Discrimination Against Women of Color in Access to Health Care Continues in U. S.

When it ratified the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), the United States committed to ensure the right to health care free from all forms of racial discrimination to all within its borders. Yet, as the U.S. prepares to report to the U.N. expert body charged with monitoring U.S. progress on implementation of these commitments, discrimination in health care remains entrenched. This report evaluates the U.S. record on addressing racial and gender discrimination in sexual and reproductive health care. Recognizing that discrimination exists in both law and fact, we focus on the need for policy change as well as proactive measures to address the structural forms of discrimination that inhibit the ability of women of color and immigrant women to exercise their human right to health.

RACIAL DISPARITIES IN MATERNAL MORTALITY

Maternal mortality is a human rights crisis in the United States. Between 1990 and 2013, as the overwhelming majority of countries dramatically reduced the incidence of maternal mortality, the maternal mortality ratio in the U.S. more than doubled from 12 to 28 maternal deaths out of every 100,000 live births. Racial disparities fuel this crisis. For the last four decades, Black women have been dying in childbirth at a rate three to four times their White counterparts. Cities and states with a high African American population also have the highest rates of maternal mortality in the country; in some areas of Mississippi, for example, the rate of maternal death for women of color exceeds that of Sub-Saharan Africa, while the number of White women who die in childbirth is too insignificant to report.

In addition to race, drivers of maternal mortality in the U.S. include social determinants of health such as poverty and lack of health insurance. Women of color are much more likely than White women to live in poverty and to lack health insurance. Because of these barriers to health care access, women of color are far more likely to exhibit risk factors for maternal death, such as diabetes and heart disease. Disparities in quality of care also persist for women of color and poor women and, in some cases, are growing worse—the U.S. Department of Health and Human Services identified maternal mortality as one of the most rapidly deteriorating areas of health quality over the past three years.

In its 2008 Concluding Observations, the Committee on the Elimination of Racial Discrimination (Committee) expressed concern about persistent disparities in sexual and reproductive health, including maternal mortality. It recommended the U.S. increase efforts to expand health insurance coverage, facilitate access to maternal health care and family planning, and improve sexuality education and information. The U.S. government has taken some steps to improve coverage, primarily through passage of the Affordable Care Act. However, political resistance to this law—especially in states with the highest rates of uninsured, people living in poverty, and maternal mortality—threaten to undermine the goals of the legislation to increase access to health care and reduce health disparities.

In May 2014, the Center for Reproductive Rights and SisterSong Women of Color Reproductive Justice Collective gathered first-hand accounts of Black women living in the South in order to better understand the role of racial and gender discrimination in their reproductive and sexual lives. The narratives, analyzed for the first time in this report, show that the U.S. government has failed to implement the Committee’s recommendations. Women living in Georgia and Mississippi—two states with the highest rates of maternal death in the country— shared their experiences with the health care system from the time of their first sexual activity through childbirth. Their stories reveal key inequalities in the health care system for women of color, including:

lack of information about sexuality and sexual health;

discrimination in the health care system;

lack of access to sexual and reproductive health care; and

poor quality of sexual and reproductive health information and services.

Policy change is necessary, but these stories demand much more. Eliminating disparities in reproductive health care, including maternal mortality, will require proactive steps by the U.S. government to: increase both general and pregnancy related coverage of uninsured women; improve access to contraceptive services and maternal health care; train healthcare providers to avoid racial stereotypes and provide high quality care to all women; ensure comprehensive sexuality education and information; and provide adequate social supports for recent parents, including paid parental leave. In addition, the U.S. should strengthen monitoring and accountability measures for maternal mortality in line with human rights standards.

U.S. policy excludes large groups of immigrants from eligibility for public health insurance, thereby greatly restricting the ability of immigrants to access health care. The Affordable Care Act incorporated restrictions set in place in 1996 that require non-citizens who are lawfully present in the U.S. to wait five years before they can enroll in Medicaid (although some states, including those with large immigrant populations like Texas, do not allow lawfully residing immigrants to enroll even after completion of the waiting period). Moreover, undocumented immigrants are completely barred from Medicaid, and the Affordable Care Act prohibits this group from purchasing private insurance on the newly developed health insurance exchanges, even with their own money.