Regional Resource by Policy Analyst, Erin Twomey | etwomey@csg.org

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The United States has the highest maternal mortality rate (MMR) of any developed country in the world.¹ Each year, the Centers for Disease Control and Prevention (CDC) releases data showing maternal mortality rates for each state, and the states in the Southern Region consistently make up the majority of the top ten highest maternal mortality rates in the nation. Since the early 2000s, the U.S. MMR has been on the rise, and while it is beginning to decline, it is still the highest of any developed nation.² While better measurement and reporting tools explain part of the difference, the data suggests the change over the past 25 years is due primarily to the increase in prominent maternal health conditions and declining healthcare accessibility nationwide.

As states across the United States begin to recognize contributing factors, MMRs are starting to fall; however, the South still ranks among the highest.³ In 2023, the nation’s Top 8 highest maternal mortality rates were in these Southern states: Arkansas, Kentucky, Alabama, Tennessee, Louisiana, Mississippi, South Carolina, and Georgia.⁴ Compared to other Southern states, Florida, Missouri, North Carolina, Texas, and Virginia tend to have lower MMRs, but they still average higher than the national MMR.⁵

As a region, the South has made concerted efforts to reduce its MMRs. Since 2022, maternal mortality rates have declined in most Southern states⁶ (see Table 1) due to proactive legislation and public health programming initiatives in four overarching categories:

• Maternal Mortality Data Reporting and Review Committees
• Improving Access to Maternal Healthcare
• Addressing Maternal Health Conditions
• Expanding Insurance Coverage Requirements

A state looking to improve its overall maternal healthcare and reduce its MMR might consider looking at its statutes and programming under each category to ensure a holistic and comprehensive action plan.

TABLE 1. Maternal mortality rates in the 15 Southern states compared to the national average, 2021–2023.
Based on CDC maternal mortality data for 2021,⁷ 2022,⁸ and 2023.⁹

Understanding Maternal Mortality

Maternal mortality is a death while pregnant or within 42 days of termination of pregnancy.¹⁰ Pregnancy-related deaths is a broader term that references the death of a woman during pregnancy or up to a year postpartum due to a pregnancy-related health concern.¹¹ The maternal mortality rate (MMR) is how many maternal deaths per 100,000 deaths.¹²

Approximately 84 percent of maternal deaths are due to preventable health events.¹³ The top contributors to maternal mortality are complications that develop during pregnancy or childbirth, like severe bleeding (hemorrhaging), infection and sepsis, high blood pressure during pregnancy (preeclampsia and eclampsia), complications during birth (like amniotic embolism),¹⁴ and unsafe abortions.¹⁵ Preexisting conditions may worsen throughout pregnancy and lead to complications, especially when not appropriately managed by a physician or care team.¹⁶ Examples of these types of conditions are cardiovascular disease, diabetes, hypertension, and mental health conditions.¹⁷ Of these contributing factors, hemorrhaging is the leading cause of maternal mortality, followed by hemorrhaging.¹⁸

Who Is Most at Risk?

Rural Mothers

Women in rural parts of the South face an increased risk of maternal mortality due to limited access to care. Around a third of the counties in the nation are considered maternal health deserts (counties without obstetrics hospitals or birth centers), and all of these are rural communities.¹⁹

These maternal care deserts are primarily communities in the Midwest and South, as can be seen in Figure 1. According to the March of Dimes, a nonprofit maternal health organization, Oklahoma, Missouri, and Arkansas are within the Top 6 states in the union with the most significant percentage of maternity care deserts.²⁰

Mothers with overall lower levels of health are generally more likely to be affected by common pregnancy complications,²² and aspects of rural life, especially Southern rural life, typically lead to poorer overall health. As a region, the South tends to see higher rates of health concerns like diabetes, hypertension, heart disease, and obesity.²³ Much of this is believed to be attributed to the region’s traditionally high-fat and sugary diet.²⁴ Additionally, due to financial and geographical constraints, rural areas have limited access to wellness supports like healthy foods²⁵ and exercise facilities.²⁶

FIGURE 1. County-level access to maternal care in the United States.²¹

Black, Non-Hispanic Mothers

Even when controlling for variables like education and socioeconomic status, Black non-Hispanic women are nearly three times more likely to die from pregnancy-related complications than white women.²⁷ A CDC study showed that in 2020, Black non-Hispanic mothers had the highest maternal mortality rate among racial and ethnic groups.²⁸ Another study published in the American Journal of Public Health found data that suggests Black mothers do not have a higher prevalence of potentially fatal conditions (like hemorrhaging and preeclampsia) compared to other racial ethnic groups, but they are nearly three times more likely to die from those conditions.²⁹

Approximately 8 percent of rural America is Black, with more than 80 percent of the rural Black population living in the South.³⁰ Over the past decade, the South’s rural communities have been and continue to diversify (see Figure 2 and 3).³¹ Because Black mothers are disproportionately affected by maternal mortality, Black mothers in rural communities are experiencing a compounded risk. In response, Kentucky, Louisiana, and Georgia have passed resolutions to recognize the disparity in Black maternal mortality compared to other races.

Older Mothers

Many of the complications and health concerns associated with maternal mortality are more prevalent and often exacerbated by age.³² The number of women aged 35 and older giving birth rose over the past four decades.³³ As women continue to become pregnant later into their birthing years, this is an ever-growing concern for all mothers, not just those in the South.

FIGURE 2. Racial diversity in rural communities (ages 18 and over), 2020.

FIGURE 3. Racial diversity in rural communities (ages 0 to 17), 2020.

What Methods Are Southern States Using to Bring Down Their Maternal Mortality Rates?

Maternal mortality is a multifaceted issue and thus cannot be addressed with a simple solution. Therefore, states have chosen to confront maternal health challenges from various angles. By engaging with each of these avenues for change, state lawmakers can broach the subject holistically and, hopefully, more effectively.

Maternal Mortality Data Reporting and Review Committees

Before enacting legislation and funding maternal health programs, all Southern states piloted a Maternal Mortality Review [Advisory] Committee (MMRCs). The committees were charged with researching maternal health, evaluating the scope of maternal health disparities, and consulting with relevant stakeholders on the most practical path forward for their state.

Eleven states established their committees by enacting legislation. The states that have not explicitly passed legislation to develop MMRCs (Florida,³⁴ Kentucky,³⁵ Missouri,³⁶ and South Carolina)³⁷ also have MMRCs (or comparable), but they were established through state health departments. It is typical for these committees to comprise various healthcare professionals (physicians, nurses, midwives, etc.), state public health officials, and community members. MMRCs gather data on maternal mortality through program evaluations and data reporting before consolidating the information and making recommendations to the state’s Department of Public Health.³⁸

Legislators have initiated MMRCs and, most recently, updated and expanded the committee membership to ensure all relevant stakeholders are represented. Additionally, legislators focused on perfecting their data reporting systems, so the review committees receive and analyze all pertinent information. See Table 2 for a list of legislation relating to MMRCs. Table 3 shows proposed legislation on MMRCs.

TABLE 2. Enacted legislation relating to the establishment, membership expansion, or reporting requirements of Maternal Mortality Review [Advisory] Committees, by state.

TABLE 3. Legislation proposed during the 2025 session related to Maternal Mortality Review [Advisory] Committees, by state.

Improving Access to Care

States have opted to invest in measures to improve access to care, especially in rural communities and for high-risk mothers. One way they have done this is by meeting patients where they are — figuratively and literally! Virginia’s 2023 law, S.B. 1119, allows for a telemedicine option for continuity of care when a patient cannot meet with a practitioner in person. Similarly, Florida recently enacted H.B. 1381 in 2021, which mandates establishing a pilot program for telehealth and minority maternal care in two Florida counties. In 2023, Georgia took a slightly different direction in passing S.B. 106, which mandated a pilot program for home health visits during pregnancy for mothers at a higher risk and in underserved communities. This act also requires additional reporting on remote health services for Medicaid recipients to ensure appropriate care oversight.

Other states are improving access to care by bolstering their maternal health workforce. Arkansas enacted S.B. 51 in 2024, establishing the UAMS Maternal Health Workforce Trust Fund. This fund supports the maternal health workforce by supporting training and education. Virginia has tapped into the midwife industry by allowing licensed midwives to obtain, possess, and administer drugs and devices within the scope of their practice (VA S.B. 1275, 2023).

Several bills on improving access to care are progressing through their state’s general assembly this session. Table 4 lists those bills by state and provides the bill’s status and a general description of each bill. The bills focus on establishing licensing or certification requirements for midwives and doulas, creating a regulatory framework for these maternal health professionals, and providing oversight of quality of care.

There have also been discussions on expanding privileges for nurse practitioners and physician assistants to fill the gap in maternal care deserts. Presently, none of the Southern states allow nurse practitioners to practice independently, meaning they must collaborate with a physician. However, Kentucky, Oklahoma, Tennessee, Texas, and West Virginia recognize nurse practitioners as primary care providers. Physician assistants have full prescribing privileges in all states except Arkansas, Georgia, Kentucky, Missouri, Oklahoma, and West Virginia.³⁹ This session, West Virginia proposed a bill (H.B. 2544) that would remove supervising restrictions for nurse practitioners and physician assistants.

TABLE 4. Legislation proposed during the 2025 legislative session focused on improving access to maternal

Expanding Insurance Coverage Requirements

Another method states have explored is expanding insurance coverage requirements for maternal health providers and services not already covered (for instance, midwives and doulas). There is sufficient evidence that health insurance coverage improves access to care and better health monitoring overall. Thus, states are beginning to mandate that private health insurance providers include maternal health services like midwifery and doula services in their plans. For example, in 2023, Louisiana enacted H.B. 190 and H.B. 272 on this topic. Similarly, in 2024, Virginia enacted S.B. 118 to mandate private insurance companies to cover doula services.

States have also expanded public insurance coverage to improve access to care for low-income mothers. Approximately 21 percent of Americans receive insurance coverage through Medicaid.⁴⁰ Figure 4 shows Medicaid enrollment rates by state. By federal law, all states currently provide Medicaid benefits to pregnant women within 133 percent of the federal poverty level, up to 60 days postpartum. However, states determine the scope and type of services covered.⁴¹ Medicaid recipients’ access to care is significantly higher than that of the uninsured;⁴² therefore, expanding coverage for specific services, like those of midwives and doulas, should, in theory, improve individual access to care for that service, assuming the service is readily available. Figure 5 shows the demographic breakdown of Medicaid recipients. American Indian/Alaskan Native Americans had the highest percentage of recipients, followed by Black individuals and Hispanic individuals.

FIGURE 4. Medicaid enrollment rates by state.⁴³

NATIONALLY, ONE IN FIVE PEOPLE HAVE MEDICAID, BUT THIS VARIES ACROSS THE STATES

FIGURE 5. Demographics of Medicaid recipients.⁴⁴

MEDICAID IS A KEY SOURCE OF COVERAGE FOR CERTAIN POPULATIONS

The percentage of people within a group who have Medicaid

NOTE: FPL = federal poverty level. Estimates include the civilian, non-institutionalized population. Children includes people ages 0–18 and nonelderly adults includes people ages 19–64. Disability is defined as having one or more difficulty related to hearing, vision, cognition, ambulation, self-care, or independent living.

Conclusion

The data show that reviewing maternal mortality data, improving access to care, addressing maternal health conditions, and expanding insurance coverage requirements is helping to reduce MMR across the region, but there is still work to be done. Due to the complexity of the issue, there is no one simple “fix” for maternal mortality. Therefore, lawmakers should examine the topic through a holistic lens and determine how the unique needs of their state would be best served. Additionally, knowing which groups are most affected can inspire lawmakers to design legislation that targets improvements for those groups specifically.

End Notes

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2. MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Recent Increases in the U.S. Maternal Mortality Rate. Obstetrics & Gynecology, 128(3), 447–455. https://doi.org/10.1097/aog.0000000000001556
3. Hoyert, D. (2025, February 4). Maternal Mortality Rates in the United States, 2022. Cdc.gov. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm
4. Maternal Mortality Rate by State 2023 – Wisevoter. (2023, June 9). Wisevoter. https://wisevoter.com/state-rankings/maternal-mortality-rate-by-state/#google_vignette
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6. Hoyert, D. (2025, February 4). Maternal Mortality Rates in the United States, 2023. Cdc.gov. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm
7. Hoyert, D. (2023, March 16). Maternal Mortality Rates in the United States, 2021. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm
8. Hoyert, D. (2024, May 2). Maternal Mortality Rates in the United States, 2022. www.cdc.gov; Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022/maternal-mortality-rates-2022.htm
9. Hoyert, D. (2025, February 4). Maternal Mortality Rates in the United States, 2022. Cdc.gov. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm
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39. Rudowitz, R., Burns, A., Hinton, E., & Mohamed, M. (2023, June 30). 10 Things to Know About Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/
40. Gifford, K., Walls, J., Ranji, U., Apr 27, I. G. P., & 2017. (2017, April 27). Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey. KFF. https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-pregnancy-and-perinatal-benefits-results-from-a-state-survey/
41. Rudowitz, R., Burns, A., Hinton, E., & Mohamed, M. (2023, June 30). 10 Things to Know About Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/
42. Rudowitz, R., Burns, A., Hinton, E., & Mohamed, M. (2023, June 30). 10 Things to Know About Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/
43. Rudowitz, R., Burns, A., Hinton, E., & Mohamed, M. (2023, June 30). 10 Things to Know About Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/