Maternal Health

Overview

Maternal health—defined by the World Health Organization as the health of pregnant people throughout pregnancy, childbirth, and the postnatal period—is in a state of crisis in the US. Nationwide, thousands of women experience severe complications with pregnancy, and most maternal deaths are due to preventable causes. The United States has the highest rate of maternal mortality among wealthy nations. While data show that rates decreased for White and Latina women in 2023, Black women continue to die from pregnancy-related causes at rates three times higher than White women.

In the United States, a range of factors contribute to the high rate of maternal mortality, from medical system failures to harmful gender norms to other social determinants of health, like socioeconomic status. On top of all these, medical racism is a major contributing factor to the elevated rates of Black maternal mortality and morbidity. High rates of maternal mortality are universal for Black women in the United States, regardless of socioeconomic background. The COVID-19 pandemic exacerbated maternal mortality rates and widened racial disparities among Black women nationwide, and there is every indication that gaps in maternity care will only worsen as abortion restrictions and other factors continue to reduce access to obstetric and gynecological care.

Note: IWPR uses “women” to refer to those who self-identify as female. IWPR acknowledges that not all individuals who can become pregnant identify as women, including transgender and gender-nonconforming people. The term reflects a lack of data on gender identity and transgender status in the datasets consulted for this analysis (CPS, BLS, CDC, etc.).

What the Research Says

• Nationally, women of color are more at risk of dying from pregnancy-related complications than their White counterparts. Black women are approximately three times more likely to die from a pregnancy-related cause than White women. According to the Centers for Disease Control (CDC), maternal mortality rates for American Indian/Alaska Native and Native Hawaiian/Pacific Islander birthing people was over four times that of White birthing people.
• Data from maternal mortality review committees finds that more than 80 percent of pregnancy-related deaths were preventable. According to the CDC, leading causes of pregnancy-related death include mental health conditions (23 percent), hemorrhage (14 percent), and cardiac conditions (13 percent).
• Maternal death rates in abortionrestricted states are 62 precent higher than in states with abortion access, according to research from the Commonwealth Fund. Among the 11 states with the highest maternal mortality rates from 2020 to 2022, 8 currently have total abortion bans.
• A nationwide abortion ban would increase maternal mortality by 24 percent, according to a study from the University of Colorado Boulder. For Black women, the study found even more extreme impacts, estimating that the maternal mortality rate would jump by 39 percent if such a ban was enacted.
• The March of Dimes reports that nearly 35 percent of all counties are maternity care deserts—places without a hospital or birth center offering obstetric care and an obstetric medical provider. These are concentrated in states with abortion restrictions. More than 2.3 million women of reproductive age live in these maternity care deserts, and one in ten birthing people lives in a county without full access to maternity care.
• There is a growing shortage of maternal health providers. A 2021 study from the Department of Health and Human Services projected that, by 2030, there would be a shortage of about 5,170 OB-GYNs needed to meet nationwide demand. The 2022 Supreme Court Decision overturning Roe v. Wade has increased stress on the field, with indications that it may exacerbate shortages by driving providers out and leading medical students to pursue different specialties.

Why It Matters

The data show there are stark differences in maternal mortality rates for people based on their race and ethnicity. This is largely due to decades of medical and structural racism, which perpetuate a health system in which Black patients are not safe. The impacts of this racism are seen throughout the medical system, with research published by the Mayo Clinic indicating that implicit bias of health care providers results in lower rates of pain medication offered to Black patients and fewer treatment and intervention options presented to them.

Inequities in health are also socially determined; those experiencing poor housing conditions or job insecurity are more likely to experience bad health outcomes. Since nearly every area of life has an impact on health, and by extension, maternal health, including wage gaps, educational attainment, student debt, reproductive justice, and more, a multifaced approach is needed to save pregnant people and babies.

One component of this approach is to integrate midwives and doulas into maternity care systems. It is well established that the care provided by doulas and midwives leads to better maternal health outcomes, including fewer interventions and complications and greater patient satisfaction with the birthing experience. A recent study published in the American Journal of Public Health of Medicaid beneficiaries found doula care lowers the risk of cesarean delivery by nearly 50 percent. Those supported by a doula were also 46 percent more likely to attend a postpartum checkup—a critical opportunity for addressing causes of maternal morbidity and mortality after birth when many complications occur. Despite these life-saving benefits, doula care is rarely covered by health insurance. Similarly, limitations on insurance coverage and scope of practice for midwives vary across the country. While midwives make up the majority of the maternity care workforce in other high-income countries with better maternal and infant outcomes than those found in the United States, only 12 percent of US births were attended by a midwife in 2021, according to the Government Accountability Office.

Abortion restrictions are another contributing factor to the maternal mortality crisis, and this is supported by the horrifying reports coming out of Texas. After the passage of SB8—the Texas law banning abortion as early as six weeks of pregnancy—maternal deaths skyrocketed. This bill effectively bans abortions by restricting them once cardiac activity is detected, when many people may not even realize they are pregnant. Consequently, the Gender Equity Policy Institute estimates that maternal deaths in Texas rose by 56 percent between 2019 and 2022, five times the national increase of 11 percent in the same period. Since the overturn of Roe, ProPublica has documented at least three cases where women in Texas have died because of delays in care created by the state’s abortion bans. At least two others have died in Georgia.

Finally, the data show that maternity care is increasingly inaccessible. Many pregnant people don’t have access to prenatal care, skilled birth attendants, or family planning services. This is illustrated in the uptick of maternity care deserts across the country. These deserts will expand if restrictions continue to be imposed on abortion, as medical professionals are now opting not to practice or study in states with restrictions. This will have devastating impacts on health care access and health workforce diversity.

Policy Solutions

In light of the ongoing maternal health crisis in the US—and in the face of indications that the recent Dobbs decision overturning Roe v. Wade and subsequent rollback of reproductive health care access throughout many regions of the country—addressing maternal health should be a priority for federal policymakers. In particular, it is imperative that federal policymakers prioritize ending the Black maternal health crisis. This state of emergency can be addressed through a myriad of systems, including:

Support diversification of the health care industry and ensure that health care professionals are educated on addressing and mitigating the Black maternal health crisis. Policymakers should promote the diversification of medical students by promoting changes to medical school admissions that include holistic views of candidates and consider lived experiences. Policymakers should invest in and support historically black colleges and universities (HBCUs), which are essential to the graduation of Black doctors and medical professionals. They should also seek to lower the cost of medical school education and create pathways for lower-income or economically disadvantaged applicants to pursue medical school admissions and education.

Expand access to midwives and doulas, particularly Black midwives and doulas. This includes promoting expanded and flexible licensure for midwives and doulas, as well as increased reimbursement rates. In particular, policymakers should increase Medicaid coverage for doula services to ensure the accessibility of doula care for low-income women enrolled in the health insurance program. Policymakers must also consider the historic institutional obstacles and hurdles that have prevented midwives and doulas from practicing.

Prioritize health care accessibility for birthing people, particularly in rural areas. Policymakers should direct federal funding to underserved regions and under-resourced hospitals, with particular consideration to maternity care deserts in rural regions. By directing federal funding to rural hospitals, policymakers can prevent closures of obstetrics and maternity wards, eliminate maternity care deserts, and increase the number of maternity care providers in rural federally qualified health centers, including Health Resources and Services Administration Health Center Program (HCP) grantees. This is particularly critical as evidence suggests that, due to the Dobbs decision, providers are leaving states with restrictive abortion laws, often lengthening the distances that pregnant patients must travel to access care. Additionally, policymakers should consider options to invest in digital tools to help expand care in underserved areas, including telehealth.

Support and fund maternal mortality review committees (MMRC). Policymakers should increase investments in MMRCs— multidisciplinary groups that convene at the state or local levels to review maternal and postpartum deaths. These groups can play a critical role in counting and documenting deaths, understanding why they occurred, and supporting evidence-based solutions to the maternal health crisis. Policymakers should seek opportunities to better resource the work of MMRCs, as well as to promote transparent and equitable recruitment and community engagement and improve the sharing of data.

Invest in better data collection. Policymakers must prioritize the improvement of data collection processes and quality measures to adequately assess and address the maternal health crisis. As part of this effort, the CDC should standardize the definitions used by state and federal agencies to collect and report maternal health data. Policymakers must further support training opportunities for states and agencies to use standardized definitions and ensure proper completion of death certificates and reporting. Federal policymakers should enact legislation to facilitate data sharing between federal agencies, state bodies, and other research institutions.

Expand access to social benefit programs like the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Medicaid. Policymakers should expand WIC eligibility in the postpartum and breastfeeding periods. Policymakers should also promote full implementation of the Medicaid coverage extension included in the American Rescue Plan to promote access to health care in the postpartum period. Additionally, Medicaid reimbursement rates must be adjusted to cover the true cost of reproductive health, maternity care, and postpartum services.

Policymakers must look beyond maternal and postpartum health care to address many of the root causes of the maternal mortality crisis. By utilizing an intersectional lens, policymakers can address a full scale of social determinants that impact health and influence maternal health outcomes, including structural racism and systemic inequality, and address issues like climate change that significantly impact life and health outcomes. Additionally, policymakers should recognize how abortion restrictions have exacerbated the maternal mortality crisis and promote legislative solutions to promote nationwide access to abortion. For IWPR’s full recommendations on abortion access, click here.

Enact and enforce policies that support workplace protections for pregnant and postpartum people. This includes enforcing the Pregnant Workers’ Fairness Act, legislation enacted in 2023 to require employers to offer reasonable accommodations to pregnant or postpartum workers based on limitations related to pregnancy or childbirth. Policymakers should explore additional options to support pregnant, postpartum, and lactating people in the workforce, including passing paid family leave and paid sick leave and ensuring access to lactation facilities.

Key Legislation

The Black Maternal Health Momnibus Act: This bill aims to comprehensively address maternal mortality, morbidity, and disparities in the US. The Momnibus is made up of 13 individual bills addressing aspects of the maternal health crisis, including, but not limited to:

• Social Determinants for Moms Act: Legislation to invest in addressing the nonmedical factors that impact maternal health outcomes. Among other things, the legislation would establish a wholeof-government task force to address the United States maternal health crisis. It would also provide sustained funding to tackle the social determinants of health during and after pregnancy.
• Extending WIC for New Moms Act: A bill to extend WIC eligibility in the postpartum period from 6 months to 24 months. This bill also sets out to extend WIC eligibility in the breastfeeding period from 12 months to 24 months.
• Kira Johnson Act: Legislation to address bias and racism in health care. The bill would provide funding directly to community-based organizations working to advance maternal health equity and prevent and respond to cases of bias, discrimination, and racism in maternity care settings.
• Perinatal Workforce Act: Legislation to invest in increasing the number of perinatal health workers who support women throughout pregnancies, labor and delivery, and postpartum, with a particular focus on promoting a diverse workforce offering culturally congruent care.
• Data to Save Moms Act: A bill to improve data collection on maternal mortality and morbidity by investing in improving and diversifying state and tribal maternal mortality review committees.
• Tech to Save Moms Act: Legislation to promote the use of digital tools, including telehealth, to improve maternal health outcomes, particularly in rural and underserved areas.
• Protecting Moms and Babies Against Climate Change Act: Legislation to invest in community-based efforts to mitigate exposure to—and effects of—climate change risks that threaten pregnant and postpartum people and their infants.

NIH IMPROVE Act: Bipartisan legislation to authorize sustainable funding for the National Institute of Health’s IMPROVE initiative, providing resources for research into the causes of maternal mortality and funding studies aimed at reducing preventable maternal deaths and addressing racial, socioeconomic, and other disparities in maternal health outcomes.

Executive Priorities

Fully implement the 2022 White House Blueprint for Addressing the Maternal Health Crisis—a whole-of-government approach to cutting the rates of maternal mortality and morbidity, reducing the disparities in maternal health outcomes, and improving the overall experience of pregnancy, birth, and postpartum for people across the country.

This brief is part of IWPR’s Federal Policy Solutions to Advance Gender Equity. Click here to see the full series.