Maternal and Child Health Inequities Emerge Even Before Birth

In 2019, ZERO TO THREE and Child Trends unveiled the first-of-its-kind State of Babies Yearbook: 2019, bridging the gap between science and policy with national and state-by-state data on the well-being of America’s babies. The data were clear: the state where a baby is born makes a big difference in their chance for a strong start in life. Ensuring that our youngest children have a healthy start requires understanding the influence of race and ethnicity in the care mothers and their babies receive no matter where they are born. To do so, the State of Babies Yearbook: 2020 disaggregates national and state averages on key indicators of child well-being to explore key subgroups. This brief is focused on the serious disparities in maternal health and birth outcomes among babies and families of color.

Whether infants are born healthy and with the potential to thrive as they grow greatly depends on their mother’s well-being—not just before birth, but even prior to conception. To have a healthy pregnancy and positive birth outcomes, women and their infants require access to appropriate health care services, before, during, and after birth. Extensive data indicate serious racial and ethnic disparities in infant and maternal health care and health outcomes. For example, Black, American Indian, and Hispanic women^a are more likely than their White counterparts to receive late or no prenatal care.¹

They are also more likely to experience serious health problems² or die during or after birth from resulting complications. In comparison to White infants, Black and American Indian infants have a much higher risk of being born preterm and/or with low birthweight,³ are less likely to be breastfed,⁴ and are more likely to die within their first year.⁵

Researchers have explored connections between these disparities and factors such as poverty due to parents not earning a living wage, unemployment, or underemployment; living in under-resourced neighborhoods; or low educational attainment, and numerous studies reach the same conclusion: Even after considering the influence of these factors, racism accounts for huge differences.^6,7 Two women of different ethnicities or races—for example, a Black woman and a White woman—can have otherwise identical demographic characteristics; in this case, though, the Black woman (and her baby) is likely to experience much worse outcomes. When it comes to how mothers and their infants fare in pregnancy and delivery, race—or, more precisely, racism—matters.

This brief intentionally focuses on the experiences of both mothers and infants, whose well-being is intrinsically interdependent, although they are often considered separately. This is particularly important when it comes to babies and women of color, due to the intergenerational effects and lived experiences of racism. These factors are influential throughout pregnancy and affect their babies’ start in life. The health and well-being of mother and baby are particularly tightly interwoven during the perinatal period. This shared experience, which includes the impact of racism with the particular threats families of color face, is the subject of this brief.

We summarize evidence of serious disparities in infant and maternal outcomes and present potential strategies to ameliorate them. Underlying the stark differences in these outcomes are disparities in access to health care, the experiences women have in the health care setting, and the cumulative effects of stress (including the stress of experienced racism) on women’s health. No single strategy will sufficiently achieve greater racial equity in preconception and prenatal care and the outcomes they influence. Instead, to measurably improve these conditions, which have become entrenched over many years, we must identify and address inequities on multiple fronts. States as well as federal policymakers have several opportunities to adopt policies that can address and lessen these inequities. In addition, there are a number of promising practices that programs and/or communities can implement.

We begin by reviewing the evidence of disparities, exemplified by indicators of prenatal care, preterm births, low birthweight, infant and maternal mortality, and breastfeeding, as tabulated from national data sources through September 2019 for the State of Babies Yearbook: 2020.^b Next, we explore possible causes of these disparities, drawing from the literature on 1) the effects of stress related to institutional and interpersonal racism and poverty on women’s health, 2) the impact of differential access to medical care and other family support services, and 3) the differential experiences of women with the medical care system.

Finally, we review existing policies and programs that may help to address these disparities (e.g., Medicaid; the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]; paid family and medical leave; home visiting programs). We also discuss a set of promising practices states can pursue to further examine and address these disparities.