Health inequities, or avoidable and unjust differences in health status across groups, are

widely considered public health and social problems. Maternal and child health (MCH)

inequities, such as those in maternal and infant mortality, low birthweight, or preterm birth, are

some of the most enduring and marked inequities in the US. Given the way that MCH outcomes

are used as a metric to understand the functionality of a health and social service system overall,

these inequities point to deep-seated structural issues in US healthcare. Additionally, a growing

body of literature demonstrates that more than genetics, individual behavior, or even quality of

medical care, it is the social determinants—the conditions in which we live, learn, work, play,

and age—that determine MCH and other health inequities. Despite this growing

acknowledgment, little is known about the role and experiences of frontline health and social

service workers who are charged with applying this knowledge in day-to-day practice. Moreover,

little is known about how such frontline workers are shaping this knowledge when it “hits the

streets.”

This dissertation analyzes the enactment of the social determinants of health (SDOH)

framework, or the public health framework that outlines the role of upstream factors in

determining health outcomes. To do so, I conducted an institutional ethnography of frontline

health and social service workers charged with addressing racial, ethnic, and economic MCH

inequities. My field site is a mid-size (approximately 90 employees) non-profit providing a range

of MCH services in a large, West Coast City where health inequities reflect the broader MCH

inequities in the US. I sought to uncover what the everyday routines, experiences, and practice

dilemmas of this workforce could reveal about tackling MCH inequities and implementing the

SDOH framework., This work employed discourse analysis of agency documents, participant

observation, and semi-structured, in-depth interviews throughout a nine-month period of

fieldwork. Data were analyzed using a grounded theory as well as directed and conventional

content analysis approach to coding and theme development. Analysis was informed by streetlevel

bureaucracy theory and a materialist and structuralist approach to the production and

amelioration of MCH inequities.

Several primary findings emerged from this study. First, I explore interprofessional

collaboration as it relates to enacting and animating the SDOH framework. I find that the

frontline workforce relies on three key types of collaboration to bring the SDOH to life: within

agency collaboration and role-blurring, collaboration with a safety-net hospital, and common

cause, or the engagement in a shared analysis and framework for political action. Next, I explore

the impact of prevailing social norms on implementation of the SDOH framework. Specifically, I

consider how definitions of the private, heteronormative, nuclear family emerge in a health and

social service setting. I find that frontline workers negotiate the legacy of problematic and often

contradictory health and social service policies regarding who constitutes a family and when

during pregnancy a family is understood to exist. Finally, I explore a continuum of frontline

provider perspectives regarding the SDOH framework and health inequities. I consider provider

engagement with the SDOH framework through the lens of sociologist C. Wright Mills’

“sociological imagination,” or the ability to understand one’s actions and circumstances as part

of broad, historically-contingent social forces. I understand engagement with the SDOH

framework to exist on a continuum from apathy and burnout to possessing a sociological

imagination, and, finally, to structural competency, or the trained ability to analyze and intervene

upon the upstream factors that produce health inequities.

Enacting the SDOH framework in MCH and other settings is an important part of

addressing health inequities and ultimately, ameliorating social disadvantage. The SDOH

framework informs the development of an emerging SDOH workforce, or a network of health

and social service professionals who are integrating practice systems and institutional resources

to adequately meet social as well as physical health needs and ultimately, address health

inequities and social disadvantage. Studying frontline SDOH-related work from the vantage

point of those with the most intimate experiences of service delivery, I investigate up close the

role of health and social services in integrating social and clinical care. Additionally, this

workforce is shaping SDOH knowledge and practice with their daily decisions and strategies to

meet client need. I conclude that strategies to combat health inequities must be understood in

terms of frontline workers’ lived experiences and perspectives for meaningful and impactful

practice change to occur.

Abstract

The United States lags in its progress in preventing infant mortality and critical infant health outcomes compared to other high-income countries. Moreover, empirical research has demonstrated that racial and socioeconomic perinatal health inequities persist despite rising government expenditures on health care. Given the lack of success of clinical interventions in reducing infant health disparities, researchers have looked outside the healthcare setting to the places where families live, work, and play as sites for intervention. Public health researchers have contributed to health inequities research by examining where, how, and why various places such as neighborhoods, disadvantaged areas, and urban and rural areas impact infant health to improve or intervene on contributing health factors. Furthermore, by using a legal epidemiological approach to advance knowledge on how to disrupt upstream factors such as political structures, policies, and practices that codify infant health risks, policymakers, practitioners, and communities can start to diminish the reproduction of health inequities by altering, improving, and holding accountable our political system and actors.Infants in the eight-county San Joaquin Valley of California fare worse than most of the state’s population on maternal and infant health outcomes across key indicators. Particularly concerning are pockets of entrenched poverty, which include 450 disadvantaged unincorporated communities that have documented detrimental environmental and social conditions, such as contaminated water and air and lack of adequate housing. Many detrimental environmental exposures associated with poor infant health outcomes are present in these disadvantaged unincorporated communities. Communities outside of city boundaries are unincorporated communities, defined as settled populated areas whose community identity is commonly known but that lack incorporation status as a city. Moreover, in California, unincorporated communities lack municipal government representation and rely primarily on their county board of supervisors for local representation. Lack of representation can lead to political exclusion and diminished access to resources (i.e., power, money, influence, material resources, and services). Unfortunately, the limited attention to unincorporated communities in infant health research—and public health research, writ large—has created a blind spot to the potential structural vulnerability of communities outside city boundaries with no local governance. This project bridges the research gap on unincorporated communities by using multiple methods to examine incorporation status as a political determinant of infant health. The first study examined places (i.e., cities, towns, and settled communities) with or without incorporation status to understand if there is a relationship between incorporation status and adverse birth outcomes among singleton births in California’s San Joaquin Valley. We used population-level data from the California Department of Public Health Birth Statistical Master Files of births between January 1, 2006, and December 31, 2015, for the eight-county region to assess the relationship between residence in an unincorporated community and adverse infant health outcomes (small for gestational age, preterm birth, very preterm birth, and low birth weight). First, this project described a retrospective cohort of 531,668 births within the 8-county San Joaquin Valley summarizing the characteristics and risk factor distribution for infant health outcomes by incorporation status for a ten-year period (2006-2015). Second, using logistic regression analysis, we observed a relationship between living in an unincorporated community and elevated odds of preterm birth. When considering both a community’s incorporation status and economic disadvantage together, we similarly observed higher odds of a preterm birth in disadvantaged unincorporated communities compared to disadvantaged and advantaged incorporated communities. In the second study, qualitative methods were employed, leveraging a constructivist grounded theory approach with reflexive thematic analysis to understand how lack of incorporation status impacted the efforts of residents from a disadvantaged unincorporated community to address an infant health threat. Between 2007-2010, approximately 11 infants were identified as part of a birth defect cluster, three of whom died in Kettleman City, a small rural disadvantaged unincorporated community in the San Joaquin Valley of approximately 1,648 residents. Using semi-structured in-depth interviews, this study gained insights from 13 resident and 11 non-resident participants on how they understood the political arrangement for their disadvantaged unincorporated community to be an inadequate political structure for and generally unresponsive during a community health threat. Most participants perceived that the political structure for unincorporated communities is disenfranchising, constraining the capacity and will of county officials to act responsively to residents whose political power is diluted within the general county voting body. Participants attributed the marginalization by county officials who chose political inaction because of “who they are”- a “small rural Latino farmworker town.” Resident participants desired localized responsive political representation, as they felt disconnected from county officials who did not deploy their authority or government resources to help residents navigate the infant health threat in a timely manner. This dissertation suggests structural vulnerabilities for infant health in unincorporated communities in California’s San Joaquin Valley. It provides a foundation for future research on perinatal health and other health outcomes in unincorporated communities in California and beyond. Greater policy and research efforts are needed to understand and address the precarity of people in unincorporated communities that are structured as insignificant within the current political arrangement for those outside of a municipal boundary.

Abortion is a fundamental component of people’s ability to decide if, when, and under what circumstances to have a child. The ability to obtain an abortion is critical to both reproductive autonomy and public health. Despite this, a large body of evidence demonstrates that it is often difficult to obtain an abortion in the United States (U.S.). State-level policies restrict abortion availability and create logistical, financial, and emotional barriers. Difficulty accessing abortion disproportionately and inequitably burdens those who have been historically and systematically marginalized—low-income people, Black, Brown, and other people of color, young people, and those who live in rural or non-metropolitan areas. The existing body of literature demonstrates that the current political climate and service delivery landscape create a gap in which some people who want an abortion are not able to obtain one at all or in a manner that is acceptable to them. This amounts to an urgent public health and health equity problem—in the U.S., people’s abortion needs are not being met.

In public health, medicine, and the field of family planning, lack of access to critical services is commonly framed and documented as “unmet need,” such as with the longstanding measure of “unmet need for family planning” as a tool to understand population-level contraceptive access. Documenting “unmet need for abortion” could be one potential tool those working in abortion access could use to direct advocacy efforts, service delivery, and resource allocation to meet abortion need(s). However, it is not clear whether conceptualizing problems in abortion access as unmet need would be valuable and, if it is, how to define or measure that need.

This dissertation uses multiple methods to explore the concept of unmet need for abortion in the U.S. My first aim is to present a nuanced and critical analysis of unmet need for abortion, including its conceptualization and utility as both a concept and a tool for the abortion rights movement. My second aim is to quantitatively describe the prevalence of not obtaining a wanted abortion among a nationally representative sample.

Chapters 2 and 3 present findings from in-depth qualitative interviews with 30 stakeholders in abortion access from around the U.S. about their perspectives on unmet need for abortion. Stakeholders included people working in direct service settings, research, advocacy, grassroots abortion funds, reproductive justice organizations, and philanthropy. Chapter 2 explores the potential benefits and harms of using unmet need for abortion as a tool to frame and measure problems with abortion access in the U.S. Findings from this study point to the complexity of the concept of unmet need for abortion. As a tool for advocates, researchers, policymakers, and others working for abortion access, unmet need for abortion could draw necessary attention to and broaden public dialogue about crises in abortion access. However, participants’ hopes for positive shifts in public discourse and resource allocation for abortion were counterbalanced by their concerns—that the tool could be misused, that the limits of quantification come at too great a cost, and that by centering abortion alone it would serve to further disconnect abortion from the broader fight for reproductive justice.

Chapter 3 describes how stakeholders understood unmet need for abortion. I identified two distinct conceptualizations: outcome-based unmet need for abortion, in which need is defined as obtaining an abortion; and process-based unmet need for abortion, in which need is additionally defined in terms of the experience of getting an abortion, including navigating obstacles, preferences in method and setting, and quality of care. While some participants primarily leaned toward one conceptualization, most utilized both. Participants debated the relative importance of these conceptualizations based on which they projected could be useful for mobilizing support and resources for abortion access.

Chapter 4 describes the prevalence of not obtaining a wanted abortion in a nationally representative sample of adults (ages 18-44) who had ever been pregnant. Nearly 6% of respondents reported having wanted an abortion they did not obtain. In open-ended text describing why they did not obtain the wanted abortion, participants most frequently reported personal reasons for not getting an abortion (e.g., changing their mind; personal moral or religious opposition), though it was also common to report policy-related reasons (e.g., gestational limits set by state or facility policy). These findings suggest that people in a national sample will answer questions about whether and why they did not obtain a wanted abortion. In addition, these data provide some insight into the complexity of wanting an abortion. Rather than framing this experience as not getting a wanted abortion, for some people, it may be more accurate to describe this as not getting an abortion that was wanted at one point.

Unmet need for abortion is a complex concept that has potential benefits and potential harms as a tool to document and improve abortion access. In addition, it can be conceptualized in multiple ways that affect its utility. As threats to abortion access increase, people not getting abortions they want, either at all or in a manner that is acceptable to them, will only become of greater concern. This dissertation contributes to a growing and timely body of research about devising new ways to understand and meet abortion needs.