L. A., & Parmer, P. (2001). Economic Change in Health Benefits: Structural Trends in Employer-Based Health Insurance. Journal of Health & Social Behavior, 42(1), 45-63. D’Angelo, D.V., Le, B., O’Neil M,E., W, L., Ahluwalia, I.B., Harrison, L.L., Floyd, R.L., & Grigorescu, V. Patterns of Health Insurance Coverage Around the Time of Pregnancy Among Women with Live-Born Infants-Pregnancy Risk Assessment Monitoring System, 29 States. Retrieved on March 8, 2018 from https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6404a1.htm D'Angelo, K. A., Bryan, J. K., & Kurz, B. (2016). Women's Experiences with Prenatal Care: A Mixed-Methods Study Exploring the Influence of the Social Determinants of Health. Journal of Health Disparities Research & Practice, 9(3), 127-149. Demby, G. & Meraji, S.M. (2018, Jan 10). NPR’s Code Switch: This Racism is Killing Me Inside [Audio podcast]. Retrieved from https://www.npr.org/templates/transcript/transcript.php?storyId=576818478 Egerter, S., Braveman, P., & Marchi, K. (2002, March). Timing of Insurance Coverage and Use of Prenatal Care Among Low-Income Women. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447093/ End the Assault on Women's Health. (2017). Scientific American, 317(3), 9. Espstein, A.M., & Newhouse, J.P. (1998). Impact of Medicaid Expansion on Early Prenatal Care and Health Outcomes. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194521/ Ferre-Saduri, L (2018, April 22). New York to Expand Use of Doulas to Reduce Childbirth Deaths. Retrieved from https://www.nytimes.com/2018/04/22/nyregion/childbirth-death-doula-medicaid.html Flanders-Stepans, M. B. (2000). Alarming Racial Differences in Maternal Mortality. The Journal of Perinatal Education, 9(2), 50–51 Fortune. (2017). These are the Women CEOs Leading Fortune 500 Companies. Retrieved from http://fortune.com/2017/06/07/fortune-500-women-ceos/ Frank, R.H. (2017, July 7). Why Single-Payer Health Care Saves Money. Retrieved on April 20, 2017 from: https://www.nytimes.com/2017/07/07/upshot/why-single-payer-health-care-saves-money.html Frauenholtz, S. (2014). Responding to the Affordable Care Act: A Leadership Opportunity for Social Workers in Employee Assistance Programs. Health & Social Work, 39(3), 153-160. doi:10.1093/hsw/hlu021 Gamble, C. & Taylor, J. ( 2017) Maternity Care Under ACA Repeal Implication for Black Women’s Maternal Health. Retrived from https://www.bwhi.org/2017/08/09/maternity-care-aca-repeal/ Garfield, R., & Damico, A. (2017, November 01). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. Retrieved March 10, 2018, from The Henry J. Kaiser Family Foundation: https://www.kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ Garfield, R. & Damico, A. (2018). Status of State Action on the Medicaid Expansion Decision. Retrieved from https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Gavin, S. (2017, April 10). Researchers uncover alarming trend in U.S maternal death statistics. Retrieved on April 20, 2017 from: https://medicalxpress.com/news/2017-04-uncover-alarming-trend-maternal-death.html Ginsburg, P. B. (2008). Employment-Based Health Benefits Under Universal Coverage. Health Affairs, 27(3), 675-685. doi:10.1377/hlthaff.273.675 Heuser, C., & Karkowsky, C. E. (2017, May 23). Why Is U.S. Maternal Mortality So High? Poverty and Lack of Access to Health Care. Retrieved from http://www.slate.com/articles/health_and_science/medical_examiner/2017/05/medical_error_isn_t_to_blame_for_our_high_maternal_mortality_rate.html Hoffman, M. (2017, June 05). Texas has highest pregnancy-related death rate in developed world, study says. Retrieved from http://www.chicagotribune.com/lifestyles/health/ct-texas-pregnancy-death-rate-20170605-story.html Hope, S., Nunes, V, Lambert, C. & Miller, E. (2017). The Impact of the Affordable Care Act on U.S. Maternal Mortality, Obstetrics & Gynecology, 129(108). doi: 10.1097/01.AOG.0000514996.69681.e0 Howard, J. (2017, Nov 15). Childbirth is killing black women in the US, and here’s why. Retrieved from https://www.cnn.com/2017/11/15/health/black-women-maternal-mortality/index.html How does infant mortality in the U.S. compare to other countries? (2017, July 7). Retrieved March 9, 2018, from Peterson-Kaiser Health System Tracker: https://www.healthsystemtracker.org/chart-collection/infant-mortality-u-s-compare-countries/#item-start Institute for Women’s Policy Research (n.d.). Pay Equity and Distribution. Retrieved from https://iwpr.org/issue/employment-education-economic-change/pay-equity-discrimination/ Irwin, N. (2017, June 23). The Health Debate Shows What Both Parties Care About Most . Retrieved March 10, 2018, from New York Times: https://www.nytimes.com/2017/06/23/upshot/the-health-debate-shows-what-both-parties-care-about-most.html Johnson, K. (2012, August). Addressing Women’s Health and Improving Birth Outcomes: Results from a Peer-to Peer State Medicaid Learning Project. Retrieved March 11, 2018, from http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2012/aug/1620_johnso_addressing_womens_htl_needs_improving_birth_ib Jones, R. K., & Sonfield, A. (2016). Health insurance coverage among women of reproductive age before and after implementation of the affordable care act. Contraception, 93(5), 386–391.http://doi.org/10.1016/j.contraception.2016.01.003 Julion, W. J. (2018, January 11). Black Mothers are Dying: The toll of racism on maternal health. Retrieved March 14, 2018, from STAT: https://www.statnews.com/2018/01/11/racism-maternal-health-erica-garner/ Kantarjian, H.M. (2017). The Affordable Care Act, or Obamacare, 3 years later: A reality check. Cancer (0008543X), 123(1), 25-28. Doi:10.1002/cncr.30384 Kaiser Family Foundation (2018) Status of State Action on the Medicaid Expansion Decision. Retrieved from https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Khazan, O. (2017, Sep 2). How Graham-Cassidy Retrieved from https://www.theatlantic.com/health/archive/2017/09/graham-cassidy-and-womens-health/540792/ Kronenfeld Jacobs, J., Parmet, W. E., & Zezza, M. A. (2012). Debates on U.S. Health Care. New York, NY: Sage Publications Inc. Lazariu, V., Nguyen, T., McNutt, L., Jeffrey, J., & Kacica, M. (2017). Severe maternal morbidity: A population-based study of an expanded measure and associated factors. Plos ONE, 12(8), 1-13. doi:10.1371/journal.pone.0182343 Legerski, E. M. (2012). The Cost of Instability: The Effects of Family, Work, and Welfare Change on Low-Income Women's Health Insurance Status. Sociological Forum, 27(3), 641-657. doi:10.1111/j.1573-7861.2012.01339.x Martin, N. (2017, December, 7). NPR: Black mothers keeping dying after giving birth. Shalon Irvings story explains. Retrieved from https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues Short title: U.S. Maternal Mortality Trends. Obstetrics and Gynecology, 128(3), 447–455. http://doi.org/10.1097/AOG.0000000000001556 MacDorman, M.F., Declercq, E., & Thoma, M.E. (2017). Trends in maternal mortality by socioeconomic characteristics and cause of death in 27 states and the District of Columbia. Obstetrics & Gynecology, 129(5), 811-818. doi:10.1097/aog.0000000000001968 Mathur, P., Srivastava, S., Mehta, J.L., (2015). High Cost of Healthcare in the United States - A Manifestation of Corporate Greed. Journal of Forensic Medicine, 1(103), 1-4. doi:10.4172/2472-1026.1000103 Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, Race-Based Discrimination, and Health Outcomes Among African Americans. Annual Review Of Psychology, 58(1), 201-225. doi:10.1146/annurev.psych.57.102904.190212 Medicaid expansion & what it means for you. (2017, January). Retrieved from HealthCare.gov: https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/ Metz, S. (2014, November 11). Implementing a Universal Healthcare System Costs Less, Provides Better Care. Retrieved on April 20, 2017 from: http://www.pnhp.org/news/2014/november/implementing-a-universal-healthcare-system-costs-less-provides-better-care Mills,A.J., Durepos,G., and Wiebe,E. (2010, December 17). Encyclopedia of Case Study Research. Retrieved on April 20, 2017 from: https://www.researchgate.net/publication/230557680_15_Mills_A_J_Durepos_G_and_Wiebe_E_Eds_2010_Encyclopedia_of_Case_Study_Research_Volumes_I_and_II_Thousand_Oaks_CA_Sage Molina, R. L., & Pace, L. E. (2017). A Renewed Focus on Maternal Health in the United States. New England Journal of Medicine, 377(18), 1705-1707. doi:10.1056/NEJMp1709473 Napikoski, N. & Lewis, J.J, (2017). Patriarchal Society: Feminist Theories of Patriarchy Retrieved from https://www.thoughtco.com/patriarchal-society-feminism-definition-3528978 National Institute on Drug Abuse. (2017, October 2). The Federal Response to the Opioid Crisis. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/federal-response-to-opioid-crisis National Partnership for Women and Families. (2017). America’s Women and the Wage Gap. Retrieved from http://www.nationalpartnership.org/research-library/workplace-fairness/fair-pay/americas-women-and-the-wage-gap.pd Nour, N.M. (2008). An Introduction to Maternal Mortality. Reviews In Obstetrics & Gynecology, 1(2), 77-81. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505173/pdf/RIOG001002_0077 Novack, Sophie. (2017, June 5). Texas’ Maternal Mortality Rate: Worst in Developed World, Shrugged off by Lawmakers. Retrieved from https://www.texasobserver.org/texas-worst-maternal-mortality-rate-developed-world-lawmakers-priorities/ Ota, S. (2017, September, 28). 3 ways politicians are attacking women’s health this fall. Retrieved from https://www.plannedparenthoodaction.org/blog/3-ways-politicians-are-attacking-womens-health-this-fall Partnership for Maternal, Newborn & Child Health (2007). Conceptual and Institutional Framework. Retrieved from http://www.who.int/pmnch/activities/cif/conceptualandinstframework Ployhart, R.E. & Vandenberg, R.J. (2010). Longitudinal Research: The Theory, Design, and Analysis of Change. Journal of Management, 36(1), 94-120. doi: 10.1177/0149206309352110 Quinn, M. (2017, September 13). States with the Highest and Lowest Uninsured Rates. Retrieved from http://www.governing.com/topics/health-human-services/gov-uninsured-rate-census-2016-states.html Qureshi, S. (2004). "Displaying Sara Baartman, the 'Venus Hottentot'". History of Science. 42 (136): 233–257. doi:10.1177/007327530404200204 Ranji, U., Salganicoff, A., Sobel, L., & Rosenzweig, C. (2017). Ten Ways That the House American Health Care Act Could Affect Women. Retrieved from https://www.kff.org/womens-health-policy/issue-brief/ten-ways-that-the-house-american-health-care-act-could-affect-women/ Rutgers Eagleton Institute of Politics (2018). Women in the U.S. Congress 2018. Retrieved from http://www.cawp.rutgers.edu/women-us-congress-2018 Salganicoff, A. (2015). Women and Medicare: An Unfinished Agenda. Generations, 39(2), 43-50. Shavers, V. L., Fagan, P., Jones, D., Klein, W. M., Boyington, J., Moten, C., & Rorie, E. (2012). The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care. American Journal of Public Health, 102(5), 953-966. doi:10.2105/ajph.2012.300773 Shiffman, J. & Smith, S. (2007) Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet, 370(9595), 1370-1379. Sifferlin, A. (2016) Time; Why U.S. Women Still Die During Childbirth. Retrieved from http://time.com/4508369/why-u-s-women-still-die-during-childbirth/ Sifferlin, A. (2018, January 5). Why are so many Mothers dying in Texas? Retrieved from http://time.com/5088014/maternal-mortality-pregnancy/ Sommers, B. D., Baicker, K., & Epstein, A. M. (2012). Mortality and Access to Care among Adults after State Medicaid Expansions. New England Journal Of Medicine, 367(11), 1025-1034. doi:10.1056/NEJMsa1202099 Sonfield, A. (2010). The Potential of Health Care Reform to Improve Pregnancy-Related Services and Outcomes. Guttmacher Policy Review, 13(3), 13-17. Squires, D.A. (2012). Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality. The Commonwealth Fund, 10, 2-11. Stewart, D. E. (2006). A broader context for maternal mortality. Canadian Medical Association Journal, 174(3), 302–303. http://doi.org/10.1503/cmaj.050775 Sustainable Development Goals Fund (2016). From MDGs to SDGs. Retrieved from http://www.sdgfund.org/mdgs-sdgs Tavernise, S. (2016, Sept 21). Maternal Mortality Rate in U.S. Rises, Defying Global Trend, Study Finds. Retrieved from https://www.nytimes.com/2016/09/22/health/maternal-mortality.html Thomson, S. (2016, May 9). The US has the highest maternal mortality rate in the developed world. Why? Retrieved from https://www.weforum.org/agenda/2016/05/what-s-behind-america-s-shockingly-high-maternal-mortality-rate/ Tucker, M. J., Berg, C. J., Callaghan, W. M., Hsia, J. The Black–White Disparity in Pregnancy-Related Mortality From 5 Conditions: Differences in prevalence and case-fatality rates. American Journal of Public Health 97(2), 247-251. United Nations. (2015). Violence Against Women. Retrieved from https://unstats.un.org/unsd/gender/chapter6/chapter6.html United Nations Children’s Fund. (2016, Nov 7). Maternal and newborn health. Retrieved February 24, 2018, from https://www.unicef.org/health/index_maternalhealth.html Vagins, D. J., McCurdy, J. (2006). Cracks in the System: Twenty years of the unjust federal crack cocaine law. American Civil Liberties Union. Retrieved from https://www.aclu.org/files/pdfs/drugpolicy/cracksinsystem_20061025 Villarosa, L. (2018, April 11). Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis. Retrieved from https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html Wachino, V., Artiga, S., & Rudowitz, R. (2014, May 5). How is the ACA Impacting Medicaid Enrollment? Retrieved from The Hery J Kaiser Family Foundation: https://www.kff.org/medicaid/issue-brief/how-is-the-aca-impacting-medicaid-enrollment/ World Health Organization. (2015). Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Retrieved from http://www.afro.who.int/sites/default/files/2017-05/trends-in-maternal-Mortality-1990-to-2015 World Health Organization (2016). What is the Global Strategy? Retrieved from http://www.who.int/life-course/partners/global-strategy/global-strategy-2016-2030/en/ World Health Organization. (2018). Health Statistics and Information Systems. Retrieved from http://www.who.int/healthinfo/statistics/indmaternalmortality/en/ Yoon, C.K. (1997, May 12). Families Emerge as Silent Victims Of Tuskegee Syphilis Experiment. Retrieved from https://www.nytimes.com/1997/05/12/us/families-emerge-as-silent-victims-of-tuskegee-syphilis-experiment.html APPENDICES APPENDIX A Capstone Proposal Background In 2015, the United Nations (UN) set seventeen Sustainable Development Goals (SDGs) to accomplish by 2030 (Sustainable Development Goals Fund, 2016). SDGs built upon the foundation established by the Millennium Development Goals (MDG), which were presented in 1990 (SDGF, 2016). One MDG the UN planned to focus on was reducing 1990 maternal mortality rate (MMR) of 385 deaths per 100,000 by seventy five percent over a period of fifteen years (SDGF, 2016). The UN reaffirmed their plan to decrease MMR through the mobilization of the Global Strategy for Women's, Children's and Adolescent's Health 2016-2030 (World Health Organization, 2016). The Global Strategy provides a roadmap for how nations can achieve and provide the highest standards of healthcare for women, children and adolescents (WHO, 2016). This plan is geared towards not only assuring that women receive the necessary care to survive childbirth, but to thrive throughout their lives (WHO, 2016). According to Tavernise (2016), between 2005 and 2015, the global maternal death rate fell by one third. However, the United States (U.S.) has managed to defy this global trend. A 2010 study by Amnesty International found that maternal mortality is the highest in the U.S. compared to 49 other countries in the developed world. For example, in Australia, which has wealth similar to that of the U.S., the maternal mortality rate decreased by 25% between 2005 and 2015. During the same time period, the U.S. saw a 16.7% rise in MMR (WHO, 2015). Ironically, Howard (2017) states that the U.S. spends more on healthcare than any other country in the world. Howard (2017) goes on to state that more than two women die every day during childbirth in the U.S. In addition, Bryant, Worjoloh, Caughet, and Washington (2010) argue that disparities in access to care and quality of care have resulted in varying maternal health outcomes for women of different backgrounds. Literature suggests that insurance status and the racial backgrounds of mothers may be precipitating factors in the rising rates of maternal death. The high MMR and high healthcare spending in the U.S. indicate that a paradox exists within the system. Unresolved Problem Based on the history of this paradox, the unresolved problem of this study is that although most states in the U.S. provide prenatal care to all women regardless of insurance or race, the country’s high maternal mortality rate seems to be associated with the health insurance status and racial background of mothers. The U.S. spent $60 billion on maternal care in 2012, yet an estimated 1,200 women experienced fatal complications during childbirth (Agrawal, 2015). Additionally, America spent $3.2 trillion on healthcare in 2015, yet the MMR has nearly doubled in the past two decades (Centers for Medicare & Medicaid Services, 2018, WHO, 2015). The umbrella issue of maternal mortality has brought more attention to the inequalities that women of color face when seeking and receiving care, as well as the overall lack of efficiency of such a costly healthcare system. Purpose Statement A purpose statement is a summary of a specific topic and goals of a paper. It gives the reader an accurate, concrete understanding of what the paper will cover and what he/she can gain from reading it. The purpose of this study is to determine whether the maternal mortality rate in the U.S. is affected by the health insurance status and racial background of mothers. Research Questions Our first research question is what is the relationship between the health insurance status of mothers and maternal mortality in the U.S.? The second question is: what is the relationship between the racial background of mothers and maternal mortality in the U.S.? The purpose of this study is to examine whether lack of health insurance and race contribute to the rise in maternal mortality in the U.S. in the recent years. Hypotheses As previously mentioned, the first research question inquires about the relationship between the health insurance status of mothers and the maternal mortality in the U.S. The null hypothesis indicates that there is no relationship between health insurance status and maternal mortality. Whereas, the alternative hypothesis states that there is a relationship between health insurance status and maternal mortality. Furthermore, the second research question asks about the relationship between racial background of mothers and maternal mortality in the U.S. The null hypothesis says that there is no relationship between the racial background of mothers and maternal mortality. The alternative hypothesis, on the other hand, suggests that there is a relationship between the racial background of mothers and high maternal mortality. Delimitations and Scope This study will be limited to maternal mortality rates at a national level, as well as the health insurance status of each state’s residents and racial background of mothers who died during maternity. Additionally, this study will not focus on women who died due to complications from abortions, the mother’s health or lifestyle choices before pregnancy, genetic or predisposed conditions, education, income, or social class as well as ethnicity. In an effort to conduct a clear and concise study, we will only be focusing on data and research from the year 2016. Key Terms For the sake of the study, the following key terms will be defined according to the World Health Organization and the U.S Census Bureau’s delineation of each: Maternal mortality rate (MMR) : Maternal mortality rate reflects the number of maternal deaths per registered 100,000 live births. There are many factors that contribute to the high maternal mortality rate in the United States but for this study we will explore health insurance status and racial background of mothers. Maternal death/maternal mortality: Maternal death and maternal mortality can be used interchangeably and is defined as the death of a woman while pregnant or within 42 days of delivery. Live birth: A live birth is described as the complete expulsion or extraction of a baby from it’s mother. The baby must show evidence of life after the separation, such as the ability to breathe on its own. Prenatal care (Antenatal care): Prenatal care is the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both the mother and baby during pregnancy. Most states in the U.S provide prenatal care to all women regardless of their health insurance Race: Race is defined as the way a person self-identifies through one or more of the following social groups · White, Black or African American, Asian, American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander For this study, any race outside of White will be considered a person of color. Nature of the Problem The issue of maternal mortality has received increasing attention in the past two decades as the U.S. government has failed to curb high maternal mortality rates, despite global progression. Global maternal mortality rates have decreased by 44 percent between 1990 and 2015 (UNICEF, 2015). In 1990 there were a reported 385 maternal deaths per 100,000 live births. That number decreased to 216 deaths in 2015 (UNICEF, 2015). As mentioned previously, the United States has been able to defy this trend. According to Thomson (2016), the U.S. currently spends 17.1 percent of its Gross Domestic Product (GDP) on healthcare costs, however, the country has been unable to decrease its maternal mortality rate. In 1990 there were about 16.9 maternal death per 100,000 live births in the U.S. In 2015 that number increased to about 26.4 deaths (UNICEF, 2015). The failure of the U.S. government to curtail these high maternal mortality rates has led to an increased focus on how federal funds are being allocated. Policymakers, healthcare providers, and scholars are now focusing their attention on putting an end to preventable maternal mortality. It is important to do so in a timely manner, especially amid the current administration’s attacks on family planning and women’s health policy. An end to the Title X Family Planning program by the Trump administration, “would cut off millions of pregnant women from access to complete and unbiased information about their medical options” (Ota, 2017). If this issue is not resolved soon, matters may only worsen for the fate of American mothers and their children. It is also important to understand the magnitude of the issue at hand. According to Thomson (2016), U.S. women are three times as likely to die during childbirth than women from the United Kingdom, Germany, and Japan (p. 1). Thomson (2016) goes on to state that most of these cases, about 60 percent, are preventable (p.1). This leads us to believe there is a gross inefficiency in healthcare policy and government monetary allocation. This issue is also very pertinent, as we believe it violates social justice. Flanders-Stepans (2000) states that black women are two to six times more likely to die due to complications during pregnancy than their white counterparts (p. 50). In most cases, disparities among different races that exist in access to quality healthcare contribute to these complications. Every human has an unalienable right to life, regardless of race, and should therefore have access to equitable healthcare. Significance of the Study As healthcare costs are projected to continue to rise, it is imperative to aid policymakers in identifying areas of healthcare that need monetary support and attention. At the current rate, researchers predict that national health care spending will reach $5.7 trillion by 2026 (CMS, 2018). The government also estimates that between 2017 and 2026, healthcare expenditures with grow 1.0 percentage point faster than the GDP (CMS, 2018).This study will investigate the driving forces behind high maternal mortality rates in the United States. The qualitative findings in this study coupled with quantitative statistics play a significant role in determining the elements that sustain maternal mortality. Once these areas are identified, policymakers can focus their attention on extending funds to ensure mothers get the care and support they need for a healthy and happy pregnancy. Through careful research this study also strives to create awareness of the disparities that exist in healthcare overall, but more specifically in women’s health. By addressing these issues, policymakers and healthcare providers may be inclined to allocate resources into correcting these disparities and putting an end to preventable maternal mortality in the United States. Our research, which explores the factors that contribute to high maternal mortality rates, can help in designing policy proposals for addressing such injustices. Lastly, this study hopes to fill in any gaps in public administration research regarding how socioeconomic factors contribute to maternal mortality rates globally, as well as in the United States. Conceptual Framework The following diagram illustrates the relationship between the variables in this study and also serves as a road map to understand how each variable will be conceptualized. The dependent variable is maternal mortality. The aim of this study is to determine whether maternal mortality is affected by the independent variables, which are health insurance status and racial background of mothers. Health Insurance status will be conceptualized as uninsured versus insured individuals. Racial background of mothers will be conceptualized by Caucasian versus women of color. Moreover, operational definitions are important to further understand how the dependent and independent variables will be identified or measured in a study (Leedy & Ormrod, 2016, p. 43). For example, in this study, the dependent variable, maternal mortality will be operationalized as the number of maternal deaths per 100,000 live births. The first independent variable, health insurance status will be measured by the number of uninsured individuals as a percentage of the state’s population. Racial background of mothers, which is the second independent variable, will be measured by the number of maternal deaths categorized by race in each state. Methodology To determine the relationship between our independent and dependent variables, we will conduct a cross sectional study with a mixed method design. Through the use of peer reviewed articles we will perform a synthesis matrix to determine the general consensus among the literature on maternal mortality in the United States. We will develop a table to organize our secondary data. The data will be organized by state, percent of uninsured residents, racial background of mothers, and maternal mortality rate. Our unit of analysis will be black and uninsured women in 48 states plus the District of Columbia. We will be analyzing data and research from the year 2016 from sources such as the Centers for Disease Control, the U.S Department of Health, America’s Health Rankings, and the U.S Census Bureau. APPENDIX B Annotated Bibliographies Alexander, G. R. (2001). Assessing the Role and Effectiveness of Prenatal Care: History, Challenges, and Directions for Future Research. Public Health Reports,116(4), 306-316. doi:10.1093/phr/116.4.306 This article reviews the history of prenatal care, defines it in terms of utilization, content, and quality, highlights the challenges in presenting the value of prenatal care, and provide direction for future research. The authors seek to solidify the importance of prenatal care and its relation to maternal mortality rates. Prenatal care must be treated on a case-by-case basis and not support a one size fits all approach. It is assumed that women experiencing high-risk pregnancies and low risk pregnancies should not follow the same prenatal care routine because the needs are different. Little research exists about the content of prenatal care delivery and the educational messages included. Agrawal, P. (2015) Maternal mortality and morbidity in the United States of America. Bulletin of the World Health Organization, 93, 135. doi: http://dx.doi.org/10.2471/BLT.14.14862 In this article, Agrawal explains how the United States has managed to defy the global maternal mortality trend. Between 1990 and 2013, maternal mortality rates in the U.S. more than doubled from 12 to 28 maternal deaths per 100,000. Even though the U.S. spent $60 billion on maternal care in 2012, an estimated 1,200 women experienced fatal complications during childbirth. This article proves that there is a paradox in healthcare that must be addressed. Amnesty International. (2011). Deadly Delivery: The maternal health care crisis in the USA. Retrieved from https://www.amnestyusa.org/wpcontent/uploads/2017/04/deadlydelivery- Oneyear This report is a one year update of report released in March 2010 by Amnesty International, which clearly demonstrated the many barriers women face in accessing high quality maternal care. The update examines developments and new data on maternal health in the United States. It addresses expected impacts of the Affordable Care Act on maternal health and health care and it covers some of the progress made over the year from 2010 to 2011. The report suggests that with concerted effort, progress can be made in improving maternal health and reducing maternal mortality in the United States. This is a helpful source to gather a clear understanding of the developing issue of maternal mortality in the U.S. and the inequities involved in accessing quality maternal care. The recommendations and campaign goals identified in this report can help to determine steps for change. Association of State and Territorial Health Officials. (2012). Disparities and Inequities in Maternal and Infant Health Outcomes. Retrieved from http://www.astho.org/Programs/Health-Equity/Maternal-and- Infant-Disparities-Issue-Brief/ The authors of this article delve into several determinants of health that have contributed to the high number of preventable maternal deaths in the United States. Determinants include socioeconomic status, educational attainment, geographical location, and racial differences. Interestingly enough, even after controlling for socioeconomic status, African American women still experience more deaths per 1,000 live births. The intervention of unhealthy pregnancy behaviors and detection of conditions like diabetes were listed as ways to decrease maternal mortality. improvement in maternal health. Attanasio, L., McPherson, M., & Kozhimannil, K. (2014). Positive Childbirth Experiences in US Hospitals: A Mixed Methods Analysis. Maternal & Child Health Journal, 18(5), 1280- 1290. doi:10.1007/s10995-013-1363-1 The authors use a mixed methods analysis to understand the relationship between childbirth experiences and the roles of clinicians. Qualitatively, open-ended survey responses revealed that women who had a positive birthing experience felt that they had great communication with their clinicians. Quantitatively, a logistic regression analysis revealed several findings about first time and experienced mothers including that first-time black mothers had higher confidence than white women. Higher confidence was associated with a positive childbirth experience. Ben, J., Cormack, D., Ricci, H., & Paradies, Y., (2018, Dec 18) Racism and health service utilization: A systematic review and meta-analysis. PLoS ONE, 12(12), Retrieved from https://doi.org/10.1371/journal.pone.0189900 In this article, Ben et al. explored whether race had an impact on the utilization of healthcare within the United states. Using a meta-analysis of quantitative, empirical studies, the authors were able to determine that there was no direct association between race and health service usage. What they did find was that race was greater associated with healthcare outcomes. Racism greatly dictated the trust minorities had in the healthcare system and professionals. Those who experienced racism while receiving care were more likely to delay seeking treatment and reported lower satisfaction and poor perception of quality of care. This research would be incredibly important in determining whether implicit bias has been a root cause of high maternal mortality rates amongst women of color. Bentley, T. G. K., Effros, R. M., Palar, K., & Keeler, E. B. (2008). Waste in the U.S. Health Care System: A Conceptual Framework. The Milbank Quarterly, 86(4), 629–659. The authors of this article propose a guide to policymakers that would help reduce unnecessary health care spending. The United States spends the most on health care than many other developed nations yet produces similar or worse outcomes than countries who spend less. Health insurance has a big impact on waste but the authors believe improving the market for health insurance will generate efficiency and ultimately decrease waste. Blair, I.V., Steiner, J.F., & Havrane, E.P. (2011) Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here? The Permanente Journal, 15(2), 71-78. This study provides a research roadmap to aid in understanding the impact that implicit, or unconscious, bias has on medicine. The authors examined the mechanisms in which implicit bias operates, where it is present in healthcare systems and provided suggestions on how to address the issue. This roadmap is essential in addressing disparities that exist in healthcare, specifically women’s health. Board, T. E. (2016, September 03). America's shocking maternal deaths. Retrieved from https://www.nytimes.com/2016/09/04/opinion/sunday/americas-shocking-maternal-deaths.html2 . This article explains how inequality in America’s healthcare system affects millions of families who still cannot afford healthcare. Based on their beliefs about contraception and abortions, lawmakers and Republicans have prevented reproductive health programs from opening up in communities where they are most needed. Texas, one state that refuses to expand Medicaid under the Affordable Care Act is also known to have the highest maternal mortality rate. Maternal death is much higher for black women in comparison to whites and Hispanics. Two known health risk during and after pregnancy are cardiac problems and overdose of medication such has prescription opioids and illegal drugs. Brinlee, M. (2017, May, 14). America’s maternal death rate is rising and it’s completely preventable. Retrieved from https://www.bustle.com/p/americas-maternal-death-rate-is-rising-its-completely-preventable-57715 In this article Brinlee speaks about the decrease in global maternal mortality rates since 2000. She goes on to state that unfortunately, the U.S. has reported a different trend; a rising maternal mortality rate. According to Brinlee, the U.S. maternal mortality ratio has more than doubled since 1990. Research also indicates that maternal mortality disproportionately affects African Americans, low-income women, and those who live in rural areas. Factors leading to high maternal mortality rates in the U.S. include inconsistent access to reproductive health services and unaddressed chronic health problems in new mothers. This source can be helpful in developing our background and history, as well as nature of the problem sections. The statistics in this articles are viable and can contribute to a better understanding of the issue at hand. Bryant, A.S., Worjoloh, A., Caughet, A.B., & Washington, A.E. (2010). Racial/Ethnic Disparities in Obstetrical Outcomes and Care: Prevalence and Determinants. American Journal of Obstetrics and Gynecology, 202(4), 335–343. This article presents a review of the most common roots of disparities in obstetrical care and outcomes. Identifying the roots responsible for health disparities is one of the first steps to eliminating inequities and providing quality healthcare for all women. The authors examine outcomes from five domains, which include behavioral patterns, genetic predispositions, social circumstances, environmental exposures, and shortfalls in medical care. Burns, C.T., (2017, November 18). Maternal mortality is the shame of U.S. healthcare. Retrieved on February 25, 2018 from https://www.cnn.com/2017/11/15/opinions/op-ed-christy-turlington-burns-every-mother-counts-2017/index.html This article touches on the magnitude of the risk of maternal death and a mother’s mission to end preventable maternal deaths. Thea author states that women who are healthy before they become pregnant are more likely to survive childbirth and women with consistent access to healthcare are more likely to identify complications early on, which can impact their birth outcomes. She also states that the U.S. is the only industrialized country with a rising maternal mortality ratio even though we spend more on healthcare per capita than any other developed country. The author of this article also addresses the disparities that exist among maternal outcomes, like other articles. This source can be combined with others found in our research to help develop our background and literature review sections. Callaghan, W.M. (2012). Overview of Maternal Mortality in the United States Seminars in Perinatology, 36(1), 2-6. Retrieved from http://www.seminperinat.com/article/S0146-0005(11)00148-0/fulltext The data found in this article was pulled from the Pregnancy Mortality Surveillance System which was developed to reveal more information concerning maternal deaths in the United States through the use of death certificates sent in by the states. The authors note both an increase in the number of maternal deaths in the 21st century and a disparity in black and white maternal mortalities. The article considers the varying factors attributed to maternal mortality such as age, race, and chronic conditions. When age is considered as a factor, the mortality rate for black women exceeds 160 per 100,000 live births. Women over the age of 35 but younger than 40 are reported to be two times more likely to have a pregnancy related death compared to women between 25-29. The stakes are even higher when a woman is over the age of 40 because they are five times as likely to die from pregnancy related complications. Carroll, A.E. (2017). Why Is U.S Maternal Mortality Rising? JAMA, 318(4). doi:10.1001/jama.2017.8390 According to Carroll (2017), in 2005, 23 U.S mothers per 100,000 live births died from pregnancy related complications and in 2015 that number rose to 25. This number doubles the number in the UK, which is less than 9, and Canada, which is less than 7. It is reported that about 50% of pregnancies in the U.S are unplanned which means the mothers may lack preventative care. The author states that the growing prevalence of chronic conditions is very likely to contribute to maternal mortality. If mothers are not practicing preventative health than their chronic conditions aren’t being managed well and complications are more likely to arise during childbirth. Centers for Disease Control and Prevention. (2015). Patterns of health insurance coverage around the time of pregnancy among women with live-born infants: Pregnancy risk assessment monitoring system, 29 states, 2009. Retrieved from https://www.cdc.gov/mmwr/pdf/ss/ss6404 This report presents summarizes data from 29 states that conducted the Pregnancy Risk Assessment Monitoring System (PRAMS) in 2009, on the prevalence of health insurance coverage stability the month before pregnancy, during pregnancy, and at the time of delivery. The results of the study show that nearly one third of women who delivered a live infant in 2009 experienced a change in their health insurance coverage around the time of pregnancy. Levels of any health insurance increased by close to 25 percent in the month before pregnancy. The most common pattern examined was from being uninsured in the month before pregnancy to having Medicaid coverage at the time of delivery. This is a helpful source to gather an understanding of the most common trends in the health care coverage of mothers in the United States. The information provided can be combined with other research to determine if the health insurance status of mothers has an effect on maternal mortality in the country. Centers for Disease Control and Prevention. (2017, November 09). Pregnancy Mortality Surveillance System. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html The CDC defines pregnancy-related death as the death of a pregnant women up to one year after her pregnancy. The data used to determine this information is gathered by linking copies of death certificates of woman and fetal deaths from all 50 states. CDC scientist then release data found from CDC’s Morbidity, Mortality Weekly reports, CDC websites and peer-reviewed literature. A graph illustrates the trend in pregnancy-related deaths which increases from 7.2 deaths per 100,000 live births in 1987 to 17.8 in 2009 and 2011. During the years of 2011-2013 12.7 deaths were of white women, 43.5 deaths were of black women, and 14.4 were other races. The Center For Reproductive Rights. (2016). Research Overview Of Maternal Mortality And Morbidity In The United States. Retrieved from https://www.reproductiverights.org/sites/crr.civicactions.net/files/documents/USP The Center For Reproductive Rights state in this article that maternal mortality is highest among black women and most instances of maternal death in the United States are preventable. The authors shed light on poverty and discrimination as a major obstacles to access and quality to care. They conclude by recommending more advanced data collection from the CDC and stronger systems for analyzing maternal health information. Chen, J., Vargas-Bustamante, A., Mortenson, K, & Ortega, A.N. (2016, February) Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act. Medical Care, 54(2), 140-146. The Affordable Care Act (ACA) was implemented in an effort to close gaps and disparities in health insurance access. The ACA expanded insurance coverage, reducing the percentage of uninsured from 18% to 12%. This article examines the effect that the ACA had on minority groups and their access to care. The authors found that insurance coverage was a major factor that contributed to the disparities in healthcare and the ACA aided in addressing these disparities. This article may be useful in tailoring a policy to address inequalities in women’s health that lead to high maternal mortality rates amongst women of color, particularly black women. Chuck, E. (2017, August 12). Texas Has the Highest Maternal Mortality Rate in the Developed World. Why? Retrieved February 14, 2018, from https://www.nbcnews.com/news/us- news/texas-has-highest-maternal-mortality-rate-developed-world-why-n791671 The author cited a study by Obstetrics and Gynecology and uses as a platform to discuss Texas’ high maternal mortality rate, at 35.8 per 100,000 live births. The article then discusses reasons for maternity death, two of which include a delay in receiving prenatal care until late pregnancy and a lack of proper postnatal care of mothers. Though women of all races contribute to Texas’ high maternal mortality; black women contribute the most with 11% of live births but 29% of maternal deaths. The information provided in this article helps to add to the background knowledge of maternal mortality in a state in the U.S. Coeytaux, F., Bingham, D., & Strauss, N. (2011). Maternal Mortality in the United States: A Human Rights Failure. Association of Reproductive Health Professionals Journal of Contraception. The authors of this article seek to dismiss the false assumption that maternal mortality is not a problem in the United States. Although the global trend for maternal mortality has decreased, the United States rate has doubled in numbers. The authors of this article highlight this poor return on the $86 million investment Americans make towards childbirth related care. The article also takes “near misses” into account which have increased by 27% and are defined as women who had maternal complications so severe that they almost died. They group the explanations for the increase of maternal mortality into two categories, the overall health of each woman and the quality of care the woman receives. Comfort, A. B., Peterson, L. A., & Hatt, L. E. (2013, December). Effect of Health Insurance on the Use and Provision of Maternal Health Services and Maternal and Neonatal Health Outcomes: A Systematic Review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021700/ This article discuss how financial difficulties can affect timely access to maternal health services. Health insurance can control the use and quality of these services to improve maternal health outcomes. A study was conducted on health insurance and its effects on maternal health services in middle- and low-income countries. Consistent with economic theories, the studies identified a positive relationship between health insurance and the use of maternal health services. Committee on Health Care for Underserved Women. (2015, December) Racial and Ethnic Disparities in Obstetrics and Gynecology. American College of Obstetricians and Gynecologist, (649). The Committee on Health Care for Underserved Women examined factors at a patient, practitioner and healthcare system level which contribute to disparities within obstetrics and gynecology. They found that patients of color tend to have less access to care and education, making it more difficult for them to adhere to treatment plans or seek prenatal care. Stereotyping and implicit bias of practitioners further contributed to these inequalities. At a healthcare system level, the inability of all citizens to afford healthcare widened the gap in access to proper women’s health. Since health care is driven by market forces, the poor are most likely to suffer as they cannot afford the insurance. The authors pinpoint three factors in an effort to encourage providers and policy makers to eliminate the inequalities in health, which may lead to a decline in the maternal mortality rate. Creanga, A.A., Berg, C.J., Ko, J.Y., Farr, S.L., Tong, V.T., Bruce, C., & Callaghan, W.M. (2014). Maternal mortality and morbidity in the United States: Where are we now? Journal of Women’s Health, 23(1), 3-9. doi:10.1089/jwh.2013.4617 This article defines maternal mortality as a pregnancy-related death per 1000,000 live births. The number of maternal mortality is presented in several bar graphs from 1987 to 2009 in the United States. This is helpful because the data shows the rise of maternal mortality and is also, divided by reasons for the number of maternal deaths as well as the race of the mothers. Dahlem, C.H., Vilarruel, A.M., & Ronis, D.L. (2014, May). African American Woman and Prenatal care: Perceptions of Patient-Provider Interaction. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4233201/ This article explains how poor patient-provider interaction among minorities can be associated with disparities in healthcare. A cross-sectional study was performed to examine African American women’s experience of patient-provider interaction. The analysis showed that patient-provider communication had a positive effect and improved the prenatal care experience for African American women. D'Angelo, K. A., Bryan, J. K., & Kurz, B. (2016). Women's Experiences with Prenatal Care: A Mixed- Methods Study Exploring the Influence of the Social Determinants of Health. Journal of Health Disparities Research & Practice, 9(3), 127-149. This study examines disparities in prenatal care among Connecticut’s Black/African American and Hispanic/Latino residents. Self-administrated surveys were provided to participants and data was then organized and analyzed to see how women’s experiences with prenatal care compared. The results of this study revealed that the importance of prenatal care is known among participants. However, among Black/African American and Hispanic/Latino communities, women experienced discrimination and that they did not have any input when it came to their care. This finding is important because it may help to eliminate racial and ethnic disparities that influences birth and maternity outcomes. Dieleman, J.L., Baral, R., Birger M., Bui, A.L., Bulchis, A., Chapin A, Hamavid, H., Horst, C., Johnson E.K., Joseph, J., Lavado, R., Lomsadze, L., Reynolds, A., Squires, E., Campbell, M., DeCenso, B., Dicker, D., Flaxman, A.D., Gabert, R., Highfill, T., Naghavi, M., Nightingale, N., Templin, T., Tobias, M.I., Vos, T., & Murray, C.J.L. (2016). US Spending on Personal Health Care and Public Health, 1996-2013. JAMA, 316(24), 2627–2646. doi:10.1001/jama.2016.16885 This article presents an investigation into the areas and people that benefit from government spending. The authors analyzed the United States’ federal budgets, health insurance claims, facility surveys, household surveys and official records from the year 1996 to 2013 and found that most money are spent on treating illnesses among older individuals, like heart disease, diabetes, and palliative care. Regarding gender, about one quarter of the funding for women, are spent on issues such as pregnancy, postpartum care, family planning and maternal conditions. The Economist (2017, Aug 5) Is pregnancy in America much deadlier than in other rich countries? Retrieved February 24, 2018, from https://www.economist.com/news/united-states/21725832-question-harder-answer-you-might-think-pregnancy-america-much-deadlier This article seeks to standardize the definition of maternal death and understand how the data is tracked. It is believed that the coding used to identify cause of death is more responsible for the steep rise in MMR, than actual deaths during childbirth. If a mother dies during pregnancy, even from unrelated complications, it is classified as a maternal death. This article may provide insight on why rates are so high in a country that spends so much money on healthcare. Over reporting or incorrect coding may be a reason the US has such a high MMR. Egerter, S., Braveman, P., & Marchi, K. (2002, March). Timing of Insurance Coverage and Use of Prenatal Care Among Low-Income Women. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447093/ The authors of this article examined the relationship between the timing of Insurance coverage and prenatal care. A cross-sectional statewide survey was performed including 5455 low-income participates. The results state that one-fifth of woman lacked coverage in the first trimester. Rates show that less than 64 % of women were uninsured throughout their pregnancy. Woman who did obtain coverage during their pregnancy were at low risk of having too few visits. Ensor, T., & Ronoh, J. (2005, December). Effective financing of maternal health services: a review of the literature. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16298228 This article explains the different ways health care can be funded ranging from direct user charges payments to indirect methods. Most healthcare systems have both equity and efficiency aspects that combine to impact on health and status. Available literature suggests that financing mechanisms for maternal health services could be improved by systems that increase transparency, help to alleviate demand-side costs of services and provide funding for that promote charging for services. Espstein, A.M., & Newhouse, J.P. (1998). Impact of Medicaid Expansion on Early Prenatal Care and Health Outcomes. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194521/ This article highlights the impact of Medicaid expansion for pregnant women in South Carolina and California. The article compares the rate of change in the quality of care for women who are uninsured or covered by Medicaid verse woman with private coverage. As expected there is a significate difference in the care. It is suggested that provision of coverage may be the first logical step in improving health care for the uninsured. Flanders-Stepans, M. B. (2000). Alarming Racial Differences in Maternal Mortality. The Journal of Perinatal Education, 9(2), 50–51 This purpose of this study is to determine if both black and white infants benefitted equally from the 15 percent decrease in the infant maternal mortality rate in the past decade, reported by the U.S. Center for Disease Control and Prevention in 2017. Trends in the absolute difference in overall and cause-specific infant mortality rates between non-Hispanic black and white infants were examined. The report found that in 2015, the infant mortality rate for black infants vs. white infants was 11.7 vs. 4.8 deaths per 1000 births. This source can be useful in our literature review to expand on the concept of racial disparities in healthcare and its impact on the maternal mortality rate in the U.S. Forde-Mazrui, K. (2016). The Canary-Blind Constitution: Must Government Ignore Racial Inequality? Law & Contemporary Problems, 79(3), 53-88. The author of this article discusses the disparities in infant mortality in the United States. A large portion of his research explores the reasons behind high infant mortality among black/African Americans. As examined in this paper, black/African women have a disproportionately lack of access to prenatal care, contributes to high infant mortality among black/African American babies. The information regarding lack of access to prenatal care is also essential to understand maternal mortality among black/African American women. Gadson, A., Akpovi, E., & Mehta, P.K. (2017) Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Seminars in Perinatology, 41, 308-317, Retrieved from http://dx.doi.org/10.1053/j.semperi.2017.04.008 In this study, Gadson et al present a theoretical framework connecting race, prenatal care utilization and maternal mortality. Through a review of qualitative and quantitative literature, they found that there was more of a focus on how prenatal care utilization affected infant birth weight and infant mortality than how it affected maternal mortality. The research presented in this article will be essential in reevaluating the effectiveness of prenatal care in the U.S. and will also address the disparities causing non-Hispanic black women to die at higher rates during childbirth than their white counterparts. Gaskin, I. M. (2008). Maternal death in the United States: A problem solved or a problem ignored? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409165/ This article clarifies that even though the United States spends more money per capita for maternity care, the U.S still has the highest ratio of maternal death in comparison to several other developed countries. The United Kingdom’s Confidential Enquiry into Maternal and Child Health has been recognized for their high achieving standards in the prevention of maternal mortality. Gomez, G. B., Foster, N., Brals, D., Nelissen, H. E., Bolarinwa, O. A., Hendriks, M. E., et al. (2015). Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost- Effectiveness Study in Rural Nigeria. PLOS ONE, 10(9), 1-17. doi:10.1371/journal.pone.0139048 This study examines the cost-effectiveness of maternal care provide within the new Kwara State Health Insurance Program (KSHI) in rural Nigeria. It provides an incremental cost effectiveness ratio of the KSHI scenario compared to the current standard of care. The researchers generated this outcome through probabilistic sensitivity analysis and conducted one-way sensitivity analyses to ensure the data’s credibility. They also assessed the sustainability and feasibility of KSHI’s scale up within the State’s healthcare financing structure through a budget impact analysis. The results of this study show that the investment made by the KSHI program is likely to have been cost-effective, however further investments are still necessary for this program to be successfully expanded within Kwara state. This is a helpful source as it acts as a model for a universal healthcare program for maternal health in the United States; one that may aid in decreasing the country’s high maternal mortality rate. Gonzalez, C.M., Kim, M.Y, & Marantz, P.R. (2014) Implicit Bias and Its Relation to Health Disparities: A Teaching Program and Survey of Medical Students, Teaching and Learning in Medicine, 26(1), 64-71, doi: 10.1080/10401334.2013.857341 In this article, Gonzalez, Kim, and Marantz sought to present an educational intervention that could address implicit bias amongst physicians, which would in turn decrease health disparities. The authors asserted that targeting medical students would ensure equity in treatment for patients despite racial background. Through a survey of students, the researchers collected data on whether a group of medical students accepted or denied the role implicit biases plays in patient treatment. The results concluded that it would take more than one session to teach medical students how unconscious bias impacts medicine. The authors state that schools should integrate coursework that would encourage students to recognize and correct their biases. By doing this, there will be a decrease in disparities, an improvement in patient encounters and an increase in the quality of care and healthcare outcomes for all. Hartman, M., Martin, A. B., Espinosa, N., Catlin, A. (2017). National health care spending in 2016: Spending and enrollment growth slow after initial coverage expansions. Health Affairs, 37(1), 150-160. doi.org/10.1377/hlthaff.2017.1299 This article offers an overview of United States health care expenditures in 2016 addressing the changes experienced over the past ten years. Factors accounting for the growth in health care costs are discussed as well as the specific categories where funds have been allocated. This is a helpful source to gather an understanding of the current healthcare climate in the United States and the changes that have occurred over the past current years. Hasstedt, K., Sonfield, A., & Benson Gold, R. (2017, April). Public funding for family planning and abortion services, FY 1980-2015. Retrieved from https://www.guttmacher.org/sites/default/files/report_pdf/public-funding-family-planning-abortion-services-fy-1980-2015 This report presents the results of a survey of public expenditures for family planning and abortion services in the United States for the fiscal year 2015. Expenditures are examined nationally, by state and by funding source. This data is also compared with data from prior surveys between FY 1980 and FY 2010. The major national trends in public funding for family planning client services and abortion services over the past 35 years are then discussed in their findings. This is a helpful source for examining trends in public funding for maternal health over a long period of time. It can be useful when trying to identify gaps in healthcare services and coverage for mothers. Healy, A.J., Malone, F.D., Sullivan, L.M., Porter, T.F., Luthy, D.A., Comstock, C.H., Saade, G., Berkowitz, R., Klugman, S., Dugodd, L., Craigo, S.D., Timor-Tritsch, I., Carr, S.R., Wolfe, H.M., Bianchi, D.W., D’Alton, M.E. (2006). Early Access to Prenatal Care: Implications for Racial Disparity in Perinatal Mortality. Obstetric Anesthesia Digest, 26(3), 120. doi:10.1097/00132582-200609000-00018 The objective of this study was to investigate the racial disparities of perinatal mortality in women with early access to prenatal care and results displayed that minority races experienced higher rates of membrane rupture, preterm birth, c sections, and heavy vaginal bleeding than white women. These results led the authors to conclude that racial disparities in perinatal mortality persist in obstetric practice despite early access to prenatal care. The authors believe that independent factors outside of early access to prenatal care must be identified and interventions must be developed in order to eliminate these obvious racial disparities. Heaman, M. I., Sword, W., Elliott, L., Moffatt, M., Helewa, M. E., Morris, H., and Cook, C. (2015). Barriers and facilitators related to use of prenatal care by inner-city women: perceptions of health care providers. BMC Pregnancy and Childbirth, 15, 2. According to the authors of this article, socioeconomic disparities in the use of prenatal care exist even where care is universally available and publicly funded. Ongoing prenatal care is important to a healthy pregnancy and delivery because it allows women the opportunity to identify risks associated with her pregnancy. A study in Canada listed factors contributing to the lack of prenatal care utilization as the following: lack of awareness about prenatal care services along with a lack of time, transportation, and education about the importance of prenatal care. Heuser, C., & Karkowsky, C. E. (2017, May 23). Why is U.S. maternal mortality so high?: Poverty and lack of access to health care. Retrieved from http://www.slate.com/articles/health_and_science/medical_examiner/2017/05/medical_error_isn_t_to_blame_for_our_high_maternal_mortality_rate.html This article explains how poverty is one of the many leading causes of maternal mortality in the United States. Woman who are poor, and lives in low-income neighbors and have least access to healthcare are most vulnerable to maternal death. With the potential loss of Obamacare and new budget cuts, will result in limited funding for women’s healthcare. African American women are more likely to die in childbirth than white woman. Planned pregnancies are safer for women because it allows them to address any underlying health problems before conception. Hodgson, Z. G., Saxell, L., & Christians, J. K. (2017). An evaluation of Interprofessional group antenatal care: a prospective comparative study. BMC Pregnancy & Childbirth, 171-9. doi:10.1186/s12884-017-1485-3 This study discusses the maternal outcomes of the prenatal system in Canada. The researchers use the pre-natal system in the United States to set a background for comparison between the two countries. Data was analyzed through Chi-square test, general linear models and logistic regression. Their results showed that there are two ways that Canada approve prenatal care to mothers, in an individual and group environment, with group care being preferred and having better health outcomes for mothers and infants. This study is important because it opens the conversation about what the United States can do to reform their prenatal care system, to emulate better maternal outcomes. Hoffman, C. & Paradise, J. (2008) Health Insurance and Access to Health Care in the United States. Annals of the New York Academy of Sciences, 1136(1) 149-160, doi: 10.1196/annals.1425.007 Hoffman and Paradise performed a qualitative review of literature to examine the effects income has on access to quality healthcare in the United States. The authors emphasized that minorities are particularly affected, as they are most likely to earn lower wages. The authors found that lower income populations were less likely to have access to health insurance, creating a barrier to primary and preventative care. The inability to afford wellness visits thus led to higher instances of acute and traumatic conditions as well as high rates of individuals with preventable, chronic diseases. This article will further support the point that disparities in health insurance access and quality healthcare are a contributing factor to high maternal mortality rates. Hoffman, M. (2017, June 05). Texas has highest pregnancy-related death rate in developed world, study says. Retrieved from http://www.chicagotribune.com/lifestyles/health/ct-texas-pregnancy-death-rate-20170605-story.html This article explains how in the state of Texas the maternal mortality rate has doubled between 2010 and 2012. Not only is this rate the highest in the U.S. but also in the developed world. Black women make up 11 percent of births, but 28 percent of deaths. Failed proposals could have helped this problem by extended Medicaid coverage to low-income adults and mothers. However, too many have failed as a results of the rising rate. Holland, K. (2017, Jun 6) Why is the United States’ Maternal Death Rate so High? Retrieved February 24, 2018, from https://www.healthline.com/health-news/why-is-maternal-death-rate-so-high-in-us Holland begins her article with the story of an American woman who experienced horrific complications after a routine cesarean section. She goes on to state that 700-900 women die each year due to childbirth related issues. She goes on to state that there is a need for policy change to improve maternal health outcomes in the U.S. Hollowell, J., Oakley, L., Kurinczuk, J. J., Brocklehurst, P., & Gray, R. (2011). The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review. BMC Pregnancy and Childbirth, 11(13). http://doi.org/10.1186/1471-2393-11-13 This report aims to strengthen the evidence base on interventions to reduce infant mortality, particularly focusing on reducing inequalities in infant mortality or its three major causes (preterm birth, congenital anomalies, sudden infant death syndrome (SIDS)). Data was gathered through bibliographic databases, specialist databases and online resources. Many of these studies were related to interventions evaluated in socioeconomically disadvantaged populations and predominately disadvantaged groups at risk of adverse pregnancy outcomes. This source is helpful in determining the effectiveness of antenatal care programs in reducing infant mortality in countries such as the U.S. and Canada as well as the disparities that exist among women of different socioeconomic backgrounds, regarding access to such care. Howard, J. (2017, November 15). Childbirth is killing black women, and here's why. Retrieved from http://www.cnn.com/2017/11/15/health/black-women-maternal-mortality/index.html The author presents data from Center for Disease Control and Prevention on the increase of pregnancy-related death nationwide. Women die from pregnancy or childbirth-related complication every day around the world. Black women are more likely to die of pregnancy or delivery complication than white women. The rate of obesity and high blood pressure are risk factors for pregnancy complication and tend to be higher among Black women. Socioeconomic status, housing, education, insurance coverage, and access to health care with their community have a significant impact in how health care is delivered to black versus white women. Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., & Rising, S. S. (2007). Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial. Obstetrics and Gynecology, 110, 330–339. http://doi.org/10.1097/01.AOG.0000275284.24298.23 Research from this article states that African American women are two times more likely to experience preterm birth as opposed to their counterparts. Pre term births are accompanied by many consequences that may potentially have a lifelong effect on the quality of life for infants. Prenatal care is an essential part of ensuring healthy outcomes for infants and mothers but research shows that group prenatal care may lead to even better health outcomes. Group prenatal care provides an integrated approach by including family members and peer support in prenatal education. Studies have shown that group prenatal care lowered the risk of preterm births thus increasing reproductive health outcomes for all women. Institute of Medicine (US) Committee on the Consequences of Un-insurance. (2002). Health Insurance is a Family Matter. Health-Related Outcomes for Children, ‘ Pregnant Women, and Newborns. Washington, DC. This article points out the obstacles that uninsured women face in obtaining prenatal care services. The authors believe that health insurance status affects the care that women receive thus determining their health outcomes during or after delivery. Studies show that uninsured women have higher rates of pregnancy related complications such as placental abruption than privately insured women. The authors suggest expanding health insurance coverage to improve maternal outcomes but also state that other initiatives should be paired with insurance expansion to really make a difference. Jarlenkshi, M., Hutcheon, J.A., Bodnar, L.M., & Simhan, H.N. (2017). State Medicaid coverage of medically necessary abortions and severe maternal morbidity and maternal mortality. Obstetrics & Gynecology, 129(5), 786-794. doi: 10.1097/aog.0000000000001982 This article discusses state Medicaid programs’ coverage of medically necessary abortions and its impact on severe maternal morbidity as well as maternal mortality. The authors’ used data from the Nationwide Inpatient Sample for the number of pregnancy-related hospitalizations from 2000 to 2011. Their results suggest that state Medicaid coverage of medically necessary abortion does not harm the mother’s health. The authors’ results and discussion are important to understanding how insurance, whether it is Medicaid or private, is essential to maternal health. Johnson, K. (2012, August). Addressing Women’s Health and Improving Birth Outcomes: Results from a Peer-to Peer State Medicaid Learning Project. Retrieved from http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2012/aug/1620_johnson_addressing_womens_htl_needs_improving_birth_ib High rates of maternal mortality and other disparities in pregnancy outcomes have attracted the attention of many state Medicaid agencies. In this project, seven Medicaid agencies worked to develop policies that would identify and reduce women’s health risks. Medicaid agencies have a special interest in this issue because they bear the financial burden of at least half the births and care for neonatal and premature children in their states (Thompson, 2012). According to the authors, the results from this study led to a policy checklist that would serve as a guide for other states to identify improvement opportunities for women’s health care. The authors suggested that Medicaid agencies either expand eligibility for low-income women or enhance the quality of services for women on Medicaid. Joseph, K.S., Lisonkova, S., Muraca, G.M., Razaz, N., Sabr, Y., Mehrabadi, A., & Schisterman, E.F. (Jan 2017). Factors Underlying the Temporal Increase in Maternal Mortality in the United States. Obstetrics & Gynecology, 129 (4), 91-100. doi: 10.1097/AOG.0000000000001810 The authors conducted a retrospective study to determine the factors that contributed to the increase in maternal mortality rates in the United States between 1993 and 2014. Using mortality data during this time period, the authors quantified maternal deaths using two approaches. The results indicated that the increase in maternal deaths in the U.S. is due to improved surveillance of maternal deaths. The authors also stated that the broad definitions of maternal mortality contribute to the high statistics in the U.S. This study will be helpful in examining whether the standardizing of the definition of maternal mortality would cause a lowering in rates. It will also help in exploring whether over reporting is skewing maternal mortality rates in the U.S. Kassebaum, N.J., Steiner, C., Murray, C., Lopez, A.D., & Lozano, R. (2016) Global, Regional and National Levels of Maternal Mortality, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet, 388(10053), 1775-1812. doi:10.1016/S0140-6736(16)31470-2. The purpose of this study was to quantify maternal mortality throughout the world between 1990 to 2015 and its underlying causes. The authors sought this information to identify the causes, challenges governments were facing in reducing the maternal dates, and how policy should be framed to address the issue. Based on their research findings, they concluded that governments had to work to improve the quality of health for women worldwide. This article will aid in developing our discussion of how the United States should respond to the paradox of high health care costs and high maternal mortality rates. Kenney, M. K., Kogan, M. D., Toomer, S., & Van, P. C. (2012, February). Federal expenditures on maternal and child health in the United States. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21318294 The article reviews how the goal of this study is to estimate federal maternal and child health expenditures and identify their sources. The data on federal maternal and child health expenditures exams federal legislation, department/agency budgets, and various web-based program documents posted by federal agencies. This is based on selected criteria, programs targeting children under 21 or pregnant/parenting women within the United States. The funding sources for maternal and child health were collected within the U.S. Department of Health and Human Services. Kottke, T. E., & Isham, G. J. (2010). Measuring Health Care Access and Quality to Improve Health in Populations. Preventing Chronic Disease, 7(4), A73. The authors of this article discuss the disconnect between the investments in the United States healthcare system and the health outcomes of the American population. They argue that participation from accountable care organizations and coordination of care would help to control health care cost, improve health of Americans and reduce disparities in care. This article is important because it displays the paradox of the United States’ healthcare system, which is the input into the healthcare system is not being reflected in the output, in terms of improving the health of its people. Lazariu, V., Nguyen, T., McNutt, L., Jeffrey, J., & Kacica, M. (2017). Severe maternal morbidity: A population-based study of an expanded measure and associated factors. Plos ONE, 12(8), 1-13. doi:10.1371/journal.pone.0182343 The overall discussion of this article is that serious medical conditions can extend hospital stays for mothers in New York and affects their health in the long term. Also, the longer stays and severe conditions results in a substantial increase in medical expenses. Race and ethnicity and levels of hospitals were independent variables in this study, whereas maternal mortality was the dependent variable. The article explains that New York’s effective prenatal protocols, and care as well as its facilities, helps to reduce risk of maternal death. Legerski, E. M. (2012). The Cost of Instability: The Effects of Family, Work, and Welfare Change on Low-Income Women's Health Insurance Status. Sociological Forum, 27(3), 641-657. doi:10.1111/j.1573-7861.2012.01339.x A study on the effects of family, work and welfare change on low-income women’s health insurance status. This article emphasizes that due to the increasing cost of healthcare insurance, more women are unable to afford coverage. Many women in the U.S. are either not able to afford healthcare or do not qualify for coverage under Medicaid because of its strict financial guidelines. This leaves many women uninsured; a lack of insurance creates disparities in healthcare. If an uninsured woman becomes pregnant, she is then covered under Medicaid but also had a previous temporary gap of coverage. Gaps in coverage can put the woman at a higher risk of poor health outcomes. Loftis, L. (2017). U.S. maternal mortality is rising, but not for the reason the left claims. Retrieved from http://thefederalist.com/2017/07/13/u-s-maternal-mortality-rising-not-reason-left-claims/ This author of this article argues that U.S. maternal mortality rates are rising, but not due to the assumed cesarean section rate. According to the CDC, the rate of low-risk C-section deliveries has been declining since 2009. The article offers other reasons as to why our maternal mortality rate has been on the rise, one being the rising maternal age. The Gates foundation tells us that the risk of maternal mortality increases greatly with age. A section on the rise of maternal age as a factor contributing to high maternal mortality rates may be effective in our literature review and this source can be useful to develop the risks involved with pregnancy at an older age. Loudon, I. (2000). Maternal mortality in the past and its relevance to developing countries today. The American Journal of Clinical Nutrition, 72 (1), 241-246. According to Loudon (2000) a major determinant of maternal mortality has been identified as maternal care provided by a health care provider. The author of this article seeks to educate readers about the history and lessons of maternal mortality to produce some suggestions for today. Interestingly enough, historical data shows that maternal mortality rates were lower for home deliveries and high in countries where deliveries were done by a physician in a hospital. The author states that history shows an overwhelming amount of evidence that social and economic conditions were a weak determinant of maternal mortality whereas the standard of care was a strong determinant. MacDorman, M.F., Declercq, E., & Thoma, M.E. (2017). Trends in maternal mortality by socioeconomic characteristics and cause of death in 27 states and the District of Columbia. Obstetrics & Gynecology, 129(5), 811-818. doi:10.1097/aog.0000000000001968 The authors used data from 2008-2009 and 2013-2014 to analyze trends in maternal mortality in 27 U.S. states and the District of Columbia. Their results revealed that there was a 23% increase in maternal mortality during the 5-year period. The age and race of the women were the two socioeconomic characteristics categories used to group the mothers. Women ages 40 or older and of non-Hispanic black race had the greatest increase in maternal mortality. The results of this study support that women of a particular age or race are dying during childbirth. Martin, N., & Montagne, R. The Last Person You'd Expect to Die in Childbirth. Retrieved February 16, 2018, from https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care- system This article has several personal stories about American mothers who contribute to the country’s high maternal mortality rate. Reasons for maternal death discussed include a woman’s age, lack of care before pregnancy, or healthcare status for proper care, C-section procedures, and/or attention being focused on the baby and less on the mother after birth. Although women of all races die during maternity, African American women die at higher rates than any other race or ethnicity of women in the U.S. Additionally, the article opens up the discussion about how 60% of maternal deaths can be prevented in the U.S. Overall, the authors establish a solid foundation, which gives a concise summary of maternal mortality in the U.S. versus the rest of the world and informs readers about current proposed plans in states like California, to decrease the number of maternal deaths. Maruthappu, M., Ng, KYB, Williams, C., Atun, R., Agrawal, P., & Zeltner, T. (2014, Dec 10) The association between government healthcare spending and maternal mortality in the European Union, 1981-2010: a retrospective study. BJOG 2015, 122, 1216-1224. doi: 10.1111/1471-0528.13205 This research was conducted to determine the correlation between reductions in government healthcare spending and maternal mortality rates in 24 countries in the European Union (EU) over a thirty-year period, 1981-2010. The authors found that increases in maternal mortality rates were associated with reductions in healthcare spending. This study supports the notion that as healthcare spending increases, maternal death rates should fall, which is not the trend in United States data. The data collected will serve in comparison to the U.S., aiding in the exploration of the paradox. Mathur, P., Srivastava, S., Mehta, J.L., (2015) High Cost of Healthcare in the United States - A Manifestation of Corporate Greed. Journal of Forensic Medicine, 1(103), 1-4. doi:10.4172/2472-1026.1000103 This article focuses on the rising cost of healthcare in the United States. Currently, 18% of the country’s GDP is used for health care cost for its citizens. Given, that percentage calculates to about $3 trillion dollars, it means that the government spends over $9,000 on each American’s health annually. However, the authors argue that government funding contributes to the pharmaceutical industry mostly, for treatments for diseases instead of each citizen’s well-being. Healthcare in the U.S. is a business and for socio-economical disadvantaged people to be helped by these funds, a revolution is needed. Mitchell, C., Lawton, E., Morton, C., McCain, C., Holtby, S., & Main, E. (2014). California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings. Maternal & Child Health Journal, 18(3), 518-526. doi:10.1007/s10995-013-1267-0 This article is about California’s attempt to decrease its maternal mortality rate by implementing preventive strategies as well as reviewing maternal mortality cases in the state. The mixed methods study found that cardiovascular disease is the leading cause of maternal deaths, with African Americans significantly represented. The findings and information presented in this article are important because it can help other states, if they use California as an example, to decrease their maternal mortality rate. Moaddab, A., Dildy, G.A., Brown, H.L., Bateni, Z.H., Belfort, M.A., Sangi-Haghpeykar, H., & Clark, S.L. (2016). Health care disparity and state-specific pregnancy-related mortality in the United States, 2005-2014. Obstetrics & Gynecology, 128(4), 869-875. doi:10.1097/aog.0000000000001628 The authors of this study conducted a population-level analysis to examine the relationship between state mortality ratios and demographic factors of mothers. They found that there has been an increase in maternal mortality ratio from 2007 to 2013-2014, with the most drastic increase of maternal mortality being among non-Hispanic black women. Their results add to the supporting studies and published works, which indicate that women of color have higher mortality rates. Molina, R. L., & Pace, L. E. (2017). A Renewed Focus on Maternal Health in the United States. New England Journal of Medicine, 377(18), 1705-1707. doi:10.1056/NEJMp1709473 The authors' purpose is to inform readers about the increasing public awareness of maternal mortality in the U.S. and how much research and data have been performed or analyzed about maternal deaths. The findings and results indicate that women’s health conditions before pregnancy, as well as racial, ethnic and socioeconomic equities seem to be in the trend in most maternal deaths. For a high-income country, the U.S. has the highest maternal mortality rate and this has raised the question, what are the gaps in healthcare that must be tackled now for a lower maternal mortality rate in the future. Overall, this article is important because it speaks on how the ACA, Medicaid and the Trump administration has either helped or threatens the reform of women's health through its associated political initiatives. Morong, J.J, Martin, J.K., Ware, R.S., Colditz, P.B, & Robichaux, A.G. (2017) Comparison of In-Hospital Maternal Mortality Between Hospital Systems in Queensland, Australia and Louisiana, United States. Ochsner Journal, 17(3), 243-249. This study was designed to determine if American and Australian women have the similar rates of preventable maternal deaths. The authors compared the rates of maternal mortality in the U.S. and Australia between 2000 and 2005. They found that death amongst Australian women was less likely to occur. This study will be helpful in comparing the trends of healthcare coverage and quality, as well as maternal death rates in the United States and other developing countries. National Center for Health Statistics. (2016). Health, United States, 2015: With special feature on racial and ethnic disparities. (DHHS Publication No. 2016-1232). Washington, D.C.: U.S. Government Printing Office. This report presents and annual overview of national trends in health statistics on selected measures of morbidity, mortality, healthcare utilization and access, health risk factors, prevention, health insurance, and personal health expenditures. This report specifically features a special on racial and ethnic disparities. The report includes an At a Glance table displaying selected indicators of health and their determinants, cross-referenced to charts and tables in the report. A highlights section follows, a Chart book, and then detailed Trend Tables. Many of the tables present data according to race and Hispanic origin. This source can be useful in determining disparities in healthcare that exist among different races overall, as well as specifically in maternal mortality. It can be used in our literature review when discussing the impact of healthcare disparities among women of color on the maternal mortality rate in the U.S. Novack, Sophie. (2017, June 5). Texas’ Maternal Mortality Rate: Worst in Developed World, Shrugged off by Lawmakers. Retrieved from https://www.texasobserver.org/texas-worst-maternal-mortality-rate-developed-world-lawmakers-priorities/ This article explains how Texas has rejected a federally funded to expand Medicaid that would have covered 1.1 million more of their residents. A little more than half of all births in Texas are paid for by Medicaid, yet coverage for new mothers ends 60 days after childbirth. The majority of maternal deaths from 2011 to 2012 occurred after the 60-day mark. The task force suggested that lawmakers extend health care access from 60 days to one year after childbirth. One bill, from Representative Jessica Farrar, was filed to do so. However, it didn’t get a committee hearing. Despite what seems to be an alarming crisis, many lawmakers set modest goals for the session. Legislation focused on extending research efforts, rather than addressing the underlying problem lack of access to healthcare. Quinn, M. (2017, September 13). States with the Highest and Lowest Uninsured Rates. Retrieved from http://www.governing.com/topics/health-human-services/gov-uninsured-rate-census-2016-states.html According to the U.S. Census Bureau, in 2016 8.8 percent of Americans were uninsured. With Trump Administrations denying funding to organizations that help people enroll in Obamacare, this percent is expected to increase. In the past, states with lower rates of uninsured all expanded Medicaid. However, with all the new changes, states with highest rates are uninsured choose not to expand Medicaid. Five top states with the highest rates of uninsured are as followed, Texas 16.6 present, Oklahoma 13.8 percent, Georgia 12.9 percent, Florida 12.5 percent and Mississippi 11.8 percent. Say, L., Chou, D., Gemmill, A., Tuncalp, O., Moller, A., Daniels, J.,Gulmezoglu, A. M., Temmerman, M., Alkema, L. (2014). Global causes of maternal death: a WHO systematic analysis. Lancet Global Health, 2, 323-333. http://dx.doi.org/10.1016/ S2214-109X(14)70227-X. This study developed and analyzed global, regional, and sub regional estimates of the causes of maternal deaths between 2003 and 2009. Peer reviewed articles from general bibliographic databases were used to gather secondary research data. Additionally, data was taken from registration data was taken from the WHO mortality database. These were used to analyze the causes of maternal deaths. The study found that 27.1 percent of maternal deaths between the years 2003 and 2009 were due to hemorrhage, 14 percent due to hypertensive disorders, and 10.7 percent due to sepsis. The remaining deaths were due to abortion, embolism, and all other direct causes of death. This can be useful in our literature review to identify the most common causes of maternal death and how they can be prevented. Sifferlin, A. (2016, Sept 27) Why U.S. Women Still Die During Childbirth. Retrieved February 24, 2018, from http://time.com/4508369/why-u-s-women-still-die-during-childbirth/ This article explores how the UN managed to tackle to global issue of maternal mortality, while the US rates nearly doubled in two decades. Sifferlin states that between 2010 and 2012, the MMR in Texas doubled. The article states that the World Health Organization found that the US MMR rate was higher than that of Iran, Libya, and Turkey. Sifferlin goes on to argue that half of these deaths were preventable. Unequal access to quality care and the increased push toward cesarean sections are factors that may be playing a part in the rise of MMR. Young women are dying, often leaving young children behind. This article will aid in supporting the argument that the precipitating factors must be addressed to reduce MMR. Sifferlin, A. (2018, January 5). Why are so many Mothers dying in Texas? Retrieved from http://time.com/5088014/maternal-mortality-pregnancy/ This article explains how in 2015 Texas maternal death rate was 32.5 per 100,000 live births. Researcher MacDorman and her colleagues noticed when comparing data from 2006-2010 to 2011-2015 the highest maternal mortality rates were among woman over the age of 40. The researchers believe the reasons for this high rate are, woman of this age group are having more babies increasing their chances of complication, they have a higher chance of chronic disease than in the past, lack access to proper healthcare and have a higher prevalence of cesarean section. Squires, D.A. (2012). Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality. The Commonwealth Fund, 10, 2-11. This article compares health care spending, supply, utilization, prices, and quality among 13 industrialized countries. The article attempts to debunk many assumptions behind high health care spending such as the increased need for care and services for the growing baby boomer population. The authors state that higher spending in the United States has been associated with higher drug prices and advanced technology, yet our quality of care is still no better than other developed countries. The United States prices for commonly prescribed drugs are 1/3 higher than in other countries and the use of expensive tests and scans are direct triggers of increased spending. Tavernise, S. (2016, September 21). Maternal Mortality Rate in U.S. Rises, Defying Global Trend, Study Finds. Retrieved from https://www.nytimes.com/2016/09/22/health/maternal-mortality.html This article points out how despite improvement in health care, maternal mortality rates have risen. One primary reason is the complication caused by pregnancy or childbirth. According to research, the analysis found that not only has maternal death increased in 48 states but was nearly doubled in the state of Texas. Black woman have a higher maternal mortality rate than a white woman. Increase in obesity (more commonly found in black woman) may be a contributing factor. Maternal death is hard to count, due to the lack of details indicating whether or not the death was pregnancy related. United Nations Children’s Fund. (2016, Nov 7). Maternal and newborn health. Retrieved February 24, 2018, from https://www.unicef.org/health/index_maternalhealth.html In this article, UNICEF provides a general overview of the status of global maternal death rate. According to the authors, there has been impressive progress in decreasing the maternal mortality rate, with it decreasing by forty-four percent over a 25-year period. This statistic, however, did not meet the UN goal of decreasing MMR by 75%. The authors also provide context on how the world has improved in the reduction and prevention of neonatal mortality. The article goes on to provide solutions and mechanisms to further reduce these mortality rates. UNICEF asserts that solutions will close the disparities disadvantaged populations face in healthcare. This article will provide context to the history of the problem, as well as show how the world has made progress in reducing MMR, while the U.S. has not. World Health Organization. (2015). Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Retrieved from http://www.afro.who.int/sites/default/files/2017-05/trends-in-maternal- M ortality-1990-to-2015 This report present maternal mortality estimates from the years 1990 to 2015, which are used to examine the global, regional and country progress of maternal mortality. The estimates presented in this report were generated using the Bayesian maternal mortality estimation model. Trends are examined for all countries through national data, which include civil registration systems, population based surveys, specialized studies, surveillance studies and censuses. The estimates show that over the course of the 25 years between 1990 and 2015, the world has made steady progress in reducing maternal mortality. The report also offer goals for the future to work towards ending preventable maternal mortality and address the challenges faced when measuring and collecting data. This source is helpful to understand the progress that has been made towards reducing maternal deaths all over the world. It can also be used as a tool for improving data collection for future studies. World Health Organization. (2015). Strategies toward ending preventable maternal mortality (EPMM). Retrieved from http://who.int/reproductivehealth/topics/maternal_perinatal/epmm/en/ This report present targets and strategies aimed at ending preventable maternal mortality. The focus is on eliminating significant inequities that lead to disparities in access, quality and outcomes of care within and between countries. It prioritizes equity in the development of targets for maternal mortality reduction post-2015. A strategic framework is offered to guide policy making and programme planning towards EPMM. Guiding principles for EPMM as well as cross-cutting actions to reach the goal are also provided. This is a helpful source to develop an understanding of the inequities associated with maternal health care and the current actions being taken towards ending preventable maternal mortality. World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. Retrieved from http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/ WHO would like to ensure that every pregnant woman and newborn receives quality care through pregnancy, childbirth, and postnatal period, especially at a time where pregnancy-related preventable morbidity and mortality remains unacceptably high. In this report WHO present a comprehensive guideline on routine Antenatal care (ANC) for pregnant woman and adolescent girls. The information was collected through a systematic review of women’s views, to understand what women want, need and value in pregnancy and ANC. Through this process priority questions and outcomes related to the effectiveness of clinical, test accuracy, and health systems interventions aimed at achieving a positive pregnancy experience were identified. The recommendations and guideline presented in this report were than formed from these questions and outcomes. This is a useful source for identifying the importance of ANC for all women and adolescent girls during pregnancy. It can be used in the portion of our literature review where we will be speaking on ANC and its impact on maternal mortality in the United States. World Health Organization. (2017). World health statistics 2017: Monitoring health for the SGDs. Retrieved from http://apps.who.int/iris/bitstream/10665/255336/1/9789241565486- eng This report presents an annual compilation of health statistics for 194 states in the World Health Organization’s network. It focuses on health and health-related Sustainable Development Goals (SDGs). The status of health-related SDG indicators, both globally and regionally, are summarized, including information on maternal deaths. Six lines of action are described to promote better health systems and to achieve the health-related SDGs. A selection of stories that highlight successful efforts to improve and protect the health of communities through one or more of these six lines of action are presented. This is a helpful source for obtaining statistics on maternal mortality globally and understanding the issues that surround the topic. The source can also offer suggestions for improvement in maternal health. APPENDIX C Project Timetable APPENDIX D Research Grid APPENDIX E Secondary data Data Input for Health Insurance & MMR into SPSS State % Uninsured Women in State # Maternal Deaths (per 100,000 live births) AL 19.9 9.8 AZ 18.2 18.3 AR 18.8 35.4 CA 17.1 5.9 CO 13.7 10.1 CT 8.7 14.1 DE 9.4 13.9 DC 4.5 40.7 FL 24.0 23.6 GA 23.6 39.3 HI 6.7 14.8 ID 21.8 20.2 IL 13.4 16.0 IN 17.9 34.9 IA 9.0 15.4 KS 16.1 19.6 KY 12.9 20.4 LA 22.6 35.0 ME 14.2 8.2 MD 11.1 25.7 MA 3.6 5.8 MI 12.3 22.7 MN 7.8 13.9 MS 22.0 26.5 MO 18.0 28.5 MT 21.3 24.6 NE 15.7 14.6 NV 20.3 6.8 NH 12.8 15.8 NJ 15.7 37.3 NM 21.7 23.0 NY 11.8 20.9 NC 20.0 12.1 ND 10.3 18.0 OH 10.7 20.9 OK 23.1 26.0 OR 13.7 13.2 PA 12.1 16.7 RI 10.2 18.3 SC 21.0 27.1 SD 14.4 24.9 TN 16.8 19.2 TX 28.3 31.5 UT 16.4 18.3 VA 15.4 13.2 WA 13.0 14.7 WV 11.8 13.6 WI 10.3 13.6 WY 17.2 22.2 MMR (2016) NOT AVAILABLE AK 23.0 - Data Input for Race & MMR into SPSS State Total # of Females in State # of Black Women in State % of Black Women in State # Maternal Deaths (per 100,000 live births) AL 2,254,100 652,050 28.9 9.8 AZ 2,197,650 152,650 6.9 18.3 AR 1,307,150 227,550 17.4 35.4 CA 11,605,200 1,057,650 9.1 5.9 CO 407,000 105,000 25.8 10.1 CT 1,461,750 174,250 11.9 14.1 DE 408,700 98,300 24.1 13.9 DC 302,250 157,000 51.9 40.7 FL 7,512,950 1,537,450 20.5 23.6 GA 4,521,400 1,622,650 35.9 39.3 HI 531,550 10,850 2.0 14.8 ID 711,150 6,600 0.9 20.2 IL 5,141,700 900,100 17.5 16.0 IN 2,995,400 297,700 9.9 34.9 IA 1,423,600 51,500 3.6 15.4 KS 1,173,200 85,300 7.3 19.6 KY 2,014,200 169,950 8.4 20.4 LA 2,120,150 738,250 34.8 35.0 ME 612,850 7,550 1.2 8.2 MD 2,566,600 849,300 33.1 25.7 MA 2,919,150 231,800 7.9 5.8 MI 4,573,650 671,800 14.7 22.7 MN 2,453,450 174,300 7.1 13.9 MS 1,396,250 546,050 39.1 26.5 MO 2,724,900 325,400 11.9 28.5 MT 465,950 3,400 0.7 24.6 NE 793,000 36,850 4.6 14.6 NV 1,008,850 126,150 12.5 6.8 NH 629,050 8,900 1.4 15.8 NJ 3,608,950 567,550 15.7 37.3 NM 398,400 21,300 5.3 23.0 NY 7,868,750 1,366,900 17.4 20.9 NC 4,313,300 1,077,200 25.0 12.1 ND 344,750 11,300 3.3 18.0 OH 5,299,400 686,850 13.0 20.9 OK 1,553,050 142,850 9.2 26.0 OR 1,628,800 39,900 2.4 13.2 PA 5,964,600 677,350 11.4 16.7 RI 51,200 31,450 61.4 18.3 SC 2,296,400 642,500 28.0 27.1 SD 358,200 8,950 2.5 24.9 TN 3,064,600 556,950 18.2 19.2 TX 8,346,550 1,673,300 20.0 31.5 UT 1,266,100 17,350 1.4 18.3 VA 295,450 3,650 1.2 13.2 WA 2,887,750 122,600 4.2 14.7 WV 872,950 31,200 3.6 13.6 WI 2,565,450 160,850 6.3 13.6 WY 246,700 2,000 0.8 22.2 APPENDIX E.1 Literature Synthesis Chart Author Study Date Summary of Findings Health Insurance Status Variable Racial Background Variable 1 Association of State and Territorial Health Officials 2012 After controlling for socioeconomic status, black women still experienced more maternal deaths per 1,000 live births than their white counterparts. x 2 Baudry,E., Gusman, N., Strang, V., Thomas, K., & Villarreal, E. 2017 Prenatal care interventions appear to be effective in reducing adverse maternal outcomes. The decision of states to not expand Medicaid has created a coverage gap. x x 3 Ben, J., Cormack, D., Ricci, H., & Paradies, Y. 2017 Healthcare outcomes are greatly influenced by the race of the patient x 4 Board, T.E. 2016 Inequality in access to healthcare has led to higher maternal mortality rates in certain communites. E.g. Texas x x 5 The Center For Reproductive Rights 2016 Most maternal deaths in the U.S. are preventable. Discrimination in care causes MMR to be higher amongst black women. x 6 Comfort, A. B., Peterson, L. A., & Hatt, L. E. 2013 Two out of three studies which examined the effect of health insurance status on maternal mortality found that having health insurance does, in fact, decrease maternal mortality x 7 Institute of Medicine (US) Committee on the Consequences of Un-insurance. 2002 Health insurance status affects the care that women receive thus determining their health outcomes during or after delivery x 8 Nour, N.M. 2008 Proper management of a woman’s health before pregnancy is just as important to health during and after pregnancy. x 9 Centers for Disease Control & Prevention 2015 Most women who were uninsured just a month before pregnancy were non-white/a person of color x x 10 The American Public Health Association 2011 Historically, black women experience significan gaps in health coverage & access. Black women also experience higher MMR than white women. x x 11 Tucker, M. J., Berg, C. J., Callaghan, W. M., Hsia, J. 2007 Black women are 2-3x more likely to die due to common conditions associated with maternal mortality x 12 Shavers, V. L., Fagan, P., Jones, D., Klein, W. M., Boyington, J., Moten, C., & Rorie, E. 2012 74% of blacks and 69% of other non-whites report race-based discrimination in a medical setting which detered individuals from using available services x 13 Mays, V. M., Cochran, S. D., & Barnes, N.W. 2007 Experiences with chronic race-based discrimination has been proven to set off physiological responses (i.e. elevated blood pressure, heart rate) x x 14 Ota, S. 2017 An end to Title x Family Planning, by the Trump administration, can cut off millions of pregnant women from access to complete information about their medical options. x 15 Bryant, A.S., Worjoloh, A., Caughet, A.B., & Washington, A.E. 2010 Disparities in access to care and quality of care have resulted in varying maternal health outcomes for women of different backgrounds x x 16 Agrawal, P. 2015 The U.S. spent $60 billion on maternal care in 2012, yet an estimated 1,200 women experienced fatal complications during childbirth x 17 Molina, R. L., Pace, L.E. 2017 In America, low-income mothers, women living in rural areas, and non-Hispanic black women are three times more likely to die during childbirth than white women with median incomes. Reasons for these disparities include social determinants of health and biases in care delivery. x x 18 Legerski, E. M. 2012 The increasing cost of healthcare has caused American women to either not be able to afford coverage or not qualify for coverage under Medicaid because of the program’s strict financial guidelines x 19 Egerter, S., Braveman, P., Marchi, K. 2002 21 percent of the women lacked coverage in the first trimester and two percent were uninsured throughout their pregnancy. The period in which the woman does not have insurance coverage may contribute to issues faced during maternity and lack of preventative care is due to affordability factors of healthcare coverage x 20 Sommers, B. D., Baicker, K., & Epstein, A. M. 2012 Medicaid expansions in New York were associated with a significant reduction in maternal mortality rates. x 21 Centers for Disease Control & Prevention 2017 Revealed that black women had the highest pregnancy related deaths, at 43.5 deaths compared to 12.7 and 14.4 (per 100,000 live births) of white and other races of women, respectively x 22 Blair, J. V., Steiner, J. F., & Havranek, E. P 2011 Implicit biases in healthcare are a major driving force in the high rates of disease and maternal mortality amongst women, in particular black women x x 23 D'Angelo, K. A., Bryan, J. K., & Kurz, B. 2016 Results of this study revealed that the importance of prenatal care is known among participants, however among Black/African American communtiies, women reported discrimination and that they did not have any input when it came to their care. x x 24 Forde-Mazrui, K. 2016 Black/African women disporportionately experience a lack of access to prenatal care which can contribute to high infant and maternal mortality rates within the community. x x 25 Moaddab, A., Dildy, G. A., Brown, H. L., Bateni, Z. H., Belfort, M. A., Sangi-Haghpeykar, H., & Clark, S. L. 2016 There has been an increase in maternal mortality ratio from 2007 to 2013-2014, with the most drastic increase of maternal mortality being among non-Hispanic black women. x APPENDIX F Resumes APPENDIX G NIH Certificates Maternal Mortality Health Insurance Status Insured Uninsured Racial Background of Women White Dependent Variable Independent Variables Conceptualization Black Racial background contributes to MMR Insurance status influences MMR Both factors are major influencers on MMR 8.0 8.0 9.0 Bibi Alli 107-03 122nd Street Queens, NY, 11419 Phone: (347) 288-9997 Email: Bibi.Alli@my.liu.edu EDUCATION Long Island University, Brooklyn, NY Expected Graduation: May 2018 Master of Public Administration, GPA: 4.0 ● Specialization in Healthcare Administration ● Advanced Certificate in Gerontology and Long-Term Care Administration Hunter College, New York, NY May 2015 Bachelor’s Degree, GPA: 3.4 ● Major: Psychology ● Minor: Religion WORK EXPERIENCE DonorsChoose.org, New York, NY July 2017– Present Customer Experience Agent, Part-Time • Communicate with teachers about their project materials and experiences over email, resolving concerns swiftly and effectively, with understanding, a dash of compassion, and a healthy dose of patience • Interact with vendors to troubleshoot fulfillment issues, and set up returns when items arrive not quite as expected • Identify patterns and recurring issues in customer inquiries; resolving and escalating as needed • Review order status updates to help keep teacher projects on track • Collaborate with colleagues to improve the fulfillment experience and reduce incoming customer support inquiries Country-Wide Insurance, New York, NY June 2015– August 2016 Claims Analyst, Full-Time • Engaged in the process of investigating, evaluating and resolving No Fault/Medical claims utilizing police reports, hospital records, progress notes and medical forms • Communicated with claimants and their lawyers to verify facts of the claim and schedule appropriate independent medical examinations • Performed medical bill audits, analyses, and review of medical records to verify the claimant’s entitlement to payment • Analyzed the facts of loss and assessed submitted police reports, hospital records on date of loss, and billing from specific medical providers, to determine if Special Investigation Unit referral was required Kumon Math and Reading Center, Queens, NY June 2013– July 2015 Tutor and Office Assistant, Part-Time • Interacted with young children and parents to develop an individualized curriculum to achieve higher level goals in math and reading • Assisted and motivated students with learning disabilities to facilitate development of time management skills • Answered phone calls, emails and scheduled orientations for interested parents of potential students • Entered data for test scores and conducted analysis to understand the student’s growth ADDITIONAL SKILLS Computer Skills: Microsoft Office (Powerpoint, Excel, Word), IBM iSeries (AS400 database), SPSS Statistics, Guided User Interface (GUI), CMS Standard -SQL Database Manager, Zendesk Volunteer Activities: New York Cares, Jamaica Hospital, GlamourGals, Key Club Bibi Alli 107-03 122nd Street Queens, NY, 11419 Phone: (347) 288-9997 Email: Bibi.Alli@my.liu.edu EDUCATION Long Island University, Brooklyn, NY Expected Graduation: May 2018 Master of Public Administration, GPA: 4.0 ● Specialization in Healthcare Administration ● Advanced Certificate in Gerontology and Long-Term Care Administration Hunter College, New York, NY May 2015 Bachelor’s Degree, GPA: 3.4 ● Major: Psychology ● Minor: Religion WORK EXPERIENCE DonorsChoose.org, New York, NY July 2017– Present Customer Experience Agent, Part-Time · Communicate with teachers about their project materials and experiences over email, resolving concerns swiftly and effectively, with understanding, a dash of compassion, and a healthy dose of patience · Interact with vendors to troubleshoot fulfillment issues, and set up returns when items arrive not quite as expected · Identify patterns and recurring issues in customer inquiries; resolving and escalating as needed · Review order status updates to help keep teacher projects on track · Collaborate with colleagues to improve the fulfillment experience and reduce incoming customer support inquiries Country-Wide Insurance, New York, NY June 2015– August 2016 Claims Analyst, Full-Time · Engaged in the process of investigating, evaluating and resolving No Fault/Medical claims utilizing police reports, hospital records, progress notes and medical forms · Communicated with claimants and their lawyers to verify facts of the claim and schedule appropriate independent medical examinations · Performed medical bill audits, analyses, and review of medical records to verify the claimant’s entitlement to payment · Analyzed the facts of loss and assessed submitted police reports, hospital records on date of loss, and billing from specific medical providers, to determine if Special Investigation Unit referral was required Kumon Math and Reading Center, Queens, NY June 2013– July 2015 Tutor and Office Assistant, Part-Time · Interacted with young children and parents to develop an individualized curriculum to achieve higher level goals in math and reading · Assisted and motivated students with learning disabilities to facilitate development of time management skills · Answered phone calls, emails and scheduled orientations for interested parents of potential students · Entered data for test scores and conducted analysis to understand the student’s growth ADDITIONAL SKILLS Computer Skills: Microsoft Office (Powerpoint, Excel, Word), IBM iSeries (AS400 database), SPSS Statistics, Guided User Interface (GUI), CMS Standard -SQL Database Manager, Zendesk Volunteer Activities: New York Cares, Jamaica Hospital, GlamourGals, Key Club T a s h i y a B a p t i s t e Brooklyn, NY, 11236 (347)254-5337 Tashiyab1@gmail.com E d u c a t i o n L o n g I s l a n d U n i v e r s i t y - Brooklyn, NY May 2018 Master of Public Administration Specialization-Health Administration Phi Alpha Alpha Honor Society S U N Y C o l l e g e a t O l d W e s t b u r y -Old Westbury, NY May 2015 Bachelor of the Arts, Journalism E x p e r i e n c e N o r t h w e l l H e a l t h - L I J V a l l e y S t r e a m H o s p i t a l December 2018-Present Coordinator n Act as a liaison between patients and healthcare professionals to ensure appropriate communication and coordination of care. n Be an advocate for patients by providing guidance, support, and advice to those in complex medical dilemmas. n Serve as a project manager for departments looking to improve patient experience on their units. n Act as a data owner by collecting, organizing, and tracking all HCAHPS scores pulled from Press Ganey. n Communicate with managers about their department’s HCAHPS scores on a bi weekly basis. n Conduct volunteer interviews and evaluate their ability to follow and understand hospital protocols and procedures. n Attend department councils to help foster a work environment of collaboration, innovation, and improvement. N o r t h w e l l H e a l t h - L I J V a l l e y S t r e a m H o s p i t a l July 2017-December 2018 Administrative Assistant n Created weekly schedules for all staff members within the emergency department. n Developed new filing and organizational processes for keeping the staff up to date with mandatory certifications, licenses, and competencies. n Coordinated meetings and interviews for the nurse manager and director of the emergency department. n Recorded, transcribed, and distributed minutes from meetings. N o r d s t r o m January 2014-July 2017 Sales Associate § Connected and built relationships with customers through “Personal Book”. § Helped with floor moves designed to increase exposure and improve sales. V o l u n t e e r W o r k Intern- LIJ Valley Stream May 2017-August 2017 § Collected data on patient experience by conducting surveys on admitted patients in the emergency department. § Provided service recovery for unsatisfied patients. § Rounded on patients on the telemetry unit of the hospital to ensure their needs were met. S k i l l s § Proficient in Microsoft Word, Excel, Publisher, and PowerPoint § SPSS § Press Ganey J O E L L E A . C A N G É 1 3 3 0 E 4 8 T H S T R E E T B R O O K L Y N , N Y 1 1 2 3 4 3 0 5 . 9 6 5 . 7 4 6 2 j c a n g e 1 2 4 @ g m a i l . c o m V O L U N T E E R A C T I V I T I E S Mott Haven Community High school - Dance Team Coach (2014 – Present) • Choreograph and teach dance and step routines to high school students • Coordinate shows, competitions, and volunteer activities for team members H O N O R S • Phi Kappa Phi Honor Society • Pi Alpha Alpha Honor Society C R E D E N T I A L S A N D S K I L L S �Proficient in Leonardo MD Renaissance, E Clinical Works, Cerner �SPSS �Microsoft Office: Word, Excel, PowerPoint� �Project Management� Strategic Planning� Organizational Leadership E D U C A T I O N 01/2016 – PRESENT 09/2009 – 05/2013 Long Island University – Brooklyn Campus School of Business, Public Administration and Information Sciences Master of Public Administration, Health Administration/Healthcare Policy Expected May 2018 Binghamton University: State University of New York Harpur College of Arts and Science Bachelor of Arts, May 2013 Major: History Minor: Biology P R O F E S S I O N A L E X P E R I E N C E 0 2 / 2 0 1 7 – P R E S E N T 0 6 / 2 0 1 3 – 0 2 / 2 0 1 7 0 6 / 2 0 1 0 – 0 6 / 2 0 1 2 New York Hotel Trades Council – Harlem Health Center New York, NY Administrative Assistant • Ensure physician coverage in all departments and liaison with administration • Complete monthly reports to monitor health center workflow • Maintain compliance for rounds scheduling and yearly mock survey reports • Create databases, track and maintain the credentials for over 50 physicians • Facilitate correspondence between four health centers and headquarters • Process payroll, generate and approve monthly invoices for contracted physicians • Oversee paid time off scheduling for over 90 employees on a weekly basis • Assure timely approval and payment of all external accounts • Maintain petty cash account through bi-weekly log-review and replenishment • Organize center-wide meetings, create agendas and presentations on a monthly basis Manhattan Allergy, Immunology, & Rheumatology/Carnegie Medical PC New York, NY Administrative Assistant • Provided administrative support to physicians and maintained office efficiency • Developed scheduling system to optimize physician productivity; which led to 20% increase in patients seen per day • Scheduled appointments, verified insurance and entered patient billing • Assisted clinical staff during any in-office procedures Zanine’s Clinical & Support Services (Seasonal position) Rosedale, NY Administrative Assistant • Scheduled appointments and maintained filing system • Assist in billing, managed personnel calendar, and maintained office supply stock and purchase orders JOELLE A. CANGÉ 1330 E 48TH STREET BROOKLYN, NY 11234 305.965.7462 jcange124@gmail.com VOLUNTEER ACTIVITIES Mott Haven Community High school - Dance Team Coach (2014 – Present) · Choreograph and teach dance and step routines to high school students · Coordinate shows, competitions, and volunteer activities for team members HONORS · Phi Kappa Phi Honor Society · Pi Alpha Alpha Honor Society CREDENTIALS AND SKILLS �Proficient in Leonardo MD Renaissance, E Clinical Works, Cerner �SPSS �Microsoft Office: Word, Excel, PowerPoint� �Project Management� Strategic Planning� Organizational Leadership EDUCATION 01/2016 – PRESENT 09/2009 – 05/2013 Long Island University – Brooklyn Campus School of Business, Public Administration and Information Sciences Master of Public Administration, Health Administration/Healthcare Policy Expected May 2018 Binghamton University: State University of New York Harpur College of Arts and Science Bachelor of Arts, May 2013 Major: History Minor: Biology PROFESSIONAL EXPERIENCE 02/2017 – PRESENT 06/2013 – 02/2017 06/2010 – 06/2012 New York Hotel Trades Council – Harlem Health Center New York, NY Administrative Assistant · Ensure physician coverage in all departments and liaison with administration · Complete monthly reports to monitor health center workflow · Maintain compliance for rounds scheduling and yearly mock survey reports · Create databases, track and maintain the credentials for over 50 physicians · Facilitate correspondence between four health centers and headquarters · Process payroll, generate and approve monthly invoices for contracted physicians · Oversee paid time off scheduling for over 90 employees on a weekly basis · Assure timely approval and payment of all external accounts · Maintain petty cash account through bi-weekly log-review and replenishment · Organize center-wide meetings, create agendas and presentations on a monthly basis Manhattan Allergy, Immunology, & Rheumatology/Carnegie Medical PC New York, NY Administrative Assistant · Provided administrative support to physicians and maintained office efficiency · Developed scheduling system to optimize physician productivity; which led to 20% increase in patients seen per day · Scheduled appointments, verified insurance and entered patient billing · Assisted clinical staff during any in-office procedures Zanine’s Clinical & Support Services (Seasonal position) Rosedale, NY Administrative Assistant · Scheduled appointments and maintained filing system · Assist in billing, managed personnel calendar, and maintained office supply stock and purchase orders Dana Marie Cortese !Email: dana.cortese94@gmail.com 537 3rd Street Cell: (347) 633 5751 Brooklyn, NY 11215 EDUCATION Long Island University Brooklyn Brooklyn, NY Master in Public Administration in Healthcare Administration Expected Graduation: May 2017 Seton Hall University South Orange, NJ Bachelor of Arts in Social and Behavioral Sciences; Minor in Psychology Graduated: May 2016 Merit Scholar, Dean’s List LEADERSHIP EXPERIENCE Long Island University - Masters in Public Administration Department Brooklyn, NY Graduate Assistant January 2018 – May 2018 • Tutoring individual or small groups of students • Assisting with the grading of homework or exams or written assignments; Administering tests or exams • Conducting literature reviews or library research • Collecting, coding, cleaning or analyzing data • Preparing materials for submission to funding agencies and foundations • Preparing materials for IRB • Writing reports or designing conference presentations Seton Hall University - Freshman Studies South Orange, NJ Peer Adviser Summer 2013 – May 2015 • One of 55 campus ambassadors in charge of acclimating 1,200 freshmen into college life • Co-taught two University Life classes of 20 students each • Coordinated projects, developed lesson plans, and graded student work • Partnered with other advisers to organize and direct two-day overnight Freshman Orientations, informational sessions, social activities and entertainment • Organized and conducted innovative class activities to encourage participation • Maintained attendance logs and reported on individual student progress in weekly report meetings with professor WORK EXPERIENCE Calexico Restaurant Brooklyn, NY Bartender, Server August 2016-Present • Ensure that guest’s needs and expectations are exceeded and their experience is enjoyable • Keep up with a fast-paced environment and work in collaboration with the team to deliver the best service • Complete daily opening and closing tasks, mainly ensuring the restaurant is clean and presentable • Provide training to new employees to uphold restaurant policies and sustain guest satisfaction Arturo’s Osteria and Pizzeria Maplewood, NJ Server, Hostess, Cashier 2013 – July 2016 • Ensured that guest’s needs and expectations were exceeded and their experience was enjoyable • Kept up with a fast-paced environment and worked in collaboration with the team to deliver the best service • Completed daily opening and closing tasks, mainly ensuring the restaurant was clean and presentable • Balanced the register during opening and closing and processed customer payments by cash and credit; recorded invoices and adjusted tips; Calculated total payments received during the day and reconciled with total sales • Supervised staff and restaurant operations when managers were unavailable • Provided training to new employees to uphold restaurant policies and sustain guest satisfaction Dimino Physical Therapy Office Staten Island, NY Receptionist, Therapist Aid January 2012- 2013 • Prepared medical apparatuses for patients and set up electrical stimulation when needed • Guided and trained patients with specialized exercises and helped them work through and evaluate these exercises • Greeted and checked-in patients, and collected personal, medical, and insurance information. • Scheduled, rescheduled, and verified patient appointments • Maintained patient flow by communicating patient arrivals or delays. • Used EMR software to manage patient records and files; reinforce and uphold patient confidentiality as required by HIPAA and clinic. • Collected patient co-payments and recorded payment transactions; Obtained third-party payer authorization for services provided Dana Marie Cortese !Email: dana.cortese94@gmail.com 537 3 rd Street Cell: (347) 633 5751 Brooklyn, NY 11215 EDUCATION Long Island University Brooklyn Brooklyn, NY Master in Public Administration in Healthcare Administration Expected Graduation: May 2017 Seton Hall University South Orange, NJ Bachelor of Arts in Social and Behavioral Sciences; Minor in Psychology Graduated: May 2016 Merit Scholar, Dean’s List LEADERSHIP EXPERIENCE Long Island University - Masters in Public Administration Department Brooklyn, NY Graduate Assistant January 2018 – May 2018 · Tutoring individual or small groups of students · Assisting with the grading of homework or exams or written assignments; Administering tests or exams · Conducting literature reviews or library research · Collecting, coding, cleaning or analyzing data · Preparing materials for submission to funding agencies and foundations · Preparing materials for IRB · Writing reports or designing conference presentations Seton Hall University - Freshman Studies South Orange, NJ Peer Adviser Summer 2013 – May 2015 · One of 55 campus ambassadors in charge of acclimating 1,200 freshmen into college life · Co-taught two University Life classes of 20 students each · Coordinated projects, developed lesson plans, and graded student work · Partnered with other advisers to organize and direct two-day overnight Freshman Orientations, informational sessions, social activities and entertainment · Organized and conducted innovative class activities to encourage participation · Maintained attendance logs and reported on individual student progress in weekly report meetings with professor WORK EXPERIENCE Calexico Restaurant Brooklyn, NY Bartender, Server August 2016-Present · Ensure that guest’s needs and expectations are exceeded and their experience is enjoyable · Keep up with a fast-paced environment and work in collaboration with the team to deliver the best service · Complete daily opening and closing tasks, mainly ensuring the restaurant is clean and presentable · Provide training to new employees to uphold restaurant policies and sustain guest satisfaction Arturo’s Osteria and Pizzeria Maplewood, NJ Server, Hostess, Cashier 2013 – July 2016 · Ensured that guest’s needs and expectations were exceeded and their experience was enjoyable · Kept up with a fast-paced environment and worked in collaboration with the team to deliver the best service · Completed daily opening and closing tasks, mainly ensuring the restaurant was clean and presentable · Balanced the register during opening and closing and processed customer payments by cash and credit; recorded invoices and adjusted tips; Calculated total payments received during the day and reconciled with total sales · Supervised staff and restaurant operations when managers were unavailable · Provided training to new employees to uphold restaurant policies and sustain guest satisfaction Dimino Physical Therapy Office Staten Island, NY Receptionist, Therapist Aid January 2012- 2013 · Prepared medical apparatuses for patients and set up electrical stimulation when needed · Guided and trained patients with specialized exercises and helped them work through and evaluate these exercises · Greeted and checked-in patients, and collected personal, medical, and insurance information. · Scheduled, rescheduled, and verified patient appointments · Maintained patient flow by communicating patient arrivals or delays. · Used EMR software to manage patient records and files; reinforce and uphold patient confidentiality as required by HIPAA and clinic. · Collected patient co-payments and recorded payment transactions; Obtained third-party payer authorization for services provided SKILLS • Proficiency in Microsoft Office (Word, PowerPoint, Excel) • Languages: English, conversational Italian and Spanish References Upon Requests SKILLS · Proficiency in Microsoft Office (Word, PowerPoint, Excel) · Languages: English, conversational Italian and Spanish References Upon Requests Vanessa T. Dasque 894 Jefferson Avenue Apt. 2, Brooklyn NY, 11221 I (631) 741-0922 I Vtdasque@gmail.com Detail-oriented Administrative Coordinator bringing 8 years of positive experience in office roles. Meticulous and hardworking with an aptitude for vendor and client relationship management. Education MASTER OF PUBLIC ADMINISTRATION LONG ISLAND UNIVERSITY BROOKLYN, BROOKLYN NY · Concentration: Healthcare Administration BACHELOR DEGREE IN BIOSCIENCE S.U.N.Y FARMINGDALE, FARMINGDALE NY Computer Skills Microsoft Excel, Word, Outlook and PowerPoint EPIC SPSS Experience DERMATOLOGY DEPARTMENT- OFFICE COORDINATOR/MANAGER NYU LANGONE MEDICAL CENTER - NEW YORK, NY 05/2018 05/2013 11/16- PRESENT Delegate tasks to administrative staff; supervise office employees, including performance evaluation and scheduling. Established efficient workflow processes, monitor daily productivity and implement modifications to improve the overall effectiveness to ensure patient satisfaction. Prepare weekly payroll, reports, and budgeting. OPERATING ROOM DEPARTMENT-MEDICAL RECEPTIONIST HOSPITAL FOR SPECIAL SURGERY - NEW YORK, NY Assisted in the maintenance of medical charts and electronic medical records. Obtained prior authorizations for medication and outpatient procedures. 02/16 - 11/16 Interacted with providers regarding billing, documentation policies, procedures, and regulations. NURSING & REHABILITATION DEPARTMENT- UNIT RECEPTIONIST ST. CATHERINE OF SIENA - SMITHTOWN, NY 05/13 - 01/16 Oversee inventory activities, including materials monitoring, ordering, and supply re-stocking. · Answered inquiries and addressed, resolved or escalated issues to management personnel. NURSING & REHABILITATION DEPARTMENT- RECEPTIONIST GURWIN JEWISH CENTER, COMMACK, NY Greet daily visitors and patients upon entrance. · Scheduled patient's Doctor Appointments and treatments. 11/10-07/13 The National Institutes of Health (NIH) Office of Extramural Research certifies that Bibi Alli successfully completed the NIH Web-based training course "Protecting Human Research Participants." Date of Completion: 02/02/2017 Certification Number: 308283 The National Institutes of Health (NIH) Office of Extramural Research certifies that Tashiya Baptiste successfully completed the NIH Web-based training course "Protecting Human Research Participants." Date of Completion: 02/13/2017 Certification Number: 2397180 The National Institutes of Health (NIH) Office of Extramural Research certifies that Tashiya Baptiste successfully completed the NIH Web-based training course "Protecting Human Research Participants." Date of Completion : 02/13/2017 Certification Number : 2397180 Certificate of Completion The National Institutes of Health (NIH) Office of Extramural Research certifies that Joelle Cange successfully completed the NIH Web-based training course "Protecting Human Research Participants". Date of completion: 10/01/2016. Certification Number: 2192607. Certificate of Completion The National Institutes of Health (NIH) Office of Extramural Research certifies that Joelle Cange successfully completed the NIH Web-based training course "Protecting Human Research Participants". Date of completion: 10/01/2016. Certification Number: 2192607. The National Institutes of Health (NIH) Office of Extramural Research certifies that Dana Cortese successfully completed the NIH Web-based training course "Protecting Human Research Participants." 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School Segregation is Alive and Well: Race, Income and Reform

Jack

Alcineus, Adiba Chowdhury, Kimberly Jean-Charles & Leong Pang

MPA

and MPA 799

Mentor: Dr. Bakry Elmedni

Instructor: Dr. Helisse Levine

Table of Contents

Introduction

Unresolved Problem

Research Goal/Purpose

Subproblems

Research Questions

Hypotheses

Definitions of Key Terms

Nature of the Problem

Delimitations

Importance of the Study

Study Objectives

Conceptual Framework

Research Methodology

Variable Measures

District Makeup

Project Timeline

References

Jack

Introduction

The Brown vs. Board of Education trial in 19

was a landmark case that deemed racial segregation of schools in the United States to be unconstitutional (Brown v. Board of Ed, 1954).

Sixty years later, segregation in NYC public schools has become a growing trend.

“Out of 895 slots in Stuyvesant High School’s freshman class, only seven slots were offered to Black students” (Shapiro, 2019)

Household income and educational funding appear to have been the driving forces of this trend.

Source: Brown v. Board of Education of Topeka,

47 U.S. 483 (1954); Shapiro, E. (2019, March 2

). Segregation Has Been the Story of New York City’s Schools for 50 Years. Retrieved from https://www.nytimes.com/2019/03/26/nyregion/school-segregation-new-york.html?auth=link-dismiss-google1tap

2
3

KIM

Unresolved Problem

Despite the national and local efforts for social and cultural integration, public schools in NYC, the biggest school district in the country, are now more segregated today compared to when segregation was legal.

Within the last decade (2010-2020), segregation driven by household income and funding formula has become so prevalent that it has caused a public outcry which has prompted policymakers to search for a proper solution.

Source: Source: Brown v. Board of Education of Topeka, 347 U.S. 483 (1954); Shapiro, E. (2019, March 26). Segregation Has Been the Story of New York City’s Schools for 50 Years. Retrieved from https://www.nytimes.com/2019/03/26/nyregion/school-segregation-new-york.html?auth=link-dismiss-google1tap

JACK

Research Goal/Purpose

The purpose of this study is to determine whether the level of household income and funding formula used to allocate resources to schools across the city contribute to the resegregation of public schools in New York City.

JACK

Subproblems

Household income affects the type of neighborhood that a family lives in that determines which public school their children attends.

The funding formula used by school districts determine the amount of resources allocated to each New York City public school.

Jack

Research Questions

What effect has household income had on resegregation of public schools in NYC within the past ten years?

In what ways does the funding formula used by the city contribute to resegregation of public schools in NYC?

LEONG

Hypotheses

H1: Children from low-income households located in minority concentrated neighborhoods are more likely to attend segregated public schools in NYC.

H2: Public schools located in minority-concentrated neighborhoods are likely to receive less funding per student compared to public schools located in majority white neighborhoods.

H0: There is no relationship between household income and resegregation in NYC public schools.

H0: There is no relationship between the funding formula and public school resegregation in NYC public schools.

Adiba

Definition of Key Terms
9

Segregation
04
The institutionalized separation of an ethnic, racial,
or other minority groups from the dominant majority (Farley, Frey, 1996).

Funding Formula
03
The way NYC department of education allocates resources to various school districts in the city (Mezzacappa, 2014).

Household Income
The combined total gross income of every member in a household who is 15 years and older (Kagan, 2019).
01
02
A demographic change that leads to an increase of minority schools or schools concentrated with poverty. In turn, expanding the gap between minority and Caucasian students within the school population (Burr, 2018).

Resegregation

LEONG
Census Bureau for household income definition
Levine Feedback: add citations
Source: Kagan, J. (2020, January 29). Household Income Definition. Retrieved from https://www.investopedia.com/terms/h/household_income.asp; Mezzacappa, D., Mezzacappa, D., Dale, & Dale. (2018, March 29). What is a state education funding formula? Retrieved from https://thenotebook.org/articles/2014/10/02/what-is-a-state-education-funding-formula/

https://www.theatlantic.com/education/archive/2018/03/school-segregation-is-not-a-myth/555614/

Affirmative Action?

Nature of the Problem
Magnitude
School resegregation is a socioeconomic issue that not only affects the quality of education children receive based on where they attend school, but has also had far reaching implications in areas pertaining to social equity and social harmony.
Timeliness
Lack of meaningful integration has always been a concern for policymakers, but the level of school resegregation seen in the past decade has caused loud public outcry.
10
Source: The Fight to Desegregate New York Schools. (2019, October 18). Retrieved from https://www.nytimes.com/2019/10/18/the-weekly/nyc-schools-segregation.html

ADIBA
Levine Feedback: add citations

Delimitations
Scope, this study is limited to:
New York City public school districts, excluding charter schools.
The time frame 2010 – 2020.
Role of household income and funding formula.
The study will not cover segregation in other cities or states.
The study will not explore other factors that might be driving segregation.
11

LEONG

Importance of the Study
As public administrators, it is important to examine the causes driving resegregation of public schools in NYC so as to understand their immediate and long-term implications such as:
Low graduation rates of minority students
Large academic achievement gaps
Limited educational and career opportunities for minority students

12
Source: Dalton, J. C., & Crosby, P. C. (2015). Widening income inequalities: Higher education’s role in serving low income students. Journal of College and Character, 16(1), 1-8. doi:http://0-dx.doi.org.liucat.lib.liu.edu/10.1080/2194587X.2014.992914

ADIBA
Levine Feedback: add a source

Study Objectives
To explore the role that household income has played in school resegregation within NYC in the past ten years.
To determine if the funding formula the city uses to allocate resources contributes to school resegregation across NYC.
13

KIM

Conceptual Framework
14

LEONG

Research Methodology
Design: Mixed Methods – Quantitative & Meta-Analysis
Exploratory study using mixed methods.
Quantitative: Data Processing
To examine the relationship between household income and resegregation in NYC public schools.
To examine the relationship between the the amount of resources allocated by the state to each district and resegregation in NYC public schools.
Qualitative: Meta-Analysis
Using 25 peer reviewed articles, conduct systematic review and quantify how many support the independent and dependent variables.

Kim

Research Methodology cont.
Data Analysis:
Correlation Design
Unit of Analysis:
Average household income in each district
Amount of funding per student in each district
Racial disparities within each district
16
Data Sources:
NYC Department of Education
U.S. Government Accountability Office
Time Dimension of Study Design:
Longitudinal Study

Kim

Variable Measures
Variables Conceptualization Operationalization Data Source
Independent
Variable Individual Household Income The combined total gross income of every member in a household who is 15 years and older. Median Household Income per District Kagan, 2019
NYC Public School Funding Formula The way NYC department of education allocates resources to various school districts in the city. Funding per Student Mezzacappa, 2014
Dependent
Variable Level of Segregation in NYC Public Schools The institutionalized separation of an ethnic, racial,
or other minority groups from the dominant majority. Percentage of White, Black, Asian/Pacific Islander, Hispanic, American Indian/Alaska Native, and Multiracial Students per District Farley, Frey, 1996

JACK

Sources: Calgary, O. (n.d.). School Districts. Retrieved from https://data.cityofnewyork.us/Education/School-Districts/r8nu-ymqj; Keeping Track Online. (n.d.). Retrieved from https://data.cccnewyork.org/data/map/66/median-incomes#66/49/3/107/40/102; NEW YORK COUNTY: NYSED Data Site. (n.d.). Retrieved from https://data.nysed.gov/profile.php?county=31; School Based Expenditure Reports. (n.d.). Retrieved from https://infohub.nyced.org/reports/financial/financial-data-and-reports/school-based-expenditure-reports;
Manhattan Public School Districts
18
Quantitative: Data Processing

Qualitative: Meta-Analysis

ADIBA

District Makeup
Sources: Calgary, O. (n.d.). School Districts. Retrieved from https://data.cityofnewyork.us/Education/School-Districts/r8nu-ymqj;
19

Adiba

Project Timeline
20

TASKS DUE DATE MEMBER IN CHARGE
Team PowerPoint #1 2/3/30 Team
Team PowerPoint #2 2/18/20 Team
Conceptual Framework 2/24/20 Leong
Written Explanation 2/24/20 Team
Proposed Methodology 2/24/20 Team
Project Timeline 2/24/20 Adiba
Research Grid 2/24/20 Kim
Team PowerPoint #3 2/24/20 Team
Proposal Narrative 3/1/20 at midnight Team
Proposal Presentation 3/2/20 Team
End of Text References in APA Style 3/16/20 Team
Team PowerPoint #4: Background/Literature Review 3/23/20 Team
Team PowerPoint #5: Research Hypotheses 3/30/20 Team
Draft of Background/Literature Review 4/8/20 Kim
Team PowerPoint #6: Conceptual Framework/Study Variables 4/13/20 Team
Draft of Conceptual Framework 4/15/20 Leong
Draft of Research Design/Methodology 4/22/20 Jack
Team PowerPoint #7: Research Design/ Methodology 4/27/20 Team
Draft of Results/Findings 4/29/20 Adiba
Team PowerPoint #8: Results/Findings/Conclusion 5/4/20 Team
Project Submission 5/10/20 Team
Final Capstone Presentation 5/11/20 Team

Jack

Literature Review
Equality and Equity of Education Funding
Research by Moser and Rubenstein (2002) suggested that states that have less school districts are more likely to have a more equal distribution of financial resources compared to states with more school districts.
New York City Public School Funding Formula
New York City Department of Education adopted a new funding formula in 2007 for its public school system which is called the Fair Student Funding (FSF) allocation formula
Cooper et al. (2004) suggested that the weighted student formula is the most effective way to determine how adequately funds are allocated and being spent school-by-school in each district

Brown, C. A. (2007). Are America’s Poorest Children Receiving Their Share of Federal Education Funds? School-Level Title I Funding in New York, Los Angeles, and Chicago. Journal of Education Finance, 33(2), 130–146.
Cooper, B. S., DeRoche, T., & Ouchi, W. G. (2004). From Courtroom to Classroom: Operationalizing “Adequacy” in Funding Teaching and Learning. Educational Considerations, 32(1), 19–32.

Literature Review (continued)
Frankenberg, Siegel-Hawley, & Wang, (2011) stated that minority schools are disadvantaged in the terms of funding due external factors such as inadequate housing, unemployment levels rising, and poor classroom ratios that drastically affect the quality of education .

Frankenberg, E., Siegel-Hawley, G., & Wang, J. (2011). Choice without equity: Public school segregation. Education Policy Analysis Archives/Archivos Analíticos de Políticas Educativas, 19, 1-96.

References
Anderson, M.W. (2004). Colorblind Segregation: Equal Protection as bar to Neighborhood Integration. California Law review, 92 (841), 843-890
Bischoff, K., & Reardon, S.F. (2013) Residential Segregation by Income, 1970-2009. US 2010 Project. Retrieved from:
http://www.s4.brown.edu/us2010/Projects/Reports.htm
Brown v. Board of Education of Topeka, 347 U.S. 483 (1954); Shapiro, E. (2019, March 26). Segregation Has Been the Story of New York City’s Schools for 50 Years.
Retrieved from https://www.nytimes.com/2019/03/26/nyregion/school-segregation-new-york.html?auth=link-dismiss-google1tap
Burr, K. H. (2018). Separate but (un)equal: A review of resegregation as curriculum: The meaning of the new racial segregation in U.S. public schools. The Qualitative
Report, 23(7), 1773-1776. Retrieved from http://0-search.proquest.com.liucat.lib.liu.edu/docview/2256508400?accountid=12142
Conger, D. (2004). Understanding Within-School Segregation in New York City Elementary Schools. Educational Evaluation and Policy Analysis, 27 (3) 225-244
Demonte, J., & Hanna, R. (2014) Looking at the Best Teachers and Who They Teach Poor Students and Students of Color are Less Likely to Get Highly Effective Teaching, Center for American Process. Retrieved from: https://www.americanprogress.org/wp-content/uploads/2014/04/TeacherDistributionBrief1
Frey, W. H., & Farley, R. (1996). Latino, Asian, and Black Segregation in U.S. Metropolitan Areas: Are Multiethnic Metros Different? Demography, 33(1), 35-50.
22

Kagan, J. (2020, January 29). Household Income Definition. Retrieved from https://www.investopedia.com/terms/h/household_income.asp;
Mezzacappa, D., Mezzacappa, D., Dale, & Dale. (2014, October 2). What is a state education funding formula? Retrieved from
https://thenotebook.org/articles/2014/10/02/what-is-a-state-education-funding-formula/
Owens, A., Reardon, S., & Jencks, C. (2016). Income Segregation Between Schools and School Districts. American Educational Research Journal, 53(4), 1159-1197.
Retrieved from www.jstor.org/stable/24751626
Shapiro, E. (2019, March 26). Segregation Has Been the Story of New York City’s Schools for 50 Years. Retrieved from
https://www.nytimes.com/2019/03/26/nyregion/school-segregation-new-york.html?auth=link-dismiss-google1tap
The Fight to Desegregate New York Schools. (2019, October 18). Retrieved from https://www.nytimes.com/2019/10/18/the-weekly/nyc-schools-segregation.html

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