“Push, push, push, Mama; push,” my wife, Joia Crear-Perry, implored. Quiana, angled upright on the birthing bed, replied with grunts of effort. Quiana’s husband, Dooley, offered his support from where he stood at the head of the bed. I stood on the opposite side. It was my first time seeing my wife in action as a gowned and gloved ob-gyn.

“He’s almost here—push, Mama.” Joia sat on a rolling stool between Quiana’s legs, which were hoisted in stirrups. The attending physician stood behind Joia, who repeated the same exhortation to push that was nearly a chant: “Push, push, push, Mama; push.”

I couldn’t see the particulars because of the gown, but I watched in amazement as Quiana birthed Robeson Perry, my biological son with Joia. My wife had assisted in the birthing of her own son by Quiana, our surrogate or “gestational carrier.” After years of fertility treatments and thousands of dollars, our last frozen embryo, of 13, had finally arrived.

I shared the story with my family of how Joia and I had hired a surrogate and were having a baby in December. After my family let out oohs and aahs, the room became silent. Then one of my cousins shouted, “Andre has made it! They’re having babies like white people now.” Laughter erupted. I thought to myself, “She’s kind of right.”

Instead of restricting women’s basic rights or limiting conversations on reproductive justice to abortion, the focus of federal policy should be on creating conditions that enable Black women to expand the ways they choose to make a family. Understanding racial birthing disparities requires us to examine structural racism.

Every person, regardless of race or class, should have the opportunity to have and raise a child. The American Society for Reproductive Medicine says creating a family is a basic human right. The United States and other countries should codify that right in their public policy and health care systems. In Britain, for example, three rounds of in vitro fertilization are available to those under 40 through the National Health Service. However, in the United States, only New York state covers infertility medications through Medicaid, the country’s income-restricted public insurance program for people of reproductive age. No state Medicaid program offers other critical fertility services like artificial insemination, in vitro fertilization, and egg freezing. Hiring a surrogate is only available to people with the means and networks to do so—“like white people.”

Only about half of employer-sponsored insurance plans cover infertility evaluation, and only a quarter offer infertility treatment, leaving Black, Hispanic, and Native American women, who are less likely to have employer coverage, with significantly fewer options. Less than half (47 percent) of working-age Black Americans were covered by employer plans in 2019, compared with 66 percent of whites, 42 percent of Hispanics, 65 percent of Asian Americans, and 36 percent of Native Americans, according to the Kaiser Family Foundation.

Fertility treatments should not just be a luxury for a privileged class; people who don’t receive those benefits are burdened by health care and other systems that are supposed to protect us.

The United States is the only industrialized nation with a rising maternal mortality rate; from 2000 to 2014, there was a 26 percent increase in maternal mortality, according to the American College of Obstetricians and Gynecologists and research published in Obstetrics and Gynecology. However, Black women are three to four times more likely to die from a pregnancy-related complication than non-Hispanic white women. And most maternal deaths are preventable (60 percent).

Underlying these differences isn’t the individual behaviors of Black women or economic status. It’s racism. We are inundated with insulting and infantilizing research and commentary about how Black people cause their own poverty by not getting married or by having too many children. For those writers, family planning strictly means that low-income women must figure out how to not have children. In 1970, President Richard Nixon codified these attitudes in policy. His anti-poverty strategy included placing family planning clinics in urban communities. This is a reason why so much focus on Black women’s reproductive health is on abortion and contraception.

UCLA professors of public health Gilbert Gee and Chandra Ford define structural racism as the “macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups.” People living in regions with racial disparities in housing, education, criminal justice, and health care have worse birthing outcomes. Results from a 2014 study in Social Science & Medicine “indicated that Blacks living in states with high levels of structural racism were generally more likely to report past-year myocardial infarction than Blacks living in low-structural racism states.”

We must dismantle the architecture of inequality that generates worse birthing outcomes for Black women.

Among his first acts as president, Joe Biden signed an executive order to advance racial equity, declaring that the nation must take “a systematic approach to embedding fairness in decision-making processes.” The heart of this order calls for the Office of Management and Budget to measure the effects of racism. However, we already know that Black women can’t buy or educate their way to better outcomes. When it comes to improving birthing outcomes, Biden should seek to require states—through congressional action, while his party controls the House and Senate—to cover infertility evaluation and treatment as an essential benefit of the Medicaid program. And he should dedicate an office in the White House to facilitate this process.

As memorable as experiencing the birth of my son was, looking back, I see how the pain from multiple miscarriages, financial loss, and the risks to my wife could have been mitigated through equitable policy. Roby is a healthy, smart, handsome 10-year-old who has brought nothing but joy to our lives. More of us can experience the joy of childbirth if our society and government learn to reckon with Black women’s pain, not generate it.