Maternal and Child Health Inequities Emerge Even Before Birth

ReportEarly ChildhoodJul 1 2020

In 2019, ZERO TO THREE and Child Trends unveiled the first-of-its-kind State of Babies Yearbook: 2019, bridging the gap between science and policy with national and state-by-state data on the well-being of America’s babies. The data were clear: the state where a baby is born makes a big difference in their chance for a strong start in life. Ensuring that our youngest children have a healthy start requires understanding the influence of race and ethnicity in the care mothers and their babies receive no matter where they are born. To do so, the State of Babies Yearbook: 2020 disaggregates national and state averages on key indicators of child well-being to explore key subgroups. This brief is focused on the serious disparities in maternal health and birth outcomes among babies and families of color.

Whether infants are born healthy and with the potential to thrive as they grow greatly depends on their mother’s well-being—not just before birth, but even prior to conception. To have a healthy pregnancy and positive birth outcomes, women and their infants require access to appropriate health care services, before, during, and after birth. Extensive data indicate serious racial and ethnic disparities in infant and maternal health care and health outcomes. For example, Black, American Indian, and Hispanic womena are more likely than their White counterparts to receive late or no prenatal care.1

They are also more likely to experience serious health problems2 or die during or after birth from resulting complications. In comparison to White infants, Black and American Indian infants have a much higher risk of being born preterm and/or with low birthweight,3 are less likely to be breastfed,4 and are more likely to die within their first year.5

Researchers have explored connections between these disparities and factors such as poverty due to parents not earning a living wage, unemployment, or underemployment; living in under-resourced neighborhoods; or low educational attainment, and numerous studies reach the same conclusion: Even after considering the influence of these factors, racism accounts for huge differences.6,7 Two women of different ethnicities or races—for example, a Black woman and a White woman—can have otherwise identical demographic characteristics; in this case, though, the Black woman (and her baby) is likely to experience much worse outcomes. When it comes to how mothers and their infants fare in pregnancy and delivery, race—or, more precisely, racism—matters.

This brief intentionally focuses on the experiences of both mothers and infants, whose well-being is intrinsically interdependent, although they are often considered separately. This is particularly important when it comes to babies and women of color, due to the intergenerational effects and lived experiences of racism. These factors are influential throughout pregnancy and affect their babies’ start in life. The health and well-being of mother and baby are particularly tightly interwoven during the perinatal period. This shared experience, which includes the impact of racism with the particular threats families of color face, is the subject of this brief.

We summarize evidence of serious disparities in infant and maternal outcomes and present potential strategies to ameliorate them. Underlying the stark differences in these outcomes are disparities in access to health care, the experiences women have in the health care setting, and the cumulative effects of stress (including the stress of experienced racism) on women’s health. No single strategy will sufficiently achieve greater racial equity in preconception and prenatal care and the outcomes they influence. Instead, to measurably improve these conditions, which have become entrenched over many years, we must identify and address inequities on multiple fronts. States as well as federal policymakers have several opportunities to adopt policies that can address and lessen these inequities. In addition, there are a number of promising practices that programs and/or communities can implement.

We begin by reviewing the evidence of disparities, exemplified by indicators of prenatal care, preterm births, low birthweight, infant and maternal mortality, and breastfeeding, as tabulated from national data sources through September 2019 for the State of Babies Yearbook: 2020.b Next, we explore possible causes of these disparities, drawing from the literature on 1) the effects of stress related to institutional and interpersonal racism and poverty on women’s health, 2) the impact of differential access to medical care and other family support services, and 3) the differential experiences of women with the medical care system.

Finally, we review existing policies and programs that may help to address these disparities (e.g., Medicaid; the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]; paid family and medical leave; home visiting programs). We also discuss a set of promising practices states can pursue to further examine and address these disparities.



a As used by the Office of Management and Budget and the Census Bureau, Hispanic ethnicity can be a characteristic of people of any race. In this brief, we use “Black” and “White” to refer to non-Hispanic members of those racial groups. Except where otherwise indicated, the analysis in this brief is limited to Black, White, and Hispanic women and children, because data on other groups, particularly at a state level, are not reliable.

b The State of Babies Yearbook: 2020 was produced as part of ZERO TO THREE’s Think Babies™, with data and indicator analysis powered by Child Trends. Funding partners for the 2020 Yearbook include the Perigee Fund and the Tikun Olam
Foundation. Data provided by this effort are examined in this brief to better understand the inequities that begin before birth
for both infants and mothers.


1 Martin, J. A., Hamilton, B. E., Osterman, M.J. K., and Driscoll, A.K. Births: Final data for 2018. National Vital Statistics Reports, 68(13), 1-46. Table 13. Retrieved from

2 Rubin, R. (2018). Rate of severe childbirth complications has increased. Health Agencies Update. JAMA, 320(16), 1630

3 Martin, J. A., Hamilton, B. E., Osterman, M.J. K., and Driscoll, A.K. Births: Final data for 2018. National Vital Statistics Reports, 68(13), 1-46. Table 13. Retrieved from

4 Beauregard, J. L., Hamner, H. C., Chen, J., Avila-Rodriguez, W., Elam-Evans, L. D., & Perrine, C. G. (2019). Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015. Morbidity and Mortality Weekly Report, 68(34), 745-748.

5 Ely, D. M. & Driscoll, A. K. (2019). Infant mortality in the United States, 2017: Data from the period linked birth/infant death file. National Vital Statistics Reports, 68(10), 1-20.

6 Institute of Medicine. (2002). Unequal treatment: What health care system administrators need to know about racial and ethnic disparities in healthcare. Washington, DC: National Academy of Sciences.

7 Collins, J. W., Jr., David, R. J., Handler, A., Wall, S., and Andes, S. (2004). Very low birthweight in African American infants: The role of maternal exposure to interpersonal racial discrimination. American Journal of Public Health, 94(12), 2132-2138.