Birth Equity Requires Hard Truths and New Leadership

January 14, 2021

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

In the wake of the COVID-19 pandemic, the United States is finally experiencing a cultural shift in consciousness and awareness of racial disparities. And meanwhile, the maternal health community’s reckoning with racism is accelerating.

Black women in the United States die from pregnancy-related complications at three-to-four times the rate of white women. This stark mortality has embedded itself within Black and Indigenous communities throughout the US. To examine what leads to these inequitable outcomes, we must look at their root causes… and root them out. Previous thinking about racial disparities in maternal health outcomes pointed to differences in behavior, genetics, failure of Black women’s reproductive capabilities, and other erroneous assumptions. However, burgeoning evidence demonstrates that these disparities have little to do with race itself and instead, all to do with racism.

When maternal healthcare solutions ignore the existence of systematic racism, equity action plans are ineffective for Black birthing people. It is important to consider how well-intentioned maternal health interventions reinforce racism by ignoring the pervasiveness and impact of racism when working to reduce maternal mortality.

Several factors define Black women’s experience with maternal health in the United States:

  • Control of Black women’s bodies for monetized value;
  • Medical racism; and
  • Mistreatment of Black women’s lives and experiences. 

Since the first enslaved African women were brought to the United States, Black women’s reproductive capacity has been defined by its value for white society. This legacy lingered after the abolition of slavery with continued medical mistreatment and experimentation (e.g. forced gynecological research participation, female partners of those in the Tuskegee experiment, Henrietta Lacks, and other unconsented medical practices).

Unique to Black women’s experience is the fact that Black women’s reproductive capacity was utilized to generate centuries of unpaid workers to build the economy. Once Black women’s bodies could no longer be commoditized, the eugenics movement painted Black women as sexually depraved and unfit, popularizing social control of Black women, which carries through to today.

What is Reproductive Justice?

Racism is a root cause of inequities. And improving the maternal healthcare system for all requires a commitment to anti-racism and Black women-led solutions. One of these solutions lies within Reproductive Justice, a Black women-led framework and global movement.

SisterSong defines Reproductive Justice as the following:

The human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.

The founders of the Reproductive Justice framework sought to utilize a broad definition, highlighting the socio-political and economic conditions that dictate women’s reproductive health outcomes. This framework shifts from blaming women for poor health outcomes to system-level accountability for programs/policies that directly impact quality of care and accessibility of healthcare services necessary for individuals to achieve positive health outcomes. Reproductive Justice advocates are the providers in our community who understand and acknowledge the annihilation of midwifery care by our medical system—an urgent need for Black birthing people that must be educated and legislated back into place.

Reproductive Justice forces acknowledgement that social determinants of health are dictated by upstream factors and are held firmly in place by societal and structural belief systems—by racism, policies, practices, leadership, and organizational governance.

At the root of Reproductive Justice is the belief that all people have fundamental human rights and should be supported by governments and health systems to achieve the best possible health outcomes across the reproductive lifespan. Applying these basic frameworks not only ensures positive outcomes for Black women and other marginalized groups but can also improve health outcomes for all birthing people.

Moving towards birth equity

Poor outcomes are preventable, yet our approaches to addressing maternal mortality look to organizations to generate solutions to problems they are complicit in generating. So, how do we move towards birth equity?

First, we expand the existing models of health equity. There is a need for advanced theoretical models of care and quality—informed by actual patients—to support intentional patient engagement in systems, inform advocacy, and develop educational tools to address birth equity in maternity care.

Second, we look for more solutions from Black women. Black women-centered experiences that measure quality of care should be at the center of anti-racist quality improvement initiatives. This is the most impactful thing we can do. When we look for solutions outside of the population experiencing the negative impact, we reinforce racism. When we look for solutions inside the most impacted populations, we find rich innovation, like the University of California San Francisco (UCSF) SACRED Birth and National Birth Equity Collaborative Respectful Maternity Care initiatives.

In 2018, the Black Mamas Matter Alliance developed a core set of principles describing holistic maternity care for Black women, then followed up with Black Maternal Health Research Re-Envisioned: Best Practices for the Conduct of Research With, For, and By Black Mamas in 2020.

The following are recommendations for those who provide and fund care for Black women, drawing on research and principles from the Black Mamas Matter Alliance:

  • Recognize and respect the rights of Black women;
  • Replace white supremacy and patriarchy with a new healthcare model;
  • Invest in culturally congruent providers and paraprofessionals;
  • Invest in Black women to conduct ethical research;
  • Include health equity and social justice as key themes in research; and
  • Build a system of quality care that is:
    • Accessible, confidential, safe, and trauma-informed;
    • Culturally-informed and includes traditional practices;
    • Responsive to the needs of all genders and family relationships; and
    • Provides wraparound services and connections to social services.

Now, let us envision a world without maternal health inequities. To do so, we must grapple with how we got here, and we must confront our healthcare system’s racist and repressive history related to Black women’s bodies. Undoing harm includes critically analyzing our respective organizations’ methods, funding, programming, and internal and external-facing policies. Birth equity calls upon us to uniformly identify racism as a root cause of inequities, commit to anti-racism, and enthusiastically support and disseminate Black women-led solutions.

**Feature photo obtained with standard license on Shutterstock.


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Joia Crear-Perry

Joia Crear-Perry, MD, is the Founder and President of the National Birth Equity Collaborative, which creates solutions to optimize Black maternal and infant health through training, research, policy, advocacy, and community-centered collaboration.



Carmen GreenCarmen Green, MPH, is the Vice President of Research and Strategy at the National Birth Equity Collaborative.




Inas Mahdi

Inas Mahdi, MPH, is the National Director of Training and Evaluation at the National Birth Equity Collaborative.


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