The U.S. Black Maternal and Child Health Crisis Is Centuries in the Making

An in-depth analysis of how 405 years of indifference to the health of Black women and their children has created the stark inequities seen today.

By Julia Craven

When It Comes to Maternal Mortality, The U.S. Has Outdone Itself

The weeks leading up to Shalon Irving’s death on January 28, 2017 had a familiar blueprint. She'd given birth three weeks prior, on January 3, via C-section, a procedure Black women are more likely to receive despite many medical providers not preferring it due to an increased risk of postpartum complications. Irving's case seemed to warrant the risk, however, due to having a prior fibroid surgery that left scarring on her uterus—another risk factor that disparately affects Black women. (Though, unlike Irving, many Black women don’t get surgery to reduce or remove their fibroids.)

A couple of days after Irving was discharged from the hospital, a painful hematoma developed at her incision site. The first doctor she saw on January 12 said it was of no concern. The second diagnosed the hematoma as such on the same day, drained it, and set Irving up to receive home visits from a nurse. By January 16, her blood pressure spiked to terrifying levels, coming in at 158/100, putting Irving in the second stage of hypertension—a concern for anyone but especially someone who’s just given birth. Two days later, it was 174/118, just short of being the type of reading that mandates emergency medical care. Irving didn’t see a doctor that day, though. When she sought care on January 19, her blood pressure had fallen, and she wasn’t showing any other symptoms of preeclampsia, a blood pressure disorder.

On January 24, Irving sought care one last time. Her legs were swollen, she was having mild headaches, and her blood pressure read 163/99. Once again, the test for preeclampsia and another for blood clots came back normal. Irving was insistent that something was wrong. Still, she went home. Later that night, she collapsed in her bedroom. Four days later, on January 28, she died from high blood pressure complications.

What happened to Irving, an epidemiologist at the Centers for Disease Control, was initially reported in depth by ProPublica. Soon after, it went viral, bringing unprecedented national attention to a crisis that has haunted Black birthing persons for centuries. Maternal health outcomes for Black women have not improved in the seven years since Irving’s passing. When Irving died in 2017, Black birthing persons experienced 37.3 deaths from 100,000 live births, according to the CDC. The following years saw that number rise to 44 in 2019, 55.3 in 2020, and 69.9 in 2021. The data for 2022 was released on May 2, placing the rate at 49.5 deaths per 100,000—a post-COVID-19 pandemic course correction that remains far too high.

For Black women, the primary causes of death in the pre-and postpartum periods are the blood pressure disorders preeclampsia and eclampsia.

A 2024 study released by the Commonwealth Fund found that, among high-income nations, the U.S. has a markedly higher rate of overall maternal mortality. There are 22 deaths for every 100,000 live births—nearly double the rate for Chile (14.3) and more than triple the rate for the United Kingdom (5.5). When looking at specific populations, the disparities worsen. Black American women, as a single demographic, have a higher maternal death rate than every single country included in the study.

Photo by Mustafa Omar on Unsplash

What is Maternal Mortality?

Maternal mortality refers to the death of a pregnant person within 42 days of giving birth from a pregnancy-related health issue or a preexisting condition that was worsened by pregnancy.

Accidental or incidental deaths are not considered causes of maternal mortality—meaning the official numbers from the CDC do not include deaths by suicide or drug overdoses, for example. They also don’t account for deaths that occur more than 42 days after giving birth.

The 42 day metric is considered too narrow by the World Health Organization (WHO), which includes deaths up to one year postpartum.

In the U.S., 30 percent of pregnancy-related deaths happen between 43 days to 365 days after delivery, according to a report from the CDC.

This brutal reality, researchers have found, is due to a lack of competent care for Black mothers and their children, the racism present in American medical establishments—which causes their care needs to be dismissed or ignored by clinicians—gender inequity, economic disenfranchisement, and other structural and social determinants of health.

Health Outcomes Are Dire for Black Children, Too

Once a Black child is born, the health risks that will hover over many of them for their entire lives begin.

Black babies die at an overall rate of 10.6 per every 1,000 live births—more than twice the rate of white babies—but they're also disproportionately represented across the five leading causes of death for infants. Black infants are also more likely to be born preterm, which increases their risk of experiencing a medley of health issues as they age.

In addition to the adverse health outcomes that affect them as infants, Black children experience higher rates of food insecurity and stress. They’re less likely to receive all their recommended childhood immunizations. The rate of asthma for Black children is twice that of white children, and Black kids have a higher incidence of adverse childhood events.

These are the quintessential narratives of adverse Black maternal and child health in America—and 405 years of systemic racism is to blame.

That Which Is Born Follows the Womb

A photograph shows an enslaved Black family or families posed in front of a wooden house on the plantation of Dr. William F. Gaines, Hanover County, Virginia. (Source: Library of Congress)

An engraving of the slave quarters on a plantation in Charleston, S.C. shows Black children and adults, who appear to be their caretakers, sitting outside. (Source: Slavery Images)

A Black family in Beaufort, S.C., sits outside of their home. (Source: Slavery Images)

An enslaved woman nursing a child. (Source: Mothering Slaves)

In 1824, Mary, a formerly enslaved woman, filed for her children’s freedom. Mary was emancipated once she turned 31, as requested in the will of her first enslaver, and it seemed pretty straightforward that the status of her four children—Maria, Nancy, Solomon, and Samuel—would follow suit.

A Virginia court disagreed. Since her children were born before she was freed, her children would remain enslaved. According to one of the judges who ruled against the case, emancipation was not a transfer of “the property of a slave to” themselves. Instead, the current enslaver was entitled to the “increase” in “property” unless the original enslaver willed otherwise. In simpler terms, the “increase” in “property” refers to the children born to an enslaved mother, meaning those babies, those human beings, now belonged to their mother’s enslaver, regardless of whether she was freed at a later date.

It seems like a convoluted, hypocritical doctrine because it is. The precedent for Mary’s children was set in 1662 when the state of Virginia still belonged to Britain, meaning before America was born herself, those colonizing the land found ways to bend the rules to their benefit. Officials ensured that enslaved Black children would belong to whoever owned their mother via partus sequitur ventrem. This legal doctrine translates to “that which is born follows the womb,” which was then woven into the laws of enslavement. It mandated children born in the colonies inherited their mothers’ social standing—meaning if a child’s mother was enslaved when they were born, so were they. Enslavement became a Black child’s codified birthright, and their mother’s womb became the conduit. As such, birthing became a way of ensuring that an enslaved workforce would remain.

Still, enslavers initially avoided seeking medical care for enslaved persons. They frequently accused the ill of "malingering” or pretending to be sick to get out of work. If a doctor was called, they often contributed to the systemic mistreatment of the enslaved. In her book Medical Apartheid, author Harriet Washington recounts an instance where a doctor started his examination of an enslaved man by stating that pretending to be ill was a common trait among Black people. Physicians would exchange notes on which strategies returned enslaved persons to work the quickest, often resorting to violent medical procedures or outright physical abuse—which were cited as being the most effective tactics.

The foundation of modern Western medicine began on the plantation. Race became a biological justification for mistreatment with the specific aim of reinforcing notions that Black people were inferior. Enslaved persons were exposed to substandard living conditions, inadequate sanitation, and food insecurity because of it. Lacking access to clean water and suitable clothing increased their disease susceptibility. These environmental conditions also prevented them from engaging in activities promoting health, such as securing sufficient medical care or rest while ill.

When the transatlantic slave trade was banned in 1808, white doctors and enslavers became more interested in the health of their chattel—particularly an enslaved woman’s ability to bear children. Birthing during enslavement was frequently orchestrated for economic gain. “Strong” enslaved women were sold as “breeders” and forced to reproduce so that more children could be birthed into enslavement. And it’s estimated that enslavers or other white men sexually assaulted 58 percent of Black women. The children were often stillborn or died within the first year of their life. When the U.S. first began breaking infant mortality data down by race in 1850, the overall rate that year was nearly 400 babies per every 1,000 live births—a jarring number that had been steadily declining since 1800 when it was 463. In 1850, according to official numbers, the rate for Black babies was 340 per 1,000 compared to 216.8 per 1,000 for white babies.

As Black kids aged, their growth was slower than that of non-enslaved children. Their diet also lacked essential nutrients such as protein, niacin, magnesium, calcium, and vitamin D, resulting in many health issues like night blindness and rickets.

“Without a well-developed field of pediatrics, White physicians had little to offer,” write historians Deirdre Cooper Owens and Sharla Fett. “Consequently, they often blamed enslaved mothers and midwives, using harsh gendered and racist language, for infant deaths that were more likely a result of mothers’ hard labor and poor nutrition. Beyond these verbal attacks, antebellum U.S. physicians also began to use their access to Black and enslaved bodies to expand their scientific knowledge and build their professional reputations.”

Results from nonconsensual gynecological and reproductive surgeries performed on Black women were often hailed as feats of medical advancement. Between 1845 and 1849, James Marion Sims, a physician who contributed heavily to the development of modern gynecology, maimed Lucy, Anarcha, and other Black women who were unable to refuse or consent to the procedures. Black women’s genitalia and other body parts were often displayed as medical specimens.

During Jim Crow (1865-1965), Black people continued to be terrorized. Women and children experienced forced sterilization via state eugenics programs. Lynchings, which often involved genital mutilation and public gang rapes, were also at their peak, and state laws did not protect Black people from these evils. In 1946, the Hill-Burton Act authorized the use of federal funds to build segregated facilities within hospitals, exacerbating the inequities in healthcare. After the Civil Rights Movement, such exploitation continued—a prime example being Johns Hopkins University taking a sample of Henrietta Lacks’ cervical cancer cells without her consent. HeLa cells, named for the first two letters of her first and last name, were integral in many significant medical feats, such as developing vaccines for polio, HPV, and COVID-19, testing and treatment for various cancers, and understanding how HIV advances into AIDS.

How Racism Has Interfered with Black Women’s Reproductive Health and Well-Being since 1619

246 Years of Enslavement (1619-1865)

Childbirth Is Commodified

One way enslavers maintained their labor force was by forcing enslaved men and women to reproduce and through the rape of enslaved women by white men. One way the enslaved resisted was through abortion and running away—as Ann Maria Jackson did with her seven remaining children following the sale of her two oldest.

246 Years of Enslavement (1619-1865)

Family Disruptions

A Black woman's attempt to bond with her child was constantly under threat of being broken. This could happen via her or the child's sale to another enslaver and other practices like wet nursing, which refers to a woman who breastfeeds a child that isn’t theirs. Enslaved Black women were forced to stop nursing their babies to provide milk to their enslaver’s child. This not only disrupted Black mothers' bonding with their children but prevented enslaved kids from receiving the health benefits associated with breastfeeding.

100 Years of Jim Crow (1865-1965)

Reducing the Number of Black Clinicians

In 1910, Abraham Flexner published a report that would result in the closure of 50 percent of America’s medical schools in the two decades following its release. The Carnegie Foundation hired Flexner to assess whether the nation’s medical schools were up to par in hopes of improving and standardizing medical education. Flexner investigated six Black medical schools, and four of them were closed by 1923. While improved medical care was a good thing, Black communities paid the cost. Aspiring Black medical students weren’t widely accepted into white institutions, which limited the number of providers who were willing to work with Black populations.

100 Years of Jim Crow (1865-1965)

Forced Sterilization Is Rampant

Permanent forced sterilizationfollowed a wretched pattern for many Black women. They'd go into the hospital for a different issue and come home not knowing they'd received a tubal ligation or total hysterectomy. In the South, the transgression was so common that it was referred to as a “Mississippi Appendectomy”—a phrase some researchers believe was coined or at least popularized by Fannie Lou Hamer, one of the most prominent voices within the Civil Rights Movement.

The Mississippi Appendectomy was an offense with which Hamer was familiar. In 1961, a doctor in Sunflower County, Mississippi, performed an involuntary hysterectomy on Hamer during surgery to remove a uterine tumor. To make matters worse, Hamer didn’t know this happened to her until she overheard people gossiping about it on the plantation where she worked. Later, during her time as an activist, Hamer estimated that 6 out of 10 Black women in Sunflower County were also victims of this violence—a statistic later confirmed by medical historian Harriet Washington. The transgression is what pushed Hamer into the Civil Rights Movement.

De Jure Citizenship (1965-Present)

Limited Reproductive Freedom

Abortion bans following the Supreme Court's decision to overturn Roe v. Wade in 2022 pose a significant threat to Black maternal and child health. Limited access to safe and legal abortions disproportionately impacts Black women, who already face higher rates of pregnancy-related complications and maternal mortality. These bans also exacerbate existing healthcare disparities, often leaving Black women with fewer healthcare choices and increasing the risk for poor maternal and child health outcomes.

The systems and policies that harm Black communities, including inequitable access to health care, limited access to paid leave, discriminatory health care practice, and more, have led to a maternal health crisis for Black women. These same barriers undermine access to abortion care and have been worsened by abortion bans that have been or are likely to be enacted in the two years since the Dobbs ruling.

Currently, almost 55 percent of all Black women of reproductive age in the U.S. live in states that have both banned or are likely to ban abortion. These states also have maternal mortality rates that are above average.

Nine Factors Currently Contributing to Adverse Maternal and Child Health Outcomes

Implicit bias in healthcare: In December 2023, Shakima Tozay told The New York Times that a nurse referred to her unborn son as “a hoodlum.” The doctor who came in afterward downplayed the nurse’s comment as “a joke.” This situation is indicative of the implicit bias that affects the health of Black mothers and children. Black women are more likely to feel unheard or dismissed by clinicians when they describe symptoms. Research has shown that providers with a higher level of implicit bias tend to talk over patients and are less interpersonal.

Stress during the first 1,000 days of life: There’s a clear connection between adversity in childhood and increased risk for a range of adverse health consequences during adulthood. The first 1,000 days of a child’s life— from conception to two years old—is a period of significant development for the brain, body, and immune system. Any stress or instability during this time can affect the baby and their future. Kids who are exposed to high levels of psychological stress, including “toxic stress,” have a higher risk of contracting common childhood diseases. When these children age into adulthood, they’re met with an increased chance of developing diabetes, heart disease, various cancers, depression, substance abuse disorders, and other mental health conditions.

Weathering: Dr. Arline T. Geronimus coined the term in 1992 after discovering that pregnancy outcomes for Black women worsened as they aged, compared to white women whose outcomes tended to improve. Weathering describes how the relentless stress of racism on Black people could result in premature biological aging and adverse health outcomes.

This includes significantly higher disease burden stemming from chronic health conditions —including high blood pressure, heart disease, various cancers, and elevated cortisol levels, which can lead to diabetes, damage DNA, and shift brain structure. Research has also found that it’s less likely Black women will be able to escape many of life’s stressors due to a higher risk of violence, job instability, or living in poverty.

Exposure to environmental toxins: Due to racist residential patterns, Black families are more likely than white families to live near sources of pollution—such as highways, power plants, and construction sites—thus increasing their exposure to toxins. This is especially concerning for Black children, who are still developing and breathe more air, drink more water, and eat more food per pound of body weight than adults. Black children have higher exposure rates to lead, second-hand tobacco smoke, chemical toxins, and air pollution—including fine particulate matter, which is more detrimental to human health—alongside higher blood lead levels. Being in a developmental state makes them more susceptible to the effects of these toxins, which include developmental delays, neurological problems, and behavioral challenges.

Black birthing persons and children are also more likely to have inadequate access to quality prenatal and postpartum care, live in unsafe neighborhoods, experience disparities in pediatric healthcare, and have higher rates of chronic health conditions.

A Better Future Is Possible

Addressing the Social Determinants of Health

Social determinants of health are non-medical factors that influence the environments in which people are born, live, learn, work, play, worship, and age. They’re typically organized into five key areas: economic stability, education, social and community contexts, healthcare, and neighborhood. These factors heavily influence health and well-being. If a family doesn’t have access to nutritious foods, their health can suffer alongside that of their children. If a family is facing an eviction, this adverse event could upend their sense of stability and predictability—two factors necessary for children to thrive. Stable housing is critical to healthy childhood development. Disruptions due to eviction can lead to low birth weights, premature births, poor cognitive development, infant mortality, and heightened food insecurity.

Addressing the social determinants of health will include family-supportive public policies such as guaranteed income for low-income Americans, guaranteed housing, ending eviction, universal paid family and medical leave, universal healthcare, universal 0-5 child care, and universal afterschool and summer school programs.

One intervention that is proven to work is eviction diversion programs. Philadelphia’s Eviction Diversion Program (EDP) requires landlords to participate in a 30-day mediation with tenants who owe less than $3,000 in back rent before pursuing a formal eviction. It began as a city pilot initiative and was bolstered by federal COVID-19 relief funding into a national exemplar of eviction prevention, with 85 percent of cases reaching a settlement or an agreement to continue negotiations beyond the mandated 30 days. The program has been incredibly beneficial to Black women raising children in Philadelphia, where, according to city data, 74 percent of evictions involved a Black tenant, 70 percent involved a woman, and 50 percent involved a parent or caretaker. Philly’s EDP program is bolstered by being coupled with rental assistance. Between May 2020 and January 2023, Philadelphia’s Emergency Rental Assistance Program distributed almost $300 million in federal, state, and local emergency COVID-19 relief funds to more than 46,500 households, according to city data.

Full Medicaid Expansion in States That Haven’t Done So

Fifty-three percent of pregnancy-related deaths occur up to one-year post-childbirth. Disruptions in postpartum health coverage, particularly among Medicaid enrollees, are a prevalent issue in preventing the birthing person from accessing necessary care during this time. The American Rescue Plan Act of 2021 introduced a provision that allows states to extend Medicaid postpartum coverage from 60 days to 12 months through a state plan amendment (SPA). Initially effective for five years, starting on April 1, 2022, the 2023 Consolidated Appropriations Act made this option permanent.

As of May 10, 46 states and the District of Columbia have implemented Medicaid postpartum coverage for the full 12 months, two states are making the shift, and Wisconsin has implemented limited coverage for up to 90 days. While this is a great thing overall, 10 states haven’t fully expanded Medicaid, revoking eligibility from those with incomes between approximately $20,780 annually for a single person or $35,630 for a family of three.

Medicaid expansion is associated with lower rates of maternal mortality. Nearly 40 percent of births in the United States are covered by Medicaid, with this figure rising to 65 percent for Black birthing people. Fully expanding coverage will improve access to prenatal care, mental health services, and preventive screenings for Black mothers and children.

Diversifying, Increasing, and Better Training the Perinatal Workforce

Racial concordance between a patient and care provider mitigates impact biases in health services. It also fosters trust, healthy communication, and the likelihood of patients following medical advice, improving their well-being. It’s widely believed that unsatisfactory communication due to implicit bias against Black patients is a crucial factor in poor maternal and child health outcomes, showing the critical need for more Black care providers in the workforce.

One way to go about this is by covering doula care under Medicaid.

As of May 2024, 13 states and the District of Columbia actively cover doula services for people on Medicaid, according to data from the National Health Law Program’s Doula Medicaid Project. Those states include California, Florida, Massachusetts, Maryland, Michigan, Minnesota, New Jersey, New York, Nevada, Oklahoma, Oregon, Rhode Island, and Virginia. Fourteen states are in the process of implementing doula coverage under Medicaid, and 17 others have programs in place that are adjacent to Medicaid coverage for doulas—such as doula pilot programs or other efforts to investigate how doula coverage under Medicaid would be helpful.

While doulas aren’t a cure-all for maternal mortality, they play several critical roles in improving the overall well-being of childbearing people. Research shows that doula support is associated with a myriad of benefits, such as a lower rate of invasive medical interventions, reduced anxiety and stress for childbearing people, and providing trauma-informed care.

In addition to diversification, better training for the perinatal workforce would help address the implicit bias experienced by Black birthing persons. Irth began as an app for pregnant people of color to leave reviews on perinatal care received at the hospital. Now, it’s expanded to include a hospital pilot program, using data gathered from app reviewers to improve the bias training that clinicians receive. As of June 2024, the program is active at Ascension St. John’s Hospital in Detroit, Temple University Hospital in Philadelphia, MemorialCare Miller Children’s & Women’s Hospital in Long Beach, Calif., and UC Davis Medical Center in Sacramento, Calif.

Job-Protected Paid Family and Medical Leave

America is the only high-income country without nationally guaranteed access to paid maternity leave. This lack has increased the risk of overall maternal mortality, especially for Black birthing persons. The U.S. is also one of just a few high-income countries that does not guarantee paid paternity, family care, or personal sick or medical leave to working people.

Black women are on the short end of the racial wealth and pay gaps, with those who work full-time making just 67 cents for every dollar made by their white male counterparts.

This disparity limits the amount of money available for expenses, affecting the chance of building longer-term financial safety nets—such as an emergency fund to weather job losses—and elevates stress, further predisposing Black birthing people to a medley of negative health issues. Working a low-wage job increases the odds that a Black pregnant person lives in substandard housing or has a more challenging time accessing healthy foods. Low-wage workers are also less likely to have paid family and medical leave—a care support proven to boost the health of the birthing parent, the infant, and their community. Higher labor participation rates among Black women can also play a role in poor maternal health since the idea of returning to work too quickly can place additional stress on a new mom.

Thirteen states plus the District of Columbia have or will soon implement statewide paid family and medical leave programs. But relying solely on a state-level approach leaves too many Black families behind—and most Black Americans live in states that do not have paid leave policies or a track record of passing family-supportive legislation.

Challenging Harmful Narratives about Black People

When we ask “why” Black pregnant people are experiencing such a stark inequity and investigate the problem thoroughly, we move away from “mother blame,” an individual’s health behaviors or conditions, the way they dress, their personalities, or the belief that Black women make poor health decisions, and shift our focus onto the real issue: the systemic inequities that prevent Black pregnant people, their children, and their communities from living healthy thriving lives.

While these initiatives are not a cure for the racism that causes adverse maternal and child health outcomes for Black families, they do help actualize a path forward. There is much to learn from the eviction reduction data out of Philadelphia and the long-term consequences of keeping people housed. Qualitative and quantitative data gathered by Irth can not only guide patients into the care of high-quality providers but also boost the number of well-trained clinicians available to the populations that need them most. Medicaid expansion won’t solve poverty, but it will make sure more Black birthing persons receive care throughout their pregnancy.

Addressing these root causes and implementing policies that prioritize the health and well-being of Black mothers and children can rewrite the narrative of giving birth as a Black person in the U.S.—and every step brings us closer to ensuring that all Americans, regardless of race, have an equal opportunity to live healthy, thriving lives.

This project was researched, written, and created by Better Life Lab senior writer and editor Julia Craven. If you have any questions about the lab's Black maternal health work, you can contact her at craven@newamerica.org.