In the United States, NICUs are disproportionately populated by non-Hispanic black infants because of high preterm birth rates among Black women. Despite increases in coverage of essential maternal and newborn care interventions, inequities persist. There is considerable evidence that social factors influence outcomes, and these upstream elements must be considered if we are to optimize outcomes for all. Inequities may result from discrimination or differential treatment at the point of care, or from patients delaying care due to historical reticence to engage with the health care system. There may be other barriers to accessing quality care such as local availability, direct and indirect costs, influence of others on decision making or transportation. Wealth-based inequities have been seen in access to maternal, newborn, and child health interventions, particularly for presence of a skilled attendant at birth. Additionally, structural factors such as staff awareness of bias and privilege, respectful trauma-informed care and women’s empowerment for decision-making are also associated with use of maternal health services, including skilled delivery services. How can we address these challenges in our NICUs to narrow the gap and achieve the best outcomes for all?