The mother most likely to die is not the one you would guess
A college degree does not protect Black mothers from America’s maternal-health crisis in the way most people assume it should.
Between 2007 and 2016, the pregnancy-related mortality ratio for Black women in the United States with a college education or higher was 40.2 deaths per 100,000 live births. For White women who had not completed high school, it was 25.0. The CDC’s conclusion was stark: Black college-educated women had a pregnancy-related mortality ratio 1.6 times higher than White women with the least formal education.
Linked California administrative data, covering approximately two million births, reached a similar conclusion through income. Black mothers in the highest income quintile had a maternal mortality rate of 7.0 deaths per 10,000 births, more than double the 2.5 per 10,000 rate among White mothers in the lowest quintile. The authors concluded that policies aiming for racial health equity “cannot succeed if they only target economic disadvantage.”
September is National Infant Mortality Awareness Month. It is an opportunity to confront not just the numbers, but the systems that produce them.
The numbers behind the crisis
The United States recorded 5.52 infant deaths per 1,000 live births in 2024, according to CDC and National Center for Health Statistics data released in 2026. The rate was 10.98 among infants born to non-Hispanic Black mothers, compared with 4.41 among infants born to non-Hispanic White mothers.
Among 38 OECD countries, the United States ranked 32nd for infant mortality in 2023: 5.6 deaths per 1,000 live births, against an OECD average of 4.2. The Commonwealth Fund has placed the US infant mortality rate between Qatar and Romania, while its maternal mortality rate fell between Palestine and Chile. Yet the US spends roughly 18 percent of GDP on health care, nearly twice the OECD average.
Several federal maternal and infant-health goals are also moving in the wrong direction. Healthy People 2030 sets a target of 9.4 percent for preterm births; the most recent figure is 10.4 percent for 2024, with the status marked “getting worse.” Its target for early and adequate prenatal care is 80.5 percent. The current figure is 75.0 percent, also marked “getting worse.”
Maternal mortality itself requires precision. The US maternal mortality rate was 17.9 deaths per 100,000 live births in 2024, down from 18.6 in 2023; the CDC says the difference was not statistically significant. But the more revealing number comes from Maternal Mortality Review Committees: more than 80 percent of pregnancy-related deaths from 2017 to 2019 were deemed preventable. In practical terms, reviewers found a point in the chain of care where a different action could have changed the outcome.
The conditions around care
The federal government calls these forces the social determinants of health: the conditions in which people are born, live, learn, work, play, worship and age. Healthy People 2030 groups them into five areas, economic stability; education access and quality; health care access and quality; neighbourhood and built environment; and social and community context. Clinical care is one part of the picture, not the whole picture.
That does not mean medical care is unimportant. A widely repeated claim that clinical care accounts for only 20 percent of health outcomes comes from County Health Rankings, which assigns weights to factors for population-health ranking purposes. The organisation has cautioned that there is no single correct formula. It is a useful framework, but not proof that 80 percent of health happens outside the clinic.
Maternity-care access is part of the healthcare crisis
March of Dimes reported in August 2026 that 34.6 percent of US counties are maternity-care deserts: places with no obstetric clinicians and no birthing facilities. Around 2.4 million women of reproductive age live in those counties, where roughly 149,000 babies are born each year. Another 3.4 million women live in counties with only low or moderate maternity-care access. More than half of US counties have no hospital labour-and-delivery services.
Between January 2024 and May 2026, at least 96 labour-and-delivery units closed in 35 states. In nearly 60 percent of affected counties, the closure removed the community’s only birthing facility. Those closures added an average of 25 minutes to travel times for care.
Housing insecurity also has measurable consequences. A 2021 JAMA Pediatrics study of 88,862 births in Georgia found that an eviction filing during pregnancy, compared with an eviction action at another time, was associated with lower birth weight, shorter gestation and increases of roughly one percentage point each in low birth weight and prematurity. The effects were strongest in the second and third trimesters.
Transport is intuitive but less comprehensively studied. Research in Dallas found that women receiving no prenatal care faced longer public-transit journeys to their nearest county prenatal clinic, 42 minutes versus 30 minutes for women who did receive care, and had 2.65 times the adjusted odds of preterm birth. A 2025 review found most studies pointed in the same direction, while also noting substantial gaps in the evidence.
Food insecurity matters, though the evidence is more nuanced than popular wellness messaging often suggests. A 2024 meta-analysis of 25 studies involving 93,871 women in high-income countries found that food insecurity during pregnancy was associated with high stress, mood disorders and gestational diabetes. It did not find a statistically significant association with birth weight, preterm delivery, small-for-gestational-age birth or NICU admission. Food insecurity remains widespread: USDA data found that 13.7 percent of US households experienced it in 2024.
The disparity that remains
These conditions are unequally distributed, but improving them alone will not erase racial disparities.
The CDC’s education comparison and the California income analysis make that clear. So does a 2026 analysis of 9.36 million infants using CDC linked birth and infant-death data from 2017 to 2019. It found that Black infants born at 36 to 40 weeks had higher gestational-age-specific infant mortality than White infants at every level of maternal education except the lowest.
That distinction matters for anyone designing an intervention. Better housing, transport, income and access to prenatal appointments can improve health. But if an intervention changes nothing about the quality of communication, trust, advocacy or decision-making inside the clinical encounter, it may improve outcomes without closing the gap.
That is where continuous, culturally responsive support has a role.
What doula support can do
Toni Curtis, CD(DONA), LCCE, CLC, CVD(TVL), CHW, SpBCPE and SpBAP, has worked in birth education and support for nearly three decades, beginning as a teen peer educator in 1996. In 2020, she founded BirthWise Doula Services in Charlotte, North Carolina, and developed The Lifespan Birth Method™, which approaches birth as a physiological process shaped across a woman’s lifespan rather than as an isolated clinical event.
Curtis’s framework includes education, career development, financial stability, nutrition, environment and culturally comprehensive care. It is a practical interpretation of the social-determinants model: a mother does not arrive at a hospital disconnected from the housing, transport, work, financial and support systems that shape her pregnancy.
Her August 2026 Charlotte conference, Embrace & Evolve: The Reinvention of Women’s Health, brought those issues together rather than treating them as separate conversations.
A doula is not a physician, midwife or licensed therapist. Doula care is non-clinical: it does not diagnose, prescribe, treat or replace medical care. Curtis works alongside hospital-based obstetric teams and describes birth as “a natural process that is medically observed.” Her critique is not of medicine itself, but of care that can become detached from what a person needs to understand, ask for and navigate while medical treatment is being properly delivered.
“A good doula knows how to help you ask the questions you didn’t even know to ask,” she says.
Continuous labour support has an evidence base that is notable precisely because it does not rely on a drug or device. A 2017 Cochrane review pooling 27 randomised trials and more than 16,000 women found that continuous support during labour was associated with improved outcomes, including a higher likelihood of spontaneous vaginal birth and lower likelihood of caesarean birth.
In a Medicaid-focused study, researchers found a 22.3 percent caesarean rate among doula-supported births, compared with 31.5 percent in a comparison group. For context, the national caesarean rate was 32.4 percent in 2024, and 26.6 percent among low-risk births.
The value of a doula is not confined to the delivery room. Continuous support can help identify a transport problem before it causes a missed appointment, clarify a patient’s questions before an induction or surgery, reinforce informed consent, help families understand warning signs and provide continuity in a system built around brief encounters.
The receipts, and the route forward
BirthWise completed a two-year partnership with AmeriHealth Caritas North Carolina, supporting approximately 200 families across Mecklenburg, Union, Cabarrus and Gaston counties. The programme’s cost analysis estimated average savings of $2,000 per birth. It is now expanding statewide as a value-added service for plan members, including families with high-risk pregnancies, inductions and surgical births.
Curtis reports an 88 percent vaginal-delivery rate across her practice, including VBAC births; a 98 percent breastfeeding-initiation rate; and no preventable maternal or infant losses across her career. Those are practice-wide figures, not guarantees for individual families. National breastfeeding initiation was 86.1 percent for 2023 births.
“This partnership proves that skilled doula support delivers better outcomes for families and measurable savings for the system,” Curtis says. “The evidence is built. The work now is to make it accessible. We stand to fight against disparities, but my expertise is for everyone.”
The route to that access matters. As of March 2026, 26 states and Washington, DC reimbursed doula services through Medicaid. North Carolina did not.
Medicaid financed 35.7 percent of North Carolina births in 2024, 43,842 births, and the state expanded Medicaid in December 2023. Yet legislation to introduce Medicaid doula coverage has repeatedly failed to become law. Senate Bill 964, filed in April 2026, would require coverage for doula services during pregnancy and postpartum and support the doula workforce.
The AmeriHealth Caritas arrangement is therefore not a statewide public benefit. It is a managed-care plan that uses its own cost analysis to decide doula support is worthwhile. Without a state benefit, the plan became the available route.
“The medical model can’t argue with the receipts,” Curtis says.
North Carolina recorded its lowest-ever infant mortality rate in 2024: 6.3 deaths per 1,000 live births, down from 6.9 the previous year. But the racial gap remained severe. The rate for non-Hispanic Black infants was 12.8, compared with 4.3 for non-Hispanic White infants.
In Mecklenburg County, where BirthWise is based, an infant-mortality report published in March 2026 found roughly 70 infant deaths each year from 2014 to 2023. Black infants were more than three-and-a-half times as likely as White infants to die before their first birthday.
North Carolina is improving. The disparity is not closing fast enough.
For Toni Curtis, the argument for doula care is not that it replaces a strained medical system. It is that it adds a form of continuous, culturally responsive support that the system often lacks, and that mothers should not need exceptional resources, education or luck to receive.
More information is available at: birthwisedoulas.com.
