18.3 Maternal Health Disparities, Structural Racism & Inclusive Care

Maternal Health Disparities & Social Determinants of Health

The United States Maternal Health Crisis

The United States faces the highest maternal mortality rate among industrialized high-income nations. The National Center for Health Statistics reported 17.9 maternal deaths per 100,000 live births in 2024, and Maternal Mortality Review Committees (MMRCs), which review a full year after the end of pregnancy, determined 84% of pregnancy-related deaths preventable in their 2020 data from 38 states. Leading etiologies of pregnancy-related death include cardiovascular conditions, mental health conditions (including suicide and overdose), severe obstetric hemorrhage, sepsis, and hypertensive disorders of pregnancy.

Severe Racial & Ethnic Inequities

Deeply entrenched racial and ethnic disparities permeate maternal healthcare in the United States:

• Black Women: In 2024 the NCHS maternal mortality rate for non-Hispanic Black women was 44.8 per 100,000 live births against 14.2 for non-Hispanic White women — roughly a threefold difference.
• American Indian and Alaska Native (AI/AN) Women: Experience pregnancy-related mortality 2 to 3 times higher than White women.
• Persistence Across Socioeconomic Strata: Epidemiological data demonstrate that maternal mortality disparities persist across all education and household income levels. A Black woman with a college degree or higher still faces a pregnancy-related mortality rate 1.6 times higher than a White woman with less than a high school education—disproving the fallacy that socioeconomic status is the primary driver of disparate outcomes.

Drivers of Maternal Inequity & Midwifery Countermeasures
├── Root Causes of Inequity
│   ├── Structural Racism (Redlining, unequal access to quality care, wealth gap)
│   ├── Weathering Hypothesis (Accelerated biological aging from chronic allostatic load)
│   └── Implicit Bias & Obstetric Violence (Dismissal of pain, delayed intervention)
└── Midwifery Clinical Countermeasures
    ├── Culturally Congruent Care (Workforce diversification matching patient communities)
    ├── CLAS Standards (Culturally and Linguistically Appropriate Services)
    ├── Respectful Maternity Care (Autonomy, trauma-informed pelvic exams)
    └── Gender-Affirming Healthcare (Inclusive language, chestfeeding, GAHT safety)

Structural Racism & The Weathering Hypothesis

• Structural Racism: Institutional, legal, and systemic policies (historic redlining, economic segregation, environmental hazards, unequal access to advanced healthcare facilities) that systematically disadvantage communities of color.
• The Weathering Hypothesis: Formulated by public health researcher Arline Geronimus, the weathering hypothesis posits that marginalized individuals experience accelerated biological aging and physiological wear-and-tear as a consequence of chronic, cumulative exposure to systemic racism, socioeconomic stressors, and environmental hazards. This chronic physiological burden (allostatic load) leads to earlier onset of chronic vascular disease, hypertension, and cellular dysfunction, increasing susceptibility to adverse perinatal outcomes.
• Implicit Bias in Clinical Practice: Unconscious attitudes and racial stereotypes that influence clinical decision-making. Research reveals that health providers systematically underestimate pain in Black individuals, dismiss patient concerns regarding shortness of breath or headache, and delay urgent interventions.
• Culturally Congruent Care & CLAS Standards: The National Culturally and Linguistically Appropriate Services (CLAS) standards mandate equitable, respectful, understandable care. Midwives must utilize certified medical interpreters (never family members), ensure linguistic access, and foster a racially diverse midwifery workforce that mirrors the communities served.

LGBTQ+ & Gender-Affirming Care in Midwifery

Certified nurse-midwives provide inclusive, affirming gynecologic, preconception, and obstetric care to lesbian, gay, bisexual, transgender, and gender-diverse individuals:

• Affirming Terminology: Consistently ask for and use the patient's affirmed name and correct pronouns. Adopt inclusive language: utilize "chestfeeding" alongside breastfeeding, and refer to "gestational parent" or "pregnant person" when preferred.
• Trauma-Informed Pelvic Examinations: Gender-diverse and queer individuals frequently experience healthcare-related trauma and gender dysphoria during pelvic examinations. Principles of trauma-informed care include: explaining each step in advance; establishing a stop signal allowing the patient to pause or halt the exam at any time; utilizing the smallest comfortable speculum; offering patient-assisted speculum insertion; and always providing a professional chaperone.
• Gender-Affirming Hormone Therapy (GAHT) Considerations:
  • Testosterone Therapy & Contraception: Testosterone administration induces amenorrhea, vocal deepening, facial hair, and clitoromegaly. However, testosterone does NOT reliably suppress ovulation or prevent pregnancy! Midwives must provide contraception counseling (e.g., copper IUD, progestin-only implants, progestin IUDs) to transgender men engaging in sexual activity with sperm-producing partners who do not desire pregnancy.
  • Preconception & Pregnancy Rules: Exogenous testosterone is teratogenic (causes virilization of a female fetus). Testosterone therapy must be discontinued prior to attempting conception and kept discontinued throughout pregnancy and lactation.
  • Chest Surgery (Top Surgery): Transgender men who have undergone bilateral mastectomy or chest contouring surgery may still retain functional glandular tissue and can be supported in chestfeeding if desired, with close monitoring of milk supply and dysphoria.

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Measuring the Crisis: Two Different Numbers

Two distinct statistics are reported for US maternal death, and confusing them is a common examination error because they use different time windows and produce different values for the same country in the same year.

• The maternal mortality rate published by the National Center for Health Statistics counts deaths during pregnancy or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management, excluding accidental and incidental causes. For 2024 this rate was 17.9 deaths per 100,000 live births (649 deaths), compared with 18.6 in 2023 (669 deaths) — a decline NCHS reported as not statistically significant.
• Pregnancy-related deaths reviewed by state Maternal Mortality Review Committees (MMRCs) extend the window to one full year after the end of pregnancy, so they capture substantially more deaths and support cause-specific and preventability findings that vital statistics cannot. In MMRC data from 38 states for 2020, 84% of pregnancy-related deaths were determined to be preventable.

NCHS Maternal Mortality Rates, 2024 (per 100,000 live births)

Two patterns carry most of the clinical weight. The Black–White gap in 2024 was 44.8 versus 14.2, roughly a threefold difference. And maternal age is an independent multiplier: the rate at age 40 and older was about 4.5 times the rate under age 25, which is why advanced maternal age changes surveillance intensity even in an otherwise uncomplicated pregnancy.

Underlying Causes and Timing (MMRC, 38 States, 2020)

Mental health conditions are the single leading underlying cause of pregnancy-related death. This reframes depression, anxiety, and substance use screening as mortality prevention rather than as psychosocial nicety, and it explains why a validated perinatal mood screen, a suicide-risk question, and naloxone counseling belong in routine midwifery care rather than only in a behavioral-health referral.

About three-quarters of pregnancy-related deaths occur after the pregnancy ends, and more than a quarter occur between 43 days and one year — that is, after the traditional single six-week visit, and historically after pregnancy-related Medicaid coverage ended. That one distribution is the evidence base for three practice changes the examination expects a candidate to connect to the data:

1. Restructured postpartum care. Contact within the first 3 weeks after birth, ongoing contact as individually needed, and a comprehensive postpartum visit no later than 12 weeks — replacing the single six-week check with an ongoing process across the "fourth trimester."
2. Twelve-month postpartum Medicaid coverage. Created as a state option by the American Rescue Plan Act of 2021 effective April 1, 2022, and made a permanent option by the Consolidated Appropriations Act, 2023. It has now been adopted by the large majority of states plus the District of Columbia and the US Virgin Islands. Coverage that ends at 60 days terminates exactly when a quarter of the deaths are still ahead.
3. Urgent maternal warning-sign education at discharge. A patient who presents to an emergency department five months after giving birth may never be asked whether she was recently pregnant. Teach patients the warning signs explicitly — severe headache, visual change, chest pain, shortness of breath, seizure, thoughts of self-harm, fever, heavy bleeding, a swollen or painful leg — and teach them to open the encounter with the sentence "I gave birth n months ago."

Turning the Data Into Practice Change

Recognizing structural causes obliges specific clinical behavior, not just awareness:

• Believe and escalate reported symptoms. The documented pattern is dismissal — of pain, of headache, of shortness of breath. Treat a patient's report that "something is wrong" as a clinical finding that requires a workup and a documented differential, not reassurance.
• Use certified interpreters, never family members or children. This is both a CLAS requirement and a safety control: a family interpreter filters disclosure of violence, coercion, and symptoms.
• Standardize what bias can distort. Structured hemorrhage quantification, standing order sets for severe hypertension, and checklist-driven escalation reduce the space in which implicit bias operates, because they remove individual discretion from the moment of highest risk.
• Support continuity models with evidence behind them. Midwifery-led continuity of care, group prenatal care, community birth workers, and doula support are the interventions with the strongest equity evidence, and all four are within the midwife's power to advocate for at the practice level.