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Issue Brief
Black Women’s Maternal Health

A Multifaceted Approach to Addressing Persistent and Dire Health Disparities

November 2023
Maternal Health

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Background

Regardless of socioeconomic status, Black women and birthing individualsNOTE: We recognize and respect that pregnant, birthing, postpartum, and parenting people have a range of gender identities and do not always identify as “women” or “mothers.” In recognition of the diversity of identities, this issue brief uses both gendered terms, as well as gender-neutral terms such as “people,” “pregnant person,” and “birthing people.” In referencing studies, we use the typically gendered language of the authors. in the United States are three times more likely to die from pregnancy than their white counterparts. This disparity widens in various cities and states.Donna L. Hoyert. “Maternal Mortality Rates in the United States, 2021,” U.S. National Center for Health Statistics Health E-Stats, March 2023, https://dx.doi.org/10.15620/cdc:124678 Black women are also disproportionately affected by severe maternal morbidity– unexpected outcomes in labor and delivery (e.g., hypertension and anxiety) that result in significant short- or long-term consequences to the childbearing person’s health and well-being.U.S. Centers for Disease Control and Prevention. “Severe Maternal Morbidity in the United States,” July 3, 2023, https://tools.cdc.gov/medialibrary/index.aspx#/media/id/230281

  • Compared to white women, the incidence of severe maternal morbidity for Black women was 166 percent higher from 2012 to 2015.U.S. National Institutes of Health Office of Research on Women’s Health. Maternal Morbidity and Mortality: What Do We Know? How Are We Addressing It?, 2020, https://orwh.od.nih.gov/sites/orwh/files/docs/ORWH_MMM_Booklet_93020_508c.pdf
  • 84 percent of maternal deaths are preventable.Susanna Trost, Jennifer Beauregard, Gyan Chandra, Fanny Njie, Jasmine Berry, et al. “Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 U.S. States, 2017–2019,” U.S. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, accessed October 5, 2023, https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf
  • An 11-year analysis of more than 9 million hospital deliveries found that Black women had a 53 percent higher risk of dying in a hospital setting during childbirth, regardless of income level, insurance type, or any other social driver of health.American Society of Anesthesiologists. “Systemic Racism Plays Role in Much Higher Maternal Mortality Rate among Black Women,” October 22, 2022, https://www.asahq.org/about-asa/newsroom/news-releases/2022/10/systemic-racism-plays-role-in-much-higher-maternal-mortality-rate-among-black-women
  • Thirty percent of Black women who delivered in hospitals in the United States reported they were treated poorly because of a difference of opinion with their caregivers about the right to care for themselves or their baby.Saraswathi Vedam, Kathrin Stoll, Tanya Khemet Taiwo, Nicholas Rubashkin, Melissa Cheyney, et al. “The ‘Giving Voice to Mothers’ Study: Inequity and Mistreatment during Pregnancy and Childbirth in the United States,” Reproductive Health, June 11, 2019, https://doi.org/10.1186/s12978-019-0729-2
  • Nearly one in four Black women are likely to report at least one form of mistreatment by health care providers. They are twice as likely as white women to report that a health care provider ignored them, refused a request for help, or failed to respond to requests for help in a reasonable amount of time.Saraswathi Vedam, Kathrin Stoll, Tanya Khemet Taiwo, Nicholas Rubashkin, Melissa Cheyney, et al. “The ‘Giving Voice to Mothers’ Study: Inequity and Mistreatment during Pregnancy and Childbirth in the United States,” Reproductive Health, June 11, 2019, https://doi.org/10.1186/s12978-019-0729-2
  • Black women historically have experienced higher rates of pregnancy complications such as hypertension, preeclampsia, and hemorrhage.
  • Among the larger racial and ethnic groups, Black women experience the highest cesarean rate – 36 percent – even including low-risk births, largely due to medical coercion.Amanishakete Ani. “C-Section and Racism: ‘Cutting’ to the Heart of the Issue for Black Women and Families” Journal of African American Studies, December 2015, https://www.jstor.org/stable/44508234
  • Black women who have recently given birth are less likely than white, non-Hispanic women to have health insurance. Eighty-nine percent of Black women who have given birth in the last 12 months have health insurance, compared to 93 percent of white, non-Hispanic women.National Partnership for Women & Families analysis of the American Community Survey 2017–2021 five-year data set via IPUMS. Data limitations do not permit an estimate of individuals during the months of pregnancy and are additionally limited to women who have survived giving birth. These data may fail to include women who had miscarriages or otherwise suffered pregnancy loss. In this analysis, the category of Black women includes Afro-Latinas, though it is important to note that Afro-Latinas may face unique barriers and risks. Women in this analysis are ages 16–50 due to data constraints. Due to data limitations, this analysis does not include people who do not identify as women but may become pregnant, including transgender men and nonbinary people. However, an estimated 1.3 million transgender adults and 1.2 million LGBTQ nonbinary adults live in the United States, many of whom have or will become pregnant. UCLA School of Law Williams Institute. “1.2 million LQBTQ adults in the US identify as nonbinary.” https://williamsinstitute.law.ucla.edu/press/lgbtq-nonbinary-press-release/;
    Herman, Jody L, Andrew R. Flores, Kathryn K. O’Neill. “How Many Adults and Youth Identify as Transgender in the United States?” UCLA School of Law, June 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/

Drivers of the Black Maternal Health Crisis

The reproductive health of Black women has long been compromised by interpersonal, institutional, and structural racism. In addition to contending with social and economic drivers of poor health that undermine Black Americans, they have experienced discriminatory health care practices and abuse from slavery to the present.

From non consensual medical experimentation, to failing to listen to patients or providing an adequate standard of care, health care itself has been a driver of the death and severe complications that Black birthing people face.Cynthia Prather, Taleria R. Fuller, William L. Jeffries IV, Khiya J. Marshall, A. Vyann Howell, et al. “Racism, African American Women, and Their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity,” Health Equity, September 24, 2018, http://doi.org/10.1089/heq.2017.0045 The history of racism within health care must be understood to enable us to dismantle institutional racism in health care systems to create policies, programs, and practices that protect Black women.Anuli Njoku, Marian Evans, Lillian Nimo-Sefah, and Jonell Bailey. “Listen to the Whispers before They Become Screams: Addressing Black Maternal Morbidity and Mortality in the United States,” Healthcare, February 3, 2023, https://doi.org/10.3390/healthcare11030438

For generations, the health care system has mistreated, disrespected, and undermined the safety of Black women, which has fueled their deep mistrust of health care institutions and, for many, undermined their relationship with maternity care. Health care providers’ and medical students’ racial biases manifest in false beliefs about biological differences between Black and white bodies, which can result, for example, in inadequate pain management for Black people, as well as dismissing or ignoring Black people and forcing them to endure undiagnosed illnesses without treatment.Kelly M. Hoffman, Sophie Trawalter, Jordan R. Axt, and M. Norman Olive. “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences between Blacks and Whites,” Psychological and Cognitive Sciences, April 4, 2016, https://doi.org/10.1073/pnas.1516047113

The impact of high-level chronic stress caused by living as a Black person in a racist society can cause weathering of the body – premature aging and poor health that can be seen in a person’s DNA.Harvard T.H. Chan School of Public Health. “How Discrimination Can Harm Black Women’s Health,” accessed October 5, 2023, https://www.hsph.harvard.edu/news/hsph-in-the-news/discrimination-black-womens-health/ The current Black maternal health crisis is a stark and urgent example of how all these factors conspire to sabotage Black health.

Following the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe. v. Wade, the United States has become even more dangerous for Black people to give birth. A National Partnership for Women & Families analysis reveals that Black women who have recently given birth are substantially more likely than other women to live in a state that has banned abortion or is likely to ban it. Sixty-one percent of Black women who have given birth in the last 12 months were living in states that have banned abortion or are likely to ban it post-Dobbs, compared to 50 percent of women overall and 53 percent of white, non-Hispanic women.See note 9. These figures are not directly comparable to Robbins and Goodman because these data include women age 50, and Black women in this analysis include Afro-Latinas (in that analysis, Latinas are analyzed separately). Access to maternity care providers and facilities is worsening in states with abortion bans or restrictions.Eugene Declercq, Ruby Barnard-Mayers, Laurie C. Zephyrin, and Kay Johnson. “The U.S. Maternal Health Divide: The Limited Maternal Health Services and Worse Outcomes of States Proposing New Abortion Restrictions,” The Commonwealth Fund, December 14, 2022, https://doi.org/10.26099/z7dz-8211 While abortion restrictions are harmful for everyone, people of color, especially Black women, are disproportionately harmed, and will likely continue to be harmed, by barriers to quality and timely care, largely due to the current maternity care climate. Indeed, the policy changes unleashed by Dobbs are expected to worsen Black maternal mortality, although the data may take years to reveal the true toll.Kavitha Surana. “Maternal Deaths Are Expected to Rise under Abortion Bans, but the Increase May Be Hard to Measure,” ProPublica, July 27, 2023. https://www.propublica.org/article/tracking-maternal-deaths-under-abortion-bans

Black women cannot buy or educate their way to healthier outcomes. The inequities of social drivers of health have a profound biological impact on the lives of birthing people and their babies.Sinsi Hernández-Cancio and Venicia Gray. “Racism Hurts Moms and Babies,” 2021, https://nationalpartnership.org/report/racism-hurts-moms-and-babies/ This is especially true for Black birthing people: The conditions where they are born, live, grow, work, and age differ from those of white Americans, which are largely shaped by historical inequities of segregation, discrimination, and other socioeconomic structural inequities.Felicia Hill-Briggs, Patti L. Ephraim, Elizabeth A. Vrany, Karina W. Davidson, Renee Pekmezaris, et al. “Social Determinants of Health, Race, and Diabetes Population Health Improvement: Black/African Americans as a Population Exemplar,” Current Diabetes Reports, March 3, 2022, https://doi.org/10.1007/s11892-022-01454-3

Black individuals deserve bodily autonomy in safe and health-promoting environments to decide whether, how, or when to become parents. To improve Black maternal health, health care itself must make institutional and structural changes to transform the delivery and quality of care. Decisionmakers must allow Black women and their families to thrive by enacting policy change to address the social drivers impacting health: conditions in the environment where people are born, live, learn, work, play, worship, and age that also affect a wide range of quality-of-life outcomes.U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. “Social Determinants of Health,” accessed October 6, 2023, https://health.gov/healthypeople/priority-areas/social-determinants-health This includes listening to, supporting, sustainably funding, trusting, and respectfully engaging with Black-led organizations in relationship building, ceding or sharing power with them, and creating pathways that allow community-based solutions to succeed.

COVID Worsened the Black Maternal Health Crisis

The COVID-19 pandemic further exposed the extent of the United States’ history of structural and systemic racism. Disruptions and barriers to care during the emergency widened disparities, which exacerbated the Black maternal health crisis. Black childbearing people were three times more likely than white parents to have a COVID-19–attributable maternal death.National Partnership for Women & Families. Raising the Bar for Maternal Health Equity and Excellence, accessed October 7, 2023, https://nationalpartnership.org/health-justice/raising-the-bar/ Black people were more likely to be essential workers, increasing their risk of COVID-19 exposure, while receiving limited access to reproductive and other routine health care services due to work schedules or appointment availability.Joia Crear-Perry and Sinsi Hernández-Cancio. “Addressing Racism and Socioeconomic Influencers,” accessed October 7, 2023, https://nationalpartnership.org/wp-content/uploads/2023/02/saving-the-lives-of-moms-and.pdf

Black Maternal Health Is Resistance, Resilience, and Joy

Black communities have long resisted systems designed to harm Black bodies, while remaining resilient and joyful in the fight for autonomy and liberation. Although Black America is a diverse, nuanced, and growing population, more than half of the nation’s Black population – 56 percent – live in the South, which means many Black mothers live in states without access to the full scope of reproductive care.

The ability to create a community regardless of location is a throughline for many Black Americans. This often inspires Black Joy – the act by Black people of finding a positive nourishment of self and others that is safe, healing, and rests mind, body, and spirit, in response to the racialized and traumatic experiences they continue to encounter.National Museum of African American History & Culture. “Community Building,” accessed October 7, 2023, https://nmaahc.si.edu/learn/talking-about-race/topics/community-building Elaine Nichols. “Black Joy: Resistance, Resilience, and Reclamation,” National Museum of African American History & Culture, accessed October 7, 2023, https://nmaahc.si.edu/explore/stories/black-joy-resistance-resilience-and-reclamation

Black Joy is at the center of Black maternal health community solutions. Community-based organizations that center Black maternal health are largely led by Black women who have had to contend with racism, sexism, and misogynoir – misogyny directed at Black women.Dictionary.com. “Misogynoir,” accessed October 7, 2023, https://www.dictionary.com/browse/misogynoir These movements and their advocates have pioneered models of care beyond hospital settings. They support culturally congruent perinatal support, midwifery care, community birth settings like home birth and birth centers, doula support, and the services of community-led and -based perinatal health worker groups.Carol Sakala. “Improving Our Maternity Care Now,” National Partnership for Women & Families, accessed October 7, 2023, https://nationalpartnership.org/health-justice/maternal-health/improving-our-maternity-care/

Reproductive Justice Movement: created by a collective of Black women to uplift the needs of the most marginalized women, families, and communities by positing reproductive justice as a human right that analyzes power systems, centers those most marginalized, and addresses intersecting oppressions.SisterSong. “Reproductive Justice,” accessed October 7, 2023, https://www.sistersong.net/reproductive-justice

Birth Justice Movement: created and led by Black and other women of color to recognize and safeguard the rights of birthing people in communities of color, as well as immigrant, LGBTQIA+, low-income, and disabled birthing people to make decisions for their pregnancies, the choice to continue a pregnancy, and parent the children they have in safe and supportive environments.University of California San Francisco, Advancing New Standards in Reproductive Health, “Birth Justice,” accessed October 7, 2023, https://www.ansirh.org/pregnancy/birth-justice

Transform the Delivery of Black Maternal Care

Our maternity care and health care systems spectacularly fail Black birthing people and their families. Health care systems, policies, and practices must transform to address the widening inequities that plague Black birthing people. To address the racism, ableism, and other structural inequities that undermine Black birthing people’s health, delivering respectful, whole-person care should be a North Star, especially during the vulnerable time of pregnancy, childbirth, and postpartum.

Provide Culturally Centered Care by Diverse Care Teams

Black women and birthing people deserve to receive comprehensive, high-quality, culturally centered, and respectful whole-person health care that meets their physical, emotional, and social needs. Transforming the delivery of maternity care must focus on the dignity, personal agency, and bodily autonomy of birthing people – implicit bias training of existing providers is insufficient.National Partnership for Women & Families. “Raising the Bar for Moms & Babies: The Maternal and Newborn Care Provider Role,” accessed October 7, 2023, https://nationalpartnership.org/wp-content/uploads/2023/04/rtb-care-provider.pdf It also includes ensuring Black birthing people are cared for by teams who are diverse in two ways: racial background and job titles. Black birthing individuals have better outcomes with care teams that include providers who share their backgrounds, or who have been educated by institutions that have designed, tailored, and prioritized anti-racist curricula for all instructors, including clinicians who provide training for medical, nursing, doula, and midwifery students and other support personnel. In addition, birthing people have better outcomes when their care teams include a range of clinical care providers, from obstetricians to midwives, to maternal-fetal medicine specialists, to mental health providers and nonclinical support personnel, such as care navigators, community health workers, and community-based doulas, and other perinatal health workers.

  • Nearly half the babies born in the United States come from Black or other communities of color. Often, clinical staff do not share their background – which can engender mistrust, misunderstandings, and disrespect.National Center for Health Workforce Analysis. “State of the Maternal Health Workforce Brief,” August 2022, https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/dataresearch/maternal-health-workforce-brief-2022.pdf
  • Black women have expressed a preference for racial concordance with their pregnancy and childbirth providers – that is, a shared racial identity between a physician and a patient. Racial concordance between Black newborns and their physicians has halved mortality, compared to white newborns.Julie L. Ware, Dominique Love, Julietta Ladipo, Kiera Paddy, Makina Starr, et al. “African American Breastfeeding Peer Support: All Moms Empowered to Nurse,” Breastfeeding Medicine, February 12, 2021, https://doi.org/10.1089/bfm.2020.0323; Elizabeth C. Rhodes, Grace Damio, Helen Wilde LaPlant, Walter Trymbulak, Carrianne Crummett, et al. “Promoting Equity in Breastfeeding through Peer Counseling: The U.S. Breastfeeding Heritage and Pride Program,” International Journal for Equity in Health, May 27, 2021, https://doi.org/10.1186/s12939-021-01408-3 and Elizabeth Bogdan-Lovis, Jie Zhuang, Joanne Goldbort, Sameerah Shareef, Mary Bresnahan, et al. “Do Black Birthing Persons Prefer a Black Health Care Provider during Birth? Race Concordance in Birth,” Birth, May 30, 2022, https://doi.org/10.1111/birt.12657
  • In 2019, Black obstetrician-gynecologists made up 11 percent of the ob-gyn workforce and only 6.7 percent of midwives.Zippia. “Ob-Gyn Demographics and Statistics in the U.S.,” accessed January 14, 2023, https://www.zippia.com/ob-gyn-jobs/demographics/; U.S. Centers for Disease Control and Prevention, “About Natality, 2016–2021 Expanded,” accessed January 14, 2023, https://wonder.cdc.gov/natality-expanded-current.html

Maternity services must be co-created with those who are most adversely affected, to support accessible and respectful maternal-newborn care. Services should regularly request and address patient feedback.National Partnership for Women & Families. “Checklist to Raise the Bar for Maternal Health Equity and Excellence as a Provider of Whole-Person Maternal & Newborn Care,” March 2023, https://nationalpartnership.org/wp-content/uploads/2023/04/rtb-provider-checklist.pdf Hospital systems and other health care provider institutions can implement evidence-based practices associated with promoting vaginal birth and a reduction of safely avoidable cesarean births. They can also participate in their state’s perinatal quality collaborative and identify, track, and address inequities within their quality improvement programs.

Congress must pass the Black Maternal Health Momnibus Act (S. 1606 and H. R. 3305), which addresses every driver of maternal mortality, morbidity, and disparity in the country by:

  • Making investments in social drivers of health that influence maternal health outcomes.
  • Providing funding to community-based organizations.
  • Improving data collection processes and quality measures to better understand the causes of the maternal health crisis and inform solutions to address it.
  • Investing in federal programs to address maternal and infant risks during public health emergencies.
  • Growing and diversifying the perinatal workforce.
  • Investing in digital tools to improve maternal health in underserved areas.U.S. House of Representatives Black Maternal Health Caucus. “About the Black Maternal Health Momnibus Act,” accessed October 7, 2023, https://blackmaternalhealthcaucus-underwood.house.gov/Momnibus

Congress must pass the Community, Access, Resources, Empowerment (CARE) for Moms Act, which addresses the one in two women nationwide who live in maternity care deserts and rural areas by improving access to maternal health care services, extending Medicaid 12-month postpartum coverage nationwide, and growing and diversifying the doula workforce.

 

Destigmatize and Treat Black Maternal Mental Health

Black women bear a heavier burden of perinatal mood and anxiety disorders that appear during pregnancy and postpartum. When left undiagnosed and unmanaged, maternal mental health (MMH) conditions can lead to long-term adverse health consequences for the birthing person, infant, and family. MMH complications are compounded by the COVID-19 pandemic, which has disproportionately harmed the health and economic well-being of Black communities.Martiza Vasquez Reyes. “The Disproportional Impact of COVID-19 on African Americans,” Health and Human Rights Journal, December 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762908/ Preventing and consistently managing MMH conditions is crucial in fighting the larger Black maternal mortality and morbidity crisis in the United States.

  • MMH conditions affect one in five women and are a leading cause of maternal mortality.Norma I. Gavin, Bradley N. Gaynes, Kathleen N. Lohr, Samantha Meltzer-Brody, Gerald Gartlehner, et al. “Perinatal Depression: A Systematic Review of Prevalence and Incidence,” Obstetrics & Gynecology, November 2005, https://doi.org/10.1097/01.AOG.0000183597.31630.db For Black women, the risk is twice as high.Amy Balbierz, Susan Bodnar-Deren, Jason J. Wang, and Elizabeth A. Howell. “Maternal Depressive Symptoms and Parenting Practices 3-Months Postpartum,” Maternal and Child Health Journal, June 1, 2016, https://doi.org/10.1007%2Fs10995-014-1625-6
  • Black mothers are more likely to experience perinatal mood and anxiety disorders and receive lower-quality mental health care than white women.Christine Pao, Jerry Guintivano, Hudson Santos, and Samantha Meltzer-Brody. “Postpartum Depression and Social Support in a Racially and Ethnically Diverse Population of Women,” Archives of Women’s Mental Health, July 3, 2018, https://doi.org/10.1007/s00737-018-0882-6 https://doi.org/10.1016/j.sapharm.2014.02.007
  • Sixty percent of Black mothers do not receive any treatment or support services for prenatal and postpartum emotional complications due to lack of insurance coverage, social and cultural stigma related to mental health needs, logistical barriers to services, and lack of culturally appropriate care.Green, Stephanie. “The Maternal Mental Health Crisis Undermines Moms’ and Babies’ Health,” National Partnership for Women & Families, accessed October 9, 2023, https://nationalpartnership.org/report/the-maternal-mental-health-crisis-undermines-moms-and-babies-health/

Congress should increase and sustain current funding levels at $15 million or greater to support the Alliance for Innovation on Maternal Health (AIM) Maternity Care Safety Bundles to all states and health provider institutions. By doing so, Congress would enable more states to implement AIM bundles, which allow them to effectively implement standardized screening, referral, intervention, and follow-up for MMH conditions in maternity care and pair birthing parents with resources to aid in their utilization. Decision makers must fund initiatives spearheaded by Black and other people of color-led birthing justice organizations, and work with them.

 

Protect and Expand Access to Reproductive Health Care

Black women and birthing people already face an escalated risk in giving birth. Compulsory pregnancy – that is, carrying to term when abortion is denied, delayed, or made difficult to access – is a matter of life, death, and disability.Equality Now. “Forced Pregnancy,” accessed October 9, 2023, https://www.equalitynow.org/forced_pregnancy/ Therefore, addressing the Black maternal health crisis requires equitable access to reproductive health care. Increasing abortion bans will intensify poor maternal health because barriers to obtaining reproductive health care obstruct good health.Lauren J. Ralph, Eleanor Bimla Schwarz, Daniel Grossman, and Diana Greene Foster. “Self-Reported Physical Health of Women Who Did and Did Not Terminate Pregnancy after Seeking Abortion Services: A Cohort Study,” Annals of Internal Medicine, August 20, 2019, https://doi.org/10.7326/M18-1666; National Partnership for Women & Families. “Maternal Health and Abortion Restrictions: How Lack of Access to Quality Care Is Harming Black Women,” October 2019, https://nationalpartnership.org/wp-content/uploads/2023/04/maternal-health-and-abortion.pdf; Adam Thomas and Emily Monea. “The High Cost of Unintended Pregnancy,” Center on Children and Families at Brookings Institution, July 2011, https://www.brookings.edu/wp-content/uploads/2016/06/07_unintended_pregnancy_thomas_monea.pdf Women who were denied an abortion and then gave birth report worse health outcomes up to five years later, compared to women who received a desired abortion. Studies also show that women denied abortion care are more likely to experience serious medical complications during the end of pregnancy, including death.Alina Salganicoff, Laurie Sobel, and Amrutha Ramaswamy. “The Hyde Amendment and Coverage for Abortion Services,” Women’s Health Policy, March 5, 2021, https://www.kff.org/womens-health-policy/issue-brief/the-hyde-amendment-and-coverage-for-abortion-services/ Even before Dobbs, abortion was often difficult to access, especially for Black women. In some cases, Black birthing people are forced into pregnancy and parenthood despite the devastating impacts forced childbearing can have on their physical and mental health.National Partnership for Women & Families. “Threats on All Fronts: The Links Between the Lack of Abortion Access, Health Care and Workplace Equity,” August 2022, https://nationalpartnership.org/report/threats-on-all-fronts/

Policies like the Hyde Amendment, which outlaws the use of federal funds for nearly all abortion care, have perpetuated the crisis and threaten the limited existing reproductive care access for millions of people.American Civil Liberties Union. “Access Denied: Origins of the Hyde Amendment and Other Restrictions on Public Funding for Abortion,” December 1, 1994, https://www.aclu.org/documents/access-denied-origins-hyde-amendment-and-other-restrictions-public-funding-abortion It limits funding for programs like Medicaid, which provides critical reproductive care and health care benefits for people with low incomes, disabilities, or advanced age. More than 3.3 million Black women, or one in four nationally, are covered by Medicaid programs.Lauren J. Ralph, Eleanor Bimla Schwarz, Daniel Grossman, and Diana Greene Foster. “Self-Reported Physical Health of Women Who Did and Did Not Terminate Pregnancy after Seeking Abortion Services: A Cohort Study,” Annals of Internal Medicine, August 20, 2019, https://doi.org/10.7326/M18-1666; National Partnership for Women & Families. “Maternal Health and Abortion Restrictions: How Lack of Access to Quality Care Is Harming Black Women,” October 2019, https://nationalpartnership.org/wp-content/uploads/2023/04/maternal-health-and-abortion.pdf; Adam Thomas and Emily Monea. “The High Cost of Unintended Pregnancy,” Center on Children and Families at Brookings Institution, July 2011, https://www.brookings.edu/wp-content/uploads/2016/06/07_unintended_pregnancy_thomas_monea.pdf

To remove the hurdles Black and other marginalized communities face in accessing reproductive health care,U.S. House of Representatives, Office of Rep. Ayanna Pressley, “Pressley, Lee, Degette, Schakowsky Unveil Each Act for Reproductive Justice: Bill Repeals Harmful and Discriminatory Hyde Amendment as House GOP Continue Attack on Abortion Rights,” January 26, 2023, https://pressley.house.gov/2023/01/26/pressley-lee-degette-schakowsky-unveil-each-act-for-reproductive-justice/ Congress must pass laws like the Equal Access to Abortion Coverage in Health Insurance (EACH) Act (S. 1031 and H.R. 561) to restore abortion coverage to people who receive health care or insurance through the federal government. The bill also prohibits political interference with health insurance companies that decide to offer coverage for abortion care. Federal policymakers should also pass the Women’s Health Protection Act, S. 701 and H.R. 12 to protect the right of health care providers to provide abortion care and the right for their patients to receive that care, free from medically unnecessary restrictions that single out abortion and impede access. State lawmakers must follow in the footsteps of states like Michigan and replace abortion bans with legislation that guarantees access to high-quality, affordable, culturally responsive reproductive care.National Partnership for Women & Children. “Maternal Health and Abortion Restrictions: How Lack of Access to Quality Care Is Harming Black Women,” October 2019, https://nationalpartnership.org/wp-content/uploads/2023/04/maternal-health-and-abortion.pdf

 

Eliminate Economic Inequities

Black women face wealth and income gaps that negatively impact economic outcomes. These gaps remain due to a stark history of deliberate policy choices based in white supremacy, systemic racism, sexism, misogynoir, and ableism, designed to keep Black women and other women of color in poverty. According to 2019 data, the median wealth, excluding vehicles, for non-Hispanic Black women was $1,700, compared to $298,000 for non-Hispanic white men.Mariko Chang, Ana Hernández Kent, and Heather McCulloch. “Section I: Understanding the Gender Wealth Gap, and Why It Matters,” The New Baseline: The State of Family Wealth and Wealth Inequality Today, Federal Reserve Bank of St. Louis and the Aspen Institute’s Financial Security Program, July 2021, https://live-future-of-building-wealth.pantheonsite.io/wp-content/uploads/2021/09/Sec1-Ch5-Chang-Kent-McCulloch.pdf Several factors have contributed to this wealth gap, including, but not limited to, lower incomes, increased debt (including medical and student loans),Justyce Watson and Ofronama Biu. (2022, July 1). “You Can’t Improve Black Women’s Economic Well-Being without Addressing Both Wealth and Income Gaps,” Urban Institute, July 1, 2022, https://www.urban.org/urban-wire/you-cant-improve-black-womens-economic-well-being-without-addressing-both-wealth-and lending discrimination, and redlining that has deprived Black families of generational wealth.Rashawn Ray, Andre M. Perry, David Harshbarger, Samantha Elizondo, and Alexandra Gibbons. “Homeownership, Racial Segregation, and Policy Solutions to Racial Wealth Equity,” Brookings Institution, September 1, 2021, https://www.brookings.edu/articles/homeownership-racial-segregation-and-policies-for-racial-wealth-equity/

Black women are integral to the American workforce, yet they have faced generations of inequities in the labor market. The COVID-19 pandemic further exposed and exacerbated these inequities: Black women were overrepresented in low-paying service jobs and hit hardest by job loss.Mathilde Roux. “5 Facts About Black Women in the Labor Force.” U.S. Department of Labor Blog, August 3, 2021, https://blog.dol.gov/2021/08/03/5-facts-about-black-women-in-the-labor-force And while Black women have among the highest labor-force participation rate of all women (62.0 percent in 2022, compared to 58.1 percent for women overall), Black women experience higher rates of unemployment (5.6 percent in 2022, compared to 3.3 percent for women overall).Mathilde Roux. “5 Facts About Black Women in the Labor Force.” U.S. Department of Labor Blog, August 3, 2021, https://blog.dol.gov/2021/08/03/5-facts-about-black-women-in-the-labor-force A National Partnership for Women & Families analysis reveals that nearly two-thirds (62 percent) of Black women who have given birth in the last 12 months are employed.Amanishakete Ani. “C-Section and Racism: ‘Cutting’ to the Heart of the Issue for Black Women and Families” Journal of African American Studies, December 2015, https://www.jstor.org/stable/44508234

Economic policies impact the health outcomes of pregnant and postpartum Black women and birthing people. In a 2022 Financial Health Network study, only one-third of respondents working in low-wage jobs reported receiving employer-sponsored health insurance.Financial Health Network. “Financial Health of Workers in Low-Wage Jobs,” July 28, 2022, https://finhealthnetwork.org/research/financial-health-of-workers-in-low-wage-jobs/ Even with employer-sponsored insurance, more than one-third of respondents reported skipping medication or not seeking health care within the last 12 months.Financial Health Network. “Financial Health of Workers in Low-Wage Jobs,” July 28, 2022, https://finhealthnetwork.org/research/financial-health-of-workers-in-low-wage-jobs/ With Black women more likely to be in these low-wage roles, inability to access health care based on employment status and other economic factors increases the risk for maternal mortality and morbidity.Theresa Chalhoub and Kelly Rimar. “The Health Care System and Racial Disparities in Maternal Mortality,” Center for American Progress, May 10, 2018, https://www.americanprogress.org/article/health-care-system-racial-disparities-maternal-mortality/ Housing and nutritional concerns also impact outcomes for pregnant and postpartum women and birthing people.American Public Health Association. “Reducing U.S. Maternal Mortality as a Human Right,” November 1, 2011, https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/11/15/59/reducing-us-maternal-mortality-as-a-human-right Our research shows that Black women who have recently given birth are significantly more economically insecure, which can further impact postpartum health outcomes. Sixty percent of Black women who have given birth in the last 12 months were economically insecure, compared to 41 percent of women overall and 31 percent of white, non-Hispanic women.See note 9. While people across the income spectrum may have difficulty making ends meet, in this analysis we define “economically insecure” as living in a family below 200 percent of the federal poverty line. For ease of comprehension, these percentages are not limited to people in the Census-defined poverty universe but figures differ by less than a percentage point if limited to that population.

Close the Wage Gap

Women of color are overrepresented in minimum wage and other low-paying jobs due to continued systemic discrimination and worker exploitation.Bixby Center for Global Reproductive Health and University of California San Francisco Advancing New Standards in Reproductive Health. “Turnaway Study,” accessed October 9, 2023, https://www.ansirh.org/sites/default/files/publications/files/turnaway_study_brief_web.pdf; National Partnership for Women & Families. “Threats on All Fronts: The Links Between Lack of Abortion Access, Health Care, and Workplace Equity,” August 2022, https://nationalpartnership.org/report/threats-on-all-fronts/ The National Partnership for Women & Families found that low and unfair wages undermine people’s ability to parent their children safely and sustainably, to make a better life for themselves and their families, and to care for, and make decisions about, their own health and reproductive lives.Asees Bhasin. “Minimum Wage and Abortion Access: Getting What You (Can’t) Pay For,” National Partnership for Women & Families, August 2021, https://nationalpartnership.org/wp-content/uploads/2023/02/minimum-wage-and-abortion.pdfNational Partnership for Women & Families. “Threats on All Fronts: The Links Between Lack of Abortion Access, Health Care, and Workplace Equity,” August 2022, https://nationalpartnership.org/report/threats-on-all-fronts/ Our analysis shows that, if the wage gap were eliminated, on average, a Black woman worker would have enough money for about two years of child care.National Partnership for Women & Families. “Quantifying America’s Gender Wage Gap by Race/Ethnicity,” September 2023, https://nationalpartnership.org/wp-content/uploads/2023/02/quantifying-americas-gender-wage-gap.pdf

The wage gap harms Black women and their families

  • Nearly 70 percent of Black mothers are primary or sole breadwinners.Sarah Jane Glynn. “Breadwinning Mothers Continue to Be the U.S. Norm,” Center for American Progress, May 10, 2019, https://www.americanprogress.org/article/breadwinning-mothers-continue-u-s-norm/
  • Black mothers with children under 18 have the highest labor-force participation of all mothers.Mariko Chang, Ana Hernández Kent, and Heather McCulloch. “Section I: Understanding the Gender Wealth Gap, and Why It Matters,” The New Baseline: The State of Family Wealth and Wealth Inequality Today, Federal Reserve Bank of St. Louis and the Aspen Institute’s Financial Security Program, July 2021, https://live-future-of-building-wealth.pantheonsite.io/wp-content/uploads/2021/09/Sec1-Ch5-Chang-Kent-McCulloch.pdf
  • Even when they are employed, Black women face a wage gap: Black women are only paid 66 cents for every dollar earned by white, non-Hispanic men.Vasu Reddy. “Attention Employers: The Pregnant Workers Fairness Act Is Now the Law of the Land,” National Partnership for Women & Families, March 2023, https://nationalpartnership.org/attention-employers-the-pregnant-workers-fairness-act-is-now-the-law-of-the-land/ This gap is particularly large after giving birth. A National Partnership for Women & Families analysis shows that Black women who are employed the year after they have given birth are paid 50 cents for every dollar paid to white, non-Hispanic men of the same age group.See note 9: Figures compare median earnings for all workers with positive earnings age 16-50.

Congress must address this disparity by strengthening equal-pay legislation and raising the national minimum wage to at least $17 an hour.

 

Pass a National Paid Leave Policy

Paid maternity leave improves maternal and infant health, including physical health and well-being.Sarah Coombs. “Paid Leave Is Essential for Healthy Moms and Babies,” National Partnership for Women & Families, May 2021. https://nationalpartnership.org/report/paid-leave-is-essential-for/ Despite these clear, positive outcomes, the United States is one of the few high-income countries without a national paid leave policy. Black and low-wage workers bear the brunt of the inequity: They are less likely than white workers to have any paid leave, due in part to systemic racism that has resulted in stark health and economic inequities. For example, Black women are more likely to work in low-paying or part-time jobs, which are less likely to offer paid leave policies.Jessica Mason and Katherine Gallagher Robbins. “Women’s Work Is Undervalued, and It’s Costing Us Billions,” National Partnership for Women & Families, March 2023, https://nationalpartnership.org/wp-content/uploads/2023/04/womens-work-is-undervalued.pdf; Robin Bleiweis, Jocelyn Frye, and Rose Khattar. “Women of Color and the Wage Gap,” November 17, 2021, Center for American Progress, https://www.americanprogress.org/article/women-of-color-and-the-wage-gap/

A National Partnership for Women & Families analysis shows that Black women who have recently given birth are less likely to live in a state with paid leave. Seventeen percent of Black women who have given birth in the last 12 months live in states that have implemented mandatory paid family and medical leave, compared to 27 percent of women overall and 22 percent of white, non-Hispanic women.States that have implemented mandatory paid family and medical leave include CA, CT, DC, MA, NJ, NY, OR, RI, and WA. Additional states have passed paid leave but the laws are not yet in effect. Some states also have paid sick leave laws which can provide important time off for medical appointments that positively contribute to maternal health. “Paid Sick Days Statutes,” https://nationalpartnership.org/wp-content/uploads/2023/02/paid-sick-days-statutes.pdf, October 2023, National Partnership for Women & Families; and “State Paid Family & Medical Leave Insurance Laws,” https://nationalpartnership.org/wp-content/uploads/2023/02/paid-sick-days-statutes.pdf, October 2023, National Partnership for Women & Families The introduction of paid maternity leave in California, Hawaii, New Jersey, New York, and Rhode Island led to a reduction in low birthweight and preterm births, especially for Black mothers.Emily DiMatteo, Osub Ahmed, Vilissa Thompson, and Mia Ives-Rublee. “Reproductive Justice for Disabled Women Ending Systemic Discrimination,” Center for American Progress, April 13, 2022, https://www.americanprogress.org/article/reproductive-justice-for-disabled-women-ending-systemic-discrimination/

Policymakers must pass the Family and Medical Insurance Leave (FAMILY) Act (s. 1714 and H.R. 3481), which guarantees access to paid leave to meet the needs of pregnant people, caregivers, and families. Until a comprehensive federal paid leave law is passed, states and businesses should join those that have created or expanded paid leave programs. Employers should consider supplementing the baseline benefit provided through the existing Family and Medical Leave Act by providing additional weeks of leave or supplementing the amount of wage replacement employees receive.

 

Implement Pregnant Worker Accommodations

Based on data from 2011 to 2015, Black women represent a disproportionate share of workplace pregnancy discrimination claims. These claims include being fired for taking parental leave, being denied, or not offered maternity leave, enduring physically taxing work conditions or extreme levels of manual labor while pregnant, and being denied promotions or raises due to pregnancy.Emily DiMatteo, Osub Ahmed, Vilissa Thompson, and Mia Ives-Rublee. “Reproductive Justice for Disabled Women Ending Systemic Discrimination,” Center for American Progress, April 13, 2022, https://www.americanprogress.org/article/reproductive-justice-for-disabled-women-ending-systemic-discrimination/

Reasonable accommodations will be critical to Black women’s ability to work safely and free from discrimination for the duration of their pregnancy and postpartum. Many pregnant people are willing and able to continue working during their pregnancy, but may require modest adjustments at work to do so safely. All too often, however, these adjustments are denied. Accommodations are especially relevant to Black pregnant people, who are disproportionately represented in the types of physically demanding, low-wage jobs that, without accommodation, can pose significant risks to pregnancy.

The Pregnant Workers Fairness Act, which took effect in June 2023, requires employers to provide reasonable accommodations to employees due to pregnancy, childbirth, or related medical conditions, unless doing so would be an undue hardship for the employer.National Partnership for Women & Families. “Threats on All Fronts: The Links Between Lack of Abortion Access, Health Care, and Workplace Equity,” August 2022, https://nationalpartnership.org/report/threats-on-all-fronts/ Businesses and other institutions should follow the law in a thorough and thoughtful manner that minimizes the burden to pregnant employees exercising their rights under the law.

Collect Intersectional Data for Disabled Black Birthing People

Black civil rights advocate Kimberlé Crenshaw coined the word intersectionality to describe the ways multiple forms of inequality compound and create obstacles for those with multiple marginalized identities.Kimberlé Crenshaw. “Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics,” University of Chicago Legal Forum, December 7, 2015, https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8/ Applying this framework, the National Partnership for Women & Families recognizes that Black disabled people are more likely to experience adverse birth outcomes than nondisabled or non-Black people.Caroline Signore, Maurice Davis, Candace M. Tingen, and Alison N. Cernich. “The Intersection of Disability and Pregnancy: Risks for Maternal Morbidity and Mortality,” Journal of Women’s Health, February 2, 2021, https://doi.org/10.1089/jwh.2020.8864 Pregnant women with disabilities have a much higher risk for severe pregnancy- and birth-related complications and death than other pregnant women.U.S. National Institutes of Health. “NIH Study Suggests Women with Disabilities Have Higher Risk of Birth Complications and Death,” December 15, 2021, https://www.nih.gov/news-events/news-releases/nih-study-suggests-women-disabilities-have-higher-risk-birth-complications-death However, we need additional research and data on the intersection of disability, gender, race, and other identities, in order to improve policies for Black, disabled birthing people.Emily DiMatteo, Osub Ahmed, Vilissa Thompson, and Mia Ives-Rublee. “Reproductive Justice for Disabled Women Ending Systemic Discrimination,” Center for American Progress, April 13, 2022, https://www.americanprogress.org/article/reproductive-justice-for-disabled-women-ending-systemic-discrimination/

Birthing people with disabilities face unique challenges accessing care. They often have to deal with health care providers who lack the knowledge or are uncomfortable managing their pregnancies, which can result in heightened risk of pregnancy-related complications.Jessica L. Gleason, Jagteshwar Grewal, Zhen Chen, Alison N. Cernich, and Katherine L. Grantz. “Risk of Adverse Maternal Outcomes in Pregnant Women with Disabilities,” JAMA Network Open, December 15, 2021, http://www.doi.org/10.1001/jamanetworkopen.2021.38414; National Center for Health Workforce Analysis. “State of the Maternal Health Workforce Brief,” August 2022, https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/dataresearch/maternal-health-workforce-brief-2022.pdf This lack of knowledge, as well as discrimination within health care, can create a number of barriers, including inadequate resources to support their health, little or no institutional readiness, lack of proper or working equipment or accessible signage, and insufficient staff training or other required modifications or supports.Jessica L. Gleason, Jagteshwar Grewal, Zhen Chen, Alison N. Cernich, and Katherine L. Grantz. “Risk of Adverse Maternal Outcomes in Pregnant Women with Disabilities,” JAMA Network Open, December 15, 2021, http://www.doi.org/10.1001/jamanetworkopen.2021.38414; National Center for Health Workforce Analysis. “State of the Maternal Health Workforce Brief,” August 2022, https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/dataresearch/maternal-health-workforce-brief-2022.pdf The challenge is compounded for Black, disabled birthing people, who already experience medical racism.

Decision makers must commit to collecting standardized data on disability status, in addition to disaggregated race/ethnicity (with subgroups) and sexual orientation and gender identity data, as well as how these identities interact with each other, so that we can understand and solve for inequalities and their root causes. Hospital leaders should assess their current capability to effectively and respectfully serve specific groups of people who wish to become pregnant, are currently pregnant, or have recently given birth, including people with disabilities. Hospital systems should allocate the necessary budgets to improve institutional readiness and accessibility to exemplary maternity services.

 

By Venicia Gray, Stephanie Green, Ariel Adelman, and Blen Asres

The authors are grateful to Marissa Dikowsky, Sinsi Hernández-Cancio, Erin Mackay, Anwesha Majumder, Jaclyn Dean, Vasu Reddy, Jessi Leigh Swenson, and Carol Sakala for their review and thoughtful comments. With deep gratitude to Katherine Gallager Robbins for her data analysis.

This issue brief was made possible thanks to the generous support of the Skyline Foundation.

 

Read the 2-page fact sheet that accompanies this issue brief.

To access the 2018 version of this issue brief, click here.