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Using the Ecological Systems Theory to Understand Black/White Disparities in Maternal Morbidity and Mortality in the United States

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Abstract

Maternal morbidity and mortality (MMM) is a significant problem in the USA, with about 700 maternal deaths every year and an estimated 50,000 “near misses.” Disparities in MMM by race are marked; black women are disproportionately affected. We use Urie Bronfenbrenner’s ecological systems theory to examine the root causes of racial disparities in MMM at the individual (microsystem), interpersonal (mesosystem), community (exosystem), and societal (macrosystem) levels of influence. This review discusses the interaction of these levels of influence on racial disparities related to MMM—covering preconception health, access to prenatal care, implicit bias among health care providers and its possible influence on obstetric care, “maternity care deserts,” and the need for quality improvement among black-serving hospitals. Relevant policies—parental leave, Medicaid coverage during pregnancy, and Medicaid expansion—are considered. We also apply the ecological systems theory to identify interventions that would most likely reduce disparities in MMM by race, such as revising the educational curricula of health care professionals, enhancing utilization of alternate prenatal care providers, and reforming Medicaid policies.

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Notes

  1. Defined as death “while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (Hoyert & Miniño, 2020), which excludes deaths from suicide, homicide, and overdose

  2. Other factors relevant to MMM disparities that could be considered with the ecological systems theory include maternal age, education, and socioeconomic status (individual); intimate partner violence (interpersonal); pollution and toxins in the local environment (community); and mass incarceration and weathering (societal).

  3. Notably, one of these bundles specifically addresses racial and ethnic disparities in maternal health.

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Acknowledgments

The authors gratefully acknowledge the assistance of Lori Whitten, PhD, in editing the manuscript and providing additional assistance with research. This work was performed as part of an NIH Office of Research on Women’s Health contract with Synergy Enterprises, Inc.

This manuscript was developed during research internship of Bani Saluja and Leah Richey, graduate students at the University of Maryland, under Dr. Noursi’s supervision. The authors are grateful to Janine Clayton, MD, Associate Director for Research on Women’s Health, NIH; Director of the Office of Research on Women’s Health (ORWH) for her support throughout the development of this manuscript.

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  1. Office of Research on Women’s Health, National Institutes of Health (NIH), 6707 Democracy Boulevard, Suite 400, Bethesda, MD, 20817, USA

    Samia Noursi

  2. Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD, USA

    Bani Saluja

  3. University of Maryland School of Public Health, College Park, MD, USA

    Leah Richey

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  1. Samia Noursi
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Noursi, S., Saluja, B. & Richey, L. Using the Ecological Systems Theory to Understand Black/White Disparities in Maternal Morbidity and Mortality in the United States. J. Racial and Ethnic Health Disparities 8, 661–669 (2021). https://doi.org/10.1007/s40615-020-00825-4

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