Striving for Birth Equity: Family Medicine's Role in Overcoming Disparities in Maternal Morbidity and Mortality

August 6, 2020

Executive summary

Maternal death is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”1 According to the World Health Organization, global maternal mortality declined nearly 40% between 2000 and 2023.2 In the United States, the maternal mortality rate decreased from 22.3 deaths per 100,000 live births in 2022 to 18.6 deaths per 100,000 live births in 2023.3 However, the U.S. maternal mortality rate is still one of the highest among high-income countries.4

According to data from maternal mortality review committees (MMRCs), approximately 87% of pregnancy-related deaths in the United States result from preventable causes.5 There are significant disparities in the distribution of maternal mortality rates, with higher rates of mortality occurring among Black women, women with low income and women living in rural areas.6 The factors driving these inequities are complex and intersect with clinical care, patient health, and systemic and public health factors on many levels. The American Academy of Family Physicians (AAFP) believes family physicians must play a significant role in addressing inequities in maternal morbidity and mortality. They are trained to provide comprehensive care across the life course—including prenatal, perinatal and postpartum care—for people in the communities where they live.7

Introduction

From 2017 through 2023, there were 796 pregnancy-related deaths per year on average in the United States, with a peak of 1,222 reported deaths in 2021.8 Among the maternal deaths in 2021 for which timing is known5:

  • 19.5% occurred during pregnancy
  • 9.1% occurred on the day of delivery
  • 14.1% occurred one to six days postpartum
  • 29.2% occurred one week to 42 days postpartum
  • 28.1% occurred 43 days to one year postpartum

Data from maternal mortality review committees in 46 states indicated that approximately 87% of pregnancy-related deaths in 2021 were preventable.5,9 The leading underlying causes of death included infection, mental health conditions, cardiovascular conditions, hemorrhage, embolism and hypertensive disorders of pregnancy.5 In addition to underlying causes, the MMRCs noted circumstances that were present and contributed to the chain of events leading to a pregnancy-related death (e.g., obesity, substance use disorder, mental health conditions). In particular, discrimination was cited as a circumstance that contributed to nearly 33% of pregnancy-related deaths in 2021.5

In 2023, the maternal mortality rate in the United States was 18.6 deaths per 100,000 live births.3 The rate was significantly higher for pregnant people aged 40 and older (59.8 per 100,000 live births). At 50.3 deaths per 100,000 live births, the maternal mortality rate for non-Hispanic Black people was more than triple that of non-Hispanic white people (14.5 per 100,000 live births ) and Hispanic people (12.4 per 100,000 live births). These reported rates notably exclude the approximately 28% of maternal deaths that occur 43 days to one year postpartum.3,5

Social determinants of health exacerbate many of the inequities in maternal morbidity and mortality. The closure of rural hospitals and obstetrics (OB) programs has severely limited access to prenatal and perinatal services for pregnant people living in rural and underserved communities. Gaps in insurance coverage and a lack of affordable care for pregnant people with low income also increase the risk of morbidity and mortality, particularly during the postpartum period.

Call to action

Family physicians have a vested interest in policies and practices that advance the health of their patients and their communities. A number of structural and institutional barriers to achieving better outcomes and equity in prenatal, perinatal and postpartum care exist. They must be addressed with actionable solutions supported by broad-based policy changes. As medical experts and trusted members of their communities, family physicians serve as effective agents to facilitate and advocate for change.

Physician level

  • Understand how implicit bias may influence patient interactions and clinical decisions, and implement practical approaches to identify and reduce its impact on daily practice
  • Provide obstetrical and maternity care in a rural community or partner with other clinicians providing these services in rural communities
  • Identify and encourage development of CME and other training opportunities on topics such as patient safety bundles, implicit bias and health/birth equity
  • Participate on local MMRCs and hospital credentialing boards
  • Advocate for policies to increase birth equity at the practice level and within the hospital system, including continued robust, standardization, and mandatory data collection and reporting
  • Advocate for Medicaid expansion, payment parity and postpartum coverage to increase access to care for patients across their reproductive life course

Practice level

  • Perform universal depression screening during the perinatal and postpartum (i.e., fourth trimester) periods
  • Screen for social determinants of health, including food insecurity, housing instability and unreliable transportation
  • Integrate local public health services and programs into maternity care visits

Education level

  • Learn about the effects of implicit bias and develop an action plan for addressing personal biases
  • Develop best practice guides to help family physicians retrain and gain privileges to provide obstetrical care
  • Support family medicine preceptorship programs in rural and underserved communities
  • Advocate for funding to expand medical education opportunities for students in rural and underserved communities
  • Advocate for funding to expand graduate medical education opportunities for family physicians and obstetricians to train in rural and underserved communities

Advocacy level

  • Advocate for the expansion of Medicaid coverage, extension of Medicaid maternity coverage to one year postpartum and provision of adequate reimbursement for obstetrical services
  • Advocate for the expansion of current loan repayment programs or incentives—including the National Health Service Corps and the federal Public Service Loan Forgiveness Program—to obstetrical care provided by clinicians that include family physicians, OB-Gyns, certified nurse midwives, and labor and delivery nurses, as well as to community health centers
  • Advocate to allow rural obstetrical care providers—and potentially rural hospitals—to be eligible for Federal Tort Claims Act medical malpractice liability protection
  • Increase payment parity for obstetrical and maternity care provided by family physicians
  • Advocate for policies that incentivize hospitals to use credentialing measures (including those for surgical procedures) that are more equitable and inclusive of family physicians
  • Advocate for reimbursement of nonmedical maternal support (e.g., doula programs, community health worker programs, food vouchers, education, breastfeeding and support-system care, nutritionist programs, home visits) in rural and urbanized communities with a higher risk of maternal morbidity and mortality
  • Advocate for investment in telehealth access in underserved areas

Barriers to achieving equity in maternal morbidity and mortality

Institutional and structural racism
The AAFP recognizes that the root causes of racial and ethnic inequities in maternal morbidity and mortality are complex and interconnected. They include institutional racism, personally mediated racism, implicit bias, and a lack of leadership diversity in the health care and social service delivery systems, as well as broader social and economic inequities.

Institutional racism is characterized by governments and organizations imposing patterns, procedures, practices and policies that consistently penalize and exploit people because of their race, color, culture or ethnic origin.10 In health care systems, these policies and practices may lead to less recruitment and retention of clinicians who can provide culturally responsive care. Institutional racism can affect physicians’ attitudes, beliefs and behaviors toward their patients, resulting in differences in treatment and quality of care.11

While institutional racism operates at the systemic level, racism can also occur at the individual level. Personally mediated racism happens when physicians’ conscious or unconscious attitudes and stereotypes about racial or ethnic groups result in substandard patient care.11 A significant aspect of personally mediated racism is implicit bias, which often operates unconsciously. In the U.S. health care system, implicit bias is shaped by a long, sordid history of institutional racism and discrimination against people of color. Evidence indicates that implicit bias is pervasive among health care professionals and has deleterious effects on patient health.12-14

Implicit bias modifies the physician-patient relationship by reducing trust, self-efficacy, understanding and satisfaction.15 For patients, this affects their ability to manage their own health and adhere to treatment. For example, this form of discrimination can lead to delayed preventive health screenings, such as mammograms and Pap smears.16-18 For physicians, implicit bias limits their level of cultural proficiency, patient centeredness and job satisfaction.

The academic medical community has recognized that changes in the knowledge, behaviors and practices of students, residents and physicians are necessary to limit the detrimental effects of implicit bias on patient health outcomes. This requires the development and implementation of medical education and training approaches rooted in both theory and research. In recent years, medical education programs have started to address implicit bias and institutional racism. On a 2018 Council of Academic Family Medicine Educational Research Alliance (CERA) survey, 78% of family medicine residency programs reported having faculty and resident training focused on these topics.19 Most family medicine residencies also reported having initiatives to address workforce diversity. However, responses to the CERA survey in 2020 indicated that many program directors considered structural racism an important topic but had no formal racial justice curriculum.20 A 2021 CERA survey of family medicine residents found that most respondents viewed addressing racism as an important goal, but few programs had a longitudinal curriculum.21 These gaps in formal curricula and longitudinal approaches indicate that more comprehensive efforts are needed. Additional research must be done to develop best practices for decreasing the impact of implicit bias on the standard of care for underserved populations and increasing access to quality care.19

Research has shown the persistent nature of implicit bias and its impact on clinical decision-making and patient health. For example, studies have found that some students entering medical school harbor implicit bias toward patients from racial and ethnic minority groups and that their level of bias remains constant or increases over time.22 In a study involving a sample group of white medical students and residents, half endorsed false beliefs about biological differences between Black people and white people.23 As a result, they viewed Black patients’ pain levels as lower than white patients’ pain levels and made less accurate treatment recommendations for Black patients.

The AAFP considers racism a public health crisis and continues to strongly advocate for addressing health inequities and negative health outcomes of racism in patients who often have a higher risk of heart disease, stroke, diabetes, low birth weight, premature birth and infant mortality.24 However, the elimination of health disparities will not be achieved without first acknowledging racism’s contribution to health and social inequities, including inequitable access to quality health care services.

Continuing loss of rural obstetrical services
Access to obstetrical services in rural areas is declining. Between 2010 and 2022, more than 238 rural hospitals in the United States closed their obstetrical units, with additional rural units at risk.25 As of 2022, 59% of rural U.S. counties were without hospital-based obstetrical services.26 In addition to a lack of facilities, rural communities face complex issues that include transportation challenges, increased poverty, higher rates of chronic diseases, and difficulty recruiting and retaining physicians.27,28 These factors further restrict access to quality maternity care and contribute to poorer maternal health outcomes.

Recent federal legislation has attempted to address access to health care in rural areas, but results have been mixed. The Rural Physician Workforce Production Act (H.R. 1153)—originally introduced in 2019 and reintroduced in February 2025—aims to provide federal support for rural residency training to help alleviate physician shortages.29 As of November 2025, this legislation had not yet passed the House. The One Big Beautiful Bill Act, passed in July 2025, reduces access to care by cutting Medicaid and may result in loss of revenue and funding for rural hospitals due to loss of patients covered by insurance.30,31 However, the law also includes $50 billion for a rural health transformation program that runs from fiscal year 2026 to fiscal year 2030. States must submit plans outlining how they will utilize the funds to address issues such as health care access and outcomes, technology adoption and financial stability. It is unclear how this legislation will affect rural health progress.

Medicaid is a vital source of maternity care coverage in rural areas. According to the Centers for Disease Control and Prevention (CDC), 40.2% of all births in 2024 had Medicaid as the payment source for the delivery.32 To help improve health outcomes and maintain coverage stability, the American Rescue Plan Act of 2021 gave states the option to extend Medicaid postpartum coverage to one year.33 As of January 17, 2025, 49 states and Washington, DC, had implemented the 12-month extension, a change expected to reduce postpartum coverage gaps and improve access to essential care in rural communities.

Rural communities comprise about 46 million people, or 14% of the U.S. population.34 Family physicians are more likely than other specialists to live and work in rural areas,35 and approximately 50% of all outpatient visits in the United States are to primary care physicians.36 The AAFP is committed to eliminating health disparities in rural communities through strategies that include supporting the retention of family physicians in these areas and advocating for payment reform, medical malpractice reform and loan repayment expansion.

Impact of allostatic load and weathering
Allostatic load refers to cumulative physiological "wear and tear" resulting from chronic stress and helps explain how structural inequities negatively influence birth outcomes.37 The persistent activation of stress pathways—often linked to racism, poverty and discrimination—contributes to conditions such as hypertension, preterm birth and low birth weight. This concept aligns with the theory of “weathering,” which suggests that prolonged exposure to chronic stress and social adversity accelerates biological aging and increases maternal risk, particularly among African American women.38 The chronic stress experienced by these women can lead to a higher prevalence of adverse birth outcomes, underscoring the need for targeted interventions.

To achieve more equitable birth outcomes and improved maternal health, the AAFP advocates for a comprehensive approach that addresses both allostatic load and the effects of weathering by reducing chronic stress and social adversity. Structural interventions might include policies that combat systemic racism and economic inequities, while social interventions could involve community support programs that provide resources and stress-relief opportunities. Clinical interventions could focus on providing pregnant people with adequate prenatal care and stress management strategies. Each of these interventions plays a vital role in supporting maternal well-being and mitigating the cumulative impact of stress.39

Evidence-based methods to decrease maternal morbidity and mortality
A number of evidence-based methods are being used to address maternal morbidity and mortality at the national and state levels. These methods include, but are not limited to, the following:

  • Alliance for Innovation on Maternal Health (AIM) patient safety bundles
  • Maternal mortality review committees
  • California Maternal Quality Care Collaborative (CMQCC) toolkits
  • Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE) initiative

The AAFP supports the dissemination and use of existing evidence-based tools and resources within hospitals and physician practices by practicing physicians and medical trainees to address inequities in maternal health outcomes. In addition, the AAFP calls for standardization and continuation of robust data collection and reporting on maternal mortality to enable stakeholders to better define data collection needs and identify gaps in existing research.

AIM patient safety bundles
The AIM program is a quality improvement initiative designed “to reduce maternal mortality and severe maternal morbidity (SMM) within the United States” and has been used concurrently with other maternal safety initiatives (e.g., MMRCs).40 The building blocks of the program’s efforts are AIM patient safety bundles, which are collections of best practices for maternity care developed and endorsed by national multidisciplinary organizations.41 These bundles focus on key issues for pregnant and postpartum patients (e.g., obstetric hemorrhage, hypertensive disease in pregnancy, perinatal mental health) to help standardize care and reduce preventable maternal complications. The AIM program’s objectives include increasing technical assistance for participating states that are implementing AIM patient safety bundles, increasing the number of birthing facilities implementing the bundles, supporting widespread implementation of the core bundles, and increasing the overall number of core bundles being implemented and sustained.40 The AAFP supports the development of AIM patient safety bundles through its participation in the AIM Clinical and Community Advisory Group, a collaboration of professional organizations in women’s health care.

Maternal mortality review committees
MMRCs play an important role in the collection and dissemination of maternal health data, and many U.S. states have started implementing them.42 These committees study local maternal death cases and identify key factors that inform strategies for making pregnancies safer and preventing tragic outcomes.43 It is important for all stakeholders—including researchers, policymakers and clinicians—to support MMRCs and for family physicians to participate in these collective efforts.

As MMRCs emerged, it became evident that defined data standards would allow better access to population health data across state lines. The CDC partnered with MMRCs and subject matter experts to create the Maternal Mortality Review Information Application (MMRIA).44 The MMRIA provides standardized data that can be used for surveillance, monitoring and research related to maternal mortality. It also provides a common data language to help MMRCs collaborate in case review and analysis.45

The AAFP supports efforts to develop, implement and sustain MMRCs. It strongly advocated for the successful passage of the Preventing Maternal Deaths Act in 2018. This law, which incorporated provisions of the Maternal Health Accountability Act, “sets up a federal infrastructure and allocates resources to collect and analyze data on every maternal death, in every state in the nation. [It] is intended to establish and support existing [MMRCs] in states and tribal nations across the country through federal funding and reporting of standardized data.”46

CMQCC maternal quality improvement toolkits
CMQCC is dedicated to enhancing maternal and infant health outcomes through data-driven quality improvement strategies.47 It leverages comprehensive datasets to create evidence-based toolkits that address the primary causes of preventable maternal morbidity and mortality. Hospitals participate in quality improvement collaboratives to facilitate the implementation of these resources, utilizing CMQCC’s Maternal Data Center for essential metrics and analytics to guide internal modifications. These initiatives are achieved through collaboration with state and national partners (e.g., government agencies, professional associations, consumer advocacy groups, policymakers) with the objective of advancing clinician and patient education.

IMPROVE initiative
Established in 2019, the National Institutes of Health’s IMPROVE initiative provides grant funding and financial awards to support “research to reduce preventable causes of maternal deaths and improve health for women before, during, and after pregnancy. It includes a special emphasis on populations that are disproportionately affected.”48 Initiatives that fund research on the crisis of maternal morbidity and mortality are essential for advancing evidence-based solutions and improving outcomes. The AAFP supports allocating resources to address this critical issue through continued research.

Educational strategies to support family physicians providing obstetrical care
Research findings published in the Annals of Family Medicine showed that physicians who graduated from residency between 2010 and 2013 had a narrower scope of practice than those who graduated between 1996 and 1999.49 Although they report feeling more prepared than previous cohorts, family medicine graduates are providing significantly less obstetrical care. A separate study showed that among recent graduates who intended to practice OB, having lifestyle concerns and finding a job that did not include OB were the most significant reasons that respondents did not end up with their intended scope of practice.50

Family medicine residency programs vary in the obstetrical training and opportunities they offer, as well as in how they meet the Review Committee for Family Medicine requirements. There are opportunities to work with family medicine residency educators on models of training that ensure core competency while also providing comprehensive obstetrical training and higher volume and acuity.51

One strategy to encourage medical students and residents to train in and provide obstetrical care is to offer opportunities to experience the full scope of family medicine practice in a broad range of settings. State and local preceptorship programs have shown significant results in influencing medical students to choose primary care.52,53 However, over the years, these programs have suffered due to decreases in funding that limit the opportunities for exposure. Preceptorship programs, including the Society of Teachers of Family Medicine’s Preceptor Expansion Initiative, face challenges finding family medicine training sites that provide obstetrical care.54

The AAFP is committed to improving access to quality health care, including comprehensive pregnancy, perinatal and newborn care, for all people regardless of where they live.7 It advocates that all family medicine residents receive basic pregnancy, perinatal and newborn care training and that those residents who plan to practice the full scope of pregnancy, perinatal and newborn care receive advanced training to include management of complications and surgical intervention.

The role of doulas in maternity care
Support from doulas during pregnancy, childbirth and the postpartum period has been shown to decrease the likelihood of cesarean sections, premature births and newborn health complications and reduce rates of postpartum depression.55 By reducing unnecessary procedures, minimizing complications and decreasing admissions to neonatal intensive care units, doula involvement can help lower health care expenses. In addition, people who receive doula care often report higher levels of satisfaction with the birth experience and are more likely to begin and continue breastfeeding.56,57 Despite these proven advantages, doula services are not widely utilized, with cost being a key barrier for many families.58-60 Expanding Medicaid coverage for doula care could help remove this obstacle, making these benefits available to those who need them most.57,61,62

Call for research
Continued research focused on birth equity is crucial for addressing the persistent disparities in maternal and infant health outcomes. Despite significant advancements, substantial gaps in understanding of the social, economic and environmental factors that contribute to these disparities still exist. Ongoing research is essential to uncover underlying causes and develop effective interventions that can be implemented at both the community and policy levels. Research should include the impact that the closure of labor and delivery units has in areas with high patient to physician ratios. Investing in this research ensures that all pregnant people have access to the highest standard of care and support. As a result, patient outcomes improve, social justice and equity are promoted, and communities become healthier and more resilient.

AAFP efforts to address maternal morbidity and mortality

Striving for birth equity policy
The AAFP recognizes that significant disparities exist in the rates of maternal morbidity and mortality, with higher rates occurring among Black women, women who have a low income and women living in rural areas.63 The AAFP also recognizes that the root causes of racial and ethnic disparities in maternal morbidity and mortality are institutional racism in the health care and social service delivery system and social and economic inequities. Family physicians are well positioned to address these root causes as they are trained to provide comprehensive care, including prenatal, perinatal and postpartum care, for patients in the communities in which they live.

The AAFP defines birth equity as the assurance of the conditions of optimal births for all people, with a willingness to address racial and social inequalities in a sustained effort.63 It recommends educating physicians about inequities in maternal morbidity and mortality and supports strategies that integrate birth equity into the delivery of family-centered maternity care.

Implicit bias training
The AAFP supports physician education and development by creating and disseminating health equity-focused education and practice tools that are based on evidence and align with accepted educational standards. In 2020, the AAFP released the Implicit Bias Training Guide for use by members and other health care professionals. Its primary goals are to promote awareness of implicit bias among all members of the health care team and to provide resources for mitigating the negative effects of implicit bias on patient care. A number of AAFP chapters have facilitated the dissemination and implementation of this training across the country. 

Training activities include self-assessments, application of skills to case-study examples, small-group discussions and development of an implementation plan. The training format incorporates both online modules and in-person activities. Learning objectives of this training include the following:

  • Increase self-awareness by reflecting on the results of the implicit bias self-assessment
  • Demonstrate conscious mitigation strategies to overcome implicit bias
  • Apply implicit bias reduction skills to case-study examples
  • Understand the effect of implicit bias on real-life patients

Center for Diversity and Health Equity
In 2017, the AAFP launched the Center for Diversity and Health Equity (CDHE) to support its strategic priority of striving for health equity by taking a leadership role in addressing diversity and the social determinants of health as they impact individuals, families and communities across their lifespan. The CDHE provides education and training resources to AAFP members and other stakeholders to raise awareness and develop physician leaders who can provide solutions for patients and work to eliminate the social inequities that cause disparities. The CDHE focuses its work in four core areas: advocacy, workforce diversity, multisector collaboration and education/training.

Education on recognizing obstetrical emergencies
The AAFP has courses to provide education and build skills focused on recognizing obstetrical emergencies. Advanced Life Support in Obstetrics (ALSO®) and Basic Life Support in Obstetrics (BLSO™) are evidence-based, interprofessional, multidisciplinary programs designed to train medical staff and first responders through a blend of didactic learning and simulated obstetrical emergencies, with a focus on team-based care.

The ALSO program equips the entire pregnancy care team with skills to effectively manage obstetrical emergencies. This comprehensive course encourages a standardized team-based approach among physicians, residents, certified nurse midwives, registered nurses and other members of the pregnancy care team to improve patient safety and positively impact maternal outcomes. The ALSO curriculum covers a robust range of topics that include leading factors contributing to maternal morbidity and mortality, such as postpartum hemorrhage, cardiovascular complications, venous thromboembolism and hypertensive disorders of pregnancy.

The BLSO program encourages a team-based approach to managing both normal labor and obstetrical emergencies. It is designed for prehospital care professionals, emergency department personnel, medical and nursing students, and nondelivering physicians. BLSO promotes teamwork and standardized care to support early identification and stabilization of common pregnancy-related complications in a prehospital setting.

The AAFP believes it is vital for practice teams, first responders, hospitals, communities and maternity care professionals to build competencies in basic and advanced obstetrical care so they are “OB ready.” For low-resource hospitals and communities where physicians no longer provide obstetrical services, becoming OB ready requires adequate funding and the ability to connect with training and appropriate health care resources. In rural areas, health care professionals and first responders need access to necessary supplies and equipment to handle obstetrical emergencies. This includes basic or prepackaged delivery kits, postpartum hemorrhage kits, and medications for both deliveries and common complications. The AAFP is eager to collaborate with public and private stakeholders to further develop and implement the OB ready concept and better support communities in need.

Investment in rural maternity care
Maternity care deserts—counties with no birthing facilities or clinicians providing obstetrical services—are an ongoing and growing concern in the United States.64 Living in a maternity care desert is associated with poorer health before pregnancy, less prenatal care and higher rates of preterm birth. In 2021 and 2022, approximately 107 obstetrical care units closed nationally.64 Although these closures affected both urban and rural areas, the impact was especially severe in rural communities, where many residents depended on the closed hospitals as their main source of maternity care.

Although the number of family physicians trained in obstetrical care has declined in recent decades, they remain a critical source of maternity care in rural communities. In rural counties, 17% of family physicians deliver babies, compared with approximately 7% of family physicians nationwide.64 In areas with few obstetrical care options, family physicians often serve as the primary source of care for pregnant patients. In fact, family physicians account for one in four obstetric clinicians in rural counties, compared with one in 20 in urban counties. To strengthen this workforce, the Health Resources and Services Administration invested more than $11 million in 2024 to support 15 organizations establishing new rural residency programs, six of which are focused on creating family medicine residencies with enhanced obstetrical training.65

The AAFP is committed to empowering family physicians who live and work in rural areas by providing evidence-based resources to address their unique needs and offering a variety of pregnancy and maternity CME opportunities. It also supports partnerships between academic medical centers and rural communities to train rural physicians.66 In addition to advocating for policies that support physicians serving rural communities, the AAFP supports programs and initiatives that ensure financial stability and delivery system support to eliminate disparities in access to quality care.67

Conclusion
Factors driving the high rates of maternal morbidity and mortality in the United States are complex and highly relevant to the practice of family medicine. Workforce shortages, closures of rural hospitals and OB programs, and social determinants of health limit access to high-quality prenatal, perinatal and postpartum care, creating inequities that family physicians are uniquely positioned to address. The AAFP is committed to working with stakeholders across the health care continuum to implement evidence-based strategies that advance equity in maternal health outcomes. Through continued engagement, ongoing learning and a willingness to confront implicit bias, family physicians can continue to lead efforts to overcome this critical public health challenge.

References

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2. World Health Organization. Trends in maternal mortality 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. April 7, 2025. Accessed November 7, 2025. https://www.who.int/publications/i/item/9789240108462

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18. Mouton CP, Carter-Nolan PL, Makambi KH, et al. Impact of perceived racial discrimination on health screening in black women. J Health Care Poor Underserved. 2010;21(1):287-300.

19. Potts SE, McLean I, Saba GW, et al. Diversity and facing discrimination in family medicine residencies: a CERA survey of program directors. Fam Med. 2021;53(10):871-877.

20. Wusu MH, Baldwin M, Semenya AM, et al. Racial justice curricula in family medicine residency programs: a CERA survey of program directors. Fam Med. 2022;54(2):114-122.

21. Ho T, Laskow B, Zaballa A, et al. Family medicine resident perceptions on racial justice training in residency: a CERA study. PRiMER. 2022;6:517073.

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24. AAFP condemns all forms of racism. News release. American Academy of Family Physicians; May 31, 2020. Accessed November 7, 2025. https://www.aafp.org/news/media-center/statements/aafp-condemns-all-forms-of-racism.html

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26. Kozhimannil KB, Interrante JD, Fritz AH, et al. Loss of hospital-based obstetric services in rural counties in the United States, 2010-2022. July 2024. Accessed November 7, 2025. https://rhrc.umn.edu/publication/loss-of-hospital-based-obstetric-services-in-rural-counties-in-the-united-states-2010-2022/

27. Coughlin SS, Clary C, Johnson JA, et al. Continuing challenges in rural health in the United States. J Environ Health Sci. 2019;5(2):90-92.

28. Weichelt B, Shakespear KD, Fallgatter T. National Rural Health Association policy brief. Rural workforce recruitment and retention factors. March 2025. Accessed December 22, 2025. https://www.ruralhealth.us/nationalruralhealth/media/documents/advocacy/nrha-policy-brief-workforce-retention-factors-final-3-7-25.pdf

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(July2020BC) (April 2026 BOD)