Health Care Civil Rights: Addressing the American Maternal Mortality Disparity Through Health, Law, and Policy
The United States is facing a pressing issue in maternal health, standing out as uniquely dangerous among similarly situated nations, with significant disparities in maternal mortality rates, particularly affecting Black American pregnant people. This paper, “Health Care Civil Rights: Addressing the American Maternal Mortality Disparity Through Health, Law, and Policy,” argues that by addressing the root cause of the Black Maternal Mortality Disparity (BMMD)—structural racism—and implementing rigorous, enforced standards of care, the United States can ensure safer childbirth experiences for Black pregnant people. Utilizing intersectional and anti-racist frameworks, the analysis identifies inferior medical care, particularly in diagnosing and treating preventable causes of death such as preeclampsia, and systemic failures as contributing causes of BMMD. The analysis further identifies legal and policy avenues—including civil rights enforcement under Section 1557, Congressional initiatives, enhanced Maternal Mortality Review Committees, standardized clinical protocols, and hospital accreditation—as pathways to reform, while acknowledging significant obstacles to enforcement and federal action. Evidence from California and other states indicates that robust, accountable implementation can substantially reduce mortality. Expanded support for Black midwives and doulas, patient education, and postpartum care are also identified as vital solutions. The paper concludes that while structural change is complex, immediate progress can be achieved at the state, institutional, and provider levels; coordinated, community-driven action and rigorous enforcement of standards are necessary to end preventable injustices in American maternity care.
Analytical Frameworks Include Anti-Racism and Intersectionality
An anti-racist framework is a strategic, action-oriented approach that actively identifies, challenges, and seeks to dismantle racism at multiple levels—individual,[1] interpersonal, and structural—within institutions and society.[2] This framework emphasizes the use of explicit and shared language about racism, clear definitions of the problems to be addressed, a strong leadership commitment, dedicated resources, and ongoing, tailored education and training.[3] It also prioritizes transparent accountability mechanisms and the meaningful engagement of marginalized racial and ethnic communities throughout the process.[4] Throughout this paper, I explicitly describe racism as a part of the maternal mortality issue.[5] When we fail to address structural racism, the root of the BMMD, we render solutions to it ineffective. Structural or institutional racism is defined as “a system where public policies, institutional practices, and cultural representations work to reinforce and perpetuate racial inequity.”[6] Interpersonal racism involves direct interactions between individuals, where prejudice or discriminatory behavior is expressed from one person to another based on race.[7] Interpersonal racism is a component of structural racism because the prejudiced beliefs and discriminatory behaviors exhibited by individuals (interpersonal racism) both reflect and reinforce the broader systems, policies, and social norms that create and sustain racial inequities (structural racism). In other words, individual acts of racism are shaped by, and contribute to, the larger framework of societal structures and institutions that systematically disadvantage certain racial groups.
Intersectionality is a framework that examines how multiple social identities, such as race and gender, intersect to create unique and compounded experiences of discrimination.[8] In a healthcare setting, intersectionality helps us to understand how and why women of color consistently report facing bias and discrimination in health care environments based on both their race and gender.[9] This paper focuses on women’s experiences of discrimination and health disparities at the intersection of race and gender.[10] However, bias related to additional social factors—such as education level, income, sexual orientation, disability, and immigration status—can also negatively impact patients’ experiences within health care settings and their health outcomes.[11]
Terminology
A health disparity refers to a health difference that negatively affects marginalized populations, who experience higher rates of disease, poorer health outcomes, or reduced survival compared to the general population.[12] A health disparity population is characterized by a pattern of poorer health outcomes, indicated by the overall rate of disease incidence, prevalence, morbidity, mortality, or survival in the population as compared with the general population.[13] According to health equity researchers, “Ongoing efforts to improve population health may plateau without addressing persistent disparities among patient populations that have been historically marginalized.”[14]
I will refer to the disparity in maternal mortality outcomes for Black American women as the Black Maternal Mortality Disparity (“BMMD”). I describe Black women and Black pregnant people. The latter term is considered more inclusive. I recognize that members of the transgender, non-binary, a-gender, and other genders outside of the gender binary can and do experience pregnancy. I sometimes use the term “woman” for simplicity, readability, and to align with certain studies that only include pregnant women. I also use “pregnant person” for inclusivity of the Transgender community, although the two terms are not necessarily interchangeable. Furthermore, I use the term Black, as opposed to African American, because it is preferred by many Black people in the United States and encompasses a modern description that touches on culture, community, and identity.[15]
To interpret the data presented in this paper, it is essential to understand the role of Maternal Mortality Review Committees (MMRCs). MMRCs are multidisciplinary teams established at the state or local level to systematically review deaths that occur during pregnancy or within one year after the end of pregnancy.[16] MMRCs typically submit their findings to the Centers for Disease Control, where aggregated data is analyzed.[17] MMRCs comprise experts from various fields, including medicine, public health, nursing, epidemiology, and social work, ensuring that both clinical and non-clinical perspectives are considered.[18] MMRCs play a vital role in improving maternal health because they are uniquely positioned to conduct thorough, case-by-case analyses of maternal deaths.[19] A central function of MMRCs is to determine whether a maternal death was preventable.[20] A death is defined as “preventable” if there was at least some chance the death could have been averted with one or more reasonable changes to patient, community, provider, facility, or system factors.[21] By collecting and assessing data from multiple sources—such as medical and autopsy records, interviews with family members and care providers, and social and environmental information—they can identify all factors, both medical and social, that contribute to these deaths.[22]
Methodology
In this study, I explore why Black American pregnant people face higher maternal mortality rates and what can be done to reduce these disparities. To answer the question of why Black American pregnant people face higher maternal mortality rates and what can be done to mitigate this, a comprehensive review of existing literature and data was conducted, comprising two primary phases: (1) identifying the root causes of BMMD,[23] and (2) evaluating potential solutions through health, law, and policy perspectives.[24]
Literature Review
I. U.S. Maternal Mortality Rates are Exceptionally High
The United States is one of the most dangerous places in the world to give birth.[25] Every year, more than 700 women die from birth and postpartum complications,[26] with this number reaching over 1,200 deaths in 2021.[27] An additional 60,000 American women suffer pregnancy-related complications that are near-fatal each year.[28] Cardiovascular conditions, infection, and hemorrhage were the leading causes of pregnancy-related deaths from 2007 through 2016.[29] While most countries have seen a decrease in their maternal mortality rates, the U.S. is one of just thirteen countries that have experienced an increase over the past twenty-five years, and it is the only “developed” nation on that list.[30] Notably, ninety-eight billion dollars is spent per year on pregnancy and childbirth-related care, which, as one commentator puts it, “is a shockingly poor return on investment.”[31]
II. Black Pregnant People are Disproportionately Dying from
Pregnancy-Related Causes
It is critically important to recognize that the American maternal mortality issue is a racialized problem. The national maternal mortality rate is approximately 32.9 per 100,000 live births, but the maternal mortality rate for Black, non-Hispanic women is 69.9 deaths per 100,000 live births.[32] In 2023, the maternal mortality rate decreased for every racial and ethnic group except for Black women.[33] Black and white pregnant people have experienced significant differences in health outcomes for over a century.[34] However, the root causes of these disparities—particularly why Black Americans face higher rates of maternal mortality—remain the focus of ongoing academic debate.[35] Much of the scholarship in this area examines how social determinants of health (SDOH), such as access to care and socioeconomic status, contribute to persistent gaps in maternal mortality.[36] This paper builds on prior scholarship by moving beyond the social determinants of health, while acknowledging their importance, to foreground the direct impact of structural racism and systemic clinical failures, offering a multidisciplinary analysis and proposing concrete, enforceable policy and legal interventions.
[37]
III. Social Determinants of Health (SDOH) Cannot Fully Explain Racial Disparities in Maternal Mortality Outcomes
Social determinants of health (SDOH) are the “conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”[38] Access to healthcare is a significant barrier for many rural, low-income, and Black Americans. Black Americans, disproportionately affected by poverty,[39] face financial and structural challenges in obtaining care.[40] Over 40% of U.S. births, especially among women of color and those in rural areas,[41] are covered by Medicaid or CHIP,[42] programs aimed to support
low-income people. In rural states like Mississippi, inadequate healthcare infrastructure and workforce shortages are prevalent, with the majority of primary care shortage areas located in rural counties.[43] Nationwide, the closure of over 100 hospital obstetric units since 2022, alongside recent Medicaid cuts,[44] threatens to limit further access to essential maternal care,[45] especially in rural communities where nearly 60 million Americans depend on rural hospitals—hundreds of which are at risk of closure due to financial concerns.[46] As a result, rural areas are home to many maternity care deserts, likely leading to poorer maternal and infant health outcomes.[47]
Other examples of SDOH examined in this context include poor neighborhood conditions[48]—including exposure to toxins;[49] redlining, and white flight;[50] chronic stress due to racism, known as “weathering,”[51] which leads to worsening maternal mortality;[52] and indirect obstetrical causes, which also disproportionately affect Black pregnant people.[53]
Some argue that high levels of maternal mortality in the United States are due, at least in part, to America’s high levels of poverty and worsening health generally,[54] but this argument does not stand further analysis. Researchers, such as those in the United Kingdom, demonstrate that maternal mortality rates have decreased in countries with similarly high levels of income inequality[55] and health risks, such as an older average age for first birth[56] and high rates of obesity and diabetes.[57] Population factors should be considered, but are not an appropriate scapegoat for lagging maternal mortality rates. BMMD is a systemic and policy failure, not an individual one caused by factors within the mothers’ control.[58]
Another argument remains about access to healthcare, which is a serious issue for many Americans, especially those living in rural areas, but the lack of access to healthcare still cannot explain the disparities found between patients at the same hospitals or in the same counties with similar levels of access.[59] For example, in Chickasaw County, Mississippi, the maternal mortality rates for women of color stand at 595 deaths per 100,000 live births.[60] It means she would be safer giving birth in rural Kenya[61] than in Chickasaw County. Simultaneously, white women in Mississippi, even those living in rural areas like Chickasaw County with similar levels of poverty and access to care, have a relatively normal chance of survival (rates comparable to the national average).[62] According to the 2020 U.S. Census, Chickasaw County has a population of under 20,000, comprising about 50% white and 43% Black.[63] The mix of Black and white residents in the county strengthens the argument that inferior care is the cause because in rural areas like Chickasaw, Black pregnant people still have significantly worse health outcomes despite relatively equal access to care (in this case, equally difficult to access).
If patient outcomes are the fruits of a tree, and SDOH its bark, then cutting down the poisoned branches will not eliminate BMMD. We must reach the roots. Medical researchers conclude that more Black women die from preventable diseases during pregnancy, like preeclampsia, because of inferior care.[64] I will argue, as do medical researchers, that poor maternal health outcomes result from laws, policies, and institutional practices that can be changed, and that it is possible to identify root causes, implement solutions, and enforce standards of care.
IV. Physician Bias and the Provision of Inferior Care Compounds Risks for
Black Pregnant People
Racial Bias
Black Americans, generally, are more likely to receive inferior medical care compared to their white counterparts. According to the health literature and Maternal Mortality Review Committee (MMRC) reports, disparities in quality of care for racial minorities in the U.S. “have long been documented.”[65] The problem is racism, and this is clear when we examine data surrounding the treatment of Black patients by Black doctors. For instance, Black people live longer in areas with more Black primary care physicians.[66] For every 10% increase in Black primary care physicians, life expectancy for Black people increased by about one month.[67] Studies also show that patients are more satisfied with their care when they have a doctor of the same race.[68] Unfortunately, only 5% of doctors in the United States are Black.[69]
A landmark report from the Institute of Medicine (IOM) that analyzed over 100 American studies of at least 4 million patients over ten years confirmed disparities in care even when controlling for insurance status, income, age, and severity of conditions.[70] In other words, the disparity in maternal mortality cannot be explained by SDOH such as socioeconomic status or education alone. For instance, a single white woman with less than a high school education and living in poverty is statistically safer to give birth than a married black woman with a college degree.[71] This fact is important because it identifies the root issue as racism, and not as much the social determinants of health, like poverty or education, that may coexist with Blackness or womanhood.
Gender Bias
Addressing health disparities for Black women requires an intersectional analysis that considers both race and gender in medical outcomes and patient care. Black women face the stereotypes and biases associated with being women and people of color. Women are perceived as less credible than men, a phenomenon known as the credibility gap.[72] Women are also seen as more likely to complain and exaggerate their medical issues to medical professionals.[73] As a result, men typically receive quicker responses to things like complaints of pain[74] and receive more pain relief. Applying the credibility gap to Black pregnant women, physicians are less likely to take their complaints and symptoms seriously, especially some of the subtle symptoms of preeclampsia like headaches, nausea, and severely swollen hands and feet,[75] which may be too readily shrugged off as standard parts of pregnancy.
Women are more likely to survive adverse health events when treated by female doctors.[76] For instance, a study of Medicare claims from 2016 to 2019 found that the mortality rate for female patients treated by female doctors was lower than when treated by male physicians.[77] Researchers suggest that women physicians tend to listen more, which increases the chances of patient recovery and survival odds.[78] Interestingly, patients of women physicians also had lower readmission rates; this finding was found between male and female patients.[79] Although there are more women doctors than in the past, Black pregnant people are still most likely to be treated by a doctor who is both male and white.[80] There is little data on Transgender doctors, but initial reports indicate that less than 1% of doctors identify as Transgender,[81] and Trans patients presumably fare no better, if not worse, than women.[82]
Despite advances in modern medicine, pervasive biases and historical oversights continue to undermine the health care received by women and gender non-conforming individuals. Women have been, until recently, excluded from medical research.[83] In 1993, the inclusion of women became mandatory in most research studies.[84] Women’s prior exclusion significantly limited research on women’s health issues and led to a lack of understanding about how medications and treatments affect female bodies.[85] As a result, for instance, women are much less likely to be accurately diagnosed for a heart attack compared to men because the medical industry misunderstands that women may experience coronary distress symptoms differently.[86] The protocol developed to identify heart attacks was essentially developed by and for men.[87] Even today, approximately 2% of medical funding goes to studying women’s health.[88] Issues like endometriosis,[89] polycystic ovarian syndrome, and menopause—conditions that affect people with a uterus—are inadequately understood by the medical community.[90] This leads to discrepancies in the way we understand disorders and diseases that affect both sexes and a profound misunderstanding of medical issues females face, including disorders in pregnancy.[91]
Black Women’s Experiences with Healthcare Highlight Pervasive Bias and Poor Treatment
In a report from the Center for Reproductive Justice, Black women from Jackson, Mississippi and Atlanta, Georgia shared firsthand accounts that expose deep-rooted racial and gender discrimination in reproductive health care.[92] Many described how their sexual health education was either nonexistent or abstinence-only, forcing them to seek information from unreliable sources or peers.[93] As teens, they felt stigmatized and shamed by parents, teachers, and medical providers when asking for contraception or sexual health advice. Several reported being discouraged or denied contraception by clinics and school staff.[94] Discrimination extended into health care encounters, where negative stereotypes about Black women led to demeaning treatment—such as repeated accusations of drug use when presenting for labour or when their babies had congenital issues.[95]
Even as adults, participants described limited access to contraception, poor quality of prenatal care, and lack of support after childbirth. Health providers often made biased assumptions about their reproductive intentions and judged them, rather than offering care or counseling.[96] The women experienced rushed, impersonal postnatal checkups and were often forced by financial necessity to return to work only weeks after delivery, despite physical and psychological stress.[97] Labour and delivery environments were described as chaotic and neglectful, with women sometimes left in hallways to give birth due to a lack of beds.[98] In summary, these stories highlight a recurring pattern of inadequate education, provider bias, limited access, and systemic barriers to high-quality reproductive health care for Black women in the South; however, these experiences are not limited to the South.[99]
Systemic racism and sexism in medicine affect even the most privileged. For example, Serena Williams, an incredibly famous and wealthy former professional tennis player, suffered from pregnancy complications. Serena published an account of developing a pulmonary embolism—that is, a blood clot that formed in her lung—shortly after giving birth, in which she described her healthcare providers dismissing her symptoms.[100] She had to figuratively jump up and down and scream to get the attention of her providers.[101] Serena’s complications were, fortunately, non-fatal; however, closely examining her story reveals problems that are emblematic of Black pregnant people’s experiences with healthcare.
These studies and shared experiences paint a bleak portrait for Black pregnant women seeking quality medical care in the United States. Studies findings that Black patients receive inadequate care align with their self-reports. Black pregnant people may be best treated by Black female physicians, who would be poised to understand them and take their concerns seriously, but most doctors today are still white men.[102] On an individual level, Black women are more likely to receive inadequate care and face the credibility gap that comes with being a woman and a person of color. As a result, doctors are more likely to overlook their symptoms compared to their white counterparts, which leads to improper delays in diagnosis and treatment. On a systemic level, the medical community spends less time and money on women’s issues and health concerns, which leads to deep misunderstandings about medical issues that women face.
V. Black American Women are Dying from Preventable Causes, Such As Preeclampsia, that Differ from White American Women
Black American women are three to four times more likely to die from pregnancy complications than white American women, and they are dying from different causes than white women—namely, cardiac and coronary conditions, and preventable causes such as preeclampsia,[103] and severe bleeding.[104] On the other hand, white American pregnant women are most likely to die from mental health conditions, which include suicide and substance abuse disorders.[105] Based on data from 36 state Maternal Mortality Review Committees (MMRCs), the Centers for Disease Control estimates that over 80% of maternal deaths are preventable.[106] This difference in cause profiles demonstrates systemic inequities within the healthcare system: Black women are more likely to die from physical conditions for which effective treatments exist, indicating failures in timely diagnosis, access, and intervention, while white women are more likely to receive adequate care for preventable medical complications but face unmet mental health needs.
According to the World Health Organization (WHO), preeclampsia[107] is one of the leading preventable causes of maternal mortality worldwide.[108] However, in other countries, preeclampsia is not a death sentence. For example, “the United Kingdom had only two deaths from preeclampsia and eclampsia, suggesting deaths [by preeclampsia] … are highly preventable.”[109] I focus on preeclampsia in this section because it represents a profoundly preventable cause of maternal death that disproportionately impacts Black women[110]—despite the existence of effective, well-established strategies for early recognition, diagnosis, and treatment.[111] While preeclampsia is not the leading cause of maternal death among Black women nationwide,[112] it exemplifies an area where specific interventions can dramatically improve outcomes. In California, for example, recognizing preeclampsia as a leading preventable cause of death among Black mothers led to the implementation of targeted programs that successfully reduced the maternal mortality rate by 65%.[113]
Unlike complications such as massive hemorrhage—which are more difficult to anticipate and control[114]—preeclampsia is often detectable before it becomes life-threatening.
Preeclampsia is a condition that typically develops in the third trimester of pregnancy and is characterized by high blood pressure and potential damage to organs, especially the kidneys and liver.[115] If left untreated, it is fatal to pregnant mothers and dangerous to in-utero babies. To be clear, although developing preeclampsia may be mostly unavoidable,[116] death by preeclampsia is.[117] Despite this dire reality, there is no national standard for recognizing or treating it.
Provider-factors comprised 51.8% of the total contributing factors for preeclampsia deaths.[118] Provider-factors include providers’ lack of knowledge[119] and proper referrals, delayed diagnosis or treatment, misdiagnosis, use of ineffective treatments, and failure to seek consultation.[120] Still, obstetricians and gynecologists have a duty to treat their patients, and hospitals have a duty to maintain patient safety standards.[121] Organizations such as the American College of Obstetricians and Gynecologists (ACOG) aim to educate certified physicians about preeclampsia; however, certification does not guarantee compliance. The consistent implementation of these standards is left to the organization itself, its leadership, and healthcare providers.[122] Organizations like the AGOC lack enforcement authority, raising concerns that implementation and consistent enforcement may be lacking across organizations.
To discover preeclampsia, doctors must regularly monitor patients and, more specifically, monitor blood pressure and protein concentration in the urine.[123] Frequent ultrasounds are also necessary to measure amniotic fluid levels, which, if too low, are harmful to the developing baby.[124] There are medications to treat preeclampsia, or at least, its most deadly symptom for pregnant women: high blood pressure.[125] These include but are not limited to, anti-hypertensives[126] and magnesium sulphates, the latter of which can prevent seizures.[127] For the health of the developing baby, corticosteroids may also be prescribed,[128] especially if early inducement and delivery are deemed necessary.[129] By the third trimester of pregnancy, most pregnant people know they are pregnant.[130] Although Medicare providers cover all prenatal visits, access to care may still be an issue.[131] Still, just under 80% of Americans receive prenatal care in the first four months of pregnancy,[132] and the majority of births (98%) occur in hospitals.[133] How are healthcare practitioners so often missing a common diagnosis like preeclampsia, and why might they delay treatment?
First, the healthcare professional may fail to recognize the signs and make a diagnosis. Preeclampsia is diagnosed by monitoring blood pressure and confirming high blood pressure (typically 140/190 mmHg or higher) alongside the presence of protein in the urine, which is called proteinuria.[134] This normally occurs after at least 20 weeks of pregnancy.[135] Further testing can be done to assess liver and kidney function, platelet count, and fetal monitoring.[136] Other symptoms that indicate preeclampsia include severe headaches, upper abdominal pain, sensitivity to light, sudden swelling in the face, hands, and feet, decreased urine output, and nausea and vomiting.[137]
Next, once a diagnosis is made, the physician may fail to provide adequate treatment. Unfortunately, in many American healthcare facilities, less than half of maternity patients are treated for dangerously high blood pressure when it is found.[138] From this, we can draw that many healthcare professionals fail to monitor patients’ blood pressure and respond to problems despite recommended guidelines to the contrary.[139] There is also concern that healthcare professionals provide ineffective treatment, such as recommendations for rest without other interventions or supplementation with vitamins.[140]
VI. State-by-State Comparison Further Demonstrates that Maternal Disparity is Rooted in Policy Failures
State-by-state data and policies further illustrate how these deaths result from varied, complex webs of systemic factors and failures.[141] According to the Commonwealth Fund, “[s]ix states—California, Colorado, Delaware, Massachusetts, Minnesota, and Utah—reported a ratio of pregnancy-related deaths of less than 25 per 100,000. Meanwhile, Alabama, Arkansas, Georgia, Louisiana, Mississippi, Montana, North Carolina, Tennessee, Wyoming, and the District of Columbia all had rates at least twice that high.”[142] To narrow in on one comparison, in California, 5.5 (between five and six) women die from pregnancy-related causes for every 100,000 live births,[143] whereas in Louisiana, 41 women die from pregnancy-related causes for every 100,000 live births.[144] Notably, however, between 2011 and 2016, the maternal mortality of white women in Louisiana was 5.6 deaths per 100,000 births, which is lower than the national average.[145] These patterns underscore that systemic factors drive poor outcomes. The fact that most maternal deaths are deemed preventable by review committees, coupled with persistently higher risk for Black women even in “average” states, reveals how structural racism and policy failures shape who survives childbirth.
Moreover, although maternal deaths account for less than 2 percent of all deaths among women of reproductive age, state-by-state pregnancy-related mortality ratios from 2019 to 2023 strongly mirror overall female death rates.[146] In just five years, while there were
6,282 pregnancy-related deaths, over 334,000 women of reproductive age died in total—concentrated in states like Alabama, Mississippi, and Tennessee, which have all the highest pregnancy-related and overall death rates among women ages 15 to 44.[147] Conversely, states like California and Massachusetts, with low overall female death rates, also see lower maternal mortality.[148] Similarly, states with high rates of pregnancy-related mortality, such as Alabama, Mississippi, South Dakota, and Tennessee, also have high rates of infant mortality.[149] This correlation signals a broader crisis of avoidable deaths among women, not just those related to pregnancy.
Using racially-coded state-level data, the California Maternal Quality Care Collaboration (CMQCC) identified preeclampsia as the leading cause of preventable death for Black pregnant people in the state; it went on to implement programs that significantly decreased the California maternal mortality.[150] Although systemic racism may be complex, BMMD is not an inevitable issue; providing equal treatment to pregnant Black women is an action that the healthcare industry can take now.
Potential Solutions
I. Section 1557 as a Tool to Combat BMMD is Limited by the
Current Administration
Section 1557 is a key provision of the Affordable Care Act (ACA) that prohibits discrimination in healthcare programs and activities based on race, color, national origin, sex, age, or disability.[151] More specifically, based on any of these protected characteristics, patients must not “be excluded from participation in, be denied benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving federal financial assistance.”[152] This part of the ACA broadened the scope of protections against discrimination in healthcare settings by building on previous civil rights statutes such as Title VI (race), Title IX (sex), the Age Discrimination Act (elderly and age), and Section 504 of the Rehabilitation Act (disabilities).[153] Because of the non-discrimination clause, “any differential treatment or denial of care…” in health care settings “must have a legitimate, non-discriminatory reason that is not rooted in animus or bias.”[154] Section 1557, combined with the Congressional laws it references, addresses identity-based inequalities.[155] The Office of Civil Rights (OCR) at the Department of Health and Human Services (HHS) has been taking complaints to enforce the ACA since it passed in 2010.[156]
However, enforcing these rights still poses significant challenges for plaintiffs–namely, proving intent and causation. Historically, civil rights laws require victims to prove discrimination with precise, often unattainable, evidence of intent or bias.[157] A focus on the individual limits its effectiveness in addressing structural inequities in health care, which may be systemic rather than discrete, intentional acts. Most civil rights statutes at the federal and state levels require that the person claiming a right make an argument that their rights were infringed based on one or more of the protected traits.[158] Next, a plaintiff must also establish causation, which aligns with general tort law principles.[159] Section 1557 incorporates the grounds for discrimination from four federal statutes: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, and the Rehabilitation Act of 1973. Each of these statutes has its own causation standard, which Section 1557 adopts depending on the type of discrimination alleged.[160] For claims based on race, color, or national origin under Title VI, the plaintiff must establish that the discrimination occurred “on the ground” of these protected characteristics, which courts have interpreted to require a showing of intentional discrimination.[161] Thus, to use non-discrimination laws in a healthcare setting, one must bear the heavy burden of precisely identifying the root causes of identity-based inequalities.[162]
The Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization,[163] which overruled Roe v. Wade[164] and Planned Parenthood of Southeastern Pennsylvania v. Casey[165] has further complicated the legal landscape surrounding Section 1557.[166] These rulings have called into question the stability of rights related to healthcare, reproductive autonomy, and protections against sex and gender discrimination.[167] For instance, in Texas v. Becerra,[168] the court noted that guidance documents that rely on precedent, such as Casey, may no longer be valid in light of Dobbs. This development highlights the ongoing challenges in enforcing non-discrimination protections in the post-Dobbs era.[169]
Before 2025, HHS could apply impact-based agency enforcement, which means it could enforce rules based on disparate impact—not only individual claims.[170] The 2023 Biden-era HHS guidelines that explicitly ban the use of patient care tools, like algorithms, that discriminate based on race and sex are an example of recent non-discrimination enforcement success by the HHS.[171] Additionally, in 2023, the Department of Justice (DOJ), HHS, and Alabama Department of Public Health (2023) reached an interim resolution that sought to minimize the effects of environmental racism.[172] A limitation of this approach is that HHS has limited funds and capacity[173] and, unfortunately, the Trump administration’s severe rollback of 1557 protections.[174] HHS guidelines that target racial discrimination and disparate impact claims are, sadly, in limbo.[175] BMMD, as an issue affecting Black women broadly, would be best addressed through disparate impact claims; however, such claims are not feasible unless or until future administrative changes.
II. Congressional Policy to Decrease Maternal Mortality Is Vital, but Should Further Address BMMD and Include Evidence-Based Protocols
Congress possesses significant authority to regulate health care under the Commerce Clause, which empowers it to regulate activities that substantially affect interstate commerce.[176] In healthcare, rights are typically legislative elements, like the ACA, because the federal government has the “power of the purse” to make requirements of any entity that accepts federal funding.[177] Healthcare is a national, multi-billion-dollar business that looms over a fifth of the American GDP.[178] This Congressional power of the purse entails the ability to condition funding on compliance with civil rights laws and public safety regulations, a principle repeatedly affirmed by the courts,[179] although there are limitations.[180] The federal Medicare Program was passed in 1965 and, as scholar Dr. Anna Kirkland describes it, is “the most important federal level for civil rights compliance, perhaps ever.”[181] Facilities accepting federal money must comply with specific operational, civil rights, and safety regulations, or risk losing eligibility for funds.[182] One of the most significant intersections of federal funding, healthcare regulation, and civil rights emerged in Simkins v. Moses H. Cone Memorial Hospital,[183] where the Fourth Circuit held that private hospitals receiving federal funds under the Hill-Burton Act were subject to constitutional prohibitions against racial discrimination. The court found that substantial federal funding, combined with close state and federal regulatory oversight, was enough to convert discriminatory acts by private hospitals into “state action,” thereby making them subject to the Fifth and Fourteenth Amendments.[184] The decision relied on the “symbiotic relationship” doctrine from Burton v. Wilmington Parking Auth.,[185] and led to the condemnation of “separate but equal” segregation in federally funded health facilities; others have built on these principles.[186] Moreover, the Department of Health and Human Services is authorized to enforce health, safety, and welfare requirements in Medicare and Medicaid-certified facilities,[187] and has “look behind” authority to ensure ongoing compliance. A key to protecting civil rights in healthcare may rest on this power,
the carrot and stick of federal funding, to require compliance with
anti-discriminatory laws.[188]
Currently, there are two systems on the national level that collect information about maternal mortality, both of which are housed at the CDC.[189] These classification and surveillance systems identify disparities
and causes of death, but they cannot answer why women are dying and what can be done to prevent it.[190] To respond to the data gap, based in the idea that local data is better, Maternal Mortality Review Committees (MMRCs) came to life in most states.[191] Experts consider them a
“gold standard” for analyzing maternal deaths.[192] These bodies comprise interdisciplinary groups of professionals, including public health specialists, physicians, and hospital administrators. MMRC’s purpose is to get to the “why” and make recommendations for states to improve standards and outcomes.[193] For instance, Mississippi’s 2016 report emphasized expanded access to Medicare and telehealth connections to rural residents as potential solutions.[194] In the United Kingdom, its version of an MMRC is credited with making recommendations that decreased BMMD specifically.[195] MMRCs are poised to make recommendations that target state-wide policies and practices. The first round of the Preventing Maternal Death Act allocated twelve million dollars to fund state MMRC in 2018.[196]
Even if HHS cannot or will not enforce patient safety regulations or bring a disparate-impact claim, Congress can regulate the healthcare industry by passing laws. In response to persistently high—and inequitable—rates of maternal mortality in the United States, Congress enacted “Safe Motherhood” in 2000 (and since strengthened the legislation with significant amendments in 2018 and 2022),[197] the “Preventing Maternal Deaths Reauthorization Act” in 2023,[198] and, recently, “Innovation for Maternal Health” funding program in 2025.[199] This evolving legislation empowers the CDC to enhance surveillance and reporting of maternal deaths and funds multidisciplinary review committees at the state and tribal levels. It expands research into risk factors and preventive strategies. Approved by Congress in June 2025, the “innovation for maternal health” grant program will be administered by the Secretary of Health and Human Services to further support MMRCs.[200] The program aims to identify and disseminate best practices, collaborate with state maternal mortality review committees, provide technical assistance, and develop new models of care to reduce preventable maternal deaths and severe morbidity, thereby enhancing maternal and infant health.[201] The statute authorizes $9 million in funding for each fiscal year from 2023 to 2027.[202] The Rural Obstetrics Readiness Act, with bipartisan support, passed the U.S. Senate and House in February 2025, and now waits to be signed into law by the President.[203]
Some actionable ways to reduce maternal deaths, according to medical researchers, which could be enforced through Congressional policy, include:
The broad implementation of evidence-based toolkits, safety bundles, protocols, and/or checklists, which ensures providers meet the standard of care required,[204] and can be implemented into already existing electronic systems;[205]
Engaging in simulation training in hospitals;[206]
The implementation of a disparity dashboard that tracks disparate health outcomes in the facility;[207] and
Enhanced funding for pregnancy-related care, including midwives and doulas.
III. The California Model is a State-Wide Example of Success That Directly Addresses BMMD and Involves Evidence-Based Protocols and Networks
California has a lower maternal mortality rate than other states due to its highly effective MMRC state implementation plan,[208] which engages leaders and healthcare workers, and sufficient funding of programs aimed at improving maternal health. California focused “narrowly on problems that arise during labor and delivery, using data collection to quickly identify deficiencies (such as failing to have the right supplies on hand or performing unnecessary Caesarean sections) and training nurses and doctors to overcome them.”[209] The California Maternal Quality Care Collaborative (CMQCC), a state task force housed at Stanford University, describes itself as a multi-stakeholder organization “committed to ending preventable morbidity, mortality, and racial disparities in California maternity care.”[210] The CMQCC’s success in reducing California’s maternal mortality by 65% since its founding in 2006 highlights that addressing racism directly is the key.[211]
To support California hospitals in adopting the evidence-based practices outlined in the toolkits, CMQCC launched extensive outreach collaboratives across the state. Separate statewide collaboratives were initially established for hemorrhage and preeclampsia.[212] In 2013, these efforts were combined, and a joint collaborative was introduced to help hospitals implement both the obstetric hemorrhage and preeclampsia patient safety bundles.[213] As a result, maternal morbidity decreased by 20.8% between 2014 and 2016 among the 126 hospitals participating in the California Partnership for Maternal Safety—the unified hemorrhage and preeclampsia initiative.[214] CMQCC publishes dozens of toolkits, offers training throughout the year, and partners with local hospitals to guarantee standards of care are met.[215] The complete toolkit, available for free, can be found on their website.[216] Positive results have been found in other states and clinics that adopted the toolkits.[217] California’s next step has been to partner with the American College of Obstetricians and Gynecologists to develop an electronic learning (e-learning) module and a simulation scenario.[218]
A part of what makes California different, and successful, is its comprehensive network of partner hospitals, which effectuates change between professionals, administrators, and the state, and its funding of maternal programs.[219] The goals are recommended and set by the State, and then implemented in facilities, and monitored based on outcomes. California collected data but did not stop there. It acted.
IV. Accreditation & Certification Sets Standards, but Lacks
Enforcement Mechanisms
Accreditation
Accreditation is widely regarded as a hallmark of quality and safety in American healthcare, with hospitals investing considerable resources and attention to obtain and maintain these credentials. Institutions like The Joint Commission confer status, public trust, and crucial financial benefits through their recognition, thereby making accreditation a top priority for healthcare administrators.[220] Yet, while the accreditation process promises to uphold rigorous standards and foster continual improvement, it is essential to examine these claims critically. Beneath the badges and annual inspections, significant questions remain about how much accreditation guarantees safe, equitable care—and how well it addresses persistent disparities and preventable harm. A key challenge is the system’s limited enforcement mechanisms: hospitals may earn the coveted Gold Seal of Approval even as serious problems persist, and research shows compliance does not always translate into better patient outcomes.[221] As new standards prompt healthcare organizations to address racial inequities, it is more crucial than ever to examine not only accreditation itself, but also its enforcement and impact, to ensure that policies designed to protect patients and promote equity are genuinely effective.
The Joint Commission[222] is a non-profit healthcare organization that evaluates and accredits healthcare organizations across the United States. It sets standards for quality patient care and safety to ensure high-quality healthcare delivery by inspecting facilities and assessing their compliance with established standards,[223] and partners with health care organizations, such as American College of Obstetricians and Gynecologists (ACOG).[224] ACOG’s R3 Report provides the rationale and references that The Joint Commission employs in developing new requirements.[225] By making health equity a formal accreditation priority, these standards represent a significant shift toward more equitable and accountable health care for all patient populations, based on the recognition that disparities in care are both a social justice issue and a fundamental quality concern. The 2023 R3 Report applied and revised requirements to reduce racialized healthcare disparities in organizations. Accredited healthcare facilities must now record and document patient race and ethnicity data. In the report, race is described as a factor leading to inadequate care.[226] It also describes the difference between social determinants of health (SDOH) and health-related social needs (HRSN); SDOH describes populations, whereas HSRN is pointed to as the proximate cause for inadequate care and better suited to pinpoint outcomes for individual patients.[227] The report also emphasizes that these changes require leadership, stating that “success demands leadership,” implying that everyone, including facility management and C-suite executives, must be on board to achieve equity.[228] The new standards went into effect on January 1, 2023.[229] It remains unclear how these new standards have impacted healthcare facilities.[230]
Hospital administrators care about accreditation for several reasons. Achieving the Joint Commission accreditation symbol signifies a healthcare facility meets high standards, recognized by the “Gold Seal of Approval.”[231] Many insurance companies and government programs consider—if not require—accreditation when deciding which healthcare facilities to contract with.[232] Since most Americans do not pay out of pocket for healthcare, there are strong financial incentives for accreditation for reimbursement purposes.[233] Beyond fiscal reasons, public perception and trust are also affected. Being accredited signals to the community and its patients that the facility prioritizes high standards of care.[234] All of this provides significant motivation for hospitals to comply with established standards, and research shows that accreditation does “improve the process of care” and clinical outcomes for patients.[235] Still, a problem with enforcement remains.
Accreditation remains a near-universal convention of the U.S. health care system, as evidenced by the fact that nearly 90% of American hospitals are accredited. However, there are still substantial differences among accredited hospitals themselves, and a 2018 JAMA study found no difference in mortality or readmission rates between accredited and non-accredited facilities.[236] Additionally, inspection reports from 2014 through 2016 show numerous safety violations among 350 Gold Star Hospitals.[237] These violations illustrate an ongoing problem with compliance and enforcement. Nonetheless, medical researchers still describe accreditation as a “cornerstone for ensuring at least a basic level of quality” but emphasize that, to be successful, standards must focus on patient safety, which is what matters most, and there must be a clear process for holding hospitals in violation accountable.[238] In this context, this should mean tracking patient outcomes by race within facilities, as now mandated by the R3 Joint Commission report, and ensuring that outcomes are adequate. The Gold standard is for process and outcome, or else we risk prioritizing data over lives. Thus, once the process is up to standard and racial data is recorded, continued accreditation should be based, to some extent, on satisfactory health outcomes for patients across races.[239]
Certification
Certification matters because it serves as a formal recognition of a provider’s expertise and commitment to maintaining established standards within their specialty. For patients, certification signals that their physician has met rigorous requirements for training and ongoing education, and shapes how they select providers.[240] For healthcare providers, certification is widely viewed as vital for demonstrating professional competence and maintaining public trust; however, it is also criticized for its high financial costs, exam design, and uncertain relevance to specialized practice—concerns that raise questions about its actual impact on patient care and physician well-being.[241] The American College of Obstetricians and Gynecologists (ACOG) is a professional organization that advocates for women’s health care and maintains standards for clinical practice.[242] Unlike accreditation, ACOG membership for individual medical professionals requires certification by the American Board of Obstetrics and Gynecology. Like the CMQCC, the ACOG recommends the adoption
of standardized, evidence-based clinical guidelines for the management of preeclampsia to reduce adverse maternal outcomes.[243] The ACOG has
no enforcement authority over organizations, and there are few well-developed avenues to hold violators accountable; thus, its role in systemic change is possible but limited and slow.
V. Midwives and Doulas May Further Improve Maternal Outcomes,
Especially for Black, Low-Income, and Rural Americans
Doula support improves maternal outcomes because they are experts in supporting and serving pregnant women as advocates.[244] Studies regularly demonstrate that doula and midwife support improves health outcomes and decreases maternal mortality.[245] Therefore, low-income and Black patients may benefit from doulas and midwives, especially given the context that Black women receive inferior care. Doulas, trained in culturally relevant and trauma-informed care, can address the widespread impacts of racism.[246] Doula support and advocacy could help more Black pregnant people receive not only supplemental care outside of the medical system, such as in rural areas to address access needs, but also support during what may be a traumatic and difficult experience, leading to better health outcomes and further trust in the medical system.[247]
Thirteen states, including California, New York, and Michigan, currently cover some Doula benefits,[248] and many “states are increasingly seeking federal authorization to provide doula services as an optional benefit under their state Medicaid programs to pregnant beneficiaries.”[249] New York also created a directory of doulas, whose services are now covered by Medicaid through the state, and earmarked $4.5 million dollars to support the project.[250]
When considering programs to help Black pregnant people, Black people, and women should always be included. Organizations like Black Mamas Matter, which is led by Black women professionals, publish comprehensive policy plans annually.[251] Black women’s organizations identify community-based doulas, which are integrated within the communities they serve, as a key factor to improving BMMD and improving Black women’s birth experiences, among other recommendations.[252]
VI. Patient Education Empowers Pregnant People to Recognize Symptoms,
but it Cannot Address Systemic Issues Alone
Another solution is patient education. The Preeclampsia Foundation has published a Preeclampsia Patient’s Bill of Rights,[253] which includes statements like “I can expect my blood pressure to be measured accurately,” and “I can expect my severe high blood pressure to be treated within an hour of diagnosis.”[254] Unfortunately, less than half of women are informed about the signs and symptoms of preeclampsia—a gap that reflects shortcomings in our healthcare and public health education systems.[255] Educating preeclampsia patients is important because it empowers them to recognize and report early symptoms, which may help doctors provide timely intervention and ultimately reduce preventable maternal deaths. More specifically, patients should know whether they are at high risk for preeclampsia and be able to report problematic symptoms, such as headache and severe swelling.[256] Additionally, understanding the condition can improve compliance with treatment plans.[257] When patients are well informed, they can take a more active role in their treatment and health management. The Preeclampsia Foundation has developed a marketplace tool where providers can order preeclampsia education materials in bulk.[258] Additionally, the California Surgeon General’s recommendations highlight patient education and discuss funding at-home tools for pregnant people to assess their risks.[259] However, this solution focuses on what women should know and is limited by education and access issues. In other words, it cannot be the only step toward equity; it must focus on systemic change.
VII. Expanding Access to Postpartum Care Prevents Maternal Deaths
Most postpartum deaths occur within 47 days of birth; however, women are at higher risk of death for up to a year after birth.[260] Some complications, such as embolism, like the pulmonary embolism that Serena Williams’ experienced, are common after birth.[261] Heeding the call by advocates to extend Medicaid coverage to one year after birth,[262] the Biden administration worked to pass the American Rescue Plan Act of 2021, which gave states the option to extend Medicaid postpartum coverage from 60 days to 12 months.[263] The Consolidated Appropriations Act of 2023 made this option permanent.[264] States that extend coverage receive federal matching funds.[265] As of 2025, all states but one have taken this opportunity to extend coverage, significantly increasing postpartum care access in these states.[266]
Improving postpartum care is crucial because it provides a critical window to address a woman’s physical and mental health needs after childbirth, especially to prevent maternal mortality.[267] Expanded postpartum care can give physicians more time to address lingering concerns from complications such as preeclampsia, cardiovascular concerns, or gestational diabetes.[268] It can also allow for early intervention into issues such as postpartum depression, breastfeeding challenges, and other problems relating to parenting.[269]
For individuals with private insurance, most commercial insurance plans cover the postpartum period; however, the extent and cost of coverage vary significantly. According to the Peterson Center on Healthcare,
the average American woman pays just under $3,000 out-of-pocket to give birth.[270] This figure is higher if she delivers by C-section.[271] Out-of-pocket costs are a barrier to care for most Americans who have little savings.[272]
Without insurance, the cost of giving birth without complications ranges from $13,000 to $35,000 on average.[273] It is unclear how much uninsured postpartum complications cost because healthcare costs are different across states and depend on the complications themselves. Regulating private insurance is difficult and complicated;[274] however, it is important to advocate that all private insurance companies, and employers who purchase these plans, adopt12-month coverage of postpartum care. Hopefully, the Trump administration does not roll back postpartum coverage.[275]
Paths Forward
Expanding the capacity of the Department of Health and Human Services (HHS) to monitor, investigate, and address racial discrimination complaints in healthcare could help ensure that all pregnant people, regardless of their race, receive the same level of care.[276] Next, nationwide implementation of standardized clinical protocols, such as the Preeclampsia Early Recognition Tool (PERT) from California’s CMQCC,[277] would be ideal; however, it is unlikely HHS under the Trump administration would undertake such a measure Still, hope remains for future administrations and for states to take action. In the short to medium term, securing federal and state funding to support maternal health programs, such as the Maternal Health Innovation Awards, is vital. Offering grants to states that show measurable improvements in maternal health outcomes will provide the necessary financial resources for these programs’ successful implementation and sustainability.
Given the current Federal climate, states must invest in state-wide MMCRs and in programs geared toward preventing maternal mortality.[278] Enhancing compliance can be achieved by fostering a culture of adherence through frequent training, simulations, regular audits, and incorporating compliance metrics into performance reviews with feedback mechanisms.[279] States may collect their own maternal health data, and hospitals and facilities should implement disparity dashboards to monitor maternal mortality and morbidity, regularly tracking and stratifying outcomes by race—tools endorsed by leading medical experts and recommended by organizations focused on patient safety and quality improvement.[280]
Researchers suggest that the plan-do-study method can be utilized in an updated format (FOCUS) for continuous improvement and demonstrated impact.[281] Rapid-cycle continuous quality improvement “identifies, implements, and measures changes” over a series of weeks and months rather than years.[282] The Institute for Healthcare Improvement (IHI) also offers an improvement tracker on its website to allow easy visualization of changes in quality metrics over time. The use of these visual graphs, available free online, can serve as robust evidence of improvement to patients, physicians, and administrators.[283] Priorities include investing in ongoing education and training programs for healthcare providers, which could be delivered online such as the E-learning module being developed by California’s MQRRC. Developing and supporting health programs focusing on maternal health, including local health worker initiatives and partnerships with community organizations and partnerships between medical schools and professional organizations. By prioritizing these actions, policymakers can address the most pressing issues contributing to BMMD and lay a solid foundation for long-term progress.
Conclusion
Despite high levels of healthcare spending, the United States stands out among wealthy nations for having the highest and most alarming maternal mortality rates, with deep divisions by race. The American maternal mortality crisis, and particularly the stark Black Maternal Mortality Disparity (BMMD), is rooted in structural racism and the routine provision of substandard care to Black pregnant people. While factors like access, geography, and poverty exacerbate the problem, even controlling for income and education reveals persistent racial disparities in care quality and outcomes. Throughout this analysis, anti-racist and intersectional frameworks were used to illuminate how racism, gender bias, and other intersecting forms of discrimination compound to shape maternal health outcomes and perpetuate disparities. Evidence shows that Black pregnant people receive inferior healthcare, which remains a core driver of these disparate outcomes. However, state-by-state differences in maternal mortality rates make clear that this crisis
is rooted in systemic factors that can be either exacerbated or alleviated
by state policies.
State-level variations reveal that poor outcomes are not inevitable but are shaped by states’ choices regarding healthcare standards, investment, and oversight. While preeclampsia may not be the single most significant cause of maternal death, it powerfully illustrates how a known, preventable issue continues to claim lives due to the persistent failure to enforce clinical standards. Providers need more support and education in recognizing and treating avoidable causes of death in pregnancy. Still, the good news is that effective training materials, protocols, and clinical toolkits already exist—they must be widely disseminated, adopted, and enforced. Utilizing these resources benefits everyone involved: medical staff receive more precise guidance, hospitals meet higher standards, states achieve improved outcomes, and patients receive safer, more effective care. In many cases, our healthcare systems have already developed the knowledge and tools to save lives; equitable outcomes ultimately depend on both effectively disseminating this information and enforcing its use in practice to guarantee equal, life-saving treatment for all.
Among the potential solutions, federal civil rights law, such as
Section 1557 of the Affordable Care Act, offers vital protections against discrimination. Its strength lies in establishing patient rights and providing avenues for redress and enforcement; however, its effectiveness is blunted by the high burdens of proof for plaintiffs and, increasingly, by the Trump administration’s erosion of 1557 protections and its general retreat from civil rights enforcement. Furthermore, theoretically, strong disparate impact claims against hospitals that consistently provide inferior care to Black patients, especially when there is clear evidence of racial disparities in treatment and outcomes. However, due to significant federal funding cuts, regulatory uncertainty, and the current political climate, such claims face substantial procedural hurdles. They are unlikely to be vigorously pursued or enforced at this time.
Congressional policy and funding initiatives—like Safe Motherhood and the Preventing Maternal Deaths Reauthorization Act—enable surveillance, fund MMRCs, and encourage best practices. Congressional policies like these are commendable and vital. However, these laws often lean heavily on data collection without prioritizing action or requiring enforcement.
The California model demonstrates the power of state-level leadership. By engaging a multidisciplinary network, rolling out evidence-based protocols, and requiring accountability, California’s MMRC accomplished a 65% reduction in maternal deaths—especially from preventable causes like preeclampsia. This approach’s great strength is enforceable, transparent standards, though replicability hinges on strong state infrastructure and political will.
Accreditation and certification systems (e.g., The Joint Commission, ACOG) signal hospitals’ commitment to quality and now include equity requirements. Accreditation can drive improvement, but without rigorous enforcement and outcome-based accountability, credentials alone do not guarantee safe or equitable care.
Expanding the use of Black midwives and doulas brings culturally competent, community-centred care directly to those most at risk, with clear evidence of improved birth outcomes. Still, coverage and access vary by state, and without public funding and integration, their reach remains limited.
Patient education—empowering birthing people to recognize and advocate for timely care—has significant preventive potential but cannot substitute for institutional change. Without broad access to care or attention to systemic bias, placing the onus on patients is insufficient.
Expanding postpartum coverage, particularly through Medicaid, ensures continuity of care and access to interventions for life-threatening complications. This policy has demonstrated benefits but remains vulnerable to federal policy shifts and lacks parallel requirements for private insurance.
Given the current federal landscape and likely continued inaction at the national level, genuine progress must come from state and community coalitions and local healthcare systems. States can invest in robust MMRCs, enforce clinical protocols, fund supportive services like doulas, and actively monitor racialized outcomes. Healthcare systems and individual hospitals can implement a disparity dashboard within their facilities to track outcomes by race and highlight gaps in care. Such tools make disparities visible at the institutional level and can drive real change when paired with action. It can also demonstrate growth over time and provide real-time data on improvement. Hospitals and health systems must embrace ongoing education, cultural humility, and compliance auditing as baseline professional obligations. Even within a racist system, medical professionals and policymakers have ample room for immediate, meaningful action.
It is critical to acknowledge that broader reforms—such as universal healthcare, paid childcare, and national maternity or parental leave—would dramatically advance equity and address underlying SDOH. However, these solutions require sweeping federal action, which is unlikely under the current administration. This paper focuses on outlining interventions that health professionals, hospital administrators, and state governments can adopt now. The scope and complexity of racism in healthcare cannot become an excuse for inaction: many tools for change are ready at hand, and lives can be saved while broader reforms remain out of reach.
Ultimately, tackling the Black maternal mortality crisis will require unwavering attention to equity, rigorous enforcement of standards, and collaborative, community-driven action. Success will require coordinated efforts that draw on the strengths of each of these strategies: adopting state-based models, such as California’s, restructuring institutional priorities, expanding supportive services, empowering patients, and, someday, enforcing civil rights at a federal level. We cannot wait for federal leadership to rescue us; we must build accountability and innovation from the ground up—state by state, hospital by hospital, and provider by provider—until lives are no longer lost to preventable injustice in American maternity care.
[1]. Camara P. Jones, Levels of Racism: A Theoretic Framework and a Gardener’s Tale, 90 Am. J. Pub. Health 1212 (2000), [https://perma.cc/56K2-GA43] (Individual racism refers to the “negative attitudes, beliefs and actions taken on by people of a racialized group about their own abilities and worth.” It may also be called internalized racism).
[2]. Agnes Calliste Power, Knowledge and Anti-Racism Education: A Critical Reader 144 (Margarida Aguiar, Agnes Calliste & George Dei, eds., 2000).
[3]. See, e.g., Nadha Hassen, Aisha Lofters, Sinit Michael, Amita Mall, Andrew D. Pinto & Julia Rackal, Implementing Anti-racism Interventions in Healthcare Settings: A Scoping Review, 18 Int’l. J. Env’t. Rsch. Pub. Health, March 2021, at 1, 13 [https://perma.cc/WW2P-HU4E].
[4]. Id.
[5]. Pamela Roach, Shannon M. Ruzycki, Kirstie C. Lithgow, Chanda R. McFadden, Adrian Chikwanha, Jayna Holroyd-Leduc & Cheryl Barnabe, A Logic Framework for Addressing Medical Racism in Academic Medicine: An Analysis of Qualitative Data, 25 BMC Med. Ethics, April 2024, at 1, 2 (“Race is a social construct without biological meaning that is used to categorize people into groups based on their appearance, which are then assigned societal value.”).
[6]. Jamila Taylor, Cristina Novoa, Katie Hamm, & Shilpa Phadke, Eliminating Racial Disparities in Infant and Maternal Mortality: A Comprehensive Policy Blueprint, Ctr. for Am. Progress (May 2, 2019) (citing Aspen Inst. Roundtable on Cmty. Change, Glossary for Understanding the Dismantling Structural Racism/Promoting Racial Equity Analysis (2017), [https://perma.cc/NHY5-ZRLQ].
[7]. Interpersonal racism is as “what white people do to people of color up close–the racist jokes, the stereotypes, the beatings and harassment, the threats.” The Four “I’s” of Oppression, Scripps Coll., [https://perma.cc/AN7X-DA9G].
[8]. Kimberlé Crenshaw, Demarginalizing the intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory, and Antiracist Policies, 1989 Univ. Chi. Legal F. 139, 140.
[9]. See e.g., Carol Sakala, Eugene R. Declercq, Jessica M. Turon, & Maureen P. Corry, Nat’l P’ship for Women & Families, Listening to Mothers in California: A Population-Based Survey of Women’s Childbearing Experiences, Full Survey Report (2018); Nina Martin & Renee Montagne, Lost Mothers: Nothing Protects Black Women From Dying in Pregnancy and Childbirth, ProPublica (December 7, 2017), [https://perma.cc/L355-GVYP].
[10]. Misogynoir is a term coined by Moya Bailey to describe the unique form of discrimination that Black women face, which is informed by the intersection of anti-Black racism and misogyny. It refers explicitly to how Black women are stereotyped, devalued, and mistreated based on both their race and gender simultaneously. The term highlights how attitudes, representations, and policies often uniquely disadvantage Black women, setting their experiences apart from those of White women (who may face sexism) or Black men (who may face racism), but not the compounded prejudice experienced by Black women. Moya Bailey, Misogynoir in Medical Media: On Caster Semenya and R. Kelly, 2 Catalyst: Feminism, Theory, Technoscience 1 (2016).
[11]. See e.g., How to Reduce Implicit Bias, Inst. for Healthcare Improvement (September 28, 2017), [https://perma.cc/VF9P-NZPT] (“Implicit bias is not limited to race; implicit bias can exist for characteristics such as gender, age, sexual orientation, gender identity, disability status, and physical appearance such as height or weight.”); see also Crenshaw, supra note 8, at 140.
[12]. Jennifer Alvidrez, Dorothy Castille, Maryline Laude-Sharp, Adelaida Rosario & Derrick Tabor, The National Institute on Minority Health and Health Disparities Research Framework, 109 Am. J. Pub. Health S16, S16 (2019).
[13]. S. 1880, 106th Cong. §485E(d) (2000).
[14]. Anand K. Narayan, Nia Foster, Nadja Kadom, Jinel A. Scott, Efren J. Flores, Jennifer C. Broder, Charlotte J. Yong-Hing, Dania Daye, Nolan J. Kagetsu & Helen Burstin, Six Steps to Improving Health Equity Using Quality Improvement and Patient Safety Tools, 314 Radiology, Feb. 18, 2025, at 1, 1.
[15]. Gretchen Neidhardt, African American and Black Identity and Research Terms, Chicago Hist. Museum (Aug. 20, 2021) (“Black has been used throughout the last three centuries in the United States, but its use as a community identifier emerged with rise of the Black Power Movement in the 1960’s (replacing Negro). Invoking the term Black aimed to reclaim a negative term (and also as a counter to “white”)”) (quoting Zenobia Bell, African-American Nomenclature: The Label Identity Shift from ‘Negro’ to ‘Black’ in the 1960s 16 (2013) (M.A. thesis, University of California, Los Angeles)), [https://perma.cc/5BAA-MRGL].
[16]. About Maternal Mortality Review Committees, Ctr. for Disease Control (May 15, 2024), [https://perma.cc/3TQN-QAZU].
[17]. Id. See also Shannon Emmett, Why Are States Trying to Bury the Truth About Preventable Deaths of Pregnant Women?, Inst. for Women’s Pol’y Resch. (Feb. 14, 2025), [https://perma.cc/B62A-FPTR] (“The Centers for Disease Control and Prevention’s (CDC) standardized case review process has been adopted by 41 states, but only
10 states consider racial disparities in their reviews, and only 6 states require committee reports to address racial inequities.” (emphasis added)).
[18]. Id. See also Issue Brief: Maternal Mortality Review Committees, Am. Coll. of Obstetrics & Gynecologists, [https://perma.cc/FJE8-NKCN].
[19]. About Maternal Mortality Review Committees, supra note 16.
[20]. Id.
[21]. See Susanna Trost, Jennifer Beauregard, Gyan Chandra, Fanny Njie, Jasmine Berry, Alyssa Harvey, David A. Goodman, Pregnancy-Related Deaths: Data From Maternal Mortality Review Committees in 36 U.S. States, 2017-19, Ctr. for Disease Control & Prevention (Sept. 19, 2022) [hereinafter Trost et al.], [https://perma.cc/U7N8-SNVT] (“A death is considered preventable if the committee determines that there was at least some chance of the death being averted by one or more reasonable changes to patient, community, provider, facility, and/or systems factors. MMRIA allows MMRCs to document preventability decisions in two ways: (1) determining preventability as a yes or no, and/or 2) determining the chance to alter the outcome by using a scale that indicates no chance, some chance, or good chance. Any death with a yes response or a response that there was some chance or a good chance to alter the outcome was considered preventable. Deaths with a no response or no chance were considered not preventable.”).
[22]. See e.g., Maternal Mortality: Georgia 2020-2022, Georgia Dep’t of Pub. Health (2022), [https://perma.cc/ZFR6-W9GS] (finding that “87% of pregnancy related deaths had at least some chance of being prevented.”).
[23]. The initial phase involved an extensive review of health literature to uncover causes of BMMD. Databases such as PubMed, the National Institutes of Health (NIH), and the Centers for Disease Control and Prevention (CDC) were utilized to source relevant academic articles, reports, and research studies. Keywords included “Black maternal mortality disparities,” “causes of maternal mortality,” and “racial health disparities in pregnancy.” Priority was given to research published after 2018 to ensure contemporary relevance. Key findings were further explored by reviewing references within these sources, leading to significant studies from earlier years that provided foundational insights. Primary resources, such as foreign, national, and state health reports from medical bodies, were also utilized.
[24]. In the second phase, the focus shifted to identifying and evaluating legal and policy measures to address BMMD. Primary research such as legislative documents, research reports from congressional statutes, including the Preventing Maternal Deaths Act, and accreditation reports from the Joint Commission were reviewed to understand current enforcement mechanisms and potential policy interventions. Additionally, secondary legal sources were analyzed, including legal databases such as Lexis Nexis and Google Scholar, for court cases and legal interpretations of Section 1557 of the Affordable Care Act (ACA).
[25]. In 2022, there were 22 maternal deaths for every 100,000 live births in the U.S.—more than double, sometimes triple, the rate for most other high-income countries.
See Munira Z. Gunja, Evan D. Gumas, Relebohile Masitha & Laurie C. Zephyrin, Insights into the U.S. Maternal Mortality Crisis: An International Comparison, Commonwealth Fund (June 2024) [hereinafter Gunja et. al], [https://perma.cc/Z2CG-6355]. In half of the other high-income nations analyzed, there were fewer than five maternal deaths per 100,000 live births. Id.
[26]. See Eliminating Preventable Maternal Mortality and Morbidity, Am. Coll. of Obstetrics & Gynecologists, [https://perma.cc/3GYE-N2QJ]. 45% of postpartum deaths occur within 42 days of birth; however, some reporting continues up to a year postpartum, while others cease at six months. Building the U.S. Capacity to Review and Prevent Maternal Deaths: Report From Nine Maternal Mortality Review Committees, Ctr. for Disease Control & Prevention 14 (2018) [hereinafter
Nine Committee Report], [https://perma.cc/SE44-LCSZ].
[27]. See What can we do to address maternal mortality?, Mayo Clinic Press (Nov. 29, 2023), [https://perma.cc/3E2A-JQR7].
[28]. Id. Maternal mortality refers to deaths being caused by pregnancy complications within a year (or so) or birth and maternal morbidity refers to the development and progression of disease in pregnancy. Maternal death and pregnancy-related death, March of Dimes, [https://perma.cc/A7HL-XRR9].
[29]. U.S. Gov’t Accountability Off., Maternal Mortality: Trends in Pregnancy Related Deaths and Federal Efforts to Reduce Them 13 (2021).
[30]. John A Ozimek & Sarah J. Kilpatrick, Maternal Mortality in the Twenty-First Century, 45 Obstetrics & Gynecology Clinics North Am. 175, 176 (2018). The other thirteen nations are the Bahamas, Georgia, Guyana, Jamaica, North Korea, St. Lucia, Serbia, South Africa, Suriname, Tonga, Venezuela, and Zimbabwe. Id. See also infra note 61 (explaining the problematic, and often racist, history behind the term “developed” or “developing” nations).
[31]. Debra Bingham, Nan Strauss & Francine Coeytaux, Maternal Mortality in the United States: A Human Rights Failure, 83 Contraception 188, 189 (2011) [hereinafter Bingham et al.].
[32]. Donna L. Hoyert, Maternal Mortality Rates in the United States, 2021, NCHS Health
E-Stats (Mar. 16, 2023).
[33]. Donna L. Hoyert, Maternal Mortality Rates in the United States, 2023, U.S. Centers for Disease Control and Prevention (Feb. 2025), [https://perma.cc/7TEC-D3VQ].
[34]. Population Council, CDC on Infant and Maternal Mortality in the United States: 1900-99, 25 Population & Dev. Rev. 821, 824 (1999) (“The gap in maternal mortality between black and white women has increased since the early 1900s. During the first decades of the 20th century, black women were twice as likely to die of pregnancy-related complications as white women.”); see also Andreea A. Creanga, Maternal Mortality in the United States: A Review of Contemporary Data and Their Limitations, 61 Clinical Obstetrics & Gynecology 296, 298 (2018) [hereinafter Creanga, Maternal Mortality].
[35]. See, e.g., Khiara M. Bridges, Racial Disparities in Maternal Mortality, 95 N.Y.U. L. Rev. 1229 (2020).
[36]. See, e.g., Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes, Centers for Medicaid & Medicare Services, [https://perma.cc/XKP9-5ZF9].
[37]. Gunja et. al, supra note 25 (comparing 2024 data across nations).
[38]. Examples of SDOH include safe housing, transportation, neighborhoods, education, job opportunities, income, access to nutritious foods, physical activity opportunities, discrimination, violence, polluted air and water, and language and literacy skills. U.S. Dep’t of Health & Hum. Servs., Off. of Disease Prevention and Health Promotion, Healthy People 2030: Social Determinants of Health, [https://perma.cc/FFN2-662V].
[39]. Em Shrider, Black Individuals Had Record Low Official Poverty Rate in 2022, U.S. Census Bureau (September 12, 2023), [https://perma.cc/D7RP-FTBG].
[40]. Peiyin Hung, Carrie E. Henning-Smith, Michelle M. Casey & Katy B. Kozhimannil, Access to Obstetric Services in Rural Counties Still Declining, with 9 Percent Losing Services, 2004-2014, 36 Health Affairs 1663 (2017) (finding that rural counties with more African American and low-income families were less likely to have hospital obstetric services.).
[41]. Births Financed by Medicaid by Metropolitan Status, KFF,[https://perma.cc/UM6H-YEZE].
[42]. Centers for Medicare and Medicaid Servs., 2024 Medicaid and CHIP Beneficiaries at a Glance: Maternal Health 1 (2024), [https://perma.cc/Z4T8-KSD7].
[43]. Miss. State Dep’t of Health, Off. Rural Health & Primary Care, Mississippi Primary Care Needs Assessment 8 (Mar. 2021) [hereinafter Miss. State Dep’t of Health], (“Mississippi is one of the most rural states in the nation with 79% of the counties classified as rural as defined by the federal Office of Management and
Budget (OMB)… According to data from HRSA, as of July 2020, rural Mississippi had thirty-two (32) critical access hospitals, 186 rural health clinics, 197 Federally Qualified Health Centers, and forty-four (44) short-term hospitals outside of urban areas. Rural areas face more significant challenges with recruiting and retaining healthcare professionals. Eighty-four percent of the single county primary care Health Professional Shortage Areas (HPSA) designations are in these rural counties.”).
[44]. President Trump’s “One Bill Beautiful Bill Act,” Explained, LDF: Policy Watch, [https://perma.cc/4X96-SJCT].
[45]. See e.g., Jamila Taylor, Cristina Novoa, Katie Hamm & Shilpa Phadke, Eliminating Racial Disparities in Maternal and Infant Mortality: A Comprehensive Policy Blueprint, Crt. for Am. Progress (May 2, 2019) [hereinafter Taylor et. al], [https://perma.cc/YCL7-MBQQ].
[46]. Rick Pollack, Ensuring Access to Quality Care for Patients in Rural America, Am. Hospital Ass’n (Feb. 21, 2025, 8:30 AM), [https://perma.cc/Z4S8-DHFK].
[47]. Nowhere to Go: Maternity Care Deserts Across the U.S., March of Dimes, [https://perma.cc/294F-C8FQ].
[48]. Taylor et. al, supra note 45. (citing Andreea A. Creanga, Performance of Racial and Ethnic Minority-serving Hospitals on Delivery-related Indicators, 211 Am. J. Obstetrics & Gynecology (2014)) (“African American women are more likely to live in segregated neighborhoods and the hospitals within those communities tend to be of lower quality, especially for maternity care.”).
[49]. Rejane Frederick, The Environment That Racism Built, Ctr. for Am. Progress (May 10, 2018), [https://perma.cc/4FJ9-L8L2].
[50]. Redlining, a practice initiated in the 1930s whereby government and private lenders designated certain neighborhoods—typically those with predominantly Black and other minority populations—as “hazardous” for mortgage lending, resulted in decades of disinvestment and structural inequality. See Mapping Inequality Project, Univ. of Richmond, [https://perma.cc/ST8H-PB3C]. This systemic exclusion from resources, compounded by subsequent white flight as white residents relocated to suburban areas, led to decreased tax bases and chronic underfunding of healthcare and social services in these neighborhoods. Id. Such inequality in healthcare access and persistent socioeconomic disadvantage is recognized contributors to higher rates of severe maternal morbidity and mortality among Black and Hispanic women. Xing Gao, Rachel Morello-Frosch, Amani M. Nuru-Jeter, Jonathon M. Snowden, Suzan L. Carmichael & Mahasin S. Mujahid, Historical Redlining, Contemporary Gentrification, and Severe Maternal Morbidity in California, 2005-20018, 7 JAMA Network Open, Sep. 3, 2024, at 1, 1-2.
[51]. See generally Allana T. Forde, Danielle M. Crookes, Shakira F Suflia & Ryan T. Demmer, The Weathering Hypothesis as an Explanation for Racial Disparities in Health: A Systematic Review, 33 Annals of Epidemiology, 1, 1-18 (2019).
[52]. Kayla Yup, Black Women Excluded from Critical Studies Due to ‘Weathering’, Yale Sch. Med. (Nov. 30, 2022), [https://perma.cc/ZWG7-97NK]. The “weathering” hypothesis asserts that Black women experience accelerated physiological aging as a result of cumulative exposure to societal stressors such as racism, discrimination, and socioeconomic disadvantage. See Arline T. Geronimus, Margaret Hicken, Danya Keene & John Bound,”Weathering” and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States, 96 Am. J. Pub. Health 826, 830–31 (2006). This chronic stress burden leads to higher allostatic load, telomere shortening, and epigenetic changes, which in turn increase the risk of adverse health outcomes, including earlier onset of hypertension, cardiovascular disease, and diabetes—key contributors to increased rates of maternal morbidity and mortality in Black women. Id. Notably, these biological effects cannot be explained by socioeconomic status alone and Black women, regardless of income, bear a disproportionately higher risk. Id.
[53]. Gopal K. Singh & Hyunjung Lee, Trends and Racial/Ethnic, Socioeconomic, and Geographic Disparities in Maternal Mortality from Indirect Obstetric Causes in the United States, 1999-2017, 10 Int’l J. Maternal and Child Health and AIDS 43, 44 (2020) (“Although the leading causes of maternal deaths in the United States are hemorrhage, pregnancy-related hypertension, embolism, and obstetric infection, maternal deaths due to indirect obstetric causes, including chronic medical conditions such as cardiovascular disease (CVD), diabetes, respiratory disorders, and mental health conditions, have increased substantially in the past two decades. Globally, including the United States, 25-30% of all maternal deaths are attributed to these indirect causes.”).
[54]. See e.g., N. Tanya Nagahawatte & Robert L. Goldenberg, Poverty, Maternal Health, and Adverse Pregnancy Outcomes, 1136 Ann. N.Y. Acad. Sci. 80, 80 (2008).
[55]. Amnesty Int’l, Deadly Delivery: The Maternal Health Care Crisis in the USA One Year Update 7 (2011), [https://perma.cc/6KKZ-2KJ8]; see also Nine Committee Report, supra note 26.
[56]. Rosaly Correa-de-Araujo & Sung Sug (Sarah) Yoon, Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age, 30 J. Women’s Health 160, 164 (2021), (Advanced maternal age, typically defined as age 35 or older, is associated with elevated risks of pregnancy-related complications and maternal death. Women aged 35–39 experience more than double the risk of pregnancy-related mortality compared to women aged 25–29, while women over 40 faces about a five-fold increased risk. The maternal mortality rate increases progressively with age, with women aged 40 and above having a risk of maternal death more than seven times that of women under age 25).
[57]. Maternal obesity is a risk factor for pregnancy-related disorders, including gestational hypertension, preeclampsia, and gestational diabetes. Joana Lourenço & Luís
Guedes-Martins, Pathophysiology of Maternal Obesity and Hypertension in Pregnancy, 12
J. Cardiovascular Dev. & Disease, March 3, 2025, at 1, 2.
[58]. Amnesty Int’l, supra note 55.
[59]. For example, Black maternal mortality in Washington, DC is disproportionately high: although Black women make up about half of all births in the city, they account for 90% of pregnancy-related deaths. Crucially, these disparities persist even when Black women have access to medical care. The 2019–2020 DC Maternal Mortality Review Committee found that systemic factors—such as racism, provider bias, and failures in care coordination—undermine the quality and effectiveness of the care received. Social determinants of health, like housing instability and poverty, and inequitable treatment within the healthcare system further compound the risk, demonstrating that access alone does not guarantee equitable outcomes. D. C. Maternal Mortality Rev. Comm., 2019–2020 Annual Report 14–20 (Dec. 2021), [https://perma.cc/D7SV-KJUJ].
[60]. Ctr. For Reprod. Rights, SisterStrong & the Nat’l Latina Inst. For Reprod. Health, Reproductive Injustice: Racial and Gender Discrimination in U.S. Healthcare 12, 13 (2014) [hereinafter Ctr. For Reprod. Rights, et. al]. While the cited study does not solely focus on maternal mortality rates for Black birth parents, Mississippi has the highest percentage of Black/African American residents in the U.S., with 51.5% of residents female and nearly 80% of counties classified as rural. See Health Res. & Servs. Admin. Maternal & Child Health Bureau, III.B. Overview of the State – Mississippi – 2021, U.S. Dept. Health & Hum. Servs. (2021) [https://perma.cc/G5PZ-HR4D]. Together, this data demonstrates that the BMMD rate in Chickasaw County is significant.
[61]. The notion of developing nations is often racist. Many developing countries are more aptly called previously colonized, and their health problems are rooted in sex inequality; however, the notion stands that the United States, a country that spends billions on healthcare with well-developed medical systems, should comport to a high standard of safety. The Kenyan maternal mortality rate is 414/100,000 live births. Symposium, Maternal Mortality Causality a Kenyan Experience, 78 Linacre Quarterly 211, 213 (May 2011).
[62]. Ctr. For Reprod. Rights, et. al, supra note 60.
[63]. See Hispanic or Latino, and Not Hispanic or Latino by Race, U.S. Census Bureau, [https://perma.cc/QPR9-M587] (linking to underlying data from U.S. Census Bureau table “P2: HISPANIC OR LATINO, AND NOT HISPANIC OR LATINO BY RACE, 2020: DEC Redistricting Data (PL 94-171)”). According to 2023 data, approximately 24% of the county lives below the poverty line. Miss. State Dep’t of Emp. Sec., Percent Below Poverty by County (map), [https://perma.cc/FB7V-HYDS]. According to the 2021 Census, 59.1% of Mississippi residents identify as non-hispanic white and 37.8% as Black/ African American, together making up the population majorities. See Health Res. & Servs. Admin. Maternal & Child Health Bureau, supra note 60.
[64]. Black women at higher risk of pregnancy-related deaths, Scripps: Black Maternal Health: Why It Matters (March 24, 2025), [https://perma.cc/T7G9-5RLY].
[65]. Ctr. For Reprod. Rights, et. al, supra note 60, at 13.
[66]. Cooper et al., Delving below the surface: Understanding how race and ethnicity influence relationships in health care,21 Journal of General Internal Med., 21-27 (2006).
[67]. John E. Snyder, Rachel D. Upton & Thomas C. Hassett, Black Representation in the Primary Care Physician Workforce and Its Association With Population Life Expectancy and Mortality Rates in the US, 6 JAMA Network Open, April 14, 2023, at1 [hereinafter Snyder et al.].
[68]. Snyder et al., supra note 67.
[69]. Jacqueline Howard, Only 5.7% of US doctors are Black, and experts warn the shortage harms public health, CNN (Feb. 21, 2023), [https://perma.cc/NA9C-QR3Z].
[70]. Brian D. Smedley et al., Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare 5 (Inst. Of Med. 2003) at 1-2. This comprehensive Institute of Medicine (IOM) study represents one of the most thorough examinations of racial and ethnic disparities in U.S. healthcare, reviewing hundreds of peer-reviewed studies across multiple clinical areas and services. The committee conducted an extensive literature review—prioritizing studies that controlled for confounding factors such as insurance, socioeconomic status, and disease severity—to isolate disparities attributable directly to race and ethnicity rather than access or clinical need. The analysis spans administrative, clinical, and patient outcome data, assesses differences in both basic and high-technology services, and incorporates evidence from diverse healthcare settings (public, private, military, and VA hospitals). The findings are robust and consistent, demonstrating that racial and ethnic disparities in healthcare are pervasive, cannot be fully explained by factors like insurance or income, and are linked to worse outcomes for minority patients. This breadth and depth provide a strong evidentiary foundation for policy recommendations aimed at reducing these unacceptable disparities.
[71]. Better Data and Better Outcomes: Reducing Maternal Mortality: Hearing on H.R. 1318 Before Subcomm. On health of the comm. On Energy & Commerce, 115th Cong. 62 (2018).
[72]. Jamie Newton, The Gender Credibility Gap (That’s What She Said), TEDxMileHigh
(Oct. 1, 2019), [https://perma.cc/W463-GGTR].
[73]. See Katz Institute for Women’s Health, Gaslighting in Women’s Health: No, it’s not just in your head, Northwell Health, [https://perma.cc/2LL9-NLWJ] (“women’s health issues are likely to be misdiagnosed or dismissed by doctors as something less critical”); see also Esther H. Chen, Frances S. Shofer, Anthony J. Dean, Judd E. Hollander, William G. Baxt, Jennifer L. Robey, Keara L. Sease & Angela M. Mills, Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain, 15 Acad. Emergency Med. 414, 416 (2008) (finding a gender disparity in the administration of adequate pain relief for acute abdominal pain relief).
[74]. Darcy Banco, Jerway Chang, Nina Talmor, Priya Wadhera, Amrita Mukhopadhyay, Xinlin Lu, Siyuan Dong, Yukun Lu, Rebecca A. Betensky, Saul Blecker, Basmah Safdar & Harmony R. Reynolds, Sex and Race Differences in the Evaluation and Treatment of Young
Adults Presenting to the Emergency Department With Chest Pain, 11 J. Am. Heart Ass’n, May 4, 2022, at 1, 7.
[75]. Although the credibility gap has not been specifically studied in Black pregnant women, Black patients are believed less than white patients. See Jamie Smith, Physicians More Likely to Doubt Black Patients, Johns Hopkins Med.: News & Publs. (June 5, 2021), [https://perma.cc/UC9V-UXLX].
[76]. Atsushi Miyawaki, Anupam B. Jena, Lisa S. Rotenstein & Yusuke Tsugawa, Comparison of Hospital Mortality and Readmission Rates by Physician and Patient Sex, 177 Ann. Intern. Med. 598, 603 (2024) [hereinafter Miyawaki et. al].
[77]. Id. Another study found that women operated on by male surgeons had a higher chance of death following the operation. Christopher J. D. Wallis, Angela Jerath, Natalie Coburn, Zachary Klaassen, Amy N. Luckenbaugh, Diana E. Magee, Amanda E. Hird, Kathleen Armstrong, Bheeshma Ravi, Nestor F. Esnaola, Jonathan C. A. Guzman, Barbara Bass, Allan S. Detsky & Raj Satkunasivam, Surgeon-Patient Sex Concordance With Postoperative Outcomes, 157 JAMA Surg. 146, 146 (2022) [hereinafter Wallis et. al].
[78]. Tara Parker-Pope, Should You Choose a Female Doctor?, N.Y. Times (Aug. 14, 2018) [https://perma.cc/YD7K-U2N7].
[79]. Miyawaki et al., supra note 76, at 598.
[80]. See Howard, supra note 69.
[81]. Lala Toma Das, We need more transgender and non-binary doctors, AAMC (Sept. 1, 2020) [https://perma.cc/Q6LN-RWUV].
[82]. Kathy Katella, What does medical care look like when you’re transgender?, Medical Xpress (Mar. 15, 2022) [https://perma.cc/RED3-7N26].
[83]. History of Women’s Participation in Clinical Research, Nat’l Institute of Health Off. Of Research on Women’s Health, [https://perma.cc/MM28-JG3X] (last updated April 24, 2024).
[84]. Eli Y. Adashi, Daniel P. O’Mahony & I. Glenn Cohen, The White House Initiative on Women’s Health Research: A Presidential Boost, 33 J. Women’s Health 1151, 1151–52 (2024).
[85]. Bridget Balch, Why we know so little about women’s health, AAMC (March 26, 2024), [https://perma.cc/27DT-E5CW].
[86]. British Heart Found. Press Off., Women are 50% more likely than men to be given an incorrect diagnosis following a heart attack, British Heart Found. (Aug. 30, 2016), [https://perma.cc/YYV9-FWJU]
[87]. Am. Heart Ass’n News, Changing the way we view women’s heart attack symptoms, Am. Heart Ass’n (December 2024), [https://perma.cc/72AV-ZVEL].
[88]. Kate Whiting, Why the women’s health gap exists – and how to close it – according to experts at Davos, World Econ. F. (Jan. 31, 2024), [https://perma.cc/NW5F-HM35] (reports that McKinsey Health Institute found less than 2% of healthcare research and innovation funding is invested in female-specific conditions beyond cancer, highlighting major underinvestment despite women comprising half the global population.); see also Kweilin Ellingrud, Lucy Pérez, Anouk Petersen & Valentina Sartori, Closing the women’s health gap: a $1 trillion opportunity to improve lives and economies, McKinsey Health Inst. (Jan. 17, 2024) (estimating that, if the 25 percent more time that women spend in “poor health” relative to men was addressed, it would improve the health and lives of millions of women and could boost the global economy by at least $1 trillion annually by 2040) .
[89]. Isabella Backman, Endometriosis, Yale Sch. Med. (March 20, 2024), [https://perma.cc/593W-YMVM].
[90]. Higgs LLP, Misdiagnosis: The Overlooked Crisis In Women’s Health (July 16, 2024) [https://perma.cc/B9RS-CPGL] (finding that misdiagnosis disproportionately affects women, especially regarding gynecological, neurological, and hormonal conditions. The article documents delays in diagnosis, medical gaslighting, overprescription of painkillers and antidepressants, and lack of research funding for women’s health).
[91]. The United States does, in fact, spend a lot of money on healthcare and prenatal care; however, research to understand disorders affecting women are still underfunded and misunderstood. Hence why it is a “shockingly poor return on investment.” Bingham et al., supra note 31. We are paying more for lower quality care.
[92]. Ctr. For Reprod. Rights, et. al, supra note 60.
[93]. Id. at 15, 16–17.
[94]. Id. at 17, 19.
[95]. Id. at 17.
[96]. Id. at 19–21.
[97]. Id. at 21–22.
[98]. Id. at 22.
[99]. See e.g., Amelia Dmowska, Priya Fielding-Singh, Jodi Halpern & Ndola Prata, The Intersection of Traumatic Childbirth and Obstetric Racism: A Qualitative Study, 51 Birth 209, (2023) (Black American women in the study described experiencing traumatic childbirth shaped by obstetric racism, where healthcare providers treated them based on harmful racial and gender stereotypes. Providers often assumed they were uneducated, dismissed their pain due to false beliefs about high pain tolerance, questioned their ability or willingness to care for their babies, and labelled them as dramatic when they voiced concerns. These behaviors made Black mothers feel ignored, dehumanized, and unsafe, leading to lasting effects such as anxiety, depression, medical mistrust, and hesitation to pursue future pregnancies).
[100]. Emily Dwass, Serena Williams Saved Her Own Life—But Too Many Women’s Voices Are Not Heard in Medical Crises, Especially Women of Color, MedPage Today (Aug. 12, 2022) [https://perma.cc/B7FK-34K4] (describing how Serena Williams, after an emergency C-section, identified her own life-threatening pulmonary embolism and repeatedly advocated for appropriate treatment despite initially being dismissed by medical staff; her persistence led to life-saving intervention and highlights the dangers women face when their symptoms and concerns are not taken seriously).
[101]. Id. (“The day after giving birth to her daughter, Williams was short of breath. Having experienced blood clots in the past, she had no doubt that she was struggling with a life-threatening pulmonary embolism. The trouble was no one believed her…,” “When her entreaties were finally taken seriously, the imaging revealed deadly blood clots in her lungs, which required life-saving surgery and 6 weeks of bed rest.”).
[102]. Howard, supra note 69.
[103]. See Four in 5 pregnancy-related deaths in the U.S. are preventable, CDC, [https://perma.cc/VUR4-PT3L] (“Cardiac and coronary conditions were the leading underlying cause of pregnancy-related deaths among non-Hispanic Black persons; mental health conditions were the leading underlying cause of death among Hispanic and non-Hispanic White persons; and hemorrhage was the leading underlying cause of death among non-Hispanic Asian persons. The leading causes of pregnancy-related death among non-Hispanic American Indian or Alaska Native and non-Hispanic Native Hawaiian and other Pacific Islander (NHOPI) persons were not ranked because of small population size.”).
[104]. Black Women Over Three Times More Likely to Die in Pregnancy, Postpartum Than White Women, New Research Finds, Population Reference Bureau, (Dec. 6, 2021) [https://perma.cc/GG5B-UE3Z].
[105]. See Trost, et al., supra note 21.
[106]. Id.
[107]. Preeclampsia is a medical condition, usually appearing in the third trimester, that is characterized by hypertension and swelling. It can lead to eclampsia, which causes seizures and, possibly, brain injury and death.
Preeclampsia, WebMD (last updated July 19, 2025) [https://perma.cc/WF43-MTC3].
[108]. WHO recommendations for prevention and treatment of preeclampsia and eclampsia, World Health Organization (WHO), (last updated Oct. 2019) [https://perma.cc/49QH-R268].
[109]. Nine Committee Report, supra note 26, at 6.
[110]. Id. at 26.
[111]. See infra section III.
[112]. See, e.g., K.S. Joseph, Amélie Boutin, Maternal mortality in the United States: recent trends, current status, and future considerations, 137 Obstetrics & Gynecology 763, 766 (2021).
[113]. What We Do, California Maternal Quality Care Collaborative, [https://perma.cc/EZT2-2LUY].
[114]. CMCQ identifies hemorrhage as preventable; however, “20% of postpartum hemorrhage occurs in women with no risk factors,” making it difficult to anticipate. Ann Evensen, Janice M. Anderson & Patricia Fontaine, Postpartum Hemorrhage: Prevention and Treatment, 95 Am. Fam. Physician 442, 442–49 (2017).
[115]. See Preeclampsia, supra note 107.
[116]. Can Women Reduce Their Risk For Preeclampsia?, Lompoc Valley Medical Ctr. (Aug. 2, 2022) [https://perma.cc/KVP8-4THV].
[117]. The California Maternal Quality Care Collaboration (CMQCC) identified preeclampsia as the leading cause of preventable death for Black pregnant people in the state.
See infra section III.
[118]. Nine Committee Report, supra note 26, at 28.
[119]. See also Heike Roth, Grace LeMarquand, Amanda Henry & Caroline Homer, Assessing Knowledge Gaps of Women and Healthcare Providers Concerning Cardiovascular Risk After Hypertensive Disorders of Pregnancy—A Scoping Review, 6 Front. Cardiovasc. Med. 178, (2019) at 4-5 (finding that, although obstetricians had a higher level of knowledge compared to other types of doctors, knowledge among most U.S. doctors, especially internists and family physicians, showed persistent knowledge gaps and many doctors routinely fail to ask patients about history relating to preeclampsia).
[120]. Id. The Nine Committees identified 193 recommendations for 58 pregnancy-related deaths. These recommendations were boiled down into recurring themes, such as improving training, enforcing policies and procedures, improving access to
care, improving patient-provider communication, and improving standards regarding diagnosis. None of the recommended actions took race into account.
[121]. Professional standards and regulatory expectations in the U.S. require physicians, including OBGYNs, to uphold patient safety by staying current on preventable causes of morbidity and mortality—such as preeclampsia. Licensure, board certification, and the influence of medical societies obligate clinicians to demonstrate ongoing competence, knowledge of safety practices, and attention to preventable harm.
This duty is reinforced through education, continuing assessment, adoption of evidence-based guidelines, and participation in systems that promote error reduction. Failure to recognize and address preventable conditions can lead to avoidable patient harm, underscoring why comprehensive knowledge and adherence to safety protocols is considered an ethical and professional obligation for all clinicians. See Institute of Medicine, To Err Is Human: Building a Safer Health System (Linda T. Kohn, Janet M. Corrigan & Molla S. Donaldson eds., Nat’l Acad. Press 2000); see also, Institute of Medicine, Clinical Practice Guidelines: Directions for a New Program (Marilyn J. Field & Kathleen N. Lohr eds., Nat’l Acad. Press 1990).
[122]. Abdullah Alkehizan & Charles Shaw, Impact of Accreditation on the Quality of Healthcare Services: A Systemic Review of the Literature, 31 Ann. Saudi Med. 407, 407 (2011).
[123]. Treatment Pre-eclampsia, Nat’l Health Service, [https://perma.cc/6R7T-JFXA].
[124]. Id.
[125]. See, e.g., Davidson et al., Aspirin used to prevent preeclampsia and related morbidity and mortality, 326 JAMA 1 (2021).
[126]. Id.
[127]. Leandro De Oliveira, Henri Korkes, Marina de Rizzo, Monica Maria Siaulys & Eduardo Cordioli, Magnesium Sulfate in Preeclampsia: Broad Indications, Not Only in Neurological Symptoms, 36 Pregnancy Hypertension 101126 (2024), https://doi.org/10.1016/j.preghy.2024.101126 (discussing that magnesium sulfates should be given for all women with preeclampsia with severe features).
[128]. See, e.g., Alice Hurrell, Paula Busuulwa, Louise Webster, Kate Duhig, Paul T. Seed, Lucy C. Chappell & Andrew H. Shennan, Optimising Timing of Steroid Administration in Preterm Pre-eclampsia, 37 Pregnancy Hypertens. 101314 (2022) (discussing how antenatal corticosteroids are an established intervention to improve fetal outcomes in preterm birth, especially when preterm birth is caused by pre-eclampsia).
[129]. “Whether by Caesarian delivery or induced natural birth.” Amanishakete Ani, C-Section and Racism: “Cutting” to the Heart of the Issue for Black Women and Families, 19 J. Afr. Am. Stud. 343, 343-61 (2015) (“[Women] of African descent currently hold the highest
C-section rate in the USA at nearly 36 % … even among low-risk pregnancies.”).
[130]. The average timing of pregnancy awareness is 5.5 weeks. See Katie Watson & Cara Angelotta, The Frequency of Pregnancy Recognition Across the Gestational Spectrum and Its Consequences in the United States, 54 Persp. Sex & Reprod. Health 32, 33 (2022).
[131]. Fifteen percent of pregnant women receive inadequate prenatal care, and six percent receive late or no prenatal care. Kimberly Fryer, Chinyere N. Reid, Naciely Cabral, Jennifer Marshall & Usha Menon, Exploring Patients’ Needs and Desires for Quality Prenatal Care in Florida, United States, 12 Int’l J. Maternal & Child Health & AIDS, [https://perma.cc/G9MZ-U55W].
[132]. See Adequate Prenatal Care in the United States, United Health Found, [https://perma.cc/RY62-35SX].
[133]. See National Academies of Science, Engineering, and Medicine, Birth Settings in America: Outcomes, Quality, Access, and Choice (2020), [https://perma.cc/W2ZZ-EXUH].
[134]. Preeclampsia: Diagnosis & Treatment, Mayo Clinic, Mayo Clinic [https://perma.cc/N5PQ-CG9L].
[135]. Id.
[136]. Id.
[137]. Id.
[138]. See Alison Young, Hospitals know how to protect mothers. They just aren’t doing it., USA Today (July 26, 2018), [https://perma.cc/LKF3-9833].
[139]. Hospital Guidelines and the Preeclampsia Patient’s Bill of Rights, Preeclampsia Found. (January 14, 2022), [https://perma.cc/TP53-4E77].
[140]. Barton & Sibai, Prediction and prevention of recurrent preeclampsia 112 Obstetrics & Gynecology 359, at 366 (2008).
[141]. Nine Committee Report, supra note 26 (For instance, “on average, four contributing factors were identified for each pregnancy-related death.”).
[142]. Evan D. Gumas & Munira Z. Gunja, Maternal and Child Mortality: How Do U.S. States Compare Internationally?, Commonwealth Fund (Oct. 1, 2025), [https://perma.cc/E38P-CAAS].
[143]. Pregnancy-Related Mortality – 2019–2021, California Dep’t Pub. Health (Jan. 2025), [https://perma.cc/M2A4-59B3] (reporting that California’s pregnancy-related mortality rate increased during the COVID-19 pandemic).
[144]. See Gumas & Gunja, supra note 142 (“Despite declines in 2023, the overall U.S. maternal mortality rate (18.6 deaths per 100,000 live births) is higher than rates in the majority of all high-income countries. Mothers in Louisiana had the highest state rate of death in 2023 (41.9)”).
[145]. Louisiana Department of Health, Office of Public Health, Bureau of Family Health, Louisiana Maternal Mortality Review Report 2011–2016, at 21–22 (Aug. 2018), [https://perma.cc/ZY6Z-9ZUT] (reporting that only 24% of pregnancy-related maternal deaths in Louisiana from 2011–2016 were among non-Hispanic white women, who had a pregnancy-related maternal mortality ratio of 5.6 deaths per 100,000 live births—compared to 68% of deaths and a ratio of 22.8 per 100,000 among Black women; noting white women had the lowest risk of any major demographic group).
[146]. Eugene Declercq & Laurie C. Zephyrin, Maternal Mortality in the United States, 2025, Commonwealth Fund. (July 29, 2025), [https://doi.org/10.26099/kdfd-fc19].
[147]. Id.
[148]. Id.
[149]. Id. Infant mortality rates vary widely across the U.S., with the worst-performing state, Mississippi, having more than double the rate of the 11 top-performing states. As is the case with pregnancy-related mortality, southern states generally had the highest infant death rates. States with low mortality rates like California, Minnesota, and Washington fare better on both outcomes. According to the Commonwealth Fund, “[t]he strong positive statistical correlation (r =+.61; a perfect relationship would be 1.00) serves as a familiar reminder that maternal health and infant health cannot be separated.” Id.
[150]. See What We Do, supra note 113.
[151]. 42 U.S.C. § 18116 (2010).
[152]. Anna Kirkland, Health Care Civil Rights: How Discrimination Law Fails Patients (Univ. of Cal. Press 2025) [hereinafter Health Care Civil Rights].
[153]. 45 C.F.R. § 92 (2024), [ https://perma.cc/89XU-34S4].
[154]. Health Care Civil Rights, supra note 152, at 2.
[155]. Notably, 1557’s reference to Title IX brought in the first protection against sex discrimination in healthcare.
[156]. Section 1557: Frequently Asked Questions, U.S. Dep’t of Health & Human Servs., [https://perma.cc/3JXY-BMZX] (explaining nondiscrimination requirements under the Affordable Care Act).
[157]. See, e.g., Lucas v. VHC Health, 128 F.4th 213 (4th Cir. 2024) (holding that claims under Section 1557 require proof of intentional discrimination; disability discrimination claims failed absent evidence of exclusion or denial “solely by reason of” disability, adopting Rehabilitation Act standards); Francois v. Our Lady of the Lake Hosp., Inc., 8 F.4th 370 (5th Cir. 2021) (finding that plaintiff’s failure to show the hospital’s actual knowledge of need for an interpreter resulted in failure to prove intentional discrimination, underscoring the intent requirement under the Rehabilitation Act for Section 1557 claims); Callum v. CVS Health Corp., 137 F. Supp. 3d 817 (D.S.C. 2015) (finding plausible Section 1557 discrimination claims where plaintiff alleged denial of benefits based on protected traits, but emphasizing that evidentiary standards of the incorporated statutes must be met); Doe v. CVS Pharm., Inc., 982 F.3d 1204 (9th Cir. 2020) (rejecting argument that Section 1557 plaintiffs can apply the least stringent evidentiary standard and holding that evidentiary requirements of the specific civil rights statute control); Basta v. Novant Health Inc., 56 F.4th 307 (4th Cir. 2022) (dismissing claim for compensatory damages where plaintiff failed to allege facts of intentional discrimination and reaffirming application of deliberate indifference standard from the Rehabilitation Act).
[158]. Health Care Civil Rights, supra note 152 at 5.
[159]. The causation requirement under Section 1557 reflects general tort law principles, particularly the “but-for” causation standard. In Bostock v. Clayton County, 590 U.S. 644, 662–63 (2020), the Supreme Court clarified that “but-for” causation means that the adverse action would not have occurred in the absence of the prohibited factor. Courts have applied this reasoning to Section 1557 claims, particularly in the context of sex discrimination, as incorporated from Title IX. See PFLAG, Inc. v. Trump, 766 F. Supp. 3d 535 (D. Md. 2023); PFLAG, Inc. v. Trump, 769 F. Supp. 3d 405 (D. Md. 2024).
[160]. Briscoe v. Health Care Serv. Corp., 281 F. Supp. 3d 725, 738 (“If Congress intended for a single standard to apply to all § 1557 discrimination claims, repeating the references to the civil-rights statutes and expressly incorporating their distinct enforcement mechanisms would have been a pointless (and confusing) exercise.”).
[161]. See e.g.,; T.S. v. Heart of Cardon, LLC, 43 F.4th 737.
[162]. Id. at 5.
[163]. Dobbs v. Jackson Women’s Health Org., 597 U.S. 215 (2022).
[164]. Roe v. Wade, 410 U.S. 113 (1973).
[165]. Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833 (1992).
[166]. Health Care Civil Rights, supra note 152, at 4.
[167]. Id.
[168]. Texas v. Becerra, 89 F.4th 529 (5th Cir. 2023).
[169]. See, e.g., 45 C.F.R. § 92.206; Texas v. Becerra, 89 F.4th 529 (5th Cir. 2023); Lukaszczyk v. Cook County, 47 F.4th 587 (7th Cir. 2022).
[170]. As an agency under the Executive Branch, it enforces laws passed by Congress, including the ACA and Section 1557.
[171]. HHS Applies Discrimination Prohibitions to Use of Automated and Non-Automated Patient Care Decision Support Tools, Crowell & Moring LLP (May 8, 2024), [https://perma.cc/YWX8-LMPW] (summarizing a Biden-era HHS final rule implementing ACA § 1557 that prohibits covered entities from using clinical decision support tools—including algorithms—in ways that discriminate on the basis of race or other protected categories, and requiring steps to mitigate racial bias in patient care); see also Katie Adams, Navigating AI in Health Care, Bipartisan Policy Ctr., (July 19, 2024), [https://perma.cc/UBK6-P9GP].
[172]. U.S. Dep’t of Just., U.S. Dep’t of Health & Hum. Servs. & Ala. Dep’t of Pub. Health, Interim Resolution Agreement, DOJ No. 171-3-14, HHS Off. for Civ. Rts. Transaction No. 22-451932 (May 3, 2023)
[173]. See, e.g., U.S. Dep’t of Health & Hum. Servs., Staffing Shortages Limited IHS’s Capacity to Effectively Administer Much-Needed Sanitation Projects Funded by the Infrastructure Investment and Jobs Act (2024), [https://perma.cc/CGL5-QL84].
[174]. In 2025, the Trump Administration released an Executive Order announcing its intention to “eliminate the use of disparate-impact liability in all contexts to the maximum degree possible to avoid violating the Constitution, Federal civil rights laws, and basic American ideals.” Exec. Order No. 14,281, 90 Fed. Reg. 17,537 (April 23, 2025), [https://perma.cc/8BAL-ES7P].
[175]. The 25% of hospitals that provide substandard care are a potential target for Section 1557 and Title VI enforcement, namely against discrimination based on race. This avenue does not require an individual claimant but instead a showing of disparate outcomes.
[176]. In St. Luke’s Health Sys., Ltd. v. Labrador, No. 1:23-cv-00333-BLW, 2025 U.S. Dist. LEXIS 52979, at *67–71 (D. Idaho 2025), the court explained that Congress may regulate hospitals already engaged in the provision of healthcare—an active form of commerce—distinguishing this from the situation in NFIB. Likewise, courts have long recognized that Congress may use its Commerce Clause power to regulate conduct that substantially affects the interstate market for healthcare services, as seen in Freilich v. Bd. of Dirs. of Upper Chesapeake Health, Inc., 142 F. Supp. 2d 679, 684 (D. Md. 2001) (upholding the Freedom of Access to Clinic Entrances Act), and Cheffer v. Reno, 55 F.3d 1517, 1520 (11th Cir. 1995) (regulating private conduct that has a substantial effect on interstate commerce).
[177]. The federal government’s “power of the purse” under the Spending Clause enables Congress to attach unambiguous conditions to federal funding, ensuring that recipients—such as healthcare providers—clearly understand and agree to comply with anti-discrimination laws as a prerequisite for receiving funds; violation of such conditions may subject recipients to remedial actions, as the Supreme Court and Eleventh Circuit have held. See Cummings v. Premier Rehab Keller, P.L.L.C., 596 U.S. 212, 223–24 (2022) (requiring clear notice of funding conditions); United States v. Sec’y Fla. Agency for Health Care Admin., 21 F.4th 730, 752–53 (11th Cir. 2021) (treating conditions on federal funds as enforceable, contract-like obligations)
[178]. Still, Medicaid pays for 40% of births in the United States. Priority Policies: Medicaid, Am. Coll. Obstetricians & Gynecologists, [https://perma.cc/2FWE-JHRG].
[179]. See, e.g., Oklahoma v. Schweiker, 655 F.2d 401, 414 (D.C. Cir. 1981).
[180]. In National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012), the Supreme Court examined the individual mandate of the Affordable Care Act (ACA), ultimately holding that Congress could not use the Commerce Clause to regulate inactivity or compel individuals to purchase health insurance. Though Congress could not justify the mandate under the Commerce Clause, the Court upheld it as a valid exercise of Congress’s taxing power. The Court also addressed the ACA’s Medicaid expansion, finding it unconstitutionally coercive to threaten existing Medicaid funds as a penalty for state noncompliance.
[181]. Health Care Civil Rights, supra note 152, at 8.
[182]. Under statutes such as 42 U.S.C. § 290ii (resident rights and restraint protections) and 42 U.S.C. § 254h (admitting privileges).
[183]. Simkins v. Moses H. Cone Mem’l Hosp., 323 F.2d 959 (4th Cir. 1963).
[184]. Id.
[185]. Burton v. Wilmington Parking Auth., 365 U.S. 715 (1961).
[186]. See also Smith v. Hampton Training Sch. for Nurses, 360 F.2d 577 (4th Cir. 1966), and Ascherman v. Presbyterian Hosp. of Pac. Med. Ctr., Inc., 507 F.2d 1103, 1106 (9th Cir. 1974).
[187]. Northport Health Servs. of Ark. v. U.S. Dep’t of Health & Hum. Servs., 438 F. Supp. 3d 956 (W.D. Ark. 2020); Beverly Cal. Corp. v. Shalala, 78 F.3d 403, 406 ( 8th Cir. 1996).
[188]. The Supreme Court also ruled that requiring states to expand Medicaid or face denial of federal funds is “too coercive,” so the threat of withdrawing all funding may
also be off the table. Id.(quoting National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012)).
[189]. Cal. Dep’t of Pub. Health, Maternal, Child & Adolescent Health Div., CA-PMSS Surveillance Report: Pregnancy-Related Deaths in California, 2008–2016 Frequently Asked Questions (2021) [https://perma.cc/CBE3-AN8C].
[190]. Id. While both the National Vital Statistics System (NVSS) and the Pregnancy Mortality Surveillance System (PMSS) provide valuable information about national trends and characteristics of maternal deaths, their reliance primarily on death records and linked vital statistics limits them to identifying patterns and assigning standardized causes of death. As such, these systems are unable to deeply explore the underlying reasons behind maternal mortality. In contrast, Maternal Mortality Review Committees (MMRCs) incorporate a wide range of data sources, including medical records, social service records, autopsy findings, and informant interviews, enabling them to analyze specific contributing factors, assess preventability, and make tailored recommendations for prevention.
[191]. Nine Committee Report, supra note 26, at 9 [https://perma.cc/3U5X-HJ9V]; Maternal Mortality Prevention, Enhancing Reviews and Surveillance to Eliminate Maternal Mortality, CDC (Aug. 7, 2024), [https://perma.cc/2R63-TXV8].
[192]. Creanga, Maternal Mortality, supra note 34, at 297.
[193]. Maternal Mortality Prevention, About Maternal Mortality Review Committees, CDC (May 15, 2024), [https://perma.cc/3KXS-YT7N].
[194]. Maternal & Infant Health Bureau, Miss. State Dep’t of Health, Mississippi Maternal Mortality Report 2016–2020 26 (2023), [https://perma.cc/HP8R-DFJ5] (“Medicaid expansion should be incorporated for rural hospitals to remain open and include access to telehealth services. There is a need for rural healthcare facilities to provide higher levels of critical care, recruit and retain adequate providers, and have access to life saving equipment, especially in the most vulnerable areas of the state.”).
[195]. Ozimek & Kilpatrick, supra note 30, at 181. Notably, the United Kingdom also faces many of the same problems as the United States does, such as relatively high levels of pre-existing conditions that increase the risk of pregnancy.
[196]. Nina Martin, “Landmark” Maternal Health Legislation Clear Major Hurdle, ProPublica (Dec. 12, 2018), [https://perma.cc/9LLH-UV5L].
[197]. 42 U.S.C. § 247b-12.
[198]. H.R. 3838, 118th Cong. (2023).
[199]. 42 U.S.C. § 247b-12.
[200]. 42 U.S.C § 254c-21.
[201]. Id. (a)(1)(A)-(C) , (c)
[202]. Id. at (d)
[203]. S. 380, 119th Cong. (2025). The Rural Obstetrics Readiness Act bill aimed at improving emergency obstetric care—particularly in rural areas. Id.§ 2. Its provisions would strengthen the federal maternal health law at 42 U.S.C § 254c-21 by requiring the development and facilitation of training for practitioners at rural health facilities lacking dedicated obstetric units. Id. This would include training for providers to handle emergencies, such as hemorrhage, hypertension, sepsis, mental health crises, and more, as well as protocols for urgent transfers to other facilities. Id. The bill also proposes new grant programs and support for equipment, workforce development, teleconsultation pilots, and a national study on maternity ward closures in rural regions. Id. § 3.
[204]. Safety bundles are evidence-based sets of care protocols designed to standardize maternal health care and reduce preventable deaths during pregnancy, childbirth, and the postpartum period. By providing clear, step-by-step practices for recognizing and managing severe conditions such as postpartum hemorrhage and preeclampsia, safety bundles reduce missed or delayed diagnoses and ensure that all patients receive timely, effective treatment regardless of provider or hospital. Importantly, these bundles help mitigate disparities caused by provider variation and implicit bias, which have contributed to strikingly higher maternal mortality rates among Black, American Indian, and Alaska Native women. Research has demonstrated that the implementation of safety bundles can lead to significant reductions in severe complications, with one large California study showing a 21% decrease in severe postpartum hemorrhage among participating hospitals. The evidence also indicates that safety bundles may help address racial disparities, with a 9% reduction in hemorrhage complications for Black women compared to 2% for white women after bundle adoption. As a result, national accreditation bodies now include perinatal safety bundles as certification standards, promoting their use as a powerful strategy to reduce maternal mortality and advance health equity in the United States (Williamson; Main et al.; Kuklina et al.). See Laura Williamson, ‘Safety bundles’ may reduce pregnancy-related deaths, particularly among Black women, Am. Heart Ass’n: News (Apr. 11, 2024), [https://perma.cc/RB8V-5LMR]; Elliott K. Main, Valerie Cape, Anisha Abreo, Julie Vasher, Amanda Woods, Andrew Carpenter & Jaffrey B. Gould, Reduction of Severe Maternal Morbidity From Hemorrhage Using a Statewide Perinatal Quality Collaborative, 216 Am. J. Obstetrics & Gynecology 298.e1, 298.e11 (2017); See also Elena V. Kuklina et al., Reducing Maternal Morbidity and Mortality: Data-Driven Quality Initiatives, 222 Am. J. Obstetrics & Gynecology 575, 575-576 (2020).
[205]. Enabled by the widespread use of electronic health records (EHRs), hospitals are increasingly adopting EHR-based decision support tools, including embedded order sets to assist doctors with treatment decision-making. By analyzing the hospital version of the National Survey of Healthcare Organizations and Systems, researchers found that hospital adoption of electronic tools to manage preeclampsia is effective. See, e.g., Linh N. Bui, Cassondra Marshall, Chris Miller-Rosales, Hector P. Rodriguez, Hospital A doption of Electronic Decision Support Tools for Preeclampsia Management, 31 Quality Mgmt. in
Health Care 59; see also Kavita Shah Arora, Larry E. Shields, William A. Grobman, Mary E. D’Alton, Justin R. Lappen & Brian M. Mercer, Triggers, Bundles, Protocols, and Checklists—What Every Maternal Care Provider Needs to Know, 214 Am. J. Obstetrics & Gynecology 444 (2016).
[206]. Medical professionals recommend simulation-based team training in obstetric emergencies because it helps improve team performance and may contribute to specific maternal and perinatal outcomes, by enabling multidisciplinary teams to practice managing high-risk scenarios and anticipate errors before patient harm can occur. Evidence from randomized trials demonstrates that such training likely enhances behavioral skills like communication and decision-making under pressure, and may reduce rates of cesarean delivery and trauma from shoulder dystocia, with some evidence suggesting possible reductions in neonatal mortality. However, high-certainty evidence for broad improvements in patient outcomes remains limited, and effect sizes vary by outcome and context, so ongoing research is needed to determine optimal training approaches and establish definitive patient benefits. See, e.g., Annemarie F. Fransen, Joost van de Ven, Franyke R. Banga, Ben Willem J. Mol, S. Guid Oei , Multi-Professional Simulation-Based Team Training in Obstetric Emergencies for Improving Patient Outcomes and Trainees’ Performance, Cochrane Database of Systematic Revs., Dec. 2020, at 1.
[207]. See, e.g., Olufisayo Olakotan, Jennifer N. W. Lim & Thillagavathie Pillay, Challenges and Opportunities in Perinatal Public Health: The Utility of Perinatal Health Inequality Dashboards in Addressing Disparities in Maternal and Neonatal Outcomes, BMC Pregnancy & Childbirth (Dec. 2024). The disparity dashboards, which may also be required by new Joint Accreditation standards (described infra note 280) could be monitored by the 1557 Coordinator. This person could act as a risk mitigator to note and recommend action when disparities arise.
[208]. Since its founding in 2006, the California maternal mortality rate has declined by
sixty-five percent. See What We Do, supra note 113.
[209]. Michael Ollove, A shocking number of U.S. women still die of childbirth. California is doing something about that., Washington Post (Nov. 4, 2018), [https://perma.cc/7Y52-GHT3].
[210]. Cal. Maternal Quality Care Collaborative, [https://perma.cc/NTK7-425B] (providing its mission on the main home page). Since 2006, California’s maternal mortality rates have fallen while the national average has generally continued to rise. See Cal. Dep’t of Pub. Health, Pregnancy-Related Mortality 2019–2021, CA-PMSS (2025), [https://perma.cc/M2A4-59B3].
[211]. California explicitly addresses racism as a root cause of maternal mortality disparities through both policy and targeted funding. The “Centering Black Mothers in California” initiative, coordinated by the California Department of Public Health’s Maternal, Child and Adolescent Health Division (MCAH), highlights the impact of structural racism and discriminatory policies on maternal health and is informed by Black community leaders. The state backs its commitment with funding for programs such as the Birthing Care Pathway, launched by the California Department of Health and Human Services to reduce maternal mortality disparities—especially the Black Maternal Mortality Disparity—across racial and ethnic groups. Additionally, Strong Start & Beyond, developed by the Office of the California Surgeon General, sets out to reduce the state’s maternal mortality rate by 50% by December 2026, focusing on the 80% of pregnancy-related deaths that are preventable. The 2024 California Maternal Health Blueprint further outlines goals for advancing maternal health equity beyond compliance.
See Centering Black Mothers, California Department of Public Health, [https://perma.cc/G2DS-ES94]; Strong Start & Beyond, Off. Cal. Surgeon Gen., [http://perma.cc/AHP6-LCX8]; See also Zinzi D. Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos & Mary T. Bassett, Structural R acism and Health Inequities in the USA: E vidence and Interventions, 389 Lancet 1453 (2017).
[212]. See What We Do, supra note 113.
[213]. Id.
[214]. Id.
[215]. For example, the Improving Health Care Response to Hypertensive Disorders of Pregnancy (HDP) toolkit was developed to support timely recognition and response to maternal hypertension and preeclampsia, and an updated version was published in November 2021. The updates included updated terminology, diagnostic criteria, and management guidelines that align with the American College of Obstetrics and Gynecology (ACOG) recommendations. The HDP toolkit includes best practice guidelines, including accurate blood pressure measurement, a Preeclampsia Early Recognition Tool (PERT), and nursing assessment protocols. Doctors and nurses can use these tools; however, usage of the tool must be standardized, implemented, and monitored by hospital administrators. It takes leadership to make these changes. As many as 200 hospitals in California use the tool, and some states have followed suit.
[216]. Hypertensive Disorders of Pregnancy, Cal. Maternal Quality Care Collaborative, [https://perma.cc/SXG8-XG3W] (accessed December 18, 2024). The toolkit creation was funded by the California Department of Health and supported by Title V funds.
[217]. Researchers have noted that there is no standardized national procedure for recognizing preeclampsia, so they put the HDP to the test in a New York clinic. Positive screens increased by 16% in only a few weeks, which strongly suggests that it is a valid intervention tool. Omowumi Susan Awe-Odigie, Preeclampsia Risk Factors Screening and Early Detection Using CMQCC Toolkit (Apr. 5, 2023) (D.N.P. project, Grand Canyon Univ.) (ProQuest No. 30631417).
[218]. Jennifer Serratos, Preeclampsia: Understanding and implementing the California maternal quality care collaborative toolkit (May 2015) (M.S.N. project, California State University, Stanislaus) [https://perma.cc/Q37X-TUSM].
[219]. See What We Do, supra note 113.
[220]. About Us, Joint Commission, [https://perma.cc/FV9Q-AMSX].
[221]. See e.g., Ashiha K. Jha, Accreditation, Quality, and Making Hospitals Better, 320 JAMA Forum 2410, (December 18, 2018).
[222]. “Accreditation formally started in the United States with the formation of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1951.” Alkehizan & Shaw, supra note 122. Although the terms accreditation and certification are often used interchangeably, accreditation usually applies only to organizations, while certification may apply to individuals and organizations. Id. at 407–408.
[223]. Id. at 407.
[224]. Our Partnerships, Joint Commission, https://www.jointcommission.org/en-us/about-us/our-partnerships [https://perma.cc/WGY3-KWZT].
[225]. R3 Report Issue 36: New Requirements to Reduce Health Care Disparities, Joint Commission 1 (June 20, 2022), [https://perma.cc/6T6A-2R74].
[226]. Id. at 8.
[227]. Id. at 2.
[228]. Id. at 3.
[229]. Id. at 1.
[230]. R3 Report Issue 41: New and Revised Requirements for Infection Prevention and Control for Critical Access Hospitals and Hospitals, Joint Commission (Dec. 20, 2023), [https://perma.cc/JVM2-9CFX].
[231]. The Gold Seal of Approval® is an internationally recognized symbol awarded by
The Joint Commission, a leading healthcare accrediting body in the United States.
It demonstrates that a healthcare organization—such as a hospital, clinic, or other care facility—has met The Joint Commission’s rigorous national standards for quality and safety. Promote your Certification, Joint Commission, [https://perma.cc/4YAD-PSRY] (last accessed Sept. 23, 2025).
[232]. Id., see also What is Accreditation?, Joint Commission, [https://perma.cc/G7G8-FLTJ].
[233]. In 2023, an estimated 180 million individuals (54.7% of the U.S. population) and
46 million individuals (13.9% of the U.S. population) were covered by group coverage and direct purchase coverage, respectively. See Sylvia L. Bryan & Ryan J. Rosso, Cong. Rsch. Serv., IF10830, U.S. Health Care Coverage and Spending, [https://perma.cc/V7SA-F5K3] (last updated Feb. 19. 2025).
[234]. Katherine Lewis & Reece Hinchcliff, Hospital Accreditation: An Umbrella Review, 35 Int’l J. for Quality in Health Care 7, 1, 1–16 (2023) (reviewing 33 studies and finding that hospital accreditation, while not conclusively shown to improve clinical outcomes, is widely viewed by the public and patients as a signal that a facility prioritizes high standards of care; accreditation boosts public confidence, serves as a marketing and accountability tool, and is perceived as emblematic of quality and safety—even though its true effect on quality improvement remains contested and largely associative rather than causal).
[235]. Alkhenizan & Shaw, supra note 122, at 415.
[236]. Ashish K. Jha, Accreditation, Quality, and Making Hospitals Better, 320 JAMA For. 2410, 2411 (2018).
[237]. Stephanie Armour, Hospital Watchdog Gives Gold Seal of Approval, Even After Problems Emerge, Wall Street Journal (Sep. 8, 2017), [https://perma.cc/E7XL-AT83].
[238]. Jha, supra note 221, at 2411.
[239]. Some may argue that this would create a chilling effect on facilities that serve high numbers of Black Americans; however, I question if this would be a big thing. They cannot simply turn away Black patients, nor do they want to lose their accreditation.
If hospitals take extra care to attend to Black pregnant women, and doctors are more cautious during their appointments, and that lessens BMMD, then so be it.
[240]. Board Certification Remains Important to Consumers, Am. Board Med. Specialties (Oct. 20, 2025), [https://perma.cc/JWP8-LGWA] (reporting that the vast majority of surveyed patients consider board certification a critical factor in choosing physicians and expect regular, ongoing demonstration of current medical expertise; high percentages held these views for nearly two decades). Furthermore, certification has a significant impact on how patients choose doctors, serving as a key indicator of quality, expertise, and ongoing commitment to professional development. Most patients prioritize board certification when selecting a physician, regularly verify certification status, and may even switch doctors if certification is not maintained. Id.
[241]. Manjot Singh, Brian McCrae Jr., Joseph E. Nassar, Michael J. Farias, Ashley Knebel, Bassel G. Diebo & Alan H. Daniels, The $12 Billion Board Certification Process: Examination Characteristics, Revenues, and Expenditures, 138 Am. J. Med. 626, 626–33.e3 (2025) (analyzing the costs, requirements, and financial growth associated with board certification; includes a literature review highlighting physician attitudes, such as support for certification’s role in ensuring professional competence and public trust, but also significant concern over the financial burden, exam design, perceived lack of relevance to specialized practice, and insufficient evidence connecting certification to improved patient care); see, e.g.,, Howard Bauchner, Phil B. Fontanarosa & Amy E. Thompson, Professionalism, Governance, and Self-regulation of Medicine, 313 JAMA 1831, (2015) (describing how physicians view board certification as central to professionalism and self-regulation, but also detailing widespread concerns about maintenance of certification).
[242]. Armour, supra note 237; About, ACOG [https://perma.cc/647V-AJY9].
[243]. American College of Obstetricians and Gynecologists Committee on Obstetric Practice, Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period, 133 Am. J. of Obstet. & Gynecol. e174, e175 (2019); Kirkpatrick & Burkman, Does standardization of care through clinical guidelines improve outcomes and reduce medical liability? 116 Am. J. of Obstet. & Gynecol. 1022, 1022-26 (2010).
[244]. Kenneth J. Gruber et al., Impact of Doulas on Healthy Birth Outcomes, 22 J. Perinatal Educ. 49, 49–50 (2013).
[245]. April M. Falconi, Samantha G. Bromfield, Truc Tang, Demetria Malloy, Denae Blanco, Susan Disciglio & Winnie Chi, Doula Care Across the Maternity Care Continuum and Impact on Maternal Health: Evaluation of Doula Programs Across Three States Using Propensity Score Matching, EClinicalMedicine, August 2022, at 1, 9-10. The ACOG supports evidence-based findings that “continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.” Am. Cong. Of Obstetricians & Gynecologists, Comm. On Obstetric Practice, Approaches to Limit Intervention During Labor and Birth (2019).
[246]. Daneka Stryer, The Role of Doulas in Addressing Black Women’s Maternal Mortality, Drexel College (May 10, 2023), [https://perma.cc/UY65-BA4V].
[247]. Id.
[248]. Id. The full list is California, Maryland, Massachusetts, Michigan, Minnesota, Nevada,
New Jersey, New York, Oklahoma, Oregon, Rhode Island, Virginia, and Washington DC.
[249]. National Academy for State Health Policy, State Approaches to Doula Service Benefits [https://perma.cc/7W2R-XVAK].
[250]. Governor Hochul Takes on Infant and Maternal Mortality Crisis, New York State (Nov. 6, 2023), [https://perma.cc/27NC-VECN].
[251]. Report: 2024 Black Maternal Health Week, Black Mamas Matter Alliance
(April 2024) [https://perma.cc/WJD5-523C].
[252]. Id.
[253]. Despite its name, the Preeclampsia Patient’s Bill of Rights is not an enforceable mechanism or tool for patients; rather, it encourages and empowers pregnant people to advocate for themselves. If that advocacy fails, there is little guidance on what one should do next, other than to seek out another physician or make a complaint with the facility.
[254]. Preeclampsia Bill of Rights, supra note 139.
[255]. Educating Patients, Preeclampsia Found. (Mar. 20, 2023), [https://perma.cc/Y7D3-UNGJ].
[256]. Id.
[257]. Eleni Tsigas, The Preeclampsia Foundation: The Voice and Views of the Patient and Her Family, 226 Am. J. Obstetrics & Gynecology S1254 (2022).
[258]. Educating Patients, supra note 255.
[259]. Strong Start & Beyond, supra note 211.
[260]. Mayo Clinic Staff, Labor and Delivery, Postpartum Care, Mayo Clinic (Oct. 26, 2023), [https://perma.cc/A63M-Q4DG].
[261]. Singh & Lee, supra note 53.
[262]. See, Policy Priorities: Medicaid, Am. Coll. Obstetricians & Gynecologists (Oct. 2024), [https://perma.cc/2FWE-JHRG].
[263]. American Rescue Plan, WH.GOV (Mar. 11, 2021), [https://perma.cc/8QR8-6RLN].
[264]. Consolidated Appropriations Act of 2023, H.R. 2617, 117th Cong. (2022).
[265]. Id.
[266]. See Medicaid Postpartum Coverage Extension Tracker, Kaiser Family Found. (Jan. 17, 2025), [https://perma.cc/E3KT-PR3Z]; State Tracker, Nat’l. Acad. for State Health Pol. [https://perma.cc/YXL9-NTU2].
[267]. American College of Obstetricians and Gynecologists Optimizing Postpartum Care, 131 Obstet. Gynecol. E140, 140–50 (2018), [https://perma.cc/5T6V-X2QL].
[268]. Id.
[269]. Id.
[270]. Mathew Rae, Cynthia Cox & Hanna Dingell, Health Costs Associated with Pregnancy, Childbirth, and Postpartum Care, Peterson Ctr. on Healthcare (July 13, 2022), [https://perma.cc/TMP3-55QW].
[271]. Id.
[272]. According to Experian Credit, the average transactional account total for people under 35 is $5,400. Gayle Sato, Average Savings by Age: How Americans Compare, Experian (Nov. 22, 2024) [https://perma.cc/25GH-MB9R].
[273]. Rajeev Dhir, How Much Does It Cost to Have a Baby in America?, Investopedia (Apr. 7, 2025), [https://perma.cc/W876-D6QJ].
[274]. Regulating private health insurance is challenging because it involves complex federal and state laws, constitutional principles, and shifting judicial interpretations regarding regulatory authority and preemption. Courts have nonetheless upheld nuanced regulatory initiatives where legislatures provide adequate statutory standards and agencies act within delegated authority. See, e.g., Nat’l Ass’n of Mut. Ins. Cos. v. State Dep’t of Bus., 524 P.3d 470, 476–81 (Nev. 2023) (upholding agency authority to address unfair insurance practices under statutory and constitutional constraints); Tex. Mut. Ins. Co. v. PHI Air Med., LLC, 610 S.W.3d 839, 848–53 (Tex. 2020) (finding no federal pre-emption of state insurance reimbursement standards); Doe v. Becerra, 711 F. Supp. 3d 1112, 1125–28 (C.D. Cal. 2023) (sustaining state intervention to address market failures and rebalance insurance relationships); Valley Med Flight, Inc. v. Dwelle, 171 F. Supp. 3d 930, 940–44 (D.N.D. 2016) (addressing the limits of state regulatory reach under the McCarran-Ferguson Act).
[275]. As of August 2025, the state tracker shows that 49/50 states chose to extend Medicaid coverage to one year. See Medicaid Postpartum Coverage Extension Tracker, supra note 266; State Tracker, supra note 266.
[276]. A comprehensive enforcement mechanism to address BMMD should begin with robust federal oversight, where the federal government sets baseline standards for maternal healthcare through legislation. These standards should mandate evidence-based protocols for diagnosing and managing preeclampsia and established training requirements, and data collection. At the state level, health departments can actively monitor compliance by conducting inspections and audits of healthcare facilities. Government Accountability Offices (GAOs) can conduct independent audits and investigations and recommend systemic improvements; however, we must again consider diverse state contexts.
[277]. Preeclampsia Task Force, Preeclampsia Early Recognition Tool (PERT), Cal. Maternal Quality Care Collaborative (last accessed Oct. 2, 2025), [https://perma.cc/7H7F-RM22]. As discussed, these evidence-based toolkits ensure that healthcare providers follow uniform standards in diagnosing and treating preeclampsia, reducing maternal mortality rates swiftly and effectively.
[278]. The effectiveness of MMRCs is evidenced by California’s success, which has utilized its MMRC alongside comprehensive state-level plans and collaborative networks to significantly reduce its maternal mortality rate. Adopting EHR-based decision support tools, like California’s Preeclampsia Early Recognition Tool (PERT), even if nationally mandated, must be implemented locally with buy-in from state actors, healthcare workers, and managers. According to the ACOG’s What Every Maternal Care Provider needs to know, implementation of consistent patient safety tools in maternal care faces several barriers such as the perception of reduced individualization, sustainability to local environments, low-compliance rates, and the need for periodic reassessment. Some providers believe that protocols limit care customization and undermine physician autonomy, even though these tools are meant to enhance reliability and support clinical judgment.
[279]. Compliance with these tools is often low (10-20%), impacting their efficacy. Universal and consistent implementation is crucial for their success. See Inst. for Healthcare Improvement, How‑to Guide: Prevent Obstetrical Adverse Events 5 (2012); Continuous evaluation and refinement of these safety tools, involving ongoing quality monitoring and feedback mechanisms, are necessary to improve their sensitivity and utility. To overcome the limitations of implementing consistent patient safety tools in acute care, education and training for healthcare providers are essential. These tools support, rather than diminish, clinical judgment and personalization of care. Reliability is enhanced in high-stress situations.
[280]. Elizabeth A. Howell & Zainab N. Ahmed, Eight steps for narrowing the maternal health disparity gap: Step-by-step plan to reduce racial and ethnic disparities in care, Contemp. Ob Gyn., Jan. 16, 2019, at 30 (reviewing the crisis of maternal mortality in the U.S., documenting persistent and significant racial and ethnic disparities—especially the finding that Black women are three to four times more likely than white women to die from pregnancy-related causes; recommending eight actionable steps including enhanced communication, implicit bias training, and the creation of disparity dashboards; explains that disparity dashboards require hospitals to track self-identified race, ethnicity, language, and place of birth in patient records, and to stratify quality metrics by these demographics, thereby facilitating the identification and remediation of racial gaps in care through targeted quality improvement initiatives).
[281]. See Micael J Taylor, Chris McNicholas, Chris Nicolay, Ara Darzi, Derek Bell, Julie E Reed, Systematic Review of the Application of the Plan–Do–Study–Act Method to Improve Quality in Healthcare, 23 BMJ Qual. & Saf. 290, 290–98 (2014). FOCUS is a quality improvement framework developed to precede and support the PDCA (Plan–Do–Check–Act) cycle. The acronym stands for “Find a process to improve, Organize a team that knows the process, Clarify current knowledge of the process, Understand the causes of variation, and Select the process improvement.” It provides a structured approach to identifying and planning improvements before iterative testing cycles.
[282]. Rapid Cycle Improvement Programs Require Effort but Deliver Speedy Results, Zynx Health, [https://perma.cc/GHG4-LQ65].
[283]. Quality Improvement Essentials Toolkit, Institute for Healthcare Improvement, [https://perma.cc/6HSS-HE7N].
