The United States has the highest maternal death rate among high-income countries (Gunja et al., 2022). Between 2018 and 2021, the rate rose from 17.4 to 32.9 deaths per 100,000 live births across all racial groups (Hoyert, 2023). These rates highlight racial disparities when reviewed in detail; in 2021, the maternal death rate for Black women was 69.9 deaths per 100,000 live births compared to 26.6 deaths for White women. Equally troubling, racial health disparities are evident across the lifespan. Black infants have worse health outcomes than White infants; chronic illnesses are far more common among middle-aged Black people than White people; and life expectancy of Black people is considerably shorter than that of White people (Hill et al., 2023; Simons et al., 2021). These health disparities are often erroneously attributed to risky behavior, poor health choices, or bad genes (Geronimus, 2023).

Arline Geronimus (2023) presents an alternative explanation for these alarming disparities in her new book Weathering: The Extraordinary Stress of Ordinary Life in a Unjust Society. Based on decades of research conducted at the School of Public Health at the University of Michigan, she argues that a major driver of health disparities in the United States is the body's response to chronic stress. She uses the metaphor of "weathering" to describe how everyday exposures to social inequities stemming from structural racism and poverty produces wear and tear on the body at the cellular level, damaging telomeres (the caps on the end of DNA chromosomes), and cardiovascular, neuroendocrine, and metabolic systems. Her book weaves together research findings with first-person accounts to explain how people of color and those living in poverty develop chronic illnesses more rapidly and die earlier than more affluent White people (Geronimus, 2023).

Geronimus is no stranger to controversy. Early in her career, she conducted groundbreaking studies that challenged the conventional wisdom on teen mothering. As she details in her book and elsewhere, the Black teen mothers she studied had better perinatal outcomes than older Black women from similar backgrounds (Geronimus, 1996, 2023). Babies of Black teenage mothers were also less likely to die in their first year than babies born to Black mothers in their 20s. Children of Black teen mothers fared as well (and sometimes better) than their cousins whose mothers gave birth in their 20s (Geronimus, 2023; Geronimus et al., 1994). These surprising results upset the scientific view that young maternal age was a major predictor of poor maternal-child outcomes (Geronimus, 1991, 1992). Geronimus speculated that the health of Black mothers in their 20s was already deteriorating, relative to younger teen mothers, from their longer exposure to structural inequalities and racism. Her subsequent studies and research by other teams provide further evidence for how toxic stress accelerates aging and contributes to health disparities in maternal-child health (Lueth et al., 2022); and in comorbidities and mortality for racial, ethnic, and impoverished groups compared to economically secure White people (Geronimus, 2023; Simons et al., 2021).

There are no quick fixes to prevent or treat the harmful effects of weathering. Structural inequalities and racism in society in general and in health care specifically are not reversed by prescribing individual behavioral change or drug therapies. Rather, policies that promote social justice and mitigate social and racial inequities are required. To decrease perinatal disparities, extending Medicaid coverage to improve health care access for women with low incomes is a high priority (Geronimus, 2023; Society for Maternal-Fetal Medicine [SMFM] et al., 2022; Taylor, 2020). Creating a culture of safety that legitimizes reporting instances of bias and discrimination in health care interactions is also recommended along with advocating for policies that mitigate racism and poverty (SMFM, 2022). Perinatal clinicians have an important role to play in decreasing racial disparities by urging their employers to adopt SMFM's (2022) best practices and by eliciting and responding to women's concerns with openness and without stigmatizing language (Craft-Blacksheare & Kahn, 2022; Geronimus, 2023; Taylor, 2020). The Centers for Disease Control and Prevention's Health Equity Guiding Principles for Inclusive Communication (2021) provides additional recommendations.

Geronimus' election to the National Academy of Medicine of the National Academies of Science suggests that her research is being given the serious attention it deserves. Recent interviews following the publication of her book are bringing a wider audience to her work (Davies, 2023). This audience should include nurses and other health care providers who treat the insidious physiologic effects of poverty and racism. Moving in this direction is more urgent than ever in the wake of the Supreme Court decision that overturned Roe v. Wade. As of this writing, 14 states have banned most abortions with few exceptions. No matter where you stand on abortion, this evisceration of reproductive rights is likely to raise maternal death rates and racial and class disparities even higher as women with low incomes who experience pregnancy complications are denied needed care and lack the funds to travel to states where treatment is still available.

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