Delivering disparity: black maternal and infant health policies and practices in the Jim Crow South

Abstract

This thesis investigates the persistence of racial disparities in maternal and infant health outcomes in the 20th-century American South by looking at three different contexts: a state-level public health program, a federal investment in hospital infrastructure, and case-level records from a leading Black hospital. These contexts provide a multi-lens analysis of the policies and practices shaping Black maternal and infant health within the racially discriminatory social environment of the Jim Crow South. The first paper analyses Florida’s Midwife Program (1933–1960) using a social capital framework to assess how knowledge transfers and peer networks influenced maternal health. While the program succeeded in spreading hygienic practices among midwives through strategies such as philanthropic support and racial matching, it struggled to foster collaboration with physicians, limiting its long-term impact and contributing to widening racial disparities in maternal mortality as physicians monopolised control over new life-saving technologies. The second paper evaluates the Hill-Burton Act's effect on racial health outcomes using a difference-in-difference approach across six Southern states. It finds that federal funding for hospital infrastructure significantly increased hospital births—especially among Black mothers—and reduced stillbirth rates but had minimal impact on infant mortality and Black-white health disparities. The third paper focuses on Lincoln Hospital, a leading Black hospital in Durham, North Carolina, to examine why stillbirth disparities across race persisted despite medical advances. Drawing on delivery room records from the prestigious, Black-led hospital, the study finds that limited access to surgical training among Black physicians constrained the adoption of life-saving interventions like caesarean sections. Across all three studies, the thesis highlights that improvements in medical technology and access alone were insufficient to eliminate disparities. Instead, social structure, institutional design, and unequal access to professional opportunities critically shaped the reach and equity of healthcare delivery in the South.