Among developed countries, the U.S. has the highest maternal mortality rate, according to the Commonwealth Fund. In 2020, 861 women died of maternal causes in the United States, up from 754 in 2019, according to the Centers for Disease Control and Prevention (CDC). Tragically, data compiled by maternal mortality review committees working with the CDC found that 84% of pregnancy-related deaths between 2017 and 2019 were preventable.
Racial and ethnic disparities reveal that pregnancy is especially dangerous for women of color in the U.S. Black women are three times more likely to die from pregnancy-related complications than White women, according to the most recent CDC data, followed by American Indian and Alaska Native women, who are more than twice as likely to die than White women.
To understand and improve maternal health in the U.S., public health leaders need to assess the structural causes of maternal mortality, infant mortality and modifiable maternal health factors affecting mothers and babies today.
How Structural Racism, Discrimination and Social Determinants of Health Affect Maternal Health
The exact cause of death for about 6% of pregnancy-related deaths in the U.S. is unknown. However, experts like Ingrid Mburia, teaching assistant professor at the University of Nevada, Reno, recognize the many structural causes that contribute to maternal morbidity and mortality.
“Some of the factors associated with maternal health disparities include structural racism, discrimination and social determinants of health,” Mburia says.
Social Determinants of Maternal Health
Social determinants of health are the external forces that influence individuals’ health, such as their access to health care, income, education, secure housing, safe neighborhoods and strong social support networks.
Having access to health care before, during and after pregnancy leads to positive maternal and infant health outcomes, according to the Agency for Healthcare Research and Quality. However, women of color are more likely than White women to be uninsured and to lack access to culturally and linguistically appropriate care, reports KFF, a nonprofit focused on national health issues.
Some of the treatable and preventable health factors that have been found to cause pregnancy-related deaths include:
- Accidents related to the cerebrovascular system (the system of blood transport to and from the brain)
- Cardiomyopathy (a disease of the heart muscle that disables necessary functioning)
- Complications from anesthetics
- Embolism (blocked arteries preventing blood flow)
- Obstetric hemorrhage (pregnancy-related excessive bleeding)
- Hypertensive disorders such as preeclampsia and eclampsia which occur during pregnancy (these disorders lead to dangerously elevated blood pressure)
- Sepsis (extreme bodily responses to infection)
Racism Produces Toxic Stress
In addition to issues related to health care access, women of color generally experience earlier health deterioration than White women because of the cumulative impact of stressors due to racism and sexism, according to 2022 research published in Population Research and Policy Review.
In public health, the term “weathering” refers to early health deterioration as a result of cumulative harms incurred under adversity. The threat of racial discrimination, institutional bias, social alienation and prejudice all contribute to negative health outcomes for people experiencing racism and other forms of oppression.
Research linking racism with chronic and toxic stress underscores how these negative experiences and conditions can physiologically affect pregnant people of color:
- Stress and inflammation. Inflammation during pregnancy is associated with adverse birth outcomes and infant growth defects. Exposure to racial discrimination and segregation in childhood is also reliably predictive of inflammation in adulthood — and even more reliable than traditional risk factors such as diet, exercise, smoking and poverty, according to a 2021 report published by the National Partnership for Women & Families.
- Traumatic stress due to racism. Race-based traumatic stress contributes to trauma reactions such as depression, dissociation, sleep disturbances and anxiety, which can contribute to postpartum depression, according to 2020 research published in the journal Traumatology.
- Racism’s harms are cumulative. The maternal mortality rates of Black women in their early 20s (an age typically associated with a lower risk of maternal mortality compared to older or younger patients) aligned with the maternal mortality rates of White women in their mid-30s or older, according to 2022 research published in Population Research and Policy Review.
Maternal Health Worsened During COVID-19
Maternal health disparities are exacerbated by other public health crises. After the beginning of the COVID-19 pandemic, research showed a 33% increase in maternal mortality rates in the U.S. — higher than the 22% excess death estimate associated with the pandemic, according to a 2022 study published in JAMA Network Open.
How Community Health Programs Can Help
Community health programs can mitigate and reduce maternal health disparities in many ways. Mburia recommends that community health programs:
- Increase health care access for women of color
- Increase access to prenatal care for women of color
- Provide access to medically advanced treatments in neonatal care to women of color, such as antenatal corticosteroids and surfactants
- Provide resources to help women quit smoking, drinking and misusing drugs during pregnancy — all factors associated with negative birth outcomes
- Improve access to public transportation, which can increase access to colleges, low-income neighborhoods, places of employment, hospitals and places with affordable healthy foods
- Develop programs to improve minority student retention rates and increase minority student graduation rates at universities
- Address structural racism through a combination of cultural competency training and policy reform
Successful Health Programs That Address Maternal Health Disparities
Mburia notes that many health programs and initiatives are already doing important work to address maternal health disparities in the U.S., such as:
- CDC’s Hear Her Campaign aims to raise awareness of maternal warning signs both during and after pregnancy as well as improve communication between patients and their health care providers.
- A public-private partnership between the Office of Intergovernmental and External Affairs (housed in the U.S. Department of Health and Human Services) and the March of Dimes developed an initiative to improve the quality of care in hospital settings for Black mothers. The partnership will develop information for hospitals to adopt evidence-based best practices in their facilities.
- The National Health Services Corps provides money for tuition, fees and stipends to students who commit to working in underserved areas after they graduate. Physicians, advanced practice nurses, certified nurse midwives and other clinicians are offered a loan repayment incentive if they spend at least two years serving in a high-need health professional shortage area.
- The American College of Obstetricians and Gynecologists provides protocols and checklists to help guide the management of a clinical situation or process of care. These guidelines are designed to standardize best practices and improve quality of care in hospitals, ultimately resulting in improved patient outcomes.
- The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program provides health and social services to pregnant and postpartum mothers as well as families with infants or young children. The program focuses on the topics of maternal and child health, good parenting practices, ensuring a safe home environment, and access to services.
- Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC is a federally funded program for low-income pregnant and postpartum women, infants and children up to age 5 who are at nutritional risk. WIC provides access to healthy foods to supplement diets, as well as information on healthy eating and health care referrals. Receiving WIC benefits during pregnancy has been shown to reduce preterm birth and infant mortality rates, according to a JAMA Network Open
- Farmers Market Nutrition Program (FMNP). The Farmers Market Nutrition Program is part of the WIC program. In addition to WIC benefits, eligible participants are given FMNP coupons to buy eligible foods from farmers markets. The FMNP program provides at-risk groups (low-income pregnant women, infants, children, postpartum mothers and their families) access to healthy foods.
- 1-800-QUIT NOW. A network of state quitlines, 1-800-QUIT NOW offers evidence-based support such as counseling, referrals to local programs and free medication to people who want to quit tobacco. The quitlines have trained coaches in various languages (Spanish, Chinese, Korean and Vietnamese). Most states have a special program to help pregnant women quit smoking during pregnancy.
Start a Career That Improves Maternal Health Outcomes
Maternal mortality is a significant health crisis in the U.S., claiming hundreds of lives each year through largely preventable deaths. Public health experts can play a significant role in addressing maternal health disparities.
Looking for a degree program that will prepare you to support maternal health? The online Master of Public Health in Public Health Practice from the University of Nevada, Reno is designed to strengthen your knowledge of current issues in public health, including an examination of the social determinants of health and public health policy. Take courses with experts in public health who care about your success, such as Ingrid Mburia. Discover how a leading MPH program can prepare you to make a difference in public health.
Health Resources & Services Administration, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) ProgramJAMA Network Open, “Association of Special Supplemental Nutrition Program for Women, Infants, and Children With Preterm Birth and Infant Mortality”
The New York Times, “Black Maternal Mortality Is Still a Crisis”