II. Introduction

‍The Current State of Black Maternal Mortality in the United States

Maternal mortality, or morbidity, is defined as “the annual number of female deaths from any cause related to or aggravated by pregnancy or its management—excluding accidental or incidental causes—during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy” (Collier and Molina, 2019). Although there is a standardized definition of maternal mortality, maternal deaths should be tracked on different scales—maternal mortality, pregnancy-associated deaths, and pregnancy-related deaths. These scales, while similar, have important timeline differentiations that can help create solutions for this maternal mortality crisis. Maternal mortality is death while pregnant or within 42 days of the end of pregnancy. Pregnancy-associated deaths is death while pregnant or within one year of the end of the pregnancy, irrespective of cause. While pregnancy-related deaths relate to death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, or the aggravation of an unrelated condition by the physiological effects of pregnancy.

Though the United States is one of the most developed nations and has the highest healthcare spending per person in the world—exceeding four trillion dollars—the US continues to be one of the dangerous places to give birth (Wager et al., 2024; Welteroth and Williams, 2024). Most maternal mortality rates are the number of maternal deaths per 100,000 live births, and as of 2023 it was 18.6 deaths per 100,000 live births (Hoyert, 2023). Maternal mortality had leveled in recent years with a rate of 20.1 in 2019 but was exacerbated by the recent COVID-19 pandemic with a rate of 23.8 deaths in 2020 and a rate of 32.9 deaths in 2021(Hoyert, 2023; Katella, 2023). The most common causes of pregnancy-related deaths in the United States include mental health conditions, hemorrhages, cardiac and coronary conditions, infections, thrombotic embolism, cardiomyopathy, hypertensive disorders of pregnancy, amniotic fluid embolism, injuries, cerebrovascular accident, cancer, metabolic/endocrine conditions, and pulmonary conditions (Tu, 2024). The already concerning rate of maternal mortality in the United States is even higher among Black women—50.3 deaths per 100,000 live births (American Hospital Association, 2025). Black women in the United States are three times more likely to die during pregnancy, labor, and delivery than any other race (Stafford, 2021). The disparities are especially apparent in comparison to the maternal mortality rate of non-Hispanic White women, 14.5 per 100,000 live births (Hoyert, 2023). 

Institutional Causes of Maternal Mortality in the United States

There is a historical and cultural paradigm in this country that continues to fuel these maternal mortality rates, especially among Black women. Additionally, birth trauma is often passed onto future generations affecting women’s ability to utilize necessary maternity care services, as well as attain care early in their pregnancy (Collins et al.,2004; Beck et al., 2018). To understand the deep-rooted systemic causes of high Black maternal mortality and morbidity rates in the United States, one cannot ignore the role of slavery. Black women were brought to America through the first slave ships in 1619 (Elliot and Hughes, 2021). Many of the maternity care practices that are used on women today can be attributed to physicians who experimented on enslaved women’s bodies without anesthesia. The pain experienced by these Black women have been historically disregarded because of harmful stereotypes, created by doctors like Dr. Samuel Cartwright, including that Black people do not feel pain and have thicker skin (Franklin, 2023). Cartwright created and fueled more harmful stereotypes such as if enslaved persons ran away or thought about running away they had a mental illness. He also used the spirometer— an apparatus used for measuring the volume of air inhaled and exhaled by the lungs— to support his findings that Black people have a smaller lung capacity than white people ( Franklin, 2023). His findings were used to fuel a stereotype that there are biological differences that make white people superior to Black people. 

The first notable physician is James Marion Sims, “The Father of Modern Gynecology,” who enslaved and experimented on dozens of Black women in Montgomery, Alabama. Sims is known for inventing the vaginal speculum, a tool still used today for dilation and examination, and more notably pioneering the surgical technique to repair vesicovaginal fistula (Holland, 2018). Vesicovaginal fistula is a common complication of childbirth in which a tear between the uterus and bladder causes pain and urine leakage. Sims’s research was conducted without anesthesia, performing more than 30 consecutive surgeries on slaves including women he notes in his entries named Anarcha, Betsy, and Lucy without consideration of medical ethics (Boomer, 2021; Zhang, 2021). During his procedures, these Black women were completely naked, perched on their knees, and bent forward onto their elbows so their heads rested on their hands. Sims built his reputation among rich, white plantation owners who brought their slaves so they could reproduce and work for their masters. There are even records that Sims built a hospital for the sole purpose of experimenting on enslaved women (Franklin, 2023). 

Then there was Dr. Marie Francis Prevost, “The Father of Cesarean Sections,” who performed 30 to 37 experimental cesarean sections on slaves (The Olbios Team, 2022). Prevost first experimented on women in Haiti and then on women in Louisiana because, “ …Louisiana had used Black women's bodies for C-Sections, more so than any other state in the union. They were number one in the disproportionate use of Black women and birthing peoples bodies for C-sections” (Goldbaum, 2022). His first successful C-section baby was named Cesarean. 

Finally, the Mississippi Appendectomies, a term coined by civil rights activist Fannie Lou Hammer. Hammer went into the hospital for removal of fibroids and instead was given an unwanted hysterectomy. After her experience, Hamer discovered that 3 out of 5 of all the Black women in her community, Sunflower, Mississippi, also experienced unwanted sterilizations (Allison, 2022). By 1980, there were over 700,000 cases of involuntary sterilization of Black women who were deemed “unfit to reproduce” in more than 30 states across the country (Tafesse, 2019; Villarosa, 2022). Coerced sterilizations are embedded into American history as a means of controlling “undesirable populations”—people of color, immigrants, poor people, the disabled, and those dealing with mental illness— a movement that was fueled by eugenics. The Eugenics movement gained traction in the late 19th century and early 20th century and sought to perfect the genetic quality of populations through selective breeding (National Human Genome Research Institute, 2022). Eugenicists believed that abstract human qualities, such as intelligence and social behaviors, as well as complex diseases and disorders were solely the outcome of genetic inheritance. Modern day manifestations of eugenics and scientific racism still exist today and particularly affect people of color, people with disabilities, and LGBTQ+ individuals. 

In addition to Black women being dehumanized by physicians for centuries, medical institutions denied Black women access to medical resources. These institutions never saw Black mothers as people to be tended to, but tools to advance medical practices as their humanity could be disregarded. Through the late 1800s to the mid-1960s, Black communities faced harsh discrimination and segregation that was legally and socially accepted during the Jim Crow era (Howard University School of Law, 2023). This period denied Black people voting rights, job opportunities, education, and naturally healthcare. Black women were denied quality healthcare through laws such as a 1915 law in Alabama, “ No person or corporation shall require any White nurse to nurse in wards or rooms in hospitals, either public or private, in which [black people] are placed” (U.S National Park Service, 2018). Furthermore in the book, Listen to Me Good: The Life of an Alabama Midwife, Granny midwife Margaret Charles Smith conveyed the lasting effects of Jim Crow on healthcare, “A local doctor’s office built in the 1960s still has the two waiting rooms that once separated white and black…Mrs. Smith remembers decades of having to walk through side and back doors when visiting white homes” (Smith and Holmes, 1996)

Another systemic institution that denied Black mothers access to quality maternal health care was redlining in the 1930s (Krieger et al., 2020). As a result of the Great Migration more Black Americans came to urban environments leading to the Homeowners Association and the Federal Housing Administration to evaluate the areas too risky to invest in. A majority of these areas predominantly housed Black residents, and the lack of loan capital flowing into minority areas contributed to the deterioration and instability of these neighborhoods (Metzger, 2000) Overall, these underdeveloped areas; poor environmental exposures—heavy metals, pesticides, pollution, and traffic; and residential segregation continued to affect birth outcomes and the overall health of Black communities (Mehra et al., 2017).

Finally, the GI Bill further reinforced racial and economic inequalities that significantly contributed to the Black maternal mortality rate (Njoku et al., 2023). The GI Bill, or the Servicemen's Readjustment Act, passed in 1944 and was heralded as a transformative policy that expanded access to education, job opportunities, homeownership, and healthcare for returning World War II veterans (National Archives, 2024). However, many Black veterans and their families could not access these benefits because they were not given an “honorable discharge”, a formal release from the military that recognizes a service member's faithful and competent service, or they were discharged dishonorably, a punitive separation from the military after convictions of serious offenses (Law for Veterans, 2024). Even if Black veterans did not face challenges with their discharge status, the localized implementation of the GI Bill especially in the Deep Jim Crow South made it difficult for Black families to access their benefits or use their benefits at all. Only 17% of Black veterans had graduated from high school at the time, meaning only a few veterans could take advantage of the college education offered by the GI Bill (Valor Healthcare, n.d.). Additionally, Black veterans faced discriminatory admissions policies at universities, particularly in the segregated South, and were often funneled into vocational schools with limited resources (Blakemore, 2023; Horvath, 2023). Moreover, banks and the federal government denied Black veterans home loans, particularly in redlined neighborhoods, effectively shutting them out of the wealth-building opportunities that defined postwar prosperity for many white families (Horvath, 2023). Many Black veterans were turned away from segregated VA hospitals, which were often underfunded and lacked adequate facilities compared to those serving white veterans. High-quality medical care remained inaccessible to Black mothers throughout the 1940s, even though there was additional federal funding designated for hospital construction through legislation such as the 1946 Hill-Burton Act (Schumann, 2016).  The GI Bill did little to address the systemic discrimination within the medical field, where Black veterans struggled to find doctors and hospitals willing to treat them or their families (Williams, B., 2024). The lack of federal oversight allowed these disparities to persist, reinforcing inequities that limited Black women's access to adequate prenatal and postpartum care. Even when Black women could access medical care, they were often subjected to racist medical practices, including forced sterilization, inadequate pain management, and dismissive treatment by predominantly white healthcare professionals who viewed Black patients as less deserving of quality care. 

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III. Key Elements Fueling the Black Maternal Mortality Crisis in the United States

Lack of Access to Healthcare

1. Inability to Afford Maternity Care

Black women continue to face barriers that limit their ability to afford adequate care throughout their pregnancy. In the United States the cost on average for pregnancy, delivery, and postpartum care is $18,865 dollars and out-of-pocket payments on average total to $2,854 dollars (Rae, Cox, Dingel, 2022). To ensure a healthy pregnancy, women are expected to meet with their physician every 4 weeks until they reach 28 weeks in their pregnancy, then every 2 weeks until 36 weeks, and then women must have weekly visits until the end of their pregnancy to receive critical maternity care services—such as routine blood work, glucose tests, genetic tests, ultrasounds, screenings, childbirth classes, and other consultations (March of Dimes, 2017; UCLA Health, n.d.). If a pregnant person experiences complications during their pregnancy their physician often requires them to have more prenatal checkups. Obstetricians can charge a range of $90 to $500 dollars for each visit and special tests like amniocentesis—which test for certain infant health conditions— can cost more than $2,500 dollars (Abernathy, 2024). Additionally, women need to take prenatal vitamins that are about $15 dollars for a 30-day supply (Hatfield, 2013). Then vaginal deliveries can cost $14,768 dollars and cesarean sections $26,280 dollars on average (Rivelli, 2024). Finally, over the course of a full postpartum year, families on average spend above $3,100 dollars on health and childcare expenses (Martin and Bloschichak, 2020). Health insurance, like Medicaid, can cover most of these costs. However, 30% of Black women in America fall into the Medicaid coverage gap, and some states refuse to expand Medicaid coverage, leaving many women uninsured or unable to access long-term quality healthcare (Arnold, 2023). In 2022, about 10% of Black Americans were uninsured, compared with 6.6% of white Americans (Hill et al., 2024).

Medicaid was created in 1965 and is a public insurance program that provides health coverage to low-income individuals and families, funded jointly by the federal and state governments. Each state runs their own Medicaid program and determines eligibility standards within Federal guidelines that are often very broad (Medicaid and CHIP Payment and Access Commission, 2018). This program works to meet the needs during economic downturns, massive unemployment periods, and job-based health coverage (Center on Budget and Policy Priorities, 2020). The Medicaid program was improved in 2010 with the passage of the Affordable Care Act (ACA), also known as Obamacare (KFF, 2024). This program significantly reduced racial and ethnic disparities through insurance coverage and access to healthcare by allowing states to expand Medicaid eligibility to everyone below 138 percent of the federal poverty level, which in 2024 was $15,060 dollars for an individual, $25,820 dollars for a family of three, and $31,1200 dollars for a family of four, subsidizing and regulating coverage purchases through the individual health insurance market (Department of Health and Human Services, 2024; Baumgartner et al., 2023). However a Supreme Court ruling in 2012 made Medicaid expansion within the states optional (KFF, 2012). Medicaid is an entitlement program meaning that anyone who meets the eligibility standards has the right to enroll and that states have guaranteed federal financial support for part of the cost of their Medicaid programs. For people who are pregnant and have income below 138% of the poverty line, states must provide health coverage (Katch, 2020).

As previously noted, a significant number of Black women are not able to receive Medicaid benefits and are uninsured. A primary factor to the Medicaid coverage gap is that a number of states— Florida, Georgia, Alabama, Kansas, Mississippi, South Carolina, Tennessee, and Wyoming—have not expanded Medicaid provisions, even though they have a significantly large Black and low-income population (Cervantes et al., 2025; Jones, 2013). Black Americans unfortunately fall within the coverage gap as they have incomes too low to qualify for subsidized health insurance in the ACA marketplace, but too much to qualify for Medicaid under their state’s eligibility standards. Furthermore, these states that have not expanded Medicaid have strict income caps such as $8,800 dollars in yearly income for a single caregiver with two children (Lukens & Sharer, 2021). Even though Black women continue to face severe income gaps of around 64 cents to a non-Hispanic white man’s dollar (Bleiweis et al., 2021). However during the COVID-19 pandemic states kept more people continuously enrolled in Medicaid in exchange for federal funding. Nevertheless, many of these pandemic provisions have ended, resulting in the redetermination of eligibility standards for Medicaid enrollees. As of January 2024, these new standards have caused 14 million people to be disenrolled, with a projection of 24 million people to lose Medicaid coverage (Burns et al., 2023). As automatic enrollment during the pandemic ended many communities of color, specifically Black communities, were unaware of these changes and lost their coverage.

These coverage challenges make it difficult to access vital care that is already very expensive. According to the Center for Disease Control, 80% of maternal deaths are preventable (Center for Disease Control, n.d.). However due to economic insecurity that is continued to be put at risk from complex Medicaid provisions, many Black women do not access the critical care they need until their third trimester or even during their delivery—delayed care leads to increase in maternal emergencies and death (Hill, L., et al, 2024). Medicaid covers about 40% of births in the United States and 65% of births for Black mothers (Solomon, 2021). Without insurance, many Black women are forced to rely on emergency rooms and community health centers, which do not always have the best resources or support systems for maternal healthcare. To continue, while 17% of maternal deaths occur during labor, almost 52% occur the day or a year after delivery (Tikkanen et al., 2020). Many states do not cover postpartum care beyond 60 days of delivery. Women are often not inclined to get regular checkups with their physician because of the already expensive cost regarding childcare. Without extending coverage hypertensive disorders, diabetes, and other chronic conditions that are common among Black women go unaddressed and lead to death.

2. The Overturning of Roe v. Wade Impact on Accessing Maternity Care 

In June 2022 the Supreme Court overturned Roe v. Wade and Casey v. Planned Parenthood which took away women’s constitutional right to an abortion (Center for Reproductive Rights, 2024; Oyez, n.d.). After the decision, whether state constitutions have enshrined the right to privacy and equal protection under the law is more essential than ever to protect access to abortion and other reproductive rights (Sobol, 2022). Research continues to highlight that banning abortions would increase pregnancy-related deaths by 21% overall and increase the maternal mortality rates among Black women by 33% (Marshall, 2021). Additionally, 57% of Black women of reproductive age live in states with abortion bans or restrictions (National Partnership for Women & Families, 2024). Women get abortions for a myriad of reasons, and for many women having access to an abortion is the difference between life or death. A study by the University of Colorado emphasized that Black women along with other marginalized birthing communities—poor women and those with chronic health conditions—are more likely to experience severe health complications before, during, and after delivery. For example, women are often in need of abortions in high-risk cases where their water broke early putting them at risk for an infection that can lead to death. Additionally, the Dobbs decision not only makes it difficult for doctors and medical professionals to provide abortions and other reproductive services, but also, “ affects training and care for patients requiring lifesaving miscarriage and ectopic pregnancy care”(Kheyfets et al., 2023) A recent survey by KFF found that, “40% of OB-GYNs in states where abortion is banned felt constrained in their ability to provide care for miscarriages and other pregnancy-related medical emergencies. Nearly half said their ability to provide standard medical care has become worse”(Frederiksen et al., 2023).

Besides the health effects of overturning Roe, there are many financial inequities that are also being expanded. There is another limitation to Medicaid that is now legal called the Hyde Amendment. The Hyde Amendment is a federal law that bans people covered by Medicaid from using these funds for abortion care (Planned Parenthood, n.d.; Salganicoff et al., 2024). When Medicare won’t cover the abortion and other critical maternity care services, a woman is many times forced to continue a high-risk pregnancy, therefore increasing the Black maternal mortality rate. Also, Black women continue to face socioeconomic inequities that make it difficult for them to afford travel costs to access an abortion or other reproductive services that are legal in another state (Guttmacher Institute, 2022).

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III. Closure of Hospitals and Lack of Resources in Marginalized Communities

In the United States, the rise of maternity care deserts has continued to place women in marginalized communities, particularly Black women, at increased risk of adverse health outcomes. Maternity care deserts are areas where there is limited or no access to hospitals or centers offering obstetrics care or providers. Ashley Stoneburner, a data science manager at March of Dimes, a nonprofit organization that works to improve health outcomes for mothers and babies described the extent of this issue in an interview with The Yale Politic. Stoneburner emphasized, “ …there are 5.6 million women who live in counties with no or limited access to maternity care services” (Manning, 2024) Additionally, there are some cases where women have to drive more than an hour to access maternal and obstetrics care, significantly increasing the risks associated with labor and delivery. This is a reality for so many women because between 2015 and 2019 there were 89 obstetrics unit closures in U.S. rural hospitals and by 2020 more than half of rural hospitals did not offer obstetrics care at all (Rabin, 2023). For many Black women hospital closures mean fewer prenatal visits, delayed emergency care, and an increased reliance on under-resourced community health centers or emergency rooms, which are not designed to provide comprehensive maternal care. 

Even initiatives like Critical Access Hospitals, established by the Centers for Medicare and Medicaid Services (CMS) in response to the closure of over 100 rural hospitals in the 1980s, do not include obstetric care in their services (CMS.gov, n.d.; Kozhimannil et al., 2020). Designed to serve rural areas located 15 to 35 miles from the nearest medical facility, these Medicare-operated institutions—whether nonprofit or public—are limited to a maximum of 25 acute care inpatient beds and a 96-hour cap on patient stays (Rural Health Information Hub, n.d.). While this program has helped alleviate some healthcare challenges in rural communities, it continues to overlook the needs of pregnant individuals, leaving them without essential care. 

The rise in maternal care deserts is largely driven by hospital funding cuts, Medicaid reimbursement rates, and the privatization of healthcare services. As previously noted, Black women disproportionately rely on Medicaid, as do many patients in marginalized communities, to access hospital services such as obstetrics care. However, many hospitals have closed due to financial strain and having to operate on thin margins because Medicaid often reimburses hospitals at a lower rate than private insurance—and one of hospitals' leading goals is to generate revenue. This creates a financial disincentive for hospitals to serve Medicaid patients, particularly in states where reimbursement rates are significantly lower than the actual cost of care.

Furthermore, Certificate-of-Need (CON) laws make it difficult for new hospitals, birthing centers, or maternity clinics to be established in areas with severe care shortages. CON laws require healthcare professionals to prove there is a need for new facilities before they can build hospitals or expand services. “Need” can mean different things and the term is often manipulated (Georgia Public Policy Foundation, n.d.) While these laws were originally created to prevent unnecessary healthcare spending, these laws only create more barriers to expanding maternity care in marginalized communities and to Black women. For example, in Georgia, a state with one of the highest Black maternal mortality rates, CON laws have prevented the establishment of freestanding birth centers, which would provide not only obstetric and maternal care services, but also affordable mental health services, women’s support groups, adoption assistance, and a variety of community classes (Denson, 2023). 

The Struggle for Respectful, Supportive, and Equitable Healthcare

Though socioeconomic disparities contribute to the increasing Black maternal mortality rate, the historical dehumanization of Black women continues to cost them their lives. How Black women are treated in the birthing space is another story tied to slavery and racial inequality. The birthing space and maternal care used to happen within kinship networks of other women, mainly Granny midwives, based on inherited medical knowledge that centered women in the birthing space. During the 18th century, expectant mothers “called her women together,” while their husbands and other men left the birthing space. Granny midwives were Black women who arrived in America on the first slave ships and these women brought with them natural herbs, techniques, and practices that had been passed on for generations (Graninger, 1996). Granny midwives and midwifery was not a practice done in secret because rather than relying on a costly physician, many plantation owners utilized the “cheaper” services of these midwives for enslaved pregnant women (Fett, 2000). Plantation owners even rented out Granny midwives services to other plantations. Furthemore, Granny midwives were willing to travel for miles through woods and unpaved roads to treat families that white physicians did not want to treat. Granny midwives were the primary authority on maternity care for centuries. Male physicians had found learning about Obstetrics “embarrassing” and had often graduated medical school having witnessed barely any deliveries—only gaining a theoretical knowledge of natural birth (Leavitt, 1983). 

Mothers, grandmothers, and aunts shared the craft of midwifery during the 17th to early 20th century with younger generations. Overall, Granny midwives brought humanity to the experience of Black mothers and infants as she represented their experiences. Granny midwives were guided by Motherwit, herbal knowledge that was transmitted through multigenerational cultural lifeways (Logan, 1991). Alicia Bonaparte, medical sociologist, analyzed that Granny midwives “garnered respect due to their gender, age, life experiences, leadership, and spiritual positions” (Bonaparte, 2007). Granny midwives saw childbirth as a natural process, and not one that required Western medical intervention. Some of the herbal knowledge that Granny midwives utilize was “silvergrass” for preterm labor and heavy postpartum bleedings; “dodywood” to heal the umbilicus; and hen feathers to make teas. Granny midwives also carried in their bags. smelling salts, peppermint, chamomile tea, mayapple, and hot peppers to encourage birth and ease pain (Logan, 1991; Smith, 1996). Granny midwives also had many women in alternative birthing positions like squatting and standing. American historian Judith Walzer Leavitt noted, “Midwives traditionally played a noninterventionist, supportive role in the home birthing rooms. As much as possible they let nature take its course: they examined the cervix or encouraged women to walk around; they caught the child, tied the umbilical cord, and if necessary, fetched the placenta” (Leavitt, 1983). Many mothers valued Granny midwives because of the postpartum care that they provided. Granny midwives utilized “catnip” tea for colic in babies and had mothers drink herbal tea and sit over a bucket of hot water for “women troubles” (Smith, 1996). Granny midwives helped support households by bathing the mother and their other children, cooking, and keeping the house clean (Litoff, 1978).

However, between 1910 to the early 1930s the infant and maternal mortality rate in Black communities continued to increase. German classical philologist, Edward E. Schwartz, covering infant and maternal mortality among Black people noted, “The [Black] Maternal Mortality rate in 1933 was 100.0 per 10,000 live births—almost double the white rate of 56.4…Fifteen years later…1 [Black] mother died for every 298 [Black] infants born alive”(Schwartz, 1949) While data collection in the 1900s was very limited, the data collected during this time was skewed to emphasize a strong correlation between Black mortality rates and lack of hospital births. These high maternal and infant mortality rates among Black communities were alarming to physicians and government officials. Physicians who saw Granny midwives as ‘dirty’ and ‘ignorant’ blamed them for these high rates (Stoney, 1953). Additionally, State Health Officer and Physician, Dr. Felix J. Underwood attributed the huge death rate to the fact that states were not licensing midwives (Underwood, 1948). This inspired physicians and government officials to get more involved in the field of Obstetrics and to tackle the “midwife problem”—the lack of uniform provisions and standards when it came to midwives. While Granny midwives provided the best support they could offer with the limited support and resources they had access to, there were imperfections in the care they provided. There were many pregnancy emergencies and abnormalities that Granny midwives were not familiar with treating, but they listened to women, centered women, and supported women in the birthing space in a way that Western medicine has always lacked.

The role of midwives was excessively debated between 1910 to 1930. While physicians believed educational and supervisory efforts would achieve the ultimate goal of eliminating the midwife, they simultaneously invested a lot of money because Granny midwives were a “necessary evil.” There were complex and contradictory attitudes of physicians toward midwives as they recognized their importance in covering territories they could not or did not want to access because they did not want to interact with Black mothers, infants, and families. However, these physicians who refused to acknowledge their role in supporting institutions that maintained racism and poverty called for heavy regulation and oftentimes elimination of Granny midwives because they were contributing to high death rates (Stoney, 1953). 

A major contributor to the new perceptions of Obstetrics care and medical treatment was the 1910 Flexner Report. This book-length study of medical education in the United States conducted by Abraham Flexner standardized medical care and pushed for, “the hospitalization of all deliveries and rather than consult with midwives, poor women should attend charity hospitals” (Flexner, 1910). The report laid the foundation for medical education and had a devastating impact on Black communities. The respected recommendations of the report lead to the closure of nearly all Black Medical Schools, except for Meharry Medical College and Howard University College of Medicine, significantly reducing the number of Black physicians (Fleur, 2022; Webb-Detiege, 2024). The lack of Black doctors meant that Black women were more likely to be treated by white physicians who held racist and sexist medical beliefs, often dismissing Black women's pain, reinforcing harmful stereotypes, and limiting access to adequate reproductive and maternal care. The Flexner Report not only institutionalized medical racism, but also denied Black women agency by restricting the very professionals who could advocate for and understand their specific medical needs. 

As Obstetrics became professionalized, childbirth was now centered as scientific, structured, and predictable. Dr. Joseph B. DeLee was an obstetrician who was leading the movement to redefine obstetrics and diminish Granny midwives. Dr. DeLee claimed that childbirth was ‘dirty’ and ‘evil’ and should be contained within the hospital space( Leavitt, 1988). Dr. DeLee shaped Obstetrics to rely heavily on drugs and medical instruments. Physicians favored interventions such as bloodletting—the withdrawal of blood from a patient to relieve “after pains”, and accelerate labor. They also used forceps, episiotomy, opium to accelerate cervical dilation and ergot to control the birthing process (Siddall, 1980).

By 1940, most if not all Granny midwives were eliminated and approximately 14,000 African American women started visiting the more than 100 available prenatal clinics (Muigai, 2019). Maternity care and Obstetrics were grounded in performing unnecessary interventions to allow women, “ …in seeking life and health…relinquished consciousness and self-determination” (Leavitt, 1983). However the professionalization of Obstetrics did not make birthing any safer, many women continued to die because of wrongful use of medications and heavy reliance on surgery.

Today the inequities in treatment of Black pregnant persons continues to be an pressing issue and Serena Williams' birthing story highlighted that wealth and status does not protect Black women from being ignored and at risk of losing their lives after giving birth. Recent studies have even noted that a Black woman with a college education is at 60% greater risk for maternal death than a white woman with less than a high school education (Declercq et al., 2020; Weiss, 2023). Christine Morton, medical sociologist, and author described in an interview for The Yale Politic how her cousin died in 2017, six months after giving birth to her second child. Though her cousin was not a Black woman, she was dealing with obesity and hypertension, which are common underlying conditions for Black women. Morton explains, “ She went to see a doctor the day she died, but like so many women her feelings were discounted—it is because she was labeled as obese and so many other things—and she went home and had a heart attack. I think about what it would have been like if during her pregnancy her blood pressure had been taken seriously”(Manning, 2024). Implicit bias continues to significantly contribute to the maternal mortality rate as health-care providers are still influenced by centuries old stereotypes and unconscious biases leading to inadequate care for Black women before, during, and after her pregnancy. Today many doctors still operate under the assumption that Black women do not feel pain and need fewer medical interventions. These assumptions result in delays in diagnosis for chronic conditions and treatment, leading to pregnancy complications and deaths that are preventable. Additionally, cultural stereotypes often portray Black women who speak up for themselves or against certain authorities as the “Angry Black Woman,” which often causes Black women to self-censor their health needs (Dorsey, 2023).

Over-Reliance on Surgery when Treating Black Women

The medicalization of Black women’s pregnancies has historically been shaped by a legacy of racialized medical violence and exclusion from patient-centered care. This is especially evident in the overuse of surgical interventions, particularly cesarean sections (C-sections), which are disproportionately performed on Black women at alarmingly high rates (Huesch and Doctor, 2015). While surgical interventions can be life-saving, their overuse—often without informed consent or consideration of alternative birthing methods—contributes to the systematic mistreatment of Black women accessing maternal healthcare and increases their risk of severe complications or death. C-sections are a major abdominal surgery that require a much longer recovery period. Longer recovery periods are not an option for many Black families as in the United States the Family and Medical Leave Act only guarantees employees up to 12 weeks of unpaid, job-protected leave for birth and care of a newborn (U.S. Department of Labor, n.d.). All private sector employees must offer at least 10 weeks of unpaid leave, though employers of both the private and public sector may offer more generous policies (Paycor, 2023). According to the Center for American Progress, 55% of parental leaves taken by Black women are unpaid ( Milli et al., 2022). But this is not enough for women to heal, especially if they had a C-Section, as well as take care of their babies, which can lead to lost wages, job insecurity, and financial strain.

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Across the United States, Black women are significantly more likely to undergo C-sections than their white counterparts, even when controlling for socioeconomic and health factors. Studies indicate that nearly 37% of Black women give birth via C-section, compared to 31% of white women (Ferguson, 2024). However, this discrepancy cannot be fully explained by medical necessity alone. Instead, implicit bias, structural racism, and provider-driven decisions often dictate the birthing experience for Black women, pushing them toward surgical births instead of providing them with options for vaginal delivery. Researchers suggest that there may also be a financial incentive for conducting more C-Sections on Black women as the American healthcare system is paid on a service fee (Rice, 2024). 

Multiple factors contribute to this alarming trend regarding Black mothers, often without considering alternative birthing options or the long-term consequences for Black mothers. First, due to higher rates of chronic conditions in Black communities—often the result of food deserts, environmental and socioeconomic disparities—physicians may preemptively classify Black women as “high-risk” without evaluating their individual health status (Vartan, 2019). While there are biological factors that contribute to health risks, the over-reliance on race as a determining factor exposes deeper biases within healthcare systems. As noted earlier, physicians like Dr. James Marion Sims and Dr. Samuel Cartwright, set the foundation for medical racism that reinforces the idea that Black women's bodies are biologically different and continues to disregard the lived experiences of Black women to justify disparate treatments. These racist ideologies have carried into contemporary medical practice, where Black women’s pain and symptoms are often ignored or minimized. By treating Black women as inherently fragile yet paradoxically more resilient to pain, the healthcare system enforces a paradox that leaves them vulnerable to both overmedicalization and neglect. 

Second, as noted previously, hospitals that serve predominantly Black communities are often under-resourced and understaffed, leading to higher intervention rates as medical professionals attempt to manage births more quickly and efficiently. Many hospitals in marginalized communities also have fewer obstetricians, midwives, and nurses available to provide continuous labor support. As a result, laboring patients may not receive adequate monitoring, leading to premature decisions to perform C-sections rather than allowing for longer labor progression (CMS, n.d.). These understaffed medical environments also lead to the use of labor-inducing drugs like Pitocin to speed up delivery, which can lead to fetal distress and a higher likelihood of surgical intervention (Mayo Clinic, 2024). 

Finally, the financial structure of hospital reimbursements may also play a role in the overuse of surgical procedures. In some hospital systems, C-sections are financially incentivized because they are reimbursed at higher rates than vaginal deliveries (Vedantam, 2013). This economic reality disproportionately affects hospitals that serve Black women, where providers may be more likely to perform surgical births due to financial and time constraints. Black women, already facing systemic barriers to healthcare access, often give birth in facilities that prioritize cost-saving measures over patient-centered care, exacerbating their vulnerability to unnecessary medical interventions.

While cesarean sections (C-sections) can be a life-saving intervention in certain high-risk pregnancies, their overuse among Black women has created an alarming pattern of preventable health complications such as hemorrhaging, infections, and blood clots (Mayo Clinic, 2022). Beyond the immediate surgical risks, C-sections also increase the likelihood of long-term health issues that can affect Black women’s reproductive health, future pregnancies, and overall well-being. Conditions such as placenta previa where the placenta covers the cervix, causing severe bleeding; placenta accreta where the placenta embeds too deeply into the uterus, often leading to dangerous hemorrhaging and the need for a hysterectomy; and placenta abruption where the placenta detaches prematurely, increasing the risk of fetal distress and stillbirth disproportionately affect Black women (Cleveland Clinic, 2024). In addition to these risks, C-sections can cause chronic pelvic pain and adhesions, where internal scar tissue forms between organs, leading to painful menstruation, bowel obstructions, and secondary infertility—complications that are rarely discussed with Black women before or after surgery, leaving many unaware of their long-term reproductive health risks (Poole, 2016). 

Postpartum Mental Health Challenges

Black women’s mental health in the postpartum period is a critical, yet frequently overlooked factor of the Black Maternal Mortality Crisis. Mental health conditions including postpartum depression, anxiety, and postpartum psychosis are among the most leading causes of pregnancy-related deaths in the United States (CDC, 2022). For Black women, postpartum mental health challenges are compounded by systemic inequities, historical medical mistrust, and limited access to culturally competent care. These challenges are exacerbated by a healthcare system that has historically disregarded Black women’s pain and psychological distress. Many struggle to find therapists and mental health professionals who understand their unique cultural experiences and the impact of racial trauma. Studies indicate that a racial match between patient and provider significantly improves health outcomes, yet only 4% of psychologists and 2% of psychiatrists in the U.S are Black (Hughes and Oyeniyi, 2024). As a result, Black women’s symptoms of postpartum depression and anxiety are often dismissed, underdiagnosed, or misattributed to stress or personality rather than legitimate medical concerns. This systemic neglect contributes to the under-treatment of perinatal mood disorders, which can lead to self-harm, suicide, substance use, or fatal mental health crises which are the leading causes of maternal death in the first year postpartum (Howard and Khalifeh, 2020).

Postpartum health cannot be separated from physician health, as untreated conditions can lead to hypertension, cardiovascular complications, and worsened overall maternal health outcomes. Additionally, social support networks—or lack thereof—play a crucial role in postpartum well-being. Black mothers often do not have the time or space to fully acknowledge mental health challenges due to generational trauma, financial strain, and a lack of accessible maternal health resources. Many Black communities, due to centuries of racial discrimination, forced family separations, medical experimentations, and institutionalized neglect, have lead future generations to be raised in environments where survival was prioritized over emotional vulnerability, leading to the normalization of silent suffering and a reluctance to seek help (Whitfield, 2021). The transmissions of coping behaviors include the expectation to be self-sufficient, to suppress emotions, and to endure hardships without complaint, which is emotionally taxing to women already trying to navigate motherhood, physically heal, and navigate other changes during the postpartum period. Studies link untreated maternal depression to lower rates of breastfeeding, poorer infant bonding, and increased risks of developmental and behavioral challenges in children (Howard et al., 2017).

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IV. Major Alternatives and Key Recommendations

Promoting Maternal Health Awareness and Advocacy

The solutions offered are geared toward state and federal action, and the first solution is shedding more light on these maternal healthcare disparities and providing more information to Black communities. Informing Black women gives them the power to be better advocates for themselves in the birthing space. Serena Williams, who had been through numerous physical challenges, developing a blood clot in her lungs in 2010, knew the signs of chronic conditions and the necessary steps needed to get proper diagnosis and treatment. Williams emphasized, “Being heard and appropriately treated was the difference between life or death for me”(Williams, 2022) The best way to empower Black women so they are well-informed about reproductive health, pregnancy risk, and signs of complications is through telemedicine, which has been expanded through the CARES Act and improving community and public health services (American Medical Association, 2020). Through telemedicine platforms Black mothers can easily connect with healthcare providers and receive text alerts informing them of the best prenatal practices and other maternal health topics. This virtual access enables timely consultations, monitoring of pregnancy progress, and immediate responses to concerns or complications that will not be diminished. One study showed that telehealth reduced racial disparities when Black communities were receiving care (Kumar et al., 2022). Reduced racial disparities also encouraged Black communities to access health services more often, with visit completion rates increasing from 52% to 70% (Ahébée, 2022). Though it may be a concern if Black women will have the socioeconomic means to afford telemedicine for maternal care, after the COVID-19 pandemic there has been an increase in reimbursement for Medicaid providers who utilize telemedicine for pregnancy care (Gleason and Zephyrin, 2021). Additionally, there are states like Arizona who expanded coverage for audio-only telemedicine visits, which allowed more women the ability to maintain connections with their clinicians (State Health Access Data Assistance Center, 2022; Gleason and Zephyrin, 2021). Additionally, investing into community and public health services helps heal familial birth trauma through connecting Black mothers to people that they know and can trust. Meaning that more women will utilize maternal health care resources before, during, and after pregnancy to mitigate the effects of possible conditions that can lead to death. There are a variety of important and valuable community based organizations including March of Dimes, The Black Mamas Matter Alliance, National Birth Equity Collaborative, Dr. Shalon’s Maternal Action Project, Black Women’s Health Imperative, National Black Doulas Association, National Black Midwives Alliance, SisterSong, and so many other important and valuable organizations (Winny & Bervell, 2023). Empowering Black women with comprehensive maternal health education and resources within their local community is the first critical step towards achieving positive maternal health outcomes.

Establishing Maternal Mortality Review Committees

Another key strategy in reducing the Black maternal mortality rate on the state level is Maternal Mortality Review Committees (MMRCs). MMRCs collect and analyze data on pregnancy-related deaths examining the circumstances that contributed to those deaths including the quality of medical care, social determinants, and patient experiences. This thorough investigation often goes beyond medical factors to identify systemic issues such as implicit bias, inadequate access to care, socioeconomic challenges, and racial discrimination. Then based on their findings, MMRCs develop key recommendations aimed at addressing these disparities including healthcare provider training, community resources, social support systems, and working with policymakers and healthcare institutions to implement changes. Finally, MMRCs track progress, evaluate outcomes, and adjust strategies as needed to ensure sustained improvements in healthcare quality. A prime example of the positive impact of MMRCs is in California. In 2006, California’s maternal mortality ratio was 16.9 per 100,000 live births at a time when the United States maternal mortality ratio was 13.3 per 100,000 live births (California Maternal Quality Care Collaborative, n.d.). That same year, after medical professionals and state officials saw that the state maternal mortality rate had doubled, they brought together a team of nurses, doctors, midwives, and hospital administration together and were able to cut the rate of women dying in childbirth by more than half (California Maternal Quality Care Collaborative, n.d.).

‍Expanding Medicaid Eligibility and Provisions

As previously noted, a majority of maternal deaths occur during the postpartum period. It is very critical for states who have not taken up Medicaid expansion to do so and to extend Medicaid postpartum coverage up to a full year in order for women to continue receiving necessary medical care and reduce risk of severe complications. In Texas, a health maintenance organization, Parkland Community Health Plan, after implementing similar pandemic-related provisions, found that women used twice as many Postpartum services. That is, 2 to 10 times as many preventative, contraceptive, and mental/behavioral health services (Wang et al., 2022). Along with provisions to expand Medicaid coverage up to a year, states should also adopt Doula benefits. Doulas empower women with maternal healthcare knowledge about their pregnancy and birth-options, leading to informed decision making and increased confidence during labor and delivery. Doulas also help bridge communication gaps between mothers and medical professionals, advocating for culturally competent care. Under Medicaid, Doula services can be covered under various benefit categories including preventative services, clinic services, licensed practitioners, and freestanding birth center services. States that have expanded coverage for doulas such as Oregon, increased its reimbursement rate to $1,500 dollars (Chen, 2022). These reimbursement rates provide more opportunities for Black mothers to access these services which is important as a study within the American Journal of Public Health showed that the odds of cesarean delivery were 40.9% lower for Doula-supported births, meaning a decrease in Black maternal death outcomes (Kozhimannil et al., 2013).

Another important provision that should be covered is expanding paid parental leave. One major alternative to standard paid parental leave is implementing a system that provides extended leave for high-risk pregnancies, particularly for Black mothers who face disproportionately higher rates of maternal complications. Another approach is employer-sponsored paid leave, which supplements federal and state benefits, ensuring that Black mothers have financial stability during the postpartum periods. Furthermore, integrating paid leave policies with maternal health initiatives—such as mandatory postpartum care visits, mental health support, and even lactation assistance—can help address disparities in maternal mortality rates (New York State, 2024; Substance Abuse and Mental Health Services Administration, 2024). 

A lot of these suggestions align directly with the provisions of the Black Maternal Health Momnibus Act. The Momnibus Act, introduced by the Black Maternal Health Caucus, is a package of bills that expands Medicaid coverage, funds community-based maternal health programs, and improves data collection on maternal health disparities. The act also invests in social determinants of health such as housing, nutrition, and transportation, which directly impact maternal outcomes. By advancing policies that address both medical and non-medical contributors to maternal health, the Momnibus Act provides a comprehensive approach to reducing racial disparities in maternal mortality (2023). 

‍Where do we go from here?

There are several elements and solutions regarding Black maternal mortality that are only briefly discussed within this paper. While there is vast data and evidence proving that the United States is facing a Black maternal mortality crisis, as well as clear solutions to mitigate its devastating effects, action is what is most needed. Addressing this crisis requires not only structural changes in policy and medical education but also a commitment to listening to marginalized communities and providing dynamic, community-centered support. Only through these systemic shifts can equitable and safer birthing experiences be ensured for Black women.

Stakeholders across multiple sectors must take deliberate and coordinated action. Policymakers at the federal, state, and local levels must enact and enforce laws that protect Black maternal health, including increased funding for maternal health programs, federal oversight of hospital practices, and legal accountability for medical negligence. Hospitals and healthcare systems should be required to report on the care, treatment, and outcomes of Black maternity patients, ensuring transparency and accountability for disparities in care. Medical professionals must receive ongoing training in culturally competent and bias-free care, with built-in institutional mechanisms to monitor and improve their effectiveness. Community-based organizations, doulas, and midwives—who often provide the most culturally responsive care—should receive increased support and integration into mainstream maternal health systems.

Central to any progress is centering and amplifying the voices of Black women. Too often, their experiences and concerns are dismissed, leading to deadly consequences. Black women’s testimonies must not only be heard but must shape the policies, medical curricula, and care standards that dictate maternal health in the U.S. Creating patient-centered accountability systems where Black mothers can report medical mistreatment and have their concerns taken seriously is vital to ensuring their safety and dignity. Additionally, this crisis does not exist in isolation—it is deeply connected to broader human rights issues such as medical racism, healthcare disparities, economic inequities, and reproductive justice. Without addressing these systemic injustices, maternal health outcomes for Black women will remain bleak. Solutions must extend beyond hospitals and clinics to include housing stability, food security, economic mobility, and access to comprehensive reproductive healthcare.

Future research must continue to explore the intersectionality of race, gender, and class in maternal health outcomes. Areas such as the impact of environmental factors, the role of Medicaid and insurance accessibility, and the long-term effects of racial trauma on maternal health require further investigation. The work must not stop at identifying problems—it must push toward dismantling the structures that perpetuate them.

As we move forward, we must ground ourselves in these critical questions: What are the barriers to prenatal care and maternal services for Black women? How does the intersectionality of race and socioeconomic status shape maternal health outcomes? And most importantly, what immediate steps can we take to dismantle these barriers and build a system that truly values and protects Black lives?