Systemic Racism, Abortion and Bias in Medicine: All Threads Woven in the Cloth of Racial Disparity for Mothers and Infants.

• Author: Ploplis, Gabrielle

TABLE OF CONTENTS I. INTRODUCTION 372 II. LEGAL HISTORY: DISCRIMINATION IN MEDICAL CARE FOR RACIAL AND ETHNIC MINORITIES 375 III. DISPARITIES IN HEALTH OUTCOMES FOR BLACK AND INDIGENOUS WOMEN: MATERNAL AND INFANT MORTALITY 385 IV. POTENTIAL CAUSES OF RACIAL DISPARITIES IN MATERNAL AND INFANT MORTALITY RATES: WHY DO MINORITY COMMUNITIES SUFFERS MOST? 387 A. The Lack of Accessibility to Quality Obstetrics 387 1. Hospital Closures and Redlining 387 2. Accessibility for Rural Residents 394 B. Lower Quality of Care Attributable to Hospital Preparedness and Implicit Racial Bias Influencing Medical Decisions 399 C. The Irony of "Pro-Life" Abortion Restrictions: They may be Killing Mothers and Infants 404 V. SOLUTIONS: CONFRONTING RACIAL DISPARITIES IN MATERNAL A ND INFANT MORTALITY IN THE UNITED STATES 410 A. Learn from the Success of other Developed Countries: Increase Employment and Utilization of Midwives by Financing Health Care to Cover Community Health Workers 410 B. Learning from California 415 VI. CONCLUSION 417 I. INTRODUCTION

In 1978, the United States District Court for the District of Delaware reached a decision in a case that may have had far wider implications than were likely anticipated. (1) In NAACP v. Wilmington Medical Center, Inc. the court considered whether the relocation of most care components of Wilmington Medical Center from the inner-city hospital system to an outlying suburb was discriminatory as it related to health care available to underserved minorities. (2) The center planned to close two divisions completely and significantly reduce another division to eliminate maternal and infant care services (among many other types of services) at that location, and provide them solely at the new suburban division. (3) In this case, the plaintiffs argued that relocating hospital services to the suburban location would cause disparities in the availability of quality medical care for the poor, the elderly, ethnic and racial minorities, and the handicapped. (4) At that time, 72% of the county's black residents lived in the City of Wilmington where the care facilities were located. (5) However, the District Court rejected this argument stating that the plaintiffs could not make a prima facie case that the relocation violated Title VI of the Civil Rights Act of 1964. (6)

This case and others like it across the country (7) highlight one of the most influential factors of disparities in health outcomes for racial minorities: the lack of quality care available. (8) What these cases and courts may not have considered when reaching their decisions was how the lack of quality care has contributed to the alarming rate of infant and maternal mortality among black and indigenous women.

Although there is a deep-rooted and national issue of discrimination in many aspects of medical care, this article will address the disparities in black and indigenous infant and maternal mortality compared to that of white infants and mothers. (9) This issue will be addressed on the national scale as well as the state level. Both state and federal law have contributed to the racial disparities in health outcomes for mothers and infants.

This note will argue that decisions like that of Wilmington Medical Center, Inc. have been one of many contributing factors in the disparity in mortality rates of both black and American Indian/Alaska Native newborns in comparison to white newborns across the country. Part II will examine the current state of the law regarding issues of discrimination, accessibility of health care, and relocation and closure of medical centers that has disproportionately affect minorities in the U.S. (10) Part III will discuss the statistics of white, black, and American Indian/Alaska Native newborn and maternal mortality rates in the United States. Part IV will address the potential causes of this disparity, which include inadequate access to quality medical care for racial minorities, implicit racial bias, a demand for more minority doctors (11), and strict abortion restrictions (12). Part V will propose that a reduction in the racial disparities in mortality rates for black and indigenous mothers and infants can be achieved by implementing comprehensive state-level "public-private" collaborations, and increasing availability and coverage of more birthing resources like midwives. Lastly, Part VI will conclude that current condition of federal and state legislation has not eliminated the racial disparities in maternal and infant mortality rates, and further measures must be taken to achieve this goal.

2. LEGAL HISTORY: DISCRIMINATION IN MEDICAL CARE FOR RACIAL AND ETHNIC MINORITIES

   Racial discrimination, even after the end of the Civil War, has been pervasive in the United States. It was not until the 1960s that any major federal legislation was passed to deal with this discrimination. At that time, Title VI of the Civil Rights Act of 1964 was passed with the purpose of protecting people from discrimination on the basis of race, color, or national origin when participating in programs that receive federal funding. (13) In addition, Title VII of the Civil Rights Act of 1964 addressed discrimination in employment. (14)

   After the passage of the Civil Rights Act, a number of legislative efforts were made to address the different facets of racial discrimination. The Voting Rights Act of 1965 was passed in an attempt to address discriminatory voting practices (15), the Fair Housing Act of 1968 was passed to address discrimination in housing (16), the Equal Credit Opportunity Act was passed in 1974 to prevent lending discrimination based on sex or marital status, and amended in 1976 to address discrimination on the basis of race, color, religion, national origin, age (17), and the Disaster Relief and Emergency Assistance Act was amended in 1988 to address discrimination in federally funded disaster assistance programs. (18)

   Although the government began to confront racial discrimination through legislative measures, black and indigenous people continued to face disadvantage due to the countless forms that discrimination can assume. (19) For example, during Ronald Reagan's presidency, his administration made multiple budgetary changes that dramatically impacted black and indigenous people. (20) The Urban Institute conducted an analysis of the impact of the Reagan Administration's domestic policies, and found that black Americans in every income strata had "less disposable income in 1984 than in 1980". (21) Although poverty for black Americans was high in 1980, that this number had significantly increased between 1980 and 1984. (22) According to the Journal of Black Studies, "Of those Americans who fell into poverty since 1980, 22% were black even though [black Americans] ma[de] up only 12% of the U.S. population". (23) Additionally, "per capita expenditures on Native Americans by the federal government declined from $3,500 to $2,500 between 1980 and 1990. Partly as a result, the poverty rate for Native Americans rose from 23.7 percent to 27.2 percent between 1979 and

   1989". (24)

   The Reagan administration also influenced a major change the country's health system. (25) It has been asserted that the dramatic elevation of health care costs began with the Social Security Amendments of 1983 (26), which established the Medicare hospital perspective payment system. (27) As described by the New York Times:

   Before the early 1980s, payments by Medicare and other insurers were tied to costs. But then payers (private insurers and government health care programs like Medicare) began to shift financial risk to providers like hospitals and doctors. This approach later spread to other Medicare services and other payers, including private insurers. If providers could get costs down, they made money. If they could [not], they lost money. (28) In addition, the Reagan administration reduced Medicaid expenditures by over 18%, cut the Department of Health and Human Services Budget by 25%, and cut federal funding for maternal and child health by 18%. (29)

   These were not the only budgetary cuts that affected minorities during the Reagan Administration. The Title X Family Planning Program, a federal grant program through the U.S. Department of Health and Human Services designed to provide low-income individuals with family planning, reproductive and preventative health services, suffered significant budget cuts "as part of the broader Reagan Administration initiative to reduce federal spending on all social service programs... Title X funding dropped to $120-140 million and remained flat until 1992". (30) Further, Women, Infants, and Children (WIC) which provides "low-income pregnant women and children with formula and healthy food staples" could only serve a fraction of those eligible. (31)

   As black Americans are three times as likely to participate in programs aimed at protecting those with low and moderate income, these budgets cuts in particular have disproportionately affected the black community. (32) These budget cuts also resulted in hospital closures in urban areas. Between 1980 and 1991, 294 urban hospitals were shut-down. (33) The number of women who were not receiving prenatal care increased, the life-expectancy-at-birth of black Americans decreased, and the Native American community suffered dramatically. (34) In an attempt to address disparities in health for minority populations, Congress enacted the National Institutes of Health Revitalization Act of 1993 which established the Office of Research on Minority Health. (35) A number of years later, Congress enacted the Minority Health and Health Disparities Research and Education Act of 2000. (36) This legislation made recognition of the ongoing health disparities for black and indigenous people in the United States (37), and sought to reduce these racial disparities by establishing the National Center on Minority Health and Health Disparities. (38) The National...