Health policy involves the authoritative decisions, plans, and activities taken by the government that directly influences the health of individuals. These policies are established by the government at the local, state, or federal level. While health policy has positively impacted the health in the United States, there are also significant challenges that slow efforts to continue improvement. It is important to note that policies are made by humans, who are often driven by political beliefs and a mix of altruism and egoism (Longest, 2016).
Ethics help create and amend policies by influencing how individuals define problems and develop solutions. Further, they influence the political circumstances that may lead to new or modified policies. The four philosophical principles that should guide these ethical considerations include: respect for persons, justice, beneficence, and nonmaleficence (Longest, 2016).
Maternal Mortality and Respect for Persons
The ethical principle of respect for persons is recognizing individuals have the right to make decisions and choices based upon what they believe and value (Longest, 2016). An important aspect of health care is shared decision making, in which patients are presented the best available evidence to consider their options and make informed decisions, alongside their provider, about their plan of care. In order to ensure that patients can appropriately participate in their care decisions, the health system must ensure that the patient’s self-identified race, ethnicity, and primary language is documented. English language proficiency should be evaluated to assess for the need of an interpreter. Discharge materials and education should meet patients’ health literacy, language, and cultural needs. Staff should be educated regarding maternal racial and ethnic disparities and their root causes. Implementing each of these interventions has been shown to reduce disparities and promote active patient involvement in care (American College of Obstetricians and Gynecologists (ACOG), 2016).
Maternal Mortality and Justice
The principle of justice ensures that there is an element of fairness in the policymaking process, as well as within the policies themselves. Both benefits and burdens should be fairly distributed (Longest, 2016). An important component of preventing maternal mortality is adopting a culture of safety, which involves creating an environment that has the foundation of equity and respectful care. Healthcare systems and providers have a responsibility to promote and participate in this inclusive, just environment (Anderson & Foster, 2019). A mechanism should be established that allows patients, families, and staff to report inequitable care and occurrences of miscommunication or disrespect. When an incident of inequity or disrespect is reported, there must also be a system in place that ensures a timely and tailored response (ACOG, 2016).
Maternal Mortality and Beneficence
The main idea of the principle of beneficence is to do good. Practicing beneficence also includes the concept of balancing benefits and burdens. Provider should take into consideration each patient’s individual needs; what may benefit one patient, may not benefit another (Longest, 2016). ACOG (2016) recommends a disparities dashboard to be developed that is able to monitor processes and outcomes with respect to race and ethnicity. This data should be regularly disseminated to staff and leadership. Quality improvement projects should be implemented that targets disparities in healthcare access, treatment, and outcomes. When conducting reviews of maternal mortality and morbidity, the role of race, ethnicity, language, poverty, literacy, and other social determinants of health, including racism, at the interpersonal and system levels.
Maternal Mortality and Nonmaleficence
The principle of nonmaleficence is an obligation not to harm or cause injury (Longest, 2016). As discussed in my last blog post, African American mothers have a disproportionately high maternal mortality rate. Cesarean delivery, versus a vaginal birth, carries with it a higher morbidity and mortality rate and African American women have higher cesarean rates compared with Caucasian women (Anderson & Foster, 2019). This raises the issue of whether race and ethnicity contribute to whether providers choose to perform a cesarean. It may also suggest that the focus of African American pregnant women being more often considered high risk could lead providers toward performing a cesarean delivery. A high-risk woman may lose confidence in her ability to participate in shared decision making about the delivery, and providers may communicate this message indirectly or overtly (Anderson & Foster, 2019).
Practicing these ethical principles and ensuring they are considered when creating and amending policies helps to build a culture of health equity, leading to a reduction in racial and ethnic disparities (Anderson & Foster, 2019).
References
American College of Obstetricians and Gynecologists. (2016). Reduction of peripartum racial/ethnic disparities (+AIM). Retrieved from https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Reduction-of-Peripartum-Disparities-Bundle.pdf
Anderson, B. A., & Foster, J. (2019). Equity in clinical care. In B. A. Anderson & L. R. Roberts (Eds.), Maternal health crisis in America: Nursing implications for advocacy and practice (pp. 101-128). New York, NY: Spring Publishing Company.
Longest, B. B., Jr. (2016). Health policymaking in the United States. Chicago, IL: Health Administration Press.
Maternal Mortality in the United States 
I appreciate your insightful post. I agree with you that health policy has made strides towards positive changes, but its growth can also be stagnant. While healthcare policies are designed to promote optimal health among groups and individuals, efforts towards reform are largely affected by priorities, agendas, actions, and support by agency officials (Switzer, 29914). When this occurs, it is an infraction of the ethical principle, justice. As you mentioned, it is important to create healthcare policies that promote a culture of equity and respect. I believe that policy makers often do not place enough emphasis on these qualities and their decisions regarding policy reform can be influenced by what they believe is a priority. Regarding maternal mortality, I wonder if state and federal policy makers do not truly understand the significance of this health problem and if a large male presence in legislation might not be able to relate as to why this issue should be a priority. It is also possible that maternal mortality may not be a significant topic of interest in legislation due to a lack of education and awareness. The Institute for Healthcare Improvement (2020) recognizes this and has implemented the Better Maternal Outcomes Rapid Improvement Network, to use evidence-based interventions to improve maternal mortality, and educate the relevance and inequity associated with this public health concern.
However, it is important that policy makers consider ethical principles such as respect, justice, beneficence, and nonmaleficence into their decisions. This may reduce avoid bias and increase actions that reflect the best interest in healthcare equity and patients. These principles will be important to keep in mind as nurse practitioners and are essential to advocate for our patients in times that the government may not appear to have its best interest for patients and healthcare.
References
Switzer, J. V. (1994). Disabled policymaking/disabled policy. In Disabled rights: American disability policy and the fight for equality (pp.12-29). Washington DC: Georgetown University Press.
Feeley, D. (2019). Maternal Mortality Isn’t Getting the Attention It Deserves. Institute For Healthcare Improvement. Retrieved from http://www.ihi.org/communities/blogs/maternal-mortality-isnt-getting-the-attention-it-deserves
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This was an excellent, succinct discussion on the ethics involved in healthcare policy related to your topic. I especially liked the comment you made about providers taking patient preference into account. This is, in fact, a distinct and important part of utilizing evidence-based practice (EBP).1 These preferences may come from past experiences, the patient culture, family, friends, or what the individual reads online. The caveat, while the provider may be acting in accordance with beneficence by incorporating patient preferences, it is important that no harmful preferences are endorsed by providers as this then violates the principle of nonmaleficence. I think these two principles are particularly true in the realm of perinatal/maternal health. I currently work in a Women and Infant Services department and I have learned that patient preferences are quite varied from one party to another. I see how cultural influences are reflected in the birth plan formulated by the expectant mothers. I have also seen how difficult it is for some medical professionals to accept particular characteristics of certain birth plans. To this end, I think you may have a point about patients sometimes sacrificing a degree of autonomy in order to ensure nonmaleficence on the part of medical professionals. It is a bit like a game of ethical tug-of-war.
References
Siminoff, L. A. (2013). Incorporating patient and family preferences into evidence-based medicine. BMC Medical Informatics and Decision Making, 13(3), 1-7. doi: 10.1186/1472-6947-13-S3-S6
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As nurse practitioners, we need to educate ourselves in order to provide care that adheres to the four ethical principles you have explained in your post. It is important to understand why the disparities in maternal mortality exist, and we all need to look within ourselves to evaluate if we could be contributing to this injustice. The position statement published by Nurse Practitioners in Women’s Health (NPWH) on reducing maternal deaths discusses the concept of implicit bias (NPWH, 2019). Implicit bias is a term which refers to “unconscious attitudes that can influence affect, behavior, and cognitive processes” (NPWH, 2019. p.4). Although we may believe that we provide equal care to all patients, all healthcare providers should evaluate their own care for implicit bias and make every effort to eliminate this bias from their care. Educating providers about the disparities in African American mortality rates and the concept of implicit bias will help people to assess their own values and beliefs.
This topic touches on all four of the ethical principles, which you have clearly elaborated on above. The current state of maternal mortality in our country particularly goes against the principles of justice and nonmaleficence. Nurse practitioners are qualified to educate and advocate for changes to health policy which would benefit African American women and their babies.
References:
Nurse Practitioners in Women’s Health [NPWH]. (2019). Position statement: Eliminating preventable maternal deaths. Retrieved from https://www.npwh.org/lms/filebrowser/file?fileName=Eliminating%20Preventable%20Maternal%20Deaths%20Position%20Statement%20Final.pdf
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Respecting a mother’s wishes during childbirth is such an important topic. Working in labor and delivery for 3 years as a nurse, I often experienced a division between what the nurses/doctors wanted and what the patients wishes were. Many women were uneducated about the labor process and expected to just follow the instructions of others. When women did educate themselves and come with a birth plan, they would often face resistance from the staff. Nurses and providers would ridicule the mothers out of the room, label them as difficult patients or make comments that the patient is attracting bad luck when they come with a birth plan.
I found a study completed in Taiwan, 155 women worked with nurses and obstetricians together to create an individualized birth plan. The control group of 141 women did not have this opportunity to plan and receive education on birthing practices. The experimental group reported better childbirth experiences and increased control over their birth (Kuo et al., 2010).
I think education and planning with health care providers can help reduce maternal mortality. It is important for HCP to remember that childbirth is such an important moment in a family’s life and they should work with them, provide education and respect their choices.
Kuo, S. C., Lin, K. C., Hsu, C. H., Yang, C. C., Chang, M. Y., Tsao, C. M., & Lin, L. C. (2010). Evaluation of the effects of a birth plan on Taiwanese women’s childbirth experiences, control and expectations fulfilment: A randomised controlled trial. International journal of nursing studies, 47(7), 806-814.
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