What is “maternal mortality”?
The dry, clinical term obscures a devastating loss: A person dies as a result of bringing a child into the world. That child loses a parent; a household is plunged into grief; a family that should be celebrating is left to mourn. Pretty much everyone can agree that such deaths are tragic and that even one is too many. What experts don’t agree on is how to count them.
For years, researchers have been warning the public that maternal deaths in America were rising, more than doubling between the 2000s and 2010s, according to data from the Centers for Disease Control and Prevention (CDC).
That spike, shocking for one of the wealthiest countries in the world, drew concern from health professionals and policymakers alike, with many states and the federal government establishing task forces to make birth safer. Last year, for example, the Department of Health and Human Services announced $90 million in awards to fight maternal mortality.
Now, some scholars are arguing that the CDC’s methods have become too broad in recent years and capture deaths that aren’t related to pregnancy. Others, meanwhile, say the CDC numbers remain the best way to capture a complicated picture, in which underlying conditions can combine with poor prenatal and postpartum care to cause preventable illness and death.
This debate is about more than just numbers. It has thrown into question two decades of policies and practices around childbirth and its risks.
Is the maternal mortality crisis referenced repeatedly in American media outlets (including Vox) overblown? And if so, are the initiatives meant to fix the problem — and the many other efforts experts and advocacy groups have long recommended — still necessary?
Answering these questions will determine how we think and talk about pregnancy and childbirth, and how the US cares for people at an incredibly vulnerable time in their lives.
What the CDC says about maternal deaths
Maternal deaths in the US are counted in a few different ways, including analysis by state and local committees. But the topline national numbers that get the most attention come from the CDC’s National Center for Health Statistics. According to the agency, maternal mortality is a serious problem in America, one that’s only grown over the past two decades.
In 2022, the most recent year for which data are available, the agency reported that 817 women died during or soon after pregnancy from causes “related to or aggravated by the pregnancy or its management.” Maternal mortality is often expressed as a ratio of maternal deaths to live births: For 2022, that ratio was 22.3 deaths per 100,000 births. That was less than in 2021, when the rate was 32.9 per 100,000, but still a marked increase from 2003, when the rate was 12.1 per 100,000.
It’s also much higher than rates around the world. A recent study by the Commonwealth Fund, a foundation focused on health care access, found the US had the highest maternal mortality rate of any wealthy country. For comparison, Canada had 8.4 maternal deaths per 100,000 live births in 2022, Japan had 3.4, and Switzerland had just 1.2.
The CDC has also found severe inequities within the US — in 2022, the mortality rate for Black women was 49.5 deaths per 100,000 births, more than twice the rate for white women — and the agency reports that more than 80 percent of pregnancy-related deaths in the US are preventable, based on analysis by teams of OB-GYNs, midwives, and other experts.
The criticisms of the CDC’s measurement stem from a change in the way the agency counts maternal deaths. Until the 1990s, countries typically counted a death as maternal if pregnancy or a related condition was listed as the “underlying cause of death” on a death certificate, according to an analysis published in May by Saloni Dattani at Our World in Data.
But this approach missed many deaths in which pregnancy or childbirth exacerbated an underlying condition, like AIDS or cardiovascular disease. Officials with the International Classification of Diseases (ICD), a system used around the world for classifying death and illness, came to the conclusion that maternal deaths were being undercounted, and in 1994, they recommended that countries add a “pregnancy checkbox” to death certificates to signify whether the deceased had been pregnant or had recently given birth. This would help analysts determine if pregnancy contributed to a death.
US states began adding the checkbox to their death certificates in 2003; by 2017, all had done so. Over this period, nationwide maternal mortality also rose significantly, from 12.1 deaths per 100,000 in 2003 to 17.4 per 100,000 in 2018.
Now, some experts are taking a closer look at the checkbox and the effect it has had on how we understand childbirth in America. They have two separate but related criticisms. Let’s break them down.
Some critics argue that the maternal mortality rate isn’t really rising
Dattani, a researcher who specializes in global health, writes that in order to prevent maternal deaths, “it’s crucial to have accurate data.” To that end, her May analysis at Our World in Data explains research first conducted by the CDC’s National Center for Health Statistics (NCHS) in 2020, adding background and context.
Dattani concludes that the increase in maternal deaths between 2003 and 2017 — the period when states were adding the pregnancy checkbox to their death certificates — can be attributed largely, or maybe even entirely, to the addition of the box. That is, pregnancy didn’t get more dangerous during that time period, officials just got better at measuring the deaths connected to it.
This conclusion is a big deal because a lot of recent coverage of maternal mortality has been based on the notion that rates are skyrocketing. If that narrative is false, some argue, such coverage risks baselessly frightening people who are considering having kids.
In this case, the critics are right, to a point. Most experts agree with Dattani’s conclusion. The CDC’s research “shows that observed increases in nationwide maternal mortality rates between 2003 and 2017 were largely due to the implementation of the checkbox, which increased identification of maternal deaths,” a spokesperson told Vox in a statement. The CDC has been open about that fact since at least 2020, but the issue of the checkbox received little public attention until now.
However, the number of maternal deaths also continued to rise after 2017, when all states had adopted the checkbox. Some of the rise after 2020, Dattani and others say, may be due to Covid, which was especially dangerous for pregnant people, particularly before the arrival of vaccines.
The bottom line is that the pregnancy checkbox probably explains a lot of the increase in reported maternal mortality over the past several decades, but not all of it. Meanwhile, there’s another big point of contention around the checkbox and its impact.
Other researchers say the CDC overcounts maternal deaths
The addition of the pregnancy checkbox has led the CDC to classify deaths as related to pregnancy when they really aren’t, contends a research team led by K.S. Joseph, a professor of obstetrics and gynecology at the University of British Columbia. For example, pregnant women who die of cancer can be classified as cases of maternal mortality, the researchers argued in a paper published in March in the American Journal of Obstetrics and Gynecology.
Using a more conservative methodology, the researchers calculated a maternal mortality rate of 10.4 deaths per 100,000 live births in 2018-2021, compared to the 23.6 per 100,000 reported by the CDC for that timeframe.
Critics of the CDC numbers are not advocating for pulling resources away from maternal health initiatives. Women’s reproductive health in general remains underfunded, and money set aside to combat maternal mortality is often a drop in the bucket of state and federal budgets.
Still, some scholars and advocates are concerned that criticism of the CDC’s count could lead to maternal health work being deprioritized. “It would be an unfortunate setback to see all the hard work of health care professionals, policy makers, patient advocates, and other stakeholders be undermined by this publication,” Christopher Zahn, interim CEO of the American College of Obstetricians and Gynecologists, wrote in response to the research by Joseph and his team.
The CDC also strongly disputes that research, arguing that the methodology used by Joseph and his team would significantly undercount maternal deaths. A pregnant woman who dies of cancer is actually an example of maternal mortality if she has to pause her chemotherapy during pregnancy and her cancer advances as a result, the CDC spokesperson told Vox.
Without the checkbox system, the spokesperson said, many deaths would simply be missed: “Capturing these otherwise unrecorded maternal deaths is critical to understanding the scope of maternal mortality in the United States and taking effective public health action to prevent these deaths.”
Others also agree that capturing deaths from underlying conditions that may be worsened by pregnancy is crucial for public health. “We know that poor health entering into pregnancy can lead to mortality postpartum in the ‘fourth trimester,’” Louise King, a professor of obstetrics, gynecology, and reproductive biology at Harvard University, told Vox in an email. “Shouldn’t we want to classify the death of a pregnant person with hypertension as a maternal death? So that we can address what might be the underlying cause of this — lack of preventative health care, lack of appropriate postpartum care given current insurance coverage in [the] US?”
And many scholars, including Dattani, agree that the introduction of the checkbox has led to better data, not worse. “My view is not that this is overestimating,” she told Vox. “In fact, it’s identifying maternal deaths that had been missed in the past.”
So, is there a maternal mortality crisis in the US?
Even if the CDC data isn’t perfect, many scholars agree that far too many people are dying during and after childbirth in the United States.
We have many sources of information about maternal mortality, said Laurie Zephyrin, a senior vice president for advancing health equity at the Commonwealth Fund. The CDC’s National Center for Health Statistics releases the numbers that have been most debated recently, but the agency also has a Pregnancy Mortality Surveillance System that employs medical epidemiologists to comb through death records from pregnancy up to a year after birth. Meanwhile, state and local maternal mortality review committees also independently investigate maternal deaths. “All three of these ways of collecting data are showing that we have a problem in this country,” Zephyrin said.
We can also understand US maternal health better by putting it an international context. Comparing maternal mortality across countries can be complex, for some of the same reasons it’s complicated to count maternal deaths within the US. Some countries use a pregnancy checkbox like the one added in the US while others do not, leading to concerns that other nations may be underreporting maternal deaths, making the US look worse by comparison.
However, we know that the US lags behind other countries when it comes to policies proven to improve maternal (and overall) health. Among wealthy countries, the US is the only one without universal health care, said Munira Gunja, a senior researcher with the Commonwealth Fund’s International Program in Health Policy and Practice Innovations. It’s also the only one without federally mandated paid parental leave, and it’s the only country that doesn’t provide home visits and other comprehensive postpartum care, instead often limiting birthing people to a lone doctor’s appointment six weeks after birth. “The US is a clear outlier, particularly when it comes to postpartum support,” Gunja said.
Meanwhile, everyone involved in the debate over counting maternal deaths agrees that Black birthing people are dying at a disproportionately high rate. That disparity shows up whether you use the CDC’s method or Joseph’s, and it’s indicative of bigger problems within the US health care system, experts say. Black Americans in general have a lower life expectancy than white Americans, and Black babies are more likely to be stillborn or die in infancy. “This is across the board, not just in maternal health,” said Angela D. Aina, co-founder and executive director of the Black Mamas Matter Alliance.
Some have argued that the language of “crisis” is unproductive, frightening pregnant people and prospective parents and clouding the search for solutions. “The constant drumbeat that maternal mortality is ‘commonplace’ and that pregnancy is ‘deadly’ doesn’t empower me with information to make my own decisions,” Jerusalem Demsas writes at the Atlantic. “It just stresses me out.”
Reasonable people can disagree over what constitutes a crisis and over the best way to measure how often Americans experience the tragic situation in which a person who is already sick dies from their illness after giving birth.
But experts do not disagree on the basic premise that too many pregnant and birthing people are dying in America, that many of their deaths are preventable, and that we already know some of the reforms — from paid leave to better prenatal and postpartum care — that would save their lives.
