For the last few decades, pregnancy and birth in the U.S. has been in rough shape. Our maternal mortality rates are some of the worst among similarly resourced countries, while we also contend with some of the highest costs associated with birth. Under the recent Joe Biden administration, the nation finally began to see some positive changes, particularly a decrease in maternal mortality rates. Now, with Donald Trump back in office, pregnant people will likely face worsening conditions, resulting in more complications, harm, and even deaths.

So what will happen under a second Trump term? His first term, recent campaign promises, and first month in office could offer some clues. Under the first Trump administration, maternal mortality rates in the U.S. increased considerably, from 17.4 per 100,000 live births in 2018 to 32.9 in 2021. In this same timeframe, Black women died at more than double the rate of their white counterparts.

Improvements that came after Biden took office brought the maternal mortality rates back down. In 2022, maternal mortality rates decreased significantly for people of all races, with an overall rate of 22.3 deaths per 100,000 live births. Then again, in 2023, maternal mortality rates dropped even lower, with an overall rate of 18.6 deaths per 100,000 live births. (However, it should be noted that the maternal mortality rate for Black women increased, widening disparity.) While these rates are still far above the global average among our peers, the fact that maternal mortality rates have slowly started to lower is promising, and is a real start to tackling other issues impacting pregnancy and birth in this country.

However, combined with the fallout from Dobbs v. Jackson Women’s Health Organization, a second Trump administration will likely result in a deterioration of access to and quality of reproductive care that could cause mortality rates to spike again.

Insurance coverage is also likely to take a hit. Subsidies from the Affordable Care Act are set to expire at the end of 2025, and it’s very unlikely that Trump and a Republican Senate will extend them, making health insurance unaffordable for millions of Americans. In addition, Trump is expected to cut Medicaid, a program that currently covers around 40 percent of all births in the country. Both of these insurance-related issues will have dire effects. Low-income pregnant folks may no longer be able to afford coverage. And those with limited or expensive coverage may not be able to afford their medical bills. This may lead to patients cancelling prenatal appointments and recommended medical testing in hopes of saving money. The American College of Obstetricians and Gynecologists recently put out a statement urging the protection of Medicaid, stating that “cuts to Medicaid will result in preventable deaths.”

But unfortunately, the threat to the government program remains very real.

We know that those who go with little to no prenatal care are more at risk for pregnancy and birth complications. In fact, expectant parents who aren’t able to access prenatal care are three to four times more likely to experience pregnancy-related complications. The report also found that infants with parents who received no prenatal care were five times more likely to die than the children of those who did get prenatal care. Lack of affordable insurance coverage means less consistent care. Combined with an expanding epidemic of maternal care deserts, this will increase risks during and after pregnancy.

We’ve also seen a rise in complications and death in pregnant people directly related to abortion restrictions that have cropped up across various states in the wake of a Trump-stacked Supreme Court overturning Roe v. Wade. A 2023 report from the Gender Equity Policy Institute revealed that mothers living in states with abortion bans were three times more likely to die than those who did not.

“People in banned and restrictive states have worse outcomes than their counterparts in supportive states,” the report read.

More than 50 percent of women live in states that ban or restrict abortion care and other reproductive health care, making them much more vulnerable to challenging pregnancies and negative birth outcomes. Like most prenatal and birth complications, these risks impact people of color at higher rates.

And it’s not just mothers: A new study published in the Journal of the American Medical Association found infant mortality rates were 5.6 percent higher than expected in states with abortion bans.

Abortion bans are also contributing to the rising maternal care deserts as doctors flee to practice in places where they can’t be sued or prosecuted for providing the appropriate care. This is leaving many expectant families in anti-choice states with little to no care.

Trump will never sign a federal right to abortion care into law. And while some states did their best to codify access to reproductive health care into their own laws, many others are restricting the rights of their citizens, creating deteriorating conditions for pregnant people.

And worst case scenarios have already happened. Last year, a Texas teenager named Neaveah Crain died after doctors continuously delayed providing life-saving treatment. The state’s abortion ban threatens prison time for medical interventions that end a fetal heartbeat. Just this month, ProPublica reported that sepsis rates skyrocketed after Texas’ abortion ban.

Most recently, the Centers for Disease Control put the federal data collection system used to identify and track “groups of women and infants at high risk for health problems,” with the goal of improving health outcomes, on indefinite hold.

There is also Robert F. Kennedy Jr., the new head of the U.S. Department of Health and Human Services, to contend with. He espouses a dangerous amount of disinformation and has flip flopped on issues including abortion. Kennedy is a danger to reproductive rights, which by proxy will impact the state of pregnancy and birth.

So how can we push back to ensure that the risks associated with pregnancy and birth don’t increase?

The reality is that for the next four years, we cannot rely on the Trump administration to protect us. We’re going to have to take care of ourselves and our communities, while advocating at the state and local level.

Push your representatives to support legislation that expands access to care. Currently, states must act individually to extend Medicaid postpartum coverage. Check to see how long your state allows for postpartum coverage and then reach out to your state representatives to ensure they vote to expand and extend that window. You can also push them to support the Momnibus Act, a comprehensive set of bills aimed at addressing our maternal health crisis by expanding Medicaid coverage, improving maternal health data, and increasing support for mental health services.

When it comes to navigating maternal care deserts, expand your idea of what kind of providers can offer care. If you have a low risk pregnancy, you may be able to get quality care from a provider who isn’t an OB-GYN. Doctors who practice family medicine can provide quality prenatal and postpartum care, and patients are more likely to find and attend these appointments if they’re easily accessible and nearby.

In addition to expanding your idea of which kind of doctors can provide you care, consider midwives. They can be a great fit for your situation, particularly if you’re low risk. That might mean overhauling how you envisioned your birth, but depending on your health and needs, you can receive excellent, individualized care at a freestanding birth center or with midwives who attend home births.

Fourth, advocate for your state to expand what kinds of health-care providers can do work legally. Every state is different when it comes to midwifery care. If you live in a state that places a lot of restrictions on midwives, or has archaic rules about who can run and staff a free-standing birth center or other community-based model, look to see who is already pushing back and join them. Check if there are any existing bills to expand midwifery care and reach out to your local representatives to encourage their support.

Lastly, push your lawmakers to vote in favor of legislation that makes your state more abortion-friendly. Securing the right to abortion care would alleviate some of the challenges pregnant folks currently face in some states. Help keep skilled and experienced doctors in your state by supporting shield laws that protect abortion providers. And despite Trump claiming he will not make abortion illegal on a federal level, we know he is not a man of his word. Reach out to your representatives in Congress and impress upon them the importance of holding Trump to his word if the federal right to abortion is ever threatened.

We’ve seen the harm that Trump’s first term took on maternal health in this country. We can’t afford to wait around to see what the results of his next administration will be.

UPDATE, March 3, 2025: This article has been updated to clarify the CDC’s guidance on the Pregnancy Risk Assessment Monitoring System.