Structural Racism and Maternal Mortality in the United States
Maternal mortality and severe maternal morbidity in the United States are shaped by institutional and structural forces that extend beyond individual clinical risk. This paper integrates national hospital discharge data, facility surveys, and qualitative interviews with clinicians and community advocates to examine how hospital financing, payer mix, staffing capacity, and local policy environments contribute to racial disparities in maternal outcomes. Multilevel statistical models quantify facility‑level associations between Medicaid/uninsured payer share and adverse maternal events, while interviews illuminate how chronic underfunding, limited subspecialty access, and transfer delays operate on the ground. We find that hospitals serving higher proportions of publicly insured and uninsured patients experience higher rates of severe maternal morbidity even after adjusting for patient risk, and that structural constraints at the facility and county levels mediate much of this association. The paper concludes with policy recommendations—targeted investments, Medicaid postpartum coverage extensions, and equity‑oriented accountability metrics—to reduce disparities and strengthen safety‑net obstetric capacity.
Introduction
Despite clinical advances, the U.S. has rising maternal morbidity and mortality with persistent racial gaps. Structural racism—through financing, residential segregation, and policy choices—shapes institutional capacity and access to high‑quality obstetric care. This study reframes maternal mortality as a structural problem and examines facility and place‑based drivers of disparities.
Methods
We analyzed national hospital discharge data (2010–2019) to estimate facility‑level SMM and maternal mortality rates, linking outcomes to hospital characteristics (payer mix, staffing, subspecialty availability) and county socioeconomic indicators. Multilevel models partitioned variance across patient, facility, and county levels. Qualitative interviews (n=42) with clinicians and community advocates in three metropolitan regions explored resource constraints, transfer practices, and institutional decision‑making.
Results
Hospitals in the highest quartile of Medicaid/uninsured payer mix had SMM rates ~1.6 times higher than hospitals in the lowest quartile after adjustment. Staffing ratios and subspecialty availability mediated a substantial portion of the association. Interviews highlighted chronic staffing shortages, limited blood bank and ICU capacity, and delayed transfers as recurring contributors to adverse outcomes.
Discussion
Structural racism operates through health system financing and institutional capacity to produce maternal health inequities. Policy levers include Medicaid reimbursement reforms, targeted capital investments in safety‑net hospitals, and equity‑oriented quality metrics. Addressing maternal mortality requires redistributive policies that strengthen institutions serving the most affected communities.
References
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- Williams DR, Collins C. Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Rep. 2001.