Author(s): Joia Crear-Perry, National Birth Equity Collaborative, Washington D.C.; Rosaly Correa-deAraujo, Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health; Tamara Lewis Johnson, Office of Disparities Research and Workforce Diversity, National Institute of Mental Health, National Institutes of Health; Monica R. McLemore, Family Health Care Nursing Department & Advancing New Standards in Reproductive Health, University of California San Francisco; Elizabeth Neilson, Office of Disease Prevention, Office of the Director, National Institutes of Health; Maeve Wallace, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine 

Article Type: Peer-reviewed Journal 

The authors of this article make a distinction between structural and social determinants of health, describing structural determinants as the “cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)” of social determinants of health. The authors explore these concepts in the context of social determinants of maternal health. They present a theoretical framework of determinants of Black maternal health called “Restoring Our Own Through Transformation” (created by Jessica Roach, 2016) to illustrate a “web of causation” between structural and social determinants of health and wellness. Crear-Perry et al. explore structural determinants of maternal health that are features of the U.S. health care system including financial barriers to care, a shortage of primary care providers, and gaps in quality, while also considering policy levers that might improve structural factors to support better maternal health outcomes, like paid family leave, access to affordable and comprehensive health care (which could be measured using exposure to Medicaid expansion, having Medicaid coverage through 12 months postpartum, etc.), access to culturally appropriate care (e.g., with clinicians that have received education on structural determinants of health and health inequities—i.e. “structural competency” education), and investments in community-oriented primary care for diverse women of reproductive age (e.g., midwifery maternity centers, nurse practitioner practices, maternal and child clinics, etc.).

Author(s): Madeline Morcelle, Senior Attorney in the National Health Law Program's (NHeLP) Washington, D.C. Office

Article Type: Peer-reviewed journal 

The author of this journal article argues that while Medicaid presents a powerful vehicle for reproductive justice, especially for Black people and people of color, its structure allows for discriminatory eligibility and coverage policies that worsen health inequities for adults and their children. Historically, women and people of color have been advocating against reproductive oppression and advocating for “...universal, comprehensive, and affordable health coverage and access, with strong nondiscrimination protections, for everyone.” However, the author describes how voices of those experiencing oppression need to be centered or part of an “open source” framework rather than a “bottom to the top” engagement to dismantle oppressive systems. The author explains how Medicaid was designed by whites in power to only provide access to health coverage for some, “...the ‘worthy poor’,” and that these discriminatory practices continue today through policy decisions, like making Medicaid expansion a choice, for example. The author also describes the lack of adequate benefits for certain populations. While advances have been made recently, namely the Medicaid postpartum coverage extension opportunity and options to cover some immigrant groups, reproductive justice voices and frameworks should be at the center of Medicaid reform efforts to stop reproductive oppression and advance health equity for all.

Author(s): Terri-ann Monique Thompson & Yves-Yvette Young, Ibis Reproductive Health, Tanya M. Bass, North Carolina Central University, Stephanie Baker, Elon University, Oriaku Njoku, Access Reproductive Care–Southeast, Jessica Norwood, The Runway Project, Monica Simpson, SisterSong Women of Color Reproductive Justice Collective 

Article Type: Peer-reviewed journal 

This article details a community-based participatory research approach to focus groups with nearly 50 Black women living in both Georgia and North Carolina (states chosen for having relatively restrictive reproductive health policies) to understand their experiences interacting with reproductive health care. The research team focused on three aspects of the participants’ experiences: access to health care, use of health care, and experience in health care – and how these experiences were connected to structural (summarized here) and individual racism. In terms of structural factors and access to adequate care, findings include that reproductive health clinics were often located outside of participants’ communities, making accessing care difficult. Focus group participants covered by Medicaid experienced issues with copayment being too burdensome. Lack of abortion coverage in some states was also a major concern for participants. In terms of structural racism and service use, authors report inconsistencies in what services are covered by different plans (both private and Medicaid coverage are mentioned), which impacted utilization. Focus group participants also reported that being a Black woman or living in a predominately Black community and receiving public assistance (or being uninsured) negatively impacted their health care experiences. Further, there was a perception that facilities caring for primarily publicly-insured individuals were lower quality. The authors urge for policy actions that alleviate these structural barriers, such as expanding federally funded Medicaid coverage, requiring abortion coverage, increasing reimbursement for doulas and midwives, and investing in hospitals that provide uncompensated care.

Author(s): S Michelle Ogunwole, Department of Medicine, Johns Hopkins University School of Medicine & John Hopkins Center for Health Equity; J’Mag Karbeah and Katy Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health; Rachel Hardeman, Center for Antiracism Research for Health Equity & Division of Health Policy and Management, School of Public Health, University of Minnesota; Debra G Bozzi, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Kelly M. Bower, Johns Hopkins University School of Nursing, & Johns Hopkins Center for Health Disparities Solutions; Lisa A. Cooper, Department of Medicine, Johns Hopkins University School of Medicine, Departments of Health Policy and Management, Health, Behavior, and Society, and Epidemiology, Johns Hopkins Bloomberg School of Public Health 

Article type: Peer-reviewed journal 

This article presents findings from a landscape analysis of state legislation related to doula care, including Medicaid coverage and reimbursement, with specific attention to whether legislation addresses racial health equity. It is well known that disparities in birth outcomes disproportionately affect Black and Indigenous birthing people. And evidence suggests that doula care is associated with improved birth outcomes. Authors draw on reproductive justice and public health critical race praxis frameworks in formulating study questions and methods. Reproductive justice refers to women having autonomy over their own bodes and the right to have and parent children safely and with access to community supports to realize optimal reproductive health. Public health critical care praxis theory acknowledges the legacy of white supremacy and racism as a root cause of health inequities in public health research. Authors draw on this theory to develop criteria for assessing whether doula care legislation is designed to address racial health equity. Criteria included reimbursement with plans to provide a living wage, collaboration with community-based doulas, training and certification requirements and funding, and emphasis on workforce diversity, promising practices, and metrics. Authors found that of the 73 bills introduced by 24 states between 2015 and 2020, just over half focused on Medicaid reimbursement for dual care. (Twelve bills in seven states became law.) However, only two states that passed Medicaid reimbursement for doulas also met some of the authors criteria for racial equity in their laws. Authors conclude that while proposals for increased access to doula care have increased over time, a racial equity lens is lacking. Authors suggest engaging doulas and considering racial equity policy assessments in the legislative drafting process.