Outcomes Worsened and Disparities Persisted During the Pandemic (GAO-23-105871)
Summary
A GAO report to congressional addressees, GAO-23-105871, dated October 2022, on maternal health. It states that each year in the U.S. hundreds of women die from complications related to pregnancy and childbirth, known as maternal death. GAO's analysis of Centers for Disease Control and Prevention data shows that maternal deaths increased during the COVID-19 pandemic and that COVID-19 was a contributing factor in one quarter of all maternal deaths in 2020 and 2021. It notes that pregnant women with COVID-19 are more likely to experience pregnancy complications, severe illness or death. Its title states that outcomes worsened and disparities persisted.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
United States Government Accountability Office
Report to Congressional Addressees
October 2022
MATERNAL HEALTH
Outcomes Worsened
and Disparities
Persisted During the
Pandemic
Accessible Version
GAO-23-105871
October 2022
GAO Highlights MATERNAL HEALTH
Highlights of GAO-23-105871, a report to Outcomes Worsened and Disparities Persisted
congressional addressees
During the Pandemic
Why GAO Did This Study What GAO Found
The COVID-19 pandemic presented Each year in the U.S., hundreds of women die from complications related to
challenges for maternal health, as pregnancy and childbirth—known as maternal death. GAO’s analysis of Centers
pregnant women with COVID-19 are for Disease Control and Prevention (CDC) data shows that maternal deaths
more likely to experience pregnancy increased during the COVID-19 pandemic. Further, the data show that COVID-19
complications, severe illness, or death. was a contributing factor in one quarter of all maternal deaths in 2020 and 2021
Research also shows racial and ethnic combined.
disparities in maternal deaths. For
example, Black or African-American
Maternal Deaths, 2018 through 2021
(not Hispanic or Latina) women
experienced maternal death at a rate
2.5 times higher than White (not
Hispanic or Latina) women in 2018 and
2019.
The CARES Act includes a provision
for GAO to report on its COVID-19
pandemic oversight efforts. GAO also
was asked to review how the pandemic
has affected maternal health. This
report describes, among other things,
what available data show about
maternal health outcomes and
disparities during the pandemic.
To do this work, GAO analyzed the
most recently available CDC data,
including data from the National Vital
Data table for Maternal Deaths, 2018 through 2021
Statistics System, to identify trends in
maternal deaths and other outcomes, Year Death not related to Death related to COVID-19
such as preterm births, by race and COVID-19
ethnicity. In addition, GAO reviewed
agency documents and selected 2018 658
research; and interviewed officials at 2019 754
relevant HHS agencies, as well as 2020 759 102
eight stakeholders—including
researchers, advocacy groups, and 2021 777 401
professional organizations—who were Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
selected based on referrals from HHS
agency officials and reviews of CDC data also show racial and ethnic disparities in the rate of maternal deaths
published research. per 100,000 live births per year. For example:
· The maternal death rate for Black or African-American (not Hispanic or
Latina) women was 44.0 per 100,000 live births in 2019, then increased to
55.3 in 2020, and 68.9 in 2021. In contrast, White (not Hispanic or Latina)
women had death rates of 17.9, 19.1, and 26.1, respectively.
· The maternal death rate for Hispanic or Latina women was lower (12.6)
compared with White (not Hispanic or Latina) women (17.9) in 2019, but
View GAO-23-105871. For more information, increased significantly during the pandemic in 2020 (18.2) and 2021 (27.5).
contact Carolyn L. Yocom at (202) 512-7114
or YocomC@gao.gov.
United States Government Accountability Office
Disparities in other adverse outcomes, such as preterm and low birthweight
births, persisted for Black or African-American (not Hispanic or Latina) women,
according to GAO analysis of CDC data.
Stakeholders and Department of Health and Human Services (HHS) officials told
GAO that the pandemic exacerbated the effects of social determinants of
health—factors such as access to care, transportation, or technology; living
environment; and employment—on maternal health disparities. For example,
service reductions in public transportation and child care worsened existing
barriers to accessing care. In addition, stakeholders and officials said the
pandemic highlighted the effect racism has on maternal health. For example,
physiological changes caused by chronic stress can increase the risk of maternal
death, as well as severe illness from COVID-19.
Contents
GAO Highlights ii
Why GAO Did This Study ii
What GAO Found ii
Letter 1
Background 6
Some Maternal Health Outcomes Worsened during the Pandemic;
Rate of Deaths among Black Women Increased More than for
White Women 9
HHS Agencies’ Efforts to Address Maternal Health Outcomes and
Disparities during COVID-19 25
Agency comments 27
Appendix I: GAO Contact and Staff Acknowledgements 30
Table
Data table for Maternal Deaths, 2018 through 2021 ii
Data table for Figure 1: Number and Rate of Maternal Deaths by
Race and Ethnicity, 2018 through 2021 10
Data table for Figure 2: Maternal Deaths, 2018 through 2021 12
Data table for Figure 3: Number of Monthly Maternal Deaths,
January 2018 through December 2021 13
Data table for Figure 4: Percentage of Preterm Births by Race and
Ethnicity, 2016 through 2021 15
Data table for Figure 6: Percentage of Births with Mother Admitted
to Intensive Care Unit during Delivery, by Race and
Ethnicity, 2016 through 2020 20
Data table for Figure 7: Percentage of Postpartum Women Who
Reported Experiencing Symptoms of Depression Before,
During, or After Pregnancy, 2016 to 2020 21
Table 1. Selected Department of Health and Human Services
Agencies’ Initiatives to Address Maternal Health
Outcomes and Disparities during the COVID-19 Pandemic 25
Figures
Maternal Deaths, 2018 through 2021 ii
Figure 1: Number and Rate of Maternal Deaths by Race and
Ethnicity, 2018 through 2021 10
Page i GAO-23-105871 Maternal Health
Figure 2: Maternal Deaths, 2018 through 2021 11
Figure 3: Number of Monthly Maternal Deaths, January 2018
through December 2021 13
Figure 4: Percentage of Preterm Births by Race and Ethnicity,
2016 through 2021 15
Figure 5: Percentage of Low Birthweight Births by Race and
Ethnicity, 2016 through 2021 17
Data table for Figure 5: Percentage of Low Birthweight Births by
Race and Ethnicity, 2016 through 2021 18
Figure 6: Percentage of Births with Mother Admitted to Intensive
Care Unit during Delivery, by Race and Ethnicity, 2016
through 2020 19
Figure 7: Percentage of Postpartum Women Who Reported
Experiencing Symptoms of Depression Before, During, or
After Pregnancy, 2016 to 2020 21
Page ii GAO-23-105871 Maternal Health
Abbreviations
CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
NCHS National Center for Health Statistics
NIH National Institutes of Health
This is a work of the U.S. government and is not subject to copyright protection in the
United States. The published product may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may contain
copyrighted images or other material, permission from the copyright holder may be
necessary if you wish to reproduce this material separately.
Page iii GAO-23-105871 Maternal Health
441 G St. N.W.
Washington, DC 20548
Letter
October 19, 2022
Congressional Addressees
Maternal Death Each year in the U.S., hundreds of women die from complications related
Death from any cause related to or to pregnancy or childbirth, known as a maternal death.1 According to the
aggravated by pregnancy or its management Centers for Disease Control and Prevention (CDC), the U.S. averaged
(excluding accidental or incidental causes)
during pregnancy and childbirth, or within 42 about 700 maternal deaths out of 3.7 million live births per year in recent
days of the end of pregnancy, irrespective of years—a rate that exceeds almost every other developed, high-income
the duration and site of pregnancy. country.2 For example, in 2018, the maternal death rate in the U.S. (17.4
Maternal Death Rate
per 100,000 births) was more than two times greater than Canada (8.6)
Number of maternal deaths per 100,000 live
births. and the United Kingdom (6.5). In addition, there have been persistent
Source: Centers for Disease Control and Prevention. | racial and ethnic disparities in rates of maternal deaths in the U.S., with
GAO-23-105871
Black women experiencing maternal deaths at a rate 2.5 times higher
than White women in 2018 and 2019.3 These concerns prompted the
Department of Health and Human Services (HHS) in December 2020 to
state that maternal deaths are a public health crisis.4
Since the COVID-19 pandemic began, CDC has found that pregnant
women may be at higher risk for adverse outcomes from COVID-19, such
as pregnancy complications, severe illness, and death. These adverse
outcomes may be related to physiological changes that occur during
1See Centers for Disease Control and Prevention, “Maternal Mortality” (Aug. 13, 2020),
accessed July 21, 2022, https://www.cdc.gov/reproductivehealth/maternal-mortality. We
use the term “women” in this report based on definitions in the data sources, but
acknowledge this term does not include all people who may become pregnant, such as
people who do not identify as either male or female, and some transgender men.
2See D.L. Hoyert, “Maternal Mortality Rates in the United States, 2019,” NCHS Health E-
Stats (2021). The rate for the United Kingdom is from 2017. See Organization for
Economic Cooperation and Development, accessed August 1, 2022,
https://stats.oecd.org/index.aspx?queryid=30116.
3See D.L. Hoyert, “Maternal Mortality Rates in the United States, 2019.” Hispanic women
had lower rates of maternal death as compared with non-Hispanic women in 2018 and
2019. The CDC data we cite in this report use the term “Hispanic origin,” which refers to a
person of Cuban, Dominican, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin regardless of race. For purposes of this report, we use the term
Hispanic to refer to Hispanic or Latina women. Additionally, we use the term Black to refer
to Black or African American women who are not Hispanic, and White to refer to White
women who are not Hispanic.
4See Department of Health and Human Services, Healthy Women, Healthy Pregnancies,
Healthy Futures: Action Plan To Improve Maternal Health In America and Surgeon
General’s Call to Action to Improve Maternal Health (December 2020).
Page 1 GAO-23-105871 Maternal Health
Letter
pregnancy, such as decreased lung capacity and a weakened immune
system.5 Furthermore, CDC data and other research have shown racial
and ethnic disparities in the number of COVID-19 cases among pregnant
women. For example, CDC data show that among women testing positive
for COVID-19, pregnant Hispanic women make up a larger proportion of
COVID-19 cases as compared with pregnant women who are not
Hispanic.6
The CARES Act includes a provision for GAO to monitor and oversee
federal efforts to address the COVID-19 pandemic, as well as the effect of
the pandemic on the health, economy, and public and private institutions
of the U.S.7 We also received a request to review issues related to
maternal health outcomes and disparities during the COVID-19
pandemic. In this report we describe
1. what available data show about maternal health outcomes and
disparities during the COVID-19 pandemic; and
2. HHS agencies’ efforts initiated during or in response to the COVID-19
pandemic to address maternal health outcomes and disparities.
To describe what available data show about maternal health outcomes
and disparities during the COVID-19 pandemic, we reviewed data from
CDC’s National Center for Health Statistics’ (NCHS) National Vital
Statistics System, the most complete source of data on births and deaths
in the U.S., and its Pregnancy Risk Assessment Monitoring System, a
state-level surveillance system of survey-based data on maternal
behaviors, attitudes, and experiences before, during, and shortly after
pregnancy.8 Specifically, we reviewed the following:
5See L.D. Zambrano et al., “Update: Characteristics of Symptomatic Women of
Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status
— United States, January 22–October 3, 2020,” Morbidity and Mortality Weekly Report,
vol. 69 (2020).
6For example, see L.D. Zambrano et al., “Update: Characteristics of Symptomatic Women
of Reproductive Age.” COVID-19 cases are reported by local health departments to CDC,
and are limited to laboratory-confirmed infection in symptomatic women aged 15 to 44
years in the U.S.
7Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020).
8Responses to the Pregnancy Risk Assessment Monitoring System are obtained from an
annual sample of 1,000 to 3,000 women per state who recently had a live birth. The
population from which the sample is drawn covers approximately 83 percent of U.S. births.
Page 2 GAO-23-105871 Maternal Health
Letter
· NCHS data on the number of maternal deaths, including those with
COVID-19 also listed as a contributing cause of death on the death
certificate, by race and ethnicity.9 We analyzed these data from 2018,
the earliest year of comparable data, through 2021, the most recent
year of available data.10
· NCHS data on the number of live births, preterm births (including
early and late preterm births), low and very low birthweight births, and
women admitted to the intensive care unit during delivery, by race and
ethnicity.11 We analyzed these data from 2016, the earliest year of
comparable data, through 2021, the most recent year of available
data.12
· Maternal death rates—which are calculated from NCHS data as the
number of maternal deaths per 100,000 live births per year, to
account for changes and differences in population—by race and
ethnicity.13 We analyzed these data from 2018, the earliest year of
available data on maternal deaths, through 2021, the most recent
year of available data on deaths and births.
9The underlying cause of death is defined as “the disease or injury which initiated the train
of events leading directly to death, or the circumstances of the accident or violence which
produced the fatal injury” and is assigned from the conditions entered on the death
certificate. Maternal deaths are those assigned to diagnostic code numbers A34, O00–
O95, and O98–O99, while COVID-19-related deaths are identified using multiple cause-of-
death code U07.1 of the International Classification of Diseases, 10th Revision.
10We reported data on maternal deaths from 2018 onward, because of changes in data
collection and coding that were revised as of 2018. The NCHS 2021 mortality data are
provisional and subject to change; however, the data are based on over 99 percent of
deaths for 2021, as of August 2, 2022. Provisional data provide an early estimate of
deaths before the release of final data that are fully reviewed by CDC. Final mortality data
for a given year are typically released 11 months after the end of the calendar year.
11Births occurring before 37 weeks of gestation based on the obstetric estimate are
considered to be preterm. CDC further categorizes births at less than 34 weeks as early
preterm and births at 34 to 36 weeks as late preterm. Low birthweight is defined as
birthweight of less than 2,500 grams and very low birthweight is defined as less than
1,500 grams. Data were not available for maternal admission to the intensive care unit for
2021 at the time of our analysis.
12We report NCHS birth data from 2016 onward, because of changes in the coding of race
as of 2016. The NCHS birth 2021 data are provisional and subject to change; however,
the data are based on over 99 percent of births for 2021, as of February 10, 2022.
13In this report we use the term “maternal death rate” to refer to the maternal mortality
rates—specifically, maternal deaths per 100,000 live births—reported in the National Vital
Statistics System.
Page 3 GAO-23-105871 Maternal Health
Letter
· Pregnancy Risk Assessment Monitoring System data on self-reported
depression symptoms before, during, and after pregnancy from a
sample of postpartum women from 2016, the earliest year of
comparable data, through 2020, the most recent year of available
data.14
We focused our data analysis on the years 2020 and 2021 to illustrate
changes in maternal health outcomes and disparities during the
pandemic, as compared to earlier years. To describe racial and ethnic
data, we relied on the Office of Management and Budget’s Revisions to
the Standards for the Classification of Federal Data on Race and
Ethnicity.15 We also focused our analysis on the three largest racial and
ethnic groups of women in available data—White, Black, and Hispanic—
because the data elements we reviewed were suppressed or less reliable
for other racial groups due to fewer observations; however, we
acknowledge these other groups also face disparities in maternal health
outcomes.16 For example, we previously reported that American Indian or
Alaskan Native women are more than two times as likely to experience
maternal deaths as White women.17 Women of all races and ethnicities
are included in totals and national averages. We reviewed CDC
documentation regarding how these data are collected, interviewed
agency officials, and compared our tabulations with published reports to
assess the reliability and accuracy of the data. We determined that the
portions of the data we used are sufficiently reliable for the purpose of this
14CDC revises this survey periodically; the current version began in 2016. These data
were not available by race and ethnicity at the time of our analysis.
15These standards list race and ethnicity as follows: American Indian or Alaska Native,
Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific
Islander, and White. See U.S. Office of Management and Budget, Revisions to the
Standards for the Classification of Federal Data on Race and Ethnicity (Washington, D.C.:
Oct. 30, 1997). The CDC data we cite in this report use the term “Hispanic origin,” which
refers to a person of Cuban, Dominican, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin regardless of race. For purposes of this
report, we use the term Hispanic to refer to Hispanic or Latina women. Additionally, we
use the term Black to refer to Black or African American women who are not Hispanic, and
White to refer to White women who are not Hispanic.
16Data suppression is when a record or certain parts of a record are not included in the
published data to ensure that data cannot be re-identified.
17See GAO, Maternal Mortality: Trends in Pregnancy-Related Deaths and Federal Efforts
to Reduce Them, GAO-20-248 (Washington, D.C.: Mar. 12, 2020).
Page 4 GAO-23-105871 Maternal Health
Letter
report.18 Comparisons between years and race and ethnic groups are
statistically significant at the 95 percent confidence level unless otherwise
noted.
We interviewed officials from HHS agencies including CDC, Office of the
Assistant Secretary for Planning and Evaluation, and Health Resources
and Services Administration (HRSA), and reviewed written responses
from these agencies—as well as the National Institutes of Health (NIH)
and Centers for Medicare & Medicaid Services (CMS)—about maternal
health outcomes and disparities during the COVID-19 pandemic, and
factors that may be associated with such disparities.19 We also
interviewed a sample of eight knowledgeable stakeholders—individual
researchers, research organizations, and professional or advocacy
associations—that we identified through our background research and
recommendations from agency officials.20 We reviewed agency
documents and selected research that we identified through background
research or that were provided by agency officials or stakeholders.
To describe efforts the HHS agencies initiated during or in response to
the COVID-19 pandemic, we reviewed prior GAO work and agency
websites and documents to identify efforts related to maternal health and
COVID-19. We reviewed written responses officials from HHS agencies
provided to determine which agency efforts were initiated during or in
response to the pandemic, and to obtain information on the status or any
results of these efforts.
We conducted this performance audit from March 2022 to October 2022
in accordance with generally accepted government auditing standards.
18We excluded other NCHS data measures of maternal health outcomes from our
analysis, because they were not sufficiently reliable for our purposes. In addition, we did
not review severe maternal morbidity (as defined by CDC, a specific set of 21 conditions
reflecting unexpected outcomes of labor and delivery that result in short- or long-term
health consequences) or pregnancy-related deaths (deaths that occur up to one year after
pregnancy), because data were not available for 2020 or 2021 at the time of our analysis.
19NIH supports research, including on maternal mortality and morbidity, through various
grants, contracts, and other funding mechanisms. HRSA is the primary federal agency
charged with improving health care for the medically vulnerable, including pregnant
women. CMS administers the Medicaid program, which covers approximately 42 percent
of births in the U.S.
20We interviewed officials from the American College of Obstetricians and Gynecologists,
the Association of Maternal & Child Health Programs, the Maternal Child Research
Oversight Committee at Columbia University, the National Birth Equity Collaborative, and
four university-affiliated researchers with knowledge about maternal health and disparities.
Page 5 GAO-23-105871 Maternal Health
Letter
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Maternal Health Outcomes
CDC’s NCHS collects and reports data through the National Vital
Statistics System on several maternal health outcomes, such as maternal
deaths. According to CDC officials, the agency receives information from
death certificates from all states, as well as other jurisdictions, such as
the District of Columbia, and uses the underlying cause listed on the
death certificates to identify maternal deaths and compile national
statistics. These data also contain information on the person’s race,
ethnicity, and age, among other information.
NCHS also uses information from birth certificates received from states
and other jurisdictions to identify and report statistics related to live births.
These data include characteristics of the mother (such as age and race)
and infant (such as gestational age and birthweight), as well as
information from medical records related to the pregnancy or delivery
(such as whether the mother was admitted to an intensive care unit
during delivery). According to the World Health Organization, certain
infant health characteristics, such as low birthweight, are indicators of
poor maternal health, nutrition, or health care during pregnancy.21
Additionally, some pregnant women are more likely to have preterm
births, such as those who are over age 35, according to CDC.22
In addition, research shows mental health conditions, such as depression
and anxiety, are the most common condition experienced during and after
21See World Health Organization, “Low birth weight,” accessed July 8, 2022,
https://www.who.int/data/nutrition/nlis/info/low-birth-weight.
22See Centers for Disease Control and Prevention, “Preterm Birth” (Nov. 1, 2021),
accessed July 12, 2022,
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm.
Page 6 GAO-23-105871 Maternal Health
Letter
pregnancy.23 We previously reported that the COVID-19 pandemic has
been found to have negatively affected mental health generally, and
research suggests it may have exacerbated these conditions for pregnant
and postpartum women.24
Maternal Health Disparities
Health disparities are preventable differences in the burden of disease, or
in opportunities to achieve optimal health experienced by socially
disadvantaged racial, ethnic, and other populations. We have previously
reported on racial and ethnic disparities in health outcomes, and factors
that contribute to such disparities, including for maternal health.25
Social determinants of health are conditions in the environments in which
people are born, live, learn, work, play, worship, and age; for example,
access to housing and healthy food, educational and job opportunities,
and exposure to pollution. According to HHS, these conditions affect a
wide range of health outcomes and risks.26 According to CDC, social
determinants of health are key drivers of health disparities and place
communities of color at greater risk for poor health outcomes.27 Research
has shown that social determinants of health are associated with adverse
maternal health outcomes; for example, studies suggest that factors such
as lower education or exposure to pollution are associated with a higher
23See, for example, E.J. Fawcett et al., “The Prevalence of Anxiety Disorders during
Pregnancy and the Postpartum Period: a Multivariate Bayesian Meta-Analysis,” Journal of
Clinical Psychiatry, vol. 80, no. 4 (2019).
24For example, see GAO, Behavioral Health and COVID-19: Higher-Risk Populations and
Related Federal Relief Funding, GAO-22-104437 (Washington, D.C.: Dec. 10, 2021); B.
Kotlar et al., “The Impact of the COVID-19 Pandemic on Maternal and Perinatal Health: a
Scoping Review,” Reproductive Health, vol. 18, no. 10 (2021); and A. Basu et al., “A
Cross-National Study of Factors Associated with Women’s Perinatal Mental Health and
Wellbeing during the COVID-19 Pandemic,” PLoS One, vol. 16, no. 4 (April 2021).
25For example, see GAO, Maternal Mortality and Morbidity: Additional Efforts Needed to
Assess Program Data for Rural and Underserved Areas, GAO-21-283 (Washington, D.C.:
April 8, 2021); and Health Care Capsule: Racial and Ethnic Health Disparities,
GAO-21-105354 (Washington, D.C.: Sept. 23, 2020).
26See Department of Health and Human Services, “Social Determinants of Health,”
accessed July 18, 2022,
https://health.gov/healthypeople/priority-areas/social-determinants-health.
27See Centers for Disease Control and Prevention, “Racism and Health,” accessed July
21, 2022, https://www.cdc.gov/healthequity/racism-disparities/index.html.
Page 7 GAO-23-105871 Maternal Health
Letter
risk of maternal death and morbidity.28 Similarly, we have reported that
certain health system factors (such as lack of access to care),
socioeconomic factors (such as being uninsured or having Medicaid
coverage), and patient factors (such as chronic health conditions or older
age) affect maternal health outcomes. Several of these disproportionately
affect certain populations, including Black women and women in rural and
underserved areas.29
Additionally, racism negatively affects the health of millions of people,
according to CDC. We previously reported, and research has shown, that
racial and ethnic disparities in maternal health outcomes persist, even
after controlling for other factors like socioeconomic status, education,
and access to care.30 Some studies described specifically how racial
discrimination can contribute to worsened maternal health outcomes. For
example, chronic stress associated with racism can cause physiological
changes and adverse health conditions. Moreover, bias or discrimination
within the health care system can create communication challenges
between providers and their patients, which may increase the risk of
adverse outcomes. For example, pregnant women may be reluctant to
ask questions about their condition if they faced discrimination from their
provider.31 In addition, the COVID-19 pandemic has highlighted racial and
ethnic health disparities. For example, among COVID-19 cases with
known race and ethnicity reported to CDC, Hispanic persons have
generally had a higher rate of cases throughout the pandemic as
compared with non-Hispanic persons.32
28For example, see E. Wang et al., “Social Determinants of Pregnancy-Related Mortality
and Morbidity in the United States: A Systematic Review,” Obstetrics & Gynecology, vol.
135, no. 4 (April 2020): 896-915.
29See GAO-21-283.
30For example, see two studies of severe maternal morbidity in New York City: E. Howell
et al., “Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal
Morbidity Disparities,” Obstetrics & Gynecology, vol. 135, no. 2 (Feb. 2020): 285-293; and
M. Angley et al., “Severe Maternal Morbidity in New York City, 2008–2012,” New York
Bureau of Maternal, Infant and Reproductive Health (New York, N.Y.: 2016).
31See R. Hardeman et al., “Developing Tools to Report Racism in Maternal Health for the
CDC Maternal Mortality Review Information Application (MMRIA): Findings From the
MMRIA Racism & Discrimination Working Group,” Maternal and Child Health Journal, vol.
26 (2022): 661–669.
32See Centers for Disease Control and Prevention, “COVID-19 Weekly Cases and Deaths
per 100,000 Population by Age, Race/Ethnicity, and Sex,” accessed August 5, 2022,
https://covid.cdc.gov/covid-data-tracker/#demographicsovertime.
Page 8 GAO-23-105871 Maternal Health
Letter
Some Maternal Health Outcomes Worsened
during the Pandemic; Rate of Deaths among
Black Women Increased More than for White
Women
Available CDC data show that maternal deaths and maternal death rates
increased overall during the COVID-19 pandemic, and trends in other
maternal health outcomes generally worsened in 2021, the second year
of the pandemic. These data also show that racial and ethnic disparities
in maternal health outcomes continued into the pandemic.
Maternal Deaths Increased Overall during the Pandemic,
Especially for Black Women
The overall number and rate of maternal deaths increased in 2020 and
2021 during the COVID-19 pandemic, compared with 2018 and 2019,
according to CDC’s NCHS data.33 White women accounted for the
highest number of maternal deaths during this period followed by Black
and Hispanic women. However, the rate of maternal deaths was
significantly higher for Black women in 2020 and 2021, compared with
White and Hispanic women. Further, the maternal death rate increased
more for Black women than White women in 2020 compared to 2019. In
2018 and 2019, prior to the pandemic, the rate of maternal deaths was
lower for Hispanic women as compared with White and Black women;
however, in 2020 and 2021, the rate for Hispanic women increased
significantly and was similar to that of White women. (See fig. 1.)
33There were 658 maternal deaths in 2018, 754 maternal deaths in 2019, 861 maternal
deaths in 2020, and 1,178 maternal deaths in 2021. The rate of maternal deaths per
100,000 live births was 17.4 in 2018, 20.1 in 2019, 23.8 in 2020, and 32.2 in 2021. These
numbers represent all races and ethnicities. Data for 2021 are provisional.
Page 9 GAO-23-105871 Maternal Health
Letter
Figure 1: Number and Rate of Maternal Deaths by Race and Ethnicity, 2018 through 2021
Data table for Figure 1: Number and Rate of Maternal Deaths by Race and Ethnicity,
2018 through 2021
Number of deaths
Year White Black Hispanic
2018 291 206 105
2019 343 241 112
2020 352 293 158
2021 493 361 234
Mortality rate
Year White Black Hispanic
2018 14.9 37.3 11.8
2019 17.9 44 12.6
2020 19.1 55.3 18.2
2021 26.1 68.9 27.5
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
Page 10 GAO-23-105871 Maternal Health
Letter
Notes: Maternal deaths are those assigned to code numbers A34, O00–O95, and O98–O99 of the
International Classification of Diseases, 10th Revision. Maternal deaths occur while pregnant or
within 42 days of being pregnant. The 2021 mortality data are provisional and subject to change;
however, the data are based on over 99 percent of deaths for 2021 as of August 2, 2022. Other races
are not shown due to small numbers. The CDC data we cite in this figure use the term “Hispanic
origin,” which refers to a person of Cuban, Dominican, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin regardless of race. The term Hispanic refers to Hispanic
or Latina women. Additionally, we use the term Black to refer to Black or African American women
who are not Hispanic, and White to refer to White women who are not Hispanic.
According to CDC data, COVID-19-related deaths—those for which
COVID-19 is listed on the death certificate as a cause that contributed to
death—accounted for most of the increase in maternal deaths in 2020,
and all of the increase in 2021; 25 percent of the total number of maternal
deaths that occurred in 2020 and 2021 were COVID-19-related.34 (See
fig. 2.)
Figure 2: Maternal Deaths, 2018 through 2021
34COVID-19-related deaths were identified using multiple cause-of-death code U07.1 from
the International Classification of Diseases, 10th Revision. Available data do not indicate
vaccination status of those who experienced COVID-19-related deaths.
Page 11 GAO-23-105871 Maternal Health
Letter
Data table for Figure 2: Maternal Deaths, 2018 through 2021
Year Death not related to Death related to COVID-19
COVID-19
2018 658
2019 754
2020 759 102
2021 777 401
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
Notes: Maternal deaths are those assigned to code numbers A34, O00–O95, and O98–O99 of the
International Classification of Diseases, 10th Revision. Maternal deaths occur while pregnant or
within 42 days of being pregnant. COVID-19-related deaths are identified using multiple cause-of-
death code U07.1. The 2021 mortality data are provisional and subject to change; however, the data
are based on about 99 percent of deaths for 2021 as of August 2, 2022. Data includes all races and
ethnicities.
Certain demographic groups had higher rates of maternal deaths related
to COVID-19, according to our analysis of CDC data. Specifically, the rate
of maternal deaths in 2020 and 2021 that were COVID-19 related among
Black and Hispanic women was 13.2 and 8.9 per 100,000 live births,
respectively, while the rate among White women was 4.5.
Before the pandemic, the average number of monthly maternal deaths
was 55 deaths for 2018, and 63 deaths for 2019. During the pandemic,
from January 2020 through December 2021, the number of monthly
maternal deaths averaged 85 deaths, and peaked in late summer of
2021. The number of maternal deaths in August (155 deaths) and
September (173 deaths) of 2021 was higher compared to that of prior
months, according to our analysis of CDC data. (See fig. 3.)
Page 12 GAO-23-105871 Maternal Health
Letter
Figure 3: Number of Monthly Maternal Deaths, January 2018 through December 2021
Data table for Figure 3: Number of Monthly Maternal Deaths, January 2018 through
December 2021
Number of Number of Number of Number of
Deaths Deaths Deaths Deaths
Month 2018 2019 2020 2021
(Provisional)
Jan 62 64 50 79
Feb 55 48 48 57
Mar 64 68 79 74
Apr 50 61 77 79
May 44 82 78 91
Jun 44 58 69 60
Jul 62 63 82 85
Aug 70 72 82 155
Sep 52 58 86 173
Oct 49 59 71 112
Nov 59 72 66 94
Dec 47 49 73 119
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
Page 13 GAO-23-105871 Maternal Health
Letter
Notes: Maternal deaths are those assigned to code numbers A34, O00–O95, and O98–O99 of the
International Classification of Diseases, 10th Revision. Maternal deaths occur while pregnant or
within 42 days of being pregnant. The 2021 mortality data are provisional and subject to change;
however, the data are based on about 99 percent of deaths for 2021 as August 2, 2022. Data
includes all races and ethnicities.
CDC noted that the Delta variant became the predominant COVID-19
variant in the U.S in July 2021, and the risk of death for pregnant women
was more than three times greater during this time (June 27, 2021,
through December 25, 2021) as compared with previous months.35
Preterm and Low Birthweight Births and Self–Reported
Depression Increased Slightly during the Pandemic;
Racial and Ethnic Disparities Persisted
As part of our analysis, we examined CDC data on other maternal health
outcomes. CDC data show preterm and low birthweight births and
admissions to the intensive care unit during delivery remained relatively
unchanged during the first year of the pandemic, and higher rates
persisted for Black women. For 2021—the second year of the
pandemic—the percent of preterm and low birthweight births increased
from the prior year. CDC data also showed a higher percentage of
recently postpartum women reported experiencing symptoms of
depression before and during pregnancy since 2016, a trend that
continued in 2020, the first year of the pandemic.
Preterm and low birthweight births. According to our analysis of CDC
data, the rates of preterm and low birthweight births for all women
remained substantially unchanged from 2016 through 2020, and then
increased from 2020 to 2021. Existing disparities in rates of preterm and
low birthweight births for Black women, which were higher compared with
other races and ethnicities and the national average, also continued into
2020 and 2021. (See figs. 4 and 5.)
35See Centers for Disease Control and Prevention, “Data on COVID-19 during Pregnancy:
Severity of Maternal Illness” (July 25, 2022), accessed July 21, 2022,
https://covid.cdc.gov/covid-data-tracker/#pregnant-population; and Centers for Disease
Control and Prevention, “COVID-19 during Pregnancy” (July 1, 2022), accessed July 21,
2022,
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/special-populations/pregnancy
-data-on-covid-19/what-cdc-is-doing.html. Also see P. Strid et al., “COVID-19 Severity
Among Women of Reproductive Age with Symptomatic Laboratory-Confirmed SARS-CoV-
2 by Pregnancy Status - United States, Jan 1, 2020 - Dec 25, 2021,” Clinical Infectious
Diseases (June 19, 2022).
Page 14 GAO-23-105871 Maternal Health
Letter
Figure 4: Percentage of Preterm Births by Race and Ethnicity, 2016 through 2021
Data table for Figure 4: Percentage of Preterm Births by Race and Ethnicity, 2016
through 2021
Race/ethnicity Percent total Percent early Percent late
preterm birth preterm preterm
2016 Total 9.8 2.8 7.1
2016 - White 9.0 2.3 6.7
2016 - Black 13.8 4.9 8.8
2016 - Hispanic 9.4 2.5 6.9
2017 Total 9.9 2.8 7.2
2017 - White 9.1 2.3 6.8
2017 - Black 13.9 4.9 9.1
2017 - Hispanic 9.6 2.6 7.1
2018 Total 10.0 2.7 7.3
2018 - White 9.1 2.3 6.8
2018 - Black 14.1 4.9 9.2
Page 15 GAO-23-105871 Maternal Health
Letter
Race/ethnicity Percent total Percent early Percent late
preterm birth preterm preterm
2018 - Hispanic 9.7 2.6 7.2
2019 Total 10.2 2.8 7.5
2019 - White 9.3 2.3 7.0
2019 - Black 14.4 4.9 9.5
2019 - Hispanic 10.0 2.6 7.4
2020 Total 10.1 2.7 7.4
2020 - White 9.1 2.2 6.9
2020 - Black 14.4 4.8 9.5
2020 - Hispanic 9.8 2.5 7.3
2021 Total (provisional) 10.5 2.8 7.7
2021 - White 9.5 2.3 7.2
2021 - Black 14.8 5.0 9.8
2021 - Hispanic 10.2 2.7 7.6
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
Notes: Births occurring before 37 weeks of gestation based on the obstetric estimate are considered
to be preterm. CDC further categorizes births at less than 34 weeks as early preterm and births at 34
to 36 weeks as late preterm. Other races are not shown separately due to small numbers, but are
included in the national average. The 2021 birth data are provisional and subject to change; however,
the data are based on over 99 percent of births for 2021 as of February 10, 2022. The CDC data we
cite in this figure use the term “Hispanic origin,” which refers to a person of Cuban, Dominican,
Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of
race. The term Hispanic refers to Hispanic or Latina women. Additionally, we use the term Black to
refer to Black or African American women who are not Hispanic, and White to refer to White women
who are not Hispanic.
Page 16 GAO-23-105871 Maternal Health
Letter
Figure 5: Percentage of Low Birthweight Births by Race and Ethnicity, 2016 through
2021
Page 17 GAO-23-105871 Maternal Health
Letter
Data table for Figure 5: Percentage of Low Birthweight Births by Race and
Ethnicity, 2016 through 2021
Race/ethnicity Percent low Percent very
birthweight low birth
weight
2016 Total 8.2 1.4
White 7.0 1.1
Black 13.7 3.0
Hispanic 7.3 1.2
2017 Total 8.3 1.4
White 7.0 1.1
Black 13.9 3.0
Hispanic 7.4 1.3
2018 Total 8.3 1.4
White 6.9 1.0
Black 14.1 2.9
Hispanic 7.5 1.2
2019 Total 8.3 1.4
White 6.9 1.0
Black 14.2 2.9
Hispanic 7.6 1.3
2020 Total 8.2 1.3
White 6.8 1.0
Black 14.2 2.9
Hispanic 7.4 1.2
2021 Total 8.5 1.4
(provisional) White 7.0 1.0
Black 14.7 2.9
Hispanic 7.8 1.3
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
Note: Low birthweight is birthweight of less than 2,500 grams and very low birthweight is less than
1,500 grams. Other races are not shown separately due to small numbers, but are included in the
national average. The 2021 birth data are provisional and subject to change; however, the data are
based on over 99 percent of births for 2021 as of February 10, 2022. The CDC data we cite in this
figure use the term “Hispanic origin,” which refers to a person of Cuban, Dominican, Mexican, Puerto
Rican, South or Central American, or other Spanish culture or origin regardless of race. The term
Hispanic refers to Hispanic or Latina women. Additionally, we use the term Black to refer to Black or
African American women who are not Hispanic, and White to refer to White women who are not
Hispanic.
According to CDC data, pregnant women who had COVID-19 during
pregnancy were at higher risk of having preterm and low birthweight
births. Data reported by 14 states and the District of Columbia to the CDC
show that between April 2020 and April 2021, the rates of preterm and
Page 18 GAO-23-105871 Maternal Health
Letter
low birthweight births were significantly higher for infants born to women
with COVID-19 during pregnancy (12.2 percent and 9.0 percent,
respectively) compared with those without COVID-19 (9.9 percent and 7.9
percent, respectively).36
Admission to the intensive care unit. The percentage of live births
where the mother was admitted to the intensive care unit during delivery
also showed some change from 2016 through 2020, though these
changes were small in magnitude, according to our analysis of CDC
data.37 Moreover, the existing disparities in rates of intensive care unit
admissions for Black women, which are higher compared with other races
and ethnicities and the national average, also continued into 2020. (See
fig. 6.)
Figure 6: Percentage of Births with Mother Admitted to Intensive Care Unit during
Delivery, by Race and Ethnicity, 2016 through 2020
36See J. Martin, M. Osterman, and C. Valenzuela, “Maternal and Infant Characteristics
and Outcomes among Women with Confirmed or Presumed COVID-19 during Pregnancy:
14 States and the District of Columbia,” Vital Statistics Rapid Release, no. 17 (Hyattsville,
Md.: National Center for Health Statistics, December 2021.)
37Data for women admitted to the intensive care unit during delivery was not available for
2021 at the time of our analysis.
Page 19 GAO-23-105871 Maternal Health
Letter
Data table for Figure 6: Percentage of Births with Mother Admitted to Intensive Care
Unit during Delivery, by Race and Ethnicity, 2016 through 2020
Percent admission
Race/ethnicity 2016 2017 2018 2019 2020 2021
National Total 0.16 0.16 0.17 0.18 0.17
average White 0.14 0.14 0.14 0.15 0.14
Black 0.26 0.24 0.24 0.27 0.25
Hispanic 0.15 0.15 0.15 0.17 0.17
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
Note: Other races are not shown separately, but are included in the national average. The CDC data
we cite in this figure use the term “Hispanic origin,” which refers to a person of Cuban, Dominican,
Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of
race. The term Hispanic refers to Hispanic or Latina women. Additionally, we use the term Black to
refer to Black or African American women who are not Hispanic, and White to refer to White women
who are not Hispanic.
According to CDC data, pregnant women who had COVID-19 were at
higher risk of being admitted to the intensive care unit during delivery as
compared with other pregnant women. Data reported by 14 states and
the District of Columbia to the CDC show that between April 2020 and
April 2021, intensive care unit admissions were significantly higher for
pregnant women with COVID-19 (0.7 percent) compared with those
without COVID-19 (0.1 percent).38
Depression. The percentage of women who reported experiencing
symptoms of depression before and during pregnancy continued to
increase during the pandemic. Prior to the pandemic, mental health
conditions affected a substantial number of U.S. adults—especially
pregnant and postpartum women.39 The estimated rates of depression
symptoms reported before and during pregnancy rose from 2016 through
2019, according to CDC data. These increases continued into 2020, the
38These data represent approximately 27 percent of U.S. births. See Martin, Osterman,
and Valenzuela, “Maternal and Infant Characteristics and Outcomes.”
39We previously reported that over 60 million adults in the U.S. had a mental illness in
2019, the year prior to the pandemic, and that data suggest the pandemic may have
contributed to new or exacerbated mental health symptoms or conditions, particularly
among women. Also, research shows mental health conditions are the most common
condition experienced during and after pregnancy. See GAO-22-104437 and E.J. Fawcett
et al., “The Prevalence of Anxiety Disorders during Pregnancy and the Postpartum Period:
a Multivariate Bayesian Meta-Analysis.”
Page 20 GAO-23-105871 Maternal Health
Letter
first year of the pandemic.40 The percentage of women reporting
symptoms of depression after pregnancy has remained steady between
2016 and 2020. (See fig. 7.)
Figure 7: Percentage of Postpartum Women Who Reported Experiencing Symptoms of Depression Before, During, or After
Pregnancy, 2016 to 2020
Data table for Figure 7: Percentage of Postpartum Women Who Reported
Experiencing Symptoms of Depression Before, During, or After Pregnancy, 2016 to
2020
Category 2016 2017 2018 2019 2020
Self-reported depression in the 3 12.3 12.8 14.7 15.1 15.5
months before pregnancy
Self-reported depression during 11.6 12.0 14.1 14.8 15.2
pregnancy
Self-reported depression after 12.8 12.5 13.4 13.4 13.4
pregnancy
Source: GAO analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) data. | GAO-
23-105871
40Respondents to the CDC Pregnancy Risk Assessment Monitoring System survey reflect
a sample of women who recently had a live birth. Depression is defined in the survey as
“always” or “often” feeling down, depressed, or hopeless, or having little interest or little
pleasure in doing things the person usually enjoyed. Data from 30 states met CDC’s
response rate threshold to be included in the results. Data for 2021 were not available at
the time of our analysis.
Page 21 GAO-23-105871 Maternal Health
Letter
Notes: Respondents to the Pregnancy Risk Assessment Monitoring System survey reflect an annual
sample of between 1,000 and 3,000 women per state who recently had a live birth. The population
from which the sample is drawn covers approximately 83 percent of U.S. births. Postpartum
depression symptoms are defined in the survey as “always” or “often” feeling down, depressed, or
hopeless or having little interest or little pleasure in doing things the person usually enjoyed since
delivery. On average, 75 percent of states have met or exceeded the data quality threshold since
2007. As such, not all states are included in the survey results.
Moreover, selected research, stakeholders, and NIH officials indicated
that anxiety, depression, or stress may have worsened for pregnant and
postpartum women due to the pandemic—in particular, due to social
isolation and fears of COVID-19 infection.41 Additionally, NIH officials
noted that there are racial and ethnic disparities in the prevalence and
severity of depression; however, data on the percentage of women who
reported experiencing symptoms of depression were not available by race
and ethnicity at the time of our analysis.
Pandemic Exacerbated Factors that Likely Contribute to
Disparities in Maternal Health Outcomes
Stakeholders we interviewed, as well as CDC, HRSA, and NIH officials,
stated that the COVID-19 pandemic exacerbated certain social factors
that contribute to disparities in maternal health outcomes. In particular,
stakeholders and officials said social determinants of health—such as
access to care, transportation, or technology; the living environment; and
employment—are key factors that contribute to disparities in maternal
health outcomes. They said that during the COVID-19 pandemic these
factors adversely affected women from racial and ethnic minorities or
other socially disadvantaged groups more than others. For example:
· Stakeholders and HHS officials noted, and we previously reported,
that women from racial and ethnic minorities and other socially
disadvantaged groups (e.g., those in underserved areas) have faced
barriers to accessing maternal health care.42 The pandemic caused
reductions in services, such as public transportation, and increased
child care challenges, according to some stakeholders; this
exacerbated existing barriers to accessing care and likely affected
women from these groups more than others.
41For example, see Kotlar et al., “The Impact of the COVID-19 Pandemic on Maternal and
Perinatal Health”; and Basu et al., “A Cross-National Study of Factors Associated with
Women’s Perinatal Mental Health and Wellbeing.”
42See GAO-21-283.
Page 22 GAO-23-105871 Maternal Health
Letter
· Similarly, several stakeholders and NIH officials noted that increased
use of telehealth during the pandemic highlighted existing challenges
in using telehealth for those without reliable access to the internet.43
For example, two stakeholders described pregnant women needing to
drive to places with free internet to access telehealth from their car.
Others faced challenges carrying out certain health care activities at
home that would usually be conducted in person during a health care
office visit, such as monitoring their blood pressure, according to two
stakeholders.
· Additionally, research shows that women from low-income
neighborhoods already were generally at higher risk for severe
maternal morbidity or death before the pandemic.44 During the
pandemic, some stakeholders reported and research found that
pregnant women who lived in such neighborhoods were also more
likely to test positive for COVID-19 than others, in part, because they
were not able to maintain distance from others to prevent infection.45
Because COVID-19 infection during pregnancy increases the risk of
maternal death, it could exacerbate existing disparities for low-income
women.
· Similarly, data show that Hispanic women had higher rates of COVID-
19 infection. Two stakeholders said, and some research suggests,
this may be because these women were more likely to be essential
workers who could not work from home or had more people living in
43Certain clinical services can be provided via telehealth, such as through audio-only,
audio/video, or other telecommunication technologies, and has been used during the
pandemic to provide health care, while reducing patients’ risk of exposure to COVID-19.
We previously reported on barriers Medicaid beneficiaries faced accessing telehealth
services. See GAO, Medicaid: CMS Should Assess Effect of Increased Telehealth Use on
Beneficiaries’ Quality of Care, GAO-22-104700 (Washington D.C.: Mar. 31, 2022).
44For example, see Wang et al., “Social Determinants of Pregnancy-Related Mortality and
Morbidity in the United States”; and K. Kozhimannil et al., “Rural-Urban Differences In
Severe Maternal Morbidity and Mortality in the U.S., 2007–15,” Health Affairs, vol. 38, no.
12 (2019): 2077–2085.
45For example, see U. Emeruwa, C. Gyamfi-Bannerman, and R. Miller, “Health Care
Disparities in the COVID-19 Pandemic in the United States: A Focus On Obstetrics,”
Clinical Obstetrics and Gynecology, vol. 65, no. 1 (March 2022): 123-133; H. Burris et al.,
“Neighborhood Characteristics and Racial Disparities in Severe Acute Respiratory
Syndrome Coronavirus 2 (SARS-CoV-2) Seropositivity in Pregnancy,” Obstetrics &
Gynecology, vol. 139, no. 6 (June 2022): 1018-1026; and C. Buhimschi et al., “Prevalence
and Neighborhood Geomapping of COVID-19 in an Underserved Chicago Pregnant
Population,” American Journal of Perinatology Reports, vol. 10, no. 4 (Sept. 16, 2020):
413-416.
Page 23 GAO-23-105871 Maternal Health
Letter
their household, and thus faced increased exposure to COVID-19, as
compared with other groups.46
Stakeholders and HHS officials also stated that racism is a key factor that
contributes to disparities in maternal health outcomes. This includes
structural racism (historical and contemporary social factors that
systematically disadvantage people of color through inequities in housing,
education, employment, health care, etc.) and bias or discrimination
(conscious or unconscious assumptions that result in differential actions
toward others based on their race) on the part of providers. They provided
examples of how the pandemic highlighted the impact racism has on
maternal health outcomes and disparities. For example:
· Most stakeholders and HHS officials stated that structural racism
contributes to disparities in social determinants of health, like access
to healthy food and health care. Racism has also been shown to
cause direct physiological changes due to stress.47 Research shows
that Black women have higher rates of chronic conditions like
hypertension and diabetes (as compared with White women) and that
women with these conditions are at higher risk for pregnancy-related
complications and maternal death, as well as severe illness from
COVID-19.48 CDC data and research indicate that pregnant Hispanic
and Black women are more likely to experience higher rates of severe
illness and death relative to their distribution among pregnant women
with reported cases of COVID-19.49
· Several stakeholders said racial discrimination has led women from
racial and ethnic minority populations to distrust the health care
46For example, see Zambrano et al., “Update: Characteristics of Symptomatic Women of
Reproductive Age”; Burris et al., “Neighborhood Characteristics and Racial Disparities”;
and A. Sakowicz et al., “Risk Factors for Severe Acute Respiratory Syndrome Coronavirus
2 Infection in Pregnant Women,” American Journal of Obstetrics & Gynecology MFM, vol.
2, no. 4 supplement (Nov. 2020).
47For example, see Hardeman et al., “Developing Tools to Report Racism in Maternal
Health.”
48See Centers for Disease Control and Prevention, “Disparities in Preconception Health
Indicators — Behavioral Risk Factor Surveillance System, 2013–2015, and Pregnancy
Risk Assessment Monitoring System, 2013–2014,” Morbidity and Mortality Weekly Report,
vol. 67 (Jan. 19, 2018); and J. Allotey et al., “Clinical Manifestations, Risk Factors, and
Maternal and Perinatal Outcomes of Coronavirus Disease 2019 in Pregnancy: Living
Systematic Review and Meta-Analysis,” BMJ, vol. 370 (2020).
49For example, see Zambrano et al., “Update: Characteristics of Symptomatic Women of
Reproductive Age.”
Page 24 GAO-23-105871 Maternal Health
Letter
system or feel they are not listened to by providers. Most stakeholders
and HHS officials said there was mistrust among pregnant women in
general during the pandemic. According to these stakeholders and
officials, this was due to factors such as frequently changing guidance
and lack of or misinformation about COVID-19, and added stress from
hospital policies that did not allow partners or other support persons in
the delivery room. Some stakeholders said these issues particularly
affected Black women and may have worsened disparities.
HHS Agencies’ Efforts to Address Maternal
Health Outcomes and Disparities during
COVID19
Our review of agency websites and interviews with officials found that
HHS agencies, including CDC, CMS, HRSA, and NIH, utilized various
efforts to address maternal health outcomes and disparities during the
COVID-19 pandemic.50 Table 1 describes selected initiatives from the
HHS agencies.
Table 1. Selected Department of Health and Human Services Agencies’ Initiatives to Address Maternal Health Outcomes and
Disparities during the COVID-19 Pandemic
Agency Initiative Description
Centers for Disease CDC-supported Research on the effects of COVID-19 on maternal health. For example, CDC
Control and research reviewed electronic health records to assess complications in delivery for women
Prevention (CDC) with and without COVID-19 diagnosis at the time of hospitalization, and
disseminated research on COVID-19-associated maternal deaths and infant
outcomes after COVID-19 infection during pregnancy.
Supported efforts to better understand experiences of pregnant and postpartum
women during the pandemic and COVID-19 vaccine hesitancy by including
questions on types of prenatal and postpartum barriers to care in its Pregnancy
Risk Assessment Monitoring System survey for 2020 and questions on
vaccinations for 2021, and funding focus groups on vaccine perception.
COVID-19 Data Tracker Began reporting COVID-19 case surveillance data on the number of cases and
severity of illness (e.g., hospitalization, death) for pregnant women on its COVID-
19 tracker. Updated this information weekly starting in early 2020 and ending on
July 25, 2022.
Reported data related to COVID-19 and pregnant women using its existing
Surveillance for Emerging Threats to Mothers and Babies Network on timing of
infection during pregnancy, and pregnancy and infant outcomes.
50We focused our review on HHS efforts that specifically address maternal health
outcomes and disparities in response to the COVID-19 pandemic. As such, it does not
include other broader efforts aimed at improving maternal health.
Page 25 GAO-23-105871 Maternal Health
Letter
Agency Initiative Description
Guidance on COVID-19 Issued guidance on the risk for severe COVID-19 illness and pregnancy
and pregnancy complications among pregnant people with COVID-19.
Developed public health messaging on pregnancy and COVID-19 vaccine safety,
and partnered with community-based organizations to promote vaccination, in
particular for women from racial and ethnic minority groups.
Perinatal Quality Provided supplemental funding to collaborative teams for COVID-19-related
Collaboratives activities, such as working with providers to improve vaccination confidence for
pregnant women.
Centers for Medicare Maternal and Infant Offers technical assistance to states to address foregone postpartum care visits,
& Medicaid Services Health Initiative which according to CMS, declined during the pandemic.
(CMS)
Health Resources and National Maternal A free, confidential 24/7 hotline for women experiencing mental health
Services Mental Health Hotline challenges before, during, and after pregnancy. Launched on May 8, 2022, as
Administration part of HHS efforts to address mental health challenges exacerbated by the
(HRSA) pandemic. Counselors can provide real-time support, resources, and referrals in
English and Spanish to providers and support groups, with interpreters available
in 60 languages.
Maternal Telehealth Aims to increase telehealth access and infrastructure for families and providers,
Access Project and to improve access to maternity care, including mental health care, during the
pandemic. Focuses on increasing access for women at highest risk of maternal
death and morbidity, and who have experienced the effects of the pandemic the
hardest, including Native American, Black, and Hispanic women, and women
who live in rural areas.
National Institutes of Guiding Principles: Sex Created guiding principles for the study of the effect of COVID-19 on women’s
Health (NIH) and Gender Influences health.
in COVID-19
Implementing a Supports research to reduce preventable causes of maternal deaths and
Maternal Health and improve health for women before, during, and after delivery, and emphasizes
Pregnancy Outcomes mitigating health disparities. In fiscal year 2021, NIH officials reported awarding
Vision for Everyone over $13 million to 22 projects focusing on the impacts of the pandemic,
structural racism, and discrimination on maternal health outcomes in the context
of COVID-19.
NIH-Supported Evaluating ways that COVID-19 affects pregnancy outcome, the efficacy of
Research COVID-19 vaccinations in pregnant and recently postpartum women; and the
psychological, behavioral, and socioeconomic impact of the pandemic on
vulnerable groups, including pregnant women.
Source: GAO analysis of interviews with agency officials and websites. | GAO-23-105871
Note: CDC collects and reports health-related data on maternal health and COVID-19, and works to
improve maternal health through research, scientific assistance, and partnerships. NIH supports
research, including on maternal deaths, through various grants, contracts, and other funding
mechanisms. HRSA is the primary federal agency charged with improving health care for the
medically vulnerable, including pregnant women. CMS administers the Medicaid program, which
covers approximately 42 percent of births in the U.S.
Page 26 GAO-23-105871 Maternal Health
Letter
Agency comments
We provided a draft of this report to the Department of Health and Human
Services for review and comment. HHS provided technical comments,
which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Health and
Human Services and appropriate congressional committees. In addition,
the report will be available at no charge on the GAO website at
http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs are on the last page of this
report. GAO staff who made major contributions to this report are listed in
appendix I.
Carolyn L. Yocom
Director, Health Care
Page 27 GAO-23-105871 Maternal Health
Letter
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
Page 28 GAO-23-105871 Maternal Health
Letter
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Alma S. Adams, Ph.D.
House of Representatives
The Honorable Cori Bush
House of Representatives
The Honorable Robin L. Kelly
House of Representatives
The Honorable Gwen Moore
House of Representatives
The Honorable Ayanna Pressley
House of Representatives
The Honorable Lauren Underwood
House of Representatives
Page 29 GAO-23-105871 Maternal Health
Appendix I: GAO Contact and Staff
Acknowledgements
Appendix I: GAO Contact and
Staff Acknowledgements
GAO Contact
Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov
Staff Acknowledgements
In addition to the contact named above, Karen Doran (Assistant Director),
Erika Huber (Analyst-in-Charge), Rotimi Adebonojo, Drew Long, Jeanne
Murphy-Stone, Eric Peterson, and Sirin Yaemsiri made key contributions
to this report. Also contributing were Joycelyn Cudjoe, Leia Dickerson,
Christie Enders, Naomi Joswiak, Jennifer Rudisill, and Ethiene Salgado-
Rodriguez.
(105871)
Page 30 GAO-23-105871 Maternal Health
GAO’s Mission
The Government Accountability Office, the audit, evaluation, and investigative
arm of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of the
federal government for the American people. GAO examines the use of public
funds; evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance to help Congress make informed
oversight, policy, and funding decisions. GAO’s commitment to good government
is reflected in its core values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony
The fastest and easiest way to obtain copies of GAO documents at no cost is
through our website. Each weekday afternoon, GAO posts on its website newly
released reports, testimony, and correspondence. You can also subscribe to
GAO’s email updates to receive notification of newly posted products.
Order by Phone
The price of each GAO publication reflects GAO’s actual cost of production and
distribution and depends on the number of pages in the publication and whether
the publication is printed in color or black and white. Pricing and ordering
information is posted on GAO’s website, https://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card, MasterCard,
Visa, check, or money order. Call for additional information.
Connect with GAO
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Subscribe to our RSS Feeds or Email Updates. Listen to our Podcasts.
Visit GAO on the web at https://www.gao.gov.
To Report Fraud, Waste, and Abuse in Federal
Programs
Contact FraudNet:
Website: https://www.gao.gov/about/what-gao-does/fraudnet
Automated answering system: (800) 424-5454 or (202) 512-7700
Congressional Relations
A. Nicole Clowers, Managing Director, ClowersA@gao.gov, (202) 512-4400, U.S.
Government Accountability Office, 441 G Street NW, Room 7125, Washington,
DC 20548
Public Affairs
Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Strategic Planning and External Liaison
Stephen J. Sanford, Managing Director, spel@gao.gov, (202) 512-4707
U.S. Government Accountability Office, 441 G Street NW, Room 7814,
Washington, DC 20548
File and source
- File
- gao-23-105871.pdf
- Size
- 1,505,781 bytes
- SHA-256
- e89e485a34ac435afcbe5c6e55c24177a770a8259aa7f5914fe33ff5cac3fa03
- Our copy
- gao-23-105871.pdf
- Original
- www.gao.gov