High rates of pregnancy-related deaths among women of African descent in North and South America are likely due largely to racism in the form of verbal and physical abuse from health care providers, denial of quality care, and refusal of pain relief, a U.N. report found.

The new analysis by the United Nations Population Fund (UNFPA) refutes misconceptions that Black women’s lifestyle choices or genetics underlie their poorer childbirth experiences, the authors said.

Drawing on government data and published studies, they found Black and mixed race women of African descent face disadvantages rooted in racist assumptions in medical education, policymaking, and health service delivery.

Medical textbooks, for example, teach childbirth based on a pelvic shape common to European women yet highly variable among women of other ethnicities, increasing their risk of obstetric intervention, the report said.

Many doctors also learn, incorrectly, that Black people feel less pain because of thicker skin and are less likely to experience postpartum hemorrhage because their blood clots more quickly, the report added.

Furthermore, Black women more often face structural barriers related to transportation, medical insurance, and a lack of acceptable, culturally appropriate health services, the researchers found.

They were able to compare pregnancy outcomes in only nine of the 35 countries in North and South America: Brazil, Colombia, Costa Rica, Cuba, Panama, Suriname, Trinidad and Tobago, the United States and Uruguay. These were the only countries with comparable recent national survey data stratified by ethnicity, race or skin color.

The largest discrepancy in maternal death rates was in the United States, where Black women are three times more likely to die within six weeks of giving birth compared to non-Black and non-Hispanic women, according to the report.

However, Black women in the United States fare better than non-Black women in other countries, the researchers said.

Higher income and education were not protective. Maternal deaths among U.S. African-American college graduates were 5.2 times higher than among white college graduates and 1.6 times higher than among white women with less than a high school diploma, the researchers found.

Maternal health policies rarely measure racial differences in outcomes, said Patricia Da Silva, program adviser for UNFPA’s Initiative for People of African Descent.

Governments must ensure data is collected and analyzed in ways that allow for targeted policies that can shrink the gaps in quality of care, she said.