Women in the US face a problem unique in the developed world: A startlingly high percentage are dying before, during, or soon after childbirth. And it’s worse for women of color.

According to a 2018 study by the Commonwealth Fund, there were 14 deaths for every 100,000 pregnant women in 2015. And per an investigation by ProPublica and NPR, 700 to 900 women had died of childbirth-related complications in 2016. That’s more than twice the maternal mortality rate in Canada, Sweden, and Germany, and far higher than that of any other developed country. There’s also a major racial disparity in the women who are affected: Black women are currently dying at three to four times the rate of white women.

This problem is shocking, and it’s only gotten worse in the past two decades. As the maternal mortality rate has risen, the issue has attracted growing scrutiny from policymakers — including the 2020 Democratic candidates.

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While only a few 2020ers, including Sens. Elizabeth Warren, Kamala Harris, Cory Booker, and Kirsten Gillibrand, have laid out specific plans on the subject, candidates are increasingly calling out the need to address this issue. And plenty of voters are raising the question at key policy forums, such as She the People, a gathering in Texas that centered specifically on women of color.

Candidate proposals would target a couple of gaps, including the lack of federal data about why women are dying, the need for more standardized hospital training to address complications during childbirth, and the need for implicit bias training to counter discrimination by physicians and medical institutions.

Several candidates also support providing mothers with expanded Medicaid coverage, something that pregnant women are only currently guaranteed for two months after childbirth, leading to a sudden loss of health insurance for many new parents.

Given the urgency of this public health crisis, it’s evident that combating maternal deaths should be at the forefront of any 2020 conversation about health care. The candidate and voter focus on the issue is making sure it is.

Several candidates have proposed bills that would address this problem on a federal level

Multiple 2020 candidates who currently serve in Congress have introduced bills that try to target maternal mortality at the federal level, and they would build on legislation that passed last year, which authorized more than $10 million for states to track maternal deaths.

Presently, the effort to combat maternal mortality lies primarily with the states. While more than 35 have commissions established to target this issue, experts say a more robust, centralized setup could ensure better resources and policy recommendations. In many other countries, including England, a nationwide focus on this problem has helped reduce the rate of maternal deaths significantly.

Additionally, policymakers could use more comprehensive information at a federal level to further understand the causes of maternal deaths — fatalities that have been tied to chronic cardiovascular health conditions and an increasing use of C-sections, as well as lack of medical care in the months after childbirth.

The various proposals offered by 2020 Democratic candidates would take a few different approaches.

A bill from Gillibrand, co-sponsored by Harris and Booker, would call on states to submit an annual report to the Department of Health and Human Services and allocate funding to hospitals to improve their training procedures. Another from Booker and Rep. Ayanna Pressley that’s also backed by several other 2020 Democrats, would expand Medicaid coverage for pregnant women.

Proposals from Harris and Warren, respectively, would also seek to home in on racial disparities. Harris’s, reintroduced in the Senate this year, includes funding for implicit bias training and the establishment of a pilot program that includes additional support for mothers on Medicaid throughout their pregnancy. Warren’s, meanwhile, would penalize hospitals that do not show sizable reductions in the maternal mortality rates of black moms.

Several states have seen some success in their attempts to address maternal mortality, including California, which has cut its maternal mortality rate by 55 percent since 2006. A key aspect of its approach is a central, state-run group that helps different hospitals develop standardized toolkits and training for dealing with common pregnancy complications.

North Carolina, too, has seen progress in reducing racial disparities after assigning pregnant Medicaid beneficiaries a caseworker who checks in with them throughout the process and keeps tabs on their appointments and medical needs. Across programs that have been effective in curbing maternal deaths, 60 percent of which are preventable according to the Centers for Disease Control and Prevention, the focus has been on better in-hospital training as well as more comprehensive support of mothers before and after pregnancy.

Whether the success of these approaches could be replicated on the federal level is an open question. With the Democratic primary well underway, we asked the 25 candidates where they stand on the issue and how they would attempt to address it.

Here’s where the candidates stand on maternal mortality based on responses they’ve shared

Sen. Amy Klobuchar (D-MN)

If elected, Klobuchar has pledged to address maternal and infant mortality in her first 100 days as president. In her First 100 Days plan, she writes that she “will immediately implement a new law that tackles the shortage of maternity care health professionals — including nurses, midwives, and obstetricians — in underserved areas,” and she “will develop best models of care to address racial disparities in maternal and infant mortality.”

In the Senate, Klobuchar is a co-sponsor of Harris’s bill, the Maternal CARE Act, which provides funding for bias training and support for mothers on Medicaid. She is also a co-sponsor of similar legislation introduced by Illinois Sens. Dick Durbin and Tammy Duckworth, and a bill introduced by Ohio Sen. Sherrod Brown that would make pregnancy a qualifying life event allowing people to enroll in Affordable Care Act marketplace insurance plans outside of open enrollment periods.

Andrew Yang

Yang did not immediately respond to Vox’s request for comment.

Sen. Bernie Sanders (I-VT)

“Black women and Native American women are about three times more likely to die from pregnancy than white women — and that gap is also growing,” said Sarah Ford, deputy communications director for the Sanders campaign, in a statement to Vox. “The United States is the only high-income nation where maternal mortality has been increasing. If we are serious about fixing our unjust health care system, we must address racial disparities in America as we work to make health care a right to all.”

Sanders is a co-sponsor of Harris’s Maternal CARE Act as well as the maternal health legislation introduced by Durbin and Duckworth.

Former Rep. Beto O’Rourke (D-TX)

As president, O’Rourke would work with Congress on legislation to guarantee universal access to health care, ensuring that pregnant people and new parents get the care they need, a campaign spokesperson told Vox in an email. He would also work to increase funding for Title X family planning programs, which pay for screenings for cervical cancer and other problems that can affect maternal health.

O’Rourke would also support the congressional Black Maternal Health Caucus. “As he did while serving in the House, he will support legislation to provide grants to states designed to collect accurate data on the causes of maternal deaths, make recommendations to help reduce maternal deaths, and ensure health providers are educated on how they can improve care,” the spokesperson said. “The key to tackling the maternal mortality crisis head-on will be listening to women of color and learning from their experiences.”

New York City Mayor Bill de Blasio

The de Blasio campaign has not yet answered Vox’s question on maternal mortality.

Sen. Cory Booker (D-NJ)

Along with Rep. Ayanna Pressley (D-MA), Booker earlier this year introduced the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act, which would extend Medicaid coverage for new mothers to a full year past childbirth; ensure that all their health care is covered, not just pregnancy-related services; and facilitate access to doula care, among other provisions.

“Black women are nearly four times as likely to die from complications related to pregnancy than white women — in New Jersey they are five times as likely,” Booker said in a statement introducing the bill. “By expanding Medicaid coverage for pregnant women, we can begin to stem the rising tide of maternal mortality and close the egregious racial gaps that exist in maternal and infant health outcomes.”

Sen. Elizabeth Warren (D-MA)

At the She the People forum in April, Warren proposed a plan to reward hospitals that reduce black maternal mortality rates and punish those that fail to do so. “I want to see the hospitals see it as their responsibility to address this problem head-on and make it a first priority,” she said.

The proposal initially received some criticism, with Sarah Jones of New York magazine writing that “a financial penalty for low-quality care could overburden hospitals that already lack the resources they need to serve their patients.”

But Warren subsequently laid out more details in an op-ed in Essence. Her plan, based on payment and care delivery reforms under the Affordable Care Act, would track how hospitals perform when it comes to safe and healthy childbirth and postpartum care.

“If health systems are able to coordinate their care and improve overall outcomes — like raising survival rates, reducing complications, and narrowing the mortality and morbidity gap between white women and women of color — they can earn a bonus,” Warren wrote. “If care doesn’t improve, they’ll be on the hook. But they won’t be abandoned. Paying for better care means both rewarding excellent health systems and identifying, investing in, and demanding more from struggling ones.”

In her op-ed, she also called for pushing hospitals “toward greater workforce diversity so care teams look more like the communities they serve,” and wrote that “women who have given birth, experienced complications, and lost babies — particularly women of color — and family members who have lost loved ones should not just be at the table: they should be calling the shots.” She also expressed support for both Harris’s and Booker’s bills.

Rep. Eric Swalwell (D-CA)

Swalwell told Vox in a statement that he would invest in maternal health as part of his initiative to find cures for health problems affecting Americans.

The California Democrat said he is “the only candidate calling for a massive public investment in finding cures and treatments for the deadliest and most debilitating diseases that ail us. Investing in maternal health must be part of that.”

He also said he would set aside funds for research into racial disparities in maternal mortality, as well as education for health care workers in avoiding unconscious bias.

“We also must be mindful of social and environmental justice issues that impact Black women’s health, from urban industrial pollution to nutritional access and food security,” he added.

Washington Gov. Jay Inslee

Inslee sees maternal mortality “as a racial equity issue, as women of color face maternal mortality rates as high as those in developing countries,” a campaign spokesperson told Vox in an email. To address the problem, the candidate “believes we should create local maternal mortality review committees, comprised of local health experts to evaluate local issues around maternal health,” the spokesperson added.

Meanwhile, Inslee would also “require that federally-funded health research include focused studies on women’s health,” including efforts to evaluate the effects of medications on women specifically, the spokesperson said.

Former Vice President Joe Biden

“Vice President Biden believes it is inconceivable that we have the highest maternal mortality rates in the developed world,” the Biden campaign said in a statement to Vox.

“Vice President Biden is committed to addressing this epidemic and believes we must invest significant resources, including by gathering critical data, investigating the deaths of those lives lost and increasing funding and access to services to improve the overall health and health care of women before, during, and after pregnancy.”

The campaign also said that the candidate would soon be releasing “a health care plan that builds upon the success of the Affordable Care Act and dedicates the full force of our nation’s expertise and resources to tackle our greatest public health challenges, including maternal mortality.”

Former Rep. Joe Sestak (D-PA)

Sestak’s campaign did not immediately respond to a request for comment.

Former Rep. John Delaney (D-MD)

“For the amount of money the US spends on health care, the high maternal mortality rate is unacceptable,” a campaign spokesperson told Vox in an email. “Delaney’s universal health care plan, BetterCare, would guarantee health care for all Americans and ensure that all women receive the necessary medical services for pregnancy, maternal care, and pre-existing conditions. In addition, Delaney would protect funding for critical organizations and programs that support women’s health care, including Planned Parenthood and community health centers.”

Former Colorado Gov. John Hickenlooper

As president, Hickenlooper would support the passage of Durbin and Duckworth’s maternal health legislation, the Mothers and Offspring Mortality and Morbidity Awareness (MOMMA) Act. Among other provisions, the bill would extend Medicaid coverage for mothers to one year postpartum, and include support for data collection and analysis around maternal mortality.

Former Housing and Urban Development Secretary Julián Castro

Castro’s campaign did not immediately respond to a request for comment.

Sen. Kamala Harris (D-CA)

Harris reintroduced a bill to target the racial disparities in maternal mortality earlier this year. Her legislation, the Maternal CARE Act, includes $25 million in grant funding for implicit bias training. Additionally, it would allocate $125 million for programs providing support to moms throughout their pregnancies, including an effort modeled after North Carolina’s successful Medicaid initiative.

“Black mothers across the country are facing a health crisis that is driven in part by implicit bias in our health care system,” Harris said in a statement. “We must take action to address this issue, and we must do it with the sense of urgency it deserves.”

Harris is also a co-sponsor of bills from Gillibrand and Booker that would try to expand postpartum Medicaid coverage for new moms and establish a nationwide approach to tracking data on the subject.

Sen. Kirsten Gillibrand (D-NY)

Gillibrand introduced a bill, dubbed the MOMS Act, last August. The legislation would expand a program at HHS dedicated to examining maternal deaths and identifying standardized solutions. It would also press states to send data about maternal deaths to HHS on an annual basis, and authorize $40 million in grant money to help hospitals implement training for doctors responding to complications that arise during pregnancy.

“This much-needed legislation would help our hospitals monitor all mothers before, during, and after they give birth, for preventable but potentially fatal conditions like hemorrhage and preeclampsia, and it would provide them with the federal funding they need to purchase supplies to implement new procedures and effectively treat patients,” Gillibrand said in a statement last year.

As part of a Family Bill of Rights she rolled out this year, Gillibrand also noted that she’s dedicated to increasing the number of OB-GYNs in rural areas. She is a co-sponsor of bills from Booker and Harris that address this subject as well.

Marianne Williamson

“We need to review the cases of women who have died, figure out what went wrong, and take action to prevent more maternal deaths,” says a Williamson spokesperson. Williamson pointed to the “Every Mother Initiative” established by the Association of Maternal and Child Health Program as an “encouraging model.”

The initiative spanned 12 states and reviewed the causes of maternal death in each to pinpoint potential solutions. “It would be good to explore building this capacity nationwide to reduce maternal mortality,” Williamson’s spokesperson said.

Sen. Michael Bennet (D-CO)

“Michael believes that first and foremost, we must expand access to health care — including primary and maternity care,” said a Bennet spokesperson. “He also believes that the best path to achieve that is with Medicare-X, his plan to create a strong public option that provides people with the choice of buying into that option or keeping the insurance they receive through their employer or union.”

Medicare-X would include maternity care, the spokesperson noted. Additionally, Bennet backs home visitation programs to help support new moms, the use of telemedicine to help assist moms in rural areas, and increasing the number of OB-GYNs in rural areas.

Former Sen. Mike Gravel (D-AK)

Gravel’s spokesperson noted that the campaign does not have a specific maternal mortality policy but indicated that its plans to expand health care coverage would help address the issue.

“We also need to increase the numbers of doctors per patient, and we make this happen by making it a funding commitment,” a Gravel spokesperson said. “In systems where there is a greater ratio of doctors to patients, maternal mortality falls.”

South Bend, Indiana, Mayor Pete Buttigieg

“He will address the maternal mortality crisis by taking a comprehensive approach to improving the health and well-being of women before, during, and after pregnancy, with special attention to eliminating the disparities for women of color,” a Buttigieg spokesperson said.

Buttigieg’s plans include supporting the expansion of Medicaid coverage for pregnant mothers to one year post-childbirth, backing implicit bias and discrimination training for the health and human services workforce, and establishing state-based maternal mortality registries to track the problem.

Buttigieg would also support training for non-OB-GYN clinicians to provide maternal care in rural areas and urban hospitals, and encourage prenatal home visits and the use of telemedicine to expand access to care.

Rep. Seth Moulton (D-MA)

“California’s example in this is important and illustrative,” said a Moulton spokesperson. “It substantially lowered its maternal mortality rate by taking up the recommendations of a commission, the CMQCC, that it formed to study the problem. They found, among other initiatives, that lowering the rate of C-section births and requiring easy access to hemorrhage carts during labor can lower mortality rates substantially.”

Moulton proposes implementing reforms that have been used in California on a nationwide basis.

He also notes that addressing the issue of maternal mortality is closely tied with tackling systemic problems of racial bias and discrimination. “Closing regional and racial gaps in education funding and achievement, criminal justice, and other socioeconomic disparities will be a focus of my administration,” the spokesperson said.

Montana Gov. Steve Bullock

Bullock would “increase federal funding to community health centers, health care providers, and state and local health departments,” according to a campaign spokesperson, focusing more support on places that have high rates of maternal mortality.

“Governor Bullock will also ensure we’re continually improving care by establishing maternal mortality review committees (MMRCs) comprised of local health experts to study maternal deaths and recommend improvements for future care,” the spokesperson said. Bullock has overseen Medicaid expansion in his state as governor and established a public-private partnership aimed at improving mothers’ access to prenatal and perinatal care.

Rep. Tim Ryan (D-OH)

Ryan’s campaign did not immediately respond to a request for comment.

Rep. Tulsi Gabbard (D-HI)

Gabbard’s campaign did not immediately respond to a request for comment.

Miramar, Florida, Mayor Wayne Messam

Messam’s campaign did not immediately respond to a request for comment.

We want to hear from you

For now, the US remains one of the most dangerous high-income countries in the world for women to give birth. That’s why ProPublica and Vox are teaming up for a reporting project about mistreatment in pregnancy and childbirth, and how gaps in health insurance and access affect women’s health care experiences. Please help our reporting by filling in our callout or emailing the reporters at maternal@propublica.org.