Maternal & Child Health: a Public Health Model for Social Justice (video)


A few weeks ago, I gave the guest reflection at the Unitarian Universalist Church of Tucson on maternal and child health in Arizona. Below is the text of my talk or you can listen to the podcast here. I have been talking with people for months about this topic, and many of you have expressed an interest in working on solutions to improve maternal and child health. My plan is to hold stakeholder meetings on the state of Maternal and Child Health in Arizona, with the goal of crafting bills for the 2020 session. Stay tuned on the blog and on my Facebook page. I will be giving another talk on this topic at the Salt of the Earth Labor College on September 21, 2019.

Prevention: A Public Health Model for Social Justice (reflection text)

As the Public Health Parable in the Message for All Ages previewed, today, we are going to talk about prevention not only a public health strategy but also a social justice strategy.

Like the industrious carpenter in the video, we are going to assess the current problems, walk upstream to examine the root causes, and brainstorm long-term solutions to tackle those root causes.

Rather than focus solely on putting out fires today—as our government often does—the Public Health Parable teaches us to not only put out the current fire but also to devote significant effort to preventing those fires in the future.

My original idea for today was to discuss three unfolding public health crises: migration, housing security, and maternal and child health, but when I started to pull everything together, I realized we would be here all day if we tackled upstream solutions for those three, highly complex issues.

These three seem like disparate topics– migration, housing security, and maternal and child health—but they have commonalities.

Can you name some?  

[Pause for audience to shout out ideas.]

Poverty is a big factor in all of these, right?

But many of the “isms” are also involved: racism, sexism, classism, capitalism. And let’s not forget capitalism’s destructive cousins: war, austerity and bad policy.

How we tackle the unfolding crises of migration, housing security, and maternal and child health could have wide-ranging, positive OR negative repercussions on children, families, communities, future generations, and the climate.

Now we’re talking interconnectedness of all life, right?

Today, I want to focus on the area that has received the least amount of attention: maternal and child health. We hear a lot in the news about migration and housing, but there is a statewide and nationwide crisis in maternal and child health that is being ignored.

When you came in, you received an index card. Keep that handy because as we discuss maternal and child health challenges, you will be asked to jot down your ideas for upstream solutions. My plan is to collect these cards and study your answers for trends and ideas. I collected audience ideas and opinions at the healthcare forum I organized a couple of years ago. That direct input on healthcare from Tucson residents was invaluable to me in the Legislature. I plan to pursue all three of these issues– migration, housing security, and maternal and child health. If you want to work on these issues, put your name, phone number and email on the back.

Maternal and Child Health Challenges

One overarching public health tenet that was drummed into us when I was in the Masters in Public Health Program at the University of Arizona was: If the mother is healthy, the family will be healthy. The theory was that a healthy woman would have the knowledge and have the life skills to not only seek medical care for her and her family when they needed it but also would not use tobacco or illicit drugs and would comply with preventive measures like cancer screening, well-woman check-ups, well-baby and well-child check-ups, and vaccinations. The Public Health Super Mom would keep herself and her family healthy, which would, in turn, help the community and the population be healthier.

The problem is that Moms and their children are in crisis.

I didn’t realize this until my granddaughter Selah was born with a birth defect last fall and spent the first three months of her life in the Nursery Intensive Care Unit. I learned a lot about premature birth, birth defects, and high-tech healthcare for tiny babies. While I was sitting there with Selah, I got to know the nurses, the new Moms, and their little babies. I got to hear their stories.

My first impression was that the face of premature birth in Arizona was young, brown and rural. When I started investigating my hunch, I realized that the state of women and children in Arizona was much worse that I had imagined. It goes far beyond education and access to abortion, which are the topics we hear the most about.

Too many Moms are dying from preventable pregnancy or childbirth-related causes. Too many babies are dying in infancy. Too many babies are being born prematurely or born with birth defects or both. And on a related note, too many women are not getting adequate—or sometimes any—prenatal care.

Compared to other states, Arizona ranks in the 40s on overall policies related to the health of women and children, according to America’s Health Rankings, a service of United Health Foundation. Arizona ranks at the bottom of the states for: availability of publicly funded women’s health services (46), children with health insurance (41), clinical care for women (47), concentrated “disadvantage” (47), and intimate partner violence (47).

The Annie E. Casey Foundation also ranks Arizona near the bottom in its 2019 Kids Count Data Book. Compared to other states, Arizona ranks #46 in overall child well-being, #43 in economic well-being, #46 in education, #35 in health, and #46 in family and community.

There are vast geographic and racial differences in maternal and child health across the United States, which begs the question: WHY? To put the disparities into perspective, let’s look at maternal death, which is defined as death within 42 days after the end of a pregnancy. California ranks number one with only 4.5 maternal deaths per 100,000 live births, while some states—like Georgia, Louisiana and Indiana have more than 10 times the number of maternal deaths as California does. Arizona ranks in the middle — #25 in maternal mortality, with 18.8 maternal deaths per 100,000 births. This year—thanks to advocacy from a family who lost a young Mother—the Legislature voted to look at the maternal death data it has been collecting but has not analyzed.

Looking at the national data, two of the biggest single factors for predicting maternal death are African American race and being uninsured. For more than 100 years, the maternal death rate for African American women has been three to four times higher than the death rate for white women. Uninsured women of any race are three to four times more likely to die of pregnancy-related deaths. Native American women have a death rate that is twice that of white women, but both Asian/Pacific Islander and Hispanic women have lower maternal death rates than white American women.

Nationwide the statistics for pregnancy-related death increased by 26.6 percent between 2000 and 2014. Compared to other high-income countries in North America and Western Europe, the US has the highest rate of maternal mortality—and it’s increasing in the US—despite a global trend of deceasing maternal death. There is a lot of information to unpack in these statistics, but the bottom line is that many of these women are dying preventable deaths. Again, why?

We hear a lot about Arizona shortchanging school children by chronically underfunding education, but Arizona’s antipathy for the wellbeing of children begins before birth. Racial and ethnic health disparities in access to care are clearly visible in data provided on the Arizona Department of Health Services website.

Looking at economic indicators first, we know that age of the mother, years of education, and marital status all impact economic viability.

  • Native American Moms are most likely to be under 19 years old (10.7%). This is three times the rate for White Moms.
  • Asian/Pacific Islander Moms are mostly likely to be over 30 years old (60.8%). This is significantly higher than the other racial and ethnic groups. Being an Old New Mom has risks. For example, Asian Moms are far more likely to have cesearean deliveries.
  • Hispanic Moms are most likely to have less than 9 years of education (6.2%). This is six times the rate for White Moms.
  • Native American Moms are most likely to be unmarried (78.1%). This is more than double the rate for White Moms. I put marital status in here not as an indicator of morality but as an economic indicator.

What can we learn from these numbers?

When you look at age, education and marital status, I believe we see access to care challenges and unintended pregnancy. Arizona has been in the forefront of the fight against access to cheap or free contraception and the morning after pill, access to abortion, and against medically accurate sex education. The result is: the largest group living in poverty is single Moms and their children.

Once Arizona women become pregnant, there are disparities in care.

  • White Moms are most likely to receive prenatal care in the first trimester (74.7%)
  • Native American Moms are most likely to get no prenatal care (4%)
  • Native American Moms are least likely to get more than 13 prenatal visits (19%)

Consequently, we see disparities in outcomes in Arizona.

  • Black Moms are most likely to have a preterm baby (less than 37 weeks)
  • Black Moms are most likely to have a low birth weight baby (under 2500 grams)
  • And nationally, as mentioned, African American Moms are three to four times as likely to die from pregnancy-related causes than White Moms.

Besides the obviously human impact of limited care and poor health outcomes, there is a significant cost to the state of Arizona and to our nation’s healthcare system. Here is a table with the total number of births, the percentage of preterm births and estimated total cost. NICU doctors have told me that each preterm or low birth weight baby costs between $500,000 and $1 million. I calculated the cost for each baby at one million and at $750,000.

The annual cost for preterm babies in Arizona is between $6 and 8 billion. Because of our state’s low wages and high poverty rates, 52% of Arizona births are funded by AHCCCS, the state’s Medicaid system.

So, the state is paying billions of dollars in NICU charges because we’re not providing adequate prenatal care, access to contraception, access to abortion and medically accurate sex education.

Now you know the scope of the problem, what are the upstream solutions?

Here are a few…

  • Look at national goals from March of Dimes and Healthy People 2020 and 2030 to formulate Arizona goals and plans.
  • Specific outreach to poor and rural women
  • Develop community health worker program to provide prenatal care and referrals
  • Re-establish rural health clinics. (Five rural counties are maternal and child health deserts because lack of doctors.)
  • Dental care for pregnant Moms.
  • Cheap or free contraception and morning after pill.
  • Medically accurate sex education in schools.
  • Educate girls and help them stay in school.
  • Repeal anti-abortion laws.
  • Tackle poverty in a meaningful way.

The following video was shown for the “Message for All Ages” segment of the service.

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