Structural Inequity in Prenatal Care: What the Data Actually Show

A 10-part series by Amos Grünebaum, MD

I have practiced obstetrics for 50 years. I have watched Black women die at rates that should not exist in a wealthy country, and I have watched a policy response build that addresses almost everything except the actual mechanisms of death. This series is my attempt to say, with evidence, what is really happening and what would actually help. The first three posts are free. The rest are for paid subscribers at obmd.com.

I want to tell you why I wrote this series.

I have been an obstetrician for more than 50 years. I have delivered thousands of babies. I have sat with families after losses. I have watched this specialty evolve through sonography, through the cesarean epidemic, through the evidence-based medicine movement, and now through the arrival of artificial intelligence in clinical practice. I have seen many things improve. I have seen some things not improve at all.

Black maternal mortality is in the second category. The three-times gap, the persistent excess in pregnancy-related deaths among Black women compared with white women, has not closed in any meaningful way despite decades of awareness, advocacy, publication, and policy attention. In some periods it has widened. The problem is not invisible. It is not unstudied. It is not undiscussed. And yet it persists.

I believe it persists, in significant part, because the dominant policy response has been aimed at the wrong targets. The conversation about Black maternal mortality has centered on clinician attitudes: implicit bias, cultural competency, racially insensitive care. These are real phenomena. They deserve attention. But the evidence for attitude-focused interventions as mechanisms for reducing maternal mortality is, at this moment, essentially nonexistent. And the structural mechanisms that the evidence does implicate, insurance payment hierarchies, hospital quality stratification, postpartum coverage gaps, faculty practice non-participation, have received a fraction of the policy energy directed at training modules and doula billing codes.

This is not ignorance. It is a choice. And choices have beneficiaries. Understanding who benefits from the current policy response, and who does not, is as important as understanding the clinical evidence itself.

I wrote this series to say directly what I believe the data show, and what I believe a rational, evidence-based response to Black maternal mortality would look like. I am aware that some of what follows will be contested. I have tried to be precise about what the evidence establishes and what it does not. I have tried to engage with the strongest version of arguments I disagree with before explaining why I disagree with them. I have tried to write in the same voice I would use if I were presenting this material at grand rounds: direct, evidence-grounded, and unwilling to let the comfort of the audience substitute for the accuracy of the argument.

The women whose lives this series is about deserve that standard. I have tried to meet it.

Why This Series, Why Now

Three things brought this series into focus at this particular moment.

First, the April 2026 publication in JAMA Network Open of the most comprehensive systematic review of doula care outcomes to date. The review examined 21 studies covering 26 years of evidence. Its strongest findings were for reduced maternal anxiety and improved breastfeeding initiation. Maternal mortality was not a demonstrated outcome. At the same moment, 26 states have enacted Medicaid coverage for doula care, and California has written doula programs into law as a mechanism for addressing racial disparities in birth outcomes. The gap between what the evidence shows doulas accomplish and what policy is claiming they will accomplish is significant, and it deserves to be named.

Second, a separate systematic review, published in Science Advances in 2024, examined 77 studies of implicit bias training in healthcare settings. It found that not one of those 77 studies had examined patient outcomes. Zero. California has mandated implicit bias training for all perinatal clinicians based on this evidence base. The mandate is in place. The evidence for its clinical benefit does not exist.

Third, my own observation, documented in a LinkedIn post that generated significant response, of a specific and concrete structural failure: the faculty obstetric practices of every major academic medical center in Manhattan list their accepted insurance plans prominently on their websites. Aetna. Cigna. United. Blue Cross. Medicare. Medicaid does not appear on any of them. A pregnant woman with Medicaid in Manhattan cannot be seen for prenatal care in any of the faculty practices of the institutions that train the next generation of obstetricians, that sit on the committees that write national guidelines, and that publish the research on maternal health disparities. She is directed to the resident clinic. This is not a written policy. It is the cumulative result of individual practice decisions that together constitute a two-tier system operating inside institutions that claim, in their mission statements and their grant applications, to be committed to health equity.

These three things describe the gap between what is claimed and what is done, between what is evidence-based and what is policy-adopted, between who is served and who is left outside the faculty office door. That gap is what this series examines.

A Note on What This Series Is Not Arguing

This series is not arguing that racism does not exist in clinical settings. It does. It has been documented. The experiences of Black women who have reported dismissive, disrespectful, or discriminatory treatment in maternity care are real and are supported by patient-reported outcome data and qualitative research. I do not dispute any of that.

What I am arguing is that the causal path from racial bias to maternal mortality runs primarily through structural mechanisms, not primarily through individual clinical encounters, and that the structural mechanisms are both more powerful in their effects and more tractable as policy targets than the attitude mechanisms. I am arguing that a medical specialty that claims to be evidence-based should apply its evidence standards to the interventions it adopts for this problem with the same rigor it applies to its clinical interventions. And I am arguing that when a policy response systematically benefits institutions and systems at the expense of patients, that alignment of interests deserves to be acknowledged and examined.

The series is pro-patient. It is pro-evidence. It is impatient with responses to a mortality crisis that generate institutional activity without generating measurable improvement in the outcomes that define the crisis.

How This Series Is Structured

This series runs to ten posts published regularly The first three posts are free to all readers. Posts 4 through 10 are for paid subscribers.

Posts 1, 2, and 3 are free. Read them, share them, send them to anyone who should be thinking about this problem.

Posts 4 through 10 are for paid subscribers. An annual subscription to ObGyn Intelligence is $60 per year — less than $1.20 per week for evidence-based analysis of women’s health that you will not find written this way anywhere else. Subscribe at obmd.com.

Posts 4 through 10 cover the evidence on continuity of care, hospital quality stratification, maternity care deserts, the implicit bias training research, the doula evidence review, the postpartum coverage cliff, and the closing argument about who benefits from the current policy response. They are where the series makes its strongest case. They are what you are subscribing for.

If you are already a paid subscriber, every post arrives in your inbox automatically. You do not need to do anything. Thank you for being here.

The Ten Posts

Each post stands alone. Together they build an argument. The recommended reading order is the publication order.

Post 1 [FREE]: The Three-Times Number Everyone Cites — and What It Actually Means — Unpacking the racial mortality gap. Why the income-stratified data should have changed this conversation — and why it did not.

Post 2 [FREE]: The Insurance Ladder Nobody Draws — The reimbursement hierarchy from commercial insurance through ACA marketplace plans, union Taft-Hartley funds, and Medicaid. The access problem runs through the entire lower half of the insurance market, not just at the Medicaid threshold.

Post 3 [FREE]: Two Doors, One Building — The documented two-tier system inside academic medical centers. The global billing loophole that allows OB/GYNs to enroll in Medicaid, collect deliveries, and provide no prenatal care. The Manhattan faculty practice observation, with evidence.

Post 4 [PAID]: The “Own Doctor” Problem: Continuity, Rotating Residents, and the Patient Nobody Knows — What is lost in a rotating-provider clinic model. Why Black women with public insurance attend significantly fewer of their scheduled prenatal appointments — and what the structure of care has to do with it.

Post 5 [PAID]: The Hospital You Deliver In Is the Most Powerful Variable Nobody Discusses — The 47.7 percent simulation. Hospital quality stratification by insurance type as the dominant structural determinant of severe maternal morbidity. What actually saved lives in California.

Post 6 [PAID]: Maternity Care Deserts: When the Hospital Closes, the Root Cause Is the Same — Over 35 percent of American counties have no obstetric providers. The same reimbursement economics driving urban faculty practice refusal are closing rural delivery hospitals in Black-majority counties.

Post 7 [PAID]: The Implicit Bias Industry Has No Outcome Data — 77 studies. Zero examined patient outcomes. The evidentiary gap between what bias training is mandated to accomplish and what it has been shown to do. A mandate built on a surrogate marker that has not been validated.

Post 8 [PAID]: Window Washing: Doulas, Bias Training, and the Politics of Avoiding Hard Fixes — The April 2026 JAMA Network Open systematic review of doula outcomes. What the evidence actually shows. The regulatory vacuum. The substitution of low-cost visible interventions for structural ones.

Post 9 [PAID]: The Fourth Trimester: The Coverage Cliff Nobody Fixed — More than half of pregnancy-related deaths occur after delivery. The historical 60-day Medicaid postpartum coverage limit and what it cost in lives. Where the 12-month extension stands and what it still does not fix.

Post 10 [PAID]: Who Benefits From Keeping the Focus on Attitudes Rather Than Systems? — The closing argument. Academic medical centers, professional societies, legislators, and insurers: what each gains from the current policy response and what each would have to give up for a structural one.

The first post publishes this week. A new post follows regularly.

If this series is useful to you, share it. Send the introduction to colleagues, to residents, to anyone trying to understand what the data actually show about one of the most consequential problems in American medicine. The free posts are designed to be shared widely. That is their job.

If you have been reading ObGyn Intelligence and finding it useful, this is the series that makes the subscription worth it. Fifty years of obstetric practice, five decades of watching what works and what does not, ten posts making the case that what we have been doing is not working and what we should do instead. Sixty dollars. Forty-six cents per post. Subscribe at obmd.com.

And if you disagree with something I have written, I want to hear it. Evidence-based disagreement is the engine of the enterprise. My contact is on the site.

Amos Grünebaum, MD | Professor of Obstetrics and Gynecology | Maternal-Fetal Medicine Specialist | Senior Ethics Consultant

New York | obmd.com | ObGyn Intelligence -- Evidence Matters

ObGyn Intelligence -- Evidence Matters | obmd.com

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