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Introduction
Deaths and life-threatening complications related to or associated with pregnancy are among the most glaring and persistent health disparities in New York State and across the nation. Until recently, New York consistently ranked among the states with the highest rates of maternal mortality (death) and severe maternal morbidity (serious complications related to childbirth).¹, ², ³ While negative outcomes affect women and birthing people⁴ across all demographics, Black birthing New Yorkers experience disproportionately higher rates than their white counterparts.⁵ In New York, Black birthing people are four times more likely to die than white birthing people.⁶, ⁷
Many of these disparities stem from structural racism. For instance, residential segregation, community disinvestment, income inequality, weathering from racism-related stressors, and lack of healthy food access and affordability threaten the health and wellbeing of people of color.⁸, ⁹ Notably, racial inequities in maternal health often persist regardless of education or income, pointing to systemic issues beyond socioeconomic status.¹⁰ Black women and birthing people experience implicit bias and discrimination; barriers to preventive, prenatal, and postpartum care; underlying chronic conditions; disparities in health care quality and patient experience; overuse of cesarean deliveries; and providers failing to address serious complications.¹¹, ¹², ¹³, ¹⁴, ¹⁵ The compounding effect of these challenges leads to vastly different maternal health experiences and outcomes.¹⁶, ¹⁷, ¹⁸
In response, New York State is pursuing strategies to address racial maternal health disparities within and beyond health care settings. These include chronic disease prevention and management before pregnancy, prenatal care, and services up to one-year postpartum (perinatal care). Black birthing people are more likely to experience complications, in part, because of pre-existing health conditions like hypertension and diabetes, which heighten their risk of severe illness.¹⁹, ²⁰ Primary and preventive care²¹ play a key role in addressing maternal health inequities and must be accessible to and affordable for all.²²
Suggested Citation: Okonkwo, C. Ford, MM. Foti, A. Tettamanti, N. Cobbs, E. Havusha, A. Sandman, D. 2024. “Racial Disparities in Maternal Health: Opportunities to Leverage Primary Care in New York State.” New York Health Foundation. New York, NY.
Photo Credit: Chasi Annexy
[1] U.S. Department of Health and Human Services. “National Outcome Measures,” https://mchb.tvisdata.hrsa.gov/PrioritiesAndMeasures/NationalOutcomeMeasures, accessed September 2024.
[2] Wheelock, S., Zezza, M., and Athens, J. (2020). “Complications of Childbirth: Racial & Ethnic Disparities in Severe Maternal Morbidity in New York State,” https://nyhealthfoundation.org/wp-content/uploads/2020/08/severe-maternal-morbidity.pdf, accessed September 2024.
[3] Maternal mortality refers to deaths during pregnancy or within 42 days of pregnancy termination, while “severe maternal morbidity” involves life-threatening complications during childbirth.
[4] In this brief, we use the term “birthing people” to acknowledge that women, non-binary, and other gender-diverse individuals can experience pregnancy and childbirth.
[5] “New York State Health Department releases Maternal Mortality reports detailing stark racial, ethnic disparities,” press release, March 14, 2024, on New York State Department of Health website, https://www.health.ny.gov/press/releases/2024/2024-03-14_maternal_mortality.htm, accessed October 2024.
[6] CDC Wonder. Centers for Disease Control and Prevention. Accessed October 2024. https://wonder.cdc.gov/.
[7] New York State Department of Health. “New York State Maternal Mortality and Morbidity Advisory Council Report, 2023,” https://health.ny.gov/community/adults/women/maternal_mortality/docs/2023_mmm_council_report.pdf, accessed September 2024.
[8] Centers for Disease Control and Prevention. “Working Together to Reduce Black Maternal Mortality.” https://www.cdc.gov/womens-health/features/maternal-mortality.html, accessed October 2024.
[9] Maternal Mortality Review Committee – NYC Health. “Pregnancy-associated mortality in New York City, 2020,” https://www.nyc.gov/assets/doh/downloads/pdfata/maternal-mortality-annual-report-2023.pdf, accessed October 2024.
[10] Winny, A.; Bervell, R. “Solving the Black Maternal Health Crisis,” https://publichealth.jhu.edu/2023/solving-the-black-maternal-health-crisis#:~=This%20heightened%20risk%20spans%20all%20income%20and%20education,maternal%20mortality%20than%20the%20least%20wealthy%20white%20woman, accessed October 2024.
[11] Souza, J.P. et al. (2023). A global analysis of the determinants of maternal health and transitions in maternal mortality. The Lancet Global Health, 12(2). doi:10.1016/s2214-109x(23)00468-0.
[12] New York State Department of Health. “New York State Maternal Mortality Review Report, 2018-2020,” https://www.health.ny.gov/community/adults/women/maternal_mortality/docs/maternal_mortality_review_2018-2020.pdf, accessed September 2024.
[13] Emechebe, O. (2024). “Strategies to Improve Black Maternal Health Outcomes and Advance Health Equity,” https://www.hsph.harvard.edu/ecpe/strategies-improve-black-maternal-health-outcomes-advance-health-equity/, accessed September 2024.
[14] Brislane, Á. et al. (2021). “Access to and Quality of Healthcare for Pregnant and Postpartum Women During the COVID-19 Pandemic,” Frontiers in Global Women’s Health, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8593955/, accessed October 2024.
[15] The American College of Obstetrics and Gynecologists. (2018) “Optimizing Postpartum Care,” https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care, accessed October 2024.
[16] Dovile, V., Wallace, M., Dyer, L., Harville, E., and Theall, K. (2019), Income Inequality and Racial Disparities in Pregnancy-Related Mortality in the US. SSM – Population Health, 9, 100477, https://doi.org/10.1016/j.ssmph.2019.100477.
[17] Ndugga, N.; Pillai, D.; Artiga, S. (2024). “Disparities in Health and Health Care: 5 Key Questions and Answers,” https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-healthcare-5-key-question-and-answers/, accessed October 2024.
[18] Walker, S. L., Walker, R. J., Palatnik, A., Dawson, A. Z., Williams, J. S., & Egede, L. E. (2024). Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women. American Journal of Perinatology, 41(S 01), e2326–e2335. https://doi.org/10.1055/s-0043-1771256.
[19] Bornstein, E. et al. (2020). Racial Disparity in Pregnancy Risks and Complications in the US: Temporal Changes during 2007–2018. Journal of Clinical Medicine, 9(5), p. 1414. https://doi.org/10.3390/jcm9051414.
[20] Walker, S. L., Walker, R. J., Palatnik, A., Dawson, A. Z., Williams, J. S., & Egede, L. E. (2024). Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women. American Journal of Perinatology, 41(S 01), e2326–e2335. https://doi.org/10.1055/s-0043-1771256.
[21] “Primary and preventive care” are defined as services delivered in various clinical settings (e.g., family medicine, pediatrics, obstetrics-gynecology, behavioral health), in addition to community-based settings where there are strong linkages to primary care.
[22] The American College of Obstetrics and Gynecologists. (2018) “Optimizing Postpartum Care,” https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care, accessed October 2024.
Methods in Brief²³
This data brief presents the most recent data from the New York State Department of Health’s Maternal and Child Health (MCH) and Pregnancy Risk Assessment Monitoring System (PRAMS) Dashboards. We chose measures for analysis based on data availability and relevance to critical points in perinatal care.
We examine trends in maternal death and serious complications related to childbirth by race and ethnicity, as well as by socioeconomic status (income quartiles) and insurance type—two factors that are closely tied to health care access in New York.
To explore differences in primary and preventive care access or utilization during pregnancy, we analyze data on healthy pregnancy conversations with providers, prenatal visits in the first trimester, postpartum visits, and dental visits during pregnancy. For further details on data sources, see the Appendix.
Note: This brief includes pre-calculated measures from the MCH and PRAMS Dashboards, limiting additional analyses (e.g., significance testing). It’s important to note that there are small counts for most outcomes and variation in regional data access and reporting. These factors may affect the magnitude of variation seen and mask regional variation at the local level.
[23] Note: Because of changes in reporting of race categories for Asian populations by the Health Resources and Services Administration, data are suppressed for most recent years and are not comparable with years prior. The reported race and ethnicity categories in this brief are mutually exclusive.
Key Findings
- Maternal death rates: Between 2018 and 2021, Black women and birthing people in New York State experienced maternal death rates more than four times higher than their white counterparts (65.2 vs. 15.5 deaths per 100,000 live births).
- Serious complications related to childbirth: Black birthing New Yorkers faced life-threatening complications at a rate 2.5 times higher than white birthing New Yorkers (192.5 vs. 77.9 life-threatening complications per 10,000 delivery hospitalizations).
- Healthy pregnancy conversations: Black (26.0%) and Hispanic (18.8%) women and birthing people reported lower engagement in healthy pregnancy conversations with providers, compared to white birthing people (30.9%).
- Early prenatal care: Black (71.5%) and American Indian/Alaska Native (69.8%) women and birthing people reported lower rates of early (i.e., first trimester) prenatal care compared to white women and birthing people (85.8%).
- Postpartum visits: Black (89.1%) and Hispanic (88.5%) women and birthing people reported lower rates of postpartum visits compared to white women and birthing people (93.2%).
Annual Suicide Rate by Veteran Status in New York City, 2012–2021
Veteran suicide rates varied annually and were notably higher than civilian suicide rates. The suicide rates for veterans peaked in 2013 and 2017, with a relative decline afterward. Civilian suicide rates remained stable over the past decade.
Borough Suicide Rate by Veteran Status, 2012–2021
On average, veterans died by suicide at twice the rate of civilians in New York City. The Bronx had the highest borough-specific suicide rate for both veterans and civilians; in the Bronx, veterans had a higher suicide rate than the overall New York State veteran suicide rate.³
[3] New York Health Foundation, “Data Snapshot: Veteran Suicide in New York State (2012–2021)”, https://nyhealthfoundation.org/resource/data-snapshot-veteran-suicide-in-new-york-state-2012-2021/, accessed August 2024.
Borough Suicide Rate by Veteran Status, Disaggregated by Sex, 2012–2021
Both male and female veterans died by suicide at about twice the rate as male and female civilians in New York City. Note: because of low counts, some borough-specific suicide rates for female veterans could not be analyzed.
Borough Suicide Rate by Veteran Status, Disaggregated by Age, 2012–2021
Young veterans (ages 18–34) had the highest suicide rate of all age groups in New York City. The highest suicide rate for any borough-specific age group was among 35–54-year-old veterans in Manhattan.
Borough Suicide Rate by Veteran Status, Disaggregated by Race/Ethnicity, 2012–2021
Suicide rates for veterans had greater variation by race and borough compared to civilians. Overall, white veterans had the highest suicide rates in New York City. However, in the Bronx, Black veterans had higher suicide rates than white veterans.
Maternal Death in New York State (2014–2021)²⁴
Maternal death in New York is worsening overall, with the rate increasing from 17.8 deaths per 100,000 live births (2014–2018) to 20.5 (2019–2021)—an approximately 13% rise. While there was a slight improvement between 2015–2019 and 2016–2020, the most recent data (2018–2021) show a sharp increase in maternal deaths.
[24] New York State aggregates maternal mortality rates over multi-year periods.
Maternal Death by Race/Ethnicity (2018–2021)
Racial disparities are stark. Black women and birthing people experience maternal death rates of 65.2 deaths per 100,000 live births—more than four times higher than white women and birthing people (15.1). Maternal death rates for Hispanic women and birthing people, however, are lower (12.6) compared to white women and birthing people.
Serious Maternal Complications by Race/Ethnicity (2020)
There are also racial and ethnic disparities in serious complications related to childbirth. Black birthing New Yorkers experience the highest rates of severe complications, with 192.5 life-threatening incidents per 10,000 delivery hospitalizations—about 2.5 times higher than for white birthing people (77.9). Hispanic (130), Asian (121.4), and other birthing people (119.1) also experience higher rates of complications, 1.5 to 1.7 times that of white New Yorkers.
Serious Maternal Complications by Income and Insurance Type (2020)
There are notable differences in rates of serious complications related to childbirth by income. Birthing people in the lowest income quartile (median ZIP code income <$50,000) had the highest rate of severe maternal complications at 136.5 per 10,000 delivery hospitalizations, compared to 98.4 for those in the highest income quartile (>$86,000). Similarly, Medicaid-covered birthing people experience a higher rate of severe complications (127.3) than those with private insurance (98.6). In New York, 49.6% of Medicaid beneficiaries in 2021 were Black or Hispanic.²⁵
[25] University of Minnesota. SHADAC analysis of Health Insurance Coverage Type, statehealthcompare.shadac.org, accessed October 2024.
Deaths of Despair and Suicide Modality by Veteran Status in New York City, 2012–2021
Veterans were more likely to die by suicide with a firearm, while civilians were much more likely to use other modes. Veteran deaths of despair were more likely to be alcohol-related; civilian deaths of despair were more likely to be drug–related.
Healthy Pregnancy Conversations by Race/Ethnicity (2021)
Preconception counseling—discussions between people of reproductive age and their primary care providers about planning for a healthy pregnancy—is a critical component of preventive care.²⁶, ²⁷, ²⁸ These conversations are a key measure of engagement in reproductive health, assessing whether individuals have discussed healthy pregnancy preparation as part of their routine care. Hispanic (18.8%) and Black (26.0%) birthing people report the lowest rates of engaging in these discussions with a provider, compared to white birthing people (30.9%) and birthing whose race/ethnicity was “other” (33.1%).
[26] Hall, J., et al. (2023). Addressing Reproductive Health Needs across the Life Course: An Integrated, Community-Based Model Combining Contraception and Preconception Care. The Lancet Public Health, 8(1). https://doi.org/10.1016/s2468-2667(22)00254-7.
[27] Khekade, H. et al. (2023). Preconception care: A strategic intervention for the prevention of neonatal and birth disorders. Cureus. https://doi.org/10.7759/cureus.41141.
[28] Johnson, K. et al. (2006). “Recommendations to improve preconception health and health care—United States.” https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm, accessed October 2024.
Prenatal Visits in the First Trimester by Race/Ethnicity (2021)
Prenatal visits offer essential health monitoring and preventive care, serving as a key indicator of primary care access and overall health care accessibility during pregnancy. American Indian/Alaska Native (69.8%) and Black (71.5%) women and birthing people report significantly lower rates of first-trimester prenatal care compared to white women and birthing people (85.8%).
Postpartum Visits by Race/Ethnicity (2021)
Postpartum care is crucial, as more than half of maternal deaths in New York State occur after pregnancy.²⁹ During this period, essential follow-up services are provided to monitor recovery after childbirth, manage any post-birth health complications, and support overall maternal wellbeing in the first six to eight months after childbirth.³⁰ Hispanic (88.5%) and Black (89.1%) women and birthing people report lower rates of postpartum visits compared to white women and birthing people (93.2%).
[29] New York State Department of Health. “New York State Maternal Mortality Review Report, 2018-2020,” https://www.health.ny.gov/community/adults/women/maternal_mortality/docs/maternal_mortality_review_2018-2020.pdf, accessed September 2024.
[30] Lopez-Gonzalez, D.M. (2022). Postpartum care of the new mother. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK565875/ accessed October 2024.
Dental Visits During Pregnancy by Race/Ethnicity and Medicaid Status (2021)
Routine dental care is a critical component of prenatal health, as poor oral health is linked to adverse pregnancy outcomes, including preterm birth and low birthweight.³¹ Dental visits during pregnancy serve as a valuable indicator of preventive care engagement, but barriers—such as a dearth of dentists accepting Medicaid—exist for communities of color and low-income communities. Black women and birthing people reported the lowest rate of dental visits during pregnancy (28.2%), about half the rate of white women and birthing people (49.3%). Medicaid recipients also had lower rates of dental visits during pregnancy (32.1%) compared to those not on Medicaid (51.1%).
[31] March of Dimes. “Dental Health during Pregnancy,” https://www.marchofdimes.org/find-support/topics/pregnancy/dental-health-during-pregnancy accessed September 2024.
In New York, Black birthing people experience worse maternal health outcomes and lower rates of preventive health engagement than their white counterparts. Between 2018 and 2020, nearly three out of four (73.6%) pregnancy-related deaths³², ³³ in New York were found to be preventable, with cardiovascular issues, mental health conditions, infections, and injuries among the leading—and avoidable—causes.³⁴
Primary care presents a critical opportunity to address maternal health disparities. Primary care providers are well-positioned to coordinate care before, during, and after pregnancy, supporting early interventions that prevent chronic conditions, mental health and substance use disorders, and pregnancy-related complications from worsening.³⁵ Primary care providers can also partner with community organizations and members to ensure that care is culturally appropriate and meets the needs of marginalized groups.
But primary care is currently underused. Only one-third of pregnant people report receiving care from a primary care provider in the past year.³⁶ Patients of color, in particular, encounter barriers to accessing primary and preventive care before, during, and after pregnancy, and available care may lack cultural competence—potentially undermining trust and effective communication between providers and patients.
Community-centered primary and preventive care can support early intervention and strengthen partnerships between community-based organizations and clinical providers that serve Black and other birthing people of color. By leveraging primary care, health systems can foster more equitable maternal health outcomes.³⁷ Diverse care teams—including community health workers, midwives, and doulas—can provide culturally sensitive care that meets the needs of historically marginalized populations.³⁸, ³⁹, ⁴⁰ Training and employing staff of color to support patients during prenatal and post-hospital periods can enhance culturally competent care, build trust and communication between patients and health care providers, and reduce the impact of systemic racism and implicit bias on patient outcomes.⁴¹
Significant attention and resources are being devoted to expanding access to and improving the delivery of primary and preventive care services to low-income birthing people and birthing people of color. Federal programs are testing novel models of maternal health in primary care. New York State recently extended Medicaid coverage for birthing people up to one year postpartum; instituted Medicaid reimbursement for maternity care provided by community health workers and doulas; and expanded coverage for nutrition counseling, lactation support, and remote monitoring. New York City also launched citywide and neighborhood initiatives to significantly reduce maternal death. By ensuring broader access to perinatal services, New York is taking important steps toward reducing health disparities and enhancing maternal health outcomes statewide.⁴²
[32] New York State Department of Health. “New York State Maternal Mortality Review Report, 2018-2020,” https://www.health.ny.gov/community/adults/women/maternal_mortality/docs/maternal_mortality_review_2018-2020.pdf, accessed October 2024.
[33] Pregnancy-related deaths refer to deaths that occur during pregnancy or within one year after the end of pregnancy.
[34] New York State Department of Health. “New York State Maternal Mortality Review Report, 2018-2020,” https://www.health.ny.gov/community/adults/women/maternal_mortality/docs/maternal_mortality_review_2018-2020.pdf, accessed September 2024.
[35] New York State Department of Health. “New York State Maternal Mortality Review Report, 2018-2020,” https://www.health.ny.gov/community/adults/women/maternal_mortality/docs/maternal_mortality_review_2018-2020.pdf, accessed September 2024.
[36] Kozhimannil, K.B. and Westby, A. (2019). What family physicians can do to reduce maternal mortality. American Family Physician, 100(8), 460-461.
[37] Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), 457–502. https://doi.org/10.1111/j.1468-0009.2005.00409.x.
[38] Falako, S., et al. (2023). Utilizing Community-Centered Approaches to Address Black Maternal Mortality. Health Education & Behavior, 50(4), 500–504. https://doi.org/10.1177/10901981231177078.
[39] Falconi, A. M. et al. (2022). Doula care across the maternity care continuum and impact on maternal health. EClinicalMedicine, 50, 101531. https://doi.org/10.1016/j.eclinm.2022.101531.
[40] Israel, G. (2023). Integrating Community Health Workers and Nurse Midwives on the Health-Care Team to Improve Birth and Breastfeeding Outcomes. Journal of Perinatal Education, 32(1), 8–13. https://doi.org/10.1891/JPE-2022-0025.
[41] Commonwealth Fund. “Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity.” https://www.commonwealthfund.org/publications/issue-briefs/2021/mar/community-models-improve-maternal-outcomes-equity, accessed September 2024.
[42] “New York State Health Department releases Maternal Mortality reports detailing stark racial, ethnic disparities,” press release, March 14, 2024, https://www.health.ny.gov/press/releases/2024/2024-03-14_maternal_mortality.htm, accessed October 2024.
Veterans Treatment Courts Across New York State
As of 2023, there are 35 VTCs operating in New York State. Of the 62 counties in New York, 25 counties operate at least one VTC.
Top Veterans Treatment Courts by Participation
Since 2013, when the first VTC was established, 1,318 veterans have participated. Just three courts—the Buffalo City Court, Suffolk 1st District Court, and Nassau District Court—together account for approximately half of all cases and number of participants (n = 684). These courts were some of the first established VTCs in New York. VTCs established more recently would have fewer cases.
[1] Feuer, Alan; Hong, Nicole; Weiser, Benjamin, and Ransom Jan. “N.Y.’s Legal Limbo: Pandemic Creates Backlog of 39,200 Criminal Cases,” The New York Times, June 22, 2020.
Veterans Treatment Court Completion Rates
The court system measures participants’ completion of the New York State VTC program by tracking “program closures” when a participant’s case is closed in the system. Three-quarters (74.5%) of program closures from 2013 through 2023 were successful, with VTC participants graduating from their program or having adjournment in contemplation of dismissal. Approximately 1 in 10 closures (11.1%) were defined as unsuccessful, meaning the participant failed to complete the program. Another 13.4% of all closures were reported as administrative.