Maternal health outcomes in the United States are far from ideal—the country has the highest maternal mortality rate among high-income countries. In 2022, the United States experienced approximately 22 maternal deaths per 100,000 live births—a rate that jumps dramatically to about 50 deaths per 100,000 live births for Black women.1 While there has been a slight decline in maternal mortality rates since the height of the COVID-19 pandemic, these numbers are a national failing, particularly when juxtaposed with the significantly lower rates in other developed countries. Half of high-income nations report fewer than five maternal deaths per 100,000 live births, underscoring the stark disparity.2 In direct terms, this means more than 800 mothers die every year in the United States, the majority of which are preventable.3
To further contextualize the issue, the United States has the worst maternal health outcomes while also having the highest healthcare expenditures. Families in the United States face some of the highest childbirth costs in the world, which can vary significantly based on access to insurance coverage. While the country invests heavily in advanced medical technology and specialized care, barriers to accessing these services are significant and uneven.
Barriers
Poor maternal health outcomes in the United States are the direct result of significant barriers—geographic, socioeconomic, systemic—which impede access, progress, and equity in care. By highlighting these gaps and the nuanced compounding effect they have on one another, stakeholders can be better positioned to ensure efforts to improve the maternal health landscape are both targeted and effective.
Maternity care deserts
A significant barrier to maternal health is the lack of access to care. More than 35% of counties in the United States are classified as maternity care deserts—regions where pregnant women have limited or no access to maternity care services, specifically a lack of hospitals, birth centers, and/or specialized and obstetric providers.4 This statistic translates to 2.3 million women of childbearing age who live in areas where obtaining necessary maternal healthcare is a significant challenge. An additional three million women reside in counties where access to maternity care is limited, though not entirely absent.5
The absence of local services in maternity care deserts forces women to travel long distances to receive care. The strain and financial tradeoffs of long travel times, combined with the lack of continuous care and time barriers to accessing care in critical or crisis moments, significantly increases the risk of pregnancy-related complications.
The inequity of maternity care deserts is more complex than just the time it takes to access services. Women living in these areas face various factors that compound their risks.
- Higher Fertility Rates: Women in maternity care deserts often experience higher fertility rates, leading to more frequent needs for hard-to-reach services. This increases the risk of complications and creates additional challenges that exacerbate geographic inequities.
- Higher Health Risks: Communities in maternity care deserts are more likely to suffer from chronic conditions such as asthma and hypertension, as well as have higher rates of tobacco use compared to their counterparts in areas with full access to care.6 This increases the risk for health complications during critical periods of pregnancy and childbirth, which need to be addressed with more frequent and specialized maternal care.
- Lower Insurance Coverage: The rate of uninsured women living in maternity care deserts is two times that of women living in areas with full access; the combined impact of geographic barriers and financial constraints may increase the likelihood of delaying or forgoing maternal care.7
Racial disparities
The maternal health crisis in the United States is underscored by stark racial disparities, with Black and Indigenous women facing disproportionately higher risks during pregnancy and childbirth than their white counterparts. Black women are three to four times more likely to die from pregnancy-related complications than white women, and American Indian and Alaska Native women are over two times more likely to experience severe maternal morbidity.8 This disparity persists even when accounting for factors such as income and education—college-educated Black women are still more likely to suffer from severe maternal morbidity than white women with less education.9
Maternal outcomes for Black women are deeply entwined with the historical and ongoing discrimination that Black women face within the healthcare system. Surveys have revealed that 34% of Black women reported their health concerns or symptoms were not taken seriously by healthcare providers, and that 63% of Black women have experienced at least one negative healthcare interaction, such as feeling rushed, receiving lower quality care, or being treated with less respect compared to other patients.10 These biases and inequitable treatment are worsened when medical professionals harbor false beliefs about biological differences between Black and white patients, as reported in a study that uncovered that a significant number of medical professionals held the idea that Black patients have thicker skin or higher pain tolerance.11
The systemic racism and bias which permeate healthcare interactions often lead to delays in diagnosis, mismanagement of treatment, and insufficient medical attention, contributing to poorer health outcomes for Black women. These experiences of discrimination also harm patients by negatively impacting trust, communication, and health-seeking behaviors.
Limited funding for community-based organizations
The funding landscape for maternal health in the United States remains fragmented, contributing to the widening of existing disparities, particularly in underserved communities. The bulk of funding from state and federal agencies, as well as philanthropic giving, is directed toward large health care systems, nonprofit hospitals, and networks. As established, these institutions are inequitably distributed across the country – 70% of birth centers are located within just 10 states, and 1,104 counties have no obstetric clinicians.12 Additionally, these institutions often lack the local engagement and trust-building that is needed to appropriately support mothers and are misaligned with the actual needs on the ground.
There is a funding gap for community-based organizations (CBOs), which not only provide critical services in maternity care deserts where healthcare systems are absent, but also often provide culturally appropriate and accessible care to marginalized populations. These CBOs fill the vital gap for the more than 150,000 births that occur annually in maternity care deserts, yet they are frequently overlooked in funding allocations.
There is also a noticeable funding gap for maternity care services led by Black leaders. Black-led organizations receive 24% less funding compared to their white-led counterparts and their unrestricted net assets are 76% smaller.13 These funding disparities severely limit the capacity of organizations embedded in communities most affected by maternal health disparities to scale their services and provide essential care.
Limited funding for CBOs has a compounding impact on low-income populations. Medicaid covers about 42% of all births in the United States,14 but CBOs that support Medicaid recipients frequently struggle to stay afloat due to inadequate reimbursement rates. With the cost of delivering comprehensive prenatal and postpartum care often exceeding Medicaid's reimbursement, many of these organizations are unable to sustain their operations without additional support.15 CBOs face funding shortfalls every year, preventing them from scaling essential services like doula care, midwifery, and maternal mental health services.
Opportunities
While the maternal health landscape may be challenging, significant opportunities for progress are emerging. Innovations, new approaches, and the dedicated efforts of advocates and organizations are creating pathways to improve care and promote greater equity in maternal health outcomes. These opportunities, some of which are listed below, offer a path for engagement and a clear direction for meaningful advancements.
Improve access through telehealth
Enhanced telehealth services are becoming an essential tool to overcome the barriers faced by communities with limited access to healthcare facilities. Telehealth enables real-time consultations with obstetricians, midwives, and other maternal health specialists, providing critical support and guidance throughout pregnancy and childbirth. By leveraging technology, telehealth services can help bridge gaps in care, ensuring that women receive timely and adequate support. Access to telehealth services can particularly be useful for prenatal services - screenings, education, and early interventions – and wrap-around services for families after birth for postpartum support and mental health. Yet, expansion of telehealth services across the country is contingent on reliable broadband access, which remains inconsistent in many rural and underserved areas. Adequate funding, enabling policies, and expanded insurance coverage are necessary to scale telehealth to the communities that need it.
Expand culturally competent care
A notable gap in the maternal health landscape that worsens racial disparities is the lack of culturally competent care, which refers to healthcare that acknowledges and responds to the cultural, social, and linguistic needs of patients. This includes everything from who is providing maternal health services and the ways in which they deliver care, to the actual services that are made available to communities.
Providing culturally competent care includes the integration and availability of holistic maternal services and alternative medicine in health offerings. One example of this is doula services, which provide continuous support during labor and have been shown to improve outcomes by reducing cesarean rates and enhancing maternal satisfaction. These services are especially beneficial for low-income women of color, who face disproportionate risks in childbirth. California’s decision to include doula services as a Medi-Cal benefit is a step in the right direction, providing a model for how these services can be integrated into broader healthcare systems. Such integration acknowledges the vital role doulas play—not just as comforters, but as advocates for the mother’s needs, ensuring that her voice is heard and her rights respected during childbirth.
Support community-based birth centers and midwifery care
Community-based birth centers, primarily led by midwives, provide culturally responsive care tailored to the specific needs of local communities. These centers are particularly impactful in underserved areas, offering a holistic approach to maternal health that reduces reliance on overburdened hospital systems. Research shows that 80% of people giving birth in the U.S. could safely deliver in a birth center. These centers often prioritize patient-centered care, resulting in improved maternal outcomes and greater patient satisfaction. Culturally affirming care provided by Black, Indigenous, and people of color-led birth centers benefit all birthing people, with particularly protective effects for Black mothers.17
Despite compelling evidence supporting these care models, many birth centers face significant challenges, primarily due to limited financial resources and partial Medicaid reimbursements. While demand for midwifery care in both hospital and community settings grows, much of this demand remains unmet. A California-wide survey demonstrated a significant mismatch between the desire for midwifery care and actual access to it, particularly among Black childbearing individuals, who experience the biggest gap between demand and access.18 Expanding Medicaid reimbursements for midwifery services is critical to meeting the growing demand for community-based care and addressing maternal health inequities.
Train and diversify workforces
The quality of maternal care is deeply tied to the workforce that delivers it. Improving the quality of service for all women, especially Black women, and addressing care gaps requires creating environments where healthcare professionals understand the diverse needs of their patients, including recognizing and addressing implicit biases. Training maternal health providers in culturally competent care is a clear intervention to improve the quality of services. When healthcare providers are trained in culturally competent care, they are better equipped to address the unique needs of diverse populations, including Black women, who often face implicit bias and discrimination during medical interactions. Studies have also shown that the presence of culturally appropriate maternity care frequently leads to positive effects on care-seeking behaviors.19
In addition to upskilling maternal health providers, systemic reforms must prioritize the expansion of a healthcare workforce that reflects the diversity of the communities it serves. Diverse workforces are shown to improve communication and trust between patients and providers, reduce implicit bias, and enhance overall maternal health outcomes by ensuring patients receive care that is sensitive to their cultural and social circumstances. One study showed that in states where the nurse workforce was more diverse, there was a notable reduction in severe adverse maternal outcomes (SAMO): 32% for white mothers, 20% for Black mothers, 31% for Hispanic mothers, and 50% for Asian and Pacific Islander mothers.20
Ensure wrap-around services
Wrap-around services are essential for supporting maternal health as they provide comprehensive, integrated care that addresses the physical, emotional, and social needs of mothers throughout their journey. One area of support that is often overlooked yet vital for the long-term health of both mother and child is the postpartum period. Alarmingly, most maternal deaths occur during the postpartum period, with more than half happening between one day and one year after delivery.21 Recent policy changes have made strides toward improving access, with nearly all states extending Medicaid postpartum coverage beyond the previous 60-day limit—some up to 12 months.22 This expansion is crucial for ensuring that new mothers receive continuous care during this vulnerable time. However, these efforts, while meaningful, remain insufficient to address the widespread need, particularly in underserved areas where postpartum care is still viewed as a luxury rather than a standard part of maternal healthcare.
Maternal mental health is another aspect of health that is critically overlooked, with one in five mothers experiencing mental health conditions.23 Initiatives like the Health Resources & Services Administration’s (HRSA) Maternal Mental Health Hotline are making strides in providing accessible mental health support, yet the gap can only be addressed if services are offered and women take advantage of the services. This requires addressing stigmas around mental health, distrust of the healthcare system, and lack of provider training in culturally responsive care that currently contributes to low engagement with available services. Black women are disproportionately affected, as they are less likely to be screened for postpartum depression and less likely to follow up on mental health referrals even when diagnosed.
Advance policy reforms
Ongoing policy advocacy efforts are beginning to confront the systemic inequities in maternal healthcare head-on. These efforts are pushing for policy changes that address immediate maternal health service needs, as well as policy changes that challenge long-standing structural barriers, particularly those that disproportionately affect communities of color. Strong advocacy efforts continue to raise awareness about the impact of implicit bias and systematic racism, which pushes reforms that promote culturally competent care; the Biden-Harris Administration commitment of $558 million in funding to support local organizations and community leaders to provide home visits and postpartum support to new mothers is an example of advocacy in action.
Policy advocacy at the state level is a key opportunity to advance maternal health equity. Targeted state-level initiatives that build upon federal efforts and frameworks like the Black Maternal Health Momnibus Act of 2021, are key to fully implementing and enforcing equitable maternal health policies across the U.S. Many CBOs are at the forefront of this work and engage in broad advocacy and strategic communications to raise awareness about maternal health inequities, but they may lack the necessary support and resources to navigate the legislative process effectively. Strengthening state-level policy advocacy through collaboration with experienced policy experts will be crucial for influencing legislative outcomes and ensuring that maternal health equity is addressed in a meaningful and sustainable way.
Policy reforms that integrate social services with healthcare are another key opportunity. Linking maternal care services with housing, nutrition, mental health, and other social services helps to address the broader systemic contexts within which disparities occur. Advocacy is essential to ensure that these support services are fully funded and consistently implemented across the country.
Nonprofits Supporting Maternal Health Equity
Panorama Strategy conducted a scan of U.S.-based nonprofit organizations focused on advancing maternal health equity in underserved areas across the country. Using criteria that included women- and/or BIPOC-led with an annual operating budget under $10 million, we identified 67 organizations operating at national, state, and regional levels. These organizations address various aspects of maternal health, such as policy reform, insurance, access to care, quality of care, and the direct provision of services.
