These are all the more confounding given the big picture of health care in Massachusetts: Nearly 98 percent of the population has health insurance \u2014 the highest in the nation \u2014 and the state ranks in the top 10 for lowest rates of infant mortality, maternal mortality, and pre-term births, according to the March of Dimes 2025 report<\/a>. <\/p>\n One development that has likely triggered a domino effect is the closure of 13 maternity units, totaling more than 100 beds, over the past decade<\/a>, many of which were located in distant, rural areas far from Boston and its wealthy, celebrated medical centers.<\/p>\n As hospitals close their labor and delivery units, prenatal care declines<\/a>, making it easier for doctors to miss high-risk conditions like high blood pressure. That can set the stage for more serious complications such as the blood pressure disorder pre-eclampsia, which increases the likelihood of C-sections \u2014 procedures with serious risks of their own. <\/p>\n Low-risk driving C-sections<\/p>\n The number of C-sections in Massachusetts is a particularly telling statistic: They are on the rise, with more than one-third of all births in the state being surgical. That\u2019s higher than the national average and, more important, is nearly double the optimal rate of 15 to 19 percent<\/a>, according to the World Health Organization.<\/p>\n Maybe most shocking is that a sizable share of those \u2014 nearly 40 percent \u2014 occur in what are initially deemed low-risk pregnancies.<\/p>\n Erin Yang had at first seemed a low-risk, \u201cstress-free\u201d pregnancy and was preparing for an uncomplicated vaginal birth by staying active, following pre-natal exercise, and working with a doula. She ran, swam, and even hiked the Alps until week 34. <\/p>\n But then a placental complication convinced her doctors to induce her labor in November. After 26 hours, her baby turned sideways, and doctors recommended a C-section, which she had hoped to avoid.<\/p>\n \u201cI had done everything to prepare for a smooth vaginal birth,\u201d said Yang, a biotech engineer. \u201cPart of me was sad, but part of me was relieved. They said I\u2019d meet my baby in 10 minutes.\u201d<\/p>\n C-sections are major surgeries that carry risks, including infection, blood clots, longer recovery times, and more complicated future pregnancies.<\/p>\n They have also been linked to disruptions in babies\u2019 immune and gut development, leading to higher risks of allergies and metabolic conditions later in life, as well as to maternal stress and anxiety.<\/p>\n Yang said her care team \u201csaved my life and my baby,\u201d but the experience was harrowing: A painful second IV triggered panic before surgery, and she later developed an infection in her incision. In the weeks after, she wondered whether the surgery might have been avoidable. \u201cIf labor were spontaneous, maybe it would have been preventable,\u201d she said. \u201cI\u2019m reconciling that induction meant my baby wasn\u2019t ready.\u201d<\/p>\n By one national standard<\/a>, no more than 23.6 percent of women with low-risk pregnancies should deliver via C-section. But a review by the state several years ago found that only five of 32 reporting hospitals met that standard: Beth Israel Deaconess Hospital, Plymouth; Beverly Hospital; Cape Cod Hospital; Lowell General Hospital; and Mount Auburn Hospital.<\/p>\n The differences in C-section rates among hospitals are striking. For example, patients at Holy Family Hospital in Methuen, then owned by the for-profit Steward Health Care, were 14 percent more likely to have a C-section than those at Mount Auburn Hospital in Cambridge, despite each having similar numbers of low-risk births, according to data from the Massachusetts Health Policy Commission covering 2016 to 2024. Holy Family has since been acquired out of Steward\u2019s bankruptcy by Lawrence General and on Wednesday announced it will close its maternity unit<\/a> as part of a consolidation. <\/p>\n While complications such as those Yang experienced explain some number of C-sections, some specialists say there are many other factors that are less obvious to determine if all the surgical births are justified.<\/p>\n \u201cThe right number of C-sections isn\u2019t zero,\u201d said Dr. Neel Shah, chief medical officer of Maven Clinic<\/a>, the world\u2019s largest virtual clinic for women\u2019s and family health. \u201cSometimes they are necessary to save lives. But even on a case basis, inevitability isn\u2019t always clear, even if we know from zooming out that the majority of C-sections performed today should be avoidable.\u201d<\/p>\n One possible explanation that he and other specialists point to is the hospital itself, its culture and policies, from routines and financial incentives to staffing patterns, and risk tolerance that shape how labor units operate. <\/p>\n In many hospitals, C-sections are faster, easier to schedule, and reimbursed at higher rates, while a vaginal birth can require staffing a labor and delivery unit around the clock, often costing hospitals more. <\/p>\n Shah said if he could change one thing about maternal health, it would be for insurance companies to pay more for vaginal births than C-sections.<\/p>\n \u201cIf we want to fix problems, we have to financially support them with resources. Hospitals can bill insurance more for C-section deliveries, but a vaginal delivery costs more due to the need to staff a labor and delivery unit through an 18- [to] 24-hour labor,\u201c he said.<\/p>\n Through research<\/a>, Shah\u2019s team found that a shortage of hospital beds can lead to a higher rate of C-sections. <\/p>\n He called the loss of 100 obstetric beds in Massachusetts over the last decade substantial. Among the hospitals that have shut their labor and delivery wards are North Adams, Harrington Memorial, Morton in Taunton, UMass Memorial Health Alliance Clinton\u2013Leominster, and Holyoke Medical Center \u2014 many of which served low-income communities and those of color.<\/p>\n \u201cI understand the economics that lead to hospitals closing maternity units for financial reasons, but if you look at where maternity units close, it disproportionately affects areas outside Boston, particularly rural areas of the Commonwealth like Western Massachusetts,\u201d he said.<\/p>\n \u2018Two complementary lenses\u2019<\/p>\n One hospital that can show visible progress is Mount Auburn in Cambridge, which has one of the state\u2019s lowest C-section rates. Its leaders credit a strong patient-centered approach, where midwives make up more than half of its 34 providers. The hospital delivers about 220 babies each month and invests in hydrotherapy, video translation, and team-based simulation training \u2014 efforts clinicians said help reduce unnecessary C-sections while maintaining safety. <\/p>\n \u201cYou create a culture that sees birth through two complementary lenses,\u201d said Julie Mann, a midwife and Director of Obstetrics, leading Mount Auburn\u2019s simulation training program. \u201cMidwifery training views it as a natural, physiologic process. Physician training focuses on identifying and managing medical complications. When you bring those approaches together, you get care that\u2019s both safe and deeply centered on the individual.\u201d<\/p>\n A third of Mount Auburn\u2019s patients are on MassHealth, and doula Cheyenne Bell regularly transfers her clients there because midwives and OB\/GYNs \u201ctake the time to support vaginal births,\u201d including breech deliveries that default to surgery elsewhere. <\/p>\n \u201cThey\u2019re not perfect, but Mount Auburn is almost like a birthing center inside a hospital,\u201d Bell said. <\/p>\n In 2024, Governor Maura Healey signed the Maternal Health Law, which creates licensing opportunities for birth workers, expands postpartum home visits, and extends MassHealth coverage to doulas<\/a>. A nine-member maternal health task force created by the law is expected to deliver additional recommendations this spring.<\/p>\n One fact before them: the large differences in outcomes between white patients and Black, Hispanic, Asian, and publicly insured patients, said Kara Vidal, director of the Health Policy Commission, who presented findings on the disparities to the task force last fall. <\/p>\n \u201cEven on measures where Massachusetts overall performs favorably compared to the US, we see these disparities,\u201d Vidal said. <\/p>\n Indeed, Black women consistently have the highest C-section rates in Massachusetts, at 39 percent in 2024, up from 31 percent in 2019.<\/p>\n Diana Louis of Somerville had an unplanned C-section at 33 weeks after a routine ultrasound revealed a drop in her baby\u2019s heart rate and blood flow through the umbilical cord. Louis later learned there was a problem with her placenta and questioned whether it could have been caught and addressed earlier.<\/p>\n \u201cI do wonder if I needed this and why it was overlooked in my prenatal care,\u201d she said.<\/p>\n Half of all births of Black children in Massachusetts occur at just five hospitals \u2014 Boston Medical Center, Brigham and Women\u2019s Hospital, UMass Memorial Medical Center, Beth Israel Deaconess Medical Center, and Baystate Medical Center. Some of these hospitals have elevated C-section rates, \u201cbut location alone does not fully explain the racial division,\u201d state health experts say.<\/p>\n Bell, a Boston-area doula and UMass Lowell undergraduate studying premed to become an OB\/GYN, said much of her work involves educating clients and fiercely advocating for vaginal births in people who previously had C-sections when they\u2019re safe. As a Black doula, she is especially vigilant, given the higher rates of complications faced by many Black women.<\/p>\n \u201cI warn all of my clients about places where doulas consistently report poor care,\u201d said Bell, 30, some of which she points to a \u201chistory of racism.\u201d<\/p>\n More often, Bell sees rushed inductions including overuse of the induction drug Pitocin, relying too heavily on monitors and other machines, which can cascade into what she believes are avoidable C-sections. She said external fetal monitoring feeds this trend. <\/p>\n \u201cDoctors err on the side of caution. If a baby\u2019s heart rate dips for seven minutes, they\u2019re already rushing to surgery. But by the time you get to the OR, the baby\u2019s usually fine. It wasn\u2019t truly necessary.\u201d<\/p>\n Some in the industry say there are broader societal issues at play that contribute to these disparities.<\/p>\n For example, a highly dangerous form of blood disorder known as preeclampsia, said Dr. Chenchen Sun<\/a>, a Tufts Medical Center obstetrician who also teaches at Tufts University School of Medicine, \u201cdisproportionately affects Black patients and those with lower socioeconomic status \u2014 not because of biology, but because of health care disparities.\u201d<\/p>\n \u201cFrom a systems standpoint, we have to train providers to recognize their biases and deliver culturally competent, trauma-informed care, especially for our most vulnerable patients.\u201d<\/p>\n \u2018The risk doesn\u2019t end when the baby is born\u2019<\/p>\n For some mothers, the danger doesn\u2019t end with delivery.<\/p>\n Experts say substance use disorder and mental health are now the leading drivers of the death of new mothers in Massachusetts.<\/p>\n Many of those deaths happen months after delivery, said Dr. Allison Bryant<\/a>, an obstetrician and associate chief health equity officer at Mass General Brigham. <\/p>\n \u201cThey reveal how vulnerable the postpartum period is, especially when support systems fall away,\u201d she said.<\/p>\n A recent study by Massachusetts General Brigham<\/a> also found that patients who undergo an unscheduled C-section face a much higher risk of stress in the weeks after birth.<\/p>\n \u201cSubstance use is the leading cause of death among young people, so it\u2019s also the leading cause among pregnant and postpartum individuals,\u201d Bryant said. \u201cDuring pregnancy, we monitor people closely, but six months later, they may be disconnected from care. That\u2019s when relapse, withdrawal, or mental health crises can occur.\u201d<\/p>\n For Brianna Smith-Thomson, a 35-year-old mother of three girls who lives on the North Shore, the loss of follow-up care was devastating. She remembers that after her first daughter, Kennedy, was born, the baby was jaundiced, and instead of having her stay in the hospital overnight, they were discharged and told to return the next day for an appointment.<\/p>\n \u201cI remember not having transportation, taking my newborn baby on the T as a first-time mom, and as I was standing there, I started crying and didn\u2019t know what to do next or what was wrong with her,\u201d Smith-Thomson said. \u201cI knew I needed professional help when I started to get overwhelmed, crying for no reason.\u201d<\/p>\n She is in therapy for postpartum anxiety and grief and wishes there had been more hands-on support \u2014 transportation, group care, practical help \u2014 beyond the standard six-week visit. <\/p>\n More than 80 percent of pregnancy-related deaths are preventable, state data show. Reviewers found discrimination and mental health conditions in 44 percent of cases, substance use in more than half, and care-coordination failures in nearly as many, according to a 2024 report<\/a>.<\/p>\n \u201cWe know half of maternal deaths occur postpartum, and one in five is tied to mental health,\u201d said Tufts\u2019 Dr. Sun. \u201cThe key is identifying risks early and putting the right supports in place before and after birth.\u201d<\/p>\n Postpartum depression figures heavily in a painfully public tragedy with the trial of Lindsay Clancy of Duxbury for the deaths of her three children<\/a> in 2023 before attempting to take her own life. Clancy had repeatedly sought help<\/a> for severe postpartum illness and her attorney has indicated he will cite extreme mental distress in her defense.<\/p>\n Maternal health providers say that improving outcomes will require confronting racism and other forms of discrimination in care, including to those with disabilities, and strengthening the economic and community supports that shape a person\u2019s health long before pregnancy.<\/p>\n \u201cMaternal outcomes aren\u2019t determined by health care alone,\u201d Bryant said. \u201cThey\u2019re shaped by nutrition, housing, transportation, social support, and by lifetime stress and inequity. Even with excellent care, those factors matter.\u201d<\/p>\n Sarah Rahal can be reached at sarah.rahal@globe.com<\/a>. Follow her on X @SarahRahal_<\/a> or Instagram @sarah.rahal<\/a>.<\/p>\n![\"An](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/RN3ABLPQE6RZ3PRKLZQAAACGQ4.JPG\")
An incubator sat near a window inside the neonatal intensive care unit at Mount Auburn Hospital in Cambridge.Erin Clark\/Globe Staff<\/p>\n![\"Erin](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/F3JFHS2CRGS5ZAPENSFNNNMJ5A.JPG\")
Erin Yang with her daughter at her home in Somerville.Jessica Rinaldi\/Globe Staff<\/p>\n![\"Nurses](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/MN2SNM3XRH5EPQ6YNMN2UB6E5E.JPG\")
Nurses worked at computer stations inside the neonatal intensive care unit at Mount Auburn Hospital in Cambridge. The hospital integrates midwives and obstetricians in its maternity care model, emphasizing patient-centered care and maintaining one of the lowest Cesarean section rates in the state.Erin Clark\/Globe Staff<\/p>\n![\"Certified](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/EDGXSBDNOOPJ7EZHTGCRIIISJI.JPG\")
Certified nurse-midwife Julie Mann (left) and Dr. Brett Young posed for a portrait inside a labor and delivery room at Mount Auburn Hospital in Cambridge.Erin Clark\/Globe Staff<\/p>\n![\"Dr.](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/PYVIITYP7JNJBSWUDKFLMQEZXY.jpg\")
Dr. Allison Bryant, an obstetrician and associate chief health equity officer at Mass General Brigham worked in the Labor and Delivery Unit at Massachusetts General Hospital on Feb. 17.Suzanne Kreiter\/Globe Staff<\/p>\n![\"Brianna](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/B5QEMI7TZPKVNVWTYKSQRRZ27Q.JPG\")
Brianna Smith-Thomson, a 35-year-old mother of three, reached out as her daughter Kennedy, 10, passed her sister 5-month-old Serenity back to her mom as Heavyn, 4, watched television in the family\u2019s living room in Lynn.Jessica Rinaldi\/Globe Staff![\"Brianna](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/04\/MUHAGDAS7PYYXXWTKVZITXZ3RE.JPG\")
Brianna Smith-Thomson\u2019s daughter Serenity looked up from her crib.Jessica Rinaldi\/Globe Staff<\/p>\n