After a pandemic-era surge in maternal deaths, the latest federal figures suggest modest improvement. Yet the United States continues to record far higher maternal mortality and severe complications than its peer nations, with stark and persistent disparities: Black and Native American birthing patients face risks several times those of white patients. Safety threats range from hemorrhage and hypertensive disorders to infections and perinatal mental health conditions, while nearly one in three births occurs by cesarean section. Millions of Americans live in maternity care deserts, and staffing shortages and labor-and-delivery unit closures are reshaping where and how people give birth.
The policy and legal landscape is shifting, too. Post-Dobbs restrictions complicate clinical decision-making in obstetric emergencies, while states expand-or roll back-Medicaid coverage, midwifery integration, and doula services. Hospitals have adopted standardized safety bundles and data-driven protocols, but implementation remains uneven, and gaps in reporting obscure the true scope of preventable harm.
This report examines the latest data on maternal outcomes and birthing patient safety, the drivers behind them, and the interventions showing promise-from early warning systems to community-based care-alongside the accountability, workforce, and access challenges that will determine whether progress can be sustained.
Table of Contents
- Maternal Mortality and Morbidity Trends Expose Racial Disparities and Gaps in Prenatal Access
- Inside the Delivery Room Safety Playbook: Hemorrhage Bundles Early Warning Scores and Team Drills
- Community Led Care Improves Outcomes: Midwifery Integration Doulas and Culturally Responsive Practices
- What Works Now: Extend Medicaid Through the Postpartum Year Mandate Data Transparency and Enforce Respectful Care Standards
- Insights and Conclusions
Maternal Mortality and Morbidity Trends Expose Racial Disparities and Gaps in Prenatal Access
New analyses from federal and state datasets show the national downturn in pregnancy-related deaths has not erased inequities: Black and Indigenous patients continue to face disproportionately high risks, with severe maternal morbidity climbing and concentrated in communities with fewer resources. Researchers point to intersecting drivers-chronic disease burden, delayed care entry, hospital resource constraints, and exposure to bias-that help explain why outcomes diverge even when patients deliver at the same facilities. Emerging evidence also links heat, air quality, and pandemic-era disruptions to worsening outcomes for high‑risk pregnancies, underscoring the fragility of maternal care systems.
- Mortality and morbidity are unevenly distributed: hospitals serving majority-minority and low-income populations report higher complication rates and transfers.
- Late or no prenatal care is more common among Medicaid-covered and uninsured patients, amplifying preventable risks.
- Maternity care deserts are expanding amid rural unit closures, staffing shortages, and limited specialist coverage.
- Procedural variation persists, including higher non-medically indicated cesarean use and inconsistent hemorrhage management.
Access gaps begin early and compound across the perinatal timeline. Patients report barriers tied to coverage churn, transportation and childcare, limited appointment availability, and language access, with implicit bias and underinvestment in community-based care eroding trust. Quality collaboratives show progress where implemented, but gains are uneven without sustained funding and accountability metrics that reflect patient experience and community risk.
- Continuity of coverage during pregnancy and a full year postpartum reduces delayed care and medication lapses.
- Team-based models-midwives, doulas, and community health workers-improve engagement and culturally responsive care.
- Standardized safety bundles for hemorrhage, hypertension, and sepsis narrow outcome gaps when reliably adopted.
- Granular data transparency by race, ethnicity, geography, and payer enables targeted interventions and oversight.
Inside the Delivery Room Safety Playbook: Hemorrhage Bundles Early Warning Scores and Team Drills
Hospitals are tightening the chain of response for obstetric bleeding with standardized hemorrhage bundles that move teams from ad‑hoc reactions to preset, rehearsed action. The playbook centers on readiness, recognition, response, and reporting-from stocking a hemorrhage cart and pre‑assigning roles to using quantified blood loss (QBL), rapid labs, and massive transfusion protocols (MTP). Systems are embedding EHR order sets, stopwatch‑based timing, and pharmacy pathways to deliver uterotonics and tranexamic acid within 3 hours, while maintaining blood bank standby and device availability (e.g., balloon tamponade). State and national collaboratives report fewer severe events when units hard‑wire these steps and audit compliance in real time.
- Prevention & readiness: risk stratification on admission, stocked kits, crossmatch/Type & Screen policies, team role cards.
- Recognition: QBL at every birth, trigger thresholds, point‑of‑care hemoglobin/fibrinogen.
- Response: staged algorithms (uterotonics → tamponade → escalation), MTP activation, rapid TXA, OB anesthesia at bedside.
- Reporting: event checklists, time stamps, debriefs, and dashboards tracking severe maternal morbidity.
Alongside bundles, units are deploying obstetric early warning scores (EWS) to catch deterioration from hemorrhage, preeclampsia, and sepsis earlier and to trigger rapid escalation. The emphasis is on signal fidelity-smart alerts, closed‑loop communication, and explicit “call now” thresholds that cut through alert fatigue. To make behaviors automatic under pressure, leaders are increasing in‑situ team drills with observers scoring performance against checklists and equity safeguards. Facilities with fewer deliveries are clustering practice sessions and using tele‑coaching. The result: faster activation, cleaner handoffs, and fewer misses during the highest‑risk minutes of care.
- EWS integration: vital‑sign trend monitoring in the EHR, color‑coded flags, rapid response criteria tied to pages/orders.
- Team drills: scenario playbooks, SBAR handoffs, role assignments, simulated MTP calls, and post‑event debriefing.
- Equity lens: bias‑aware escalation checks and stratified outcomes review to close disparities.
- Accountability: monthly run charts, PDSA cycles, and public reporting to sustain gains.
Community Led Care Improves Outcomes: Midwifery Integration Doulas and Culturally Responsive Practices
Hospitals and health plans increasingly report that integrating midwives, reimbursing doulas, and centering culturally responsive practices are linked with safer births and fewer preventable complications. Systems that embed community-led models-especially in neighborhoods with limited access to obstetric services-are seeing measurable gains for Black, Indigenous, and immigrant families, alongside higher trust and continuity of care. Clinicians describe smoother handoffs and clearer escalation pathways when midwifery-led care is fully integrated into perinatal teams with shared protocols, credentialing, and data reporting.
- Improved outcomes: lower cesarean and preterm birth rates, fewer severe morbidities, reduced readmissions.
- Stronger patient experience: higher satisfaction, better communication, and greater perception of safety and respect.
- Effective postpartum support: increased breastfeeding initiation, timely depression screening, and enhanced linkage to community resources.
- Equity impact: narrowed disparities when services reflect language, traditions, and preferences of the birthing family.
Operational success hinges on alignment across licensing, payment, and quality oversight. Health systems that formalize collaborative practice agreements, credential midwives for full scope, and embed doula services within care pathways report fewer gaps during labor and postpartum. Community partners extend reach through home visiting, group prenatal care, and peer lactation support, while Medicaid and commercial payers increasingly back these models with bundled payments and doula reimbursement-moves that stakeholders say stabilize access and scale.
- Key enablers: equitable reimbursement for doulas and midwives; hospital privileging and liability alignment for team-based practice.
- Standardized safety: shared risk assessment, real-time consult/transfer protocols, and integrated EHR documentation.
- Workforce and training: paid pathways for community birth workers; anti-racism, trauma-informed, and language-access training.
- Accountability: disaggregated outcomes and patient-reported experience measures to track respectful care and close gaps.
What Works Now: Extend Medicaid Through the Postpartum Year Mandate Data Transparency and Enforce Respectful Care Standards
12-month postpartum coverage is emerging as a high-yield intervention, keeping birthing patients connected to primary, behavioral, and specialty care through the medically vulnerable first year after delivery. With CDC data showing that nearly a third of pregnancy-related deaths occur between 43 and 365 days postpartum-and that most are preventable-states that maintain continuous eligibility are reporting steadier chronic disease management, better follow-up after hypertensive disorders, and more reliable access to substance use treatment. Early signals also point to fewer avoidable emergency visits and reduced financial strain for families. Key gains:
- Continuity of care for hypertension, cardiomyopathy, diabetes, and mental health
- Timely screening and treatment for depression, anxiety, and substance use disorders
- Access to lactation support and contraception that aligns with patient goals
- Stability for rural and safety-net providers through predictable coverage and payment
- Lower medical debt risk and improved engagement in preventive care
Closing outcome gaps also requires enforceable data transparency and standards for respectful, rights-based care. Hospitals can be held to measurable expectations when they report severe maternal morbidity using uniform definitions, publish stratified outcomes by race/ethnicity and payer, and integrate patient-reported experience metrics focused on autonomy, communication, and bias. Regulators and payers are tying compliance to reimbursement, corrective action plans, and licensure. Policy levers now in use:
- Facility-level public dashboards with quarterly, stratified maternal outcomes
- Standardized audits and learning reviews for deaths and near-misses, with rapid feedback loops
- Requirements for informed consent, language access, and doula integration in care teams
- Anti-bias and obstetric emergency training linked to payment and credentialing
- Grievance pathways and penalties for coercive, disrespectful, or discriminatory practices
Insights and Conclusions
As federal agencies, state regulators, and hospital systems recalibrate their strategies, the throughline is clear: progress hinges on consistent standards, reliable data, and sustained investment across the full continuum of care-from prenatal screening and labor management to postpartum follow-up and mental health. Persistent gaps in outcomes for Black and Native patients, rising risk factors such as chronic disease, and the erosion of services in rural areas continue to test the system’s capacity to deliver safe, timely, and culturally responsive care.
The policy signals to watch are equally clear. Lawmakers are weighing extensions of postpartum coverage, reimbursement for doulas and midwives, and stricter reporting on severe maternal morbidity. Health systems face pressure to hardwire evidence-based protocols, strengthen workforce pipelines, and expand team-based models that integrate community providers. Technology, from telehealth to predictive tools, offers promise but will draw scrutiny over equity and privacy.
For birthing patients, the stakes remain immediate. The trajectory of maternal health and patient safety will be measured not only in mortality statistics, but in everyday encounters-whether complications are anticipated, voices are heard, and care teams are prepared. The next year will test whether momentum translates into measurable, durable gains.