By Leigh Graham, PhD, MBA

The U.S. is the only high-income country in the world where maternal mortality and morbidity is on the rise. Racial inequities in mortality and morbidity — particularly for African American and Native American and Alaska Native women — are pronounced and enduring. Advocates, researchers, and the media, have helped bring significant public attention to this maternal health crisis. Yet, much more is needed, especially outside the hospital setting, and at the local level. Two-thirds of maternal deaths happen prior to childbirth or a week or more after birth. This suggests that birthing people* at risk for injury or death in childbirth are dying in their communities where they live. And Black and tribal communities are experiencing maternal death and injury at much higher rates than white neighborhoods.

Considered this way, maternal mortality and morbidity become leading indicators of a deeper problem of racial and community inequity in the U.S. Unequal geographies of well-being within U.S. cities mean social circumstances across a person’s life course unevenly influence maternal well-being, with structural racism creating pronounced disparities for Black and Indigenous birthing people. To improve maternal health, clinicians, advocates and policymakers must attend to inequitable neighborhood conditions and the support people receive during the perinatal period.

The Delivery Decisions Initiative team has responded to the national call to action to reverse the maternal mortality trend by using Ariadne Labs’ Design/Test/Spread approach, the Ariadne Arc, which relies on design thinking and data-driven research. Our interdisciplinary team spanning obstetrics, public health, and urban policy identified a key gap in maternal health interventions that have to date focused primarily on clinical practice improvements and improved data surveillance at the state and federal level.

Given the clear need for community-level interventions, we observed an opportunity to expand these data infrastructure efforts to the local setting by building on two recent trends in public policy: data-driven urban governance and addressing social determinants in public health and medicine. To date, popular indicators used to measure urban health have not been linked clearly and systematically to maternal health and well-being.

Our team aims to bridge this gap through a data dashboard that measures maternal wellbeing by tracking social determinants of maternal health in U.S. cities.

Measuring maternal wellbeing in communities

The Maternal Wellbeing City Dashboard is organized around a framework of community livability adapted to measure the wellbeing of birthing people and their families in neighborhoods nationwide. It was developed from a baseline set of social determinants that influence maternal health. The CDC defines the social determinants of health as “the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Community (or urban) livability is a widely used framework in high-income countries in both research and practice, given its integration of urban planning and public health, and its emphasis on indicator development to track investments and outcomes in wellbeing in cities. Community livability thus offers a key organizing framework for holistic interventions in maternal health in communities.

We define livable communities as inclusive, equitable places that

• ensure access to the social determinants that improve wellbeing;
• deliver respectful, anti-racist, integrated care for birthing people and their families; and
• foster representation and belonging.

After more than a year of research and development in partnership with a diverse range of stakeholders spanning communities, health systems, research, and public policy, we have developed a prototype of a data dashboard that measures the social determinants of maternal health at the local level. Our goal with this dashboard is to equip advocacy networks with the data and framing that advance community livability and family wellbeing. Through the curation of publicly available neighborhood indicators, we aim to tell a story of how to increase racial equity in childbirth by prioritizing local investments for Black, Indigenous, and disinvested communities that experience the worst maternal health outcomes.

In this story, we start with the need for stable housing over the life course — beginning with earliest childhood. The history of urban development that underpins racial segregation, gentrification and neighborhood disinvestment, has shaped where Black and low-income mothers with children can live safely and affordably. Urban development has determined whether those communities offer reliable transportation, access to healthy food, and access to jobs that provide enough wages and benefits that allow mothers to afford childcare and have the time and resources necessary to raise their children with meaning and a sense of efficacy. These children may or may not have access to responsive, inclusive schools that operate as community institutions, teaching health literacy from the earliest age to foster lifelong wellness. For birthing people, transportation, work, and nutrition options should facilitate access to healthcare settings that are respectful and responsive to their health and wellbeing. These settings should offer a range of provider models and doulas should be widely available, representative of the birthing population, and covered by all forms of insurance.

Neighborhood conditions include but are not limited to

1. police presence and activity,
2. housing market forces manifesting as displacement or abandonment,
3. access to and use of open space, and
4. community cohesion all influence birthing people’s perceptions, mobility, and overall well-being.

Housing instability, neighborhood conditions, and associated health and safety risks cause stress that can be measured physiologically. Heightened exposure or risk of worse/disproportionate outcomes, Intimate Partner Violence, substance use disorder, and entanglements with the child welfare system can be particularly harmful within the home or family unit.

In telling this story, illustrated with local level data capturing structural determinants of maternal health in cities across the U.S., our team is shifting the national narrative of merely surviving childbirth to thriving during pregnancy, as a parent, and as a community. We envision advocacy coalitions committed to improving maternal health coming together around our data-driven narrative in service of community-level and regional interventions that address that racial inequities in healthcare, housing, job markets, schools and political power that disproportionately harm Black birthing people and their households.

This spring, we will test this dashboard with local partners in at least three U.S. cities. We will assess its feasibility and acceptability for maternal health advocates from the non-profit and public sectors, with use cases spanning policy advocacy, service delivery, and local governance produced to guide uptake beyond these pilot sites.

Maternal health is a bellwether for societal health, and reversing the maternal mortality trend is a racial, generational, and gender justice issue. Fostering livable communities for birthing people requires reframing childbirth and parenting as societal investments that enrich us all.

The development of the Maternal Wellbeing City Dashboard was supported by funding from Merck, through its Merck for Mothers program and is the sole responsibility of the authors. Merck for Mothers is known as MSD for Mothers outside the United States and Canada.

Leigh Graham, PhD, MBA is Senior Advisor to the Cities Challenge at Ariadne Labs, and is a Research Scientist at the Harvard T.H. Chan School of Public Health.

Illustration by izumikobayashi / iStock

*We define ‘birthing people’ as people who are experiencing pregnancy or in their first year postpartum.