It’s widely known that low-income Black women suffer far higher maternal health risks than low- income white mothers, often because they lack access to quality health care. But in a new book, UC Berkeley law professor Khiara M. Bridges makes a forceful argument that maternal health disparities affect Black women at every rung of the socioeconomic ladder.
How can this be, when wealth presumably gives access to the best care money can buy? That question is at the heart of Bridges’ book, “Expecting Inequity: How the Maternal Health Crisis Affects Even the Wealthiest Black Americans” (MIT Press, March 2026). Her answer is startling: A key cause is the racism that Black people commonly experience, literally from the moment they are conceived.
Khiara M. Bridges
“Expecting Inequity” begins in the neutral tone that is customary in scholarly writing, but a more passionate voice quickly emerges. Bridges raises an objection against a medical system and a society that seems indifferent to the risks faced by Black people during the profoundly human experience of childbearing.
She cites a 2019 report released by the U.S. Centers for Disease Control and Prevention showing that Black people with less than a high school education are almost two times more likely to die during pregnancy, childbirth or the postpartum period than their white peers. Meanwhile, college-educated Black people were more than five times more likely than their college-educated white peers to die from a pregnancy-related cause.
Bridges is a constitutional law scholar who specializes in race and gender, but she was also educated as an anthropologist. Her work weaves together medical research with the sometimes haunting human stories that emerged from more than 200 interviews with pregnant cisgender women and one transgender man, along with medical professionals and others.
In an interview with UC Berkeley News, she described her journey through the parallel worlds of pregnancy in America, and how profit-driven medicine fails Black people.
UC Berkeley News: What inspired you to take up the topic of maternal health? Was there a Eureka! moment, or did the focus come to you more gradually?
Khiara M. Bridges: In a lot of ways, the book is a sequel to my first book, which was about low-income, Medicaid-insured, pregnant folks, largely of color, who were trying to get their prenatal care from a public hospital in New York City.
That book, ”Reproducing Race,” allowed me to consider what racism looked like for low-income people. But immediately after publication, it became apparent to me that we have a really good idea of what racism looks like in the lives of poor people of color: It looks like mass incarceration, it looks like police violence, it looks like segregated, high-crime neighborhoods with dilapidated housing.
It became important to me to document what racism looks like when one is not low-income, when one is not poor. I wanted to write a book that focused on class-privileged people of color because it would allow me to think about how racism shifts in form — but nevertheless persists — as one moves up the socioeconomic ladder.
Q: It’s striking, in your book, that Black people at higher levels of the ladder are aware of these disparities in health outcomes, and navigate the health system with this awareness.
Black folks engage in all sorts of strategies for not dying during pregnancy. And the strategies seem — well, most of them involve performing class privilege. It involves demonstrating to your healthcare provider that you are not poor, that you have a degree from an elite or a selective university, that you have had an education.
It also involves demonstrating marital status, the importance of wearing a wedding ring at all times, even when it was uncomfortable during pregnancy, because you’d want to signal that, first, you’re not a stereotype: a poor, unmarried Black person who is having babies to increase the size of their welfare check. But also you want to signal that somebody cares for you deeply. And that because somebody else cares for you, the provider should care for you as well.
But then also, one of the more surprising things that I found was that when a Black woman was married to a non-Black man, specifically a white man, they would bring their white husbands into their appointments to say, ‘Hey, a white man cares about me. So I am deserving of quality health care.’
What was surprising to me about it all was the awareness that Black women had that they were making these strategic choices. They were deliberately undertaking these efforts in order to avoid becoming yet another Black maternal death.
As I read the book, I was struck by your own exasperation, sometimes your own anger. Did I read that right?
In a lot of ways in my scholarship, I’ve become a petulant 2-year-old. Where I’m saying, ‘It’s not fair. It’s just not fair.’ And that’s the book in a nutshell: It’s just not fair that we have created these conditions.
Over the course of several generations, we have naturalized these conditions. Many people hear about the statistics describing Black people’s higher rates of maternal deaths — and they move on with their days. So it’s perceived as this natural, normal feature of American life that Black people are just dying more frequently than white folks during pregnancy and childbirth.
It’s just not fair that individuals who have no culpability, no responsibility for these systemic failures, are being asked to figure out a way to navigate them during one of the most vulnerable moments of their lives. It strikes me as an incredible injustice.
[Listen to Khiara M. Bridges on “Voices Carry,” the Berkeley Law podcast hosted by Gwyneth Shaw, at the link or below.]
Your book uses both quantitative data and human stories to illustrate the risks confronting Black people who want to have a baby. Are there one or two stories of women and their experiences that linger with you?
The story that comes back to me time and time again is the one that I tell at the beginning of the book. It’s this woman who was pregnant with her second child when I interviewed her. She was in her late 40s. She’d had her first experience with gynecological care when she was 15 years old — after she had been sexually assaulted.
During the rape, she contracted a sexually transmitted infection, which was later identified as herpes. This was her first sexual experience. What a trauma, right? Trauma on top of trauma.
Credit: Getty Images via Unsplash+
And so, as a 15-year-old girl, she seeks healthcare, and the gynecologist that she sees was horrible, like a movie villain. He tells her she’s worthless, that she’s promiscuous and that she brought this on herself, and that she’s dirty. And this is happening during her first gynecology appointment.
One reason this story stays with me is that this 15-year-old girl at the time was at the top of her class. She was the daughter of a physician. She was going to an elite private school. She had access to all of these opportunities. She actually had been sexually assaulted while she was doing a study abroad program in Italy.
So many of the Black people I interviewed are “winning”: they’re wealthy, they have high incomes, they have degrees from Yale and Harvard and Stanford and UC Berkeley. They have all of the accoutrement of success, but they still encounter neglectful and negligent healthcare. They still are not believed when they report their symptoms. They still are presumed to be undeserving of quality healthcare.
In so many of the stories that I tell in the book, the point is to demonstrate that we can’t buy an exit from racism in this country.
Your book suggests that society tends to assume that Black people are affected by these health conditions at higher levels because of genetics or culture. But you dismiss those assumptions forcefully.
Proposing that Black people have genes that predispose them to death, first of all, has no empirical basis. There is no theory of evolutionary biology that would explain why people with African ancestry evolved to have genes that predispose them to hypertension, and diabetes, and kidney disease, and lung diseases, and maternal deaths and infant deaths.
Second, in addition to having a law degree, I’m a sociocultural anthropologist by training. The object of anthropology is culture. If you look at the literature — the literature that proposes that culture has some explanatory value when it comes to racial disparities in health — they’ll say Black culture is religiosity, believing that one’s religion will heal you as opposed to medication. Black culture is not exercising. Black culture is fried foods. Black culture is feeling close to family. But it’s such a caricature of Blackness.
Blaming racial disparities in health on culture as well as genes is a way to get us to not focus on the things that are actually causing higher rates of morbidity and mortality among Black people. If we want to stop Black people from being sicker and dying earlier than others, we need to reckon with structural racism.
Blaming genetics or culture allows society to abdicate responsibility for the avoidable deaths that are happening every day.
You make a powerful argument that stress — the stress of being Black in a white and often hostile society — has a devastating impact.
This is such an important part of the story. In the book, I emphasized the fact of “weathering.” The research around weathering demonstrates that when individuals are exposed to chronic stress, it ages their organ systems. They are literally older than those who are not exposed to chronic stress — and racism is a stressor.
There’s an argument to be made that when one is at the higher ends of the socioeconomic ladder as a Black person, you’re exposed to more stress. We have jobs in these amazing workplaces – but we’re the only Black person there, or we’re one of only a few in our position.
We may have access to elite institutions – but those institutions are not exactly designed to ensure that we thrive. And then, when we manage to live in a community that is not predominantly Black, we’re exposed to the stressors of our neighbors being suspicious of us and being unkind to us. And so weathering is systemic, it’s a structural problem that explains higher rates of maternal deaths among class-privileged Black folks.
Take us to the next step of that argument. You describe how the environmental stress of racism has a genetic impact, a sort of traumatic injury that can be handed down from one generation to the next.
I write about the science around epigenetics. Epigenetics is a somewhat controversial topic among progressive scholars, because it can be easily misunderstood. The science of epigenetics does not propose that people of color have genetic variations that are unique to them. That would be a misdescription of epigenetics. Instead, the science proposes that genes express themselves in different ways as a result of environments.
Epigenetics doesn’t refer to changes in the gene, which is mutation. Instead, it involves the expression of the gene. When one is exposed to hostile environments, genes express themselves in ways that are not health-affirming, not life-affirming. And the opposite is true: When you’re exposed to hospitable and resource-rich environments, then your genes express themselves in ways that are compatible with life and health.
Can you give us an example?
During World War II, Nazi Germany cut off food supplies to the Netherlands and caused the Dutch Famine of 1944-45. Women who were pregnant during the famine gave birth to children who, when they grew up, had heart disease and kidney disease and other illnesses. Then, when those adults had children themselves, their kids had health issues related to obesity.
Epigenetics explains why the grandchildren of women who survived the famine would have these illnesses. The famine didn’t change their grandmothers’ genes. Instead, the famine caused their grandmothers’ and parents’ genes to be expressed in a way that they inherited.
In the book, I talk about my own grandmother, who was a maid in the Jim Crow South. She was exposed to the violence of anti-Blackness in its most virulent forms. She was pregnant with my mother during the Jim Crow era in the South. And so the prenatal environment that my mother existed in was one in which we should expect that her genes would be expressed in a way that is not life and health-affirming.
And even though I have all of this class privilege, even though I’m a tenured professor at one of the most selective universities in the nation, if not the world, I have inherited that environment through the expression of my genes — through epigenetics.
Most class-privileged Black folks in the U.S. are either one or two generations removed from formal degradation and deprivation. And so are we surprised then that we have higher rates of pregnancy complications and maternal deaths?
What does all of this say about how society should address the Black maternal health crisis?
How we frame the problem changes what we think of as a solution.
If the problem is that providers have implicit biases, if the problem is that health providers are just being mean to Black people, then we need to fix providers. But if the problem is systemic, if the problem is one of hostile environments, then the solution involves changing these environments.
My book focuses on maternal mortality and morbidity, but this is true across the board. So we have to transform environments if we want to eliminate racial disparities in the rates of hypertension, kidney disease, diabetes. We can explain some portion of those disparities in terms of chronic weathering and epigenetics.
The dynamics that you discuss are so profound, so deeply rooted. What does it take to improve, or to create, a health system that provides better outcomes for Black people?
The solution to this problem is not simply or solely implicit bias trainings. It doesn’t involve solely making sure that health care providers are aware of the implicit biases that they have or are aware of “Black culture,” whatever that is, and provide culturally competent care. Maybe that is part of a multi-prong program of remedying this particular problem, but again, I’m interested in the structural issues.
We have to take racism seriously. Black people will not have outcomes on par with their non-Black counterparts when they are enduring chronic stress just to exist, to go to work, to drive home, to go on the internet. That is incompatible with health. And so I don’t see a solution to this problem without actually confronting the fact that racism is incompatible with life and health.
This interview has been edited lightly for length and clarity.
