Confronting the Maternal Mortality Crisis in the United States: Insights From the 2025 Commonwealth Fund Brief

Despite medical advancements and increased attention to perinatal care, the maternal mortality crisis continues to rise in the United States. In the Commonwealth Fund’s updated July 2025 brief “Maternal Mortality in the United States, 2025,” Eugene Declercq, PhD, MBA, and Laurie Zephyrin, MD, MPH, MBA, offer an analysis of these trends and a clarion call for reform across policy, clinical care, and public health systems.1

In 2023, the World Health Organization (WHO) named the United States as being 1 of only 7 countries that had experienced a significant rise in maternal mortality since 2000, a distinction that placed the US alongside Venezuela, Cyprus, Greece, Mauritius, Belize, and the US Commonwealth of Puerto Rico. The US significantly lags behind other high-income countries at an approximately 3 times higher ratio of maternal mortality than Sweden, Japan, the Netherlands, Germany, the United Kingdom, and France. This classification not only isolates the US from its economic peers but highlights the scale of systemic failure within its maternal health infrastructure, especially in light of the US’s overall higher spending on health care than other high-income countries.

In 2020, The Commonwealth Fund had found the US had the highest maternal mortality rate among 11 developed countries, and it was the only country that did not guarantee access to provider home visits or paid leave in the postpartum period.2

Rising Mortality in the US Amid Global Decline

Data from the CDC’s Pregnancy Mortality Surveillance System (PMSS) show that the US pregnancy-related mortality ratio rose by 22.8% between 2000 and 2009, stabilizing around 660 deaths per year in the pre-pandemic years. However, the onset of the COVID-19 pandemic marked a turning point: From 2019 to 2021, the number of maternal deaths nearly doubled, reaching 1222. Although preliminary data from 2023 indicate a return to near pre-pandemic levels with 676 deaths reported, the long-term trajectory remains troubling, particularly as US birth rates continue to decline.1

Young mother holding a newborn in the maternity ward of a hospital. Image Credit: © Andy Dean - stock.adobe.com

The Commonwealth Fund’s 2025 Scorecard on State Health System Performance further reinforces this picture. States with the highest maternal mortality rates often coincide with those that rank lowest on overall health system performance, suggesting that maternal mortality serves as a sentinel indicator for broader health system dysfunction.

The scope of the US maternal health crisis becomes clearer when considering not just absolute numbers but underlying causes. During the pandemic, a significant proportion of deaths were directly attributed to COVID-19, but non–COVID-19–related deaths also surged. This suggests that system-wide disruptions, such as reduced access to prenatal and postpartum care, overwhelmed hospitals, delayed diagnoses, and exacerbated social stressors, contributed meaningfully to the increase in maternal deaths.

Furthermore, the true burden of maternal mortality may be understated. While PMSS captures pregnancy-related deaths up to one year postpartum, the National Vital Statistics System (NVSS) uses a narrower definition: maternal deaths during pregnancy and up to 42 days post-delivery. Analyses indicate that extending the observation window to one year adds as much as 50% more deaths to the total. For example, data from Tennessee’s maternal mortality review committee found a substantial increase in captured deaths when using the broader timeframe, a pattern consistent across other states.

Disparities by Race, Age, and Geography

Maternal mortality in the United States is deeply stratified along racial, ethnic, geographic, and age-based lines. These disparities are not merely statistical anomalies—they reflect systemic issues rooted in access to care, socioeconomic status, and structural inequities within health systems.

Racial and Ethnic Disparities

Non-Hispanic Black women remain the most disproportionately affected group in the US maternal mortality crisis. Between 2017 and 2019, the pregnancy-related mortality ratio for non-Hispanic Black women was 2.9 times that of non-Hispanic White women. Non-Hispanic American Indian and Alaska Native women also faced elevated risk, with ratios 2.3 times higher than White women. These disparities only worsened during the COVID-19 pandemic.1

Pregnancy-related mortality among non-Hispanic Black women increased by 58% during the pandemic. The burden on non-Hispanic American Indian and Alaska Native women surged even more dramatically, rising 184%. Hispanic women, who had previously demonstrated lower mortality ratios compared with White women, experienced a 125% increase in pregnancy-related deaths during the pandemic—resulting in higher mortality than non-Hispanic White women during this period. Although their post-pandemic rates have since returned to near parity with White women, the temporary reversal highlighted the volatility of these disparities under stress.1

Age-Related Disparities

Age is another significant risk factor. Pregnancy-related mortality increases steadily with maternal age, and women aged 40 and older face dramatically higher risks. In every period studied, pregnancy-related death ratios for women aged 40 and older were at least 80% higher than those for women aged 35 to 39 years. During the COVID-19 pandemic, the ratio for women aged 40 and older peaked at 106.3 deaths per 100,000 live births.1

Geographic Disparities

Geographic variation in maternal mortality was also shown to be pronounced and persistent in the report. States in the South, including Alabama, Mississippi, Louisiana, and Georgia, continue to report the highest pregnancy-related death ratios at approximately 50 deaths per 100,000. According to Declercq and Zephyrin, these states are also among those that have not expanded Medicaid under the Affordable Care Act (ACA), a policy choice with well-documented consequences for health equity and access.1

In contrast, 6 states—California, Colorado, Delaware, Massachusetts, Minnesota, and Utah—reported pregnancy-related mortality ratios below 25 deaths per 100,000 live births. These states also score higher on health system performance and have made proactive investments in maternal health infrastructure, including the preservation of obstetric services, community-based care models, and extended postpartum Medicaid coverage.1

Notably, many of the states with the highest mortality also have a large proportion of rural areas within their boundaries. Rural communities are disproportionately affected by hospital and maternity ward closures, shortages of obstetricians, and lack of integrated behavioral health services. According to the report, rural areas had maternal mortality ratios more than 50% higher than large urban areas before the pandemic. During the pandemic, pregnancy-related death ratios increased by 74% in small-to-medium metro areas, 64% in large metro areas, and 62% in rural areas, where baseline risk was already high. Post-pandemic, rural ratios improved slightly but remained elevated.1

Even in urban settings, gaps persist. An estimated 24% of urban areas report having no clinical obstetrician, reflecting the impact of workforce shortages and strained provider networks. Meanwhile, maternity care deserts—defined as areas with limited or no access to obstetric services—remain common in both rural and urban low-income communities.1

The Postpartum Period

In a shift from traditional focus, data from the CDC’s PMSS show that only 11% of maternal deaths occur on the day of delivery. The majority (63%) of maternal deaths occur in the first year after birth. This finding underscores the need for extended postpartum care and consistent standards of care well beyond childbirth. Despite efforts to improve clinical care during labor and delivery, long-term solutions must include policy, social support, and integrated care models that extend into the postpartum period.1

One of the most consequential policy shifts has been the expansion of postpartum Medicaid coverage from 60 days to 12 months, a change that nearly all states have adopted. However, some states have enacted only time-limited expansions that could expire without renewed legislative or administrative action. Sustaining and expanding such coverage is essential for improving maternal outcomes.1

Behavioral Health and Preventable Deaths

Data from maternal mortality review committees provide a more detailed view of causes of death than federal systems such as PMSS and NVSS. Behavioral health conditions, including substance use and mental health disorders, now account for over 20% of maternal deaths, making them the leading cause. These deaths disproportionately affect non-Hispanic White women, who die from mental health conditions and severe hemorrhage at higher rates, while Black women are more likely to die from cardiac conditions, embolisms, and COVID-19.1

The findings also point to broader concerns about women’s health. Between 2010 and 2023, over 16,000 additional deaths occurred among women of reproductive age (15-44 years), excluding those related to COVID-19. Nearly three-quarters of this increase (11,969 deaths) were classified as drug-induced, including overdoses, suicides, and homicides. These trends suggest a worsening crisis in women’s behavioral health that extends beyond pregnancy.1

Intersections With Infant Mortality

Newborn holding an adult finger. Image Credit: © Rattanachat - stock.adobe.com

Using CDC data from 45 states that reported at least 10 maternal deaths between 2020 and 2022, Declercq and Zephyrin observed a strong positive correlation (r = +0.61) between pregnancy-related mortality and infant mortality. This suggests that high rates of maternal death are a signal of inadequate systems of care for infants as well. States such as Alabama, Mississippi, South Dakota, and Tennessee had both high pregnancy-related and infant mortality rates. In contrast, states such as California, Minnesota, and Washington demonstrated lower mortality across both measures.1

Before the COVID-19 pandemic, US infant mortality rates had shown a modest but consistent decline. However, these gains were reversed during the pandemic, with infant deaths increasing across many states. Several factors contributed to this reversal, including delayed or restricted access to prenatal and pediatric care, greater exposure to respiratory illnesses, and the cascading effects of maternal health deterioration, especially in underserved communities.1

Disparities by state also remain striking. Mississippi, for instance, has the highest infant mortality rate in the nation—more than double the rate found in the 11 best-performing states (ie, Massachussetts, New Jersey, Vermont, New Hampshire, California, Rhode Island, Oregon, New York, North Dakota, Connecticut, Washington). These wide differences are not explained solely by clinical risk factors. They also reflect state-level policy choices, including decisions related to Medicaid expansion, investment in maternal and child health programs, and strategies for addressing social determinants of health.1

Importantly, the relationship between maternal and infant mortality is more than correlative—it is causal in many instances. Poor maternal health, delayed or inadequate prenatal care, untreated chronic conditions, and lack of postpartum follow-up contribute directly to adverse birth outcomes such as preterm birth, low birth weight, and neonatal complications. Conversely, when mothers receive comprehensive, high-quality care before, during, and after pregnancy, infants benefit from greater odds of survival and long-term health.1

Recognizing this dynamic, Declercq and Zephyrin call for a systems-level response that integrates maternal and pediatric care.1 Models such as “dyadic care,” in which mother and infant receive coordinated services through the same health team or facility, have shown promise in improving both maternal and infant outcomes.3 Community-based birthing centers and home-visiting programs led by midwives and doulas can also bridge gaps in access and cultural competency.1

The Role of Medicaid and Policy Decisions

Declercq and Zephyrin emphasized the pivotal role of Medicaid policy in shaping maternal health outcomes. States that have not expanded Medicaid eligibility under the ACA report pregnancy-related mortality rates 18% to 49% higher than expansion states. Nonexpansion states also experience higher infant mortality rates, at 23% greater on average.1 Medicaid expansion has consistently been associated with improved health outcomes, including increased use of preventive services and reduced racial disparities.1,4

Furthermore, Declercq and Zephyrin noted that preserving postpartum Medicaid extensions is critical. These policies ensure continuity of care during the high-risk postpartum year when most maternal deaths occur. Without federal support or state action, temporary extensions could lapse, eroding progress made in maternal health equity.1

Community and Clinical Responses

Since the 2020 edition of the Commonwealth Fund brief, notable progress has been made in maternal mortality surveillance through expanded support for state review committees and Perinatal Quality Collaboratives. Yet access to maternal and reproductive care remains at risk due to potential federal budget cuts and declining data availability, which could undermine recent gains.1

Key solutions include expanding Medicaid coverage—especially the one-year postpartum extension—and investing in best practices for managing obstetric emergencies, community-based birthing centers, and culturally responsive care. Given the rising mortality among women of reproductive age and the close link between maternal and infant outcomes, integrated, equity-focused approaches are essential. According to Declercq and Zephyrin, promising community-led models exist but require sustained funding to deliver long-term impact.1

Conclusion

The Commonwealth Fund’s 2025 update underscores that maternal mortality remains a persistent challenge in the United States, with wide variation across states and populations. Recent progress in surveillance and policy reform has laid important groundwork, but disparities in access, insurance coverage, and outcomes continue to shape maternal health. Improving these outcomes will require coordinated efforts across policy, clinical care, and community settings, with a focus on extending postpartum coverage, supporting the workforce, and advancing integrated care models. Sustained investment and evidence-based strategies will be essential to strengthen maternal and infant health nationwide.1

REFERENCES
1. Declercq E, Zephyrin LC. Maternal mortality in the United States, 2025. The Commonwealth Fund. July 29, 2025. Accessed July 30, 2025. https://www.commonwealthfund.org/publications/issue-briefs/2025/jul/maternal-mortality-united-states-2025

2. Melillo G. US ranks worst in maternal care, mortality compared with 10 other developed nations. AJMC®. December 3, 2020. Accessed July 30, 2025. https://www.ajmc.com/view/us-ranks-worst-in-maternal-care-mortality-compared-with-10-other-developed-nations

3. Choy CC, McAdow ME, Rosenberg J, Grimshaw AA, Martinez-Brockman JL. Dyadic care to improve postnatal outcomes of birthing people and their infants: A scoping review protocol. PLoS One. 2024;19(4):e0298927. doi:10.1371/journal.pone.0298927

4. Eliason EL. Adoption of Medicaid expansion is associated with lower maternal mortality. Womens Health Issues. 2020;30(3):147-152. doi:10.1016/j.whi.2020.01.005