Legal Reform to Address Key Drivers of Racial Inequities in Maternal Health: A Multi-method Analysis of California...

California has taken various actions with the goal of advancing maternal health equity. We analyze recent California laws and regulations using a novel conceptual model to understand whether and how they target expert-identified drivers of inequities in maternal health.

Using policy review and deductive thematic analysis, we evaluated whether recent state laws and regulations in California sought to directly intervene on healthcare-based drivers of racial inequities in maternal health as conceptualized by a CDC-convened expert workgroup.

We identified 13 laws/regulations enacted between 2019-2023 that aimed to improve maternal health. All intervened on one or more healthcare-based drivers of inequities. Two (15%) targeted Driver 1 - Problems in communication, stereotyping, and other interpersonal interactions, resulting from interpersonal racism, by e.g., requiring provider anti-bias training. One (8%) targeted Driver 2 - Differential and/or suboptimal treatment for minoritized populations within healthcare settings (e.g., lower-quality care, inequitable burdens of hospital policies; resulting from institutional racism), by making reporting discrimination easier for patients. Twelve (92%) targeted Driver 3 - Lack of resources and/or policies that could support the health and healthcare of minoritized populations, stemming from structural racism, by e.g., expanding access to midwifery and doula care or diversifying the maternal health workforce.

California's recent maternal health-focused laws/regulations have primarily targeted inadequate or inequitable structural resources (Driver 3). Few directly intervened on Drivers 1 or 2. These findings provide a useful grounding for future policy research and reveal the advantages of assessing policies in terms of mechanism-focused intervention targets. Policy implications and potential levers are discussed.