Learning Objectives
By the end of this section, you will be able to:
- Identify families in the community at higher risk for poor health outcomes and their experiences with the health-care system
- List health risk factors affecting families who are at increased risk during pregnancy and birth
- Identify and discuss social determinants of health in the childbearing population
Families can be at higher risk due to discrimination, poverty, injustice, or psychosocial issues. The nurse encounters these families in health-care settings as well as in the community. The nurse should use culturally sensitive approaches with these families and join community or professional groups to address health disparities in the community. The United States used nonmedical factors that influence health outcomes to develop Healthy People 2030 objectives in an attempt to address these disparities.
Characteristics of Families at Higher Risk for Poor Health Outcomes
Racial, sexual, or gender minorities; children; older adults; and people who are underinsured, socioeconomically disadvantaged, incarcerated, or disabled are at higher risk for poor health outcomes. Many low-income jobs do not provide health insurance, which reduces access to health care. These families can be stigmatized and may refrain from seeking health care due to fear of being marginalized. The nurse must be aware of different types of families at higher risk and how to provide them with fair and safe care.
Black Families
Black Americans in the United States have experienced a long history of racism, and inequity has become part of the infrastructure causing structural racism (Lloyd et al., 2021). Culturally, many Black Americans value marriage and children; however, barriers such as low income have often prevented these family structures from occurring. A study by Lloyd et al. (2021) found that having a low income led to increased issues with the criminal justice system, another influence on children and parents living together. They note that Black children lived in several different family structures. such as single-parent homes (some single persons live with an unmarried partner) and with extended families, grandparents, or kin. For pregnant Black people, prolonged stress has led to epigenetic changes causing higher incidences of preeclampsia, gestational diabetes, and maternal mortality in their population (Riggan et al., 2021). The nurse must recognize examples of racism and discrimination in the health-care system and become a change agent to overcome health inequities.
Immigrant and Migrant Families
Health-care access is limited for immigrant and migrant families. HealthCare.gov (n.d.) states that “lawfully present immigrants” can apply for the Health Insurance Marketplace, but undocumented immigrants are not eligible. Further eligibilities include living in the United States and not being incarcerated. Undocumented immigrants can be eligible for “emergency Medicaid” for prenatal care, depending on state regulations (Alarcon, 2022). Federally qualified health centers (FQHC) have bridged the gap for some immigrant families; FQHC’s mission is to serve those with limited access to health care and to improve the quality of life for millions, including immigrants (Alarcon, 2022).
Migrant families, like immigrant families, have limited access to health care. Many migrant families move from place to place for work. The frequent movement does not allow pregnant persons to receive consistent prenatal care, which can lead to poor outcomes for the person and their fetus. It is important for the nurse to determine all the previous providers for this pregnancy and request records to review all prenatal care.
LGBTQIA+ Families
LGBTQIA+ families are also at increased risk for domestic violence, discrimination, marginalization, and social exclusion. A study by Medina-Martínez et al. (2021) reveals that the LGBTQIA+ population has poorer physical and mental health and more depression, substance misuse, and suicide than the straight population. They also found higher incidences of colon, liver, breast, ovarian, and cervical cancers in lesbian and bisexual women. The study showed that many LGBTQIA+ people feel uncomfortable and unsafe in the health-care system because of discriminatory attitudes and practices. The health inequities/minority stress model proposes that adults from underrepresented groups who are socially stigmatized experience more stress and use maladaptive coping strategies, leading to rumination, substance misuse, and risky sexual behaviors (Medina-Martínez et al., 2021). Nurses can establish relationships with these patients by incorporating transcultural nursing interventions to help LGBTQIA+ families feel more included in and trusting of the health-care system.
People Who Are Incarcerated
In the United States, the rate of women who are incarcerated has dramatically increased to the second highest rate internationally, second only to Thailand (Friedman et al., 2023). The Friedman et al. (2023) study found that 75 percent of women who are incarcerated had children under 18 years old, and less than 33 percent of these children lived with their father during the mothers’ incarceration. They report that pregnant persons who are incarcerated have a higher risk of complications due to lack of prenatal care, trauma, poor nutrition, substance use, mental illness, chronic medical conditions, low socioeconomic status, and limited social support. Over the years, organizations such as ACOG, the Federal Bureau of Prisons, and the National Commission on Correctional Health Care have created standards for pregnant persons who are incarcerated, including the recommendation to allow patients to labor without restraints or shackles. Nurses caring for a laboring person who are incarcerated can provide nonjudgmental care and avoid discussing “taking the baby home.” Nurses can help the person work through feelings of sadness and grief over being separated from their baby.
Life-Stage Context
Grandparents as Caretakers
A grandparent can become the primary caregiver to a grandchild for different reasons, such as premature death of the child’s parent or the parent’s incarceration, mental health issues, or substance use disorder. According to the 2017–2021 U.S. census, 7.1 million grandparents are living with and caring for grandchildren under the age of 18 (U.S. Census Bureau, n.d.). Of these grandparents rearing grandchildren, approximately 2.5 million of them may need to return to the workforce to provide for the grandchild (Saxena, 2021). Other challenges grandparents face include changes in family dynamics because the grandparent is now the disciplinarian; psychosocial impact because the grandparents and children are in different social groups with peers; lack of resources due to low income related to retirement or disability; and challenges of parenting later in life, such as not having the energy to raise small children or discipline teens (Martin et al., 2020). Grandparents and grandchildren should receive resources for counseling for potential depression and financial resources.
Families with Lower Incomes
According to the National Health Council (Witting, 2023), 37.2 million Americans were living in poverty in 2020. Poverty causes poor health outcomes due to lack of available and quality health care for those who cannot afford reliable care. The National Health Council also noted that people living in poverty have more chronic diseases, such as heart, liver, and kidney disease. When people living in poverty could schedule health-care appointments, many times they did not have reliable transportation to get to the office (Witting, 2023). Pregnant persons living in poverty also have higher risk for poor outcomes owing to lack of prenatal care, poor nutrition, and stress (Witting, 2023). Nurses can provide supportive care while suggesting resources for the family to help with financial assistance.
Families Living in Rural Areas
Families living in rural areas in the United States face more health disparities than families living in urban areas. The CDC (2023) states that 46 million people in the United States live in a rural area. Areas without obstetric hospitals, birth centers, or obstetric providers are called maternity deserts (Treisman, 2022). These areas are mostly rural and have higher rates of maternal and newborn mortality than urban areas (Treisman, 2022). Statistics show that members of families living in rural areas have a higher risk of dying from heart disease, cancer, unintentional injury, chronic respiratory disease, and stroke than members of families living in urban areas (CDC, 2023). Children in rural areas are at risk for mental, behavioral, and developmental disorders. Some reasons for rural families’ increased risk of death from these diseases include long travel distance and time, higher rates of cigarette smoking, high blood pressure, obesity, higher rates of poverty, less access to health care, and more uninsured people (CDC, 2023). Nurses can address some of these issues when families who live in rural areas are present in the office or hospital. The nurse can educate the family on smoking cessation, weight loss, and increased physical activity, and can conduct recommended screenings for cancer. Some community-based mobile clinics can provide nursing care to these rural areas as well.
Social Determinants of Health of the Birthing Person and Newborn
The nonmedical factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life are called the social determinants of health. Health outcomes impacted by social determinants of health are referred to as health disparities or health inequalities.
Various factors contribute to health inequalities among different cultural groups. Socioeconomic status, race, educational level, and physical proximity to health-care facilities are all causes of health inequalities. For example, Black and Native American populations have higher rates of obesity, diabetes, hypertension, and heart disease when compared to White populations (National Academies of Sciences, Engineering, and Medicine, 2017). The history of racism and discrimination in the medical system has resulted in widespread distrust, especially for Black, Indigenous, and Latinx populations. This distrust manifests in less seeking of care and a general skepticism of the care rendered. Nurses can perpetuate this distrust, or they can begin to heal these relationships by considering the patient’s background. If they practice trauma-informed care, they acknowledge all past and present parts of a person’s life situation, including any trauma they have endured (Center for Health Care Strategies, 2021) in an effort to provide treatment that supports the patient’s autonomy, strength, and control over making health-care decisions.
Several social determinants of health causing disparities in the care of the birthing person include financial barriers to health care, shortage of obstetric providers, prevalence of unhealthy behaviors (illicit drug and alcohol use; consumption of cheap, less nutritious foods), lack of equal education causing financial inequality, and racially segregated communities (Crear-Perry et al., 2021).
The Five Domains
The five domains of the social determinants of health include economic stability, education access and quality, health-care access and quality, neighborhood and built environment, and social and community context (Figure 2.4).
These five domains are the foundation of addressing inequities in education, economics, health care, communities, and neighborhoods.
Healthy People 2030
Healthy People 2030 is an initiative of the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services. From its initial report in 1979 and its subsequent new iterations, it consists of national objectives aimed at improving health and well-being over the preceding decade. Social determinates of health are keys to creating the Healthy People objectives. Several objectives for pregnancy and childbirth include reducing preterm births, increasing the proportion of people who receive early and adequate prenatal care, increasing abstinence from alcohol during pregnancy, reducing pregnancy in adolescents, and reducing maternal deaths (U.S. Department of Health and Human Services, n.d.-b). (See Chapter 3 Health Promotion, Disease and Injury Prevention, and Well-Person Care for more discussion of Healthy People 2030.) The nurse can become active in professional organizations to help fulfill these objectives.
Legal and Ethical Issues
Caring for Patients Who Cannot Afford Their Necessary Health-Care/Prescriptions
The nurse is giving discharge instructions to a pregnant woman, describing how to take the prescribed medication. The woman quietly asks if it will hurt her baby if she does not take the medication. The nurse realizes the woman cannot afford the necessary medication. What can the nurse do?
When this situation occurs, the nurse can feel helpless and hopeless. The following suggestions can sometimes help in this situation.
- Ask the health-care provider if there is a less expensive medication that can be prescribed.
- Discuss drug assistance programs provided by many pharmaceutical companies, state programs, and nonprofit organizations.
- Contact the social services department to determine if the person qualifies for pregnancy Medicaid or other state and financial assistance.
- Recommend prescription assistance programs or websites such as GoodRx to find the lowest price for the medication.