Structural Violence and Moral Injury in Academic Medicine: Provider and Staff Perspectives on Segregated Pregnancy Care

• In Event: Policies and Health

Abstract

Although perinatal care is the closest the United States has to universal insurance, with 96 percent of births covered by public or private insurance, coverage alone has not ensured equity in care or outcomes. The United States faces a maternal health crisis, with maternal mortality rates exceeding those of comparably wealthy nations. Pregnant people who are Black, Indigenous, or enrolled in Medicaid face significantly higher rates of maternal mortality, preterm birth, and pregnancy-related complications. Within this context, academic medical centers are among the few institutions that accept both Medicaid and private insurance, yet most sort patients into separate clinics, providers, and care protocols based on insurance status, and de facto, socio-economic status and race. Drawing on 78 semi-structured interviews conducted between 2022 and 2025, including 54 interviews across two public academic medical centers and 24 interviews with national experts and direct service providers, as well as over 190 hours of ethnographic observation, this study examines how payer-segregated pregnancy care is experienced, interpreted, and at times contested by obstetricians, midwives, trainees, and staff in academic medical centers. Guided by constructivist grounded theory, the findings show how institutional arrangements embedded in our health care laws, financing structures, and clinical training practices produce stratified systems of care that assign the most clinically and socially complex patients to the least experienced providers and normalize denials, delays, and resource constraints. Participants describe ethical conflict, distress, and disillusionment arising from their participation in these systems. Drawing on theories of structural violence and moral injury, this article argues that payer segregation reinforces structural inequities and is internalized as moral injury by clinicians, trainees, and staff as moral injury in academic medical centers.

Author

• Jennifer Templeton Dunn, University of California-San Francisco