DATA BRIEF DECEMBER 2020 Maternal In 2017, at a time when maternal mortality was declining worldwide, the World Health Organization (WHO) reported that the U.S. was one of only two countries (along with the Dominican Republic) to report a significant increase in its maternal mortality ratio Mortality (the proportion of pregnancies that result in death of the mother) since 2000. While U.S. maternal deaths have leveled in recent years, the ratio is still higher than in comparable countries, and significant racial disparities remain. in the United Understanding the evidence on maternal mortality and its causes is a key step in crafting health care delivery and policy solutions at the state or federal level. This data brief draws States: on a range of recent and historical data sets to present the state of maternal health in the United States today. A Primer HIGHLIGHTS The most recent U.S. maternal mortality ratio, or rate, of 17.4 per 100,000 pregnancies represented approximately 660 maternal deaths in 2018. This ranks last overall among industrialized countries. More than half of recorded maternal deaths occur after the day of birth. The maternal death ratio for Black women (37.1 per 100,000 pregnancies) is 2.5 times the ratio for white women (14.7) and three times the ratio for Hispanic women (11.8). A Black mother with a college education is at 60 percent greater risk for a maternal death than a white or Hispanic woman with less than a high school education. Causes of death vary widely, with death from hemorrhage most likely during Eugene Declercq pregnancy and at the time of birth and deaths from heart conditions and mental Professor health–related conditions (including substance use and suicide) most common in the Boston University School of Public Health postpartum period. Laurie Zephyrin State ratios vary widely: in 2018, some states reported more than 30 maternal deaths Vice President per 100,000 births, while others reported fewer than 15. The Commonwealth Fund Maternal Mortality in the United States: A Primer 2 What do we mean by maternal mortality? What do we mean by maternal mortality? There are three commonly used measures of maternal deaths in the United States. It is important to note that, while they all capture some Pregnancy-associated mortality: aspect of maternal deaths, they are not equivalent. Deaths during pregnancy and up to Pregnancy-associated mortality: Death while Pregnancy-associated one year postpartum mortality pregnant or within one year of the end of the (one year) pregnancy, irrespective of cause. This is the starting point for analyses of maternal deaths. Pregnancy-related mortality: Death during Pregnancy-related mortality: pregnancy or within one year of the end of Deaths during pregnancy and pregnancy from: a pregnancy complication, a up to one year postpartum that chain of events initiated by pregnancy, or the Pregnancy-related are related to pregnancy aggravation of an unrelated condition by the mortality physiologic effects of pregnancy. Used by the (one year) Centers for Disease Control and Prevention (CDC) to report U.S. trends, this measure is typically reported as a ratio per 100,000 live births. In this Maternal Maternal mortality: mortality Deaths during pregnancy and brief, when we discuss causes of maternal deaths (42 days) up to 42 days postpartum that and current rates, we will generally be using are related to pregnancy pregnancy-related mortality as our index. Maternal mortality ratio: Death while pregnant or within 42 days of the end of pregnancy, Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). irrespective of the duration and site of the https://doi.org/10.26099/ta1q-mw24 pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Used by the World A NOTE ON TERMINOLOGY: For consistency, we use the term “maternal mortality ratio,” which is used in international comparisons of maternal deaths. Official U.S. reporting uses “rate.” However, in epidemiological terms, the figure reported is a ratio, since the numerator Health Organization in international comparisons, (maternal deaths) can include deaths that do not involve a live birth (e.g., in early pregnancy), while the denominator is only live births. The this measure is reported as a ratio per 100,000 live worldwide standard is used because of inadequate reporting on miscarriages and fetal deaths internationally. In addition, we refer to “women” and “mothers” throughout to describe pregnant and postpartum individuals. However, we recognize that births. When we examine historical trends, we will people of various gender identities, including transgender, nonbinary, and cisgender individuals, give birth and receive maternity care. be using maternal mortality as our index. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 3 Half ofHalf pregnancy-related deaths occur of pregnancy-related afteroccur deaths the day of birth. after the day of birth. There are various causes of maternal mortality; deaths during delivery 52% are significant but only a part of the problem. Slightly more than half (52%) of all deaths occur after the 31% day of delivery, while almost a third 17% occur during pregnancy. There have been considerable efforts to improve Maternal deaths during Maternal deaths around Postpartum maternal clinical care, but efforts that focus pregnancy time of delivery deaths (up to 1 year) on the birth hospitalization will only solve a portion of the problem. To improve outcomes, it will also be critical to address causes of maternal mortality that arise during CONCEPTION DELIVERY/BIRTH pregnancy (such as hypertension, or high blood pressure) and in the postpartum period (such as Post-pregnancy or cardiomyopathy, or weakened Preconception Pregnancy heart muscle), through upgrades to “fourth trimester” women’s health care before, during, and after pregnancy. POSTNATAL CARE PRENATAL CARE PRECONCEPTION CARE Primary care, including Primary care, including midwife services midwives Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). https://doi.org/10.26099/ta1q-mw24 commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 4 Maternal mortality had been gradually declining before recently rising. Maternal mortality had been gradually declining before recently rising. Deaths per 100,000 births For decades in the U.S. and around the world, maternal mortality dropped as women gained healthier living 1,000 conditions, better maternity services, safer surgical 900 16 procedures, and access to antibiotics. Then, 20 years ago, 15 the U.S. maternal mortality ratio began to rise. 800 14 13 Systematic, comprehensive collection of data on 700 12 maternal mortality in the U.S. began in the early 20th 11 600 10 century in individual states. In 1915, the state data began 9 to be compiled into a national estimate; by 1933, all states 500 8 were participating and the nationally reported ratio was 7 400 6 619 deaths per 100,000 live births. By way of contrast, the ratio in 1927 for England and Wales was 411 per 100,000 300 and for Italy was 264 per 100,000. 200 For most of the 20th century, maternal mortality ratios 100 dropped rapidly around the world with the introduction of healthier living conditions, improved maternity 0 services, safer surgical procedures, and antibiotics. By 1915 1918 1921 1924 1927 1930 1933 1936 1939 1942 1945 1948 1951 1954 1957 1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 1960 the U.S. ratio was 37 per 100,000 live births. During the for Note: Shifts in measurement (e.g., not all states were part of registration system prior to 1933; infant race was based on race of the child until 1980 and on race of the mother post-1980) account 1980s some and into the 1990s, clinical interventions as of the variation over time. Years 2007–2016 based on two-year estimates of the pregnancy-related mortality rate: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Data for 2017 unavailable; data for 2018 based on official NVSS rate. well as public health efforts further reduced maternal Data: NCHS, Maternal Mortality and Related Concepts, Vital & Health Statistics, Series 33, #3. & annual data reports. 1915–1960 data from NCHS, Vital Statistics Rates in the United States, 1940–1960. mortality; it declined until the late 1990s, when it leveled Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). off at about nine deaths per 100,000. After 1997, the U.S. https://doi.org/10.26099/ta1q-mw24 ratio began rising again until 2008, when it plateaued at Note: Shifts in measurement (e.g., not all states were part of registration system prior to 1933; infant race was based on race of around 14 deaths per 100,000 births. the child until 1980 and on race of the mother post-1980) account for some of the variation over time. Years 2007–2016 based on two-year estimates of the pregnancy-related mortality rate: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Data for 2017 The focus on improving maternity care in hospitals unavailable; data for 2018 based on official NVSS rate. has had consequences, for example by diminishing the Data: National Center for Health Statistics (NCHS), “Maternal Mortality and Related Concepts,” Vital and Health Statistics, series importance of community-based care and overlooking 33, no. 3 (Feb. 2007); and NCHS annual data reports. Data for 1915–1960 from NCHS, Vital Statistics Rates in the United States 1940–1960. persistent racial and ethnic disparities. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 5 Black mothers have been more likely to die than white mothers for the last 100 years. Black mothers have been more likely to die than white mothers for 100 years. Ratio of Black to white maternal mortality Black–white disparities in maternal mortality have existed since the 6.0 beginning of the collection of such data. In 1915, the maternal mortality ratio for Black mothers (1,065 per 5.0 100,000 births) was 1.8 times that of white mothers (601). As white maternal mortality ratios 4.0 declined more rapidly than those for Black mothers after World War II, the disparity increased until the 3.0 maternal mortality ratio for Black mothers was four times that of white 2.0 mothers. Since the early 1970s, Black mothers have been three to four times more likely to die than white 1.0 mothers. In the recently reported 2018 maternal mortality data, the Black–white disparity was 2.5 0.0 (37.1 for Black mothers vs 14.7 for 1915 1917 1919 1921 1923 1925 1927 1929 1931 1933 1935 1937 1939 1941 1943 1945 1947 1949 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 whites) — the same as the disparity seen in the 1940s. Notes: Shifts in measurement account for some of the variation over time. For example, not all states were part of registration system prior to 1933, and infant race was based on race of the child until 1980 and then race of the mother after 1980. Data: National Center for Health Statistics (NCHS), “Maternal Mortality and Related Concepts,” Vital and Health Statistics, series 33, no. 3 (Feb. 2007); and NCHS annual data reports. Data for 1915–1960 from NCHS, Vital Statistics Rates in the United States 1940–1960. Data for 2007–2016 based on two-year estimates of the pregnancy-related mortality rate, from Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Notes: Shifts in measurement account for some of the variation over time. For example, not all states were part of registration system prior to 1933, and Source: infant race was based on race of the child until Eugene Declercq 1980 and on raceand ofLaurie Zephyrin, the mother Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). thereafter. https://doi.org/10.26099/ta1q-mw24 Data: National Center for Health Statistics (NCHS), “Maternal Mortality and Related Concepts,” Vital and Health Statistics, series 33, no. 3 (Feb. 2007); and NCHS annual data reports. Data for 1915–1960 from NCHS, Vital Statistics Rates in the United States 1940–1960. Data for 2007–2016 based on two-year estimates of the pregnancy-related mortality rate, from Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 6 Race and ethnicity are tied to different causes of pregnancy-related death in the U.S. Different race and ethnicities, different causes of pregnancy-related deaths, U.S., 2007–16 Cause-specific pregnancy-related mortality in the U.S. by race/ethnicity, 2007–2016 (%) This figure, drawing on a decade (2007–16) of data on causes of maternal deaths broken down by race/ 100% ethnicity, illustrates the diversity of factors that contribute to maternal deaths in different groups. The percentages represent the distribution of causes of deaths within each group. 80% The same study also reported widely disparate pregnancy- related mortality ratios for each group, specifically: white Other (12.7), Black (40.8), American Indian/Alaska Native (29.7), Amniotic fluid embolism Asian Pacific Islander (13.5), and Hispanic (11.5). For 60% Stroke example, hemorrhage (severe bleeding) is a cause of death Hypertension most frequently seen in pregnancy and at the time of birth. Blood clots It was the leading cause of death among American Indians Weak heart muscle and Alaska Natives (AIANs) and Asian Pacific Islanders Severe bleeding (APIs), accounting for twice the proportion of deaths as 40% Other noncardiac condition seen among white or Black people. Cardiomyopathy, most Infection commonly seen in the postpartum period, accounts for Other cardiac condition one of seven deaths among Black and AIAN people, but less than half that proportion among Hispanic and API people. 20% To reduce such disparities, it is critical to understand the particular risks that women face and then address all relevant factors, including access to treatment before and after birth, the quality of clinical care, the effects of 0% structural racism, and social determinants of health. All White Black AIAN Asian PI Hispanic Note: AIAN = American Indian and Alaska Native. Asian PI = Asian Pacific Islander. Data: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Note: AIAN = American Indian and Alaska Native. Asian PI = Asian Pacific Islander. Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). Data: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and https://doi.org/10.26099/ta1q-mw24 Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 7 Even higher education does not protect Black mothers from pregnancy-related death. Even higher education does not protect Black mothers from pregnancy-related death (U.S., 2007–16). Pregnancy-related mortality ratios per 100,000 births in the U.S., 2007–2016 While educational advancement is typically seen as protective in terms of health, that’s not the case for Black mothers. Education Maternal deaths are more common among Black mothers with a college education exacerbates rather than mitigates than they are among white mothers with less than a high school education. Black–white differences in maternal deaths. Five times as many Black mothers with a college education 59.1 die as white mothers with a college education. Mortality ratios for white mothers decrease with higher education, but the difference in 45.6 mortality risk for a Black mother 41.0 40.2 with less than a high school education and one with a college degree is minimal. This leads to the startling finding that maternal 25.0 25.2 deaths are more common among Black mothers with a college education than they are among 12.6 11.7 white mothers with less than a 11.2 9.4 9.3 high school education (40.2 vs. 7.8 25.0). Mortality ratios for Hispanic mothers decrease slightly with < High school High school Some college College education but are generally lower at White Black Hispanic each level. Data: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Data: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). https://doi.org/10.26099/ta1q-mw24 commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 8 Pregnancy-related deaths are a clinical and a public health challenge. Pregnancy-related deaths are clinical and public health challenges. Leading clinical causes of pregnancy-related mortality up to one year post-birth, U.S., 2007–2016 (%) It is important to understand the clinical causes of pregnancy-related mortality. According to a recent CDC Other cardiovascular conditions report, the majority relate to cardiovascular conditions 15.3 such as heart muscle disease (cardiomyopathy) (11%), Other noncardiovascular conditions 13.3 blood clots (9%), high blood pressure (8%), stroke (7%), and a category combining other cardiac conditions (15%). Infection 13.3 Infection (13%) and severe postpartum bleeding (11%) are also leading causes. When many of these conditions are Severe bleeding 11.1 identified early, there are clinical interventions that can save lives. And a number of these conditions, particularly Heart muscle disease 11.1 cardiomyopathy, occur up to a year after childbirth. Blood clots 9.2 Improvements in hospital care have, according to a recent study, decreased the number of maternal deaths occurring High blood pressure 7.8 at the time of birth hospitalization. Pregnancy-related mortality ratios associated with hospital care (such as Stroke 7.2 hemorrhage, eclampsia, and infection) have declined in recent years. Amniotic fluid embolism 5.4 In addition to hospital-focused interventions, key efforts Anesthesia complications 0.4 involve identifying higher-risk women earlier, enrolling women in insurance, and keeping them in care after Unknown 5.8 childbirth. Additionally, many new mothers feel torn between the economic pressure to return to work and the need to focus primarily on their infant’s health, perhaps at the cost of their own care. Data: E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). https://doi.org/10.26099/ta1q-mw24 Data: Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 9 The underlying causes of pregnancy-related maternal deaths vary according to when mothers die. The underlying causes of pregnancy-related maternal deaths vary according to when mothers die. The causes of maternal death vary considerably and depend Causes of pregnancy-related mortality during pregnancy and the postpartum period, U.S., 2007–2016 (%) on when mothers die. These data are based on a report from maternal mortality review committees. Mental health condition During pregnancy, hemorrhage and cardiovascular High blood pressure/seizures conditions are the leading causes of death. At birth Embolism 32 and shortly after, infection is the leading cause. In the Heart muscle disease postpartum period, often during the time when new parents are out of the hospital and beyond the traditional Infection six- or eight-week post-pregnancy visit, cardiomyopathy Other heart conditions (weakened heart muscle) and mental health conditions Severe bleeding (including substance use and suicide) are identified as leading causes. 22 The diversity of causes at different times throughout pregnancy until one year postpartum can best be addressed 20 20 through integrated care delivery models. Those that leverage telehealth, midwives, and doulas can improve access to care. 16 Since almost 7 percent of non-Hispanic Black women in 2018 did not start prenatal care until their third trimester, and an additional 3 percent report no prenatal care at all, efforts to 12 12 enroll women into insurance early in pregnancy would be 11 an appropriate place to begin. The large proportion of deaths 9 9 occurring after birth also suggests too many mothers are lost 7 to care after they’ve given birth, a problem exacerbated by 7 7 6 current Medicaid policies that drop expanded coverage for 5 5 pregnant women 60 days after birth. 4 3 0 3 3 Given that large-scale policy changes may take longer to implement, there are also more immediate practice changes Pregnant Within 42 days 43 days to one year that can reduce disparities and save lives in the short term; these include increasing support for programs like community-based doulas and wraparound services, which have been found to act as effective buffers against larger Data: Centers for Disease Control and Prevention, Report from Nine Maternal Mortality Review Committees (CDC, 2018). social determinants of health. The varying conditions require different approaches to treatment. Source: Eugene Declercq and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Therefore, Fund, Dec. 2020). providing women with optimal care, https://doi.org/10.26099/ta1q-mw24 including mental health care, throughout the 21 months from conception through the year after they have given birth Data: Centers for Disease Control and Prevention, Report from Nine Maternal Mortality Review Committees (CDC, 2018). is essential. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 10 A woman’s chance of dying in childbirth is twice as high in some states as in others. A woman’s chance of dying in childbirth is twice as high in some states than in others (maternal mortality by state, U.S., 2018). Variation in state maternal mortality rates, 2018 State maternal mortality ratios vary widely. The recent report on Maternal mortality ratio maternal deaths in 2018 included (per 100,000 births) ratios for the 25 states reporting at Not available least 10 maternal deaths. A cluster of states in the South (Alabama, <15 Arkansas, Kentucky, and Oklahoma) reported ratios of greater than 30 per 15.0–19.9 100,000 live births, while California, 20.0–29.9 Illinois, Ohio, and Pennsylvania all reported ratios less than half the 30.0+ figures in those states. It is striking that the data are missing for approximately half of all U.S. states and territories. It is expected that with subsequent annual reports, multiple years can be combined to enable the comparison of all states. Data: National Center for Health Statistics, Maternal Mortality by State, 2018. Source: Eugene Data: National Center for Health Statistics, Maternal MortalityDeclercq by State,and Laurie Zephyrin, Maternal Mortality in the United States: A Primer (Commonwealth Fund, Dec. 2020). 2018. https://doi.org/10.26099/ta1q-mw24 commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 11 Black women are more likely than white women to report that their concerns and preferences regarding birth were disregarded; women with Medicaid coverage reported inadequate postpartum care and support. Listening to Mothers is a series of national surveys fielded by the nonprofit As these findings illustrate, different women have different experiences with National Partnership for Women and Families. Below is a summary of some maternity care, childbirth, and parenting. For example, both Black women of the key findings from the Listening to Mothers 2011–12 survey, as well as a and those with Medicaid coverage were less likely than white women and California survey conducted in 2016, about the experiences of mothers who those with private health coverage to say they had autonomy about childbirth had hospital births in the United States. decisions and were treated with respect by their providers. Compared with white women, non-Hispanic Black women were more likely When we consider causes of racial and other disparities in maternal mortality, to report: it is essential to consider women’s interactions with the maternity care system and understand how bias and racism manifest in these experiences. Because • Being treated unfairly and with disrespect by providers because of experiences of pregnancy and parenthood differ by race and insurance their race coverage, our health care systems need to address structural factors — • Not having decision autonomy during labor and delivery including racism and bias — that affect treatment while meeting the full needs of all pregnant and birthing people. • Feeling pressured to have a cesarean section • Not exclusively breastfeeding at one week and six months. DISCUSSION Compared with women with private health insurance, women with Medicaid As these charts show, relatively high maternal mortality ratios in the U.S. as coverage were more likely to report: compared with other countries, and disparities between Black and white women, are not new problems, nor are they improving. Even if you looked • No postpartum visit just at non-Hispanic white women in cross-national comparisons of maternal • Returning to work within two months of birth mortality, the U.S. would still be in last place. Even with varying ways to • Less postpartum emotional and practical support at home measure maternal mortality, the U.S. does not perform well on any analysis of this sentinel measure of a society’s health. • Not having decision autonomy during labor and delivery Preventing maternal mortality is complicated by the multifactorial nature • Being treated unfairly and with disrespect by providers because of of the problem. The causes vary across racial and ethnic groups as well as their insurance status timing — whether during pregnancy, at birth, or postpartum. And a woman’s • Not exclusively breastfeeding at one week and six months. chance of dying in childbirth is more than twice as high in some states. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 12 The fact that the U.S. has the highest maternal mortality ratio among wealthy countries even when we limit the U.S. data only to white HOW WE CONDUCTED THIS STUDY women suggests that our maternal health care system needs dramatic The figures cited in this study are based on data from a wide range of contemporary change. The U.S. has to intentionally focus on disparities between Black and historical sources. The historical data are drawn from early national vital statistics and white women, in particular by naming and seeking to reduce the reports. The current breakdowns of maternal death by timing of deaths and causes of impacts of structural racism. death are from the Pregnancy Mortality Surveillance System and the Maternal Mortality Structural racism leads to disparities in income, housing, safety, Review Information Application, both developed by CDC. The 2018 state ratios were education, and other circumstances that are associated with poorer published by the CDC’s National Vital Statistics System. The Listening to Mothers survey health and increased rates of chronic disease. These, in turn, place Black methods and results are all available from the National Partnership for Women and women at greater risk than white women of pregnancy-related deaths Families website. from cardiomyopathy and hypertension, among other causes. The National Vital Statistics System (NVSS) provides the official reports of maternal Racism in the health care sector compounds the issue, with Black mortality, and in 2020, after a decade-long hiatus, reported a national ratio (17.4 deaths women less likely to have access to treatment and receive good-quality per 100,000 births) for 2018. Meanwhile, the CDC has been publishing a pregnancy- related mortality ratio for more than two decades. However, the CDC data cannot be care. And the intersection of sexism and racism can mean women of used to make international comparisons because the CDC reports deaths up to one year color are not listened to or respected by their providers, contributing to postpartum, while other countries report deaths that occur up to 42 days postpartum. preventable morbidity and mortality due to delayed diagnosis or care. While the CDC data could be truncated at 42 days for comparison, the CDC is not allowed This has been reported by women in multiple surveys and illustrated to report those rates, because the NVSS is the only governmental body allowed to report by the high-profile cases of Serena Williams, Shalon Irving, and Kira an official maternal mortality ratio. Finally, CDC has developed the Maternal Mortality Johnson. Review Information Application system, for which data from states’ maternal mortality Moreover, although recent efforts to improve hospital maternity care review committees are gathered to produce multistate reports on maternal deaths. have been valuable, only a third of pregnancy-related deaths occur at the The major limitation in examining maternal mortality is that there is no single national time of birth. We need to improve women’s health services before and system in the U.S. for collecting maternal mortality data. Rather, there is a federal system after pregnancy — not just at the time of birth. wherein deaths are reported at the local and state levels and those reports conveyed Policies are also needed to promote continuous health insurance to federal officials. Therefore, the system relies on the quality of data collected locally coverage before and after pregnancy. In particular, the large proportion and the quality-control processes for converting those reports into national data. Documentation and analysis of maternal mortality over time have been hampered of maternal deaths that occur after childbirth suggests that too many by limited funding, changing definitions, and inconsistent reporting by states. These women are losing connections to health care after giving birth. shortcomings have resulted in notable gaps in our understanding of the problem, High maternal mortality in the U.S. is not the result of any single factor, including the degree of difference in maternal mortality between urban and rural and reducing it will require an integrated effort involving policy and areas, though there is considerable evidence reporting the growing problem of gaps in practice changes to improve hospital and community care for all women maternal health services in rural areas. while advancing racial equity. commonwealthfund.org Data Brief, December 2020 Maternal Mortality in the United States: A Primer 13 ABOUT THE AUTHORS ACKNOWLEDGMENTS Eugene Declercq, Ph.D., M.B.A., is a professor of community health sciences The authors thank Ebere Oparaeke, M.P.H., and Ruby Barnard Mayers, M.P.H., at the Boston University School of Public Health and professor on the faculty for research and technical support, and Jodie Katon, Ph.D., for her careful of Obstetrics and Gynecology at the Boston University School of Medicine. His review.] current research focuses primarily on maternal mortality and morbidity. He is part of the team that has produced six reports on women’s experiences in childbirth, Listening to Mothers. He is a current member of the Massachusetts Editorial support was provided by Martha Hostetter. Maternal Mortality Review Committee and is on the board of March for Moms. He is the founder of the website www.birthbythenumbers.org, where additional data on maternal mortality and other maternal and infant health outcomes can be found. He has Ph.D. and M.S. degrees from Florida State University and an For more information about this brief, please contact: M.B.A. from University of Massachusetts at Amherst. Eugene Declercq, Ph.D., M.B.A. Professor, Community Health Sciences Laurie Zephyrin, M.D., M.P.H., M.B.A., joined the Commonwealth Fund in Boston University School of Public Health 2019 as vice president, Health Care Delivery System Reform. Dr. Zephyrin is a declercqbu.edu board-certified physician and has extensive experience leading the envisioning, design, and delivery of innovative health care models across national health systems. She earned her M.D. from the New York University School of Medicine, her M.B.A. and M.P.H. from Johns Hopkins University, and her B.S. in Biomedical Sciences from the City College of New York. She completed her residency training at Harvard’s Integrated Residency Program at Brigham and Women’s Hospital and Massachusetts General Hospital. commonwealthfund.org Data Brief, December 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.