This survey report arrives at a pivotal moment in the nation's longstanding maternal health crisis. There is now widespread recognition that the United States has higher rates of pregnancy-related deaths than any other high-income country and that the great majority of these deaths are preventable. In response, policies to address this crisis have proliferated. Forty-nine states and Washington, D.C. have extended Medicaid coverage from 60 days to 12 months postpartum. The federal government established the National Maternal Mental Health Hotline to offer 24/7 support during pregnancy and the first year after birth. And federal investments expanded maternal mortality review, perinatal quality collaboratives, and community-based perinatal support programs – including HRSA's Healthy Start initiative, the Maternal Health Innovation Program, and community-based doula support.

These hard-won gains are now at risk. Federal actions, including deep cuts to Medicaid, scaled-back maternal health programs, and curtailed federal maternal health data and workforce investments, threaten to unravel the supports that childbearing families most need. The findings that follow make clear how much more is needed to improve outcomes, experiences and equity, and what is at stake if these hard-won successes are reversed.

Widespread systemic improvements are needed

More than 3,800 respondents from all 50 states and the District of Columbia completed an in-depth questionnaire about their views and experiences of childbearing. Given the widely recognized maternal health crisis of substandard and inequitable outcomes with troubling implications for the nation’s population health, we aimed to identify concrete opportunities for improvement. The questionnaire was available in English or Spanish, and participants shared their experiences about 2023 and 2024 births. Results were carefully weighted by key demographic variables to create a nationally representative dataset of new mothers, at least 18 years old at the time of the survey, who gave birth to single babies in U.S. hospitals.

Our questionnaire covered the time beginning several months before the participants’ pregnancies through pregnancy, birth, and early postpartum months. Many respondents also completed a second in-depth questionnaire exploring postpartum well-being, infant care, parental leave and employment, and many other topics. A companion report presents those results. Together, these reports and our rich, combined data set identify many actionable opportunities to improve conditions for mothers, babies, and families.

Experiences and outcomes are inequitable

They treated me like I ... had no feelings, no mind of my own because I was young and black. They had no concerns for my health, safety or wellbeing or my child’s.

I felt like if I had the right insurance the right income or the right color I would have been treated different or at least respected.

Overall, the survey results are troubling, and the challenges were further intensified for many groups facing greater barriers and worse outcomes and experiences. Across many analyses, consistent patterns and disparities emerged including:

• American Indian/Alaska Native and Native Hawaiian/Pacific Islander respondents, Black respondents, and Multiracial/Multiethnic respondents often fared worse than others
• Participants covered by Medicaid frequently had worse results than those with private insurance
• Younger respondents reported worse experiences and outcomes than older ones
• Those who identified one or more disabilities often faced greater difficulties
• People who were single, and in some cases unmarried respondents with a committed partner, often faced added challenges relative to those who were married
• In some instances, those living in nonmetropolitan counties faced more challenges than those in metropolitan counties

Women have too little access to the high-quality care they need and want

I didn't have prenatal visits until 1 week before delivery, because of health insurance issues.

I wish that more insurance companies would pay for doulas for women who have to go through labor on their own. It was really lonely.

Even on Medicaid I struggled with … paying for my regular visits. It was a billing nightmare and caused SO much unnecessary stress on my pregnancy and postpartum self.

Access to high-quality care remains far too limited. Missed opportunities to better support families include:

• Midwives – whose performance stood out repeatedly in the data both prenatally and during birth – were used by only a small percentage of respondents
• The great majority had no doula support; only a small fraction had doula support spanning pregnancy, birth, and the postpartum period
• Many were unable to have an initial prenatal visit as early as they wanted, during a critical window when toxic exposures can harm developing embryos and fetuses, miscarriage risk is high, and people have many questions and concerns
• Group prenatal visits were rare, despite the fact that most who did experience this model preferred to have groups visits as part of their care
• Virtual prenatal visits were similarly uncommon, even though most who had access to virtual visits as part of their care valued it and respondents were very confident with performing 4 kinds of self-monitoring
• Mobile clinics were used by a tiny fraction of people for prenatal care despite the steady closure of many rural maternity services
• Many who wanted to feed their babies breastmilk – exclusively or at all – were not doing so a week after the birth and had not had the benefit of supportive hospital practices
• Many did not feed their babies exclusive or any breastmilk for as long as they wanted

Women receive too much counterproductive, low-value care contrary to best evidence

I wanted to change positions while in labor and sit on a ball but was not allowed.

Just a fraction of respondents experienced what is defined as physiologic childbirth. Through evolution, mothers and babies have developed finely tuned biological processes that – when supported rather than disrupted – optimize safe labor, birth, and the lasting benefits of breastfeeding and bonding. Judicious use of medical interventions when truly needed is an essential complement to these processes. As described in our companion report, respondents overwhelmingly told us that birth is a process that should not be interfered with unless medically necessary.

I just believe the treatment of women is really sad and unfair and they push c sections and neglect mothers wishes. I was the 5th c section in 24 hours by one doctor. That’s insane and shouldn’t have been allowed.

I switched to a midwife after having two babies with a regular OBGYN, because I wanted to feel more involved/knowledgeable about the birth process and I also wanted to try to give birth naturally.

In practice, however, our respondents’ births were overwhelmingly shaped by widely used medications, procedures, and interventions that started labor, drove it forward, and surgically removed the baby. These powerful interventions often trigger additional co-interventions to prevent, monitor, or treat their side effects in a cascade of intervention. Most births were scheduled, and labor inductions and cesareans took place before signals of readiness from pregnant women caused the onset of labor. This common technology-intensive model works against rather than with healthy biological processes, and in fact disrupts them.

I don’t feel like the doctor on call tried hard enough to stick to my plan of a vaginal birth and lied about me needing a C-section just so she could be done quicker. The was little to no communication from the doctors while the C-section was being performed, I got no updates on my baby once he was delivered. I got little to no instructions on C-section care after I left the hospital.

Other examples of substandard care and missed opportunities include:

• Too many women had no paid time off for prenatal visits, and too many were denied the workplace accommodations they needed for a healthy pregnancy
• Many were admitted to the hospital in early labor, a practice associated with higher cesarean rates compared to waiting for active labor
• Nearly all who arrived at the hospital in labor experienced few of the beneficial practices that help move labor along and avoid unplanned cesareans
• Too many babies were taken by staff for routine care like weighing and bathing during the critical golden hour after birth; too many babies who stayed with parents were not held skin-to-skin
• A majority of babies admitted to NICUs were full-term, of normal birth weight, and had short stays - suggesting many admissions were avoidable; unnecessary NICU admissions separate mothers and babies, expose babies to risks, and drive up costs
• Many who intended to exclusively feed their babies breast milk did not consistently experience the beneficial practices that support achieving this goal.

Women experience disrespect, lack of options, poor engagement in decisions, and other types of mistreatment

I was yelled at to shut up and told nobody needs to make noise during labor.

[I]t makes a world of a difference when you’re actually listened to and respected as a mother, and as a team member in your prenatal care.

A validated measure of respectful, person-centered intrapartum care found that many received suboptimal support during their hospital stay. Respondents reported shortcomings relating to:

• Not feeling heard, listened to, or valued.
• Being treated disrespectfully
• Not feeling informed about what was happening and being involved in care decisions
• Experiencing discrimination
• Being ignored, neglected, or having requests go unanswered
• A lack of support for infant feeding goals
• A lack of trust in care providers
• Feeling physically unsafe
• Not having their customs and culture respected

I would not choose induction and hospital birth again .... It is not a pleasant experience. I was never asked if I wanted to be induced, and I was too tired to fight with my OB.

Repeatedly, survey results revealed a troubling disregard for the women’s dignity, agency, and desire to optimize outcomes and experiences for themselves and their babies, including:

• Many were pushed to have elective inductions (and even cesareans) based on predictions of a large baby that turned out to be of normal or even low birth weight
• A shared decision-making tool showed that many women encouraged to have elective inductions at term received incomplete or no information about alternatives
• Many with one or two prior cesareans wanted to plan a vaginal birth but were denied that option due to provider and/or hospital unwillingness
• Many who wanted to eat and drink during the hard physical work of labor were prohibited from doing so
• Most who had an episiotomy (a cut in their perineum to enlarge the vaginal opening) had no say in the decision, despite the procedure being rarely beneficial and having clear risks
• Many who intended exclusive breastmilk feeding encountered hospital practices, such as formula samples and supplemented feeding, that actively worked against that goal

Because I was on methadone and temporarily homeless, they were terrible to me and my husband.

Perinatal mental health conditions are common and mostly untreated

I felt unheard at my prenatal appointment. I was moderately depressed, and the doctor said nothing about it and didn't supply me with any support.

Mothers reported high rates of symptoms of anxiety and depression before pregnancy, during pregnancy, and in the initial months after birth – yet most received no treatment, whether counseling or medication. Particularly alarming is how many experienced severe psychological distress while simultaneously caring for a newborn and navigating the many adjustments of early parenthood. Substance use disorder and the continuing effects of traumatic experience were also identified. Respondents also shared a range of other diagnoses they had received.

I wish there was more support for me and the depression I felt early on after delivery. I felt like my feelings and concerns were ignored and felt very alone.

Whereas postpartum depression has historically received the most attention, symptoms of anxiety were consistently more prevalent than depression. Rates of both depression and anxiety were high across all time periods - before pregnancy, during pregnancy, and in the initial months after birth.

Women and their families had unmet social needs

[The worst thing was] becoming homeless while my newborn was 2 months old and breast milk drying up from the stress and switching her to formula.

A validated social needs screener identified the percentage of respondents facing the following challenges during pregnancy and the percentage whose pregnancy social needs had not resolved when they completed the questionnaire:

• Unemployment or a lack of a regular income
• Trouble paying utility bills
• Child care needs
• Difficulty finding or paying for transportation
• Food insecurity
• Homelessness or housing instability
• Threats or abuse by someone at home
• Feeling unsafe in daily life
• Concern about alcohol or drug use by someone in the home

Respondents completed the questionnaire an average of 52 weeks after giving birth. Most reported that the social needs they had identified had not been resolved at that time.