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Despite having the most advanced medical technology in the world, the U.S. has the highest rate of pregnancy-related deaths of any high-income nation — and the problem has gotten worse even as the rate has declined globally.

When a woman dies from pregnancy-related causes in this country, the factors that led to this tragic event often go unexamined. We need better data to understand what happened, and then use what we’ve learned to save women’s lives.


Promising efforts underway are helping states get to the root causes of these deaths and determine what can be done to prevent them in the future.

Several states are taking bold steps to establish review committees to examine every pregnancy-related death, identify trends, and use the findings to change policy and clinical practice. The Every Mother Initiative, with support from the organization I direct, Merck for Mothers (known as MSD for Mothers outside the United States and Canada), helped 12 states strengthen their maternal mortality review committees, turn their findings into action, and test-drive a range of creative ways to save women’s lives. These states — Colorado, Delaware, Florida, Georgia, Illinois, Louisiana, Missouri, New York, North Carolina, Ohio, Oklahoma, and Utah — represent one-third of the nation’s nearly 4 million births each year.

For each pregnancy-related death, these review committees identified the causes. Some were well-known, such as high blood pressure and hemorrhage. The committees also uncovered emerging causes of death, such as chronic disease, mental health issues, substance use, and domestic violence. They then used the insights from their individual states to design lifesaving solutions for women, health providers, and communities.


Findings from these states have shed much-needed light on why maternal deaths have more than doubled in the U.S. since 1990. Until recently, these tragic events have been shrouded in a cloak of invisibility because they were not properly accounted for: Death certificates do not always link these deaths to pregnancy and childbirth; underlying causes, like depression or substance abuse, are not always apparent; and, state by state, systems of reporting and record keeping are fragmented and inadequate.

Thanks to information gleaned by the Every Mother Initiative, a clearer picture of pregnancy-related deaths is emerging. The CDC Foundation’s Review to Action — another relatively new effort funded by Merck for Mothers — now helps states share data on maternal deaths, identify common trends, and learn from one another.

Here are some of the findings from the state-based review committees:

Hemorrhage and various forms of heart disease account for the majority of maternal deaths. Yet there’s a complex mix of medical and social reasons behind these deaths that provides essential information for addressing the problem more effectively. For example, untreated mental health conditions are an emerging driver of maternal mortality, particularly related to deaths from suicide and drug overdose.

Obesity is another underlying cause that surfaced from the states’ data. Obesity increases the risk of developing pulmonary embolism — a potentially deadly blood clot in the lungs — and cardiovascular disease. Research shows that obesity and untreated illness are often influenced by socioeconomic factors like poverty, inadequate health insurance and health care, and lack of access to nutrient-rich food. As the CDC says, “conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes.”

Translating findings into action

With their findings in hand, the 12 states forged ahead with a range of innovative programs to save lives.

Colorado, Delaware, and Louisiana zeroed in on issues related to mental health. Colorado created resources to help providers identify pregnant women suffering from depression or at risk of domestic violence. Louisiana ran an English/Spanish awareness campaign on domestic violence that included tiny “shoe cards” — vital information and emergency numbers that could be hidden from a perpetrator in a shoe. Delaware introduced the nation’s first course for nurses to safely transport pregnant women by ambulance.

Georgia, Missouri, and North Carolina each identified poor health before pregnancy as a key problem. Georgia now has a toolkit to help providers counsel women on managing health conditions before conceiving. North Carolina’s “Show Your Heart Some Love” campaign, targeting women with cardiovascular disease and high blood pressure, does the same.

New York, Ohio, North Carolina, Oklahoma, and Utah are improving hospital protocols and training for managing obstetric emergencies like postpartum hemorrhage and pre-eclampsia/eclampsia.

All of these efforts offer lessons for other states, and many are beginning to take notice. Maternal mortality review committees in more than 30 states and two cities across the country are capitalizing on the tools and information offered through CDC’s Review to Action to build the country’s capacity to review and prevent maternal deaths.

The U.S. does not currently have a national report on pregnancy-related deaths. It’s sorely needed to provide a country-wide perspective on the problem, identify trends, and track progress. The CDC is playing a pivotal role in helping states strengthen their reviews to get the U.S. closer to a national report on maternal mortality. For the past two years, the CDC has worked intensively with states on rigorous data collection, and recently released a report from nine states using standard data collection.

This first multistate analysis of maternal mortality is an important milestone in improving maternal health. I am optimistic that the findings will inspire national-level attention to maternal mortality and drive continued changes in policy and clinical practice.

Momentum is building to change the trajectory of maternal deaths in this country. We must make sure that what individual states are learning is shared nationally and translated into actions that can save lives. Only then will the tide on maternal deaths start to turn.

Mary-Ann Etiebet, M.D., is the executive director of Merck for Mothers, Merck’s 10-year, $500 million initiative to help create a world where no woman dies while giving life. The organization is known as MSD for Mothers outside the United States and Canada.