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• Published: 18 June 2022

Reducing infant mortality: maternal health is infant health

• Kristen H. Shanahan 1 , 2 , 3 ,
• Kendall J. Burdick 4 &
• Lois K. Lee 1 , 3 , 5

on behalf of the Pediatric Policy Council

Pediatric Research volume  92 ,  pages 623–625 ( 2022 ) Cite this article

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Maternal health and infant health are inextricably linked. Fetal development is dependent on a healthy in utero environment, which is influenced by the mother’s health and her associated environmental stressors. Furthermore, healthy mothers are needed to care for infants after birth. Thus, to improve infant health and reduce infant mortality, we must optimize maternal health. Ultimately the health of infants and children are a critical foundation for adult health and overall population health. Policies and interventions to improve maternal health are essential for population health as they will pay future dividends for maternal and infant health.

Without healthy mothers, we will not have healthy infants. During the prenatal period, pregnancy-related disorders are risk factors for worse infant outcomes, including infant mortality. In this issue of Pediatric Research, Yurkiw et al. report twofold greater odds of mortality in preterm (<29 week gestation) twin infants born to mothers with hypertensive disorders of pregnancy, compared to those born to normotensive mothers. Two basic questions arise: (1) How does this happen? and (2) Why does this happen? The cellular pathways by which hypertensive disorders of pregnancy affect infant health capture only one part of the problem, answering the “how” of the pathophysiology. A more daunting aspect of the problem begs to know “why”? Why did the mothers of these infants develop hypertension? If we know the “why” there is potential to develop approaches for prevention, which is important to improve maternal health and infant health outcomes.

The social determinants of health are major drivers of hypertensive disorders of pregnancy. 1 Social determinants of health are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” 2 These conditions include financial instability, food insecurity, inadequate housing, and poor access to education, employment, and healthcare. The social determinants of health also include community conditions, such as neighborhood violence, greenspace, environmental pollution, and access to healthy food.

Racism, poverty, education, and geography all contribute to worsening maternal health outcomes and thereby worse infant health outcomes. 3 For example, maternal mortality has risen sharply in the United States (U.S.) for the past several decades. 4 The maternal mortality rate increased threefold from 7.2 deaths per 100,000 live births in 1978 to 23.8 deaths per 100,000 live births in 2020. 4 Effects of systemic racism 3 are striking—mortality rates are almost threefold higher for non-Hispanic Black women in 2020 than for non-Hispanic White women. 4

Systemic racism and the burdens of social determinants of health also plague infant mortality, defined as death <365 days old. In the U.S., infant mortality has shown progress in overall trends, with a decline from 10.9 infant deaths per 1000 live births in 1983 to 5.4 infant deaths per 1000 live births in 2020. 5 Despite this progress, existing racial inequities have been exacerbated. In 2018, the mortality rate for non-Hispanic Black infants was 2.3-fold higher than for non-Hispanic White infants, increased from a 2.1-fold difference in 1983. 5 To improve infant health, we cannot invest in infant health alone, we must also invest in maternal health.

Investing in maternal health

The social determinants of health accumulate to impact maternal health in the pre-pregnancy, prenatal, and postpartum periods. Exposure to poor social determinants of health is associated with higher rates of chronic disease, which is one manifestation of the effects of systemic racism. 3 Chronic diseases in the pre-pregnancy period can lead to poorer health during pregnancy and subsequent effects on fetal development. The same populations of pregnant women who experience chronic diseases due to social determinants of health also face challenges in accessing high-quality healthcare during and after their pregnancy, which may result in further complications.

Major investments in reducing the effects of social determinants of health on maternal health throughout the lifespan are needed to create meaningful change—finally reducing maternal mortality and reducing racial health inequities for Black mothers and infants. These investments may include financial support in the form of cash transfers, safe housing, access to education and employment, improvements in the built environment in the community, and reductions in community violence. Another essential investment is improved healthcare access through increased health insurance coverage.

Maternal health and Medicaid expansion in the United States

Lack of health insurance is a substantial barrier to access timely prenatal and postpartum care for women in the U.S. Insurance disruptions and periods of lack of coverage are common due to changes in employment and eligibility for insurance before and after delivery. 6 Few options exist for women who are uninsured at the time of the pregnancy and do not qualify for Medicaid.

The Affordable Care Act state option for Medicaid expansion provides expanded coverage for Medicaid to adults with incomes below 138% of the Federal Poverty Level. States can also opt to extend coverage to higher-income women for prenatal care. In 2022, 12 states have not adopted Medicaid expansion: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming (Fig.  1a ).

a shows states by status on adoption of Medicaid expansion in 2020. Data obtained from the Kaiser Family Foundation. b shows quintiles of state-level maternal mortality in 2020 (maternal deaths per 100,000 live births). c shows quintiles of state-level infant mortality in 2020 (infant deaths per 1000 live births). Data are obtained from the CDC WONDER database.

By covering low-income women before, during, and after pregnancy, Medicaid expansion provides much improved access to health insurance and healthcare. From 2013 to 2015, the percentage of reproductive age women covered by Medicaid increased fivefold in states that adopted Medicaid expansion compared to those that did not. 6 Early enrollment in health insurance and timely access to prenatal care improved in Ohio after the adoption of Medicaid expansion. 7 These women were more likely to receive guideline-concordant pregnancy screenings and prenatal vitamins. This type of care is essential for all pregnant women, including those with hypertensive disorders of pregnancy, multi-gestational pregnancies, and those at risk for pre-term delivery.

States who have adopted Medicaid expansion have shown a relative decrease in maternal mortality compared to states that have not adopted Medicaid expansion. 8 Although maternal mortality continues to rise across the U.S., this increase is attenuated in Medicaid expansion states compared to non-expansion states (Fig.  1b ). 8 Data suggest that Medicaid expansion is one strategy for advancing maternal health equity by increasing health insurance coverage and ultimately access to prenatal care—the effects of Medicaid expansion were greatest among non-Hispanic Black women. 8

Women living in poverty with special healthcare needs, including mental health disorders and substance use disorders, also benefit from the extended healthcare coverage before, during, and after pregnancy. Coverage is especially important in these populations. Improving access to and quality of prenatal care is essential for optimizing health outcomes for mothers and their infants, especially for multi-gestational pregnancies and preterm births.

Infant health and Medicaid expansion

In addition to Medicaid expansion’s association with improved maternal health outcomes, it has also been associated with improved infant health outcomes with reductions in infant mortality (Fig.  1c ). Medicaid expansion states have demonstrated decreased rates of infant mortality, which has been rising in non-expansion states. 9 Furthermore, state Medicaid expansion has advanced health equity in infants, potentially countering the effects of systemic racism. Declines in infant mortality were greatest in Black infants. 9 Disparities for Black infants in preterm birth, very preterm birth, low birth weight, and very low birth weight declined in states that adopted Medicaid expansion compared to non-expansion states. 10

Conclusions

Infant health flows directly from maternal health, which provides a foundation for strong population health. Therefore, it must be a priority to have a healthy maternal population with access to high-quality healthcare, especially among populations who experience worse health outcomes related to their social determinants of health. We must address the “why” related to infant mortality as well as researching the causes and treatment for the “how” of infant mortality. Investments in maternal and infant health and health equity must include comprehensive interventions to counteract the effects of poor social determinants of health. Solutions to these issues will be complex in nature and will require a multi-pronged policy approach. Improved access to health insurance and optimal maternal and child healthcare are essential to improve health outcomes in pregnant women and their infants.

Harris, M., Henke, C., Hearst, M. & Campbell, K. Future directions: analyzing health disparities related to maternal hypertensive disorders. J. Pregnancy 2020 , 7864816 (2020).

World Health Organization. Social determinants of health. Nosileftiki 54 , 231–240 (2015).

Bailey, Z. D. et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet 389 , 1453–1463 (2017).

Article   Google Scholar  

CDC. Pregnancy mortality surveillance system. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm (2022).

Federal Interagency Forum on Child and Family Statistics. Infant mortality. America’s children: key national indicators of well-being. https://www.childstats.gov/americaschildren/health2.asp (2021).

Daw, J. R., Hatfield, L. A., Swartz, K. & Sommers, B. D. Women in the United States experience high rates of coverage “churn” in months before and after childbirth. Health Aff. 36 , 598–606 (2017).

Adams, E. K. et al. Prepregnancy insurance and timely prenatal care for medicaid births: before and after the Affordable Care Act in Ohio. J. Women’s Health 28 , 654–664 (2019).

Eliason, E. L. Adoption of Medicaid expansion is associated with lower maternal mortality. Womens Health Issues 30 , 147–152 (2020).

Bhatt, C. B. & Beck-Sagué, C. M. Medicaid expansion and infant mortality in the United States. Am. J. Public Health 108 , 565–567 (2018).

Brown, C. C. et al. Association of state Medicaid expansion status with low birth weight and preterm birth. JAMA 321 , 1598–1609 (2019).

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Shanahan, K.H., Burdick, K.J., Lee, L.K. et al. Reducing infant mortality: maternal health is infant health. Pediatr Res 92 , 623–625 (2022). https://doi.org/10.1038/s41390-022-02142-4

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The Division of Maternal-Fetal Medicine is engaged in clinical, basic bench and epidemiological research as one of its primary missions. Our strength lies in the expertise and diverse interests of our faculty, as well as in the collaborations with multiple other disciplines and departments throughout the School of Medicine, The Bloomberg School of Public Health, and the School of Biomedical Engineering. The strong research infrastructure of the Johns Hopkins University forms a solid foundation for the success of our integrated research program for Maternal-Fetal Medicine.

We have established the JH Womb (Johns Hopkins Well-being of Mothers and Babies) Program and Physiology In Pregnancy Program.

Our research faculty participate in The Johns Hopkins Women’s Health Research Group , a collaborative network of researchers from the Schools of Medicine, Nursing and Public Health.

Our research program now provides semi-monthly meetings (“Work in Progress/laboratory data” and “Research concepts”) to foster multi-disciplinary research through pilot programs and retreats.

Active Studies and Clinical Trials Hydrops Research Study

For many pregnancies with hydrops, the cause is unknown. Comprehensive genetic testing may help expecting parents find answers. The Johns Hopkins  Prenatal Genetic Counseling team , along with our  Maternal-Fetal Medicine specialists , are partnering with researchers at the  University of California, San Francisco (UCSF)  to study and better understand the genetic causes of non-immune hydrops fetalis in pregnancy.

Our Research Director

Ahizechukwu eke, mbchb mph phd.

Expertise: Maternal and Fetal Medicine, Obstetrics

Research Interests: HIV in pregnancy, Maternal Health Policy, Medical and Surgical Complications in Pregnancy, Pharmacodynamics, Pharmacoepidemiology, Pharmacogenomics, Pharmacokinetics, Pharmacomicrobiomics, Preterm birth

Faculty Research

Abby aina, md.

• Assistant Professor of Gynecology and Obstetrics

Research Interests: Cervical incompetence, Preterm labor, Thrombophilia in pregnancy

Cynthia Holcroft Argani, MD

• Director, Labor and Delivery at Johns Hopkins Bayview Medical Center

Research Interests: perinatal disease, placental histopathology

Ahmet Alexander Baschat, MBBChBAO

• Director, Center for Fetal Therapy
• Professor of Gynecology and Obstetrics

Jessica L. Bienstock, MD

• Director, Division of Education, Department of Gynecology and Obstetrics

Research Interests: fetal genetic disorders, fetal ultrasound abnormalities, medical education in obstetrics and gynecology

Karin Blakemore, MD

• Director, Prenatal Genetics

Expertise: Medical Genetics, Maternal and Fetal Medicine, Obstetrics

Research Interests: Fetal genetic disorders, Hemoglobinopathies, In Utero Hematopoietic Stem Cell Transplantation, Intrapartum physiology and outcomes, Placental development and abnormalities, Prenatal Diagnosis and Fetal Treatment, Red cell and platelet alloimmunization

Rita Wesley Driggers, MD

• Medical Director, Maternal Fetal Medicine, Johns Hopkins Medicine, Sibley Memorial Hospital
• Associate Professor of Gynecology and Obstetrics

Research Interests: Pregnancy and diabetes, Preterm birth

Ernie M. Graham, MD

• Director, Maternal-Fetal Medicine Fellowship Program

Research Interests: intrapartum fetal monitoring, perinatal brain injury

Janice L. Henderson, MD

• Director, Fetal Assessment Center

Research Interests: obesity in pregnancy

Nancy A. Hueppchen, MD

• Associate Dean for Undergraduate Medical Education, School of Medicine

Research Interests: abnormal maternal serum screening, fetal genetic disorders, fetal ultrasound abnormalities, resident and medical student education

Angie Jelin, MD

• Program Director, Maternal-Fetal Medicine Fellowship

Research Interests: fetal genetic disorders, whole exome sequencing

Lorraine Anne Milio, MD

• Co-Director, HALO Program

Jena Lyn Miller, MD

Andy Satin, MD

• Director of Gynecology and Obstetrics

Jeanne S. Sheffield, MD

• Director of the Division of Maternal-Fetal Medicine

Expertise: Infectious Diseases, Maternal and Fetal Medicine, Obstetrics

Research Interests: Infectious diseases in pregnancy, maternal immunizations, medical and surgical complications in pregnancy

Julia Timofeev, MD

Arthur Jason Vaught, MD

• Director, Labor and Delivery

Expertise: Critical Care Medicine, Maternal and Fetal Medicine, Obstetrics

• Research article
• Open access
• Published: 05 February 2015

A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda

• Primus Che Chi 1 , 2 ,
• Patience Bulage 3 ,
• Henrik Urdal 1 &
• Johanne Sundby 2  

BMC Pregnancy and Childbirth volume  15 , Article number:  18 ( 2015 ) Cite this article

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Armed conflict has been described as an important contributor to the social determinants of health and a driver of health inequity, including maternal health. These conflicts may severely reduce access to maternal health services and, as a consequence, lead to poor maternal health outcomes for a period extending beyond the conflict itself. As such, understanding how maternal health-seeking behaviour and utilisation of maternal health services can be improved in post-conflict societies is of crucial importance. This study aims to explore the determinants (barriers and facilitators) of women’s uptake of maternal, sexual and reproductive health services (MSRHS) in two post-conflict settings in sub-Saharan Africa; Burundi and Northern Uganda, and how uptake is affected by exposure to armed conflict.

This is a qualitative study that utilised in-depth interviews and focus group discussions (FGDs) for data collection. One hundred and fifteen participants took part in the interviews and FGDs across the two study settings. Participants were women of reproductive age, local health providers and staff of non-governmental organizations. Issues explored included the factors affecting women’s utilisation of a range of MSRHS vis-à-vis conflict exposure. The framework method, making use of both inductive and deductive approaches, was used for analyzing the data.

A complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings. Exposure to armed conflict affects women’s utilisation of these services mainly through impeding women’s health seeking behaviour and community perception of health services. The factors identified cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, status of women empowerment and support at the household and community levels, removal of user-fees, proximity to the health facility, and attitude of health providers.

Conclusions

Improving women’s uptake of MSRHS in post-conflict settings requires health system strengthening initiatives that address the barriers across the individual, socio-cultural, and political and health system spheres. While addressing financial barriers to access is crucial, attention should be paid to non-financial barriers as well. The goal should be to develop an equitable and sustainable health system.

Peer Review reports

Although the 2013 UN Millennium Development Goals (MDGs) progress report shows that many regions of the world have made progress on the fifth goal of improving maternal health, the region of sub-Saharan Africa (SSA) is still lagging behind, and will not be able to meet the agreed targets of ‘reducing by three quarters, between 1990 and 2015, the maternal mortality ratio’ and ‘achieving, by 2015, universal access to reproductive health’ [ 1 ]. Within SSA, countries in or emerging from armed conflicts are among the hardest hit. The deteriorating impact of armed conflict on maternal health is well acknowledged, and tends to linger even after the end of the conflict [ 2 - 4 ]. Armed conflicts are associated with higher total fertility and maternal mortality rates [ 5 ]. A 2010 review [ 6 ] of maternal mortality in 181 countries spanning 1980–2008 revealed that in 2008, 50% of all maternal deaths occurred in only six countries (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo); all of which have experienced recent armed conflict. For over a decade, the 10 countries ranked lowest on the Save the Children’s ‘State of the World’s Mothers Index’ have been conflict and post-conflict states [ 7 ]. Similarly, the 10 countries ranked lowest in the UN Human Development Index for the last decade are either in conflict or emerging from conflict. In this regard, armed conflict has been described as an important contributor to the social determinants of health [ 8 - 10 ] and a driver of health inequity [ 11 ]. Armed conflicts tend to limit access to maternal, sexual and reproductive health services (MSRHS) due to high levels of insecurity and high opportunity costs of accessing such services.

The uptake of MSRHS is closely associated with improvements in maternal health. For instance, quality antenatal care (ANC) should optimally reduce the risk of poor pregnancy outcomes, and a caesarean section can be obtained only when a woman seeks care at a health facility. To enhance women’s utilisation of these health services in post-conflict societies, an important step will be to explore the factors that may hinder and facilitate their uptake of services in these contexts. While much work has been done on the determinants of maternal health utilisation [ 12 - 16 ] including demographic, socio-economic, cultural, and health related factors, a general conclusion appears to be that the importance and impact of the factors varies from one setting to another. With health systems in conflict and post-conflict countries faced with challenges such as damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations without proper coordination, this results in the delivery of disrupted and fragmented health services [ 17 ]. Hence, the utilisation of MSRHS is likely to be affected.

Burundi and Uganda are among the countries in Sub-Saharan Africa that are not poised to meet the fifth MDG goal of improving maternal health. They have both experienced brutal civil wars that claimed tens of thousands [ 18 ] of lives and displaced millions of people. Burundi experienced an ethnic conflict from 1993–2005 that led to the displacement of approximately 1.2 million people [ 19 ]. Although the country has been experiencing some gradual improvements in general population health, the population life expectancy stands at 53.9 years, with one of the highest maternal mortality ratios (800 deaths per 100,000 live births) and total fertility rates (6.1) in the world (UN World Fertility Patterns 2013; UN MDG indicator monitoring database). The Northern region of Uganda is recovering from over 20 years of armed conflict between the Lord’s Resistance Army and the Ugandan Government that resulted in the disruption of health services, massive population displacement and erosion of traditional and family structures [ 20 ]. The number of people displaced by the conflict was estimated at 2 million [ 17 , 20 ]. With a total fertility rate of 6.3, the Northern region ranks the highest in the country, with a median age at first birth of 17.8 years [ 21 ]. Uganda has a life expectancy of 59 years and maternal mortality ratio of 310 per 100,000 live births (UN World Fertility Patterns 2013; UN MDG indicator monitoring database), and the corresponding data for the Northern region might be worse.

The health system in Burundi is organized as a pyramid structure with three levels, comprising the central, intermediate and peripheral levels. The central level involves the Office of the Minister with its associated directorates, departments, programmes and related services, and it is responsible for formulating sector policy, strategic planning, coordination, mobilization and allocation of resources and oversight-evaluation. The intermediate level is comprised of 17 provincial health bureaus, in charge of coordinating all health activities of the province, supporting the health districts and ensuring proper collaboration between sectors. The peripheral level is responsible for the delivery of healthcare, and as of 2010 it was comprised of 45 health districts, including 63 hospitals and 735 health centres (423 public, 105 approved religious facilities and 207 private facilities) distributed throughout the 129 cities in the country [ 22 ]. All health centres are expected to offer a minimum package of services, including treatment and prevention consultation services, laboratory, pharmacy, health promotion and health education services, as well as in-patient observation. However, a recent survey found that 45% of health centres were unable to provide the complete recommended minimum package due to lack of personnel, infrastructure, equipment or medication [ 22 ]. For example, the survey reported that the physician-to-resident, and midwife-to-woman of child bearing age ratios are 1 per 19,231 (WHO recommended ratio is 1 per 10,000) and 1 per 123,312 (WHO recommended ratio is 1 per 5,000), respectively. Furthermore, a 2010 national survey of emergency obstetric and neonatal care (EmONC) facilities found that only five health centres were offering the recommended basic EmONC services, while 17 hospitals could provide comprehensive EmONC services – with the latter having a poor geographical distribution nationally [ 22 ]. These are recurrent challenges that appear to be happening against the backdrop of low government expenditure on health, as shown in Table  1 . The current health situation in Burundi is described as precarious, with a fragile health system characterized by a high burden of communicable and non-communicable diseases, particularly affecting pregnant women and children [ 23 ]. According to the 2009 statistics, the diseases that were the primary causes of morbidity and mortality were malaria, acute respiratory infections, diarrheic diseases, malnutrition, HIV/AIDS and tuberculosis [ 22 ]. Following the end of the armed conflict in 2007, Burundi has been gradually restructuring the health system, with the introduction of the district health system to implement primary health care, coupled with the implementation of a performance-based financing (PBF) programme [ 24 ]. Furthermore, the government has introduced a free health care policy for pregnant women and children under 5, and a health insurance scheme for the informal sector. With these reforms in place, it is estimated that about 50% of the population (mainly pregnant women and under-fives) have universal access to health care [ 23 ]. The reforms have equally led to an increase in the use of health services, better quality of treatment, and a greater number of health personnel in rural areas [ 23 ].

Uganda equally operates on the district health system model, with the decentralization of health service delivery to the health district and health sub-district levels. The delivery of healthcare is done by both public and private actors, with the government owning 2,242 health centres and 59 hospitals, compared to 613 health facilities and 46 hospitals run by private not-for-profit actors (PNFP), and 269 health centres and 8 hospitals run by private health practitioners as of 2010 [ 25 ]. A major proportion of the PNFP providers are faith-based religious organizations, including the Uganda Catholic, Protestant, Orthodox and Muslim Medical Bureaus. A minimum package of health services is provided at all levels of health care in both the public and private sectors. Since 2001, user fees have been abolished in all public health facilities, but utilisation of health services has been hampered by poor infrastructure, lack of medicines and other health supplies, shortage of health workers, and low salaries [ 25 ]. Furthermore, concerns around long waiting times, unofficial fees in public facilities, and poor attitudes among health workers have also limited the utilisation of health services [ 26 ]. The disease burden in the country is dominated by communicable diseases, with maternal and perinatal health conditions contributing to the high mortality [ 27 ]. While Uganda is experiencing a shortage of health workers (as highlighted in Table  1 ), following a recent government recruitment exercise, overall staffing levels at higher level health centres such as Health Centres IV and III has improved from 57% in 2012 to approximately 70% in 2013 [ 27 ].

Some key reproductive health indicators in Burundi and Uganda are displayed in Figure  1 . While ANC coverage for at least one visit in both countries is quite satisfactory, the other health indicators such as contraceptive uptake, unmet need for family planning and ANC coverage for at least four visits are disappointing and require some improvement.

Reproductive health outlook for Burundi and Uganda. Source of data: UN MDG indicators monitoring database ( http://mdgs.un.org/unsd/mdg/data.aspx ). SBA: Skilled birth attendance; CPR: Current contraceptive use among married women 15–49 years old, any method; ANC 1: Antenatal care coverage, at least one visit; ANC 4: Antenatal care coverage, at least four visits; FP: Family planning.

This study aims to explore the determinants of women’s utilisation of MSRHS in the post-conflict settings of Northern Uganda and Burundi and how exposure to armed conflict may affect these factors. Our main research question was ‘ what are the factors that encourage and discourage women’s uptake of maternal and reproductive health services and how does exposure to armed conflict affect these factors? ’ Through this study, we seek to contribute to the broader literature on determinants of maternal health and health-seeking behaviour in conflict and post-conflict settings.

Study settings

The study was undertaken in two provinces in Burundi (Bujumbura Marie and Ngozi) and a district in Northern Uganda (Gulu). In Burundi, participants were recruited from the cities of Bujumbura and Ngozi and the rural and semi-urban communes of Ruhororo in Ngozi Province and Kinama in Bujumbura Mairie province respectively. In Gulu district, the participants were recruited from the rural sub-counties of Koro, Bobi and Bungatira, and the municipality of Gulu, which comprises of four sub-counties. Maps of the study areas are found in Additional file 1 .

Data collection method

This is a qualitative study based on in-depth interviews (IDIs) and focus group discussions (FGDs). Interviews and FGDs were conducted in the local languages (Kirundi in Burundi and Luo in Northern Uganda), French or English (where applicable). All English interviews and FGDs were carried out by the principal investigator (PCC), while those in the local languages and French were conducted by trained local research assistants. The fieldwork took place from June until September 2013.

Study participants

Study participants were recruited from staff members of local and international NGOs and local health providers (LHPs) working in the domain of maternal, sexual, and reproductive health (MSRH). The second group of participants consists of women of reproductive age, living in rural and semi-urban areas. Since we are interested in also capturing the effect the conflict had on MSRHS, NGOs and health providers invited to participate in the study had developed, supported and/or provided MSRHS during the conflict or shortly after the conflict. Similarly, the women we invited to participate in the study had sought or attempted to seek for such services as well during such periods.

Issues discussed

The interviews and FGDs focused specifically on the general state of MSRH in Burundi and Northern Uganda, aimed at describing the general state of maternal health and understanding the factors affecting women’s utilisation of basic MSRHS, taking into consideration the possible effects of the recent conflict. The detailed guides for the interviews and FGDs for each of the participant categories can be found in Additional file 2 . A sample of some of the questions posed to participants during the interviews and FGDs include:

What factors do you think affects women’s utilisation of health services during pregnancy and childbirth? (explore possible factors such as quality of care/treatment provided by health provider, costs for services, travel distance, lack of knowledge on when to seek care etc).

Have these factors changed over time? (probe to inquire how?).

Do you have any ideas how the past conflict might have affected this? (probe to inquire how was the use before and after etc).

Ethical considerations

Ethics approval for the study was obtained from the Regional Committee for Medical and Health Research Ethics, South-East (Norway); le Comité National d’Ethique pour la Protection des êtres Humains Participant à la Recherche Biomédicale et Comportementale (Burundi); and Gulu University Institutional Review Committee (Uganda). We also received permission from local administrative and health authorities. All participants/informants gave their informed consent before participating in the study, and their anonymity, privacy and confidentiality was respected. Written or oral consent was acceptable and approved by the relevant ethics committees.

Data management and analysis

All interviews and FGDs were audio-recorded and later transcribed and translated into English (where applicable). English transcripts were imported into the QRS Nvivo (QSR International, 2012). Considering the multidisciplinary nature of the research team and that the data were mainly made up of semi-structured interview transcripts, the framework method [ 28 ] was used to manage and analyze the data. Three team members open-coded the transcripts on Nvivo and Microsoft® Word. Microsoft® Word was used for coding and analysis by one of the co-authors who did not have access to Nvivo. The codes were descriptions or labels of specific ideas identified as the transcripts were read. Two team members reviewed the codes that were developed, and the inter-coder reliability was high. Inter-related or similar codes were then clustered into different categories, and the categories were subsequently grouped into specific themes. The themes were inductively and deductively developed. Inductive means that they were anticipated from the design of the interview and FGD guides and consciously explored in the interviews and FGDs. Deductive means that they were not anticipated during the design, but rather identified during the review of the transcripts. There was a constant interplay between data collection, analysis and theme development, with new and dominant ideas that emerged in earlier interviews and FGDs being explored deeper in subsequent and later interviews and discussions. The themes were also developed taking into consideration the main factors affecting women’s utilisation of maternal health services proposed by Wild et al.’s [ 29 ] multilayered explanatory model (i.e. individual, social, cultural, political and health system factors).

A detailed description of the methods is provided in Additional file 1 .

Characteristics of study participants

As shown in Table  2 , we had 63 interviews and 8 FGDs across the study settings in Burundi and Northern Uganda. A total of 115 individuals participated in the study: 46 women of reproductive age (‘women’), 32 ‘LHPs’ and 37 NGO staff. The LHPs included those working at the facility (LHP) and senior administrative officials working at the local ministry of health (LHP-Policy maker). Within the NGO category we had three sub-categories of respondents: NGO, NGO-Health providers (NGOs that also provide health services) and NGO-Policy makers (mainly UN-based NGOs).

In the following paragraphs we present the participants’ perceived current status of MSRH and level of utilisation of MSRHS, and the determinants of women’s utilisation of these services vis-à-vis the possible effects of exposure to conflict. The individual determining factors were quantified by obtaining the percentage of participants within each of the categories that mentioned a specific factor during an interview or FGD.

Current status of maternal and reproductive health

Over two-thirds of the LHP and NGO respondents in both Northern Uganda and Burundi felt that the general status of MSRH is poor, but has been improving in the aftermath of the conflict. They mentioned positive evolution of some MSRH indicators such as maternal mortality, skilled attendance at birth and contraceptive uptake coupled with the initiation of some specialized services like cervical cancer screening as key pointers to improvements in maternal health.

“ During the time of the war maternal mortality was very high in this region. But currently it is between 300 and 400 per 100 000. But around that time it was around 600 to 700… ” NGO, FGD – Gulu, Northern Uganda “[In Ngozi Province] in 2005, the percentage of women who deliver at the health facility was 40 percent but now it is about 70 percent. The uptake of family planning in 2005 was 10 percent but now it is around 25 percent. ” LHP-Policy maker, IDI – Ngozi, Burundi

The positive observations made by the LHP and NGO respondents were also affirmed by the women, most of whom felt that the number of pregnant women from their communities attending ANC and delivering at the health facility had been increasing since the conflict ended. The increasing uptake of these services was largely associated with improved physical safety, an increase in the number of health facilities that has reduced the distance people have to travel to seek care, and an ongoing government health policy of free healthcare for all in government health facilities (for Uganda), and free healthcare for pregnant women and children under five years (for Burundi).

“ With the president’s law ( free health care for pregnant women and children under five ), things have evolved in a positive way. Death rate for pregnant women has reduced considerably…Today a death of a pregnant woman is considered as an accident. ” Woman, IDI – Kinama, Burundi “ In the past it was very difficult to reach the hospital but now services are closer…If you compare the time that one would take to reach the hospital in the past, you will find that it is better now ” Woman, IDI – Bungatira, Northern Uganda

Determinants of women’s utilisation of MSRHS and the effect of conflict exposure

A combination of complex and inter-related factors affecting the utilisation of MSRHS by women were identified across the study sites. A number of these factors were associated with exposure to past conflict. Using the Wild et al. [ 29 ] multilayered person-centred exploratory model on the utilisation of maternal health services we grouped the factors into the following themes: individual, socio-cultural, and political/health system levels. Table S2 (Additional file 3 ) shows the main factors identified by the different categories of participants across the study sites. The perspectives of the LHP and NGO categories of respondents were highly similar, hence these were merged. The determinants were largely presented as ‘push’ (barrier) or ‘pull’ (facilitating) factors and included both supply and demand side factors. The factors identified are presented vis-à-vis the various participant categories.

Individual level

The most common individual level factor that encouraged women across the study sites to utilise MSRHS like family planning was the difficulty with catering for existing children. This factor was raised by over 80% of the women. This is because following the end of the conflict there has been a very strong cultural desire to replace family members lost during the conflict. The demand for family planning services was also facilitated by desire for women to recuperate after child birth, prevailing pressure on the existing limited land resources, and high incidence of land disputes following relocation of families back to their communities from internally displaced persons (IDP) camps as the insurgency ended. This has limited the quantity of food that can be cultivated.

“ In general, the living conditions are very difficult. You cannot give birth to too many children when you do not have something to give them. Nowadays, there is not enough space for those children. These are some of the reasons why women seek for family planning services ” Woman, IDI – Koro, Northern Uganda

Previous experience with or fear of a complicated or abnormal delivery and the development of an obstetric danger sign (as well as the severity of the manifestation of the sign) were also important individual level facilitating factors (76%). Most of these decisions tended to have been undertaken with the backdrop of little or no help with household chores for many of these women.

In Burundi, the desire to ensure that the newborn was registered and granted a birth certificate which gave free access to healthcare under the new targeted healthcare policy was a very strong ‘pull’ factor (90%) for facility delivery.

“ The reason why women are motivated to visit the health facility when pregnant is because they are afraid of delivering at home. When you deliver at home, your baby is not registered .” Women, FGD - Ruhororo, Burundi

Normally, the birth notification document that is required to make a birth certificate is provided at the facility after delivery, hence women who do not deliver at the facility often struggle to have a birth certificate issued for their newborn. Other ‘pull’ factors that emerged included the desire to know their HIV status and to learn about the evolution of the pregnancy.

One main barrier identified across the sites, and especially in Northern Uganda, included past unpleasant experiences or fear of such experiences at the hands of health providers at the health facility, discouraging some women from seeking services (60%). With extensive impoverishment among the rural women who were temporarily displaced from their communities during the conflict, many of them felt despised, looked down upon, and poorly received by health personnel when visiting the health facility. Also, 43% of the women cited past experience of severe side effects of contraceptives, such as heavy bleeding and increase in weight, as a barrier to the uptake of modern contraceptives. In Burundi, approximately 20% of the women reported that some women were discouraged from seeking maternal health services for fear of being diagnosed with HIV infection. A few respondents mentioned the lack of ‘good clothes’ to wear as a barrier to facility delivery. Some who could not afford ‘good’ clothes preferred to deliver at home, especially within urban and semi-urban areas.

“ The things that discourage some are…lack of good clothes to wear in order to go to the hospital or health centre without being laughed at; lack of clothes for the newborn; and ashamed of being laughed at if they do not have something to eat whereas other patients have relatives to bring them good food .” Woman, IDI - Kinama, Burundi

The educational level was also mentioned (24%) as an individual level determinant for women’s utilisation of MSRHS, with more educated women being more likely to seek these services. Lack of safety was identified as an important barrier to education during the conflict. Some respondents (41%) also felt that the high burden of domestic chores that some women have to undertake, ranging from cooking, cleaning, and farming, may discourage the use of facility-based health care.

“… I think that it is because of the too much work that women have at home that stops them from going to the hospital. ” Woman, IDI – Bobi, Northern Uganda

LHPs and NGOs

Most of the individual level factors that the LHP and NGO respondents felt affected women’s utilisation of MSRHS were largely similar to those mentioned by the women themselves across the study settings. In Northern Uganda, the main facilitators mentioned only by LHPs and NGOs included availability of contraceptive methods that could be concealed from the male partners/husband (such as implants) (60%); and a deep sense of trust that their privacy and confidentially would be respected by the health providers (50%) – especially for HIV positive women, and for those secretly requesting family planning and post-abortion care services. The corresponding facilitators for Burundi included HIV positive women’s desire to protect their unborn child from HIV infection (70%); and realization of the importance of family planning – including personal positive experiences with contraceptive use (65%); improving knowledge; and understanding the evolution of their pregnancy. The barriers were similar across the participant categories in Northern Uganda, and many respondents (74%) in this participant category felt that the poor health-seeking behaviour of some women was due to the conflict-engendered low literacy levels among the population.

Barriers mentioned only by LHPs and NGOs in Burundi were ignorance of the importance of these services, lack of money for transport and medication, in some areas confidence in traditional birth attendants to undertake home deliveries, and personal religious convictions.

Socio-cultural level

The most common socio-cultural factors raised across the study sites were poverty (85%), community- and male-partner perceptions about modern contraceptives (80%), and the ease of reaching the health facility (70%), including the distance to the facility and the nature of the road network. These were to some extent associated with the conflict, as huge segments of the population, especially in rural areas, are still struggling to rebuild their livelihoods destroyed by the conflict. Infrastructure, including roads, schools and health facilities, was generally disrupted during the conflict. With respect to contraceptive uptake, rumours and myths about modern contraceptives, fear of side effects, and male-partner opposition to uptake were perceived as important barriers.

“ There are some women who do not believe the contraceptive methods because they think that these methods will prevent them from reproducing in the future ” Woman, IDI – Kinama, Burundi “ Some say that family planning [modern contraceptive] is going to kill their eggs…While others think family planning can make one produce children without a head. ” Woman, IDI – Koro, Northern Uganda

While the main barriers to the uptake of modern family planning methods in Northern Uganda were linked to strong male-partner opposition and fears of possible side effects, in Burundi concerns about male-partner opposition were less common.

The main facilitator for utilisation of family planning services was pressure on limited resources (60%), including land on which cultivation is done. This was considered a growing problem in some of the sites as the incidence of land disputes was reported to have sharply increased, especially following the return of displaced populations.

Factors that were raised only by women in Northern Uganda included the perception of women on contraceptives as ‘men’ or ‘without womanhood’, discouraging some from seeking such services; male-partner opposition to spousal uptake of HIV voluntary counselling and testing (VCT) services for fear of being diagnosed with HIV; and fear of undergoing a caesarean section.

Most of the socio-cultural level factors mentioned by the women were also emphasised by the LHPs and NGO respondents. Factors that were only mentioned by the LHPs and NGOs in Northern Uganda included a great respect for and availability of traditional birth attendants (TBAs) to undertake deliveries in some rural areas (40%); and a cultural perception of pregnancy as a normal condition that may discourage some women from seeking ANC and facility delivery services (50%). In some settings, pregnant women who regularly attended ANC sessions were perceived as ‘ not strong enough ’.

“ People think that when you are pregnant it is a normal condition and you do not have to go to the health facility. They feel that when you go there you are a coward .” NGO-health provider, IDI – Gulu, Northern Uganda

Respondents to some extent associated the great respect for TBAs to the conflict, as skilled birth attendance was almost non-existent for huge segments of the population during conflict, and TBAs were regarded as heroines within some communities.

Other sociocultural factors were the perception among some men that women on contraceptives are stubborn (difficult to control) and sexually promiscuous (25%); a desire to replace family members lost during the war (85%); and the cultural desire for large family size (77%). These factors also accounted for the often mentioned male-partner opposition to contraceptive use by their spouses. The strong position of the Catholic Church against the use of modern contraceptives was reported to be a key barrier (70%) for the uptake of family services in both Burundi and Northern Uganda, as more than 60% of the population are Catholics. The strong negative impact of the Catholic Church on the uptake of modern family planning services observed among these categories of respondents was not mentioned as a major concern among the women respondents.

In Burundi, a few respondents (26%) identified the cultural practice of concealing a pregnancy for the first trimester as a major barrier to early ANC service uptake. This is a practice that is not only limited to uneducated women in rural areas, but also common among educated women in the cities.

The occasional financial costs incurred by women at the level of the facility also discouraged some women from seeking services, while the improved security situation has been an important pull factor.

Political and health system level

Most of the women (95%) in both Burundi and Northern Uganda felt that the most important political and health system level pull factor for uptake of MSRHS is the universal and selective healthcare policy for Uganda and Burundi respectively that facilitates access to services through the removal of user fees. All respondents in Burundi were generally more appreciative of the health system, especially the manner in which they are received and treated at the level of the health facility, compared to their counterparts from Northern Uganda. As such, most respondents from Burundi felt that no barriers existed at the level of the political and health system domain.

“ Women are well treated and whenever you go [to the health facility] when you are pregnant, they receive you and they treat you well .” Woman, IDI – Ruhororo, Burundi “W e know that there are nurses at the health centres and hospitals who are ready on a daily basis to receive a woman who is coming to bear a child. They are always ready to help that woman. We thank the government for this. They do not discriminate in receiving patients. ” Woman, FGD – Kinama, Burundi

On the other hand, over half of the women respondents from Northern Uganda felt that although the cost of basic health care is free, some health providers tend to extort money from them. A number of women narrated incidents at the health facility where health providers requested unauthorised financial tips following the delivery of a service.

“ Sometimes you can go [to the health facility] and you are told by the nurses to give them some money for the help they have given to you … ” Woman, IDI – Bobi, Northern Uganda “ When I went to give birth, the nurse told me that ‘since you have given birth well I want you to give me something but don’t tell the in-charge (supervisor)’. Then I removed 5,000 Shillings and gave her .” Woman, IDI – Bungatira, Northern Uganda

Furthermore, the provision of some services such as family planning, ANC, and VCT through mobile outreach clinics and village health teams in the case of Northern Uganda, and TBAs and community health workers in the case of Burundi was also a strong pull factor for the demand for these MSRHS. Of all the women respondents, especially in Northern Uganda, 40% reported that they are drawn to attending ANC services and undertake delivery at a health facility because of material incentives provided along with the services, such as bed nets and delivery kits.

“ Some women go to the health facilities because another woman has gotten that incentive and you hear them saying that ‘if my friend has gotten this there, then I have to also give birth from the hospital in order to get mine’ .” Woman, FGD – Koro, Northern Uganda

A common barrier discouraging some women from seeking facility services was that the attitude of some health providers was occasionally perceived as abusive and degrading to the clients (57%), at times because of their perceived state of poverty. This perceived barrier was, however, very uncommon in Burundi.

“ Some women fear those nurses because they like harassing women when they go to seek for services and some can even abuse you ” Woman, IDI – Bobi, Northern Uganda

Specifically in Burundi, most women (90%) felt that the construction of more health facilities, hence reducing the travel distance, and the recruitment of more health personnel were other facilitators, especially in rural areas. In Northern Uganda, the common barriers raised were the irregular presence and frequent absence of personnel at some facilities (60%), especially in the rural areas, and the policy of insisting that pregnant women must be accompanied by the male partner during some ANC consultations if they are to receive prompt service delivery (63%).

“ If the child the woman is carrying does not have a father, it discourages the woman from going for ANC visits because some facilities require you to come with your husband. ” Woman, IDI – Bungatira, Northern Uganda

A number of women felt that tying prompt ANC service delivery to being accompanied by the male partner unfairly treated women without partners, and women whose partners refused to accompany them or were unavailable for other reasons. The prevailing practice of insisting on male partner involvement was also associated with the reluctance of some women to seek other MSRHS, such as family planning and VCT. In many situations women that were unaccompanied by their spouse were reportedly attended to much later, or even sent away unattended. This practice of prioritizing accompanied women, or even not providing some services to unaccompanied women, was a major concern among some women in Northern Uganda.

“ I would think the health personnel should improve the way they treat mothers when they go for maternal and other services available in the health unit. Not that if they do not go with their husband they should leave without services because there are men who are also very difficult to deal with and so their wives should not be dropped out from services because of their husband’s conduct. ” Woman, IDI – Bobi, Northern Uganda

The political and health system level factors that were identified by the health providers and NGOs were highly similar to those reported by the women. The common facilitating factors that emerged across the study sites included the policy of removal of user-fees (100%), the increasing level of community sensitization on health issues (90%), the prohibition of TBAs from undertaking deliveries, which had directly pushed some women to deliver at health facilities (75%), and the delivery of some services at community level.

In Burundi, the introduction of the performance-based financing (PBF) programme was highlighted as the most important facilitating factor to the delivery and uptake of MSRHS (100%). Through the PBF scheme health personnel are remunerated specifically for the quantity and quality of specific services provided in addition to their regular salary. Facilities are also better stocked with basic supplies than before, the range of services offered has increased, and more lay health workers have been trained from the community to intensify community health sensitization activities. Also, competent personnel tend to always be at the facility, TBAs have been trained and assigned a new role in health promotion and community sensitisation, and the attitude of personnel towards the clients has reportedly improved. All these have encouraged more women to seek MSRHS. On the downside, some respondents (25%) felt that the strong increase in the number of women seeking MSRHS following the introduction of the selective health care and PBF policies has not been sufficiently matched with a corresponding increase in the number of skilled personnel at the facility, nor in the quantity of medical supplies. The end result has been a decline in service quality and delays in the provision of services, which has negatively affected the demand for some services.

Some facilitating factors that were mentioned only by LHPs and NGOs in Northern Uganda are effectiveness in the integration and follow-up of clients, especially in the domains of VCT and prevention of mother-to-child transmission of HIV; professional competence of personnel with respect to safeguarding clients’ privacy and confidentiality; payment of the cost for skilled birth attendance and related services at a reputable private hospital by some local politicians; and availability of youth-focused and youth-friendly services. Moreover, the availability of free antiviral therapy coupled with the provision of nutrition support for HIV positive mothers, and the provision of some incentives (such as a delivery kit and a washing basin) for women who deliver at the facility, were also important pull factors. The main barriers mentioned only by LHPs and NGOs were poor management of pregnant teenagers and teenage mothers; the poor drug supply policy and regular stock-out of some essential supplies at the facility level; and in some areas, the poor coordination among NGOs, health facilities and the district health office affecting the pattern of service delivery.

This study has demonstrated that a complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings, and that armed conflict are among them. These factors cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, situation of women empowerment and support at the community and household levels, removal of user-fees, proximity to the health facility, and attitudes of health providers. The main negative effects on family planning service uptake related to the exposure to conflict were associated with a generally low level of appreciation of the importance of some services, due to low educational attainment partly as a result of the conflict. Another effect has been a strong cultural desire for a large family size, especially among men, partly as a response to the loss of family members during the conflict. Furthermore, the disruption of infrastructural development such as roads and health facilities during the conflict, means that proximity to functional health facilities for many rural dwellers remains a considerable problem in some areas. While related studies have been undertaken in Uganda, largely employing a quantitative design, we are not aware of any such studies undertaken in Burundi.

Our findings are consistent with those of other researchers in related settings. Previous studies in Northern Uganda have identified lack of finance, of information, and of decision-making powers as key challenges to access to health care services for women [ 30 ]. Also, the abusive and unwelcoming attitude of some health providers towards women, financial demands by some health providers, and uncooperative husbands, have been reported in other regions of Uganda as important barriers to the uptake of family planning, ANC visits, and other health services by women [ 31 ]. A systematic review of access to and utilisation of health services for the poor in Uganda [ 32 ] identified distance to service points, perceived quality of care, and availability of drugs as key determinants. In addition the review concluded that perceived lack of skilled staff in public facilities, late referrals, health worker attitudes, costs of care, and lack of knowledge were important barriers to service utilisation. Although many women appreciate the importance of ANC visits and facility delivery, when they cannot find someone to take care of their families, (especially their children) while they are away at the facility, they opt not to go, as was observed in post-conflict Sierra Leone [ 33 ]. In post-conflict Timor-Leste, women’s choice of delivery in a health facility has been linked to previous perinatal deaths or complications, such as prolonged or painful labour, bleeding, or referral in a past pregnancy, as well as the parity status, with primiparous women more likely to deliver at the facility [ 29 ]. In post-conflict Liberia, Lori et al. [ 34 ] reported that there was a strong sense of secrecy around pregnancy and childbirth, similar to our observation in Burundi, and distrust of the health care system among a proportion of the population, factors that in our study were associated with late attendance of ANC consultations and possibly with home deliveries among some women. Secrecy around such issues might be linked to concerns about witchcraft, in particular that an enemy may bewitch the unborn child or prolong its delivery. Similar views were expressed by some of our study participants. During the 2006 conflict in Lebanon, Kabakian-Khasholian et al. [ 35 ] equally observed that the key determinants for seeking maternal care were the availability of health services and experiences of complications. In some conflict settings, the choice of place of delivery is affected by the availability of appropriate clothing to wear to the facility, and the preference of key decision makers in the family, such as mothers-in-law and husbands [ 36 ].

In the aftermath of the internal conflict in Timor-Leste in 2006, the country was plagued with similar challenges to those we observed in Burundi and Northern Uganda, and one key response employed by the authorities was the institution of a maternity waiting camp for pregnant women [ 37 ]. At one of the facilities we visited in Northern Uganda, such a home was recently introduced especially to deal with pre-identified clients in rural remote areas with the risk of an abnormal delivery. Although this practice seems to be uncommon in our study settings it might be an important intervention to extend to other major health facilities. Accommodating the women and their companions may be a particularly important intervention for those who have to travel over a long distance to come to the facility.

Both Uganda and Burundi have waived user fees for maternal health related services; Uganda introduced a universal healthcare policy in March 2001, while Burundi introduced a selective healthcare policy for women giving birth and children under 5 years in May 2006. This policy seems to be the most important determinant of women’s uptake of MSRHS in our study settings, highlighting the importance of financial barriers in determining the demand for health services. A study in rural Burkina Faso showed that substantial reductions in user fees for ANC and skilled attendance at birth improved equity in access to these services across socio-economic groups, but did not ensure that all women benefited from the services [ 38 ]. These observations highlight the importance of also focusing on policies aimed at addressing other barriers. For instance, the current strategy of community provision of some MSRHS such as contraceptives, ANC, and postnatal care through mobile outreaches and local community structures, including traditional birth attendants, community health workers and village health teams, is a welcome model for delivering services, and needs to be strengthened. Furthermore, the level of engagement of the health system and other key community structures with males in the community on the importance of utilisation of MSRHS, including contraceptive uptake, also has to be intensified. Men might not have been appropriately engaged on these issues, and their knowledge of the services may be erroneous, which possibly accounts for the level of resistance that has been observed among some men vis-à-vis the uptake of MSRHS. Health providers might therefore have to coin their messages more efficiently to enhance male partner support for the utilisation of maternal and child health services. For example, a study of Northern Uganda concluded that the introduction of community and health facility capacity strengthening interventions such as training of health workers, provision of medical supplies including delivery kits, and community mobilization using village health teams, dance, drama and “male partner access clubs”, led to improvements in first ANC visit attendance, in VCT service uptake for attendants of first ANC visits, in facility delivery, and in VCT service uptake by couples [ 39 ]. While the current free healthcare policy for pregnant women and children under five has had a positive influence on the number of women going for ANC and facility delivery, other associated expenses such as transportation to the health facility, food to eat, clothes for the baby and the mother, and care for the other children at home when the mother is away continue to prevent some women from utilising ANC and facility-based delivery services. Similar observations in Timor-Leste are reported by Wild et al. [ 29 ]. In war-torn Afghanistan, Hadi et al. found that with appropriate conditions in place, many women and families will continue to seek facility-based delivery [ 40 ]. These conditions include providing free services and transport facilities at night, incentives to health providers, maintaining privacy in the delivery room, and the quality of services.

In many settings where stimulating demand for health services has largely been sought through the removal of user fees, but where proper planning and coordination has been lacking, other challenges on the supply side have arisen [ 41 , 42 ]. This happened in Burundi in May 2006 following the sudden abolition by the president of all user fees for children under five, and for women giving birth in all public health centres and hospitals. This was closely followed by a reduction in financial flows to the facilities, resulting in frequent drug stock-outs, reduced quality of the services, and disruption of the referral system [ 42 ]. These are similar challenges to those that we observed across the sites, although these challenges were more acute in the case of Northern Uganda. In Burundi, the nationwide introduction of the PBF programme in April 2010 to complement the earlier introduced free health care policy for children under five and pregnant women, seems to have mitigated some of the challenges that were observed following the introduction of the free healthcare policy. This has led to a generally more positive perception of the health system among women in Burundi compared to the women in Northern Uganda, as we observed in our study. The PBF scheme is a supply-side results-based financing programme which involves a ‘fee-for-service–conditional-on-quality of care’ mechanism that rewards hospitals and health facilities with monthly payments determined by service utilisation levels and performance on quality measures [ 43 ]. In the absence of a similar and well-coordinated personnel remuneration system like the PBF, health personnel in Northern Uganda may be more demoralized, less enthusiastic in the delivery of basic health services, and more prone to request unofficial payments from clients. The initial challenges faced by Burundi in the wake of the introduction of the selective healthcare policy, and nowadays in Northern Uganda, where a universal healthcare policy is in place, points to the importance of careful planning, implementation and coordination of such policies. However, failure to do so may seriously compromise the quality of services, as was observed across the study sites, and especially those in Northern Uganda. While the positive impact of the PBF programme on the utilisation and quality of maternal and child health services was widely reported by participants in Burundi, a few participants equally acknowledged that challenges with respect to staff burn-out and service quality as a result of the increasing demand for services remain. Although a number of post-conflict countries in Africa including Burundi and Rwanda have rolled-out nationwide PBF schemes as a means of improving health worker performance and as a tool for health sector reform, Ireland et al. have questioned the validity of PBF as a tool for health sector reform. They argue that the “debate surrounding PBF is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the PBF package” [ 44 ] (p. 695).

Based on our findings and those of previous studies [ 12 - 16 ], the determinants seem to be largely the same in post-conflict and non-conflict settings except for the fact that the barriers in post-conflict settings tend to be more widespread and exacerbated . We demonstrate that exposure to armed conflict affected women’s utilisation of MSRHS mainly through low educational attainment for both men and women translating into ignorance of the importance of health services and into high levels of impoverishment. Another commonly observed effect was the strong desire, especially among men, to replace lost family members, resulting in their general opposition to modern contraceptives. Working in the opposite direction, great pressure on limited land for cultivation coupled with reported increased incidence of land disputes as conflict-displaced populations return to their communities, appear to encourage some women to consider modern family planning services for birth control.

Our findings also highlight some similarities and differences in the perceived determinants of women’s uptake of MSRHS between and within the categories of participants and study settings. For example, almost all factors identified by the women were also highlighted by the LHP and NGO respondents. This is not particularly surprising, as the latter serve within the communities where these women reside, and have a generally good knowledge of the socio-cultural context of these women. Also, a number of the NGOs and local health providers have local community projects within our study areas that may further improve their level of engagement with the women in those communities. This possible practice of engagement of health personnel with local communities is worth encouraging and supporting as it may improve the delivery of services, thus providing better client satisfaction. However, while the LHP and NGO respondents across the study sites perceived the Catholic Church as having a very strong negative effect on the uptake of modern contraceptives, this was not a concern among the women respondents. The major barriers for the women were opposition from their male partner and the fear of possible side effects. The non-mention of a strong religious influence on modern contraceptives uptake by the women might reflect the fact that the religious values that some women hold may not necessarily be in keeping with the official teachings of their religion, or that their local cultural values may have a much stronger impact on their belief systems. Alternatively, the women might simply not want to apportion blame on their religion as a sign of respect. It is also important to note that the issue of seeking facility delivery in Burundi was strongly associated with the desire to obtain a birth certificate for the child. This highlights the importance that women in rural Burundi place on the free healthcare policy, as the birth certificate of the child might be required at times in public facilities before services are provided free of charge. The issue of limited land that has served as a facilitator to family planning uptake was raised only by the women, across the study sites. This might reflect the reality these women go through on a daily basis to raise their children and put food on the table for their families. Since the women were largely based in rural areas, with farming as their main occupation, they might have personally experienced the challenges of having a large family living off a limited piece of land, and how such pressure affects household- and community cohesion. This may explain why some women disregard personal risk and seek for concealable modern contraceptives against the backdrop of male-partner- and cultural opposition. The other concerns raised about the uptake of modern contraceptives are not unique to our study. A study in Ghana found that a third of women considered modern contraceptives as unsafe, 20% reported opposition from their male partner as a barrier to uptake, and 65% of users reported at least one side-effect [ 45 ]. Therefore, in order to improve the uptake and continual usage of modern contraceptives in these areas, these concerns have to be addressed.

The challenges of delivering health care and rebuilding health systems in conflict and post-conflict settings have been well acknowledged. The major challenges are the lack of security; acute shortage of skilled health professionals due to migration to safer areas; lack of infrastructure and medical supplies and drugs; obstruction of access to health facilities by warring parties; security forces harassing, arresting and prosecuting health providers; poor coordination among government, health care providers and humanitarian organizations; and assaults on patients within hospitals, among others [ 46 - 50 ]. These challenges make the health system non-functional, resulting in limited availability of, limited access to, and poor quality of health services. As such, rebuilding health systems must take into consideration the prevailing challenges to ensure efficient use of limited resources and provide maximum impact. In this regard, experts have recommended that health system strengthening programmes in such settings should put more emphasis in the short-term on the provision of primary health care services, using existing human resources for health, community structures, NGOs and mobile outreach clinics [ 51 ]. Programmes such as the renovation and construction of health facilities and the development of human resources for healthcare are more likely to succeed in the medium- and long term. This happens to be the approach that both governments have eventually embarked on, although in the earlier post-conflict years in Northern Uganda so many resources were channeled into the construction of health facilities, especially in rural areas, that to date many remain non-functional due to acute shortage of human and material resources. A more stepwise approach, rather than thinning out the limited resources over a large area without much progress taking place, could have been more effective. Furthermore, governments of post-conflict settings along with their development partners must carefully design the core elements of the health system to provide reliable essential health while ensuring that it addresses issues around equity, government accountability to citizens, and governments’ capacity to manage important social programs [ 47 ].

Limitations

A limitation of the study was that the women participants were mainly staying within the catchment areas of some local health centre or had regular weekly access to basic healthcare services through mobile outreach clinics. We were unable to recruit women participants in much disadvantaged remote areas that were not regularly served with basic health services. As such, the perspectives of that group of women are not well captured in our study.

In post-conflict settings, a vast and complex set of factors affect women’s utilisation of MSRHS ranging from the individual, socio-cultural, political to health system levels. The main determinants include the removal of financial barriers to access; level of household, community and facility support for women; proximity to health services; and community perceptions of some services. Exposure to conflict generally exacerbated the barriers to women’s uptake of services, mainly through low educational attainment and stronger cultural desire for increased fertility to replace family members lost to the conflict. To improve women’s uptake of MSRHS in such settings, robust health system strengthening programmes addressing the barriers across the individual, socio-cultural and political spheres are needed. While addressing financial barriers to access is important, attention should also be paid to non-financial barriers. The goal should be developing an equitable and sustainable health system.

UN Department of Economic and Social Affairs. The Millennium Development Goals Report 2013. New York: UN Department of Economic and Social Affairs; 2013. http://www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdf .

Google Scholar  

Ghobarah HA, Huth P, Russett B. Civil wars kill and maim people—long after the shooting stops. Am Polit Sci Rev. 2003;97(2):189–202.

Article   Google Scholar  

Ghobarah HA, Huth P, Russett B. The postwar public health effects of civil conflict. Soc Sci Med. 2004;59(4):869–84.

Article   PubMed   Google Scholar  

Li Q, Wen M. The immediate and lingering effects of armed conflict on adult mortality: a time-series cross-national analysis. J of Peace Res. 2005;42(4):471–92.

Urdal H, Chi PC. War and gender inequalities in health: the impact of armed conflict on fertility and maternal mortality. Int Interact. 2013;39(4):489–510.

Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards millennium development goal 5. Lancet. 2010;375:1609–23.

Save the Children. State of the World’s Mothers Report. http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.8585863/k.9F31/State_of_the_Worlds_Mothers.htm

Roberts B, Odong VN, Browne J, Ocaka KF, Geissler W, Sondorp E. An exploration of social determinants of health amongst internally displaced persons in Northern Uganda. Confl Health. 2009;3:10.

Article   PubMed   PubMed Central   Google Scholar  

Watts S, Siddiqi S, Shukrullah A, Karim K, Serag H. Social determinants of health in countries in conflict and crises: the eastern Mediterranean perspective. Geneva: World Health Organization; 2007.

Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.

Bornemisza O, Ranson MK, Poletti TM, Sondorp E. Promoting health equity in conflict-affected fragile states. Soc Sci Med. 2010;70(1):80–8.

Sarma S, Rempel H. Household decisions to utilize maternal healthcare in rural and urban India. World Health Popul. 2007;9(1):24–45.

Birmeta K, Dibaba Y, Woldeyohannes D. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC Health Serv Res. 2013;13:256.

Ononokpono DN, Odimegwu CO, Imasiku E, Adedini S. Contextual determinants of maternal health care service utilization in Nigeria. Women Health. 2013;53(7):647–68.

Mohammed A, Woldeyohannes D, Feleke A, Megabiaw B. Determinants of modern contraceptive utilization among married women of reproductive age group in North Shoa Zone, Amhara Region, Ethiopia. Reprod Health. 2014;11(1):13.

Joshi C, Torvaldsen S, Hodgson R, Hayen A. Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data. BMC Pregnancy Childbirth. 2014;14(1):94.

Roberts B, Guy S, Sondorp E, Lee-Jones L. A basic package of health services for post-conflict countries: implications for sexual and reproductive health services. Reprod Health Matters. 2008;16(31):57–64.

Themnér L, Wallensteen P. Armed conflicts, 1946–2013. J of Peace Res. 2014;51(4):541–54. See also Uppsala Conflict Data Program (Date of retrieval: 2014/11/12) UCDP Conflict Encyclopedia: www.ucdp.uu.se/database , Uppsala University.

Voors MJ, Nillesen EE, Verwimp P, Bulte EH, Lensink R, Van Soest DP. Violent conflict and behavior: a field experiment in Burundi. Am Econ Rev. 2012;102(2):941–64.

Ministry of Health, Republic of Uganda. Health and mortality survey among internally displaced persons in Gulu, Kitgum and Pader districts, Northern Uganda. Kampala: MoH & WHO; 2005. http://www.who.int/hac/crises/uga/sitreps/Ugandamortsurvey.pdf .

Uganda National Bureau of Statistics. Uganda National Household Survey 2009/2010. Kampala: UNBS; 2010.

Ministry of Health and Fighting AIDS. National Health Development Plan (2011–2015). Ministry of Health and Fighting AIDS, Burundi. http://www.nationalplanningcycles.org/sites/default/files/country_docs/Burundi/burundi_pnds_2011_-_2015-en.pdf .

World Health Organization: Burundi. The Country Cooperation Strategy. WHO, May 2014. http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_bdi_en.pdf

Nsengiyumva G, Musango L. The simultaneous introduction of the district health system and performance-based funding: the Burundi experience. Field Actions Science Reports [Online], Special Issue 8 | 2012, Online since 13 February 2013, connection on 02 March 2013. http://factsreports.revues.org/2351

Ministry of Health, Republic of Uganda. Health Sector Strategic Plan III (2010/11 – 2014/15). Ministry of Health, Government of Uganda. http://www.health.go.ug/docs/HSSP_III_2010.pdf .

Jitta J, Arube-Wani J, Muyiinda H. Study of client satisfaction with health services in Uganda. Final report submitted to the Ministry of Health, 2008. http://chdc.mak.ac.ug/publications/CHDC%202008%20Client%20Satisfaction%20with%20Health%20Services%20in-Renamed.pdf

World Health Organization. Uganda: The Country Cooperation Strategy. May 2014. http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_uga_en.pdf?ua=1

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117.

Wild K, Barclay L, Kelly P, Martins N. Birth choices in Timor-Leste: a framework for understanding the use of maternal health services in low resource settings. Soc Sci Med. 2010;71(11):2038–45.

Orach CG, Musoba N, Byamukama N, Mutambi R, Aporomon JF, Luyombo A, et al. Perceptions about human rights, sexual and reproductive health services by internally displaced persons in Northern Uganda. Afr Health Sci. 2009;9 Suppl 2:S72–80.

PubMed   PubMed Central   Google Scholar  

Jaramogi P. Maternal health still an issue - study. New Vision Dec 13, 2013. http://www.newvision.co.ug/news/650478-maternal-health-still-an-issue-study.html

Kiwanuka SN, Ekirapa EK, Peterson S, Okui O, Rahman MH, Peters D, et al. Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence. Trans R SocTrop Med Hyg. 2008;102(11):1067–74.

Article   CAS   Google Scholar  

Dorwie FM, Pacquiao DF. Practices of traditional birth attendants in Sierra Leone and perceptions by mothers and health professionals familiar with their care. J Transcult Nurs. 2014;25(1):33–41.

Lori JR, Boyle JS. Cultural childbirth practices, beliefs, and traditions in post-conflict Liberia. Health Care Women Int. 2011;32(6):454–73.

Kabakian-Khasholian T, Shayboub R, El-Kak F. Seeking maternal care at times of conflict: the case of Lebanon. Health Care Women Int. 2013;34(5):352–62.

RHRC Consortium. Emergency Obstetric Care: Critical Need among Populations Affected by Conflict. New York: RHRC Consortium; 2004.

Wayte K, Zwi AB, Belton S, Martins J, Martins N, Whelan A, et al. Conflict and development: challenges in responding to sexual and reproductive health needs in Timor-Leste. Reprod Health Matters. 2008;16(31):83–92.

De Allegri M, Ridde V, Louis VR, Sarker M, Tiendrebéogo J, Yé M, et al. Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy. 2011;99(3):210–8.

Ediau M, Wanyenze RK, Machingaidze S, Otim G, Olwedo A, Iriso R, et al. Trends in antenatal care attendance and health facility delivery following community and health facility systems strengthening interventions in Northern Uganda. BMC Pregnancy Childbirth. 2013;13:189.

Hadi A, Rahman T, Khuram D, Ahmed J, Alam A. Raising institutional delivery in war-torn communities: experience of BRAC in Afghanistan. Asia Pac J Fam Med. 2007;6(1):51.

Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya CK, et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy Plan. 2011;26 Suppl 2:ii16–29.

PubMed   Google Scholar  

Nimpagaritse M, Bertone MP. The sudden removal of user fees: the perspective of a frontline manager in Burundi. Health Policy Plan. 2011;26 Suppl 2:ii63–71.

World Bank. Burundi’s national performance based financing (PBF) program: results based financing at the world bank. Washington DC: World Bank; 2011. https://www.rbfhealth.org/sites/rbf/files/Burundi_country_example.pdf .

Ireland M, Paul E, Dujardin B. Can performance-based financing be used to reform health systems in developing countries? Bull World Health Organ. 2011;89(9):695–8.

Aryeetey R, Kotoh AM, Hindin MJ. Knowledge, perceptions and ever use of modern contraception among women in the Ga East District. Ghana Afr J Reprod Health. 2010;14(4):27–32.

Acerra JR, Iskyan K, Qureshi ZA, Sharma RK. Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services. Int J Emerg Med. 2009;2(2):77–82.

Kruk ME, Freedman LP, Anglin GA, Waldman RJ. Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: a theoretical framework and research agenda. Soc Sci Med. 2010;70(1):89–97.

Ministry of Health Uganda. Mapping and Assessment of Health Services Availability in Northern Uganda: A Tool for Health Co-ordination and Planning. Kampala, Uganda: Ministry of Health, Uganda; 2006.

Rubenstein LS. Protection of health care in armed conflict and civil conflict: Opportunities for breakthroughs. A Report of the CSIS Global Health Policy Center. Center for Strategic and International Studies. January 2012. http://csis.org/files/publication/120125_Rubenstein_ProtectionOfHealth_Web.pdf

The PLoS Medicine Editors. Health care systems and conflict: a fragile state of affairs. PLoS Med. 2011;8(7):e1001065.

Article   PubMed Central   Google Scholar  

Bisika T. Health systems strengthening in conflict situations. East Afr J Public Health. 2010;7(3):277–81.

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Acknowledgements

We are grateful to all the participants who took time off to participate in the study. Ms. Foglabenchi Lily Haritu assisted with coding the transcripts. We thank our local collaborators across all the study sites for logistic and administrative support. We thank the reviewers, Kate Teela and Maree Porter, and the editor for their comments. This fieldwork received funding from Folke Bernadotte Academy, Sweden and the Institute of Health and Society, University of Oslo, Norway. The entire work has been supported by: the EU 7th Framework Marie Curie ITN ‘Training and Mobility Network for the Economic Analysis of Conflict’ – TAMNEAC (Grant agreement 263905), the Research Council of Norway – Project 230861 ‘Armed Conflict and Maternal Health in Sub-Saharan Africa’, and the Peace Research Institute Oslo (PRIO).

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Institute of Health and Society, University of Oslo, PO Box 1130, Blindern, Oslo, Norway

Primus Che Chi & Johanne Sundby

International Organization for Migration, Plot 6A, Naguru Crescent, Kampala, Uganda

Patience Bulage

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Authors’ contributions

PCC: Participated in the conception and design, data collection and analysis, and drafting and revising the first manuscript; PB: participated in data analysis, and drafting and reviewing the manuscript; HU: participated in the conception and design, data interpretation, and reviewing the manuscript; JS: participated in the conception and design, data interpretation, and reviewing the manuscript. All authors participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors reviewed and approved the final manuscript.

Additional files

Additional file 1:.

Methods. This is a detailed description of the materials and methods used for undertaking the study. It includes a description of the study settings and participants, data collection, management and analysis methods, collaborative partnership, recruitment of participants and ethical considerations.

Additional file 2:

Data Collection Tool: Interview and Focus Group Discussion Guides. This is a detailed description of the interview and focus group discussion guides for the various categories of research participants. The guides are for the entire study from which this paper is one of the outcomes.

Additional file 3: Table S2.

Factors affecting women’s utilisation of Maternal, Sexual and Reproductive Health Services (MSRHS) in post-conflict Burundi and Northern Uganda. This is a summary of the factors affecting women’s utilisation of maternal, sexual and reproductive health services in Burundi and Northern Uganda as perceived by women of reproductive age, local health providers and staff of NGOs working in the domain of maternal and reproductive health. The factors are further classified into individual level factors, socio-cultural level factors and political and health system level factors.

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Chi, P.C., Bulage, P., Urdal, H. et al. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy Childbirth 15 , 18 (2015). https://doi.org/10.1186/s12884-015-0449-8

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DOI : https://doi.org/10.1186/s12884-015-0449-8

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How Can We Solve the Black Maternal Health Crisis?

A special three-part series of Public Health On Call shines light on the heightened risks faced by Black birthing people in the U.S., the history and racism behind this crisis, and what can be done to address it—by policymakers, hospitals and practices, community advocates, and a new generation of medical trainees.

Annalies Winny

Rachel Bervell, MD

Dire statistics about maternal health outcomes for Black women in America have become front-page news in recent years, in part because of the high-profile deaths of new mothers like CDC scientist Shalon Irving, MPH ’09, as well as the deep racial health inequities laid bare by the COVID-19 pandemic. 

But this problem isn’t new—in fact, it has roots in the very fabric of American society and health care, with structural and systemic racism at its core.  

CDC data show that Black women are  two to three times more likely to die from pregnancy-related complications than white women, with most of the maternal deaths being  preventable . This heightened risk spans all income and education levels. According to the study from the  National Bureau of Economic Research, the wealthiest Black woman in California is at a higher risk of maternal mortality than the least wealthy white woman. 

Black birthing people are also more likely to experience life-threatening conditions like preeclampsia, postpartum hemorrhage, and blood clots, as well as increased incidence of other pregnancy-related complications like preterm birth and low birth weight. 

Amid a national reckoning with the systemic racism underpinning American society and health care, advocates are pushing forward solutions from multiple angles, including reforming policy, health systems and medical education, and bolstering community-based organizations that advocate for better care and resources for Black moms. 

Policy Solutions  

Sixty-five percent of Black birthing people in the U.S. rely on Medicaid—the joint state and federal health care program for low-income Americans—for pregnancy and postpartum care, compared to  42% of all U.S. mothers overall. 

With nearly half of maternal deaths happening within the first year postpartum, maternal health advocates have long advocated for expanding postpartum Medicaid benefits to a full year—rather than the 60 days required under federal law—to ensure women have access to adequate care as they navigate new motherhood.  

And dozens of states have done so, in part thanks to the expansion of federal policies —originally put in place to help Americans recover from the COVID-19 pandemic—which made it more appealing for states to expand Medicaid. Those states have lower rates of maternal death, particularly for Black women. States with less generous benefits, on the other hand, have worse maternal health outcomes and  higher uninsured rates for women of reproductive age—again, particularly for Black women. 

But even with expanded Medicaid coverage, the prospect of being forced to return to work too soon after birth is a major strain on mothers. The U.S. is  one of only a handful of countries that have no national policy guaranteeing paid leave to new parents. 

Evidence shows that job-protected paid parental leave is essential for  healthy moms, babies, and communities —and that Black women are less likely to have access to paid leave through their jobs than white women, adding to their risk of the worst maternal health outcomes. 

Fortunately,  efforts to provide paid family leave are garnering more support, and  13 states and the District of Columbia have passed their own paid family and medical leave laws. 

Telehealth services are another way to foster healthy pregnancies—and their footprint is expanding, allowing more Americans to video conference with doctors, check test results online, and remotely monitor health conditions.  One study found that implementing telehealth for postpartum care amid the pandemic was linked to decreased racial disparities in postpartum visit attendance.   

Many telehealth policies were made official through  the landmark COVID-19 relief bill known as the CARES Act . While they have yet to be codified into federal law, the 2022 Omnibus spending bill extended COVID-era rules that made it easier for many Americans to access telehealth services.  

Expanding telehealth and many other policies have been written into the largest, most ambitious effort to confront the Black maternal health crisis from the federal level: The Black Maternal Health  Momnibus Act of 2021. 

Introduced by The Black Maternal Health Caucus, the package proposes big changes in maternal health  through 12 standalone bills that address the full slate of socio-economic factors that impact a pregnancy, including investing in the social determinants of health, growing and diversifying the perinatal workforce, and improving data collection for maternal health. 

“At the heart of these investments is the principle that in America every family has the right to thrive, a principle that begins with a safe and healthy pregnancy and birth,” said Illinois Representative Lauren Underwood, MSN/MPH ’09, a lead sponsor of the Momnibus. 

So far only one element of the Momnibus has been signed into law— the Protecting Moms Who Served Act . If passed in full, the Momnibus package could make a major impact on maternal health outcomes.

Health Care System and Education Reform  

Reforms to the way medicine is practiced and taught are also central to the effort to improve outcomes for Black moms. At the center of this work is a reckoning with systemic racism that is baked into the history of the American health system. 

The  1910 Flexner Report —funded by the American Medical Association—laid the foundation for American medical education and led to the closure of  all but two historically Black medical schools. This created severe shortages of Black health professionals that persist today, contributing to a lack of cultural humility when caring for Black patients. 

At the same time, Black providers such as  Granny midwives —who attended  half of all births at the beginning of the 20th century—were increasingly undermined and discredited. By 1975,  less than 1% of births were attended by midwives as hospital births became the health care standard.    

Advocacy for reform in health systems and education seeks to unravel the legacy of these practices by reckoning directly with racism, seeking to diversify the health care workforce, and providing Black moms with  culturally sensitive care .  

That includes expanding access to midwives and doulas to assist Black mothers. People who receive care from midwives are  less likely to have a preterm birth, less likely to have a C-section, and more likely to breastfeed . Doulas—non-clinical health care providers who offer physical, emotional, and informational support during pregnancy, labor, delivery, and postpartum—can play a critical role in reducing  racial disparities in maternal health , and their services  have been associated with fewer birth complications and a reduced risk of having a low birth weight infant.  Some states cover these services under Medicaid, and advocates are pushing for expanded access to these services nationwide.  

When it comes to clinical care, addressing biased care practices within clinical care is a top priority for physician advocates—and that includes calling out biased care practices, such as the excessive drug testing of Black women on labor and delivery wards. A  recent study of Pennsylvania hospitals found that Black women were less likely to test positive for drugs than white women, despite being tested more.  

A commitment to addressing discriminatory hospital policies has led many physicians to refocus their energy on advocacy, says Jamila Perritt, MD, MPH ’10, president and CEO of Physicians for Reproductive Health. 

“These are policies that are deeply misinformed, misguided, not grounded in science or medical evidence, and in fact, are directly misaligned with principles of public health," says Perritt. “It’s recognition that [physicians] are not infallible. We will make mistakes and we will cause harm and the question becomes, what did we do after it?” 

Meanwhile, a new generation of medical trainees is also putting equity front and center of their education, both by participating in the larger anti-racism movement through groups like White Coats for Black Lives and leading the charge to change their curricula, says Neel Shah, MD, assistant professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. 

“One of the things I've seen the last couple of years is that medical students themselves are driving the change,” Shah says. “They're the ones who are calling for implicit bias curricula or calling for health equity to be part of the curriculum.”  

Bolstering Community Organizations  

The movement for birth equity is also being led with growing momentum by community-based organizations (CBOs) focused on caring for Black moms and advocating for system change across policy and health systems.   

“Health isn't produced in the four walls of the clinic,” says Shah. “It's produced in people's homes and their communities and their workplace. And you have to not only have the right technical expertise to serve someone; you have to have the right lived experience, particularly when it comes to childbirth.” 

CBOs are often the vital intermediary between individuals and policymakers, working at both the grassroots level, empowering everyday people, and at the “grass tops” level, mobilizing political support and influence. They are particularly well-suited to address the unique needs of their communities, including the challenges faced by Black birthing people seeking quality care. 

These organizations are critical partners in efforts to reduce disparities in maternal health outcomes. They collaborate with health care providers, policymakers, and other stakeholders to advocate for programs that target the issue at hand, and they step up to provide much-needed resources such as access to doulas, home visits, social services referrals, and education. 

Supporting for the work already being done in Black communities has been written into policy efforts like the Momnibus and the proposals in the  2022 White House Blueprint for Addressing the Maternal Health Crisis . 

As complex and deep-rooted as the Black maternal health crisis is, solutions are at play at all levels of society. There is promise in policy, potential in system change, and renewed energy with the next generation of medical trainees. Communities are using collective efforts to transform experiences. Families affected by the crisis are raising their voices.  

But it’s not just policymakers, physicians, and Black birthing people who can help solve this problem by staying informed about the roots of the problem, and supporting the work being done to fight it.  

If you’re interested in learning more about the Black maternal health crisis, the history of the issue, and solutions to it, check out the links and book recommendations below.

Organizations mentioned in the podcast series  

• The Black Mamas Matter Alliance , founders of Black Maternal Health Week, advances Black maternal health, rights, and justice. 
• National Birth Equity Collaborative works to optimize Black maternal, infant, sexual, and reproductive wellbeing. 
• 4Kira4Moms is a nonprofit dedicated to eradicating maternal mortality. 
• Dr. Shalon's Maternal Action Project is part of an advocacy collective focused on the postpartum period for BIPOC birthing people.
• Review to Action connects states to Maternal Mortality Review Committees.
• Physicians for Reproductive Health aims to ensure safe and compassionate access to care. 
• Maven Clinic, a digital health platform focused on family care. 
• The Century Foundation , a progressive, independent think tank that drives policy change for issues including for maternal health. 
• The Bloom Collective focuses on providing a nurturing, supportive and empowering space for mothers, parents and families. 
• Mamatoto Village creates career pathways for Black women in maternal health. 
• Black Women’s Health Imperative , the first and only national non-profit solely dedicated to achieving health equity for Black women in America. 
• National Black Doulas Association, connects Black birthing professionals and provides resources and support with families seeking doula service. 
• National Black Midwives Alliance establishes a representative voice at the national level that organizes, advocates, and brings visibility to the issues impacting Black midwives and the communities they serve. 
• SisterSong, created by the founders of the reproductive justice movement, is a national activist organization amplifying the collective voices of indigenous women and women of color to achieve reproductive justice. 

Additional Reading  

• Under the Skin by Linda Villarosa 
• Medical Apartheid by Harriet Washington 
• Killing the Black Body by Dorothy Roberts 
• Medical Bondage by Deirdre Cooper Owens 
• Policing the Womb by Michele Goodwin 
• Reproducing Race by Khiara Bridges 
• Birthing Justice by Julia Chinyere Parah and Alicia Bonaparte 
• Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society by Arline Geronimus 
• The Philadelphia Negro by W.E.B. DuBois 
• Film : Aftershock (2022)  

Rachel Bervell, MD, is a physician and MPH candidate at the Bloomberg School, and co-founder of @TheBlackObGynProject . Her insights have been featured on Health Affairs, NPR, and more.

Annalies Winny is a producer of Public Health in the Field and Associate Editor of Global Health NOW at the Johns Hopkins Bloomberg School of Public Health. 

• Black Maternal Mortality: ‘It is Racism, not Race’
• Black Women’s Biggest Health Issue Is the System

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Maternal and child health news, resources and funding for global health researchers

Fogarty has a strong commitment to improving the health of children, adults, families and communities throughout the world. Several Fogarty programs currently address issues related to maternal and child health, including vaccinations, trauma, birth defects, prevention of mother-to-child transmission of HIV (PMTCT), fetal alcohol syndrome and childhood nutrition.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) leads NIH research efforts in the fields of child health and development, including pregnancy and fertility. The NIH Office of Research on Women's Health (ORWH) works in partnership across NIH to ensure that women's health research is part of the scientific framework at the NIH and throughout the scientific community.

Fogarty participated in the MAL-ED program to investigate linkages between malnutrition and intestinal infections and their effects on children in the developing world. Fogarty and NIH partners also support research to reduce household air pollution from elemental stoves for cooking or heating, which impacts women and children.

Fogarty Grants

View a full list of active and recent grant awards focusing on maternal and child healthresearch

Recent Maternal and Child Health News

• When overweight and undernourished live under one roof Global Health Matters , July/August 2024
• Empowering women and children from Nepal to the Amazon Global Health Matters , July/August 2024
• Exploring the genomic traits of infant-associated microbiota members from a Zimbabwean cohort , co-authored by Fogarty trainee Danai Tavonga Zhou BMC Genomics , July 25, 2024
• Umbilical cord milking does not appear to increase risk of neurodevelopmental delay in non-vigorous infants NIH News, July 1, 2024
• Prognostics of multiple malaria episodes and nutritional status in children aged 6 to 59 months from 2013 to 2017 in Dangassa, Koulikoro region, Mali , co-authored by Fogarty grant recipient Seydou Doumbia and Fogarty trainees Soumba Keita, Mahamoudou Toure, Daouda Sanogo and Mahamadou Diakite Malaria Journal, June 13, 2024
• Impacts of heat exposure in utero on long-term health and social outcomes: a systematic review , co-authored by Fogarty grant recipient Matthew F. Chersich BMC Pregnancy and Childbirth , May 4, 2024

NIH News and Resources

• NIH Office of Research on Women's Health (ORWH): Global Health Research
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): Office of Global Health (OGH)

Other US Government Resources

• United States Agency for International Development (USAID):  maternal and child health
• Centers for Disease Control and Prevention (CDC): maternal and infant health
• Health Resources and Services Administration (HRSA): Maternal and Child Health Bureau

Other Online Resources

• Integrated Public Use Microdata Series (IPUMS), supported in part by the NIH: Harmonized international survey data on maternal, child and reproductive health
• Kaiser Family Foundation Fact Sheet: The U.S. Government and Global Maternal, Newborn and Child Health
• Saving Lives at Birth: A Grand Challenge for Development USAID, the Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, DFID and KOICA
• WHO on Maternal Health
• Global Strategy for Women's, Children's and Adolescents Health 2016-2030 , published 2015
• WHO report: Air pollution and child health: prescribing clean air , published October 2018
• Maternal Health
• Child Mortality  
• UNICEF annual State of the World's Children reports

Updated August 23, 2024

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Accelerating Research to Prevent Maternal Morbidity and Mortality (MMM)

The United States experiences about 700 maternal deaths each year, and American Indian/Alaska Native and Black women are 2 to 3 times more likely to die from a pregnancy-related cause than white women. The Centers for Disease Control and Prevention (CDC) estimates that two-thirds of maternal deaths may be preventable. 1 Thousands more suffer from near misses or severe morbidity.

Maternal health is a priority for multiple NIH institutes that have heavily invested in research to prevent morbidity and mortality and improve overall health. In the past year, with base funding of $223 million, 2 NIH has worked across its Institutes, Centers, and Offices (ICOs) and with federal and community partners to support research to reduce preventable causes of maternal deaths and improve health for women, before, during, and after pregnancy. In a year that was dominated by both the COVID-19 pandemic and renewed calls to understand and resolve health disparities and inequities, NIH ensured these challenges were integrated into our efforts to reduce MMM.

Select a link to learn more:

Generating Evidence to Change Practice and Save Lives through NIH-Supported Research

Emphasizing community engagement, pivoting to address covid-19, looking to the horizon.

• Minority women tend to deliver disproportionately in hospitals with lower quality ratings; however, evidence shows that initiatives targeted at quality improvement can substantially improve outcomes. 3
• Risk of death during pregnancy and up to 1 year postpartum is significantly elevated among women residing in maternity care "deserts," which are counties that lack hospitals with obstetric care or midwives. Identifying and transporting women with high-risk pregnancies to facilities equipped for specialized care can mitigate MMM risks. 4
• Homicide was identified as a leading cause of pregnancy-associated death . Increased contact with the healthcare system during pregnancy provides clinicians with an opportunity to offer potentially life-saving violence prevention services and interventions. 5
• Women facing eviction from their homes while they were pregnant are more likely to have poor birth outcomes. Thus, providing housing, social, and medical assistance to pregnant women at risk for eviction may improve infant health. 6

Tackling the challenge of reducing MMM requires strong partnerships with and among local communities and resources, particularly with racial and ethnic minority populations that experience stark health disparities. To that end, several ICOs held community engagement activities to hear first-hand how patient communities can inform future research and what engagement strategies might enhance local efforts to improve maternal health. 7 , 8 , 9 A common refrain was that research conducted in a community should be developed with and vetted by the community to ensure success and improved outcomes. These engagement activities informed the development of NIH’s IMPROVE ( I mplementing a M aternal health and PR egnancy O utcomes V ision for E veryone) initiative, which aims to build an evidence base that will improve maternal care and outcomes from pregnancy through one year postpartum. 10

As COVID-19 ravaged the country in early 2020, research increasingly showed that pregnant women were at higher risk for severe disease, including hospitalization, need for intensive care unit monitoring, and mechanical ventilation. NIH research showed that pregnant COVID-19 patients with severe disease are at higher risk for cesarean delivery, postpartum hemorrhage, hypertensive disorders of pregnancy, and preterm birth . 11 These findings come from the G estational R esearch A ssessments for CO VID -19 (GRAVID) study, which evaluated data from more than 1,200 pregnant women at 33 hospitals across the country. Additional research on maternal health related to COVID-19 includes:

• Developing Common Data Elements that can be used in any study involving pregnant women, facilitating data analysis across different research studies 12
• Evaluating the effects of remdesivir in pregnant women being treated with the drug for COVID-19 13

NIH is accelerating research on factors that affect pregnancy-related and pregnancy-associated morbidity and mortality to improve care and outcomes. NIH’s Fiscal Year 2020 investments included:

• Supplements to expand existing research projects or support pilot projects for community-partnered research to resolve health disparities, strengthen evidence-based care and improve outcomes, and explore comorbidities to identify preventable risk factors and develop effective early interventions 14
• " Addressing Racial Disparities in Maternal Morbidity and Mortality ” funding opportunity to support research that tests clinical, social-behavioral, and healthcare system interventions to address racial disparities 15 and needs of underserved women 16
• Institutional Development Award (IDeA) States, created to expand research and research capability in states that have historically received low levels of NIH funding to address women’s health and maternal and infant morbidity and mortality 17 ; reissued in Fiscal Year 2021 18

Funding opportunities for Fiscal Year 2021 include:

• IMPROVE initiative supplements to add or expand research focused on the intersection of maternal health, structural racism, and discrimination, and how these were affected by the COVID-19 pandemic 19
• Small Business Innovation Research and Small Business Technology Transfer (SBIR/STTR) awards to develop technologies or tools to quantitatively predict or indicate an increased risk for MMM 20
• Early Intervention to Promote Cardiovascular Health of Mothers and Children (ENRICH) for testing the effectiveness of an implementation-ready intervention designed to promote cardiovascular health (CVH) and address CVH disparities in marginalized birthing people and children in clinical or community sites 21
• Partnership with CDC, the Patient-Centered Outcomes Research Trust Fund, and the Office of the National Coordinator for Health Information Technology to create standards to link electronic health record data on maternal and infant health for use in studying the effect of medical conditions and/or interventions on pregnant, postpartum, or lactating women and their infants 22
• Interdisciplinary community-engaged research to reduce or eliminate infections and sepsis as MMM causes 23

For additional information on NIH-supported MMM research and funding opportunities:

• NIH MMM Web Portal: https://orwh.od.nih.gov/womens-health-research/maternal-morbidity-and-mortality/welcome
• IMPROVE initiative: https://www.nih.gov/research-training/medical-research-initiatives/improve-initiative
• NICHD MMM website: https://www.nichd.nih.gov/health/topics/maternal-morbidity-mortality
•   Centers for Disease Control and Prevention. (2019). Pregnancy-related deaths: Data from 14 U.S. maternal mortality review committees, 2008-2017 . Retrieved June 8, 2021, from https://www.cdc.gov/maternal-mortality/php/erase-mm .
•   FY 2020 funding amounts are estimates.
•   Janevic, T., Zeitlin, J., Egorova, N., Hebert, P. L., Balbierz, A., & Howell, E. A. (2020). Neighborhood racial and economic polarization, hospital of delivery, and severe maternal morbidity. Health Affairs 39 (5), 768-776. Retrieved June 8, 2021, from https://pubmed.ncbi.nlm.nih.gov/32364858/ .
•   Wallace, M., Dyer, L., Felker-Kantor, E., Benno, J., Vilda, D., Harville, E., & Theall, K. (2021). Maternity care deserts and pregnancy-associated mortality in Louisiana. Women’s Health Issues, 31 (2), 122-129. Retrieved June 8, 2021, from https://pubmed.ncbi.nlm.nih.gov/33069560/ .
•   NIH. (2020). Homicide is a leading cause of pregnancy-associated death in Louisiana . Retrieved June 8, 2021, from https://www.nih.gov/news-events/news-releases/homicide-leading-cause-pregnancy-associated-death-louisiana .
•   NICHD. (2021). Science update: Eviction during pregnancy linked to earlier births, reduced birthweight, according to NICHD-funded study . Retrieved June 8, 2021, from https://www.nichd.nih.gov/newsroom/news/031221-birth-outcomes-eviction .
•   NICHD. (2019). Community engagement forum on improving maternal health. Retrieved June 8, 2021, from https://www.nichd.nih.gov/about/meetings/2019/040819 .
•   NICHD. (2020). Pregnancy and maternal conditions associated with increased risk of morbidity and mortality workshop. Retrieved June 8, 2021, from https://www.nichd.nih.gov/about/meetings/2020/051920 .
•   National Institute of Nursing Research. (2020). Workshop on innovative models of care for reducing inequities in maternal health. Retrieved June 8, 2021, from https://www.ninr.nih.gov/newsandinformation/events/maternalhealth2020 .
•   NIH. (n/d). Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE) initiative. Retrieved June 8, 2021, from https://www.nih.gov/research-training/medical-research-initiatives/improve-initiative .
•   NICHD. (2021). Media advisory: Severe COVID-19 in pregnancy associated with preterm birth, other complications. Retrieved June 8, 2021, from https://www.nichd.nih.gov/newsroom/news/012821-GRAVID .
•   NICHD. (2021). Recommendations for Common Data Elements for COVID-19 Studies Involving Pregnant Participants. Retrieved June 8, 2021, from https://tools.niehs.nih.gov/dr2/index.cfm/resource/24206 .
•   NICHD. (2021). Release: NIH funds study to evaluate remdesivir for COVID-19 in pregnancy. Retrieved June 8, 2021, from https://www.nichd.nih.gov/newsroom/news/021721-COVID-19-remdesivir .
•   Notice of Special Interest (NOSI): Administrative Supplements for NIH grants to Add or Expand Research Focused on Maternal Mortality (NOT-OD-20-104). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-104.html .
•   Addressing Racial Disparities in Maternal Mortality and Morbidity (R01 Clinical Trial Optional) (RFA-MD-20-008). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/rfa-files/RFA-MD-20-008.html .
•   NOSI: Research on the Health of Women of Understudied, Underrepresented and Underreported (U3) Populations (Admin Supp Clinical Trial Optional) (NOT-OD-20-048). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/notice-files/not-od-20-048.html .
•   NOSI: Administrative Supplements for Research on Women’s Health in the IDeA States (NOT-GM-20-017). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/notice-files/NOT-GM-20-017.html .
•   NOSI: Administrative Supplements for Research on Women’s Health in the IDeA States (NOT-GM-21-018). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/notice-files/NOT-GM-21-018.html .  
•   NOSI: Administrative Supplements and Urgent Competitive Revisions for NIH Grants to Add or Expand Research Focused on Maternal Health, Structural Racism and Discrimination, and COVID-19 (NOT-OD-21-017). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/notice-files/NOT-OD-21-071.html .
•   NOSI: Small Business Initiatives for Innovative Diagnostic Technology for Improving Outcomes for Maternal Health (NOT-EB-21-001). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/notice-files/NOT-EB-21-001.html .
•   ENRICH Multisite Clinical Centers (Collaborative UG3/UH3 Clinical Trial Required) (RFA-HL-22-007) and ENRICH Multisite Resource and Coordinating Center (U24 Clinical Trial Required) (RFA-HL-22-008). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/rfa-files/RFA-HL-22-007.html and https://grants.nih.gov/grants/guide/rfa-files/RFA-HL-22-008.html .
•   Office of the Assistant Secretary for Planning and Evaluation, HHS. (2021). Severe Maternal Morbidity and Mortality-Electronic Health Record Data Infrastructure. Retrieved June 8, 2021, from https://aspe.hhs.gov/severe-maternal-Morbidity-and-Mortality-ehr .
•   Community Engaged Research on Pregnancy Related and Associated Infections and Sepsis Morbidity and Mortality (UG3/UH3 Clinical Trial Optional) (RFA-HD-21-033). Retrieved June 8, 2021, from https://grants.nih.gov/grants/guide/rfa-files/RFA-HD-21-033.html .

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Listen to the Whispers before They Become Screams: Addressing Black Maternal Morbidity and Mortality in the United States

Associated data.

No new data were created or analyzed in this study. Data sharing does not apply to this article.

Black women in the United States (U.S.) disproportionately experience adverse pregnancy outcomes, including maternal mortality, compared to women of other racial and ethnic groups. Historical legacies of institutionalized racism and bias in medicine compound this problem. The disproportionate impact of COVID-19 on communities of color may further worsen existing racial disparities in maternal morbidity and mortality. This paper discusses structural and social determinants of racial disparities with a focus on the Black maternal mortality crisis in the United States. We explore how structural racism contributes to a greater risk of adverse obstetric outcomes among Black women in the U.S. We also propose public health, healthcare systems, and community-engaged approaches to decrease racial disparities in maternal morbidity and mortality.

1. Introduction

The Centers for Disease Control and Prevention (CDC) reports that 50,000 women in the United States (U.S.) suffer from pregnancy complications annually, but that Black women are at least three times more likely to die due to a pregnancy-related cause when compared to White women [ 1 , 2 ]. The estimated maternal mortality rate in 2019 was 20.1 and, in 2020, was 23.8 per 100,000 births which represents about 861 maternal deaths. For Black women, that rate is about 55.3 per 100,000 live births, representing an estimated 1800 maternal deaths, the highest amongst any racial group; this is a number that has continued to increase over the past few years [ 3 , 4 ]. While each mortality or morbidity circumstance is different, the leading causal factors associated with maternal mortality and morbidity in the U.S. include hypertensive disorders of pregnancy, thrombotic pulmonary embolism, hemorrhage, infection, cardiovascular conditions, cardiomyopathy, and non-cardiovascular medical conditions [ 5 ]. While predisposition to underlying health conditions such as hypertension, cardiovascular disease, diabetes, and obesity plays a role in racial disparities in pregnancy-related deaths and other adverse pregnancy outcomes, when these medical conditions are not present, racial disparities persist.

More recent studies have shown that social factors such as historical exposure to racial trauma, discrimination, and marginalization; systemic barriers such as systematic racism and implicit bias within the healthcare system; the possibility of being uninsured; reduced access to reproductive healthcare services; and socioeconomic factors also contribute to pregnancy complications for Black women and have to be given consideration [ 2 , 5 , 6 , 7 , 8 ]. These social determinants of health show that poor maternal outcomes for Black individuals are caused by factors of racism that are embedded in healthcare and affect marginalized groups of individuals disproportionately. Based on socioeconomic status, race, age, and other identifying factors, the health disparities amongst individuals in communities that lack resources and education is exacerbated and continues to expand the gap in access to equitable health [ 9 ]. The history of racism within healthcare must be understood to dismantle institutionalized racism in healthcare systems and to create policies that protect Black women. Social and systemic changes are imperative to reduce Black maternal morbidity and mortality. Therefore, the stark differences in reproductive health outcomes for Black women necessitate an increased focus on the intersectional roles of racism, discrimination, and other social determinants of health in influencing disease and mortality risk.

Within the 21st century, healthcare has seen drastic shifts, especially with the ongoing COVID-19 pandemic. Research has shown that maternal mortality increased by 33% after the start of the pandemic and that late maternal deaths increased by 41% [ 10 ]. Moreover, the percentage of maternal deaths was even higher among Black and Hispanic women during the early part of the pandemic period, with increases in underlying cause-of-death codes for conditions such as other viral diseases (2374.7%), diseases of the respiratory system (117.7%), and diseases of the circulatory system (72.1%) [ 10 ]. COVID-19 represents a major social stressor for all at many levels but especially regarding maternal health [ 11 ]. While pregnant women overall were not found to have a higher risk for COVID-19 infection, women of color that were infected often experienced more adverse outcomes, as well as faced disproportionately adverse socioeconomic consequences. Maternal health was impacted due to the current COVID-19 pandemic both explicitly due to a life-threatening infection and indirectly due to the necessary changes in healthcare for infection control purposes. Isolation and quarantine as age-old infectious disease prevention protocols were instituted and strictly enforced. Some examples of healthcare COVID-19 protocols and hospital instituted labor and delivery changes consisted of less familial support available in the delivery room, long wait times, provider shortages, and overall hesitancy to seek prenatal care, which affected pregnant women’s mental health drastically, with studies showing increases in depression and anxiety [ 12 ]. Overall, during the COVID-19 pandemic, pregnant women experienced the stress of social changes in their jobs, families, and the fear of how to keep themselves healthy and safe.

The purpose of this paper is to discuss structural and social determinants of Black maternal mortality in the United States This perspective paper will also propose some public health, health systems, and community-engaged approaches that reduce racial disparities in maternal mortality and morbidity while striving to achieve equity in maternal health outcomes among Black women in the United States.

Theoretical Framework

The effects of racism in our society erode Black people’s health in a multitude of intersectional ways and dimensions. One of the theoretical frameworks that guide this paper is the “Weathering” framework. This framework’s foundation was originally rooted in maternal health, morbidity, and mortality and directly challenges the historical societal narratives of teen pregnancy, fertility peaks, and birth timing for African American women. In 1992, Dr. Arline Geronimus hypothesized correctly that the effects of racism in our society cause “premature biological aging”, hence the “weathering” in African American women, which has a direct effect on infant and maternal morbidity and mortality, and overall birth outcomes [ 13 ]. This weathering creates an overall “general health vulnerability” [ 14 , 15 ], which is a consequence of all levels of racism in the United States. Data reveal that there are increasingly poor pregnancy and birth outcomes as young Black women delayed fertility past their late teens, while this was not seen in White females. Since Dr. Geronimus’ seminal article, multiple quantitative biological marker studies have borne out the detrimental racial effects of a concept entitled, “allostatic load” or chronic stress [ 14 , 15 , 16 ]. Wakeel (2021) and colleagues further expanded the weathering theoretical framework by synthesizing the intersectionality of an older socioecological model (SEM) and the social determinants of health (SDOH) considering COVID-19 [ 11 ]. A “stressful life event” such as COVID-19 exacerbates all other social determinants of health [ 11 ]. Furthermore, we propose a theoretical framework adapted from Roach’s Restoring Our Own Through Transformation (ROOTT) Theoretical Framework [ 17 ], which explores how structural and social determinants impact maternal and infant mortality in the United States ( Figure 1 ). In this conceptual framework ( Figure 1 ), structural determinants of health are characterized by factors such as slavery, structural racism, and institutional policies and practices such as Jim Crow laws, the G.I. Bill (the Servicemen’s Readjustment Act of 1944), redlining, mass incarceration, and the 13th Amendment. These structural determinants of health shape social determinants of maternal and infant mortality, with this process indicated by the connection of dashed lines. These social determinants of health include food stability, education, income, built environment, neighborhood demographics, safety, housing, access to care, and incarceration. Structural determinants of health and social determinants interact in multiple and interrelated ways to influence increased maternal and infant mortality in the United States and work to exacerbate disparities in health outcomes. Furthermore, social determinants of health shape and are influenced by increased maternal and infant mortality. It is also important to consider intersectionality as an analytical framework that explores the unique experiences of Black women encountered at the intersections of race, class, and gender [ 18 ].

Application of Theoretical Framework on Structural and Social Determinants of Maternal and Infant Mortality in the United States.

2. Social Determinants of Health

Social determinants of health are non-medical factors that affect health outcomes and include biology, individual behavior, socioeconomic status, physical and social environment, support, racism, discrimination, access to affordable health services, and legislative policies [ 19 , 20 ]. Social determinants of health can occur across multiple levels for women and children, intersecting across several domains of influence including biological, behavioral, physical, and sociocultural environments and the healthcare system [ 21 ]. Social determinants of health are primarily responsible for health inequities, or avoidable and unfair differences in health status between diverse groups of people within the same country and between countries [ 20 , 22 ]. Mitigating the root determinants of health to reduce health inequities is vital because health is a fundamental human right, and the inability to prevent inequities results in health disparities [ 20 , 22 ]. Various social determinants play a key role in producing and maintaining adverse maternal outcomes in the United States, with empirical studies showing that race and ethnicity, education, and insurance (including access to prenatal care) contribute to the establishment and continuation of pregnancy-related mortality and severe maternal morbidity risk [ 23 , 24 , 25 ]. Place-based factors such as neighborhood conditions, access to quality healthcare and amenities, environmental exposures (heavy metal exposure, pesticides, pollution, and traffic), and residential segregation have been associated with unfavorable birth outcomes among Black and Hispanic women and increased maternal morbidity and mortality [ 7 , 26 , 27 , 28 ].

Structural and social determinants can be further explored to demonstrate their link to racial disparities in maternal and infant mortality. The historical legacy of slavery is linked to Black maternal and infant health, and contemporary maternal and infant mortality [ 29 ]. Maternal and infant health disparities are rooted in the institution of slavery, which commodified enslaved Black women’s childbearing and empowered physicians to authorize the interests of slaveowners [ 29 , 30 ]. Moreover, while overall infant death rates have declined since the 19th century, the disparity in death rates between Black and White infants is greater today than it was under prewar slavery [ 31 , 32 ]. Currently, the stressor of structural racism permeates and reverberates within the lives of Black women and their children [ 29 ]. Racism’s effects are seen at the genetic and physiological levels and reveal persistent maternal and infant death disparities [ 15 ]. For example, conditions such as hypertension have been associated with the stress of inhabiting a racist society and can further exacerbate disparities in pregnancy-related complications such as pre-eclampsia. Such factors prompt critical exploration into the underlying initiators of such disparities [ 33 ].

Racism as a social construct has been identified as a persistent population health emergency and a fundamental cause of disease both in the U.S. and globally. Studies have comprehensively illustrated the multidimensional associations between racism at the cultural (e.g., derogatory, and exclusionary stereotypes), interpersonal (e.g., macroaggressions rooted in implicit bias and decreased likelihood of receiving patient-centered care), and structural levels (e.g., laws, regulations, and policies that steadily lead to reduced access to opportunities and services based on race), and health outcomes among Black persons [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Experiences of racism are also apparent across the sexual and reproductive health lifespan. Structural racism can impact Black women’s use of reproductive services and can sustain reproductive healthcare disparities; structural racism can influence access to care through the ability to attain timely services, the use of healthcare services, and experiences with care related to interactions with the healthcare system [ 8 ]. Notably, there can be an intergenerational transmission of the stress that stems from cumulative exposure to interpersonal racism, illustrated by the fact that both stressful life events and perceived stress, before, during, and after pregnancy, have been associated with unfavorable pregnancy and childbirth outcomes; effects include pregnancy complications, preterm birth, and low birth weight, which resultantly have significant and multifaceted implications for longstanding maternal and child health outcomes [ 6 , 40 , 41 , 42 , 43 ]. Moreover, the intergenerational transmission or risk associated with structural racism is particularly manifested in the greater risk of adverse obstetric outcomes and increased infant mortality rates in U.S. Black communities [ 26 , 27 ].

Regarding policies and practices, Jim Crow laws legalized segregation in Southern U.S. states from the 1870s through the mid-1960s and exposed Black persons to noxious social, economic, and physical conditions that could influence access to care [ 44 ]. Being born in a Jim Crow state has been shown to influence population health indicators such as infant death, and the health effects of state-sanctioned racism in the 1960s to this day can be seen in infant death inequities. Specifically, Black infant death rates were almost two times higher in Jim Crow states than non-Jim Crow states from 1960 to 1964 [ 45 ]. It is known that early-life traumatic exposures can influence the risk of any type of health issue. Understanding determinants of health inequities within and across generations involves recognizing that people carry the history of a country within their bodies [ 45 , 46 ].

In another example of structural determinants of health, President Roosevelt’s race-neutral G.I. Bill, a law that went into effect in 1944 and provided a range of benefits for qualifying returning World War II veterans and their families, had state-controlled oppositions that kept many Black veterans from acquiring its full benefits. Resultantly, Black veterans and their families were deprived of their fair portion of the multigenerational, enhancing effect of home ownership, educational, and economic security that the G.I. bill bestowed on most White veterans, their children, and their grandchildren [ 47 ]. Redlining, or government-sponsored disinvestment in non-White neighborhoods, to be explained further in this paper, is a structural determinant of adverse maternal and infant health outcomes [ 9 ].

The mass incarceration of Black persons in the U.S. is largely the result of institutional policies in U.S. police and judicial systems, including aggressive enforcement of low-level drug offenses and mandatory punitive sentencing laws that excessively affect Black persons [ 48 ]. Furthermore, incarceration in the family can play a crucial role in affecting Black, Indigenous, and people of color (BIPOC) women’s life, including during a pandemic. Mass incarceration can have important maternal and child health considerations such as the availability of sufficient social support during pregnancy and delivery and can adversely impact BIPOC populations during the COVID-19 pandemic [ 49 ]. Additionally, Black women may have to contend with the increased likelihood of having a partner suffer an injurious or fatal interaction with law enforcement due to the persistent issue of police brutality against Blacks in the United States [ 50 ].

In another example, while the 13th Amendment abolished slavery by the start of the twentieth century, the interstate slave trade was still legal under U.S. law. Children of the enslaved were enslaved by birthright, Black women’s bodies were commodified as their ability to reproduce was of utmost importance, and enslaved women’s reproductive lives garnered increasing attention from White physicians. Lastly, we believe that these social conditions are intersectional and interlaced and have reinforced lasting effects that can be manifested in the bodies of Black women. These issues highlight various concerns related to reproductive justice, human rights, and birthing autonomy [ 51 ].

3. Black Maternal Morbidity and Mortality

3.1. contributing factors.

The Weathering Framework is germane to this paper as it combines the Socioecological Model and Social Determinants of Health. The socioecological model shows that behavior has multiple levels of influence; the model helps examine factors that influence a specific behavior (See Figure 2 ). The CDC considers this model as a framework for prevention [ 52 ]. The model contains five levels: individual, interpersonal, organizational, community, and societal, as recreated in this paper (See Figure 2 ). Following this socioecological model for prevention, contributing factors toward racial disparities in maternal morbidity and mortality can be examined ( Figure 2 ). Through this lens, a range of factors that put Black women at risk can be understood. Racism is a social construct, root cause, and determinant of maternal morbidity and mortality. Historically, when social support is increased in the U.S., maternal morbidity, and mortality as an indicator of a society’s well-being are improved. This is due to the intersectionality of the following levels of influence. Furthermore, the relationship between factors at one level of influence that can impact factors at another level can be studied.

Socioecological Model for Prevention.

3.1.1. Individual Factors

Individual contributing factors describe biological and personal traits that cause certain behaviors. Examples include biological and genetic factors, beliefs, attitudes, education, stress response, and even coping skills. One biological factor is age, which is a nonmodifiable risk factor. Data show that the maternal mortality rate for Black women between ages 30 and 34 is over four times higher than the rate for White women [ 53 ]. Existing health conditions such as cardiovascular disease, diabetes, and high blood pressure can be detrimental to a pregnant woman. These health problems are preventable if quality care is given and access to education is available.

Black women have a maternal mortality rate of 2.9 times that of White women in the United States [ 11 ]. For several years, Black women have been ignored and dismissed by medical providers in the United States. Even as medicine progresses, racial disparities persist [ 54 ]. Black women continue to be failed by blatant negligence and ignorance. As a result, Black women may lose the fight to be heard by their providers.

Individual traits of women can either help or work against them. For example, an individual contributing factor is education and knowledge. Unfortunately, many women are not well informed about the importance of preconception health, their specific pregnancy milestones, or even frequently occurring conditions. As a result, this makes them more susceptible to being ignored. They may not be capable of advocating for themselves and may reluctantly be mistreated because they are unaware. On the other hand, a very educated woman who is more knowledgeable about her pregnancy and concerns may still be misheard or ignored by medical providers because “they know best”.

Stress response and chronic stress are other types of individual contributing factors. Humans produce stress hormones when stressed. However, when stressed all the time, the body will have elevated levels of stress hormones. Elevated stress relates to physical and mental health conditions that can lead to death [ 55 ]. Studies have shown that just being a woman is a stressor in our society. Being a Black woman causes a “double pressure” influence on women [ 56 ]. The pressure of being a Black woman is immense and can have effects on a pregnancy [ 55 ]. Different types of stress that can occur during pregnancy include negative life events, catastrophic events, long-lasting stress, chronic stress, and racism [ 57 ]. Racism is a large contributor to stress, and it is evident through data that shows African American women in the United States deliver a higher rate of premature and low-birthweight babies than their counterparts [ 58 ]. Attitudes and beliefs are important individual factors. There is compelling data to suggest that when Black Women and babies are dying due to pregnancy complications or possible negligence from providers and the healthcare system, this puts Black women on edge [ 54 ]. They enter situations with preconceived notions about how they will be treated. This in turn affects their expectations of care and whether they feel empowered to speak up about the care they are receiving. Other individual factors such as alcohol intake, being a current or former smoker, nutritional status (e.g., chronic energy deficiency vs. good nutrition), and occupational status (e.g., whether a person is working or not) have been shown to increase a woman’s risk for maternal morbidity and mortality [ 59 , 60 , 61 ]. Living in a disadvantaged neighborhood has been linked to a higher allostatic load in African American women at risk for obesity and related chronic diseases [ 62 , 63 , 64 ]. Moreover, neighborhood disadvantage in the context of allostatic load can influence individual health behaviors such as alcohol and tobacco consumption, diet, and exercise [ 65 ]. Economic and psychosocial factors have been shown to explain 36–42% of racial and ethnic inequalities in postpartum allostatic load [ 66 ]. Therefore, structural factors that shape social determinants such as neighborhood features can also influence individual behaviors that place Black women at increased risk for maternal morbidity and mortality.

3.1.2. Interpersonal Factors

Interpersonal contributing factors describe relationships. An individual’s immediate social circle (friends, spouse, and family members) influence their behavior and affects their experiences. During pregnancy, several relationships will be formed. Examples include doctor–patient relationships as well as family and peer relationships. International and national studies commonly find that preventable maternal deaths are due to provider factors. These include ignoring and withholding diagnoses, lack of appropriate referrals, and poor documentation and communication [ 67 ]. Doctor–patient relationships are especially important from the start of a pregnancy. However, several studies have shown negative maternal and child health providers’ attitudes and behaviors affect patients’ well-being, satisfaction with care, and care-seeking [ 68 ]. Trust is a crucial factor in relationships. Social roles and social isolation must be considered as well in these contributing factors. History of mistreatment can affect the support received from family and friends. This occurrence could influence an expecting mother’s thoughts or behaviors toward her pregnancy journey.

Social isolation is an interpersonal contributing factor, and it can be damaging to health. COVID-19 further perpetuates its occurrence. COVID-19 negatively impacted the social life of pregnant women. Loss of social support can affect how a mother will advocate for herself. Women reported that the pandemic created fear and anxiety among pregnant patients because of limited doctor visits and financial issues. Women reported fear and anxiety concerning poor perinatal services [ 69 ]. There can also be a lack of advocacy on a woman’s behalf from family and friends. Lack of this support causes anxiety about giving birth as well. A study showed that women felt that COVID-19 separated them from their families and put a strain on interpersonal relationships. An increased fear of catching the new disease weakened support systems and increased dependency on providers that mothers did not feel close to [ 69 ]. Lack of support during the delivery or labor process isolates mothers and contributes to their concerns being disregarded.

3.1.3. Organizational Factors

Systemic inequalities are often first seen at organizational levels. Organizational contributing factors include schooling and educational opportunities, community services, and access to resources. Quality access to health care, especially in terms of physical proximity, can be a challenge for individuals in certain neighborhoods and communities. Regardless of race, mothers living in impoverished areas are prone to die from maternal mortality [ 70 ]. Implicit bias among providers and staff highlights the importance of cultural competency, shared decision-making, and acknowledgment of personal biases to address disparities in care [ 67 ]. Furthermore, implicit bias can lead to racial disparities in maternal morbidity and mortality in the U.S. [ 71 ]. Implicit bias and discrimination within the healthcare system can be revealed in the dismissal of Black women’s symptoms and concerns, which can elucidate the poor outcomes even for Black women with higher levels of education and income [ 72 ]. Provider actions and their interactions with patients are strongly linked to racial disparities in the endurance of trauma during childbirth. Thirty percent of Black and Hispanic women in the United States who delivered in a hospital reported provider mistreatment compared to twenty-one percent of White women [ 73 ]. In a survey on maternity care among women in California, Black women were ten times more likely to report unfair treatment and discrimination from maternity care providers when compared to White women [ 74 ]. Community-based care could be used as an effective method of providing more access to care and resources to mitigate maternal mortality. Community-based care can include home-based care by more certified midwives, community-operated clinics, and health campaigns [ 75 ]. These efforts should include reinforcement of preconception and postpartum care to target racial disparities in maternal morbidity and mortality. Furthermore, multidisciplinary quality care initiatives that partner with communities can enhance the quality of care and reduce disparities [ 67 ]. Social mobilization, health promotion and education, and advocacy are needed to promote health, and to give people the knowledge and skills needed to improve their health or to advocate for themselves.

3.1.4. Community Factors

Relationships will occur in community settings (i.e., schools, workplaces, and neighborhoods) and can become a contributing factor to how maternal health is affected and the outcomes in maternal health for Black women. As mentioned at the organizational level, discrimination in one’s surroundings has a notable impact on healthcare and health outcomes. For example, a recent study in Chicago showed a relationship between racial residential segregation and the presence of hypertensive disorder in Black pregnant women living in impoverished neighborhoods [ 76 ]. This further supports that there is a correlation between health and racial residential segregation. These urban communities with large Black populations tend to be impoverished and underfunded and lack adequate resources such as stable housing and suitable transportation, which are fundamental causes of poor physical health and further disadvantage the people who live there, which include Black pregnant women. This is caused by instances of systematic racism, which cause social and structural determinants of maternal and infant mortality in the United States.

There are many practices within communities that originate from structural racism. For example, redlining (defined as home mortgage denial based on race and government-backed disinvestment in non-White neighborhoods) was created as an oppressive form of housing historically and underserved individuals living in these areas. This created unhealthy habits within a community such as less emphasis on physical activity. This causes health disadvantages for those who are in this community such as financial barriers to care, access to quality healthcare, lack of education, and a shortage of primary care providers [ 77 ]. Racial and ethnic disparities in postpartum care before and after the COVID-19 pandemic also influence maternal mortality and severe morbidity among Black women [ 78 , 79 ]. The postpartum period is a crucial time for women to recover from childbirth and to adjust to several biological, social, and psychological transitions [ 80 ]. The postponement and absence of prenatal care, which was more likely to occur among Black and Hispanic women even before the COVID-19 pandemic [ 81 , 82 ], can obstruct prevention of maternal mortality and increase the likelihood of emergency room visits, childbirth complications, postpartum depression, and unmet postpartum care needs [ 83 , 84 ]. One study showed that, when compared to White women, Black women had an increased probability of not scheduling postpartum care and the slowest reduction in postpartum care canceling rate during the COVID-19 pandemic [ 85 ]. Black women have also been at increased risk for worries about prenatal care [ 79 ] and postpartum stress during the COVID-19 pandemic [ 86 ]. It is important to acknowledge the role of structural inequities and intersectional vulnerabilities that increase risks for unfavorable maternal health outcomes and fuel health disparities [ 85 ]. One way to address this contributing factor is to invest in primary care within a community that can tend to diverse women that differ in race, age, and socioeconomic status in a variety of settings. Midwifery, doulas, maternity centers, nurse practitioners, and clinical settings can greatly impact maternal health in Black communities [ 87 ].

3.1.5. Societal Factors

The goal of reducing Black maternal mortality involves a vast approach that includes the patient, provider, and public health policies. Concepts such as structural racism have been proven to be the main reason for the disparities that occur across the different levels of influence. Structural racism is a large and deep-rooted force in society that can factor into health care. For example, there may be a racial bias that is present among certain healthcare professionals, which can cause hindrance to the care and treatment of Black pregnant patients. These patterns cause mistrust among Black patients and their providers as well as the medical community at large [ 8 ].

One of the structural determinants of maternal health that is linked to U.S. health disadvantages for individuals is the suffering of financial barriers to care [ 24 ]. This results in the lack of primary care providers, which creates poor, insufficient care for individuals. With healthcare facilities understaffed and overworked, many patients have a feeling of being overlooked and healthcare professionals are reporting burnout. There is a shortage of obstetricians, nurse midwives, and well-women nurses that serve in low-income, racially, and ethnically diverse communities. The lack of medical personnel can drastically affect the outcome of a pregnancy. Another structural determinant at the societal level is education [ 9 , 47 ]. Structural racism can also manifest in historical and contemporary practices such as redlining and segregation, which can hinder access to educational resources and opportunities and perpetuate intergenerational poverty due to less access to parental materials [ 7 , 9 , 36 , 39 ]. Additionally, the intergenerational transmission of risk attributed to structural racism is most concretely illustrated through the increased risk of adverse obstetric outcomes and higher infant mortality rates in African American communities. For example, research has indicated that African American women exposed to residential segregation are more likely to experience adverse birth outcomes, even after controlling for individual and neighborhood-level poverty [ 26 , 27 ]. While socioeconomic inequities rooted in structural racism and discrimination are primary drivers in racially disparate maternal health outcomes, differences in insurance coverage also play a role [ 88 ]. The Medicaid coverage gap, which can occur when individuals of low income lack a path to affordable coverage due to living in one of 12 U.S. states that have refused to expand Medicaid, is rooted in structural racism, and affects maternal morbidity and mortality [ 89 ]. Medicaid covers over 40 percent of U.S. births and 65 percent of births to Black mothers; almost 30% of Black women of reproductive age are in the Medicaid coverage gap, which limits their access to quality preconception and prenatal services and prospects of a safer pregnancy and birth for a parent and baby [ 89 ].

4. Discussion

An exploration of the factors that contribute to racial disparities in maternal morbidity and mortality among Black women in the U.S. calls for public health, the healthcare system, and community-engaged approaches to achieve equity in maternal health outcomes. These types of barriers could be addressed by targeting the underlying social determinants that fuel the rates of Black maternal morbidity and mortality and by incorporating policy and educational modifications to the healthcare system and industries that supply the healthcare system. We propose the strategies below to reduce racial disparities in maternal morbidity and mortality.

4.1. Enhance Curriculum and Diversify the Workforce to Address Implicit Bias and to Improve Cultural Humility

Evidence strongly supports the impact that structural racism continues to have on our healthcare sector [ 11 ]. Diversifying the medical workforce is imperative to help with this crisis. Currently, although Black individuals make up 13% of the population, they comprise just about 5% of the active physician workforce. “Black female physicians comprise even less, representing only 2% of physicians overall” [ 90 ]. This illustrates the importance of racially concordant care and encourages efforts to address implicit bias and to improve cultural humility within the healthcare workforce. Healthcare providers can use clinical resources and tools to recognize and address unconscious bias and stigma in themselves and in their offices to promote cultural awareness and health equity [ 77 ]. To remedy implicit bias across the continuum of maternal health care, hospitals and healthcare systems can train obstetric and non-obstetric care providers to build knowledge and skills on cultural humility, cultural competency, and person-centered care [ 87 ].

Medical schools and health profession programs should incorporate social determinants of health and health disparities education into the curriculum to equip students with an appreciation of cultural competence, to help them identify and address racial bias in themselves and medicine, and to clarify how health disparities can unfavorably affect both patient and healthcare system outcomes [ 91 ]. Outlining how health disparities and contributing social determinants can result in excess medical care costs, lost productivity, and premature deaths can help reduce healthcare system costs and improve the quality of care for everyone [ 92 ]. Additionally, curriculum development should consider interprofessional, collaborative efforts with other health professions disciplines to foster a multidisciplinary approach to addressing health disparities [ 93 ]. Patient education and clinical workforce training initiatives can partner with community health organizations and academic researchers to raise awareness about racial disparities in maternal and child health outcomes [ 94 ]. There should also be enhanced training and education in maternal–fetal medicine to improve the management and medical care of pregnant women to address racial disparities in maternal mortality and severe morbidity [ 95 ]. Additionally, there should be efforts to increase and diversify the perinatal workforce (e.g., doulas, certified and lay midwives, and perinatal social workers) to decrease maternal and neonatal morbidity and mortality [ 96 ].

4.2. Explore the Impact of Environmental and Occupational Exposures on Maternal Morbidity and Mortality

There is a need to explore the impact of disparate environmental and occupational exposures on maternal morbidity and mortality [ 7 , 26 , 27 , 28 , 97 ]. Psychosocial stressors such as police brutality can impact Black mothers’ lives when Black mothers endure a gendered racial vulnerability with their added responsibility of teaching their children to respond to police violence in the “police talk” [ 98 , 99 ]. Such responsibilities that stem from structural racism can cause physical manifestations of stress and psychological distress and have been associated with depressive symptoms among Black women [ 58 , 100 , 101 , 102 , 103 ]. Moreover, as previously mentioned, incarceration in the family can play an immense role in affecting BIPOC women’s life and have important maternal and child health considerations, including adversely impacting the availability of adequate support during pregnancy and childbirth among BIPOC populations [ 49 ]. It is also important to examine how structural racism and discrimination in the workplace environment can take a toll on Black mothers through manifestations such as microaggressions, increased emotional trauma, the gender pay gap, invisibility, negative stereotypes, tokenism, and isolation [ 101 , 102 ].

When further considering environmental impacts on maternal mortality, it is evidenced that racial and ethnic inequities in social determinants of health, such as neighborhood environment (e.g., access to healthy food, neighborhood safety, housing, air pollution, pest, and mold exposure), environmental exposures (e.g., experiences of racism, discrimination, immigration, and acculturation), socioeconomic status (e.g., income, wealth, educational attainment, and employment), housing (e.g., housing conditions such as indoor air pollution and microbial/pest allergen exposures), and health care access and quality, add to the excess burden of chronic disease incidence, prevalence, morbidity, and mortality among particular racial and ethnic groups, including Black communities. Other recommendations include safe housing and environmental justice efforts that include the reduction, remediation, and prevention of environmental lead hazards in older housing to remedy inequitable exposure of lead to Black residents, including disparate lead exposure to Black children [ 103 ]. Moreover, BIPOC and low-income communities, both in residential and workplace settings, as well as in rural and urban areas, shoulder a disproportionate burden of the harms caused by pesticides in the United States, which have maternal and child health implications. There is an increased application of pesticides in urban and low-income public housing [ 104 ]. Remediation policies are needed where women and children in these communities may be disproportionately exposed to pesticides through an increased likelihood to reside near pesticide manufacturing facilities that may possibly violate environmental laws [ 104 ].

4.3. Address Social Determinants of Health by Exploring the Impact of Structural Racism on Maternal Health Outcomes

There is also a need to address social determinants of racial disparities in maternal morbidity and mortality by exploring the impact of structural racism on access to factors such as quality healthcare (e.g., the effect of structural racism/historical abuses on health-seeking behaviors and confidence in the health care system), education, income and employment, and quality food. Structural racism affects health through its past and present effects on the quality of, and equal access to, key social, and environmental determinants of health. For example, the practice of redlining inhibited communities of color from acquiring residential mortgages and, accordingly, access to public transportation, supermarkets, and healthcare, contributing to the proliferation of residential segregation in the United States [ 35 , 44 , 105 , 106 ]. Resultantly, in U.S. communities plagued by segregation, Black persons and other racial and ethnic minority groups are more likely to live in neighborhoods with increased levels of poverty; to have reduced access to employment, credit, housing, educational, transportation, nutritional, and healthcare resources; and to live in health-inhibiting environments, compared to the White population [ 35 , 107 ]. Systemic racism also inhibits access to vital healthcare services, such as access to reproductive and sexual health services [ 8 ]. Therefore, there is a need to address these structural barriers and to acknowledge their role in racially disparate maternal health outcomes.

4.4. Improve Social Policies and Programs

In the wake of the United States Supreme Court’s decision to overturn Roe v. Wade (Dobbs decision), women of color, communities of low income, and other marginalized populations will be disproportionately impacted by barriers to accessing care [ 108 ]. This can lead to increased maternal and infant mortality and an enduring impact on women and families, particularly for Black and rural populations [ 109 ]. For example, reduced access to reproductive services could impact high-risk pregnancies. Nationally, Black women are three times more likely to die from a pregnancy-related cause than White women [ 87 ]. Another way to address structural racism in birth outcomes through policymaking is to expand access to care in terms of health insurance to include coverage for nonhospital care, doula care, and labor and delivery classes [ 110 ]. Policymakers should tackle barriers to doula services that include low reimbursement for Medicaid clients, conflicting certification requirements, and complicated paperwork [ 111 ]. There should also be continued Medicaid expansion for postpartum women, including women living in non-expansion states, as timely postpartum care is linked with lower maternal morbidity and mortality [ 112 , 113 ], particularly for Black women [ 89 ]. Expanded coverage for behavioral health care should also be considered [ 88 ]. There should be an extension of the Medicaid postpartum coverage limit from 60 days (about 2 months) to at least one year [ 114 ]. Furthermore, in addition to the need to improve access to reproductive health services, it is imperative to address gaps in maternal support in the U.S., including in the areas of paid family leave, income for women, and child-care affordability [ 115 ].

5. Conclusions

Pregnancy-related deaths are tragic and mostly preventable. The stark racial disparities in adverse pregnancy outcomes in the U.S. requires a deeper exploration into the role of social determinants and how structural racism contributes to a greater risk of adverse obstetric outcomes among Black women in the U.S. These social determinants include, but are not limited to, neighborhood environments such as access to healthy food, neighborhood safety, housing, air pollution, pest, and mold exposure; environmental exposures including experiences of racism, discrimination, acculturation, and immigration; socioeconomic status factors such as income, education, and occupation; housing conditions; and health care access and quality. Moreover, structural determinants of health such as slavery and structural racism influence social determinants of maternal and infant mortality. The amelioration of these social determinant disparities may also be the answer to decreasing or eliminating the dismal maternal morbidity and mortality rates and may lead to improved health outcomes for Black women in the U.S. Strategies are needed to undo the legacy of racism that fuels unfavorable pregnancy outcomes among Black women in the United States. Recommendations include addressing implicit bias and improving cultural humility in the healthcare sector, diversifying the workforce, incorporating social determinants of health and health disparities into the medical and health professions curriculum, exploring the impact of environmental and occupational exposures on maternal morbidity and mortality, addressing the impact of structural racism on health outcomes, and improving social policies and programs.

Funding Statement

This research received no external funding.

Author Contributions

A.N. conceived the project; A.N., M.E., L.N.-S. and J.B. conducted the literature review; A.N., M.E., L.N.-S. and J.B. wrote the manuscript; and A.N., M.E. and L.N.-S. reviewed the manuscript and formatted it for publication. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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• UNC Chapel Hill

Research Topic: Maternal and Fetal Health

Gillings School of Global Public Health > Department of Maternal and Child Health > Division: None

Alison Stuebe is interested in modifiable risk factors for metabolic disease in the perinatal period, gestational diabetes, pregnancy-associated weight gain, maternal health effects of lactation, effects of postpartum depression on breastfeeding physiology, the role of subclinical infection in breast pain, and the etiology of racial and ethnic disparities in breastfeeding, breastfeeding difficulties, and postpartum depression. (Keywords: Asymptomatic infection, breastfeeding, breastfeeding (complications), ethnic disparities (etiology), gestational diabetes, lactation (health aspects), maternal health, metabolic diseases, metabolic diseases (risk factors), perinatology, postpartum depression, postpartum depression (epidemiology), pregnant women (weight gain in), race disparities (etiology))

School of Medicine > Department of Obstetrics and Gynecology > Division: Global Women's Health

Jennifer Tang is interested in family planning, maternal neonatal health, and global women’s health. (Keywords: Family planning, global women’s health, maternal health, neonatal health)

School of Medicine > Department of Cell Biology and Physiology > Division: None

Kathleen Caron is interested in mouse models of fetal growth restriction and preeclampsia. (Keywords: Fetal growth restriction, mouse models, preeclampsia)

School of Medicine > Department of Obstetrics and Gynecology > Division: Maternal-Fetal Medicine (MFM)

Kim Boggess is interested in infection and inflammation in pregnancy outcomes. (Keywords: Infection, inflammation, pregnancy outcome)

Neeta Vora is interested in reproductive genetics and prenatal diagnosis as they pertain to maternal obesity, fetal neurodevelopment, preterm labor, and growth parameters. (Keywords: Fetal neurodevelopment, growth, maternal obesity, prenatal diagnosis, preterm labor, reproductive genetics)

Tracy Manuck is interested in preterm labor, cervical insufficiency, preterm premature rupture of membranes, multiple gestations, and caring for pregnancies complicated by fetal chromosomal or structural anomalies. (Keywords: Human chromosomes (abnormalities), multiple pregnancy, obstetric labor complications, pregnancy care, pregnancy complications (chromosomal), preterm labor, uterine cervical incompetence)

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What is maternal health?

In the DHS , maternal health refers specifically to health care surrounding childbearing; that is, antenatal care, delivery assistance, and postnatal care.

Which DHS data are related to maternal health?

The DHS maternal health indicators measure maternal health care against national recommendations, such as the recommended number of antenatal care visits and the preferred timing for postnatal care. The measures of maternal health care are also compared to women’s status.

• Antenatal care
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Which SPA data are related to maternal health?

SPA surveys conduct assessment of maternal health services, including availability of antenatal care and associated equipment and medicines, counseling and observation of client examinations. Delivery services are also assessed, including availability of emergency transport, items for delivery services and essential supplies for delivery.

Why is maternal health important?

Health care and counseling before, during and after birth – or the lack of if – impact the survival of both mothers and children. Maternal health indicators help program staff identify the groups of women and infants at the national and sub-national level who are not accessing maternal health services.

The DHS Comparative Report, Levels and Trends in the Use of Maternal Health Services in Developing Countries , shows that overall, the use of antenatal care services has increased worldwide.

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Effect of Maternal Diet during Pregnancy and Lactation on Offspring Gut Microbiome

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The infant gut microbiome plays a vital role in shaping an infant's health and well-being, both in the short term and over the long term. Consequently, the process of proper colonization after birth has become a significant area of focus for many scientists. Various maternal and environmental factors are crucial in influencing this colonization. For instance, the mode of delivery—whether vaginal or cesarean—can significantly impact the initial microbiome composition. Additionally, breastfeeding practices are known to provide beneficial bacteria and essential nutrients that support healthy microbiome development. Exposure to different environments and the maternal diet during and after pregnancy also play significant roles in shaping the infant's gut microbiome. Each of these factors contribute to the complex interplay that ultimately influences an infant's immune system, digestion, and overall health trajectory. Therefore, understanding and optimizing these factors can lead to better health outcomes for children. The goal of this research topic is to explore the effect of maternal diet during pregnancy on offspring microbiota. Recent advances have highlighted the importance of maternal nutrition and dietary patterns in shaping the infant gut microbiome, a critical factor for the child's health and development. While direct transfer of maternal microbiota during gestation has not been conclusively demonstrated, emerging evidence indicates significant interactions between maternal microbiota and metabolites with the developing fetus. Traditionally considered sterile, breast milk is now recognized as a key microbial exposure for infants, particularly when delivered through the entero-mammary pathway. This pathway links maternal nutrition to maternal microbiota and, ultimately, to the infant's microbial colonization. This research topic aims to address the gaps in our understanding by collecting the latest findings on how maternal diet influences these processes. By examining these connections, we aim to provide evidence that can inform nutritional recommendations and interventions to optimize health outcomes for both mothers and their children. Through this collection, we hope to advance knowledge in this field and contribute to better strategies for promoting proper childhood development. We invite submissions of original research articles and reviews that offer innovative insights into the following subtopics, among others: • Assessing the nutritional adequacy of maternal dietary patterns to improve the infant gut microbiota colonization • Evaluating the breast milk microbiota impact of different maternal dietary patterns • Exploring maternal vertical transmission of microbiota and microbial metabolites • Examining the interactions between the maternal diet, the infant gut microbiome and the immune system development

Keywords : mother’s diet, gestation, lactation, microbiome, infant health, microbiota colonization

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A qualitative study exploring the factors influencing maternal healthcare access and utilization among Muslim refugee women resettled in the United States

Affiliations.

• 1 The University of Arizona Cancer Center, Tucson, Arizona, United States of America.
• 2 Education and Language Education Department, International Christian University, Tokyo, Japan.
• 3 Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America.
• 4 Chan Medical School, University of Massachusetts, Worcester, Massachusetts, United States of America.
• 5 Epidemiology and Biostatistics Department, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America.
• 6 Department of Global Health, Denison University, Granville, Ohio, United States of America.
• PMID: 39150938
• PMCID: PMC11329121
• DOI: 10.1371/journal.pone.0307192

Although a large number of Muslim refugees have resettled in the United States for the last decades, few studies have looked into maternal healthcare access and utilization among Muslim refugee women in the country. This qualitative study was conducted to explore the factors influencing maternal healthcare access and utilization among Muslim refugee women resettled in the United States. In-depth interviews were conducted among Afghan, Iraqi, and Syrian refugee women (n = 17) using an interview guide informed by Social Cognitive Theory and its key constructs. The interviews were recorded and transcribed verbatim, imported into MAXQDA 2020 (VERBI Software), and analyzed based on qualitative content analysis. Data analysis revealed several themes at the micro, meso, and macro-levels. Micro-level factors included women's attitudes toward hospitals and prenatal care, as well as their life skills and language proficiency. Meso-level factors, such as cultural norms and practices, social support and network, as well as health care provider characteristics, were also identified. Macro-level factors, such as the complex healthcare system and access to insurance, also appeared to influence maternal healthcare access and utilization. This study revealed the complex contextual factors that refugee populations face. Given the population's heterogeneity, a more nuanced understanding of refugee maternal health is required, as are more tailored programs for the most vulnerable groups of refugee women.

Copyright: © 2024 Yeo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Fig 1. Qualitative content analysis process, adapted…

Fig 1. Qualitative content analysis process, adapted from [22].

Fig 2. A conceptual framework to explore…

Fig 2. A conceptual framework to explore refugee maternal health.

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