Addressing Disparities: Policy Solutions for Combating the Black Maternal Health Crisis

Written by Anglecia Askew

College of Health and Human Services
Department of Health Management and Policy, University of North Carolina at Charlotte HLTH 6213: Health Policy & Leadership
March 14, 2025

There is no shortage of evidence that Black women in the U.S. are more likely to face adverse maternal health outcomes. According to the CDC (2024), Black women are three times more likely to die from a pregnancy-related cause than white women. Racial disparities in maternal mortality have been documented since collection of such data begin in 1915. While white maternal mortality rates declined after World War II, the gap widened, reaching a point in the early 1970s where Black mothers faced mortality rates four times higher than white mothers (Declercq & Zephyrin, 2020). Research indicates that these disparities increase with age and persist regardless of education or income level (Hill et al., 2024). There are numerous factors that contribute to these preventable deaths, including systemic racism, limited access to quality healthcare, chronic health conditions, and implicit bias in medical care.

Dating as far back as the 17th century, the age of slavery, Black women were expected to reproduce at a high rate to expand the labor force while also caring for their enslavers’ children.

The average enslaved woman at this time gave birth to her first child at nineteen years old and thereafter, bore one child every two and a half years... expected to put the needs of the master and his family above her own children... the slave mother returned to the fields soon after giving birth, leaving her child to be raised by others. (Hallam, n.d.)

This established a historical pattern in which Black mothers were unable to properly recover during the postpartum period, forced to prioritize the needs of others over their own, and denied the opportunity to form a nurturing connection with their children. The postpartum period, which begins immediately after birth and lasts up to six months, is a critical time for maternal recovery and infant development (Romano et al., 2010). The ability of a mother to care for her own child during this period is vital to both her well-being and the child’s development.

Adding to this trauma, many of these pregnancies were the result of sexual violence. Some estimates suggest that over 58% of all enslaved women between the ages of 15 and 30 were sexually assaulted by their enslavers and other white men (Wilson, 2021). The psychological impact of such experiences was profound—having no autonomy over own’s own body, being forced to bear children conceived through rape, lacking access to medical care during pregnancy and postpartum, and being required to return to grueling labor soon after childbirth. These historical injustices have lasting implications for Black maternal health today.

During this time, enslaved Black individuals were frequently used as medical test subjects. In the 1840s, James Sims, a white doctor in Montgomery, Alabama, began conducting experiments on enslaved Black women and girls without their consent (Equal Justice Initiative, 2019). This marked the beginning of a widespread practice in which enslaved Black women were subjected to invasive medical procedures. They were often denied anesthesia, forcibly drugged to prevent resistance, and had no ability to refuse treatment due to their enslaved status.

Both during and after slavery, Black individuals were routinely mistreated by physicians who denied them basic dignity and personhood. This mistreatment was rooted in the racist and dehumanizing myth that Black people had a higher tolerance for pain that white people (Equal Justice Initiative, 2019). As a result, implicit bias within the healthcare system and widespread medical distrust among Black communities began to take shape. Implicit bias refers to the unconscious stereotypes and attitudes that influence perceptions and decision-making in patient care (Edgoose et al., 2019). These biases have led to Black women frequently being dismissed by their doctors when reporting symptoms and seeking medical assistance, contributing to persistent disparities in healthcare.

The lack of access to quality healthcare is deeply connected to systemic racism in the U.S. and is a key factor contributing to maternal health disparities. One of the biggest barriers to healthcare access is inadequate health insurance coverage, which is unequally distributed and fuels disparities in health outcomes (Office of Disease Prevention and Health Promotion, n.d.). Without sufficient insurance, many women experience delays in receiving essential prenatal care which is crucial for ensuring a healthy pregnancy.

Black women, on average, are nearly twice as likely as white women to receive late or no prenatal care (Hill et al., 2024). When it comes to health insurance coverage, nearly one in eight Black women (12.0%) ages 19 to 64 in the U.S. lacked insurance between 2017 to 2021 (National Women’s Law Center, 2023). For pregnant woman who have never had health insurance or have had limited access to care, navigating the system to obtain coverage can be particularly challenging. Many may be unaware of the services available to them or how to access the care they need, further exacerbating health disparities.

Complications from pre-existing chronic conditions are the fastest-growing cause of maternal mortality in the U.S. These conditions include chronic respiratory disease, chronic hypertension, substance use disorders, pre-existing diabetes, chronic heart disease, chronic renal disease, human immunodeficiency virus (HIV), and chronic liver disease (Admon et al., 2017). Black women experience these health issues at disproportionately higher rates than white women. For instance, between 2017 and 2018, non-Hispanic Black or African American women were 50% more likely to have high blood pressure (hypertension) than non-Hispanic white women (Office of Minority Health, n.d.). Additionally, 59% of Black women ages 20 and over are living with some form of cardiovascular (heart) disease (American Heart Association, n.d.). Furthermore, systemic racism-related stressors contribute to increased allostatic load—the cumulative

physiological impact of chronic stress. Research indicates that the biological age of Black women (which reflects the rate of bodily aging) can be up to 10 years older than that of their white counterparts (Katella, 2023).

Medicaid and Children’s Health Insurance Program (CHIP) are federal policies that ensure maternity-related services for women who meet specific income criteria, covering them up to 60 days postpartum. In 2018, these programs funded nearly half of all births in the U.S. (Medicaid and CHIP Payment, 2023). Coverage varies by state, with some extending postpartum benefits up to 12 months. This is particularly significant as 66% of births to Black women are covered under these programs (Eckert, 2020). One challenge with this policy is that all states have not chosen to expand Medicaid, leaving some families who earn above 138% of the Federal Poverty Level (FPL) without coverage. Additionally, some states have not opted to extend postpartum care beyond the mandated 60-day period.

Another key federal policy protecting pregnant women is the Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986. This law mandates that hospitals provide emergency medical care to all patients, regardless of their ability to pay. EMTALA is especially relevant for pregnant patients experiencing complications, as it ensures necessary stabilizing treatment, which may include abortion in certain cases (Chernoby & Acunto, 2024). This law plays a crucial role in managing pregnancy-related medical emergencies and can be lifesaving. A limitation of EMTALA is that it only applies to pregnant women experiencing emergency medical situations and does not ensure access to other types of care.

More recently, The Further Consolidated Appropriations Act of 2024, passed in March, provides funding for key maternal and child health initiatives. It directs the Health Resources and Services Administration (HRSA) to develop a plan for expanding birth centers in maternity care

deserts and requires the CDC to report on maternal care surveys. The law also allocates additional funding to the CDC, HRSA, NIH and SAMHSA to improve maternal health and reduce maternal mortality rates (American Hospital Association, 2024). As with all federal funding, states will likely have discretion in how they allocate the funds, leading to variations in initiatives across different states.

Due to the complexity of this issue, change is necessary on multiple levels. Policies must tackle socioeconomic challenges, barriers to healthcare access, and implicit bias. Implementing these changes requires collaboration among various community partners. Organizations dedicated to improving outcomes for Black mothers—such as the American Hospital Association (AHA), the Black Maternal Health Caucus, and the Black Mamas Matter Alliance—are actively advocating for these reforms.

The American Hospital Association (2024) introduced the Further Consolidated Appropriations Act of 2024 and supports several key initiatives aimed at improving maternal health. They back the Preventing Maternal Deaths Reauthorization Act, a bipartisan bill that would renew federal support for state-based maternal mortality review committees and require collaboration between the CDC and HRSA to share best practices for reducing maternal deaths. Additionally, the AHA advocates for funding the Title V Maternal and Child Health Block Grant, which ensures access to quality maternal and child health care services, particularly for low- income individuals or those with limited healthcare access. They also support the Healthy Start Program, which provides assistance to high-risk pregnant women, infants, and families in communities facing high infant mortality rates and socioeconomic challenges such as poverty, education, and healthcare access.

The Black Maternal Health Caucus (n.d.) has introduced the Momnibus Act, a comprehensive package of 13 bills aimed at improving maternal health outcomes. The Act prioritizes investments in social determinants of health, extends WIC eligibility for postpartum and breastfeeding mothers, and increases funding for community-based organizations focused on promoting equity in maternal care. It also addresses the unique needs of veterans, incarcerated mothers, and those with a history of mental health conditions or substance use disorders. Additionally, the Act promotes innovative payment models to enhance maternity care quality and non-clinical support throughout pregnancy and postpartum. It emphasizes the need for improved data collection and surveillance to identify solutions to the Black maternal health crisis. Furthermore, the Act advocates for maternal vaccinations and supports community driven initiatives to mitigate climate change risks affecting mothers.

The Black Mamas Matter Alliance (2023) is dedicated to advancing Black maternal health, rights, and justice. They offer technical assistance, training, and capacity-building for grassroots organizations, maternity care service providers, academic institutions, and the public health sector. Their work focuses on fostering connections between mainstream organizations and Black women-led initiatives. By centering Black women’s leadership, they provide platforms to support, elevate, and amplify their efforts in improving maternal health outcomes.

Medicaid expansion under the Affordable Care Act (ACA) has been a significant policy in addressing the Black maternal health crisis. Before this expansion, Medicaid and CHIP provided insurance coverage to nearly 18% of nonelderly Americans, including many low-income individuals, such as children, parents, pregnant women, and those with disabilities. While federal law mandated coverage for school-age children up to 100% of the Federal Poverty Level (FPL), parental eligibility varied, with two-thirds of states setting limits below that threshold.

Furthermore, individuals without children were largely ineligible for Medicaid, with only nine states offering state-funded benefits to childless adults in 2009 (Lyon et al., 2014).

The original proposal required Medicaid expansion for non-elderly adults with incomes up to 133% of the FPL and threatened to withhold funding from states that did not comply. However, the U.S. Supreme Court ruled that the federal government could not penalize states by withholding their entire Medicaid funding for failing to implement the expansion, effectively making it optional (Mitchell, 2021). Under the expansion, states can choose to provide coverage for adults up to 138% of the FPL with an enhanced federal matching rate (KFF, 2025). For pregnant women, the coverage threshold increases to 185% of the FPL. Additionally, the expansion required states to extend postpartum coverage from 60 days to a maximum of 12 months and allowed states to offer CHIP coverage to uninsured pregnant women (Medicaid and CHIP Payment, 2023). As of February 2025, 41 states (including D.C.) have adopted Medicaid expansion, while 10 states have not (KFF, 2025).

While it is difficult to determine the exact number of pregnant women who have gained coverage under Medicaid expansion, there is no doubt that more women now have access to insurance who previously did not. This increased coverage has allowed women to prioritize their health before pregnancy, potentially reducing pregnancy-related complications. Additionally, research suggests improvements in postpartum health, with one study finding that states that expanded Medicaid experienced a 17% reduction in hospitalizations during the first 60 days postpartum compared to non-expansion states (Steenland & Wherry, 2023).

To further improve the Medicaid expansion policy, additional changes at the federal level are necessary to close existing coverage gaps and enhance maternal health outcomes. A key step would be to require all states to extend coverage to women earning up to 185% of the FPL and

provide postpartum care for a full 12 months. Additionally, a broader range of maternity services should be covered, including midwifery care, doula services, and mental health support. Attention must be given to addressing provider shortages, particularly in underserved rural and urban areas, and tackling implicit bias in healthcare. Finally, integrating social determinants of health, such as transportation, housing assistance, and nutritional support, should be prioritized as these factors significantly impact maternal health beyond clinical care.

Implementing these policy changes offers numerous benefits. Improved maternal health outcomes will result in fewer pregnancy-related complications, lower mortality rates, and better overall health for both mothers and babies. Expanding access to care will ensure that those most in need receive essential prenatal and postnatal services. Lower healthcare costs will be achieved by reducing emergency interventions, hospitalizations, and long-term health complications. Enhancing health equity by prioritizing vulnerable populations, particularly Black women, and addressing social determinants of health, will help close existing disparities. Ultimately, healthier mothers and babies will lead to better long-term outcomes, including fewer complications, increased productivity, and broader economic benefits.

However, these policy changes may also present several challenges. States will need to allocate funding to accommodate the increased demand resulting from Medicaid expansion. A rise in the number of individuals accessing care could exacerbate existing provider shortages. States that have previously opposed Medicaid expansion may continue to resist further policy changes. Additionally, implementing expanded services—such as mental health care, addressing social determinants, and ensuring continuity of care—may strain administrative systems, particularly in states with existing gaps in healthcare infrastructure.

To advance this initiative, further research and data collection are needed in states that have expanded Medicaid to provide strong, evidence-based support. Collaboration with community partners as key stakeholders is essential to align efforts and drive progress. Additionally, increasing public awareness of Medicaid expansion and its benefits for maternal health is crucial. Engaging with lawmakers to draft proposals based on successful models from expansion states will also be instrumental in moving the initiative forward.

Key decision-makers at the state level include governors and legislators, who must be persuaded of the economic and health benefits for their state. At the federal level, policymakers, focused on healthcare and maternal health will serve as essential advocates. Leaders within health departments at the federal, state, and local levels will be instrumental in implementing proposed changes. Additionally, healthcare providers and insurance stakeholders must be engaged to ensure the healthcare system can accommodate increased demand and actively participate in Medicaid coverage expansions.

To secure legislative support, it is essential to engage directly with lawmakers, providing them with evidence-based research demonstrating the economic and health benefits of these policies. Grassroots campaigns at the community level, led by maternal health advocates— especially from marginalized communities—will be crucial in raising awareness and applying public pressure on decision-makers. Partnering with organizations such as the AHA, Black Mamas Matter Alliance, and others can help build a strong coalition of supporters and leverage their platforms to drive momentum for policy change. Additionally, utilizing media engagement will be an effective way to disseminate information. By implementing these strategies, there is significant potential to improve maternal health outcomes, particularly for underserved populations, while addressing systemic disparities in care.

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