Racial Disparities in Maternal Health: Understanding Structural Factors and Opportunities for Change

By Birth & Baby University · Last updated: October 2026 · 7 min read

Black women in the United States die from pregnancy-related causes at a much higher rate than White women, and American Indian and Alaska Native women also face higher rates. These gaps are among the best documented in maternal health. Why they persist is harder to answer, and the research is careful to separate what is measured from what is inferred. This article reviews what the data show, which structural explanations have evidence behind them, where the evidence is thin, and what a doula can and cannot do about it.

Key takeaways

Quick answer: the disparities are large, they persist across age and education, and the research points to differences in where and how care is delivered, plus social and structural conditions, instead of individual behavior. No single factor explains the gap, and doula care is one possible support, not a fix.

• In the National Center for Health Statistics’ 2024 data, the maternal mortality rate was 44.8 per 100,000 live births for Black non-Hispanic women and 14.2 for White non-Hispanic women.
• A Centers for Disease Control and Prevention (CDC) analysis of 2007 to 2016 found that Black and American Indian and Alaska Native women with at least some college education had higher pregnancy-related mortality ratios than women of other racial and ethnic groups who had not finished high school.
• Hospital-level differences contribute to disparities in severe maternal morbidity, according to a national study, but they do not explain all of it.
• Experiences of mistreatment are also reported more often by women of color, which matters for trust, though the survey does not measure clinical outcomes.

What the numbers show

NCHS Health E-Stat 113 reports a 2024 maternal mortality rate of 44.8 per 100,000 live births for Black non-Hispanic women, compared with 18.1 for Asian non-Hispanic women, 14.2 for White non-Hispanic women and 12.1 for Hispanic women. The report notes that rates fluctuate year to year because the events are relatively few. Our companion article on what the national maternal mortality data reveal explains the definitions behind these figures.

Earlier CDC work by Petersen and colleagues (2019) analyzed pregnancy-related deaths from 2007 to 2016. Pregnancy-related mortality ratios were 40.8 per 100,000 live births for non-Hispanic Black women and 29.7 for non-Hispanic American Indian and Alaska Native women, compared with an overall ratio of 16.7. The gap persisted over time and across age groups. For Black and American Indian and Alaska Native women aged 30 and older, the ratio was approximately four to five times that of their White counterparts. Black and American Indian and Alaska Native women with at least some college education had higher ratios than women of all other groups who had not completed high school, which tells us the disparity is not explained by education alone. The authors also reported significant differences in the causes of death across groups, and recommended action at the community, health facility, patient, provider and system levels.

Structural explanations with evidence behind them

Where care happens. Howell and colleagues (2016) analyzed a national inpatient sample from 2010 and 2011. Seventy-four percent of Black deliveries occurred at hospitals with high or medium proportions of Black patients. Severe maternal morbidity occurred more often among Black women than among White women (25.8 versus 11.8 per 1,000 deliveries before adjustment), and after adjusting for patient characteristics and comorbidities the gap narrowed but remained (18.8 versus 13.3). Hospitals serving higher proportions of Black patients had higher rates of severe morbidity, and Black women at those hospitals had the highest risk of poor outcomes. The authors concluded that quality improvement at these hospitals could improve care for all deliveries and disproportionately help Black women. The study is based on 2010 and 2011 data, so it describes a pattern that needs rechecking against newer data.

Social and structural conditions. Crear-Perry and colleagues (2021) reviewed the literature on social and structural determinants of maternal health. They argue that the term “social determinants” has lost meaning through misuse, and that understanding the forces behind the distribution of conditions, including racism, classism and gender oppression embedded in social and political structures, is needed to explain the inequities. This is a review and an argument built on the literature, not a trial. It offers practice and policy proposals instead of causal estimates.

Experiences of care. In the Giving Voice to Mothers study (Vedam and colleagues, 2019), 17.3 percent of 2,138 survey respondents reported one or more types of mistreatment, such as loss of autonomy, being shouted at or threatened, or being ignored. Rates were higher for women of color: for example, 27.2 percent of women of color with low socioeconomic status reported mistreatment versus 18.7 percent of White women with low socioeconomic status. Mistreatment was also more common in hospital births (28.1 percent) than home births (5.1 percent). The study is a self-selected online survey, so it cannot give national prevalence, and it measures experience, not clinical outcomes.

What the evidence cannot tell us

• Cause and effect. Most of this literature is observational. It documents patterns and tests associations, but it cannot prove that a given structural factor produces a given gap.
• Single explanations. The hospital study narrowed the gap but did not close it after adjustment, and the education finding rules out simple socioeconomic explanations. Other explanations remain under study, and these sources do not rank them.
• Dated data. The Petersen analysis covers 2007 to 2016 and the hospital study 2010 to 2011. Current NCHS figures show the disparity continuing, but the mechanisms need current evidence.

What this means for doulas

• Stay in scope. Doulas offer emotional, physical and informational support. They do not diagnose, treat or make care decisions, and they cannot fix hospital quality or structural racism. Their contribution is one piece of a larger response.
• Take reports seriously. If a client says they were not listened to, or that their symptoms were dismissed, write down what they describe in their own words, and help them raise it with their care team or through the facility’s patient advocate process.
• Know the warning signs. The CDC Hear Her campaign lists urgent maternal warning signs for pregnancy and the year after birth. Share the list and encourage prompt care when any appear.
• Know your community’s care options. Where there is a choice of hospital, midwife or clinic, help families find reliable information, such as quality reports or patient reviews, and let them decide.
• Be honest about what doula care can do. Our article on whether doula support can help address disparities reviews that evidence, with its limits.

Putting it into practice

1. Learn the local picture: which hospitals and clinics your clients use, and what patient safety and respectful care resources they offer.
2. Practice language for supporting clients who want to ask questions or request clarification without making medical decisions for them.
3. Offer every client the same written warning-sign list and postpartum follow-up reminders.
4. Reflect on your own assumptions. Training in cultural humility and trauma-informed care helps, and our article on trauma-informed doula care is a starting point.
5. Keep records of referrals and what clients tell you, within your agreement and privacy rules.

Limits and uncertainty

The evidence here combines surveillance data, observational studies, a survey and a narrative review. Each has limits, noted above. The hospital study and the CDC analysis are from before 2017, the Giving Voice to Mothers survey was not a random sample, and the review by Crear-Perry and colleagues gives a framework and recommendations, not tested solutions. Disparities are also not limited to Black and American Indian and Alaska Native women: rates for other groups vary by age, place and cause. Check current CDC and NCHS releases before quoting numbers.

The bottom line

Racial disparities in maternal health are real, large and persistent, and the best evidence points to care settings and social and structural conditions. Doulas can support families with information, presence and referrals, but responsibility for change rests with health systems and policy. A doula who knows the evidence can speak accurately about it and work respectfully within the limits of the role.

Birth & Baby University’s For Doulas page outlines its online, self-paced birth and postpartum doula training, recertification and mentorship, for those building their skills to support families.

This article is for professional education. It is not medical, legal, financial or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• Hoyert DL. Maternal Mortality Rates in the United States, 2024. NCHS Health E-Stats 113 (March 2026). Read the source
• Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths, United States, 2007-2016. MMWR (2019). Read the source
• Howell EA, Egorova N, Balbierz A, Zeitlin J, Hebert PL. Black-white differences in severe maternal morbidity and site of care. American Journal of Obstetrics and Gynecology (2016). Read the source
• Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, et al. Social and structural determinants of health inequities in maternal health. Journal of Women’s Health (2021). Read the source
• Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reproductive Health (2019). Read the source
• Centers for Disease Control and Prevention. Urgent Maternal Warning Signs (Hear Her campaign; page last reviewed May 15, 2024). Read the source

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