Racial disparities in birth outcomes in the United States are long-standing and by now well-known. Black women are three times more likely than white women to die, or experience severe maternal complications, or have a cesarean birth. Social determinants of health – the conditions where people live, learn, work, and play that affect health– have been put forth as an explanation for racial disparities in birth outcomes, and addressing them as a means to eliminate that disparity.  

But if these social factors were the actual explanation, we wouldn’t keep hearing the same tragic stories. Consider Drs. Shalon Irving and Chaniece Wallace, physicians who had strong social supports in their lives – yet they died shortly after giving birth. Only their partners remain to talk about their experiences. Both these women had caesarean deliveries and reported not being listened to when something went wrong despite their medical expertise. There is research, too, showing that an array of social advantages — education, insurance status, health care access — do not protect Black women, even when they have no medical problems. 

This echoes our own experience as two women, one Black and one white, with exceptional social advantages for good health (e.g., married, with family and community support, living in “nice” homes in “safe” neighborhoods, highly educated with good jobs and health insurance, and generally healthy). Both of us actively chose where to give birth to increase our odds of getting high quality care – and we had very different birth experiences and outcomes. The Black woman experienced absent and delayed care during her labor, with little or no communication from physicians and nurses, racist assumptions about where she lived and how she would parent, and a cesarean birth; the white woman had the opposite experience.  

The media, too, is full of stories of Black women whose exceptional advantages were trumped by their skin color (i.e., racism). Tennis star Serena Williams had a history of blood clots, and when this happily married, highly educated athlete correctly told providers that she was experiencing another clot after giving birth, she was told to return to her room. A recent paper using data from California further underscored the secondary nature of social factors in the face of racism, finding that wealthy Black women have poorer outcomes than poor white women.  

In the years since the senseless murder of George Floyd, there have been more concerted efforts to combat the racism that has always existed. The California Maternal Quality Care Collaborative, for instance, has been a national leader in state-level perinatal quality improvement initiatives. They acknowledge their own “past misalignment of strategies to address birth equity” and have had some success in narrowing racial disparities in birth outcomes. Many of the initiatives, however, are more recent, their approaches vary, and their impact remains to be seen. The White House Blueprint for Addressing the Maternal Health Crisis, for instance, acknowledges the role of racism in poor maternal outcomes. The only recommendation, however, that explicitly includes racism is “5.2 Address the social determinants of maternal health”. Medicaid has rolled out an initiative to address low-risk cesarean birth. They acknowledge that low-risk cesarean birth is a racially disparate outcome, and that Medicaid has a role in reducing that disparity, but most of the suggested interventions focus on social factors rather than racism. If social factors were the root cause of poor birth outcomes, then we would expect healthy, highly educated, married, wealthy Black women who carefully select where they give birth to have stellar outcomes. That is not the case.  

Focusing on social factors is, at best, treating a symptom rather than the disease. At worst, the focus on social factors reinforces racism. It does so by 1) providing a rationale to avoid talking about racism in one’s own workplace and actions, 2) being another way to blame the woman (e.g., “she’s poorly educated, what do you expect?”), and 3) supporting racial assumptions about one’s social standing (like the nurse practitioner who assumed that one of the authors lived in a poor neighborhood because of her skin color).  

It is time to take responsibility for the racism – historic and contemporary, structural, and interpersonal – that drives racial disparities in birth outcomes in the United States. Only if we own it do we have the opportunity to change.  

Black women, no matter their social supports, are at higher risk of enduring poor quality, racist care when they go to the hospital to give birth. Providers, and their institutions, need to take an objective look at their data – the care they provide and the outcomes their patients experience. Tangible solutions include standardizing labor induction protocols so that women receive the same management, standardizing postpartum pain management and protocols for how pain is assessed and treated, and identifying opportunities to improve respectful communication.  

Providers and their employers can focus on taking responsibility for institutional racism by 1) recognizing practices that perpetuate racial disparities (e.g., the use of biased algorithms), 2) engaging in ongoing institutional learning around racism in care with a focus on taking action, and 3) developing a tailored model to support Black birth in partnership with Black women. We recommend moving away from asking social questions. Women can advocate for themselves by 1) educating themselves on birth options, 2) shopping around for prenatal care and where they want to give birth, as they are able, 3) considering changing practices if they are receiving sub-standard care, and 4) working with a doula as an additional advocate. We recommend that funding bodies and professional organizations consider that racism, not social factors, is at the root of continued Black maternal health disparities when they craft calls for research proposals and care guidelines.  

We ask folks to consider that, whoever you are, we have the capacity to treat others as human beings, as we ourselves would want to be treated, and that this makes a world of difference. 


Rebecca Clark, PhD, RN

Assistant Professor, Family and Community Health, Penn Nursing

Rachel French, PhD, RN

Postdoctoral Fellow, Center for Mental Health, Perelman School of Medicine; Postdoctoral Fellow, Penn Nursing

Carrie Arthur

Cardiac Sonographer

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