Maternal Health and Pregnancy Care

Reproductive Justice can only be achieved when Black women, girls, and gender-expansive individuals can experience pregnancy and childbirth without endangering our lives. 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. It is important to note, however, that not all women face the same risks.

Rates of maternal mortality increased significantly during the pandemic, rising from 23.8 in 2020 and 20.1 deaths per 100,000 live births in 2019 to 2021 was 32.9 in 2021. 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.

Black 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.

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 success of the Affordable Care Act (ACA), 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 harm maternal and infant health outcomes—including diabetes, hypertension, obesity, and cardiovascular disease.

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.

The impact of this structural racism is clearly indicated by findings about what happens when newborn Black babies are cared for by Black doctors. When Black babies are treated by Black providers (e.g., pediatricians, neonatologists, family practitioners), their mortality rate compared to white newborns is halved. 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, especially in rural and remote areas or regions where physicians refused to care for Black people.

This section examines key health issues that impact the overall well-being of Black women, girls, and gender-expansive individuals, including maternal health and pregnancy care, reproductive health care for Black incarcerated individuals, access to abortion care, comprehensive sexual health education, contraceptive equity, chronic health conditions, reproductive cancers, behavioral and mental health, assisted reproductive technology and fertility care, and scientific research.

The privatization of medicine and increased hospitalization of childbirth in the 20th century decimated Black midwifery; white male physicians founded the field of obstetrics and gynecology and pushed them out of the delivery room.

Achieving better outcomes for Black women, birthing people, and their babies requires a commitment to birth justice—including increasing the availability of Black midwives and doulas. As defined by Ancient Song Doula Services:

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.

Reducing racial/ethnic disparities in maternal and infant health requires multifaceted, comprehensive, and holistic solutions to address the root causes of structural racism and gender oppression . Policy solutions to the maternal and infant mortality crisis must be grounded in an awareness of racism’s impact, and in social justice frameworks that are intentionally designed to address these power imbalances.

• Establish a Federal Office of Sexual and Reproductive Health and Wellbeing
To fully address racial/ethnic health disparities, a comprehensive and holistic approach to sexual and reproductive health must be prioritized at all levels of government. An Office of Sexual and Reproductive Health and Wellbeing (OSRHW) should be established within the federal government. Congress should establish and fund the OSRHW so that it extends across Presidential administrations and is not vulnerable to a hostile administration. It should have the authority to inform, lead, and provide guidance for regulations that center the sexual and reproductive needs of marginalized individuals and communities. This authority cannot and should not be limited to one single entity but must engage all agencies to ensure health equity and the human right to health care.

• Increase funding for doulas and midwifery care in federal health care programs
Doulas provide non-medical physical and emotional support to birthing people that is effective in reducing stress and achieving better outcomes.18 Midwives are qualified medical practitioners who can deliver babies. Engagement of doulas and/or midwives during pregnancy and childbirth can help address Black maternal and infant mortality. Increased access to doula or midwifery services can help address the needs of all birthing people— particularly those from underserved and low-income communities, communities of color, and communities facing linguistic and/or cultural barriers. These supports are, however, under-utilized by the health care system, and under-compensated by coverage systems. Funding for doulas and midwifery care in federal health care programs should be congruent with a living wage and comparable doula and midwifery rates. Moreover, doula training and educational programs are not adequately supported on either the community or national levels.

• Support and fund an epidemiological infrastructure that accurately tabulates morbidity and mortality across all states and U.S. territories
Congress should create a Task Force or Maternal Mortality Review Board to provide guidance and oversight nationwide. Specifically, states and U.S. territories should be required to collect and disseminate maternal mortality and morbidity data that are disaggregated by race and ethnicity so long as privacy can be maintained. This information can be used to better understand the specific groups that are at heightened risk, implement programs to reduce those risks, and address racially discriminatory policies and regulations.

• Require states to extend comprehensive, holistic maternity care and newborn care for a minimum of one year postpartum
Medicaid covers almost half of all U.S. births (42%) and two-thirds (66%) of Black births. This public insurance program also supports access to care during the prenatal period and for the first 60-days postpartum.22 After that, however, coverage depends on state policy and can vary widely—particularly in states that did not expand Medicaid as part of the ACA. The Biden-Harris Administration has incentivized all states to implement 12-month postpartum coverage expansion for all birthing people. Congress should go further and require states to extend Medicaid postpartum coverage to 12 months and to provide 12-month continuous coverage via Medicaid or the Children’s Health Insurance Program (CHIP) for newborn children. Doing so will have significant benefits for women’s health, and expand services for pregnancy related complications, chronic conditions, family planning, and mental health needs.

• Implement monthly financial supplements or universal incomes for low-income pregnant people
Guaranteeing a monthly income will ensure that Black women and gender-expansive individuals have the resources needed to receive prenatal care, as well as secure appropriate housing, food, and support services needed to maintain a healthy pregnancy.

• Remove cost-sharing for preconception care; labor-, delivery-, and pregnancy-related labs; mental health; and postpartum visits
All barriers to health care before, during, and after childbirth must be removed in order to reduce Black maternal and infant mortality rates. Medical costs can be a significant source of stress and strain for pregnant people and new parents and come at times when they can least afford mounting debt. Removing cost-sharing could make all the difference for a low-income person.

• End coercive, non-consensual drug testing and criminalization of substance use for patients, including pregnant people
Laws that limit pregnant people’s autonomy and penalize them for substance use while pregnant harm Black women and gender-expansive individuals and their families. Criminalization is not only discriminatory in practice but also physically and emotionally harmful for both the pregnant person and the baby. Instead, legislators should strive to provide funding for effective treatment for substance use, including opioid use disorder.

• Pass the Black Maternal Health Momnibus Act
The collection of 12 pieces of legislation was first introduced in the 116th Congress by Representatives Lauren Underwood (IL-14), Alma Adams (NC-12), and then-Senator Kamala Harris (D-CA). The Act seeks to comprehensively address the myriad issues and factors that contribute to the Black maternal health crisis. Its passage would be a critical step toward addressing the systemic and structural racism that contributes to health disparities driving the national maternal mortality crisis.

Reproductive Justice can only be achieved when Black women, girls, and gender-expansive individuals can experience pregnancy and childbirth without endangering our lives. 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.