The scale of the analysis sets it apart from most previous work on maternal health disparities. Researchers drew on data from almost 1.5 million births between 2012 and 2023, including 108,805 births to Black people and 1,388,090 births to White people. Crucially, the team linked Canada’s 2021 long-form Census, which contains self-reported race information, to national birth, hospitalization, immigration, and tax databases covering all provinces and territories except Quebec. This linkage allowed the investigators to examine outcomes across income levels and immigration histories with a precision that hospital records alone cannot provide, and it addressed a persistent gap in Canadian health data, where race has historically been inconsistently recorded.

The headline numbers are unambiguous. The rate of severe maternal morbidity was 47.8 per 1,000 births among Black people, compared with 27.7 per 1,000 among White people, a difference of more than twenty additional severe complications for every thousand births. Rates were consistently higher among Black people across every category of severe maternal morbidity studied, suggesting the disparity is not driven by one or two specific conditions but reflects a broader pattern of unequal outcomes. Because the study was observational, it cannot by itself identify the mechanisms producing these differences, but the consistency of the pattern across conditions and subgroups narrows the range of plausible explanations.

One of the most important aspects of the study is what the disparity was not explained by. Differences in income and immigration status did not account for the gap: Black people had higher rates of severe maternal morbidity than White people across all income levels, and among both immigrant and nonimmigrant populations. The researchers also conducted sensitivity analyses excluding people with preeclampsia-related conditions, sickle cell disease, and HIV, conditions that occur at different baseline rates in Black and White populations and could theoretically have driven the overall difference. The findings remained consistent even after these exclusions, indicating that the elevated risk is not simply a statistical artifact of differing disease prevalence.

The study’s authors are explicit that the results should not be read as evidence of biological difference. Being Black is not a cause of severe pregnancy complications, according to Dr. Giulia Muraca, a perinatal epidemiologist and associate professor in the Departments of Obstetrics and Gynecology and Health Research Methods, Evidence and Impact at McMaster University in Hamilton, Ontario. Race, she emphasizes, is a social rather than biological construct, and the higher rates of severe maternal morbidity observed among Black people should not be interpreted as reflecting inherent biological differences. Instead, she argues, the findings point to the need for further investigation of the social, structural, and health care factors that may contribute to inequities in maternal health.

This framing aligns with a substantial body of international evidence. Prior research, particularly from the United States, has documented that Black patients experience dismissal of symptoms, objectification, and inequitable care in diverse health care settings, and that these experiences are associated with worse maternal outcomes. Dr. Muraca and her co-authors write that their results are consistent with this broader evidence base, in which structural and systemic factors, including anti-Black racism, contribute to inequities in maternal health. In the clinical setting, such mechanisms could include delayed recognition of warning signs, differences in treatment offered for identical presentations, communication barriers, and reduced trust in the health care system rooted in historical and ongoing discrimination.

Dr. Cynthia Maxwell, co-lead of the Black Reproductive Health Working Group in Ontario, a maternal fetal medicine specialist at Women’s College Hospital and Mount Sinai Hospital, and a professor of obstetrics and gynaecology at the University of Toronto, reinforced the point that Black race is not a biological risk factor for severe pregnancy complications. She noted that when inequities persist across income levels, immigration groups, and different medical conditions, the question becomes what it is about health and social systems that is producing different outcomes, and she stressed that Black communities need to be part of answering that question and shaping the solutions. Her involvement reflects the study’s partnership model: the research was conducted through CanHEAL, the Canadian network for Health Equity using Advanced Data Linkage, in collaboration with the Black Reproductive Health Working Group.

From a methodological standpoint, the study represents a significant advance for Canadian perinatal epidemiology. Self-reported race from the Census is generally considered more accurate than race recorded by health care providers, which can be subject to misclassification, and the linkage to tax records allowed income to be measured at the individual or household level rather than through crude area-based proxies. The exclusion of Quebec, a consequence of provincial data-sharing arrangements, means the results describe Canada outside that province, and the observational design means residual confounding, unmeasured clinical factors that differ between groups, cannot be entirely ruled out. Nevertheless, the sheer size of the cohort and the robustness of the findings across multiple sensitivity analyses give the results considerable weight.

The policy implications outlined by the authors are concrete. They call for the responsible collection and use of race information in health data, arguing that without accurate race-disaggregated data, inequities remain invisible and unmeasurable. They recommend public reporting of race-stratified outcomes so that institutions and communities can see where disparities exist, along with accountability mechanisms to track progress and sustain improvements over time. Antiracism training for health care providers and partnerships with Black communities to co-design programs are also proposed, with the goal of ensuring access to high-quality care from pregnancy through the postpartum period. These recommendations echo calls from maternal health advocates in other countries who have argued that data transparency and community engagement are prerequisites for closing racial gaps in outcomes.

Severe maternal morbidity sits at the extreme end of a spectrum of pregnancy-related harm, and its causes are typically multifactorial, involving patient health before pregnancy, the quality of prenatal care, the responsiveness of labour and delivery services, and the vigilance of postpartum follow-up. That a 66 percent elevated risk persists among Black people in Canada, a country with universal health insurance for physician and hospital services, underscores that coverage alone does not guarantee equitable care. The study, published as a peer-reviewed population-based cohort analysis covering 2012 to 2023, adds Canada to the list of high-income countries where maternal health outcomes are demonstrably shaped by race, and it provides the national baseline against which future interventions, from data reforms to community-designed care models, can be measured.

Subject of Research: Racial inequities in severe maternal morbidity among Black and White people in Canada

Article Title: Black people at higher risk of severe complications during pregnancy, labor, and postpartum

Article References: Black people at higher risk of severe complications during pregnancy, labor, and postpartum. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: severe maternal morbidity, maternal health, health equity, Black maternal health, Canada, population-based cohort study, preeclampsia, postpartum complications, anti-Black racism, health data linkage, CMAJ, perinatal epidemiology