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Overview of Maternal Morbidity and Complications in the United States

Maternal morbidity and complications in the United States are a significant concern despite being relatively rare. Data from various sources reveal rates of maternal illness, severe morbidity, and maternal deaths associated with pregnancy and childbirth. Blood transfusions during childbirth are a common indication of severe maternal morbidity, with significant variations between the U.S. and other high-income countries. Factors such as race/ethnicity, age, region, community-level income, and hospital type play crucial roles in the incidence of severe maternal morbidity. Understanding these relationships is essential for addressing disparities and improving maternal health outcomes.

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Overview of Maternal Morbidity and Complications in the United States

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  1. Serious maternal illnesses and complications are rare. Rates of maternal illness and complication during pregnancy Uncomplicated pregnancies Some complications Severe maternal morbidity (60,000/year) All maternal morbidities Maternal deaths (700/year) Data: Adapted from Lale Say et al., “Maternal Morbidity Measurement Tool Pilot: Study Protocol,” Reproductive Health 13, no. 69 (June 9, 2016). Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  2. Neither prenatal nor postpartum morbidities are included in estimates of severe maternal morbidity. Rate per 10,000 live births 0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200 Miscarriage* 1,100 2,200 Prenatal hypertension 720 PRENATAL Depression/Anxiety 700 Preeclampsia 300 Ectopic pregnancy 200 Hyperemesis gravidarum* 30 300 Postpartum depression (up to 6 mos.) 1250 Endometritis* (42 days) POSTPARTUM 600 1,100 Postpartum PTSD (up to 18 mos.) 400 Postpartum hemorrhage (42 days) 270 Pulmonary edema/Heart failure** (42 days) 11.2 Sepsis** (42 days) 7.8 Notes: Miscarriage is defined as the spontaneous loss of a fetus before the 20th week of pregnancy. * Best-available estimates produce a range rather than a single rate. ** Among those on Medicaid. Data: Miscarriage: https://pubmed.ncbi.nlm.nih.gov/22511535/; Prenatal hypertension: CDC Wonder; Depression/Anxiety: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/depression-during- pregnancy/art-20237875; Preeclampsia: https://pubmed.ncbi.nlm.nih.gov/23973398/; Ectopic pregnancy: https://pubmed.ncbi.nlm.nih.gov/32412215/; Hyperemesis gravidarum: https://pubmed.ncbi.nlm.nih.gov/28641304/; Postpartum depression: https://www.cdc.gov/prams/prams-data/mch-indicators/states/pdf/2018/All-PRAMS-Sites-2016-2017_508.pdf; Endometriosis: https://pubmed.ncbi.nlm.nih.gov/29433350/; Postpartum PTSD: https://pubmed.ncbi.nlm.nih.gov/24952134/; Postpartum hemorrhage: https://pubmed.ncbi.nlm.nih.gov/28367647/; Pulmonary edema/Heart failure & Sepsis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856547/. Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  3. Blood transfusions are the most common indication of severe maternal morbidity. Severe maternal morbidity at birth, per 10,000 U.S. births, 2015 Percentage of deliveries involving blood transfusion among those with condition indicating severe maternal morbidity, 2015 Procedures 36.8 Any delivery with severe morbidity 121.1 Blood transfusions 72.0 Shock 11 Hysterectomy 1.2 Ventilation 63.1 Amniotic fluid embolism 0.1 Temporary tracheostomy Diagnoses 54.0 Sickle cell disease with crisis 50.5 Disseminated intravascular coagulation 11 Disseminated intravascular coagulation 6.5 Acute renal failure 46.9 Cardiac arrest/ventricular fibrillation 5.9 Adult respiratory distress syndrome 45.6 Adult respiratory distress syndrome 5.2 Sepsis 43.7 Heart failure/arrest during surgery 4.3 Shock 3.2 Pulmonary edema/acute heart failure 39.0 Acute renal failure 3.1 Eclampsia 37.0 Air and thrombotic embolism 1 Puerperal cerebrovascular disorders 30.9 Acute myocardial infarction 1 Air and thrombotic embolism 0.9 Sickle cell disease with crisis 25.9 Sepsis 0.7 Cardiac arrest, fibrillation 24.1 Severe anesthetic complications 0.7 Conversion of cardiac rhythm 21.6 Pulmonary edema/acute heart failure 0.5 Severe anesthesia complications 0.4 Heart failure or arrest 15.7 Eclampsia 0.3 Amniotic fluid embolism 14.6 Puerperal cerebrovascular disorders 0.1 Aneurysm Data: Kathryn R. Fingar et al., Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Mortality, 2006–2015, HCUP Statistical Brief #243 (Agency for Healthcare Research and Quality, Sept. 2018). Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  4. Blood transfusions during childbirth in the U.S. occur at a much higher rate than in many parts of Europe. Transfusions per 1,000 births in selected high-income countries, 2010–14 U.S. 12.2 Belgium-Flanders 11.5 Denmark 11.0 Germany-Bavaria 10.7 Spain-Valencia 6.5 Netherlands 6.4 Italy 4.6 France 2.1 Data: U.S.: Centers for Disease Control and Prevention, “How Does CDC Identify Severe Maternal Morbidity?,” last updated Dec. 26, 2019; Other countries: Marie-Hélène Bouvier-Colle et al., “What About the Mothers? An Analysis of Maternal Mortality and Morbidity in Perinatal Health Surveillance Systems in Europe,” BJOG 119, no. 7 (June 2012): 880–90. Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  5. There are strong relationships between severe maternal morbidity and race/ethnicity, age, region, community-level income, and hospital type. Severe maternal morbidity per 10,000 births, 2016–17 Race/Ethnicity Age Region Community income quartile (1st = poorest) Hospital ownership 246 226 196 190 175 173 163 153 147 138 137 136 135 132 131 124 118 115 110 105 Data: Clare C. Brown et al., “Associations Between Comorbidities and Severe Maternal Morbidity,” Obstetrics and Gynecology 136, no. 5 (Nov. 2020): 892–901. Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  6. Racial inequities in severe maternal morbidity exist among both Medicaid and commercial insurance enrollees. Severe maternal morbidity in New York City hospitals, per 10,000 births, by race/ethnicity and insurance type, 2010–14 435 373 299 288 224 201 154 131 Black Latina White All Black Latina White All Medicaid Commercial insurance Data: Elizabeth A. Howell et al., “Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities,” Obstetrics and Gynecology 135, no. 2 (Feb. 2020): 285–93. Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  7. Women who experience a severe maternal morbidity are much more likely to be readmitted to the hospital during the postpartum period than women who do not experience one. Likelihood (risk ratio) of postpartum hospitalization with and without severe maternal morbidity, Massachusetts, 2002–11 <42 days (postpartum) <365 days 42–364 days 2.48 2.27 2.04 2.04 1.65 1.65 Severe maternal morbidity with transfusion Severe maternal morbidity with no transfusion Data: Elizabeth M. Harvey et al., “Severe Maternal Morbidity at Delivery and Risk of Hospital Encounters Postpartum,” Journal of Women’s Health 27, no. 2 (Feb. 2018): 140–47. Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

  8. Births that involve severe maternal morbidity are far more expensive than births that do not. U.S. mean costs without and with severe maternal morbidity, by timing and insurance type, 2013 $25,000 Prenatal Delivery Postpartum $20,380 $20,000 $14,840 $15,000 $10,134 $10,000 $6,894 $5,000 $0 No severe maternal morbidity Severe maternal morbidity No severe maternal morbidity Severe maternal morbidity Commercial insurance Medicaid Data: Kimberly K. Vesco et al., “Costs of Severe Maternal Morbidity During Pregnancy in U.S. Commercially Insured and Medicaid Populations: An Observational Study,” Maternal and Child Health Journal 24, no. 1 (Jan. 2020): 30–38. Source: Eugene Declercq and Laurie Zephyrin, Severe Maternal Morbidity in the United States: A Primer (Commonwealth Fund, Oct. 2021).

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