Keywords

1 Maternal Health Outcomes: A Reflection of Decisions

Maternal health outcomes reflect decisions about maternal health and wellbeing made at all levels within a nation. These decisions may result in positive and negative outcomes. They are grounded in the moral foundations, history, traditions, and cultural values of a nation. American cultural values are a strong driver in decisions that operates from the individual, family, and community levels to national policy.

Maternal health in the United States (USA) does not compare favorably to other high income countries (Weil & Reichert, 2021; World Health Organization [WHO], 2019). While not exclusively so, poor outcomes disproportionally reflect health disparities and less privileged mothers in the nation (Hoyert, 2021). The question is why do these poor outcomes persist in a very affluent country. Examining the process by which decisions affecting maternal health are made is a beginning step in answering this question. This chapter explores the theoretical foundations of decision-making and cultural values that can drive decision-making.

2 Theoretical Foundations of Decision-Making

Decision-making is the study of the allocation of limited resources among conflicting purposes. Some decisions are relatively straightforward (e.g., the individual decision to brush one’s teeth versus facing tooth decay, providing one has access to a toothbrush or other tool, such as eucalyptus twigs). Other decisions are agonizing, requiring enormous discussion about resource allocation. An example is governmental budgeting decisions. Every act from individual to collective level involves due consideration, even if purely subconscious. Subconscious attention in decision-making is particularly valuable as it allows us to attend to cues in our environment even when not focusing on them (de Becker, 1998; Gigerenzer, 2007; Gladwell, 2005). Routinized decisions, such as getting up or eating breakfast at a specific time, makes life easier and demands minimal attention. Many decisions, however, require significant attention and time.

2.1 The Study of Decision-Making

Studies of decision-making are an important research domain in economics, anthropology and the social sciences (Gladwin, 1989). The basis of this work is the perception that individuals usually act on the basis of considered decisions, based upon knowledge. In order to make a decision, one must be cognizant of the options, the likely outcomes of a choice, and what factors to consider. If knowledge is certain, decisions are usually easy, but knowledge is often imperfect and uncertain. Sometimes there is no way to know and decisions are made based upon the best available knowledge and hope.

Researchers ask detailed questioning in capturing the sequential steps in making a decision. They query informants about the process as it leads to a particular decision. Examples are when and what crops to plant (Gladwin, 1989), what to do when someone in the family is sick (Young & Garro, 1994; Anderson [published under Frye], 1995), or how to fish sustainably (Aswani & Weiant, 2004).

Christina Gladwin’s classic work (1989) involved agricultural crop choice. Another classic study, with methodological reflections, is Medical Choice in a Mexican Village (Young & Garro, 1994). Frye (1995) described algorithms used by Cambodian refugee women, who were culturally acknowledged in the family health guardian role. These algorithms describe how the women decided who received healthcare and under what conditions it was traditional or allopathic care. Aswani and Weiant (2004) went beyond economic and biological methods in fishing research to a thoughtful analysis of how decisions are made for sustainability. This line of questioning is foundational, explaining who, what, when, where, and how much is involved in a decision.

This questioning technique assumes that decisions can be broken down into ordered sequences of yes/no answers: Can I get the seed for this crop? Can I get fertilizer for it? Can I get enough water for it? It assumes that making a complex decision involves a series of yes/no decisions to form a decision tree or an algorithm. In clear-cut matters, one can usually break down decisions into yes vs. no or more vs. less choices. Sometimes when it appears that an individual is acting on impulse, when, in fact, he is subconsciously integrating several pieces of knowledge simultaneously. Careful sequential questioning allows the researcher to facilitate the process, expand information through in-depth interviewing, and formulate a decision tree analysis.

It is a powerful technique for decisions that involve known, important and routine choices with a good knowledge base, important consequences, and fairly clear-cut answers. Examples are the management of cardio-pulmonary arrest or whether to introduce a new agricultural crop. For instance, an experienced gardener normally knows exactly what crops she can plant in her environment, the conditions of the soil, and whom to ask for further information. Another example affecting everyday life is the decision about what toothpaste to use. One observes the price, asks others in his social circle and/or his dentist for recommendations, and may even taste the toothpaste. Other factors in the final decision might include the appearance of the tube and marketing claims. However, in new, unforeseen, and emergency situations, knowledge base may be less definitive, consequences unknown or unforeseen, and credible information sources unclear. Public response to the COVID-19 pandemic demonstrates a complex situation in which many persons find decision-making very difficult.

In short, decision-making research is designed to find out how decisions are made. In practice, this means asking informants what they do in given situations. Then one asks why they do so. This often produces unhelpful results: “I’ve never thought about it,” “we always do it that way,” “everybody does that.” Such answers require further observation and questioning, to watch what people actually do. They almost always have alternatives: We usually do it this way, but we can do it this other way. The researchers then asks: Why did you pick Choice A instead of B? Informants may or may not be clear about why they do it a certain way.

Some decisions are simple: “I got that toothpaste because it was the cheapest in the store.” However, if a rural hospital has a high caesarian section rate, difficult and involved decisions may not be apparent until it becomes evident the only obstetrician in the county is in the hospital one day a week, the nursing workforce is highly understaffed, and there are no nurse-midwives in the country available to support physiological birth (Hung et al., 2016; Seigel, 2018). Young and Garro (1994) found that in poverty-stricken Michoacan, Mexican villagers preferred allopathic care at a clinic or hospital, but rarely had the money. They would borrow money and go without food or other necessities for a few days. They also knew a range of traditional practices, garden and wild-gathered herbs with medicinal value, magical practices, and prayer, as well as basic first aid. They balanced these traditional remedies according to knowledge about effectiveness of care compared to allopathic care. This decision-making process involved a complex mixture of economic calculation, values, and personal preferences.

2.2 Cultural Alternatives in Decision-Making

Studies of decision-making have proven conclusively that people do not just mindlessly follow the rules of their culture. Cultures require survival and adaptation. Every culture provides alternative solutions for almost any situation. Even strictly within their cultural rules, people are forced to consider multiple choices all the time. These decisions usually involve a certain amount of risk and uncertainty. “I shot an arrow into the air. It fell to earth I knew not where.” (Longfellow, 2015).

To reduce uncertainty, people search for information. The cost of getting this information is often the greatest cost and source of distress in making decisions. It involves constructing different models. An example is a single-factor economic model is one in which the person making the decision opts for the cheapest option. “Cheapness” may not be strictly monetary; it may involve the least time-consuming option, the least physical effort, the most accessible option, or the solution that requires no further effort.

Most models are more complex. There are trade-offs in emotional satisfaction, fun, social obligations, desires for control, and compliance with cultural messages as well as economic solutions. All factors being equal, people tend to decide based upon prior knowledge and cultural sensitivities, sometimes missing the chance to learn quicker, easier, or more efficient ways. Sometimes, they decide impulsively deciding that the cost of acquiring full information is simply too much effort. Usually, however, people weigh their choices, including all those alternatives provided within their culture and sometimes stretch the culture to expand alternatives. Culture is not a strait-jacket. It helps to define a set of possible, practical, and often creative choices. In his biography Steve Jobs, Walter Isaacson (2011) describes the famed Apple cofounder as having the skill to expand cultural alternatives.

The result of such modeling is cost-benefit analysis: how people calculate the benefits versus the costs of getting them. These costs are not solely financial. They may be emotional or social. Even the apparently “cheapest” models can be complicated, the financial cost and benefits balanced against cost and benefit to one’s emotional, spiritual, and social self. The values of the culture speak to these issues and such decisions are not made in isolation of the culture. People make decisions with those they trust within their culture and those who guide them in the path of cultural knowledge. One of the most profound examples cultural guiding is the story of the two wolves.

Box 2.1 The Story of the Two Wolves

“My child, it’s time to teach you the most important lesson about life and people. It is that everyone has within two wolves: a good wolf that wants to help everyone and do what’s best for all, and a bad wolf that wants to do evil and hurt people and the world.”

“Father, that’s scary. It really worries me. Which wolf wins out in the end?” asked the child.

The father replied,” “The wolf you feed.”

Native American folktale

(Anderson & Anderson, 2021. p. ix)

3 Cultural Models: Guide to Decision-Making

Decision-making studies have led to scholars in developing cultural models of how to act appropriately or what to expect (cf. Frake in Dil, 1980). There are cultural models of greeting (“Hello, how are you?”) or expressing sympathy (“I’m so sorry to hear that.”). Cooking recipes are cultural models as are plans and expectations for celebrating holidays. Serious scholarship on cultural modeling has emerged, including specific instructions on how to conduct this research and analyze the findings (Kronenfeld, 2008). There are excellent examples of research utilizing cultural modeling including notable contributions by Victor de Munck (2011), Giovanni Bernnardo, Naomi Quinn, Claudia Strauss, Bradd Shore, and others (Kronenfeld et al., 2011).

3.1 Norms and Values

Cultural models orient people morally and emotionally as well as cognitively. They are expressed in norms and values. Norms are rules for behavior with the expectation that behavior will follow a prescribed cultural model. Norms can range from simple and automatic, like greeting rituals, to highly complex. They can change fairly rapidly. For example, the standard American greeting ritual “Hello, how are you?” has added “Have a nice day!” within the last few decades. Norms remain somewhat understudied, despite their obvious importance.

Far better studied are values, broad principles for orienting one’s life. These are much less apt to be simple. They involve valuing the natural environment or seeing it as something to be “tamed” and destroyed; valuing human life or regarding it as expendable; valuing hallowed traditions or seeing them as an intolerable restraint. Values are generally thought to be moral, and moral rules are values, but this is relative. Such things as valuing promptness and efficient use of time are less morally compelling than valuing human life. Morals and values are, in turn, based on ethical principles.

Anthropologists have been seriously studying values since the 1950s. An epochal book for launching this research was Variations in Value Orientations by Florence Kluckhohn and Floyd Strodtbeck (1961). They, with Clyde Kluckhohn, John Whiting, Kimball Romney, and others, studied values of different ethnic groups in New Mexico (Vogt, 1966). These studies encompass values relating to time, space, and person. These values were expressed historically in different ways by Hispanics, Mormon and Protestant settlers, and Native Americans. Particularly insightful anthropological studies examined Hopi (Brandt, 1954) and Navaho values and ethics (cf. Brandt, and Ladd 1957).

3.2 Decisions and Cultural Values

Decisions are inevitably grounded in cultural values. These are embedded in moral foundations, beliefs, and traditions. Values complicate decision-making, especially when two values run counter to each other. Values often involve choice between narrow, short-term interests and wide, long-term ones. The normal human tendency is to overvalue the former, on the proverbial theory that a bird in the hand is worth two in the bush (Gigerenzer 2007; Kahneman 2011). Saving on healthcare in the short term very often leads to enormously greater costs in the long run. This is an example of heuristics: natural biases that may cause one to infer incorrect conclusions without adequate consideration. Another common heuristic is exposure to information. If one has been reading many articles recently or hearing about a particular group committing crimes, it will lead to suspicion of persons from that population group. This bias may occur even as one understands that this information is not consistent with the wide, long-term profile of this group. The conflict between noble principles of sharing and short-term material acquisition can be phrased as competition between need and greed. However, the salient point is that decisions are about allocating resources among competing ends. The result is that values are not fixed rules. They are interpreted within specific context that may require negotiation (Bourdieu 1977).

When decisions are being made and there is difference in interpretation, negotiating the meaning of the specific cultural values can lead to conflict. This conflict can be driven by assumptions of how “worthy” or “deserving” specific persons or groups are. At worst, people may be dehumanized, such as occurs in genocide (Anderson & Anderson, 2021; Smith 2011, 2020, 2021). Nobel Prize winner, economist, and philosopher Amartya Sen sums up much of this conflict in his theory of social choice (Sen, 2018). Social choice involves rectifying divergent interests and concerns. This process requires widespread public communication and reasonable standards with majority rule among populations that share cultural values and norms (Sen, 2018).

Reality, however, may be very different. Majority rule may not be present; it does not always work; and minorities are easily repressed. Resilience by minorities in the face of such repression does not imply they are free of suffering or abuse or have full social choice. Among mainstream populations without significant repression, there are also conditions of suffering and abuse that limit social choice. Cultural values frame how a society calculates social choice that includes personal well-being (the affordances of adequate food, shelter, safety, and healthcare) and personal freedom.

4 American Cultural Values

The US Constitution, drafted in 1787, describes core American cultural values. Subsequently, these values have been continually debated. Contemporary consideration of American cultural values is well described in the work of Jonathan Haidt (2012) and the writing of Graham et al. Mapping the Moral Domain (2011). American cultural values influence decisions that influence social and environmental conditions affecting the health of the nation.

These decisions, made by individuals, communities, professional groups, and government, are mirrored in the health of mothers. This work is a critical analysis of five American cultural values that influence decisions around maternal health at all levels:

  • Personal control.

  • Individualism.

  • Action-orientation.

  • Practicality.

  • Self-reliance.

4.1 Personal Control

From the perspective of decision-making, the cultural value of personal control embodies Sen’s theory of social choice (2018). As described by Sen, there must be majority rule, standards deemed reasonable, and shared values for social choice to function in society. In addition, there must be public communication to rectify different ideologies of personal well-being and personal freedom (2018). A key example of cultural clash in the USA around the value of personal control is the public response to the COVID-19 pandemic. Controversy has surrounded public health decisions and recommendations. There has been mixed public response to personal control measures (masks and vaccines) to prevent exposure to and spread of the virus.

4.2 Individualism

Individualism implies autonomy. American individualism speaks to autonomy in terms of the uniqueness of each person, the right to opinions, liberty of conscience, and freedom of expression (Kohls, 1984). It is a cherished value protected by the United States Bill of Rights, ratified in 1791 as an addition to the Constitution (https://www.archives.gov/founding-docs/bill-of-rights/what-does-it-say). Perhaps more than any of the values selected for this work, it supports the personal freedom of each American.

Individualism implies the importance of the individual in contrast to collectivist values. As such, the expression of this value may lead to conflict about rights: where do my rights stop and yours start? Decisions about fetal rights and maternal rights, if they are in conflict, center on this value. Federal law, per Supreme Court decision in Roe vs. Wade, formerly protected maternal autonomy and individual decision-making about pregnancy continuation, but has now been overturned. Regional statutes, third-party payers, and institutional policies have placed restrictions around individual decision-making, not only for the pregnant person but also for healthcare providers. Different ideologies of personal well-being and personal freedom (see Sen, 2018) drive the debate and the implementation of federal law at local and state levels.

4.3 Action-Orientation

The cultural value of action-orientation encourages pro-active decision-making to make change. It encourages the use of personal power in making change (Kuhl, 1994). When there are differing views of what action needs to happen and who makes the decision, social choice theory speaks to rectifying divergent interests and concerns with acknowledgement of shared values, appropriate use of power, and attention to well-being (Sen, 2018).

Action-oriented decision-making about maternal health can lead to swiftly-implemented changes that diminish risk and save the lives of mothers. An example is the development of systematic protocols (safety bundles) for managing obstetrical emergencies (The Council on Patient Safety in Women’s Health Care, 2018). (See https://safehealthcareforeverywoman.org/patient-safety-bundles/).

Conversely, the value of action-orientation can lead to distress when a person values personal control and individualism but feels powerless to influence action in decision-making. The risk is greatest for those who have less personal freedom and well-being (Fernando, Kashima, & Laham, 2014; Harmon-Jones & Harmon-Jones, 2002).

4.4 Practicality

Americans highly value and are expected to be practical. History speaks to many practical inventions encouraged by this cultural ethos. The innovation and hard work of Americans is legendary (Metcalf et al., 2013; Yang & Gamble, 2013). While highly productive economically, this value may interfere the time needed for deep analysis and creative thinking (Kahneman, 2011) or for attending to human needs.

Economics and practicality can drive thinking about attention needed in caring for the sick, weak, and frail. It can undercut proposals to support family development, such as family leave, child care credits, community-based mental health programs, and postpartum home visiting. In some cases, practicality ends up costing more in the long run and can contribute to poorer maternal outcomes (Kozhimannil, et al. 2015). An example is the widespread closure of maternity care services, especially in rural areas, related to inadequate staffing (Hung et al., 2016; Seigel 2018). More than 50% of rural hospitals in the USA no longer offer full-scope maternity services (Seigel, 2018). Conversely, decisions to implement community-based birth centers is in line with the cultural value of practicality that have improved maternal health outcomes. (Alliman, J., & Phillippi, J. 2016; Stapleton, S., Osborne, C., & Illuzzi, J., 2013).

4.5 Self-Reliance

Self-reliance views the individual as a self-managing human, able to take care of oneself without undue dependence upon on others. It is a strongly held value aimed at developing trust in one’s ability to deal with the trials of everyday life. The ability to be self-reliant is encouraged in raising children. Not only is one expected to be self-reliant (Schaumberg & Flynn, 2017), but the failure to do so is highly criticized, even when facing seemingly impossible barriers like intransigent poverty (Lane, 2001).

The value of self-reliance can plays a powerful role in motivating one to make decisions to improve personal well-being. However, it can be daunting when facing difficulties, especially if isolated from community support (Huberfield & Roberts, 2016). Social and environmental conditions, the social determinants of health, can support or undermine health. These determinants are economic stability, education and healthcare access, quality of life in the community, and social cohesion (Healthy People, 2030). To be a healthy people, these social determinants all require cooperative community support (Healthy People, 2030).

Decisions influencing maternal healthcare are made with many considerations such as funding availability, provision of services, adequate staff to provide care, and acceptability. Minimal staffing in obstetrical units can lead to greater reliance upon technology-driven interventions and less direct human contact. The values of self-reliance and personal control can converge to create tensions in this low-touch situation. As described in the section on practicality, maternal health may be jeopardized by the decision to close formerly self-reliant hospitals. Maternity care deserts, such as those that exist in many rural areas in the USA, have very limited access to services and skilled maternal healthcare providers. At all levels, decisions to limit services and access contribute to poor maternal outcomes (Surgo Ventures, 2021).

5 Summary

Decisions about maternal health are made in the context of cultural values. This chapter describes a theoretical framework for decision-making and provides exemplars of value-driven decisions affecting maternal health outcomes within the American context. It explores five leading American cultural values with historic and ongoing influence that drive decision-making about maternal health.