Addressing Inequities to IMPROVE Maternal Health for All 

By Drs. Diana W. Bianchi, Janine A. Clayton, and Shannon N. Zenk

Today marks the beginning of Black Maternal Health Week, an observance that brings awareness to the state of Black maternal health in the United States, gives voice to the experiences of Black families, and highlights the critical need to improve maternal health outcomes nationwide.

Pregnancy-related deaths are higher in the United States than in any other high-income country, with more than 1,200 deaths from complications related to pregnancy or delivery in 2021, the most recent year for which data are available. Additionally, each year tens of thousands of Americans experience life-threatening pregnancy-related complications, also known as severe maternal morbidity. The racial and ethnic disparities in these maternal health outcomes are stark. Non-Hispanic Black people are about three times as likely as White people to die from a pregnancy-related cause, regardless of income or education level. For some causes of maternal death, these disparities are even more pronounced. Findings from an NICHD-funded study suggest that Black women are five times more likely than White women to die of postpartum cardiomyopathy (disease of the heart muscle) or the blood pressure disorders preeclampsia and eclampsia. 

In response to these high rates of pregnancy-related complications and deaths, the National Institutes of Health in 2019 launched the Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE) initiative. This NIH-wide initiative aims to reduce preventable maternal mortality, decrease severe maternal morbidity, and promote health equity. NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Office of Research on Women’s Health (ORWH), and National Institute of Nursing Research (NINR) co-lead the IMPROVE initiative. As the newest member of the IMPROVE leadership team, NINR supports research that is rooted in nursing's holistic, contextualized approach and focuses on solutions to help eliminate maternal health inequities.

The magnitude and persistence of maternal health disparities—many of which have been exacerbated during the COVID-19 pandemic—underscore the need for research to identify tailored, evidence-based solutions that are responsive to women’s lives and living conditions to improve health outcomes across the nation. In addition to racial and ethnic disparities, there are disparities by age, education, and geographic region. Millions of U.S. women of childbearing age live in areas with limited access to maternity care. One study found that women living in rural areas are at 9% higher risk of experiencing severe maternal morbidity and mortality, compared to urban residents.

In fiscal years 2020 and 2021, NIH awarded more than $20 million to support 58 IMPROVE projects to enhance our understanding of the leading causes of pregnancy-related deaths and complications and to develop mitigation strategies. These projects are diverse in scope, with focus areas ranging from biological risk factors related to maternal morbidity and mortality to the impact of structural racism and discrimination on maternal health outcomes during the COVID-19 pandemic. 

The physical demands of pregnancy are intense, and pregnancy-related complications can reveal risk for chronic diseases in later life. For example, blood pressure disorders during pregnancy are linked to a higher risk for developing cardiovascular diseases. To understand women’s health across the life course, it is important to consider biological factors, such as genetics and hormones, in combination with behaviors and contextual factors, such as social and environmental conditions. This multidimensional view, illustrated in ORWH’s Maternal Morbidity and Mortality fact sheet, is critical to improving maternal health outcomes in the United States.

Bringing in diverse voices helps to rapidly spur innovation and problem solving. Last year, we launched two ongoing challenge competitions as part of the IMPROVE initiative. The Rapid Acceleration of Diagnostics Technology (RADx® Tech) for Maternal Health Challenge is advancing development of easy-to-use technologies for people or their local health clinics to assess whether additional medical care is needed after delivery. The Connecting the Community for Maternal Health Challenge encourages U.S.-based nonprofit organizations to develop the infrastructure and capabilities necessary to conduct maternal health research. In addition, we are building our connection with the community to drive adoption of evidence-based practices to improve maternal health through our support of the IMPROVE Community Implementation Program and a focus on implementation and dissemination research.

This summer, we look forward to issuing grants to establish Maternal Health Research Centers of Excellence. Awardees will work collaboratively with each other and with community partners to design and conduct research projects to address the biological, behavioral, environmental, sociocultural, and structural factors that affect maternal morbidity and mortality in populations that experience health disparities. With these awards and future funding announcements through IMPROVE, NIH will continue to support research to help understand maternal health, improve pregnancy outcomes, and help eliminate inequities. 

To stay up to date on new developments in maternal health research, visit the IMPROVE website and the NIH Maternal Morbidity & Mortality (MMM) Web Portal. An initiative of ORWH, the MMM Web Portal offers trustworthy, science-based resources relevant to maternal health across the lifespan for scientists, researchers, consumers, and advocates.

Diana W. Bianchi, M.D.
Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development
National Institutes of Health 

Janine Austin Clayton, M.D., FARVO 
Associate Director for Research on Women’s Health
Director, Office of Research on Women’s Health
National Institutes of Health 

Shannon N. Zenk, Ph.D., M.P.H., RN, FAAN
Director, National Institute of Nursing Research
National Institutes of Health