School Segregation is Alive and Well Race, Income and ReformJ.docx

School Segregation is Alive and Well: Race, Income and
Reform
Jack Alcineus, Adiba Chowdhury, Kimberly Jean-Charles &
Leong Pang
MPA 798 and MPA 799
Mentor: Dr. Bakry Elmedni
Instructor: Dr. Helisse Levine
1
Table of Contents
Introduction
Unresolved Problem
Research Goal/Purpose
Subproblems
Research Questions
Hypotheses
Definitions of Key Terms
Nature of the Problem
Delimitations
Importance of the Study
Study Objectives
Conceptual Framework
Research Methodology

Variable Measures
District Makeup
Project Timeline
References
2
Jack
Introduction
The Brown vs. Board of Education trial in 1954 was a landmark
case that deemed racial segregation of schools in the United
States to be unconstitutional (Brown v. Board of Ed, 1954).
Sixty years later, segregation in NYC public schools has
become a growing trend.
“Out of 895 slots in Stuyvesant High School’s freshman class,
only seven slots were offered to Black students” (Shapiro,
2019)
Household income and educational funding appear to have been
the driving forces of this trend.
Source: Brown v. Board of Education of Topeka, 347 U.S. 483
(1954); Shapiro, E. (2019, March 26). Segregation Has Been the
Story of New York City's Schools for 50 Years. Retrieved from
https://www.nytimes.com/2019/03/26/nyregion/school-
segregation-new-york.html?auth=link-dismiss-google1tap
2
3

KIM
Unresolved Problem
Despite the national and local efforts for social and cultural
integration, public schools in NYC, the biggest school district
in the country, are now more segregated today compared to
when segregation was legal.
Within the last decade (2010-2020), segregation driven by
household income and funding formula has become so prevalent
that it has caused a public outcry which has prompted
policymakers to search for a proper solution.
4
Source: Source: Brown v. Board of Education of Topeka, 347
U.S. 483 (1954); Shapiro, E. (2019, March 26). Segregation Has
Been the Story of New York City's Schools for 50 Years.
Retrieved from
JACK
Research Goal/Purpose
The purpose of this study is to determine whether the level of
household income and funding formula used to allocate

resources to schools across the city contribute to the
resegregation of public schools in New York City.
5
JACK
Subproblems
Household income affects the type of neighborhood that a
family lives in that determines which public school their
children attends.
The funding formula used by school districts determine the
amount of resources allocated to each New York City public
school.
6
Jack
Research Questions
What effect has household income had on resegregation of
public schools in NYC within the past ten years?

In what ways does the funding formula used by the city
contribute to resegregation of public schools in NYC?
7
LEONG
Hypotheses
H1: Children from low-income households located in minority
concentrated neighborhoods are more likely to attend segregated
public schools in NYC.
H2: Public schools located in minority-concentrated
neighborhoods are likely to receive less funding per student
compared to public schools located in majority white
neighborhoods.
H0: There is no relationship between household income and
resegregation in NYC public schools.
H0: There is no relationship between the funding formula and
public school resegregation in NYC public schools.
8
Adiba
Definition of Key Terms

9
Segregation
04
The institutionalized separation of an ethnic, racial,
or other minority groups from the dominant majority (Farley,
Frey, 1996).
Funding Formula
03
The way NYC department of education allocates resources to
various school districts in the city (Mezzacappa, 2014).
Household Income
The combined total gross income of every member in a
household who is 15 years and older (Kagan, 2019).
01
02
A demographic change that leads to an increase of minority
schools or schools concentrated with poverty. In turn,
expanding the gap between minority and Caucasian students
within the school population (Burr, 2018).
Resegregation
LEONG

Census Bureau for household income definition
Levine Feedback: add citations
Source: Kagan, J. (2020, January 29). Household Income
Definition. Retrieved from
https://www.investopedia.com/terms/h/household_income.asp;
Mezzacappa, D., Mezzacappa, D., Dale, & Dale. (2018, March
29). What is a state education funding formula? Retrieved from
https://thenotebook.org/articles/2014/10/02/what-is-a-state-
education-funding-formula/
https://www.theatlantic.com/education/archive/2018/03/school-
segregation-is-not-a-myth/555614/
Affirmative Action?
Nature of the Problem
Magnitude
School resegregation is a socioeconomic issue that not only
affects the quality of education children receive based on where
they attend school, but has also had far reaching implications in
areas pertaining to social equity and social harmony.
Timeliness
Lack of meaningful integration has always been a concern for
policymakers, but the level of school resegregation seen in the
past decade has caused loud public outcry.
10
Source: The Fight to Desegregate New York Schools. (2019,
October 18). Retrieved from
https://www.nytimes.com/2019/10/18/the-weekly/nyc-schools-
segregation.html

ADIBA
Levine Feedback: add citations
Delimitations
Scope, this study is limited to:
New York City public school districts, excluding charter
schools.
The time frame 2010 - 2020.
Role of household income and funding formula.
The study will not cover segregation in other cities or states.
The study will not explore other factors that might be driving
segregation.
11
LEONG
Importance of the Study
As public administrators, it is important to examine the causes
driving resegregation of public schools in NYC so as to
understand their immediate and long-term implications such as:
Low graduation rates of minority students

Large academic achievement gaps
Limited educational and career opportunities for minority
students
12
Source: Dalton, J. C., & Crosby, P. C. (2015). Widening income
inequalities: Higher education's role in serving low income
students. Journal of College and Character, 16(1), 1-8.
doi:http://0-
dx.doi.org.liucat.lib.liu.edu/10.1080/2194587X.2014.992914
ADIBA
Levine Feedback: add a source
Study Objectives
To explore the role that household income has played in school
resegregation within NYC in the past ten years.
To determine if the funding formula the city uses to allocate
resources contributes to school resegregation across NYC.
13

KIM
Conceptual Framework
14
LEONG
Research Methodology
Design: Mixed Methods - Quantitative & Meta-Analysis
Exploratory study using mixed methods.
Quantitative: Data Processing
To examine the relationship between household income and
To examine the relationship between the the amount of
resources allocated by the state to each district and
Qualitative: Meta-Analysis
Using 25 peer reviewed articles, conduct systematic review and
quantify how many support the independent and dependent
variables.
15

Kim
Research Methodology cont.
Data Analysis:
Correlation Design
Unit of Analysis:
Average household income in each district
Amount of funding per student in each district
Racial disparities within each district
16
Data Sources:
NYC Department of Education
U.S. Government Accountability Office
Time Dimension of Study Design:
Longitudinal Study
Kim
Variable
MeasuresVariablesConceptualizationOperationalizationData
SourceIndependent
VariableIndividual Household IncomeThe combined total gross
income of every member in a household who is 15 years and
older.Median Household Income per DistrictKagan, 2019NYC

Public School Funding FormulaThe way NYC department of
education allocates resources to various school districts in the
city.Funding per StudentMezzacappa, 2014Dependent
VariableLevel of Segregation in NYC Public SchoolsThe
institutionalized separation of an ethnic, racial,
or other minority groups from the dominant majority.Percentage
of White, Black, Asian/Pacific Islander, Hispanic, American
Indian/Alaska Native, and Multiracial Students per
DistrictFarley, Frey, 1996
17
JACK
Sources: Calgary, O. (n.d.). School Districts. Retrieved from
https://data.cityofnewyork.us/Education/School-Districts/r8nu-
ymqj; Keeping Track Online. (n.d.). Retrieved from
https://data.cccnewyork.org/data/map/66/median-
incomes#66/49/3/107/40/102; NEW YORK COUNTY: NYSED
Data Site. (n.d.). Retrieved from
https://data.nysed.gov/profile.php?county=31; School Based
Expenditure Reports. (n.d.). Retrieved from
https://infohub.nyced.org/reports/financial/financial-data-and-
reports/school-based-expenditure-reports;
Manhattan Public School Districts
18
Quantitative: Data Processing

Qualitative: Meta-Analysis
ADIBA
District Makeup
Sources: Calgary, O. (n.d.). School Districts. Retrieved from
https://data.cityofnewyork.us/Education/School-Districts/r8nu-
ymqj;
19
Adiba
Project Timeline
20

TASKSDUE DATEMEMBER IN CHARGETeam PowerPoint
#12/3/30TeamTeam PowerPoint #22/18/20TeamConceptual
Framework2/24/20LeongWritten
Explanation2/24/20TeamProposed
Methodology2/24/20TeamProject
Timeline2/24/20AdibaResearch Grid2/24/20KimTeam
PowerPoint #32/24/20TeamProposal Narrative3/1/20 at
midnightTeamProposal Presentation3/2/20TeamEnd of Text
References in APA Style3/16/20TeamTeam PowerPoint #4:
Background/Literature Review3/23/20TeamTeam PowerPoint
#5: Research Hypotheses3/30/20TeamDraft of
Background/Literature Review4/8/20KimTeam PowerPoint #6:
Conceptual Framework/Study Variables4/13/20TeamDraft of
Conceptual Framework4/15/20LeongDraft of Research
Design/Methodology4/22/20JackTeam PowerPoint #7: Research
Design/ Methodology4/27/20TeamDraft of
Results/Findings4/29/20AdibaTeam PowerPoint #8:
Results/Findings/Conclusion5/4/20TeamProject
Submission5/10/20TeamFinal Capstone
Presentation5/11/20Team
21
Jack
Literature Review
Equality and Equity of Education Funding

Research by Moser and Rubenstein (2002) suggested that states
that have less school districts are more likely to have a more
equal distribution of financial resources compared to states with
more school districts.
New York City Public School Funding Formula
New York City Department of Education adopted a new funding
formula in 2007 for its public school system which is called the
Fair Student Funding (FSF) allocation formula
Cooper et al. (2004) suggested that the weighted student
formula is the most effective way to determine how adequately
funds are allocated and being spent school-by-school in each
district
Brown, C. A. (2007). Are America’s Poorest Children Receiving
Their Share of Federal Education Funds? School-Level Title I
Funding in New York, Los Angeles, and Chicago. Journal of
Education Finance, 33(2), 130–146.
Cooper, B. S., DeRoche, T., & Ouchi, W. G. (2004). From
Courtroom to Classroom: Operationalizing “Adequacy” in
Funding Teaching and Learning. Educational
Considerations, 32(1), 19–32.
Literature Review (continued)

Frankenberg, Siegel-Hawley, & Wang, (2011) stated that
minority schools are disadvantaged in the terms of funding due
external factors such as inadequate housing, unemployment
levels rising, and poor classroom ratios that drastically affect
the quality of education .
Frankenberg, E., Siegel-Hawley, G., & Wang, J. (2011). Choice
without equity: Public school segregation. Education Policy
Analysis Archives/Archivos Analíticos de Políticas Educativas,
19, 1-96.
References
Anderson, M.W. (2004). Colorblind Segregation: Equal
Protection as bar to Neighborhood Integration. California Law
review, 92 (841), 843-890
Bischoff, K., & Reardon, S.F. (2013) Residential Segregation by
Income, 1970-2009. US 2010 Project. Retrieved from:
http://www.s4.brown.edu/us2010/Projects/Reports.htm
Brown v. Board of Education of Topeka, 347 U.S. 483 (1954);
Shapiro, E. (2019, March 26). Segregation Has Been the Story
of New York City's Schools for 50 Years.
Retrieved from
Burr, K. H. (2018). Separate but (un)equal: A review of
resegregation as curriculum: The meaning of the new racial
segregation in U.S. public schools. The Qualitative

Report, 23(7), 1773-1776. Retrieved from http://0-
search.proquest.com.liucat.lib.liu.edu/docview/2256508400?acc
ountid=12142
Conger, D. (2004). Understanding Within-School Segregation in
New York City Elementary Schools. Educational Evaluation and
Policy Analysis, 27 (3) 225-244
Demonte, J., & Hanna, R. (2014) Looking at the Best Teachers
and Who They Teach Poor Students and Students of Color are
Less Likely to Get Highly Effective Teaching, Center for
American Process. Retrieved from:
https://www.americanprogress.org/wp-
content/uploads/2014/04/TeacherDistributionBrief1.pdf
Frey, W. H., & Farley, R. (1996). Latino, Asian, and Black
Segregation in U.S. Metropolitan Areas: Are Multiethnic Metros
Different? Demography, 33(1), 35-50.
22
Kagan, J. (2020, January 29). Household Income Definition.
Retrieved from
https://www.investopedia.com/terms/h/household_income.asp;
Mezzacappa, D., Mezzacappa, D., Dale, & Dale. (2014, October
2). What is a state education funding formula? Retrieved from
https://thenotebook.org/articles/2014/10/02/what-is-a-state-
education-funding-formula/
Owens, A., Reardon, S., & Jencks, C. (2016). Income
Segregation Between Schools and School Districts. American
Educational Research Journal, 53(4), 1159-1197.

Retrieved from www.jstor.org/stable/24751626
Shapiro, E. (2019, March 26). Segregation Has Been the Story
of New York City's Schools for 50 Years. Retrieved from
The Fight to Desegregate New York Schools. (2019, October
18). Retrieved from https://www.nytimes.com/2019/10/18/the-
weekly/nyc-schools-segregation.html
23
Thank You !
24
Running Head: MATERNAL MORTALITY IN THE U.S.

140
MATERNAL MORTALITY IN THE U.S.
THE PARADOX OF HEALTH CARE:
MATERNAL MORTALITY IN THE UNITED STATES
By:
Bibi Alli
Tashiya Baptiste
Joelle Cange
Dana Cortese
Vanessa Dasque
A Master’s Project Presented to the Faculty
Of the School of Business, Public Administration and
Information Sciences,
Long Island University, Brooklyn Campus
In Partial Fulfillment of the Requirements for the Degree of
MASTER OF PUBLIC ADMINISTRATION

Dr. Bakry Elmedni
Mentor
Dr. Helisse Levine
Professor
May 2018
Acknowledgments
First and foremost, we would like to thank God Almighty for
giving us the strength, knowledge, ability, and opportunity to
undertake this capstone project and complete it successfully.
Without His blessings, this achievement would not have been
possible. We would like to convey our heartfelt thanks to our
mentor, Dr. Elmedni Bakry, our capstone professor, Dr. Helisse
Levine, and to all of the MPA professors for providing their
invaluable guidance throughout the course of this project and
our careers at LIU-Brooklyn. Thank you for motivating us to
work harder, challenging us to think critically, and reminding us
that we are the future of public administration. Tomorrow's
change begins with us. To our family and friends, thank you for
being our biggest cheerleaders and for the constant love and
support. You remind us every day that sky is the limit, and we
would not have been able to complete this journey without
you. Lastly, we would like to say congratulations to the class
of 2018. “It always seems impossible until it’s done.” We made
it!
TABLE OF CONTENTS

CHAPTER ONE7
Introduction7
1.1 Research Problem8
1.2 Nature of the Problem9
1.3 Significance of the Study10
1.4 Methodology11
1.5 Study Organization11
CHAPTER TWO12
Background and Literature Review12
2.1 Background12
2.2 U.S. Healthcare Policies & Women15
2.3 Maternal Mortality: A result of policy failure23
2.4 Maternal Mortality and Racial Background29
2.5 Health Insurance and Maternal Mortality33
CHAPTER THREE38
Conceptual Framework38
3.1 Health Insurance Status and Maternal Mortality40
3.2 Race and Women’s Health40
3.3 Assumptions42
3.4 Research Questions and Hypotheses42
3.5 Key Stakeholders43
3.6 Terminology44
3.7 Concluding Remarks45
CHAPTER FOUR45
Methodology45
4.1 Research Questions46
4.2 Research Design47
4.3 Delimitations and Scope47
4.4 Measures and Participants48
4.5 Data Collection and Processing49
4.6 Concluding Remarks49
CHAPTER FIVE49
Results and Findings49
5.1 Results50
5.2 Findings53

CHAPTER SIX54
Discussion and Conclusion54
6.1 Discussion54
6.2 Recommendations & Conclusion58
REFERENCES63
APPENDICES76
APPENDIX A76
Capstone Proposal76
APPENDIX B85
Annotated Bibliographies85
APPENDIX C125
Project Timetable125
APPENDIX D126
Research Grid126
APPENDIX E127
Secondary data127
APPENDIX E.1131
Literature Synthesis Chart131
APPENDIX F138
Resumes138
APPENDIX G144
NIH Certificates144
Abstract
The United States spends the most on healthcare but has the
highest maternal mortality rate in the developed world. When
inspected further, black women’s contribution to the country’s
high maternal mortality rate, is disproportionately greater than
any other race. This study examines whether race and health
insurance status of women has an effect on maternal mortality
rate in the U.S. The dual study was conducted using secondary
data, which were collected from America’s Health Rankings

2016 Health of Women and Children Report. The data was
analyzed using Pearson’s Correlations. Additionally, 25 peer-
reviewed studies were reviewed and organized, to gain a
consensus regarding the relation between race, health insurance
status and maternal mortality. The results, supported by the
qualitative analysis, showed that there is a direct relationship
between black women, uninsured women and maternal mortality
in the U.S. (p < 0.5). This indicates that there is a disparity
when it comes to the health and care of black women in the U.S.
Keywords: Maternal Mortality, Health Insurance Status,
Race
CHAPTER ONEIntroduction
In 2015, the United Nations (UN) set 17 Sustainable
Development Goals (SDGs) to accomplish by 2030 (Sustainable
Development Goals Fund, 2016). SDGs built upon the
foundation established by the Millennium Development Goals
(MDG), which were presented in 1990 (SDGF, 2016). One MDG
the UN planned to focus on was reducing the 1990 maternal
mortality rate (MMR) of 385 deaths per 100,000 by 75 percent
over a period of 15 years (SDGF, 2016). The UN reaffirmed
their plan to decrease MMR through the mobilization of the
Global Strategy for Women's, Children's and Adolescent's
Health 2016-2030 (World Health Organization, 2016). The
Global Strategy provides a roadmap for how nations could
achieve and provide the highest standards of healthcare for
women, children and adolescents (WHO, 2016). This plan was
geared towards not only assuring that women receive the
necessary care to survive childbirth, but to thrive throughout
their lives (WHO, 2016).
According to Tavernise (2016), between 2005 and 2015, the
global maternal death rate fell by one third. However, the
United States (U.S.) has managed to defy this global trend. A
2010 study by Amnesty International found that maternal
mortality is the highest in the U.S. compared to 49 other
countries in the developed world. For example, in Australia,
which has wealth similar to that of the U.S., the maternal

mortality rate decreased by 25% between 2005 and 2015.
During the same time period, the U.S. saw a 16.7% rise in MMR
(WHO, 2015). Ironically, Howard (2017) states that the U.S.
spends more on healthcare than any other country in the world.
She also goes on to say that more than two women die every day
during childbirth in the U.S. In addition, Bryant and his
colleagues (2010), argue that disparities in access to care and
quality of care have resulted in varying maternal health
outcomes for women of different backgrounds. Literature
suggests that insurance status and the racial backgrounds of
mothers are precipitating factors in the rising rates of maternal
death. The high MMR and high healthcare spending in the U.S.
indicates that a paradox exists within the system.
1.1 Research Problem
Although most states in the U.S. provide prenatal care to all
women regardless of insurance or race, the country’s high
maternal mortality rate is associated with the health insurance
status and racial background of mothers. The U.S. spent $60
billion on maternal care in 2012, yet an estimated 1,200 women
experienced fatal complications during childbirth (Agrawal,
2015). Additionally, America spent $3.2 trillion on healthcare
in 2015, yet the MMR has nearly doubled in the past two
decades (Centers for Medicare & Medicaid Services, 2018,
WHO, 2015). The umbrella issue of maternal mortality has
brought more attention to the inequalities that women of color,
specifically black women, face when seeking and receiving
care, as well as the overall lack of efficiency of such a costly
healthcare system.
The inequality in America’s healthcare system affects millions
of families who still cannot afford healthcare. Poor women
living in low-income neighborhoods have the least access to
quality care, making them more vulnerable to maternal death.
Black women are particularly affected by this problem. (Heuser
& Karkowsky, 2017). During the years of 2011-2013, 12.7
deaths per 100,000 live births were white women, 14.4 were

other races, and 43.5 were black women (CDC, 2017). We
designed this study in response to these findings and the
apparent paradox in healthcare. This study was conducted to
determine whether there is a correlation between high maternal
mortality rates in the U.S. and whether it is influenced by the
health insurance status and racial background of mothers.
1.2 Nature of the Problem
The issue of maternal mortality has received increasing
attention in the past two decades as the U.S. government has
failed to curb high maternal mortality rates, despite global
progression. Global maternal mortality rates have decreased by
44 percent between 1990 and 2015 (UNICEF, 2015). In 1990
there were a reported 385 maternal deaths per 100,000 live
births. That number decreased to 216 deaths in 2015 (UNICEF,
2015). According to Thomson (2016), the U.S. currently spends
17.1 percent of its Gross Domestic Product (GDP) on healthcare
costs, however, the country has been unable to decrease its
maternal mortality rate. In 1990 there were about 16.9 maternal
death per 100,000 live births in the U.S. In 2015 that number
increased to about 26.4 deaths (UNICEF, 2015).
The failure of the U.S. government to curtail these high
maternal mortality rates has led to an increased focus on how
federal funds are being allocated. Policymakers, healthcare
providers, and scholars are now focusing their attention on
putting an end to preventable maternal mortality. It is important
to do so in a timely manner, especially amid the current
administration’s attacks on family planning and women’s health
policy. An end to the Title X Family Planning program by the
Trump administration, “would cut off millions of pregnant
women from access to complete and unbiased information about
their medical options” (Ota, 2017). If this issue is not resolved
soon, matters may only worsen for the fate of American mothers
and their children.
It is also important to understand the magnitude of the issue at

hand. According to Thomson (2016), U.S. women are three
times as likely to die during childbirth than women from the
United Kingdom, Germany, and Japan. Thomson (2016) goes on
to state that most of these cases, about 60 percent, are
preventable. This leads us to believe there is a gross
inefficiency in healthcare policy. This issue is also very
pertinent, as we believe it violates social justice. Flanders-
Stepans (2000) states that black women are two to six times
more likely to die due to complications during pregnancy than
their white counterparts. In most cases, disparities among
different races that exist in access to quality healthcare
contribute to these complications. Every human has an
unalienable right to life, regardless of race, and should
therefore have access to equitable healthcare.
1.3 Significance of the Study
As healthcare costs are projected to rise, it is imperative to aid
policymakers in identifying areas of healthcare that need
monetary support and attention. At the current rate, researchers
predict that national health care spending will reach $5.7
trillion by 2026 (CMS, 2018). The government also estimates
that between 2017 and 2026, healthcare expenditures with grow
1.0 percentage point faster than the GDP (CMS, 2018). This
study will investigate the driving forces behind high maternal
mortality rates in the United States. The qualitative findings in
this study, coupled with quantitative statistics play a significant
role in determining the elements that sustain maternal mortality.
Once these areas are identified, policymakers can focus their
attention on extending funds to ensure mothers get the care and
support they need for a healthy and happy pregnancy.
Through careful research this study also strives to create
awareness of the disparities that exist in healthcare overall, but
more specifically in women’s health. By addressing these
issues, policymakers and healthcare providers may be inclined
to allocate resources into correcting these disparities and
putting an end to preventable maternal mortality in the United

States. Our research, which explores the factors that contribute
to high maternal mortality rates, can help in designing policy
proposals for addressing such injustices. Lastly, this study
hopes to fill in any gaps in public administration research
regarding how socioeconomic factors contribute to maternal
mortality rates globally, as well as in the United States.
1.4 Methodology
To determine the relationship between our independent and
dependent variables, we conducted a cross-sectional study with
a mixed method design. Through the use of peer reviewed
articles we performed a systematic review of quantitative
empirical studies to determine the general consensus among the
literature on maternal mortality in the United States. We also
developed a table to organize our secondary data. The data was
organized by state, percent of uninsured residents, racial
background of mothers, and maternal mortality rate. We then
used this data to conduct a Pearson’s Correlation Test for each
of our two independent variables to help us identify significant
correlations between each variable and our dependent variable,
maternal mortality. We performed a state level analysis of
uninsured women and black women in 48 states plus the District
of Columbia. We analyzed data and research for the year 2016
from sources including the Centers for Disease Control, the U.S
Department of Health, and the U.S Census Bureau and
America’s Health Rankings.
1.5 Study Organization
This study has been organized into six concise chapters. The
first chapter introduces the premise of the research, including
the problem statement, the nature of the problem, the purpose
and significance of the research, and a brief introduction to the
methodology used. Chapter two provides historical background
and a detailed review of current literature regarding MMR and
its relationship to health insurance status and racial background.
The conceptual framework, which explains in depth how each

independent variable affects the dependent variable, is
presented in the third chapter. The fourth chapter outlines the
research methods used to conduct the study, the unit of
measure, as well as the resources used to gather data. The
results and findings of this research is presented and explained
in the fifth chapter. Finally, the study concludes with the
evaluation of the results, as well as recommendations for future
research. CHAPTER TWOBackground and Literature Review
We have developed a thorough review of literature within our
study to gain a general consensus among scholars and
researchers who have published current works in regard to
maternal mortality and its relationship with health insurance
status and race. Through this literature review we were able to
identify several main factors that are related to, and may affect
maternal mortality within the United States. This section will
speak to five main factors including a brief background of the
issue of maternal mortality within the U.S., as well as U.S.
policies that have affected women’s health, and how those
policies have failed to provide appropriate care for all women.
Additionally, we have touched on issues of race and racism, as
it affects maternal mortality rates, and how health insurance
status may determine a mother’s health outcomes throughout
pregnancy.
2.1 Background
There has been a long-standing debate regarding healthcare
policy and practice in the United States. Main points of
contention have included healthcare expenditures, access to and
quality of care, and the idea of universal healthcare
(Kronenfeld, Jacobs, Parmet, & Zezza, 2012). The government
has struggled with the concept of whether society as a whole or
individuals should be held responsible for health costs
(Kronenfeld Jacobs et al., 2012). Within the last decade, the
debate has only intensified. The introduction of the 2010 Patient
Protection & Affordable Care Act (ACA), also referred to as
Obamacare, ignited a fervent battle between the Democratic and

Republican parties (Irwin, 2017). The passing of the bill,
however provided hope that years of political deadlock would
end. The ACA promised to extend coverage to 30 million
uninsured Americans, while also slowing the growth of
healthcare expenditures (Irwin, 2017). Obamacare, however,
only led to a greater divide on the subject of American
healthcare and increased partisan tensions within the White
House.
A key provision of the ACA was the expansion of Medicaid, a
joint federal and state health insurance program (“Medicaid
expansion & what it means for you,” 2017). Medicaid was
designed to provide medical coverage to those with limited
income (“Medicaid expansion,” 2017). Under the Act, states
were required to amend Medicaid eligibility and cover all
adults, ages 18-65, with incomes at or below 138% of the
United States poverty level (“Medicaid expansion,” 2017). The
previous requirements provided benefits to low-income
children, elderly, disabled persons, and pregnant women, but
often excluded other low-income adults (Garfield & Damico,
2017). The ACA required that coverage be extended regardless
of age, sex, or health status (Wachino, Artiga, & Rudowitz,
2014). In 2012, however, the U.S. Supreme Court ruled that
Medicaid provisions were voluntary for states; therefore, some
have not expanded the program (Garfield & Damico, 2017).
As of October 2017, nineteen states have chosen not to
implement the expansion of Medicaid (Garfield & Damico,
2017). This decision has upheld the disparities in access to care
that the ACA sought to diminish. In states that adopted the
provision, historical gaps in health insurance coverage were
quickly filled (Garfield & Damico, 2017). Ironically, uninsured,
low-income adults that are not eligible for Medicaid under the
previous laws are concentrated in states that refused Medicaid
expansion (Garfield & Damico, 2017). More than 25% of adults
that fall into the coverage gap reside in Texas, which refuses to
broaden the stipulations of eligibility (Wachino, Artiga, &
Rudowitz, 2014). Minority groups living in these areas are

directly affected by the lack of progression in health policy.
They are less likely to receive the adequate care they need due
to lack of Medicaid coverage and face difficulties in accessing
low quality health services.
With 2014 health care expenses exceeding $3 trillion, it is
difficult to understand why certain groups are still dying due to
minor health issues (Mathur, Srivastava and Mehta, 2015). The
maternal mortality rate (MMR) in the U.S. is higher than any
other developed nation in the world (Molina & Pace, 2017).
Other high-income countries have experienced decreases in
MMR, while the rate has doubled since 1990 in the U.S.
(Molina & Pace, 2017). Despite the growth of healthcare
expenditures, racial and socioeconomic inequalities have
contributed to growing MMR (Molina & Pace, 2017). In
America, low-income mothers, women living in rural areas, and
non-Hispanic black women are three times more likely to die
during childbirth than white women with median incomes
(Molina & Pace, 2017). The high health costs and high maternal
death rates indicate a major issue and lack of effectiveness in
healthcare policy and implementation.
There is a general assumption that development in medical
technology and increased health spending would lead to
improved health outcomes, however the U.S. has managed to
contradict this idea. The American government spends the most
on healthcare than any other country in the world, however not
only struggles with tackling MMR, but increasing life
expectancy and decreasing rates of infant mortality as well. The
U.S. spends approximately $9,237 on healthcare per person, yet
only has a life expectancy of 79.1 years (Brink, 2017). The
United Kingdom, which spends only $3,749 on healthcare per
person has a higher life expectancy of 80.9 years (Brink, 2017).
Even though America spends the most, it ranks 12th in life
expectancy among twelve of the world’s wealthiest, developed
nations (Brink, 2017).
In relation to infant mortality, which is defined as “death
within the first year of life,” the U.S. also falls behind (“Infant

Mortality in the U.S.,” 2017, p. 1). When compared to other
developed countries, the U.S. rate of infant mortality is 71%
higher (“Infant Mortality in the U.S.,” 2017). Similar to MMR,
infant mortality rates are the highest amongst non-Hispanic
blacks (“Infant Mortality in the U.S.,” 2017). The inability of
the U.S. government to effectively address these issues and
redirect the allocation of funds has left minorities susceptible to
preventable deaths. A paradox has appeared in American
healthcare; though trillions of dollars is funneled into health
spending, gaps and disparities still exist and rates of mortality
amongst black infants and mothers remain at unconventionally
high rates for one of the most developed nations in the world. In
order to gain a better understand of the influencing factors of
maternal mortality rates, a thorough review of current literature
was conducted. The research included examined how U.S.
healthcare policy and its failures have affected women, as well
as how racial background and health insurance status have
impacted maternal death.
2.2 U.S. Healthcare Policies & Women
Comfort, Peterson and Hatt (2013) acknowledge that in the
U.S., health insurance status is tied to health care costs and
therefore, cannot be discussed without understanding how the
introduction of Medicare impacted the country’s current
healthcare spending. Medicare is not the only source that draws
on the government’s funding to allocate resources to eligible
Americans. Other similar healthcare policies include Medicaid
and most recently, The Affordable Care Act (ACA). Results of a
2015 study, which surveyed 8,000 women ages 18 to 39,
revealed that 18.2% of the participants had insurance under
Medicaid, 69.5% had private insurance, 11.5% were uninsured
and the remaining 0.8% had another type of health insurance
coverage (Jones & Sonfield, 2016). To understand the
healthcare policies that currently exist in the U.S., it is
imperative to acknowledge how these policies came to be. The
history of American healthcare policies has been complex

because of the difficulty to create a standard and equal medical
care system for all citizens. Regardless, healthcare policies have
always aimed to help vulnerable populations. Today, one of the
vulnerable populations affected by healthcare policies are
women. In the proceeding section, all healthcare policies
developed to help vulnerable populations will be discussed,
along with employer-centered coverage for those of the working
class.
Employer-centered coverage. One form of healthcare insurance
for Americans is employer-based coverage. Appropriately
named, this type of coverage is when employers purchase
healthcare insurance for their employees. Ginsburg (2008)
shows that the employer-based health insurance system was
accidental because it was developed “to evade wage controls
during World War II,” (p. 676), adding that it still exists
because employees prefer it. Many workers prefer this type of
coverage because it not only secures their access to healthcare
but also their family members (Cubbins & Parmer, 2001).
Approximately 44.5 percent of American workers are covered
under their employer’s insurance, which leaves the remaining
55.5 percent to seek coverage under privately-purchased
insurance, Medicare, Medicaid or the military (Frauenholtz,
2014; Mendes, 2013). Over the last decade, however, the
percentage of individuals covered through employer-based
coverage has decreased due to the increased cost of healthcare,
making it difficult for employers to afford (Ginsburg, 2008).
Also, as more women join the workforce with needs differing
from the usual male employees, employer-based health
insurance would need to be expanded to include coverage for all
employees. For women, employer-based insurance would need
to consider possible pregnancies and coverage for the mother,
along with the infant.
Medicare and Medicaid. A large portion of Americans who are
not covered via their employer receive coverage through
Medicare and/or Medicaid. Medicare was implemented in 1966
with the purpose of reducing social and economic inequality

between men and women, 65 years or older (Salganicoff, 2015).
Since women only comprised 39% of the paid labor force
compared to the 81% of men, upon retirement, more women
were living in poverty than their male counterparts (Salganicoff,
2015). Also, many women did not have the financial support as
they age, especially in areas pertaining to their healthcare
coverage because they were dependent on their working
husband. However, Medicare did not satisfy all the necessary
care for women initially, and still does not today. As pointed
out by Salganicoff (2015), with much growth and transitions,
Medicare began to cover routine mammography screenings and
pap smears to women in 1990 and 1991, respectively. Today,
although Medicare has been an effective government
intervention, women’s healthcare costs are only partly covered.
Medicare has high deductible costs, and does not cover
necessities such as hearing aids, eyeglasses, dental care,
personal care and extended nursing home stays; all of which
becomes out-of-pocket expenses for people covered
(Salganicoff, 2015). In 2010, women’s out-of-pocket expenses
ranged from $4,173 to $8,574, whereas men’s out-of-pocket
costs for the same year ranged from $3,842 to $7,399
(Salganicoff, 2015).
While disparities in Medicare tend to exist among older
Americans, Medicaid focuses on reducing the inequality gaps in
terms of access to healthcare between financially stable
Americans and Americans from low income households (Epstein
& Newhouse, 1998). One of the important roles Medicaid has
taken on is assisting low-income women with health necessities,
especially during pregnancy and childbirth. According to
Johnson (2012), more than 12 million (1 out of 10) women in
the U.S. are covered under Medicaid. Additionally, the program
“finances 40 percent of prenatal care and births” (Johnson,
2012, p. 3). Prenatal care is essential for women. It is important
to note that women do not always qualify for Medicaid if their
household income is above the poverty line and are also not
eligible for Medicare if they are under 65 years of age.

Moreover, Legerski (2012) contends that the increasing cost of
healthcare has caused American women to either not be able to
afford coverage or not qualify for coverage under Medicaid
because of the program’s strict financial guidelines. This leaves
many women uninsured, creating disparities in healthcare. If an
uninsured woman becomes pregnant, she is then covered under
Medicaid. However, having previous temporary gaps of
coverage can lead to issues during pregnancy.
Gaps in coverage can put the woman at a higher risk of poor
health outcomes. As individuals become more aware of the
benefits of prenatal care, more women have opted to start
paying for Medicaid prior to starting a family. A 2015 report by
the Centers for Disease Control and Prevention revealed that
nearly one third of women who delivered a live infant in 2009
experienced a change in their health insurance status around the
time of pregnancy. The most common pattern found was that
women went from being uninsured in the month before
pregnancy to having Medicaid coverage until the time of
delivery (Centers for Disease Control and Prevention, 2015). To
support this statement, Egerter, Braveman & Marchi, (2002)
conducted a study of the relationship between the timing of
insurance coverage and prenatal care. Using a cross-sectional
statewide survey with a sample of 5455 low-income
participants, they showed that 45 percent of the women were
uninsured before pregnancy. The results also revealed that 21
percent of the women lacked coverage in the first trimester and
two percent were uninsured throughout their pregnancy (Egerter
et al., 2002, pp. 425-426). Egerter and team (2002) discussed
that the period in which the woman does not have insurance
coverage may contribute to issues faced during maternity and
lack of preventative care is due to affordability factors of
healthcare coverage.
The Affordable Care Act. Since the implementation of Medicare
and Medicaid, there had not been any relevant changes made to
U.S. healthcare policies until The Affordable Care Act (ACA).
The ACA was signed into law on March 23, 2010 by President

Barack Obama, but was not implemented until October of 2013
(Kantarjian, 2017). The goal of the ACA was to decrease the
number of uninsured Americans, at a reasonable cost. This goal
was partially achieved, as the ACA expanded insurance
coverage by reducing the percentage of uninsured Americans
from 18 percent to 12 percent within two years of being put into
effect (Chen, Vargas-Bustamante, Mortenson, & Ortega, 2016).
This means more than 15 million of the 48 million uninsured
Americans gained healthcare insurance under the ACA (Chen et
al., 2016). The Act has been a step in the right direction for
universal healthcare for all Americans, but particularly has been
a success for women. An article by Scientific American (2017)
explains that under the ACA, organizations like Planned
Parenthood gained block funding towards “routine health
services such as gynecological exams, cancer screenings, STD
testing and contraception,” (p. 9). Medicaid also received
funding to provide better maternity care to uninsured mothers.
However, with a new president in office, the ACA is under
attack as the new administration has promised to have it
repealed and replaced. Heuser and Karkowsky (2017) argue that
the potential loss of the ACA under the current administration
would lead to budget cuts in women’s healthcare. With limited
funding for women’s healthcare, issues like the high maternal
mortality rates in the United States will continue to rise.
Driving forces of costs. The growth of technology has
contributed to increasing healthcare expenditures in the U.S.
Technology has resulted in longer lifespans due to its assistance
in the discovery of cures or treatments for many illnesses.
Simultaneously, with technology’s growth, healthcare costs
have increased as well. Squires (2012) argues that the U.S. uses
expensive technology more frequently when compared to other
countries. The use of costly equipment for medical procedures
has had a reverse domino effect on health insurance prices. The
expense for research and invention of more technological
advancements has become greater as well. Therefore, the price
of healthcare coverage has risen. Even with Medicare and

Medicaid assistance, as well as the emergence of the ACA, gaps
in women’s healthcare still exist. How could this be? Although
these programs are implemented at a federal level and driven by
the growth of technology and cost, the driving forces of
acceptance differs at a state level.
As previously mentioned, Medicaid expansion is voluntary
by state, and so many states are opting out of the program due
to high healthcare costs. For example, states like Texas,
Oklahoma, Georgia, Florida and Mississippi, which already
have the highest rates of uninsured residents, are choosing not
to expand Medicaid due to its high costs (Quinn, 2017). Within
these states, people who are currently receiving Medicaid will
no longer be receiving the associated benefits. Individuals who
would meet the qualifications with Medicaid expansion, will not
be able to afford insurance coverage under the current market
prices and will be uninsured. Ironically, the states that chose
not to expand Medicaid will only increase their uninsured
population.
To take a case in point, Texas’ rejection of the federal fund to
expand Medicaid would have covered over 1 million more of its
inhabitants, in addition to already covering half of all births in
the state, as well as the care for mothers sixty days after giving
birth (Novack, 2017). At a state level, the forces that drive
healthcare policies are political party affiliation and ideological
worldviews. Texas is heavily Republican and has been
associated with conservative outlooks on issues like women’s
health. Putting money into caring for women is not a priority. It
is not surprising that the latest data shows that Texas has the
highest maternal death rate in the U.S., at 32.5 per 100,000 live
births in 2015 (Sifferlin, 2018). Ultimately, without funding
through federally assistance programs, states like Texas will
continue to have high maternal mortality rates as there is no
money going into the care for its women.
On the other hand, a predominantly Democratic state’s, such as
New York, driving force for health care policies specific to
maternity has become the care and well-being of the mothers

and their babies. New York was one of the states that supported
the expansion of Medicaid eligibility for its residents
(Sommers, Baichek & Epstein, 2012). In a study by Lazariu,
Nguyen, McNutt, Jeffrey, and Kacica (2017), it was revealed
that New York has established an effective prenatal protocol to
ensure the care for mothers and babies within its facilities to
reduce the risk of the state’s number of maternal deaths. In
addition, it was found that Medicaid expansions in New York
were associated with a significant reduction in maternal
mortality (Sommers et al., 2012). Unlike Texas, New York is
more progressive in passing healthcare policies that serve to
help its vulnerable population.
Values and healthcare. Lastly, values that are necessary to
consider in healthcare policies are the economy, equity and
justice. Economically, the U.S. spends a large amount of its
Gross Domestic Product (GDP) on healthcare expenditures.
Mathur, Srivastava and Mehta (2015) explain that 18 percent of
the U.S.’s GDP is used for health care costs for its citizens. To
reiterate, that percentage calculates to about $3 trillion dollars,
or over $9,000 on each American’s health annually (Mathur et
al., 2015). That cost is projected to increase in the upcoming
year. According to Mathur and his research partners (2015), 20
percent of the country’s GDP will be spent on healthcare by
2022 and it is estimated that it will continue to rise if
appropriate steps are not taken.
Moreover, a major part of the government funding goes to
the pharmaceutical industry for developing treatments for
diseases, rather than to each citizen’s medical well-being or
preventative care. According to Mathur and his colleges (2015),
spending on prescription drugs and related pharmaceutical
devices “increased from around $61 billion dollars in 1980 to
$349 billion dollars in 2011” (p. 2). This massive growth can be
credited to the simple price increase of common antibiotics, like
doxycycline, which increased from $20 a bottle in 2013 to
$1,849 a bottle in 2014 (Mathur et al., 2015). There is a clear
inefficiency in how government funds are being allocated.

Monetary support needs to be designated to areas that need
funding, especially when it comes to women’s healthcare. As
shown in other sections, the U.S. has the highest maternal
mortality rate among its other developed counterparts. If a
majority of its GDP is being spent on healthcare, it’s baffling
that it’s women are dying at higher rates.
Unfortunately, healthcare in the U.S. is treated as a business. It
is time to consider the values of equity and justice, an image of
which the U.S. displays to the world with government
innovations like Medicare, Medicaid and the ACA. The purpose
of government programs is to aid the socially and economically
disadvantaged American, particularly of a certain gender, race
and/or socioeconomic class. In reference to the U.S.’s high
maternal mortality rate, a 2017 report by Centers for Disease
Control and Prevention revealed that black women had the
highest pregnancy related deaths, at 43.5 deaths compared to
12.7 and 14.4 (per 100,000 live births) of white and other races
of women, respectively. The funding under Medicare, Medicaid
and the ACA’s coverage can help women in general but women
of color immensely. Not only race but socioeconomic inequities
are contributing factors to the high maternal mortality trend
(Molina & Pace, 2017). It is only fair for the allocated funds to
be used rightfully. It is important to maintain equity and justice
in medical care, regardless of race or socioeconomic status.
2.3 Maternal Mortality: A result of policy failure
Motherhood should be a joyful and positive experience, but for
many women lack of healthcare coverage can make pregnancy
and childbirth a dangerous and frightening struggle. According
to the World Health Organization (2016), “about 830 women die
from pregnancy or childbirth-related complication around the
world every day” (p.1). In 2015, 303,000 women died from
preventable causes either during or after childbirth (WHO,
2016). Unfortunately, many government policies have failed to
protect the safety of motherhood and our countries rates of
maternal mortality continues to rise. This failure, combined

with the reality of our current patriarchal government, has
ensured that little progression is made in protecting the mothers
of our country.
Conceptualization. Current literature has conceptualized
maternal mortality in similar ways, however authors have
explored the influencing factors of maternal mortality
differently. In 2007, the Partnership for Maternal, Newborn and
Child Health (PMNCH, 2007) presented a conceptual framework
depicting maternal mortality in relation to the continuum of
care. PMNCH emphasized a linkage between women seeking
consistent care throughout their lifetime and lower maternal
death rates (PMNCH, 2007). In this framework, maternal
mortality, the dependent variable, was conceptualized as the
rate of maternal mortality (PMNCH, 2007). The continuum of
care was presented as the independent variable and was
conceptualized as the time of care during a woman’s lifetime
and the location where care is received (PMNCH, 2007). Time
of caregiving was broken down throughout a woman’s lifetime,
starting with adolescence and pre-pregnancy, and ending with
postpartum care (PMNCH, 2007). PMNCH asserted that early
health interventions, such as improving the nutritional intake of
young girls and family planning counseling prior to pregnancy,
would aid in the reduction of the maternal death rate (PMNCH,
2007). The places of caregiving were presented in three
dimensions; health facilities, communities, and households
(PMNCH, 2007). PMNCH also stated that through the
promotion of healthy home practices, encouraging women to
seek care at healthcare facilities, and the integration of the
access quality care throughout the community, MMR would be
significantly reduced (PMNCH, 2007).
Straying from the traditional conceptualization, Stewart (2006)
broadens the context of maternal mortality. The study explores
different approaches to improve maternal death rates in Canada.
Stewart bases her concept of maternal death not only on
obstetric indicators, but also includes deaths due to mental
health conditions and violence (Stewart, 2006). The dependent

variable, maternal death, is influenced by nutrition, education,
poverty, and mental health factors (Stewart, 2006). These
factors are described as “nonobstetric” indicators (Stewart,
2006). Stewart asserts that exploring both obstetric and
nonobstetric factors, as well as expanding the scope of
surveillance of death past the standard 42 days would aid in
targeting maternal death (Stewart, 2006).
In their research, Shiffman and Smith (2007) explore why
certain global health initiatives receive more political priority
than others. The authors shift away from attributing high
maternal death rates to socioeconomic and health factors, and
instead explain how politics play a major role in how
governments tackle the problem (Shiffman & Smith, 2007).
Shiffman and Smith link the affects that political acting powers,
the comprehension of the detriments of high MMR, the political
context, and the characteristics of the issue has on how maternal
mortality has been addressed globally (Shiffman & Smith,
2007). Actor power is conceptualized as “the strength of the
individuals and organizations concerned with the issue”
(Shiffman & Smith, 2007). Acting power can influence the
MMR through how political groups and grassroots organizations
mobilize to bring attention to the issue and how mechanisms are
implemented to address the problem (Shiffman & Smith, 2007).
The authors also state that global MMR can be influenced by
how the issue is understood and portrayed (Shiffman & Smith,
2007). The way in which governments choose to frame and
define the problem and how the public responds influences how
policy will be shaped to counter high MMR (Shiffman & Smith,
2007). In addition, the environment in which political acting
powers operate, such as global political conditions can impact
how governments attack MMR (Shiffman & Smith, 2007). The
political climate and policy windows create or prohibit the
opportunities to decrease maternal death rates (Shiffman &
Smith, 2007). Lastly, the features of the concern of high global
MMR, including the severity of the problem, the way MMR is
measured and monitored, and how the interventions are

explained and implemented will have an impact on the
dependent variable (Shiffman & Smith, 2007).
In conclusion, the study found that the global safe motherhood
has encountered many obstacles (Shiffman & Smith, 2007). In
respect to acting powers, there is no strong, influential global
leader to head the initiative, causing a fragmented response to
the high maternal death rate (Shiffman & Smith, 2007). There is
also inconsistent methods of measurements and interventions,
causing a lack of consensus on how to decrease MMR (Shiffman
& Smith, 2007) The article goes on to state that the victims of
MMR, poor women of color, hold little political power to
generate support for the cause (Shiffman & Smith, 2007).
Though the political climate has opened windows to allow for
the implementation of effective strategies, the world’s
governments have not effectively taken advantage of the
opportunities to pass impactful policies (Shiffman & Smith,
2007). The research suggests that increased political momentum
and a universal consensus on the approach to reducing MMR
should be implemented, as well as continued research and
refinement of the framework will aid in eliminating this
complexity (Shiffman & Smith, 2007).
Patriarchy in Government and Healthcare. The United States
can be viewed as a patriarchal society, a general structure in
which men hold the positions of power and have more privilege
to which women are not entitled. Men typically hold high
positions such as the head of government or household, a boss
in the workplace, and leader of social groups (Napikoski &
Lewis, 2017). For example, the Trump Administration
composed of high ranking white men, has attempted to repeal
policies implemented to assist in the best outcome for women’s
health. Countless women in the United States still lack the
opportunity for informed decision-making to ensure that they
receive high-quality care (Coeytaux, Bingham, & Strauss,
2011). Though there have been many strides in gender equality
in areas such as education and the labor force, women and girls
still face crucial health disparities. A World Health

Organization (2009) study found that due to patriarchal
ideologies, women are typically viewed as subordinates,
therefore become more susceptible to mistreatment, leading to
high instances of illness and death (p. 9). Though more women
are participating in politics, men are still the wielders of power,
making them the controllers of the allocation of socioeconomic
resources (WHO, 2009). Implicit biases in healthcare are a
major driving force in the high rates of disease and maternal
mortality amongst women, in particular black women (Blair,
Steiner, & Havranek, 2011).
The U.S. government has not taken hasty initiative to address
maternal mortality as it has other issues. One can say that the
issue is not seen as priority due to lack of consideration for the
population affected by this crisis. Women, and more
specifically women of color, have endured years of being
devalued and considered less than their white, male
counterparts. Still, women have yet to gain the respect they
deserve to be seen as equal. Today, women make up about one-
fifth of Congress; only 19.6 percent and 38.5 percent of those
women are women of color (“Women in the U.S. Congress,”
2018). 2017’s Fortune 500 CEOs list included only 32
companies with female CEOs (“Women CEOs,” 2017). The
gender wage gap is still present within our society, as woman
earn 80.5 cents for every dollar earned by men, and this number
is even lower for women of color, at about 63 cents (“Pay
Equity & Discrimination,” n.d.; “Women and the Wage Gap,”
2017). And lastly, about 35 percent of women have reported
being victims of domestic violence in the United States
(“Violence Against Women,” 2015). Additionally, according to
Justice Bureau Statistics, African American women experience
domestic violence from an intimate partner at rates 35 percent
higher than white women.
The Affordable Care Act. The Patient Protection and Affordable
Care Act (ACA) was fully implemented in 2014 with the
provision to increase access to prenatal care and health
insurance (Hope et al., 2017). It has been effective in providing

affordable, quality health care to millions of Americans, and
especially American women (Gamble & Taylor, 2017). Before
the ACA, pregnant women seeking healthcare coverage were
turned away because most individual plans did not cover
maternity services. Individual plans that did offer coverage
ranged in price from $15 to $1600 a month (Ranji, Salganicoff,
Sobel, & Rosenzweig, 2017). Additionally, Ranji and her
colleagues (2017) state that the ACA Medicaid expansion was
implemented to provide continuous coverage to pregnant women
who automatically lose coverage 60 days after the birth of their
baby. Before the enactment of the ACA, only a few states
required coverage for maternal care in the individual insurance
market. In fact, eight out of ten health insurance plans failed to
cover maternity care at all (Sonfield, 2017). Additionally, this
would affect women who opt out of maternity care coverage
through their job health insurance coverage thinking they would
not need it, only to fall short if they unintentionally become
pregnant (Ranji et al., 2017). The ACA has taken strides in
narrowing the gap in health insurance coverage. However, under
the current administration, these progressions have come to a
screeching halt. Despite the critical role of the ACA in securing
access to maternity care, Congress has pushed to undo the law’s
most critical protections for women concerning personal
decisions and family planning (Molina & Pace, 2017).
According to Gamble & Taylor (2017), in May of 2017 the
House of Representatives passed the American Health Care Act
(AHCA), a bill to repeal and replace critical requirements of the
ACA. Gamble and her colleague also state that the
Congressional Budget Office (CBO) estimated that 23 million
people would lose insurance coverage in the next ten years if
passed. In July 2017, the Senate then released its version of the
repeal and replace bill, the Better Care Reconciliation Act
(BCRA) and if approved, CBO estimated that 22 million people
would become uninsured (Gamble & Taylor, 2017). Again, in
July 2017, a proposal for the Obamacare Repeal Reconciliation
Act was released, which would repeal the ACA entirely with no

immediate replacement. CBO estimated that in the next ten
years 32 people million would lose their health insurance as a
result of such an act (Gamble & Taylor, 2017). The Senate
provision to defund Planned Parenthood was also added to the
legislation (Gamble & Taylor, 2017). Even though these
proposals failed, the ACA faces continuous difficulties,
including efforts by the Trump administration to repeal
payments to insurance companies that help reduce cost-sharing
for low-income people (Molina & Pace, 2017).
What does this mean for American women? The ACA has
provided numerous women a range of protection and benefits
such as mandatory maternity and newborn coverage, prenatal
screening, and breastfeeding support (Sonfield, 2017). Many
women have relied on Medicaid rather than private insurance, to
cover the cost of pregnancy. Eliminating required maternity
coverage would weaken progress made under the ACA, resulting
in 23 million fewer people with insurance by 2026 (Sonfield,
2017) Obamacare also provides women with access, free of
charge, to contraceptives which allow for family planning and
the prevention of unwanted pregnancies (Sonfield, 2017). The
Trump administration plans to allow states to opt out of this
requirement as well block women from using Medicaid to visit
Planned Parenthood Federation of America (PPFA) clinics
(Khazan, 2017). Planned Parenthood is an organization which
provides reproductive health services to many low-income
women across the nation (Ranji et al., 2017). Terminating
access to the care provided at PPFA clinics not only removes
access to a trusted and available provider but also removes
access to essential preventative and reproductive health services
that are crucial to proper maternal health outcomes (Gamble &
Taylor, 2017). The replace and repeal also abandons the
obligation of the coverage of maternal health care under
Medicaid (Khazan, 2017). The passage of this bill could not
only affect public insurance, but also impact the health benefits
that employers provide, limiting the access women have to pre-
natal and maternal care (Khazan, 2017). If passed, there could

be detrimental effects on the progress made through the ACA,
and a spike in negative health outcomes for American women.
2.4 Maternal Mortality and Racial Background
According to the American College of Obstetricians and
Gynecologists Committee on Health Care for Underserved
Women (2015), “projections suggest that people of color will
represent most of the U.S. population by 2050” (p. 1).
Unfortunately, significant racial and ethnic disparities continue
to persist in women’s health and health care within our country.
As mentioned earlier, research has shown that maternal
mortality disproportionally affects African American women
and other women of color. Howard (2017) states that 700 to
1,200 women die each year in the United States from pregnancy
or childbirth complications. Additionally, a 2007 study
conducted by Tucker, Berg, Callaghan, and Hsia found that
black women are two to three times more likely to die from
preeclampsia, eclampsia, abprutio placentae, placenta previa,
and postpartum hemorrhage, common conditions associated with
maternal mortality, than their white counterparts. Many of these
health disparities are directly linked to inequities in income,
housing, education, and job opportunities (ACOG, 2015). Long-
lasting issues of racism and discrimination have influenced
individual health in our country and has contributed to our
current women’s health crisis.
Lack of national response. All over the world, rates of
maternal mortality have decreased significantly. According to
the World Health Organization (2015), developed regions have
experienced an estimated 2.4 percent average yearly reduction
in their maternal mortality rates over the past 25 years.
However, we have made it clear several times that the United
States has not experienced quite the same trend. However, the
issue may be deeper than the government’s inability to allocate
proper funds towards an initiative to end preventable maternal
mortality within the country. It could be, instead, that dying
American mothers are simply not a priority. Fathalla (2006), as

cited in the American Public Health Association (2011), states
that “Women are not dying because of untreatable diseases.
They are dying because societies have yet to make the decision
that their lives are worth saving” (p.1). Furthermore, when one
understands that maternal mortality is a greater issue among
American women of color than among American white women,
it is easier to further realize why the issue may have been
ignored for so many years, given the racial climate over the past
several decades.
The national response to opioid epidemics in comparison to
maternal deaths makes the case in a point. For several decades,
health disparities among the black Americans have been largely
blamed on the population’s susceptibility to illness (Martin,
2017). New research, however, has indicated that the problem
may not so much be race, but instead racism, that is leading to
such a disproportionate rate of maternal deaths among black
mothers. Systemic issues are instead to blame for the social
inequities experienced by African Americans, that has led to
their negative health outcomes and unequal access to care. Take
the crack and opioid epidemics as an example. During the
1980s, the use of crack-cocaine was rampant among the black
community. The epidemic was the biggest story in the news at
the time, however, efforts to combat the issue were, needless to
say, minimal as a health concern. A very different approach is
seen today, as policy-makers work hard to put an end to the
opioid epidemic that has ravaged the country; one that has
affected mainly the white population.
In the 1980s, lawmakers were swift in implementing an
incarceration-based response to the crack epidemic. In 1986
congress passed the Anti-Drug Abuse Act, which established
mandatory minimum-sentences for specific quantities of
cocaine. The act required a minimum five-year federal prison
sentence for distribution of just five grams of crack-cocaine; a
much harsher sentence than that required for distribution of
powder cocaine, a predominately “white” drug. The distribution
of 500 grams of powder cocaine – 100 times the amount of

crack cocaine – carries the same sentence (Vagins and
McCurdy, 2006, p. i). Instead of working to help those addicted
to the lethal drug, the government’s solution was to throw them
in prison, further adding to the oppression of black Americans
within the U.S.
In comparison, great efforts have been put towards ending the
opioid epidemic that has taken the lives of so many Americans;
predominately those of Caucasian decent. Devastated by
increased prescription and illicit opioid use, abuse, and
overdose, governments, both federal and local have put much of
their resources into improving access to prevention, treatment,
and recovery support services as well as supported research that
looks to find alternatives to opioids for pain and new treatment
options for individuals plagued by the epidemic (National
Institute on Drug Abuse, 2017) On October 26, 2017, President
Trump declared the opioid crisis a “Health Emergency,” making
the issue a priority for the government and the American
people. When the opioid crisis hit rural areas and the Caucasian
population, addiction was no longer a crime as it was in the
1980s. Instead, addicted individuals were encouraged to seek
help and the burden was shifted to the government to offer the
services needed to aid these people in getting back on their feet.
Inequalities among women of color and maternal mortality. The
devaluation of many people of color in American History has
contributed to the social inequalities that many women of color
face during pregnancy and childbirth. Martin (2017) found that
differing access to healthy food and safe drinking water, safe
neighborhoods and good schools, decent jobs and reliable
transportation are all types of social inequities that have
stemmed from systemic failures that have plagued this specific
population. As mentioned previously, black women are more
likely to have chronic conditions such as diabetes,
cardiovascular heart disease, hypertension and obesity (Mays et
al., 2007), which can cause complications during pregnancy.
Many behavioral risk factors that contribute to early disease and
death among these individuals are an unhealthy diet, smoking,

living in substandard housing or dangerous neighborhoods, and
living in communities with environmental hazards (Julion,
2018). Black women are also less likely to be insured than their
white counterparts (Martin, 2017). Without routine visits to the
doctor, many of these women could have diseases heading into
pregnancy that they were unaware of. Martin (2017) goes on to
state that many of the hospitals where black women give birth
are often products of historical segregation and lower in quality
than those where white women deliver.
These issues are amplified by unconscious biases that exist
within the medical system. According to Shavers and her
colleagues (2012), 74 percent of African Americans, and 69
percent of other non-whites report personally experiencing
general race-based discrimination in a medical setting, and has
been found to deter these individuals from using available
services. Negative racial attitudes and experiences have
contributed to the decision of many women of color to delay
prenatal services that can lead to better health outcomes for the
mother and her child. Experiences with chronic race-based
discrimination, both actual and perceived, has also been proven
to set off physiological responses such as elevated blood-
pressure and heart rate; issues that can lead to further
complications during pregnancy (Mays et al., 2007).
2.5 Health Insurance and Maternal Mortality
According to Comfort and colleagues (2013), studies have
shown a positive relationship between health insurance and the
use of maternal health services. Two out of three studies which
examined the effect of health insurance status on maternal
mortality found that having health insurance does, in fact,
decrease maternal mortality. Maternal health services, which
include prenatal care, are essential in ensuring the best health
outcomes for both the mother and child. Therefore, it is safe to
assume that the lack of maternal health services can contribute
to rising maternal mortality rates in the United States. Although

prenatal care is provided to all women in most states, women
across many low-income neighborhoods and minority
backgrounds may not understand the importance of prenatal care
and might be unsure of how to access it (Baudry, Gusman,
Strang, Thomas, & Villarreal, 2017). Futhermore, Baudry and
colleagues (2017) state that this lack of knowledge can result in
disproportionate health outcomes for women who are unable to
identify warning signs of possible complications during their
pregnancies. According to the CDC (2015), nearly a quarter of
black women begin prenatal care late in their pregnancy or not
at all. This percentage is more than two times higher for black
women than their white counterparts. Having health insurance
and access to maternal health services prior to pregnancy,
during pregnancy, and after pregnancy is the most ideal
situation to prevent negative health outcomes for both the
mother and child.
Women can gain insurance through their employer, the
government, or a private company. Depending on which option
is most suitable for their financial situation, the quality and
access to care may vary. A 2008 study conducted by the
National Women's Law Center discovered that among more than
3,500 insurance plans sold across the country, only 12%
included comprehensive maternity coverage (Sonfield, 2010). In
other words, women who opt for private insurance may be able
to obtain better benefits and higher quality of care than women
who depend on Medicaid (Comfort et al., 2013). The authors
further drive this point by stating that there is significant
evidence demonstrating the effectiveness of having access to
skilled care at the bedside during delivery, a benefit that low-
income women will not be able to reap. The thought that all
women are not provided the same quality of care based on their
insurance is disturbing when you consider the fact that about
four in ten U.S births are paid for through Medicaid (CDC,
2015). Seeing that a government program funds almost half of
every ten births in the United States, the quality of care
provided by Medicaid should be equally beneficial to the

mother as the care provided by a private insurance.
Health insurance status. Thankfully, as a result of the
Affordable Care Act, opportunities for women to receive health
insurance have increased. The ACA requires Medicaid to
provide insurance for women throughout their pregnancy, which
enables them to use their prenatal care services as a detection
and surveillance of pregnancy complications and chronic
diseases (Molina, 2017). However, the lack of health insurance
coverage prior to pregnancy can play a notable role in
exacerbating maternal mortality rates. According to Nour
(2008), the consensus among international organizations is that
quality care requires services throughout a woman’s
reproductive life. Nour’s point is that proper management of a
woman’s health before pregnancy is proven to be just as
important to the management of a woman’s health during and
after pregnancy.
Additionally, many states without Medicaid waivers stop
covering these mothers sixty days after delivery (Sonfield,
2010). The author states that this process leaves many low-
income women without insurance again, tossing them into a
never-ending cycle of moving in and out of insurance coverage.
The CDC (2015) reports that women who experienced unstable
coverage were more likely to be young, minority, have no
higher than a high school diploma, unmarried, and have incomes
lower than 200% of the federal poverty level. These factors all
serve as barriers to practicing preventative health care and limit
a woman’s opportunity to monitor chronic conditions.
Consequences associated with lack of healthcare coverage. The
CDC (2015) identified cardiovascular diseases and hypertensive
disorders along with a few others as conditions that can put
women at risk for poor maternal outcomes. Without insurance,
these conditions often go unmanaged and possibly unidentified.
A woman with an unmanaged chronic condition is more likely
to experience risks during pregnancy and delivery, even if she
receives prenatal care somewhere down the line (CDC, 2015).
However, the importance of prenatal care is still relevant.

Baudry and colleagues (2017) assert that prenatal care
interventions appear to be effective in reducing adverse
maternal outcomes. Unfortunately, the authors argue that the
decision of many states to not expand Medicaid funds has
created a coverage gap where people are not poor enough to get
Medicaid, yet not financially stable enough to pay for their own
insurance or better coverage. It is estimated that 1.1 million
women included in the coverage gap could qualify for Medicaid
if their states expanded program eligibility (Kaiser Foundation,
2015).
There is a possibility that women in this coverage gap could be
left to suffer if the treatment is costly, but there is not enough
research to prove it. According to the Kaiser Foundation (2017),
women are less likely to be covered through their own job and
more likely to be covered as a dependent. The authors
emphasize the raised stakes for coverage if a woman were to
ever become a widow or divorcee. A loss in coverage can force
a woman to forgo medical services, even ones crucial for
women’s health such as mammograms and pap tests. Due to the
lack of funds to pay for treatment, Weinick, Byron, and
Bierman (2005) report that one in six people avoid necessary
health care. This includes putting off, postponing, or never
seeking medical services, not filling a prescription, and not
following the doctor’s treatment plan. Health care providers are
increasingly finding themselves in situations where they are
concerned about their patient’s ability to pay for the necessary
treatment (Weiner, 2001).
Some physicians do what they can to help and others feel that
there is no additional help they can provide to patients unable to
pay for treatment. Weiner (2001) indicates that some physicians
may attempt to under code or waive deductibles for people who
cannot afford treatment but those actions mean committing
fraud. On the other side of this ethical dilemma, people across
the United States have witnessed the dumping of patients from
health care facilities into the streets without proper housing
placement. Since most health care facilities are run like a

business, if a patient lacks the insurance or money to pay for
services, the providers may find themselves doing whatever
they can to discharge the patient as quickly as possible. It can
be assumed that denying health care to a pregnant woman due to
lack of insurance can affect the U.S maternal mortality rate, but
further research should be collected to determine a significant
relationship between the two.
Likely victims of healthcare coverage. According to the CDC
(2015), the Pregnancy Risk Assessment Monitoring System
concluded that most women who were uninsured just a month
before pregnancy were non-white/a person of color. A woman
who receives health insurance right before the start of her
pregnancy should be taught what her insurance covers, how to
utilize it, and the importance of prenatal care. The lack of
preventative health care, maternal education, and guidance puts
low-income African American women at a higher risk for
negative maternal outcomes. The American Public Health
Association’s (2011) also points out that since 1950, African
American women have consistently had a higher maternal
mortality rate than White women. Additionally, many of the
communities that these African American women come from
have substantial gaps in access to quality health care for
pregnant women.
Due to their community’s lack of resources, African American
women may attempt looking outside of their neighborhood for
health care services. However, Baudry and colleagues. (2017)
mention that after trying a health care facility outside of their
neighborhood, African American women may be discouraged to
continue receiving care because of the negative interactions and
discrimination they face in healthcare settings. Studies have
shown that implicit bias can affect the care received by a
woman of color (Blair, Steiner, & Havranek, 2011).
Additionally, the authors state that research suggests African
American people receive lower quality and intensity of care
than White people even when their insurance is the same. The
failure of healthcare providers to listen, respect, and create an

appropriate treatment plan for women of color, directly affects
their quality of care (Baudry et al., 2017) and can potentially
contribute to the maternal mortality rate in the United States.
CHAPTER THREEConceptual Framework
In this chapter, we discuss the factors that contribute to the high
maternal mortality rates in the U.S. First, we present the
conceptual framework, which serves as the road map for this
study. Next, we explain the variables we believe are responsible
for high maternal mortality within the United States. These
variables are health insurance status and racial background of
women. Then, we discuss our assumptions, research questions,
and corresponding hypotheses. After, we acknowledge the
stakeholders to whom this study pertains to and present the key
terms we believe are essential to understanding the key issue.
Lastly, we conclude with this chapter’s main points.
Figure 3.1 illustrates the relationship between the dependent
and independent variables in this study.
Figure 3. 1
The dependent variable is maternal mortality. The aim is to
determine whether maternal mortality is affected by the
independent variables, which are health insurance status and
racial background of American women. Health insurance status
is conceptualized as uninsured versus insured. Racial
background of American women is conceptualized as white or
black women. Moreover, to further understand how the
dependent and independent variables will be measured, the
following operational definitions are important. Maternal
mortality is operationalized as the number of maternal deaths
per 100,000 live births. The first independent variable, health
insurance status, is measured as the percentage of uninsured
women in the state. The second independent variable, racial
background of women, will be measured by the percentage of
black women in the state, or per capita. Below, Table 3.2
summarizes how each variable will be operationalized.

Figure 3. 2
3.1 Health Insurance Status and Maternal Mortality
In a recent article by Chuck (2017), the reasons behind
Texas’ high maternal mortality rates are explored. One of the
two major reasons for Texas’ high rates includes a delay in
receiving prenatal care until late pregnancy. Novack (2017)
explains that the state’s policy makers have rejected a federally
funded expansion of Medicaid under the ACA, which would
have covered 1.1 million more of their residents. The choice not
to expand through the ACA will also affect more than half of all
births in Texas that are paid for by Medicaid already. The
state’s legislation is focused on extending research efforts,
rather than addressing the underlying problem: lack of access to
healthcare. Sifferlin (2018) argues that a lack of access to
proper healthcare before pregnancy and a push for cesarean
section do not properly prepare a woman’s body for birth. This
leaves these women more vulnerable to dying during childbirth.
Overall, the U.S. has experienced a decrease in the number
of uninsured women. According to a Health of Women and
Children Report (2018) by America’s Health Rankings, in 2015
the number of uninsured women was about 20 percent, this
percentage dropped to approximately 17 percent a year later.
The reason for this decline is due to the ACA, as referenced
previously in chapter 2 of this paper. Despite the dip in the
number of uninsured, the maternal mortality rate is still high in
the country, at almost 20 percent in 2016 (America’s Health
Rankings, 2018). There must be another contributing factor that
affects maternal mortality. In this study, we deem it to be race.
3.2 Race and Women’s Health
Though women of all races contribute to Texas’ high maternal
mortality; black women contribute to the state’s live birth rate
at about 10 percent, but contribute to its maternal deaths with
more than 25 percent (Chuck, 2017; Hoffman, 2017). These
skewed statistics have led researchers to inquire why African

American women in Texas are dying at such a high rate during
childbirth. In a systematic review and meta-analysis study,
regarding racism and health service utilization by researchers
Ben, Cormack, Ricci and Paradies (2018), it was concluded that
an association exists between race and healthcare outcomes.
Overall, racism greatly dictates the trust minorities had in the
healthcare system and professionals. Those who experienced
racism while receiving care were more likely to delay seeking
treatment and reported lower satisfaction and poor perception of
quality of care (Cormack et al., 2018). Similarly, D'Angelo,
Bryan and Kurz’s (2016) mixed methods study, which examined
disparities in prenatal care among Connecticut’s female
residents, found that although the participants understood the
importance of prenatal care, experiences differed among women
of different racial backgrounds. Black/African American women
were one of the groups that expressed that they experienced
discrimination stating that they did not have any input when it
came to their care (D’Angelo et al., 2016).
In addition, Creanga, Berg, Ko, Farr, Tong, Bruce and
Callaghan (2014) presented several bar graphs from 1987 to
2009 in the United States. The trend in data depicted the rise of
maternal mortality across the nation and also provided the data
by reasons for the number of maternal deaths as well as the race
of the mothers. The pregnancy related mortality ratio is greater
in every year for black women in comparison to white women.
Supporting this trend, MacDorman, Declercq and Thomas
(2017) analyzed data from 2008-2009 and 2013-2014 to
understand the patterns in maternal mortality by socioeconomic
characteristics and cause of death in 27 states and the District
of Columbia. Their results revealed that there was a 23%
increase in maternal mortality during the 5-year period and non-
Caucasian women had the greatest increase in maternal
mortality (MacDorman et al., 2017). Centers for Disease
Control and Prevention (2017) adds more support that race
contributes to high maternal mortality rates in the U.S. by
pointing out that during the years of 2011-2013, per 100,000

live births, 12.7 maternal deaths were white women, 43.5 deaths
were black women, and 14.4 were other races.
3.3 Assumptions
Based on the existing published work about health insurance
status, race, and maternal mortality mentioned prior, there are
three main assumptions driving this study. The first assumption
is that due to implicit bias of healthcare providers, black women
do not have equal access to healthcare. Our second assumption
is that being uninsured leads to a lack of preventative care. This
in turn, leaves women more susceptible to complications during
pregnancy. The third assumption is that women who are
uninsured before pregnancy are less likely to successfully
utilize and navigate prenatal care for optimal maternal
outcomes.
3.4 Research Questions and Hypotheses
Along with our assumptions, we also derived two research
questions based on research conducted. The first research
question examines the relationship between the health insurance
status of American women and maternal mortality in the
country. The second research question asks about the
relationship between the race of women and maternal mortality
in the U.S.
With the support of existing literature and studies regarding
maternal mortality, null and alternative hypotheses were
developed for each study question proposed. In regards to the
relationship between health insurance status and maternal
mortality, the null hypothesis indicates that no relationship
exists between health insurance status and maternal mortality.
However, the testing hypothesis states the greater the percent of
uninsured women in the state, the greater the number of
maternal deaths per 100,000 live births within that state.
Pertaining to the research question that inquires about the
relationship between racial background of women and maternal
mortality in the U.S, the null hypothesis states that no

relationship exists between the racial background of women and
maternal mortality. On the other hand, the testing hypothesis
suggests that the greater the percentage of black women in the
state, the greater the number of maternal deaths per 100,000
live births within that state.
3.5 Key Stakeholders
There are several key stakeholders who the conclusion of this
study concerns. We have grouped these individuals into three
categories: women, policy makers and health care providers.
The aim of this study is double layered. It is not only to
increase the level of awareness regarding maternal mortality
and how it is affected by insurance status and race. But, also to
help create active universal health policies, which will decrease
and ultimately eliminate implicit bias that contributes to the
U.S.’s high maternal mortality rates.
Women: The main stakeholders of this study are American
women, and particularly black American women. Every woman
should have the right to equitable healthcare before pregnancy,
regardless of race. One of our sub-purposes is to inform women
of the benefits of preventative care. Giving birth is a strenuous
experience and caring for her body will better prepare women,
in the chance that she becomes pregnant. Access to health care
is another issue we want to inform the female population about.
If she cannot afford healthcare or does not qualify under her
state’s guidelines for public health coverage, it is important to
take initiative in their government policies. Whether it is taking
part in a march, signing or starting a petition, and/or voting,
women need to take the lead in the political sphere, especially
pertaining to their health.
Policy makers: The driving point of this study is significant for
policy makers. As elected officials, they need to consider the
best interest of the individuals that voted them in for their role.
The funding designated to women’s healthcare should be used
effectively and the overall health of all women should be a main
priority. As communicated beforehand, allocating resources

efficiently in areas of preventative care and health insurance for
women through public assistance programs will help with the
issue of the U.S.’s high maternal mortality rate.
Healthcare providers: As discussed earlier in this chapter,
healthcare providers implicitly are biased to black women. The
purpose of this research study is to raise this issue among health
care providers and point out that black women are less likely to
routinely go to their doctor appointments if they feel
discriminated against. Healthcare providers need to be aware
that women in general are a vulnerable population and women’s
healthcare is a sensitive subject. Therefore, they need to be
more mindful and conscious of their language and actions when
speaking to women about her prenatal, maternal and overall
care.
3.6 Terminology
The following key terms are necessary to gain a better
understanding of this study. Definitions are gathered according
to the World Health Organization and the U.S Census Bureau.
Maternal mortality rate (MMR): Maternal mortality rate reflects
the number of maternal deaths per registered 100,000 live
births. There are many factors that contribute to the high
maternal mortality rate in the United States but for this study
we will explore health insurance status and racial background of
mothers.
Maternal death/maternal mortality: Maternal death and maternal
mortality can be used interchangeably and is defined as the
death of a woman while pregnant or within 42 days of delivery.
Live birth: A live birth is described as the complete expulsion
or extraction of a baby from his/her mother. The baby must
show evidence of life after the separation, such as the ability to
breathe on its own.
Prenatal care (Antenatal care): Prenatal care is the care
provided by skilled health-care professionals to pregnant
women and adolescent girls in order to ensure the best health
conditions for both the mother and baby during pregnancy. Most

states in the U.S provide prenatal care to all women regardless
of their health insurance
Race: Race is defined as the way a person self-identifies
through one or more of the following social groups
· White, Black or African American, Asian, American Indian
and Alaska Native, Native Hawaiian and Other Pacific Islander
For this study, Black or African American women are the main
focus.
3.7 Concluding Remarks
In this chapter, we presented and explained the conceptual
framework in which the variables in this study are related. The
assumptions based on current published work, research
questions that this study aims to answer, and hypotheses were
discussed as well. After, the key terms and stakeholders were
recognized, as it was relevant to supporting the goal in this
study. In the next chapter, the methodology to accomplish our
study will be discussed.CHAPTER FOURMethodology
Although the maternal mortality rate has significantly declined
on a global scale from 1995 to 2015, the United States rate is
steadily rising. Prenatal care has been
identified as a key component to ensuring the best health
outcomes for both the mother
and child, however not all women receive the same access and
quality of care (Blair et
al., 2011). Black women comprise a disproportionate number of
maternal
deaths in the United States and it assumed that varying factors
such as race and health
insurance status can influence that number. First, we will state
the research questions and

hypotheses to further develop the focus of this study. Next, this
chapter will discuss the
design of the study and how it will help determine the
relationship between health
insurance status, race, and maternal mortality. Finally, we will
share the level of analysis,
followed by the description of measures and data collection.
4.1 Research Questions
1. What is the relationship between the health insurance status
of mothers and maternal
mortality in the U.S.?
2. What is the relationship between the racial background of
women and maternal
mortality in the U.S.?
Hypothesis
H0: There is no relationship between health insurance status and
maternal mortality.
H1: The greater the percentage of uninsured women in the state,
then the greater the number of maternal deaths per 100,000 live
births within that state.
H0: There is no relationship between the racial background of
women and maternal

mortality.
H2: The greater the percentage of black women in the state,
then the greater the number of maternal deaths per 100,000 live
births within that state.
4.2 Research Design
The purpose of this study is to determine the role that
health insurance status and
race play in rising maternal mortality rates in the United States.
To do this, we conducted
a cross-sectional, state-level study using mixed methods
research. According to O’Sullivan, Rassel, and Berner (2008),
“A cross-sectional design collects data on all relevant variables
at one time” (p. 27). Rather than studying or analyzing a
population over a long period of time, cross-sectional studies
offer “snapshots” of a population of interest at one point. The
design’s greatest value is in describing the relationships among
several variables and was used in our study to determine the
relationship between each of our independent variables and our
dependent variable.
Through the use of peer-reviewed articles, we performed a
systematic review of
quantitative studies to identify trends within the existing
literature on the topic. Examining this literature has helped to
guide our research process in the right direction. The secondary
data collected from these quantitative studies, as well as
governmental sources and websites, will give readers a more
comprehensive understanding of the number of maternal deaths
by state and the population who is affected by this issue the
most. Some common themes found among the literature on
maternal mortality included our variables, racial background
and health insurance status, as well as prenatal care, health care

expenditures, and policy failures related to maternal health
services.
4.3 Delimitations and Scope
There are several factors that contribute to maternal
mortality in the United States,
however, to keep our study clear and concise we only focused
on health insurance and
race, as well as maternal mortality rates at a national level. This
study will not focus on
women who died due to complications from an abortion, the
mother’s lifestyle choices,
genetic conditions, education, income, social class, or ethnicity.
To provide an overview
of the most recent trends within the United States, we collected
data and research from the year 2016. Data from 2016 is the
most recent data available.
4.4 Measures and Participants
This study does not include any participants because we are
using secondary data,
but our units of analysis are uninsured women and black women
within 48 states plus the District of Columbia (2016 maternal
mortality rates were unavailable for Alaska and Vermont). Our
independent and dependent variables were measured as the
following:
Dependent

· Maternal mortality was conceptualized by maternal mortality
rate and
operationalized as the number of maternal deaths per 100,000
live births.
Independent
· Health insurance status was conceptualized by insured versus
uninsured and
operationalized as the number of uninsured as a
percentage of the state
population.
· Race was conceptualized by white women versus black women
and operationalized as the number of maternal deaths of black
women
per state.
4.5 Data Collection and Processing
For the qualitative portion of this study, we synthesized 25
peer-reviewed articles to identify the general consensus and
common conclusions among the literature on maternal mortality
in the United States. To organize this data, we developed a chart
with the author of each article’s name, the year of publication,
and a brief summary of the study’s findings, we then indicated
whether each study spoke to either of our study variables, health

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