Racial Disparities in Maternal Mortality: What You Need to Know

Even though giving birth is much less dangerous today than it was for previous generations, around 700 women still die each year as a result of pregnancy or related complications. And one factor continues to significantly increase a woman’s chances of dying as a result of her pregnancy: race.

Black, Native American, and Alaska Native women are up to three times more likely to die from pregnancy than white women, according to a report from the Centers for Disease Control and Prevention. This disparity gets worse as women get older.

For women over 30, pregnancy-related mortality was four to five times higher for Black, Native American, and Alaska Native women than it was for white women. And it persists across all education levels, with Black, college-educated women 5.2 times more likely to die in pregnancy than white women with college degrees.

Understanding Race and Pregnancy

In a statement, Dr. Emily Peterson, medical officer at CDC’s Division of Reproductive Health, and lead author on the study, called for more research to understand the cause of the problem and find solutions. “These disparities are devastating for families and communities and we must work to eliminate them,” she said.

The findings were reported last year in the CDC’s Morbidity and Mortality Weekly Report, based on national data recorded between 2007 and 2016. If a woman died during pregnancy, up to one year after pregnancy because of a pregnancy complication, as a result of events that were initiated by pregnancy, or from an unrelated condition that was aggravated by pregnancy, it was counted as a pregnancy-related death.

Researchers found the following pregnancy mortality rates:

• 40.8 deaths per 100,000 births for Black women
• 29.7 deaths per 100,000 births for Native American and Alaska Native women
• 13.5 deaths per 100,000 births for Asian/Pacific Islander women
• 12.7 deaths per 100,000 births for white women
• 11.5 deaths per 100,000 births for Hispanic women

These disparities remained consistent and didn’t change significantly over the nine years the researchers studied. Here are four more concerning facts about race and pregnancy:

1. Most pregnancy-related deaths are preventable

A review of maternal mortality in 13 states found that at least 60% of pregnancy-related deaths could have been prevented. Some of the most common causes of pregnancy-related death include:

• Cardiomyopathy
• Heart disease
• Preeclampsia and eclampsia
• Stroke
• Thrombotic pulmonary embolism
• Hemorrhage
• Infection
• Amniotic fluid embolism
• Mental health issues including depression and postpartum depression
• Other underlying health conditions, like diabetes, kidney disease, and pneumonia

A 2006 analysis of five common pregnancy complications (preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage) found that, while Black and white women were equally likely to experience complications during pregnancy, Black women were two to three times more likely to die as a result.

According to the 2019 CDC study, cardiomyopathy and thrombotic pulmonary embolism were more likely to contribute to the deaths of Black mothers, and hemorrhage was more likely to kill Native American and Alaska Native mothers than mothers who were white. Both groups were more likely to die as a result of hypertensive disorders related to pregnancy than white women.

2. Health disparities can’t be explained by socioeconomic factors alone

It’s true that Black women are more likely to experience challenges like poverty, limited access to prenatal care, and underlying health issues like hypertension and diabetes, all of which are risk factors for maternal mortality. These problems are linked to forms of systemic racism, such as housing and job discrimination. But socioeconomic differences alone can’t explain why Black women are more likely to die as a result of pregnancy.

Numerous studies have found that Black women remain at higher risk for maternal mortality even after controlling for factors like education and socioeconomic status. One study found that Black women were three times more likely to die from pregnancy or delivery complications than white women, even after controlling for income, gestational age, maternal age and health status.

3. Systemic racism and racial discrimination play a role

In addition to social and economic risk factors, Black women are less likely to receive quality health care during pregnancy, delivery, and the postpartum period than white women.

Studies have found that Black women receive lower-quality health care over their entire lifespan, and are also less likely than white women to have access to reproductive and sexual health services like family planning, abortion, and health screenings.

Once they’re in the hospital or clinic, Black women are also more likely to experience racial discrimination and implicit bias. Black mothers are less likely to be treated for pain (a disparity that’s been documented for all African Americans), and frequently report receiving unequal treatment during and after childbirth, including being treated disrespectfully, and being ignored by health care providers when they report something is wrong.

Tennis star Serena Williams famously wrote about how she alerted nurses to symptoms of a pulmonary embolism a day after giving birth, and nearly died after they dismissed her concerns, delaying treatment.

Finally, there’s increasing evidence that “weathering” — the long-term accumulation of stress that comes from dealing with racism on a day-to-day basis — takes a physical toll on the body, increasing Black women’s vulnerability to chronic disease.

4. Disparities affect future generations.

It’s not just women who are harmed by racial disparities around maternal health. Infant mortality rates are more than twice as high for babies born to Black mothers as those of white mothers, with 10.97 infant deaths per 1,000 live births compared to 4.67 infant deaths. Infant mortality was also significantly higher for the Native American and Alaska Native population, with 9.21 deaths per thousand live births.

And a 2019 study by the CDC found that, per 100,000 live births, 83.3 Black babies died due to maternal complications, compared to 23.6 white babies. This data was not available for Native American and Alaska Native babies.

Closing the Gap

While racism and inequality in health care may be a longstanding problem, the report identified steps that could help close the gap. These include having hospitals standardize their protocols in caring for birthing mothers, especially at facilities that serve disproportionately affected communities.

Hospitals should also work to identify and address implicit bias in health care to improve doctor-patient interactions, communication, and outcomes, researchers said. The CDC is awarding more than $45 million over five years to state and local Maternal Mortality Review Committees to look for more ways to reduce disparities.

The National Birth Equity Collaborative has outlined five policy recommendations to reduce racial disparities in maternal health:

• Promote and protect reproductive health equity at the highest levels of government by creating an Office of Reproductive Wellbeing in the White House.
• Recognize access to health care as a human right and require government to ensure that affordable, quality health care is available to all.
• Hold individuals and institutions accountable for discrimination by eliminating laws, policies, and practices that cause preventable inequalities in health outcomes, and make sure that the standards for assessing discrimination in health care takes unequal outcomes into account.
• Make sure that maternal deaths are accurately counted by requiring all U.S. states and territories to collect data on maternal mortality and morbidity, broken down by race and ethnicity.
• Ensure reproductive autonomy by removing laws and policies that restrict women’s ability to make reproductive decisions for themselves, like “gag rules,” and requiring that health care providers offer services in a non-coercive manner. The organization also provides racial equity training.

Training and education is also available from the Black Mama’s Matter Alliance, which organizes Black Maternal Health Week annually in April and offers webinars on a variety of topics, from breastfeeding, to maternal health during COVID, to advocacy. The organization calls for greater access to holistic care for Black women, including doulas and midwives, and for changes including demanding that health care providers listen to Black women and learn more about the historical experiences of Black women and families.

What Black Mothers Can Do

Experts and advocates offered some tips for how Black mothers can advocate for themselves and improve their likelihood of having a safe and positive birth experience:

• Take time to choose a health care provider you feel good about. Ask questions and interview the person about their experience, values, and approach to childbirth. Take note of whether the person seems to be really listening to you and paying attention to your concerns. It’s a good sign if the person asks you questions and listens to your responses.
• Speak up and advocate for yourself. If you have concerns about your medical care or you have questions that aren’t being answered, repeat back what the doctor is telling you and explain what you need or why you disagree. Stand your ground until you get an acceptable response. If you feel unsafe, don’t be afraid to ask for a different nurse or doctor.
• Consider using a doula. Even if you give birth in a hospital, there’s evidence that having a doula improves birth outcomes, especially for women of color. In addition to helping you prepare throughout your pregnancy, a doula can help you come up with a birth plan, and advocate for you.
• Learn as much as you can about what’s normal and healthy during pregnancy and delivery, and how you can recognize the warning signs that something might be wrong. Don’t forget to get information about the postpartum period, as a significant number of maternal deaths come from complications in the days and weeks after birth.