Pregnancy-related complications are urgent public health crises in the United States (Howell, 2018). The U.S. has more than twice the rate of maternal deaths compared to any other high-resource nation (Tikkanen et al., 2020). Even more alarming are the stark racial differences in maternal mortality. Between 2007 and 2016, at 40.8 per 100,000 live births, Black women had the highest pregnancy-related mortality rate than any other racial group (Petersen et al., 2019). Paralleling this trend, for every mother that dies due to pregnancy, there are 100 mothers who suffer a severe maternal morbidity (SMM) event (Howell, 2018; Leonard et al., 2019; Hirshberg and Srinivas, 2017; Metcalfe et al., 2018). SMM is the occurrence of life-threatening physiologic conditions during childbirth and/or postpartum, which have serious implications for the long- and short-term outcomes of a birthing person, including survival. It comprises of severe dysfunctions (e.g. heart failure), which are common precursors to maternal mortality. (Centers for Disease Control and Prevention) SMM has seen increases in prevalence throughout the past few decades, with persistent and widening racial/ethnic disparities. Each year SMM affects more than 50,000 women in the U.S., and Black women face a 2-fold higher risk of SMM compared with White women (Callaghan et al., 2012; Creanga et al., 2014a). Prior research has also documented alarming racial/ethnic disparities in the prevalence of leading causes of maternal mortality such as hypertensive disorders of pregnancy (Ford et al., 2022). Addressing this dire maternal health crisis requires a close examination of root causes behind maternal morbidity and mortality, and their racial/ethnic disparities (Jain and Moroz, 2017; Jain et al., 2018).

Studies investigating the underlying factors contributing to racial disparities in pregnancy-related complications primarily focus on individual-level explanations, such as health-related behaviors (“lifestyle factors”) and clinical comorbidities (“biomedical risks”) (Lindquist et al., 2013; Howland et al., 2019; Wang et al., 2020; Krieger, 1994, 2011). However, stark racial/ethnic differences in maternal morbidity and mortality persist even after accounting for numerous individual-level factors. This work has also been insufficient in explaining the increased prevalence of these adverse maternal health outcomes and their widening racial/ethnic gaps (Howland et al., 2019; Creanga et al., 2014b; Guglielminotti et al., 2019; Carmichael et al., 2021). Hence, there is a pressing need to examine contextual factors that influence disease risk. The Ecosocial theory posits that addressing structural health determinants with attention to history and power is key in improving population health, as failing to do so reproduces health inequities and maintains the uneven distribution of disease (Krieger, 1994, 2001). Thus, it is increasingly important to focus on socio-political forces, such as structural racism, that disproportionately disenfranchise racially/ethnically marginalized individuals.

Structural racism has received increasing attention as the main driver of racial health inequities (Williams and Mohammed, 2013). Scholars have documented its ill health-effects and how it may shape racial health disparities across a wide-range of health outcomes (Bailey et al., 2017). However, the links between structural racism and adverse maternal health outcomes are severely under-investigated, and there are theoretical and methodological gaps that have yet to be addressed (Alson et al., 2021). We begin this paper by defining structural racism, describing mechanisms by which it determines health outcomes broadly, and by offering a conceptual framework that outlines the pathways through which structural racism influences pregnancy-related outcomes. We then systematically synthesize the current literature on the links between place-based measures of structural racism and maternal morbidity/mortality and identify areas of theoretical and methodological advancement for future research.

A note on language: Throughout this manuscript, we use gendered language (e.g. “maternal,” “mothers,”, “women”) and gender-inclusive language (e.g. “people”) interchangeably with the acknowledgement that not all people who give birth are women. These terms in this paper are intended to be inclusive of all birthing persons including cisgender, transgender, queer, non-binary, and gender-diverse individuals.

Structural racism, a legacy of settler colonialism and African slavery in the Americas, is recognized as a fundamental driver of racial/ethnic health inequities (Williams et al., 2019; Gee and Ford, 2011; Cogburn, 2019; Phelan and Link, 2015). It is defined as the totality of ways by which intrinsically linked and mutually reinforcing cultural domains and social/political institutions work in concert to disenfranchise racially/ethnically marginalized populations (Bailey et al., 2017; Phelan and Link, 2015). These institutions, including but not limited to, the criminal legal system, housing, education, health care, and employment, together reinforce hierarchies, while perpetuating inequitable policies/practices and discriminatory social norms based on a socially ascribed identity used to subordinate members of specific racial/ethnic groups—“race.” (Williams et al., 2019; Gee and Ford, 2011; Roberts, 2011; Bonilla-silva, 1997) Structural racism transcends interpersonal prejudice/bias and internalized racism, other key dimensions of racism (Jones, 2000). It is an upstream determinant of such norms, whose roots are embedded within the very policies, laws, and institutions that constitute the social fabric of the U.S. and consequently the everyday contexts that surround individuals (Crenshaw et al., 1995; Bailey et al., 2021).

In addition to outright hate crimes and violence targeted towards racially/ethnically minoritized populations in the U.S., there have been/are multiple instances of historic and contemporary state-sponsored discriminatory laws/practices that continue to harm the health and well-being of racially/ethnically marginalized people. Through restrictive housing covenants and redlining practices, Black and other people of color were unfairly denied housing and loans, were prohibited from attaining wealth in the form of homeownership, and their neighborhoods were deemed unworthy of investment (Rothstein, 2017). Federal economic subsidies that excluded Black and other people of color, together with educational and occupational segregation, denied racially/ethnically marginalized individuals access to socio-economic mobility and hindered the beneficial health rewards that come from it (Johnson, 2019; O'Brien et al., 2020). Structural racism also patterns the types of hospitals where racially/ethnically marginalized individuals receive care. Despite the integration of hospitals in the wake of the civil rights movement, segregated medical care still persists—pushing Black and Brown individuals to seek treatment in lower-quality facilities and receive poor care due to provider bias (Ly et al., 2010; Smedley et al., 2003). School discipline policies that disproportionately target Black and Brown youth, not only interrupt educational trajectories and hence influence health, but also directly contribute to the large/growing prison population in the U.S., which incarcerates more people per capita than any other nation (Vable et al., 2020; Duarte et al., 2020; Skiba et al., 2002; Subramanian et al., 2015; Widra and Herring, 2021). Law-enforcement violence is yet another manifestation of structural racism that causes death and injury to thousands of individuals every year, with Black individuals bearing the greatest burden (Bor et al., 2018). Specific instances of police/state violence also lead entire Black communities to experience vicarious violence and trauma (Alang et al., 2017). Mass incarceration, aided by governmental campaigns, such as the war-on-drugs and harsh mandatory sentencing laws, is another important axis of structural racism that continues to institutionalize millions of Black and Brown Americans and tear-apart countless families, depleting community resources and dismantling social fabrics (Alexander, 2010). It is also critical to note the role that intersectionality plays in how structural racism shapes health inequities (Crenshaw, 1989). Structural racism interacts with and is fueled by other forms of marginalization, including sexism, classism, ableism, homophobia, transphobia, xenophobia etc, to create new forms of social adversities, which collectively are greater than the sum of each individual source of oppression (Crenshaw et al., 1995; Crenshaw, 1991; Lorde, 1984).

The compounding of these deeply intertwined policies, practices, and norms that exist within multiple societal/institutional domains, perpetuates racial/ethnic inequities in maternal health outcomes through multiple mechanisms (Williams and Mohammed, 2013). Figure 1 outlines the proposed pathways by which structural racism across the life-course influences uneven risk of maternal morbidity/mortality.

Through the aforementioned historical and contemporary discriminatory policies and practices, structural racism has led to the concentration of poverty and unhealthy social and physical environments within racially/ethnically segregated neighborhoods in which people of color primarily reside (Williams and Collins, 2001; Kramer and Hogue, 2009). Such neighborhoods may lack healthy amenities, e.g. healthy grocery stores and parks, which are important predictors of health-related behaviors, preconception health, and consequently a healthy pregnancy/childbirth (Diez Roux, 2007; Vinikoor-Imler et al., 2011; O'Campo et al., 2008). Consistent with this framing, research has documented links between racial residential segregation, poor neighborhood environments, and pregnancy-related outcomes (Mehra et al., 2017; Mendez et al., 2014, 2016; Pickett et al., 2005). The limited availability of safe and secure housing, and the physical proximity to sources of environmental toxins and pollutants is also another pathway through which structural racism shapes maternal health outcomes. Research has shown that historically redlined neighborhoods have increased concentration of air pollution, given that these neighborhoods are the mainstays for industrial plants, railroads, and other generators of environmental pollutants (Lane et al., 2022). As such, structural racism predisposes birthing people to respiratory illnesses, such as asthma, which have been linked with pregnancy-related complications (Miranda et al., 2009).

Poor educational opportunities and low-wage jobs are other important manifestations of structural racism, which hinder upward social mobility among racially/ethnically marginalized individuals (Krieger, 2001, Williams and Mohammed, 2013). Structural racism patterns the distribution of health-promoting material goods/resources and socioeconomic opportunities, including access to quality and timely health care, health literacy, disposable income, and social capital (Krieger et al., 2020). Both before and during pregnancy, these resources can be utilized to promote/maintain health, and to avoid pregnancy-related complications. Therefore, socioeconomic resources have been linked to health behaviors such as delayed prenatal care initiation, and consequently adverse maternal health outcomes and their clinical precursors (e.g. pregnancy-induced hypertension) (Gazmararian et al., 1996).

Structural racism also shapes the distribution of psychosocial stressors and assets that influence risk of pregnancy-related complications (Clark et al., 1999). Inter-personal experiences of racism in every-day contexts have been linked with multiple mental and physical health outcomes, as well as subclinical indicators of disease, which may increase risk of adverse pregnancy-related complications (Williams et al., 2019). Stress also arises from contending with social disorder, crimes, and heightened vigilance against aggressive policing in neighborhoods negatively impacted by structural racism (Alang et al., 2017; Jahn et al., 2021; Goin et al., 2021; Hardeman et al., 2021). Being chronically exposed to such stressors across the life-course triggers a cascade of maladaptive physiologic stress responses, dysregulating and compromising a large range of organ-systems and accelerating premature biological aging (Geronimus et al., 2006). This physiological wear and tear can then heighten a mother's likelihood of experiencing complications during pregnancy and/or childbirth (Mendez et al., 2014). By limiting the availability of community-based resources such as social support networks and neighborhood social cohesion, that may buffer the negative health consequences of stressful experiences, structural racism also leaves mothers vulnerable to adverse pregnancy outcomes (Brondolo et al., 2009). The biological embodiment of structural racism through stress pathways over and above material resources is also evident in research documenting that higher socio-economic status does not produce the same level of health benefits for Black individuals as it does for White individuals (Williams and Collins, 1995; Farmer and Ferraro, 2005). There is evidence indicating adverse outcomes among upwardly-mobile Black individuals, as they may contend with additional racism-related stress due to prejudiced treatment from their colleagues in higher paying jobs and/or neighbors in more affluent neighborhoods (Hudson et al., 2020). Consistent with this phenomenon, research shows that racial disparities in adverse birthing outcomes persist regardless of high socio-economic status, with Black women bearing a disproportionate risk (Johnson et al., 2020; Brase et al., 2021).

Partially influenced by racial and economic segregation, and referral patterns, Black individuals have been found to disproportionally receive care in a concentrated set of hospitals that generally provide lower quality of care across multiple indicators (Ly et al., 2010; López and Jha, 2013; Jha et al., 2007). Prior research has documented greater risk of pregnancy-related complications associated with giving birth in primarily Black-serving hospitals, and such hospitals have also been shown to mainly serve populations whose clinical profile is at a higher risk for adverse maternal outcomes (Howell et al., 2016; Ona et al., 2021). Implicit and explicit interpersonal bias in medical care settings is another pathway through which structural racism influences adverse maternal outcomes. Black women are often given less attention and dismissed when expressing concerns about their well-being, with several examples of Black birthing individuals whose health has been compromised because of medical provider bias (including refusal to listen), regardless of their individual socioeconomic status (Sacks, 2019; Saluja and Bryant, 2021).