For a wealthy country, the United States is a dangerous place to be a newborn. But it’s not equally risky for all babies.
In the United States, the richest mothers and their newborns are the most likely to survive the year after childbirth — except when the family is Black, according to a groundbreaking new study of two million California births. The richest Black mothers and their babies are twice as likely to die as the richest white mothers and their babies.
Research has repeatedly shown that Black mothers and babies have the worst childbirth outcomes in the United States. But this study is novel because it’s the first of its size to show how the risks of childbirth vary by both race and parental income, and how Black families, regardless of their socioeconomic status, are disproportionately affected….
“It suggests that the well-documented Black-white gap in infant and maternal health that’s been discussed a lot in recent years is not just explained by differences in economic circumstances,” said Maya Rossin-Slater, an economist studying health policy at Stanford and an author of the study. “It suggests it’s much more structural….”
Rich Families Have More Premature Babies. But Those Babies Are Less Likely to Die.
Perhaps unexpectedly, babies born to the richest 20 percent of families are the least healthy, the study finds. They are more likely to be born premature and at a low birth weight, two key risk factors for medical complications early in life. This is because their mothers are more likely to be older and to have twins (which are more common with the use of fertility treatments), the researchers found.
But even with those early risk factors, these babies are the most likely to survive both their first month and first year of life.
A similar pattern emerged when it came to the health of the parents themselves: Rich and poor mothers were equally likely to have high-risk pregnancies, but the poor mothers were three times as likely to die — even within the same hospitals. Rich women’s pregnancies “are not only the riskiest, but also the most protected,” the paper’s authors wrote.
This finding suggests that the American medical system has the ability to save many of the lives of babies with early health risks, but that those benefits can be out of reach for low-income families.
Resources outside the medical system also play a role. Separate research on children with leukemia, for example, has found that even when treated at the same hospital and using the same protocol, those from high-income families fared better than those from poorer families.
“It’s not just about the medical care that kids are receiving,” said Anna Aizer, a health economist at Brown University. “There are all sorts of other things that go into having healthy babies. If you’re a higher-income mom who can take time off work, who doesn’t have to worry about paying rent, it’s not surprising you’ll be able to manage any health complications better.”
Money Protects White Mothers and Babies. It Doesn’t Protect Black Ones.
The researchers found that maternal mortality rates were just as high among the highest-income Black women as among low-income white women. Infant mortality rates between the two groups were also similar.
The babies born to the richest Black women (the top tenth of earners) tended to have more risk factors, including being born premature or underweight, than those born to the richest white mothers — and more than those born to the poorest white mothers. It’s evidence that the harm to Black mothers and their babies, regardless of socioeconomic status, begins before childbirth.
“As a Black infant, you’re starting off with worse health, even those born into these wealthy families,” said Sarah Miller, a health economist at the University of Michigan. She was an author of the study with Professor Rossin-Slater and Petra Persson of Stanford, Kate Kennedy-Moulton of Columbia, Laura Wherry of N.Y.U. and Gloria Aldana of the Census Bureau.
Black mothers and babies had worse outcomes than those who were Hispanic, Asian or white in all the health measures the researchers looked at: whether babies were born early or underweight; whether mothers had birth-related health problems like eclampsia or sepsis; and whether the babies and mothers died. There was not enough data to look at other populations, including Native Americans, but other research has shown that they face adverse outcomes nearing those of Black women and infants in childbirth.
Even before the new paper, research found that Black women with the most resources, as measured by education and class mobility, did not benefit during childbirth the way white women did. The new study demonstrates that disparities are not explained by income, age, marital status or country of birth. Rather, by showing that even rich Black mothers and babies have a disproportionately higher risk of death, the data suggests broader forces at play in the lives of Black mothers, Professor Rossin-Slater said.
“It’s not race, it’s racism,” said Tiffany L. Green, an economist focused on public health and obstetrics at the University of Wisconsin-Madison. “The data are quite clear that this isn’t about biology. This is about the environments where we live, where we work, where we play, where we sleep.”
There is clear evidence that Black patients experience racism in health care settings. In childbirth, mothers are treated differently and given different access to interventions. Black infants are more likely to survive if their doctors are Black. The experience of the tennis star Serena Williams — she had a pulmonary embolism after giving birth, yet said health care professionals did not address it at first — drew attention to how not even the most famous and wealthy Black women escape this pattern.
But this data shows how the effects of racism on childbirth start long before people arrive at the hospital, researchers across disciplines say, and continue after they leave. The stress of experiencing racism; air pollution in Black communities; and inequitable access to paid family leave, for example, have all been found to affect the health of mothers and babies.
“Even when it’s not about the direct disrespect that’s going on between the patient and the care provider, there are many ways systemic racism makes its way into the well-being of a pregnant or birthing person,” said Dr. Amanda P. Williams, the clinical innovation adviser at the California Maternal Quality Care Collaborative….
By the time a woman is pregnant, Professor Miller said, “it’s almost too late.”
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