New maternal mortality data in the United States have been published (Hoyert & Minino, 2020). Due to a change in how maternal deaths were reported and to allow states to begin using the new system, this was the first time the National Center for Health Statistics had published rates since 2007. Results were not good, with 17.4 maternal deaths per 100,000 live births within 42 days of pregnancy. This translates to 658 maternal deaths in 2018 within 6 weeks of giving birth and does not account for pregnancy-related deaths from 6 weeks to a year postpartum. In 2018, there were an additional 277 maternal deaths after a pregnancy that occurred >42 days but <1 year, a late maternal mortality rate of 7.3 deaths per 100,000 live births (Hoyert & Minino).

The U.S. maternal mortality rate compares poorly with other wealthy countries and with the rest of the world. Black women are still three to four times more likely to die from a childbirth-related complication, a disparity that has not changed the past 6 decades (Hoyert & Minino, 2020; Srinivas, 2020). Even in California where use of safety bundles and toolkits decreased the maternal mortality rate, racial and ethnic disparities persist (National Academies of Sciences, Engineering, and Medicine [NASEM], 2020). Women >= 40 years old were 7.7 times more likely to die of pregnancy-related death than women <25 years (Hoyert & Minino). Direct obstetric causes were attributed to 77% of deaths and indirect for the remaining 23% with abortive outcomes (primarily ectopic pregnancies), hemorrhage, eclampsia/preeclampsia, and obstetric embolism responsible for almost 21% of the direct obstetric caused deaths (Hoyert & Minino). Women who died by suicide or overdose are not included in these numbers, even if the death was within 6 weeks of giving birth, despite postpartum depression increasing risk of these events; nor are homicides, even if it was the result of intimate partner violence. The U.S. maternal mortality rate has continued to rise, despite spending more on hospital-based maternity care than any other country; from 1990 to 2015, the rate of death per 100,000 live births increased from 17 to 26 (Srinivas).

Some experts suggest preconception care would be the most critical place to start to bring the rate down but that there are not enough Maternal-Fetal Medicine specialists to effectively provide this service and primary care providers are not always focused on potential pregnancy risks (Srinivas, 2020). Higher risk women coming from resource-poor settings may be under- or uninsured that may prohibit ability to receive preconception counseling or to access preventive and primary care. Many women in the United States do not have access to reproductive healthcare and contraception, so for women who should not, or do not want, to get pregnant, they may have difficulty in preventing or terminating a pregnancy (Srinivas). The population of pregnant women is changing (older women and complicated comorbidities), but this is not always reflected in availability of appropriate healthcare to meet the complex needs of a high-risk pregnancy. It can be difficult for women to access nonsurgical maternity care to decrease the cesarean rate such as vaginal birth after cesarean or external cephalic version with reproductive and birth choices often being limited by a woman's ability to pay out of pocket for them (NASEM, 2020).

Many areas of research are needed to address this ongoing problem. Listening to women from all backgrounds who use maternity care in the United States to create equitable and sustainable improvements is a critical first step (NASEM, 2020). Solutions and working groups should include all stakeholders from all disciplines of obstetric healthcare providers, their professional organizations, and policy makers.

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