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Thesis
Racial gaps in pregnancy-related deaths in the United States can't be closed by focusing only on individual patients' risk factors. Health systems and policymakers must address structural racism directly, because the evidence shows that the gaps persist regardless of education and age.
The scale of the disparity
About 700 women die each year in the United States from pregnancy or its complications. Analyzing CDC surveillance data for 2007 to 2016, Petersen et al. (2019) found an overall pregnancy-related mortality ratio of 16.7 deaths per 100,000 live births. The ratio was 40.8 for non-Hispanic Black women and 29.7 for American Indian/Alaska Native women, higher than for all other groups. The disparity persisted over time and across age groups.
Argument 1: Education and age don't explain the gap
If differences in deaths reflected only individual factors, such as education, the gap would narrow among women with more education. It doesn't. Black and American Indian/Alaska Native women with at least some college education had higher pregnancy-related mortality ratios than women in all other racial and ethnic groups who had less than a high school diploma, and among women aged 30 or older, their ratios were about four to five times those of White women (Petersen et al., 2019).
Argument 2: Structural racism provides an explanation that fits the evidence
Bailey et al. (2017) define structural racism as the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care and criminal justice. These systems shape where women live, their insurance coverage, which hospitals they give birth in, and whether their concerns are taken seriously. The authors argue that focusing on structural racism offers a concrete and promising route to advancing health equity.
Argument 3: System-level strategies are available
Petersen et al. (2019) call for strategies at the community, health facility, patient, provider and system levels. Examples include:
- Health facilities: standardized protocols for obstetric hemorrhage and severe hypertension, applied to every patient, which reduce the room for unequal treatment; reviewing outcomes by race to find gaps.
- Providers: training on listening to and acting on patients' reported symptoms, especially in the postpartum period.
- Systems and policy: continuous insurance coverage through the year after birth; support for community-based doulas and midwives; and investment in maternity care in under-resourced areas.
Counterarguments and responses
"The differences are due to underlying health conditions." Chronic conditions such as hypertension do contribute, but their unequal distribution is itself shaped by structural factors like neighborhood resources and access to care. Treating them as purely individual risks ignores their causes.
"Naming racism is divisive and doesn't change care." Avoiding the term doesn't change the data. Bailey et al. (2017) argue that naming structural racism points to specific, measurable targets, such as hospital quality in neighborhoods with mostly Black residents and coverage gaps after birth.
Conclusion
The persistence of racial gaps across education and age points beyond individual risk to the systems surrounding women before, during and after pregnancy. DNP-prepared nurses, who lead quality improvement and policy work, are well placed to put structural solutions into practice and to measure whether they close the gap.
References
Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453–1463. https://doi.org/10.1016/S0140-6736(17)30569-X
Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/ethnic disparities in pregnancy-related deaths — United States, 2007–2016. MMWR Morbidity and Mortality Weekly Report, 68(35), 762–765. https://doi.org/10.15585/mmwr.mm6835a3
