Non-Hispanic Black Women Have the Highest Maternal Mortality After Adjustment for Socioeconomic Status
Non-Hispanic Black women experience the highest maternal mortality rates in the United States even after controlling for socioeconomic factors, with rates 1.44 times higher for severe maternal morbidity and approximately 3 times higher for pregnancy-related death compared to non-Hispanic White women. 1
Evidence from Adjusted Analysis
The most compelling evidence comes from a large California study of over 8.2 million live births (1997-2014), which found that after adjusting for sociodemographic factors, obstetrical factors, comorbidity, anemia, and cesarean delivery, Black women were 1.44 times (95% CI, 1.39-1.50) more likely to experience severe maternal morbidity compared to White women. 1 This demonstrates that the disparity persists independent of socioeconomic status.
Magnitude of the Disparity
The racial disparity in maternal mortality is stark and well-documented:
- The maternal mortality ratio for non-Hispanic Black women was 56.3 per 100,000 live births compared to 20.3 for non-Hispanic White women in 2014 1
- Black women face pregnancy-related mortality rates 3.2 times higher than White women 2
- This disparity is not explained by patient-level factors alone, including socioeconomic status 1
Why Socioeconomic Adjustment Doesn't Eliminate the Gap
The persistence of this disparity after socioeconomic adjustment points to systemic factors:
- Exposure to racism and discrimination contributes through chronic stress and inadequate healthcare responses to expressed concerns 2
- Provider implicit bias affects clinical decision-making regarding pain recognition, treatment counseling, and management of complications 1
- Structural racism within healthcare systems creates differential quality of care regardless of insurance status or education level 2
American Indian/Alaska Native Women as Second Highest Risk Group
While Black women have the highest rates, American Indian/Alaska Native women also experience significantly elevated maternal mortality at 2.3 times the rate of White women 1. Between 1999 and 2019, this population experienced the largest increases in median state maternal mortality ratios, rising from 14.0 to 49.2 per 100,000 live births 3.
Clinical Implications
The most striking disparity in maternal mortality risk is that of race, and this cannot be attributed to socioeconomic differences alone. 1 This means that:
- Risk assessment tools must account for race as an independent risk factor beyond socioeconomic markers 1
- Implicit bias training and culturally responsive care practices are essential interventions 1
- Continuous risk reassessment using validated tools throughout pregnancy and the postpartum period is critical for Black women 1
Common Pitfall to Avoid
Do not assume that Black women with higher socioeconomic status, better insurance, or more education are at equivalent risk to White women—the disparity persists across all socioeconomic strata 1. The gap reflects systemic healthcare inequities, not individual patient characteristics.