Black babies in SF are at greater risk of early birth than ever

Teaja Watts wasn’t sure her daughter was going to make it.

It had been a difficult pregnancy. Watts was expecting twins but had a miscarriage at 11 weeks, when one fetus died in the womb. At her job as a security guard, she wasn’t able to sit. She went into labor at just over 25 weeks.

When her daughter Kaori was born, she was small enough to fit in her mother’s hand. She weighed 1 pound, 10.8 ounces, and was unable to breathe on her own.

It was the scariest day of Watts’ life. 

“I just remember seeing her so small,” Watts said. “I just didn’t know if she was going to live or not.”

Watts was statistically more likely to experience this nightmare because she was Black in San Francisco. She is one of an increasing percentage of local Black mothers who are having babies well before their due dates, with worsening health outcomes for both child and mother. 

Pre-term birth is a basic metric by which health officials determine perinatal risks. It’s a proxy that is associated with and predicts risks that include anything from developmental delays and trouble breathing for the infant to postpartum depression and post-traumatic stress disorder for the mother. And it disproportionately affects Black people. 

The overall rate of preterm birth in San Francisco is 8.5%, lower than the California average of 9.1%, according to the most recent state data, from 2023. But the Black rate of preterm birth in the city, at 16%, is the highest it’s been since the state began collecting data in 2007. 

An alarming 1 in 6 Black babies is born early in the city, versus 1 in 17 white babies. While outcomes are getting better for white mothers, they’re getting worse for Black ones. The disparity between early birth rates for Black and white mothers is the largest it has been since the state began collecting data, and the third highest of all counties in the state that track racial inequities.

But while outcomes for Black birthing parents and their babies are declining, the San Francisco Department of Public Health is not fully investing in potential solutions. 

An investigation by The San Francisco Standard found that the city has underspent its budget to address maternal inequities by at least $8 million since 2021.

The city has also failed to fill key positions at a program meant to improve Black maternal health. And with the city and local nonprofits becoming targets of a growing movement against diversity, equity, and inclusion policies, maternal health advocates are concerned about how they’ll be able to make progress. Addressing a race- and gender-based problem necessitates race- and gender-based programs and spending, which critics claim runs afoul of constitutional equal rights protections.

“If 1 in every 6 Black births is early, that is more kids with health conditions who need better healthcare and more medical bills for the parents,” said Zea Malawa, a pediatrician, founder of the nonprofit Expecting Justice, and director of the Abundant Birth Project. 

“In that system, what chance does the Black community have?"

With the 2019 Dignity in Pregnancy and Childbirth Act, California became a national model for addressing racial disparities in maternal health. The law required training on implicit bias for medical professionals, in an attempt to reduce high Black maternal and infant mortality rates. In California, Black women account for 5% of pregnancies but 21% of maternal deaths.

“We need to listen to this data,” Attorney General Rob Bonta said in 2023. “It’s screaming at us to do something.”

After an investigation by his office found that most hospitals were out of compliance with the DPCA, including Zuckerberg General Hospital and Kaiser in San Francisco, another bill was passed in 2024 to require proof that training was completed. Additional studies were completed, offices opened, and programs funded. 

While California has invested in closing the gap between Black and white maternal health outcomes, the statewide preterm birth rate among this cohort has changed little in the few years since the DPCA was passed. But in San Francisco, as the rate of preterm Black births has climbed, the city has declined to fully staff and invest in state-designed initiatives.

The city’s branch of the statewide Black Infant Health Initiative has been acutely understaffed since it launched in 2021. According to the California Department of Public Health, the city’s BIH branch has been without a director for four years, and without “critical” personnel “at different points for the last five years.” 

BIH programs include support groups, breastfeeding programs, food vouchers, and nurse referrals. The BIH budget pulls from state grant money and the city general fund, with reimbursement available from the state. 

From fiscal 2021 through 2024, San Francisco’s BIH branch has underspent its budget by $7.3 million, or 55%. So far in fiscal 2025, the program has underspent by more than $3 million. 

A spokesperson for the San Francisco Public Health Department said in a statement that “the program has continued its vital work and met its requirements.”

The Perinatal Equity Initiative was intended to fund group prenatal care, parenting classes, home visitation services, and health resources. 

Since 2021, San Francisco has received between $459,560 and $919,120 each year in program funding. But when Public Health director Daniel Tsai presented the 2025-26 budget for maternal health projects in front of the Budget and Appropriations Committee on June 12, it did not include a clear accounting of that funding.

Malawa was shocked and horrified. “I was like, where are the PEI dollars?” 

Much of the money is now back with the state. According to city health department records, $791,434 — 34% of the funds disbursed between 2021 and 2024 — was unspent and returned. 

As the health disparity between Black and white mothers grew through 2024, San Francisco returned the highest portion of its PEI funds yet back to the state: 43% of what it had originally budgeted.

The SF Public Health Department did not answer questions about how initiative funds were used or why portions had been returned.

While California has not backed down from its investment in and attention on racial health disparities, it’s becoming more difficult and risky for municipalities and nonprofits to engage in race- and gender-based work, as the backlash against DEI policies and programs grows.

The Abundant Birth Project’s San Francisco pilot began the same summer the state launched the Black Infant Health Initiative. The Abundant Birth Project, funded by the state, was the first of its kind in the country. It provided direct assistance to Black and Pacific Islander parents: $1,000 a month for the last six months of pregnancy and the first six months postpartum. The pilot included 151 people.

The hypothesis was that the aid would allow parents financial flexibility to reduce stress, and potentially avoid the kind of demanding work that may have sent Watts into early labor. The Abundant Birth Project cited a study that found direct financial aid during pregnancy reduced preterm birth and low birth weight.

For Sabrina Hall, it was lifesaving. She was pregnant with her fifth child and relying on food stamps. Abundant Birth’s $1,000 boost was “instant relief.” 

“It gave me the ability to provide for my kids,” Hall said. “If my son needed a new pair of shoes, I could get those for him without having to worry about affording food that week.”  

It was because of the money from Abundant Birth, Hall said, that she was able to go back to school. She now works as a medical assistant and phlebotomist at UCSF. 

But as Abundant Birth director Malawa was gearing up to negotiate a second contract with the city that would expand the program in 2023, a conservative legal advocacy organization called the Californians for Equal Rights Foundation filed a lawsuit alleging that San Francisco was violating the 14th amendment by financially supporting a program that benefited only specific racial groups. 

The lawsuit calls the program an “intense matter of public concern,” naming Abundant Birth Project and several other assistance programs that provide aid to artists, transgender, and young Black people. 

In July, the foundation won a settlement against Sacramento County forcing the removal of race as a selecting factor for a direct assistance program intended to help families of color. In a post on CFERF’s website, director Frank Xu characterized it as “a major legal victory.”

Xu said in a statement that the foundation would consider the pending lawsuit a success when “the city of San Francisco refrains from using race and gender to select recipients of government assistance/welfare.” 

Malawa said that even prior to the lawsuit, negotiations with the city were tense. “They wanted us to operate on almost zero administrative costs,” she said. “It was impossible.” 

Soon after the suit was filed, the city stopped communicating with Abundant Birth Project staff, according to Malawa. 

The city would not provide documents or answer questions about the pending case. A spokesperson for the public health department pointed to its other available services and said the city intends to launch another guaranteed income program focused on birthing parents, this one financed by San Francisco. It won’t be a relaunch of the Abundant Birth Project. 

The program is no longer headquartered or operating in the city. But Malawa has not backed down from its mission. After nearly two years waiting for San Francisco to come back to the table, she decided to use the state funding to launch pilots in cities in Contra Costa, Alameda, Los Angeles, and Riverside counties.

Michaela Taylor, program director for Abundant Birth, said the project is still processing data and has not been able to determine if participating parents experienced fewer preterm births. Recipients reported that the payments reduced their overall stress — something Gaea Moore, an obstetrician-gynecologist in Oakland said is “significantly associated” with preterm birth. 

Moore is concerned about how anti-diversity activism may prevent her and other providers from appropriately treating Black patients. 

“We’re not going to be able to move the needle without research supporting these efforts,” Moore said. “We as a society must continue our efforts to call this out as a public health issue.”

Ranesha Mims didn’t get a chance to participate in Abundant Birth. Weeks after the program wrapped its first San Francisco pilot, she went into labor. 

Arriving at Zuckerberg General Hospital during a wave of Covid, Mims wasn’t allowed to have her partner with her while she labored. But what was worse, she said, was the lack of attention she received from the staff. 

Mims, who is Black, suspected racial bias when she saw the other pregnant woman in her room, who was not Black, receive more attentive care from nurses. 

“I guess they forgot about me somewhat,” said Mims. After she delivered her son, Mims said, she was separated from the newborn, and the staff would not tell her where he was for hours at a time. 

Mims is pregnant again. Despite her last experience, she feels hopeful. And she has taken steps to protect herself. She is working with a team of Black female doctors and spending time and sharing notes with other mothers at the Homeless Prenatal Program, which serves families struggling with housing insecurity.

“This time I am going to really advocate for myself and make sure I have someone in the room with me,” Mims said. 

Meanwhile, Watts’ daughter Kaori has been in the NICU at UCSF for more than six months. She is scheduled to be released Aug. 18.

“I am really excited, and I really hope she comes home” in a few weeks, said Watts. But she has practiced not getting her hopes up. 

Malawa is scared for mothers like Mims and Watts — Black mothers struggling to make ends meet and receive adequate care, or dealing with the outcome of a traumatic birth. She sees San Francisco continuing on the wrong trajectory. But she feels hope in intervening on behalf of Black lives as soon as they’ve begun.

“Racism is going to take generations to treat,” Malawa said. “But babies are born every day.”