Study: Wealthiest Black Moms More Likely To Die In Childbirth Than Poorest White Moms

Even the wealthiest Black women can’t escape the effects of structural racism.

A Black mom holding and kissing her baby.
Cavan Images/Getty

When women in America suffer, Black women suffer the most. Never is this truer than when it comes to pregnancy, where staggering racial disparities in maternal and infant health represent an ongoing public health crisis in dire need of solutions. Here, in the only industrialized country where overall maternal mortality is rising, Black women remain between three and four times more likely than their white or Hispanic counterparts to die from pregnancy-related complications. And although Black women suffer above-average rates of pregnancy-related complications such as preeclampsia, uterine fibroids, and preterm birth, they’re also less likely to have access to quality care, creating a double-edged sword with compounding factors on both sides. A new study finds that even the wealthiest Black women are unable to escape this harm.

“One hypothesis has been that at least some of this racial gap that we see is explained by economic circumstances,” says Maya Rossin-Slater, Ph.D., an associate professor of health policy at the Stanford University School of Medicine and a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR). But individual anecdotes have long demonstrated that wealth, education, and status are not foolproof safeguards against preventable catastrophe for Black women. Take the story of Shalon Irving, a CDC epidemiologist whose own work on the health effects of structural inequality was cut short by her death weeks after giving birth, or of Serena Williams’ account of struggling to receive medical attention for a postpartum pulmonary embolism. You can now add the formal backing of a peer-reviewed study to accounts like these.

For the new study, Rossin-Slater and her colleague Petra Persson, Ph.D., used California administrative data to show for the first time that household income plays absolutely no role in determining maternal and infant health outcomes. In fact, the effects caused by structural racism are so strong that even the wealthiest Black women and their newborns experience worse outcomes than those from the lowest-income white families. In other words, the maternal health gap is a trap of systemic racism with roots so deep that no amount of money can buy a Black woman a path out of it.

“The maternal health gap is a trap of systemic racism with roots so deep that no amount of money can buy a Black woman a path out of it.”

And because the data used in the study all came from California, a state that regularly lands way above national averages for different maternal health metrics, these trends are likely to also be true elsewhere in the country — and may even be more exaggerated in other states. “In general, in the state [of California], there is a lot of empathy towards the idea that this is a big important problem,” says Rossin-Slater. “If anything, I guess I would expect to see things be worse in other states.”

The risks for Black mothers are growing in many states, particularly in those where revised abortion laws are limiting access to necessary care. In 2020, maternal death rates were 62% higher in states where abortion was restricted or banned than in the rest of the country — and the race gap carried over. In December, the Texas Maternal Mortality and Morbidity Review Committee released a report showing that as abortion access has become more restricted in the state, the risks of pregnancy-related hemorrhage have gone up 10% in recent years for Black women despite going down overall across the state.

The research team was able to look at data from patient groups at each California hospital they included in the study, which allowed them to rule out the possibility that their findings were merely reflecting trends from a small handful of locations or healthcare systems.

Examining the potential roots of such systemic inequality means taking a tour of the unthinkably numerous ways in which racism can chip away at Black women’s health. Rossin-Slater breaks them down into three categories: social, environmental, and healthcare-specific. The social and environmental factors include everything that places Black women in harm’s way before they’ve even arrived for their first OB-GYN appointment.

“This is not just in your head. This is not something that's made up. It’s real, and it’s confirmed by data.”

The emotional and physical load racism places on Black Americans can have compounded consequences for expectant mothers. The stressors that influence Black people from birth cause a form of premature aging not seen in sufferers of regular chronic stress. That “from birth” part is crucial — Black women born in the United States are more likely to experience preeclampsia during pregnancy than those who immigrated to the country. Other common pregnancy complications, such as high blood pressure, are strongly linked to chronic stress. Environmental factors, such as the fact that residents of historically redlined Black neighborhoods tend to be exposed to more extreme heat, similarly contribute to the development of health conditions and pregnancy complications. In all of these ways, the health effects of racism can compound over generations by causing complications that may harm a growing fetus.

Then there’s what happens at the hospital, where racism and bias in the healthcare system and of individual practitioners lead to sub-par treatment for Black women, with expressly stated needs and concerns sometimes going flat-out ignored. The healthcare-specific factors that contribute to the gap in maternal and infant outcomes also include issues surrounding access to care, including abortion and postnatal care. (This social, environmental, and healthcare-specific racism almost certainly also impacts Black non-binary people and transgender men who become pregnant, but studies haven’t yet looked into how they combine with systemic transphobia to affect them and their babies.)

The interplay between all these factors is complicated, but until it’s understood, they can only be confronted one by one. Groups like March of Dimes run programs aimed at reducing physician bias, while housing advocacy groups remain committed to fighting redlining. But for Black women today, women living with the health consequences of racism and more, community-level efforts are often the best way to reclaim a sense of power.

Advocates encourage Black women to take control of their care plans in the early stage of pregnancy. Resources online, like this guide published by the New York Times in 2020, outline helpful ways to bring up each specific concern a mother has with providers to understand how they approach different problems that could arise. Advocacy groups such as the Black Mamas Matter Alliance, as well as local organizations and doula programs, also work to connect women with each other and support systems.

“If you feel like your provider is not listening to your concerns, or somehow mistreating you, don't be afraid to try to seek out a different provider or a different hospital,” says Rossin-Slater. “This is not just in your head. This is not something that's made up. It’s real, and it’s confirmed by data.”