The USA is one of the most developed countries globally and home to cutting-edge research, sophisticated technology, and highly trained professionals. However, a sobering reality persists. The maternal mortality rate in the US is the highest among high-income countries, with Black women experiencing disproportionately higher rates than any other ethnic group (CDC, 2022). These persistent inequitiesundermine healthcare access and quality for Black women.

Mississippi ranked highest for maternal mortality rate in 2021, with 82.5 deaths per 100,000 births, closely followed by New Mexico (79.5 deaths per 100,000 births). Conversely, California had the lowest maternal mortality rate (9.7), and Massachusetts was the second lowest (17.4) (National Vital Statistics Report, 2023).

As part of an academic research initiativeand motivated by a deep commitment to maternal and child health, I examined maternal mortality in non-Hispanic Black women in Iowa. A critical finding from the Iowa Maternal Mortality Review Committee’s data revealed that almost 100% of maternal deaths are deemed preventable. In 2020, Iowa’s maternal mortality rate (MMR) was 19.5 deaths per 100,000 live births, more than doubling from 10 deaths per 100,000 live births in 1999 to 22 deaths per 100,000 in 2019 (Iowa Department of Public Health, 2022). The state also has high rates (10.4%) of preterm births (Iowa Perinatal Report, 2022). Non-Hispanic Black women have a significantly higher MMR—about six times that of non-Hispanic White women in Iowa (Smith et al., 2019). Of all pregnancy-related deaths in Iowa, 50% occurred in women aged 20-34 (Iowa MMRC, 2021).

Iowa’s maternal health data also reveals disparities in supportive maternal health behaviors, such as accessing prenatal care in the first trimester and breastfeeding rates. Black individuals are more likely to initiate prenatal care later and breastfeed at rates consistently 10–20% lower than White individuals annually. Care deserts, chronic health conditions, mental health risks, low healthcare workforce representation, poverty, and limited social support influence maternal mortality among non-Hispanic Black women in Iowa. While some issues require systemic change, others—like improving access, culturally competent care, and health education—can be addressed through targeted interventions (Williams & Carter, 2022).

Delayed prenatal care is prominent among key behavioral determinants: approximately one in three women do not receive care during the first trimester (National Prenatal Care Survey, 2023). This delay significantly increases the risks of preterm birth, low birth weight, and pregnancy-related death—which rise fivefold without early care (Green et al., 2018). Financial, structural, and geographic barriers, especially in rural areas, limit access to prenatal services (Anderson & Martinez, 2019). Additionally, limited culturally aligned social support reduces early care initiation and increases maternal stress, while women with strong social support are twice as likely to start prenatal care early (Davis et al., 2017). Enhancing awareness, access, and community support can shift behaviors toward improved outcomes (Thomas & Nguyen, 2020).

Timely prenatal care (first trimester) is essential for healthy maternal and infant outcomes. In Iowa, only 68% of Black women begin prenatal care early compared to 87% of White women, revealing significant disparities (Iowa Department of Public Health, 2022). Early care enables accurate assessment of pregnancy risks, education, and management of conditions like hypertension and diabetes (World Health Organization, 2016). The World Health Organization emphasizes the importance of care by 12 weeks as foundational for a child’s development. Early prenatal care correlates with reduced low birthweight, preterm births, and maternal mortality.

Prevention strategies to improve maternal outcomes span the continuum of care. Primary prevention focuses on reducing risk before complications arise, including early prenatal care, vaccinations, family planning, and health education to promote healthy behaviors (Miller & Thompson, 2020). Secondary prevention detects and manages risks early through routine screenings for mental health, gestational diabetes, blood pressure, infections, mental health support, and emergency preparedness (Brown et al., 2021). Tertiary prevention supports recovery and reduces long-term complications with postpartum and post-abortion care, intensive obstetric services, and community-based rehabilitation programs (Garcia et al., 2018).

Doulas provide emotional, physical, and informational support throughout pregnancy, childbirth, and postpartum. Their culturally competent care bridges gaps in trust and communication between Black women and the healthcare system—addressing disparities rooted in racism, bias, and systemic barriers. A 2013 study found that individuals supported by doulas were twice as likely to avoid birth complications (Harrison & Moore, 2013). A 2019 study highlighted doulas’ role in mitigating social determinants of health, including racism. By advocating for clients, promoting health literacy, and fostering respectful care, doulas improve maternal outcomes and help reduce racial disparities in maternal mortality (Jackson & Williams, 2020).

Iowa is already implementing a multi-level, culturally responsive doula care model to address maternal health disparities among Black women. The Iowa Black Doula Collective (IBDC) trains Black doulas through free workshops and mentorship, offering breastfeeding and parenting support groups to improve outcomes. Since 2020, they have trained over 30 doulas statewide (Iowa Black Doula Collective, 2023). In 2021, the Iowa Department of Health and Human Services launched the Title V Community-Based Doula Project, integrating culturally congruent doula services into the state’s maternal health system (Iowa DHHS, 2021). The project collaborates with local Title V agencies to increase early prenatal care among African American families in key counties. These efforts align closely with recommended intervention strategies targeting community, organizational, and interpersonal levels to improve access, trust, and culturally competent prenatal care.

Building on these efforts, we propose a multi-level intervention strategy to reduce maternal mortality among non-Hispanic Black women in Iowa. This includes expanding doula training, strengthening health system partnerships, and scaling culturally responsive, evidence-based peer support models. Effective interventions operate across multiple levels of influence (Green & Taylor, 2023).

Furthermore, education and advocacy on primary care and annual health screening of women prior to pregnancies are effective ways to identify chronic diseases and implement early intervention helping prevent high-risk pregnancies.

At the community level, IBDC offers an 18-hour Community Doula Training Program through monthly in-person and online workshops promoting culturally responsive prenatal care (Iowa Black Doula Collective, 2023). At the organizational level, partnerships with local healthcare centers will facilitate biannual cultural awareness training led by Community Health Workers and Doulas, including discussion panels on real-world challenges. At the interpersonal level, doula-led peer education sessions in churches, nonprofits, and health centers will enhance health literacy and build trust with the healthcare system. Pregnant women will be matched with culturally concordant doulas who support them in navigating and attending the recommended 12–14 prenatal visits, ensuring consistent, personalized care. Sustaining these efforts will require ongoing state partnerships, grant support, and Medicaid reimbursement for doula services—an emerging policy priority in Iowa.

A Community-Based Participatory Research (CBPR) approach will ensure community-centered and effective interventions. This includes co-developing goals and materials with local partners, conducting listening sessions with community leaders, and using relationship brokers to build trust. Faith-based outreach will be tailored to cultural values to improve prenatal care access and outcomes for Black women in Iowa through culturally competent, collaborative support (Wilson et al., 2023).

To monitor success, the program includes clear SMART objectives over five years. The primary goal is to reduce maternal mortality among non-Hispanic Black women in Iowa from 19.5 to 13 deaths per 100,000 live births and increase early prenatal care visits to 2–3 in the first trimester. Additional objectives include improving women’s understanding of prenatal care, increasing timely visit scheduling, expanding peer-support sessions from 10 to 25 annually, and growing community partnerships from three to nine local health departments (Iowa Department of Public Health, 2024). These objectives will guide and evaluate the program’s impact.

Reducing maternal mortality among non-Hispanic Black women in Iowa demands targeted and competent interventions. A solid path to saving lives and transforming maternal health outcomes in Iowa is through a multi-level strategy that broadens doula care, strengthens health partnerships, and empowers women through support and education, thereby bridging existing gaps in care and equity.

REFERENCES

1. CDC. Pregnancy Mortality Surveillance System. 2022.
2. National Vital Statistics Reports. Maternal Mortality by State. 2023.
3. Iowa Maternal Mortality Review Committee Report. Iowa Dept of Public Health. 2021.
4. Johnson H, Lee K. Prenatal care disparities in Iowa. Matern Child Health J. 2020;24(5):629-636.
5. Jones E, Carter S, Nguyen T. Social determinants of health and maternal outcomes. Public Health Rep. 2021;136(2):156-164.
6. Green M, Brown L, Patel N. Impact of delayed prenatal care on maternal outcomes. Obstet Gynecol. 2018;132(4):757-764.
7. Davis S, Nguyen M, Thompson J. Social support and prenatal care initiation. Matern Child Health J. 2017;21(9):1835-1843.
8. Lee H, Jackson R, Williams S. Early prenatal care and infant outcomes. Pediatrics. 2019;143(6):e20183435.
9. WHO Recommendations on Antenatal Care. 2016.
10. Miller A, Thompson K. Prevention strategies for maternal mortality reduction. J ObstetGynecol Neonatal Nurs. 2020;49(3):195-203.
11. Harrison D, Moore S. The role of doulas in reducing birth complications. Birth. 2013;40(3):192-197.
12. Iowa Black Doula Collective Annual Report. 2023.
13. Iowa Dept of Health and Human Services. Title V Community-Based Doula Project Report. 2021.
14. Johnson M, Lee K, Nguyen T. Cultural competency training in maternal health. Health Educ Res. 2022;37(1):55-65.
15. Wilson R, Carter J, Green S. CBPR, and maternal health interventions. Prog Community Health Partnersh. 2023;17(1):45-53.
16. Iowa Department of Public Health. Maternal Health Program Objectives. 2024.
17. Preconception Health Indicators: A Comprehensive Scoping review https://www.ijwhr.net/pdf.php?id=738