'It is no wonder' the US has a maternal mortality crisis: Here's why and what can be done

Key takeaways:

• As many as 80% of maternal deaths in the U.S. are preventable.
• Experts discussed the factors driving the nation’s crisis and how PCPs can help care for mothers at their most vulnerable time.

The U.S. maternal mortality crisis is driven by various factors, but primary care providers are uniquely positioned to prevent pregnancy-related complications, according to experts.

In a recent report from the Commonwealth Fund, data revealed that the United States had 22 maternal deaths for every 100,000 live births in 2022 — by far the highest maternal mortality rate of other high-income nations. The rate in the U.S. was “double, sometimes triple” that of comparable countries, according to the report.

In fact, some high-income countries that have systems and policies supporting women — guaranteed paid leave, home visits, etc. — during pregnancy “report virtually no maternal deaths,” according to the data. In half of the countries analyzed, there were fewer than five maternal deaths per 100,000 births.

Teresa A. Hubka, DO, FACOOG, FACOG, CS, an osteopathic physician specializing in OB/GYN and president of the American Osteopathic Association, told Healio that the majority of maternal fatalities result from complications or conditions that are identifiable and treatable.

“It could be [anything from] your inadequate access to health care services to delayed recognition of warning signs,” she said. “Mothers have to manage their chronic conditions and we have to provide counseling on all the risks associated with high-risk labors depending on a mother’s age.”

The report indicated that more than eight in 10 maternal deaths are preventable.

However, Cynthia Chen-Joea, DO, MPH, CPH, FAAFP, a new board member of the American Academy of Family Physicians, said that PCPs are optimally trained to “address the full spectrum of physical, emotional, mental and social needs that a patient has.” And in many cases, where there are maternity care deserts, they are the only option.

“Family doctors play such a crucial role in providing treatment in the prenatal and the postpartum period,” she said. “It's really, I think, our relationships and our connection with our patients that's really that key, powerful tool.”

But it takes more than PCPs to address the entirety of the maternal mortality crisis. The issue is multifaceted, and there are numerous contributing factors at play, according to Hubka and Chen-Joea.

“We have to understand that our health care system is complex and often fragmented, leading to inconsistencies in the quality of care,” Hubka said.

Disparities in care

A key piece to this puzzle is inequity.

“This is something I'm very passionate about,” Chen-Joea said. “I so strongly believe that everyone — regardless of their insurance status, regardless of their ethnic or racial dentifications — deserves equal access to care before, during and after pregnancy.”

Yet, Black women suffer from maternal mortality at the highest rates, most likely from persistent inequities, Chen-Joea said.

The Commonwealth Fund report also stressed this point, noting that maternal mortality “is exceptionally high” for Black women. Among Black women in the U.S., there were 49.5 maternal deaths per 100,000 live births. Among white women, the rate was 19 deaths per 100,000 births. Asian American mothers saw the lowest rates, at 13.2 deaths per 100,000 births.

“The U.S. does have racial and socioeconomic disparities whether you are talking about Black and Indigenous women who experience significantly higher maternal mortality than white women,” Hubka said. “And we can’t forget economic barriers. Depending on where you live, you are not receiving adequate prenatal and postpartum care. That can increase risk of complications.”

Also, patients from underrepresented populations — those with a low income, living in rural areas or who identify as a racial or ethnic minority — often face obstacles to accessing both prenatal and postnatal care.

“This lack of access can lead to untreated medical conditions, inadequate prenatal care, and poor health outcomes,” she said.

And even when these patients do have access to health care, its quality “can be subpar.”

“Implicit biases among health care providers can lead to misdiagnosis, inadequate treatment or a lack of culturally competent care, all of which can contribute to higher maternal mortality rates,” Hubka said.

Chen-Joea also mentioned hospital closures, workforce shortages and other overlooked social determinants of health as contributing barriers.

“Social determinants of health that really strongly influence all health, but I think particularly maternal health, include access to nutritious foods, basic needs, housing, transportation,” she said. “There are other things that maybe people don't think about as often, and those can include, for example, education, employment and even exposure to violence or discrimination. All of that can really affect maternal health and make a difference.”

Health insurance can also “play a critical role in maternal health,” Hubka said. Naturally, patients who are under- or uninsured may feel forced to “delay seeking care due to cost concerns or face limitations in the services available to them,” which can then lead to adverse outcomes.

“Women from lower socioeconomic backgrounds often experience higher rates of maternal mortality due to factors such as limited access to health care, poor nutrition and inadequate living conditions,” Hubka added. “Socioeconomic status can also affect education levels, which, in turn, influences health literacy and awareness of maternal health issues.”

Hubka also noted that the prevalence of chronic conditions in the U.S. like “obesity, hypertension, and diabetes,” which is higher than in other comparable, high-income countries, could be a factor.

The fourth trimester

Chen-Joea stressed the importance of recognizing mental health problems, especially in the postpartum period — what she called “the fourth trimester.”

“Studies have shown that a significant number of maternal deaths occur 1 day to 1 year after their baby is born, and this is often due to pregnancy-related complications that could have been prevented,” she said. “I think by prioritizing postpartum care, we are able to recognize the unique role family physicians have in our patients’ lives and be able to make significant strides toward addressing the maternal health crisis.”

According to the Commonwealth Fund report, about 66% of maternal deaths occur during the postpartum period, up to 42 days after delivery.

Additionally, mental health is a leading cause of maternal deaths, Chen-Joea said. CDC data back this, noting that mental health — typically related to either substance use or suicide — was the underlying cause of pregnancy-related deaths in 23% of cases.

“Family physicians, because we have that close relationship with our patients, we're in a great place to be able to screen, detect, prevent and be able to treat those diseases,” she said. “Evaluating a patient's physical mental health and performing the necessary screenings can, I think, really optimize a pregnant woman's health during this time.”

For example, Chen-Joea recalled a recent experience with a patient being seen for a completely unrelated issue, revealing she had virtually no care for the postpartum depression she had been dealing with for a year.

“For whatever reason, due to life, she had just become lost to follow-up with her OB/GYN at that time,” she said. “[Preventive care screening] is a great opportunity to catch those patients [who] did slip through the cracks.”

Chen-Joea said she wanted to stress the importance of the fourth trimester because of her experience as a new mom.

“We place so much emphasis on the three trimesters during pregnancy, but that fourth trimester is part of pregnancy and often forgotten, and I think, incredibly important,” she said. “I have a daughter, who just turned 17 months yesterday, and that postpartum period, I have to say, is by far the hardest thing I have ever experienced my entire life. And I'm a physician.”

“I have insurance, and I have access to adequate resources and support,” she continued. “So if you can just imagine someone who maybe didn't have continuous prenatal and postpartum care, someone who doesn't have insurance, who doesn't have transportation, who doesn't have adequate access to nutritious foods... what that woman has gone through? And think about the type of care that she might be getting. It is no wonder that we have this maternal health crisis in the U.S.”

Resources

Aside from advocating for equitable policy, there are many ways PCPs can help prevent maternal mortality and support their pregnant patients, according to Hubka and Chen-Joea.

“Primary care physicians can play a significant role in preventing adverse maternal outcomes,” Hubka said.

She said that prevention efforts include:

• timely interventions;
• improving access to quality care; and
• addressing systemic barriers.

“As a frontline physician, we understand that addressing these issues requires coordinated efforts among health care providers, policymakers and communities to ensure timely care, equitable access and comprehensive education for all individuals at risk of maternal complications,” Hubka said.

Chen-Joea also mentioned various resources the AAFP have that can help family physicians prevent maternal adverse events.

“Family physicians, we are such in a unique place — we have that relationship and connection with our patients — that we're able to connect our patients with resources, with any kind of social needs,” she said. “The AAFP neighborhood navigator is a great tool to use. You can actually search for over 40,000 social services in your area by zip code. So, for example, if you're in a clinic, and you have this patient who might need help, you can quickly hop onto the search engine, put in your zip code, and it will give you a list of services available.”

References:

• Four in 5 pregnancy-related deaths in the U.S. are preventable. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html. Published Sept. 19, 2022. Accessed Feb. 7, 2025.
• Neighborhood Navigator. https://www.aafp.org/family-physician/patient-care/the-everyone-project/neighborhood-navigator.html. Accessed Feb. 7, 2025.
• Insights into the U.S. maternal mortality crisis: An international comparison. https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison. Published June 4, 2024. Accessed Feb. 7, 2025.