A Framework to Address Maternal and Child Health Inequities as a Place-Based Issue

Tonni Oberly, Jason Reece, & Leigh Graham

https://doi.org/10.56927/725809

Abstract

Maternal and child health inequities are a key indicator for community health and wellbeing. Black communities are especially burdened with unjust maternal and infant mortality. These outcomes are upheld by place-based factors known as the social and structural determinants of health, including structural racism. While attention to inequitable MCH outcomes has grown, the authors argue that MCH should be addressed as a place-based issue. With this, we demonstrate the utility of translating the individual-level Black Mamas Matter Alliance (BMMA) Holistic Care Principles to the community level. This approach is akin to other Black-led planning paradigms and can lead to further reintegrating the fields of public health and city planning.

Introduction

Maternal and child health (MCH) outcomes are a key indicator for community health and especially highlight deficits in how communities care for their most marginalized populations.¹ Consider Guinier’s canary in the coal mine analogy for political-race:

"The canary is a source of information for all who care about the atmosphere in the mines—and a source of motivation for changing the mines to make them safer. The canary serves both a diagnostic and innovative function. It offers us more than a critique of the way social goods are distributed. What the canary lets us see are the hierarchical arrangements of power and privilege that have naturalized this unequal distribution."²

Importantly, the problem does not lie within the canary; the problem is the coal mine, the detrimental environment. With the growing recognition of the impact of place on health outcomes in public health,^3,4and likewise the role of health in fostering livable communities in urban planning practice, both fields must further address MCH as a place-based issue. In this essay, we demonstrate the utility of scaling a framework developed by the Black Mamas Matter Alliance (BMMA) research working group from an individual care model to a place-based approach that offers a path forward for public health and urban planning practitioners and scholars to address community inequities through a focus on MCH inequities.

Racial inequities in MCH

We hear Guinier’s canary singing when we look at the persistent racial inequities in childbirth in the US: Infants born to Black birthing people are more than twice as likely to die before their first birthday compared to infants with non-Hispanic white mothers.⁵ Wide inequities in maternal mortality between non-Hispanic Black, non-Hispanic white, and Hispanic birthing people are persistent and increasing (Image 1).⁶ Maternal mortality in the United States has been rising since 2010, making the U.S. an outlier among high-income countries.⁷ Notably, only 35% of maternal deaths occur during childbirth and in the immediate days following. The remaining two-thirds occur during pregnancy and in the first year post-partum,⁸ as negative structural determinants of health including racism, poverty, gaps in healthcare access, community and interpersonal violence, and other factors put birthing people’s lives in jeopardy.⁹ These indicators are another measure of the racism that permeates all aspects of life in the United States including access to housing, education, transportation, healthful food, quality clinical care, and disaster preparedness and upholds the systems that perpetuate inequities in MCH outcomes.^9-14 These disturbing trends have generated longstanding and newfound concern^15,16 and long overdue policy action.^17,18

Image 1: U.S. Maternal Mortality Rates by Race 2018-2020

In the US, public health and urban planning are sister fields with joint origins in urbanization and industrialization¹⁹ that, after carving out parallel paths for community improvement over the 20th century, are again reintegrating over shared interests in sustainable, healthy communities. Yet, maternal health is mostly overlooked in planning practice (see Reece,²⁰ for a notable exception), and public health responses to maternal health overly focus on the individual and mother-child dyad instead of structural factors such as access to quality education, housing, food, and transportation.

Due to the intersectional and nested nature of the factors contributing to MCH inequities, the authors suggest an interdisciplinary approach that spans planning and public health, and centers feminist epistemology to address these deeply entrenched inequities. The authors leverage the "Best Practices for the Conduct of Research With, For, and By Black Mamas" developed by the BMMA research working group.¹⁵ While the unit of care of the BMMA framework is the individual patient, we scale these principles to the community level through city and regional planning theory and practice.

Learning from Black Mamas: Holistic Research and Practice for Healthy Communities

The BMMA’s best practices start with the recognition of the intersectional impacts of historic and current systems of oppression, including racism and sexism. Although acknowledgement of historical structures of oppression is growing in public health and planning,^4,21,22 a gap remains in moving from scholarly attention to practical action, and participatory or collaborative approaches to research are still frequently discounted as less rigorous.²³

The working group establishes three truths that underpin their work:

1. There are no solutions or interventions to improve MCH outcomes for Black birthing people that they do not already possess.
2. “Shame and blame” narratives are racist and harmful.
3. Separating the social determinants of health from clinical determinants of health is unethical and problematic.²⁴

These truths demand a recognition of the structural and systemic factors that contribute to inequitable outcomes rather than an individualistic understanding of health. Guided by these position statements, the BMMA working group’s best practices connect theory and practice to create an actionable framework of holistic care principles that center Black birthing people’s experiences. We demonstrate the translation of the BMMA care principles to the community-level to address MCH inequities as a place-based issue in Table 1 below.

Table 1: Principles of Holistic Research and Practice for Healthy Communities
BMMA Holistic Care Principles (24)	Translation for Community-level Practice
Addresses gaps in care and ensures continuity of care	Addresses gaps in community need
Is affordable and accessible	Creates affordable and accessible communities
Is confidential, safe, and trauma-informed	Is confidential, safe, and trauma-informed
Ensures informed consent	Ensures community participation, leadership, and ownership
Is Black Mama-, family-, and parent-centered, and patient-led	Is Black mama, family, and community centered and led
Is culturally-informed and includes traditional practices	Is culturally and historically informed and includes traditional practices
Is provided by culturally competent and culturally congruent providers	Is conducted by culturally humble and culturally congruent planners, public health practitioners, and community members
Respects spirituality and spiritual health	Respects spirituality and spiritual health
Honors and fosters resilience	Honors and fosters community resiliency
Includes the voices of all Black Mamas	Uplifts community voices
Is responsive to the needs of all genders and family relationships	Plans for the needs of diverse family structures
Provides wraparound services and connections to social services	Integrates physical and social community needs

The BMMA framework is a trauma-informed care approach. This means it understands trauma as a community health issue rather than solely an individual’s health burden. Trauma-informed planning recognizes communal trauma, stemming from historic and structural conditions of racism, sexism, disenfranchisement, and isolation.²⁵ Examples of trauma informed planning practice include acknowledging harm done and promoting consciousness, honoring history and celebrating culture, fostering social cohesion, removing participation barriers, and promoting safety.²⁵ By integrating the principles and practices of trauma-informed care, planners can more holistically uplift and meet the needs of Black birthing people and Black communities.

The principles of holistic care outlined by BMMA should guide planning and public health theory and practice to improve maternal and child health in Black communities. Black-led community-based doulas are perhaps one of the best aligned, evidence-based interventions with the community principles outlined.²⁶ Similarly, the foundational strategies of Best Babies Zones which take a place-based, community-driven approach to drive a social movement harkens to the holistic approach needed to improve birth outcomes.²⁷ Housing mobility programs which provide financial and social support to enable families to move to areas of opportunity such as Central Ohio’s Move To Prosper could be further enhanced by centering the highlighted principles.²⁸ For example, while Move To Prosper provides wrap-around services to individual families, community needs are not addressed.

Joining Otherwise Black-led Planning Paradigms for Healthier Communities

Venerable planning paradigms spanning from advocacy²⁹ and equity planning³⁰ to communicative planning³¹ have failed to shift power and agency to Black communities. Our framework joins “otherwise” planning paradigms that critique and counter conventional planning theory by centering Black communities.³² Similarly, Robert’s Critical Sankofa planning recognizes alternative modes of knowledge such as collective memory, cultural performance, and oral tradition to uncover unrecognized historical wisdom that can be applied to shape the future.³² Expanding the BMMA working group’s framework to the community-level provides opportunities to imagine new spatial and communal Black futures with wellbeing and flourishment as a reality.

Planning and public health should center maternal and child health as a primary outcome for community wellbeing, supporting, enabling and partnering with Black mamas as the experts leading the way forward. Scaling BMMA’s framework to the community level for holistic research and practice for healthy communities is a demonstrable approach that bridges aligned fields interested in community wellbeing without marginalizing or tokenizing lived experience. We have argued that MCH outcomes are an overlooked and underutilized metric for community and societal wellbeing. Metaphorically, MCH inequities, particularly Black birthing people’s higher rates of mortality and morbidity and infant loss, are the canary in the coal mine. Planners and public health practitioners must be reflective in their research and practice with, for, and by Black communities, including birthing people, shifting power in who is driving research and action. The fields must continue to diversify their workforce and prioritize uncovering anti-Blackness endemic in the professions and communities,²¹ including in so much well-regarded scholarship on community and health inequities that finds correlation or causation with race, rather than racism, thus implicitly blaming Black people for their poor health.³³ In doing so, we ask our planning and public health colleagues to consider this: the canary does not only sing songs of despair. We sing songs of joy, love, and community.

About the Authors

Tonni Oberly, MPH is a doctoral candidate in City and Regional Planning at The Ohio State University Knowlton School of Architecture and a Birth Equity Research Scholar at the National Birth Equity Collaborative (NBEC). Oberly's research sits at the intersection of planning and reproductive justice, with a focus on Black maternal and child health outcomes.

Jason Reece, PhD is an associate professor of city and regional planning at the Knowlton School and interim executive director at The Kirwan Institute for the Study of Race & Ethnicity. His research seeks to understand the role of city planning in fostering a built and social environment which supports a just city and healthy communities.

Leigh Graham, PhD, MBA is the Senior Advisor for Innovation Research at the Bloomberg Center for Public Innovation at Johns Hopkins University. Dr. Graham is an expert in neighborhood and racial equity in urban policy and public health, particularly after disasters and in times of crisis.

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