Discrimination and Challenges during Pregnancy

Overview

Discrimination during pregnancy has been an issue for decades, particularly in Western countries. In the past ten years, over "50,000 pregnancy discrimination claims were filed in the United States" alone. The large majority of reported experiences of discrimination relate to race and ethnicity, specifically within the BIPOC population. Related to these issues are cultural differences and discrimination that may arise from a lack of knowledge or understanding of differing cultural practices and traditions. Another pertinent concern is the stigma surrounding teen pregnancy and the discrimination and prejudice that come with being pregnant at a young age.

Racial Discrimination

Discrimination and problems concerning patient-provider communication during prenatal care is largely understudied, although nearly two million American women are affected each year. Black and Hispanic women are more likely to experience judgment and lower-quality care due to race, language, and culture during their hospital stay compared to White women. These individuals are considered "visible minorities", which is defined as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour”.These women are susceptible to maltreatment in the healthcare system, and maternity care is no exception. Mothers are given the choice to decline procedures in a hospital setting, such as an epidural or a cesarean section. When deciding on birth plans or choosing to decline a procedure, in particular when it is against the views of the provider, Black and Latina women are more likely to be perceived as “uncooperative or non-compliant patients,” whereas White women are viewed by healthcare workers as “well educated and decisive”. Other risks such as morbidity during childbirth is twice as likely to affect Black and Latina women in New York City compared to White women. Statistics such as these imply that patient-provider communication in the heath care system is in need of improvement and is the root cause of the drastic disparity between mothers of different races and/or ethnicities.

Many women of colour describe their prenatal care as stressful and disrespectful, due to race, ethnicity, and/or language. A proposed theory is that White healthcare workers may hold stereotypes and implicit racial biases which influence how they treat their patients. This is where an individual holds "oversimplified ideas about groups of people". The reason for this is due to "white privilege", which is where those in a dominant group believe that their experiences are the norm and a failure to see this is "an example of a dominant group’s often unconscious racism". There are also false-beliefs held by practitioners, one being that Black mothers have children for the sole reason of obtaining public assistance. Because of this, Black women feel obligated to change their behaviour in order to receive better quality prenatal care, such as dressing well and/or displaying intelligence. This "hypervigilance to racial microaggression" can have a negative impact on health care experience and patient-provider communication due to the stress associated with feeling the need to act or present oneself a certain way.

Socioeconomic Factors

Level of education and income are factors that can influence one’s experience and satisfaction with the healthcare system. Research suggests that patients with a higher education and income level are more likely to report a lower rating of care experience whereas those in a racial/ethnic minority group report similar or higher ratings. One proposal has suggested that women who obtain a higher education might have higher expectations concerning the responsiveness and care from clinicians versus those who have less education, and therefore evaluate their experiences more negatively. It is also noted that mothers who are uninsured or have public insurance are more likely to report discrimination in comparison to those who have private insurance.

Long-term Impact

Discrimination during pregnancy has not only immediate impacts on the mother and the prenatal experience, but also long-term impacts on the infant. Discrimination during pregnancy predicted "greater inhibition/separation problems and greater negative emotionality" of the child at six months and one year old. Those that are part of a racial/ethnic or socioeconomic minority face challenges such as poor behavioural, health, and cognitive problems during the first year of life. Black and Latinx infants as well as those from a low socioeconomic background are at a higher risk for these disparities compared to white infants and those from high socioeconomic backgrounds. Some negative outcomes that adolescents face as a result of parent discrimination are "greater distress, and internalizing symptoms, as well as lower self-esteem" . Therefore, it is crucial to prevent and reduce discrimination and maltreatment during maternity care to ensure the development of the child's "well-being, development, and achievement outcomes later in life".

Policy Implications and Interventions

In order to help women in maternity care, particularly those who experience higher levels of discrimination, policies and training need to be implemented. Cultural competency training and awareness concerning implicit racial biases in the healthcare system might help reduce patient-reported discrimination. These trainings can be made mandatory in hospital and clinical settings, and can be a requirement for employment in healthcare fields to ensure positive relationships and improved communication between patients and their providers. Women who are facing social disadvantages have been shown to have benefits when a doula present during pregnancy and childbirth. Improved communication and more perceived control over the childbirth experience are ways in which doula care can positively impact those who are more at risk for racial-ethnic discrimination during maternity care. There should also be more awareness on the impact that discrimination from healthcare providers has on the mother and the child's well-being. "Screening pregnant women for exposure to discrimination and maternal distress might help to identify women to target for interventions" and therefore can help support and aid in coping with distress as a result of harmful experiences. "Organization of care and positive communication practices" are some examples of interventions that may help to "mitigate or prevent perceived racial-ethnic discrimination" in maternity care in the U.S..

Cultural Discrimination and Differences

Mothers coming from different cultural backgrounds often encounter challenges when faced with the Western healthcare system. Significant differences in beliefs and practices exist in matters such as women’s abilities to make decisions, parental obligations to children, the value of life, views on disabilities, and how patients and clinicians interact with one another.

Aboriginal Women in Australia

Indigenous Australians have been consistently observed to have poorer health outcomes compared to the general population. Socioeconomic inequalities, risky health behaviours, and a lack of culturally safe maternity services contribute to poorer health outcomes in Indigenous mothers, much of which is rooted in Australia’s colonial history. Aboriginal women often report experiencing discrimination in health care services, with many practitioners dismissing the importance of their cultural practices related to childbirth. The lack of support and recognition for their cultural practices led to sentiments of alienation and loneliness, as well as feeling insignificant and undermined when faced with racism.

Close the Gap

The Close the Gap campaign was started in 2007 by the Australian Human Rights Commission, in an attempt to improve and reduce “Indigenous disparities in health, education, employment and incarceration rates, and draw attention to service delivery inadequacies”. The campaign targeted areas where maternal health inequalities existed and took action by, for example, hiring more Indigenous maternity workers and providing “culturally competent maternity care”. One way they implemented this was by dedicating programs for ‘birthing on country’, which means “giving birth on the land of an Aboriginal woman’s own birth or on the land of the father of the child”. Recognizing how differences in maternal care can impact health outcomes and health care experiences in the future has allowed for a deeper examination of Aboriginal women's birthing practices and stories.

The Spirit Catches You and You Fall Down

The Spirit Catches You and You Fall Down is one story about an immigrant family's struggles with the Western healthcare system. Although the majority of the novel is not related to pregnancy, it effectively conveys the emotional, mental, and physical obstacles that can be encountered in American healthcare. A willingness to learn about and understand Hmong culture would have had a positive impact on Lia Lee's treatment and fostered a better relationship between the healthcare providers and her parents. With the language barrier, however, it is difficult to know if the doctors would have understood the parents' wishes even if they were open to considering their values. Many medical centres have inadequate or no access to interpreters. This lack of resources leads to poorer quality health care and an "increased risk of experiencing medical errors".

Cultural Competency and Ethics

It is understandable that many medical professionals may be unsure of what to do when they encounter patients with differing cultural views and practices. However, research has shown being empathetic can often go a long way. While clinicians should not blindly accept all patients' or mothers' requests, “acknowledging and exploring a patient’s cultural perspective may be ethically required”. Ethics in medicine, particularly pertaining to reproduction, are some of the most challenging concepts to navigate. Healthcare workers must be able to determine which practices would be safe to allow and when to refuse, such as if it puts the mother or the child in danger. While the relationship between the patient and the clinician is important, it is also crucial to not go against professional obligations. Cultural competency has been argued to be an ethical obligation in order to ensure patients receive effective care while maintaining a sense of respect for their culture. As such, learning about cultural competency was made a requirement in the United States for undergraduate and graduate students pursuing a career in the medical field

Teen Pregnancy Discrimination

Stigma

Adolescents who become pregnant experience judgment from peers, family, even strangers, and are subject to the stigma surrounding teen pregnancy. They are often looked down upon for reasons such as their engagement in sexual activity, their choice about going through with the pregnancy, or getting an abortion. Approximately 70% of pregnant adolescents drop out of school largely due to the discrimination and lack of support they receive from peers and adults around them. “Peer isolation, lowered self-esteem, and alcohol use during pregnancy” are also reported in teens who experience stigma, which can have negative outcomes on both the adolescent and the baby.

Gender Double Standard

While societal views on teen pregnancy are generally negative, a gendered double standard no doubt exists. Girls are shamed for being sexually active, while boys are praised for it as if it is an expectation. In the event of pregnancy, most of the blame and responsibility is placed on the girl. Not all boys experience the same consequences and repercussions of teen pregnancy like girls do; they are not subject to the same discrimination and judgment that girls experience and have the ability to remove themselves from the situation, being uninvolved during the pregnancy.

Portrayal in the Media - Juno

Juno is one film that tackles the topic of teen pregnancy and sheds light on the stigma that accompanies it. One scene shows Juno getting an ultrasound, sharing with the technician that she is giving up her baby for adoption. The ultrasound technician replies by saying “thank goodness for that”, since being a teen mom is “obviously a poisonous environment to raise a baby in''. Comments like these are unfortunately common for many pregnant adolescents; discrimination in the form of “disapproval, negative comments and argumentative encounters” have been regularly reported by teen moms.

Room for Improvement

Past research has highlighted the detrimental effects of stigma and discrimination on pregnant teens. Putting the blame on adolescents for making “poor” life choices and shaming them for their actions leads to impoverishment and feelings of abandonment. It is crucial for family members and friends to offer support and stand by these teens during such a tumultuous time.