PHILADELPHIA — The Philadelphia Department of Public Health (PDPH) today released Philadelphia Maternal Mortality, 2019-2023, a comprehensive report examining maternal deaths in Philadelphia over a five-year period and identifying opportunities to improve care and prevent future deaths.
Compiled by Philadelphia’s Maternal Mortality Review Committee (MMRC), the report examines the medical and social circumstances surrounding maternal deaths to identify gaps in health care delivery, social services, and community resources. The findings inform recommendations aimed at improving maternal health and perinatal outcomes across Philadelphia.
Maternal mortality (defined as death during pregnancy or within one year of the end of pregnancy) has risen nationally over the past three decades. In Philadelphia, the MMRC conducts in-depth, multidisciplinary reviews of maternal deaths to better understand the medical, social, and systemic factors contributing to each loss and identify opportunities for prevention.
“Maternal health is a fundamental indicator of our city’s overall health,” said Dr. Palak Raval-Nelson, Commissioner, Philadelphia Department of Public Health. “Every maternal death and severe complication has a profound impact on families and communities. This report is more than just a collection of data; it is a roadmap for structural change, policy updates, and targeted programmatic interventions designed to save lives and ensure perinatal well-being across all Philadelphia communities.”
Key highlights and context from the Philadelphia Maternal Mortality, 2019-2023 report include:
- This report describes findings from 120 cases of pregnancy-associated death that occurred between 2019 and 2023, which were reviewed by the MMRC.
- The report identifies the leading causes of pregnancy-related deaths as unintentional drug overdose, infection, and cardiovascular conditions.
- Mental health conditions (other than substance use disorder) were determined to be a contributing factor in 42% of pregnancy related death cases.
Managed by the PDPH Division of Reproductive, Adolescent, and Child Health (ReACH), the MMRC operates within the Birth Justice Philly program, leveraging data directly from these reviews to implement community-centered perinatal health initiatives. The report presents recommendations to strengthen clinical care, enhance cross-system coordination, integrate behavioral health supports, and rebuild trust between communities and health care institutions.
“Data is our most powerful tool for accountability and action,” said Dr. Aasta Mehta, ReACH Director, Philadelphia Department of Public Health. “The findings from the 2019-2023 report will directly shape our community-centered initiatives under Birth Justice Philly, ReACH, and the entire Health Department. By using these insights to break down silos across systems, we can ensure that every birthing person in Philadelphia has the support and resources they deserve to thrive.”
While these deaths occurred in 2019-2023, maternal mortality case review takes a significant time to identify cases, conduct all necessary data collection and abstraction, and then review at a committee meeting, which is why these recommendations are being released in 2026.
Established in 2010 as the first city-level (non-statewide) review committee in the country, the Philadelphia MMRC has reviewed more than 400 cases to date, providing community-informed insight into the specific local factors driving maternal mortality.
The full report, Philadelphia Maternal Mortality, 2019-2023, is available at BirthJusticePhilly.com.