Maternal Mortality in the

United States, 1935-2007:

Substantial Racial/Ethnic, Socioeconomic, and Geographic Disparities Persist

Gopal K. Singh, PhD

U.S. Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau
Figure 1: Maternal Mortality by Race, United States, 

1935–2007

 Maternal mortality in the United States has declined 

dramatically over the past century (1-4). The rate declined 

from 607.9 maternal deaths per 100,000 live births in 1915 

to 12.7 in 2007 (1-3). However, maternal mortality in the 

United States has changed very little in the past 25 years 

(1, 3). Achieving further reductions in the maternal mortality 

rate is an important public health priority for the nation as 

the rates for certain ethnic minority and socioeconomic 

groups remain relatively high (3, 4, 5). A cross-national 

comparison of the 2005 statistics by the World Health 

Organization (WHO) reveals that the U.S. rate of 15 maternal deaths per 100,000 live births exceeded the rates for at 

least 41 other countries, including Canada, Australia, Japan, 

and all the Western and Northern European countries (6).

In this brief report, we analyze long-term trends in 

maternal mortality according to race/ethnicity, socioeconomic position (family poverty level), and state and region 

of residence by using both historical and the latest national 

vital statistics data (2, 3). As shown below, despite the 

massive drop in maternal mortality over the long term, 

substantial racial/ethnic, socioeconomic, and geographic 

disparities remain, with many of the sociodemographic 

groups currently far from achieving the national goal for the 

year 2010 (7). 

Figure 2: Maternal Mortality Rate by Race/Ethnicity, 

United States, 2005-2007

Trends in Maternal Mortality by Race

Maternal deaths are those related to or aggravated by 

pregnancy or pregnancy management and which occur 

during or within 42 days after the end of pregnancy (3). 

Although mortality trend data extend farther back in time 

for the entire United States and the birth registration area 

(1, 2), we chose 1935 as the start of the time trend analysis 

since it coincided with the inception of Title V of the Social 

Security Act, a national public health legislation aimed at 

promoting and improving the health and welfare services 

for all mothers and children. The maternal mortality rates in 

the United States showed a consistently downward trend 

between 1935 and 1982, decreasing at a rapid rate of 8.6% 

per year (Figure 1). During 1935-1982, the rate of decline 

in maternal mortality was significantly faster among white 

women than among black women. The risk of maternal 

mortality remained 3 to 4 times higher among black women 

than white women during the past 6 decades (Figure 1). 

The trend in maternal mortality from 1982 through 1998 was 

fairly stable barring yearly fluctuations, but since 1999, there

appears to be an upturn in maternal mortality among both 

white and black women, which has partly been attributed to 

changes in the coding and classification of maternal deaths 

resulting from the implementation in 1999 of the International Classification of Diseases, 10th Revision (ICD-10) in 

the United States.
Figure 3: Maternal Mortality Rate by County-Level Family 

Poverty Rate, United States, 1969-2007

Figure 4: Relative Risk of Maternal Mortality by County-Level 

Family Poverty Rate, United States, 1969-2007

In 2007, the maternal mortality rate for black women was 

26.5 deaths per 100,000 live births, 2.7 times higher than 

the rate for white women (10.0). According to the 2005-2007 

detailed racial/ethnic data, the maternal mortality rate per 

100,000 live births was highest among non-Hispanic black 

women (34.0), followed by American Indians/Alaska Natives 

(16.9), Asian/Pacific Islanders (11.0), non-Hispanic whites 

(10.4), and Hispanics (9.6) [Figure 2]. 

Trends in Socioeconomic Disparities in Maternal 

Mortality

Since reliable socioeconomic data are lacking on death 

certificates, which are the basis for the national mortality 

statistics, county-level family poverty data from the 1990 

and 2000 censuses were linked with county-level mortality 

data to compute maternal mortality rates from 1969 to 2007 

in three poverty rate categories: <5% (i.e., less than 5% of 

families below the poverty level in a county, referred to as 

the low poverty group), 5-14.99% (middle poverty group), 

and 15% or higher (high poverty group) [3, 8, 9]. Details 

of the linkage methodology are provided elsewhere (10). 

During 1969-2002, the maternal mortality rate for women in 

the low poverty group declined by 41%, whereas the rate 

for women in the middle and high poverty groups decreased 

by 50.5% and 53.9%, respectively (Figure 3). The faster 

decline in maternal mortality among higher poverty groups 

contributed to the narrowing of the socioeconomic differentials in maternal mortality. Note that the maternal mortality 

rate increased significantly between 1999-2002 and 2003-

2007 for women in all socioeconomic groups. All relative 

risks of mortality for the poverty groups were statistically 

significant. Compared to women in the low poverty group, 

women in the middle poverty and high poverty groups had 

90% and 220% higher maternal mortality risks in 1969-1971 

and 58% and 102% higher maternal mortality risks in 

2003-2007, respectively (Figure 4). Higher poverty rates 

were associated with higher maternal mortality risks among 

both white and black women in each time period (data not 

shown). For example, in 2003-2007, black women in the 

high poverty group had a 35% higher maternal mortality 

rate than black women in the low poverty group. For white 

women, the corresponding relative risk of mortality was 50% 

higher in the high poverty group compared to the low poverty group. Moreover, within each poverty group, significant 

racial disparities in maternal mortality existed, with black 

women experiencing an approximately three times higher 

maternal mortality risk than white women in each poverty 

group (data not shown).
Figure 5: Maternal Mortality Rate per 100,000 Live Births, 2003-2007
Figure 6: Maternal Mortality Rate by Geographic Region, United States, 2003-2007 

Geographic Disparities in Maternal Mortality 

During 2003-2007, the maternal mortality rate varied 

considerably by state of residence, ranging from a low of 4.3 

deaths per 100,000 live births for Indiana to a high of 41.6 

for the District of Columbia and 26.0 for Michigan (comparison based on only those states where a total of at least 16 

maternal deaths occurred during 2003-2007) [Figure 5]. 

The states with at least 50% (and statistically significantly) 

higher maternal mortality rates than the national average 

include the District of Columbia, Michigan, Oklahoma, 

Idaho, New Jersey, Maryland, New York, and Mississippi. 

Maine, Alaska, North Dakota, Indiana, Massachusetts, 

Illinois, Minnesota, and Rhode Island had at least 50% (and 

statistically significantly) lower maternal mortality rates than

the national average (Figure 5). Women in all regions had 

significantly higher risks of maternal mortality than women 

in New England (Figure 6). Compared to women in New 

England, the risk of maternal mortality was 3.1 times higher 

among women in the Mid-Atlantic region, 2.6 times higher 

in the South Atlantic region, 2.4 times higher in the West 

South Central region, and 2.0 times higher in the Pacific 

region. Excess maternal mortality risks in the Mid-Atlantic, 

Southern, and Pacific regions existed among both white and 

black women (data not shown). 

In a state-level ecological analysis, higher levels of 

poverty rates, percentage of immigrant population, and 

cesarean rates were independently associated with higher 

maternal mortality rates. Specifically, states, in which poverty rates exceeded 18%, immigrant population exceeded 

15%, and cesarean rates exceeded 33%, had 77%, 33%, 

and 21% higher risks of maternal mortality, respectively, 

than states with lower rates of poverty, immigration, and 

cesarean deliveries (data not shown).
Discussion

Reducing the overall maternal mortality rate as well as 

the associated racial/ethnic and socioeconomic disparity 

is an important health objective for the nation (7). The 

long-term trend from 1935 to 1982 indicates a dramatic 

decline in the U.S. maternal mortality rate. However, the 

recent trend appears to indicate a substantial increase in 

maternal mortality rates, some of which could be attributed 

to recent coding and classification changes (1, 3). With the 

implementation of ICD-10 effective with mortality statistics 

in 1999 and thereafter, additional deaths due to indirect 

maternal causes of death have begun to be included in the 

official mortality statistics, which would not have otherwise 

been classified as maternal deaths in the previous ICD revisions (1, 3). In addition, a number of states have, in recent 

years, started using a pregnancy checkbox item on death 

certificates, which has led to an increase in the identification 

of maternal deaths (1, 3). As of 2007, there were 34 states 

and the District of Columbia with a separate item on the 

death certificate indicating pregnancy status of the decedent 

(3). 

It is important to note that the maternal mortality statistics 

analyzed in this report are those compiled by the National 

Center for Health Statistics in accordance with the WHO 

regulations and, therefore, exclude late maternal deaths 

occurring more than 42 days after the end of the pregnancy 

and deaths of pregnant women from external causes such 

as unintentional injuries, homicides, and suicides (1, 3). 

In 2007, for example, 548 deaths were reported to have 

occurred due to maternal causes during or within 42 days 

of pregnancy termination and 221 deaths were classified as 

late maternal deaths from direct or indirect causes occurring 

more than 42 days but less than a year after termination of 

pregnancy (3).

The leading causes of maternal deaths in the United 

States are hemorrhage, pregnancy-induced hypertension, 

embolism, infection, and other chronic medical conditions 

(3, 4). In pregnancies with abortive outcomes, ectopic pregnancy is the leading cause of maternal death (3, 4). While 

maternal mortality from hemorrhage, pregnancy-induced 

hypertension, and embolism has declined during the past 

two decades, maternal deaths due to other medical conditions, including cardiovascular and neurological problems, 

appear to have increased (4). The rising trend in cesarean 

rates may have also contributed to the apparent increase 

in maternal mortality during the past decade. The cesarean 

delivery rate in the United States has risen by more than 

50% during the past decade, from 20.7% in 1996 to 31.8% 

in 2007 (11). Complications of cesarean sections have been 

associated with increased maternal mortality, and a recent 

study indicates 8 to 10 times higher maternal mortality risks 

for cesarean delivery compared with vaginal birth (12). Our 

ecological analysis showing increased maternal mortality 

rates for states with higher cesarean rates is consistent with 

this finding. 

Despite the dramatic reductions in overall maternal 

mortality between 1935 and 2007, black women, women in 

lower socioeconomic groups, and women in several states 

continue to experience substantially increased risks of 

maternal mortality. These marked social disparities pose an 

important challenge for the U.S. health care system, as they 

may indicate important inequities in access to high-quality 

obstetric care. Currently, the maternal mortality rates for 

most states as well as for all racial/ethnic groups fall short 

of the Healthy People 2010 goal – which is set at 4.3 deaths 

per 100,000 live births (7). While none of the major racial/

ethnic groups in 2007 met the 2010 target, the 2005-2007 

maternal mortality rates for American Indian/Alaska Native 

women and non-Hispanic black women were 4 and 8 times 

higher than the 2010 target, respectively. During 2003-2007, 

women in all states except Indiana, North Dakota, Alaska, 

and Maine had higher maternal mortality rates than the 

Healthy People 2010 target. In fact, during this time period, 

there were 10 states with a rate of 20 or more maternal 

deaths per 100,000 live births. 
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Copyright Information:

All materials appearing in this report are in the public domain and may be reproduced or copied without permission; citation as

to source, however, is appreciated.

Suggested Citation:

Singh GK. Maternal Mortality in the United States, 1935-2007: Substantial Racial/Ethnic, Socioeconomic, and Geographic 

Disparities Persist. A 75th Anniversary Publication. Health Resources and Services Administration, Maternal and Child Health 

Bureau. Rockville, Maryland: U.S. Department of Health and Human Services; 2010. 

This publication is available online at http://www.mchb.hrsa.gov/

All photos are credited to iStockphoto.