Black Mothers Die at 3x the Rate of White Mothers — In the Same Hospitals

Serena Williams — the greatest tennis player who has ever lived, a woman whose body has been trained to the tolerances of a precision instrument, whose physical awareness operates at a level most human beings will never approach — nearly died after giving birth to her daughter in September 2017, and the reason she nearly died is a story that this country has been refusing to hear for as long as Black women have been having babies in American hospitals. The day after her cesarean section, Williams felt short of breath. She knew her own history of blood clots. She told the nurse she needed a CT scan with contrast and a heparin drip. The nurse thought she was confused from pain medication. A doctor performed an ultrasound of her legs instead. Williams insisted again. They finally performed the CT scan. They found blood clots in her lungs. She had been right. She had nearly died because the people charged with saving her life did not believe her when she told them what was happening inside her own body.

If Serena Williams — famous, wealthy, insured, married, physically elite — could not get a nurse to listen to her in a hospital, what happens to the Black woman in the Medicaid ward who has no name the world recognizes, no platform from which to demand attention, no husband in the waiting room to raise his voice on her behalf? The data answers that question with a precision that should make every hospital administrator in this country unable to sleep: she dies. She dies at 2.6 to 3.5 times the rate of her white counterpart, depending on the year and the state and the specific way her death is counted, and she dies not because she is poor, not because she is uneducated, not because she failed to attend her prenatal appointments, but because the medical system in which she places the most extraordinary trust a human being can extend — the trust that says, I am handing you my body and the body of my child — does not, at some fundamental and documented level, take her pain seriously.

The Numbers That Should Haunt Us

The CDC’s Pregnancy Mortality Surveillance System has been tracking maternal deaths in the United States for decades, and the data it has produced is not ambiguous, not open to creative interpretation, not susceptible to the kind of methodological quibbling that allows uncomfortable findings to be filed away and forgotten. Black women in America die from pregnancy-related causes at a rate of approximately 55.3 per 100,000 live births, compared to 19.1 per 100,000 for white women. That disparity — roughly three to one, sometimes higher — has persisted for as long as the data has been collected. It has not narrowed over time. In some states and some years, it has widened.

What makes this statistic particularly devastating is what it does not respond to. The disparity does not disappear when you control for income. Black women with college degrees have higher maternal mortality rates than white women who never finished high school. The disparity does not disappear when you control for insurance status. Black women with private insurance die at higher rates than white women on Medicaid. The disparity does not disappear when you control for the hospital. In the same facility, delivering with the same physicians, Black women experience more severe complications and worse outcomes.

This is the fact that disables the usual explanations. If the disparity were simply about poverty, it would narrow with income. If it were about access, it would narrow with insurance. If it were about education, it would narrow with degrees. It does none of these things. Something else is operating in the space between a Black woman and her physician, something that persists regardless of how much money she has or how many credentials she carries into the examination room, and that something has been documented with a rigor that should have produced a national reckoning years ago.

“The function, the very serious function of racism is distraction. It keeps you from doing your work. It keeps you explaining, over and over again, your reason for being.”
— Toni Morrison

The Bias That Lives in the Examination Room

In 2016, a team of researchers at the University of Virginia published a study that should have been front-page news in every newspaper in the country and was instead treated as an interesting academic finding, noted and moved past. Kelly Hoffman and colleagues surveyed white medical students and residents — people who were, at the time of the study, actively training to be physicians — and found that a substantial proportion of them held demonstrably false beliefs about biological differences between Black and white patients. Forty percent of first- and second-year medical students believed that Black people’s skin is thicker than white people’s skin. Some believed that Black people’s blood coagulates more quickly. Some believed that Black people’s nerve endings are less sensitive.

These are not beliefs held by ignorant people. These are beliefs held by people enrolled in medical school in the twenty-first century, people who have passed organic chemistry and cellular biology and the MCAT, people who will, within a few years, be making life-and-death decisions about Black women in labor and delivery rooms. And the study found exactly what one would predict: the students who held these false beliefs about biological differences were more likely to rate Black patients’ pain as lower and to recommend less adequate treatment.

Apply this finding to a labor and delivery ward. A Black woman says she is in pain. The physician, operating with an unconscious bias that has been documented in peer-reviewed literature, assesses that pain as less severe than it actually is. The woman says something is wrong. The physician, whose training has not equipped him to recognize his own bias, attributes her concern to anxiety, to a low pain threshold, to the particular kind of unreliability that has been projected onto Black bodies since the days when slaveholders argued that Black people did not experience suffering in the way white people did. The woman’s preeclampsia is caught late. Her hemorrhage is responded to slowly. Her cardiomyopathy is missed entirely. And she dies, and her death is recorded as a complication of pregnancy rather than a complication of a medical system that could not bring itself to believe her.

The Conditions That Kill

The specific medical conditions that drive the disparity are well-documented, and each one tells the same story from a slightly different angle. Preeclampsia — a pregnancy complication characterized by high blood pressure and organ damage — affects Black women at a rate 60% higher than white women. The condition can progress rapidly to eclampsia, which involves seizures and can be fatal. When preeclampsia is caught early, it is manageable. When it is caught late, because a woman’s symptoms were not taken seriously or her blood pressure readings were attributed to anxiety rather than pathology, it kills.

Postpartum hemorrhage, the leading cause of maternal death worldwide, is more likely to be fatal for Black women in American hospitals, not because Black women bleed more but because the bleeding is recognized and responded to more slowly. Studies of hospital response times have documented that Black women experiencing obstetric emergencies wait longer for intervention than white women experiencing the same emergencies in the same facilities. The delay is measured in minutes, but in obstetric hemorrhage, minutes are the difference between a blood transfusion and a funeral.

Peripartum cardiomyopathy — a form of heart failure that occurs in the last month of pregnancy or in the months after delivery — affects Black women at a rate significantly higher than other groups and carries a higher fatality rate. The reasons are complex, involving both genetic predisposition and the accumulated physiological toll of living in a society that treats your body as less worthy of attention, your pain as less real, your concerns as less legitimate.

Weathering: The Body Keeps the Score

In 1992, Arline Geronimus, a researcher at the University of Michigan, proposed a hypothesis that was initially met with skepticism and has since been confirmed by a growing body of evidence. She called it “weathering” — the theory that the chronic stress of living as a Black person in America produces a cumulative physiological deterioration that accelerates aging, degrades organ systems, and creates a biological vulnerability that compounds over a lifetime. Weathering is not metaphorical. It is measurable. It shows up in telomere length, in allostatic load scores, in cortisol levels, in inflammatory markers, in the premature aging of cells and systems that should still be functioning at peak capacity.

The implications for maternal mortality are direct and devastating. A Black woman arriving at the hospital to give birth is not arriving with the same physiological baseline as a white woman of the same age, income, and education level. She is arriving with a body that has been subjected to years of elevated stress hormones, chronic inflammation, and the particular kind of hypervigilance that comes from navigating a world in which you are constantly, subtly, and sometimes not so subtly, reminded that your life is valued less. Her cardiovascular system is already under strain. Her immune function is already compromised. Her organs have already been doing more work, for longer, with less rest, than her white counterpart’s.

This does not excuse the medical system. It indicts the entire society. Weathering means that the maternal mortality disparity is not simply a product of what happens in the hospital — it is a product of everything that happens before the hospital, every day, for every year of a Black woman’s life. The microaggressions, the housing discrimination, the employment stress, the environmental racism, the vigilance, the performative composure, the thousand daily negotiations required to exist as a Black person in white spaces — all of this accumulates in the body, and the body brings it to the delivery room, and the delivery room is not equipped to recognize it, let alone address it.

“No one is more dangerous than he who imagines himself pure in heart; for his purity, by definition, is unassailable.”
— James Baldwin, Nobody Knows My Name

The Doula Solution

And now we arrive at the part of this story that matters most, because despair is not a strategy and outrage is not a program, and the women who are dying right now need something more than our indignation. They need someone in the room who will listen to them, believe them, advocate for them, and refuse to leave until they have been heard. They need doulas.

The evidence on doula care is not preliminary. It is not suggestive. It is overwhelming. A landmark study published in the Journal of Perinatal Education found that continuous doula support during labor was associated with a 39% decrease in the risk of cesarean section, a 15% increase in the likelihood of spontaneous vaginal birth, a 10% decrease in the use of pain medications, and shorter labor times. For Black women specifically, the results are even more dramatic, because doulas do something that the medical system has consistently failed to do: they listen.

Community-based doula programs targeting Black women have reported reductions in preterm birth, low birth weight, and cesarean delivery that approach and in some cases exceed 40%. The By My Side Birth Support Program in New York, the Commonsense Childbirth School of Midwifery in Florida, the SisterSong Women of Color Reproductive Justice Collective — these programs are staffed by Black women who understand, from the inside, what it means to be dismissed in a medical setting, and they serve as translators between their clients and a system that has demonstrated, through decades of data, its inability to see Black women clearly.

The mechanism is not mysterious. A doula provides continuous emotional and physical support. She knows the medical language. She knows the warning signs. She knows how to say, clearly and without the deference that the medical hierarchy demands, “This woman is telling you she is in pain. Listen to her.” She is the corrective to the bias that lives in the examination room — not by changing the physician’s unconscious beliefs, which is the work of years and may never fully succeed, but by providing an additional set of eyes, an additional voice, an additional source of authority that the physician must contend with.

California’s Proof of Concept

In 2006, California had a maternal mortality problem. Its rate was rising while other developed nations’ rates were falling, and the state did something remarkable for a government entity: it looked at the data, admitted the problem, and built a system to fix it. The California Maternal Quality Care Collaborative (CMQCC) developed a series of standardized protocols — toolkits, in their language — for the most common causes of maternal death: hemorrhage, preeclampsia, and venous thromboembolism. They trained hospitals to implement these protocols uniformly, regardless of who the patient was, what she looked like, or how the attending physician felt about her pain level.

The results were dramatic. Between 2006 and 2013, California’s maternal mortality rate declined by 55% while the national rate continued to rise. The improvement was most significant among populations that had previously experienced the worst outcomes, including Black women. The toolkit approach worked because it removed individual judgment — and individual bias — from the critical decision points where delays kill. When the protocol says to check blood pressure at specific intervals and intervene at specific thresholds, the physician’s unconscious assessment of whether this particular patient is really in danger becomes less relevant. The protocol does not care about race. It cares about numbers.

Implicit bias training has become the fashionable response to racial disparities in medicine, and the evidence on its effectiveness is mixed at best, because you cannot train a person out of biases they do not believe they hold. But you can build systems that function independently of those biases, systems that trigger automatic responses to objective measurements, systems that do not require a physician to first believe a patient is in danger before acting as though she is. California proved this. The question now is whether the rest of the country is willing to learn from it.

What Must Be Done

The solutions are not theoretical. They exist. They have been tested. They have been measured. They have been published in peer-reviewed journals and presented at medical conferences and endorsed by the American College of Obstetricians and Gynecologists. Medicaid coverage of doula services, which several states have now implemented, makes continuous labor support available to the women who need it most and can afford it least. Standardized protocols for hemorrhage, preeclampsia, and other obstetric emergencies, modeled on California’s approach, remove the bias from the decision point. Diversity in the obstetric workforce — Black women are significantly more likely to survive pregnancy complications when treated by Black physicians, according to a study of 1.8 million hospital births in Florida — provides the concordance that saves lives.

But here is the harder truth, the one that the policy solutions cannot fully address: Black women will continue to die at disproportionate rates in American hospitals until this country decides, at the level of culture and not merely the level of protocol, that Black women’s pain is real, that Black women’s bodies deserve the same urgent attention as white women’s bodies, and that the belief systems that have justified the devaluation of Black life for four centuries cannot be eliminated by a two-hour workshop on unconscious bias. The protocols are necessary. The doulas are necessary. The Medicaid expansion is necessary. But what is most necessary is a transformation in the fundamental regard with which Black women are held when they are at their most vulnerable, and that transformation requires something more than policy. It requires the kind of moral reckoning that this country has been postponing since its founding.

Every day that reckoning is delayed, another Black mother enters a hospital and places her life in the hands of a system that, by every measure we have available, values it less than the life of the white woman in the next room. The data is clear. The solutions are known. The only thing missing is the will to act as though Black women’s lives are worth the investment required to save them. And every year we fail to make that investment, the three-to-one ratio holds, and the hospitals that were supposed to be places of healing continue to be, for Black mothers, places of unconscionable and preventable death.