Racial Inequities in Severe Maternal Health Outcomes

Authored by: Surabhi Shastry

Art by: Stefanie Chen

Racial inequities in severe maternal morbidity (SMM) and pregnancy-related mortality in the United States are a critical, persistent public health crisis. National data consistently show that Black birthing people face pregnancy-related deaths and SMM at rates three times higher than White birthing people, and these disparities have not shown substantial improvement over time [1]. State-level analyses reveal that the magnitude of these inequities varies widely, with some regions exhibiting even more pronounced gaps due to local policies, fragmented health systems, and differing investments in public health infrastructure, which is concerning because it means that a birthing person’s risk of severe maternal complications or death depends largely on where they live, highlighting the urgent need for equitable healthcare access and policy reform [2,3].

Structural determinants, including residential segregation, access to stable housing, insurance coverage gaps, and the prevalence of maternity care deserts, represent key upstream drivers of these disparities. Historical and ongoing structural racism has causedBlack and other marginalized communities to be disproportionately concentrated in under-resourced neighborhoods, where high-quality maternity care is often unavailable or difficult to access [2]. Studies show that counties with higher Black populations are more likely to lack obstetric care facilities, resulting in delayed or forgone prenatal and emergency obstetric care [3]. Insurance gaps further exacerbate challenges in accessing both routine and emergency services—especially in states that have not expanded Medicaid coverage—leaving many birthing people without the continuous care necessary for optimal maternal health. These structural factors are compounded by cumulative life stressors related to racism, discrimination, housing instability, and economic insecurity, each of which contributes to adverse pregnancy outcomes [2,5].

Interpersonal dynamics within healthcare settings further intensify these inequities. Implicit bias among clinicians can lead to the underestimation of Black patients' pain, dismissal of their health concerns, and failures in effective communication. These circumstances are frequently documented in both qualitative research and firsthand accounts [4].

Communication breakdowns can erode patient trust and make it more difficult for individuals to navigate healthcare processes, understand their medical risks, and access timely interventions when complications arise. At the hospital level, research indicates that facilities serving predominantly Black birthing people often face major resource constraints, are less likely to use evidence-based protocols consistently, and see higher SMM and mortality rates than those serving mostly White patients [5].

Given these intersecting challenges, a mixed-methods research approach is necessary for a comprehensive understanding. Quantitative analysis of national datasets—including the National Vital Statistics System, hospital discharge records, and the Pregnancy Risk Assessment Monitoring System (PRAMS)—enables systematic mapping of disparities, geographic trends, and the links between structural factors, SMM, and mortality [1]. Complementing these analyses, qualitative interviews with Black birthing people, doulas, and clinicians can provide critical context about lived experiences, discrimination, and the systemic barriers that shape perinatal care [2].

Multi-level interventions offer promising solutions. Community-based doula programs provide culturally competent support and advocacy, resulting in improved birth outcomes and patient satisfaction [5]. State-level perinatal quality collaboratives and initiatives to extend postpartum Medicaid coverage strive to ensure high-quality, consistent care during and after pregnancy, particularly in underserved communities [5]. Implicit bias and communication training for clinicians, especially when implemented as part of broader anti-racist health system reforms, can improve trust and patient-provider relationships, although durable change requires robust institutional support [2,5]. From my perspective, these interventions are only truly effective when paired with systemic accountability measures—without institutional commitment to equitable resource allocation, bias training risks becoming performative rather than transformative. I think that combining clinician education with structural reforms, such as ensuring consistent staffing, adequate facility resources, and community-informed care models, could meaningfully strengthen patient outcomes and foster genuine trust. Policy recommendations emerging from this literature—including expanding Medicaid and insurance coverage, targeted investments in healthcare infrastructure for maternity care deserts, mandatory anti-racism training, and systematic collection and public reporting of race-stratified maternal health data—reflect strategies that I believe are both practical and necessary to hold health systems accountable and to create sustainable, measurable improvements in maternal health equity [2,5]. Personally, I see these combined approaches as essential: clinician-level interventions cultivate immediate relational improvements, while systemic and policy changes create the structural foundation necessary for long-term equity.

Investigating and addressing the interacting impacts of structural, interpersonal, and systems-level determinants is essential for reducing preventable maternal harm and achieving equity in perinatal health outcomes in the United States, and I believe that combining policy reforms, such as expanding access to quality prenatal care, with community-based interventions and provider training on implicit bias could meaningfully reduce disparities and improve outcomes for marginalized populations.

Works Cited:

1. Petersen, E. E., et al. (2019). Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. Centers for Disease Control and Prevention (CDC). MMWR Morbidity and Mortality Weekly Report, 68(35), 762–765. https://pmc.ncbi.nlm.nih.gov/articles/PMC6730892/​

2. Hailu, T., Mehta-Lee, S., & Admon, L. K. (2023). Structural racism, maternal health inequities, and the need for anti-racist clinical practice. American Journal of Obstetrics & Gynecology MFM, 5(3), 100745. https://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1794&context=honorstheses​

3. Hung, P., et al. (2022). Racial and Ethnic Disparities in Severe Maternal Morbidity Before and During the COVID-19 Pandemic. JAMA Network Open, 5(10): e2237496. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797496​

4. Creanga, A. A., Bateman, B. T., Kuklina, E. V., & Callaghan, W. M. (2014). Racial and ethnic disparities in severe maternal morbidity: A multistate analysis, 2008–2010. American Journal of Obstetrics and Gynecology, 210(5), 435.e1–435.e8. https://pubmed.ncbi.nlm.nih.gov/24295922/​

5. Howell, E. A., Brown, H., Brumley, J., Bryant, A. S., Caughey, A. B., Cornell, A. M., et al. (2020). Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle. Obstetrics & Gynecology, 135(3), 770–782. https://saferbirth.org/wp-content/uploads/Reduction_of_Peripartum_Racial_and_Ethnic.4.pdf​

6. JAMA Network (2025). Pregnancy-Related Deaths in the US, 2018–2022. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2832320​