Kobi V. Ajayi, Texas A&M University Seven years ago, at 30 weeks into a seemingly low-risk pregnancy, I unexpectedly began to bleed. Doctors diagnosed me with complete placenta previa. Then, while on bed rest at 32 weeks, my placenta suddenly ruptured, leading to an immediate emergency cesarean section. I became one of about 10% of women giving birth in Nigeria to experience a preterm birth, which means before 37 weeks of pregnancy. Now, as a maternal and child health researcher in the U.S., I’m struck by the stubbornly high preterm birth rate here. According to the most recent March of Dimes Report Card on maternal and infant health, released on Nov. 17, 2025, 10.4% of babies in the U.S. were born prematurely in 2024. Preterm birth is the second-leading cause of infant deaths in the U.S., contributing to over 20,000 infant deaths each year. Some who survive are at increased risk of immediate and long-term health problems, with substantial emotional and financial tolls. That rate has not budged for three years, according to the report – and it is consistently higher than in many other countries, particularly those in the Global North. That’s also true for other crucial aspects of maternal and infant health, such as cardiovascular diseases and mental health needs. One key factor underlying the problem of preterm birth in the U.S. is extensive disparities in health care access for expectant mothers. In Texas, where I conduct my research and where I managed the state’s maternal mortality and morbidity review committee in 2023 and 2024, this issue plays out very clearly.

Revealing disparities that drive preterm birth rates

The March of Dimes report scored the U.S. overall a D+ grade on preterm birth rate at 10.4%, but states differ dramatically in their scores. New Hampshire, for example, scored an A- with 7.9% of infants born prematurely, while Mississippi, where 15% of infants are born prematurely, scored an F. Texas’ rates aren’t the worst in the country, but it scores notably worse than the national rate of 10.4%, with 11.1% of babies – 43,344 in total – born prematurely in 2024. And Texas has an especially large effect on the low national score because 10 of the 46 cities that receive a D or F grade – defined in the report as a rate higher than the national rate of 10.4% – are located there. In 2023, Texas had the highest number of such cities in the U.S. That may be in part because access to maternal care in Texas is so limited. Close to half of all counties across the state completely lack access to maternity care providers and birthing facilities, compared with one-third of counties across the U.S. Moreover, more counties in Texas are designated as health professional shortage areas, meaning they lack enough doctors for the number of people living in these areas. Shortages exist in 257 areas in Texas for primary care doctors, 149 for dentists and 251 for mental health providers. But even against the backdrop of geographic differences in health care access, the starkest contribution to the state’s preterm birth rates comes from ethnic and racial disparities. Mothers of non-Hispanic Black (14.7%), American Indian/Alaskan Native (12.5%), Pacific Islander (12.3%) and Hispanic (10.1%) descent have babies prematurely much more often than do mothers who are non-Hispanic white (9.5%) or Asian (9.1%). These numbers reflect the broader landscape of maternal health in the U.S. Although nationwide maternal mortality rates decreased from 22.3 to 18.6 deaths per 100,000 live births from 2022 to 2023, Black women died during pregnancy or within one year after childbirth at almost three times the rate (50.3%) of white (14.5%), Hispanic (12.4%) and Asian (10.7%) women.

Preterm birth in context

Having a baby early is not the normal or expected outcome during pregnancy. It occurs due to complex genetic and environmental factors, which are exacerbated by inadequate prenatal care. According to the World Health Organization, women should have eight or more doctor visits during their pregnancy. Without adequate and quality prenatal care, the chances of reversing the preterm birth trends are slim. Yet in Texas, unequal access to prenatal care remains a huge cause for concern. As the March of Dimes report documents, women of color in Texas receive adequate prenatal care at vastly lower rates than do white women – a fact that holds true in several other states as well. In addition, Texas has the highest uninsured rate in the nation, with 17% of women uninsured for health coverage, compared with a national average of 8%. Nationwide, public health experts, community advocates and families are calling for comprehensive health insurance to help cover the costs of prenatal care, particularly for low-income families that primarily rely on Medicaid for childbirth. Cuts to funding for the Affordable Care Act and Medicaid outlined in the 2025 Budget Reconciliation Act make it likely that more Americans will lose access to care or see their health care costs balloon. But state-level action may help reduce access barriers. In Texas, for example, a set of laws passed in 2025 may help improve access to care before, during and after pregnancy. Texas legislators funded initiatives targeted at workforce development in rural areas – particularly for obstetrician-gynecologists, emergency physicians and nurses, women’s preventive safety net programs, and maternal safety and quality improvement initiatives. Rising rates of chronic diseases, such as hypertension, obesity and diabetes, also contribute to women giving birth prematurely. While working with the state maternal mortality and morbidity review committee, my team and I found that cardiovascular conditions contributed to the 85 pregnancy-related deaths that occurred in 2020. An upward trend in obesity, diabetes and hypertension before pregnancy are pressing issues in the state, posing a serious threat to fetal and maternal health.

Learning from other countries

These statistics are grim. But proven strategies to reduce these and other causes of maternal mortality and morbidity are available. In Australia, for instance, maternal deaths have significantly declined from 12.7 per 100,000 live births in the early 1970s to 5.3 per 100,000 between 2021 and 2022. The reduction can be linked to several medical interventions that are based on equitable, safe, woman-centered and evidence-based maternal health services. In Texas, some of my colleagues at Texas A&M University use an equitable, woman-centered approach to develop culturally competent care centered on educational health promotion, preventive health care and community services. Utilizing nurses and nonmedical support roles such as community health workers and doulas, my colleagues’ initiatives complement existing state efforts and close critical gaps in health care access for rural and low-income Texas families. Across the country, researchers are using similar models, including the use of doulas, to address the Black maternal health crisis. Research shows the use of doulas can improve access to care during pregnancy and childbirth, particularly for women of color.

It’s all hands on deck

There isn’t one, single risk factor that leads to a preterm birth, nor is there a universal approach to its prevention. Results from my work with Black mothers who had a preterm birth aligns with what other experts are saying: Addressing the maternal health crisis in the U.S. requires more than policy interventions. It involves the dismantling of system-level and policy-driven inequities that lead to high rates of preterm births and negative pregnancy and childbirth outcomes, particularly for women of color, through funding, research, policy changes and community voices. Although I had my preterm birth in Nigeria, my story and those shared by the Black mothers I have worked with in the U.S. show eerily similar underlying challenges across different settings. Kobi V. Ajayi, Research Assistant Professor of Maternal and Child Health, Texas A&M University This article is republished from The Conversation under a Creative Commons license. Read the original article.

I treat menopause and its symptoms, and hormone replacement therapy can help – here’s the science behind the FDA’s decision to remove warnings

Genevieve Hofmann, University of Colorado Anschutz Medical Campus For more than 20 years, hormone therapy for menopause has carried a warning label from the Food and Drug Administration describing the medication’s risk of serious harms – namely, cancer, cardiovascular disease and possibly dementia. On Nov. 10, 2025, the FDA announced that drugmakers should remove these “black box” safety warnings. The Conversation U.S. asked Genevieve Hofmann, a women’s health nurse practitioner at the University of Colorado Anschutz Medical Campus, to explain how the decision will affect health care for people going through menopause or postmenopause.

How did the FDA’s decision come about?

When people think of hormone therapy for menopause, they generally think of systemic estrogen and progestogens – for example, pills or patches that deliver hormones throughout the body. Health care providers prescribed hormone therapy to manage symptoms of menopause such as hot flashes, night sweats and brain fog much more widely in the 1980s and 1990s than they do today. That’s because in the early 2000s, researchers analyzed data from a study called the Women’s Health Initiative and reported that hormone therapy increased the risk of breast cancer, heart disease, blood clots and stroke, as well as cognitive decline after menopause. After this research was first published in 2002, the use of hormone therapy fell by 46% within six months – both because clinicians were reluctant to prescribe it and patients were fearful of taking it. In 2003, the FDA added black box warnings – the most serious warnings, indicating a risk of serious harm or death – to all estrogen-containing hormone products for menopause.

But researchers soon pointed out methodological flaws in the analysis. And over the past two decades, careful reanalyses of data from that study, as well as newer studies, have shown that systemic hormone therapy is very safe for most women, though there are nuances surrounding its use. Meanwhile, women’s health experts have been increasingly vocal in the past five years in calling to remove the black box warnings from a form of hormone menopause therapy that’s applied locally, not systemically. Topical localized estrogen is applied directly to the vagina and surrounding areas, usually in the form of a cream or vaginal insert. It’s used to treat the genitourinary syndrome of menopause, which manifests as genital and urinary symptoms. Even though topical estrogen products are extremely safe and were not evaluated in the Women’s Health Initiative study, the FDA warnings were added to them, too. In July 2025, the FDA held an expert panel to discuss what’s currently known about the risks and benefits of hormone therapy for menopause. At the meeting, most experts urged the agency to remove the warning labels on topical vaginal estrogen products. The Nov. 10 announcement was the outcome of that discussion, and it included both systemic and topical hormone therapy.

Why is systemic estrogen no longer considered unsafe?

Researchers are now finding that the balance of risks and benefits of systemic hormone therapy for menopause seems to depend strongly on when someone starts hormones, as well as the type, dose and length of use. For women under 60 or within 10 years of their final period, the therapy is much safer than it is for older women. A 2017 follow-up of Women’s Health Initiative participants showed that overall deaths from any causes actually decreased in this younger cohort of menopausal women taking hormones. For women who are more than 10 years from their final menstrual period, starting hormone therapy may increase their risk of cardiovascular disease. Researchers now refer to this as the timing hypothesis. Newer studies also support this idea. Also, some ways of delivering hormones to the body turned out to be safer than others. Taking estrogen orally, as pills or tablets, carries a higher risk of blood clots. Those risks go away when it’s delivered through the skin using a patch, gel or spray. Many more options for hormone therapy exist today than in the early 2000s. Additionally, it’s well established that hormone therapy improves bone health by preventing bone loss. Some studies suggest that in younger menopausal women, it may actually protect against cardiovascular disease, though this link is not yet proven and needs more study. Unfortunately, many people missed out on the timing window. In my practice, I see patients who went through menopause 10 or 15 years ago and either didn’t get hormone therapy at the time or stopped taking it when the initial Women’s Health Initiative results came out. Now, they are hearing about the benefits, and many want to try it. But their higher cardiovascular risk may overshadow the benefit.

What about topical estrogen?

Genitourinary syndrome of menopause is ubiquitous – it affects every person with ovaries who goes through menopause, and the symptoms tend to worsen with age. They include vaginal dryness, painful sex and urinary issues such as an increase in urgency or frequency, along with incontinence. Urinary tract infections often tend to get more frequent with menopause, particularly in older women. Treating them can require multiple courses of antibiotics. Tissues in the genitourinary area are loaded with estrogen receptors – proteins in cells that bind the hormone. So adding some estrogen back to these areas can help restore the quality and thickness of these tissues, and possibly even promote the growth of healthy bacteria around the vagina and the urinary tract. The treatment can greatly improve quality of life and promote better health and longevity. Despite topical estrogen’s safety and effectiveness, the FDA did not distinguish between it and systemic estrogen when adding the black box warnings in 2003. For this reason, many providers whose patients have symptoms relating to the genitourinary syndrome of menopause have been reluctant to prescribe it. Often, providers simply don’t know that it has a different safety profile than systemic estrogen.

How will removing the black box warnings affect patients?

Overall, I see this as a big win for women and their ability to manage the symptoms of menopause. I think this will make clinicians and patients far less anxious about prescribing and taking this medication. Clinicians like me who specialize in women’s health and menopause – and who have been following the research – have been safely prescribing hormone therapy all along. But many general practitioners who often lacked either menopause-specific training or the time and resources to stay on top of the latest findings have been more reluctant to do so. Safety concerns that led to the black box warnings, especially in regard to local vaginal estrogen, have turned out to be overblown. While clinicians still need to consider who is a good candidate for systemic hormone use, the evidence shows that for most people, it is a safe option. Even more important, patients who were previously convinced that hormone therapy was unsafe may feel more comfortable discussing it with their provider and considering it. And if they do receive a prescription for hormone therapy, I hope that the likelihood of them starting this effective treatment is no longer hindered by reading a scary package insert that was based on outdated evidence. While this medication is not a silver bullet that reverses aging, starting hormones at the right time can safely improve symptoms that diminish people’s quality of life. So if you’re having symptoms that are bothersome, consider asking your provider about menopause hormone therapy to help manage them. Genevieve Hofmann, Assistant Professor of Nursing and Women’s Health, University of Colorado Anschutz Medical Campus This article is republished from The Conversation under a Creative Commons license. Read the original article.