America’s Rising Maternal Mortality Rate Paints a Troubling but Incomplete Picture

Janell Green Smith spent her career caring for others. A certified nurse-midwife and scholar based in Charleston, South Carolina, who dedicated herself to healing, she understood the vulnerabilities of the human body better than most. The 31-year-old, who proudly called herself the “Loc’d Midwife,” had delivered more than 200 babies and trained the next generation of midwives at a community birth center. She had earned her Doctor of Nursing Practice degree in 2024, just two years after becoming a certified midwife in 2021. Yet when she gave birth to her first child early this month, that expertise couldn’t save her. Ms. Smith died from complications of childbirth, her death a stark reminder that, in America, even medical professionals who specialize in maternal health aren’t immune to a crisis that has made headlines nationwide — though the truth of that crisis may be more complex than it appears.The numbers paint a disturbing picture. According to the Centers for Disease Control and Prevention, the maternal mortality rate in the United States nearly doubled to 32.9 deaths per 100,000 live births in 2021 from 17.4 deaths in 2018. The World Health Organization declared the United States one of only seven countries worldwide to report a significant increase in maternal deaths since 2000, placing America alongside Venezuela, Cyprus, Greece, Mauritius, Belize and the Dominican Republic.Yet beneath these alarming statistics lies a tangled story of measurement changes, data collection challenges, racial disparities and genuine health crises that make answering a simple question remarkably complex: Is maternal mortality actually rising in America, or are we counting deaths differently than we did two decades ago?The Checkbox That Changed EverythingIn 2003, health officials added a seemingly innocuous feature to United States death certificates: a checkbox asking whether the deceased was pregnant at the time of death or had been pregnant within the previous year. The change was designed to address a serious problem. Research has shown that as many as 50 percent of physicians completing death certificates failed to report that a woman was or recently had been pregnant, meaning half of all maternal deaths went unidentified.The checkbox worked, perhaps too well. A 2020 CDC analysis found that between 2003 and 2017, the pregnancy checkbox was associated with an increase of 9.6 deaths per 100,000 live births on average. The impact was particularly dramatic for women over 40, where checkbox errors were most common. In one quality assurance pilot involving four states, researchers found false-positive rates of up to 32 percent, meaning in nearly one-third of cases where the pregnancy checkbox was marked, the investigators found no evidence the deceased was actually pregnant when they reviewed medical records and other documentation.The checkbox identified more than 300 women in 2013 who died at age 65 or older as maternal deaths, nearly half of whom were over 84 years old. Deaths from brain cancer, malignant neoplasms and other conditions unrelated to pregnancy began appearing in maternal mortality statistics at unprecedented rates. One study found maternal deaths with malignancy listed as a cause increased 46-fold from 1999 to 2021.Dueling DataThe issue flared in March 2024 when researchers from the University of British Columbia, Rutgers, and others published a study in the American Journal of Obstetrics and Gynecology, referred to as AJOG, rejecting the CDC’s reliance on the pregnancy checkbox. Counting only deaths with explicit pregnancy-related causes, they concluded that maternal mortality stayed essentially flat from 1999 to 2021, at just over 10 deaths per 100,000 live births.The CDC quickly disputed the findings, warning that the researchers’ method undercounts deaths, and the American Journal of Obstetrics and Gynecology called the conclusions irresponsible. Yet the CDC has acknowledged serious flaws in the use of the checkbox, finding false-positive rates above 50 percent in mid-2010s audits. While the agency narrowed its definition in 2018 to women aged 10 to 44, it still counts any nonaccidental death with a checked pregnancy box as maternal, including fatalities from unrelated causes like cancer.“The CDC’s pregnancy-related mortality system (PMSS) rate is the most reliable national measure through 2024,” a professor in the Community Health Sciences Department at Boston University School of Public Health, Eugene Declercq, tells The New York Sun. “Aside from a major increase in 2020 to 2022 associated with COVID, the pregnancy-related mortality rate has been relatively steady for the past two decades.”Real Deaths, Real DisparitiesAmid the methodological disputes, one fact remains undeniable and troubling. Black women in America die from pregnancy-related causes at rates dramatically higher than women of other races. The maternal mortality rate for 2023 showed black women facing 50.3 deaths per 100,000 live births, compared to 14.5 for white women and 12.4 for Hispanic women.This disparity persists regardless of which counting methodology researchers use. The Commonwealth Fund disclosed that after excluding COVID-related deaths, more than 16,000 additional women of reproductive age died in 2023 compared to 2010. Nearly three-quarters of this increase, 11,969 deaths, were attributed to drug-induced causes, including unintentional overdoses, suicides and homicides.“There’s not one factor that explains it, but overall weakness in our care of women’s health in general plays a big role since it’s difficult to correct all ongoing health problems during pregnancy,” Mr. Declercq explains. “Part of the challenge is that maternal deaths can occur over a 21-month time frame from pregnancy through a year postpartum, and black women suffer from higher rates of cardiac-related difficulties that often don’t manifest until the postpartum period when women’s health care is less accessible.”The vice president of programs and impact at Every Mother Counts, Divya Sooryakumar, frames the issue in starker terms. “Systemic and interpersonal racism and weathering, the cumulative physical toll of chronic exposure to racism over a lifetime, are primary drivers of the profound inequities in maternal health experiences and outcomes that disproportionately affect black women in the U.S.,” Ms. Sooryakumar tells the Sun. “These inequities don’t happen by accident. They happen by design and are the predictable result of structural and policy choices that shape where, when, and how people receive care.”Ms. Sooryakumar says black women “too often report being ignored, discriminated against, or pressured by their care providers, with few meaningful mechanisms for accountability when harm occurs.”The pandemic added another layer of complexity. Two in five pregnancy-related deaths in 2021 were attributed to COVID-19, with the number of such deaths jumping to 1,222 in 2021 from 664 in 2018. These figures reflect genuine health crises affecting pregnant women, not mere statistical anomalies.Geography matters enormously in maternal health outcomes. Louisiana has the nation’s highest maternal mortality rate at 58.1 deaths per 100,000 births, more than 14 times higher than California’s rate of 4.0. California achieved its dramatic improvement through the formation of the California Maternal Quality Care Collaborative in 2006, demonstrating that focused interventions can work.Pregnancy-related mortality rates also tend to be low in states with low overall female death rates, including California, Massachusetts, Minnesota and Utah. This correlation suggests that maternal health reflects broader women’s health infrastructure rather than just pregnancy care. States with the highest maternal mortality rates rank among the worst in overall health system performance, indicating systemic rather than isolated failures.The Healthcare Safety Net UnravelsBeyond the data disputes, real problems plague American maternity care. Hospitals are often unprepared for maternal emergencies during childbirth. Some doctors entering maternal-fetal medicine complete their training without ever working in a labor and delivery unit. Indiana has 33 counties in which there is no hospital providing obstetric services.“Maternal deaths are not separate from overall challenges in women’s health care, and overall death rates for women of reproductive age have been going up while maternal deaths have remained steady,” Mr. Declercq observes.Other experts say those trends are closely tied to how maternity care works in the United States. “Preventable maternal deaths in the U.S. are not random but rather reflect how maternity care is structured and paid for,” Ms. Sooryakumar says. “Chronic provider shortages, fragmented care, discrimination without accountability, and long-standing underinvestment in evidence-based models of care, such as midwifery and freestanding birth centers, put people at risk.”She points to systemic gaps: “With payment systems that don’t adequately value maternity care, postpartum insurance coverage that ends too soon, and outdated rules limiting who can provide care, predictable gaps emerge with fatal yet entirely avoidable consequences, especially for those navigating barriers to quality care.”Experts say these failures are not isolated mishaps but the predictable result of how maternity care is organized and financed in the United States.“The tragic death of Dr. Janell Green Smith, who died after childbirth, shows us just how urgent the black maternal health crisis is,” a co-founder of Chamber of Mothers and journalist who has reported extensively on maternal health, Cassie Shortsleeve, tells the Sun. “The most critical systemic failure in the U.S. is that mothers and families are woefully undersupported.”What the Data Really ShowsThe reality of maternal mortality in the United States lies between two extremes. Official figures likely overstate the crisis due to checkbox-related misclassification, but dismissing the trend entirely ignores real increases in specific causes of death and enduring racial disparities.While direct obstetrical deaths from complications such as preeclampsia, hemorrhage, and sepsis have declined in some analyses, indirect deaths — particularly from cardiovascular disease and drug overdoses worsened by pregnancy — have risen sharply, reflecting broader public health failures as much as gaps in maternity care. The CDC’s own modeling suggests maternal mortality rates changed little from 1999 to 2018 when earlier coding methods are applied.The paradox persists: the crisis may be less dire than headlines imply, yet more entrenched than official statistics reveal — especially as black mothers continue to die at vastly higher rates and drug-related deaths have surged among women of reproductive age.Health policy specialists argue that resolving this paradox requires shifting attention from debating the numbers to strengthening the systems that shape maternal outcomes.“This includes investing in community-based care models that have been proven to lead to better outcomes and respectful experiences of care, reduce disparities in preventable maternal deaths, and support a diverse maternity care workforce that reflects the communities served,” Ms. Sooryakumar says.

America’s Rising Maternal Mortality Rate Paints a Troubling but Incomplete Picture

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