2024 State Scorecard on Women’s Health and Reproductive Care

Scorecard Highlights

• Massachusetts, Vermont, and Rhode Island top the rankings for the 2024 State Scorecard on Women’s Health and Reproductive Care, which is based on 32 measures of health care access, quality, and health outcomes. The lowest performers were Mississippi, Texas, Nevada, and Oklahoma.
• Deaths from all causes among women of reproductive age — 15 to 44 — were highest in southeastern states. Causes of death include pregnancy and other preventable causes such as substance use, COVID-19, and treatable chronic conditions.
• The highest maternal death rates were in Tennessee, Mississippi, and Louisiana. Vermont, California, and Connecticut had the lowest rates. Nationally, rates were highest for Black and American Indian and Alaska Native (AIAN) women.
• Mental health conditions are the most frequently reported cause of preventable pregnancy-related death, including deaths by suicide and overdoses related to substance use disorders. States that screened for postpartum depression at the highest rates also had lowest rates of postpartum depression.
• Among women of reproductive age (ages 15–44), those in Texas, Georgia, and Oklahoma were uninsured at the highest rates; those in Massachusetts, the District of Columbia, and Vermont had the lowest uninsured rates. Women in states that had not expanded Medicaid eligibility were among those most at risk of lacking coverage.
• The U.S. Supreme Court decision overturning Roe v. Wade in June 2022 has significantly altered both access to reproductive health care services and how providers are able to treat pregnancy complications in the 21 states that ban or restrict abortion access.

Overview

The health of women in the United States is in a perilous place. Deaths from preventable causes are on the rise and deep inequities persist, leading to stark racial differences in maternal mortality and deaths from breast and cervical cancers. Despite a small rebound in women’s life expectancy in 2022, it remains at its lowest since 2006.¹

These troubling health trends are occurring while women are experiencing the consequences of state policy choices and judicial decisions that limit their access to the full range of health services and reproductive care. Ten states have yet to expand eligibility for Medicaid, leaving nearly 800,000 women uninsured.² A highly variable state-by-state approach to the unwinding of pandemic-era Medicaid coverage has left millions of women either newly uninsured or with significant gaps in their coverage.³

These coverage losses are not only interfering with women’s access to care, but they’re also leaving providers that serve low-income women at risk of closure. A recent survey found that 95 percent of community health centers, which care for 40 percent of low-income women nationwide — almost half of whom are covered by Medicaid — reported having patients who were disenrolled.⁴

The 2022 U.S. Supreme Court case overturning Roe v. Wade has further fractured women’s health care access and dramatically affected the ability of providers to treat pregnancy complications. In the wake of the decision in Dobbs v. Jackson Women’s Health Organization, 21 states have tightened or imposed new limits or bans on abortion.⁵ Florida’s six-week ban went into effect in April 2024, severely limiting abortion access for women across the South, since all southern states now ban or restrict abortion. Even prior to Dobbs, most of these states had few maternity care providers; higher rates of maternal mortality, especially among women of color; and wide racial and ethnic disparities in their health systems.⁶ In 2022, the year of the Dobbs decision, residents of more than one-third of U.S. counties had little or no access to maternity care.⁷

Tighter limits and additional bans on abortion are certain to drive more maternal and reproductive health care providers to shut down or leave their states, deepening the crisis of access to maternity care. Abortion bans threaten American’s future access to care across all medical specialties; in fact, since 2022, medical residency applications in states with bans have declined by more than those in other states.⁸

Women’s access to contraception and infertility treatments is also at risk. In February 2024, Alabama’s supreme court gave stored embryos the same legal protections as children. This ruling disrupted the care of women undergoing in vitro fertilization (IVF) treatment in Alabama until the state’s governor signed legislation in March providing civil and criminal immunity to IVF providers. In some states, widespread misinformation and misunderstanding could also lead policymakers to place limits on contraception in the new landscape created by the Dobbs decision.⁹

Clearly, women’s health is under threat. That’s why the Commonwealth Fund has developed the first-ever state scorecard to track trends in women’s health over time and document how policy choices and judicial decisions may impact women’s access to timely health care.

Our State Scorecard on Women’s Health and Reproductive Care uses the most recent data to assess how well the health care system is working for women in every U.S. state. We measured performance by 32 different metrics across three areas: health outcomes; health care quality and prevention; and coverage, access, and affordability. This report presents state rankings for each area.

Massachusetts is the best-performing health system for women overall, ranking among the top states on each of the three dimensions of health system performance. Vermont, Rhode Island, Connecticut, and New Hampshire rounded out the top five.

The lowest-ranked states overall are Mississippi, Texas, Nevada, Oklahoma, and Arkansas. The highest-ranked states are concentrated in New England, the Mid-Atlantic, and the northern Midwest. The lowest-ranked states fan out across the Southeast and Southwest.

Key Scorecard Findings

Health Outcomes

For health outcomes, we measured all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence. The top-performing states are Massachusetts, New Jersey, and Connecticut, while Mississippi, Arkansas, and West Virginia rank lowest.

A key measure of health outcomes is the all-cause mortality rate for women of reproductive age, 15 to 44. The top causes of mortality for women in this age group include those from preventable causes such as pregnancy-related, substance use, breast and cervical cancer, and COVID-19.¹⁰ In 2022, mortality for women of reproductive age was higher in the Southeast than in any other region. The death rate ranged from 203.6 per 100,000 in West Virginia to 70.5 in Hawaii.

Inadequate access to health services before, during, and after pregnancy, combined with disparities in socioeconomic status, underlying health, and quality of care, have helped drive the maternal mortality rate in the U.S. higher than that of other high-income countries.¹¹ Maternal death rates are highest among Black and American Indian and Alaska Native (AIAN) people,¹² as both populations were hit hard by the COVID-19 pandemic, especially AIAN women. Despite historically lower rates of maternal mortality, Hispanic women also experienced a rising maternal death rate during the pandemic.¹³

Research shows that in addition to the effects of COVID-19 infections, the pandemic exacerbated existing barriers to maternal care, including reductions in transportation services and childcare.¹⁴ Maternal mortality rates fell back to prepandemic levels in 2022, but the highly elevated rates among Black and AIAN women persist.

The highest rates of maternal mortality can be found in the Mississippi Delta, which includes Arkansas, Louisiana, Mississippi, and Tennessee. A substantial percentage of counties in all these states don’t have a single hospital or birth center with obstetric providers offering obstetric care.¹⁵

These states also rank low on other potential contributors to maternal mortality: low rates of postpartum depression screening, high rates of low-risk cesarean births, and high uninsured rates prior to pregnancy. All four states had abortion restrictions prior to Dobbs, and they all now have full bans on abortion.

Syphilis infection among women of reproductive age has increased in nearly all states since 2019, with the highest rates in South Dakota, New Mexico, Mississippi, Arkansas, and Oklahoma. This continues an upward trend in syphilis infections among women that began in 2013.²² Rates are highest for AIAN women.²³ Research indicates that rising rates have been driven by nationwide increases in substance use, which may increase sexually risky behavior; limited access to care and health services for screening, diagnosis, and treatment, including screening during pregnancy; and isolated sexual networks within segregated communities.²⁴

Congenital syphilis rates have risen concomitantly with the growth in rates among women since 2013. Rates are highest for AIAN births.²⁵ Left untreated, syphilis during pregnancy can lead to severe complications, including increased risk of miscarriage, stillbirth, or early infant death. Newborns exposed to syphilis may experience long-term effects such as developmental delays and hearing loss.

To ensure timely detection and treatment, the U.S. Centers for Disease Control and Prevention recommends that all pregnant women be screened for syphilis early in pregnancy and again in the third trimester, as well as at birth for those at high risk. Some states, like California, recommend additional screening given the significant rise in infection rates.²⁶ Delays in accessing prenatal care can result in postponed screening and treatment. Early and effective treatment of syphilis during pregnancy can prevent adverse outcomes.²⁷

Health Care Quality and Prevention

In the area of health care quality and prevention, we measured births by cesarean section for low-risk pregnancies, preventive care use, prenatal and postpartum care, and mental health screening. Massachusetts, Rhode Island, and Connecticut are the top-performing states, while Nevada, Mississippi, and Texas are the lowest-performing.

Nearly one-third of U.S. births are performed through a cesarean section surgery, or c-section. While cesarean delivery can be lifesaving in certain situations, the procedure is also associated with increased maternal morbidity and mortality, longer recovery, adverse outcomes in subsequent births, and negative impacts on infant health.²⁸ As such, high rates of cesarean births for low-risk pregnancies are a key indicator of lower-quality health care.

The U.S. Department of Health and Human Services (HHS) set a goal of 23.6 percent or lower c-sections for low-risk births by 2030.²⁹ It was 26.3 percent in 2022.

Low-risk cesarean births are performed at the highest rates in the Deep South and in a few states in the Northeast, including New York and Connecticut. A county-level analysis found that rates of c-sections in the South were high in both urban and rural areas.³⁰ This research also found that regions with the highest rates of cesarean births were home to more Black and Hispanic people.

Low-risk c-sections were also more prevalent among people with private insurance versus Medicaid; older women versus younger women; and those admitted to hospitals on weekdays, which may reflect scheduling preferences. National low-risk cesarean birth rates have dropped since their peak in 2009, possibly reflecting national and state quality initiatives.³¹

The most frequent cause of pregnancy-related deaths during or after a pregnancy are suicide, overdoses, and other deaths attributable to underlying mental health conditions.³⁷ In a recent study, mental health conditions were the leading cause of pregnancy-related deaths up to a year postpartum among white and Hispanic women.³⁸

Postpartum depression, a common mental health condition after childbirth, can make it difficult for mothers to take care of themselves and their babies. Screening for postpartum depression is an important preventive tool. In June 2023, the American College of Obstetricians and Gynecologists released new recommendations to screen for depression at least twice during pregnancy and at postpartum visits.³⁹ Enhanced screening, support, and treatment before, during, and after pregnancy are key to improving maternal health outcomes.

Southeastern states, including Mississippi, Arkansas, and Alabama, had lower rates of depression screening for women who recently gave birth and higher rates of self-reported postpartum depression. Vermont, Massachusetts, and Minnesota had higher-than-average rates of screening and lower-than-average rates of self-reported postpartum depression.

Deaths from breast and cervical cancer are considered preventable and treatable with timely screening and health care. There is significant regional variation in death rates from both cancers. States with among the highest rates are clustered in the Southeast. Northeastern states generally have the highest breast and cervical cancer screening rates and the lowest mortality rates from these cancers; southern states tend to have higher-than-average mortality from these cancers and lower screening rates.

Significant inequities exist in breast and cervical cancer rates despite similar or higher screening rates among Black women.⁴⁰ Black women are more likely to be up to date on screening tests for breast cancer than white women and less likely to be diagnosed with breast cancer, but they are more likely to die from the disease. A combination of factors account for the higher breast cancer mortality that Black women experience, including a lower likelihood of adequate follow-up screening and treatment from health systems, poorer quality of care after an abnormal test, and diagnoses being made at a more advanced stage.⁴¹ Research has found that Black and Hispanic women have longer gaps between an abnormal mammogram and diagnostic follow-up than do white women.⁴²

Black women are similarly more likely to die from cervical cancer than white women. All women experience delays in follow-up care after abnormal cervical cancer screens, but Black women experience this at the highest rate.⁴³

One reason women may not get recommended follow-up tests after an abnormal cancer screen is cost.⁴⁴ While the Affordable Care Act (ACA) requires all private and public insurance plans to cover mammograms and cervical cancer screenings without copayments, the same does not apply to follow-up screenings like ultrasounds and colposcopies.⁴⁵

More rigorous collection of self-reported data on race and ethnicity in medical records and more research that includes Black, Hispanic, and AIAN women could shed more light on the wide disparities in cancer outcomes and aid in the development of targeted policies to close the gap.⁴⁶

Coverage, Access, and Affordability

In the area of coverage, access, and affordability, we measured insurance coverage, usual source of care, cost-related problems getting health care, and system capacity for reproductive health services. The top-ranked states are Vermont, the District of Columbia, and Maine; the lowest-ranked are Texas, Georgia, and Nevada.

Before the ACA became law, younger adults were uninsured at much higher rates than older working-age adults because they were less likely to have coverage through a job. The ACA provided new coverage options and protections for younger people. These include: the option to stay on a parent’s plan up to age 26; subsidized coverage through the marketplaces or Medicaid; bans on charging women of reproductive age higher premiums than men in the same age group; and requirements to cover services that women in this age group might need, including pregnancy care and contraception.

While the coverage age gap has narrowed since 2010, younger adults continue to be uninsured at higher rates than older working-age adults.⁴⁷ Among women, that gap persisted in most states in 2022. Women of reproductive age were uninsured at higher rates than women ages 45 to 64. Uninsured rates for women of reproductive age ranged from a low of 2.6 percent in Massachusetts to a high of 22 percent in Texas.

Persistent gaps reflect the lack of Medicaid expansion in 10 states; barriers to enrollment in Medicaid and the marketplaces for undocumented immigrants; and barriers for those eligible for coverage such as cost, lack of awareness, and periodic disenrollment from Medicaid due to fluctuations in income and other eligibility criteria.

Federal law requires all state Medicaid programs to provide pregnancy-related coverage up to 138 percent of the federal poverty level. Most make the income threshold higher, with 32 states setting it at 200 percent of poverty or above.⁴⁸

Additionally, states cannot impose cost sharing for pregnancy-related services in Medicaid, and they must cover women for 60 days postpartum, with the option to extend the postpartum period to 12 months. Forty-seven states have implemented the 12-month extension, and three states are either planning to or are seeking approval. Delaware and Tennessee recently received federal approval to provide diapers for Medicaid-insured newborns.⁴⁹

Because of these federal requirements and state options, Medicaid is a critical source of insurance for pregnant women, covering 42 percent of births in the U.S. It’s a particularly important source for Black people and AIAN people, covering two-thirds of their births. Consequently, in most states, uninsured rates for pregnant women are considerably lower than they are for women prior to conception. This gap is particularly wide in states that haven’t expanded their Medicaid programs, including Alabama, Georgia, Mississippi, and Tennessee.

Insurance coverage is essential for timely health care. In states with the highest uninsured rates, including Texas, women of reproductive age report skipping care because of costs at much higher rates than in states like Hawaii, where most women in this age group have coverage.

Women living in states that have not expanded Medicaid eligibility report skipping care because of costs at higher rates than those in states that have expanded. Of the 10 states with the highest rates of access problems, seven had not expanded Medicaid by January 2022; Oklahoma did so only recently, in 2021.

Immigration status can also undermine access to care. For example, Nevada, which has expanded its Medicaid program, has the highest number of undocumented immigrants, as a share of population, of any state.⁵⁰ Undocumented immigrants there are ineligible for Medicaid or subsidized health plans through the marketplaces; they can only get insurance through an employer or by purchasing a plan outside the marketplace, which is prohibitively expensive for most people.

A few states, including California, Colorado, Oregon, and Washington, have used state funds to expand access to health insurance for undocumented immigrants through Medicaid or the marketplaces.⁵¹ The Biden administration recently announced that it would allow young adult “Dreamers” — people who came to the United States as children and are protected against deportation by the Deferred Action for Childhood Arrivals (DACA) program — to gain coverage through the marketplaces starting in November 2024.⁵²

Finally, it’s important to note that while insurance is necessary for accessing care, it must also provide good-quality coverage. Thirty percent of women ages 19 to 44 are underinsured, meaning they have high out-of-pocket costs or deductibles relative to their income.⁵³ In this age group, women are underinsured at higher rates than men. Being underinsured, along with having a poor-quality provider network, paying off medical debt, and other factors, can leave even women with coverage unable to afford health care.⁵⁴

Having health insurance also doesn’t guarantee access to care if people don’t have ready access to providers. In 2023, 36 percent of U.S. counties were maternity care “deserts,” meaning they lacked a hospital or birthing center providing obstetric care and they had no obstetric providers.⁵⁶ Limited access to providers means that people will struggle to access obstetric care and face barriers to getting the full continuum of prenatal and postnatal care.⁵⁷ States where a large share of residents live in rural areas also tend to have the fewest obstetric providers.

Many experts are concerned that abortion bans or limits may inadvertently reduce the number of providers offering maternity care, owing to increased risk of legal action that practices face. The following states now ban abortion in nearly all circumstances or impose gestational limits:⁵⁸

• There are abortion bans in Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and West Virginia.
• There are gestational limits of six weeks in Florida, Georgia, and South Carolina; 12 weeks in Nebraska and North Carolina; and 15 to 18 weeks in Arizona and Utah.
• Courts in Montana and Wyoming have temporarily blocked those states' abortion bans, leaving in place their viability limits. The Iowa Supreme Court has ruled that the state's six-week gestational limit can soon be enforced as lawsuits against it proceed.

Of these 24 states, 21 have the fewest number of maternity care providers relative to the number of women who might need them. In 2023 and 2024, fewer medical school graduates applied to residency programs in states that banned abortion, both in obstetrics and gynecology and across all specialties, compared to states without bans.⁵⁹ This is an ominous development for these states, where providers are already scarce.

Women’s Health Is In a Perilous Place

Women of reproductive age have unique health care needs that have long left them vulnerable to health industry profit motives and discrimination, and political and judicial decisions that create barriers to their ability to access timely health care. Over the past 15 years, however, there has been a push to remove some of those barriers. For example:

• The ACA banned insurers in the individual market from charging young women higher premiums than young men and required them to cover maternity care, which they had rarely done prior to the law.⁶⁰
• The law required all private and public insurers, as well as employers, to cover contraception, with workarounds for religious objections subsequently added.
• The ACA expanded Medicaid eligibility and provided subsidies for marketplace coverage, reforms that halved the uninsured rate among women ages 19 to 64, from 18.5 percent to 9.7 percent, helping 8.4 million women gain coverage by 2022.⁶¹
• The Inflation Reduction Act of 2022 gave states the option of extending postpartum coverage to a full year. Prior to the ACA, pregnant women with incomes under 133 percent of poverty were made eligible for Medicaid up to 60 days postpartum. With more than half of pregnancy-related deaths occurring up to a year postpartum, nearly all state Medicaid programs have adopted this extension of coverage.⁶²
• The federal government and several states have implemented policies to reduce maternal mortality, including supporting state perinatal quality collaboratives and maternal mortality review committees.⁶³ Quality collaboratives are state or multistate networks of pediatricians, obstetricians, and midwives that are identifying weaknesses in perinatal care in their states and creating new approaches. Forty-nine states and the District of Columbia, New York City, and Philadelphia have formal maternal mortality review committees or legal requirements to review pregnancy-related deaths.⁶⁴
• In many states, efforts are underway to improve access to mental health care, substance use treatment, and preventive actions to control the upswing in syphilis cases.⁶⁵

But for women in many parts of the U.S., state variation in the implementation of federal law, along with recent court decisions, have erected obstacles to health care. Ongoing judicial action at the federal level, along with the potential for a policy reversal under the next administration, raise further concerns over the future of women’s health. For example:

• Ten states have yet to expand Medicaid, leaving nearly 800,000 poor women uninsured. While one or two smaller southern states may move forward in the next few years, expansion in the populous states of Florida and Texas continues to face political headwinds. A federal policy solution is needed to correct this major ongoing gap in insurance coverage for poor people, who are disproportionately Black and Hispanic.
• The future of women’s access to the full spectrum of reproductive health care is bleak in the nearly half of states where abortion access is either banned or significantly restricted.
• Women’s ability to prevent pregnancy using contraception, or to become pregnant using IVF, is under threat. Two landmark Supreme Court decisions in the 1960s and 1970s granted Americans a constitutional right to contraception.⁶⁶ But widespread misunderstanding and misinformation about reproduction and contraception could limit people’s access to contraceptives or interfere with widely used methods of getting pregnant.
• The outcome of the 2024 presidential election also may be a factor in women’s future access to reproductive health care. While the Biden administration has promulgated regulations and guidance in the wake of the Dobbs decision aimed at safeguarding women’s health and privacy, a Trump presidency may seek to undo those protections.⁶⁷

The State Scorecard on Women’s Health and Reproductive Care provides evidence of stark regional and racial and ethnic divides in state health system performance on women’s health care. The current and future policy environment could make those divides deeper still and weaken performance in even more states. Our findings suggest that urgent action by Congress and state policymakers is necessary to ensure women have timely access to complete health and reproductive care, regardless of who they are, what they earn, or where they live.