Black Maternal Health as a Reproductive Justice Issue
Black birthing people have unacceptably poor maternal and infant health outcomes in the U.S— including staggering rates of preventable illnesses and deaths related to pregnancy and childbirth. Reproductive Justice can only be achieved when Black women, girls, and gender-expansive individuals can experience pregnancy and childbirth without endangering our lives. The United States has the highest maternal and infant mortality and morbidity outcomes than any other industrialized nation, which disproportionately impacts Black birthing people in the U.S. due to vast racial disparities. Yet, Black birthing people have unacceptably poor outcomes in the U.S— including staggering rates of death related to pregnancy and childbirth. At the heart of America’s maternal health crisis is a woefully fragmented health care system that perpetuates vast racial disparities in maternal and infant morbidity and mortality.
The United States’ overall rate of 32.9 maternal deaths per 100,000 live births is cause for alarm as it is the highest rate among high-resource countries.1 It is important to note, however, that not all women face the same risks.
Black women have the highest rates of maternal mortality in the country and are 2.6 times more likely to die of pregnancy- and childbirth-related causes compared to women of other races and ethnicities.2 3Black newborns also have worse outcomes than their counterparts: they face the highest rate of infant death compared to all other races/ethnicities and is more than double the rate of white babies’ mortality.4
Structural racism and the resulting biased health care system contribute to Black women’s poor health outcomes, including maternal mortality. Systemic barriers that Black women face include racism, sexism, and income inequality that result in lower wages. As a result, too often, we have to choose between essential resources like safe housing, childcare, food, and medical care.
Despite the positive impacts of the Affordable Care Act (ACA) and Medicaid’s expansion from 60 days of postpartum coverage to one year postpartum in certain states, Black women are still more likely to be uninsured, face greater financial barriers to health care services, and have less access to timely prenatal care. Additionally, Black women experience higher rates of chronic health conditions that may worsen maternal and infant health outcomes—including diabetes, hypertension, obesity, and cardiovascular disease.5
Research points to substandard care at hospitals, driven by anti-Black racism and discrimination, as another critical driver of disparities across the care continuum. These include overt acts of interpersonal discrimination. On a broader level, implicit biases, stereotypes, and institutional and structural discrimination harm Black birthing people and their families. The inequities and exposure to racism that Black women experience throughout their lives, including while seeking health care, increases health risks and drives racial disparities in preventable maternal and infant deaths.
According to a 2024 In Our Own Voice: National Black Women’s Reproductive Justice Agenda national poll, nearly one-quarter of Black women 18 to 44 surveyed felt worried about their health and safety during pregnancy or childbirth because of their race. Nearly 20 percent reported feeling that a health care provider didn’t take their pain seriously during pregnancy or childbirth because of their race and/or gender.
The impact of this structural racism is clearly indicated by findings about what happens when newborn Black babies are cared for by Black clinicians. When Black babies are treated by Black providers (e.g., pediatricians, neonatologists, family practitioners), their mortality rate compared to white newborns is halved.6 Black midwives have been a pillar of Black communities since the antebellum period. Forcibly, they cared for enslaved birthing Black women and their infants on plantations and provided critical care to newly freed reproducing Black women. In the late 19th to early 20th century, the privatization of medicine, increased hospitalization of childbirth, and racist stigmatization of Black health care providers decimated Black midwifery; white male physicians, eager to “found” the field of obstetrics and gynecology, often collaborated to push Black midwives out of the delivery room through legislation, misinformation.7 Black midwives were, and remain, critical practitioners, especially in rural and remote areas or regions where physicians do not provide care to Black people.
Achieving better outcomes for Black women, birthing people, and babies requires a commitment to birth justice—including increasing the availability of Black midwives and doulas. Birth justice is achieved when individuals can make informed decisions during pregnancy, childbirth, and postpartum, that is free from racism, discrimination of gender identity, and implicit bias. Birth justice requires that individuals fully enjoy their human rights regarding reproductive and childbirth-related health decisions, without fear of coercion, including coercion to submit to medical interventions, reprisal for refusal of care, and/or face the threat of inadequate medical care. Birth justice centers the intersectional and structural needs of individuals and communities.8
Progress to Date
Thanks to the tireless efforts of Reproductive Justice and Black birthing advocates nationwide, addressing Black maternal mortality and morbidity has become a key policy priority for federal and state lawmakers in recent years. This increased focus has resulted in notable policy progress, including the Biden-Harris Administration’s successful push for states to expand Medicaid coverage to 12 months postpartum under the American Rescue Plan. More than three dozen states, the District of Columbia, and the U.S. Virgin Islands have adopted this expansion.
Key Policy Recommendations to Improve Black Maternal Health
- Require all states to extend comprehensive, holistic maternity care and newborn care for a minimum of one year postpartum
- Remove cost-sharing for preconception care; labor-, delivery-, and pregnancy-related labs; mental health; and postpartum visits
- Require coverage for doulas and midwifery care in insurance programs and increasing funding for doulas and midwifery care federal health care programs
- End coercive, non-consensual drug testing and criminalization of substance use for patients, including pregnant people
- Pass the Black Maternal Health Momnibus Act, CARE for Moms Act, and other legislation that advance Black maternal health outcomes.
1 Hoyert DL, Maternal mortality rates in the United States, 2021, National Center for Health Statistics, Health E-Stats. 2023. DOI: https://dx.doi.org/10.15620/cdc:124678.
2 Centers for Disease Control and Prevention (CDC), Pregnancy Mortality Surveillance System, Atlanta (GA): CDC, 2023. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm.
3 Hoyert DL, Maternal mortality rates in the United States, 2021, National Center for Health Statistics, Health E-Stats, 2023. DOI: https://dx.doi.org/10.15620/cdc:124678.
4 Centers for Disease Control and Prevention (CDC), Infant Mortality, Atlanta (GA): CDC, 2022. https://www.cdc.gov/maternal-infant-health/infant-mortality/
5 Doshi RP, Aseltine RH, Sabina AB, Graham GN, “Racial and ethnic disparities in preventable hospitalizations for chronic disease: prevalence and risk factors,” Journal of racial and ethnic health disparities, 2017; 4(6): 1100-1106.
6 Cunningham A, “What we can learn from how a doctor’s race can affect Black newborns’ survival,” Science News, August 25, 2020. https://www.sciencenews.org/article/black-newborn-baby-survival-doctor-race-mortality-rate-disparity.
7 Smithsonian Institution (SI), The Historical Significance of Doulas and Midwives, Washington (DC): SI, no date. https://nmaahc.si.edu/explore/stories/historical-significance-doulas-and-midwives
8 Ancient Song Doula Services, Full Spectrum Doula Training, Montclair (NJ): Ancient Song Doula Services, 2018. https://www.ancientsongdoulaservices.com/training.
