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Maternal care inequality

A closer look: How has history impacted the poor health outcomes of black mothers and infants?

April 13, 2019

This year’s The Report on the Status of Women and Girls in California™ focuses on identity, access and equity. Rather than thinking about women as one group, the Report interrogates the intersections of race, socio-economic status and age to understand the conditions under which some women thrive, and the obstacles that continue to undermine the success of other women across California. We acknowledge that the Report’s intersectional focus precludes the exploration of other important identity areas such as sexual orientation and identity and ability.

Here is an excerpt from the 2019 Report.

A CLOSER LOOK: How has history impacted the poor health outcomes of black mothers and infants?

By Sarah Shealy, CNM, IBCLC
Assistant Professor, Nursing
Mount Saint Mary’s University

Motherhood in the United States is less safe than it is in ten other developed nations,116 and it is particularly dangerous for Black* mothers and babies.117 Black mothers in the United States suffer more interventions, complications,118 and deaths119 than all other racial and ethnic groups. In all maternal and infant health studies, Black infants and mothers have the worst outcomes.120 These persistent health inequalities are rooted in systemic and institutional sexism and racism.

In order to better understand the United States’ current maternal and infant health crises, one must consider the historical context. The late 1800s saw the beginning of the U.S. maternity care system, and the sexist and racist approaches to women and birth at the time influenced the creation of that system.121 A combination of economic motivation, racism, and anti-immigrant sentiment further influenced the medical community to view midwives as inferior, “unscientific” competitors in the birth business that needed to be eliminated. Combined with the politics of the day, these views led to a systematic medicalization of birth and an invalidation of the practice of midwifery.122 Between 1910 – 1950, tens of thousands of Black and immigrant midwives were pushed out of the workforce, unable to meet tightening regulatory restrictions enforced on their practice. Care for Black and poor mothers and babies deteriorated. The southeastern states were hit especially hard. In this region, women previously served by Black midwives had very limited access to care. As a consequence, today the southeastern states have the highest numbers of Black births with some of the worst maternal care outcomes in the nation.123

Black women in the United States have experienced generations of racism and reproductive trauma. During slavery, Black women were valued for their ability to produce more slaves. Enslaved women were subjected to sexual abuse and rape. Black women were instrumental in the development of modern gynecology as both unconsenting subjects as well as operating room assistants in medical reproductive experiments.124 During segregation, access to healthcare was either inferior or unavailable. Since its beginning, the U.S. healthcare system has been an unsafe place for Black women and babies.125

Current discussions of how to understand and address health inequality center around the social determinants of health.126 The health of the baby is tied to the health of the mother; consequently, the health of the pregnant person is closely tied to the environment in which they live. Access matters — not only access to quality healthcare, but access to clean water, air, food, exercise, education, meaningful work, and a safe place to sleep collectively impact health outcomes. The complex intersectional web of social, economic, legal, and criminal justice systems impact health outcomes for mothers and babies. Improvement of the current maternity care system is possible and will take multi-disciplinary teams led by those who have been most marginalized.127

*In this piece, the term “Black” describes the people of the African diaspora. The use of the capital B is intentionally adopted by the author.

 For more on this topic, read the Collectif contribution by Sarah Shealy. MSMU.EDU/COLLECTIF


117 Tharps, L. (November 18, 2014). The Case for Black With a Capital B. The New York Times.

118 Jain, J., et al. (February 2018). SMFM Special Report: Putting the “M” back in MFM: Reducing racial and ethnic disparities in maternal morbidity and mortality: A call to action. American Journal of Obstetrics & Gynecology 218(2): B9 – B17.

119 World Health Organization, et al. (November 2015). Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. WHO Document Production Services. Geneva, Switzerland. reproductivehealth/publications/monitoring/maternal-mortality-2015/en

120 Maternal and Infant health measures include cesarean section rates, infant mortality, pre-term birth rate, low birth weight, and breastfeeding rates. See: Martin, J., et al. (January 31, 2018). Births: Final Data for 2016. Tables, I – 16. Total cesarean delivery and low risk cesarean delivery, by race and Hispanic origin of mother: United States, each state and territory, 2016. National Vital Statistics Report. 67(1).; Centers for Disease Control and Prevention. (August 3, 2018). Infant Morality. Infant Mortality Rates by Race and Ethnicity, 2016. maternalinfanthealth/infantmortality.htm; Centers for Disease Control and Prevention. (April 24, 2018). Preterm Birth. reproductivehealth/maternalinfanthealth/pretermbirth.htm; Martin, J., et al. (January 31, 2018). Births: Final Data for 2016. Tables, I – 21. Low birthweight births, by race and Hispanic origin of mother: United

States, each state and territory, 2016. National Vital Statistics Report. 67(1).; Centers for Disease Control and Prevention. (August 7, 2018). Pregnancy Mortality Surveillance System. Maternal morbidity and mortality. maternalinfanthealth/pregnancy-mortality-surveillance-system.htm; California Department of Public Health. California In-Hospital Breastfeeding as Indicated on the Newborn Screening Test Form: Statewide, County and Hospital of Occurrence by Race/Ethnicity: 2017. BFP/BFP-Data-InHospital-Occurrence-RaceEthnicity-2017.pdf

121 Prather, C., et al. (September 24, 2018). Racism, African American Women, and Their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity. Health Equity 2(1): 249 – 59.

122 Rooks, J.P. (1997). Midwifery and Childbirth in America. Philadelphia: Temple University Press.

123 Vedam, S., et al. (February 21, 2018). Mapping Integration of Midwives Across the United States: Impact on Access, Equity, and Outcomes. PLoS ONE 13(2): e0192523.

124 Prather, C. et al. Racism, African American Women, and Their Sexual and Reproductive Health. Also see: Washington, H. (2006). Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Doubleday.

125 Owens, D. (2017). Medical Bondage: Race, Gender, and the Origins of American Gynecology. Athens: University of Georgia Press.

126 Office of Disease Prevention and Health Promotion. (2019). Social Determinants of Health. topic/social-determinants-of-health

127 Jain, J., et al. SMFM Special Report: Putting the “M” back in MFM. Also see: Oparah, J.C. et al. (2017). Battling Over Birth: Black Women and The Maternal Health Care Crisis. Amarillo: Praeclarus Press.