Maternal mortality in the United States

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this metric only includes causes related to the pregnancy, and does not include accidental causes.^[3] Some sources will define maternal mortality as the death of a woman up to 42 days after the pregnancy has ended, instead of one year.^[4] In 1986, the CDC began tracking pregnancy-related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System.^[3] According to a 2010-2011 report although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest (12.7 deaths per 100,000 births) when compared to 49 other countries in the developed world.^[5]

Maternal deaths per 100,000 births. CDC: "Maternal deaths include deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."^[1][2]

As of 2021, the US had an estimated 32.9 deaths per 100,000 births.^[2] The CDC reported an increase in the maternal mortality ratio in the United States from 18.8 deaths per 100,000 births to 23.8 deaths per 100,000 births between 2000 and 2014, a 26.6% increase.^[6] The mortality rate of pregnant and recently pregnant women in the United States rose almost 30% between 2019 and 2020.^[7] According to the CDC, a study that included data from 36 states found that more than 80% of pregnancy-related deaths were preventable between 2017 and 2019.^[8]

Monitoring maternal mortality

In 1986, the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) created the Pregnancy-Related Mortality Surveillance System to monitor maternal deaths during pregnancy and up to one year after giving birth. Prior to this, women were monitored up to six weeks postpartum.^[3]

In 2016 the CDC Foundation, the Centers for Disease Control and Prevention (CDC) and the Association of Maternal and Child Health Programs (AMCHP) undertook a collaborative initiative—"Building U.S. Capacity to Review and Prevent Maternal Deaths"— funded by Merck under the Merck for Mothers program. They are reviewing maternal mortality to enhance understanding of the increase in the maternal mortality ratio in the United States, and to identify preventative interventions.^[9] Through this initiative, they have created the Review to Action website which hosts their reports and resources. In their 2017 report, four states, Colorado, Delaware, Georgia, and Ohio, supported the development of the Maternal Mortality Review Data System (MMRDS) which was intended as a precursor to the Maternal Mortality Review Information Application (MMRIA).^[10] The three agencies have partnered with Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina, and Utah to collect data for the Maternal Mortality Review Information Application (MMRIA); the nine states submitted their first reports in 2018.^[11]

After decades of inaction on the part of the U.S. Congress towards reducing the maternal mortality ratio, the United States Senate Committee on Appropriations voted on June 28, 2018, to request $50 million to prevent the pregnancy-related deaths of American women.^[12] The CDC would receive $12 million for research and data collection. They would also support individual states in counting and reviewing data on maternal deaths.^[12] The federal Maternal and Child Health Bureau would receive the remaining $38 million directed towards Healthy Start program and "life saving, evidence-based programs" at hospitals.^[12] MCHB's Healthy Start was mandated to reduce the infant mortality rate.^[13]

In 2019, Black maternal health advocate and Parents writer Christine Michel Carter interviewed Vice President Kamala Harris. As a senator, in 2019 Harris reintroduced the Maternal Care Access and Reducing Emergencies (CARE) Act which aimed to address the maternal mortality disparity faced by women of color by training providers on recognizing implicit racial bias and its impact on care. Harris stated:

"We need to speak the uncomfortable truth that women—and especially Black women—are too often not listened to or taken seriously by the health care system, and therefore they are denied the dignity that they deserve. And we need to speak this truth because today, the United States is 1 of only 13 countries in the world where the rate of maternal mortality is worse than it was 25 years ago. That risk is even higher for Black women, who are three to four times more likely than white women to die from pregnancy-related causes. These numbers are simply outrageous."

In the 1930s Maternal Mortality Review Committees (MMRCs), state and local committees that review pregnancy-related deaths, formed in New York City and Philadelphia in response to high maternal mortality rates. Philadelphia saw success with reducing the rates through data collected from their MMRC and over the next two decades MMRCs popped up throughout the country. MMRCs have grown and shrunk in popularity since, but the CDC now recommends MMRC data as the gold standard for understanding the causes of maternal mortality and planning intervention.The reasoning is that MMRCs are uniquely poised to identify opportunities for action despite difficulties in classifying deaths as pregnancy-related.^[14]

 

Graph showing the trend in pregnancy related deaths in the United States from 1987 to 2014.

Measurement and data collection

According to a 2016 article in Obstetrics and Gynecology by MacDorman et al., one factor affecting the US maternal death rate is the variability in the calculation of maternal deaths. The WHO deems maternal deaths to be those occurring within 42 days of the end of pregnancy, whereas the United States Pregnancy Mortality Surveillance System measures maternal deaths as those occurring within a year of the end of pregnancy.^[6] Some states allow multiple responses, such as whether the death occurred during pregnancy, within 42 days after pregnancy, or within a year of pregnancy, but some states, such as California, ask simply whether the death occurred within a year postpartum.^[6]

In their article, the authors described how data collection on maternal mortality rates became an "international embarrassment".^{[6][15]: 427} In 2003 the national U.S. standard death certificate added a "tick box" question regarding the pregnancy status of the deceased. Many states delayed adopting the new death certificate standards. This "muddied" data and obstructed analysis of trends in maternal mortality rates. It also meant that for many years, the United States could not report a national maternal mortality rate to the OECD or other repositories that collect data internationally.^{[6][15]: 427}

In response to the MacDorman study, revealing the "inability, or unwillingness, of states and the federal government to track maternal deaths",^[16] ProPublica and NPR found that in 2016 alone, between 700 and 900 women died from pregnancy- and childbirth-related causes. In "Lost Mothers" they published stories of some of women who died, ranging from 16 to 43 years of age.^[16]

Healthy People is a federal organization that is managed by the Office of Disease Prevention and Health Promotion (ODPHP) at the U.S. Department of Health and Human Services (HHS). In 2010, the US maternal mortality ratio was 12.7 (deaths per 100,000 live births). This was three times as high as the Healthy People 2010 goal, a national target set by the US government.^[17]

According to a 2009 article in Anthropology News, studies conducted by but not limited to Amnesty International, the United Nations, and federal programs such as the CDC, maternal mortality has not decreased since 1999 and may have been rising.^[18]

By November 2017, Baltimore, Philadelphia, and New York City had established committees to "review deaths and severe complications related to pregnancy and childbirth" in their cities to prevent maternal mortality. New York's panel, the Maternal Mortality and Morbidity Review Committee (M3RC), included doctors, nurses, "doulas, midwives and social workers".^[19] New York City will be collaborating with the State of New York, the first such collaboration in the US.^[19] In July 2018, New York City's de Blasio's administration announced that it would be allocating $12.8 million for the first three years of its five-year plan to "reduce maternal deaths and life-threatening complications of childbirth among women of color".^[20]

Causes

Medical causes

Maternal death can be traced to maternal health, which includes wellness throughout the entire pregnancy and access to basic care.^[21]

The World Health Organization and the CDC's National Vital Statistics System (NVSS) define maternal death as that which occurs within the first 42 days after birth.

Since 1986, the Center for Disease Control conducts a Pregnancy Mortality Surveillance Service (PMSS) to study the medical causes of maternal death.^[22] This tool defines pregnancy-related death as death during or within one year of completion of a woman's pregnancy by any cause attributed to the pregnancy to capture all deaths which might be pregnancy-related.

Race, location, and financial status all contribute to how maternal mortality affects women across the country. Non-Hispanic blacks account for 41.7% of maternal deaths in the United States. Additionally to race, According to a study published in (Jones et al.,2022), a woman's social determinants of health can affect both her health and her ability to conceive. Black women are more likely than other races to experience life-threatening complications, such as hemorrhage and even worse maternal outcomes. The research investigates the link between maternal morbidity and social determinants of health. The study's author also mentioned a few risk factors for adverse pregnancy outcomes that were related to the social determinants of these women's lives. These include the mother's age, any existing health conditions, and so on (Jones et al., 2022).

Maternal Mortality Review Committees (MMRCs), state and local committees that review pregnancy related deaths, found that the leading causes of maternal mortality from 36 participating states 2017–2019 are:

1. Mental health conditions including deaths of suicide, overdose/poisoning related to substance use disorder, and other deaths determined by the MMRC to be related to a mental health condition, including substance use disorder. (23%)
2. Excessive bleeding (hemorrhage): Excluding aneurysms or cerebrovascular accident  (14%)
3. Cardiac and coronary conditions (relating to the heart) (13%)
4. Infection (9%): including deaths of coronary artery disease, pulmonary hypertension, acquired and congenital valvular heart disease, vascular aneurysm, hypertensive cardiovascular disease, Marfan Syndrome, conduction defects, vascular malformations, and other cardiovascular disease; and excludes cardiomyopathy and hypertensive disorders of pregnancy.
5. Thrombotic embolism (a type of blood clot) (9%)
6. Cardiomyopathy (a disease of the heart muscle) (9%)
7. Hypertensive disorders of pregnancy (relating to high blood pressure) (7%)^[8]

Social factors

Social determinants of health also contribute to the maternal mortality rate. Some of these factors include access to healthcare, education, age, race, and income.^[23]

Access to healthcare

Women in the US usually meet with their physicians just once after delivery, six weeks after giving birth. Due to this long gap during the postpartum period, many health problems remain unchecked, which can result in maternal death.^[24] Just as women, especially women of color, have difficulty with access to prenatal care, the same is true for accessibility to postpartum care. Postpartum depression can also lead to untimely deaths for both mother and child.^[24]

Insurance companies reserve the right to categorize pregnancy as a pre-existing condition, thereby making women ineligible for private health insurance. Even access to Medicaid is curtailed to some women, due to bureaucracy and delays in coverage (if approved). Many women are turned down due to Medicaid fees, as well. According to a 2020 study conducted by Erica L. Eliason, cutting Medicaid funding limits access to prenatal healthcare, which has been shown to increase maternal mortality rates. This study concluded that Medicaid expansions directly correlated to decreases in maternal mortality rates.^[25] Although the supportive care practice of a doula has potential to improve the health of both the mother and child and reduce health disparities,^[26] these services are underutilized among low-income women and women of color, who are at greater risk of poor maternal health outcomes.^[27] Women may be unable to find or afford services or unaware that they are offered.^[27] A 2012 national survey by Childbirth Connection found that women using Medicaid to pay for birth expenses were twice as likely as those using private insurance to have never heard of a doula (36% vs. 19%).^[28] Medicaid does not cover doula care during a woman's prenatal or post-partum period.^[26] Women have also reported access and mobility as reasons why they are unable to seek prenatal care, such as lack of transportation and/or lack of health insurance. Women who do not have access to prenatal care are 3–4 times more likely to die during or after pregnancy than women who do.^[29]

Education

It has been shown that mothers between ages 18 and 44 who did not complete high school had a 5% increase in maternal mortality versus women who completed high school.^[30] By completing primary school, 10% of girls younger than 17 years old would not get pregnant and 2/3 of maternal deaths could be prevented.^[31] Secondary education, university schooling, would only further decrease rates of pregnancy and maternal death.

Of note, higher education still does not improve the racial differences in maternal mortality and is not protective for Black mothers in the way they are for White mothers. It has been found that Black mothers with a college education have greater maternal mortality than White mothers with less than a high school education.^[32]

Age

Young adolescents are at the highest risk of fatal complications of any age group.^[33] This high risk can be accounted for by various causes such as the likelihood of adolescents giving birth for the first time compared to women in older age groups.^[34] Other factors that also may lead to higher risk among this age group includes lower economic status and education.^[35] While adolescents face a higher risk of maternal mortality, a study conducted between 2005 and 2014 found that the rate of maternal mortality was higher among older women.^[36] Additionally, another study found that the rate is higher specifically among women aged 30 years or older.^[34]

Intimate partner violence

Intimate partner violence (IPV) constitutes many forms of abuse or the threat of abuse, including sexual, physical or emotional abuse and manifests as a pattern of violence from an intimate partner. Protective factors include age and marital status, while risk factors include unplanned pregnancy, lack of education and low socioeconomic status, and a new HIV positive diagnosis. The greatest at-risk group is a young, unmarried woman.^[37] During pregnancy IPV can have disastrous maternal and fetal outcomes, and it has been found that between 3% and 9% of pregnant women experience IPV.^[38]

Maternal adverse outcomes include delayed or insufficient prenatal case, poor weight gain, and an increase in nicotine, alcohol and substance abuse. IPV is also associated with adverse mental health outcomes such as depression in 40% of abused women.^[38] Neonatal adverse outcomes from IPV include low birth weight and preterm birth, an infant who is small for gestational age and even perinatal death.

Through adequate training of healthcare professionals, there is opportunity for prevention and intervention during routine obstetric visits, and routine screening is recommended. During prenatal care, only 50% of women receive counselling on IPV.^[39] Pregnancy is a unique time during a woman's life and for many women is the only time when regular healthcare is established, heightening the need for effective care from the provider.

Race

Main article: Black maternal mortality in the United States

African American women are four times as likely to experience maternal morbidity and mortality as Caucasian women,^[5] and there has been no large-scale improvement over the course of 20 years^[when?] to rectify these conditions.^[40] Furthermore, women of color, especially "African-American, Indigenous, Latina and immigrant women and women who did not speak English", are less likely to obtain the care they need. In addition, foreign-born women have an increased likelihood of maternal mortality, particularly Hispanic Women.^[41] Cause of mortality, especially in older women, is different among different races. Caucasian women are more likely to experience hemorrhage, cardiomyopathy, and embolism whereas African American women are more likely to experience hypertensive disorders, stroke, and infection. In the case of Black women in the United States, a study from the World Journal of Gynecology and Women's Health found that in addition to the link between cardiovascular disease and maternal mortality, racism in healthcare contributes to these outcomes. Notably, experiencing racism and discrimination in healthcare makes Black mothers less likely to trust the healthcare system, and the authors of this study recommend that addressing this is key to rebuilding trust and encouraging reliance on healthcare system.^[42] Distrust in the healthcare system can be detrimental for the health and wellbeing of Black and minority mothers and their infants. Distrust in the healthcare system often results in reduced encounters with the system, which can be very harmful given the established association between late and inadequate prenatal care and poor pregnancy outcomes such as low birth weight, preterm birth, and infant mortality.^[43] According to the Listening to Mothers III Survey, 40% of minority participants experienced communication issues and nearly one-quarter of minority mothers felt discriminated against during birth hospitalization. The same survey revealed that Black and Hispanic mothers were nearly three times more likely to experience discrimination in the healthcare system due to their race, language or culture.^[43] These issues are exacerbating the observed maternal and infant morbidity and mortality disparity between minority mothers and White mothers in the United States.

Another factor contributing to the increased maternal and infant morbidity and mortality rates in African American and minority women is the difference in delivery hospital quality between minority women and White women. According to a study conducted by Dr. Elizabeth A. Howell, racial and ethnic minority women deliver "in different and lower quality hospitals" than White women. According to Dr. Howell, hospitals where African American women were disproportionately cared for during birth, "had higher risk-adjusted severe maternal morbidity rates for both Black and White women in those hospitals."^[43] In NYC, Black women were more likely to deliver in hospitals with a higher rate of "risk-adjusted severe maternal morbidity rates" and a study conducted in the same City revealed that if African American women delivered in the same hospitals as White women, "1000 Black women could avoid severe morbid events during their delivery hospitalization, which could reduce the Black severe maternal morbidity rate from 4.2% to 2.9%."^[43]

The US has been shown to have the highest rate of pregnancy-related deaths o/c maternal mortality amongst all the industrialized countries. The CDC first implemented the Pregnancy Mortality Surveillance System in 1986 and since then maternal mortality rates have increased from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 live births in 2015. The issue of maternal mortality disproportionately affects women of color when compared with the rate in white non-Hispanic women. The following statistics were retrieved from the CDC and show the rate of maternal mortality between 2011 and 2015 per 100000 live births: Black non-Hispanic – 42.8, American Indian/Alaskan Native non-Hispanic – 32.5, Asian/Pacific Islander non-Hispanic – 14.2, White non-Hispanic – 13.0, and Hispanic – 11.4.^[44]

There are racial disparities present when considering maternal mortality in the United States, with black women being 3 to 4 times more likely to die from pregnancy-related complications in comparison to white, Asian, and Hispanic women. The causes of death amongst these women were also different, some being more unconventional like hypertension and venous thromboembolisms.^[45]

Income

It is estimated that 99% of women give birth in hospitals with fees that average between $8,900–$11,400 for vaginal delivery and between $14,900–$20,100 for a cesarean.^[46] Many women cannot afford these high costs, nor can they afford private health insurance, and even waiting on government-funded care can prove to be fatal, since delays to coverage usually result in women not getting the care they need from the start.

Other risk factors

Some other risk factors include obesity, chronic high blood pressure, increased age, diabetes, cesarean delivery, and smoking. Attending less than 10 prenatal visits is also associated with a higher risk of maternal mortality.^[30]

Researchers have found that another factor contributing to the elevated maternal mortality rates in the United States is the lack of attention given to black women during childbirth and the failure to recognize preexisting health conditions like diabetes and hypertension, which can cause preeclampsia and eclampsia. Despite the epidemic level of maternal mortality among black women, several states, like California, are working to lower the numbers.

Even in cases where they had never before experienced chronic hypertension, Black women are more likely to pass away from hemorrhage, cardiomyopathy, and hypertensive diseases of pregnancy than Hispanic women are (Howell, 2018). A national study examined the death rates from pregnancy in white and black women. The study found that for five particular pregnancy problems, the death risk was 2.4 to 3.3 times higher among black women. Preeclampsia, placenta abruptio, placenta previa, and postpartum hemorrhage were among them (Howell, 2018).

The Healthy People 2010 goal was to reduce the c-section rate to 15% for low-risk first-time mothers, but that goal was not met and the rate of c-sections has been on the rise since 1996 and reached an all-time high in 2009 at 32.9%.^{[clarification needed]} Excessive and non-medically necessary cesareans can lead to complications that contribute to maternal mortality.^[5]

Geographic location has been found to be a contributing factor as well. Data has shown that rates of maternal mortality are higher in rural areas of the United States. In 2015, the rate of maternal mortality in rural areas was 29.4 per 100,000 live births as compared to 18.2 in metropolitan areas.^[47]

Table. Overall and by race, age, ethnicity

Number of live births, maternal deaths, and maternal mortality rates, by race and Hispanic origin and age: United States, 2018-2021.^[2]

Race and Hispanic origin and age	2018			2019			2020			2021
	Number of live births	Number of deaths	Maternal mortality rate^1	Number of live births	Number of deaths	Maternal mortality rate^1	Number of live births	Number of deaths	Maternal mortality rate^1	Number of live births	Number of deaths	Maternal mortality rate^1
Total^2	3,791,712	658	17.4	3,747,540	754	20.1	3,613,647	861	23.8	3,664,292	1,205	32.9
Under 25	907,782	96	10.6	877,803	111	12.6	825,403	114	13.8	797,334	163	20.4
25–39	2,756,974	458	16.6	2,739,976	544	19.9	2,658,445	607	22.8	2,731,223	854	31.3
40 and over	126,956	104	81.9	129,761	98	75.5	129,799	140	107.9	135,735	188	138.5
Non-Hispanic Black^3	552,029	206	37.3	548,075	241	44.0	529,811	293	55.3	517,889	362	69.9
Under 25	176,243	27	15.3	169,853	32	18.8	159,541	46	28.8	149,435	62	41.5
25–39	358,276	137	38.2	360,206	179	49.7	351,648	198	56.3	349,170	242	69.3
40 and over	17,510	42	239.9	18,016	30	166.5	18,622	49	263.1	19,284	58	300.8
Non-Hispanic White^3	1,956,413	291	14.9	1,915,912	343	17.9	1,843,432	352	19.1	1,887,656	503	26.6
Under 25	391,829	41	10.5	374,129	49	13.1	348,666	40	11.5	336,792	57	16.9
25–39	1,504,888	207	13.8	1,480,595	248	16.8	1,433,839	253	17.6	1,486,249	364	24.5
40 and over	59,696	43	72.0	61,188	46	75.2	60,927	59	96.8	64,615	82	126.9
Hispanic	886,210	105	11.8	886,467	112	12.6	866,713	158	18.2	885,916	248	28.0
Under 25	275,553	21	7.6	270,948	23	8.5	258,635	20	7.7	255,806	36	14.1
25–39	579,553	72	12.4	584,109	71	12.2	576,690	111	19.2	597,703	184	30.8
40 and over	31,104	12	*	31,410	18	*	31,388	27	86.0	32,407	28	86.4

* Rate does not meet National Center for Health Statistics standards of reliability.

¹Maternal mortality rates are deaths per 100,000 live births.

²Includes deaths for race and Hispanic-origin groups not shown separately, including women of multiple races and origin not stated.

³Race groups are single race.

NOTES: Maternal causes are those assigned to code numbers A34, O00–O95, and O98–O99 of the International Classification of Diseases, 10th Revision. Maternal deaths occur while pregnant or within 42 days of being pregnant.

Prevention

Inconsistent obstetric practice,^[48] increase in women with chronic conditions, and lack of maternal health data all contribute to maternal mortality in the United States. According to a 2015 WHO editorial, a nationally implemented guideline for pregnancy and childbirth, along with easy and equal access to prenatal services and care, and active participation from all 50 states to produce better maternal health data are all necessary components to reduce maternal mortality.^[49] The Hospital Corporation of America has also found that a uniform guideline for birth can improve maternal care overall. This would ultimately reduce the amount of maternal injury, c-sections, and mortality. The UK has had success drastically reducing preeclampsia deaths by implementing a nationwide standard protocol.^[48] However, no such mandated guideline currently exists in the United States.^[5]

To prevent maternal mortality moving forward, Amnesty International suggests these steps:

1. Increase government accountability and coordination
2. Create a national registry for maternal and infant health data while incorporating intersections of gender, race, and social/economic factors
3. Improve maternity care workforce
4. Improve diversity in maternity care
5. Public health sector/government (federal/state/local level) should collaborate with the local community leaders in creating more awareness of maternal mortality rate in local communities.
6. Enlighten women on importance of early prenatal care registration.

According to the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, out-of-hospital births (such as home births and birthing centers with midwifery assistance) "generally provided a lower risk profile than hospital births."^[50] Consistent home-nurse visitations have been found to reduce mortality both in infants and their mothers.^[51]

Procedures such as episiotomies and cesareans, while helpful in some cases, when administered unnecessarily increase the risk of maternal death.^[5] Midwifery and mainstream obstetric care can be complementary,^[18] which is commonly the case in Canada, where women have a wide arrange of pregnancy and birthing options, wherein informed choice and consent are fundamental tenants of their reformed maternity care.^[52] The maternal mortality rate is two times lower in Canada than the United States, according to a global survey conducted by the United Nations and the World Bank.^[53]

Gender bias, implicit bias, and obstetric violence in the medical field are also important factors when discussing maternal wellness, care, and death in the United States.^[54]

According to the Centers for Disease and Prevention, state prevention strategies are best developed using data from Maternal Mortality Review Committees.^[8]

Comparisons by state

It is clear that the U.S. has one of the highest maternal mortality rates in the Western Hemisphere. The U.S. is to be considered one of the wealthiest and most developed countries on the globe but seems to lack in some areas in the health system. In the U.S., hospital bills for maternal healthcare total over $98 billion, and concerns about the degradation of the maternal^{[clarification needed]} resulted in a state-by-state breakdown. In the United States, maternal mortality has been increasing in the South for the past couple of years,^{[as of?]} specifically in Georgia. The lack of health professionals has limited access to healthcare, especially in communities where residents lack knowledge of prevention. Maternal mortality is one of the health issues that can be prevented if addressed appropriately. This is a gap in healthcare that needs to be addressed for further prevention, especially as the demand for maternal healthcare workers was expected to increase by 6% by 2020.^{[needs update]} It is clear that Georgia lacks prevention because they do not have access to care and providers in their community.^{[citation needed]} The Spotlight in Poverty states 730,000 Hispanics and Blacks are below 200% level. Less than a quarter of Georgia's population lives in poverty and they are minorities. Living in poverty does increase the chances of maternal mortality because women and children do not have the finances to travel to areas in Georgia that have healthcare access. As of 2018, only 79 counties have an OB-GYN; within the past two years this has declined, especially under the Trump administration.^{[citation needed]} This shortage of maternal healthcare workers is prevalent throughout the country, where as of 2016, 46 percent of U.S. counties have no OB-GYNs and 56 percent have no nurse midwives, according to data from the U.S. Department of Health and Human Services.^[55]

Differences in Medicaid coverage also factor into disparities in maternal mortality, given that over 40% of births nationally are covered by Medicaid, which is administered by state governments and therefore can vary based on location.^[56] Currently, all pregnant people at or below 138% of the federal poverty level qualify for Medicaid coverage; however, states can choose to include pregnant people with higher incomes, or allow people to receive covered healthcare temporarily while their application is still being processed.^[57] Some state-by-state variations consist of eligibility to qualify for Medicaid, which services fall under the umbrella of covered prenatal and maternity care and how patients are reimbursed for care they receive. Medicaid coverage affects birthing parents from the process of receiving prenatal care through birth and postpartum care, although not all states cover the same range of prenatal services or offer postpartum care after the federally mandated 60-day period.^[56] Expansion of care past the 60-day period may prevent some pregnancy-related deaths, 11.7% of which occur between 42 days and 1 year.^[57] Only 27 states had expanded this coverage period as of September 2022, with 9 others proposing some sort of extension.^[58] As of the same date, 12 states had not implemented any Medicaid expansions.^[59]

Another difference is in how much of the state's hospitals are considered rural, since rural hospitals are 6% less likely to offer delivery services than urban hospitals. Rural hospitals also have higher rates of Cesarean sections, which can increase the risk of complications for the person giving birth, although why rates are higher is still unclear.^[60]

Table

From CDC source: "Maternal deaths include deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."^[1]

The overall rate for the US is for 2021,^[2] and is from a more recent CDC reference than the CDC reference for the individual states.^[1]

The asterisk (*) in the data columns is data suppressed due to reliability and confidentiality restrictions.

* next to state indicates "Healthcare in STATE"

Maternal mortality rates per 100,000 births. 2018-2021.^[1][2]

States and D.C.	Maternal mortality rate	95% lower confidence limit	95% upper confidence limit
United States *	32.9	-	-
Alabama *	41.4	33.5	50.5
Alaska	*	*	*
Arizona	31.4	25.5	38.3
Arkansas *	43.5	33.4	55.7
California *	10.1	8.6	11.6
Colorado *	15.2	10.7	20.8
Connecticut	16.7	10.6	25.0
Delaware	*	*	*
District of Columbia *	*	*	*
Florida *	26.3	22.9	29.7
Georgia *	33.9	28.8	39.0
Hawaii *	*	*	*
Idaho *	*	*	*
Illinois	17.3	14.0	21.1
Indiana	31.1	25.0	37.3
Iowa	20.2	13.6	28.9
Kansas	22.0	15.0	31.3
Kentucky	38.4	30.5	47.7
Louisiana	39.0	31.4	47.9
Maine	*	*	*
Maryland *	21.2	16.2	27.4
Massachusetts *	15.3	11.1	20.7
Michigan	19.4	15.5	24.1
Minnesota *	12.6	8.7	17.7
Mississippi *	43.0	32.9	55.1
Missouri	25.7	20.4	32.3
Montana *	*	*	*
Nebraska	26.2	17.1	38.4
Nevada	21.7	14.7	31.0
New Hampshire	*	*	*
New Jersey	25.7	20.8	30.7
New Mexico	30.2	19.9	44.0
New York *	21.7	18.6	24.8
North Carolina *	26.5	21.9	31.2
North Dakota *	*	*	*
Ohio	23.8	19.7	28.0
Oklahoma *	30.3	23.0	39.0
Oregon *	16.4	10.8	23.8
Pennsylvania	16.7	13.4	20.5
Rhode Island	*	*	*
South Carolina *	32.7	25.6	41.0
South Dakota	*	*	*
Tennessee	41.7	34.6	48.7
Texas *	28.1	25.4	30.8
Utah *	16.1	10.9	23.0
Vermont *	*	*	*
Virginia *	29.1	23.8	34.5
Washington *	20.4	15.9	25.8
West Virginia *	*	*	*
Wisconsin	11.6	7.8	16.7
Wyoming	*	*	*

Comparisons with other countries

See: List of countries by maternal mortality ratio.

Comparison of the US maternal death rate to the death rate in other countries is complicated by the lack of standardization. Some countries do not have a standard method for reporting maternal deaths and some count in statistics death only as a direct result of pregnancy.^[61]

In the 1950s, the maternal mortality rate in the United Kingdom and the United States was the same. By 2018, the rate in the UK was one-third of that in the United States^[62] due to implementing a standardized protocol.^[48] In 2010, Amnesty International published a 154-page report on maternal mortality in the United States.^[63] In 2011, the United Nations described maternal mortality as a human rights issue at the forefront of American healthcare, as the mortality rates worsened over the years.^[64] According to a 2015 WHO report, in the United States the MMR between 1990 and 2013 "more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births."^[65] By 2015, the United States had a higher MMR than the "Islamic Republic of Iran, Libya and Turkey".^[49][66] In the 2017 NPR and ProPublica series "Lost Mothers: Maternal Mortality in the U.S." based on a six-month long collaborative investigation, they reported that the United States has the highest rate of maternal mortality than any other developed country, and it is the only country where mortality rate has been rising.^[67] The maternal mortality rate in the United States is three times higher than that in neighboring Canada^[48] and six times higher than in Scandinavia.^[68] As of 2020, the United States maternal mortality rate was two times higher than Canada and 10 times higher than New Zealand's.^[69]

In the United States specifically, maternal mortality is still a prevalent issue in health care. From the year 2003 to 2013, only 8 countries worldwide saw an increase of the maternal mortality rate. The United States was included in this group, seeing an increase in the pregnancy-related mortality ratio over the past 3 decades. Looking at the years 1990-2013 from a world-wide perspective, the United States of America was the only country to see an increase in the maternal mortality rate over this time period.^[45]

The US has the worst rate of maternal deaths in the developed world.^[70] The US has the "highest rate of maternal mortality in the industrialized world."^[71] In the United States, the maternal death rate averaged 9.1 maternal deaths per 100,000 live births during the years 1979–1986,^[72] but then rose rapidly to 14 per 100,000 in 2000 and 17.8 per 100,000 in 2009.^[73] In 2013 the rate was 18.5 deaths per 100,000 live births.^[74] It has been suggested that the rise in maternal death in the United States may be due to improved identification and misclassification resulting in false positives.^[75] The rate has steadily increased to 18.0 deaths per 100,000 live births in 2014.^[73] Between 2011 and 2014, there were 7,208 deaths that were reported to the CDC that occurred for women within a year of the end of their pregnancy. Out of this there were 2,726 that were found to be pregnancy-related deaths.^[73]

Since 2016, ProPublica and NPR investigated factors that led to the increase in maternal mortality in the United States. They reported that the "rate of life-threatening complications for new mothers in the U.S. has more than doubled in two decades due to pre-existing conditions, medical errors and unequal access to care."^[71] According to the Centers for Disease Control and Prevention, c. 4 million women who give birth in the US annually, over 50,000 a year, experience "dangerous and even life-threatening complications."^[71]

According to a report by the United States Centers for Disease Control and Prevention, in 1993 the rate of Severe Maternal Morbidity, rose from 49.5 to 144 "per 10,000 delivery hospitalizations" in 2014, an increase of almost 200 percent. Blood transfusions also increased during the same period with "from 24.5 in 1993 to 122.3 in 2014 and are considered to be the major driver of the increase in SMM. After excluding blood transfusions, the rate of SMM increased by about 20% over time, from 28.6 in 1993 to 35.0 in 2014."^[76]

The past 60 years have consistently shown considerable racial disparities in pregnancy-related deaths. Between 2011 and 2014, the mortality ratio for different racial populations based on pregnancy-related deaths was as follows: 12.4 deaths per 100,000 live births for white women, 40.0 for black women, and 17.8 for women of other races.^[77] This shows that black women have between three and four times greater chance of dying from pregnancy-related issues. It has also been shown that one of the major contributors to maternal health disparities within the United States is the growing rate of non-communicable diseases.^[77] In addition, women of color have not received equal access to healthcare professionals and equal treatment by those professionals.^[78]

"Black women's poor reproductive outcomes are often seen as a women's personal failure. For example, Black women's adverse birth outcomes are typically discussed in terms of what the women do, such as drinking alcohol, smoking, and having less than optimal eating habits that lead to obesity and hypertension. They may be seen to be at risk based on the presumption that they are 'single,' when in fact they have a partner- but are unmarried.".^[79] Black women in the United States are dying at higher rates than white women in the United States. The United States has one of the worst maternal mortality rates despite it being a developed nation.^[80]

It is unclear why pregnancy-related deaths in the United States have increased. It seems that the use of computerized data servers by the states and changes in the way deaths are coded, with a pregnancy checkbox added to death certificates in many states, have been shown to improve the identification of these pregnancy-related deaths. Before 2016, there was not a standardized way to report maternal deaths in the United States. Each state was using a different method causing variation in MMR across the country. As more and more states implemented the checkbox, however, there was a large increase in the number of maternal deaths reported. However, this does not contribute to decreasing the actual number of deaths. Also, errors in reporting of pregnancy status have been seen, which most likely leads to an overestimation of the number of pregnancy-related deaths.^[73] Again, this does not contribute to explaining why the death rate has increased but does show complications between reporting and actual contributions to the overall rate of maternal mortality.^[77]

Even though 99% of births in the United States are attended by some form of skilled health professional, the maternal mortality ratio in 2015 was 14 deaths per 100,000 live births^[81] and it has been shown that the maternal mortality rate has been increasing. Also, the United States is not as efficient at preventing pregnancy-related deaths when compared to most of the other developed nations.^[77]

The United States took part in the Millennium Development Goals (MDGs) set forth from the United Nations. The MDGs ended in 2015 but were followed-up in the form of the Sustainable Development Goals starting in 2016. The MDGs had several tasks, one of which was to improve maternal mortality rates globally. Despite their participation in this program as well as spending more than any other country on hospital-based maternal care, however, the United States has still seen increased rates of maternal mortality. This increased maternal mortality rate was especially pronounced in relation to other countries who participated in the program, where during the same period, the global maternal mortality rate decreased by 44%.^[77] Also, the United States is not currently on track to meet the Healthy People 2020 goal of decreasing maternal mortality by 10% by the year 2020^{[needs update]} and continues to fail in meeting national goals in maternal death reduction.^[77] Only 23 states have some form of policy that establishes review boards specific to maternal mortality as of the year 2010.^[77]

In an effort to respond to the maternal mortality rate in the United States, the CDC requests that the 52 reporting regions (all states and New York City and Washington, DC) send death certificates for all those women who have died and may fit their definition of pregnancy-related death, as well as copies of the matching birth or death records for the infant.^[73] However, this request is voluntary and some states may not have the ability to abide by this effort.

The Affordable Care Act (ACA) provided additional access to maternity care by expanding opportunities to obtain health insurance for the uninsured and mandating that certain health benefits have coverage. It also expanded the coverage for women who have private insurance. This expansion allowed them better access to primary and preventative health care services, including for screening and management of chronic diseases. An additional benefit for family planning services was the requirement that most insurance plans cover contraception without cost-sharing. However, more employers are able to claim exemptions for religious or moral reasons under the current administration. Also under the current administration,^{[as of?]} the Department of Health and Human Services (HHS) has decreased funding for pregnancy prevention programs for adolescent girls.^[4]

Those women covered under Medicaid are covered when they receive prenatal care, care received during childbirth, and postpartum care. These services are provided to nearly half of the women who give birth in the United States. Currently,^{[as of?]} Medicaid is required to provide coverage for women whose incomes are at 133% of the federal poverty level in the United States.^[4]

Deaths per 100,000 live births

Country	MMR (deaths per 100,000 live births)
United States	26.4
U.K	9.2
Portugal	9
Germany	9
France	7.8
Canada	7.3
Netherlands	6.7
Spain	5.6
Australia	5.5
Ireland	4.7
Sweden	4.4
Italy	4.2
Denmark	4.2
Finland	3.8

There are many possible reasons why the United States has a much larger MMR than other developed countries: many hospitals are unprepared for maternal emergencies, 44% of maternal-fetal grants do not go towards the health of the mother, and pregnancy complication rates are continually increasing.

A recent report from the US Centers for Disease Control and Prevention (CDC) showed that maternal mortality - deaths that occur during pregnancy or within 42 days after delivery - increased by 40% in 2021. This figure affirmed that the US is the most dangerous rich country to live in during pregnancy or childbirth. The figures put the maternal mortality rate at 32.9 deaths per 100,000 live births – or about one death per 3,000 births. The World Health Organization has announced this rate at 11 in high-income countries in 2017.^[82]

See also

• Maternal death
• Infant mortality
• Perinatal mortality
• Black Maternal Mortality in the United States
• Obstetric transition
• The Business of Being Born, a 2008 documentary
• Confidential Enquiry into Maternal Deaths in the UK
• List of women who died in childbirth
• Reproductive rights
• Women's reproductive health in the United States

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External links

• BBC News. November 20, 2017. Video: Why do so many US women die giving birth?
• "Maternal mortality: An American crisis" CBS News August 5, 2018