Introduction

In January of 2023, UNICEF published a report regarding neonatal mortality around the globe. A newborn is considered to be neonatal within the first four weeks of life, the period of time in which a baby is most vulnerable.¹ As of 2021, the average global rate of infant mortality is 18 deaths per 1,000 live births. In comparison to data collected in 1990 (37 infant deaths per 1,000 live births), there has been a decline in infant mortality of 51%. A 2021 study revealed an estimated 11 deaths per 1,000 live births, and the probability of dying after reaching age one, before age five, was estimated at 10 deaths per 1,000 live births. In 2021, approximately 2.3 million children died during the first month after birth, totaling about 6,400 neonatal deaths per day worldwide.

Although there has been a decline in global neonatal mortality rates, healthcare access disparities continue to exist across many regions and nations in the world.¹ As of 2023, Afghanistan holds the greatest infant mortality rate internationally, with 103.¹ deaths per 1,000 live births.² Regionally in 2021, neonatal mortality was highest in sub-Saharan Africa and South Asia, with the mortality rate estimated at 27 and 23 deaths per 1,000 live births, respectively.¹ Children in these regions are greater than 10 times more likely to die within the first month of life than a child born in a developed nation. When comparing the countries with the lowest and highest infant mortality rates, the difference in the risk of an infant dying in the first month of life is 53 times greater. With the risk of infant mortality being greater in underdeveloped countries it could be presumed that this is due to a lack of resources and education.

Infant mortality rates around the world continue to be prevalent. Compared to other developed nations, the United States has a high rate of infant mortality predominantly stemming from the lack of prenatal care, maternal education, and the increase in Sudden Infant Death Syndrome (SIDS). As of 2023, the United States has an infant mortality rate of 5.60 deaths per 1,000 live births,2 3% lower than the rate in 2021.³ Despite the decrease, this rate is still 115.49% higher than that of Singapore and Slovenia, each with 1.5 infant deaths per 1,000 live births.² Among the leading causes of infant death are birth defects, low birth weight, congenital malformations, accidents, and SIDS.4 Puerto Rico, as of 2023, experiences a rate of 5.9 infant deaths per 1,000 live births, making it 5.22% higher than the United States.²

In 2021, research has shown that up to 87% of Hispanic mothers were likely to receive delayed to no prenatal care than non-Hispanic White mothers in the United States.⁵ The infant mortality rate ranged from 3.8 deaths per 1,000 live births in Cuban Americans to 5.6 deaths per 1,000 live births in Puerto Ricans.⁶ Along with Hispanic Americans, the non-Hispanic Black population bears a high infant mortality rate, reaching about 10.86 deaths per 1,000 births.³ In 2021, only 69.7% of non-Hispanic Black women received prenatal care during the first trimester, compared to 72.5% of non-Hispanic White women.⁵ A strong prevalence of disparities can be one of the leading causes of the high infant mortality rate in the United States. A primary contributor to health disparities nationwide being socioeconomic factors, gaps have been formed that lead to suboptimal care in specific populations.⁷

Infant mortality has been linked to poverty and rural living; those living in higher poverty areas in the United States have a greater chance of infant mortality compared to low poverty areas.⁸ Although the U.S. infant mortality rate has declined over the years, healthcare disparities still have a major effect on access to prenatal care. Focusing on socioeconomic and demographic factors faced by those most impacted by these health disparities is critical in addressing the gaps experienced by pregnant women. Many countries have implemented various methods to positively impact rates of infant mortality worldwide. In 1938, the Finnish government created the Baby Box Program, to curb infant mortality rates.⁹ As a result, Finland currently has one of the lowest infant mortality rates in the world, at 1.381 per 1,000 live births,¹⁰ significantly decreasing from 6.5/1,000 in the 1930s.¹¹ The Baby Box Program is designed to provide individuals with the necessary pre- and postnatal care, as well as guidance towards healthcare professionals, regardless of their socioeconomic status.⁹ Further, a study conducted in Ecuador demonstrated that the usage of the Baby Box Program resulted in safer sleep practices than just providing a simple diaper bag.¹² The main purpose was to provide families with a safe and secure place for the baby to sleep, as well as essential materials for pre- and postnatal care. The distribution of boxes containing a mattress, onesies, teething toys, and various materials encourages good parenting and supports each family.⁹ Although the Baby Box Program proved to be beneficial in Finland, the U.S. Consumer Product Safety Rule in 2022 deemed it unlawful.¹³ This act bans the manufacturing and sale of non-compliant infant sleep products, particularly for infants up to 5 months after birth. This has led many universities and organizations to adopt variations of the Baby Box Program worldwide. 

According to the Children’s Hospital of Philadelphia, still over 4,500 babies in the United States die of SIDS each year.14 The cause of SIDS is unknown, but is suspected to be due to a baby sleeping in a prone position, co-sleeping, or sleeping on a soft surface. The infant mortality rate in the United States has been steadily decreasing since 1990 from 9.20 deaths per 1,000 births to 5.60 deaths per 1,000 live births in 2023.3 Still, families often lack necessary resources to best care for their baby. With the improvement of the U.S. infant mortality rate, it is crucial to understand the driving force of infant mortality in the United States in order to effectively combat it.

As an initiative to decrease Sudden Infant Death Syndrome, and contribute to the overall health and wellbeing of newborns, the Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program was implemented by Saint Joseph’s University’s (SJU) Institute of Clinical Bioethics (ICB), through the Health Promoter Program Model. The main objective is to examine how the implementation of this program in communities with low socioeconomic status and/or the lack of adequate health care impacts the infant mortality rate. Racial disparities in healthcare, low socioeconomic status, lack of a support system, and inadequate healthcare programs can all be driving factors for maternal and infant mortality. ^{15, 16}

Decades of systemic inequality have led to substantial health disparities, particularly in health coverage for African Americans and Hispanic Americans.¹⁷ In 2022, 10.9% of African Americans and 21.2% of Hispanic Americans were uninsured, compared with 7.2% non-Hispanic White Americans.¹⁸ In addition to healthcare disparities, one’s socioeconomic status affects mortality rates, linking low income with infant mortality. Thus, approximately 1 in 4 women in the United States give birth below the poverty line. These statistics make healthcare disparities even more evident when the official poverty measure and supplemental poverty measure for Black, non-Hispanic, and Hispanic individuals is 19.3%, 11.2%, and 17.1% respectively in comparison to White, non-Hispanic individuals.

To combat maternal and infant mortality, it is essential to increase access to critical services and improve the quality of care for pregnant women, particularly in areas where access to adequate healthcare is limited or non-existent. The Pack ‘n Play Program focuses on eliminating racial disparities in the health system and strives to establish a paradigm for healthcare providers in the United States. Prior to detailing the Program, it is vital to discuss the Health Promoter Program Model. This background will provide information regarding the demographics of the communities being served, as well as the services offered to those most vulnerable.   

Health Promoter Program

The primary goal of the Health Promoter Program is to provide preventive care to the most vulnerable communities in the surrounding communities of Saint Joseph’s University in Philadelphia and beyond. The Health Promoter Program involves five principal divisions, in order to reach a multitude of neighborhoods, and each sector operates on a monthly basis. The African Health Promoter Program is held at Saint Cyprian Roman Catholic Church in West Philadelphia, servicing two primary populations, the Nigerian community and French-speaking West African individuals. The Hispanic Health Promoter Program functions on a rotating schedule, one month being held at the Consulate of Mexico, and the other at the Consulate of Guatemala. Similarly, the Asian Health Promoter Program has two main locations, at Saint Thomas Aquinas Church in South Philadelphia, as well as in conjunction with the Philadelphia Chinatown Development Corporation; the primary demographics served include Chinese, Vietnamese, and Indonesian individuals. As a branch of the Hispanic Health Promoter Program, the Mobile/Rural Program was created, to serve individuals who do not have access to the typical locations; this program travels to other locations in the Pennsylvania tri state area with the Consulate of Mexico, as well as to blueberry and mushroom farms in rural areas of Pennsylvania and New Jersey to expand the scope. Finally, the BIPOC (Black, Indigenous, People of Color) Health Promoter Program is held at Mother of Mercy House in Kensington, Philadelphia, primarily serving the families in the neighborhood as well as individuals with substance use disorder. The Pack ‘n Play Program has been successfully implemented at each of the five sectors in conjunction with the community partners. It is important to note that due to the various different communities, a critical component of the Health Promoter Program is the volunteer interpreters, both community members and SJU students, who help to address the language barriers. Through a variety of stations outlined below (all free of charge), the team makes a commitment to continuously foster the health and wellbeing of each individual served.¹⁹ 

Height and Weight

As the first station, it is here that each patient is greeted, and given a Health Screening Tool that will assist in tracking all of their metrics as they go through the clinic. After removing shoes and any heavy clothing, the patient receives a measure of their height, weight, hip and waist circumference, and thus Body Mass Index (BMI) using a scale.

Blood Pressure and Pulse Oximetry

At the next station, the patient will sit in a chair with their feet flat on the floor, in order to get a measure of their blood pressure and pulse oximetry. A blood pressure cuff is placed an inch above the crest of the elbow and the pulse oximetry device on the index finger of the opposite arm. Readings are calculated and recorded using the initial Health Screening Tool.

Blood Glucose and Cholesterol

The patient moves to another chair in which their blood sugar and cholesterol levels are collected. A volunteer at the station first disinfects the finger that will be used for the measurements with an alcohol wipe, and the glucose and cholesterol strips are loaded into their respective monitors (a glucometer and the CardioChek Cholesterol Analyzer, respectively). The finger is then pricked with a push-button safety lancet, and the proper measurements are obtained using the blood from the finger. Results are recorded on the Health Screening Tool.

Cancer and Cardiac Screening

This station involves a substantial amount of data collection and analysis, to examine how recurring patients have progressed over the multiple months of attending the clinic. It also screens patients for potential risks, and provides insights into cardiovascular health, cancer risk factors, and rheumatological diseases. If a patient is identified as having any of the various risk factors, they are referred to a partner organization, e.g., Penn Oncology, for further testing and continuity of care.

Eyeglasses Program

The prescription eyeglasses program gives patients the opportunity to experience improved vision, by choosing a pair of free reading glasses that suit them best. If a patient has visual impairments related to reading, they are able to try a range of prescription glasses, and determine which is the best fit by using a reading tester chart, and based on the results, they can choose a pair they like. 

Healthy Mother, Health Baby

The focus of this station is to provide prenatal, infant, and adult care through the distribution of essential multivitamins, the Pack ‘n Play Program, and feminine hygiene initiatives. Both children and adults receive a month-long supply of vitamins, to encourage their return to the clinic the following month, and women and girls receive a menstrual care pack consisting of pads, tampons, and educational materials in a reusable pouch. Expectant mothers in their third trimester can also receive a Pack ‘n Play, as a measure to prevent infant mortality, which will be further described in the following section of this paper.  

Dental Evaluation and Education

The intention of the Dental Program is to promote oral health amongst the communities, through screenings, the distribution of dental hygiene packs, educational resources, and the connection of patients to further care if necessary. Patients also have the opportunity to receive a fluoride treatment to protect against tooth decay.

Physical and Occupational Therapy

This station is possible through a partnership with the Physical and Occupational Therapy departments at Saint Joseph’s University. Doctoral students and faculty of these departments provide comprehensive evaluations and personalized education and guidance to support patients in their everyday lives. They strive to improve the daily function and overall enhance each patient’s quality of life through thorough assessment and instruction. If needed, patients can be referred to receive further care at SJU’s pro bono physical and occupational therapy clinic in Philadelphia. 

Wound Care

Whether a patient works in a profession with a lot of physical labor, or they are a substance user, there is the chance that they can develop significant open wounds that, if not properly taken care of, can lead to further complications. The wound care and external wound care stations (primarily offered in Kensington), focuses on the proper care of open wounds, such as disinfection and proper dressing to avoid infection and other medical complications.

Opioid Related Resource Distribution

The overarching purpose of this station is to combat the Opioid Epidemic, as it soars throughout the Greater Philadelphia region. This station provides patients with Narcan, fentanyl strips, and xylazine strips, as well as educational materials regarding the usage of these resources and opioid overdose overall. 

H.I.V. and Hepatitis C Screening

In partnership with Drexel HOPE, the Health Promoter Program offers H.I.V. and Hepatitis C Screenings for patients, as well as educational materials for patients who are in need of related resources and guidance. 

Drug Reconciliation

The Saint Joseph’s University Department of Pharmacy conducts a drug reconciliation with each patient before they have the opportunity to meet with a doctor. They go through the patient’s current medications and then present their findings to the medical residents. 

Medical Residents

Once a patient has made their way through all of the stations described above, they have the opportunity to speak with one of the volunteer medical residents. The medical resident will analyze the completed Health Screening Tool to discuss the patient’s vital measurements, screening history, and medication reconciliation. If necessary, the medical resident will retest any measurements that are out of the ordinary, and determine if a patient requires further care beyond the clinic, in which they will be referred to one of the various free health clinics depending on their location of residence.

The Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program: In Action

As seen above, the Implementation of the Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program is a vital component of the Health Promoter Program, and its impact reaches beyond just the monthly clinics. This program has three primary elements. First, it provides prenatal vitamins, which work to reduce the risk for vitamin and mineral deficiencies and supports the health and wellbeing of both the mother and the baby during pregnancy. The most important component of these vitamins is folic acid, which is essential for prenatal care. Similarly to the daily adult and children multivitamins distributed at the same station, the prenatal vitamins are given in a one month supply to encourage the mother to return to the clinic and receive routine monitoring.

Further, the expectant mother is provided with educational tools regarding pre- and postnatal care. The maternal education pamphlet was developed as a physical reference for the mothers to refer back to for any questions or concerns during their pregnancy. The pamphlet details signs and or potential problems to look out for during the duration of the pregnancy, such as vaginal discharge, vaginal bleeding, and early contractions. It also addresses the concept of prenatal care, when to begin, best practices, and the importance of this type of care during the pregnancy period. The final panel of the pamphlet provides mothers with resources for access to prenatal care, as well as ways that the Healthy Mother and Healthy Baby Program can help. This program supports expectant mothers to gain access to some of the items crucial to prenatal care, such as free prenatal vitamins, clothing, and food. The provided resources allow each woman to identify a physician to provide additional information in regards to prenatal care and the health of both the baby and the mother postpartum. Additionally, the new mothers are provided with separate materials regarding infant care after birth. This includes information on best practices for taking care of a newborn baby, when and how often to take the baby to the doctor, when not to worry, when to call the pediatrician, and how to access healthcare resources for both the mother and the baby. The significance of this information extends beyond the scope of this program. It is important to take into consideration that there are a variety of languages spoken at the different Health Promoter Programs, depending on location. Consequently, the prenatal care pamphlet is available in languages other than English, like Spanish.

The central component of this program is the distribution of a Pack ‘n Play, along with other supplies for the baby. A Pack ‘n Play is a playpen with an attachment that becomes a bassinet with a nursery mobile. Accordingly, the Pack ‘n Play can be used for infants, and once the bassinet is removed, for children until about age three. The item is foldable and comes with a carrying case to conveniently transport it whenever needed. Along with the Pack ‘n Play itself, mothers are given a mesh bag with a pack of diapers, a bottle, pacifiers, baby wipes, and a thermometer to get them started once the baby is born. The main stipulation for this program is that the expectant mother is required to fill out a protocol form, in which she understands the details of the program. On this form, she provides her name and signature, how far along the pregnancy is, and a phone number. Data is collected in order to assess the impact of this program within the communities, by following up with the mothers by phone call at three, six, nine, and twelve months following the initial distribution of the Pack ‘n Play. The Pack ‘n Plays and supplies are distributed at each location in conjunction with the five sectors of the Health Promoter Program.

Data Analysis

The Implementation of the Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program has given families the opportunity to gain access to essential materials for the care of the mother and newborn baby. It provides a safe, secure bassinet and playpen to combat infant mortality and reduce the risk of Sudden Infant Death Syndrome (SIDS).

The leading cause of death for infants in the United States is Sudden Infant Death Syndrome (SIDS), being most prominent within the first six months postnatal.²⁰ This rate peaks between the first to fourth month of life after birth, and although the cause of SIDS is unknown, there are various risk factors. These include, but are not limited to, premature or low birth weight, sleeping on a soft surface, on the side or stomach, or with loose blankets or fabrics, and minimal or lack of prenatal care. As a result, the Pack ‘n Play Program was designed to provide educational tools and resources to address these risks, specifically a safe and secure sleeping environment.

The Pack ‘n Play Implementation team consists of four primary members who collect data with two key focuses: the general well being of the baby, and whether or not the family has been using the Pack ‘n Play and accompanying resources. The goal is to assess the effectiveness of the program as well as collect data on infant mortality among some of the most vulnerable communities. With the given phone number on the protocol form, the team calls the mothers or family members at each periodic interval, starting at the date when the Pack ‘n Play was received.

The program examines data quarterly over a one year period, at three, six, nine, and twelve months after distribution. It is important to acknowledge that the dataset is continuous; some of the twelve month periods are not yet completed, based on when the Pack ‘n Play was initially distributed. The program was first implemented in January of 2023, so twelve months of data will be collected by the end of December 2024.

Figure 1

Figure 1 represents an in depth look at the two primary factors considered as a result of this program. The left most column displays the month in which the resources were given to each recipient, and those to the right follow three, six, nine, and twelve months from that given point. In respect for each woman’s identity and anonymity, initials were used to distinguish each recipient. As seen in Figure 1, it is clear that each contact has thus far yielded positive results. Every family spoken to has confirmed that they use the provided resources, and both the mother and the baby are well and healthy.

Figure 2

Figure 2 displays the number of responses provided by the families that received a Pack ‘n Play at each three-month interval over the twelve month study. A dash in the chart indicates that none of the recipients responded to the phone call from the team. There are a variety of factors that impact the response rate within this program. Given the substantial undocumented population served through the Health Promoter Program, continuity of care and follow-up proves to be a challenge. A variety of recipients fail to answer the call, provide the incorrect phone number, or after a period of time, the phone number is no longer in service. It can be determined from the data that thus far the average response rate is 62.75%. Regardless of the rate for each interval, the Pack ‘n Play implementation team continues to contact the recipients of this program with the hope of a positive response. Something to consider with the continuation of this program is if there are other forms of communication to more effectively reach the recipients on a regular basis, such as email. 

Ethical Analysis

 In the last four decades, this nation has been trying to improve the quality of our health care delivery system. Despite the efforts to increase the quality in health care, disparities continue to be prevalent and have led to unjust consequences for racial and ethnic minorities. Advances in technology and a better understanding of the disease process have greatly improved due to research in the field of medicine. This has contributed to better management of the disease process, which has in turn improved the morbidity and mortality rates of many patients and increased life expectancy in this country. Unfortunately, this effect is being seen predominantly among white Americans while other ethnic groups are still vulnerable, especially inner-city Hispanic populations.²¹  Even though, our health care system, in principle, is considered to be the best in the world it has its own flaws and has left millions of Americans as well as documented and undocumented individuals with inadequate health care or no access to basic health care services.

Immigrants and their U.S.-born children number approximately 90.8 million people, or 27 percent of the total civilian noninstitutionalized U.S. population in 2023. This is an increase of approximately 14.7 million (or 20 percent) from 2010.²² According to the Pew Foundation, the number of undocumented individuals is estimated at 10.5 million as of 2021.²³ Among other cities in the United States, Philadelphia has seen an increase in the immigrant population over the years. A new report finds that immigrants now make up the largest percent of Philadelphia’s population since the 1940s. According to Pew Charitable Trusts' State of the City released June 13, 15.7% of Philadelphians said they were born outside the U.S. That's higher than the national percentage of 13.9%.²⁴  The following chart shows the racial/ethnic population in Philadelphia today.

This population has special needs which physicians and hospitals are not well-equipped to provide. The majority of this community is suffering from chronic diseases such as hypertension, diabetes and obesity and many others are receiving no prenatal care. As health care providers, our duty is to improve the health of the community we serve. To achieve this goal, it is important to understand the diseases prevalent in this community and to develop services tailored to meet these needs. Prenatal care and the establishment of the Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program is one area of health care that has been greatly overlooked in the Philadelphia community in regards to the undocumented population. This is certainly a medical problem, but it is also an ethical problem for all Americans. To allow race and ethnicity to play any role in providing health care to our fellow brothers and sisters goes against the basic principles of morality. It will be argued that – according to the ethical principles of respect for persons, beneficence/nonmaleficence, and justice – action must be taken immediately to address these concerns. Such action will not only save lives but will also do much to rebuild a sense of trust between the minority community and the medical establishment.

Respect for Persons

This principle incorporates two ethical convictions: first, that persons should be treated as autonomous agents; and second, that persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy.²⁵ Respect for human persons refers to the right of a person to exercise self-determination and to be treated with dignity and respect. All people deserve autonomy and to be treated with dignity and respect. Failure to provide any person with adequate health care, regardless of their race, creed, color, national origin, sexual orientation, etc., violates this basic right of respect for persons. Fear that undocumented individuals will be turned over to the Immigration and Customs Enforcement (ICE) if they seek medical care violates personal freedom. It subjects all undocumented persons to the most terrible form of slavery, to be constantly afraid, not knowing their condition or fate, and constantly fearing not living. This way of living does not promote human rights, it violates them.

Second, minorities in this country, especially the undocumented, are the most vulnerable people. When refugees, asylees and immigrants arrive, they are often traumatized and shocked. They usually have no jobs and no financial support on which to fall back. In addition, they are in poor health, often because they have moved from town to town or from one refugee camp to another. The children may have not been in school for several years, or they may have not been to school at all. As is often the case in refugee-producing situations, women and children become the most vulnerable members of the refugee community. Statistics show that racial and ethnic minorities are generally poorer than whites and more likely to have family incomes below 200 percent of the federal poverty level. The result is that many undocumented individuals are fearful of seeking health care for fear of being deported. This is especially true for women who are pregnant. Besides this fear there is always the cost factor. This fear and mistrust among the minority population in the United States is magnified with documented and undocumented individuals. The result is that many undocumented and even documented immigrants in the Philadelphia area are not seeking medical care until they are in the final stages of their disease or women have complications with their pregnancy. The reason for this, according to those who work with this population and have gained their trust, is a mistrust of the medical establishment and a fear that if they present to an Emergency Department and are found to be undocumented that they will be turned over to the ICE for deportation. Unfortunately, this has happened in several cases. Even though Catholic hospitals in the Philadelphia area will not contact ICE in these situations, there is still a great fear among this population. Because of this fear, individuals enter the medical system only out of desperation, when they can no longer stand the pain, have collapsed in a public setting or have serious complications with the pregnancy. In most cases, the disease has progressed to the extent that treatment is often futile or extremely expensive. For many pregnant women, it is because they have not received prenatal care and remain uneducated about nutritional issues, the risk of existing conditions, issues related to tobacco and alcohol use, and SIDS. This sense of fear among the undocumented population violates the basic principles of respect for persons. Failure of the medical establishment to give this population adequate health care or to withhold treatment that is the “standard of care” because the individual is undocumented or unable to afford said treatment is denying these individuals their basic rights of dignity and respect. The medical profession is based on treating all people with dignity and respect. Until we can show an improvement in the overall quality of care and work aggressively to promote public health interventions on such diseases as hypertension, diabetes, obesity and prenatal care for minorities in general and the undocumented specifically, we will never gain the trust of the minority communities and will never close the ever-widening gap in quality of care.

The failure of the medical profession to be proactive in addressing the medical needs of this most vulnerable population is causing needless suffering and even death. This clear form of prejudice clearly violates the ethical principle of respect for persons. Minority patients’ autonomy and the basic respect they deserve as human beings are being violated because they are allowed to endure pain, suffering, and even death when such hardships could be alleviated. All hospitals, and especially Catholic hospitals, governed by the Ethical and Religious Directives for Catholic Health Care Services, have a moral and ethical obligation to address the medical disparities that exist in minority communities.²⁶ If Catholic hospitals are committed to treating every person with dignity and respect, then the barriers to health care must be lifted to ensure this commitment, and emphasis must be placed on patient dignity and empowerment. The Health Promoter Program and the Pack ‘n Play Program in particular is meeting this need and is treating women who are undocumented and pregnant with dignity and respect.

Beneficence/Nonmaleficence

The principle of beneficence involves the obligation to prevent, remove, or minimize harm and risk to others and to promote and enhance their good. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others. In medical ethics, this principle has been closely associated with the maxim primum non nocere (“Above all, do no harm”). Allowing a person to endure pain and suffering that could be managed and relieved, or placing mothers and their babies at risk because of a lack of prenatal care violates the principle of beneficence, because one is not preventing harm and, therefore, not acting in the best interest of the patient. The duty to act in the patient’s best interest must be the main focus of the medical profession.

The Pack ‘n Play Program is addressing the best interests of undocumented pregnant women. The education program provided by the Health Promoter Program not only educates the women on breastfeeding, the need for prenatal vitamins, use of Vitamin D and folic acid, and the risk of SIDS, but also helps women to control their existing conditions. Diabetes and hypertension are major health factors among the undocumented population. Educating women on these health issues as well as alcohol and tobacco use is not only in the best interest of the mothers but also in the best interest of their newborns.  The Pack ‘n Play Program has been proven to be effective in decreasing the infant mortality rates in many countries. The small study done in this paper makes it clear that the Pack ‘n Play Program is indeed effective and that it is maximizing benefits and minimizing harms, not only for the newborns but for society as a whole.

It is clear, after reviewing the Pack ‘n Play data and identifying the biases and stereotyping that exist in the medical profession, that disparities in U.S. health care expose minority patients to unnecessary risks, including possible injury and even death. Physicians have a moral responsibility to do what is good for their patients. Should a physician be impeded in the exercise of his or her reason and free will because of prejudice or bias on the part of the medical establishment, then that physician has an ethical responsibility to overcome that impediment and do what is demanded by the basic precepts of medicine—seek the patient’s good. The Research Fellows in the Institute of Clinical Bioethics at Saint Joseph’s University are addressing the needs of the undocumented medically, socially and ethically. The health of pregnant women and the care of their newborns must be a priority for all health care workers, but especially for those working in Catholic healthcare facilities.  Failure to recognize the needs of the undocumented and to address them to the best of our ability is a failure not only of the test of beneficence; it may also be a failure of the test of nonmaleficence.

Justice

This principle recognizes that each person should be treated fairly and equitably and be given his or her due. The issue of medical disparities among minorities and especially among the undocumented also focuses on distributive justice: the fair, equitable, and appropriate distribution of medical resources in society. At a time when reforming healthcare in this country has become a high priority, failure to initiate preventative measures that would save medical resources in the long-run violates the principle of distributive justice. The justice principle can be applied to the problem under discussion in two ways.

Inequality concerning adequate health care for Americans is a well-documented fact. Studies have shown that socioeconomic disadvantage is linked to a higher risk of adverse birth outcomes both in the U.S. and other highly industrialized countries^.27 Some factors leading to adverse birth outcomes in lower socioeconomic populations are lack of preventative healthcare such as prenatal vitamins, education about maternal and fetal health, and suboptimal practices following birth, leading to poor maternal and infant health. The principle of justice is clear that all people must be treated fairly and equitably. Failure to provide prenatal care to pregnant women who are undocumented and to their newborn children violates this right. The Pack ‘n Play Program is meeting these needs to the best of its ability. Everyone is welcome to attend each Health Promoter Program. No one is ever turned away. The program is inclusive and unbiased and each clinic session works hard to overcome the fear and bias many in the undocumented community feel living here in Philadelphia. They not only provide needed services but are building a trust that will have long term consequences.

The principle of justice also pertains to the fair and equitable allocation of resources. The Pack ‘n Play Program has proven to save lives by decreasing the infant mortality rate in many countries. Providing undocumented pregnant women with the Healthy Mother & Healthy Baby services and the Pack ‘n Play Program will not only save lives but it will help the undocumented mothers remain healthy and have fewer complications during their pregnancies.  This paper has shown that racial disparities in healthcare, low socioeconomic status, lack of a support system and inadequate or non-existent healthcare programs are the driving factors for maternal and infant mortality in the United States. The resources that are being provided by the Pack ‘n Play Program and the maternal health education services being provided meet the needs of the mothers and their babies, their families and society as a whole. This is a prime example of a just allocation of resources.

We Americans espouse the belief that all men and women are created equal. Equality has also been a basic principle of the medical profession. If we truly believe in equality, we should insist that all men and women must receive equal medical treatment and resources. Denying certain minorities medical treatment, when White Americans receive them as a standard of care, is an unjust allocation of resources and violates a basic tenet of justice. Physicians and the medical profession have an ethical obligation to use available resources fairly and to distribute them equitably. Failure to do so is ethically irresponsible and morally objectionable. To compromise the basic ethical foundations upon which medicine stands is destructive not just to minority patients but to society as a whole.

To address these medical and ethical concerns, the Fellows in the Institute of Clinical Bioethics at Saint Joseph’s University in Philadelphia have designed a comprehensive education and prevention model that will meet the needs of the Philadelphia area undocumented community. The Health Promoter Programs are an initiative whose foundation is based on an established program in the developing world, which has not only increased medical care in these areas but has also saved countless lives. As the undocumented population continues to increase in the United States, and health care costs continue to skyrocket, this new initiative can become a paradigm for all hospitals in the United States. Racial and ethnic disparities in health care constitute a complex issue that pertains to individuals, institutions, and society as a whole. Unless we Americans address these disparities and begin to eradicate them, we will never attain the goal of equitably providing high-quality health care in the United States. The Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program through the Health Promoter Model will not only save valuable medical resources; it will also save precious human lives. If we do not make this a priority now, everyone will pay a price in the future.

Conclusion

The Research Fellows in the Institute of Clinical Bioethics at Saint Joseph’s University have sought to combat undocumented individuals’ healthcare disparities. The Health Promoter Program’s expansion has created a new paradigm in modern healthcare that creates an environment seeking to prevent life-threatening conditions and educate the Philadelphia population about their health. The Healthy Mother, Healthy Baby Initiative and Pack ‘n Play Program aims to eliminate the disparity of prenatal and postpartum health of Philadelphia mothers due to the substantial positive effects of preventing SIDS in Finland. By looking at trends between the use of the Pack ‘n Play Program in undocumented families and positive responses from families contacted, it can be inferred through the data that the program effectively helps undocumented and poverty-stricken families caring for a newborn based on the families that stayed connected.

The Health Promoter Program Model is a system that can tackle the issues presented in the Triple Aim under the Patient Protection and Affordable Care Act (PPACA). The goal of the PPACA is to reduce medical costs, save health care resources, and most importantly, provide patients access to the healthcare system before developing chronic or end-stage conditions so that they can live fuller, healthier lives. Based on these values, special attention is given to the justice and beneficence principles by highlighting the values of equal opportunities and care for all individuals. The principle of justice highlights the values of fair and equal resources distributed to all individuals. In contrast, the principle of beneficence highlights the obligation and responsibility to prevent, remove, or minimize harm and risk to others and promote and enhance their good. The Research Fellows in the Institute of Clinical Bioethics use these principles to create a sustainable and accessible way to receive prenatal care for the Philadelphia population. Thus, this preventative and accessible health care method creates an eminent standard for health care facilities across the globe to provide equal care for vulnerable populations.