The Impact of Institutional Racism on Maternal and Child Health
Infant mortality rates for America’s Black babies are more than twice the rate of white babies
Black babies are more than three times as likely to die from complications related to low birthweight as compared to white babies in the U.S.
U.S. maternal mortality rates for Black women and birthing people are three to four times higher than rates for their white counterparts
Embedded within these persistent disparities are the ongoing effects of institutional racism—racism that began with the enslavement of Black people, was embedded in our earliest institutions, and has continued to influence policies and practices ever since.
“It’s easy to say that things are different now… that the civil rights movement happened, and Jim Crow laws are gone, so everyone has access to school, services and health care; but that is only a small piece of the narrative,” says NICHQ Senior Project Director and Engagement Lead Kenn Harris. “We need to look at the full continuum to see how racism has been baked into our systems, and then come together to dismantle existing policies that still support racist practices.”
Understanding the history associated with this continuum is a vital step toward dismantling policies and practices that continue to adversely affect maternal and child health outcomes. With this knowledge, individuals working in health care institutions can provide culturally sensitive, compassionate care that recognizes why non-majority populations may mistrust health care institutions; and individuals across the country can examine organizational, state and federal policies—and work together to eliminate those that perpetuate institutional racism.
By understanding what’s happened in the past, individuals and organizations can better understand what’s causing today’s disparities and identify solutions that move toward an equitable future.
Below, we share a high-level overview of four key injustices that have adversely affected the health of Black mothers and young children. While these examples by no means constitute a comprehensive list of historic injustices, we hope that sharing them will inspire deeper conversation, reflection, and informed action.
Unequal access to resources
Historically, American systems have excluded Black women from support and resources conferred on white women, an inequity exemplified by the welfare system.
In 1935, the U.S. passed the Social Security Act, which included today’s welfare benefits of unemployment and social security. In theory, the welfare system would help all children and families in need; instead, it predominantly helped white children and families because Black people, in large part, could not participate in its benefits. The act excluded individuals who worked on farms or as domestic help—jobs often held by African Americans and people of color during the 30s, and thus created a system where government aid was largely reserved for the white population.
The welfare system has evolved and improved since 1935, but the consequences of its discriminatory origins persist in continued cycles of poverty and unequal access to resources. By not affording Black women and children the same benefits as their white counterparts, the act set a dangerous precedent and left a legacy of discrimination in a system meant to improve equity, which ultimately plays out in attitudes and treatment of African Americans in systems of care.
The communities where children and families live, work and play largely determine their health outcomes. But historically, discriminatory housing policies have disenfranchised Black communities and created a foundation for inequities.
In the 1930s, the federal government began the practice of “redlining,” where the Federal Housing Administration (FHA) mapped neighborhoods based on how secure they were to invest in and redlined Black neighborhoods as the "highest perceived risk." These redlined areas were predominantly occupied by Black families. The FHA refused to secure mortgages in these redlined areas, leading to underdevelopment. And even though the practice was banned more than 50 years ago, its aftermath continues today: a recent study showed that 3 out of 4 once redlined communities still struggle economically, meaning these communities continue to have unequal access to resources that affect birth outcomes and overall health and well-being.
Since the civil war, thousands of Black families have inherited property without a will—a practice called heirs’ property where ownership is divided between inheritors because there are no paper deeds. Now, these families are losing their land and homes as developers exploit the paperless deeds of heir’s property rights. According to ProPublica, the U.S. Department of Agriculture has recognized heirs’ property as “the leading cause of Black involuntary land loss.”
“Because of redlining, resources began to leave Black communities,” explains Harris. “Grocery stores disappeared, creating food deserts. Hospitals closed and those that remained, like the schools, were substandard because there was little funding behind them. When we talk about families that can’t access quality housing, education, hospitals, and schools, we have to remember that these things began centuries ago, and that gives us more insight into the disparities that exist today.”
In the U.S., Black women have the lowest rates of breastfeeding initiation and continuation compared with other racial and ethnic groups. This disparity is just one of the countless continued effects of forced enslavement on Black women and children.
Before abolition, the practice of wet nursing required enslaved mothers to nurse white children, often at the expense of their own children. Black women, then, were barred from giving the benefits of breastfeeding to their own children and instead forced to provide those benefits to the children of their white slave masters.
This history has put a negative taint on the act of breastfeeding, which perpetuates today’s disparities. And distressingly, it’s set the stage for a biased narrative about Black families, says Harris. “During enslavement, you had a group of women who were not able to nurse their children in early years, and those children became sicker and more needy, which built a narrative that says, ‘Black children are sicker, needier, and cost more, and Black women are unfit and unable to take care of their children.’ That narrative still lives today in the implicit biases people bring to women of color. It’s one of the reasons we need cultural sensitivity training in health care institutions, and it reflects the ongoing impact of laws that once described Black people as less than human.”
Mistrust of health care institutions
Experimental reproductive surgeries, such as cesarean sections and ovariotomy, were commonly tested on enslaved Black women. A glaring example of this abuse is from former president of the American Medical Association, James Marion Sims, who performed multiple reproductive experimental surgeries without anesthesia on enslaved African American women. Exploitation continued after abolition, with enforced eugenics programs that sterilized Black women and hospital teaching programs that performed unnecessary hysterectomies (read the full article on this history here).
Health care segregation continued into the mid-60s, with Black families barred from quality hospitals and care, even when they lived right next to these institutions. And these inequities persisted even after the Civil Rights Act: hospitals and clinics once reserved for minority families remained under-resourced. This —a pattern is still seen today—with racism and bias adversely affecting the quality of care Black families receive.
This history of abuse and neglect led to deep-rooted mistrust of health care institutions among communities of color, explains Harris. And this mistrust directly influences their engagement with those institutions today. Understanding this history can help health care professionals provide compassionate care and engage in informed and respectful conversations with Black patients. And critically, it can help individuals seeking improvement identify current policies and practices that continue to justify that mistrust.
“I always say we have to look back to leap forward,” says Harris. “As a nation, we’ve made strides to eradicate racism, but we need to acknowledge that racism is embedded in the policies that shaped our country, from health care to housing to access to needed resources. Polices don’t happen in a bubble; they have a ripple effect across institutions and individuals, and even though laws have changed, those ripples remain today.”
The examples we’ve listed illustrate only a selection of those ripples. We hope they encourage our readers to keep examining and exploring this topic with us and help drive a national conversation about health equity.
Supporting Indigenous Families for Improved Health Outcomes
Indigenous mothers and birthing people, fathers, partners, caregivers, and families, can speak for themselves. So, make sure seats are available – and filled – on your projects, your teams, your boards. Many projects within the MCH field have steering committees, and all should have family representation. As I hope you’ve intuited, it’s not enough to carry a message. When I think about justice, equity, diversity, and inclusion with regard to our committees, our faculty experts, or even in our improvement advisors, I have begun to ask the question: Are there people from American Indian and Alaska Native communities here?
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