Structural Racism, Geographies of Opportunity, and Maternal Health Inequities: A Dynamic Conceptual Framework

Journal of Racial and Ethnic Health Disparities https://doi.org/10.1007/s40615-025-02345-5 Structural Racism, Geographies of Opportunity, and Maternal Health Inequities: A Dynamic Conceptual Framework Irene Headen1 Received: 8 September 2024 / Revised: 22 December 2024 / Accepted: 18 February 2025 © The Author(s) 2025 Abstract Addressing the grave racial inequities in maternal health requires a new generation of research that better operationalizes root causes of these outcomes. Recent frameworks improving the conceptualization of structural racism have illuminated the need for better conceptual clarity when investigating neighborhoods as a site of structural marginalization for Black birthing populations as well. In particular, better conceptualization of dynamic feedback in how neighborhoods are constructed and experienced, especially as they embed vicious cycles of place-based racialization, is integral to producing conceptually relevant and translatable evidence to address inequities in Black maternal health. This study presents a newly developed framework that integrates dynamic insight on neighborhood contexts from multiple disciplines to better conceptualize how it operates during the childbearing window to drive inequitable maternal morbidity rates among Black birthing people. I also compare and contrast this framework with existing frameworks based on how they represent key domains of social and structural determinants, neighborhood context, and dynamic feedback. Illustrating the strengths and weaknesses of each framework can improve researchers’ ability to leverage these frameworks when developing project-specific conceptual models on structural racism, neighborhood context, and Black maternal health. Building a comparative repository of frameworks, in conjunction with developing new frameworks, will improve the field’s capacity to follow best practices of rooting research in conceptually explicit models that improve operationalization and translation of evidence to eventually eliminate racial inequities in maternal health. Keywords Maternal health · Structural racism · Racial inequities · Neighborhood environment · Systems thinking · Conceptualization Introduction Worsening rates of maternal morbidity and mortality in the US place these outcomes at the top of the national public health agenda [1, 2]. Black birthing people1 have persistently higher rates of maternal mortality (MM) and severe maternal 1 The term “birthing people” is used as a gender-inclusive reference to individuals who are capable of becoming pregnant and giving birth. This includes women, non-binary individuals, trans-men, and other gender expansive individuals. This paper interchanges between the use of “birthing people” when referring to the population of interest and “maternal” when referring to the outcomes in order to remain consistent with how outcomes are identified throughout the literature. * Irene Headen 1 Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA morbidity (SMM), both in comparison to national rates [3, 4] and compared to their white counterparts [5–7]. The most recent estimates place MM as 2.6 times higher [4] and SMM as approximately 1.9 times higher [8] for Black birthing people compared to their white counterparts. While MM is more severe than SMM—which denotes a near-miss, critical, but non-fatal outcome—approximately 20–30 SMM cases occur for every one maternal mortality case [9]. The severity of increasing rates and widening inequities across both of these outcomes has sparked a wealth of research to identify points of intervention across clinical, environmental, interpersonal, and social contexts [1, 10, 11]. However, the translation of existing evidence into action has not achieved desired goals, as reflected in increases in overall rates of these outcomes documented in the Healthy People 2030 objectives [12–14]. As a result, calls within the field have emphasized the need for renewed research efforts that identify novel intervention Vol.:(0123456789) Journal of Racial and Ethnic Health Disparities targets, better contextualizes the structural constraints facing communities, and more consistently centers equity [2, 12]. In conjunction with these calls, there has been increasing attention to the need for clear conceptual frameworks and models2 to guide emerging work in this area [12, 15]. In particular, health equity scholars have emphasized the importance of distinguishing between social determinants of health, which are defined as the conditions in which people are born, grow, live, work, and age [11, 16], and structural determinants of health, which consist of the upstream norms, practices, institutions, and policies that define how social determinants are distributed for different socially positioned groups [17–19]. Distinguishing between these distinct but interconnected processes is especially important as they relate to racial inequities in maternal and infant health outcomes [15, 20, 21] to better understand structural racism as a root cause [19]. Because it operates as a multi-dimensional, dynamic process [22, 23], clear conceptual frameworks and models are critical for operationalizing interactions within and between specific domains and understanding how they give rise to processes of racialization at particular time frames over the life course. Explicitly measuring placebased structural racism—through domains such as residential segregation, inequitable divestment in essential services or economic opportunity, and inequitable distributions of greenspace and recreational areas resulting from zoning practices to give a few examples—allows us to capture distinct processes of embodiment that operate in conjunction with the social determinants of health [17, 18]. Additionally, because these structural processes are explicitly designed to reinforce racial hierarchies [23, 24], they are embedded within Black and Brown neighborhoods independent of the opportunity structure of that neighborhood [22, 25, 26]. Robust conceptual models are needed to guide work investigating neighborhood context as one of the upstream domains of structural racism contributing to racial inequities in maternal morbidity and mortality [27–29]. In particular, research in this area using social determinants to proxy structural exclusion has produced mixed findings that have been attributed to a range of factors (e.g. geographic location, selection of study population, geographic level of observation, time period, and neighborhood measures used) [17, 28, 30]. However, few studies present a clear conceptual model guiding their hypotheses for how neighborhood factors interact with each other in 2 Paradies and Stevens (2005) offer a general definition of conceptual diagrams as a diagram of proposed relationships among a set of concepts, factors or variables about a particular hypothesis, question, conte (...truncated)