A groundbreaking new study conducted by researchers at the University of Oxford and published in JAMA Pediatrics has unveiled a nuanced understanding of maternal mortality trends in the United States from 2000 through 2023. This comprehensive analysis critically addresses the confounding factors that have historically complicated interpretations of rising maternal death rates, specifically scrutinizing the effects of changes in death certificate reporting practices. While previous statistics suggested a troubling escalation over two decades, this latest study reveals that much of the apparent increase can be attributed to revisions in how maternal deaths are recorded, rather than genuine worsening health outcomes for pregnant women prior to the COVID-19 pandemic.
Central to the study’s methodology is the examination of the ‘pregnancy checkbox’—a specific item added to death certificates in many U.S. states during the early 21st century intended to better capture maternal mortality data. Nevertheless, this adjustment introduced significant administrative noise into the statistics. The research team, which included experts from Brown University and Columbia University, employed a difference-in-differences analytical framework to disentangle the true epidemiological trends from artifacts caused by staggered adoption of the checkbox across states. By comparing states that integrated the checkbox with those that had not, the team was able to isolate the measurement effect with unprecedented precision.
Quantitatively, the study found that the introduction of the pregnancy checkbox accounted for approximately two-thirds (66%) of the apparent rise in reported maternal mortality rates between 2000 and 2019. This figure translates into an annual increase of 6.8 maternal deaths per 100,000 live births attributable solely to improved death certification rather than underlying health deterioration. After applying these corrections, maternal death rates were remarkably stable through much of the pre-pandemic era, contradicting earlier narratives of a persistent upward trend.
However, the COVID-19 pandemic marked a dramatic deviation from previous trends. In 2021, adjusted maternal mortality surged sharply, reaching a peak rate of 18.9 deaths per 100,000 live births—almost double the previously stable range of 6.8 to 10.2 deaths per 100,000. This alarming spike was consistent across virtually all demographic categories, spanning all age groups except teenage mothers aged 15 to 19, and crossing racial and ethnic lines uniformly. Such a pronounced increase underscores the severe impact of the pandemic on maternal health, reflecting systemic vulnerabilities exacerbated by public health crises.
Importantly, the study also addressed stark and persistent racial disparities in maternal mortality. Throughout the entire study period, non-Hispanic Black women experienced maternal mortality at rates three to four times higher than their non-Hispanic White counterparts, a ratio that remained largely unchanged despite overall mortality stabilization. Pre-pandemic statistics revealed maternal mortality rates of 20.7 per 100,000 for non-Hispanic Black women versus 5.0 per 100,000 for non-Hispanic White women, highlighting deep-seated inequalities entrenched in healthcare access, quality, and social determinants of health.
Among all racial and ethnic groups, Native American and Alaska Native women endured the most pronounced elevation in mortality during the pandemic, with rates nearly tripling from 10.7 to 27.5 deaths per 100,000 live births. This disproportionate burden reflects systemic disparities worsened by limited healthcare infrastructure and resource allocation in indigenous communities, demanding urgent attention for targeted interventions and healthcare equity improvements.
In contrast to maternal mortality trends, the study found that fetal and infant mortality rates generally declined from 2000 to 2020, suggesting improvements in neonatal care and public health measures affecting newborn survival. Infant mortality rates dropped from 6.9 to 5.4 deaths per 1,000 live births over this period, although a minor increase was observed beginning in 2021, potentially linked to pandemic-related disruptions in healthcare delivery and social determinants.
Lead author Robin Y. Park, a doctoral candidate in Engineering Science at Oxford, emphasized the importance of accurately accounting for changes in data reporting systems. Park noted that clarifying these factors is essential to understanding the true impact of large-scale public health emergencies on maternal outcomes, advocating for strengthened provisions for childbirth and postpartum care within pandemic preparedness frameworks. This insight reiterates the importance of nuanced surveillance and responsive healthcare policies sensitive to the evolving challenges posed by crises.
Co-author Robbie M. Parks, Assistant Professor at Columbia University, highlighted the critical role of precise death rate tracking in shaping public health decisions. He underscored that erroneous interpretations driven by methodological oversights can lead to misplaced resource allocation or ineffective interventions. The study thus exemplifies how rigorous data analysis that incorporates policy and procedural contexts can avert misleading conclusions, ultimately advancing public health advocacy.
Assistant Professor Alyssa Bilinski from Brown University further emphasized the implications for public health surveillance infrastructure amidst diminishing funding. She argued for continued investment in comprehensive data systems capable of systematically monitoring maternal and infant health indicators. Such investments are vital not only to inform evidence-based policy but also to address significant racial disparities and to foster comparability with global maternal health metrics, contributing to improved outcomes both domestically and internationally.
The researchers leveraged extensive datasets from the National Vital Statistics System (NVSS), managed by the Centers for Disease Control and Prevention (CDC), ensuring a robust national scope and historical depth to their analysis. The use of publicly available, standardized data allowed for reproducibility and transparency while highlighting the importance of ongoing support for such vital data resources.
The comprehensive findings of this study serve as a call to action for healthcare policymakers, medical practitioners, and public health officials. They underscore the necessity of distinguishing between administrative artifacts and genuine epidemiologic shifts to design targeted interventions effectively. Moreover, the research shines a light on persistent racial inequities that remain a pressing barrier to achieving maternal health equity in the United States.
Looking forward, the study’s revelations about the pandemic’s disproportionate impact on maternal mortality prompt urgent reassessment of healthcare preparedness and resource allocation for pregnant and postpartum individuals during future public health emergencies. Integrating such insights into policy and clinical care guidelines can mitigate preventable maternal deaths, safeguarding vulnerable populations in times of crisis and beyond.
In sum, this meticulous research not only reframes our understanding of maternal mortality trends over two decades but also spotlights the critical intersections of data methodology, health equity, and emergency preparedness. Its technical rigor and policy relevance position it as a seminal contribution to maternal health scholarship and a foundation for transformative public health strategies.
Subject of Research: Trends and determinants of maternal, fetal, and infant mortality in the United States from 2000 to 2023, focusing on the impact of death certificate reporting changes and the COVID-19 pandemic.
Article Title: Trends in Maternal, Fetal and Infant Mortality in the US, 2000-2023
News Publication Date: 28-Apr-2025
Web References:
- DOI link: 10.1001/jamapediatrics.2025.0440
- University of Oxford economic impact: https://www.ox.ac.uk/about/facts-and-figures/economic-impact
Keywords: maternal mortality, pregnancy checkbox, COVID-19 pandemic, racial disparities, maternal health, public health surveillance, infant mortality, fetal mortality, United States, health equity, data reporting, pandemic preparedness
