Literature Review

(1)  Provide the theory or evidence as to how and why social determinants are associated with the health outcome – may be adapted from your group’s Neighborhood Justification and Conceptual Framework

Imagine waking up in a country where you do not know the language nor have many people to help you communicate with the population around you. This was the case for 36-year-old Ayushi. Ayushi was 26 weeks pregnant with twins and had recently relocated to Turkey from India along with her husband. A few days after moving she started complaining about headaches, high blood pressure, and significant weight gain. Her obstetrician told her everything was fine and a normal delivery was planned. A few weeks later, she was admitted to the hospital and diagnosed with pre-eclampsia. During labor, a caesarian was performed and healthy twin girls were born. Ayushi, however, started to severely bleed and had to get a hysterectomy to save her life. Ayushi remained in the hospital for 30 days and then was promptly discharged after the horrifying experience that she had. This could have been averted if the primary obstetrician would have diagnosed her properly and given her the necessary information. Unfortunately, this case happens more than it should.

Social determinants of health impact individuals throughout the world. A plethora of factors affect health status around the world. These health factors can be social and economic in nature. Severe Maternal Morbidity (SMM) is a health outcome of great importance and is the result of many such factors. These factors can have a direct or indirect influence on the maternal reproductive life cycle leading to complications. SMM exhibits a cyclical nature in the reproductive life cycle because past pregnancies can have consequences on ensuing pregnancies (Filippi et al., 2018). SMM includes short-term and long-term consequences to a women’s health. These consequences can arise from unexpected complications of pregnancy, labor, and delivery. Multiple factors can affect maternal morbidity at various stages of the reproductive life cycle. These factors include, but are not limited to, level of education, socioeconomic status, and age at pregnancy.

Education is one of the most powerful tool an individual can possess. Often taken for granted, knowledge can help save lives. One of the social determinants of health for pregnant women who suffer from severe maternal morbidity or other complications from pregnancy, is what level of education they have completed. The level of education that an individual goes through can have a vast impact on decisions they make throughout their lives’. As with the case with mothers, not having certain knowledge about healthcare services available and problems that may arise during pregnancy can have a detrimental impact on their health.

In a study done by Tunçalp et al. (2014), women in the lower education quartile were more likely to experience SMM. This further elucidates the point that lower levels of education that a woman has will put her in a more precarious position when it comes to maternal morbidities. In this study, they discuss why women who are less educated could suffer from complications leading to SMM. This could occur through delays in seeking out care because of a lack of knowledge in healthcare and medical abnormalities leading to maternal problems. This delay could have a deleterious effect on time sensitive treatments.

In conjunction with education, health literacy is vital for maternal health. Women need to be more empowered through health literacy, leading to better health outcomes (Firoz et al., 2018). This would lead to women making more informed decisions regarding their health, possibly curtailing any complications that could arise from the pregnancy. In addition, understanding how the health system works and counseling that they can receive will provide better maternal and child outcomes (Firoz et al., 2018). Education and health literacy are often overlooked but can be lifesaving when needed.

While education is one social determinant of health for SMM, low socioeconomic status is another contributing factor. Socioeconomic status can be thought of as a combination of income, occupation, and education level. Lack of proper education can often expose individuals to restricted economic opportunities leading to a lower socioeconomic status. Low socioeconomic status needs to be considered at as an independent, antenatal risk factor to ensure that maternal morbidity cases decrease. Education and socioeconomic status are correlated in that having a low socioeconomic status can determine the level of education people receive.

Having a low socioeconomic status were twice as likely to be associated with maternal morbidity (Lindquist et al., 2015). This study was done in Australia and was the first of its kind done there. Investigators there realized that the rural population was particularly at a higher risk of developing SMM. The reason for this was having to go great distances to get adequate health services that pregnant women might need. Being predisposed to these circumstances would lead to a greater number of SMM cases. Proper access to healthcare is one of the biggest culprits when it comes to SMM. Have a lower socioeconomic status will inhibit some women from receiving the proper treatments that she may need.

In addition, certain poor/rich inequalities exist, especially in healthcare (Houweling et al., 2007). These inequalities in maternity care emphasize the need for effective running of healthcare services. In certain cases, healthcare professionals treat poor women with less concern than rich or educated women (Houweling et al., 2007). Everyone deserves to have access the proper care that they need when they need.

Not only does level of education and socioeconomic status influence SMM, but also the age at which women become pregnant. According to Lindquist et al. (2015), maternal age had a significant association with complications of pregnancies and maternal morbidities. For example, women between the ages of 30 to 34 were 1.44 times more likely to have SMM. Even more, women aged 35 and over were 2.2 times more likely to have SMM. Age can have a profound effect on complications that arise during pregnancy. It also has a big impact on the health of the child. Health care providers must pay closer attention to the care of an expecting mother who is older. Complications like gestational diabetes increases with maternal age, from 1.7% in teenage mothers to 15.7% in older mothers (Lisonkova et al., 2017). This can further fuel the fire to cause maternal morbidities of even maternal mortalities.

Several factors contribute to negative health outcomes for women. Level of education, socioeconomic status, and age at pregnancy are just some of the multitude of factors that affect maternal morbidities. These factors bolster each other’s negative effect on health consequences and complications. It is vital to study the cases of SMM and improve strategies for fighting the complications that can arise of pregnancy because of social determinants of health. Finding strategies to combat these factors is the best intervention in curtailing SMM. According to Cecatti et al. (2007), there is a lack of knowledge in how to utilize the healthcare services that are already available. Educating the population is a principal mode of trying to help alleviate this problem. From our example from earlier, Ayushi would have benefitted greatly from these services and perhaps could have been saved from the mental and physical pain that she suffered.

References

Cecatti, J. G., Souza, J. P., Parpinelli, M. A., de Sousa, M. H., & Amaral, E. (2007). Research on Severe Maternal Morbidities and Near-Misses in Brazil: What We Have Learned. Reproductive Health Matters, 15(30), 125-133. doi:10.1016/S0968-8080(07)30333-9

Filippi, V., Chou, D., Barreix, M., Say, L., & Group, t. W. M. M. W. (2018). A new conceptual framework for maternal morbidity. International Journal of Gynecology & Obstetrics, 141(S1), 4-9. doi:10.1002/ijgo.12463

Firoz, T., McCaw-Binns, A., Filippi, V., Magee, L. A., Costa, M. L., Cecatti, J. G., . . . members of the, W. H. O. M. M. W. G. (2018). A framework for healthcare interventions to address maternal morbidity. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 141 Suppl 1(Suppl Suppl 1), 61-68. doi:10.1002/ijgo.12469

Houweling, T. A. J., Ronsmans, C., Campbell, O. M. R., & Kunst, A. E. (2007). Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bulletin of the World Health Organization, 85(10), 745-754. doi:10.2471/blt.06.038588

Lindquist, A., Noor, N., Sullivan, E., & Knight, M. (2015). The impact of socioeconomic position on severe maternal morbidity outcomes among women in Australia: a national case–control study. BJOG: An International Journal of Obstetrics & Gynaecology, 122(12), 1601-1609. doi:10.1111/1471-0528.13058

Lisonkova, S., Potts, J., Muraca, G. M., Razaz, N., Sabr, Y., Chan, W.-S., & Kramer, M. S. (2017). Maternal age and severe maternal morbidity: A population-based retrospective cohort study. PLOS Medicine, 14(5), e1002307. doi:10.1371/journal.pmed.1002307

Tunçalp, Ö., Souza, J., Hindin, M., Santos, C., Oliveira, T., Vogel, J., . . . Network, N. H. R. (2014). Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey. BJOG: An International Journal of Obstetrics & Gynaecology, 121(s1), 57-65. doi:10.1111/1471-0528.12634