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Maternal Morbidity and Mortality in the US Nursing CE Course

1.5 ANCC Contact Hours

About this course:

This learning activity aims to increase the learner's knowledge of maternal morbidity and mortality. The nurse will understand the prevalence, causes, and prevention of maternal morbidity and mortality, the differences in these rates between countries and racial groups, and the prevalence of implicit bias in maternal health care.

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Maternal Morbidity and Mortality 

Disclosure Statement

This learning activity aims to increase the learner's knowledge of maternal morbidity and mortality. The nurse will understand the prevalence, causes, and prevention of maternal morbidity and mortality, the differences in these rates between countries and racial groups, and the prevalence of implicit bias in maternal health care.

This learning activity is designed to allow learners to:

  • distinguish between maternal morbidity and mortality
  • describe the causes of maternal morbidity and mortality
  • explain how implicit bias negatively affects maternal outcomes for specific patient populations
  • evaluate the differences in maternal mortality rates between racial groups
  • recognize the disparity between the prevalence of maternal morbidity and mortality in the US versus other wealthy, industrialized nations

Maternal mortality is a term used to describe the number of maternal deaths during a specified period. This number is an indicator of maternal health, which can influence neonatal health and outcomes and a population's overall health. Maternal mortality is used to describe the death of an individual as a result of complications from poor health management during pregnancy or delivery up to 6 weeks (42 days) postpartum. Unless otherwise stated, organizations use this guideline when reporting maternal mortality rates. This is also the standard that is used by the World Health Organization (WHO) when reporting global maternal mortality data (National Institute of Child Health and Human Development [NICHD], 2021). Other terms are used to describe and classify maternal mortality based on timing and cause:

  • Pregnancy-related deaths occur during pregnancy, delivery, and up to 1 year postpartum and must be directly related to the pregnancy, delivery, or the care the individual received during the prenatal and postpartum periods. The Centers for Disease Control and Prevention (CDC) and other reporting sources use this definition of maternal mortality to report statistics specific to the US; however, the CDC also reports mortality rates based on the description utilized by the WHO (NICHD, 2021).
  • Pregnancy-associated death describes a death that occurs during pregnancy up to 1 year postpartum that is not directly caused by the pregnancy. This could include motor vehicle accidents (MVAs), natural disasters, suicides, or homicides. Homicide is one of the leading causes of death among pregnant individuals or those within 1 year of delivery, with 5.23 homicides for every 100,000 live births in 2020. Pregnant and postpartum individuals are 35% more likely to be murdered than those who are not pregnant or within 1 year of delivery. Maternal deaths that result from a pregnancy-associated cause are not typically included in maternal mortality rates (Wallace, 2022).
  • Pregnancy-associated but undetermined death describes a death that occurs during pregnancy or within the first postpartum year but cannot be definitively classified as pregnancy-related or pregnancy-associated (Collier & Molina, 2019).

Maternal morbidity describes an acute or chronic health condition that impacts an individual due to pregnancy. This includes acute renal failure, the development of an amniotic fluid or pulmonary embolism, preeclampsia or eclampsia, liver failure, septic shock, a cerebrovascular accident (CVA), and complications from anesthesia use. Maternal morbidity often occurs as a result of a high-risk or complicated pregnancy. Maternal morbidity is not monitored as closely as maternal mortality, and the surveillance methods can be unreliable. Conditions that affect an individual as a result of pregnancy can lead to an increased length of hospital stay, the need for close postpartum monitoring, and a decreased quality of life. Some cases of maternal morbidity directly result from the care delivered by a healthcare professional (HCP), often classified as a near miss. Although these cases did not result in maternal mortality, they can have lasting effects on the individual. These cases are not included in some estimates of maternal morbidity rates (Lowdermilk et al., 2016; NICHD, 2021).


Maternal mortality is measured by the number of deaths for every 100,000 live births. Maternal mortality rates are used as an indicator of women's health. Significant improvements in maternal mortality rates in the US occurred during the 20th century until the mid-1980s. Maternal mortality rates decreased from more than 800 in 1900 to the lowest recorded rate of 6.6 in 1987 (Douthard et al., 2021). The improvements in maternal health during this period are attributed to the following:

  • advancements in healthcare delivery and clinical knowledge
  • an increase in patient education level
  • improvements in standards of living and access to healthcare
  • monitoring of patient outcomes (Douthard et al., 2021)

The rate of maternal mortality has risen steadily since 1987. Many experts attribute this increase to the growing prevalence of obesity-related complications during pregnancy, an increase in cesarean deliveries, and a lack of access to affordable, high-quality healthcare. In 2020 in the US, 861 individuals died as a direct result of pregnancy, equating to 23.8 deaths per 100,000 live births. This is an increase of nearly 20% from 754 maternal deaths (a rate of 20.1) in 2019 and 658 maternal deaths (a rate of 17.4) in 2018. This increase is also partly attributed to the emergence of the COVID-19 pandemic. After March 2020, the rate of maternal deaths increased by 33.3%. The increase in deaths during this period was highest among Hispanic and Non-Hispanic Black individuals. This increase can be attributed directly to complications from COVID-19 or exacerbations of underlying health conditions by a diagnosis of COVID-19. A review of death certificates and International Classification of Diseases (ICD) 10 codes revealed that COVID-19 was not listed as the sole cause of death for any maternal deaths; however, COVID-19 was included as a secondary cause of death (Douthard et al., 2021; Hoyert, 2022; Thoma & Declercq, 2022).

Maternal mortality and morbidity rates have more than doubled since 2000 despite the average number of live infant births decreasing from 14 per 1,000 people between 2000 and 2010 to 10.9 per 1,000 people in 2022. The fertility rate of a country is the number of individuals between the ages of 15 and 44 who give birth. The US fertility rate has decreased by an average of 2% annually since 2014. Certain states have experienced a drop in birth rate much more significant than the national average. The birth rates in California decreased by 6.02%, Hawaii decreased by 6.35%, Wyoming decreased by 6.81%, and New Mexico decreased by 7.16%, which was the most significant decrease in the birth rate among states and is almost double the national average. Other states, such as New Hampshire and Rhode Island, experienced a smaller decrease in birth rates at 0.56% and 0.72%, respectively. Although the rates varied, every US state experienced a decrease in birth rates in 2020 (USAFacts, 2021, 2022).

An individual's age at the time of pregnancy can influence maternal mortality rates. There is evidence that the rate of maternal mortality increases as the age of the pregnant individual at the time of delivery rises. In 2020, individuals younger than 25 years of age had a maternal mortality rate of 13.8 per 100,000 births, an increase from 10.6 in 2018 and 12.6 in 2019; those aged 25 to 39 had a rate of 22.8 per 100,000 births, an increase from 16.6 in 2018 and 19.9 in 2019; and individuals over 40 had a maternal mortality rate of 107.9 per 100,000 births, a significant increase from 81.9 in 2018 and 75.5 in 2019. The maternal mortality rate among individuals older than 40 was over

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7.8 times higher than the rate of maternal mortality among individuals under 25 years old. Over the last 22 years, individuals have been delaying pregnancy until later in life, increasing the average age at the time of delivery. Since 2020, the median age of an individual at the time of delivery increased from 24.9 to 27.1 years of age, with individuals between the ages of 30 and 44 comprising 49% of all births, representing an increase of 10% for the same age group since 2010. The changes in median age at the time of delivery from 2010 to 2020 are outlined in Table 1 (CDC, 2022d; Hoyert, 2022; USAFacts, 2022).

Table 1

Percentage of Births by Age Group in the US





< 15 years old




15 to 19 years old




20 to 24 years old




25 to 29 years old




30 to 34 years old




35 to 39 years old




40 to 44 years old




> 45 years old




(USAFacts, 2022)

Maternal Morality in the US versus Other Countries

Despite numerous initiatives and changes in the delivery of maternal care, the rate of maternal mortality in the US is higher than in other countries classified as developed and high-income or high-resource. As the rates of maternal morbidity and mortality increased in the US, the global rates of maternal morbidity and mortality decreased by 44% from 1990 to 2015. Maternal mortality rates increased in the US by 58% between 1990 and 2017. Compared to all the countries established in 2015, the US ranked 46th out of 181, with a maternal mortality rate of 20.9 for every 100,000 births. Table 2 outlines the differences in maternal mortality rates between developed, high-income countries (Douthard et al., 2021; USAFacts, 2022).

Table 2

Comparison of Maternal Mortality Rates of Select Developed Countries 
















United Kingdom




United States




(Douthard et al., 2021)

Implicit Bias

Implicit bias in reproductive healthcare can lead to disparities in health outcomes and healthcare access for underserved racial and ethnic populations. Multiple factors contribute to health disparities, including the presence of underlying chronic conditions, variations in the quality of care delivered, access to reproductive health care, structural racism, and social determinants of health (SDOH). Racial disparities are well documented in obstetrics and gynecology care. For example, non-Hispanic Black women have higher preterm birth rates than their White counterparts (Bryant, 2022; CDC, 2022c).

Implicit bias also has an impact on postpartum hemorrhage. Gyamfi-Bannerman and colleagues (2018) conducted a retrospective cohort study of 360,000 women who experienced postpartum hemorrhage. After adjusting for comorbidities, non-Hispanic Black women who experienced postpartum hemorrhage had a higher risk of severe morbidity and death than non-Hispanic White women (Gyamfi-Bannerman et al., 2018).

These examples highlight the health disparities and inequities among racial and ethnically diverse populations related to obstetrical and gynecological health outcomes. These differences may be partially attributed to patient-level variables such as biological factors or genetics. However, many of these differences persisted even after researchers controlled for multiple characteristics. Research has also highlighted numerous differences in the health care that women of diverse racial/ethnic populations receive (i.e., health screening, type of care, and level of care). Biological or genetic factors cannot explain these differences, highlighting systemic and structural barriers to care equity (Bryant, 2022).

Determining the factors that impact the disparities in health care provided to women of different races and ethnicities can be challenging. These factors can include the patient, clinician, healthcare system, and sociocultural levels. Patient-related factors may play some role in the disparities in health outcomes or care received. For example, women may advocate for varying degrees of quality care based on their education level or health literacy. Next, implicit bias among clinicians can result in different levels of care provided to women of different racial/ethnic groups. In addition to implicit bias, clinician-patient communication may be suboptimal and culturally insensitive. Also, the healthcare system creates a broader structure for health and care disparities. For example, Women of Color in the US are more likely to experience financial and insurance constraints, limiting their treatment options. Finally, SDOH plays an important role in women’s health outcomes. For example, women may be labeled as nonadherent to recommended treatments or medications when, in fact, barriers such as stable housing, transportation, or lack of food are significantly impacting their health choices (Bryant, 2022; CDC, 2022g; Ricks et al., 2021).

According to SisterSong (n.d.) Women of Color Reproductive Justice Collective, reproductive justice is "the human right to maintain bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities" (para. 1). This organization was founded in 1997 by 16 Women of Color representing Native American, Latin American, African American, and Asian American communities. The reproductive justice movement differs from the reproductive rights movement of the 1970s, which many people felt only focused on the abortion debate. Instead, the reproductive justice movement focuses more broadly on how factors such as race, ethnicity, social class, disability, and sexual identity can limit patient freedom. In addition, the reproductive justice movement focuses on limiting oppressive circumstances related to informed choices about pregnancy and access to affordable, equitable care and education (i.e., contraception, prevention, and care for sexually transmitted infections [STIs], alternative birth options, domestic violence assistance, safe homes, adequate wages, and comprehensive prenatal and pregnancy care; SisterSong, n.d.).


Certain groups experience maternal mortality and morbidity at different rates than others. African American and American Indian or Alaska Native individuals experience a higher maternal mortality rate. Hispanic individuals had the lowest maternal mortality rates at 11.8 per 100,000 live births in 2018, 12.6 in 2019, and 18.2 in 2020. However, the 44% increase in the maternal mortality rate among Hispanic individuals between 2019 to 2020 was the most significant increase among all racial groups. This was also the most significant increase in the mortality rate for this group since 2000, as Hispanic individuals tend to have lower maternal mortality rates. Non-Hispanic Whites had the next lowest maternal mortality rates, with 14.9 per 100,000 live births in 2018, 17.9 in 2019, and 19.1 in 2020. Non-Hispanic Black individuals had a disproportionately elevated maternal mortality rate compared to other racial groups. In 2018, the maternal mortality rate for this group was 37.3 per 100,000 live births, increasing to 44.0 in 2019. In 2020, the maternal mortality rate among Non-Hispanic Black individuals increased again to 55.3 per 100,000 births. The maternal mortality rate between 2016 and 2018 was 14.1 for Asian/Pacific Islanders and 26.5 for American Indian or Alaska Native individuals. This was the second-largest increase among racial groups (see Figure 1). This difference in mortality rates between racial groups may be a result of an individual's ability to access quality prenatal and postpartum care, the prevalence of chronic illness among certain groups, and the presence of structural racism and implicit bias (CDC, 2022d; Hoyert, 2020; USAFacts, 2022).

Figure 1

Maternal Mortality by Racial Group

(Hoyert, 2022)

Severe maternal morbidity (SMM) refers to a life-threatening event during pregnancy, delivery, or postpartum based on 18 indicators defined by the CDC. These indicators show an increased risk of the individual experiencing short- or long-term morbidity, mortality, increased hospital stay, and healthcare costs. There has been a rise in the number of individuals suffering from a chronic condition at the time of pregnancy diagnosis. Individuals with multiple chronic conditions during pregnancy had a 276% increased risk of SMM, and the overall rate of SMM increased from 49.5 in 1993 to 144.0 in 2014. One contributor to this increase is the number of blood transfusions administered as a result of postpartum hemorrhage, which rose from 24.5 in 1993 to 122.3 in 2014. When blood transfusions are excluded from the data, the rate of SMM increased from 28.6 in 1993 to 35.0 in 2014, which is still a 20% increase. Numerous studies have found that non-Hispanic Black individuals are more likely to experience SMM than non-Hispanic White individuals. For example, non-Hispanic Black individuals had a 115% higher risk of SMM than non-Hispanic White individuals. Similar findings were reported for all other racial and ethnic minority groups compared to non-Hispanic White individuals. In a cross-sectional analysis of a large nationwide database, Aziz and colleagues (2019) evaluated over 11.3 million births between 2012 and 2014. The researchers found that non-Hispanic Black individuals were approximately 80% more likely to be readmitted postpartum and 16% more likely to experience an SMM during readmission than non-Hispanic White individuals (Aziz et al., 2019; Bryant, 2022; CDC, 2021; Collier & Molina, 2019).

There are also maternal mortality rate disparities between geographical locations, especially for those living in urban versus rural communities. Utilizing the National Center for Health Statistics Urban-Rural Classification Scheme for Counties, data have been compiled depicting the rates of maternal death during pregnancy up to 1 year postpartum for different types of counties. These regions are divided into the categories of a large central metro, large fringe metro, medium metro, and small metro, which are metropolitan counties considered urban and micropolitan and noncore counties classified as rural counties. Large fringe metro counties had the lowest maternal mortality rate at 13.8, followed by large central metro at 15.7, medium metro at 16.3, small metro at 17.9, micropolitan at 19.5, and noncore with the highest maternal mortality rate at 24.4. These numbers indicate the presence of a disparity in maternal mortality rates between urban and rural counties, possibly due to limited or lack of access to obstetric and gynecologic-specific health providers and services and the increased prevalence of chronic conditions. The presence of a chronic prepregnancy condition may contribute to a high-risk pregnancy, along with a greater distance to institutions and providers equipped to care for these individuals (CDC, 2022d).


Risk Factors

Certain factors can increase an individual's risk for maternal morbidity and mortality. Some of these factors are modifiable, and the risk can be decreased with lifestyle changes or proper medical management. Others are nonmodifiable (NICHD, 2020b). Some individuals experience maternal morbidity or mortality without any identified risk factors or the presence of symptoms. Factors that increase an individual's risk include:

  • presence of a preexisting condition such as asthma, cardiovascular disease, obesity, or immunodeficiency
  • age greater than 40 at the time of pregnancy
  • current or past smoking history
  • multiple-gestation pregnancy
  • development of preeclampsia
  • gestational diabetes
  • delivery via vaginal birth after cesarean (VBAC)
  • race
  • socioeconomic status (NICHD, 2020b)

A person’s lifetime risk of dying due to pregnancy is calculated using the risk that a 15-year-old individual with the ability to become pregnant will die as a result of pregnancy over their lifespan. It is determined using the maternal mortality and fertility rates of the country where the individual resides. The fertility rate is the average number of births per individual over their reproductive years. Due to this, high-fertility countries have a higher mortality rate than low-fertility countries since these individuals are exposed to potential maternal mortality more frequently. The lifetime risk of maternal mortality in Africa rages from 1 in 28 to 1 in 58, and South Asia has a lifetime risk of 1 in 240. In contrast, the lifetime maternal mortality risk is 1 in 3,100 in North America and 1 in 11,900 in Western Europe (UNICEF, 2021).


There are various causes of maternal morbidity and mortality. Although the rates may differ, there are many overlapping causes between countries. Some cases of maternal morbidity and mortality are related to preexisting conditions that are exacerbated by pregnancy, and others occur as a direct result of pregnancy (NICHD, 2020a). Causes of maternal morbidity include:

  • cardiovascular disease
  • preexisting or gestational diabetes
  • chronic or pregnancy-induced hypertension
  • infection following delivery or as a complication of pregnancy (e.g., an untreated urinary tract infection)
  • blood clot
  • hemorrhage
  • anemia
  • persistent nausea and vomiting or hyperemesis gravidarum
  • perinatal mental health disorders, including depression or anxiety (NICHD, 2020a)

The WHO reports the following as the most common causes of maternal mortality worldwide:

  • hemorrhage is the leading cause of maternal mortality globally, 27% of all maternal deaths
  • infection leading to sepsis, 11%
  • pregnancy-induced hypertension leading to preeclampsia or eclampsia, 14%
  • undergoing an abortion, 8% (99% of abortion deaths are due to an unsafe abortion)
  • embolism, 3%
  • complications from a preexisting condition (NICHD, 2020a; UNICEF, 2021)

In the US between 2016 and 2018, the most common causes of maternal mortality during pregnancy up to 1 year postpartum included:

  • cardiovascular conditions not otherwise listed, 16.2% of maternal deaths
  • infection or sepsis, 13.9%
  • cardiomyopathy, 12.5%
  • hemorrhage, 11.0%
  • embolism due to pulmonary (9.4%) or amniotic fluid (5.7%)
  • CVA, 7.0%
  • pregnancy-induced hypertension leading to preeclampsia or eclampsia, 6.8%
  • complications related to anesthesia, 0.2%
  • other noncardiovascular disorders not otherwise listed (e.g., diabetes), 11.4%
  • unknown causes, 6.0% (CDC, 2022d; NICHD, 2020a)

The primary causes of maternal mortality have fluctuated over time. The rates of death due to hemorrhage, pregnancy-induced hypertension leading to preeclampsia or eclampsia, or a complication related to anesthesia have decreased; however, the rates of maternal mortality attributed to cardiovascular disease, CVA, or other medical conditions have increased. This is attributed in the US to rising cases of diabetes, hypertension, or chronic heart disease during the population’s reproductive years. These conditions can be exacerbated by pregnancy, leading to a high-risk pregnancy with an increased risk of maternal mortality and the need for close monitoring by HCPs (CDC, 2022d).

An emerging cause of maternal death is self-inflicted harm, either by suicide or overdose. One study in Colorado reported 211 maternal deaths related to self-harm over 9 years. The majority of these 211 deaths occurred during the postpartum period. Of the individuals who died from self-harm in this study, only approximately 50% had a documented history or positive screening indicating mental illness or substance abuse. A 4-year study in Philadelphia revealed that 49% of maternal deaths were related to a nonmedical cause, including homicide, suicide, overdose, or MVA. Of the 49% of maternal deaths attributed to nonmedical causes, 40% resulted from an overdose. Based on such data, researchers and HCPs are advised to consider more than medical conditions and complications when addressing maternal mortality rates. Mental illness, substance abuse, and domestic violence screenings are essential tools that can be used to identify individuals at a higher risk of maternal death due to a nonmedical cause, thereby increasing the likelihood that an individual will receive proper prenatal and postpartum treatment and intervention (Collier & Molina, 2019).


There are ways to prevent some of the causes of maternal morbidity and mortality, such as implementing healthy lifestyle choices before becoming pregnant and maintaining a healthy lifestyle throughout pregnancy. Making lifestyle changes is even more crucial for those who suffer from a preexisting condition such as diabetes, obesity, or hypertension. Examples of lifestyle changes that can improve overall health include eating whole, plant-based foods; increasing physical activity; engaging in active weight loss; and abstaining from illegal substances, alcohol, and tobacco. Seeing an HCP before becoming pregnant to determine any risk factors that can be mitigated, followed by routine prenatal care during pregnancy, can also decrease the risk of maternal morbidity and mortality (CDC, 2022e).

The American College of Obstetricians and Gynecologists (ACOG) released a position statement in 2018 endorsed by other reproductive health organizations calling for the acknowledgment of the importance of proper postpartum care during the 4th trimester (i.e., the 12 weeks following delivery). Medicaid is the largest payer of perinatal care services but only covers an individual for 60 days following delivery. Analysis of data from the National Center for Health Statistics from 1999 to 2016 demonstrated that states that expanded Medicaid coverage to 1 year postpartum had 1.6 fewer maternal deaths per 100,000 individuals than those that did not expand Medicaid coverage past 60 days postpartum (Douthard et al., 2021; Searing & Ross, 2019).

Improving Outcomes 

Numerous groups and initiatives focus on improving pregnancy outcomes and preventing maternal morbidity and mortality. Examples of these groups and initiatives include the Hear Her campaign, the Pregnancy Mortality Surveillance System, Perinatal Quality Collaboratives (PQCs), CDC Levels of Care Assessment Tool, State Strategies for Preventing Pregnancy-Related Deaths, The Ending Preventable Maternal Mortality Strategy, and Healthy People 2030 (CDC, 2022e).

The Hear Her Campaign 

The Hear Her campaign is a national campaign in the US that supports the efforts of the Division of Reproductive Health within the CDC. The Hear Her campaign seeks to educate individuals regarding maternal mortality and important signs and symptoms to report to an HCP during both the prenatal and postpartum periods. The campaign also empowers individuals to bring their questions and concerns to their HCPs and attempts to improve communication between the patient and their HCPs. This campaign promotes the idea that individuals know their bodies better than anyone else, and HCPs should listen when they report a change or a feeling that something is wrong. The Hear Her campaign also distributes educational materials and tools to HCPs to help facilitate open communication and effective patient education. The Hear Her campaign is designed for patients, HCPs, and each patient's support system, including their significant other, friends, and family (CDC, 2022b).

The Pregnancy Mortality Surveillance System 

The CDC completes the Pregnancy Mortality Surveillance System (PMSS) to gain knowledge related to the risk factors and causes of maternal mortality in the US. To gain knowledge about causes of mortality, researchers review birth and death records and any additional data relevant to maternal mortality. Data from all 50 states are included, with additional information analyzed specific to New York City and Washington, DC. The data gathered from the PMSS are also used to determine maternal mortality rates, which are regularly posted on the CDC's website and published in research on maternal mortality (CDC, 2022d).

Perinatal Quality Collaboratives 

PQCs are state-specific or multistate teams with the goal of improving maternal outcomes. The National Network of Perinatal Quality Collaboratives (NNPQC) was created by the CDC and the March of Dimes to support state-based PQCs to attain goals and improve maternal outcomes. The PQCs aim to improve the quality of care delivered to patients by changing procedures and standards of care (CDC, 2022c). The following are some of the goals of PQCs:

  • improve practices to screen for opioid use by pregnant individuals, access to substance use disorder treatment, and improve the care of infants diagnosed with neonatal abstinence syndrome
  • reduce the number of preterm births
  • reduce the prevalence of severe hypertension, including the development of preeclampsia and eclampsia
  • reduce disparities in accessibility and quality of care based on race and environment
  • reduce the rate of delivery by cesarean section, particularly among individuals categorized as low-risk (CDC, 2022c)

PQCs have a history of improving patient outcomes regarding specific metrics. Examples include the Illinois PQC increasing the number of individuals who receive treatment for severe hypertension within 60 minutes from 41% to 79%, and the California PQC reducing the rate of hemorrhage during delivery or the postpartum period by 18% after 14 months of initiating care changes (CDC, 2022c).

CDC Levels of Care Assessment Tool 

How states report maternal mortality can vary, making it difficult to analyze trends in maternal outcomes across states or geographical regions. The CDC developed the Levels of Care Assessment Tool (LOCATe) to address this issue. This online tool aims to help standardize data reporting regarding maternal outcomes. When utilized, the tool can provide data on the variances in patient outcomes, facility data, and the distribution of resources, including human resources. The purpose of the tool is to give an accurate representation of areas that need improvement to direct changes in health policy (CDC, 2022a).

State Strategies for Preventing Pregnancy-Related Deaths

The State Strategies for Preventing Pregnancy-Related Deaths: A Guide for Moving Maternal Mortality Review Committee (MMRC) Data to Action is a resource available to help guide MMRCs and act as a resource during the implementation of new initiatives focused on improving maternal health and decreasing mortality rates. This resource is intended to be utilized once data are collected and decisions regarding addressing the identified problems have been discussed. It acts as a resource or tool for successfully implementing changes to maximize positive effects while limiting adverse outcomes resulting from the changes. This process is outlined in a 4-step process, each incorporating reviewing and monitoring of the implementation process (CDC, 2022f):

  1. Gather and use patient data to identify areas of deficiency requiring action.
  2. Determine if interventions have already been implemented and identify key stakeholders and available resources.
  3. Develop goals and strategies to address identified issues (e.g., eliminate racial and geographical disparities in the care of pregnant individuals and reduce maternal mortality).
  4. Create a plan and timeline and implement the strategies outlined in step 3.

Figure 2 depicts how to use the State Strategies for Preventing Pregnancy-Related Deaths guide.

Figure 2 

How to Use State Strategies for Preventing Pregnancy-Related Deaths

(CDC, 2022f)

The Ending Preventable Maternal Mortality Strategy 

The Ending Preventable Maternal Mortality Strategy is an initiative supported by WHO that works to support countries that have high maternal mortality rates. This initiative aims to:

  • address inequalities in health care provided to pregnant individuals and their ability to access high-quality health care during the reproductive years, including prenatal and postpartum care
  • ensure that all individuals have access to universal healthcare coverage for reproductive health needs and treatment
  • focus on decreasing the prevalence of disorders or outcomes that can increase the risk of maternal morbidity and mortality
  • provide resources to facilitate health systems collecting data that can track maternal outcomes, thereby directing quality improvement initiatives
  • implement practices that ensure health system and provider accountability to provide high-quality patient care (WHO, 2019)

Healthy People 2030 

Improving maternal and newborn outcomes and decreasing rates of morbidity and mortality have been addressed in the healthy people initiative since the release of Healthy People 2000. This objective was also addressed in Healthy People 2020, but improvements toward goal achievement were not made. The goals related to maternal health listed in Healthy People 2030 are to prevent the development of maternal complications resulting from pregnancy, decrease the rate of maternal mortality, and improve the overall health of individuals during their reproductive years, including the prepregnancy, prenatal, and postpartum periods. Objectives linked to the goals that are specific to maternal outcomes with associated progress from Healthy People 2020 (if applicable) are listed in Table 3 (Office of Disease Prevention and Health Promotion [ODPHP], n.d.).

Table 3 

Healthy People 2030 Objectives and Progress 




Pregnancy and Childbirth

increase the number of individuals who are screened for postpartum depression

in the developmental stage

increase the number of pregnant individuals who receive timely and quality prenatal care

getting worse

increase the number of individuals who have a healthy prepregnancy weight

getting worse

Drug, Alcohol, and Tobacco Use

decrease the use of alcohol and illicit drugs (especially opioids) by pregnant individuals

little to no detectable change

decrease the use of tobacco by pregnant individuals


Family Planning

increase the length between pregnancies to 18 months

target met

reduce the number of unintended pregnancies

little to no detectable change


reduce maternal deaths

getting worse

reduce the number of cesarean sections performed on low-risk individuals with no birth history

little to no detectable change

(ODPHP, n.d.)


Legislatures have passed laws to decrease the rate of maternal mortality in this country (Douthard et al., 2021). Examples include the following (Douthard et al., 2021):

  • The Preventing Maternal Deaths Act authorizes the CDC to support state and local MMRCs addressing maternal mortality through the end of 2023.
  • The Improving Access to Maternity Care Act requires the Health Resources and Services Administration (HRSA) to identify areas that need maternal health services and those lacking obstetric providers.
  • The Affordable Care Act supports the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, which provides home healthcare services to at-risk individuals and families.
  • The 21st Century Cures Act promotes the sharing of health information between HCPs and systems to identify disparities in healthcare and widespread issues.

Roe v. Wade

The ACOG and other reproductive health organizations have voiced concerns that the Supreme Court's vote to overturn Roe v. Wade in 2022 will have a negative impact on maternal mortality rates in the US. The overturning of Roe v. Wade gave the power to make decisions regarding abortion rights to the states. This means that the laws governing reproductive health can vastly vary based on geographical location. This change in law amplified the concerns of HCPs about their ability to care for their patients lawfully and provide them with the same level of care they were delivering under Roe v. Wade. The president of ACOG, Iffath Abbasi Hoskins, MD, released a statement following the Supreme Court's decision on Dobbs v. Jackson Women's Health Organization and the reversal of precedence set, outlining how this decision will impact bodily autonomy, reproductive rights and health, patient safety and outcomes, and healthcare equity. Bans and restrictions imposed by individual states following this decision will create barriers to accessing appropriate medical care for many individuals. The states that have enacted restrictions on abortion have not based these restrictions on medical knowledge or scientific research and are effectively reducing the treatment options that can be offered to certain patients. These laws lead individuals to search for alternative ways to end unwanted pregnancies, increasing maternal mortality rates (ACOG, 2022).

As addressed previously in the module, illegal, unsafe avenues of abortion account for 99% of abortion-related maternal deaths compared to when the procedure is performed legally by an HCP. Maternal mortality because of abortion is 0.41 for every 100,000 procedures performed. Data from other countries that have restricted access to legalized abortions show that restricting access does not significantly decrease the abortion rates but does significantly increase the maternal death rate due to abortion. Many individuals in the US were in their reproductive years before Roe v. Wade. The New York Times published an article where some women who underwent an illegal abortion before 1973 recounted their experiences and resulting health implications, including infertility, infection leading to sepsis, and organ failure. Due to the recent and ongoing changes to state-specific legislation, limited data are available on how these changes will affect overall maternal health and mortality rates (Massachusetts Medical Society, 2022).


The American College of Obstetricians and Gynecologists. (2022). ACOG statement on the decision in Dobbs V. Jackson. https://www.acog.org/news/news-releases/2022/06/acog-statement-on-the-decision-in-dobbs-v-jackson

Aziz, A., Gyamfi-Bannerman, C., Siddiq, J. D., Goffman, D., Sheen, J., D'Alton, M. E., & Friedman, A. M. (2019). Maternal outcomes by race during postpartum readmissions. American Journal of Obstetrics and Gynecology, 220(5), 484.E1-484.E10. https://doi.org/10.1016/j.ajog.2019.02.016

Bryant, A. (2022). Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases. UpToDate. Retrieved November 1, 2022, from https://www.uptodate.com/contents/racial-and-ethnic-disparities-in-obstetric-and-gynecologic-care-and-role-of-implicit-biases

Centers for Disease Control and Prevention. (2021). Severe maternal morbidity in the United States. Division of Reproductive Health. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html#rates

Centers for Disease Control and Prevention. (2022a). CDC Levels of Care Assessment Tool (CDC LOCATe). Division of Reproductive Health. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/cdc-locate/index.html#risk

Centers for Disease Control and Prevention. (2022b). Hear Her campaign: About the campaign. https://www.cdc.gov/hearher/about-the-campaign/index.html

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