When I delivered my first child, I was diagnosed with thrombocytopenia, a condition that caused excessive bleeding and made an epidural too dangerous. After delivery, stress triggered both preeclampsia and shingles. My daughter spent her first week in the NICU while my family prayed over us both, and I remained on bed rest.

This time, I had a health care team that was prepared to support me through my pregnancy. But too many women don’t have access to that level of care or planning. And a healthy delivery is just the beginning. For many families, the challenges can mount up quickly: a lack of paid leave, unaffordable child care and limited postpartum support. These aren’t personal failings — they’re systemic gaps. And they’re among the reasons .

Recently, I’ve heard a lot of ideas about how to encourage people to have more children, including suggestions from the , such as motherhood medals or one-time baby bonuses. I’ve seen these issues from every angle as a mother, an advocate and as the executive director of the (NAFCC). The answer is clear to me. To build a country where families want to — and are able to — raise children, we must start with three core policies: improving maternal health care, expanding paid family leave and making child care more accessible and affordable.

Improve Maternal Health

The for maternal mortality among wealthy countries. The numbers are even more devastating for , who are nearly three times more likely to die from pregnancy-related causes than white women, regardless of education or income.

As a Black woman with a college education, I face a pregnancy-related mortality rate that is than that of my white counterparts. This time around, I’m fortunate to have a Black OB-GYN who understands these disparities, but many women don’t have access to culturally competent care or even basic prenatal services. Over 2.2 million women live in “,” with another 4.8 million in areas with limited access to maternity care.

Solutions exist. Expanding , especially in rural communities, and ensuring pregnant women have access are meaningful steps toward safer outcomes for all mothers. Additionally, bills like the, introduced in 2019 and 2021, seek to make sure investments are targeted where they are needed most. But there’s significantly more work to be done.

Increase Access to Paid Leave

After my newborn and I made it home in good health, I, like most other parents of young children, had to contend with the tradeoff between staying at home or maintaining employment. Unlike most other developed countries, the U.S. policy. My husband and I are fortunate enough to have paid parental leave plans from our employers, but nearly , according to the U.S. Bureau of Labor Statistics. This forces many parents to return to work before they’re ready or to leave their jobs entirely.

As of 2024, thirteen states and Washington, D.C., have . It’s time to scale these solutions nationally. No parent should have to choose between a paycheck and bonding with their newborn.

Expand Access to Affordable, High-Quality Child Care

To add to the challenge of welcoming a new baby into the family, once parents do return to work, they face yet . For many families, child care payments are and . And yet, the median wage for early educators nationally is $13.07 per hour, according to the published by the Center for the Study of Child Care Employment. 

The math doesn’t work. The cost of sustaining a quality child care system exceeds what families can pay, but still leaves educators underpaid. The solution is publicly funded, universally available child care — something states like are modeling well.

As I take this special time to bond with my new baby and adjust to being a mother of two, my greatest wish is for better family-friendly policies for all American families. Specifically, policies that improve maternal health care and increase access to paid leave and affordable, high-quality child care. If we truly want to encourage and support families in raising children, we must stop asking them to do it alone. These babies will grow up to be our leaders, caregivers and changemakers. The least we can do is ensure they, and their parents, have the support they need to thrive.

Here are our top 10 takeaways from the conversations:

1. We can look to nature for inspiration. When elephants birth in the wild, the whole herd circles around the laboring elephant. They stay for the entire labor, providing connection, support, protection and defense. “That’s what we think humans need in the perinatal period as well,” Indra Lusero, founder of Elephant Circle, said on Aug. 30. Elephant Circle brings an intersectional, feminist, reproductive justice and design-thinking approach to birth justice to make true transformation possible.

2. The current system is failing families. According to recent data from the Centers for Disease Prevention and Control, 1205 women ” in 2021, and .

The maternal mortality rate in the U.S. rose between 2018 and 2020, showcasing the impact of the COVID pandemic on the pregnant population and resulting in nationwide health care system disruptions. “Things aren’t fair, things aren’t set up justly and we’ve got to start tackling those big issues,” Lusero said.

3. Black women experience an immense burden. During the Sept. 13 talk, Stephanie Aristide of BMMA explained that gaps in the pregnancy mortality rate between racial groups have widened over the past 15 years. In 2020, Black women were disproportionately affected by maternal death, with a mortality rate of 55.3 deaths per 100,000 live births — a significant increase from 2019.

The work of the BMMA is deeply rooted in reproductive justice, birth justice and the human rights frameworks to ensure that all Black mamas have the rights, respect and resources to thrive before, during and after pregnancy.

4. History offers essential context. “When presented with the appalling statistics surrounding Black maternal health in the U.S., we must always take a deeper dive into the root causes of these issues,” explained Aristide. “The regulation of Black women’s reproductive decisions has been a central aspect of racial oppression in America.”

She provided a number of examples: “Enslaved pregnant Black women were forced to work in plantation fields until their labor, rarely given a chance to rest and bond with their babies and were required to return to the fields with their babies strapped on their backs.”

Aristide continued, “The institution of slavery in the U.S. opened the door for all types of unjust medical experimentation on Black women’s bodies, from experimental vaginal surgeries without anesthesia, to stealing cervical cancer cells, all in the name of advancing science.”

These and other atrocities set the stage for persistent harm to Black bodies. Throughout time, Black institutions such as the Tuskegee Institute, churches, community organizations and Black women’s clubs addressed these issues through health education and preventative service initiatives like the National Negro Health Week in the early 1900s.

5. Equitable health care is a human right. “Human rights is a critical dimension,” Lusero said. “When talking to people about issues facing them in the perinatal period, a sense of justice… is really important. People don’t just want clinical solutions or solutions that are familiar. People want things that get at fundamental, core issues of inequities.”

While equity is top of mind for those navigating the system today, the idea remains elusive. “There’s a lot of interest in health equity, but how health equity can be achieved is not understood,” Aristide explained. “Maternal health is still deeply entrenched in the patriarchal narrative that only cares for women’s bodies in relation to being able to have a healthy baby. And interventions to address adverse maternal health outcomes focus heavily on individual behavior change.”

George Davis, a community advocate with Elephant Circle, mused, “A lot of times, the answers to the problems that we’re looking for have not been thought up yet. We’ve only felt the pain from dealing with this thing.”

6. Solutions exist beyond the status quo. “Policies that only look at services within the traditional medical context are extremely limiting and do not address the core problems of health inequities. They often further aggravate the problem,” Aristide said in the Sept. 13 talk.

Lusero echoed the sentiment on Aug. 30: “If we’re going to change the status quo, we have to innovate. We need new feedback loops. We need accountability.”

Davis pointed out that we must start at the root to inspire meaningful solutions, “So often, things are looked at to be changed on the branches, or the leaves, by pruning, when the problem is so deep in the root. Birth equity and reproductive justice are starting at the root to create change.”

7. Birth work is a powerful pathway. Strong evidence shows that birth work improves outcomes. “Of course, we have to look really largely at the systemic issues behind maternal mortality and morbidity, but birth work is a really important piece of that puzzle,” Lauren Smith of Elephant Circle said during the August talk.

Historically, Black midwives were vital maternity caregivers for communities, especially in the South. Aristide explained, “Over time, discriminatory public policies restricted Black midwives, depleting the maternal care workforce.” BMMA aims to address this gap with its workforce development policy and programming initiatives like the Black Maternal Health Institute and Incubator Hub.

“The goal is to work toward equitable maternal and birth outcomes for Black birthing people through systemic change at the community and state levels.” Milan Spencer of BMMA said. “In very tangible ways, we are building the capacity of our workforce through training and education.”

In addition to this learning space, they annually assemble Black women, clinicians, professionals, advocates and other stakeholders working to improve maternal health at the . They host Black Maternal Health Week every April to build awareness and amplify voices.

8. We must listen to learn and learn to listen. “When listening, you’re engaging in a mindset. It requires you to be generous and generative,” Indra said when explaining the power of listening to other people’s stories.

Pia Long of Elephant Circle said, “It’s important that people tell their story, and it’s even more important that we come up with solutions so that we don’t have to keep telling these stories, so that folks don’t continue to have this pain and trauma that happens when they go to give birth in the United States.”

9. Policy efforts should require community input. “Ultimately, all conversations regarding maternal deaths, policy solutions and improvements needed to the systems contributing to maternal mortality should start and end with the community,” said Stephanie Aristide of BMMA.

To inform a set of bills in Colorado collectively called the , Elephant Circle toured 1200 miles, with stops around the state to engage those who normally don’t have a seat at the table. “By ensuring that community voices and directly impacted people were in every conversation, every stakeholder meeting, it changed the power dynamic at that stage, which helped change the power dynamics reflected in the policies, which helped us pass these bills,” Lusero said.

The essence of the bill package is beyond what’s written into statute. “It’s how we did it and the spirit we brought to it. That’s the spirit we need in the perinatal period, that feeling of being circled around, being part of the herd. Knowing that we have to take care of each other.”

10. Everyone has a part to play in improving outcomes. “You don’t need to be a lobbyist to be an advocate,” Lauren Smith said.

Similarly, you don’t need to identify as a woman to get involved in birth justice work. “As a male, at first, I was like, this isn’t for me. I don’t know what we’re doing. Then I began to listen, ask questions, and study on my own and find out this is exactly where I’m supposed to be,” George Davis said of his experience at Elephant Circle. “In fact, more fathers, men, everyone needs to know about this because this is something that we’re all in together. Reproductive justice, birth equity, we are all born. So it’s a wonderful place to start.”

For those looking to get involved, Milan Spencer from BMMA said, “Our recommendation is to seek out those community-based, grassroots organizations that are leading initiatives locally and get involved in their efforts. Express your passion. Ask what their needs are and what support looks like to them.”

Here are 5 top takeaways:

1. Racism is at the root of health disparities. Not all U.S. mothers and babies go through the same experiences in the same way. The infant mortality rate among Black newborns is more than twice that of white babies during the first year. Mothers of color die during childbirth more than three times as often as their white peers. “Racism is the root of where racial disparities begin,” said Sanchez Lloyd — whose work is an initiative of First Steps Kent.

Contrary to the hypothesis that economic circumstances can explain the gap, a conducted by the National Bureau of Economic Research shows that household income plays no role in determining maternal and infant health outcomes. Increasingly, these disparities are recognized as a problem with implicit biases within health care and other systems.

2. Educating physicians and clinical care workers is paramount. Required lessons and tools to investigate personal biases, power and privilege improve the quality of care. Recommended measures include using proper pronouns, pronouncing names correctly and appropriately addressing questions to fathers and other caregivers in the room.

Sanchez Lloyd explained that clinical workers need to “add more humanity and see the entire patient, beyond what is written on their chart.” These efforts make mothers feel they have a voice to advocate for themselves effectively. In addition to educating clinical partners, it is important to engage family and community support systems.

3. Fathers should be in the fold. “We want to break this narrative that Black fathers don’t exist or that they are not present.” Sanchez Lloyd said, “Continuing to approach this from a maternal child health standpoint, we’re leaving out a key ingredient: fathers.”

Outcomes improve when fathers are involved because mothers feel more supported. “You don’t have to be in a romantic relationship with the mother of your child to be a great dad,” she said. Strong Beginnings’ , covers unconventional topics historically left out of fatherhood and recently went virtual. The lessons range from family planning, and prenatal to 18 months after delivery. They ensure fathers feel supported by offering access to mental health therapists and other community resources.

4. Nonclinical, community support is essential. “Community-based prevention strategies help avoid hospitalization and long-term chronic illness,” Spencer explained. “We need to ensure that people have access to the resources they need,” such as housing and a living wage.

Community health workers and doulas are also part of the systemic response. “Community doulas provide physical, emotional and educational support to pregnant and postpartum people up to the first year of birth,” Spencer explained. “They are a reflection of the community. When people are assisting others in the community that they belong to, we tend to have better outcomes.”

5. Some states are making strides. States play an influential role in the implementation of effective, high-value maternity services, particularly through insurance regulations. Medicaid is the health insurer of over 40% of births in the United States and 66% of all births to Black mothers.

Virginia recently became the fourth state to reimburse doulas under their Medicaid program. As of Jan. 1, the Michigan Department of Health and Human Services recognized doula initiatives as being reimbursable. Several other states are in various stages of consideration, planning or implementation of Medicaid doula reimbursements. “There are some gaps, and doulas have shown that they can be present in those gaps, which leads to successful deliveries,” Sanchez Lloyd said.

focused on solutions for the perinatal phase, which goes from pregnancy through the first year postpartum. Nine innovators presented, then a roundtable zeroed in on Colorado’s recently passed package of birth equity bills, which highlighted how social entrepreneurship can drive policy innovation.

Promise Venture’s Vance Lewis, senior program manager and Awara Mendy Adeagbo, head of strategic initiatives) moderated the virtual event. Adeagbo referred to her personal health journey on the way to giving birth to her baby son last year, saying, “Having a positive birth outcome should not be a matter of luck. The maternal and infant health crisis… is unconscionable and it’s preventable. We can turn this tide by centering the perspectives, experiences and needs of BIPOC communities in a strength-based, holistic way.”

Here are our takeaways from :

1. The history is shameful. , Black moms are dying at 3 to 4 times the rate of their White counterparts. The statistic is the product of a long history, from slavery and Jim Crow through the disinvestment and policy choices of today. In recent decades, politicians and the media have, in essence, blamed the victim through a narrative that questions mothers’ decisions.

According to Kiley Mayfield of the , this focus on individual behavior has distracted us from systems of oppression that have been in place throughout the nation’s history. Marqi Taylor, founder of Philadelphia’s called out “centuries of racial malpractice” that have led us to the point where people of color often don’t trust the medical institutions where they live, which is why activists have formed alternative communities.

2. Birth centers and doulas listen to women and birthing people. ’s mission is to develop “abundant community birth infrastructure.” Safe, culturally relevant midwifery, explained Leseliey Welch, improves maternal health outcomes and reduces the number of caesarean deliveries. Char’ly Snow of said birth centers not only save lives, they reduce insurance costs by $2,000 per birth.

The solution isn’t expensive technology but rather caring, trusting relationships. Twylla Dillion of and Tia Murray of made similar arguments for birth doulas who help women navigate the experience, advocate for them and make them feel supported.

3. Data counts—but what kind? Echoing Lewis, who cited the human right to “maintain personal bodily autonomy,” Kimberly Seals Allers, of (that is, the word Birth minus the B for Bias) declared, “Bias-free care should be a human right.” Describing the Yelp-like app for pregnancy and new motherhood, Allers asserted, “Community-driven feedback loops lead to more respectful and equitable maternal and infant care.” Tracy Warren of made the case for better data informing decisions in government and by institutions.

4. Let communities lead. On July 6, the State of Colorado signed a groundbreaking establishing basic human rights standards in perinatal care for all people (including those who are incarcerated), aligning perinatal care data and systems for equity and continuing the Direct-Entry Midwifery program. (According to the , a Direct-Entry Midwife is “an independent practitioner educated in the discipline of midwifery through apprenticeship, self-study, a midwifery school, or a college/university-based program distinct from the discipline of nursing.”)

Show+Tell celebrated the work of , which championed the package. Founder and director Indra Lusero stressed the importance of listening to community members and letting their priorities dictate strategy.

5. Stay tuned for further progress. Activists and advocates continue to push for local and national solutions. Joy Spencer of talked about building dignity through income supports where paid parental leave is missing. Led by Alma Adams (D-NC) and Lauren Underwood (D-IL), the U.S. House of Representative’s Black Maternal Health Caucus recently unveiled the . The legislation aims reverse the tragic history of BIPOC perinatal health through targeted public investment.

Sabra Bell remembers what it was like to be pregnant and low on funds. “Extra cash would have been useful,” she says. “I would have paid off my debts and bought a nice stroller, crib, breast pump, baby clothes and more.”

Today, Bell and other mothers are drawing on their personal experience in their work as researchers on the Abundant Birth Project, an ambitious pilot seeking to reduce the incidence of premature birth in San Francisco.

Starting in 2021, the program will distribute a monthly income supplement of $1,000-$1,500 per month to 100 low-income black and Pacific Islander pregnant women. Payments will continue for the duration of a woman’s pregnancy and then for the first two months of the baby’s life.

Kara Dukakis, an early childhood development senior program officer at , which is one of the pilot’s funders, champions the Abundant Birth Project for the way it explicitly acknowledges racism as a factor in these women’s lives. “An incredibly important part of the pilot is that women of color are hired to be the researchers,” she says. “Because they have lived the experience, they can truly empathize with the women the project supports.”

Maile Chand, another researcher who has “been there” herself, adds, “Not only will this financial opportunity help San Francisco black and Pacific Islander families better provide for their children, but it will also transform the emotional and physical state mothers are in going into their birth.”

The Science Behind the Project

The Abundant Birth Project is grounded in both science and respect for moms. Thanks to advances in medical science, premature babies have a far greater chance to survive and thrive than ever before, but it’s still ideal for a pregnancy to last 40 weeks, or close to it. Cognitive deficits and physical disabilities frequently accompany preterm births, and black women give birth prematurely, as white women.

“The strain of ongoing financial insecurity,” says Dr. Zea Malawa, director of Expecting Justice, “contributes to chronic stress and is associated with premature birth. Although San Francisco has programs to address poverty, they are not enough to close the gaps. The high rates of preterm birth experienced by the black and Pacific Islander community require a more urgent and upstream intervention.”

The Abundant Birth Project builds on of Jackson, Mississippi, which distributed $1,000 monthly for 12 months to 20 women. , was found to help women to improve their nutrition, prepare for baby and engage in self-care to moderate the effect of stressful life events. Reduced incidence of low-birth-weight infants and pre-term birth also resulted.

Free Money? What’s the Catch?

There is no catch.

Unlike conditional cash transfer programs, which distribute money only when subjects adhere to certain behaviors (for example, attending school or visiting the doctor), the program commits to awarding stipends without stipulation.

“Most public assistance programs have complicated eligibility requirements,” says Deborah Karasek, a researcher with the at the University of California, San Francisco, which is partnering with on the Abundant Birth Project. “However well intentioned, these requirements often prevent black and Pacific Islander pregnant women from obtaining the resources they need—and they tend to exacerbate mistrust in the system.”

The Abundant Birth Project, in contrast, provides direct, unconditional cash aid—returning to women the power to make their own decisions.

Pregnancy can simultaneously bring great joy and acute stress. Even for mothers with a steady partner, financial resources and robust social networks, this time can be overwhelming, even traumatic. Pregnant women without these assets are susceptible to mental and physical health threats—and this is before a new person suddenly enters the picture, demanding food, attention and medical care.

The Abundant Birth Project won’t make everything right for the moms and babies it touches—but it’s a start.

I spoke to Dr. Joia Adele Crear-Perry, founder of not one but two efforts that confront these issues — and —about the scope of the crisis and what can be done.  Crear-Perry, a mother of three children, formerly served as director of clinical services for the City of New Orleans Health Department. In 2016, she addressed the United Nations Office of the High Commissioner for Human Rights to urge a human rights framework to improve maternal mortality.

“It’s in my nature to ask ‘why,’” Crear-Perry explains. For example, upon discovering that the State of Missouri would expand Medicaid access to moms addicted to opioids, her immediate question was: Why just opioids? Is there a medical reason to include just this one type of addiction that happens to be associated with poor white people? At the forum where she brought up this concern, the author of the provision said he never thought if it that way.

“We should have fixed this during the crack epidemic,” Crear-Perry insists, recalling indignantly that when a mother, a pharmacist, went to the emergency room as a patient, the staff treated her like she was there for the free drugs.

The matter of who is and is not eligible for Medicaid coverage has life-and-death consequences. of the Center on Budget and Policy Priorities, “Medicaid coverage improves families’ financial security by protecting them from medical debt and helping them stay healthy for work. Medicaid coverage also has long-term health, educational and financial benefits for children.”

It follows, therefore, that if the program is implemented in ways that discriminate against one group, there will be adverse health consequences—suffering and, let’s face it, death—for people in that group, especially if they are already vulnerable due to other social and economic factors. Crear-Perry points to Medicaid expansion in Michigan, which has work requirements, but only in Detroit and Flint, ostensibly because these two urban areas have low unemployment rates.

These problems don’t just affect Black people, though. When Crear-Perry lived in Louisiana, she could see how the racial narrative around public benefits affected all low-income families. “When poor whites start to think, ‘These are for poor people,’ they mean poor black people, and it makes them less likely to avail themselves of supports,” she notes.

Crear Perry does believe there are reasons to be optimistic about the overall health and race picture in the United States. “Students and residents are more receptive,” she says, noting that are pushing medical schools to address racism in their curricula.

Take one extremely revealing index: the perception among medical professionals that black skin doesn’t “feel pain” as much as white skin. The bias is less prevalent among younger doctors. “You can’t end racism,” she admits, “but you can fundamentally change the acceptability of it.”

For Crear-Perry, one of the most promising—and underappreciated—avenues for systemic change in the field of health care in general and reproductive justice specifically has to do with how Medicare (and private insurance companies) calculates the dollar value of a medical intervention. Initiated in 1989, the Relative Value Unit (RVU) system establishes the value of 7,000 distinct nonsurgical and physician services. (The late economist Uwe Reinhardt wrote two wonkish but relatively clear-sighted blogs about RVUs for The New York Times in 2010; see and .)

“The inherent devaluation of women’s health is embedded in our RVU system,” Crear-Perry says. “Hospital CEOs often call Labor and Delivery Units a loss leader. They know that it is underfunded, but they have data that shows women make the household decisions on health care. So they are willing to lose money on the care for a woman because she will bring her husband to that hospital for a knee surgery that they do make money off of, or cardiac catheterization for their fathers.”

Making health care professionals more aware of systemic biases may be an uphill battle, but advocates like Crear-Perry are making vital progress.