The Christmas season’s poignancy derives in part from the story of a poor, probably teenaged mother who was forced by circumstances to undertake childbirth far from home in a shelter for animals. We hope there were skilled women there in Bethlehem to help her through what must have been a fraught experience. In the days before modern medicine, childbirth was often a death sentence for women, or could result in lifelong complications.
In the 21st century, while there is still no way to completely eradicate the risk of death from pregnancy and birth, we’ve come a long, long way. UNICEF notes that just in the first 20 years of this century, global maternal mortality has decreased by 34%. And, of course, the drop for wealthy countries over the course of the 20th century was even more remarkable: the U.S., for example, witnessed a drop of more than 90% in maternal mortality during the previous century.
Today, the country with the lowest maternal mortality rate is Norway, which in 2022 recorded zero maternal deaths. But the U.S. stubbornly lags behind with approximately 22 maternal deaths per 100,000 live births; some sources put the U.S. at 65th in the world for maternal mortality, worse than Egypt, Lebanon and Palestine. In fact, the U.S. maternal mortality rate today is almost exactly what it was in 1969. And the rate for Black mothers in the US is over three times that rate.
The situation in the U.S. has become even more dangerously complex for women in recent years. There are several reasons for this. For one, homicide is the leading cause of maternal mortality in the U.S., resulting in more deaths than hemorrhage, sepsis or hypertension. This statistic alone makes the U.S. a truly deviant case worldwide. In fact, there are numerous cases of women being killed because they were pregnant and refused an abortion, and we now have troubling cases where abortion pills were secretly administered to force an abortion on an unsuspecting woman.
Greater legal restrictions on abortion have also increased maternal mortality since the Supreme Court’s Dobbs decision returned abortion law to the states. The issue primarily revolves around incomplete miscarriage, premature rupture of membranes, and ectopic pregnancy. In most of these unfortunate cases —which are completely natural — a woman’s life is at real risk unless a pregnancy termination can be obtained, typically through a D&C or D&E. Doctors, fearing prosecution, delay until the woman is at death’s door, raising the maternal mortality rate. One investigative report detailed how such delays resulted in the deaths of Amber Thurman, Candi Miller, Josseli Barnica, Nevaeh Crain and Porsha Ngumezi. This situation is poised to worsen in 2025; Republicans in the South Carolina legislature, for example, have reintroduced a bill that would make a fetus a legal person, meaning in theory that any pregnancy termination could be considered a homicide. Of note, South Carolina already has a maternal mortality rate significantly higher than the national rate.
Also, likely ahead are cuts to Medicaid under the second Trump administration; 43% of births in the U.S. are paid for by Medicaid. Births to rural women, younger women, poor women and women of color are all more likely to be paid for by Medicaid. In Louisiana and Mississippi, almost two-thirds of births are paid for by Medicaid.
That is, if one can find maternal health care in the first place.
Vast swaths of the United States, especially in rural areas, are now considered “maternity deserts,” where one would have to travel many miles to find a hospital with a maternity ward or even an obstetric clinician. The March of Dimes found that about 36% of U.S. counties have no maternity wards or obstetric clinicians at all, and a further 10% only have one. While in theory midwives might be able to pick up the slack, in 23 American states midwives are severely restricted in their practice. For-profit outpatient “advanced birthing centers” bankrolled by private equity firms are filling the obvious gap in some states, with as-yet unknown consequences for maternal mortality.
Other obstacles along the gauntlet to a healthy birth for American women abound. These days, you may be asked to pony up the estimated cost for your prenatal and birth care at your very first visit with an obstetrician, which can be up to $3,000 — or more with a high-deductible policy. The C-section rate in the U.S. is so high that about 1 out of every 3 births is now a C-section, despite the World Health Organization suggesting the rate should be closer to 10%. This means that parents’ out-of-pocket costs will be much higher, not to mention the greater physical risks of surgery.
Oh, and those painkillers they gave you in childbirth? The presence of them in your urine postpartum might lead the hospital to report you to Child Protective Services — even though the hospital gave the drugs to you to take. Consider this appalling recent case in my home state of Texas, via NPR:
“Amairani Salinas was 32 weeks pregnant with her fourth child in 2023 when doctors at a Texas hospital discovered that her baby no longer had a heartbeat. As they prepped her for an emergency cesarean section, they gave her midazolam, a benzodiazepine commonly prescribed to keep patients calm. A day later, the grieving mother was cradling her stillborn daughter when a social worker stopped by her room to deliver another devastating blow: Salinas was being reported to child welfare authorities. A drug test had turned up traces of benzodiazepine — the very medication that staff had administered before wheeling her into surgery.”
Many people, when they think of the phrase “reproductive justice,” think only of access to birth control and abortion. When I think of the phrase, I think of vast maternity deserts, sky-high C-section rates, obscene maternal mortality rates among Black mothers, and the fact that 43% of births in the U.S. can only be afforded through Medicaid. I think of the women who died from sepsis during an incomplete miscarriage while their doctors cravenly waited until they decided the state wouldn’t prosecute them for trying to save her life. I think of the men who shot their pregnant girlfriend because she wanted to keep the child, or who crushed up abortion pills to put in their wife’s smoothie.
And the more I think about it all, the angrier I get. I find myself wondering whether Mary in that stable was actually more safe and more supported than the average pregnant American woman in 2024. Five days before Christmas, a homeless woman went into labor under a Kentucky overpass. As she was waiting for an ambulance, a police officer cited her for camping without a permit. And people like Elon Musk wonder why the birth rate is so low in this country.
This Christmas, when we celebrate the childbirth that ushered the savior into the world, we should all demand real reproductive justice for American mothers.