Understanding Social Determinants of Health in Pregnancy and Postpartum Care

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

Two clients can follow the same prenatal advice and have very different experiences, because one has reliable transportation, stable housing and paid leave, and the other does not. The term for those surrounding conditions is “social determinants of health.” The idea is widely used in maternity care, but research on what to do about it is more uneven than the vocabulary suggests. This article explains the concept, what studies show about social needs in pregnancy and postpartum, where screening and referral have fallen short, and how doulas can use the framework without stepping outside their role.

Key takeaways

Quick answer: social determinants of health are the conditions in which people are born, live, learn, work and age that affect health. In pregnancy, higher levels of unmet social need are associated with more adverse outcomes, but screening alone has not been shown to change outcomes, and clinicians report unclear roles and inconsistent follow-up.

• Healthy People 2030 groups social determinants into five domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.
• In a study of 320 Black and Latina pregnant people, each one-point rise in a composite social needs score was associated with 11 percent higher odds of an adverse pregnancy outcome.
• In a hospital study, nearly one in four people screened positive for a social need, yet screening positive was not associated with whether they later linked to ongoing care.
• An umbrella review found most reviews of interventions for pregnant women facing disadvantage were of critically low or low quality, so the evidence for what works is thin.

What the term means

The U.S. Department of Health and Human Services’ Healthy People 2030 defines social determinants of health as the conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. It sorts them into five domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

The American College of Obstetricians and Gynecologists’ Committee Opinion 729 (2018) says that awareness of these broader contexts supports respectful, patient-centered care that incorporates lived experience, improves communication and can help reduce inequities. It also notes that these factors are shaped by historical, social, political and economic forces. The opinion is guidance for clinicians, and this article draws only on its abstract because the full text was not available.

What studies show about social needs in pregnancy

Association with adverse outcomes. Belak and colleagues (2025) asked 320 Black and Latina pregnant people to complete a Centers for Medicare & Medicaid Services-endorsed screening tool covering 13 domains of health-related social needs. Among them, 119 (37.2 percent) had at least one adverse pregnancy outcome. Each one-point increase in the composite score was associated with 11.0 percent higher odds of an adverse outcome, and a score of 7 or higher, compared with 0 to 4, was associated with 2.34 times the odds. The study is a single-site cohort and reports association, not cause. The authors suggest that pregnancy may be an opportunity to identify and address these needs.

Screening and what follows. Murray Horwitz and colleagues (2025) analyzed 4,941 people who received prenatal care and delivered at an urban safety-net hospital with routine screening during pregnancy and up to six weeks postpartum. Nearly one in four screened positive for a social need, and 53 percent linked to ongoing care after pregnancy. Linkage was similar for those who screened positive and those who screened negative (adjusted risk ratio 1.04, 95 percent confidence interval 0.98 to 1.10), and lower among those who were not screened (0.77). So screening positive did not predict whether someone returned for care. The abstract does not report what services followed a positive screen, and the study is from one hospital.

Clinicians’ experience. In a qualitative study of 13 physicians at an academic obstetrics clinic that serves a racially diverse, mostly Medicaid-covered population, MacEwan and colleagues (2025) found three themes: uncertainty about roles and responsibilities, inconsistent documentation of screening and referrals, and limits of clinical appointments. The authors call for assessing priorities, infrastructure and resources so screening leads to action. A small interview study cannot be generalized, but it shows why a positive screen does not guarantee help.

What is known about interventions

Vousden and colleagues (2025) conducted an umbrella review of 36 systematic reviews (covering 734 primary studies) of interventions to reduce inequalities for pregnant women facing disadvantage in high-income countries. Most reviews were of critically low or low quality. Most interventions targeted single social exposures and individual behavior. There was potential benefit from home-based interventions, psychosocial interventions, models of maternity care and interdisciplinary programs for some groups. The authors call for higher-quality research, and women with lived experience who were consulted said interventions should also account for culture, past trauma, housing and finances.

A 2026 systematic review (Samara and colleagues, 2026) of 44 U.S. studies grouped barriers to maternal care into financial, systemic, educational, geographical and comorbidity-related categories, and listed doulas and translators among promising healthcare workers. It is a synthesis of mixed study types, and the finding about doulas does not tell us the size of any effect.

What this means for doulas

• Use the framework to understand, not to label. If a client misses appointments or does not follow a plan, ask what is in the way before assuming anything about their motivation.
• Doulas do not screen clinically or treat. But a doula can listen, notice a need such as unreliable transportation or food worries, and tell the care team, with the client’s permission. The doula’s job is to connect, not to resolve.
• Keep a current resource list. Include local food assistance, housing help, transportation programs, lactation support and behavioral health services, and confirm contact details regularly.
• Support follow-through. Given that a positive screen did not predict return to care in the hospital study, practical help with scheduling, transport and reminders may matter. That is a reasonable practice idea, not a proven effect.
• Be honest. You cannot fix housing or income. Say so, and focus on what the client wants.

Putting it into practice

1. Add open-ended prompts to your intake and postpartum check-ins: “What would make the next few weeks easier?” or “Is anything getting in the way of getting to appointments?”
2. Ask permission before sharing anything with the care team, and record what was shared.
3. Build a local resource sheet with short descriptions and a date it was last checked.
4. Review your referral process: who do you contact, how, and what do you do if there is no reply?
5. Read our related article on trauma-informed doula care to see how choice and control apply to these conversations.

Limits and uncertainty

Most of the evidence cited here is observational or qualitative and comes from specific settings, often urban safety-net or academic clinics. This article draws on the ACOG opinion’s abstract only. No source cited tests whether doula-led resource connection changes outcomes. Measures of social need also vary, and the same score can mean different things in different places. Treat the numbers as illustrations, not benchmarks.

The bottom line

Social conditions shape pregnancy and postpartum health, and unmet needs are linked with worse outcomes, but identifying a need is not the same as meeting it. For doulas, the framework is a way to listen better, refer well and support follow-through, while the larger work belongs to health systems and policy.

Birth & Baby University’s For Doulas page outlines its online, self-paced birth and postpartum doula training, recertification and mentorship, for doulas who want to build skills in client-centered support.

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

• U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social Determinants of Health. Healthy People 2030 (page read October 2026). Read the source
• Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 729: Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstetrics & Gynecology (2018). Read the source
• Belak L, James K, Rana M, et al. Association of health-related social needs with adverse pregnancy outcomes among Black and Latina individuals. Obstetrics & Gynecology (2025). Read the source
• Murray Horwitz ME, Dugas JN, McCloskey L, et al. Associations between health-related social needs and postpartum linkage to care. American Journal of Preventive Medicine (2025). Read the source
• MacEwan SR, Roth LM, Bitangacha M, et al. Physicians’ experiences screening for and addressing patients’ social needs in prenatal healthcare. Pregnancy (2025). Read the source
• Vousden N, Geddes-Barton D, Hanley SJ, Roberts N, Knight M. Interventions to reduce inequalities for pregnant women living with disadvantage in high-income countries: an umbrella review. BMC Public Health (2025). Read the source
• Samara MN, Harry K, Barua A. Addressing the U.S. maternal health crisis: a systematic review of healthcare access barriers, disparate outcomes, and effective interventions. Frontiers in Public Health (2026). Read the source

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