Nov 4, 2024 Story by: Editor
For decades, stark racial disparities in maternal and infant health have persisted in the U.S., despite advancements in medical care. The COVID-19 pandemic brought greater awareness to these health inequities, particularly for people of color. Additionally, the overturning of Roe v. Wade has created new obstacles to abortion access, which may further widen maternal health disparities. Consequently, there has been a heightened focus on improving maternal and infant health and addressing these disparities.
This report provides an overview of racial disparities in specific maternal and infant health measures, explores the factors driving these inequities, and highlights recent initiatives aimed at addressing them. It relies on data from the CDC WONDER online database, National Center for Health Statistics (NCHS) Reports, and the CDC Pregnancy Mortality Surveillance System. While this report centers on racial and ethnic disparities, it acknowledges that disparities also exist based on factors such as income, education, age, and geographic location. For instance, maternal and infant health outcomes vary significantly by state, and there are notable differences between rural and urban communities. It is important to note that much of the data assumes cisgender identities and may not accurately represent transgender or non-binary individuals. In some cases, cisgender labels are used to align with the data sources.
Key Takeaways:
- Persistent racial disparities continue to impact maternal and infant health outcomes. For example, pregnancy-related mortality rates among American Indian and Alaska Native (AIAN) and Black women are over three times higher than the rate for White women (63.4 and 55.9 vs. 18.1 per 100,000). Black, AIAN, and Native Hawaiian or Pacific Islander (NHPI) women also experience higher rates of preterm births, low birthweight babies, and births with delayed or no prenatal care compared to White women. Similarly, infants born to Black, AIAN, and NHPI parents face higher mortality rates than those born to White parents.
- These disparities reflect broader social and economic inequities, rooted in systemic racism and discrimination. While access to healthcare and insurance are contributing factors, broader social determinants—such as income—play a significant role. Research shows that these health inequities persist even when income and education levels are taken into account, highlighting the impacts of racism and discrimination on health outcomes.
- Increased focus on maternal and infant health has spurred numerous initiatives aimed at improving health outcomes and reducing disparities. These initiatives include expanding healthcare access, diversifying the healthcare workforce, and improving data collection. Addressing social determinants of health is also critical, as disparities persist across income and education levels, emphasizing the need to address racism and discrimination to promote health equity.
Looking ahead, policy and legislative actions, as well as the outcome of the 2024 presidential election, could significantly impact efforts to address racial disparities in maternal and infant health. For instance, state-level variations in abortion access post-Roe v. Wade may exacerbate existing racial health disparities. Additionally, differing records and proposed policies by Vice President Harris and former President Trump on issues like abortion and maternal health could influence future disparities in maternal health outcomes.
Racial Disparities in Maternal and Infant Health
- Pregnancy-Related Mortality Rates: In 2020, approximately 900 women died due to pregnancy-related causes in the U.S. These deaths, occurring within one year of pregnancy, underscore the need for healthcare access beyond pregnancy. Data reveals that 84% of pregnancy-related deaths are preventable, with infection and cardiovascular conditions among the leading causes. Additionally, AIAN and Black individuals are over three times more likely to experience pregnancy-related deaths than White individuals (63.4 and 55.9 vs. 18.1 per 100,000). Hispanic individuals also face higher pregnancy-related mortality rates than White individuals, while Asian individuals have a lower rate.
- Birth Risks and Outcomes: Black, AIAN, and NHPI women have higher rates of certain birth risks that contribute to infant mortality and long-term health consequences for children, including preterm births and low birthweight. They are also more likely to have delayed or no prenatal care, which increases pregnancy-related complications. For instance, NHPI women are four times as likely as White women to begin prenatal care in the third trimester or receive no care at all (22% vs. 5%).
- Teen Birth Rates: Teen birth rates, though declining overall, remain higher among Black, Hispanic, AIAN, and NHPI teens compared to their White counterparts. These pregnancies often come with increased risks of pregnancy complications and long-term socioeconomic impacts, such as lower educational attainment for teen parents.
- Infant Mortality: AIAN, Hispanic, Black, and NHPI infants face higher mortality rates compared to White infants, with most deaths occurring within the first month after birth. Disparities have persisted for over a century, particularly for Black infants, who are more than twice as likely to die in infancy compared to White infants (10.9 vs. 4.5 per 1,000 in 2022).
- Mental Health and Maternal Well-Being: One in five AIAN, Black, and Asian or Pacific Islander women report symptoms of perinatal depression, which can contribute to adverse maternal and infant health outcomes. These mental health challenges are compounded by barriers to mental health services and the impacts of racism and trauma. Research indicates that perinatal depression is a significant contributor to pregnancy-related deaths, with potential long-term health risks for both mothers and infants.
Factors Driving Disparities
The causes of maternal and infant health disparities are complex, involving not only differences in healthcare access but also broader social and economic factors, and structural racism. Recently, the concept of reproductive justice has emphasized the importance of addressing social determinants of health, particularly for communities of color. Some researchers have identified the “Hispanic health paradox,” noting that Hispanic women and infants often fare better on health measures than expected given socio economic challenges. This phenomenon remains only partially understood and may be related to outcomes among subgroups, particularly recent immigrants.
Moreover, many state Medicaid programs are implementing initiatives to enhance maternity care and improve outcomes. This includes outreach and education about maternal health for both enrollees and providers; expanding coverage for services such as doula care, home visits, and treatment for substance use disorders and mental health; and adopting new payment models and performance metrics. For instance, Ohio’s Comprehensive Maternal Care program focuses on developing community ties and culturally appropriate supports for women on Medicaid as they navigate prenatal and postpartum care. Participating obstetrical practices are required to collect feedback from patients and families to understand how access to care, cultural competence, and communication affect health outcomes. Additionally, some states are leveraging managed care contracts to ensure that Medicaid plans concentrate on reducing maternal and child health disparities.
Implementing evidence-based best practices can improve maternal and infant health outcomes. As part of its maternity care action plan, CMS has introduced a “Birthing-Friendly” hospital designation to publicly recognize hospitals that follow best practices in healthcare quality, safety, and equity for pregnant and postpartum patients. More than 2,200 hospitals nationwide have received this designation, although some critics argue that additional quality metrics are necessary to enhance its impact. CMS is also proposing new baseline health and safety requirements for hospitals concerning care delivery in obstetric units, staffing, and annual training on evidence-based maternal health practices and cultural competencies. Furthermore, in 2024, CMS has initiated a new focus within its maternal and infant health program on addressing maternal mental health, substance use, and hypertension management.
Some states have integrated equity considerations into their Maternal Mortality Review Committees (MMRCs), which review pregnancy-associated deaths and make recommendations for prevention. However, these committees differ in how they approach racial disparities, with some explicitly focusing on identifying and addressing them. Since 2020, MMRCs have been allowed to report discrimination as a contributing factor in pregnancy-related deaths. For example, California examines each death through an equity lens, considering how social determinants of health, discrimination, and racism might have influenced the outcome. Similarly, Vermont revised its committee’s focus in 2020 to incorporate disparities and social determinants of health, including race and ethnicity, in their reviews of perinatal deaths. The membership of MMRCs also varies, with some requiring representation from Tribes and doulas or midwives. States like Washington, Montana, and Arizona include representatives from Native or Tribal Governments, while Oregon and Louisiana have doulas, and Vermont and Pennsylvania have midwives on their committees.
Numerous initiatives are underway to diversify the maternal health workforce and enhance access to doula services to improve health outcomes and reduce disparities. Research indicates that a more diverse healthcare workforce and the presence of doulas can lead to better birth outcomes. The percentage of maternal health physicians and registered nurses who are Hispanic or Black is lower than their share in the childbearing-age female population. The Biden Administration’s Blueprint includes initiatives by HRSA to offer scholarships to students from underrepresented communities pursuing careers in health and nursing, aiming to diversify the maternal care workforce.
Increasing access to doula services is another strategy to improve diversity and expand the maternal health workforce. Doulas, who are trained non-clinicians, provide physical assistance, labor coaching, emotional support, and postpartum care to pregnant individuals. Research shows that individuals who receive doula support experience shorter labor times, lower C-section rates, fewer complications, and are more likely to initiate breastfeeding, while their infants have a reduced risk of low birth weights. The HHS FY2025 budget allocates $5 million to support the growth and diversification of the doula workforce and another $5 million to address emerging issues related to the social determinants of maternal health. In recent years, there has also been increasing interest in expanding Medicaid coverage for doula services. The MOMNIBUS, federal legislation proposed to tackle maternal health disparities, seeks to enhance coverage for doula services, with some states beginning to include coverage in their programs. As of February 2024, 12 states reimburse Medicaid for doula services (CA, DC, FL, MD, MI, MN, NV, NJ, OK, OR, RI, VA), while Louisiana and Rhode Island have also initiated private coverage for these services. Furthermore, some states are working to increase access by educating patients about doula services, supporting the training and certification of providers, and improving reimbursement rates.
States are also collaborating with community stakeholders to enhance access to culturally responsive maternal and child care. For instance, Washington’s Birth Equity Project conducted listening sessions with Black, immigrant, and Indigenous families to understand the barriers to achieving birth equity. In 2021 and 2022, Utah’s Embrace Project Study aimed to address disparities among Native Hawaiian and Pacific Islander women by providing culturally tailored health services, focusing on mental health and self-care practices rooted in ancestral traditions. California’s Black Infant Health Program offers empowerment-focused group support and personalized life planning to improve health outcomes for Black women and their families. Arizona organizes a maternal and infant mortality summit to facilitate discussions on equity, alongside a Tribal maternal task force that develops strategic plans and training related to maternal health from an Indigenous perspective.
Various organizations advocate for more interventions and support to tackle maternal mental health and substance use issues, which are significant contributors to pregnancy-related morbidity and mortality. Studies indicate higher rates of postpartum depression among pregnant and postpartum women of color, yet many mental health conditions go undiagnosed and untreated due to stigma and inadequate access to care. These barriers also hinder access for pregnant and postpartum individuals with substance use disorders. Additionally, some states have laws that adopt a punitive stance toward substance use during pregnancy, which may deter individuals—especially people of color—from seeking help. Community organizations and provider groups are pushing for policy changes, including broader insurance coverage for behavioral health services, higher reimbursement for treatment, and increased education for healthcare providers on trauma-informed care.
Conclusion
As healthcare systems and policymakers strive to reduce maternal and infant health disparities, these collaborative and multi-faceted strategies will be essential in improving outcomes for women and infants of color, ultimately leading to healthier communities. Source: KFF
