Social Determinants of Health are big buzz words these days but what are they and what’s their impact on pregnancy? The World Health Organization (2017) defines them as the conditions in which people are born, grown, live, work, and age. These circumstances are shaped by the distribution of money, power and resources at global, national, and local levels. They are mostly responsible for health inequities – the unfair and avoidable differences in health status within and between countries. Some examples of social determinants include:
- Availability of resources to meet daily needs (e.g., safe housing and local food markets)
- Access to educational, economic, and job opportunities
- Access to health care services
- Quality of education and job training
- Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
- Transportation options
- Public safety
- Social support
- Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
- Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
- Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
- Residential segregation
- Language/Literacy – in the case of healthcare, how well can someone understand information and instructions they receive about their health
- Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
- Culture (HealthyPeople.gov, 2018)
When dealing with the Medicaid population, all these determinants can present challenges to a pregnant woman trying to manage her pregnancy. For example, although she may know that eating fresh and fruits and vegetables are important to her diet, the cost may be too high for a tight food budget or government food assistance. Transportation and childcare can be a huge challenge for a mom to make it to her prenatal appointments. In the past, we would have labeled this mom as being “non-compliant.”
Understanding social determinants can help us as healthcare providers to pause and be curious about the conditions in which our patients live rather than making quick judgements. Once we take the time to ask open ended questions giving us a better understanding of the challenges someone may have had to deal with just to get to our office. Addressing these challenges with compassion instead of judgement develops trust and allows us to become partners instead of parents in our patient’s healthcare.
Other examples where pregnancy can be directly impacted by Social Determinants include intimate partner violence and homelessness. Intimate partner violence speaks directly to the availability of safe housing. It has been associated with unplanned pregnancy, preterm birth, low birth weight, and decreased gestational age (a baby being born early). These women and their children are also at higher risk for having unstable housing or becoming homeless (CDC, 2017). Homeless women are less likely to receive prenatal care than women who are not homeless, and adverse birth outcomes are substantially higher when compared to the general population.
A Canadian study found that compared with women who are not homeless, homeless women were 2.9 times more likely to have a preterm delivery, 6.9 times more likely to have a baby with low birth weight even after adjustments for risk factors such as maternal age, number of previous pregnancies and smoking (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2017).
Care managers work with moms struggling to overcome these social determinants. First, it’s important to build trust with a mom so that an accurate assessment of these issues can be completed. The care manager can then develop a plan of care with mom to help with the issues that are most important to her. In addition, she/he will work with the provider, social workers and other community agencies to support that mom through a healthy pregnancy and beyond.