Systemic inequities in high-risk pregnancy care demand reproductive justice frameworks to dismantle structural barriers

Indigenous midwifery traditions—such as the *Kahnawake* model in Canada or the *Inuit* birth practices in Greenland—demonstrate that high-risk pregnancies are often preventable through culturally grounded care, including dietary interventions and community-based monitoring. These systems have been disrupted by colonial healthcare policies, yet their integration into modern systems (e.g., New Zealand’s *Tapuaki* program) shows measurable improvements in outcomes. The erasure of these practices in US discourse reflects a broader pattern of biomedical imperialism that prioritises Western clinical models over proven Indigenous solutions.

The US has a long history of eugenics-era policies targeting pregnant people of colour, from the forced sterilisation of 70,000+ people (1907–1979) to the coerced IUD insertions in Puerto Rico (1930s–1970s), which laid the groundwork for today’s inequities. The 1973 *Roe v. Wade* decision, while framed as a reproductive rights victory, also enabled state surveillance of marginalised pregnant people, a legacy that persists in modern fetal protection laws. The current crisis in high-risk care is thus not an aberration but a continuation of structural violence, where medical institutions act as gatekeepers of bodily autonomy.

Cross-culturally, pregnancy care is often communal: in Uganda, *birth attendants* reduce maternal mortality by 30% through home visits, while in the Philippines, *hilot* midwives address high-risk cases with herbal remedies and spiritual counselling. These models contrast with the US system’s individualised, hospital-centric approach, which prioritises profit over prevention. The *Dutch* model—where midwives lead 80% of births with lower intervention rates—demonstrates that de-medicalisation can improve outcomes, yet it is rarely emulated in the US due to lobbying by obstetric associations.

Research shows that structural racism in healthcare—measured by *weathering* (chronic stress from discrimination) and *allostatic load*—increases preterm birth risk by 2–3x for Black women, independent of socioeconomic status. The *Maternal Mortality Review Committees* (2020) found that 60% of pregnancy-related deaths in the US are preventable, with implicit bias in clinical settings a major factor. Meanwhile, studies on *doula care* (e.g., *CHAMPS* trial) prove that continuous support reduces C-sections by 22% and preterm births by 14%, yet doulas are excluded from most insurance systems.

Artistic expressions—such as the *Birth Project* by Judy Chicago or the *Quilting the Black Diaspora* initiative—challenge the medicalisation of pregnancy by centring the embodied experiences of marginalised people. Indigenous artists like *Jaune Quick-to-See Smith* critique the commodification of Indigenous bodies in reproductive healthcare, while spiritual traditions (e.g., *curanderismo* in Latin America) frame pregnancy as a sacred, communal act. These perspectives highlight how biomedicine’s reductionism obscures the emotional and spiritual dimensions of care, which are critical to healing.

Scenario modelling suggests that integrating RJ frameworks into healthcare systems could reduce racial disparities in maternal mortality by 40% within a decade if paired with policies like universal doula coverage and community-based midwifery. A *Medicare for All* system would eliminate insurance-driven inequities, while *climate-resilient* prenatal care (e.g., heat-mitigation strategies) could prevent 15% of preterm births in vulnerable regions. Conversely, continued privatisation and the erosion of *Title X* funding would exacerbate disparities, particularly in rural and Indigenous communities.

Disabled pregnant people face unique barriers, including denial of care due to ableist assumptions about parenting capacity, as documented by the *National Council on Disability* (2021). Trans and non-binary pregnant people are often misgendered in clinical settings, leading to delays in care; the *Transgender Law Center* reports that 30% avoid prenatal visits due to discrimination. Immigrant pregnant people, especially those undocumented, are excluded from safety-net programs, with ICE raids in healthcare settings (e.g., 2019 in Washington state) deterring access to prenatal care.