Protecting Mothers, Correcting Systems: A Legal and Policy Analysis of Maternal Mortality in the United States

Amala OKAFOR

Introduction

The United States continues to record one of the highest maternal mortality rates among developed countries. As of 2024, the rate stands at approximately 17.4 deaths per 100,000 live births, nearly double that of peer countries such as the United Kingdom, Canada, and Australia. Despite major initiatives like the Affordable Care Act and the Black Maternal Health Momnibus Act, the maternal health crisis in the U.S. persists.

Fragmented policies, inconsistent implementation across states, and systemic failures continue to undermine progress, costing the nation over $30 billion annually. This essay argues that current legal and policy interventions have not effectively addressed the problem because they lack a dedicated, comprehensive federal framework. Instead, the existing landscape is marked by disjointed and sometimes conflicting initiatives, as well as significant disparities in standards of care across states.

It proposes a targeted national approach establishing a minimum uniform standard of maternal healthcare, which states may strengthen based on local circumstances. This approach must incorporate three critical elements: mandatory legislative provisions supported by Congress's spending powers, protections grounded in the Equal Protection Clause, and adequate resource allocation.

Structural Drivers of Maternal Mortality

The factors driving maternal mortality are complex. The Centers for Disease Control and Prevention reports that approximately 84% of pregnancy-related deaths are preventable. This statistic underscores systemic failures, including chronic underlying health conditions, poor coordination of care, and limited access to services. Financial barriers and inconsistent insurance coverage further disrupt continuity of care, even among insured populations.

These failures are not isolated but structural, reflecting broader deficiencies in healthcare delivery and governance.

Racial Disparities and Inequities in Maternal Health

The burden of maternal mortality falls disproportionately on marginalized communities. Black, Indigenous, and People of Color (BIPOC) experience maternal mortality rates three to four times higher than those of white women.

Empirical research further demonstrates that racial disparities are widening. Soroush Saghafian's analysis indicates that the racial infant mortality gap has increased significantly over time and is projected to worsen. Pregnancy-related complications also contribute to Black infant deaths at rates substantially higher than those for white infants.

Variability in Medicaid eligibility, insurance coverage, and reproductive health laws across states further fragments access to care and undermines progress toward equity. These disparities are not merely statistical anomalies but reflect systemic inequities embedded within healthcare structures.

Systemic Failures and Lessons from Case Law

Legal cases illustrate that maternal mortality often stems from systemic failures rather than isolated medical negligence. The death of Lauren Bloomstein, a neonatal nurse who died from undiagnosed postpartum preeclampsia, exemplifies how even medically informed individuals can fall victim to institutional lapses.

Similarly, Amber Rose Isaac's death from a preventable post-cesarean hemorrhage highlights failures in timely intervention and coordination of care.

In Simpson v. University of Colorado Hospital Authority (2015), the court examined a maternal death caused by mismanaged postpartum hemorrhage, emphasising the legal duty of healthcare providers to meet established standards of care. This case underscores the role of litigation in holding institutions accountable and shaping legal standards.

However, while litigation is important, these cases collectively demonstrate that addressing maternal mortality requires systemic reform rather than reliance on post hoc legal remedies.

Fragmentation in Policy and Healthcare Delivery

Despite federal initiatives such as the CDC's maternal mortality review programmes and the Black Maternal Health Momnibus Act, structural fragmentation persists. State-level variations create significant gaps in care, particularly during the postpartum period.

Many women lose Medicaid coverage just 60 days after childbirth, precisely when ongoing care is critical. Essential services, including doula care, often remain uncovered. These "coverage cliffs" exacerbate disparities and increase the risk of preventable complications and deaths.

The decentralised nature of U.S. healthcare policy has resulted in a patchwork system that undermines consistency and equity.

Federalism, Comparative Models, and the Limits of Decentralisation

While other developed countries achieve lower maternal mortality rates through universal healthcare and comprehensive social policies, the United States cannot simply replicate these models due to its unique constitutional and political structure.

Proponents of decentralisation argue that state-level control allows for tailored policy innovation. However, this same decentralisation has produced uneven standards of care and deepened disparities.

The challenge, therefore, is not to abandon federalism but to recalibrate it using using federal authority to establish baseline standards while preserving state flexibility.

Towards Legal and Institutional Enhancement

While the existing analysis robustly interrogates the structural and constitutional deficiencies underpinning maternal mortality in the United States, certain dimensions remain underdeveloped.

Specifically, greater attention can be paid to the role of federal administrative enforcement, the potential expansion of equal protection doctrine through legislative action, and the integration of accountability frameworks that move beyond reactive litigation.

Congressional Authority

Congress possesses significant constitutional authority to address maternal mortality through its spending and commerce powers.

In National Federation of Independent Business v. Sebelius, the Supreme Court clarified the limits of conditional federal spending, introducing the coercion doctrine. Nevertheless, Congress can still incentivise state compliance by offering enhanced funding tied to maternal health reforms, including extended postpartum coverage. This strategy uses federal power to address urgent public health goals while navigating the ongoing tension between centralized regulation and state flexibility.

The Equal Protection Clause further strengthens this framework by providing a constitutional basis for addressing racial disparities. By combining federal mandates with state-level implementation, Congress can create a system that promotes both uniformity and flexibility.

Strengthening Federal Administrative Enforcement Mechanisms

Beyond congressional action, federal agencies, especially the Centers for Medicare and Medicaid Services (CMS), possess significant regulatory leverage that can be more strategically deployed. Given that a substantial proportion of maternal healthcare services are financed through Medicaid, CMS can condition participation on compliance with enhanced maternal care standards.

Such standards may include mandatory postpartum coverage of up to twelve months, uniform emergency obstetric protocols, and compulsory racial disparity reporting. Unlike broad legislative reforms, these administrative measures can be implemented with relative speed and flexibility, thereby addressing urgent gaps in care continuity.

Legislative Expansion of Equal Protection Enforcement

While judicial interpretation of the Equal Protection Clause has traditionally imposed limitations on disparate impact claims, Congress retains the authority under Section 5 of the Fourteenth Amendment to enact remedial legislation addressing systemic racial disparities.

Maternal mortality disparities like those affecting Black women present a compelling basis for such intervention. Federal legislation could explicitly recognise these disparities as a form of structural inequality and mandate corrective measures, including targeted funding, bias training, and oversight mechanisms. This approach would effectively bypass doctrinal constraints imposed by cases such as Washington v. Davis, while remaining constitutionally grounded.

Institutionalising Accountability Beyond Litigation

Although litigation remains a critical accountability tool, its reactive nature limits its systemic impact. A more proactive approach would involve institutionalising accountability through federal oversight mechanisms.

For instance, Maternal Mortality Review Committees (MMRCs) could be standardised and granted quasi-regulatory authority, with their recommendations carrying binding or semi-binding effect. Additionally, federal law could require public reporting of hospital-level maternal outcomes, thereby introducing reputational and regulatory incentives for compliance.

Conclusion

The United States already possesses sufficient legal and institutional tools to address maternal mortality. The challenge lies not in the absence of authority, but in the underutilisation and fragmentation of existing mechanisms. By strengthening administrative enforcement, expanding legislative use of equal protection powers, and institutionalising accountability, the U.S. can move closer to a coherent and effective maternal health framework.

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Chronic conditions like hypertension and diabetes increase risk

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: Martin, N. (2017, December 7). The Last Person You'd Expect to Die in Childbirth. ProPublica. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system a neonatal nurse, tragically died of undiagnosed postpartum preeclam thatrates ensure universal healthcare, paid leave, and integrated midwifery care, with national surveillance to ensurepsia despite exhibiting severe symptoms in her own hospital. Her husband, a physician at the same institution, testified that medical staff repeatedly dismissed her escalating condition.

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: Simpson v. University of Colorado Hospital Authority, No. 2014-CV-011812 (Colo. Dist. Ct. 2015)

: Roberts, Jessica L., and Alvaro M. Garza. 2022. "Litigating Maternal Health: Using the Constitution and International Human Rights to Transform Abortion and Maternal Health Care in Argentina and the United States." Harvard Law & Policy Review 16: 461--502. The authors suggests that strategic litigation can frame preventable maternal deaths not as medical mishaps, but as violations of constitutional and human rights, creating a robust legal mandate for systemic transformation

: Centers for Disease Control and Prevention. (2022). Maternal mortality review committees (MMRCs). https://www.cdc.gov/reproductivehealth/maternal-mortality/mmrcc/index.html U.S. Congress. (2021). Black Maternal Health Momnibus Act of 2021. H.R. 959. https://www.congress.gov/bill/117th-congress/house-bill/959

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: ibid.

: > U.S. [U.S. Const. art. I, § 8, cl. Congress curbed the HIV crisis > by creating the Ryan White CARE Act and enforcing civil rights via > the Americans with Disabilities Act. The Commerce Clause lets > Congress regulate healthcare and insurance across state lines, > setting basic care standards that every state must follow. > Gonzales v. Raich*,** 545 U.S. 1 (2005)*. This case reaffirmed a > broad interpretation of the Commerce Clause, citing the seminal > New Deal case Wickard v. Filburn (1942). The Court held that > Congress can regulate purely local activities that are part of an > economic "class of activities"that have a substantial aggregate > effect on interstate commerce. The healthcare market including > insurance, hospital systems, and medical services is a > quintessential example of such an activity. This precedent > provides the constitutional foundation for Congress to set > national standards for health insurance and care delivery]

: National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).