Assessing Transportation Barriers to Maternal Care for Black Women in Los Angeles County
PMCID: PMC12470221
PMID: 41007573
Abstract
The United States ranks among the worst high-income countries for maternal health outcomes, with Black women experiencing disproportionately high and alarming rates of maternal mortality and morbidity. In Los Angeles County, Black women are four times more likely to die from pregnancy-related causes than women of other racial and ethnic groups. These disparities may partially be attributed to social determinants of health, including transportation access. Lack of transportation can hinder access to healthcare, with significant consequences for reproductive health. This study investigates how transportation barriers affect Black birthing people’s access to maternal healthcare in Los Angeles. In partnership with Black Women for Wellness, we conducted a descriptive, observational study using an online survey completed by 235 respondents, all of whom self-identified as women. Findings reveal that Black women in Los Angeles face substantial transportation barriers when seeking maternal healthcare, including limited public transportation, lack of personal vehicles, and challenges in securing rides. Many participants reported that these issues caused delayed or missed prenatal appointments. These results underscore the urgent need for policy interventions and systems-level solutions to improve transportation access. Addressing these barriers is essential for reducing maternal health disparities and improving outcomes for Black women.
Full Text
The maternal mortality rate refers to the number of maternal deaths per 100,000 live births among those who are pregnant or within 42 days of termination of pregnancy [1]. In the United States, the maternal mortality rate has been steadily increasing, despite advances in modern medicine [1]. While the average maternal mortality rate in high-income countries is 12 per 100,000 live births [2], the United States had a maternal mortality rate of 18.6 per 100,000 live births in 2023 [3].
When the maternal morbidity and mortality data are stratified by racial group, the reality becomes even more grim. A 2024 study revealed that Black individuals were 1.9 times more likely than white women to experience intrapartum maternal morbidity, but the rate spikes to 2.5 times more likely than their white counterparts during the postpartum period [4]. In 2023, the maternal mortality rate among white women was 14.5 deaths per 100,000 live births, while Black women faced a maternal mortality rate of 50.3, more than three times the rate of their white counterparts [3].
In Los Angeles County specifically, these disparities are even more pronounced. Black birthing people face a maternal mortality rate four times higher than other racial groups [5]. They also experience a higher risk of cesarean sections and preterm births, while Black infants are three times more likely to die than white and Asian infants [5,6,7,8]. Although cesarean sections are necessary in some cases, they are associated with increased risks of health complications after birth [9].
Public health officials turn to the social determinants of health to explain the persistence of health disparities. Social determinants of health are non-medical factors that influence one’s health outcomes, such as income, education, food insecurity, and access to transportation [10].
Several studies explore inadequate transportation as a barrier to healthcare access in the United States. For instance, the National Center for Health Statistics found that, in 2022, 5.7% of adults did not have reliable transportation to conduct daily living tasks such as healthcare appointments. While the study did not provide statistics specifically for Black women, both identities face higher rates than the average, with 6.1% of women with no reliable transportation and 9.2% of Black individuals without reliable transportation [11]. Similarly, a North Carolina study found that one-third of people who had six or more medical appointments between 2020 and 2021 experienced transportation-related challenges. The most frequent types of transportation barriers mentioned were the lack of access to a driver or car and the cost of travel [12]. While these studies illuminate the relationship between transportation and healthcare broadly, the specific connection between transportation access and maternal healthcare, particularly for Black birthing people, remains largely unexplored.
Barriers to transportation can manifest across multiple levels of the Socio-Ecological Model, which provides a framework for understanding how health behaviors and outcomes are shaped by individual, interpersonal, community, and societal factors. At the individual level, a pregnant person may not have access to a vehicle for their prenatal appointments. Interpersonally, they may have to rely on others in their social network in order to access transportation to a healthcare provider, which may not always be reliable. At the community level, limited public transit options or the absence of nearby maternity wards can make maternal healthcare inaccessible. Lastly, societal factors, such as underinvestment in low-income areas and structural racism may exacerbate transportation inequities. For instance, the median household income in communities where maternity wards closed was $12,000 less than in communities where they remained open [13]. The Socio-Ecological Model thus provides a valuable theoretical framework for examining how transportation barriers operate at multiple, inter-related levels in accessing maternal healthcare.
Transportation barriers are further intensified by increased travel times due to maternity ward closures in California. The number of hospitals with labor and delivery services in California has diminished from 250 to 214 since 2012, with three of the hospitals completely closing [14]. Between 2012 and 2019, 19 hospitals in California closed their labor and delivery services, followed by 16 additional closures from 2020 to 2022, 11 more in 2023 [14], and another 7 in 2024 [15].
In Los Angeles County specifically, 15 hospitals closed their labor and delivery services. As a result, only 53 hospitals in Los Angeles County offer maternal care as of 2023 [14]. For example, in 2024, USC Verdugo Hills Hospital closed its 18-bed Labor and Delivery unit and directed patients to nearby alternatives such as USC Arcadia Hospital [16]. Though this facility is just 4.7 miles away, travel time can reach an hour on public transportation during peak traffic time. Similarly, the nearest Federally Qualified Health Center (FQHC), Glendale’s Comprehensive Community Health Center, is 7.5 miles away and can require up to 50 min of travel due to traffic volumes in Los Angeles County, which is 1.5 times higher than the California average and nearly 7 times higher than the national average [17]. While FQHCs provide prenatal and preventive services, they do not offer inpatient labor and delivery services, leaving significant gaps in coverage.
The majority of participants were between the ages of 25–34, comprising 86% of the sample. A total of 7% were aged 18 to 24, and another 7% were between 35 and 44 (Table 1). Most women (91%) had at least some college experience, and 82% worked full-time at the time of participation. Regarding household income, 69% reported earning between $25,000 and $49,999 annually.
Of the total participants, 160 had given birth in 2023 or 2024 (Table 1). Among women who were currently pregnant during the time of the survey, 29 were in their third trimester, 33 were in their second trimester, and 13 were in their first trimester. A total of 90% of respondents had one or two children, which included the child they were currently pregnant with, while the remaining 10% had three to four children.
A majority of new or expectant mothers, 67%, did not own or have access to a car. The primary transport mode reported by respondents was the bus (Figure 1). However, most participants (83%) used multiple modes of transportation, with the most common being car (47%), bus (42%), rideshare service (5%), and walking (5%).
Most respondents (75%) spent between $1 and $10 on one-way transportation costs. For the same proportion, the distance to their primary maternal health provider ranged from 1 to 10 miles (Figure 2). The average one-way travel time for respondents varied widely, from 0 to 79 min, with the most frequently reported travel time being 20 to 39 min (38%).
Transportation difficulties were a major barrier to accessing care. Nearly three quarters (73.6%) identified transportation issues as the primary reason for late, missed or rescheduled appointments. While some participants did not view transportation as the primary issue, 91% of respondents acknowledged they have experienced problems with their appointments due to transportation, and 89% explicitly identified transportation as a barrier that limits their ability to access maternal healthcare. The most commonly reported transportation barrier was the lack of public transit, which affected 69% of participants (Table 2).
One notable insight was that some women in the study reported feeling uncomfortable and unsafe taking public transportation, which is consistent with broader research showing that women experience high rates of sexual harassment and assault while using public transit. These risks are often magnified for Black women due to the intersection of racism and sexism, which increases their vulnerability to violence [18]. These safety concerns are not just personal experiences but systemic public health issues that must be addressed through policy and urban planning. California Senate Bill (SB) 1161, signed into law in 2022, mandates that large transit agencies examine rider safety and street harassment within their systems [19]. However, once these safety concerns are exposed, they must be followed by concrete policies to meaningfully improve the safety of public transportation for Black women and other vulnerable riders.
Geographic access emerged as a key barrier in our survey. To contextualize our findings, we examined hospital and public transportation data for the three zip codes with the highest participant representation: 90003, 90044, and 90043. In 90003, there were three hospitals within a five-mile radius that accepted Medicare and provided inpatient labor and delivery care. In the 90043 and 90044 zip codes, there are two and three Medicare-certified hospitals providing these services, respectively [20]. While this distance may seem manageable, participants’ responses align with data showing that travel times can reach up to an hour during peak traffic times due to congestion and transit delays. Furthermore, Metro buses in Los Angeles arrive over five minutes late on average 22% of the time [21], further exacerbating delays. These combined factors, limited hospital proximity, unreliable transit, and heavy traffic, can help explain the transportation barriers participants described, linking their lived experience to broader spatial and infrastructural challenges. Collaboration between maternal health providers and public transportation agencies may help address these gaps by coordinating services, improving transit routes to clinics, and prioritizing safety and reliability for new or expectant riders.
Affordability was another major theme. More affordable transportation was recommended as a solution by many participants. California has established policies that could help alleviate this issue. For instance, California’s Medicaid healthcare program for low-income residents, Medi-Cal, offers transportation services. Individuals who are pregnant or within one year postpartum can access Non-Medical Transportation (NMT) and Non-Emergency Medical Transportation (NEMT) [22]. NMT offers public and private transportation services, arranging rides to medical appointments for expecting and new mothers who lack other viable transportation options. This service is also available to individuals who fall outside that group if they have full-scope Medi-Cal coverage. NEMT includes ambulances, wheelchair vans, or litter vans for those who are unable to use public or private transportation.
In Los Angeles specifically, residents with Medi-Cal are eligible for L.A. Care, a health plan that offers free transport to appointments through a service called, “Call the Car” [23]. Los Angeles County Health Services also offers free Uber and Lyft rides to and from appointments for individuals who are not eligible for other free transportation services [23].
Sections
"[{\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B1-ijerph-22-01429\", \"B1-ijerph-22-01429\", \"B2-ijerph-22-01429\", \"B3-ijerph-22-01429\"], \"section\": \"1.1. Maternal Health Crisis in the United States\", \"text\": \"The maternal mortality rate refers to the number of maternal deaths per 100,000 live births among those who are pregnant or within 42 days of termination of pregnancy [1]. In the United States, the maternal mortality rate has been steadily increasing, despite advances in modern medicine [1]. While the average maternal mortality rate in high-income countries is 12 per 100,000 live births [2], the United States had a maternal mortality rate of 18.6 per 100,000 live births in 2023 [3].\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B4-ijerph-22-01429\", \"B3-ijerph-22-01429\"], \"section\": \"1.1. Maternal Health Crisis in the United States\", \"text\": \"When the maternal morbidity and mortality data are stratified by racial group, the reality becomes even more grim. A 2024 study revealed that Black individuals were 1.9 times more likely than white women to experience intrapartum maternal morbidity, but the rate spikes to 2.5 times more likely than their white counterparts during the postpartum period [4]. In 2023, the maternal mortality rate among white women was 14.5 deaths per 100,000 live births, while Black women faced a maternal mortality rate of 50.3, more than three times the rate of their white counterparts [3].\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B5-ijerph-22-01429\", \"B5-ijerph-22-01429\", \"B6-ijerph-22-01429\", \"B7-ijerph-22-01429\", \"B8-ijerph-22-01429\", \"B9-ijerph-22-01429\"], \"section\": \"1.1. Maternal Health Crisis in the United States\", \"text\": \"In Los Angeles County specifically, these disparities are even more pronounced. Black birthing people face a maternal mortality rate four times higher than other racial groups [5]. They also experience a higher risk of cesarean sections and preterm births, while Black infants are three times more likely to die than white and Asian infants [5,6,7,8]. Although cesarean sections are necessary in some cases, they are associated with increased risks of health complications after birth [9].\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B10-ijerph-22-01429\"], \"section\": \"1.2. Transportation Access as a Social Determinant of Health\", \"text\": \"Public health officials turn to the social determinants of health to explain the persistence of health disparities. Social determinants of health are non-medical factors that influence one\\u2019s health outcomes, such as income, education, food insecurity, and access to transportation [10].\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B11-ijerph-22-01429\", \"B12-ijerph-22-01429\"], \"section\": \"1.2. Transportation Access as a Social Determinant of Health\", \"text\": \"Several studies explore inadequate transportation as a barrier to healthcare access in the United States. For instance, the National Center for Health Statistics found that, in 2022, 5.7% of adults did not have reliable transportation to conduct daily living tasks such as healthcare appointments. While the study did not provide statistics specifically for Black women, both identities face higher rates than the average, with 6.1% of women with no reliable transportation and 9.2% of Black individuals without reliable transportation [11]. Similarly, a North Carolina study found that one-third of people who had six or more medical appointments between 2020 and 2021 experienced transportation-related challenges. The most frequent types of transportation barriers mentioned were the lack of access to a driver or car and the cost of travel [12]. While these studies illuminate the relationship between transportation and healthcare broadly, the specific connection between transportation access and maternal healthcare, particularly for Black birthing people, remains largely unexplored.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B13-ijerph-22-01429\"], \"section\": \"1.2. Transportation Access as a Social Determinant of Health\", \"text\": \"Barriers to transportation can manifest across multiple levels of the Socio-Ecological Model, which provides a framework for understanding how health behaviors and outcomes are shaped by individual, interpersonal, community, and societal factors. At the individual level, a pregnant person may not have access to a vehicle for their prenatal appointments. Interpersonally, they may have to rely on others in their social network in order to access transportation to a healthcare provider, which may not always be reliable. At the community level, limited public transit options or the absence of nearby maternity wards can make maternal healthcare inaccessible. Lastly, societal factors, such as underinvestment in low-income areas and structural racism may exacerbate transportation inequities. For instance, the median household income in communities where maternity wards closed was $12,000 less than in communities where they remained open [13]. The Socio-Ecological Model thus provides a valuable theoretical framework for examining how transportation barriers operate at multiple, inter-related levels in accessing maternal healthcare.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B14-ijerph-22-01429\", \"B14-ijerph-22-01429\", \"B15-ijerph-22-01429\"], \"section\": \"1.3. Closures of Maternal Health Wards\", \"text\": \"Transportation barriers are further intensified by increased travel times due to maternity ward closures in California. The number of hospitals with labor and delivery services in California has diminished from 250 to 214 since 2012, with three of the hospitals completely closing [14]. Between 2012 and 2019, 19 hospitals in California closed their labor and delivery services, followed by 16 additional closures from 2020 to 2022, 11 more in 2023 [14], and another 7 in 2024 [15].\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B14-ijerph-22-01429\", \"B16-ijerph-22-01429\", \"B17-ijerph-22-01429\"], \"section\": \"1.3. Closures of Maternal Health Wards\", \"text\": \"In Los Angeles County specifically, 15 hospitals closed their labor and delivery services. As a result, only 53 hospitals in Los Angeles County offer maternal care as of 2023 [14]. For example, in 2024, USC Verdugo Hills Hospital closed its 18-bed Labor and Delivery unit and directed patients to nearby alternatives such as USC Arcadia Hospital [16]. Though this facility is just 4.7 miles away, travel time can reach an hour on public transportation during peak traffic time. Similarly, the nearest Federally Qualified Health Center (FQHC), Glendale\\u2019s Comprehensive Community Health Center, is 7.5 miles away and can require up to 50 min of travel due to traffic volumes in Los Angeles County, which is 1.5 times higher than the California average and nearly 7 times higher than the national average [17]. While FQHCs provide prenatal and preventive services, they do not offer inpatient labor and delivery services, leaving significant gaps in coverage.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"ijerph-22-01429-t001\"], \"section\": \"3.1. Demographics\", \"text\": \"The majority of participants were between the ages of 25\\u201334, comprising 86% of the sample. A total of 7% were aged 18 to 24, and another 7% were between 35 and 44 (Table 1). Most women (91%) had at least some college experience, and 82% worked full-time at the time of participation. Regarding household income, 69% reported earning between $25,000 and $49,999 annually.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"ijerph-22-01429-t001\"], \"section\": \"3.1. Demographics\", \"text\": \"Of the total participants, 160 had given birth in 2023 or 2024 (Table 1). Among women who were currently pregnant during the time of the survey, 29 were in their third trimester, 33 were in their second trimester, and 13 were in their first trimester. A total of 90% of respondents had one or two children, which included the child they were currently pregnant with, while the remaining 10% had three to four children.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"ijerph-22-01429-f001\"], \"section\": \"3.2. Transportation Access\", \"text\": \"A majority of new or expectant mothers, 67%, did not own or have access to a car. The primary transport mode reported by respondents was the bus (Figure 1). However, most participants (83%) used multiple modes of transportation, with the most common being car (47%), bus (42%), rideshare service (5%), and walking (5%).\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"ijerph-22-01429-f002\"], \"section\": \"3.2. Transportation Access\", \"text\": \"Most respondents (75%) spent between $1 and $10 on one-way transportation costs. For the same proportion, the distance to their primary maternal health provider ranged from 1 to 10 miles (Figure 2). The average one-way travel time for respondents varied widely, from 0 to 79 min, with the most frequently reported travel time being 20 to 39 min (38%).\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"ijerph-22-01429-t002\"], \"section\": \"3.3. Effect of Transportation on Access to Maternal Healthcare\", \"text\": \"Transportation difficulties were a major barrier to accessing care. Nearly three quarters (73.6%) identified transportation issues as the primary reason for late, missed or rescheduled appointments. While some participants did not view transportation as the primary issue, 91% of respondents acknowledged they have experienced problems with their appointments due to transportation, and 89% explicitly identified transportation as a barrier that limits their ability to access maternal healthcare. The most commonly reported transportation barrier was the lack of public transit, which affected 69% of participants (Table 2).\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B18-ijerph-22-01429\", \"B19-ijerph-22-01429\"], \"section\": \"4. Discussion\", \"text\": \"One notable insight was that some women in the study reported feeling uncomfortable and unsafe taking public transportation, which is consistent with broader research showing that women experience high rates of sexual harassment and assault while using public transit. These risks are often magnified for Black women due to the intersection of racism and sexism, which increases their vulnerability to violence [18]. These safety concerns are not just personal experiences but systemic public health issues that must be addressed through policy and urban planning. California Senate Bill (SB) 1161, signed into law in 2022, mandates that large transit agencies examine rider safety and street harassment within their systems [19]. However, once these safety concerns are exposed, they must be followed by concrete policies to meaningfully improve the safety of public transportation for Black women and other vulnerable riders.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B20-ijerph-22-01429\", \"B21-ijerph-22-01429\"], \"section\": \"4. Discussion\", \"text\": \"Geographic access emerged as a key barrier in our survey. To contextualize our findings, we examined hospital and public transportation data for the three zip codes with the highest participant representation: 90003, 90044, and 90043. In 90003, there were three hospitals within a five-mile radius that accepted Medicare and provided inpatient labor and delivery care. In the 90043 and 90044 zip codes, there are two and three Medicare-certified hospitals providing these services, respectively [20]. While this distance may seem manageable, participants\\u2019 responses align with data showing that travel times can reach up to an hour during peak traffic times due to congestion and transit delays. Furthermore, Metro buses in Los Angeles arrive over five minutes late on average 22% of the time [21], further exacerbating delays. These combined factors, limited hospital proximity, unreliable transit, and heavy traffic, can help explain the transportation barriers participants described, linking their lived experience to broader spatial and infrastructural challenges. Collaboration between maternal health providers and public transportation agencies may help address these gaps by coordinating services, improving transit routes to clinics, and prioritizing safety and reliability for new or expectant riders.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B22-ijerph-22-01429\"], \"section\": \"4. Discussion\", \"text\": \"Affordability was another major theme. More affordable transportation was recommended as a solution by many participants. California has established policies that could help alleviate this issue. For instance, California\\u2019s Medicaid healthcare program for low-income residents, Medi-Cal, offers transportation services. Individuals who are pregnant or within one year postpartum can access Non-Medical Transportation (NMT) and Non-Emergency Medical Transportation (NEMT) [22]. NMT offers public and private transportation services, arranging rides to medical appointments for expecting and new mothers who lack other viable transportation options. This service is also available to individuals who fall outside that group if they have full-scope Medi-Cal coverage. NEMT includes ambulances, wheelchair vans, or litter vans for those who are unable to use public or private transportation.\"}, {\"pmc\": \"PMC12470221\", \"pmid\": \"41007573\", \"reference_ids\": [\"B23-ijerph-22-01429\", \"B23-ijerph-22-01429\"], \"section\": \"4. Discussion\", \"text\": \"In Los Angeles specifically, residents with Medi-Cal are eligible for L.A. Care, a health plan that offers free transport to appointments through a service called, \\u201cCall the Car\\u201d [23]. Los Angeles County Health Services also offers free Uber and Lyft rides to and from appointments for individuals who are not eligible for other free transportation services [23].\"}]"
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