How Does Structural Racism Contribute to Disparities in Maternal Health Outcomes?

How does structural racism contribute to disparities in maternal health outcomes?

The bias discussed so far lives inside individuals and the relationships they form. Structural racism is different in kind. It refers to the way that laws, institutional policies, established practices, and cultural norms work together, often without any individual intending harm, to produce and maintain disadvantage for racially and ethnically minoritized groups (Sonderlund et al., 2022). The defining feature of structural racism is that it does not require a biased person in the room. It is built into the systems themselves, so that ordinary institutional functioning automatically reproduces inequity. For this reason, structural racism is increasingly described in the health sciences as a fundamental, upstream cause of health inequities rather than as one factor among many (Sonderlund et al., 2022; Njoku et al., 2023).

In maternal health specifically, several pathways are well described, and it helps to walk through them, because each suggests a different point of intervention. One is differential access to high-quality care. Because of residential and economic segregation, Black patients in the United States are disproportionately likely to give birth in a concentrated set of hospitals, and care quality across such facilities is, on average, lower on multiple measures, so that two patients with similar needs can receive systematically different care depending on where structural forces have routed them (Montalmant & Ettinger, 2024). This is a clear example of how a structure produces a disparity without any individual at the bedside intending it: the segregation that determines neighborhood, the economics that determine which hospital serves that neighborhood, and the resourcing that determines that hospital's quality are all upstream of the delivery room, yet they shape what happens in it.

A second pathway is the cumulative physiological toll of living with chronic stress and discrimination over the life course, sometimes described through a weathering framework, in which the sustained wear of stress contributes to earlier onset and greater severity of the chronic conditions, such as hypertension and cardiovascular disease, that drive maternal risk (Njoku et al., 2023). The idea of weathering is important because it dissolves false comfort. It is tempting to assume that a patient who is educated, insured, and financially secure has escaped the effects of racism, but the weathering framework predicts, and the data confirm, that the bodily costs of navigating a discriminatory society accumulate regardless of achievement. This is one reason the Black and White disparity in maternal mortality persists, and in some analyses widens, across higher levels of education and income, with Black women who hold a college degree experiencing worse maternal outcomes than White women with far less education (Kaiser Family Foundation, 2025). If the disparity were simply a matter of poverty or schooling, it would close as those improve. It does not, which points to racism rather than race as the operative force (Njoku et al., 2023).

This Ask the Expert is an edited excerpt presented by Calista Kelly, PT, DPT, ACEEAA, Cert. MDT.